Basic income: The future of Canadian trials and implementations

This was the final project for a class I took in the summer of 2019, to propose a policy reform agenda that would improve the lives and well-being of Canadians.

Politics. Affect. You. Those we elect to power determine the circumstances of our income, our community, our environment, culture, laws, housing, access to food and water, and absolutely, positively, our health.

1 in 6 Canadians don’t know where their next meal is coming from. 1 in 5 can’t afford prescribed medication. 1 in 7 live in poverty, and all these are much higher for racialized and Indigenous people. And children. The opioid and suicide epidemics decimating our young people, have political solutions. The present and historical genocide and systemic injustices endured and resisted by the Indigenous peoples of this land, have political solutions. Politics is life and death for millions of Canadians, every single day.

Transcript with citations

Honourable ministers Morneau, Duclos, Taylor and Bains, thank you so much for joining me via webinar to hear this proposal. And you too, Justin. Please address any questions you might have via twitter.

Canada’s social safety net is frayed to the breaking point. Our income security structures are crumbling. Canadian income inequality remains rampant (Statistics Canada, 2018; Broadbent Institute, 2019; Campaign 2000, 2017), social crises like homelessness and food insecurity are rapidly growing (Gaetz, Dej, Richter & Redman, 2016; PROOF, 2016), and good jobs are disappearing fast (OECD, 2011; Yalnizyan, 2013; IPSOS, 2016). We need to change our approach to income security in this country.

Who administers and funds the social safety net? Is funding adequate? What benefits or services are provided?

Social assistance involves all levels of government. The federal government provides the universal child care benefit, the Canada pension plan, old age security and employment insurance. Provincial governments provide disability support and healthcare, and both provincial and municipal governments play roles in housing supports.

What is the problem being addressed or solved?

We could just make our social assistance programs more generous, broader and more effective. We could make programs less means-tested and more universal. Or we simply guarantee a minimum level of income for anyone who falls below it.

Funding is not only grossly inadequate to lift people out of poverty, but grotesquely mismanaged and poorly distributed. Our means-tested social assistance structures treat people like children and keep them entrenched in cycles of poverty, where they are punished for attempts to build a better life like finding a job, and systematically smacked back down (Martin, 2017a; Kennelly, 2017; Culbert & Sherlock, 2018).

Who is left out?

Our current income security structures, policies and programs provide too little financial support, leave tens of thousands to fall through the cracks, disincentivize people from improving their situations, reproduce inequalities across generations, and balance the heaviest burdens of our society on the backs of the most vulnerable (Meili, 2012; Forget, 2017; Hick, 2014; Campaign 2000, 2017; Knoll & Meili, 2015).

If you start going to work on social assistance, you can lose everything (E.g., Hick, 2014, Martin, 2016, Forget, 2017). If you decide to go back to school, you can lose everything (E.g., Hick, 2014, Martin, 2016, Forget, 2017). You can be punished for having too many people in the house, or a spouse, or not being able to fill out dozens of arcane forms every month (E.g., Hick, 2014, Martin, 2016, Forget, 2017).

“Social assistance programs that have been designed actually not just to help people who are not working, but discourage people from working because they claw back dollar for dollar any assistance that people are getting when they go to work, create really perverse incentives around people engaging with the labour market at all” (Martin, 2016).

What social inequalities or social injustice are being reinforced and solved? Which are not? What gaps would it fill? Who was missing before, who will now be included?

This is the gradient of poverty and health. People in Canada who live in the poorest neighbourhoods live about 13 years less than people in the richest neighbourhoods (Meili, 2012; Tjepkema, Wilkins & Long, 2003; Raphael, 2002; DeLuca & Kanaroglou, 2015; Marmot, 2015), and it’s even greater when you factor-in disability.

“The gradient means we’ve got to make common cause between not poor, and poor. If there’s a seventeen-year gap in disability-free life expectancy it means the average person has eight fewer years of healthy life expectancy” (Marmot, 2016).

Is money life and death? There’s so many other problems; how could just giving people money make a real difference?

“In the real world, the social determinants of health pile on, on top of the same people, and interact and intermingle with each other in really important ways, so that poverty leads to poor school readiness, leads to lower educational attainment, which limits people’s job prospects, which are further narrowed by racism, which leads to stress and chronic illness, which makes it hard to keep a full-time job, which leads to more poverty.” (2:40-3:10). (Martin, 2016).

Poverty isn’t the inability to live large. it’s not big houses, fast cars and fancy clothes. Poverty is the inability to live a healthy life at all, or at least to have any decent kind of shot at it (Marmot, 2015; Marmot, 2016; Meili, 2012; Meili & Martin, 2016; Martin, 2017a; Forget, 2019; Knoll & Meili, 2015; Knoll & Martin, 2017). The opposite of poverty isn’t wealth; it’s justice.

But poverty and inequality aren’t just morally impermissible, deeply unjust and contrary to everything we claim to stand for as Canadians – they’re extremely expensive. Our unnecessary spending on socioeconomic costs like healthcare and law enforcement are ineffective, counterproductive and unnecessary (Ivanova, 2011; Laurie, 2008; Plante & Sharp, 2014; Knoll, Plante & Partridge, 2017). The avoidable, annual costs of poverty have been calculated at up to 9.2 billion in British Columbia (Ivanova, 2011), up to 3.8 billion in Saskatchewan (Plante & Sharp, 2014), and up to 13.1 billion in Ontario (Laurie, 2008).

That works out to about one thousand dollars per year, per person for the Ontario study, two thousand dollars per year, per person for the British Columbia study, and just under four thousand dollars per year, per person for the Saskatchewan study. No national studies have been yet completed, but scaling up to the population of Canada, that gives us an average cost of poverty of more than 90 billion dollars per year. That’s a lot of wasted resources.

So we urgently need to address the crises of poverty and inequality, and we know social assistance is ineffective, wasteful and thoroughly problematic. But there’s an alternative: a universal basic income. The concept is simple.

If someone earns less money than a certain level that we decide no human should fall below, we make up the difference so that they do. A guaranteed basic income keeps you at that level even if you lose your job, or get a job, or get sick, or go back to school. It removes the paternalism of social assistance and replaces it with stability, predictability and real security.

People will just spend that money on drugs and beer. They can’t be trusted.

How did… this is a closed webinar. Anyway it turns out-

“It turns out actually when you support low-income people in getting up out of poverty, they will use that money as you would wish that they would, and there’s no need to spend extra money trying to police how they do it” (Knoll, Forget, Yalnizyan & Martin, 2017).

People will stop working if they don’t need to scrape and claw for every penny. And we need them constantly desperate, or this capitalism thing literally won’t work.

“It not only creates an incentive for people to work, and is much less judgmental and invasive into peoples’ life choices in terms of how they spend their money” (Knoll et al, 2017).

Whatever. It sounds like like communism. What even is the ideology behind basic income?

The ideology of a universal basic income guarantee depends entirely on its implementation. Neoliberal conservatives like Richard Nixon and Milton Friedman advocated for it. Radical progressives like Carole Pateman and Erik Olin Wright. Centrist private business magnates like Elon Musk, Mark Zuckerberg and Pierre Omidyar have advocated for it. The ideology comes into play, in whether a basic income is sufficient to lift people out of poverty and thrive as equal citizens, or squash social assistance into a singular, manageable allowance for base subsistence (Mendleson, 2016; Paikin & Segal, 2018).

And basic income is not just for the poor. With the rapidly changing nature of work in Canada toward greater precarity and less security (E.g., Standing, 2018; Paikin & Forget, 2019), about half of Canadians living paycheck-to-paycheck (IPSOS, 2016), and more uncertainty than ever, this is a solution for everyone. Otherwise what we’ll see is-

“What we’ll see is greater inequality, we’ll see a declining middle class, more and more people slipping into low income categories, and less able to offer their children and their families the kinds of opportunities that we’ve taken for granted for a number of years.” (Knoll et al, 2017).

What is the history of the policy? Have there been changes? Are there examples of it happening elsewhere?

Dr. Evelyn Forget has become almost synonymous with basic income in the Canadian context, from her research showing the social and health benefits of a pilot program that ran for five years in Manitoba. A limited version has also been tried in Finland, which Forget spoke on just a few months ago.

“One of the key findings was that people who received a basic income engaged in more pro-social behaviour. That is, they had greater trust in one another. They were more likely to trust government, to trust the organizations and the institutions in society. I think that allowing people to participate fully in society encourages them to become productive and healthful neighbours. I think we all want to become part of the same community that we live in” (Palkin & Forget, 2019).

The most striking fact from Forget’s findings in the Canadian context?

“We saw an 8.5% decrease in hospitalizations, kids stayed in school longer, there were fewer outpatient visits particularly around issues relating to mental health in the healthcare system, people had children later and they had fewer children. I mean if we discovered a drug that reduced hospitalizations by 8.5% we would be putting it in the water.” (Martin, 2016).

I still say it would make people lazy, stop working, and bring the whole system down. People can’t be trusted.

“Universal basic income test runs done in Canada in the 70s showed that about 1% of the recipients stopped working, mostly to take care of their kids. On average, people reduced their working hours by less than ten per cent. The extra time was used to achieve goals like going back to school, or looking for better jobs.” (Kurzgesagt, 2017).

More recently, the Ontario government ran a pilot project in the cities of Hamilton, Thunder Bay and Lindsay, where people had their income topped up to cut offs at about $17,000 for a single person and $24,000 for a couple. Since social assistance programs were rolled into the program it was not enough to raise people out of the low-income measure or low-income-cut-off levels, but it was enough to lift people to the market-basket-measure line, and out of definitional poverty (Hick, 2014). (CITE OTHERS?!) It was cancelled this spring however, one year early.

“People signed up expecting it would last a full three years” (The National, 2019). “It wasn’t long enough to open that door and actually get halfway there. It’s like you’re almost there, and it was taken away” (Jeganathan, 2018).

Aside from the stress and hardship of those who had the rug pulled out from under them, there were severe problems with the pilot project that undermined it’s ability to provide us with the sort of useful data that could have informed whether or not to roll out the policy nation-wide.

First off, it was too short. We don’t know how factors like work disincentives could play out the long-term (Forget, 2018; Mason, 2018; Hamilton & Mulvale, 2019),  a downside which already began to decrease during the last years of the Manitoba experiment in the 70s (Forget, 2011; Forget, 2018).

Secondly, the Ontario government wasn’t able to access social assistance records because of privacy barriers (Mason, 2018), and didn’t even have tax records until after participants were signed on and enrolled.  The actual enrolment process was pretty slapdash too, sending out letters to solicit participation (Mason, 2018).

All this amounted to an incredible self-selection bias, which even with the best quality data, which we absolutely did not get, would have been almost impossible to use (Mason, 2018).

Despite it’s short run and problematic implementation, the Ontario basic income pilot still demonstrated a lot of promise for this type of policy, and the human benefits we saw in the pilot’s run have been staggering. Folks struggling with homelessness got off the street. Folks suffering chronic income insecurity found a little stability, and were able to take control of their lives (E.g., Hamilton & Mulvale, 2019; Monsebraaten, 2018). The cold got warm, the hungry got fed, and the test communities got a lot healthier (E.g., Hamilton & Mulvale, 2019; Monsebraaten, 2018). It’s a call to action for another try – a real try.

What exactly are you proposing?; Who would you consult?

I’m not an economist. For a policy this important, a program this complex and a project this big, we should take advantage of every possible resource. Dr. Forget is an obvious choice, as is the prolific author and co-founder of the Basic Income Earth Network, Guy Standing. We’d want to bring in experts on poverty, inequality and the monumentous impacts they have on health and well-being, like Michael Marmot, Danielle Martin, Richard Wilkinson, Joseph Stiglitz and Armine Yalnizyan. Basic income experts who can take lead roles to navigate political obstacles will also be vital, like former conservative senator Hugh Segal, and NDP leadership candidate Guy Caron.

What I’m proposing is a sufficiently prepared, adequately sized, intelligently conducted pilot program to determine how cost-effective and beneficial a nation-wide universal basic income would be to our society. This is exactly what many experts proposed in 2016, as advice for the Ontario pilot (E.g., Forget, Marando, Surman & Urban, 2016; Laidley, 2016; Khanna, 2016).

We need a lot of really good data. I would tentatively suggest starting with about a quarter-million people, geographically diversified, with each set of cities randomly assigned to be either the control group or the test group. It doesn’t have to be these cities, but they should have similar population sizes, demographics and other factors we can control for. We’d want to adjust the parameters like the amount of income support given, to see the impacts of raising people above the market-basket poverty line, above the low-income line, and beyond.

Similar or smaller tests could be run concurrently or subsequently to flesh out this information better. After the initial run, we could expand the trial to larger cities to see if the data trends scale up.

What resources or capital would be required? Who would be responsible for rolling it out? How exactly do you expect to pay for this?

If we decide to raise people up to the low-income measure, we’d be looking at about 475 million for the first three years, gross (E.g., Parliamentary Budget Officer, 2018). Rolling in social assistance makes it about 250 million (E.g., Parliamentary Budget Officer, 2018). Roll out is simple once we determine the participants: checks in the mail. If we can learn how to eradicate poverty for just 250 million dollars, it will be one of the greatest bargains humanity has ever struck.

Factoring in the costs of poverty we’re already paying, we may very well discover that the pilot turns out to be cost-neutral (Ivanova, 2011; Laurie, 2008; Plante & Sharp, 2014; Knoll, Plante & Partridge, 2017), that giving everyone enough money to live on actually costs us nothing at all, or gives us a return back. This has some mind blowing implications for a national roll-out.

“The parliamentary budget officer said it would probably be on a national basis, to eradicate poverty, about 43 billion a year on the national account. The national account is in excess of 350 billion dollars a year, it’s less than 10%” (Paikin & Segal, 2018).

But that’s the gross cost (Parliamentary Budget Officer, 2018). Once a basic income brings people up out of poverty, social assistance programs would no longer apply. We spend more than 23 billion annually on social assistance (Paikin & Segal, 2018).

Twenty or so billion dollars. The Canada Child Benefit already costs us about that much. The Canada Pension Plan already costs that much. Tax expenditures for the rich cost us 122 billion dollars each year (Parliamentary Budget Officer, 2019).

“If we can afford 122 billion dollars for income assistance for people like you and me, can we afford 23 billion dollars to provide income assistance for lower income people?” (Paikin & Forget, 2019).

And again, that’s the cost before we see the return on investment from reducing or even eliminating poverty in Canada.

“You’re spending a whole lot of money treating the consequences of poverty. If we can take some of that money and allocate it to families up front so they can lead reasonable lives, I think you’d see the returns downstream” (Paikin & Forget, 2019).

In case you don’t remember from earlier – that could very well be up to 90 billion dollars a year! (Ivanova, 2011; Laurie, 2008; Plante & Sharp, 2014; Knoll, Plante & Partridge, 2017).

Why am I doing this?

I was born into the care system. But I had the obscene luck to be adopted into a wonderfully supportive family and community that wrapped around me and lifted me up. In my life and work I’ve met many others born into the care system who were not so lucky. Lives full of extraordinary hardship, of addictions, homelessness, incarceration and worse. Folks who really never had a decent shot at a healthy life. In what world is that okay? In what Canada should a child’s chance at life be up to a dice toss, when it doesn’t have to be? Not my Canada. Basic income isn’t a long shot. It’s our moonshot. And we should take it.



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The Next 150: Reconciliation and Health

For the better health of all of us, how do we get from colonialism to reconciliation, and what will that future look like?

Jared Knoll: Welcome to Upstream Radio, where we dive deep into all the social and economic determinants of health, the source factors of how we live and when we die. I’m Jared Knoll. It’s almost time to close the gap toward decolonization, reconciliation and the better health of all our families, communities and the whole country. Stick around until the end of the show to find out exactly how we can do that.

In this 14th episode, we’re looking at what reconciliation really means and what it means for our health. Earlier this month, we explored housing and homelessness as health issues, and spoke with indigenous homelessness scholar Jesse Thistle, who told us his very moving story of trauma, addiction, homelessness, prison, and the repetition of this vicious cycle, until he found himself with a decent roof over his head. But you only heard half the story because, while basic needs like shelter are critical to human health, they aren’t enough. Give people housing, but that’s only one half of the equation.

Jesse Thistle: Housing, but that’s only one half of the equation. The second half is restoration of healthy relationships.

JK: Your life has been so representative of colonialism and of inter-generational trauma, and of the long term impacts of what’s been done in history. Knowing now what we’re talking about now in Canada with things like a national housing system, with things like actually meaningfully talking about decolonization, do you ever think back and think, “oh, if there was just this back then, if I just had housing and sufficient income provided at this particular point in my life, things would have been very different?”

JT: Certainly at different points I’m sure it would have made a little bit of a difference. Perhaps I wouldn’t have been homeless as long term as I was, or I would have had better food so that my relationship to food isn’t all messed up the way it is now. But ultimately, if… Like, I wrote a document called “The Definition of Indigenous Homelessness in Canada” and it’s from that perspective based on my own experience and from what other indigenous people have told me, indigenous homelessness is about a disconnection from healthy relationships to self and identity, to land and family, to each other as indigenous people, to the government. The state was supposed to act as a relative to us indigenous people and it signed treaties, didn’t honor those.

So really, my homelessness as an indigenous person is both historical, the dispossession of land of my people, as well as the relationships that were cut off from me through things like my parents breaking up and my family falling apart, me being disconnected from my kin networks. From me not knowing my mom growing up and not knowing who I was as an indigenous person. Those are cultural, spiritual, emotional kinds of homelessness that stretch far beyond simply housing, simply having a job and having just money in my pocket. That’s about a really deep-seated destruction of cultural and social matrices of our people, of our culture, of our way of life, and of our world view. So through that lens, it might help to have housing, but I don’t think it would… It’s the final and be-all answer.

JT: And I do talk about this in this kind of document. The document that I made was a part of making… This kind of opened the discussion of what indigenous homelessness really is, because I can’t say if I’d had a house that maybe I would have… I’m not falling off that building. My brother Jerry worked full-time, ran restaurants, and still he was impacted by this trauma and became homeless in his later 30s and 40s. So he… On the surface, he was a working professional and had everything going for him. That shouldn’t have happened to him, but it did, because he was cut off from all these relationships that I’m talking about. And that’s a very holistic way to look at the issue. Am I making sense?

JK: You can’t have national or social healing without culture and identity to repair the cycle, emotional trauma and that deficit of homelessness.

JT: Yes, it’s almost like if know where you fit, that’s… You know when your home is. And when you know your history of your people, you feel good about knowing your family and you know where your land is, all those things are… Impact how someone perceives their home.

JK: Yeah. I’m a Saskatchewan guy too. I’m sitting in Saskatchewan right now. When you were growing up in Brampton and through all the trauma, through all of the very challenging experiences, you were under these forces of, again, generational trauma and colonialism and all of the things that came out of your… From your past. But at the time, I imagine, you didn’t really know that. You became a scholar and you have spent the last decade understanding that and helping other people to understand that. How did you process that as a young man without a clear understanding of what it was that was causing all of that?

JT: I remember growing up internalizing racism. I look a little different than like… In the ’80s, Brampton was mainly a white suburban place, so I kind of looked different, I looked like Italian. And I remember looking in the mirror and actually seeing an Italian person. That’s how powerful the broad colonialism is for the mindset. It literally changes how people perceive themselves. And I believed what people were saying about me like, “Oh, that guy, he’s like a dirty Indian.”

Other people would make war whoops to me at school, and over time that developed into a really messed up way of looking at myself. And when I started experimenting with drugs in my teens, I started to use that as fuel. So people would say, “Oh, he’s a crazy native guy. He can drink like crazy.” So I lived up to negative expectations. I became that negative stereotype. And there are a lot of ways my life is like a stereotype. It has these roots in me just trying to figure myself out and not knowing who I was or where I fit, or where my parents were. My dad went missing in 1982. He’s now presumed to be murdered. That’s from his generational trauma, that goes back to Spanish residential school on his side.

JT: But as someone who was waiting for their dad to come home to play catch, and has to teach themselves how to ride a bike without training wheels by themselves, or has to learn how to fight on their own, those things are very damaging for indigenous men. I had no idea what my roles and responsibilities were. My grandfather, who’s about the only person that acted as my father, and he couldn’t love me the same way that he loved his own son. So there’s a real interruption of that inter-generational knowledge too, right? And so that left me listless and like kind of un-anchored as an indigenous person growing up.

And so when I’m trying to process this, who I am, I remember with my brothers like pretending that we’re black sheep, we’re not black sheep. We’d put red ochre on our faces and try to pretend to be native because we didn’t know. My mom wasn’t around. She couldn’t teach us what it meant to be a Metis Cree person from Northern Saskatchewan or that our family was related to Louis Riel and that we should be very proud to be people that stood up for what we believed in. I had none of that.

JK: The sociocultural effects of colonization were devastating to Jesse’s health, but he is not alone. Dislocation from traditional lands and lifestyles, forced assimilation through residential schools and other methods, the destruction of environments and the systemic institutionalized racisms of more than a century have created grotesque inequities in health and well-being in our country. People with aboriginal status in Canada have much higher rates of infectious and chronic diseases, an 18% higher rate of diagnosed depression, a 27% higher rate of alcoholism, and experience childhood sexual abuse at a rate 34% higher. Their suicide rates vary between six and 11 times the national average, depending on region.

In 2007, the United Nations officially resolved that the ongoing effects and processes of colonization are critical social determinants of health, and came up with the United Nations Declaration on the Rights of Indigenous Peoples to reverse colonization and improve health outcomes. Ten years later, the wheels of progress have only just recently begun to rumble. Recent developments in funding equity have been a step toward justice along with plans to provide safe drinking water to remote communities, projects to address housing deficits, and promises to improve inclusive indigenous-led reforms. But we can’t just put roofs over heads and food onto tables. People need more than that to be healthy. Jesse needed more.

JT: When I started asking these questions… When I was coming out, I was in rehab and my grandmother, the woman who raised me, passed away. And before she passed away I’d seen her and I asked her… I tried to make amends and I asked her what I should do and she just said, “Well, if you’re gonna go to university, you kick it all the way. And you go and really try to figure this out and try to help people instead of hurt them.” And so I made her a promise. And that promise brought me through rehab. That promise guided me to university, and at university I started taking all these courses and trying to figure out my history, and I started… I was lucky enough to meet a woman named Dr. Carolyn Podruchny who heard about my story and who knew people in my family, and she flew me out to Saskatchewan to meet my… To reconnect with all my mom’s relatives.

And through that process, I started learning about myself. I started learning about what inter-generational trauma was. I started learning about where my family history was impacting me as a… Led to my dad’s choices to rob the store and my mom leaving my dad and me eventually becoming homeless and an addict myself. And it all just clicked, it all just made sense. I’m like, “Yes, that’s what it is.” And so now I know, and I go around and I try to tell people, other people, that these are the impacts of what happened and I use my life as a foil to show them the different historical dispossessions, the loss of culture, the loss of identity, loss of kin, all these things that happen through colonial processes are evident in my life story.

JK: Jesse’s story is important because it gives a face to the facts, more than some amorphous impersonal group.

JT: Here’s this guy right in front of me giving me concrete examples of how things like the Indian Act, the 1885 Resistance, residential schools, how it affects people today. And so that’s my purpose. That’s what I’m here to tell people and to try and educate them. And I don’t have all the answers and some things I get wrong, but I’m trying. I’m trying to honor that promise to my grandmother.

JK: After that personal reconciliation, coming back to Saskatchewan and understanding the sources of so many things that happened in your life, did that feel like a curtain being pulled up? Did you see the world differently after that?

JT: Oh, for sure, yeah. First came deep, deep anger. Because I really understood what I was up against and what has happened in my family. And a really deep sorrow for myself and for my people. And then after, pride, really, really strong pride. Because we survived, you know, I’m living proof. Even my life was a harrowing struggle, and I’m just one of many of my ancestors like that. So it shifted my perspective. It shifted the way that I look at indigenous people who are homeless. It shifted the way I look at the government and the way that policies had been structured to dispossess indigenous people and to impact their health directly.

I know we like to discount and say, “Oh that happened in the past.” But those decisions and laws are still in place today and they still work and impact the health and lives of indigenous people today, so they’re not in the past. They’re very much active.

JK: Yeah, we talk about the history and the legacy of colonialism, but it’s not history is it?

JT: No, it’s not a legacy at all, it’s ongoing. The Indian Act’s still in place. The farmer that took grandfather’s plot, is still on that plot with his family. These things have direct health, social, emotional, psycho impact today on indigenous people, that live with the trauma, that live with the dispossession, that don’t know their history or identities.

JK: How did it feel growing up, or how does it feel now, to think about how Canadians tend to think of justice as a core Canadian value? How we… We think of ourselves as maybe different from Americans, or different from other countries and we have this identity that we care about social justice. How does… If you experience that, how does that reconcile with the reality of what you learned when you came back home and what you’ve studied since then?

JT: I think it’s a case of mis-education. So we’re not… People in Canada aren’t educated from small children all the way up, of what really happened here. It’s been kind of just erased, and over-taught late Anglo foundation narrative, that it lionizes the justice and the efforts of the settlers and from there, through their will, they created this great nation that is so altruistic, aware of social justice and committed to it.

But really, they’re not seeing the mechanics of how people came to live on this land. How that process of dispossession is ongoing. How things like the Indian Act work to erode matriarchal structures and dispossess indigenous women and lead to things like murdered and missing indigenous women all across our country. And so I think it’s a problem with the way that museums operate, I think it’s a problem with the way that public history operates, and I think it’s the way that our whole education system across the country operates. It kind of indoctrinates people to believe that they’re just, that they’re on the right path. But they really don’t know the injustice of the history of the nation.

JK: I’m six or seven years younger than you, and I still didn’t hear the term “residential school” until I was in university. That’s… In Saskatchewan especially, that’s outrageous. Are you optimistic that it’s getting better? Are you optimistic with closing the gap? We’ve used the tag line “The Next 150,” talking about how we can… We can, if we choose to, collectively decide that this… Make an imaginary line in history if you will, the first 150. We can say, “We’re going to do better. We can mobilize as if going to war, that we will decolonize, and we will do better.” Are you optimistic that that’s possible?

JT: I am actually, ’cause I remember Harper. I remember the way it was under Harper and that’s not that long ago, that’s three or four years ago where there was a real concerted effort to further erase, to further marginalize, to not listen to indigenous people. I know that a lot of indigenous scholars and thinkers, they were skeptical, and rightly so. But the things that have happened, like Trudeau’s announcement the other day. We have a Justice Minister that’s Indigenous. We have people in place that are trying to change, and I’m optimistic. This could be the turning point. And I don’t know, some people might see it that I’m naïve, but I don’t know. I don’t have any… I can’t be so pessimistic. I just don’t see that positive action can come from that.

JK: What do you see as the most important things we need to change for education? If you had… If the Provincial Ministers of Education came to you and said, “What are the most important things we need to change at the elementary level, the high school levels?” What would, just off the top of your head, be some recommendations that you would offer them?

JT: Treaty history. I would have people understand where they’re rooted, in the territory or cities or wherever they are. So know the people who signed the treaties, what the treaties… What were in those treaties, and how that, where both… On both sides of that equation, treaty people, there’s rights and obligations for both sides, and we need to honor those and we need to train people from very young all the way up what those obligations and rights are.

And then beyond that, I would say that our schools and our education systems and the museums, they have an obligation to work with the indigenous people from that area about proper representation. And they have to build a relationship with those people so that we honor that relationship. And really, I would try to focus education efforts on a restoration of that relationship.

JK: So how do we do that? How do we undo 150 years of colonial influence or even begin to start down a new path with today’s young people?

Voice (JR): One thing I do with them is, I get them to connect back to their history.

JK: That’s Jordan Raymond, a Métis teacher and artist in Saskatchewan and a speaker at Closing the Gap: the Next 150.

JR: Before you can change anything, you need to know who you are as a person and know your truth.

JK: When it comes to education, and when it comes to instilling values and instilling a sense of identity, since residential schools, we have seriously lacked any semblance of genuine Indigeneity in school systems. What do we need to do for education to give kids the opportunity to learn what they need to learn to have a healthy life?

JR: It’s been touched by colonization. It’s a colonial system that has been used for thousands of years and has never actually given the chance for indigenous voice or indigenous perspectives within their system. I think we’re coming to an age where we’re seeing that this colonial system does not work and we need to fix it. And through these reconciliation processes, that calls for action that had been recently put out. The education system is now saying, “We need to start using these within our establishments.” So that’s really great and I think with these calls for action, we will see a change within our education system and within the lives of our students.

Even with me working in the education system, the kids have changed a bit of their perspective on what they will do with their lives. To give an example or a story, I had one boy who was in gangs who didn’t care about education. He’s like, “Oh, I’ll just have my grade 10, I’m gonna leave.” We built a connection with one another and built that relationship, and a positive relationship, with one another and actually, he is now going to Miguel and wants to work for the UN. And so, I think giving the opportunity for our students to use their voice within our systems to tell us what they want. Sometimes as adults we like to overshadow our youth and I think the youth do have the answers and they know what they want. And I think we just need to make that platform so that they can show us what they need at their present time.

JK: In the social determinants of health, colonization being a major one, we look at how these factors that we can change through politics and through our social mechanisms can change how we live and when we die. How many years of life, how many years of disability-free life we get to live. How have you seen colonization playing out in your work as an educator in those ways?

JR: I’ve seen it everywhere. A lot of the students I work with come from a low social economic status, so they have that pegged against them. They’re indigenous, that another thing that’s pegged against them, their race, and various other factors. And sometimes it’s really hard when you are dealt a hand where you don’t have a chance. I’ve actually had a lot of students who have passed away based on either drug use, or based on suicides because of not knowing who they are and not knowing their identity. Making programs and bringing in to the classroom all these different things so that we can actually shape our identity and shape it in a good way, can help our students live a profitable life. But also, give them the education that they need so that they can get those jobs, help their communities out for the people who are struggling and bring back knowledge to the communities as well.

JK: We know that in Canada indigenous peoples have suicide rates that are about six times higher than national average. With a lot of barriers coming down right now on mental health stigmas and a lot more willingness in government to treat mental health through public health measures and through social mechanisms, how do you see education as a way to strengthen our mental health?

JR: I use art to talk about those type of issues. For instance, with art it’s a great medium to teach about mental health but also to use it as a medium to bring about a voice that you might not be able to say with your words. And so, one great thing about art is you can use your creativity and imagination. And so, with kids, we can create a world that could be and not what is. And so, with that, the kids can understand like, “Oh, this could be the world that I want. This could be the way that I want to be.” And so, giving them that chance to be who they want to be, kids learn to have that empathetic understanding. I find that a lot of kids of today don’t have that and don’t understand why this person is different than me. And so, getting them to really jar their thinking and really think about why this person is the way they are, art could be that medium to help them learn that

JK: So when kids are able to decide who they’re going to be and use their imaginations and have that sort of autonomy, can that be an avenue for reconciliation in fostering healthy indigeniety and opening up channels for reconciliation between settler and indigenous peoples?

JR: I would say yes. The reason why is because our indigenous people are born into a colonial world. And so, getting them to see a world that is indigenous and has their value systems and their traditional cultures, they can see that this stuff can actually happen.

JK: We need to explore every avenue of reconciliation that we can find. Our health is at stake and so is the health of our democracy and our very culture. Things are not okay.

Voice (TT): We still don’t have schools and all the communities’ high schools or even proper elementary schools and all the communities that need them across Canada. First nations communities still don’t have clean water in communities all across Canada, First Nation’s communities. You need these things as part of the social determinants of health for raising a healthy child.

JK: That’s Tanya Talaga, the keynote speaker for the 3rd Annual Closing the Gap Conference in Ottawa next month on April 6th and 7th.

Tanya Talaga: Fulfilling Jordan’s principle wouldn’t be enough. I mean, you have to do everything really in order to give all children an equal bridge.

JK: Tanya, you’ve been an investigative journalist for many years and just last month won the Taylor Prize for your book, “Seven Fallen Feathers: Racism, Death and Hard Truths in a Northern City”. Maybe you can start by taking us down the path a little bit to what led you to cover these tragedies.

TT: Well, it was the 2011 federal election actually. I went to Thunder Bay to write an article on why it is that indigenous people in Northern Ontario don’t vote. I was a provential reporter at the time. I worked at the Ontario legislature, covered politics for the Toronto Star. I pitched this story because I wanted to start writing federal election stories. My editor decided it was a great idea, so I went to Thunder Bay to write a story about the election. But when I got to Thunder Bay, I sat down with grand Chief Stan Beardy, he was Grand Chief at the time of Nishnawbe Aski Nation. And when I started to ask him questions about indigenous voting patterns, he looked at me and he asked me, “Why aren’t you doing a story about the disappearance of Jordan Wabasse?” And I didn’t know who Jordan was.

And I thought maybe the Grand Chief wasn’t hearing me correctly, [chuckle] so I repeated my question on the election and he asked me again, “Why aren’t you writing about Jordan?” We went on like that for about 10 minutes until I sort of put my manic Toronto journalist self aside and sat and listened to what he had to say. And that’s when he told me that Jordan was the seventh student to go missing or to die in Thunder Bay since 2000. And so, that’s how I started writing about Seven Fallen Feathers.

JK: And in your book, you investigate the circumstances of how systemic discrimination back seven years ago was very much a matter of life and death. In past years with Closing the Gap and in Upstream’s work, and in our perspective, we’ve examined colonialism as a social determinant of health to try to mobilize public action by seeing it through the health lens. How did you find when you were doing this investigation the linkages in that between a colonial past of systemic discrimination into very much matters of life and death?

TT: Well, it still exists. We’re still seeing children, students, indigenous students, they’re still being found, sadly, dead in the waters surrounding Thunder Bay. Since Jordan died in 2011, there have been three students, or youth I should say, who have passed away. And you see the systemic racism every day in Thunder Bay. I mean, you could ask any student, indigenous student that goes to Dennis Franklin Cromarty High School if they’ve ever been called a racist name, if they’ve ever had garbage thrown at them from a moving car, and I will bet you anything that every single student you ask will tell you that’s happened to them.

This is something that everybody lives with, and through the course of writing “Seven Fallen Feathers” I also saw the discrimination that indigenous people face daily when it comes to the health system. And in some severe cases, I’m thinking about the case of Paul Panacheese who is a 21-year-old youth from Mishkeegogamang First Nation, and he actually died on his mother’s kitchen floor. And she called 911, said, “something’s wrong with my son.” Paramedics came, they took him away. At that point, he was not responsive. And noone called Marianne to tell her how her son had died. No doctor, no coroner, noone phoned her to let her know.

In fact, she waited nine years until the start of the inquest into the death of the seven students to find out what happened to her son. And when the inquest started in 2016… Well, actually it was 2015, it was October 2015 when that started, they had no answer for her still. There was no answers for her on how her son died. It was ruled undetermined. That’s just one example. I could tell you of other examples where health professionals failed to return calls or to inform even parents of the deaths of their children.

JK: Do you think we’re still looking at colonialism as a culture, as a society, as something that is a legacy, as something that is history, or in your view, are people starting to understand in the more general public, that these processes are still continuing? Do you see any paradigm shift happening right now?

TT: I would not call it a paradigm shift, I would say that people are becoming far more aware of it, especially certain jurisdictions are doing more than others. I’m more familiar with what’s happening in Ontario. Ontario seems to be taking this very seriously. I know that the Ontario Ministry of Education is doing what it can in Thunder Bay to start working with Dennis Franklin Cromarty High School, the indigenous high school I was telling you about earlier. And with the school boards and trying to get everyone working together as a community and to stop seeing everybody as silos. That’s a federal responsibility or a provincial responsibility.

I think that change is going to take time, but I think that there are people that are very aware, in Ontario anyway, and are trying to make changes. Because everyone is fully aware that colonialism, its long reach, has had a grip on relations between indigenous and non-indigenous people in this country. And that has to be severed and equity needs to come, especially when you’re dealing with services like health services, education services, social services. That all needs to be equitable, we can’t have two different systems.

JK: And you spoke about how our law enforcement system, our justice system, has built in discrimination, or developed discrimination. Do you think education is the main key, or do you see that as the keystone that if we can get education fixed that everything will come from that, or do we need more of a multifaceted approach to change all the systems that have racism built into them?

TT: I think a multifaceted approach is the best. But in the long term, education is key. Education is the great equalizer of any society. So I think that for a long term gain what we need to do is have curriculums that are reflective of indigenous reality and also too of indigenous culture and the true history of Canada. I also think we need to have schools, provincial and federal, that are reflective too, that have indigenous teachers, that have indigenous trustees, that have indigenous people working as counsellors or in the school system.

I mean, there has to just be a greater acceptance and understanding of culture. But saying that, and that’s the long gain. There’s also other things to be done for the long gain, and things like getting rid of the Indian Act, a piece of legislation that’s been in place since 1876. That needs to change. There are massive structural changes that need to be overhauled and scrapped. And then everything else hopefully will fall into place.

JK: Do you see the actions the government is taking now as the beginning of addressing everything that needs to be addressed? Do you see the cogs beginning to turn in a way that makes you optimistic?

TT: It’s the best it’s ever been, I can say that. The promises to clean up the water and the sewage systems in all First Nations communities that need them, that’s pretty huge. I don’t think anyone has come out and said that and actually tried to do that before. I hope that that actually does happen and I hope that what Minister Philpott and Minister Bennett are doing, I hope that they also are guided and they come to fruition with the things that they’re trying to do, tearing down departments such as INAC.

Those are big, big jobs. It’s gonna take a long time, but I would also say that they need to do that though in conjunction with indigenous people. And I know they’re consulting with indigenous people all the time, but if you’re gonna tear down those things too, I think it would be helpful to have elected chiefs sitting beside them, helping them going through that process. So it’s not again, just the government of Canada’s representatives doing it themselves, it’s the government of Canada sitting alongside an elected… Take the head of the AFN, for example. It’s a nationally elected chief sitting beside Perry Bellegarde and then doing it that way, or somebody from the council. The AFN executive council doing it all. So everyone’s moving together. That’s the point, everything has to be done together.

JK: You said when you went to Thunder Bay when you were initially trying to find out why indigenous peoples don’t vote in federal elections, that you set out with an idea of a story that you wanted to tell of a point that you wanted to get out and make, and then when you finally started to listen, that’s when your eyes opened to what was really going on that really mattered, that deserved your attention, that deserved action. Do you think that we’re sort of getting to that point at a societal level where when it comes to reconciliation we’re finally starting to figure out we need to listen, or do you think we still need… The Canadian public still needs a bit of time or maybe the right amount of momentum to get there?

TT: I think it’s a learning curve. I think that everyone is starting to find out a lot more that they didn’t know before. Sometimes when I go and I talk to people regarding “Seven Fallen Feathers”, they often come up to me and say, “I had no idea. I had no idea about the Indian residential school system in this country.” And these are older Canadians often that come up and tell me this and I’m always amazed by the fact that people just had no clue whatsoever that 150,000 indigenous kids were in church-run federally funded schools from the mid-1880s to 1996. Sole purpose was assimilation.

It’s remarkable to me, but I do think that things are… People are opening their ears, more Canadians are. And I think we shouldn’t expect this to happen overnight because it’s a level of misunderstanding that’s out there. We have to be patient and let education do its thing, because everyone is finally starting to get that message now. It’s also the younger people that are coming up. Our generation has basically failed on this whole thing here. So it’s the younger kids, they’re the ones that are gonna make more of a difference and they’re gonna carry this change forward that needs to happen in this country. That’s what I think anyway.

JK: What was your personal journey of understanding when you were doing this? Did you… How much did this teach you about the culture, the capacity for healing and just how bad it really is in the consciousness of Canadians, how bad it really was systemically. From where you were in 2010 to now, maybe can you tell me a little bit about what your personal journey has been, in terms of realizations, enlightenments?

TT: Well, you always sort of know these things about how… What the situation is like, but then when you start actually looking at the black and white evidence, when I look at the inquest papers, the testimonies that were given, the reports that were filed as evidence for the inquest. 200 witnesses were called. The inquest lasted eight months into the death of the seven students. When I look at that, when I see on paper black and white how deep the systemic racism was and is, that’s pretty shocking. And then when you talk to the families and hear their stories, when you hear that Dora Anderson’s nephew Jethro was missing for six days in 2000, October of 2000, before the Thunder Bay police force went to look for him, when you hear those stories, I mean, we’re not talking about 1936, we’re not talking about 1976, we’re talking about 2000.

And even now just recently with the OIPRD report on the investigation of the Thunder Bay police regarding the death a 41-year-old Rainy River man, Stacy DeBungee, and the OIPRD is an offshoot of the ministry of the attorney general’s office in Ontario, they were looking into systemic racism claims on how the Thunder Bay police handled Stacy’s death, ’cause his body was also found in the water.

Subsequently, his body was found two weeks after the inquest into the deaths of seven students had started. So, you have an inquest going on, the second biggest inquest ever in Ontario’s history happening in the Thunder Bay courthouse, down the road by the riverbank, the Thunder Bay police were responding to the call of the death of an indigenous man, Stacy DeBungee, and the exact same issues that was being discussed in the courthouse were actually unfolding at the riverbank according to the OIPRD report anyway.

They concluded that two police officers are allegedly guilty of neglect of duty. And they have quite an exhaustive report on what happened in the investigation of Mr DeBungee. So, are things gonna get better? I hope so. I really hope so. I think that now, more than ever more, people are calling out others. Like the OIPRD are doing a report and they’re doing an even broader report into the Thunder Bay police, so I think that change is coming.

JK: I think you’re right that there’s a generational transition that some things that are just so normalized, discrimination and racism are just so normalized, it’s going to be the next generation that truly can… True reconciliation when it’s actually past decolonization to a point where that is just nonexistent anymore. I think you’re right when you say it’s a generational transition. We’re coming together with this Closing the Gap Conference, our third one in April. And you’re very happily there a keynote speaker. I’m very excited to see you speak. Do you see gatherings like this where you get key, high-profile decision makers like Jane Philpott, newly the Administrator of Indigenous Services, and others, MPs and others, in one room having these conversations? What kind of impact do you think that can have on the conversation and on the societal consciousness?

TT: I think it’s fate. And it’s what’s needed. And I think that Mr Philpott and Mr Bennett, they know what’s happening, they’ve sort of say they’ve got it going on when it comes to that. They’re aware what’s going on. And they know what needs to be done. And they know that they have to work with indigenous leaders to get it there. And that the whole system needs an absolute overhaul. And also too to be fair. They have what? Another two years left in their mandates? And then it’s election time. So this is like we’re talking about change that’s gonna take a very long time to come about. And they can get it started and get it on the right path with the help of indigenous leaders. And it’s cool that an effort is being made to do that. And I just really, really hope that it starts working.

JK: What message would you have for… As Justin Trudeau likes to say, “The everyday Canadian.” The typical general public that maybe isn’t as educated as they’d like to be or isn’t as aware as they’d like to be of the systemic issues that we’re all really dealing with, that we’re all challenged by. What would you say to them to get more involved, to tune into the Live stream and to get more engaged in their communities in a participatory way, to get the wheels of change turning a little faster?

TT: Read the calls to action that the Senator Murray Sinclair and the Truth and Reconciliation Commission put out. There’s actually a little booklet you can get from the National Truth and Reconciliation Center in Winnipeg. Businesses can get them. Governments can get them. They’re these little tiny flip books, you can even carry around in your purse or your pocket they’re so small. The size of basically an iPhone. And in it is reprinted the 90 Calls to Action that all Canadians should hopefully read and then take one if… Senator Sinclair said this before, “If everyone was to take one of those recommendations and apply it to their lives, maybe we’d be getting somewhere a little bit faster.” And so, I would echo that.

JK: And we’ll be sure to make a link to that available in the show notes below for listeners to check out.

TT: Well, that’s great.

JK: Thank you so much, Tanya, for joining me and speaking for us today. And thank you so much for joining us at Closing the Gap in Ottawa to speak. What you found in your your investigation and how it’s changed your perspective and what we can all do to get there a little faster.

TT: Thank you very much for having me. I’m looking forward to meeting you.

JK: And thank you dear listener, for joining us to dive into these critical issues for the health of all of us. As always, it’ll mean a lot to us if you subscribe to Upstream Radio, connect with us on social media, help us share stories to mobilize this movement and leave us a review wherever you can. Everything we’re able to achieve is because of this incredible community. Let’s define what we want for the health of all Canadians right now and begin the next 150 together. I’ve been Jared Knoll. Until next time, keep thinking Upstream.

No human should be homelesss

Homelessness is complicated. There’s not one easy or simple solution. But we cannot let those remain excuses for doing nothing, or even too little. In this episode Upstream’s I speak with Jesse Thistle, Ritika Goel and Stephen Hwang on the health impacts of housing and homelessness, and what we can do to get better.

Housing is health care

We face several overlapping, interconnected public health crises, like homelessness, addictions and overdoses, crime and justice, and all the downstream costs we all pay for. Could the solution that really works, be the simplest one of all, right in front of our noses?

Spend upstream to improve health outcomes

We’re sick with poverty. And we have the data to prove it.

In this 11th episode of Upstream Radio, I discuss with Daniel Dutton and Monika Dutt the importance of evidence and data to mobilize pressure for political action, the necessity to include human story, and the impact of healthcare spending vs. social spending for health outcomes.

How much do lifestyle choices really matter for health?

If we want healthier communities, we must stop thinking of health only as a matter of personal responsibility and lifestyle choices, and dive deeper to the greater social determinants.

Jared Knoll: Welcome to Upstream Radio, where we dive deep into all the social and economic determinants of health  the source causes of how we live and when we die. I’m Jared Knoll. Today we’re looking at behaviour, at what we think of as the lifestyle choices that keep us in good health.

(Sound Bite; Dennis Raphael): Sociologist Sarah Nettleton termed it the holy trinity of risk: physical activity, diet and tobacco use.

JK: That probably sounds like a pretty familiar set of health risks, from visits to the doctor, from articles you’ve read and from pretty much everything you’ve ever heard and seen in popular culture. There’s just one problem.

(SB; DR): There’s a vast amount of evidence that indicates that all of the behaviours that we’re so concerned about only account for, at best, 10% to 15% of the variation in health outcomes.

JK: Now, that doesn’t mean we should stop paying attention to our diet, activity levels, and avoid unhealthy behaviours like smoking. Keep doing those, those are good things. They always have been. What it means is that those of us who adhere to those sorts of behaviours, or don’t, tend to do so because of the social and economic advantages we happen to have, or don’t. Let’s take exercise, for example.

Brendan Groat: It’s easiest for people to exercise if it fits into their life. People of higher socioeconomic status, they might consider exercising something you do after work, and something they do in their time when they’re not working.

So I guess in that context, you have to be able to have a job that provides you enough time to exercise, and to have enough funds to be able to put towards exercising, whether that’s in a gym or wherever you like to exercise. But more importantly, for lower socioeconomic status individuals, who oftentimes have poorer health, they might be working multiple jobs and might not have time to exercise, and certainly not funding to put towards going to a gym or something like that. But their exercise maybe could be fit in transportation to and from work, whether that’s walking or biking. But of course, for those you need appropriate clothing and a bicycle that is functioning.

JK: So healthy behaviors like maintaining an active lifestyle and eating a nutritious diet are extremely important for our health, but it’s not enough to just tell people to be healthy. We have to change the social, economic and political barriers that get in the way. That’s what the evidence is telling us. We can’t afford to remain in this trinity trap, stuck in the conventional wisdom of past eras, doing and saying things like:

Sound Bite: I’m Justin Trudeau. Men’s Health Week starts on June 13th, and I’m joining their Don’t Change Much campaign, which reminds us you can make small changes in your life and enjoy big benefits to your health. You don’t have to take up yoga or lace up the boxing gloves to make a difference. Drink more water, eat healthier food. Take the stairs instead of the elevator. Get off the bus one stop earlier.

JK: One of our most important pieces of literature in Canada on the broader social and economic determinants of health, is called The Canadian Facts. I asked its author, Dr. Dennis Raphael, how we got to where we are now.

JK: When we talk about lifestyle drift, what do you see as the biggest problem with understanding how behavior affects health in Canada?

DR: Historically, health has been seen as healthcare, or promoting health, or preventing disease. Over time there’s always been a tension between what we might call the broader environmental approach, and the individualized behavioral approach.

For example, during the social justice movement of the late 1800’s in the United States, there was a recognition that many of the causes of illness and disease were not rooted in individual pathology, but in the conditions under which people were living in society. And even earlier, in the 1840’s and 1850’s, Friedrich Engels wrote about the condition of the working class in England, and Rudolf Virchow in Germany wrote about the politics of disease and illness, where he said the lack of democracy and equity was responsible for disease.

In Canada there’s always been this tension, but even since the 1970’s with the Lalonde Report, and then 1980’s with the Epp Report, which the world sees as the great example of Canada being a leader in health promotion and raising broader issues. This concern with broader issues has always been secondary to a belief that health can best be promoted by getting people to behave the way we might like them to behave.

Sociologist Sarah Nettleton terms it the holy trinity of risk: physical activity, diet and tobacco use. The problem with this is that evidence has always been available that not only do people’s environmental circumstances, their living and working conditions, not only do these conditions have a much more important effect upon health outcomes, but these conditions also shape the behaviours that so many people are concerned about.

There’s a vast amount of evidence that indicates that all of the behaviours that we’re so concerned about only account for, at best, 10% to 15% of the variation in health outcomes.

JK: So if the data is telling that these behaviours, smoking, diet, exercise, have a relatively minor impact on health outcomes, and if these behaviours themselves are largely determined by things like income and education, what should health professionals like doctors be doing differently?

DR: What they should be doing is recognizing, as Randolph Virchow pointed out, that medicine is actually a political activity, and that certainly, all things considered, you don’t want people, if they have some control, to smoke. We much prefer that people have a balanced diet, and certainly all things considered, we’d want people to be more active than less active, but these factors themselves play a rather small role in health outcomes. The danger to all of this is that what it does is diverts attention from these far more important issues of living and working conditions. Also, the evidence that these so-called lifestyle approaches will actually improve the health of the most vulnerable is completely lacking.

What actually happens, with all this attention to the so-called lifestyle approach, all it really does is actually increase health inequalities, because the people that are in the best condition to actually make these changes in their lives are already the ones that are going to live longer anyway, and it’s an insidious process whereby even when governmental and other agencies recognize the broader determinants of health, what they do is in their practical recommendations they drift, such that the term “lifestyle drift” has come to refer to the tendency of all of these public health, health agencies and governmental agencies, to rather than raise the issues of income and democracy and political control and power, they end up ignoring all of those and telling and implying that the causes of disease and illness are people’s adverse behaviours.

JK: How do you think we got here? How do you think we got to the point where we are blaming personal responsibility as the determiner of our health?

DR: Well, Canada, political scientists talk about different forms of the welfare state, where the so-called liberal welfare state is the Anglo-Saxon approach to societal organization, where the marketplace and the so-called free enterprise sector is the dominant institution. The primary ideology associated with this historically is that of individual responsibility, individual control, the belief that all individuals have the ability to make decisions that will not only shape their economic future, but will shape their personal future, and this lends itself very much to the so-called lifestyle approach, biomedical approach, where the broader issues are ignored and the focus is turned to the individual. This serves interests, some interests very well. It’s in the interests of those that have power and influence to attribute disease and illness to individual failings, rather than the business and other practices that lead to gross inequalities in living and working conditions.

JK: You’ve been tackling this since the beginning of your career in the social determinants, when you beheld this thing, the American dream or the Canadian dream if you like, where it’s up to the individual to achieve their own well being and success, and then in reality doesn’t actually match up to that. And since then, since the beginning, and since you wrote The Canadian Facts, and since then we’ve seen this slowly growing movement in academia, and then more recently, a slowly growing social movement, more and more people are coming to understand that the most important things are the social things, are access to food and housing and childcare, and a decent income and stuff like that, yet we still see this resistance when it comes to behavioural choices, when it comes to smoking and eating nutritiously and getting enough exercise. Do you think, is there something missing? Is there something special that keeps people more resistant from accepting the social and economic causes of these?

DR: There are always conflicting trends and tendencies in society. For example, the typical health scientist, a typical epidemiologist, a typical health reporter, is trained in the biomedical approach, is trained in the so-called lifestyle approach, and no matter where you are, whether you’re in Norway or Holland or in Canada, if you get 150 epidemiologists who have that approach together, they’re going to talk about lifestyle, they’re gonna talk about biomedical. The difference is, is that in nations such as Germany or Norway or Belgium, the powers that be, whether they’re the business sector or the governmental sector, recognize that that’s what they’re gonna say, but they also have access to broader concepts of human health and the role of society, so they act as a counterweight.

If the broader context of a society is oriented towards individuals, is oriented towards denying the role of broader structures, then the parts of the health sector that are traditionally biomedical and/or behavioural approach continue to dominate, because there’s no counter force against them. For every one article that is about the broader determinants of health, there’s 150 articles about obesity or lifestyle.

JK: So in your experience, like if you show people that, take smoking, for example, people in low income brackets are overwhelmingly more likely to smoke, and the better education you have the less likely you are to smoke?

DR: That’s right. And the more precarious your work is the more likely you are to smoke…

JK: …the more stress in your life and the fewer opportunities to relieve stress through expensive activities like warm vacations…

DR: …or not being, having no food as an indigenous community. But what they hear, what they take away is, “oh, we have to help people to stop smoking.” It doesn’t even get processed, even when people like ourselves have these nuanced models that say 80% of the variance is due to living conditions, and these living conditions also shape the remaining 20%, which is tobacco use, the only thing people hear is tobacco use.

JK: We see the same thing happen with diet and exercise, with dozens and dozens of studies showing that socioeconomic status is correlated with obesity rates across the board, and the greater inequality of wealth in a society, the greater inequality of health too. But instead of real solutions, we get, “Walk more, breathe more, sleep more.” We get, “Don’t change much.” We get a focus on super foods and the newest fad diet or home gym gimmick, and we get blame on the individual. Patty Thille is a post-doctoral fellow with the Bloorview Research Institute in Toronto. I asked her why this is and what it costs us.

Patty Thille: There’s this belief that shame is going to create change, that shame is a good motivator. The thing about shame is that it doesn’t tend to produce those effects. It can produce loathing, self-loathing. It also damages relationships. If you’re essentially saying, “Listen, I love you but you are doing these things that are really hazardous to your health.” Would you say that to someone who has an eating disorder? Would you that as a loving, caring thing to do, a supportive thing to do? Would you say that to someone who has depression? Would you say that to someone who has red hair, and so their cancer risk is higher? “I really love you, but that red hair,” you know, like when you shame them for having red hair. Because the fundamental part about shaming people based on their larger and visibly, like visible fat on their bodies, is that you are assuming somehow that that’s changeable.

And again, the research isn’t that — there are population changes. There is something changing, and I don’t mean to deny that. But the idea that this is just all under individual control. When you think of the vast number of things that have changed over the last 50 years in this society, you start to get into a bit of a hole here. Like you’re not — it communicates, when you use shame to try and motivate somebody into changing their behaviour, it generally communicates that you have no idea really what they’ve been living with, and probably how many times they’ve already tried to lose weight.

JK: What do you think that we should try to do as advocates, as activists, as politicians, as health professionals, if people care about the health of their communities, what would be a better way than just getting so hung up on behaviour like diet and exercise?

PT: In general, I would say we’re talking about fostering the conditions in which people thrive. Those are many and they come down to things like housing and transportation systems, how easy is it to meet your basic needs and get around the place? How much are you dealing with on a daily basis? How much time does that eat up? Where are the opportunities to do things that might be really personally valuable and health enhancing if we’re talking about supporting healthy behaviours.

But beyond that, I think we really have to talk about moving away from the idea that shaming people for a bodily characteristic is going to produce better health for people. Fundamentally that’s the shift that I wanna see, that there are ways to support people and support them in living meaningful lives and that don’t have to work through shame, because shame has both very pernicious, awful effects on people’s lives when it’s sustained and so frequent. But it’s also that it takes us, it detracts our attention from better solutions. We have to think better about what we’re talking about when we’re talking about health, and this is using the example of fatness and fat bodies as becoming a really active target of political attention. But fundamentally we have done a lot of downloading of responsibility onto people when we know that there’s so much around them that can make life so much better.

JK: So, what can the health practitioners of the future do to shift that paradigm? Well, first they have to understand where to shift it to. A couple of med students named Giuliana Guarna and Elizabeth Lee recently took it upon themselves to do just that. Some of the things they discovered? Canadian smokers in the lowest income level are twice the number of the those in the highest. Smoking rates among those with a high school equivalency diploma is about three times higher than the national average. Stress is a huge factor, especially among women. And for indigenous peoples affected by unique stressors like past and continuing processes of colonialism and inter-generational trauma? The smoking rate is well over double. Do those people just need to be told to not smoke? Just need to be told to breathe more? That’s not what the evidence is telling us. I asked Elizabeth how these facts will inform her practice as a future doctor.

Elizabeth Lee: For me as a future physician, what the research has told me was that when a patient comes in and they are smoking or want to quit smoking, I need to ask about various different things that got them to smoke and are keeping them smoking, keeping them from quitting smoking so that I can actually give help that will be more helpful in the long term.

JK: This is the silver lining and the source of a whole lot of optimism. Thousands of Canadian medical students are already walking a more informed path right now in schools and residencies all over the country. But you may be wondering with all of this, is any of this really the responsibility of a doctor or a health professional to affect policy, to change the world?  [I asked Vivian Tan of the Ontario Medical Students Association and one of the contributors to Upstream Medicine, the new book we put out just this year. She’s a final year medical student at McMaster University and about to begin her practice as a newly minted doctor.]

Vivian Tam: I had a patient who came in and their child was suffering from asthma. It was starting to get really bad and her young son was starting to wake up at night and to throw up because his asthma was so poorly controlled. We talked about strategies to prevent that and we talked about increasing his puffer use. At the end of the visit, it came out that this young mother asked me, “so would it be okay for you to write a letter that I could bring to my landlord to talk about the mold in our house that hasn’t been addressed?” And so really when we listen to our patients, I think they’re telling us that they need us to do more and to take action on the root causes of their issues. For this young woman, it wasn’t just that her son had asthma, but it was also because she was living with mold in her house. And upstream of that there’s the issue of poverty and an inadequate income to move to better housing, etcetera. I think a big part of that is that it’s so wonderful that patients are saying to us, “This is what we need and we need you to advocate on our behalf.”

JK: There’s been somewhat of a backlash on progressive action recently, more in the United States than in Canada, but some of that has bled over here. There’s enough people in Canada who roll their eyes when they hear the words “social” and “justice” go together. Just this year in Alabama, Congressman Mo Brooks said “people who lead good lives don’t have preexisting conditions” — that people who make good moral choices don’t get sick. That speaks to some lingering attitudes around behaviourism. How do you think that impacts patients? How do you think that when we have had this focus on behavioural determinants of health, how does that impact the patient’s behaviour and mentality going forward after that?

VT: We’re seeing a lot of preventive health campaigns, for example like the Smoking Kills campaign in Ontario. We saw on our subways lots of signs that show the effects and impact of smoking on the body. I think for some people, these tactics can work, those who have good jobs or whose education and income level enable them to motivate themselves to quit smoking, for example. These type of tactics can motivate them to do so. But for a large segment of the population, I don’t think these types of behaviours and these types of victimization tactics are really beneficial, because they neglect to look at the larger issues that impact why people engage in these behaviours in the first place.

For example, we know that it’s those who are in lower-income brackets are much more likely to be obese, and they’re more likely to smoke as well. Children who experience poverty are twice as likely to be obese as their counterparts who do not. I think when we say, when we just target the individual behaviours, we’re neglecting to look at these systemic factors that make it stressful for someone who has a lower income to quit, and makes it more difficult for someone to want to seek out healthcare and to seek out access to the health services they need when they’re made to feel as though they should be in total control of their own health.

JK: How does knowing all that inform your intentionality? How does knowing all that inform your practice and your attitudes towards care as a health provider yourself?

VT: I think even knowing all of this, sometimes I still get it wrong and I try to keep learning from everyone, from my patients and from my allied health colleagues. I remember one time I had a patient who came in and they were… This was a man in his 60’s, and he’d come in because he had a fall. He told me that he was getting up in the middle of the night and had walked to his kitchen to get a glass of water and on the way he had tripped and then hit his head on the radiator and came in with a big gash. My preceptor and I, we sutured him up, and we made sure that everything was okay and then we said that he was good to go.

While I was writing his discharge papers, one of our nurses came up to me and said, “hey, I don’t think we can let this man go yet. It seems like he was drinking before and he’s been in the emergency department for a similar issue. I think we should get our social worker to see him.” So even in this instance, for someone who thinks that they know so much about the social determinants of health and tries to incorporate it into practice, there are areas where we can misstep and we rely on our colleagues to keep us honest and to make sure that we’re targeting upstream behaviours and upstream causes of our patients’ illness in every step of the way.

JK: Did that teach you anything specifically when in that particular case? Was that a touchstone for you?

VT: I think for me this and other instances were an impetus to always be asking why. We all know that young child who is in the back of the car, they’re asking a million and one questions about everything because they’re so curious and they want to know why. I think it’s important for us when we’re in the clinic to not just stop when we get one answer that satisfies us. For example, someone says they’re finding it hard to quit, or they’re not able to eat a healthy diet or they’re not exercising. There’s always an upstream reason and there’s always more to the story than I would say meets the eye initially.

So it’s always important to question, to question everything and to be curious about our patients as people, and to think about what other stresses might be there in their lives. Of course we’re certainly still taught in medical school and in school more generally about health behaviours. We know, for example, that for a smoker, if they quit their risk of getting like heart disease, heart attack and stroke drops to about less than half in about a year. I think it’s still really important to counsel about personal health behaviours and every time I see a patient who does smoke or who does use illicit drugs, for example, it’s certainly still a part of our conversation. But I think what’s important is that we are moving away from just looking at these behaviours, both in school and in the clinic.

JK: And it’s not just doctors, not just health professionals, social workers, lawyers, politicians… it’s every single one of us, every Canadian has a role to play in how we shape the conversation, in how this movement plays out. Let’s hear from Dr. Raphael one more time on how he plays that role. If you could just go from household to household, let’s say you have the powers of Santa Claus, and as people are eating dinner together with their families or their friends, how would you change the conversation around what makes us healthy or sick? How would you tell the average, or as Justin Trudeau says, “the everyday Canadian,” how to think about their own health and how we can make things better?

DR: Well, the entry we’ve used in the past, and we published numerous papers on this, was if we say to people, “what makes life good for you?” — when you ask the question in that way, people say, “oh, good jobs, kids doing well in school, having a good place to live, a safe neighborhood.” And then once we get them there, we will say, “the things you’ve just mentioned are also the same things that determine whether you get heart disease or not, whether you get arthritis or not, whether you get diabetes or not.” What has not been done, and Upstream has been the first organization willing to do it, is to say that all of these aspects of society that we recognize as being important are also the prior important determinants of whether you get sick and you die. Today, Canadians have increased their concern about income inequality, Canadians are increasingly concerned about housing prices, precarious work, but the connection has not been made.

JK: That’s the next step we’ve got to keep working on. For doctors in clinics and other health professionals on the front lines, for our leaders making policies that shape the future of poverty and inequality in Canada. For you at home, at work and in your community, having conversations and impacting the society around you, and for us at Upstream as we do our best to tie it all together. We’ve got to keep working on making that connection, because when we really start to get it as a society, when we fully come to grips with the social, economic and political factors in what really makes us healthy or sick, makes us live a full life or die far too young, there may be no limit to how greatly we can improve the health and well being of our families, our communities and our nation.

Thanks so much for listening and for continuing to fuel this movement towards better health for all of us. If you like Upstream Radio and want us to keep making it, please be sure to subscribe, follow, like and review. Visit us at to help us keep making the mainstream more upstream. To read, hear and see more from Dennis, Vivian, Brendan, Elizabeth and Patty, please visit us at our website and on our YouTube channel where you can find lots of great stuff with all of them. I’ve been Jared Knoll. Until next time, keep thinking upstream.


To cure hunger, prescribe income

In this ninth episode of Upstream Radio, I zoom out and look to the deepest sources of hunger and food insecurity, and what can be done to address these urgent Canadian public health crises.

The real problem is poverty — something we spend tens of billions on just to maintain, but might actually be cheaper and easier to simply eliminate. I’m joined by PROOF’s Valerie Tarasuk, Canada Without Poverty’s Harriett McLachlan and Upstream’s Cody Sharp to discuss what can be, and must be done.