Stephen Hwang, MAP 0:04
Welcome to MAPmaking, a podcast series that brings you Canada's leading voices on the health equity issues that affect us all. I'm Steven Hwang, director of the MAP research centre at St. Michael's Hospital, Unity Health Toronto. In this first season of MAPmaking, we're exploring the recommendations from our Equity Roadmap Report, a set of 13 recommendations for a more equitable COVID-19 pandemic recovery in Canada.

Linda Silas, CFNU 0:45
We will have to look at what is our line in the sand as Canadians, as citizens, on what do we expect from all levels of government when it comes to our care?

Nav Persaud, MAP 0:55
Hi, I'm Nav Persaud. I'm a family doctor, scientist at MAP, Canada Research Chair in Health Justice and co-author of the Equity Roadmap Report. Today I'm speaking with Linda Silas, registered nurse and president of the Canadian Federation of Nurses Unions. Linda has been a union leader at the local, provincial, national and international levels over the course of three decades, and has been president of the CFNU since 2003. I know her as a champion and advocate for the social determinants of health. And I'm so pleased to have her with us today. I invited Linda to MAPmaking to hear her thoughts on two of our recommendations from the Equity Roadmap Report. Here they are: During the pandemic recovery period, we strongly recommend the universal availability of unemployment insurance, parental leave, and paid sick leave. And we strongly recommend including prescription medicines in Canada's publicly funded healthcare system.

Hello, Linda, and welcome to MAPmaking.

Linda Silas, CFNU 1:52
Good afternoon. Or maybe I should just say hello, Nav.

Nav Persaud, MAP 1:56
Welcome. And thanks so much for joining. To start, can you tell us a little bit about how sick leave is accessed right now in Canada?

Linda Silas, CFNU 2:06
Well, if you're unionized, there's a little bit better chance that you do have a sick leave provision within your collective agreement. Some it's days that you accumulate per month, and you literally just have to call in sick and you get it. But we have to realize that 58% of workers in Canada that have no sick days at all, and that creates a big burden on our healthcare system. But also it was highlighted during the pandemic, and it was really highlighted was those workers making $25,000 and less. They were more impacted by having no sick time at all.

Nav Persaud, MAP 2:46
How can it be that during a pandemic of a virus that causes a cough, there are still workers who don't have access to adequate paid sick leave?

Linda Silas, CFNU 2:55
Well the federal government tried to alleviate that, and laws take a very long time to change. If I look at C-3 that was introduced just before Christmas, and literally within two weeks, it was passed by the House, passed by Senate because there was an urgent need to not only address the sick leave provision, but that sick leave provision, and it's the best system in Canada, you know, 10 paid sick leave, is only for federally regulated workplaces. So anybody who works in the public sector, in the private sector, most of the private sector, it's not there. And what the pandemic showed us because it was contagious, it was so easily transmitted, that people start saying, Why are you coming into work sick? Why are you coming into work when you have cold symptoms? And we never questioned that before. I don't know about you, but I went into work with a cold a lot in my life, and I have sick leave, because it was okay. Stayed away, wash my hands and all of that. But we had never seen it like with COVID-19. So now people, policymakers are realizing we have to find a venue for workers and employers to be able to provide some kind of sick leave to make sure that if you're contagious or potentially contagious, you're able to stay home and not go broke.

Nav Persaud, MAP 4:21
I agree with you. It's more than just the access to paid sick leave. In addition there there needs to be a culture change around people appropriately using sick leave when they are sick and not being expected to work sick. Can we switch to talking a little bit about medication access? What did the pandemic expose about the current system in Canada for accessing outpatient prescription medications?

Linda Silas, CFNU 4:47
As you probably know about you and I have been an advocate for a national pharmacare program for a very, very long time. And it's simply because we know that one in five Canadians can simply not afford their prescription drugs. And what happens is this vicious circle, the vicious circle is they end up in our healthcare system. And you will see with the pandemic, the waitlisting of surgeries as just blown out of proportion. And that might cause governments to say, Well, we cannot have patients come in because they can't afford their medication, because that's what happened. You're prescribed a medication because you have an illness that your physician and nurse practitioner needs to take under control, and to keep you healthy and out of the hospitals. But one in five Canadians cannot do that, because they can't afford it. So we're seeing that aspect. So that's the human aspect. But then there's the system constraint where, you know, those patients are in the hospitals, you know, they're either in the ER or hospitalized, because they're not getting the appropriate treatment.

Nav Persaud, MAP 5:58
What about employer based private insurance as it pertains to prescription medications? I mean, what happened during the pandemic to people who had private employer based insurance programs that covered prescription medications?

Linda Silas, CFNU 6:12
Yeah, great question Nav. Because we all thought you know that 50, 60% of employees that are covered under a health plan, they were saved, you know, they had prescription drug coverage. But when the pandemic hit, so many and so many employees lost their jobs, from small enterprise to larger enterprise. And whatever program, the federal government was providing CERB, and others, it wasn't providing the health insurance that employers were able to provide, even as small as it was. So we saw double the numbers of workers in Canada losing their coverage for prescription drugs than those that gain coverage through unionization or changing jobs.

Nav Persaud, MAP 7:02
You mentioned one important limitation of employer based insurance for medications, you lose it when you lose your job. Are there any other problems created by employer based health benefits, because I think for many people who have them, you know, who have what they view as a good plan, they might have trouble seeing that there is any wider problem because they have a good plan that meets most of their needs.

Linda Silas, CFNU 7:27
Well, we have to realize that whatever is provided by the employer is part of our salary base. So if a health and dental plan or prescription drug plan is costing about 10% of payroll, that's 10%, that could be on your wages could be on your vacation could be on your pension on other areas. As nurses, we see the prescription drug aspect of it as what we call medically necessary, you will not have anything on the national prescription list, national essential medicine list, if I use a proper term, that is frivolous, it will be what is medically necessary. We also know that unions are unions and employers are employers and insurance companies are insurance companies. So those who fear that the insurance companies are going to disappear completely is nonsense. Because we know that those who will be able to afford what I often use the example as the national pharmacare program will provide a one a day, not a one a day, a four a day pill, but my richer plan might provide the one a day plan. But what is necessary, medically necessary, is that you get that medication to start out with, and the luxury of getting the one a day or the other format can be done through an insurance program. And that's the discussions we were starting to have pre-pandemic that insurance companies and plans wouldn't disappear completely. But then the pandemic hit and all those discussions kind of stopped.

Nav Persaud, MAP 9:12
And why do you think that is? You know, what do you think is the real reason that medications are still outside of our publicly funded health care system despite multiple government reports that seem to favor national pharmacare?

Linda Silas, CFNU 9:25
Oh, the pandemic you know, pre-pandemic, we were both working with Dr. Hoskins and his team with the famous report that came in in June 2019. We had a federal election everyone was promising pharmacare. We were getting ready. And the plan that Dr. Hoskins established was by this January we would have an essential list of medications that Canadians could access and we would start that way. And then the pandemic hit. The pandemic was about paying the bills at the end of the week. And getting health care services, long-term care services if you need it. And of course, as your first topic was the whole sick leave, people kind of forgot about a national pharmacare program, because other issues took priority. But that's what the pandemic created.

Nav Persaud, MAP 10:14
Thank you. You're right that we were involved in providing input to the National Advisory Council on the Implementation of Pharmacare. One of the pieces of information we provided were the results of our Clean Meds study, which was a very simple study where we took people who could not afford medications, and we provided them with free access to medicines. And we recorded improvements in adherence, reductions in healthcare costs, including costs related to hospitalizations, and also an increase in the ability to make ends meet or afford basic necessities like food and rent without incurring debt. What's your view about the need to study this issue more? Do you think we need more studies? Or is it time to move toward policy change?

Linda Silas, CFNU 11:02
Oh, it's for sure time to move to policy change. I remember one study that CFNU hired a group of epidemiologists to look at, can we find out data, if you're not able to pay for your prescriptions, what will happen to you? And I was stunned that there's data being collected on that. And just with two diseases, diabetic and heart surgery, there's 1000 deaths a year due to the fact that these patients couldn't afford their medication. And those are working Canadians. So that was a big red flag to any policymakers out there. But also, it engaged the Heart and Stroke Foundation, they became one of the biggest and strongest advocates for a national pharmacare program, because of that study, and others like yours that we're talking, Look, there's a real impact on Canadians here. And nevermind the fact that we're one of the only countries in the world with a national public health system without a national pharmacare system. So there's really that arm missing. So yes, I wouldn't recommend no more studies. But I would recommend the federal government to take leadership and work with the premiers of the provinces and territories. Because just in three years, they haven't met face to face because of COVID-19. But also, so many have changed in the provinces and territories. We need to reengage them, and re show what the provinces will be able to gain. I always tell that story. I was meeting with the premier of PEI on a national pharmacare program. And we had done studies or we had hired economists to do all the calculation, I guarantee you I wasn't doing it. It was to show each province what they would be able to save in their public health dollars if we had one program administered by the, and funded by the National or, the federal government. And the PEI premier looked at me and he said, Linda, that's my provincial debt. So that year, if we were to have a national pharmacare program, PEI wouldn't have had a provincial debt. So that's the connections we have to get with those premiers and ministers of health. How does it impact PEI how does it impact the Yukon or BC and really get their engagement? I think it will work, it will be a step by step. But they are all going to be facing dramatic changes in our healthcare system and increased costs that everyone's going to be saying, where's the best way to spend our dollars?

Nav Persaud, MAP 13:42
I wanted also to talk about parental leave. Can you tell us about what access to parental leave looks like across Canada today? And what are some of the implications?

Linda Silas, CFNU 13:54
Well, it all depends who employs you, or is the federal government has a plan on their EI if you pay into EI, and you know, they're excellent. Yeah, you know, it's up to 18 months I have, did I have three or six months when my son was born 31 years ago, but the fact is it depends where you're employed, and that's the sad thing, if you're employed as a nurse, for example, in Quebec, you will get a longer pre-maternity or parental leave before you enter your maternity, and parental after that. Those who are independent workers, they hardly get anything unless they're ready to have no salary for certain period because they don't pay into EI so they don't get those kinds of parental leaves. So it's all that balances we have to bring into our society in to our communities and families. And I truly believe that COVID and the pandemic is really opening everyone's eyes that we have to take care of each other. So as societies, how are we going to do that, you know, childcare is in every province and territories, the parental leave, you're going to see a lot more discussions on that. And also, it'll be many discussions in collective bargaining.

Nav Persaud, MAP 15:14
It sounds like you're optimistic about this attention to inequities during the pandemic translating into public policy progress.

Linda Silas, CFNU 15:24
I'm optimistic, but I'm worried about the dollars and cents. There will be only so much provincial, territorial or federal government will be able to buy. But at the same time, if experts like yourself can bring to the provincial governments and the federal government say, well, a national pharmacare program would help save money would help control admissions in hospitals. If we look at long-term care standards, for example, saying and giving a guarantee to our seniors, these are the basics that you will get across the country, when and if you need long-term care, such as nursing, four hours of nursing care per day. So those are just basic, but we will have to look at what is our line in the sand as Canadians, as citizens, on what do we expect from all levels of government when it comes to our care. And our care goes further than if I go to my doctor's or nurse practitioner's office, or if I enter a hospital. It's about the mental health, the home care, childcare, all that care economy needs to be better talked about.

Nav Persaud, MAP 16:34
You obviously are very powerful advocate for nurses. But you and the Canadian Federation of Nurses Unions don't just advocate for nurses, you're advocating for system-wide changes that would affect everyone in Canada. Can you explain why you think those broader changes are important?

Linda Silas, CFNU 16:57
Well, we all live on the same planet. And we all live in different communities, but still in the same planet. And that's one area where CFNU started doing more work on. We had done and we still do a lot of work on the national pharmacare program. That was like our global project to help everyone living in Canada. And then three years ago, we started moving into climate and health, realizing the impact on the climate crisis, what was happening on the health of Canadians, the health of children, like I had so many nurses who work with children with asthma, and the impact on the climate change with patients and especially younger patients with asthma that couldn't afford their puffers that ended up in the hospital. So that whole vicious circle. So we're doing work on that, again, because we all live on the same planet. But it is to bring that holistic approach to not only nursing but our work life on what we can do better. I always love the saying in Ireland is, You can always go a step further. They're pushing society, thinking a step ahead, a step higher. So if you have your college degree, you want a university degree, you want a master's degree, you want to move up, and you're moving up with your community. That's on the education model, but the same thing in the community is, how do we make it better?

Nav Persaud, MAP 18:32
Beautiful. Thank you. We end every episode of MAPmaking with the same three questions for our guests. Could I ask them to you now?

Linda Silas, CFNU 18:39
Yes.

Nav Persaud, MAP 18:40
Excellent. On your very best days at work, days when you come home feeling grateful that you get to do what you do, what do those days look like?

Linda Silas, CFNU 18:48
It's when I hear our nurses speaking out. It's hard to take a microphone, it's hard to speak to a politicians. But when I hear them speaking out then, most recently, it's been the campaign in Ontario around repeal Bill 124. You know, I've been on many rallies, many picket lines in my career. But when you see just a small little group of nurses all geared up with masks and getting that attention of the public on how unfair it was. So for me the best days is when I hear a nurse, a worker or an individual, just speaking out.

Nav Persaud, MAP 19:30
On your very worst days at work, what gives you hope and motivates you to continue?

Linda Silas, CFNU 19:34
The worst days at work are when I hear politicians throwing the political football, on whose responsibility is it for health care, that are the worst days that's when I really want to hit my head against the wall. And where I see hope at the end of the tunnel is when a reporter or a public servant just cracks into it. Sees the difference that we have one healthcare system. And yes, it's administered through 13 different identities, but nothing different than if you look at Ontario with all their LHINs, and then all the long-term care facilities. It's a big system. But when we can really wedge in and hear somebody say, Yes, we have one system. I remind a lot of politicians, we're a big, big country, you know. But now the state of California has more populations than we do, or more people living in California than we do in the whole country of Canada. We're big, we're large, but only so many Canadians living in the country.

Nav Persaud, MAP 20:46
Thank you. For the final question, can you please finish this sentence: Thriving is...

Linda Silas, CFNU 20:54
Thriving is solidarity, doing it together for the betterment of all.

Nav Persaud, MAP 21:02
Perfection. Thank you so much. Linda Silas, thank you so much for joining me today.

Linda Silas, CFNU 21:08
Thank you and stay safe.

Stephen Hwang, MAP 21:12
You've been listening to MAPmaking. MAP is a St. Michael's Hospital research centre dedicated to creating a healthier future for all. Learn more at maphealth.ca. I want to acknowledge the sacred land on which MAP and St. Michael's Hospital operate. This land is the territory of the Huron-Wendat and Petun First Nations, the Seneca and most recently, the Mississauga of the Credit First Nation. We are grateful to have the opportunity to work in the community on this territory. We are also mindful of broken covenants, and the need to strive to make right with all our relations. This podcast is produced by Emily Holton with associate producer Samira Prasad. Technical production is provided by David Grein of the Acme Podcasting Company. I want to acknowledge and thank the St. Michael's Foundation and our incredible donors as well as Staples Canada for their support and commitment to MAP's work. We partnered with the team at Staples to create Even the Odds, an initiative to raise awareness of inequity in Canada and to help build vibrant healthy communities. You can learn more at staples.ca/eventheodds. I'm Stephen Hwang. Thank you for listening. Take good care, and we'll see you next time.