A World Economic Forum report finds competitive advantage is shifting from owning key technologies to combining them across data, people and ecosystems.
The biggest barriers to scaling innovative solutions are no longer individual breakthroughs but connecting a combination of AI and digital tools with real-world operations.
The research shows how technology convergence is already reshaping value chains in healthcare, manufacturing, energy, life sciences, wearable electronics and more.
Geneva, Switzerland, April 2026 – The next wave of competitive advantage will come not from individual breakthrough technologies but from the ability to combine and scale multiple technologies across entire operating systems, according to a World Economic Forum report released today. As artificial intelligence, robotics, advanced materials, spatial computing and next-generation energy systems mature simultaneously, the organizations and countries moving fastest to apply these technologies together in intelligent systems are already pulling ahead.
The report, Technology Convergence: The New Logic for Competitive Advantage, produced in collaboration with Capgemini, draws on cross-industry research and real-world case studies in 12 sectors, identifying recurring patterns, including the blending of mature and experimental technologies and the blurring of industry boundaries, that determine whether convergence scales or stalls.
“Breakthrough technologies are advancing rapidly, and value is created when they are applied together,” said Cathy Li, Head of the Centre for AI Excellence and Member of the Executive Committee, World Economic Forum. “The real differentiator is not who owns the most advanced tools, but who can combine them across systems and applications at scale.”
As advanced technologies scale, the main bottlenecks to competitive advantage are no longer time or materials but how well organizations connect digital tools with physical operations. This is already playing out across sectors and geographies. From operating rooms to factory floors, power grids to research labs, converging technologies are reshaping how systems perform worldwide.
In the United Kingdom, novel surgical robots are extending clinician capacity (this article’s feature image shows robots with surgeons at West Hertfordshire Teaching Hospitals NHS Trust first used in 2022) while preserving workflow continuity across care teams. In China, automated labs are linking robotics, AI and data platforms to accelerate discovery while coordinating workflows across research networks.
“Technology convergence has evolved from a technical discussion into a strategic leadership mandate with direct operational impact,” said Aiman Ezzat, CEO of Capgemini Group. “Competitive advantage increasingly depends on an organization’s ability to integrate technologies, teams, partners and operating processes into coherent systems that deliver value at scale. Leaders who master orchestration, not just adoption, are the ones translating convergence into sustained performance and growth.”
“This shift has implications not only for companies but also for national growth strategies and industrial policy,” said Jeremy Jurgens, Managing Director, World Economic Forum. “Economies that align talent, infrastructure, data and policy will be better positioned to capture the benefits of converging technologies amid a fast-shifting global landscape.”
The report is part of the World Economic Forum’s Technology Convergence Initiative, launched in 2024, and builds on the first edition published in 2025. It draws on two years of cross-industry research, including expert interviews, workshops and case studies in healthcare, manufacturing, energy, life sciences and emerging fields such as brain-computer interfaces. The analysis examines how eight advanced technology domains interact, using the Forum’s 3C framework (combination, convergence and compounding) and the Technology Maturity Index to track how technologies move from experimentation to real-world impact.
What do you do when Western medicine fails to heal what ails you?
Mitzi Mensch knows only too well what happens once doctors have exhausted their bag of tricks. Through her writing, Mensch hopes to raise awareness of the dangers of Aspartame, challenge doctors to find answers – not simply mask symptoms – and to bring out the hopeless romantic in her readers.
Healthcare has turned into a multi-trillion dollar industry as patients around the globe are herded into doctor’s offices, only to leave with prescriptions in-hand for brightly colored pills. But what happens when the pills don’t work and the doctor is out of ideas of how to treat your symptoms? Mitzi Mensch knows first-hand the challenges this presents and has written about her experience in The Dangers of Kissing and Diet Coke: What Your Doctor Doesn’t Know and Won’t Bother to Find Out, a neurological nightmare juxtaposed with a riveting love story.
This medical mystery has Mitzi playing dual roles of patient and detective all while embroiled in an intense affair with her long lost first love.
There was the “Go to Psych” doctor, the “We’re out of time doctor”, the “No, next” doctor. Physicians pushed pills which turned her into an emotional zombie and didn’t work. Alternative practitioners practiced protocols and provided potions which didn’t work. As Mitzi muddled through the morass she searched for anything that claimed to cure pain, calm nerves, create somnolence.
Still her headache raged on, her tics escalated, she didn’t sleep.
Mitzi was determined to find out what was wrong and fix it. And then there is the power of first love, potent and compelling. The Internet has made it so very easy for people separated by years and distance to rekindle what was long ago left smoldering. But should they? Much more than a self-help book, The Dangers of Kissing and Diet Coke sizzles, allowing the reader to voyeuristically experience an affair from the perspective of the ‘other woman.’
Mensch would like to help people through her writing. “Even if one person’s health is saved by eliminating Aspartame, or one person is cured of constant headache, or one doctor will look beyond the obvious – my words will have meant something. One thing I would like for readers to take away from this book is to be your own advocate when you get sick. As for lovers who love down through the decades, sometimes it works. They are the lucky ones. ”
Mitzi Mensch was born and raised in New England and attended college in Vermont. An island girl at heart, she lives in Hawaii.
Available on Amazon.com, AuthorHouse.com and local bookstores. The Dangers of Kissing and Diet Coke: What Your Doctor Doesn’t Know and Won’t Bother to Find Out By Mitzi Mensch Publisher: AuthorHouse ISBN-13: 978-1491814147
Ottawa’s forthcoming AI strategy needs to walk a tightrope between two equally important principles: safeguarding Canadians from possible misuses of AI but also giving our private and academic sectors the leeway to use Canada’s AI strengths to develop and commercialize new technologies and products.
Planned AI adoption rose sharply between Q3 2024 and Q3 2025, but progress remains highly uneven across industries. Knowledge-intensive sectors – such as information and cultural industries, finance and insurance, and healthcare – show the strongest gains, while several goods-producing and operational sectors, including manufacturing, wholesale trade, and mining, show stagnant or declining expectations.
The federal government must clearly define a framework for responsible, widespread AI innovation – one that encourages beneficial development and adoption while setting firm expectations about the harms innovators must avoid.
Canada’s competition reforms must keep pace with data-driven business models by empowering authorities with modern tools to detect, assess, and stop conduct that genuinely harms competition, innovation, or consumers.
The explosive growth of online shopping is reshaping Canadian retail by empowering consumers with unprecedented choice, driving omnichannel innovation, and intensifying competition.
Amid escalating crises in the Middle East and the developing world, Life for Relief and Development (LIFE) has been recognized as the third-best global humanitarian organization by Charity Navigator. The organization also secured fifth place for its humanitarian work in Palestine, and fifth place worldwide in the fight against poverty. These achievements earned LIFE a 100% rating, an endorsement from the U.S. Agency for International Development (USAID), as well as recognition by Impactful Ninja as one of the top humanitarian organizations in North America. LIFE was further honored with the Humanitarian Partnership Award for its collaborative initiatives.
Sustainable Programs and Comprehensive Seasonal Projects
Vicki Roob, Administrative Director at LIFE, explained that the organization was founded more than 33 years ago in the United States and works across more than 60 countries through 14 international offices.
Over the years, LIFE has distributed more than $624 million usd/ $859 million cad in humanitarian aid, supporting programs in food security, clean water, temporary shelter, healthcare, education, community development, family assistance, refugee support, and emergency relief during wars and natural disasters. Currently, the organization supports more than 13,100 orphans worldwide, providing essential care, nutrition, housing, and education, while also organizing annual Global Orphan Festivals filled with games, gifts, and entertainment to ensure children feel valued and supported.
Tent Camps That Saved Thousands of Lives in Conflict Zones
According to Dr. Abdulwahab Alawneh, Regional Director for Jordan and Palestine, LIFE implemented its “LIFE Organized Camps” project in Gaza, establishing nine camps across the north, center, and south of the Strip. Built with fire-resistant and durable materials, these camps provided shelter for 46,000 displaced people, featuring easily dismantled tents to accommodate recurring displacement. Each tent was equipped with bedding and essentials, alongside medical facilities, solar panels serving 7,000 individuals, and protective insulation for 3,000 residents against extreme weather. Clay ovens benefited 3,500 people, while 23 sanitation units were constructed.so LIFE Assisted 1.3 million Displaced People in general in GAZA.
Adding: “we’ve been proactively preparing to facilitate the delivery of urgent relief—shelter, food, water, medicine, and personal necessities—into Gaza. Our team on the ground has already begun implementing LIFE’s ninth camp project after tents arrived and installation began. We are now working to shelter 15,000 newly displaced families still exposed to the cold as winter approaches.
These are waterproof, cold- and humidity-resistant tents that also provide insulation against heat in summer. Made from PVC material, they have protected more than 29,000 families from fires during nighttime bombings in past years.
Using all borders to Gaza
We faced tough challenges but managed them through our extensive experience. We are not newcomers to Gaza’s relief field. We worked through approval requirements for specific items—like tent specifications—while some organizations struggled to get their tents through the crossings. Tents vary in size and function: family tents, medical point tents, hospital tents, and educational tents.
We are now awaiting approval for mobile housing units. However, shelter items like mattresses and blankets have been entering through Egypt on LIFE’s trucks without obstacles, while food parcels are transported through Jordan.
“For food items previously restricted for NGOs, we purchase them at discounted rates from local traders and distribute them to those most in need. We spared no effort to reach them—using animals or walking long distances on foot when necessary.
We also supply water—each truck carries 15,000 liters per camp, enough for 500 families for a week—alongside baby formula, infant supplies, medical kits, and medicines. We ensure field monitoring of activities, including eight camps already constructed, and we share updates regularly on social media in multiple languages.”
Emergency Relief and Orphan Care at the Forefront
In the past year alone, LIFE allocated approximately $1.1 million usd/ $1.51 million cad in emergency relief to families displaced by conflicts and natural disasters, including earthquake survivors in Afghanistan, Morocco, Nepal, Syria, and Turkey; war-displaced populations in Gaza, Sudan, Syria, and Lebanon; wildfire victims in Bangladesh; flood-affected communities in Afghanistan and Libya; and cyclone-hit regions in Myanmar.
Additionally, $6.4 million usd/ $8.81 million cad was invested in healthcare programs and medical supplies, $4.5 million usd/ $6.2 million cad in educational projects, and $2.1 million usd/ $2.89 million cad in in-kind aid shipments. Orphan support remained a priority, with more than $3.8 million usd/ $5.23 million cad dedicated to orphan sponsorship, education, and healthcare.
Seasonal projects also played a significant role: nearly $1.7 million usd/ $2.34 million cad was spent on Ramadan and Eid initiatives, with more than 11 million meals distributed across 36 countries during Ramadan alone. Over 272,620 individuals in 38 countries benefited from Qurbani (sacrifice) distributions. LIFE also allocated $1.4 million usd/ $1.93 million cad toward emergency food relief and constructed 122 water wells worldwide.
May, 2025 – Canada cannot rely on immigration alone to address the challenges posed by its ageing population and relentless decline in fertility rates [ see Canada’s Soaring Housing and Living Costs Stop Baby Making CP], according to a new report from our friends at the C.D. Howe Institute. Without a broader population strategy, rising immigration could fuel rapid growth while straining housing, healthcare, and infrastructure – without fully resolving rising old-age dependency ratios or labour force pressures.
In this post, Daniel Hiebert confronts an important policy dilemma: although immigration increases overall population and helps address short-term labour gaps, the long-term trade-offs are significant. Without corresponding investment and planning, rising immigration risks compounding the very pressures it aims to alleviate.
“This is a particularly opportune moment to reflect on how immigration fits into Canada’s long-term demographic strategy, especially as both permanent and temporary immigration surged between 2015 and 2024, and are now being scaled back,” says Hiebert. “We need to think ahead about what kind of future we are building — and how we get there.”
Based on current patterns, it takes five new immigrants to add just one net new worker, once dependents and added consumer demand are factored in — a reality that undermines assumptions about immigration as a direct fix for labour shortages.
Hiebert argues that Canada must move beyond short-term immigration planning and adopt a long-range population strategy — one that combines immigration with other tools like delayed retirement, increased workforce participation, and stronger productivity growth. The alternative, he warns, is a “population trap”: a scenario where growth outpaces the country’s capacity to support it, undercutting prosperity in the process.
The report also calls on governments to coordinate immigration levels with long-term planning in housing, healthcare, education, and infrastructure.
“There’s no question that immigration is integral to Canada’s future,” says Hiebert. “But assuming it can carry the load alone ignores the structural pressures we’re facing — and the investments we need to make today to ensure future stability.”
Balancing Canada’s Population Growth and Ageing Through Immigration Policy
Canada faces twin demographic pressures: an ageing population and rapid population growth driven by immigration. The report argues that immigration levels must strike a careful balance – sufficient to offset some effects of low fertility and an ageing workforce, but not so high as to outpace infrastructure and economic capacity.
A sustainable population strategy requires coordinated planning across immigration, infrastructure, workforce participation, and capital investment. The report calls for long-term planning that aligns immigration policy with economic and social goals and emphasizes the need to manage absorptive capacity to avoid overburdening housing, healthcare, and public services.
Introduction
Declining fertility is a global trend and is especially pronounced in countries with high levels of economic development. These countries share the common challenge of ageing populations, with rising old-age dependency ratios (OADRs)1 and a shrinking portion of the population in prime working age. Several policy responses have been established to deal with this emerging reality, including pronatalist and other family-based social programs, efforts to enhance automation and productivity, incentivization of a larger proportion of the population to enter the formal labour force, delaying retirement benefits, and increasing the rate of immigration. The success of these approaches has varied, raising critical questions for policymakers: which strategies are the most efficient? What are their costs? And which policies offer the best balance between risk and reward?
This Commentary explores the potential role and limitations of immigration in alleviating Canada’s challenges of low fertility and ageing. This is a particularly opportune moment to consider such an issue given that both permanent and temporary immigration strongly increased between 2015 and 2024 and will be reduced for the 2025 to 2027 period.
Using custom demographic projections, this paper examines how various immigration scenarios – ranging from historical rates to the peak of 2024 – will affect Canada’s demographic outlook over the next 50 years. The analysis investigates the role immigration could play in mitigating the effects of an ageing population, while also acknowledging the associated trade-offs, including pressures on infrastructure and rapid population growth. The findings highlight that Canada’s immigration policy, while important, should be framed within a long-term population strategy that aligns immigration policy with broader economic and social goals – including capital investment, productivity, delayed retirement, and expanded social infrastructure – to ensure sustainable growth and enhanced prosperity for all Canadians.
Canada’s Demographic Challenge and Recent Immigration Policy Responses
Canada’s current demographic challenge is the product of two primary factors: low fertility and the ageing and retirement of the Baby Boom generation. Canada’s fertility rate first rapidly declined from the peak of the Baby Boom (1950s) to the early 1970s, when it first fell below the replacement level. Since then, it has continued with a slower, though persistent decline, interrupted by occasional slight recoveries. Most recent calculations reveal that Canada’s fertility rate is now at 1.26 – a level unprecedented in Canadian history and among the lowest globally. The consequences of low fertility are particularly pronounced today due to the ageing of the Baby Boom generation. In 2025, this cohort ranges in age from 59 to 79 years old, while the average age of retirement in Canada was 65.1 in 2023. Around two-thirds of boomers have already reached the age of 65, with the remaining third expected to follow in the coming years. The impact of this demographic shift is therefore ongoing and continues to affect the labour market and economy at large.
Throughout its history, Canada has turned to immigration to resolve demographic challenges (Hiebert 2016). From the late 1940s to the mid-1980s, Canada admitted an average of 150,000 permanent residents annually, though numbers fluctuated. By the end of that period, concerns over low fertility began to be articulated. This prompted the government to increase annual immigration levels to 250,000, a figure that was quite consistent over the following 30 years, with annual rates ranging from the low to high 200,000s. By the end of the 20th century, immigration accounted for over half of Canada’s population growth and labour force expansion.
The most recent shift in immigration policy began in late 2015 under the Liberal government, which pursued an expansionary strategy. Annual immigration targets and admission levels increased – save for the 2020 pandemic year – leading to a target of 500,000 for 2025. However, this target will no longer be realized following the revised plan announced at the end of 2024. Along with increased permanent immigration, the government had adopted a more facilitative approach to temporary migration, leading to rapid growth in the number of international students, temporary foreign workers, and other non-permanent residents. In 2023, the Canadian population expanded by 1.27 million, representing an annual growth rate of 3.2 percent, which is highly unusual among advanced economies. For example, the average population growth rate of the other G7 countries in 2023 was less than 0.5 percent (Scotiabank 2023).2
Given Canada’s low fertility, 98 percent of this growth stemmed from net immigration, both temporary and permanent (Statistics Canada 2024a). Today, Canada is approaching a point where all population growth and most of the impetus for population renewal (Dion et al. 2015) will come from immigration. However, the “big migration” trajectory of 2015 to 2024 has shifted. While public opinion historically supported ambitious immigration targets, this sentiment changed sharply in 2024. Concerns about housing shortages, infrastructure strain, and what has been termed a “population trap” – where population growth outpaces capital investment capacity – have fueled resistance to current immigration levels. These pressures clearly influenced the 2025 to 2027 plan, which curtails permanent immigration targets by approximately 20 percent and tightens restrictions on temporary migration programs.
Short- and Long-Term Immigration Policy
Before focusing on the relationship between immigration and demography, it is instructive to explore a fundamental tension in immigration policy: should the Government of Canada prioritize the “maximum social, cultural and economic benefits of immigration”3 for today or for the future? These goals may not always align: satisfying the needs of today may have long-term consequences – a trade-off familiar to anyone who has managed a budget.
It has been long underappreciated that Canada’s immigration policy is built around a combination of short- and long-term goals. Economic selection practices provide a helpful example. Since the introduction of the points system nearly 60 years ago, selection priorities have oscillated between addressing short-term labour market needs (e.g., incorporating and/or prioritizing job offers in selection criteria) and building the human capital of the future workforce, under the assumption that highly skilled individuals can adapt and drive productivity, and therefore prosperity. Striking the right balance between these priorities is challenging and requires careful planning.
The balance between short- and long-term immigration perspectives is reflected in the combination of the economic selection system and levels planning. The former – which includes permanent skilled immigration – involves trade-offs between filling immediate labour shortages and building future human capital.4 The latter determines the scale and composition of Canada’s permanent immigration system. In contrast, temporary migration programs are almost entirely shaped by short-term planning horizons – with the partial exception of the International Student Program, which operates in accordance with a medium-term planning horizon in five-year increments.5
These issues are pivotal to considerations of the relationship between immigration and demography. The impact of immigration extends beyond the number of admissions. If immigrants are selected to enhance the human capital of Canada’s workforce and integrate productively, they can potentially raise per capita GDP and mitigate the challenges of an ageing population (Erkisi 2023; Montcho et al. 2021). Conversely, if the system prioritizes lower-skilled individuals, fails to utilize the skills of highly educated immigrants, or admits newcomers at a scale that exceeds the economy’s capacity to absorb them, it risks lowering per capita GDP and compounding demographic challenges (Smith 2024).
Immigration, therefore, has both scale and compositional effects. Scale impacts include changes to population size, age structure, and regional distribution, which directly affect housing demand and social services. Compositional impacts include broader socioeconomic outcomes such as income inequality, productivity, and trade relationships. While this paper focuses on scale impacts, readers should bear these compositional effects in mind.
Another critical consideration is the relationship between admission levels and the expected economic outcome of admitted immigrants. In Canada’s Express Entry system, admission thresholds are adjusted based on the number of entries. Larger admission cohorts tend to lower the points threshold, potentially reducing the overall human capital of entrants (Mahboubi 2024).
Immigration and Canada’s Demographic Challenge
This paper argues that long-term considerations should play a larger role in immigration levels planning. Immigration decisions made today shape Canada’s demographic structure for decades, as immigrants become part of the population, contribute to fertility, enter the workforce, and eventually retire. These stages must be incorporated into demographic projections and policy planning, yet they are often overlooked due to the focus on immediate needs and political cycles.
To illustrate the long-term demographic impact of immigration, consider two extreme scenarios. In the first, Canada’s fertility rate declines to 1.0 (the 2023 rate in British Columbia) and net migration falls to zero, implying no population growth from migration. Under these conditions, Canada’s population would shrink from 40 million in 2023 to 12.3 million by 2100. In the second scenario, the extraordinary 2023 growth rate of 3.2 percent continues indefinitely, with rising migration levels. By 2100, Canada’s population would reach 452 million.
While neither of these scenarios is realistic, they illustrate the decisive influence that fertility and migration have in shaping the future scale of Canada’s population. Despite their seemingly preposterous nature, the key point remains: with fertility rates remaining low,6 the state is entirely responsible for determining the scale of the Canadian population. Decisions about temporary visas and permanent residence serve as the primary levers of control. Policymakers must recognize that the choices made today will have profound and lasting effects on Canada’s demographic and economic future.
Population Projections and Their Implications
Statistics Canada produced a recent population projection for various scenarios in January 2025, covering the period of 2024 to 2074.7 Across the scenarios, total fertility rates range from 1.13 to 1.66, permanent immigration rates vary from 0.70 to 1.2 percent per year, and net temporary migration figures are assumed to decline in the short term before stabilizing. The selected scenarios suggest that the projected population of Canada would range from 45.2 to 80.8 million in 2074 – a difference of over 35 million people, roughly equivalent to Canada’s current population. The scale of infrastructure and social investments needed to accommodate such growth would be enormous.
Beyond sheer numbers, government policy also affects the age structure of Canada’s future population. The OADR is expected to rise, and increased immigration is often proposed as a solution. However, the retirement age is, to an important extent, a social construct and this paper explores the efficiency of changing Canada’s retirement age compared with adjusting immigration levels to address the issue.
While migration can temporarily mitigate low fertility effects by maintaining a larger workforce, it cannot fully offset population ageing (Robson and Mahboubi 2018). Even doubling Canada’s population through immigration would only reduce the average age by five years, as immigrants’ average age is close to that of the receiving population (around 30 versus 40).8 Doyle et al. (2023) argue that increasing immigration could delay ageing impacts but would require continuously higher volumes, becoming unsustainable.9 Immigrants are typically concentrated in the labour force ages (25-40) but, in 30-35 years, this group will be approaching retirement, creating an economic challenge similar to the Baby Boom generation’s retirement. Unless increasing rates of immigration are in place continuously (an unrealistic scenario), at some point society must adjust to a smaller, older population.
Moreover, there appear to be additional costs to rapid population growth that are driven by high immigration. Doyle et al. (2023 and 2024) contend that when the labour force expands faster than investment in capital and infrastructure, the result is a dilution of capital per worker, reducing Canada’s productivity and living standards. This concern highlights not only the pace of immigration-driven growth but also Canada’s historically low levels of business and infrastructure investment, suggesting a need to boost investment alongside population growth.10
Research shows that while larger immigration targets increase real GDP through a larger labour supply, they could also reduce GDP per capita (El-Assal and Fields 2018).11 Indeed, in recent years of very high population growth through net international migration (2022-2023), Canada’s level of real GDP per capita has been stagnant.12
Furthermore, house price escalation associated with a surge in demand may negatively affect fertility decisions, particularly for families renting homes (Dettling and Kearney 2014; Fazio et al. 2024). In other words, compensating for low fertility through high rates of immigration may indirectly contribute to additional fertility decline.
Studies show that immigration alone has a limited impact on altering age composition (Robson and Mahboubi 2018). Even doubling immigration rates would only slightly improve the OADR (Beaujot 2001). All of the immigrants admitted by Canada between 1951 and 2001, for example, are believed to have reduced the median age of Canadians in 2001 by only 0.8 years.
The effect of younger immigrants, as seen in Australia’s approach, would improve outcomes,13 but Guillemette and Robson (2006) found that this impact would still be modest. An unintended consequence of focusing on younger immigrants is that it contrasts with Canada’s economic selection system, which rewards human capital development. Half of the 2022 Express Entry applicants were 30 or older (IRCC 2022), challenging the idea that immigration could rapidly reduce the average age of the population.14
A Custom Glimpse of the Future
To update our understanding of the role immigration could play in Canada’s demography, this section explores the results of a special population projection, using Statistics Canada’s microsimulation model called Demosim, to assess the impact of varying immigration rates on the Canadian population in the future. Two demographic outcomes are highlighted in this analysis: population size and the OADR.
While population size is a straightforward measure, the exclusive focus on the OADR – without also considering the youth dependency ratio (YDR) – may raise questions about the completeness of the analysis. After all, both young and older people place disproportionate demands on social services. One could also argue that increasing the rate of immigration (depending on the age profile of newcomers, other things being equal) could reduce the OADR while increasing the YDR. There are two major reasons for focusing on the OADR in this analysis. First, it is the most widely used indicator of the ageing population and has particularly profound impacts on the cost of healthcare, Canada’s most expensive social program.15 Second, while the YDR and OADR reflect dependency burdens, they have very different long-term implications: a high YDR represents a short-term fiscal cost but also an investment in the future workforce. In contrast, a rising OADR signals a more permanent shift in the age structure of the population, with fewer economic offsets. For these reasons, and to maintain analytical clarity and focus, the YDR has been omitted from this analysis.
Demographic variables used in the projection, except for the immigration rate, were either held constant (e.g., fertility rate at the 2023 level of 1.33 and the temporary resident population assumed to remain constant at around two million after 2021) or based on assumptions from recent Statistics Canada projections (e.g., emigration rate, life expectancy).16 Using the 2021 base population,17 projections were provided for 50 years. Six scenarios were created based on annual permanent immigration rates ranging from 0.3 percent to 1.8 percent. These correspond to immigration levels in 2025 between around 125,000 and 750,000, based on the 2024 Q4 population estimate of 41.5 million. From 2000 to 2015, the immigration rate averaged 0.6 percent per year (Scenario 2), rising to nearly 1.2 percent per year by 2024 (Scenario 4). The 2025-2027 immigration plan aligns with Scenario 3, at a rate of around 0.9 percent. In essence, the scenarios reflect both current and recent immigration rates, allowing for expansion or contraction, as shown in Table 1.
Population projections vary significantly across the scenarios (Figure 1). As Canada’s natural population growth is rapidly approaching zero and is expected to turn negative in the coming years – and with emigration remaining steady – an immigration rate of 0.3 percent of the population would result in virtually no net international migration. Under this scenario, the population would begin to decline slightly. At the same time, Canada’s OADR would more than double, rising from 29.5 retirees (65 and older) per 100 working-age individuals (18-64) to 48.2 in 2046 and 61.6 in 2071 (Figure 2).18 Such a demographic structure would be unprecedented and pose a significant challenge to economic prosperity. For context, Japan currently has the highest OADR globally, at approximately 48 per 100.19
The second scenario, reflecting Canada’s immigration levels from 2000 to 2015, would add 4.6 million to the population by 2046 and another two million by 2071. The OADR would rise to 44.5 by 2046 and 55.8 in 2071. The third scenario most closely aligns with the 2025 to 2027 immigration plan (though it excludes the projected reduction in temporary residents). If immigration remains at 0.9 percent of the population for the next 50 years, the national population would reach 55.6 million in 2071, and the OADR would be 50.8. The fourth scenario extends the higher 1.2 percent immigration rate from 2024, projecting a population of 67.2 million by 2071. Despite this growth, the OADR would still rise to 46.5 by 2071 – similar to Japan’s current level. Reducing the immigration target from 1.2 percent to 0.9 percent in the 2025-27 plan would result in 11.6 million fewer people by 2071, assuming a stable rate. The sixth scenario, though ambitious, is instructive. If IRCC raised the permanent immigration target to 1.8 percent annually and maintained it for 50 years, Canada’s population would increase to nearly 62 million by 2046 and exceed 91 million by 2071. Even with this growth, the OADR would still rise to 39.5 by 2071. A visual scan of the relevant figure suggests that it would take an immigration rate of around 2.7 percent per year to hold the dependency ratio constant. Moreover, it would be challenging to sustain Canada’s high-human-capital selection threshold in the Express Entry system under this scenario.
Note another important trend. Figure 1 shows that the population diverges across the six scenarios over time, demonstrating the growing efficiency of immigration rates in changing Canada’s population growth over time. In contrast, the OADRs across the scenarios in Figure 2 remain roughly parallel after 2046 and begin to converge a little in the later years, illustrating that immigration ultimately becomes less efficient at altering the age structure of the population over time. Why? A population with low fertility receiving a steady flow of younger immigrants will, in the short term, have a younger average age due to the immigrants’ youth. However, as the immigrant population ages, its average age eventually surpasses that of the receiving population, making the overall population older in the long term.20 Therefore, the effect of steady immigration on the age structure diminishes over time, and only a continuous increase in immigration would prevent this.
Further, it is also important to acknowledge that once there is a sustained period of high immigration (i.e., the case of Canada between 2015 and 2024), a dramatic reduction in the rate of immigration will result in a demographic “bulge” with a large cohort followed immediately by a smaller one – akin to the relationship between the Baby Boom and Generation X. This would ultimately set in motion the same demographic dynamic that Canada faces today, with the larger generation eventually retiring and the OADR increasing. The demographic lesson is clear: shocks in the age structure of a population – whether through dramatic increases or declines in fertility or through major changes in the rate of net migration – place stress on infrastructure and, if they are large, may challenge the long-term stability of the welfare state.
Before reflecting further on these findings, consider the impact of varied immigration rates on the cultural composition of the Canadian population (Vézina et al. 2024). In 2021, approximately 44 percent of the Canadian population had an immigrant background – either as non-permanent residents, immigrants, or individuals with at least one immigrant parent (see Table 2). Under the third scenario, which aligns with the 2025 to 2027 immigration plan, this proportion would nearly reverse by 2046 and change even more dramatically by 2071, with nearly two-thirds of all Canadians being persons with an immigrant background.21
Such a shift would redefine immigrant integration and public perceptions of multiculturalism. Whether this level of cultural change would be widely accepted remains uncertain. If the high 2024 immigration rate was sustained, nearly three-quarters of Canadians in 2071 would be either immigrants or children of immigrants.
Immigration and Other Policy Levers in Addressing Population Ageing
This section assesses how immigration compares to other policy tools in addressing the demographic challenges of an ageing population. Governments have several policy tools to either shape demography directly or mitigate societal consequences. The key concern in an ageing society is the impact of a shrinking labour force on the ability to sustain social services such as healthcare, education, and pensions. The principal direct policies are encouraging fertility and increasing immigration (Lee 2014). Governments can also address the fiscal impact of ageing by: boosting workforce participation among working-age adults; delaying retirement and enlarging the working-age population; raising tax rates; reducing expenditures – especially those related to the elderly population; and increasing the productivity of labour (Lee et al. 2014; Beaujot 2017). Some of these choices are more efficient than others. Pronatalist policies have been established in some 60 countries, yet none have been successful in restoring fertility to a replacement level (UNFPA 2019). Moreover, their effects tend to be short-lived.22
How efficient is immigration in mitigating population ageing and its effects? The data explored so far indicate that while increasing the rate of immigration is highly effective at generating population growth, it is less effective at significantly changing the age composition of the population. A recent analysis by British Columbia Ministry of Advanced Education and Skills Training provides additional depth on this issue.23 Their study presents a simple but informative labour force participation ratio: for every 10 permanent immigrants admitted to the province, six will find work relatively quickly, while the remaining four will be too young or old, pursuing education, or not immediately ready to join the labour market. This reflects the broader reality that approximately half of all economic-class immigrants are spouses and dependents and that only around 60 percent of immigrants are admitted through the economic class to begin with.
It would be tempting, but also simplistic, to see this as the direct impact of immigration on the labour force (i.e., 10 newcomers equate to six net new workers), but there is an important additional dimension that must be considered. Adding 10 people to the population generates consumer demand for goods and services including shelter, food, transportation, and many other things. Meeting this demand requires four additional workers. These four additional workers expand the scale of the economy but do not create net new workers (Fortin 2025).
When 10 newcomers are admitted, given that four will not immediately enter the labour force and another four workers will be required to satisfy extra consumer demand, only two net new workers are added. That is, to add one net new worker to the labour force requires five new permanent immigrants (and therefore approximately two additional dwellings). This is nicely summarized in a ratio: 10-6-4-2. There is no reason to expect that this ratio would be appreciably different in other provinces or Canada as a whole. Just as immigration is more efficient at increasing the size of the population than it is at changing the age structure, the same holds true for the relationship between immigration and net workers added to the labour force.
An example can help illustrate this point. Imagine an ageing society with a population of one million and 1,000 doctors. As more doctors retire than can be replaced through domestic training, the government looks to immigration to fill the gap. It estimates that 100,000 newcomers must be admitted, since only a small fraction of new immigrants will be doctors. This produces the desired effect, and the number of doctors remains stable. However, the population has grown to 1.1 million, and to preserve the same level of access to care, 1,100 doctors are now required. Simply stabilizing the labour force while adding population is an insufficient way to resolve emerging labour shortages because it ignores the additional demand created by population growth (Fortin 2025). This mirrors the earlier point: immigration adds workers, but it also adds consumers. As a result, the net gain to the labour force is much smaller than the headline number of newcomers might suggest.
It is beyond the scope of this paper to investigate the efficiency of all the other measures in mitigating the effects of ageing or increasing the size of the labour force. However, Figure 3 illustrates the demographic impact of one such lever – delaying the average retirement age to 70, compared to maintaining it at 65 – as an example to demonstrate how different policies vary in their ability to influence the OADR.
Figure 3 shows that, under this policy shift, maintaining immigration at the rate of the 2025 to 2027 plan (Scenario 3) would be sufficient to stabilize the OADR to 2046 – keeping it just below 30, similar to its level in 2021. None of the immigration scenarios alone achieve this outcome if the retirement age stays at 65. While the OADR increases over time in all scenarios, delaying retirement significantly slows both the pace and magnitude of this rise.24 However, the purpose of this example is not to propose a specific change. Instead, it highlights the relative effectiveness of this particular lever and emphasizes the need for a multifaceted strategy to address demographic challenges.
In summary, Canada’s demographic challenges stem from low fertility and the retirement of the Baby Boom generation. Immigration can delay and mitigate the effects of ageing but cannot fully counteract them without immediate and dramatic increases. As long as immigration remains within historical levels, ensuring a sufficient workforce will require a combination of immigration and complementary policies.25
Demography and Levels Planning
The policy dilemma implied by demographic realities is both straightforward and immensely complex: it is now impossible to maintain the age composition of the Canadian population while also maintaining its size without turning back the clock more than 50 years in terms of fertility. At the extremes, there are two stark policy choices: maintain the current size of the Canadian population but adjust expectations to accommodate a vastly higher OADR (approximately that of Scenario 1); or maintain the age structure of the Canadian population and plan for a vastly larger population (larger than any projected in the scenarios used in this study). The real policy choice will lie somewhere between these extremes and will require a combination of accommodations.
Table 3 summarizes more realistic options by showing the level of population increase and the different OADRs projected for 25 and 50 years forward. It compares the scenarios that most closely approximate Canada’s permanent immigration targets for the recent past – Scenario 2 (pre-2015 consensus), Scenario 4 (2024 rate), and Scenario 3 (2025 to 2027 plan). Had the Liberal government maintained the earlier rate of immigration after 2015 (that is, maintaining the 0.6 percent rate of immigration), Canada’s population would have grown by around 7.5 million by 2071, but with an OADR higher than any country today (55.8 senior citizens per 100 working-age people). By shifting to, and maintaining, a 1.2 percent annual immigration rate between 2015 and 2024, the population would grow much faster – by 29 million more people over half a century – while the OADR would be lower, at 46.5 per 100. Notice that the change in policy would lead to nearly four times the population growth compared to the reduction in the OADR, which improves by only 17 percent. Scaling back the rate of permanent immigration in 2025 to 2027 moderates both the population increase and the OADR improvement. Nevertheless, it would still yield a population growth of over 17 million in the next 50 years, with Canada’s OADR surpassing that of contemporary Japan.
Regardless of the choice being made, Canada will be both larger and older in the coming decades. This shift has significant implications and calls for strategic long-term planning. For example, the country will need to invest simultaneously in child benefits and new schools, as well as in elder care facilities. Housing demand will continue to mount unless significant changes occur in housing investment policies and outcomes. It also means investing in infrastructure to sustain key public services – such as increasing hospital capacity and expanding public transit. Without these adjustments, the quality of life for Canadians would decline. Crucially, this must occur while public finances are adjusted in light of a rising OADR (or the retirement age is raised).26 It also necessitates a continuing cultural diversification of the population through immigration and temporary migration. Ongoing and growing investments in social inclusion will be required.
The greatest challenge for government is to decide on the optimum balance between ageing and growth while securing public buy-in for immigration policies.27 All of this must occur against the backdrop of other pressing issues such as global climate change, geopolitical instability, technological change, and political polarization – not to mention the need to be mindful of the relationship between immigration, ethnocultural diversity, linguistic and religious groups, Indigenous Peoples, and other equity-seeking groups. Assiduous attention must be paid to Canada’s demographic challenge, despite these powerful intersecting concerns.
Consider financial investment, where growth is based on compounded rates of interest. One of the most common recommendations made by financial advisors is to harness the power of compounded growth by starting to invest early in one’s life. Even small amounts invested in one’s twenties can pay remarkable dividends forty years later. The same logic applies to population management; demographic choices today will have far-reaching consequences in subsequent decades. Adding four to five million to Canada’s population over the next decade cannot simply be undone at the end of that period. The same ageing pressures will remain, but with a larger population that may require even higher immigration levels. As long as fertility remains well below replacement, this issue will persist – regardless of Canada’s population size. There will always be the looming threat of population decline and its consequences.
Short and Long Policy Horizons
Population change is cumulative and difficult to reverse, making it imperative to consider the long-term implications of both temporary and permanent immigration together. This requires viewing them as components of the same system – particularly given the many pathways that allow temporary residents to transition to permanent status, and the increasing reliance on temporary residents within Canada’s permanent immigration system (Crossman et al. 2020). In recent years, temporary migration has increasingly become a kind of “down payment” to Canada’s permanent immigration system, a shift that has transformed Canada’s immigration system into a more fluid, two-step process, although this flow-through process may be interrupted given the latest levels plan (i.e., there is a large gap between the number of temporary residents in Canada and the “room” accorded to that population in the new plan). A comprehensive approach also demands that levels plans, which currently establish expectations for a three-year period, be developed with longer time horizons in mind.28 In other words, immigration levels should reflect Canada’s immediate priorities as well as its long-term goals, including the potential for future population renewal. The focus on present needs should not overshadow a forward-looking vision for the country, as current policies play a decisive role in shaping Canada’s future.29
A common point made in public discussion of Canadian immigration policy is that levels planning should pay more attention to absorptive capacity. This means aligning the number of both temporary and permanent residents with the growth of social services – notably education and healthcare – as well as housing and other infrastructure. The concept of absorptive capacity can be interpreted in passive or active terms. Under a passive approach, levels planning would be guided by the current state of social services and infrastructure including housing, which would determine the appropriate level of immigration (e.g., based on an acceptable range of physicians, housing completions, etc., per 1,000 persons). Conversely, an active approach would flip the direction of causality and establish the parameters of social spending and infrastructural investment based on population growth which, in an era of low fertility, is essentially a function of the scale of temporary and permanent immigration. In this latter situation, IRCC would play a more central role in national planning, as immigration targets would shape the long-term scale of government spending across a wide range of responsibilities. This process would be greatly facilitated by a conscious, long-term population strategy at the heart of levels planning. In such a framework, all sectors of society – government, private business, and non-profit social services – could make informed decisions to guide their investments with far more assurance of long-term patterns of demand. This would be a potent indirect benefit of a population-based approach to migration and immigration management.
There are important tradeoffs between these approaches. A passive approach may be more cautious and politically feasible in the short term, but risks underestimating long-term needs and perpetuating reactive policymaking. An active approach, by contrast, allows for proactive investment and planning – but only if there is full follow-through. If governments commit to population growth targets without ensuring that social and physical infrastructure keep pace, the result could be increased strain on housing, healthcare, and public trust.
While this paper supports an active approach, its core aim is to push for long-term thinking and to encourage an informed public conversation about the choices ahead.
Regardless of which approach is chosen, the issue of social license is key. As noted earlier, a majority of Canadians have recently come to believe that population growth generated by immigration has outstripped the development of social and physical infrastructure. In 2023, this growing perception led to a substantial shift in public support for the number of newcomers that were being admitted. The government must ensure that population growth, infrastructure capacity, and capital investment are aligned – and clearly communicated to the public. This means developing a population strategy alongside an economic strategy. These are not competing priorities, but complementary and mutually reinforcing goals.
Conclusion
Given its low fertility, Canada’s demographic and economic future would be bleak in the absence of immigration. Even under low immigration scenarios (0.3 and 0.6 percent of the population per year), Canada would enter uncharted territory with respect to its OADR. At the same time, immigration is more efficient at increasing the population size than it is at either adding net new workers to the economy or fundamentally altering the age structure of the population. Higher rates of immigration may address short-term labour shortages, provide important skills, and stimulate economic activity (a higher GDP), but their effect on prosperity (GDP per capita) depends on whether they are accompanied by robust productivity growth, capital investment, and innovation. Moreover, they present challenges to Canada’s infrastructure, particularly in housing supply and healthcare availability. Without such complementary investments, rapid population growth could lead to a population trap – where population growth outpaces investment capacity – ultimately lowering prosperity, and potentially worsening fertility rates.
Canada’s demographic future depends on policy decisions made today, which carry long-term consequences that require careful planning and adaptation. While immigration level planning includes multi-year targets and considers a range of factors, in practice it often focuses on managing short-term pressures rather than shaping a long-term population vision. With fertility rates at historic lows, Canada’s reliance on immigration for population growth is intensifying. While immigration is a relevant tool for mitigating population ageing, it cannot prevent Canada from ageing on its own. This impasse highlights the need for a comprehensive population strategy that aligns with a long-term economic strategy – recognizing that growth and economic planning are complementary, not competing, goals. The strategy must also balance population growth with the challenges of an ageing society and address social priorities, including ethnocultural diversity and inclusion, Canada’s linguistic landscape, and Indigenous reconciliation.
A sustainable path forward must integrate immigration with policies to boost workforce participation, promote productivity, incentivize capital investment, and consider measures such as delayed retirement, all while recognizing the potential social and economic trade-offs involved. Without a clear and proactive strategy, Canada risks mounting economic and social pressures. A well-managed, long-term population plan, grounded in both economic realities and social capacity, will be essential to maintaining prosperity and ensuring that growth benefits all Canadians. For The Silo, Daniel Hiebert -Emeritus Professor of Geography at the University of British Columbia.
References
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World Economic Forum’s EDISON Alliance Impacts Over 1 Billion Lives, Accelerating Global Digital Inclusion.
The EDISON Alliance has connected over 1 billion people globally to essential digital services like healthcare, education and finance through a network of 200+ partners in over 100 countries.
Investments in bridging the universal digital divide could bring $8.7 trillion usd/ $11.7 trillion cad in benefits to developing countries, home to more than 70% of the Alliance’s beneficiaries.
The Alliance’s 300+ partner initiatives, including digital dispensaries in India, economy digitalization programmes in Rwanda and blended learning in Bangladesh, continue to shape a digitally equitable society.
Follow the Sustainable Development Impact Meetings 2024 here and on social media using #SDIM24.
New York, USA, September 2024 – The EDISON Alliance, a World Economic Forum initiative, has successfully connected over 1 billion people globally – ahead of its initial 2025 target – to essential digital services in healthcare, education and finance in over 100 countries. Since its launch in 2021, the Alliance has united a diverse network of 200+ partners from the public and private sectors, academia and civil society to create innovative solutions for digital inclusion.
Despite living in a digitally connected world, 2.6 billion people are currently not connected to the internet.
This digital exclusion impacts access to healthcare, financial services and education, contributing to significant economic costs for both the individuals involved and their countries’ economies.
Klaus Schwab- German mechanical engineer, economist and founder of the World Economic Forum.
“Ensuring universal access to the digital world is not merely about connectivity, but a fundamental pillar of equality and opportunity,” said Klaus Schwab, Founder and Chairman of the World Economic Forum. “Let us reaffirm our commitment to ensuring that every individual, regardless of their geographic or socioeconomic status, has access to meaningful connectivity.”
The Alliance has made substantial progress in South Asia and Africa.
In Madya Pradesh, India, The EDISON Alliance fostered the Digital Dispensaries initiative, a collaboration between the Apollo Hospitals Group and a US telecom infrastructure provider. This partnership has successfully delivered quality and affordable healthcare, improving patient engagement, addressing gender health disparities and optimizing patient convenience, and making it a scalable model for delivering patient-centric healthcare through digital solutions. Other partner projects improved digital access through economy digitalization programmes in Rwanda, provided solutions for bridging the education gap in Bangladesh with blended learning techniques and explored solutions to reduce financial exclusion in Pakistan.
“Everybody, no matter where they were born or where they live, should have access to the digital services that are essential for life in the 21st century,” said Hans Vestberg, Chair of the EDISON Alliance, Chairman and CEO of Verizon. “Making sure that everybody can get online is too big a challenge for any one company or government, so the EDISON Alliance brings people together to find practical, community-based solutions that can scale globally.”
By driving digital inclusion through its 300+ partner initiatives, the Alliance contributes to unlocking the immense potential of the digital economy. Achieving universal internet access by 2030 could require $446 billion usd/ $600 billion cad, but would yield $8.7 trillion usd/ $11.7 trillion cad in benefits for developing countries. This highlights the significant potential of digital inclusion to drive economic growth and improve lives. The EDISON Alliance has made substantial contributions to this goal, with over 70% of its impact concentrated in developing nations.
The milestone of connecting 1 billion lives was initially targeted for 2025.
Achieving this ahead of schedule demonstrates the effectiveness of its partners, through collaboration and targeted projects, in bridging the digital divide and providing access to critical services to underserved communities.
Beyond digital access, the rapidly evolving technological landscape – marked by such advancements as artificial intelligence, presents opportunities and challenges. The EDISON Alliance remains committed to ensuring that marginalized communities can fully benefit from these developments and avoid being left behind. As technology continues to advance, the Alliance will focus on expanding digital access, fostering innovation and addressing the digital gender gap to create a more inclusive digital future.
About the Sustainable Impact Meetings 2024
The Sustainable Development Impact Meetings 2024 are being held this week in New York. Over 1,000 global leaders from diverse sectors and geographies will come together to assess and renew global action around the United Nations Sustainable Development Goals (SDGs) through a series of impact-oriented multistakeholder dialogues. The meetings are an integral part of the Forum’s year-round work on sustainable development and its progress.
And all the media attention gives us a teaching moment to help illuminate the behind-the-scenes dynamics that affect international pharmaceutical markets, insurance companies, public healthcare systems and government finances. This article summarizes the various issues that have been in the spotlight and additional posts linked in the supplemental section at the end of this article will go further behind the curtain, using Ozempic as an example, to explain the interconnected and complex economic factors and government machinery that play roles in determining the supply, demand and accessibility of pharmaceutical treatments and products, as well as broader economic responses.
First, some background.
GLP-1 receptor agonists (like Ozempic) have been used for more than 16 years to treat type 2 diabetes and for weight loss for the past nine years. Ozempic is Novo Nordisk’s brand name for a semaglutide marketed and sold for treating type 2 diabetes. Other medications in the same class include Trulicity (dulaglutide, GLP-1) and Mounjaro (tirzepatide, a dual GLP-1/GIP).
While Ozempic is heavily associated with weight loss in the media, it is NOT approved by the FDA or Health Canada as a weight-loss drug.
From the globex press release: “GlobexPharma® is thrilled to announce the launch of Ozempic Chewable Gummies for Kids®, a groundbreaking prescription treatment designed to combat obesity in children aged 1 to 5 years.”
Health Canada approved it in 2018 for adult patients with type 2 diabetes, noting that there was limited information on safety and efficacy for minors or people over age 75. The FDA has authorized it for similar purposes and also includes reducing the risk of heart attacks and strokes in type 2 diabetes patients with known heart disease.
Wegovy, a similar injectable medication containing higher amounts of semaglutide and made by the same company, is approved for weight loss in obese patients by the FDA and recently entered the Canadian market (it was approved in 2021, but only became available to consumers in May 2024). Saxenda (liraglutide, GLP1), is approved for weight management in obese pediatric patients over 12 years of age in Canada.
The class of medications is not new, their effectiveness for weight loss in non-obese patients, as well as their potential to improve fertility, reduce cardiac risks, and reduce the risk of kidney failure have all increased the attention and discussion of this class of medications.
Their growing weight-loss popularity has disrupted the market, and provides an opportunity to investigate many interrelated market dynamics including:
The incentives and potential for pharmaceutical companies to expand markets for existing products by finding new applications for them.
Similarly, off-label prescribing by physicians can provide patients access to treatments, even if a full-scale clinical trial has not been conducted.
Market expansion through new indications and off-label prescribing can create surges in demand that increase financial risks for public and private drug insurance plans.
Similarly, rapidly increasing demand increases the risk of drug shortages, at least until manufacturing capacity can expand to meet the new market demand.
Both shortages and financial risk for insurance companies can lead to restricting coverage and rationing supplies to prioritize particular patient groups.
The healthcare market and broader economy respond to these dynamics in sometimes unexpected or potentially counterproductive ways. For example, counterfeit or black market versions of the regulated medications, a proliferation of virtual services advertising directly to consumers that they can provide access, and patients failing to complete treatment due to costs or shortages. There is evidence of wider economic responses as well.
For example, Nestlé is launching a new line of frozen pizzas and pastas enriched with protein, iron, and calcium designed for people taking appetite suppressing drugs.
That’s our landscape. For The Silo, Rosalie Wyonch.
About 14 percent of Canadians aged 12 and older – approximately 4.6 million people – did not have a regular health-care provider in 2022, according to Statistics Canada. Even more alarming, about 6.6 million Canadians rely on family doctors aged 65 and over, meaning that even more people could soon find themselves adrift as their physician retires.
Canada has the highest number of general practitioners per capita among comparator countries, yet ranks worst in terms of having a doctor or a regular place for medical care (only 86.2 percent of surveyed Canadians had one in 2023).
What is happening?
Several factors are at play.
First, it’s no secret that the physician workforce, much like the rest of our population, is aging. There aren’t enough new graduates to replace retiring physicians and meet the needs of a growing population. [Canada currently has one of the highest Immigration rates in the world with rates growing steadily and currently sit at around 1.2% population increase each year. CP]
Moreover, physicians have been spending fewer hours on direct patient care. Administrative tasks, such as paperwork for insurance claims, sick notes, and duplicate form requests from different organizations, consume approximately 18.5 million hours of physician time annually in Canada, equivalent to 55.6 million patient visits. Economic and cultural factors are also steering medical trainees towards specialties rather than general family practice. Without changes, the gap between the supply and demand for family physicians will only widen.
My recent C.D. Howe Institute analysis shows that under a normal retirement scenario – where 57 percent of family physicians aged 75 and over retire – the projected supply of family physicians in 2032 will meet 90 percent of the demand. If all family physicians aged 75 and over were to retire, only 78 percent of projected demand would be met, leaving us 13,845 family physicians short.
This means that about 9.6 million Canadians could be without a family physician in the next decade. The consequences of this shortage could be dire, leading to delayed or inadequate care, increased costs, and a strain on other parts of the healthcare system.
With only about 1,550 family physicians completing residency in 2022, the current pipeline of graduates is insufficient. What needs to be done?
Increasing numbers is essential, but will not suffice to meet the demands of a growing and aging population. We need a comprehensive strategy, and five well-established strategies can help.
First, we need to increase the number of training positions for prospective family doctors and accelerate pathways for international medical graduates to enter family medicine, whether direct-to-practice or through residency positions.
Second, administrative processes need to be streamlined to reduce family physicians’ unnecessary workload, freeing more time for direct patient care.
Another strategy is to introduce payment models such as capitation or bundled payments that better support family physicians, making family practice more attractive and encouraging more patient enrolment and after-hours care.
As well, allowing other primary-care providers, such as nurse practitioners and pharmacists, to take on a broader range of responsibilities could assist with sharing the workload and improving patient access.
Finally, developing and expanding team-based models of care that bring together health-care professionals to provide comprehensive and continuous patient care could also benefit Canadians.
The good news is that some of these steps are starting in some provinces.
Nova Scotia is advancing on all fronts; creating a new designated pathway to residency for international medical graduates; committed to reducing physician red tape by 80 percent by 2024; is a leader in paying family physicians with alternate payment; introduced pharmacist-delivered primary care for 31 minor ailments; and expanded team-based care at new and existing locations. Similarly, British Columbia and Ontario have made notable advancements in several of the five strategies.
Improving primary-care access is a nationwide challenge that requires concerted efforts and innovative solutions. By learning from the policies and experiences of different provinces, Canada can develop and implement effective strategies to ensure every Canadian has access to a family physician and the primary care they need. Canada’s health-care system – and the health of its people – depends on it.
For the Silo, Tingting Zhang -Junior Policy Analyst at the C.D. Howe Institute.
The intense debate pitting private versus public healthcare in Canada needs a reality check. Private aspects of healthcare exist in different forms and to varying degrees across Canadian provinces, largely depending on their respective legislation and regulations. For healthcare professionals providing insured services, most bill through the public system, but not all. The current and future scope of their role is the pressing issue at hand.
Health Canada has had success in eliminating extra billing and user fees under sections 18 and 19 of the Canada Health Act. However, provinces have considerable authority in determining key terms like “medically necessary” or “insured services” that are covered under the Act. The result has been a diversity of approaches. Provinces have the legislative tools to constrain the growth of private healthcare, if that is their objective. Similarly, provinces have considerable authority to increase the scope of private healthcare, if that is their objective (even within the current parameters of the CHA), by revising provincial legislation or regulation.
Either way, the specific policy direction undertaken would be different for each jurisdiction, as the legislative and other barriers to private healthcare (such as market size limiting the viability of private delivery) vary across provinces. This Commentary provides clarity about the different forms of “private” healthcare and a comprehensive view of the current policy landscape defining the balance between public and private healthcare.
All health systems incorporate some mix of public and private healthcare. In 2021, public sector spending in Canada amounted to 73 percent of total healthcare expenditure, exactly equivalent to the OECD average of 73 percent (OECD 2023). Yet these summary figures tell us little about the public/private contours of any healthcare system. Private healthcare can manifest in a multitude of ways, and the precise configuration of the relationship between public and private healthcare tells us more about the system than the absolute level of public or private spending.
Under the Canadian Constitution, provinces have wide-ranging jurisdiction over the provision of healthcare in Canada, both explicitly (hospitals) and through judicial interpretation (“matters of a merely local or private nature,” as well as authority over insurance). The Canada Health Act (CHA) does provide a national framework (supported by federal transfer funds) that has, for several decades, ensured a certain level of congruence across provinces in the provision of public healthcare. But each province’s health legislation is unique, and it is this interplay between federal and provincial legislation that provides a regulatory space for private healthcare. Variation across provinces means private healthcare in Canada is not a uniform phenomenon.
The objectives of this Commentary are fourfold: first, to describe the ways we can understand “private” healthcare; second, to explain the different ways provincial legislation permits or prohibits aspects of private healthcare; third, to discuss the supply- and demand-side variables causing private healthcare to take its current shape across provinces; and fourth, to analyze the relationship between provincial healthcare legislation and the CHA with reference to the expansion of private healthcare in Canada. This Commentary does not address the utility of private healthcare per se. Rather, it focuses on the confusion inherent in so many discussions referencing “private healthcare.” Both exponents and critics of private healthcare can pick and choose from numerous manifestations of private healthcare to support their respective positions. By requiring proponents and opponents to clarify precisely what they mean by “private healthcare,” the potential costs and benefits can be more clearly identified in each case.
What do we mean by “Private Healthcare”?
Critics of private healthcare point to the costs and inequities of the American healthcare system to argue against it, while proponents reference European mixed public/private models to show how effective it can be. First Aid Course Hamilton. Any discussion of the role of private healthcare should therefore first clarify what, precisely, is meant by “private healthcare.” Healthcare systems can generally be broken down into three constituent parts: delivery, financing, and regulation. Any of these elements can include a public or private (for-profit or not-for-profit) component (Wendt et al. 2009; Böhm et al. 2013; Marchildon 2022).
Much healthcare in Canada is delivered by private providers. When medicare was introduced in Saskatchewan in 1947, physicians vehemently protested. A settlement was reached only when the province agreed to recognize physicians as private independent operators rather than as employees of the state (Marchildon 2020). This model was followed by other provinces as they introduced their own medicare legislation. Ambulance services across Canada are often private, with these companies negotiating service contracts with health authorities or provinces. Nursing care in hospitals and district nursing programs is generally provided publicly, but private nursing firms (such as the not-for-profit VON for home care, or for-profit firms supplying temporary placements in hospitals) are also commonly utilized.
Historically, hospitals in Canada (especially those founded by religious orders) were largely based on a private, independent, not-for-profit model. As hospitals became amalgamated into health authorities, they were consolidated in provincial governments’ financial statements and their operation was generally subsumed within the public infrastructure – even as many (especially larger) hospitals with boards of directors remain not-for-profit organizations.
Key Takeaways
What, exactly, is a “not-for-profit” (NFP) organization in Canada, and how does it differ from a private or a public one? Legally, NFPs are “bodies corporate without share capital”: in other words, revenues must be directed to the mission of the organization rather than to shareholders. NFPs also enjoy specific tax breaks. Unlike fully public bodies, however, they are self-governing. Generally, they will have boards of directors who are accountable for funds raised and debts incurred. Like directors in a private company, these directors have a fiduciary responsibility to use resources wisely. Unlike private companies, directors of NFP organizations are directly responsible to the corporate entity rather than to members (i.e., shareholders). The corporate entity, in turn, is responsible to the government jurisdiction (federal or provincial) wherein it is incorporated.
Increased attention has been paid to private surgical companies. Individual medical specialists are generally considered independent private operators who contract their services to medical facilities or universities, although their payment models often include elements such as base salary, research stipend, fee for service, etc. Surgical specialists have in many provinces established discrete private businesses where bulk services (a specific number of certain surgical services) are provided over a set period for a negotiated price (e.g., the Shouldice Hernia Centre in Ontario or Scotia Surgery in Nova Scotia). They may use public infrastructure (hospital operating rooms) or provide their own physical space. There is considerable debate whether contracting these services is superior to establishing them as part of the public system (e.g., Day 2023; Lewis 2022; Longhurst 2023). However, as the funding and administration of these services is controlled by provinces (or provincial health authorities), and as patients use these services as they would fully public services (i.e., free at point of delivery), they are not considered a “two tier” form of access to healthcare. Patients cannot access these services directly; rather, they are routed through the public system. Grey areas of private service delivery, described in more detail below, include the private delivery of medically necessary diagnostic services, infusion clinics on hospital sites, and certain forms of virtual care.
Also relevant to the discussion of private delivery is the type of private entity under consideration. “Private” hospitals that are not-for-profit may in fact operate more like a public institution than a private one; here one might usefully distinguish institutions which are functionally embedded in provincial healthcare system (e.g., via accounting practices) from those that operate at arm’s length. Conversely, evidence from the United States suggests private not-for-profit hospitals can also show the kind of profit-driven behaviour more commonly seen in for-profit entities (Silver-Greenberg and Thomas 2022). Others have argued that small independent private health clinics (such as Algomed or Bluenose, in Canada) are in a different category from large American corporate entities (such as the Hospital Corporation of America) (Deber 2003).
As noted, some privately provided services (such as ambulance services or surgical clinics) are often funded publicly. And, while it is not as common, publicly provided services can be funded privately (e.g., in systems where money follows the patient, private insurers may be able to find places for their patients in publicly funded hospitals). Charitable NFP organizations can be another source of healthcare funding. In Canada, much attention is paid to the division of healthcare into services that are, or are not, insured publicly. For example, the provision of cosmetic surgery (undertaken for aesthetic reasons) is commonly private, and is paid for privately and directly out-of-pocket. The private provision of services that are publicly funded (such as cataract or hip replacement surgery), as noted, is more controversial, but is not uncommon within Canada. The main point of controversy in Canada is whether publicly insured services should also be available for direct purchase to individuals within the private sector, bypassing the public system altogether.
Out-of-pocket financing in Canada is largely targeted to healthcare services that are not covered by public insurance (the precise list of insured versus non-insured services varies across provinces). Only 12.6 percent of Canadian healthcare expenditure in 2021 was comprised of out-of-pocket spending (WHO 2023); the remainder was covered by public or private insurance.
Public insurance: In all provinces, most medically necessary healthcare services are largely funded on a tax-based model, where citizens support healthcare services through their general tax contributions. Some provinces do require provincial inhabitants to pay “healthcare premiums” but, as these contributions simply go into the provinces’ general operating funds, rather than a bespoke account used only for healthcare, these premiums can be considered simply as another form of taxation. As a condition of receiving federal health transfers, the CHA requires that each province has a public insurer. Böhm et al. (2013) argue, for this reason, that states such as Canada and Australia, which are structured on a public insurance system, are more properly considered to possess “national health insurance systems” rather than “national health systems,” as typified by the UK.
Each province has the authority to determine what it insures publicly (which is why coverage for “medically necessary services” varies across provinces). In general, medically necessary services provided by physicians and in hospitals are covered (as required by the CHA) but, as explained below, this is much more complicated than it appears. Services such as vision care and dental care provided in hospitals are also generally covered, as are diagnostics, physiotherapy, and other related services.
Provinces are not required to cover everyone: those in the armed forces or federal penitentiaries, for example, are insured by the Government of Canada. Although provincial healthcare systems provide many of the services for these specific groups, the provinces are reimbursed by the federal government. Those injured in the workplace are usually covered by workers’ compensation. Certain categories of migrants (such as refugees) are also insured federally until they receive permanent citizenship status, whereupon they fall under provincial insurance. Depending on the type of work and the length of stay, migrant workers are insured both through provincial health plans and workers’ compensation programs (for a fuller discussion, see Fierlbeck and Marchildon 2023).
Most provinces expand public health insurance beyond what is required by the CHA. While the CHA does not specifically mandate the public provision of dental care, optometry services, and pharmaceuticals outside of hospitals, provinces generally have some form of coverage of these services for vulnerable groups. These are determined either by cohort (e.g., seniors or children), service (pharmacare or dental care), income category (below a certain ceiling), or some combination of all three. These programs vary considerably across provinces.
Private health insurance: Formally, there are several types of private health insurance, each serving a different function.
Supplementary health insurance covers any goods or services that are not covered by public insurance. In Canada, these include companies like Blue Cross, Sun Life, or Canada Life Assurance. Any healthcare system incorporating public insurance will also have an array of private and private not-for profit supplementary health insurance companies which generally cover vision care, physiotherapy, pharmaceuticals, travel insurance, etc.
Complementary health insurance completes the cost of a service, where public or social insurance only pays partial costs. In many countries, for example, public insurance will only cover around 60 percent – 80 percent of hospital stays, pharmaceuticals, primary care, and sometimes even emergency care. In these cases, private insurance will “top up” the remaining costs so patients do not have to pay out-of-pocket. Some insurers may ask patients to pay the remaining costs up front, and reimburse them after the fact; others may cover the costs at point of payment. This “top up” system is not common in Canada, but in Quebec (which mandates pharmacare insurance) private insurers are allowed to cover any co-pays for pharmaceuticals that patients must pay directly for amounts not covered by the mandated insurers.
Substitutive health insurance applies in systems (e.g., in Germany) where citizens earning above a set income are allowed to opt out of public insurance systems altogether, and use private for-profit insurance to cover medical needs.
Duplicative (or “dual” or “parallel”) health insurance is the source of most political controversy in Canada. Duplicative insurance privately covers services that are also offered in the public sector. Four provinces (Ontario, Manitoba, Alberta, and PEI) explicitly prohibit duplicative insurance, three (Saskatchewan, British Columbia, and Quebec) explicitly permit duplicative insurance under certain conditions (i.e., only for certain services, only if the insurer is private not-for-profit, only for services provided by practitioners outside of the public system), and three (Newfoundland, Nova Scotia, and New Brunswick) neither expressly permit nor prohibit it (Appendix Table A2).1 The advantage for those with duplicative insurance is that they can access these services quicker, or access more enhanced variants of these services. It is really with this particular kind of private insurance that the issue of “two tier” healthcare arises. The argument in favour of duplicative insurance is that it “takes pressure” off of the public system (e.g., Globerman 2020), while other research has found that public wait times actually increase when publicly insured services become privately available. One reason given for this is the depletion of resources from the public sector. Policy analysts also suggest that those offering private services have incentives to keep public wait times longer, as patients will only find private services attractive if they cannot easily access them in the public sector (e.g., Besley et al. 1998; Duckett 2005). Countries such as the UK that permit duplicative insurance nonetheless continue to have considerable issues with long wait lists in the public health system (e.g., Duncan et al. 2023).
Private not-for-profit insurance: Another category of health insurance that causes much confusion is statutory health insurance (SHI; also referred to as “social health insurance” or the “Bismarck health system”). This system is quite common in Europe, although the precise configuration varies across states. In this model, health insurance is not covered in the first instance through general taxation revenue. Rather, workers and employers pay into “sickness funds,” which provide health insurance benefits depending on the terms negotiated. These sickness funds are technically “private” bodies operating on a not-for-profit basis. They are, however, highly regulated in their authority and function. Because of the degree of regulation – and the importance of the social function they fulfill – they are generally considered a form of “public” insurance. However, governments tend to differ in their approach to consolidating these operations into government expenditures.2 Jurisdictions using this model of health insurance have different methods for covering unemployed or retired persons, often including funds directed from government taxation revenue or from pooled sickness funds.
The nature of “private” healthcare is determined not only according to the way services are delivered or funded but, more importantly, according to the way they are regulated. Permitting a “private” form of health service or insurance is not an all-or-nothing condition; governments have the authority to determine the terms and conditions under which these services are to be offered. There can, for example, be limitations on the kinds of services offered or insured, on the professions allowed to offer them, on the prices that can be set for them, where they can be provided, and so on. These limits, as discussed below, can be enough to discourage the provision of health services even when these services are technically legal, as the terms within which private services are allowed may not be sufficiently profitable. In the European Union (EU), governments are more restricted in their ability to regulate private healthcare services because, ultimately, the ethos of the EU is to maintain the free movement of goods and services. Fully public health services are under the authority of member states but, where states utilize private components in their healthcare systems, attempts to limit the ability of private health firms to compete can result in charges of breaching fair-competition regulations. In Canada, however, there are fewer restrictions on the limits that provinces can place on private health providers, given the political will to do so. The regulatory aspects of healthcare financing and delivery will be addressed in more detail in the next section.
Another category of “private” healthcare is the implementation of private-public partnerships (P3s) in healthcare (McKee et al. 2006). In the past, this has been limited to large capital projects, such as the construction of hospitals, but more recently the implementation of P3s has expanded to the point where verdicts on their effectiveness can be rendered. Importantly, there is no single model of public-private partnerships; each is generally negotiated on its own terms. Proponents explain the logic of this approach as capturing the advantages of both systems: governments can access more competitive financing for projects, while firms undertake the process of construction more efficiently with each day of overrun increasing the cost of a project. Critics argue that the logic of P3s rests in the effectiveness of offloading costs to the other partner, and that the party with the most expertise in negotiating P3 contracts (generally large multinational firms with experience in this area) are those who are most able to shift costs. At the same time, because P3 projects allow costs to be diffused over a long period of time, budget-conscious governments have been eager to enter into these agreements.
Empirical evidence suggests that the effectiveness of P3 projects in Canada has been quite varied (Murphy 2008; Vining and Boardman 2008; Siemiatycki 2015). More recently, provinces have expanded the use of P3s to include large outlays for medical infrastructure. These agreements, often known as “value partnerships” or “managed equipment service agreements,” generally focus on diagnostic equipment – providing MRIs, CT scans, and X-rays – and they range from 15 to 30 years. The private partner will source, install, and maintain this equipment over the life of the agreement. As the private partner owns the equipment and covers the cost of installation, there are minimal upfront costs for the public partner. Other advantages of this model include a reduction in equipment downtime, decreased administrative burden in monitoring equipment maintenance, protection from unpredictable costs involved in equipment failure (CADTH 2022), and a replacement plan for equipment that reaches the end of its recommended useful life. At the same time, long-term service contracts can diminish flexibility in accessing different equipment over the lifespan of the contract, and the private contractor may demand confidentiality agreements which could diminish the transparency and accountability of the process. Like other forms of P3s, the effectiveness of managed equipment services will largely depend on the specifics of negotiated agreements, including clearly defined outcomes and expectations, as well as transparent and accountable protocols and public scrutiny of this documentation (CADTH 2022).
While “internal markets” are not formally an aspect of private healthcare per se, they frequently arise in discussions of the utility of private healthcare mechanisms in the reform of public healthcare. Most famously employed in the Thatcherite reforms of the National Health Service in the United Kingdom, this model simply divides public healthcare professionals into “purchasers” of acute care services (usually primary care professionals) and “providers” of acute care services (usually hospitals). The theory underlying the purchase-provider split is that GPs will select the best value for money, obliging hospitals to compete by offering quality services for less. While the results of Britain’s experiment with the internal market are mixed at best (for a discussion of the internal market reforms see, e.g., LeGrand, Mays, and Mulligan 1998; and Ham 2007), a number of other countries (such as the Netherlands) have since incorporated this mechanism into their own healthcare systems.
Conclusions
The nature and extent of private healthcare provision has always been a subcurrent in discussions of Canadian healthcare. As Flood and Archibald clearly demonstrated in 2001, however, the precise nature of private healthcare depends upon the structure of provincial legislation. In general, provinces with a critical mass of population and wealth had to be more actively restrictive in their policy instruments regarding private healthcare, with smaller provinces able to enjoy a more liberal legal framework safe in the knowledge that low demand would make the opportunity immaterial. While legal frameworks are generally holding firm, the practice and context of healthcare provision have been changing rapidly. Both supply and demand pressures are making private healthcare more available and more attractive to those requiring healthcare.
This Commentary has not discussed the provision of duplicative private health insurance in Canada. The experience of post-Chaoulli Quebec has shown that the demand for duplicative insurance is still limited given the current policy framework (see Quesnel-Vallée et al. 2020). Nonetheless, if private service provision becomes widespread, and the demand remains constant (or increases), provinces that permit private insurance (but have not experienced demand) may well see its tentative development within their jurisdictions, while provinces where duplicative insurance is proscribed may experience greater political pressure to allow it.
Laverdière (2023) has argued that a “plausible interpretation” of the CHA is that “transfer reductions can only occur when the public system in a province or territory does not provide satisfactory access to medically necessary services.” This is not an incorrect observation per se; it merely confuses the legal and political aspects of the CHA. Whether provinces have met the contractual conditions to expect the funds set out by Ottawa is a largely technical matter. The success that Health Canada has had in eliminating extra billing and user fees under sections 18 and 19 is illustrative of the utility of a clear and specific set of requirements that are monitored and enforced (with the added incentive that provinces can recoup any past losses if they make prospective changes). More complicated are the charges that provinces have been non-compliant with the CHA beyond sections 18 and 19. Because provinces have considerable authority in determining key terms like “medically necessary” or “insured services,” it is difficult to make justiciable claims against provinces for non-compliance more broadly. The contest over diagnostic services and virtual care will be an interesting one. But the terms of the dispute are more political than legal. As in the past, the federal government is using the CHA as a political statement to affirm its commitment to public healthcare; as such, the legal outcome of the controversy may be less important than the political battle.
Is the CHA obsolete? The demand that the CHA should be revised, either to prevent or facilitate private healthcare, is misplaced. The instruments determining the extent of private healthcare largely rest, as they always have, with the provinces and the political will of their electorates. In the past, the best barrier to privatization has been an effective and responsive public system. For this reason Ottawa’s role in funding provincial healthcare remains paramount. Provinces have the legislative tools to constrain the growth of private healthcare, if that is their objective. Similarly, provinces have considerable authority to increase the scope of private healthcare, if that is their objective (even within the current parameters of the CHA), by revising provincial legislation or regulation.
Either way, the specific policy direction undertaken would be different for each jurisdiction, as legislation and other barriers to private healthcare (such as market size) vary across provinces. For example, should Ontario wish to expand the private provision of healthcare, it could simply rescind sections 15(a) of the Ontario Health Insurance Act and section 10(3) of the Commitment to the Future of Medicare Act (along with the corresponding regulations). To expand the scope of private healthcare, the nine provinces that already allow physicians to opt out of the public insurance system have a number of mechanisms at their disposal. These include permitting physicians to charge above the current fee schedule where that is now explicitly prohibited, reimbursing patients who use private-sector physicians where they do not already do so, or permitting “dual” or “duplicative” insurance where it is currently prohibited. The greatest effect would be in the wealthier and more populous provinces where a critical mass of individuals who would be willing to pay to access these services would make private healthcare a viable commercial venture. The scope for expanding private healthcare in smaller provinces is more restricted, but still could be facilitated by, for example, allowing physicians to bill above the public fee schedule.
Similarly, provinces can use legislative mechanisms at their disposal to further restrict the expansion of private healthcare by, for example, refusing to reimburse patients who have paid physicians directly for services listed as “insured services” (as some already do). Doing so could also potentially expand private healthcare by increasing the number of non-participating physicians (who are outside the purview of the CHA). However, this could in turn be addressed by restricting the fee schedule of non-participating physicians or, like Saskatchewan, by permitting liberal private care only up to the point that it is deemed to undermine public care. Moreover, simply by changing the definition of “insured services” from “medically required services provided by physicians” to “medically required services provided by physicians and nurse practitioners” (which can in some jurisdictions be done through orders-in-council alone), some provinces could forestall the expansion of private nurse-practitioner-run clinics. Provinces can also control the precise scope and nature of additional private healthcare services by tightly regulating the specific terms under which these services are permitted. Quebec, for example, has for years allowed private health insurance only for specific procedures; Saskatchewan permits private health insurance, but only if offered by non-profit entities. Privatization, in this way, does not necessarily entail a “wild west” of unrestricted commercial ventures. At the same time, provinces that pursue this route will also have to commit considerable resources for monitoring and ensuring compliance (where currently most provinces simply utilize a complaint-driven system).
Canada’s unique federal system means that fears of privatization can also be useful in leveraging more funding from Ottawa. Rather paradoxically, provinces have an incentive not to contain the growth of private healthcare within their borders in order to make the case that more public funding is necessary. At the same time, Ottawa has agency with regard to going beyond the mandated provisions of sections 18 and 19. It could demand provinces cleave to the spirit of the CHA by publicly insuring services regardless of whether they are provided in the way they were when medicare was first conceived. Ultimately, however, governments are responsive to their electorates. The legal intricacies that exist in the nexus of provincial legislation and the CHA will always remain secondary to the wider political opposition to, or support for, private healthcare. To engage in this political debate, however, it is important to understand clearly what private healthcare is and is not, and how it manifests within the legislative landscape of each jurisdiction. For the Silo, Katherine Fierlbeck.
Dr. Fierlbeck is cross-appointed to the Department of Community Health and Epidemiology, the Department of International Development Studies, and the European Studies Program at Dalhousie University. She is a Senior Research Fellow at the Healthy Populations Institute, and is on the research committee for the MacEachen Institute for Public Policy.
As a Black man and a spiritual leader in the Linden community, I am concerned and am a personal victim about the disproportionate impact of prostate cancer on Black men. It is unacceptable that Black men are about twice as likely to get and die from prostate cancer than white men. While we still do not know definitively why this is the case, there are several factors that contribute to this reality.
Genetics may play a role. Studies have shown that prostate cancer in Black men has a different genetic profile, and it is a more aggressive form of the cancer. Additionally, Black men are underrepresented in clinical trials, which limits our ability to understand the disease’s impact and identify effective treatments. Lack of access to healthcare and inconsistent screening programs also contribute to the higher mortality rates among Black men.
But it’s not just genetics or lack of representation in clinical trials that cause this disparity. The cost of care, limited access to quality healthcare, and systemic racism create a barrier to care and early detection. Add to that the economic challenges faced by many Black men, such as the cost of cancer care and the inability to take time off work to recover from treatment, and it’s clear there is a multi-layered issue that must be addressed.
We cannot afford to remain silent on this issue. We must educate ourselves and our communities on prostate cancer risks and symptoms and the importance of timely screening. We must push for universal access to healthcare and encourage participation in clinical trials. And we must work to break down systemic barriers and create an equitable system of cancer care for all, regardless of race or ethnicity.
As a cancer patient myself, I understand how harrowing a prostate cancer diagnosis can be. However, it’s essential not to let the diagnosis define you and have faith that you can overcome any obstacle. Supporting each other and bringing awareness to life-saving prostate cancer screening is critical to reducing the disparities faced by Black men with prostate cancer. For the Silo, Imam Alfred
Imam Alfred Muhammed is working within the African American community on issues of leadership, peace, and interfaith outreach. Imam Alfred has inspired inner-city youth to self-actualization, promoted healthy family relationships, and improved economic development in the Linden community. He is now fighting stage 4A prostate cancer and has been forced to limit his engagements while spending more than $70,000 usd on alternative healthy treatments.
Before his conversion to Islam the Imam Alfred Muhammad was raised as a Christian in rural Virginia. His journey in religious leadership began in childhood as a Baptist preacher, but in 1960 the young minister Muhammad converted to the Nation of Islam. While in the NOI his desire was driven to become active in the 1960s Civil Rights Movement. Most notably, the Imam managed voter registration drives and worked closely with the lieutenants of Dr. Martin Luther King, Jr.
Have you ever felt like you need an upgrade on your life?
Most of us have – and there’s a way to get it, says veteran physician Sanjay Jain.
“First, I tell people, ‘Don’t be afraid of making your life clearer.’ but as we have paraphrased from Chinese philosopher Laozi, ‘The journey of a thousand miles begins with the first step,’ ”. Many argue that life is not simple and, therefore, there are no easy answers, says Jain, whose specialties include integrative medicine. He’s also an international speaker and author of Optimal Living 360 – (www.sanjayjainmd.com).
“Lives are built from many small components which, when viewed as an assembled whole, can appear overwhelmingly complex,” Jain says.
“But when we break them down and consider the pieces as we make decisions in our lives, it’s much easier to see how small adjustments can result in a better return on all of the investments we make – not only in health, but in relationships, finances, and all the other essential aspects of our lives.”
Jain offers four points to keep in mind as you start the journey.
• Life is short, so live it to its fullest potential. Live it optimally. This is your life, so don’t waste its most precious resource – time. No matter one’s spiritual leanings, economic and education status, health, intelligence level, etc. – one thing is true for all: Our time on Earth is finite. There will be a time for most of us when, perhaps after a frightening diagnosis from a doctor, we reflect deeply upon our time and consider the most important moments, and all the time that may have been squandered.
• Balance is key. Too much or too little of something, no matter how good, is actually not good. Balance is one of the easiest tenets to understand, but arguably the most difficult to maintain. Obviously, too much alcohol is bad; then again, there are some health benefits to moderately imbibing red wine. What about too much of a good thing; can a mother love her children too much? Yes, if she is an overprotective “helicopter parent.” The best antidote to overkill of anything is awareness; try to be aware of all measures in your life.
• Learn to tap your strengths and improve upon your weaknesses. Engaging your strengths at work and in your personal life is important. When we do what we’re good at and what comes easily, we feel self-confident and satisfied. Some people, however, are not in jobs that utilize their strengths, or they don’t put their talents to work at home because they’re mired in the prosaic work of living. It’s important to identify your strengths and find ways to engage them. It’s equally important to recognize our weaknesses and work on improving them (because we can!) This is essential for achieving balance.
• Life is about making the right choices. Integrative decision-making makes this easier. There are many different types of decision-making, including systematic, hierarchal, impulsive, decisive and flexible. Integrative decision-making can be used for problems large and small, and includes the following process: 1. Define the problem. 2. Frame the problem. 3. Develop all your options. 4. Analyze your options. 5. Make the decision. 6. Execute your decision. 7. Debrief yourself.
“Don’t be afraid of making your life clearer.” Dr. Sanjay Jain
While experts may be the best consultants for compartmentalized areas of your life, only you know the other aspects that affect your well-being and can determine how a decision in one area will affect another area. For the Silo, Ginny Grimsley
Only 10% of rare diseases have an FDA-approved therapy. This sobering statistic highlights why research is so imperative for patients with rare diseases. Clinical trials can be a crucial opportunity to access life-saving treatments.
However, African-American, African-Canadian and Latino patients with rare diseases face significant underrepresentation in clinical trials. This lack of representation results in drugs being developed that aren’t proven safe or effective across different populations.
A 2018 research carried out by the U.S. Census Bureau stated that out of the 12% Black or African American population across the U.S., only 2.2% had participated in clinical trials for rare diseases. Sickle cell disease is one rare disease that predominantly affects the African American community.
India has close to 50-100 million people affected by rare diseases or disorders, with almost 80% of these rare condition patients being children. As per the U.S. Census Bureau, Indian Americans constitute 1.2% of the U.S. population, which translates to 4.5 million, as of 2021, and out of the 5.8% total Asian population across the U.S., their clinical trials participation in 2018 was only 1%.
When certain groups are underrepresented, the universal right to health is jeopardized, and the economic burden of public health care rises. Inequities in clinical research participation impede applications in drug efficacy, toxicity, therapeutic indices, and other areas. Furthermore, it has the potential to raise healthcare costs.
February is “Rare Disease Month”, while February 28th is “Rare Disease Day”, and 2023 is the 40th anniversary of “The Orphan Drug Act”—a law that was passed in the United States in 1983 to facilitate the development of orphan drugs—drugs for rare diseases.
Dr. Rajasimha, Founder and Executive Chairman of IndoUSrare says, “Rare Disease Month allows the rare disease community to come together and make themselves heard.”
The future of rare disease research and treatment still requires enhanced detection techniques, dissemination of understanding concerning optimal care, and research to prevent, treat, and cure disease, and IndoUSrare collaborates with researchers in the U.S. and other western countries with their counterparts in the Indian subcontinent to engage and include the large and diverse populations of Indians in India and globally.
A study by Compare the Market Australia has analyzed each country around the world on their annual search volume for terms such as ‘relocating to [country]’ and ‘moving to [country]’ to reveal the world’s most desirable countries to relocate to.
The most desired countries to relocate to? Here comes a boring chart!
Rank
Top destination
Favourite in X countries
1
Canada
50
2
Japan
31
3
Spain
19
4
China
15
5
France
11
6
Turkey
9
6
South Africa
9
8
India
7
9
Australia
6
10
Greece
4
10
Fiji
4
Taking the top spot is Canada, with our North American nation being the most desired destination in 50 other countries around the world. Canada is a very welcoming country for expats, which has led to it becoming a very diverse and multicultural destination.
Second place goes to Japan, with 31 countries having it as their number one relocation destination, including Australia. Japan has one of the highest life expectancies in the world, which could explain why so many people are researching to move there.
Spain is another very popular choice, especially amongst those in other European countries, with 19 countries having it as their favourite in total. Known for its warm Mediterranean climate, Spain is also another destination that has excellent healthcare and quality of life.
The least desired countries to relocate to in the world include: Sweden, The Philippines, Bulgaria, Germany, Thailand, Egypt, Singapore, Myanmar, Italy, and Nigeria with only one other country wanting to move to each of these destinations.
Further Study Insights:
Each country’s most desired relocation destination
Check the map below to see where each country in the world wants to relocate to the most.
While the majority seem to prefer somewhere within the same continent, there are some notable exceptions to this.
As the most searched country overall, we can see that people from as far away as India and South Africa have Canada as their most searched destination.
However, there were also some definite regional trends though. For example, many African nations have South Africa as their most searched destination.
Methodology
Using Google Ads Keyword Planner, the annual search volume for each of the following terms was found for each country in the world:
Houses in [country]
[Country] property
Moving to [country]
Relocating to [country]
This process was then repeated for each country in the world, taking a total of the searches across all four search terms, to reveal where each country wants to relocate to the most.
Note that searches within the same country were removed from the results.
In addition, all searches were carried out in English, as results in native languages proved to give inconsistent results.
Pasadena, Calif. (November, 2020) – Innova Medical Group, Inc. (IMG) has partnered with the UK Government in its roll out of whole city screening and testing, beginning in Liverpool, with its INNOVA SARS-CoV-2 Antigen Rapid Qualitative Test Kits.
Innova Medical’s lateral flow antigen test uses nasal and throat swab samples to screen for infection, with highly accurate results in as little as 15-minutes. This test can be easily and safely administered anywhere, on both asymptomatic and symptomatic people, without costly delays and the need for a full-scale laboratory. With its low cost per test, about the same as a coffee and biscuit in London, at-risk populations and many with inequitable access to healthcare, can achieve peace-of-mind with a negative result. U.K. Government data showed the IMG rapid SARS-CoV-2 antigen test screened asymptomatic individuals with 98.98 percent accuracy.
https://youtu.be/S2qRibNrBPs
Dr. Susan Hopkins, Incident Director at Public Health England, said, “The tests we are using in Liverpool are accurate, especially in finding people who are infectious at that moment in time and so are more likely to pass it on to others. Part of the purpose of working with Liverpool to roll out whole city testing is to better understand how these tests work in the field, improve understanding of why people get tested, and the impact of this approach on reducing the transmission rate.”
Using the National Health Service (NHS COVID-19) app, people can book a test and later input their test results.
Individuals taking part in the roll out of Operation Moonshot will be notified of positive or negative results by text or email. With this important test-and-trace system in place, public health authorities can diagnose cases, isolate infected patients, trace their contacts, and implement stringent infection control policies to reduce outbreaks.
With colder months and the holiday season ahead, the risk of virus transmission accelerates with more indoor gatherings and travel. If people do not know they have COVID-19, it is unlikely they will take precautions to prevent virus spread. Research studies show that to achieve disease control both asymptomatic, people who are infected but never develop symptoms, and pre-symptomatic, infected people who develop symptoms later, must be isolated.
Under Operation Moonshot, the UK Government hopes to flatten the curve by employing proactive, rather than reactive, measures in its COVID-19 response. Up to 1-in-5 United Kingdom coronavirus infections present with no symptoms, but they are still contagious. The Centers for Disease Control and Prevention (CDC) says up to 40 percent of infected people are asymptomatic and should be tested if they have been exposed. Typically, a person develops symptoms 5 days after being infected; however, infectivity was found to be highest a day before symptom onset. After symptoms, such as a cough, fever, and shortness of breath, first appear, a person can remain contagious for at least ten days.
The Innova Rapid Antigen Test quickly identifies infectiousness. The lateral flow test can identify people with a high viral load who are the most likely to spread the virus. Daniel Elliott, President of Innova Medical Group, Inc., said, “Our lateral flow device incorporates a German nitrocellulose membrane partially composed of nanoparticles of colloidal gold. [ Colloidal gold is nanoparticles of gold in a liquid solution. These gold nanoparticles are coated in such a way that they detect Covid antibodies. CP ] This advanced, proprietary technology combined with our room temperature reagent, allows testing at point-of-care settings such as workplaces, universities, and airports.”
GLOBAL SUPPLY CHAIN AND PRODUCTION
Innova Medical Group Inc. offers a global supply chain including the innovative and respected firms, GE Healthcare (USA) and Sartorius (Germany). IMG secured exclusive manufacturing and distribution agreements for its best-in-class portfolio of screening and diagnostic tests. By the end of November 2020, IMG will produce millions of kits per day in its Brea, California plant, combined with activity from plants in other global locations. After being selected over a large number of submissions to take part in Operation Moonshot, IMG is also exploring options for production in the United Kingdom.
The Innova test carries a CE Marking indicating that this IVD device complies with the European In-Vitro Diagnostic Devices Directive (98/79/EC). This device may be legally commercialized in the European Union (EU). For the Silo, Julie R. Manley.
About Innova Medical Group
Innova Medical Group, Inc. (IMG), is a wholly-owned subsidiary of Pasaca Capital (Pasadena, Calif.). IMG strategically pivoted and leveraged its expertise in Healthcare and Medical Devices to create an ecosystem to respond to the COVID-19 pandemic. The Innova Medical Ecosystem is delivering millions of tests every day to satisfy the diverse, point-of-care requirements of the world’s governments, large corporations, and institutions. IMG offers a global supply chain including the innovative and respected firms, GE Healthcare (USA), and Sartorius (Germany). IMG secured exclusive manufacturing and distribution agreements for its best-in-class portfolio of screening and diagnostic tests. For more information, visit www.innovamedgroup.com.
As parts of the globe cautiously begin to open up, the focus is on what travel freedom and global mobility will look like in a post–Covid-19 world. Last week the EU released a list of countries whose residents would be allowed entry into the bloc from 1 July based on coronavirus-related health and safety criteria. Included on the welcome list are countries such as Australia, Canada, Japan, and South Korea that traditionally score highly on the Henley Passport Index — the original ranking of all the world’s passports according to the number of destinations their holders can access without a prior visa. However, in a move perceived as a stinging rebuke for its poor handling of the pandemic, the US was notably excluded from the list, as were Brazil and Russia.
Although not reflected in the latest ranking, which does not take temporary travel bans into account, it is eye-opening to consider what travel freedom currently looks like for the holders of once-prestigious passports. For instance, before Covid-19 the US passport usually ranked within the top 10 on the Henley Passport Index in 6th or 7th place, with its citizens able to access 185 destinations around the world without requiring a visa in advance. However, under the current EU ban, the picture looks starkly different. US nationals now have roughly the same level of travel freedom as citizens of Uruguay (included on the EU’s list of welcome countries), which ranks 28th on the index, with a visa-free/visa-on-arrival score of 153. In another striking inversion, the US’s dramatic decline in passport power means that Americans find themselves with a similar level of travel freedom usually available to citizens of Mexico (25th on the index, with a score of 159), current travel bans notwithstanding, albeit temporarily.
This is one of many extraordinary shifts in passport power caused by the temporary pandemic-related bans. Brazilian passport holders, for example, find their passport strength greatly diminished. The country usually ranks highly on the index ¾ most recently placed 19th, with a visa-free/visa-on-arrival score of 170 ¾ but the loss of access to the EU means Brazilians currently have roughly the same extent of travel freedom as citizens of Paraguay (36th on the index, with a score of 142).
Without taking the various travel bans and restrictions into account, Japan continues to hold the number one spot on the Henley Passport Index with a score of 191. Singapore remains in 2nd place with a score of 190, while Germany and South Korea are in joint-3rd place, each with a score of 189. Both Japan and South Korea have been included on the EU’s list of ‘safe’ countries, while Singapore has been excluded, which means Singaporean passport holders currently have far less travel freedom than their closest competitors on the index, which is based on exclusive data from the International Air Transport Association (IATA).
Dr. Christian H. Kaelin, Chairman of investment migration firm Henley & Partners and the inventor of the passport index concept, says the EU’s recent decision will have far reaching effects. “As we have already seen, the pandemic’s impact on travel freedom has been more drastic and long lasting than initially anticipated. This latest decision by the EU indicates that there is more upheaval to come. Look at the US passport, for example ¾ in 2014, it held the number one spot in the world on our index, but US nationals currently have far less travel freedom than most citizens of other wealthy, industrialized nations and even of some less developed nations, being effectively locked out of Europe. We see an emergence of a new global hierarchy in terms of mobility, with countries that have effectively managed the pandemic taking the lead, and countries that have handled it poorly falling behind.”
Immigration controls in US and UK tighten amid calls for co-operation
While the US looks set to be significantly affected by the EU’s latest decision, it has issued stringent immigration controls of its own over the past few months. Greg Lindsay, Director of Applied Research at NewCities, says that the Trump administration’s temporary suspension of all work visas will have far-reaching effects. “The executive order, signed on the 22 June, will bar as many as 525,000 foreign workers from entering the country for the rest of the year.” As Lindsay points out, this decision is only the latest salvo in White House aide Stephen Miller’s years-long campaign to curtail worker visas, arguing that they harm employment prospects for Americans.
In the UK, the pandemic’s effect on mobility has also been severe. Robert McNeil, Deputy Director of the Migration Observatory at the University of Oxford, says that the almost complete cessation of international arrivals into the country has generated serious challenges for industries that have become dependent on seasonal migrant workers from the EU. McNeil says that despite public attitudes around immigration softening, the Brexit process has not slowed down. “In May, the government pushed through the new Immigration Bill, paving the way for a new ‘points-based’ immigration system. The new restrictions would prevent many people from becoming key workers in the UK in future. Around half of the EU citizens currently in key worker positions in the UK would not meet the new salary and skills thresholds required to move to the country from 2021.”
Changing priorities in a transformed world
As premium passports lose their shine in a post-Covid world, experts suggest that the crisis is likely to make international mobility more restricted and unpredictable in the longer term. “Even as countries open their borders, it is expected that numerous governments will use epidemiological concerns as a justification for imposing new immigration restrictions and nationality-targeted travel bans that will mainly be aimed at citizens of developing countries,” says Prof. Dr. Yossi Harpaz, Assistant Professor of Sociology at Tel Aviv University. Noting the recent decision by the EU with respect to the US and other countries, Harpaz says, “The passports of both developing and developed nations stand to decrease in value, at least temporarily. In such uncertain times, global demand for dual citizenship and investor visas is expected to increase.”
Discussing the impact of the pandemic on global migration trends, Charles Phillips, researcher and consultant for Oxford Business Group, suggests that environmental health concerns could become a priority for those seeking alternative residence or citizenship. “We can expect places that are governed well and better equipped to deal with pandemics to become destinations people will seek to move to. Just as travel choices will likely be more strongly influenced by health considerations, we may see those acquiring alternative residence or citizenship placing a greater emphasis on a country’s health policies when deciding where to reside.”
Dr. Juerg Steffen, CEO of Henley & Partners, says the growing demand for additional residence and citizenship options comes as no surprise. “We have seen extraordinary upheaval over the past few months, with many certainties falling away. For investors and their families, having a second citizenship or an alternative residence is an even more precious asset than ever before, as concerns over access to first-rate healthcare, global mobility, and quality of life take on a new urgency. In turn, investment migration programs provide invaluable economic security to the countries that offer them.
As we enter the worst recession since the Great Depression, a small country like Montenegro, for instance, is better equipped to weather the storm. The recently launched Montenegro Citizenship-by-Investment Program provides permanent access and the right to stay in this beautiful and safe European country. It also provides the country with an immediate liquidity injection of much needed debt-free foreign capital that can be used to buffer the impact of the pandemic and create significant societal value.” For the Silo, Sarah Nicklin.
About the 2020 Henley Passport Index
Boasting cutting-edge expert commentary and historical data spanning 15 years, the Henley Passport Index is the original ranking of all the world’s passports according to the number of destinations their holders can access without a prior visa. The ranking is based on exclusive data from the International Air Transport Association (IATA), which maintains the world’s largest and most accurate database of travel information, and it is enhanced by extensive, ongoing research by the Henley & Partners Research Department. Along with the Kälin – Kochenov Quality of Nationality Index, it is considered a major reference tool for global citizens and the standard reference for governments in this field.
Tokyo edges Singapore (2nd) and Osaka (3rd) again to take the top spot globally in 2019.Two North American cities make up the top ten, including Toronto (6th) and Washington, DC, (7th).The remaining top ten cities are: Amsterdam (4th), Sydney (5th), Copenhagen and Seoul (tied 8th) and Melbourne (10th).The 2019 edition of the index includes ten new indicators, of which eight are related to environmental resilience.
The Economist Intelligence Unit today releases the third edition of the Safe Cities Index (SCI) at the Safe Cities Summit in Singapore. The index, which is the centre piece of a research project sponsored by NEC Corporation, ranks 60 cities worldwide across five continents. It measures the multifaceted nature of urban safety, with indicators organised across four pillars: digital, infrastructure, health and personal security.
Cities in the Asia-Pacific (APAC) region make up six of the top ten safest cities, with Tokyo taking the top spot for the third time in a row. Along with Tokyo, other APAC cities, as in the past, dominate the SCI2019. Singapore and Osaka come second and third, while Sydney and Melbourne also make the top ten.
Toronto and Washington, DC, are the highest ranked North American cities in the SCI2019, with Washington, DC, entering the top ten for the first time. Overall, North American cities perform well in digital security, accounting for seven of the top ten cities in this category. These cities include Chicago, Washington, DC, Los Angeles, San Francisco, Dallas, New York and Toronto.
Vaibhav Sahgal, consultant at The Economist Intelligence Unit, says: “US cities continue to perform well in digital security as the government strengthens its cyber-security regulations, while Canadian cities tend to fare better than their US counterparts in personal security. None of the cities in the US make it into the top 20 in the personal security category—Washington, DC, only ranks 23rd, together with Shanghai.”
The SCI2019 benefits from a major revision designed to better capture “urban resilience”—the ability of cities to absorb and bounce back from shocks—a concept that has had an increasing influence on thinking in urban safety over the last decade, especially as policymakers worry about the implications of climate change. The 2019 edition is the third, following the 2015 and 2017 iterations.The SCI2019 scores are not evenly spread, with a large number of cities clustered at the top, and the rest showing wider variation in scores. Just ten points separate the overall scores of the top 24 cities, while the following 36 are 40 points apart. The research shows that levels of transparency in cities correlate as closely as income with index scores.
Research shows that the performance of different safety pillars correlates very closely with each other, signifying that different kinds of safety are thoroughly intertwined. The top performers in each pillar are as follows: Digital security: Tokyo (1), Singapore (2), Chicago (3), Washington, DC, (4), Los Angeles/San Francisco (5)Health security: Osaka (1), Tokyo (2), Seoul (3), Amsterdam (4), Stockholm (5)Infrastructure security: Singapore (1), Osaka (2), Barcelona (3), Tokyo (4), Madrid (5)Personal security: Singapore (1), Copenhagen (2), Hong Kong (3), Tokyo (4), Wellington (5) The leading cities got the basics right, including easy access to high-quality healthcare, dedicated cyber-security teams, community-based police patrolling and/or disaster continuity planning. The accompanying SCI2019 report explores the index results, incorporating 14 in-depth interviews with industry experts around urban safety.
Naka Kondo, senior editor at The Economist Intelligence Unit, and editor of the SCI2019 report says: “Overall, while wealth is among the most important determinants of safety, the levels of transparency—and governance—correlate as closely as income with index scores. Our research shows the many ways that transparency and accountability are essential in every pillar of urban security, from building safer bridges to developing the trust needed for relevant stakeholders to share information on cyber-attacks. The research also highlights how different types of safety are thoroughly intertwined—that it is rare to find a city with very good results in one safety pillar and lagging in others. Policies, service planning and provision should also take this into account—and this year, we have decided to convene stakeholders from around the world in a Safe Cities Summit to discuss such matters around urban safety.”
Presently and in the not too distant future, virtual reality in healthcare will become the norm. In this piece, we’ll show you how VR can help detect, treat and cure patients in all sorts of different sectors, such as Surgery and Dentistry, as well as teaching the Nurses of the future.
VR will also be used to help the development of people suffering from mental disabilities such as Autism and help cure phobias and tend to soldiers dealing with Post Traumatic Stress Disorder. Via the Luminous Group, for the Silo, Georgia Davies.