Health Committee on July 7th, 2020

[Dr. Arjumand Siddiqi]

Thanks very much for the question. I'm happy to expand.

I think the way to do better is to understand what caused their vulnerability in the first place. There are two approaches that we could generally think about. One is to mitigate the harm done to vulnerable people, but the first is to ask why people are vulnerable in the first place. What makes us sort people into being vulnerable and not? What we've learned from the literature is that this issue of someone's social and economic position, in particular their race and their social class, creates an inherent vulnerability. Without addressing the fact that life, material conditions, stress, opportunity and so on are fundamentally sorted by race and class, we can't possibly hope to do anything about what the eventual outcomes of that vulnerability are, which are things like COVID-19 inequities, cardiovascular inequities, hypertension inequities, educational inequities, employment inequities and so on.

I think what we can do is take a good, long, hard look at how we structure opportunity in our society and say to ourselves, “We want a society in which the policies and the institutions create opportunity for everybody.” I think, as one of the members eloquently said earlier, it's the distinction between equality and equity in the sense that you want to make sure—knowing that we don't have an equitable society and that it's unfair to some—that we start to look at key policies that would get us to equity and would not just unfold opportunities as if they could be equally taken up.

A great example is that of post-secondary education. You could make an argument that anyone can apply and that this creates some equality. We don't stop anybody from applying. If you make the grades and so on, you can get into school. But that's not actually how it works, because you have to be able to pay for school. You have to have teachers who support you in feeling as though you can make it to that point. You have to have an environment around you that doesn't cause you so much stress that you can't focus on your studies and so on. The same is true for COVID. Yes, we could all shelter ourselves, social distance and technically avoid COVID, but that's not actually how things work. Some of us are more exposed than others are by virtue of our vulnerable position.

I think what I'm suggesting is that, as counterintuitive as it may seem, looking at the fundamental injustices of making some people vulnerable in our society is really the way to tackle the outgrowth of that.

[Darren Fisher, Liberal, Dartmouth—Cole Harbour, NS]

Dr. McKenzie, you listed many recommendations. Again, I was scribbling as fast as I could, but would you care to comment on this before my time runs out?

[Dr. Kwame McKenzie]

Sure, and thanks very much for the question.

I completely agree with Dr. Siddiqi that we need to go fundamentally towards equality and equity, and that there are these fundamental causes that are driving disparities.

The problem is that a lot of the things you are going to do to try to deal with those fundamental causes are not going to happen during this pandemic in the first wave, second wave or recovery. The question is what can we actually do now and what can we actually do that can practically help this group move towards a more equitable response?

I do believe that we will find, if we have the data, that different jurisdictions have had different levels of success in producing equitable responses. I'm completely sure of that. We know that different jurisdictions have had completely different rates of COVID. If you look at B.C. and compare it to Quebec and Ontario, these are very different outcomes. In fact, if both Quebec and Ontario had the same quality of response that B.C. did, there would have been about 2,000 lives saved in Ontario, and there would have probably been about 4,000 lives saved in Quebec.

There are big differences in the ways we've gone about things. If we could even get to the point of equalizing how well the different provinces have dealt with COVID, we would move towards better outcomes for all.

This idea of legislation is to try to promote equity through legislation, to make sure that provinces actually think about equity when they're thinking about their pandemic plans. At the moment, many don't, and that's why we see some of the disparities. Not all of the disparities would be dealt with by thinking about equity in the pandemic plans, but certainly, because, as Dr. Siddiqi said, there are fundamental causes of these disparities, we could make our response better and more equitable and we could certainly save lives by using a health equity lens.

Then going forward, when we're looking at the recovery, we need to use the opportunity of the recovery to try to decrease some of the fundamental drivers of inequities. I think there are things we can do now, directly in our pandemic plans, and then also in our recovery plan, that will actually make us more equitable and will save lives.

I also think that not having the data is criminal. It's 2020, right?

[The Chair, Liberal, Ron McKinnon]

Thank you, Mr. Fisher.

The floor now goes to Mr. Desilets for six minutes.

[Luc Desilets, Bloc, Rivière-des-Mille-Îles, QC]

Thank you, Mr. Chair.

My thanks to our two guests for their presentations.

Their comments are very interesting and somewhat different from the comments of witnesses we have heard from in the past.

My first question is for Mr. McKenzie.

I really liked the parallel you drew with the Titanic. For me, the image was vivid and very real.

You started your remarks by saying that Canada's response had been positive. How was it so positive, in your opinion?

As I listened to the rest of your statement, my impression is that we have completely missed the boat in terms of the black population.

[Dr. Kwame McKenzie]

Thank you, Mr. Desilets.

I would bring you back to some numbers.

If you look at the death rate per 100,000, in Canada it's been about 23 per 100,000. If you look at somewhere like the United Kingdom, it's been 50 per 100,000. In fact, Canada's rate is pretty good compared to that of many high-income countries, so we've done reasonably well.

Obviously if we compare ourselves to Germany, which has a rate of 11 per 100,000, we haven't done as well as Germany. In fact, if we had had a response that was as good as Germany, one analysis has shown we'd have saved 4,528 lives.

We're in the middle of the pack compared to lots of others. We've done very well; it could have gotten a lot worse.

The problem is that, inside that good response, it's worked better for some people than for other people, so my comments are that we have done well but if we had done equally well for everybody, we'd have all been better off and the death rate would have been significantly lower, and the morbidity would have been significantly lower. We would have been in a better place in order to rebound into recovery.

[Luc Desilets, Bloc, Rivière-des-Mille-Îles, QC]

Mr. McKenzie, do we have comparative data for other countries that are part of the G20 and that have about the same black-white population ratio? You mentioned the death rate of 23 per 100,000.

If you analyze the results in a little more detail, are there comparable countries?

How do we in Canada measure up?

[Dr. Kwame McKenzie]

I think that's a really interesting and important question. It is very difficult to make comparisons between countries. Also, most of the excess deaths, which are linked to ethnic group, are not linked to biology. They are linked to people's social situations, and people's social situations are linked to policy choices. Yes, we could say, “Oh no, we can only compare ourselves with populations that have similar ethnic groups”, but to a certain extent, that makes it sound as if race is the determinant. But race isn't the determinant; social policy and racism are the determinant.

Of course if we look at somewhere like Germany, it has a significant migrant population and significant ethnic diversity, including a very large Turkish population, but it has still managed to have a better response than we have.

[Luc Desilets, Bloc, Rivière-des-Mille-Îles, QC]

Thank you very much. That answers my question.

The fourth point you brought up dealt with the importance of obtaining Canada-wide results, so that provinces can be compared with each other and with the national level. A number of speakers have expressed that need and the gap we have. There have been requests for information to be communicated and for collaboration so that we would not have to wait for a year, say, to be able to compile the information and draw conclusions. Some countries have been much quicker than we have. They have been much more advanced and have established systems to centralize that data.

In Canada, in your opinion, whose responsibility is it to ensure this cohesion among organizations, among the provinces, and between the provinces and the federal level? Who should manage it? I feel that we are just passing the buck.

[Dr. Kwame McKenzie]

I do think there are significant difficulties with regard to data collection that are produced by the federal/provincial and territorial split. But I do think that the federal government itself can make sure it gets its own data house in order.

It is surprising that we have a census and that in our census we do not collect from everybody information on socio-demographic, race and ethnicity. We collect it from only 20% of people, on the long-form census, rather than from 100% of people, including on the short-form census. If we were able to change the short-form census so as to get a full picture of Canada, we would be able, possibly, to link that census data to other data in order to get a good picture of our pandemics, a better picture of our pandemics. It is possible to do these things but at a federal level, and it is also possible for the feds to insist that the provinces produce data.

At the moment, the feds pay a lot to the provinces. Maybe the feds should be thinking about what data the provinces produce in order to demonstrate that their responses are actually equitable. Very few people would give money to a company or a service without being very clear about what they're getting in return. At the moment, sometimes federal transfers are not transparently linked to productivity, especially not to productivity based on equity.

[The Chair, Liberal, Ron McKinnon]

Thank you, Mr. Desilets.

I'd like to advise the committee that we have set up a time for our next meeting, to be three o'clock Eastern time next Monday, at which time we can deal with Mr. Jeneroux's motion. We will also move the drafting instructions from today to following that meeting. We are still tight on time today but we will do our best to get both panels in and both rounds, so thank you all.

Mr. Davies, please go ahead. You have six minutes.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you, Mr. Chair.

Thank you, Dr. Siddiqi and Dr. McKenzie, for sharing your expertise with us today. I think both of you have laid out a very clear and powerful case for why the federal government needs to collect comprehensive national data on social, economic and other factors.

Dr. Siddiqi, you recently wrote that the Canadian government has been reluctant to routinely collect race and ethnicity data, and that the consequence is a lack of accountability, according to your writing, in addressing racial disparities in all sectors of society.

In your view, why has the federal government been reluctant to collect race and ethnicity data with respect to COVID-19 and in general?

[Dr. Arjumand Siddiqi]

I can tell you what we often hear as the primary reason, and then I can speculate about what might be going on.

We're often told that the reason for withholding this data, for not making it publicly accessible, not collecting it more widely, etc. is really to protect the privacy of Canadians, since there may be some issues particularly with a general release of the data that would compromise the safety and privacy of Canadians were those data able to identify particular Canadians. We have very little reason to believe that is enough of a concern to suppress really valuable information. Is it somehow, through de-identified data, still possible to identify particular Canadians? It almost never is. Maybe there is a slight outside possibility, the way there is with census data for that matter, but not enough for me to believe it's actually a legitimate reason for not collecting this data and not allowing it to be freely, publicly accessible to be analyzed by people like me, Dr. McKenzie and others in order to inform our country about what's happening to us.

That brings me to what I think might be going on. It's unfortunate, but I do think that when we don't collect data, that's at least one way in which we can ignore the evidence. We can equate our own opinions with a claim that those opinions are facts, because the facts simply aren't available to us.

My sense is, as you've pointed out and I've pointed out before, that with data and the ability for independent scientists to analyze that data comes a groundswell of evidence that in one way forces us to at least admit to the facts, to at least have to contend with and confront and recognize the fact that there are empirical evidence sources being put before us, rather than having a situation in which anyone can say virtually anything and we don't really have a good way to contend with or refute what people are saying.

I think that part of the hesitation may be that this actually creates some serious empirical demonstrations of what's happening in our society and that then, as Dr. McKenzie said, that's not the end; it's just the beginning, and that will make us have to move forward with action.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

Dr. McKenzie, I want to focus on mental health for a moment.

A June 29 article from Global News noted that before moving to Toronto you ran a mental health service in north London, U.K. When someone with psychosis or another serious form of mental illness was in crisis, your team of medical professionals showed up first rather than the police. You noted in that article that this was possible because the U.K. funds mental health care in ways that Canada does not.

Could you please provide the committee with further detail on the effectiveness of this program, and maybe outline the key differences between the U.K.'s and Canada's approaches to funding mental health care?

[Dr. Kwame McKenzie]

Thank you very much for the question. I didn't know quite where it was going; I thought you were going to be talking about the echo epidemic of mental health that was going to come through COVID.

The situation that we find in Canada in general is that about 7% of health care spending is spent on mental health. In the U.K., it's between 9% and 11%, depending on where you are. A lot more money is spent on mental health in the U.K.

Mental health, obviously, as you know, is about people. There's not amazing surgery to be done and all of those other things. There aren't loads of equipment. It's about people. If you're not spending the money, you don't have the people, and if you don't have the people, you don't have the service.

The difference I've seen in Canada compared to the U.K. is that there is not a comprehensive enough mental health service, and there's not a comprehensive community mental health service. Because of that, there are more crises. There are many more mental health crises and, as you know, these can end up tragically.

The actual breadth and depth of mental health services in Canada are not sufficient, I believe, to meet the needs of the population. If we are to get an echo epidemic of mental health problems due to COVID, I believe we are going to have real problems unless we significantly start investing in building capacity to deal with the mental health impacts in the community and elsewhere.

[Don Davies, NDP, Vancouver Kingsway, BC]

You spoke of the legislative—

[The Chair, Liberal, Ron McKinnon]

Thank you, Mr. Davies.

That ends round one. We'll start round two with Mr. Webber.

Mr. Webber, please go ahead. You have five minutes.

[Len Webber, Conservative, Calgary Confederation, AB]

Thank you, Mr. Chair, and thank you to our two doctors who are here today for their testimony. It is incredibly interesting, for sure.

Mr. Chair, I certainly hate going behind Mr. Davies in questioning, because once again he has brought up some points that I wanted to bring up.

It's about that same article, Dr. McKenzie, that article in Global News regarding your experience in the U.K., in north London. It was about the team of the medical professionals who showed up first—not the police—when there was a mental health crisis in the community. You talked a bit about it. Can you explain to us how this came about, how it worked and how you dealt with violent or armed non-cooperative people?

I know that this wasn't a part of your testimony today, but I think it is very relevant in the mental health side of it. Can you elaborate a little more on how you began this?

[Dr. Kwame McKenzie]

One of the things we found, and one of the things that we've always thought, is that if you can intervene early, you decrease the need for crisis intervention, so our team was very straightforward. It was community based. For every person who we saw, they and their family were given a telephone number that they could call any time, and we would go to see them. Yes, we did all the crisis calls. Yes, they called us first, rather than the police, and, yes, we went out to see them. Over the three to four years I was there, none of our staff were injured and none of our clients were injured. That didn't happen.

Some of that is because we are experts in de-escalation, and we are experts in dealing with mental health crises, and some of it is because people knew who we were, and that makes a difference. But a lot of it was because we saw people earlier in their diseases and earlier in their problems. Rather than waiting until things got so acute that people were ringing the police, families were ringing us early and we were going to see people, and we were decreasing the problem.

Community mental health services properly deployed are very important and they work. Yes, we did have problems when people were very disturbed, and we needed to have the police as backup, though we led the response. The police would be in the car outside, and if we needed them, we called them in. We had them there, but we never had anybody put in handcuffs and taken away. Part of the reason for this is that it is traumatic, and even if it's done and the person doesn't get hurt, you then have to deal with the trauma.

That's what we did. It worked well. It expanded across London. It's the way things were done at that time.

[Len Webber, Conservative, Calgary Confederation, AB]

I think that is brilliant, Dr. McKenzie. I think that we should certainly be looking at implementing something like that here across our country as well. Thank you for sharing that.

I have a quick question for Dr. Siddiqi.

Again, thank you for your presentation and for sharing your experience on your studies of relationships between race and health outcomes. In an article in The Globe and Mail on June 1, you said that the United States was “night and day” different from Canada in race-based data collection. Can you better explain those differences, Dr. Siddiqi?

[Dr. Arjumand Siddiqi]

I have a lot of experience with the U.S. because I trained there and lived there for a long time. I still do a lot of research there. That's the foundation of my comments.

In the United States, they have routinized the collection of data on race the way we have routinized it on age and gender. In the United States, you answer a question about your race nearly every time you would answer any questions about your demographics or where you live. That means you answer it when you access the health care system or the education system, when you apply for a job and when you actually get a job and your address and information are collected. Then the United States makes that information, that data, publicly accessible. You and I could, right now, go to the Internet and access datasets that are either administrative, meaning they're the collection of this routine data, or they are government surveys the way we have the Canadian community health survey and so on. We could just go to the Internet, download that data with really good documentation about how to use it, and create analyses right now of what racial inequalities and socio-economic inequalities look like.

To give you another example, we're conducting some work on inequalities in birth outcomes in the U.S. We can do that because birth certificates have information on race and we can do it because that information is downloadable off the Internet with ease. I don't have to apply to request the data, go into a StatsCan data centre to analyze it between nine and five, get certified to do that, tell them exactly what I'm going to ask and then—

[The Chair, Liberal, Ron McKinnon]

Dr. Siddiqi, could you wrap up, please?

[Dr. Arjumand Siddiqi]

Sure.

In Canada what happens is that there are all of these barriers, first, to collecting the data and therefore having data, and second, to accessing the data that we already have.

[Len Webber, Conservative, Calgary Confederation, AB]

Interesting. Thank you very much.

[The Chair, Liberal, Ron McKinnon]

We will go now to Mr. Van Bynen.

Please, go ahead. You have five minutes.