 Alright folks, let's see. Is this nice and loud for people? You can hear me pretty well, and if you're far away. And we do actually have closed captioning today in Christie, we are getting started so we have a closed captioner who's away from our site. And if a person ever wanted to check into that they could join our zoom webinar which will have the subtitles across the screen we're not having them run behind because it might be a lot of different stimuli for you folks in the room. Otherwise, but that's possible to do and if you do, however, log into the zoom webinar in order to access that while you're in the room, I just ask that you mute your computer so we don't get feedback. Okay, so that's an important aspect we want to avoid the feedback. So let's get started. I'm so glad to welcome all of you who are able to join us here in person today as well as folks joining us online. And this is the inaugural lecture of the 2022 23 Dalhousie health law and policy seminar series. I'm Sheila Wildman, and I'm associate director of the health law Institute, our director Matthew Herter is lurking over there. And our wonderful administrative coordinator Ashley Johnson is just on my right over there. We are grateful to convene today's lecture, and those that follow in McMuggy, the ancestral and unceded territory of the Mi'kmaq people. We pay respect to the indigenous knowledges held by the Mi'kmaq people and the wisdom of their elders past and present. I also acknowledge the histories, contribution and legacies of African Nova Scotians who have been in this territory for over 400 years. Before turning to introduce Dr. Gaynor Watson Creed, permit me just a couple of framing remarks. First, I want to mark an enormous loss to our school, community, and world. Professor mine heart dwell, a longtime friend and law school colleague was taken from us in untimely fashion last weekend in a road accident, while in accordance with his politics and his pleasure, riding his bike. Mineheart was a leading environmental law scholar and climate justice leader, local, national and international. He had an indelible impact on the work of environmental regulation, again local and international, and he was a generous and gentle teacher and friend. A tragic end to mine hearts life and his life's work, and the fact that this lecture falls on a day of climate action urges us to consider the deep relationship between health and the environment, and more specifically the enormous inequitable global suffering in security and the death that our resource extraction and consumption have unleashed in the form of climate change. We at the Institute will seek more ways over time to make the connections between health justice and environmental justice more explicit in the spirit of mine hearts tremendous efforts to keep the bright light of hope for humanity burning in the face So let me shift with some information about our seminar series. The Dalhousie Health Law Institute is a joint initiative of the faculties of law, medicine, health and dentistry. The Institute's long running seminar series offers an important public forum for interdisciplinary research on some of the most important and often contentious legal and policy questions of our time. This is the 26th year and 200th lecture in the series. You can learn more from Matt, Matt Herter again our director, about the Institute's doings in and beyond the seminar series at a reception that will follow immediately on today's lecture, and there will be cake. Oh, you've got to mute that cake and more in room 312, which is the faculty lounge up on the third floor so you're all invited, even those online who might want to come in when they hear that there's cake. You're all invited to come and join us there. This year we've convened our eight seminar series lectures around a deceptively simple theme health and social justice, making the connections. Today's lecture provides a foundation for those that follow as Dr. Gaynor Watson Creed reflects on the subject social and structural determinants where health really comes from. We're recording today's seminar for distribution on our website, but the camera will stay focused on the speaker. I want those in the room to be aware of that though that it is being otherwise recorded so now a little on our wonderful colleague and speaker for today. Starting her slides already. Dr. Gaynor Watson Creed. Dr. Watson Creed is Associate Dean of Serving and Engaging Society for Dalhousie University's Faculty of Medicine and his past chair of the Board of Engaged Nova Scotia. She's a public health specialist physician with 17 years experience, having served as the former Medical Officer of Health for Halifax and Deputy Chief Medical Officer of Health for Nova Scotia. She has served as a member of the One Nova Scotia Coalition Economic Strategy Table and the Federal Task Force on Women in the Economy. She is co-chair of the Advisory Council to the National Collaborating Centre for Determinants of Health and a member of the CIHI Advisory Council on Population Health. Dr. Watson Creed has an MD from Dalhousie University and an honorary doctorate from Acadia. There's much more besides I could say and as you will gauge for yourselves, she is a passionate advocate for high quality public health services in Canada. Without more ado, please join me in welcoming Dr. Watson Creed. Okay, thank you so much, Dr. Wellman and Dr. Herter and Ashley for getting me here today on this crazy September thing that we're having. Hello Health Law Institute. So lovely to be here with you and with all of the people that you draw in both in person and online. I see some colleagues here from Provincial Government. Good to see you. And so old friends and new. I'm going to take about an hour. I want to make sure that we have time for questions before cake. And give you a bit of an overview of social determinants of health and where I'm going to start that is actually with an overview of social determinants of health. Yes, but I'm then going to take you into the work of public health just for a while for a couple of reasons. I'm not going to lie. I do love public health. It is, it is my place. And it is the work of public health, the primary orientation of public health is around determinants of health and that's how I know what I know about social determinants of health. So I'll take you there and then we'll we'll talk a bit about the techniques that public health uses to uncover social determinants of health when they are contributing to health inequities. And I'll use some examples I have about six examples that I'll use just to illustrate that point and I'm sure we'll have a ton of fun. So I don't have any of the usual, you know, material or financial complex to declare but I will declare that I do truly love public health. That is my major disclosure. And thank you, Dr. Wellman for the for the land acknowledgement so I won't repeat that I'll just dive right in. So how many of you, at least here in the room I can't see the folks online but how many of you have seen this list of determinants of health somewhere. Yes, okay, quite a few right. And so you'll see this list replicated in the number of places this one comes from the government of Canada so this is on the public health agency of Canada's website. DC Atlanta has a similar list that they use you can find similar lists for the National Health Service in the UK, and it goes on and on around the world and so these are the things that we recognize contribute to health. And when I first encountered this list as my as a trainee in public health, I have to admit, you know, I can read the list and I can understand what it says, but the actual impact of any of these individual items on the list was a little bit lost on me and so my hope today is that you'll get a sense as those impacts actually really are and more specific they had a look for those impacts when they're at play. But I'm going to start with this which is, you know, this question about but why is public health interested in social determinants of health. And I think what everybody knows about public health, and certainly has seen a public health in the past two years is that you know most folks understand public health to be interested in communicable diseases we're interested in a lot more than public health diseases by the way, but I will admit that coven has not helped our image in that respect. And to be fair, the practices of public health around communicable diseases and in particular their links to the environment go back thousands of years. This is true right so even the ancient Chinese understood that there was something about the fluid of smallpox infected children that if you applied that fluid to non infected children we prevent those children from becoming infected so that focus on communicable disease control has been there. But even as we've been focusing on communicable disease in public health, we have also started over the past three or 400 years to turn our attention to other things that may be at play in any disease state. And so this is a quote from the lower the health officer of lower Canada so this would be one of my predecessors and in public health in 1816 at a time where Canada was absorbing a tremendous number of European migrants as part of colonization quite frankly. But the quote from the lower health, the lower Canada health officer is this they describe these migrants as the wretched and miserable class of starved people that annually arrive Wow. What a description. So, aside from the ugliness and judgmental nature of the quote, what is this medical officer pointing to anybody. Yeah, go ahead. Poverty. So this is 1816. And even then this medical officer with all the flaws that are attendant with this whole scenario that I'm describing for you was able to identify poverty as a resource of illness, and, and you know his goal was to prevent those illnesses from infecting those who are already here. And so the early efforts of public health, yes, we're sort of focused around communicable disease control engineering and environmental controls for that but also around poverty. I want to be clear when I'm talking about the public health system this is just a little bit of a sidebar that I do not mean the publicly funded health care system I just want to be very clear about that so I'm talking about the formal public health system that is specifically structured for this purpose and this is the definition of public health from Winslow in 1920, the science and art of preventing disease, prolonging life and promoting physical health and efficiency through organized community efforts to have been several variations on that definition of public health. But that's the system I'm talking about that's different than the publicly funded health care system that provides our hospitals doctors nurses nurses clinics MRIs etc. And we'll talk about both during this presentation but just want to be want to be clear about that. And so that prevention work that the public health system does. Thank you. I'm sure the prevention work that that public health system does includes looking at root causes of disease where where does that come from. So this is how I describe that work when I'm trying to describe it, you know, to folks who really have never seen this before, like my accountant, or my parents who get with my family, Dr sister does and they, you know, in the early days sort of looked at what I did and said yeah, we kind of get it my parents are both sociologists but they're also like is weird to see that happening in medicine, what exactly is public health. So that's how I describe it. And I had the benefit of licensing both as a family physician and as a specialist physician in public health when I did my training and I maintain both of those designations. And so as a family doctor, what I would say is I really know the experience of going to a family doctor right so you go when something is wrong with you. You might go for a preventive visit around or counseling around something but generally you'll go if something's not right. And if that family physician will see maybe 20 or 30 patients a day. And they're interested in anything that those patients bring in that is that problem of the day and so they may go from a well maybe visit to giving somebody travel immunizations to doing a mental health counseling visit to removing somebody sutures to chronic disease status. And at the end of the day they'll have seen those 20 or 30 people and they will have a sense of what was wrong with them and what they could do to move sort of their, their health forward and if they didn't know that they knew they could reach out to a specialist community that might be able to give some additional ideas and together the patient specialist the family physician will figure out a path going forward that gets the patient back on course to to health and to wellness hopefully right. And so your average family practice might have 1500 patients they're not going to see necessarily all of those patients every year, but through the course of those days they see 20 or 30 at a time and as needed. As a public health physician, I am not interested in anything that makes people sick as individuals. I am interested in anything and everything that makes them sick in groups, or has the potential to make them second groups and I want you to think just for a moment about that potential to make people second groups right. The potential for illness for bad health outcomes comes from our environment. It comes from the foods we discern from that environment. It comes from our drinking water. It comes from our air quality. It comes from the quality of social connections that we have in those environments. Those that's where the opportunity for prevention is. That's what links public health in its prevention mandate from that 1920 definition to social determinants of health, which are those conditions and communities that I just that I just outlined right. So if you had asked me, you know, as a family doctor if I knew the limits of my practice I would say of course and when I reached the limits I'm going to reach out to that specialist community community and they're going to help me figure out where to go next. You asked me as a public health physician what the limits of public health practice are my answer is I don't know. And even if I did know I'm not really sure where I would reach out to as a specialist because you can't refer the whole population. But this is why public health systems are tied to government structures around the world is because when you reach that point in public health practice where you need that extra level of support. The only agencies that have the reach into the population to put in place those interventions that might actually work in that prevention realm. Our government agencies and so you'll see attachment to municipal, provincial and federal governments around the world for public health structures. So if you had asked me as a medical student if I ever had to know anything about the life cycle of a mosquito, I would have said to you when what does that have to do with health exactly oh no wait. That's West now virus prevention malaria prevention Zika virus prevention. So if you can interfere with the acquisition in the lifecycle of that mosquito getting that disease. You prevent that mosquito from becoming a vector to pass that disease on to humans and other populations. So that's the pathology. Yes, has something to offer the practice of public health. If you'd asked me if I had to know anything about the engineering of highways. Again, I would have been like. So that's engineering. What does that have to do with medicine. Oh, that is trauma prevention. You can actually design the highways in such a way that you minimize the impact of that motor vehicle collision and a kinetic energy that's transferred from the environment to the human. You prevent that human from ending up in the emergency room that is trauma prevention. Right. Some of my most fun collaborations as a public health physician were with environmental engineers, traffic engineers, architects, urban planners on questions like these. They'd asked me if I had to know anything about city building I probably would have looked at you like you were crazy but no, that is actually chronic disease prevention what I frequently say to my colleagues who do for example chronic disease management work, like the endocrinologist and the cardiologist those types of groups is that we all know what to tell our patients to do to keep their themselves healthy right and we'll talk more about this in a while. But if we haven't physically built it in our communities, it doesn't matter what we tell them in our ivory powers, they can't do it because it physically does not exist I got a phone call from public health. This was about 10 years ago in sheet Harvard over Scotia, and I was at a meeting in Toronto my phone rings I pick it up and it says nurse on the phone and I'm thinking there's a crisis and she says no no no I just needed to share the good news with you. I'm at the opening ceremony for the sidewalks. And I was like, that's fantastic sheet harbor got sidewalks which meant that our messages around chronic disease prevention through active transportation could actually land somewhere, because there were now after transportation roots in sheet harbor right so if it hasn't been built. So again some of my favorite collaborations have been in that space. And if you would ask me as a medical student if I had to know anything about grade 12 graduation rates I would have said and why, because that's the education systems to do. Oh no way to turns out that graduation from grade 12 in the language of your choice with a high degree of literacy in that language and math skills is the major most impactful determinant of health. So you start to see the broad reach of determinants of health and the interest of public health in that work. And so when I talk about the prevention work that public health does to uncover those social determinants when they're at play, and and engage with them we have a name for that we call it primordial prevention this is different than the type of prevention I mentioned before that you might do family doctors office and so we describe it this way. So public health. Well the healthcare system is represented on the right hand side of this slide. And what you'll hear us talk about in health is these levels of prevention and so you'll hear us talk about primary prevention. That is, there are risk factors for disease out there, we should do something to prevent that risk factor from actually becoming disease in any individual so that's where you might do that counseling with your family physician around smoking cessation, or alcohol consumption or something like that. Right. Secondary prevention is too late disease has started but it's early. If we catch it early, maybe we can actually reverse the disease so this is where our screening programs come in right our cancer screening programs for example, tertiary prevention is too late again diseases actually established we can't do anything to reverse it but we can at least prevent hopefully the worst outcomes of disease so it doesn't shorten your life. It's the work of our specialist groups of specialists specialist that we might reach out to from family practice that I mentioned before. Right. So I want to just focus on those definitions for a minute, I said the primary prevention is there are risk factors for disease out there you should prevent them from coming at becoming disease in any individual of course we would all agree that's a good thing to do. So self practice primordial prevention is about this. It's about actually preventing the risk factors from ever existing. Just want to let that sit with you for the moment, preventing the risk factors from ever existing. So if you think about where those risk factors come from in communities in how those communities are structured. So that's a massive task, right, prevent the risk factors for disease remember existing so sometimes when I say this, I hear from people okay so come on Dr what's a free that's, that's a little bit like public health, you know, kind of chasing rainbows and unicorns. And then I hear from other people oh no wait a minute you've kind of done that with tobacco. Actually, we do have whole generations of young people who actually have grown up largely not seeing tobacco products in their environment. So what we're dealing is currently launching an entire tobacco prevention strategy, based on that idea of primordial prevention, right, preventing the risk factor from ever existing. And so that's the work that we do and that's what takes us into those realms around education and systems of justice and planning community services, and so on because that's where those risk factors. Put another way. Public health can be described as the practice arm of population health so you'll hear people talk about population health and so CDC sort of talks about population health is this interdisciplinary because of where all those risk factors come from and sectors outside of health, and customizable approach that allows health departments to connect to practice for policy change. And so what I would say is that public health is the practice arm of population health so lots of people are involved in in population health work but within the house system. It is public health that that has that mandate specifically. Even this piece of I'm talking about is not new practice in public health. And so I come back to stories from the 1800s and in particular the emergence of epidemiology and actually social epidemiology as a foundational construct in public health. So, how many of you have heard the story of Dr john snow and the Colorado outbreak in London. Okay, a few. So, anybody want to give us the Coles notes version on the story. So, Dr snow do. Yeah, so the famous story is that he marched up to the pub and broke the handle of nobody knows if that's actually true but it makes for a good story and saved the community that was affected by this color upgrade. But that is an accurate depiction of what happened but I want to take you through the methodology that Dr snow used so he did indeed identify that there was an excess of color and that's happening in one part of the city of London the broad street area of London that wasn't happening in other areas, this is a foundational entry point for any public health in three. These people are affected. These people are not affected. Why are these people affected. And so the question at the entry point is why. Why are the people of the broad street area affected was his first question. And his answer was, eventually, through some inquiry and some experimentation, the drinking water seems to be contaminated part of how we reached out was looking at what people were drinking and who was drinking what. Interestingly, the beer drinkers were not getting sick, because they weren't drinking the water, but the water drinkers were getting sick. So his next question that led him to investigate the water and so he didn't need find this question that the water was contaminated but his next question then was, why. Why was the water. Any guesses. Yeah, go ahead. Yes, as a matter of fact it was, and his next question was, why, any guesses. Like the sewer system was in disrepair, right wasn't functioning well, and his next question was you can see where I'm going. Why, why was the sewer system in disrepair, because the people of the broad street area didn't have the money to fix it. And his next question was, why, because the broad street area was neglected and impoverished area of London. And paying the taxes that would afford them the opportunity to keep that sewer system and drinking water system in good repair that led to the contamination. So Dr. Snow's major discovery was not that color can be transmitted through drinking water. His major discovery was that poverty is a brief cause of inequities and health outcomes in a given geographic area he and his colleagues became huge advocates for poverty reduction in the area of London. And as a result of that he himself came from poverty so it's not surprising that he was oriented to that in his inquiry. That's the methodology that we continue to use in public health today to uncover where social determinants of health are at play. And so what Dr snow left us with was this idea around that we still use in public health around the age of host environment, just briefly this says that for any disease to be at play, there needs to be an agent that's in action like the bacteria that cause cholera, there needs to be a host that's affected but also that in the environment and we've now expanded our understanding of that it's not just a physical environment is social and economic and policy environments. That can give rise to the conditions that allow the agent to be susceptible. Sorry, to be in existence and the host to be susceptible. And so that's a part of what we continue in in public health today so public health is the only branch of medical practice that's obligated to systematically look for these differences in health outcomes and expose them. And so they expose not dispose for the purposes of resolving them or deploying what we call these primary prevention strategies and we do that because we recognize that at the end of the day we can put everything we want into clinical interventions, or even productive interventions like the ones that you might see in a family doctor's office, but the biggest weight of sort of input into negative health outcomes comes from socio economic factors. And so this comes from the American Journal of Public Health is written by Tom Frieden who's a former director of the CDC, just looking at sort of where we put the weight of our interventions and we'll come back to this in a moment. So let's come back then to the social and structural determinants of health, and what we really need to understand about them in order to do those types of inquiry. So some determinants as a description is relatively new we've been calling this the social determinants of health quite some time but the addition of structural points to the idea that some of the determinants of health that we are that we're talking about are so deeply baked into our institutional structures, all of them that they are almost like the ether that those structures operate in we don't even see it when it's operating. And that we can see from the outcomes that the determinants are at play and they're having a differential impact on different populations so I currently do a lot of equity diversity inclusion work at the Faculty of Medicine. And we are doing a lot of work specifically on anti racism and what I say about racism is this is a construct that is 400 years old and by the way, physicians were in many ways responsible for the false ideas that emerged around the importance of skin color 400 years and in the 400 years since what's happened is every single societal system of influence that has been created since has been created with this false construct in mind. And so when that is the setup for all of those structures and those structures by their nature are meant to actually support life and health outcomes. Why would we expect to have people are equitable health outcomes under those circumstances. And guess what we don't right so when we look at statistics we can see in public health that we see different tools in who's incarcerated who's graduating from high school who are the children who are in custody of the state, we see it in our product disease statistics are premature death rates are poverty rates and by the way they're all kinds of ways to look at poverty, energy poverty, food insecurity housing insecurity, transportation poverty all of these disproportionately affects certain groups, chronic pain statistics the list goes on and on and on. And so structural determinants is meant to say, there are elements of our socio political environment that are baked into how we do everyday business and our major institutions of influence that are now resulting in these ongoing inequities and and we have an obligation to expose those. So let's come back to what those determinants look like so here's the list. And when I look at the list I always like to sort of point out a couple of things one is some of what we do in medicine as we talk about risk factors for disease and we talk about modifiable risk factors and non modifiable risk factors right so modifiable risk factors or things you can do something about non modifiable ones are the things that you're stuck with. Right. And so of this list, what would you describe as non modifiable risk factors. I'm going to get a hint it's highlighted. Biology and genetic endowment and you know these days with gene therapy that's only kind of sort of maybe right in terms of whether or not that's modifiable. All of the other risk factors on this list all of the other determinants on this list can be considered to be modifiable in many ways. If it's modifiable it means that we can modify them in the direction that supports good health health outcomes instead of the inequities that we've consistently seen right. The other thing I like to point out in this list is that of all of the things on the list so the 12 items on this list some people have a list of 15 some people have a list of 13, but you'll notice that access to health services is only one. I'll talk more about that in a moment. And finally I would point out that education and literacy I mean all of the ones on the left hand side of the screen, but in particular education and literacy physical environments are key determinants of health, as I mentioned before. And so, let's talk a little bit about how that actually shakes out in policy so this is data from on the left from pie high in 2021, and on the right from the Senate of Canada in 2009 and their report on population health in Canada. And the Senate diagram is a little bit busy so I'm going to walk you through it, because I think it's important that you that you're able to recognize this can folks see my cursor okay. So, I said that health access to health services was only one on the list and so the Senate of Canada actually had their research assistance do some research on what is the relative weighting of those 12 determinants of health in terms of how much they actually contribute to any individual health outcomes. And the answer they got for that one that is health services, which is over here on the far right is no more than 25%. So no more than 25% of what we spend on health care will contribute to your, you won't get more than 25% contribution to any individuals health outcome. And the bigger contributors are in this middle category where they have 50%. That's early child development, education, employment, culture, gender housing list goes on and on right. And then at the very end they have maybe 15% contribution from what does that say physical environment is 10% and then your biology and genetics is 15. 25% health care. That's it. And their estimate was actually between 13 and 25%. That's the contribution to your health you'll get from healthcare. How much do we spend on health care in the province of Nova Scotia. Oh it's on the slide. 40% of the entire provincial budget. 40%. So 40% goes in maximum 25% comes out. That's a good question about about the math there. Right. Meanwhile, all of these other determinants by comparison, get very little sort of policy weight when we're talking about health outcomes are well being outcomes in the province of Nova Scotia and for that 40% that we're spending on the provincial budget in health. That's where the slide on the left comes in 25% of that is going to building of hospitals and maintaining of hospitals 14% of that is going to our drugs, and 13% of that is going to physician So the majority of the spending is in those top three categories. Right. That is a pretty heavy weight for something that has relatively little impact compared to the other determinants of health. And so this is where you start to see the complexity of the systems that we have created and the interaction with determinants of health that's actually needed in order to sustain health and well being outcomes. So I said, why is a public health question and I always say why is a public health question and so we actually have an exercise that we use to uncover those determinants of health in public health and so you'll see this in schools of health promotion. This is on the public health agency of Canada webpage we call it the Jason's broken leg exercise of the Jason's in injured leg exercise of the five wise exercise. And so the first time I did this exercise I was a second year resident I think in family medicine that McMaster University, and our preceptor did a five wise exercise and it was, you know, 38 year old female patient comes in she's seven months pregnant and she has recently immigrated from Nigeria and her HIV status is positive and go. So we started asking the question, but why, but why, but why, but why, but why, and about 30 minutes later we've come to this point in the tutorial where the answer is the impact of the industrial revolution on African nations and in particular the impact on rural populations where men had to leave the population in the rural community to go into the cities to find work, and that left the women vulnerable and exposed to sexual diseases sexually transmitted diseases that might come back it was something like that. And as a group of family medicine residents we're sitting in this room going. And what do we do about that. We really talking about the industrial revolution but what year is it now, like what can we do now and so then what you do is you work it forward right. So this exercise goes like this wise Jason in the hospital well because he has a bad infection in his leg. Why does he have an infection well because he has cut on his leg and it got infected. But why does he have a cut on his leg well because he was playing in the junkyard next to apartment building and there was some sharp jagged steel that there that he fell on. But why was he playing in the junkyard. Well because his neighborhood is kind of run down and a lot of kids play there there's no one there to supervise them. But why does he live in that neighborhood, because his parents can't afford a nicer place to live. But why can't his parents afford a nicer place to live because his dad is unemployed and his mom is sick but why is his dad employed, because he doesn't have much education and he can't find a job, but why but why but why. And so the thing is, when you see an exercise like this and we use these in real life and public health to get to the bottom of policy opportunities. When you, when you do this exercise you may run to a point where you go okay there's nothing I can do about that because it occurred 50 years ago but if I come forward. Could I do something from an advocacy perspective around the fact that there's a junkyard where the kids play in the neighborhood, probably, at a minimum if I'm an emerged Doc, I might stop at treat the infection and send them home, but many community advocates would say okay so let's do something about the junkyard. And while we're at it let's do something about poverty rates in that community. And maybe about conditioning for a change in planning, so that we can improve the infrastructure in this community, right. Those are the starts, the, the starts of the conversations that you can get into when you do this method. And so when we do it in public health we always start with a health outcome at the top so the idea is that you look for what is the health outcome that's happening over here that doesn't happen over here you can do it for any outcome you can do it for justice education outcome, but in health we start with health outcomes so what's happening over here that's not happening over here. And we use often geography as the base for that, and then we asked the question but why is that happening and often what we come to is, because there is a difference in the risk factors that exist in community one versus in community two, we're in population one versus population two. And we, when we look for why are those risk factors different what we find is that it's because the social conditions in those communities between community one and community two are different those social conditions are described by the determinants of health. Let's look at some examples of how this works in real life. So this is a real life study 2006 I think was the last time that the city of Halifax participated, but this was a national study on street involved kids in Canada. And so our task as the Halifax site was to recruit 180 unique street involved youth for the purposes of doing two things one was to get a year example and a blood draw to check for HIV hepatitis B and C, but the other was a 45 minute qualitative interview, based on the question why. And by the way it is not difficult to recruit 180 unique street kids in Halifax. We completed recruitment in the order of something like two weeks. And so we participated in this study and the 45 minute qualitative interview gave us a tremendous amount of information right so the question is why. Why do you have HIV, but why, but why, why are you living on the street and a significant proportion of the Halifax sample we're able to tell us and this is in the national report that is on still on the public health agency of Canada website. It's a significant portion of the Halifax kids were able to tell us that the beginning of the end for them was when they were first divorced from what was at that point the only remaining stable adult structure in their little lives. The school system at the age of seven, seven kicked out of school. That was the beginning of my street involvement. Right, I had no other adults school was it. And so we were able to take that data to Halifax regional school board to say heads up, you may not have known it, we wouldn't have known it if we weren't looking for it in this way. And something about school disciplinary policies may have a link to an outcome that is living on the street with HIV in Halifax, just heads up right. The school board wasn't entirely happy to have that conversation with us, but part of what we do in public health is we have a robust relationship with schools for this reason for being available to them for policy discussions. And so we often have embedded staff in school so so we were able to have some some of the conversation. So that's one example. This is another example from south of the border this is on the Robert Wood Johnson Foundation website this is their 2016 culture of health prize winners so if you get the chance to read the story I would encourage it. This is Kansas City, Missouri. And so medical officer of health, returning to Kansas City, Dr. Richard Rex Archer. And what it says is he returned to his hometown to lead its health department he started reviewing the city's vital statistics got a handle on pressing needs because when you have 480,000 patients the whole population, you can't do a history and physical on it, everyone like you would in a medical clinic right. And so the inequities he found shocked him life expectancy for white residents was 6.5 years longer than the life expectancy of their black neighbors. And so the question becomes, why. And so Dr. Archer and his colleagues did that work and what they uncovered was inequities particularly in employment and education systems that allow them to open policy discussions around those things. And four years later they have already reduced the life expectancy gap by two years. So we say things in public health like oh public health outcomes take a lifetime that's not true. If you do this methodology well you can actually make an impact on those outcomes that are rooted in determinants of health right. Similarly, I talked about food security and this is an example from here in Halifax. I had a conversation with my sister who's a family physician as I mentioned, and we did that thing that physicians sometimes do I'm sure that lawyers probably did the same I have this really weird case and I don't know what to do about it so we had one of those one Wednesday evening. And hers was I have this patient. She's got chronic disease and as I was talking to her, you know I'm giving her the spiel and we all know what that is right so what do you have to do to maintain your health you have to eat better exercise more. And this patient started asking her questions so when you say eat better, what do you mean, Dr Watson and she said well, you know, five fruits and vegetables you guys all know this trio right five fruits and vegetables to 10 servings a day and the patient says can it be can't know I'd be worried about preservatives in the can. And so they go on and on and on and finally this patient says to my sister but Dr Watson I can't buy that food at the dollar store. My sister called me. And what she said was why is she buying food at the dollar store. Any guesses. Poverty, so location so say more about that causes. Yeah, go ahead. Yeah, go ahead. I don't believe that there's a grocery store, like there's a drug store with, you know, So at the time that this happened. My sister was working at the North End Community Health Center, and this was North End Halifax, and there is no grocery store. Right. And so then she says to me, I'm a family doctor was supposed to do with that. And I say, well you could call the planning department. Tell your local MLA and have a conversation did you know that because there's no grocery store, my patients are reduced to this what the heck is going on right who's responsible for planning around here. And that is why public health is involved in those urban planning conversations right for that very reason. So we had the conversation as we were having the conversation this community based initiative called the community carrot popped up some of you will remember the community carrot unfortunately they didn't last for very long but there was a local community effort to try and put healthy fruits and vegetables in front of residents of the North End of Halifax. We continued in the food security conversation and public health is still involved in the food security conversation I'm not there anymore but one of the initiatives that we did come up with was the mobile market some of you will remember the mobile market, or have participated. So this is was a partnership around food security that came from years and years and years of relationship building so I said for example in the case of the school system we are in the school specifically to build those relationships not to check children for headlights we don't do that anymore. But we're there to be a policy resource to the school environment around the outcome that we know is most important to them, which is great well graduation because guess what, it's also important to help. So what we can do to support that in that school environment will do the same is true with our relationship with cities and so up until Mayor Savage became the mayor, the relationship with the city of Halifax between public health I would say was a little bit fraught because the Canada Health Act actually says that health is a provincial responsibility and many municipalities across the country would say that means health people go away we don't want to talk to you we've got other stuff on our mind. But Mayor Savage came in and asked a different question, which was what would it mean if we had health alongside us and so public health got into a very deep relationship with the planning department and the mayor's office in HRM. Up to the point where I got a random call as a medical officer have helped the city of Halifax from the mayor's office from from one of his key advisors, saying, if we gave you a free bus and a driver. Could you do something useful around food security and I literally hung up the phone ran down the hallway to our health promotion team and said, somebody needs to tell me if there's a reason to say no otherwise I'm just saying yes. And so we did. I just want to tell the mobile market was born, interestingly, I went to visit the mobile market in Ottawa as part of the research for this. And when I met with a group in Ottawa, it was really interesting so this is in the north of Ottawa, I think it's an impoverished community. And I'm speaking with one of the community organizers who runs their, their program and she gave us some really good tips. She said, please don't let the health people come in and do their health thing, which is turn it into a health fair let's have a diabetes foot clinic over here and let's do this over here and let's do this over there. We just want it to be a cool place where people buy their groceries because nobody ever sees us for who we are. Everybody sees us as a problem to be fixed. Just one day a week, Saturday morning, can we just be something else. And I said to my house assistant partners, here's what we're not doing. And what happened at the early days and I haven't been to the market in a while and I know they had some ups and downs with with operations during COVID but in the early days what would happen is not only would the bus roll up and by the way we had a staff member whose husband was an architect and so she worked with him to redesign the retrofit for the buses so that we could flip the seats to actual market bin so that people could come in and out. And somebody would show up with music. And all of a sudden there's dancing happening in the lineup. As people are waiting to get their groceries on a bus because who gets to get the groceries on a bus, right, it was just that. And it was beautiful because it was dignity and gendering. And that was the point that Ottawa was making for us right so that's the type of partnership that you get into when you start doing the work around social. Another example this is the collected works on the screen of Dr Margaret Deckman he was at Cape Breton University and Dr Deckman some of you will know her work her area of study was children in custody at the state she actually started her career with community services and then went on to do a PhD. And I came across her work as I was doing some work around the one of special coalition which I'll come back to in a moment where she talked about you know sort of. Who gets to participate in the economy and who doesn't get to participate in the economy and she was able to point to high school graduation as being a major determinant of that. And in her work, you know she was asking then this, this next level of questions which is well who gets to graduate and who doesn't right who's affected, who's not for those who are affected. Why are they affected. She found when she asked the why question was that boys that they were struggling with school or with finances were more likely to drop out and for girls that was struggle with relationship and these struggles would start as early as junior high school. And so of course her next question was why in her whole area of research was around sort of delving into these dynamics in school age children. One of the things she found was school climate as a predictor of engagement with school and for those of you who are not familiar with the school climate literature this is some of my favorite literature. This is the idea that you need to provide a loving environment where every single child in the school knows that they are seen, they are valued, and they are welcome in that school environment. I say that to family medicine residents and they say, but can you actually measure being seen, valued, and welcome. And I say that to pediatric residents and they go, of course, because attachment to adults matters for kids, a whole lot, it's the setup for adverse events or not. Right. And so, Dr. Deckman's work on on on school climate uncovered the ways in which we could be doing more work around school climate in the province of Nova Scotia. And so when she looked at school climate, what she saw was that the sort of school climate markers that we could see in the public school system in Nova Scotia had things did had to do with things like how teachers perceived students and they would treat students differently, based on their perception, and how the students felt about how they were treated by the teachers and if they felt like they were not like for that by their teachers they were less likely to engage in that school environment. And this is all of this happening as we know that education is that most impactful determinant of health right. And so, and what's the antidote to feeling unwelcome or, or not valued at school. It's not difficult. We all know how to do it. Love the antidote is love. And again, I say that to the family medicine residents and they come on, really, right. And yet, the school climate literature in the United States is posting better health outcomes for those schools that are able to concretely inject love into the school, then our health and promoting schools model does, which is the public health model for doing similar but not the same in Canada, right, that injection of love is most important thing so I had this conversation with a colleague of mine who is an order of Canada recipient of millions as a pediatrician, and was the medical officer of health for regional Niagara in Ontario. And she has been a mentor of mine for a long time and I so I called Robin when I was doing this work and so Robin what do you think about that and she said gain, of course, it's a loving lap for every day. And then we both said at the same time you can't put a program on that because here's the thing so I say that the family medicine residents I say that the health system administrators I say that the education administrators I actually had an education administrator say to me a deputy minister say to me, we're not allowed to love the children. No, we can't. That's, that's taboo. And I was like, I don't know what you think I'm saying, when I say love the children, but I'm pretty sure it is actually something you can do. Right. And the kids know when they are loved in that classroom environment they know when they've been seen and again the US literature on school climate is posting health and education outcomes that are higher in highs with school in schools with high school climate than those that are not. And so the challenges that we often like to think about case of what's the program and put in place that does that like we need to teach people how to love each other. And then somehow program that in and put all kinds of fancy metrics around it. Right. And there's some things that you can't put a program on but that doesn't necessarily mean that they're not important. Right. And so this is what Dr. Williams was was pointing to. Let's look at a fifth example, poverty as a policy event so this is the one that I know policymakers hate, hate, they will say public health. Why are you trying to boil the ocean poverty is not something we'll ever solve right and so it gets seen as a wicked problem for those of you who are familiar with the wicked problems literature I encourage you to look at it. Beautiful description by Ritalin and Weber from 1972 on what constitutes a wicked problem in policy and how difficult it is for policymakers to even go there because as soon as they see the complexity of the problem they just they just want to be somewhere else right. And so I would frequently get called to tables, often by public health practitioners that sounded like this we have to do something about poverty and I would say okay but if we're going to do it we have to be strategic we need a strategic into the conversation, so that we can start mapping out those five wise and give policymakers something to look at otherwise they're going to run away from us. And so it turns out that if you can generate data you can start that five wise exercise so this is data that was put out in a report card on child and family poverty from Leslie Frank and her colleagues at Acadia University. A year and a half ago and what they were able to uncover is you know, you know the answer to these questions so who's impacted by poverty and Nova Scotia and who's not impacted. And for those who are impoverished, why are they impoverished so what are those risk factors for poverty. And so able to uncover that in Nova Scotia 25% of children live in poverty. And then regionally, 30% of children under the age of six, 53% of children in lone parent families. And then regionally, 36 and a half percent in the Sydney area. And 78% of children in and around in Subega negative. There are holes in the data, there's no race based data and so but you start to see how if you can generate some of that data you can start to generate a story of who is impacted by poverty who is not impacted by poverty and then you get to ask the questions. For those who are impacted, why are they impacted. That's the work that will lead you to policy solutions, every single time we had a good run at this actually with COVID and so this is the world happiness report where they did a series of studies looking at the impact of COVID on in particular economic productivity and participation in the economy. And world happiness report in our own department of finance reports in the province of Nova Scotia there is a story that can be put together there to around COVID right and so what we saw was that Canada which is third from the top, did indeed have an economic downturn which many of us experienced and and we could see that in our Nova Scotia labor rates as well. We looked at who was impacted. It was specific sectors, mostly private sectors that were impacted, and the compelling part of that story is that we get to ask the question and who works there. Oh, it happens to be young people. And women, and by pop. That's who was disproportionately impacted and we don't have to rely on stories. The data is right there on the department of finance website. It's just that nobody's putting together. Right. So these are the things you start to do if you use that again that five wise methodology and start to get into the conversations. All of these leads to these policy questions around something that I think is fundamentally important as important as love, which is this idea of welcome, and I love the idea of flaming framing any of the social determinants of health conversations as conversations about welcome, who is welcome to participate in the economy in education systems in our transportation systems in housing, and who was not welcome and the reason I love welcome is because again this is something that we have to teach people how to do. You say to any Maritimer, we need to be creating a welcome into any of these sectors and Maritimers take pride in their capacity to generate a welcome, right. If you ask any of us how would you welcome somebody in the community, probably there's going to be a lobster, there may be fiddle music, maybe, and a whole host of other things right we pride ourselves on welcome. It's not something that you have to teach but when you start to look at where is welcome happening and where is it not happening. You get some really great opportunities to dive into so many of the wicked problems around social determinants that I've mentioned today. And so we actually started this work this is my last example in the one of us goes to coalition when I was there so I mentioned that it was part of that economic round table, which was the response to the one of us push a commission that was read. That was led by Ray Ivan a when he was at a Canadian University. And we were having this conversation about inclusive economies and how do we generate inclusive economies from the Scotia. And we were having all kinds of conversation by the ways in which we need to increase immigration and the problems in the Scotia. I fully agree with that agenda and coming from an immigrant family myself I can't imagine growing the economy another way. However, I did pause the table to offer this, as we are thinking about inclusive economies and making sure that we make room for newcomers in our economy are there people in the province of Nova Scotia who are already systematically excluded. And while we're thinking about it. We generate 10,000 new Nova Scotians every year by the way of birthing them. That's our birth rate. Our all 10,000 of those new Nova Scotians welcome in the economy will they be welcome when they grow up that's the question we asked now imagine the table. This is the premier at the time who was Stephen McNeil. This is the two opposition leaders. This is a table of business partners, a few NGO partners, and me the lone public health physician and I've just asked them a question about whether babies are welcome in the economy. There was stunned silence, followed by an interesting comment from the mayor of Kentville, who said to the entire table. I think I just made a link that I never thought I'd make in my entire career, but yesterday my staff were badgering me about breastfeeding, and how that was important and we needed to make space for that in the municipal building and I told them to go away. I might have to rethink that. And we had a conversation about if all the babies in Kentville knew that they were welcomed in the town of Kentville, what would that mean for their activation their motivation to be involved in all manner of municipal life going forward. So I followed up with the town of Kentville. After that on their work with these tiniest citizens, and along the way met Laura Fisher, who is a graduate student now at a Katie University Laura's a single mom, and immediately got interested in this question of welcome of the 10,000 citizens that we've got here. And she was actually able to do some work in her graduate studies that uncovered the ways in which women in Kentville and their infants are actually not welcome to participate in the economy those infants are disadvantaged from the very beginning. And it's things like Facebook posts by landlords saying, don't rent to that single mom over there she's nothing but trouble every time I've rented to her. I've had to go in and do repairs after or whatever. These are Facebook posts that are known amongst landlords in the city of Kentville in town of Kentville. And so, moms and their babes are being excluded from housing that doesn't set them up very well for participation in the economy right things like mom so she interviewed these moms. Who would tell her things like we know that when we sit down on that park bench over there, we're going to get harassed by police because they've been very clear with us that that park bench is only for the people with certain strollers. And for us who don't look like those people, we have to go somewhere else. That's not very welcoming. Right. And so welcome is a really interesting way to get into the conversation about determinants of health because when you start to look at who is welcome and who is not in any festive society. You start to see some of those determinants that play. Now I appreciate that I have offered you a tremendous amount today, and it is complex and I also appreciate that not everybody loves complexity in fact many system decision makers that I know, hate complexity, they hate it, they just want the answer. Tell us how to get from a to be the challenge with working with social determinants of health is that it's never going to be a linear path, right, because as soon as you ask the next why question. It points in the direction that you might need to go in and it may not be the direction you thought you were going to go in before you ask the question. But if you don't ask the question but why but why but why but why you risk applying the wrong policy solution to what's actually it. And so, just by way of closing I would say a few things, you know talked about welcome as a as an opportunity. And I think there are all kinds of policy questions that you get to ask if you start looking at you know what has to be in place in that in order to allow for some participation of a number of groups data collection would have to be key to that. And in this sort of complex work of navigating social determinants I would point out that you can start almost anywhere with your why question I said you know in health we start with health outcomes you could start with justice outcomes really doesn't matter. So once you start, you have to commit to following that thread everywhere continuing to ask the question, so that you can uncover what's actually at play. I once went to a national CI HR led meeting on mental health that somehow strangely had a whole bunch of lawyers and chiefs of police and then me in this conversation. And I was talking about determinants of health and afterwards the head of the Canadian Association of peace police came up to me and she said, when you're talking about determinants of health. Do you mean determinants of crime. And I was like, yes, they are the same. Right. So start somewhere, but then commit to following it everywhere. I think that's all I wanted to say, I think we've still got time for questions before cake. Thank you for your attention. And I'll leave the slide deck with you so that you can have the references. Thanks everyone. For questions. And I have some that are coming. But I would just start with folks in the room. And I'll let you go ahead. Yeah, it's a good question. It's been a while since I've actually looked at that data, but I think so in particular in Western Canada, I feel like Manitoba's experiment in particular was really good at mapping to those health outcomes and what they showed was not that those health outcomes that we see. But many of you will be maybe more familiar with the state of then I am that in particular the interventions that target women heads of households, fair better than those that are more broadly applied. I think that's the best interesting because it challenges some of the assumptions that decision makers have around what women heads of households might do with the money, but consistently now in different populations around the world they've shown that actually that giving the money to the moms basically is the most impactful and impacts on health outcomes as well as the other social outcomes. Yeah. Yeah. I think I saw another hand. Oh, yeah, go ahead. So as part of the presentation in one of the diagrams. There it is a life course approach that's demonstrated. And I was curious if the life course approach is uniquely helpful in identifying and affecting public health responses and whether there are particular policy legal responses that we might think of it's distinctly advancing a life course approach. My own take on it is that the life course approach and so I didn't speak to it I'm just going to bring the slide up so that folks can see it that the life course approach is not. It is helpful in that it identifies places along the life trajectory that we can intervene, and in particular identifies transitions that might be important points where folks will more acutely feel the effects of the determinants of health and not so for example the transition from high school to the workforce for high school to university would be one of those transition points. So I think it's very helpful for pointing out those. I'm not sure that in public health we have applied it particularly well. And so I would maybe reserve judgment as to whether or not it's been particularly useful or generative in public health I think conceptually is quite helpful. And I think that we've yet landed on how we do that effectively so you'll see public health has programming for example, for early years we have programming for in some jurisdictions will have programming for seniors but we actually have a big gap in the middle where we don't look at any of those transitions, right, program, programmatically, and you know notwithstanding what I've already said about the limits of programming I do think that there's some attention there that it could be paying. Yeah, okay I see that one and two. Yep. I'm going to ask one that was came through online. And so the person has asked a sort of generally frame question around completing competing values and ask what is your approach to a public health issue. So you could land on your life that has the potential to undermine autonomy autonomy of an individual or maybe their human rights. Yeah, so it's a big question. I would start by saying I actually had a slide on that in here and then I took it out. So public health actually operates under its own set of ethical principles. And that makes it unique within the health care system others interact under an ethical framework that starts with autonomy at the top of the list. Non maleficent, beneficence and justice might be the other three principles. Public health actually has its own ethical framework and autonomy is not at the top of the list what is at the top of the list for public health is the greater good. And that's a specific reference to in particular our focus on communicable diseases and environmental health threats so if we think that the way to protect the broader population from threat from, for example, communicable disease is to restrict individual freedoms, we will do that and that is permitted under public health legislation. And ethically, it's a very difficult place to stand so it's part of the reason that public health physicians do five years of postgraduate training in public health after medical school is because you know I always say you don't want to let somebody you wouldn't put me in the OR until I had practiced those skills under supervision for several years and likewise you probably don't want to let somebody loose on the public with public health legislation, until they practice that under supervision for several years. And some of what we'll do is look at the pros and cons for any individual situation obviously in something as big as a COVID-19 pandemic, looking at every single individual situation becomes difficult to do and that's part of the challenge that we had with those, those impositions that were made for COVID-19. But in general, for example, an E. coli outbreak in a daycare where we are saying that that child cannot come back to the daycare because the risk they pose to other kids in daycare until they are free of E. coli for two negative still samples. We might also look at that and say but you know in this particular individual case that child is actually at higher risk for staying home with stressed out mom and dad, then they are being back in the daycare. And the risk for that child actually outweighs any concerns we have with the daycare, if we can work with the daycare operators to find a workaround so that that child is minimally able to interact with other kids while they're still infectious we might be able to do something. So we have those sort of permissions in our ethical framework and in our legislation. But we don't treat them lightly. If I if I can put it that way, hope I hope that answers the question. My question. It's entirely unfair. Thank you for the heads up Sean. And I was struck by how your, your case examples are all mostly individual driven fighting against the system sort of examples. So, because we still have our health system that focuses on treatment and technology and still have operational systems to focus on autonomy and privacy, instead of solidarity and still have lost focus on, or that are driven by market So, how do we move governments, we're talking about structural issues, how do we move governments off of these foundations and into a more effective way of operating. I feel like you just asked a million dollar question. And so if you have any answers I'm happy to hear them. I have a question that that certainly myself and my colleagues at the medical school actually so what I didn't say by way of introduction is that part of my portfolio the medical school includes this work called catalyzing systems change, where we are looking at how do we reorient the health system towards something more effective than what we have now, and a variety of ways and not through the tech innovations that we have 1000 vendors lining up behind to sell to the health system. And so embedded in that conversation we have regularly had in particular with colleagues at the McKecan Institute for public policy a conversation about collectivism, and whether or not we are prepared to go there, ever, and I don't know. And so my own worry is that as we look at the increasing complexity of what's going to happen in the health system, but also broader health outcomes including health outcomes related to climate. We require collective efforts, and governments aren't talking about that. So instead what's happening is people are reverting to individual pathways more and more just as an example. I gave a talk at the EAC last week the ecology action center here in health facts on sort of the climate crisis as a, as a public health issue, and the same day that I was giving the talk I think two articles from the Guardian in my newsfeed about individual Americans and their bunker strategies that they're creating it was something like that right. And on two fronts, one is wealthy Americans who literally are hiring consultants to come tell them and their 10 best friends. How do I hire the, you know, the National Guard and like other people retired soldiers to protect my bunker and what do I do when the soldiers don't want to listen to me anymore. Is there a caller that I can put on them that might help me literally, these conversations are happening, and also less wealthy Americans who are going to survivalist camps to learn basic survival skills because nobody's holding a conversation about how do we get through this collectively. And then the absence of that people are making their own way. So I'm terrified that that's what's going to happen, because, you know, one of the articles pointed very well to the idea that these systems are so complex these questions are so complex that there's no way we get at them without a fully systemic response. And I don't see our system leaders currently do that they seem distracted by other things. So I guess my call to all of you would be please help galvanize system leaders from all sectors around collectivism because I guess I should I share your worry but I don't have any answers. Thank you for the unfair question. We might have room for one more question fair or unfair. Thank you so much for your talk and so many different dimensions on this session you're taking this back to bond and wealthiness like I'll do something about trying to engender the full results in that second. But my question is about base based on what the current discussion is. Yeah, but the challenges, the opportunities, the interaction with all of them. Yeah, and I'm aware that I have colleagues from Department of Health and Wellness who may have more recent information than I do so so feel free to jump in either of you but so I was at the Department of Health and Wellness the provincial health department and especially when those conversations happened. And so a couple of a couple of things coalesce to actually have us move on race based data collection at least in the health system for the first time ever. And that is probably as old as I am I mean when I started as a medical student at Dalhousie many, many years ago 1995. That conversation was alive then. So it's taken 25 years for us to come to the point where we can actually move on it. And what seems to have happened is, you know, a few things are percolating background the Canadian Institute for health information has been with their population health council which I set on for some time, percolating a data standard for the health system to use that included race based modifiers and the reason that that's important is that if we're not collecting the data on health inequities in a way that we can disaggregate who has the inequities and who doesn't, then we can pretend they're not there. Currently the policy stands at the federal and provincial government maybe not intentionally but in the absence of data that's what we're left with, which is very different than what's happening in the US. So yes they're a pros and cons of collecting the data, but I think there became a realization at least a Kai high at which was a public health says that they are in the business of systematically exposing, you know, health inequities but we don't actually have the mechanisms do that then we're not doing our job. And so hi put on a national data standard. That was about four or five years ago. And then COVID hit. And then, you know, I think a number of opportunities start to open up to say okay, can we look at collecting COVID data differently than we've done before, and all of a sudden provinces and territories were sort of in this conversation about okay what can we do and how can we appropriate the next year, Nova Scotia was one of the first in the country and helped push a national conversation around race based data collection in health as a result, at least around COVID. So, in addition to that, in Nova Scotia for many, many years there had been a conversation with the health data folks within provincial government and health authorities around how we might do this, and a proposal had already been flooded to put a link on the health card when it's issued. So that folks could identify in a number of different ways there and then at every reissue that have the opportunity to re identify. So between the push kind of around COVID kaihi working in the background Nova Scotia working in the background those things have coalesced so the Nova Specialist made a firm commitment around that race based data collection for the health system using the health card. How it will translate out to other systems, like the education system I don't know so education is already doing some of that work with their students surveys that they send out every year in the public school system to families asking for certain identifiers they don't know what the participation rate is like in that. And I think their description of different modifiers is different than the health system descriptions are using so they'll be that kind of reconciling that will have to do. So that's as much as I know, john and Eric I don't know if you have anything else to add. Very good. Yeah, so it is, it is slowly percolating along and again and from my perspective, I've been at a lot of the tables where folks have said, we can't because to collect the data would be racist for example I've heard that for many many years and my response is always to collect the data and then stay in a place of ignorance, so that we can pretend the issues don't exist is more racist. And so that that remains my current stance I'm very happy to see that that work is happening. I have the regrettable job of bringing this to a close what a wonderful presentation. So thank you so much Dr Watson Creed for your powerful accessible critically important reflections and examples, laying a foundation for the so much of our work but for the rest of the seminar series on the connections between health and social justice in coming weeks and months will drill into further specific determinants of health, and also of poverty of criminalization of institutionalization, and the role of law as a determinant of health, as well as ill health and the role of law in reinforcing or disrupting the racism colonialism misogyny ableism that underwrite the inequitable distribution of health in our in our communities. I will be reflecting and I encourage all of you to reflect more on how law might enable what Dr Watson Creed called dignity and gendering community supports and how we might use law to open the doors to love. I hope that you'll join us for the next seminar in our series it's October 14, and that will be Professor Martha Jackman from you of Ottawa of renowned human rights and social justice scholar. She will be presenting on the topic health and social justice charter rights and charter wrongs. And you can pick up our poster I'll put it right way up. And it's easily accessible on our website. And for now I invite once again those who are here and those who are, who knows in some corner online but close by to join us in room. One, two, three, 12 on the third floor it's the faculty lounge and we will celebrate this our 200th lecture in the seminar series thank you again to Dr Watson Creed.