Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 21 - Evidence
OTTAWA, Thursday, September 25, 2003
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 11:06 a.m. to study the infrastructure and governance of the public health system in Canada, as well as on Canada's ability to respond to public health emergencies arising from outbreaks of infectious disease.
Senator Michael Kirby (Chairman) in the Chair.
[English]
The Chairman: The focus of this committee is on specific health issues and not the broad issues; they will be studied at a later time. We want to know what role the federal government and additional institutions or monies need to be put in place in order for the federal government to be able to handle infectious epidemics.
Thank you, witnesses, for agreeing to come this morning. We need your help. We are very much interested in having the advice of front-line workers.
Dr. Massé, as I travelled around the country this summer talking to people about this issue, and the consensus seemed to be that, in many ways, the best public health system in terms of it's ability to deal effectively at the grass roots level is the one in Quebec. People praised both you and the system. I compliment you on that because you helped to organize that system and you run it today.
I would like to understand what it is about your organization that has led people to praise both you and the system itself. Obviously leadership is one part of it, but is there a unique element to the organization that really makes a difference?
Dr. Colin D'Cunha, Commissioner of Health, Chief Medical Officer and Assistant Deputy Minister, Ministry of Health and Long-Term Care Ontario: Honourable senators, I have put a slide deck together for you.
The Health Protection and Promotion Act governs Ontario's public health system. There are 37 health units that form the delivery arm for public health services. At a very minimum, there are 17 mandatory programs.
We have determined that there are five key functions of public health in Canada: population health assessment, surveillance, health promotion, injury and disease prevention, and health protection.
We understand that your initial scope will focus on: population health assessment, surveillance, and disease prevention. You have touched upon health protection concerning infectious disease epidemiology.
As specified by the Health Protection and Promotion Act each of our public health units is responsible for the public health of a specific geographic area. Under the act the Medical Officer of Health is mandated to see to health- promotion and health- protection. Each health unit operates from both a population-health perspective and an individual-health perspective.
The structure of a typical public health begins with a board of health that governs each unit. Municipal councils govern ten of our units that range from populations of 150,000 to 2.5 million for the City of Toronto.
Multi-county/multi-municipal boards govern the remainder of the health units. This structure has both municipal and provincial representation with appointments lasting up to two terms of three years. When the terms come up, advice is sought from the board of health in terms of appointing new members.
Each board of health must have a medical officer of health, and yet, because of our national shortage of community medicine specialists eight of our units are without an officer. When the office of Medical Officer of Health is vacant or the officer is on vacation, or for whatever reason is absent, there must be an acting Medical Officer of Health appointed. These eight units meet that standard.
Larger health units have Associate Medical Officers of Health. They are supported by a management structure of nursing management, environmental health management, dental management, and health discipline management. Let us not forget that key to ongoing success is a strong business administration support.
Public health officials respond to communicable disease outbreaks, environmental health concerns and chronic health disease prevention and health promotion challenges.
As far as managing health programs and services guidelines are concerned, we have three general standards, and health hazard investigation will be of particular interest to your study.
We have 14 specific program standards. The last set, under the heading of Infectious Diseases, will be of interest to you at this time. The control of infectious diseases, the food safety program, infection control in institutions, rabies control, safe water, sexually transmitted diseases including HIV and AIDs, tuberculosis control, and vaccine- preventable diseases, fall under this heading.
I have decided to focus on the public health compliance staffing expenditure for the time that I have held this position. Public health historically has never been, in public health's view, adequately funded.
Ontario's mandatory program first came out in 1989 and the public health sector has been slowly trying to achieve their goals. In 1997, in response to the new science the goals were redefined. As of 2002 be have achieved 86.3 per cent compliance.
While our budgets appear to have gone up by 43.2 per cent public health needs more investment from all levels of government. This is a question of a partnership. The number of FTEs devoted to public health in Ontario is in the order of between 5,500 and 6,000 at the local level.
In the last month I have been fortunate that the government has listened to some of my comments and have released 180 additional FTEs into public health. They have given me 80 for my own staff compliment. That does not count our laboratory capacity.
When I started in this position in 1998, the central staff complement was 65. When I managed to successfully hire these additional 80, we will be at 240. I need to stress that these bodies are not available. I do not wish to poach from my neighbours because then my problem becomes theirs.
I will turn it over to Dr. Massé.
Dr. Richard Massé, Chief Executive Officer, Institut national de santé publique du Québec: While my presentation will focus on public health in Canada I will also describe the public health system in Quebec. I will also describe what needs to be done in terms of investment and the areas that need it most. In my conclusion I will point out the challenges we face in the future.
[Translation]
Several highly inspirational reports have been written about the state of public health care in Canada. The Krever Report identified all of the problems associated with the public health care system with a view to finding timely solutions. The Auditor General also tabled a report on this subject.
Also released recently was the report of the Advisory Committee on Population Health calling on the deputy ministers of health to evaluate the capacity of the public health care system. This committee's recommendation remains very timely. The Canadian Institutes of Health Research also released a report this summer and we should look to their recommendations for inspiration as well.
Canada is not the only country to be weighing in on the debate. The United States and many European nations are asking themselves similar questions because they face the same situations in terms of epidemiologic transition and the same challenges in terms of dealing with emerging pathogens that spread rapidly from country to country.
Canada's health care system is in fact made up of a series of connected, albeit disparate systems. Fundamentally, Quebec's system is based on a regional health care delivery model. Each time this regional model is altered, our ability to act is affected.
Over the past decade, a number of changes have taken place, including the development of new technologies for in- lab monitoring of health and vaccines. All of these technologies have contributed to the introduction of new treatment methods that while necessary, have also proven costly to implement.
Currently, the Quebec government is facing serious financial constraints in the area of health care services accessibility. The various levels of government, the federal government in general and the Quebec government in particular, have focused their efforts on the delivery of essential services aimed at providing care, at the expense of investments in the public health care system in general. For instance, some interprogram funding is being redirected to home care.
This situation raises some major problems with respect to chronic diseases which already place a heavy burden on the system. While this area is not the focus of the committee's study, it is nonetheless a fundamentally important consideration. With respect to emerging pathogens, we must have the ability to respond on site before a crisis occurs.
In the early 1990s, Quebec developed a long-term vision for the health care sector. It formulated a health and welfare policy, a major component of the new structure. Subsequently, we set some national public health priorities and eventually we undertook a review of the Public Health Act. An integrated, comprehensive program was implemented on a province-wide basis for all regions. The program resulted in a number of local activities the relevance and effectiveness of which has been scientifically demonstrated.
Like the other provinces, Quebec must contend with recruitment and manpower training problems. This is but one of the reasons for the creation of the Institut national de santé publique.
I will refrain from reviewing in detail the federal government's mandate, since you have already heard from the relevant authorities. However, I do want to stress the importance of clearly defining the roles, mandates and responsibilities of each level of government. Any confusion over the roles and responsibilities of the federal government and of the provinces, even within a legal framework, would result in confusion. In our view, this matter warrants priority consideration.
Lastly, both the Canadian and Quebec health care systems constitute major strengths in terms of our overall primary health care system. That is what sets us apart from the US system which has two components: the public health care network and a care and services network. The integration of the two components here in Canada constitutes a major strength, one on which we must draw.
For example, SARS brought home the point that without close ties between the public health care system and the health care network, it would be impossible to deal with emergencies that arise.
Therefore, we need to maintain a system in which integration is reinforced and ongoing.
The next slide is a familiar, classic depiction of how the health care system, a determinant of health, is organized. However, it is a well known fact that the health care system is not primarily responsible for ensuring population health. This bears mentioning, as the burden of illness does not rest on this component of the system.
Other health determinants interact. If we want to be in a position to combat illnesses and infectious diseases like HIV, we need to consider investing in the other determinants of health.
A review of Quebec's legislation brought to light the fact that public health protection legislation along the lines of what existed previously and what most provinces now have is no longer adequate. We need legislation that clearly spells out public health functions such as surveillance, population health assessment, promotion and prevention. The review was an important initiative and resulted in the recognition of these public health functions by health care organizations, CLSCs and hospitals.
It was critically important to assign a legal nature to these functions and to clarify roles and responsibilities, even at the provincial level.
No doubt you have heard people comment about epidemiological considerations in light of HIV, Hepatitis C and the West Nile virus. I will not belabour this point. Today, we are called upon to deal with problems that arise very quickly, hence the importance of good communication between all public health networks, not just in Canada but abroad as well. We must also turn our attention to vulnerable groups that often experience serious hardship. They must not be forgotten, as is generally the case with the public health care system.
A number of accomplishments are worthy of note. We have developed surveillance systems. However, these must be linked together to ensure the effective transmission of information, and this is not always the case.
In response to one of the problems identified, we developed reference laboratories. Quebec in particular established a level 3 reference laboratory in the field of biosecurity. In our view, access to this type of laboratory is critically important.
However, a problem has been identified with vaccines. Important opportunities exist and a national strategy was formulated and formed the basis of a consensus. Subsequently, it was approved by the various health ministers. However, funding problems have prevented us from using and benefitting fully from these new vaccines.
At this time, I would like to describe to you very briefly how Quebec's public health care system is set up. The lower part of the slide shows the different stages, the first having culminated in the drafting of a health and welfare policy in the early 1990s.
Various problems emerged in 1998. Outbreaks of meningococcal meningitis raised public awareness of our health care system's vulnerability. Tension was greatly eased as a result of consultations with Canadian and US experts.
In 2001, the Public Health Care Act was reviewed. This move came on the heels of the creation in 1998 of the Institut national de santé publique du Québec. In addition, the position of National Director of Public Health was created in Quebec to introduce some accountability at the provincial level and to ensure liaison with the other provinces and with the federal government.
The minister and the Institut national de santé publique represent the very heart of the system's structure. Public health branches operate at the regional level in 18 regions. Some regions such as Montreal are larger than others. At this time, I want to emphasize the links with the local community services centres, or CLSCs. Nearly 75 per cent of all health promotion, not health protection, activities are carried out by CLSCs.
Therefore, in Quebec, we have central, regional and local networks. We also have close ties to hospitals and ensure an active presence in these facilities.
Investing in the treatment of communicable diseases is unquestionably a critically important area. However, equally important is investing in the treatment of non-communicable or chronic diseases.
The other health determinants are fundamentally interrelated. Should systemic problems arise, whether it be an outbreak of a disease or bioterrorism, it is important that we be prepared. Emergency preparedness also requires some investment, not only at the federal level, but at the provincial, regional and local levels as well. In our opinion, a single national agency staffed with experts would not meet current system requirements.
If we use the example of the SARS outbreak last spring, it would certainly have proven useful to have a national agency. However, that would not have resolved the problem of needing to network with institutions in one of more regions in an effort to prevent outbreaks of this nature.
Therefore, the focus should be on investments that target the entire health care system.
We need to work with the most convincing scientific data. Quebec's public health program has identified 25 areas for targeted action based on scientific evidence. This type of activity is useful, and necessary. Failure to invest today often ends up costing us dearly down the road.
One area that has been targeted for investment and improvement is the creation of Canadian centres and networks of excellence. Other initiatives are still in the planning stages.
Problems remain with recruitment and manpower training, as well as with research and innovation.
On the subject of outbreaks, to date, we know very little about how to deal with the psychosocial problems associated with outbreaks, the repercussions of which can often be catastrophic.
Therefore, investing in the treatment of psychosocial disorders is critically important. I am not talking here about basic research, but rather about applied research.
Summing up, we face a number of challenges. We need to legally agree on core public health functions. While an agreement is in place between public health stakeholders, the terms of the agreement must be legally recognized.
Another challenge is increasing coherence between programs to enhance cooperation, for example, with respect to emergency preparedness. The system must not be inflexible. Flexibility between established structures must be maintained, as must links that ensure effective health care delivery. The roles and responsibilities of each stakeholder must be clearly identified.
Finally, there is no question that new funding is required. As some have pointed out, it is not a matter of investing in existing areas in order to make the same mistakes again. It is a matter of saying what needs to be done, not only in terms of infrastructure, but in terms of programs and activities as well. Quebec has made great strides by putting in place major infrastructure. However, program funding remains a problem area, one that greatly impedes our ability to act. It is important to focus on programs as well as on infrastructure, on developing expertise, on training, on research and on surveillance systems — as others have noted — all of which are core areas.
On the accountability issue, people have often wondered if perhaps a responsible, accountable persons should be appointed to hold office in this field in Canada. Obviously, workers across the full health network are accountable, but ultimately, individuals should be accountable, on behalf of the ministers, to the public for certain questions. Currently, that is not the case.
On the communications question, I will not get into that too much. A considerable effort was made during the SARS outbreak, but considerably more work remains to be done, not only within the health care network, but also within the community at large.
In conclusion, Canada's public health care network remains fragmented and vulnerable to current constraints. The system's considerable strengths have made it possible to weather a major crisis like the one recently experienced. However, the crisis also revealed the system's limitations. In the short term, settling for the status quo could prove potentially dangerous, particularly if two crises were to erupt simultaneously in the same region. Experience has clearly shown that we would not able to weather this kind of storm. An outbreak of SARS, coupled with a West Nile Virus alert, could be enough to paralyze our health care system. In the medium term, the status quo is costly in terms of care and services.
In my view, we must strike a better balance between prevention in the broad sense of the word, including health protection and health care. At present, an imbalance exists.
In recent years, Quebec has established a legal framework and infrastructure at the local, regional and provincial levels with the capability of meeting new public health care challenges. Although of significant importance to us, funding remains a critical issue and a fundamental concern, since our ability to act is directly tied to funding levels.
Lastly, the tools to improve systems are within our grasp. We must follow the lead of a number of other countries that have faced similar situations. Specific, concerted efforts are needed, at the federal, provincial and territorial levels, to meet current health care needs.
[English]
The Chairman: Thank you, Dr. Massé. We now know what the problem is, but how do we solve it? I agree with everything you said. You spoke about the need for legally recognized jurisdictions to respect each other's roles and responsibilities.
You have been around the system long enough to understand the inevitable quagmire that results the minute you try to get federal and provincial, and to a lesser extent provincial and municipal governments, to deal with the issues, roles and responsibilities that can turn out to be a never-ending discussion in which nothing happens.
How do we short-circuit that process and put in place something that actually works, even if it does not necessarily respect the exact letter of the law?
I am not looking for a new federal role. That is not my issue here. My issue is how we actually solve the problem. Can you give us any insight as to what the federal government could do to begin to address the issues that you have discussed?
Dr. Massé: I believe that we should have a legal basis for the definition of role and responsibilities. If we try to change the legislation without knowing exactly where we stand and what the will is behind it, and without a clear picture from everyone, it will be difficult to accept. We have been working in consultation with the federal government to change the legislation and it has been a difficult process.
Elsewhere in the world the federal government usually invests most of the funds that go into public health; that is not the case in Canada. In Canada the provinces invest most of the funds. I am not saying that the federal government does not invest, but not to the extent that other federal government invest.
If there was shared responsibility, as there was for medicare or hospital insurance in the past, we would see a real will from the federal government to reach agreement on what changes should be made.
The provinces should pay part of the cost, but not most of it. The provinces are already investing between $800 million to $1 billion for public health activities. The federal government is investing, but not nearly as much as the provinces.
If there is seen to be a willingness, the provinces will agree that, with the new financing, new roles and responsibilities should be determined. There must be more than money put on the table. There must be an agreement for reassigning roles and responsibilities, and then we can discuss legislation.
The Chairman: I agree with you that if the federal government is going to transfer money, it has the right to know where the money is being spent.
Suppose that, instead, the federal government hires a significant number of epidemiologists as public servants and places them across the country. Instead of giving cash, the federal government would give payment in kind, which happens to be a certain number of people to do various things. That has two advantages, in addition to the disadvantage that it may not be perfect in the organizational sense. The big advantages are that it gets around all the jurisdictional issues and it puts in a place a surge capacity to have the federal government bring together, anywhere in the country, a significant number of people at a time of crisis. It avoids the classic jurisdictional argument, which is, ``Send money no strings attached,'' which I think is absolutely a non-starter.
I am looking for creative ways around what has historically been the roadblock. Can it work if, instead of just sending cash, the federal government does payments in kind, such as sending people?
Dr. Massé: If certain provinces agree to receive those experts and include them in their own activities, there would be a shared responsibility and they would be completely integrated in the provinces.
The Chairman: That kind of integration is exactly what I was talking about. Can that work?
Dr. Massé: I am not sure the provinces would agree to that. Provinces that do not have the capacity right now will accept, but other provinces will feel that it is going much beyond the actual responsibility of federal government, which can be discussed and increased.
I think it would not be acceptable for most provinces. If you have two public health teams the one that is within the province is linked with services. I have pointed out that it is essential to have a strong link between public health and health recovery. If we have one team financed by the province, and another team paid by the federal government and there is not a close link that is accepted between them, then that model will not work. There is also a strong danger of isolation or separation between the two sectors. I expect that many provinces will be reluctant to accept that model.
It would be much better to negotiate with the provinces beforehand and see how the model might work. Your solution is a rapid one that can be implemented quickly. However, there is danger of distrust and little coordination in that model and I would be reluctant to recommend it.
Obviously if there is an agreement between the provinces and the federal government that those people are included or imbedded within the public health structure in the provinces, and are spending money with specific purposes that can be done and can become useful.
The conditions that are necessary for that model to work are negotiation a priori and not a decision from the federal government to pronounce a new structure and I think it has done its share.
The Chairman: I agree that unless it is completely integrated it is a crazy thing to do, and you have suggested that some provinces would have a difficult time trying to achieve that degree of integration. I like your word even better. It would be difficult to imbed them into the existing system.
Mr. Ron Zapp, Provincial Executive Director, British Columbia Centre for Disease Control: In B.C. we have a long relationship with an EPI field service, where we have two or three officers a year on rotation who come and serve very well.
As you pointed out, these people are our surge capacity as assist as events occur in a community. It is typically the field EPI from Health Canada who assists the community physicians and augments our staff to be more effective in the regions where help is needed.
The Chairman: To that extent it does work in some places?
Mr. Zapp: Yes, it does work very well.
[Translation]
Senator Morin: I have tracked your career from a distance. For several years, you were responsible for public health and now, you are the Director of the Institut.
In your closing remarks, you stated that Canada's public health care system was fragmented, vulnerable and under- funded. You talked about targeted transfers of funds and noted that the federal government should strengthen and increase funding to its own programs.
No doubt you have heard rumours about the possible establishment of a federal agency with the specific mandate of overseeing public health issues and dealing with emergencies that might arise.
I am very interested in the model as reflected in the Institut national de santé publique that you head up. This institute is unique in Canada in that it has no direct responsibility to intervene in a particular situation. That responsibility falls to the director general of public health and to regional directors. The institute does not intervene directly. I see here a certain parallel with the federal government which of course has no direct responsibility to intervene in this area.
Could we transpose the institute model to a federal agency, with the obvious variations, which would be given responsibility for education and research, and in particular, for resource mobilization?
If I understand correctly, your institute is facing a crisis. You know of resources outside certain regions that could be mobilized. You have expertise on which to draw, namely consultant and laboratory services. I am thinking here about laboratories in Winnipeg, Guelph and other locations that could be assigned certain functions.
Do you see where I am going with my question? You have a model that is different from the one in British Columbia where the focus is on infectious diseases, poisoning and radiation. Your institute deals with public health issues, risk factors, chronic diseases and so forth. Other models are more focused on acute crises such as outbreaks of infectious diseases, poisonings or radiation problems.
In light of your expertise and past incidents in Toronto and British Columbia and given the extremely effective Quebec model, in your opinion, could this model serve as a template for a future federal agency?
Dr. Massé: We could certainly capitalize on this model. As you pointed out, the British Columbia agency predates the creation of the Institut national de santé publique. However, that agency's mandate is somewhat more limited. Nevertheless, there are a number of similarities between the BCCBC and the Institut national de santé publique. Again, though, our mandate is somewhat broader.
I am favourable to the idea of creating a national agency to provide expertise in emergencies and training support, to define research requirements and to work with the Canadian Institutes of Health Research to address needs. I had an opportunity to discuss this idea with Dr. David Miller and we were in agreement. However, establishing a stand- alone central agency would be problematic.
Dr. Miller felt that a Canadian health care network could be developed without having to establish public health care institutes in every single province. A central agency could network with a lab in Winnipeg. In fact, a pan-Canadian network would guarantee third line services and even more specialized services, where necessary, for example in Winnipeg.
This is one type of model that we could embrace. Is it feasible to have a national agency with a very broad mandate? Eventually it might be feasible, but initially, the agency should focus on immediate needs and then gradually expand its focus. Several scenarios are possible. We would be very interested in taking a collaborative approach, as we increasingly do with the Canadian Institutes of Health Research. We are also keen on collaborating more extensively with other pan-Canadian organizations. I believe we can draw some inspiration from this type of model.
I want to emphasize that a networking approach must be adopted. Funding cannot be restricted to a central agency, solely as a means for one stakeholder of easing his conscience. Investing in a central agency would not resolve the problem of ensuring that the regions have the capability of dealing with issues. When a problem arises in Montreal, it is critical that an operational network of experts be in place to respond. The institute is there to lend its support and a national agency would be a added tool in our arsenal.
Components of the national agency's mandate could be assigned to and executed by the regions or by the provinces. Close cooperation could become the order of business.
Senator Morin: Thank you very much. Again, congratulations on the excellent work that you are doing.
[English]
The Chairman: Thank you very much. I want to return to the notion of the kind of coordination that could occur between the network institutes. One of our difficulties is that the provinces are of different sizes. Mr. Zapp has a large group in British Columbia whereas in Saskatchewan and Nova Scotia the groups are much smaller.
In the event of a crisis, would the federal government and some of the larger provinces become part of the surge capacity that would move in to provide assistance to the smaller provinces? Is that an unreasonable proposition?
Dr. Massé: I think it is a reasonable proposition and part of the model that I would seek. Certain provinces are ready to deal with the larger capacities because they have the necessary infrastructures; other provinces may benefit from the structure that is already in place, or the new capacity that would be developed.
Certain provinces might accept resources from the federal government that would become embodied in their function. Others could do it through the structure that they have. If they need to develop a new function they would have to make the necessary investment. The change would not be cost-free. However, they could invest and then benefit from networking and from various mandates that would be transferred to them. That is why I insist that the investment should be discussed prior, to discuss the different needs of each province.
The Chairman: Your last sentence is critical to the subject at hand; too often, one of the problems with national programs is that they have little flexibility from one province to another.
What you are saying is that the federal government has a role, but the specific way it is actually applied would vary from province to province. It would be based less on the historical issue of constitutional questions and more on the existing capacity that each province has. Do you see a degree of flexibility in that and not necessarily the classic uniform national model?
Dr. Massé: Yes.
The Chairman: I do not see any other questioners for Dr. Massé. Senator Morin might want to come chat with you in the next couple of weeks.
Mr. Zapp, I was quite surprised to discover that your organization is a provincial organization. We have heard terrific reports on what work your organization performs and we are looking forward to hearing from you.
Mr. Zapp: Senators, thank you for this opportunity. Public health does not get out much. Acute care and the needs of our emergency rooms across the country seem to get all the attention, and that has been part of our public health problem.
I have a 20-year kind of passion for what we have been building in B.C. I started it as a collection of odds and sods that were related to public health and specialized disease interest in Vancouver. In 1985-86, we coined the title ``British Columbia Centre for Disease Control'' and have been building on it every since.
The British Columbia Centre for Disease Control serves roughly 4 million people. The entire process begins with individuals who seek out treatment. If the treatment concerns a communicable disease the physician is required to report that information to the province. The reports are then monitored by surveillance systems and research teams support that work.
Key to that model is what I see as a safety net. Doctors work with patients and give them information concerning our provincial centre as well as regional centres. The medical health officers, supported by the expert reference folks at the Centre for Disease Control determine whether there is indeed an outbreak, event, or an idea that might assist with community control of the disease.
We have a $60-million dollar provincial purpose-built building with a state-of-the-art laboratory and clinic rooms for our services of which we are very proud. There are approximately 330 permanent FTEs in that building. We have some satellite services, but I will centre my discussions on how we network with the regional authorities and staff the field in different ways. We do have a satellite tuberculosis clinic in the Fraser Valley.
B.C. as a whole has a big concern around hepatitis. Largely, half of the reports that you see are for hepatitis A, B and C.
When we began the centre the original idea was to obtain clarity and develop better actions concerning communicable diseases. You will see that we have since broadened our scope to include environmental issues. The ministry continues to devolve direct service operations to our infrastructure. Interest in food, water, poison and radiation are activities on which we currently spend time. Dr. John Miller, who was our provincial health officer, early on in the creation of this organization was interested in more centres being established in B.C. Thus, we are broadening that base.
Our administration is different than other administrations. I came to this organization after serving different roles in the ministry of health. In the mid-1980s, we devolved to a separate-standing society. I was the Chief Executive Officer of that society and continue to be but under a different title. We now report to the Provincial Health Services Authority. At one point in our evolution, we were stand-alone as an incorporated society.
The major relationship that I have directly is with Dr. Robert Brunham, a partner of mine. He is the clinician who gives me a full vision of what is important and what is not and how we arbitrate in terms of activities in the centre. He is actually an employee of the University of British Columbia. That is a concept that we developed in our organization that I think you might like to consider. We have a very rich relationship with the university.
There is a UBC Centre for Disease Control and our vision is that our staff will be made up of UBC staff and have full academic expectations from the university as much as line authority and effect for how we go about our business.
They do the writing, research and teaching, but the ideal model is a 60-40 relationship: 60 service back to the people of B.C. and 40 to academic advancement. It is that kind of leading-edge expectations that the academic world has that is so important in ensuring that we have the best people available. As I think you have seen in the media, we have very well founded experts tending to our public health events.
We have an integrated organization particularly with epidemiologists and the laboratories in one building. The specialists share the hallways and that makes for the great atmosphere that we enjoy onsite. You get a feel for how they come together to support one another as a team. However, it has been a struggle, but in the last 10 years has proven that we can build some effective bridges and work quite well and in attending to common problems across different specialties.
Our key functions include surveillance and response indications to disease, the prevention and control of disease, routine surveillance and monitoring, and programs to address or to offer prevention. There is also the infrastructure and, as has been noted, the requirement for training and academic pursuit.
The centre is enriched by its location. We are on the Vancouver General Hospital Precinct that covers three or more city blocks of health care services. The UBC Faculty of Medicine is very much a part of Vancouver General Hospital and our cancer agency, a member of our Provincial Health Service Authority, is a world leader in cancer pursuits. Across the street from them, they are building a new cancer research centre.
Like-minded people have come to the centre and have in turn enriched the environment with their approaches and technologies. It is a team operation. Our network is made up of public nurses, medical health officers and public health inspectors. They continue to be the key people that work in the communities. They know best how to rise to a need in the community and deal with it effectively, as well as where the reference point is that they go to in order to ensure that they are doing the absolute best they can to serve their community.
In the last year we have pulled together the non-communicable disease specialists and plan to get moving on the new breakout. This October they will meet with medical health and environmental officers to decide in which direction they should focus their attention.
The most important aspect of infrastructure is information. A past lab director of mine, Dr. Smith, once told me, ``Mr. Zapp, we are in the information business.'' He was the director of the laboratory with 150 staff and all kinds of slides and beakers. If you think about it, that is true.
Since the late 1980s, we have been developing a public health information system, the i-PHIS. The ``I'' at the beginning of the acronym stands for Internet. Health Canada recognizes this as a tool that could be useful and have been helping us with the Canadian Integrated Public Health Surveillance system so that we can develop this tool for the rest of the country. We have an active collaborative interest in information leaders across the country, as well as medical health officers. Dr. D'Cunha is a collaborative member and is moving these interests forward.
Clearly, we need better tools. This is a very expensive enterprise and is time consuming. The public thinks we have real-time information and take real-time response to disease. The technology is there to do that and that is what we want to do, but it will take a lot of time, effort and funding.
Our infrastructure enjoys support and technology in the Vancouver area. I have learned that in the last five years an additional $3 billion has flowed into technology development. That is important as we view developing information and information systems for the country.
How do we make this thing work? We have these neat pieces and seem to be doing the right things. The British Columbia Centre for Disease Control is an accredited agency of the Provincial Health Services Authority. There is a cycle that ensures that we look hard at how we go about putting the parts together and ensuring that they are doing the best they can with the resources they have in order to achieve the best effect.
I know you are well aware of the Canadian Council on Health Services Accreditation. It is an important piece, as it goes to ensuring that accountability and performance expectations for our centre.
I believe in our performance framework. When I look back at the 1980s, I remember telling my doctor directors that we had to set objectives and how difficult that was for them to want to do. Yet now, we actually look at our performance interests based on our six goals and ask ourselves: What we can do better this year to show that we have a better service?
We performed a hindsight look at how that supports SARS. If you are to be effective at responding to new disease, what are you doing about it? How effective are our surveillance systems? How do you monitor your systems? How do you enact them to be effective in the provinces?
We tend to those functions. There are key words such as ``informatics,'' ``innovation'' and ``leadership.'' Those key words encourage us to do our jobs well.
If you want to have a real-time look at the evolving document, the performance plan is on our Website. It is all based on the following: We have to do better. We must plan, do, study, and act. My medical director now thinks research when we have our conversations. We are able to talk to one another more effectively. His academic interest provides a workable synergy between the two of us.
B.C. has double the interest in hepatitis than any other province. We have created an integrated task force and initiatives for community development for hepatitis programs in the province.
Within the aspect of biohazard response management we connect effectively with medical health officers. Following 9/11 they set out the plan of how to get better organized concerning bio-terrorism and the best model to follow. Certainly other provinces recognize that the key is the effective support of medical health officers in the appropriate communities. We are not a new agency or suggesting that we are able to do things the best way. Our objective is to ensure that we provide the best assistance possible in any event that occurs.
The SARS outbreak was very complex. At the time of the crisis, our Provincial Health Officer, Dr. Perry Kendall was instrumental in ensuring that the province did all the right things concerning the outbreak. We were very much his reference point and also the reference point for activities in the Vancouver and the Fraser Valley regions. This gives you an idea of how complex the problem is and how badly we need to think of how a national network can better improve our ability to deal with those kinds of issues.
Where are we going? There is the national CDC. As well, our premier came up with $2.6 million to kick off vaccine development with scientists at the university.
We have a great relationship with UBC, and also the Genome Science Centre, which really did lever us into all the right actions at the right time to get government support to do the right thing concerning vaccine development.
Similarly, we need to become more specific and faster at diagnostics, given the recent Kinsmen Place Lodge controversy. Western Economic Diversification Canada may invest some capital to help us create some speeder diagnostic tools in order to become more effective. We are working at laboratory design and redesign, both within our key agencies as well as laboratories in general, so the province can be more sophisticated and responsive to the needs of its citizens.
The challenge of hosting the Olympics is before us and we want to be as efficient as we can be to ensure that we are providing the proper services for all concerned.
It seems to me that the public thinks that whatever the medical problem there will be a hospital nearby to take care of the problem. We need your attention to a richer support of our public health intervention interests.
The Chairman: Thank you. We will have the final presentation from Dr. David Butler-Jones.
Dr. David Butler-Jones, Former Chief Medical Officer for Saskatchewan, as an individual: We have heard from representatives from two large provinces and from Mr. Zapp from the British Columbia Centre for Disease Control. We have focused on laboratory work and other supports to broader public health practice. My task is to try to pull some of this information together.
In the past we have been successful in the control of communicable diseases, the protection of water, and the containment of sewage, food, et cetera. However, this success has bred some complacency that has now left us in a position where we seem to be struggling. We are also facing new and emerging and re-emerging diseases in a complex world and we are dealing with reduced capacity.
The outbreak of SARS has shown this can have far-reaching effects in terms of the economy. While the disease was largely in Vancouver and mainly Toronto, the tourist industry in Banff was heavily affected. Where there was another outbreak in Southeast Asia Thailand suffered a drop of 70 per cent in its tourist trade. It has huge implications for a disease that in the big scheme of things did not kill very many people.
The lack of a solid public health foundation creates problems for the rest of the health system's ability to deal with and treat what they face. A statement from the centre for disease control a decade or so ago identified that two-thirds of premature mortality could be prevented with the technologies and the understandings we had at the time. This is the context in which some of the communicable disease issues are occurring.
Urbanization and climate change have had an impact on the spread of communicable diseases. The committee is also aware of the impact that globalization has had on these diseases. Other speakers have reported that any disease in the world can be anywhere else in the world within 24 hours. The increasing economic and technology gaps in many places augment the socio-economic issues concerning infectious diseases.
The recent SARS outbreak taught us that basics still matter. The international control of SARS was basic: People who were ill were identified and their activities were limited to avoid the spreading of SARS. Further, those who were caring for them used basic precautions and protections.
A few years ago, while I was in Kosovo I met a child with meningococcemia, which is normally the most common cause of meningitis. The point I want to make is that when our basic support around public health is challenged, the result is a situation like in Kosovo where they have as many cases of meningitis in one week as we have in five years.
This graph illustrates 100,000 smokers who are now age 15 and what will they die of before the age of 70, in other words, prematurely. About 18,000 will die as a result of smoking, 1,200 in car accidents, a little less than a thousand from alcohol, fewer from suicide, about 140 from murder and then you can see the numbers for the Hanta virus, mad cow, SARS and West Nile. They are not big killers. They represent huge issues and challenges, but they are not big killers. If we only focus on the infectious diseases, we may miss some things. I understand the challenges before the committee and focus of this work, but there is a context for it.
There have been a number of studies, an FPT process as well as smaller studies and many discussions concerning our public health capacity. Clearly, we recognize that Canada does have world-class skills and some of the best people in terms of theory and competencies in public health, but that capacity varies a great deal across the country. We have a centre, as in British Columbia, which has sophisticated personnel who do sophisticated work. We drew on the people in B.C. and on the people from the Guelph Centre for assistance with our outbreak in North Battleford. The Guelph Centre is a federal. Not every province will have such an institution, and we need to find ways to better collaborate to address some of those capacity issues.
There has been a loss of capacity at every level within the system, both human and financial resources. There has been a lack of ability for Health Canada or the provincial ministries to really coordinate strategies, to build expertise and to develop and offer the information that allows those of us — I am now working as a regional medical officer again — to have the information we need to help deal with the problems. There is a lack of leadership for public health and an understanding of public health. If there is an outbreak, you know something about it. If you have an inspector in your restaurant, you know something about it. Those comprehensive five functions that Dr. Massé outlined is what public health is about and there is an infrastructure in the country to try to address those.
Second, a personal health culture has really come to dominate the thinking. That is to the detriment of other perspectives on health, in spite of the evidence and the known solutions.
Managing insurance systems distracts. Much of the energy in governments is tying to manage the costs and issues around financing for health care in Canada. That means that much of that policy work has been focused on hospitals, clinical services and waiting lists and less on why people are healthy and what can we do as communities to move forward on that issue.
We thought we had won the battle against communicable disease. While in many ways we have, there are still huge and increasing issues in the world as we see more and more infections and the connections with infections that previously were thought to be rare.
It is interesting to see the impact of infectious diseases. The four diseases that we were talking about originated in animal species. They were animal disease that can potentially and do infect humans. That was the origin of most of the great epidemics through history.
When you think of what happened in the Americas, where 90 to 95 per cent of the population was wiped out by infectious diseases within 200 years of Columbus' arrival, that was a function of, in Europe and Asia, large domestic animals in close proximity to humans. Diseases like measles, tuberculosis, smallpox, influenza, all of which were of animal origin, those populations adapted to some degree to that, but when it came to a virgin population in the Americas, 90 to 95 per cent of the population died as a result. The same thing is true with the new diseases, the next pandemic of influenza. SARS will look tiny in that setting. I believe the general feeling is that the lack of attention to public health has set us up for problems and increasing threats to health of Canadians.
Third, North Battleford and Walkerton are examples of where we have demonstrated an ability to deal with outbreaks well one at a time, but do not give public health more than one and do not let it drag out or be large scale like SARS was in Toronto. There is not the capacity to do that. When we do that, everything else drops.
I was the chief medical officer at the time of the North Battleford outbreak. That was the life of my deputy chief medical officer for a year. He was just one of many people who did virtually nothing else. Plus, it was about 20 to 30 per cent of my time, followed by inquires and so forth. That distracts from a whole range of other things we should be doing. There is not the capacity in the system to cope with both.
The next slide relates to principles. Fundamentally, infectious diseases have little respect for borders or sensibilities. Most people acknowledge that public health is a public good and there are roles for governments at all levels. To be truly successful, it needs to be coordinated. We need to get over whatever differences we have if we are to address these things.
Often at the front lines the same people are doing both follow up on infectious diseases, contact tracing, and so forth, and the next day they are doing well-baby visits or community development or tobacco cessation or whatever.
When we talk about capacity in the system, that is, the capacity that delivers the programs. The search capacity occurs when those people have the training and expertise to do case finding, and to do that work in an epidemic, and then in the interregnum are able to do prevention of heart disease and cancer that we recognize as important.
This perspective reflects some of the consensus that is building around what a national role might be and building on the strength. The list that I have here is a mix of where we need to increase capacity and function and some that we are not doing much of now.
One relates to the facilitation and leadership for Canadian coordinated approaches and strategies to address public health issues. Thus, both on the communicable and non-communicable disease side there are strategies in place, but far too few and far too little follow up and energy that is able to actually sustain those strategies.
For example, there is now work on an immunization strategy. Different provinces have clearly different capacity in terms of an ability to afford vaccines for children. Some of the newer vaccines, for example, just one of the new vaccines costs more than all of the other vaccines that we traditionally use. If you combine hepatitis B, mumps, measles, rubella, diphtheria, tetanus, polio, hemopholus and meningitis, all of those together total about $180 per person for a lifetime of protection. Many of the new vaccines, just one dose costs that much. We have a few challenges in terms of the economics of that.
A Canadian public health agency of whatever stripe, however we call it, many people have spoken to that. There should be some mechanism by which, collectively, we could coordinate activity, centres of excellence, provide resources, whatever it is, to help us to move towards a sense of a system in Canada for addressing public health issues more consistently than we are able to do now.
Resources, obviously, in terms of assisting to rebuild that needs to occur at all levels. There are not enough trained medical officers in the country to fill the positions we have now, let alone the ratio of those professions to what you would see in Britain, Australia or other countries. That specialized expertise is in short supply. There are not enough training programs and physicians to fill that gap. That is a piece of that puzzle; the same is true for public health inspectors and others in the system as well.
Turning to the subject of interdepartmental and inter-sectorial leadership, SARS pointed out some of the inefficiencies between different government departments to come quickly to decisions. We need to find ways to get over that quickly. All emergencies are messy. Honourable senators have probably heard that from other people. The point is to make the messiness a couple of days, not a couple of weeks. Policy and technical expertise must be provided that none of us would otherwise have access to. In other words, there is no way that we will have a clinical toxicologist for direct access to Saskatchewan. We do not have the population or resources to do that. However, we need one somewhere to provide that advice to us as they do in Ontario, B.C. or Quebec.
There is a need for a collaborative system for public health at the federal, provincial, territorial and regional levels.
There is also a need for rapid research on critical disease management issues. We cannot wait for a request for proposals in the middle of a SARS outbreak or for CHR to come up with a pot of money to send out and take a year and a half even six months to figure out how we will do that. We need the ability to quickly identify what infection control methods are working and what is working in other countries and what we might apply here; if there are any medications that work; what are the public health measures proving to be the most effective. We need that at the time when the decisions are being made, not after the fact. We need a mechanism to mobilize that quickly. That is one of the aspects of why some people look to a national public health agency to bring that to bear quickly. We also need to encourage the international links that Health Canada and the government of Canada provide.
My last slide is about 150 years old and just a quote from Disraeli that I like very much.
The Chairman: What is interesting is that the quote from Disraeli was the quote that we used at the beginning of our final volume of our set of recommendations.
Senator LeBreton: Dr. D'Cunha, during the months of March, April and May of the SARS outbreak, you became the public face that tried to deal with this complex epidemic and the public hysteria attached to it. You tried not to alarm the public, yet also tried to be honest. I feel that you did an excellent job, but there was a lot of confusion between actual and probable cases. One day we would hear that the problem had been solved, and the next day, we would hear that there were more actual cases and more probable cases.
With the benefit of hindsight and having controlled the problem, was there a way to disseminate information that could have been more definitive on the actuals and the probable cases? I think that was part of the problem with the World Health Organization statements as well.
Dr. D'Cunha: Up to May 29, we were using the Canadian definition, and we so declared. The problem is that different jurisdictions across the world were using different definitions. The key learning experience was that we must be consistent with an international definition. We have to rearticulate and re-emphasize what we are counting. We did that often enough. In advocating within the country, on May 29, we went to the WHO definition, and automatically, that part of the problem disappeared.
I do not see that as a problem. The problem is when you are trying to communicate something that is complex, if people miss the nuance of the type of counting, they fail to see the nuance of the definition.
There were good reasons for the Canadian definition to be slightly different from that of the WHO. However, when you have the uninitiated, and this is not a criticism of the media, taking the probable and the suspect and transcribing it without recognizing that jump, the potential for misinterpretation increases greatly. The challenge for us was that if we used the WHO definition we would have been out of sync with the Canadian definition.
Senator LeBreton: It happens that I was in the United States for March break with my grandchildren when the news started to break. Every time I watched CNN, I understood why people were not coming to Toronto, because they were adding the numbers.
We should make very clear at the beginning what we are really talking.
Dr. D'Cunha: When Wolf Blitzer of CNN interviewed me made that mistake I challenged him and received positive feedback from some your colleagues. However, that is not why I make the point.
The point is the media had the theory that we in the public sector were burying, whereas we were counting and showing everything. The U.S. made a definition change in April and there was no hoopla about it. That still has me puzzled today, and I am no media expert.
Senator LeBreton: It is not sensationalist enough. You did excellent job.
People go chasing off after one public health issue while other important areas fall by the wayside. I see the water issues in North Battleford and Walkerton as crossover health and environmental issues. I wonder if something that has not been done at the environmental level to cause the problem to become a public health issue. I wonder about the coordination between the environmental specialists and the specialists from public health.
Is there is not something that could be done at the environmental level, before you people are confronted with major public health issues?
Mr. Butler-Jones: Part of that is how you link those perspectives. At one point, water was under health, but when the ministries of environment formed, it moved to those ministries, and quite appropriately for the other implications.
The areas of expertise and interest may be different. For example, when I was a medical office in Sault St. Marie the CBC reported that the dead fish on the river were killed from a spill at one of the paper mills. I inquired if anybody had checked to see if people were taking their water from that river. I was told that the environmentalist department did not concern itself with human health. I responded that I did indeed deal with human health and that if they had called me I would have done something about the water. After that the communication between the two departments did improve. We must have a constant dialogue.
Before the Walkerton incident when there was a bad lab result, the lab director would give me a call, and environment, myself, the director of inspection, and the municipality would have a conversation to discuss the history of the problem, whether it was a bad sample and so on, and we would determine whether to issue a boil order or take more serious measures.
When the public health connection was removed and the reports were sent to environment and the municipality only, the human health perspective was unable to say that something needed to be done immediately.
Walkerton prompted a return to closer connections between health and environment. Most provinces now have protocols: If the lab gets a positive water result, I will get a call and we will decide what needs to be done to solve the problem.
There was a period of time when it was taken for granted that the labs could look after the problems while in reality that did not happen at Walkerton.
Dr. D'Cunha: Building on what Mr. Butler-Jones said, the bulk of public health activity does not make the front page. It is the quiet thing that is not your focus at this time. We seem to forget that. When the issue of the day pops up, it distracts us in as much as managing health insurance system distracts governments from the real business of keeping the public healthy.
We should never forget the inter-sectorial key role that public health plays. One of the reasons why the Government of Ontario made the Chief Medical Officer the Commissioner of Public Health was to reintroduce the inter-sectorality at the highest level of government decision-making. At this point four ministers and their deputies meet with me on a regular basis.
Along came SARS five weeks into the appointment, which consumed a great deal of time.
Senator LeBreton: Was that as a direct result of Walkerton?
Dr. D'Cunha: No, actually, it was as a result of a study done to reaffirm a commitment to public health. The government was reaffirmed to public safety and, while they may not have been committed to public health on the surface, from my perspective, I initiated series of documents so that they would realize the significance of public health events. As Mr. Butler-Jones said, at the local level, the connections were there.
The challenge that society must not forget is that players change with retirement and moves to other jobs, et cetera. We need to institutionalize the connections so that the memory is institutional, at the local, provincial, regional and national levels.
As a public servant, if I initiate change to a system, I have to ensure that the old connections are fixed before I make that change. If a connection is broken without my realizing it a problem is in the making.
Mr. Zapp: In British Columbia, we have had the good fortune of water being a public health issue. More recently, a safe drinking water regulation came into force to increase our surveillance of drinking water in B.C. It is a health program.
Senator LeBreton: You are saying that although there may have been a disconnect, there is now a concerted effort to connect all of it back together.
Senator Morin: Mr. Zapp, I will not quote Disraeli but Premier Campbell of B.C.:
Our successful response to the recent SARS epidemic made it clear that B.C.'s disease control strategies are working.
Would you please expand on that statement? What strategies were used that led to a well-contained outbreak?
B.C. assumed some of the federal responsibilities during the SARS outbreak. I refer, of course, to airport surveillance. Could you tell us why you had to do that?
Mr. Zapp: The comment about our disease control systems working goes directly to the fact that we are vigilant. We have some of the best epidemiologists in the country in Vancouver and they monitor situations worldwide. Much of that information is available and our people were attentive to that information.
In our side-talks at meetings in January, I overheard a Chinese delegation saying that something was going on in China. At that time, no one knew just what the problem was but problems were beginning to emerge. Our epidemiologists were active in trying to interpret the conversation and to make sense of it as things went forward. We were quick to have a communiqué with medical health officers and others around the province.
Our system was in place for the surveillance, the indication and for the response. To cap it off, we have the good fortune of having the credibility to bring the medical health office and the provincial health people into communication through a longstanding, effective network of communications. When we speak, they listen.
Senator Morin: BCDC stands for the British Columbia Centre for Disease Control. Is that correct?
Mr. Zapp: Yes, that is correct.
Senator LeBreton: Our witness yesterday said that they had heard of the problems in China as early as November 2002. You just said that you heard about them in January 2003. How does that information get into the system? Are you in the position to respond to something that you hear about while still not being quite sure what the problem is? How do you get to the centre of what was happening? Do you have to wait until the problem on our shores? Is there a way to address the problem before it gets here?
Mr. Zapp: The information emerges. It becomes more prominent and more of the right people are turning their minds to it in an effective way.
Senator Morin: I would not want to debate the issue. Let us move to the federal role in the airport.
Senator Morin: I understand that you initiated surveillance of incoming passengers at the Vancouver airport.
Mr. Zapp: Correct.
Senator Morin: Was this was done with provincial resources?
Mr. Zapp: No, it was done as a team.
Senator Morin: This was not done in other airports. Why did you feel obligated to take over this federal responsibility of screening arrivals in the Vancouver airport?
Mr. Zapp: I am not close to that but my view from Vancouver was that it was very much a federal team. A physician led that activity at the airport for a couple of months. Yes, there were some people from the B.C. region and probably some individuals from our centre that assisted in the screening.
We have noted that we would probably want to get that activity more organized for future events. From the beginning it was a federal undertaking that needed some local help.
Senator Morin: Dr. D'Cunha, I do not want to get into a debate but, I would like your comments on the federal role in the Toronto outbreak of SARS, especially in respect of the recent comments of the Minister of Health in Ontario when he said that he would like to take over the federal responsibility for screening arrivals at Toronto airport.
The comments over the weekend in The Toronto Star indicated the lack of federal visibility and the lack of federal leadership during the Toronto outbreak. Would you comment specifically on the federal role?
I realize that you worked at the provincial level but what did the federal government do or not do? What do you think they should have done to help you in the SARS outbreak?
Dr. D'Cunha: That is a very broad question and I do not wish to engage in a debate. I will note for the record that I am presenting at the Campbell Commission on Monday. There are a variety of reviews and processes underway and will allow them to finish before I write my little book for publication — or perhaps not.
Simply put in context, the federal government has generally been supportive and I will use some specific examples. I will put some caveats in and what they were in my view. They were supportive when the requests went out for federal field epidemiologists they were dispatched without undue delay. Similarly, when we needed access to the facilities of the field hospital that particular weekend, the third week of March, dispatch was done promptly. This is not a criticism of the federal government so please do not leave with that impression. We recognized throughout the outbreak that we lacked surge capacity, locally, provincially and nationally. Simply put, when we put the call out for help across the country, we found that many people were willing but they could not spare the staff because they are the same people who do other such programs. It is fair to say that we generally try to help one another out.
When the Kinsman outbreak hit in August, Sean Peck said that he was willing to help to the extent that we needed help. It turned out to be a false alarm and no assistance was required. We try to help one another. We are also much constrained by our capacity. One thing struck me over the Easter weekend: We did not have surge capacity. I went about to get some provincially and I referred to that investment at the start of my remarks. I do not think that we received enough and I will chip away for more.
I am also guided practically on the ground. If the bodies are not there I will need a short-term, long-term and medium-term plan to create the trained resources to form that surge capacity.
Senator Morin: Why does the minister want to take the airport operations from the federal government?
Dr. D'Cunha: As a politician, your question is best directed to him.
Mr. Butler-Jones: There was an element of luck in the difference between Vancouver and Toronto. The person in Vancouver who presented came off a plane, from Southeast Asia, already ill.
In Toronto, she went home, got sick and died at home. It was her kids who went back and had no travel history.
Some months before there was a person who arrived from Central Africa with a fever. There was a very quick containment at the airport in Toronto concerning ebola.
Some of it is luck. On the other hand, at the same time, for example, in Singapore, follow-ups on possible contacts were within two days, at a maximum. In Toronto, there was not the capacity to do it in less than a week.
Thus, there is a mix of luck and other issues.
Senator Morin: We will tell Premier Campbell that he should add luck to his statement.
I was discussing with Dr. Massé the matter of a possible federal agency to respond to outbreaks such as SARS. As you know, there are two models. The Quebec model has a very broad mandate. If I understand it correctly, B.C. started out with infectious disease, poisoning and radiation. If I find it correctly, you are moving toward other diseases.
In terms of provincial integration in such an agency, what would be the role of the province? If we leave them out completely, the issues and the resources are at the provincial level. There is also the matter of jurisdiction. I do not think the federal government would go along with having the provinces decide with their own people and their own resources. This is probably the key issue with which we are dealing. If there were a new agency, what would it look like?
Mr. Zapp: The phrase that is used a lot is ``a network of agencies.''
Very rare experts are required for this work and we cannot afford to have a model in each province. It would be too expensive. However, as we have said, we would like to share our knowledge across the country, and modern technology allows us to do that very effectively.
The other point I would like to make probably does not appear to be too obvious. The biggest change that was made was when we were an agency separated from government, accountable to government, required to perform to expectations of a board set by government, but we were not government. That was the turning point on our ability to recognize our responsibility and our autonomy to deliver the services to the best of our ability.
Senator Morin: Are you still functioning under that system?
Mr. Zapp: Yes.
Senator Morin: Do you think it is very good?
Mr. Zapp: It made a huge difference in my transition from a decade with the ministry of health to a decade of independent authority.
The Chairman: In what way was it a huge difference?
Mr. Zapp: I like to think of it as the ability to act, fleet of foot. In a ministry you are a lot more cautious about the actions that you take. A good example is our very effective HIV work in Vancouver that received world recognition, and allowed us an opportunity to work in Vietnam. Vietnam is a high need country. I was able to say to the director who had this passion to want to provide those kinds of services and to learn from that risk society, ``Go do it.'' If I had been in the provincial ministry I would not have been able to do that because of all the intergovernmental relations and so on that are necessary to pursue in that sector.
Dr. D'Cunha: I see a national public health agency as something similar to what Quebec brought in at that level. It is similar to what Mr. Zapp just indicated. You want to give that agency the ability to act swiftly.
When it comes to interacting with the provinces and territories, as Dr. Massé said, there has to be some prediscussions so that the roles are clearly defined. Much as we may pooh-pooh the legal aspects, unfortunately, and I will use SARS as the example, we made SARS a reportable communicable disease in March. Thus, we had public health legislation right down to the local MOH level. Even if SARS was not made reportable, communicable and virulent, the Ontario Minister of Health, in statute, and the Chief Medical Officer of Health were authorized to make it such. Since the day I took the position, I have always been authorized to do so. There is a clause in the act that allows me to deal with any disease that is infectious. Just because it is not named, or a new one pops up, I still have the legislative ability to make it so.
To make it easy, instead of having two of us in Toronto, or wherever we may be, with exclusive power, once the disease entity was established, we did the appropriate paperwork and brought it into the legislative framework. Thus, we have not kept ourselves vulnerable.
Until Health Canada changed the quarantine regulations Ontario was the only jurisdiction that had smallpox covered in its legislation. The Ontario act does not bind the federal Crown, which is a bit of a challenge, because in the complex world that we call Canada and federalism, some entities are under federal jurisdiction, for example, the railways, insurance and the banks. I do not believe in letting the law come in the way of doing what an essentially good job. We have to be cognizant of that, plan for it and put it in place. I see the relationship as being collaborative and building in extra capacity. If there is one thing we have learned by now, it is that we need the capacity in public health.
Mr. Butler-Jones: Concerning SARS, we did know about it in November. WHO knew about it, but not in an official way and therefore could not act. That is why they have revised their regulations in terms of the ability to investigate outbreaks, rather than it going on for months and months.
There are many other little outbreaks like that in the world going on all the time. Most do not amount to anything. For example, there was an avian influenza in Holland at the same time as SARS was going on.
In terms of a national agency, it has to be a collaborative model. There has to be some kind of broad advisory board. It is linked to the federal government. It has to have broad advice to it. Its role is in strategic leadership, support and facilitation. It brings resources to the table, whether it is people placed into agencies at the provincial or regional level, or a combination of that, with other grants and other kinds of work, et cetera, to basically try to develop a system in collaboration. Some will agree, while others will not. However, when it comes to the middle of a crisis, for example, with the CDC in the U.S., the individual states do not say that they want to handle the problem on their own. Part of that is dependent on credibility, expertise, resources and the ability to bring experience to the problem that is not available at the state level.
Timeliness is an issue. For example, if CBC Newsworld called Dr. Paul Gully and asked him to discuss an urgent issue that they have heard about I do not think he could talk to them. Whereas Dr. Julie Gerberding, head of the CDC, is heard from if there is an issue. She provides the medial with constant messaging. She can take to state governors, if that is necessary.
Again, we must be cognizant and respectful of the political process.
Senator Callbeck: You heard the discussion this morning with Dr. Massé about the federal government putting more resources into public health. It was mentioned that one way would be for the federal government to pay a certain percentage. Another way would be for the federal government to pay for qualified people to be integrated into the existing systems. How should the federal government make that contribution?
Dr. D'Cunha: First, I welcome contribution from all levels of government because we all have a stake.
I do not necessarily reflect the views of the Government of Ontario. I will reflect my views as Chief Medical Officer and as a professional public health physician. From my perspective, I think both models can work. As Dr. Massé said, it is a matter of discussion.
As long as that enhancement comes and it works, and I understand that people do not give you money without understanding what they are buying. Reflect for a minute. When you want to buy something in a store, you want to know what you are buying. The discussion has to occur.
Let us say, hypothetically that I am in Saskatchewan and the federal government decides to place federal employees in the province. I will ask only one question, and that is a very practical question: Who has command and control over them? Frankly, I do not care who pays the cheque. If the jurisdiction does not have command and control, then I will want a negotiated protocol. One example is the CFIA. That is not a good model to use because sometimes there is a conflict of interest, being the food puller and the proponent of agriculture at the same time. However, the CFIA has negotiated an understanding, a priori, with jurisdictions. Right now in Ontario, we have food recall protocols that the CFIA and I are party to. There is a standard clause. You ask each other for mutual assistance and aid, and the command structure is clearly articulated; that is, are you using CFIA regulations to pull something or are you using public health regs in which case the accountability is defined.
Mr. Butler-Jones: It is a bit of combination. Right now, we have federal field epidemiologists who work in provincial governments and even in some regional positions. They are part of that organization, but they reserve the right to pull them out in an emergency and they have certain national responsibilities as well. That is an added resource and usually you provide office space, et cetera.
We already have some elements of that model that area similar to the U.S, but they are small and there are not very many of them. Most of us do not have them. The last time Saskatchewan had one was five years ago. There are positions, potentially, that could provide and could be pulled out to allow some flexibility and application.
The issue of cost-sharing is also complementary, because the general infrastructure gaps are an issue. I think Mr. Massé spoke of the need to tailor the system on the needs of the region, the other capacities, et cetera. Thinking in terms of the system, on the prairies, there are certain positions and we will never have a regional centre on the prairies. However, we want to be able to access the person in B.C., or Ontario or Quebec, et cetera. It requires a lot of negotiation, discussion, and some sense of where we want to get with this, what it is we are trying to accomplish, and what it will do for people.
Mr. Zapp: This is a tough one. It is not just money. Yes, the public health system has been long neglected. It sees 2 per cent or 3 per cent of the total expenditure in health care in Canada. We can do better. B.C. can do better. We can do better collectively. What is the best practice? What resources do you need for best practice? How do you build surge capacity that has the kind of performance outcomes you would enjoy in the jurisdiction when you do not have a disease? All of that has to be created. There is no ideal set-up. B.C. is not ideal; nor is Quebec. Can we learn from each other and have some accountability to a national performance expectation? Sure, we could.
Senator Callbeck: Mr. Zapp, in your presentation, under the budget, you say 40,000 prescriptions filled. How are they filled?
Mr. Zapp: That figure refers to prescriptions filled for tuberculosis. Essentially, we provide those services, for example, for sexually transmitted diseases, again, we essentially provide to treat. I think the number is a little out of date. Also, we are the kidney dialysis pharmacy for the provinces.
Senator Morin: I would like to come back to human resources at the provincial level. Dr. D'Cunha, you said that this is a serious problem. What is your view on this? How can we correct this? What can the federal government do to help correct this very serious situation of lack of human resources and the public health field at the provincial level?
Dr. D'Cunha: Speaking for all chief medical officers of health, we need to determine a long-term, medium-term and short-term strategy. We have had discussions and conversations, not with just the federal government, but with the provinces and territories, universities, polytechnics and community colleges. Our public health resources are trained in a variety of settings. We have to be careful not to cherry pick and steal from other jurisdictions to solve our individual problems while creating a problem over there. We have to look at the whole concept of public health human resources in a broader picture.
In the short term, we need to go for quick continuing education packages. Health Canada has done some pioneering work on this and is working to transfer skills to skills enhancement projects. That is the quick, short-term fix.
Through the university, community college, polytechnic approach, we need to design more capacity to teach, more spaces to teach and have some of us in the field go out as talking ambassadors and ambassadresses so that high school students recognize that public health is a dynamic place to be and as competitive as being a bank manager and so on. In this way we can begin to attract young people to the field of public health. The gain from that aspect it is five or ten years in the future.
Then, we must find a cadre of individuals who are looking for career change and who have the basic skill set, most likely in the health sector. I will pick nursing, not because I want to pick on them but to make a point.
Senator Morin: Who are the people working in that field?
Dr. D'Cunha: The people working in public health are public health physicians. Those are few in terms of percentage of the whole work force. Approximately 50 per cent are public health nurses; 30 per cent to 40 per cent are public health inspectors. There is then the component for those provinces that have public health dentistry and public health dental hygienists.
It is not that all provinces do not want to do this. Public health is a feeder fish so that when the economy shrinks, the appetite to pay for certain things generally shrinks and governments, regardless of the stripe, start to look and perceive one thing as being less important than the other, and this goes off the table. This has happened as it pertains to public health dentistry. The new public health skills are in the area of chronic diseases and epidemiology. There, you have health promotion, health education, community health nutrition and epidemiology. Without the critical epidemiology skill set, you do not have the skills to analyse the data.
I used nursing as an example to show that the subtle difference between a regular nurse and a public health nurse is there for a reason. Some frontline nurses are looking for career enhancement and change and want to move to the prevention end from the treatment end. You have to design training modules for them. None of us alone can do this. We all collectively have to work at this together.
Senator Cook: Given that there is not a school of public health in this nation, how critical is that fact to the capacity building to which you refer?
Dr. D'Cunha: We can start to build capacity while we seek to establish a school of public health. There are a few universities in Canada where some of the elements required for a school of public health exist. There are public health skill sets at the University of British Columbia and at the University of Alberta. There are some public health skill sets, and Dr. Butler-Jones will correct me if I am wrong, at the University of Saskatchewan. In fact, more than Saskatchewan and Manitoba, Ontario Quebec the Maritimes have some as well. I do not want to fool you into thinking you have a four-wheel car, but you can start the capacity-building while you try to put all four wheels on the car.
Senator Cook: How critical is this to the critical mass that we are talking about?
Dr. D'Cunha: At some point, it is critical but it should not stop the process from beginning.
Mr. Butler-Jones: The old School of Hygiene in Toronto moved into the community medicine department and community health and epidemiology department. We have elements of schools of public health like you would find in the U.S. in faculties of nursing, faculties of medicine and joint faculties. The medical officers, for example, are trained in most medical schools. They have residency training programs, et cetera.
Harvey Skinner of the University of Toronto and others has been looking at developing the essence of a virtual school of public health in Canada. For example, the University of Alberta is now looking at distance education. I have been in negotiations with the University of Alberta and the University of Saskatchewan to provide at least Master's level training to physicians who want to work in public health but are not in a position to do the four-year specialty residency. There are a number of ways you can solve the problem, but it does require some thinking outside of traditional faculty boundaries and university boundaries to do so.
Mr. Zapp: When we were thinking of the B.C. concept, we went south of the border and talked to people at CDC Atlanta and recognized their relationship with Emory University. We also went to a more county-based facility in North Carolina and found a close relationship with North Carolina University. That emphasis as we build a network around ensuring that the appropriate network of universities and colleges is also coming to support to the development is critical.
The Chairman: I thank you all for coming. When I looked at the decision tree slide that showed the B.C. coordination and management of SARS, I absolutely marvel that anything happened.
Mr. Zapp: It was a three dimensional chart.
The Chairman: I thought there was not only no one in charge but no one who really knew anything about what was going on.
Mr. Zapp: That is the white space.
The Chairman: What you pulled off in light of that organization tells me that a lot of things happen outside the normal organizational structure.
I was very intrigued by Mr. Zapp's comments that a lot of the things that he does could not be done if he were inside government. As a former federal and provincial deputy minister, I understand exactly what he meant by that. The realty is that the one thing that government is not structurally capable of doing is developing a decision-making structure that is outside the normal routine. When you are in a crisis that is exactly what you need to have.
I look at that chart, and it reinforces my view. It also tells me that, whatever the ultimate recommendations of the committee, it is clear that, in a crisis, you better not be running it by a bureaucracy. In other words, whoever is running it had better be outside the system.
I would like to you to do one thing, although not right now on the record. I would like to know who is on your board and how your board is chosen. I would like to know the exact relationship between you and the government that appointed you because it seems to me that, whatever it is, it seems to work. You are able to operate outside the basic bureaucratic system. Can you take two seconds to comment on that?
Mr. Zapp: It is in development. We had an independent board appointed by the Minister of Health with Perry Kendall, the Provincial Health Officer. We are quite connected to provincial interests and appointments to the board. We are currently in transition to the Provincial Health Authority Board, which are six authorities that are struck in B.C., and again, those appointments are made by the government of the day. It is really just a year in creation. I am an employee of this non-profit society that is responsible to that board's governance.
The Chairman: I think someone used the phrase, ``national public health agency.'' If that board, in some form or other, included all the provincial chief medical officers, my sense is you could accomplish a lot while keeping it outside, even if you structured it so you had voting and non-voting members. One of you is a chief medical officer, and one has been. Would that sort of model deal with getting around the bureaucratic problem and also deal with the coordination problem to which you refer?
Dr. D'Cunha: I have always had full rein to do professional things. To the end of this year, I was director, and now I am an ADM commissioner. For that side of the operation, when I go to spend resources, I have to follow civil service procedures and policies. I can do some emergency spending, but I would have to justify every last penny, subject to civil service rules, and sometimes that does pose a challenge. I do not want to be naive and suggest just spending the money and you will get away with it. Clearly, there are advantages to the Crown agencies, arm's-length agency, call it what you want. You have boards and agencies like CFIA at the federal level where this can be achieved.
The Chairman: Can you comment on the notion of doing the integration through the board, that is to say, having extra-provincial people on the board?
Dr. D'Cunha: I would say not only provincial chief MOHs, but you need some of the other people active in public health outside government, because that is critical. I am referring to academia, some of the field at large, to name but a few.
Mr. Butler-Jones: Just to tell you quick story, we were seeing another rise in hepatitis A, going to a new outbreak every ten years. We see nearly every kid under 15 years of age in the north in aboriginal communities develop hepatitis A. A few die. We had a new vaccine. I was discussing it with First Nations health and our health regions and decided that it will cost me $125,000 to buy the vaccine. We made the decision after two meetings. We did it, and we essentially wiped out Hepatitis A in First Nations. I got my wrist slapped for it. If that had gone through the bureaucracy, we would still be arguing over whether the federal government should be paying for part of the vaccine, because it is aboriginal peoples. et cetera. However, that is not consistent and is not available to everyone. We do not all feel that way about how we do our job.
In terms of the advisory structure, I would see not so much a council of chief medical officers as the board for this agency, but that is one of the functioning groups related to this agency, but in terms of the governance, or advisory board is perhaps the better term, that would require federal and provincial representatives, as well as some external expertise, to oversee how this thing is all coming together. Ultimately, we would report to the Minister of Health, and there are links back into the regular FPT processes, but it has a board of people who are chosen because of their perspectives in the nation, their competencies and their ability to reflect the broad issues that Canada faces in trying to pull this together.
Senator Morin: That was very well said.
The Chairman: Dr. D'Cunha, that is what you were trying to get to.
Mr. Zapp: Wynne Powell, the chair of our Provincial Health Service Authority is the head of London Drugs. He has quite a different attitude about how he thinks we operate. For example, he has at his fingertips, when he starts up every morning, exactly the movement of sales the day before and graphics, all to support his decisions around what to do next for the marketing interest of London Drugs.
My point is that I think we can learn a lot from other industries. Having them around the table, listening to problems that we bring there, and for them to apply technologies and ideas that have proven successful in their market place can be useful in ours.
The Chairman: I realize we indulged on in your time a lot longer than we intended to. Thank you very much.
The committee adjourned.