Dec. 4, 2002. 01:00 AM

 Where Romanow dared not go


 Every so often, a flicker of unease crosses Roy Romanow's face.

 It is not that he regrets anything he wrote in his 356-page report on medicare.
 He considers it "comprehensive, well-thought-out, well-reasoned and
well-argued."

 Nor is he unhappy with the debate it has produced. He anticipated that.

 But he keeps remembering the family he met in Iqualuit whose members all live
in a two-room shack.

 Like hundreds of thousands of Canadians across the country, they have health
problems that go far deeper than doctor shortages or long surgical waiting
lists.
 They need decent housing, a proper diet, a chance to work and some stability in
 their lives.

 "You can only stretch the accordion so far," Romanow said with a sigh.

 He is acutely aware of the link between poverty and illness. He knows Nunavut
has the lowest life expectancy in the country. He knows that inner-city poverty
is
 one of the biggest concerns of the doctors he met at St. Michael's Hospital in
Toronto.

 But his mandate was to come up with a plan to strengthen medicare. He felt he
had to set limits.

 The health care commissioner did take a few small steps over the elusive line
that divides medical and social spending:

   He proposed a Rural and Remote Access Fund to improve the health of people in
 smaller communities.

   He called for an overhaul of aboriginal health services to address deeply
rooted problems.

   He recommended that home care for people with mental illness be brought under
 the umbrella of medicare.

   He asked Ottawa to spend $2.5 billion to speed up the formation of teams of
health-care professionals dedicated to preventing



? not just treating ? illness.

   He wrote in the introduction to his report that "investing in public housing,
 a clean environment and education are all part of the solution leading to a
healthier
 Canada."

   And, stepping outside his role as health care commissioner, he urged the
federal government to review the level of equalization payments to Canada's
poorer
 provinces.

 But for the most part, Romanow steered clear of what medical researchers call
the "social determinants" of health. These include income, education,
employment,
 diet, housing and social connectedness.

 Politically, this was a smart thing to do. Five years ago, the National Forum
on Health, the last task force appointed by the Prime Minister to study
medicare,
 recommended a concerted effort to reduce child poverty and help the
economically marginalized.

 Jean Chrétien thanked the 24 members of the forum and promptly shelved their
report.

 Romanow knew that, this time, Chrétien was looking for a set of recommendations
 that was focused, pragmatic and palatable to middle- and upper-income
 Canadians.

 That is essentially what he provided.

 No one can blame the former Saskatchewan premier for delivering a report
designed to produce action and win broad-based public support.

 But as Chrétien and his cabinet colleagues weigh Romanow's prescriptions
against other national priorities, they owe it to Canadians to do some hard
thinking
 about the inequities that breed health problems.

 One out of every six children in this country is growing up in poverty. These
youngsters are at much greater risk than their better-off peers of developing
 behavioural and learning problems, doing poorly at school and falling into
destructive habits.

 If they had the "strong start" that Chrétien keeps promising, they would have a
 much better chance of staying healthy and becoming self-sufficient.

 An estimated 200,000 Canadians are homeless and 1.7 million families are in
"core housing need" according to Canada Mortgage and Housing Corporation.
 Every winter, a few of these people freeze to death. Thousands more develop
ailments that those with warm, secure homes will never know.

 If Canada had an adequate supply of affordable housing, these people would have
 a stepping stone out of poverty and a refuge from crowded, infection-prone
 emergency shelters.

 Close to 800,000 Canadians use food banks every month, 41 per cent of them
children. Hard as these charities try to keep their shelves stocked with
nutritious
 food, they can only hand out what they receive. That often means carbohydrates
and canned foods.

 If low-income families had enough money to buy fresh food, the incidence of
diabetes, heart disease, obesity, dental problems and certain types of cancer
would
 drop. Parents could teach their kids proper eating habits. Children would show
up for school ready to learn.

 The boundary between the health and social policy has always been somewhat
artificial.

 The Ontario government shifted it arbitrarily, 30 years ago, when it
deinstitutionalized psychiatric patients, creating Toronto's first wave of
homelessness.

 Today, the health-care system is dealing with many of the problems that flow
from homelessness; hypothermia, tuberculosis, substance abuse and personal
 injuries.

 Policy-makers are still debating whether addictions, workplace stress and
loneliness should be treated as personal, medical or social problems.

 Romanow is enough of a realist to understand that Canadians want a practical
plan to make their health-care system work, not an idealistic scheme to tackle
the
 inequities that lead to misery and premature death.

 But he is enough of a social democrat to feel a twinge of conscience.


 Carol Goar's column appears Monday, Wednesday and Friday.