Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 23 - Evidence for October 9, 2003
OTTAWA, Thursday, October 9, 2003
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 11:00 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: Honourable senators, we are here today to hear from Dr. Naylor, the Dean of Medicine at the University of Toronto. He released on Tuesday a truly outstanding report on the issue of public health in Canada. We are delighted that he agreed to spend some time with us this morning to talk about his recommendations and the steps that ought to be taken to begin to move from, essentially, the report stage to the implementation stage. There is certainly a consensus around this table that the time for talking is over and the time for action is here.
One of the witnesses yesterday put it very cleverly. One honourable senator asked when action should begin. The response was, if not now, then when? That is exactly where the committee is.
Dr. Naylor, thank you very much for coming. We are overawed, not only by the quality of the document, but also by the speed with which you were able to produce it. We have always been proud of how quickly we produce documents, but you beat us by a wide margin in terms of the speed and the volume. It is truly an outstanding document.
Dr. David Naylor, Dean, Faculty of Medicine, University of Toronto: Honourable senators, thank you for the privilege of appearing before you this morning. I also wish to congratulate this committee on its outstanding work in the health sphere. Many of us who work in health care or public health have been very impressed with the committee's output over the years and have been inspired and guided by it. Thank you for that.
Two days ago we released the report that the chairman has kindly described in positive terms. I want to return to a couple of the messages from the day of the release because they are evergreen messages.
All of us who served on the committee offer our condolences to the 44 families who lost loved ones to SARS and our sympathies to those who fell ill and the countless individuals whose lives were turned upside down or affected in many adverse ways by this outbreak.
We also want to thank and salute all the public health care personnel and workers for their efforts in containing the outbreak. They showed great courage in the face of an unknown threat. I cannot emphasize enough that seldom in the history of medicine, health care or public health have we had a situation where a new disease appeared, spread so quickly and was characterized so rapidly. We have not had a situation in recent history in this country where a disease took such a toll on health care workers and wore down public health care personnel so completely.
I also want to acknowledge the general public. With remarkably few exceptions, Canadians conducted themselves well during an extremely anxious period. We can all take some pride in that.
As I have said repeatedly on behalf of the committee, although there are many heroes of SARS and many people who rose to the occasion brilliantly, there were fundamental systems deficiencies that became apparent, many of which are longstanding.
In commenting on some of the system's deficiencies, the committee was not mandated, nor inclined, to name, blame or shame individuals. Our goal was to move and improve systems.
Our mandate, more specifically, was to provide a third party assessment of current public health efforts and lessons learned for ongoing and future infectious disease control. We were very appreciative of the Honourable Anne McLellan's support in giving us this mandate.
I would be remiss not to take a minute or two to comment briefly on some of the ways in which we were supported by Health Canada. Not only did we have excellent access to information, very fine support logistically and research evidence put at our disposal, repeatedly and well, but we also had another, more important privilege. The minister, deputy and the relevant assistant deputies all made it clear to the professionals working in Health Canada that they should be interacting with us first and foremost as professionals and second as citizens. They were to be candid, critical and open and give us their best advice, independent of any bureaucratic or political preferences.
It is remarkable that this is how things worked. It really was a privilege to be interacting with so many fine individuals on that basis.
What were the lessons that we learned? We quickly learned that Canada's ability to fight outbreaks such as SARS was integrally bound up in the strength of our public health system at all three levels — local, provincial and federal.
Members of this committee will know that public health consumes two or three cents out of every health dollar spent in Canada. It is perhaps indicative of the extent to which public health operates in the background. It is not entirely clear whether it is 1.8 or 3.5 cents on the dollar. Even the exact costs are debatable.
Public health is not glamorous. It tends to make headlines only when there are crises such as BSE, West Nile, Walkerton or North Battleford. Its focus is on the protection of health and the prevention of disease or injury for entire populations.
SARS illustrated vividly the importance of simultaneously strengthening and connecting community-based health and infectious disease control in clinical settings. In this sense, there is a continuum in public health, from the community to the clinical settings, that we have not paid full attention to in the past.
I should also note that it is easy in hindsight to second-guess the decisions and strategies of those on the frontlines battling this outbreak. The commission that is currently investigating the Ontario outbreak, led by Mr. Justice Archie Campbell, will be sorting through a number of these details.
We saw more than enough in the way of details to have a bigger picture in view. We had no trouble reaching the general conclusion that all these individuals and teams eventually succeeded in containing SARS despite multiple and serious inadequacies in our systems for disease control, surveillance and outbreak management.
There were deficiencies in the way that the public health and health care systems were organized to detect and respond to an outbreak like SARS. Some of these were due to resource constraints or shortfalls in the supply of skilled personnel. Others were due to lack of preparedness and planning, failings in organizational structures, problems of political culture and poor collaboration and communication across various institutions, agencies and governments.
These are longstanding issues and have been pointed out by many observers. Their relevance to the health of Canadians has been underscored by various health crises and disease outbreaks over the last decade.
SARS is the most recent example of emerging infectious diseases. West Nile has been another prominent, recent example.
Since 1973, more than 30 previously unknown diseases associated with viruses and bacteria have emerged. Threats that emerge in other countries can be in Canada within a few hours by airplane. Compounding the problem of emerging and resurgent infectious diseases is the tangible threat of bio-terrorism that has been brought home to all of us by the intentional release of anthrax spores in the U.S. two years ago.
Meanwhile, experts all over the world have been planning for and expecting pandemic influenza, a worldwide epidemic of killer flu that could affect 10 or 20 per cent of the population.
Let me summarize some of the recommendations for you: a national strategy for surveillance and control of emerging and resurgent infections; support and enhancement of the infrastructure necessary for surveillance; rapid laboratory diagnosis; timely intervention for infectious threats to health; coordination and collaboration in setting a national research agenda for emerging and resurgent infections; a properly funded national vaccine strategy; a centralized electronic laboratory reporting system to monitor human and non-human infections; and better capacity and flexibility to investigate outbreaks in Canada.
Another expert group convened under Health Canada's auspices made those recommendations 10 years ago, as honourable senators are aware. We have essentially repeated the recommendations one decade later. That is why my colleagues and I say that it is past time for all levels of government to take action on these issues.
Our 75 recommendations, as honourable senators will have read, have many action items. We paid particular attention, given our mandate, to the implications for the federal government and federal-provincial-territorial interactions. We also made a number of recommendations squarely directed at provincial and territorial governments, as well as institutions, local public health officials and health regions.
I will take only a few minutes to comment on some of the major recommendations because I know that honourable senators will have questions. We have recommended that the Government of Canada establish a Canadian agency for public health analogous in some respects to the U.S. Centers for Disease Control. We believe that an agency operating at arm's-length from Health Canada would enhance the federal government's ability to support local work in disease control and prevention. It would bring a professional and scientific focus and move us away from some of the issues that may be coloured by political or bureaucratic considerations. We believe that an agency has the particular merit of helping to build a more collaborative culture among public health professionals in different levels of government. In essence, we are envisaging that the traffic would occur among public health professionals who are joined together by their commitment to protecting health and preventing disease, with politics pushed aside.
Another advantage of having an agency is that it would provide a clear focal point for Canada to manage health issues at its borders and to interact with the global community. We saw during the SARS outbreak that the World Health Organization has increasingly asserted a transnational governance role in public health issues. We have felt, as a result of our deliberations, that Canada can only remain credible in the global health community if we have a focal point and if we are able to ensure that the public health systems collaborate with clarity about leadership and that they interact effectively through a single channel with our international partners.
I will say a word about leadership. We have recommended that a chief public health officer of Canada lead the agency. This individual would be a public health professional reporting directly to the federal Minister of Health.
Honourable senators will have seen that most of the short-term spending we recommended was targeted to infectious disease surveillance and control. The reasons for that are obvious. I wish to attempt to debunk some mythology about the U.S. Centers for Disease Control because it continues in all areas.
The CDC used to be called the Communicable Diseases Centre when it was established after World War II — that was its focus. Battling outbreaks continues to be a source of much of its positive press, hence the mythology of the cavalry riding in from Atlanta to rescue a municipality or a state in the throes of some infectious disease.
In the past, the CDC has addressed a full range of preventive issues and health threats. The full name of the CDC today is ``Centers for Disease Control and Prevention.'' We almost wish that they would change the acronym to make that point. The CDC has a full portfolio of public health activities. Many of those activities are closely related and mutually reinforcing.
For example, the surveillance system that one sets up for infectious diseases can be transmogrified into a surveillance system for chronic non-communicable diseases. The same information systems, the same businesses processes and the same agreements on data sharing can all be put in play to create the parallel surveillance system. This is why we have strongly recommended that the new federal agency must not only be outstanding in the field of effective disease control and prevention, but also a full-spectrum public health resource for Canada.
There is something else that we think is worth learning from the CDC: Much of its budget is directed to federal payments that flow to states and municipalities in support of their public health activities. The CDC uses spending power to leverage investments by other levels of government, to create uniformity and consistency and to promote collaboration.
A similar mechanism is used in Australia, albeit without a primary agency focus. We believe that the lessons from these two federal states are salient here in Canada, with our federal-provincial-territorial context.
Canada does not make specific federal transfers to support public health activities by the provinces and territories and the result is a flimsy patchwork for disease prevention and outbreak management.
The committee was aware of provincial centres of excellence in this field, which I will highlight: British Columbia's Centre for Disease Control, which has a strong infectious disease focus and is now broadening its mandate; and Quebec's National Institute of Public Health, which is a full-spectrum public health agency. Unfortunately, not all provinces have developed similar capacity. The lack of such capacity in Ontario was one reason why there were difficulties in managing the outbreak.
We have specifically recommended that among the new funds that will flow through the agency, there should be dollars earmarked to build up provincial and regional centres of excellence focused on infectious diseases. We are also recommending as a companion piece the creation of a national network for communicable disease control. The goal is to create a truly seamless surveillance system and a fully coordinated response to major disease outbreaks.
There is a precedent here. The federal and provincial governments currently collaborate actively on a national network for emergency preparedness and response. This network was catalyzed by the tragic terrorist attacks on the U.S.A. in September 2001. We would like to think that the tragedy of SARS in 2003 might catalyze a sister network that could draw together provincial and federal centres of excellence, including those that would emerge as the agency provided funds to nurture and support them. This confluence of provincial and regional centres of excellence would truly be Canada's second line of defence against the next SARS.
The total of new federal spending that we have recommended would reach $700 million per annum by 2007, at the earliest. I have pointed out that this is what governments spend on health in Canada between Monday and Wednesday in a typical week. We are well aware that this is not a small sum of money. We think that, under the circumstances, it is a minimally prudent investment to make. Further, we think that provincial and territorial spending should leverage it.
Rather than review the many other recommendations in this report, it would be wisest at this time to wrap up and take questions on areas such as research, international issues, local and regional matters that we delved into and, of course, the area of human resources, which is very important.
I believe I can safely say that the National Advisory Committee on SARS and Public Health found that there was much to learn from this outbreak because too many earlier lessons had been ignored. Canada's ability to contain an outbreak is only as strong as the weakest jurisdiction in the chain of disease control and health protection. We have, accordingly, recommended strategies to reinforce all levels of the public health system and also to integrate those components more fully and effectively with the clinical care sector.
One of the more than 30 submissions to our committee suggested that SARS was a reminder, a warning and an opportunity. The committee hopes that our report will also be seen as a reminder, a warning and, above all, an opportunity for us to renew public health across Canada and make some overdue improvements in our health care system.
We are grateful for the chance to present these views and to answer your questions. I sincerely hope that this committee and the Senate will be supportive of what we think is a very important set of initiatives that must be undertaken by all levels of government if we are to be better prepared for the next major disease outbreak.
Senator LeBreton: I must congratulate you on this report. I have not read every page. I have read the parts that I have been focusing more on in this particular study. I must say to you, as a person with a non-medical background, I particularly appreciated the language in which the report was written. It was clear and easily understood. It is a great help to not only the people in the profession, but the Canadian public as well.
I have two questions. First, following the line of questioning I have pursued before, we have heard from you and from other witnesses that there was first knowledge of the outbreak of SARS in November 2002. Yesterday, the Canadian Medical Association said it was like a ship without a captain suddenly appearing offshore. It did not become known to the public until March 2003, a period of some four months.
I know, from your report and the recommendations, there are many things in place that will prevent this situation in the future, including the World Health Organization changing some of its guidelines. In the interim, until we take the step of implementing the recommendations of your report and, perhaps, this committee, do you feel that there is currently a better system in place in the world that would zero in and highlight another emerging illness, so it will not take a little over four months for the scope of it to be truly realized?
Dr. Naylor: We have made progress in terms of the awareness of the global community of the need for surveillance systems to be enhanced. The World Health Organization, whatever the reservations many Canadians have about the travel advisory, has shown a very strong interest in moving the surveillance agenda forward, and coupling that with the necessary alert systems so that countries are notified of emerging threats.
It is easy to look back and see now that in November 2002, it looks like we had SARS emerging in Guangdong, China, and to wonder why we did not translate the full body of the relevant report.
I am sure that as international lessons-learned exercises unfold — and we have multiple countries trying to track back to what they should have known or could have known when — that we will be asking ourselves, ``Why not earlier? Why did we not understand this was afoot?''
The answer has two dimensions. First, we are better prepared, but there is still a huge amount of work to be done. The work is, on one level, for international self-scrutiny to occur, to figure out how we can have a better-coordinated international surveillance system. As we say in the report, there also needs to be capacity-building in developing countries. There is, I believe, an obligation — some would call it enlightened self-interest — for prosperous countries with strong knowledge-based industries and scientific capacity to work with the developing world on surveillance issues.
I also believe there is an acute need to make sure that we have better alert and intelligence systems inside Canada so that it is very clear that if information comes to Health Canada and moves down, it gets to the front lines quickly.
The doctor in the emergency room must know if she is dealing with some new and strange illness, that it emerged from somewhere else a month or two ago, and here is what is known about it. The current systems do not adequately do that.
Senator LeBreton: Your report has many recommendations on the whole issue of public health, and you made the statement in your opening remarks that public health is not glamorous. Yesterday, we had the Canadian Medical Association and the Canadian Nurses Association pointing out to us the lack of attention to the public health side of health. I know you have several recommendations. Perhaps, just for the viewing public and the committee, you could tell us what you think we could do, or the public could do, to make public health a field that is seen as more enticing and more ``glamorous,'' for lack of a better word?
Dr. Naylor: I answer this question with a bad conscience as a dean of medicine. I am sure that all of us who lead medical schools could and should do more.
In our medical faculty, we have tried to change the understanding and perception of community health issues. Our MD program, for example, has a cross-cutting theme called ``determinants of community health.'' It is designed to provide an understanding of the broader context in which physicians will work. It pays a lot of attention to public health, as well as health care issues, and tries to link them together. I believe there are similar courses in many MD programs now. I know that some nursing programs have taken similar steps.
We can and should do more to enhance students' understanding of the fact that these are very important disciplines and areas in which one can make a huge contribution. Educationally, there are things to be done.
However, on some levels, it may come down to creating a career structure and a compensation system that make these disciplines more appealing. Community medicine is not a particularly well-compensated specialty compared to other high-tech procedural specialties in medicine. The career path in public health nursing is somewhat unclear. With the introduction of baccalaureate nursing, the diploma programs of old have tended to recede in importance and move off the stage. Therefore, we have individuals who train in public health after a nursing degree, more or less on the job. One would want to see a masters in public health and a PhD program that would create public health nurse leaders.
One can go through one discipline after another and see the need for bursaries, scholarships, curricular restructuring and clarity of career path so that people have a sense that there is a future, and also that they can make a difference. What draws people into the health professions — and this is perhaps the naive view of a dean — is a desire to make a difference, to have a positive impact on the health of people. You can do that at the individual level as a caregiver, or you can do it at a community or population level in public health. These are both wonderful ways to spend a working life.
Senator Morin: First, I should like to congratulate Dr. Naylor on this remarkable report. It is one of the best reports I have read. It reads easily. It is dense. It is remarkably well written. I asked Dr. Naylor this morning who ``the pen'' was, because you always need somebody.
He told me that he was. You can understand the amount of work here. It makes for a much better report than using an expert to actually write.
The Chairman: I trust, given what one always hears about doctors' writing, that the pen was not a real pen but a word processor.
Dr. Naylor: I emphasize that this was a team effort. A huge number of people drafted items here. My role was editorial. I did do some drafting. The final manuscript did work its way through my computer but I want to give credit to a fabulous team.
Senator Morin: I like the fact that this report covers the entire field of public health. There is nothing to add to it. Our role is to make sure that these recommendations are implemented by the government. It is such outstanding work.
I would like to address one specific issue, if I may. The Winnipeg lab is the only level-4 microbiology lab in the country, and one of the few in the world. It is a reference point and focus of expertise in the country. It does play, and should play, a leadership role. It is a remarkable physical facility that I had the opportunity to visit twice. The physical infrastructure is remarkable.
It also has outstanding, even world-renowned, scientists. Its leader, Dr. Plummer, is a world-renowned scientist who testified here.
I have met with provincial public health authorities. They have past and future concerns with the Winnipeg lab. In the past, their concerns were about scientific and administrative issues. On scientific issues, they were concerned with the statements coming from the lab, made repeatedly and publicly and in various international meetings, that the corona virus was not responsible for SARS, and other more recent statements that we had a SARS outbreak in an old people's home in Vancouver.
We all cite probabilities. Perhaps these statements should not have been made publicly. I know that provincial authorities at one specific international meeting were rather embarrassed by some of these statements. They felt more prudence should have been demonstrated.
The provincial authorities also complained about a certain lack of cooperation with the provincial labs. The specific example given to me is that reagents are not shared. Apparently it is an important issue, although I am not an expert. If they want to reproduce some of the findings or diagnoses, reagents should be shared. That is one of the roles of the reference lab.
There are unacceptable delays in getting results. There was one example of a result being received 14 months after the specimen was sent.
There is a more general issue with quality control. The provincial authorities said these things.
These are important issues. I am surprised to see that they are not mentioned in your report that covers the rest of the field so well. It is extremely important because the Winnipeg lab should be the mother ship of all other public health labs in this country.
It has everything going for it. It has outstanding scientists, excellent facilities and the proximity of an animal lab. It is unique in the world on that issue. It is now well supported by Health Canada. The funding has improved over the years. There are a number of recommendations that we might make that would help it play this important role in public health.
Do you have comments on that?
Dr. Naylor: Thank you very much, senator, for the positive comments on the report and for a challenging set of observations.
On one level, my instinct is to say that the broad set of criticisms of the National Microbiology Laboratory is best addressed by those in charge of it. Replies to some of the specifics are very much in the bailiwick of the current leadership of the NML. At the same time, I do think it is incumbent upon me to reply to some of the broader issues you have raised because they are salient to the future of public health in this country.
Let us think about the question of whether the leaders of the NML stated that the corona virus was not responsible for SARS. As I heard them, those statements were, first, it was too early to be sure, and second, a metapneumovirus has appeared in some of the specimens that could be the cause.
It is intriguing that statements that represent appropriate expressions of scientific uncertainty, in the heat of an outbreak, with concerns about risk communication and desire for social solidarity even among the frequently argumentative scientific community, carry a very different weight. You used the term ``prudence.'' I would like to take that word as a jumping off point and speak to the issue of risk communication, which was one of the themes in the report.
There is clearly an art form, in which those of us in the quiet groves of the academy are not necessarily schooled, in sharing information with the public and with practitioners during an outbreak. There are risks. There are uncertainties and threats. Matters that are best hammered out in the boardroom of a scientific institution may not necessarily be best aired as public speculation.
This speaks to a broader issue. We need to have a communication strategy. We need to be able to have, in the background, absolutely brilliantly informed and intellectually honest debates about that with which we are dealing.
We should share our uncertainties to some degree with the public, because the public deserves our respect. They are able to understand risk better than we give them credit for. They can manage uncertainty, as long as they know something is being done about it and there is a set of actions they can take. However, making the call on what uncertainties should be shared is something that requires judgment and training.
On the issue of reagents not being shared, I would urge that those questions be put elsewhere. I am not aware of the specifics. I want to speak to this broader question of the reference laboratory role.
During SARS, we saw various hospital laboratories doing tests because the central public health laboratory in Ontario was overwhelmed. The result is that we had different laboratories using different reagents developed locally to test for SARS. This, in turn, can lead to quality control issues. It also undermines our ability to gather information because there is no centralized database.
This hospital has a few patients with the clinical and laboratory data and another hospital has a few patients with clinical and laboratory data, but no one is pulling the two together.
We have strongly urged that the Canadian Public Health Laboratory Network be strengthened and given a much more formal role in laboratory quality control and coordination. In so doing, we will empower provincial and private hospital laboratories to take a greater role in creating this kind of reference laboratory function for the NML and for some of the provincial labs. It will create a two-way street. That is currently the intention of the CPHLN and I think the kinds of criticisms you bring forward need to be incorporated into reforms of and enhancement to what is basically a sound structure and a very good idea.
Last, on the role of the NML in the Surrey nursing home outbreak, I am drawn back to my initial comments about the way in which one puts information out. Outbreaks are science in a fishbowl. I can only speak personally, senator. I watched the CBC coverage and I heard a colleague for whom I have the highest regard say that there are some similar sequences and this could be SARS. I did not hear a definitive statement that this was an entire genetic sequence that made us scientifically certain that this was the SARS corona virus. I winced because I could imagine how this would be interpreted.
I am drawn back again to the view that we have to learn how to put information in play so that scientific uncertainty is acknowledged without inadvertently creating confusion.
Senator Callbeck: I want to congratulate you on a comprehensive report that is very easy for the layperson to understand. I commend you for that as well.
You have many recommendations before us. If these recommendations were implemented and if there were a SARS outbreak in my province of Prince Edward Island, what would happen? Who would declare a state of emergency and who would mobilize the resources?
Dr. Naylor: May I ask a few questions to clarify the dimensions of the outbreak before I answer you? Is the outbreak confined to Prince Edward Island?
Senator Callbeck: Let us look at it both ways. It is confined to Prince Edward Island and it is not.
Dr. Naylor: First, in this imaginary and positive alternative universe, when the next SARS begins to emerge, alerts will be sent out widely. The first time that it turns up in Berlin or Singapore or anywhere, there will be a series of alerts worldwide saying that virus X or bacterium B is on the move.
Those alerts would rapidly filter through the Canadian public health and health care systems. Your medical officers of health and your health care leaders would both have immediate alerts from the Canadian agency for public health and the desk of the chief public health officer saying that there is a problem.
If it were a known agent, there would be a well-understood and agreed protocol as to what should be done. There would be a common set of business processes on how to respond. Therefore, instead of making it up as they went along, these individuals would have the comfort of knowing that there was a national consensus, if you will, on best practices, and they would be able to follow those.
Because there would be cross-discussions between jurisdictions and some understanding of the strategies to be used, they would also have had time to think through the unique challenges of battling an outbreak on an island and in a jurisdiction where some of the tertiary resources are not in place. They may have decided that individuals should be moved in a collaborative arrangement to, perhaps, the Queen Elizabeth II Hospital. They may have an understanding of where exactly the negative pressure rooms were in available hospitals and have a whole protocol to determine that a patient go from the emergency room contained area to a negative pressure room for observation, and if there is deterioration, the patient would be transferred to Nova Scotia, because a complete understanding would be in place beforehand that that would be done. We would transfer them in a secure and safe way so that ambulance paramedics transporting them are not put at risk. All the protocols would be worked out beforehand.
If it were a new agent, then you would expect that there would be rapid support from the Canadian agency for public health. The Government of Prince Edward Island would call for help. It would be understood that there are protocols for collaboration and the national agency would be in place to quickly provide support on the ground according to understood processes and protocols. Help could be called in.
If things began to spread, you would have surge capacity in the form of health emergency response teams. They would be brought in from other jurisdictions. They would be already set and mandated to help. They would be epidemic response teams that could cover public health functions or clinical care functions. They would be ready to go in advance. The licensing issues would be sorted out. The malpractice premium issues would be sorted out. They would come in within hours to help your people out.
If the outbreak spread and you needed additional support from the standpoint of public health, there would be reciprocal agreements with other provinces to send in public health nurses and quarantine officers, and you would have the on-the-ground support at the community level that would also help you to manage the outbreak.
A combination of factors: Better technical support from the federal government, agreed processes and plans and reciprocal agreements with other jurisdictions through the national network for communicable disease control. This would not be a situation in which we would simply write in a blank book. Everything would be in place. There would still be gaps to be filled in and things to be understood and investigated, but you would have the protocols and processes that you needed in Prince Edward Island to fight the outbreak.
Senator Callbeck: The agency would make the decision on whether human resources would come in.
Dr. Naylor: No. The health emergency response team concept that is being developed by the Centre for Emergency Preparedness and Response, with this national network, is clear that in an emergency, the jurisdiction would call in the emergency response team. Depending upon the nature of the threat, this would be funded by the jurisdiction that called in the response team, or it would be co-funded. If we were dealing with a national emergency, at that juncture you would be looking to the federal leadership. If multiple provinces were involved, then a clear mandate from new health emergency legislation would dictate that the chief public health officer would give the go-ahead and would provide the command structure for the whole country.
There is a need for clarity on the legislative side about when to trigger a move to a federal command and control structure. Obviously, it has to be a major threat in multiple provinces, but otherwise, the province would call in the help and it should be in place.
Senator Cordy: One of your recommendations is for one hospital in each region to deal with the outbreaks. Would that apply to the smaller provinces, such as those in the Atlantic region?
Dr. Naylor: We have recommended that one hospital in some regions is fine, but in other regions, because of the population density, you might have two or three institutions that are the leads.
The particular challenge is with both the physical infrastructure and the human resources. In some case, we need the physical infrastructure — the negative pressure hospital rooms, the anteroom so that one can gown and deal with the precautions in a closed space before entering the room or going out into the public spaces.
You also need in the same institution staff with an understanding of the special nature of the threat, and who are continually being educated to stay abreast of infection control issues. Where you have the firepower concentrated in some measure, we need to deal with patients who may be sick with a variety of highly contagious illnesses, and better protect the health care workers and allow them to care for the patients.
Whether it is one hospital, or three or four in more densely populated areas, we are emphasizing that we need to have some sense of who is ready to step in, and they need to be prepared.
Senator Callbeck: I have one other question. It will take considerable time to implement these recommendations. What do you recommend for short-term measures?
Dr. Naylor: We have given a number of immediate-term recommendations in the report. They are quite specific. They are on page 213, section 12(a) under ``Preparing for the Respiratory Virus Season.'' We are already into the season of colds and influenza. We have put down a number of recommendations for relatively urgent action, and we can only hope that these will be taken seriously and acted on.
Senator Keon: Thank you, Dr. Naylor. It is wonderful that this report has come out and been accepted by virtually everyone. I thought you were being your usual clever self at the press conference in Toronto in saying much of this is 10 years old. It had a great impact, and we must now get on and implement these ideas. Many of the ideas have been around for a long time.
The section to which you just referred includes some interim measures, but not the structural framework that you are seeking in the big picture. If we here in the Senate committee were to do something useful, it would be to lay out a critical path of implementation of your report and put some numbers and dollar signs on it in order that it become a pragmatic approach to a massive problem.
Having said that, I wonder if you would do a walk-through and give the highlights of the critical path of implementation. What things have to be in place first before we do something else if this is to work and then what things could follow a little later?
Dr. Naylor: It is very hard for me to set out the steps in specific order because reasonable people will disagree about whether it is B or A that should be first. Certainly at the committee level, we had considerable discussion around the first steps. Aside from the occasional moment when we threw up our hands and said, ``All of this should have been done yesterday,'' we did have some general agreement. I want to emphasize that this is difficult.
The first major part is the immediate recommendations. We are into the cold and flu season and we need to take some action. We need to be ready. We do not know whether SARS will come back. We do know, as we saw with the Surrey outbreak, that there will be many false alarms. There will be illnesses that look like SARS and hospitals will be inclined to put infected people into respiratory isolation and to put the staff who dealt with those patients, perhaps without protection, into isolation.
We need a series of protocols to minimize the upset and confusion in the health care system and in the public health system during this upcoming winter respiratory virus season. That is job one.
I emphasize it in part because I have heard it said that the public health and health care systems, certainly in Toronto, are still in the throes of post-traumatic stress syndrome. We have many individuals who rode a tremendously emotional roller coaster during this outbreak. There was a real threat of the unknown when this virus first appeared. There was tremendous anxiety and stress from seeing colleagues fall ill and patients die at a high case-fatality rate. There was relief when it appeared that it had been contained and a real trough of despair when the second wave of the outbreak hit us.
SARS 3 could have a devastating impact. We also have to prevent false alarms that could be demoralizing. This is the first set of priorities.
This is the set of action items that are as much in the bailiwick of the provinces and health regions as they are that of the federal government, but the federal government can do some things, as we said here.
The second major area of activity that we would recommend would be to push forward on two fronts in parallel. One front is the machinery around the agency. Obviously, we are not experts in machinery of government and can only provide so much advice on that front. We have spoken of a legislated service agency, but we would be remiss if we pretended that we are in a position to define all the steps that might be taken to get there faster.
At the same time, I do feel that we have to get there. We need an action plan to move towards an agency, because without a focal point and without strong leadership, much of what is here will simply fester in the bureaucracy. It will not get done.
There is a parallel track, because the challenge is to avoid having all the energy drawn off into creating the agency when there are some other things that need to be done in the medium term.
First, we must have much better surveillance. We need to improve and coordinate our surveillance systems, particularly for infectious diseases. In turn, that means we need to improve the alert systems back to the public health and clinical systems.
We need to have the machinery of the network for communicable disease control up and running, and we do not need an agency to do that. We need to draw together the relevant experts from public health, interweave them with health care experts and get on with a national network to think through the business processes for data sharing and how to fight multi-jurisdictional outbreaks more effectively.
Eventually, that will flow into the third stage, which involves things such as legislative review to harmonize and improve health emergency legislation. That is longer term.
The agency can be helpful there, but I only want to go as far as that second pair of steps; let us get the agency rolling, but not spend so much time and energy doing that that we are sidetracked from the fact that there are some medium-term things that we do have to spend some energy on if we are to be better prepared.
Senator Cook: This is a time for opportunity. It is reasonable, when we look at opportunity, to look at the current strengths and weaknesses and build on them. I see in the present system the strengths of a group of well-trained public health officials. We do have a corporate memory of an integrated public health system even though since the 1970s we thought we had it all fixed and did not need to focus on the infectious disease part.
We have a public health act in each province. However, looking at where we are now, we have decentralized our public health system and accountabilities. The new diseases are emerging at a rapid rate. There is a whole host of things that I try to wrap my mind around, but I see here a role for this committee, with advice from people like you. I did not have time to read your entire report. I went to chapter 12 and looked at your recommendations.
Senator Keon asked you to rate the recommendations in terms of what we should do first. I suppose the first thing we should do is get the flu shot and hope it is the right one. We need changes to our Canada Health Act. Public health has to be included in our provincial funding formula, along with the establishment of schools of public health. I know there are schools, but an enhanced curriculum is needed. These are some of the things that we can do now that will not cost a significant amount of money. It will come down to dollars and cents to do what we need to do for our people.
I can illustrate that by telling you a story. I met a couple of colleagues when I was home a couple of weeks ago and I said, ``What will we do if SARS comes? We have one tertiary hospital.'' One said: ``Do not worry, we have our public health system, we have our protocols and our plan, we are okay. However, Joan, we need you.'' I said: ``What for?'' She said: ``We need a dedicated funding formula.'' With all of the information that we are receiving here, I think we can help as a Senate committee by addressing the legislative weakness and making sure that the funding comes through, because we cannot be all things to all people.
I would like you to respond to that. If we are to be partners in a process — and there are a number of us with different skills — and to embrace this opportunity, I would like to hear your comments.
Dr. Naylor: I certainly agree with what you said about federal support to galvanize and enhance public health activities at the provincial and regional level. I just want to provide a perspective on a couple of the specifics in your remarks.
First is the question of whether we need to change the Canada Health Act to include public health more squarely. We considered as a committee whether that would be a way forward but did not feel that given the health care focus of the act, we needed to embed public health there. In fact, one of the committee members cautioned that in so doing we might find that the clinical dragon would eat up public health again, as so often happens.
We certainly agree with your sentiment that legislative renewal of some type is part of this equation. There is a chapter on legal issues in which we had excellent constitutional input from a legal expert, Sujit Choudhry. I wish to emphasize that a lot of that chapter is from Sujit Choudhry's pen. I am sure my editing has done damage to his fine prose but he deserves the credit for the fine constitutional work in the document.
The second point is that we have a public health act. Some of the decentralization has led to diffused accountability. There needs to be continuing work on defining the best practices and structures for delivering public health programs. There is probably no one-size-fits-all. We know how diverse the country is. We know that the culture and context varies by provinces and territories so that there will be differences.
Observers in Ontario informed us that the municipalization of public health in that province meant that half the funding was coming from the municipalities and a very strong local approach led to lack of coordination during the outbreak response.
Of course, public health is, in the first instance, local. You need to build it up locally from the front lines. It needs to be embedded in communities. You need medical officers of health and public health nurses who understand their communities intimately, but you do need coordination and a whole set of processes to draw the system together. We would agree with you that that is extremely important.
On the question of a funding formula, we have proposed something very much along the lines of the Australian and U.S. precedents. We are imagining a very strategic approach, rather than putting a large pot of money on the table that people can fight about and having the accountability vested in broad indicators in relation to that money. The agency itself holds funds that flow out to the provinces, so that the chief public health officer of Canada would be sitting down with the chief public health officer of Newfoundland and saying, ``Why do you not have your communicable disease chief talk to my communicable disease chief because we have this pot of money, this program, and it looks like you are already doing it, so maybe we should be moving those funds over to your non-communicable disease program to make sure you continue to get your fair share?''
In that sense we are imagining a social union framework model, in which first movers do continue to get their share of these funds, but we drive it out from the agency program by program, so there is accountability and a collaborative culture. We are, in essence, buying an integrated system by asking public health officials to sort out what it costs and how to do it.
The final point I would make is about how we create the health human resources. You mentioned schools for public health. Whether we need to go the American route of separate schools or faculties of public health, or whether we could do this in Canada as someone proposed, through a kind of virtual national public health institute, I leave to others to sort through. One can argue in either direction.
Many in this country would like to see a national public health human resource strategy that includes funding to support training and education, and certainly this issue is front and centre in this report. We have budgeted in the new agency many millions of dollars for just that purpose.
Those funds would not necessarily flow to provinces and territories. The new agency might talk to the relevant public health officials in a province, and then flow the funds to three universities in that province to get the job done — or, in Newfoundland, to Memorial University. The idea would be to put the money in the hands of the people doing the training; whether it is community colleges or universities, let us get these personnel in play. That is a long answer to a short question, but I hope that covers the issues.
Senator Cook: How do you see the role of the nurse practitioner studying for her MBA in the context of public health? Do you see a role for the nurse practitioner here, an opportunity? These people have their baccalaureate degree and are moving on to other things as they grow older. Is there an opportunity to capitalize on that?
Dr. Naylor: I would hope so. We have not created clear career paths for public health nurses. We do not have a path whereby people can enter a nursing program, get a baccalaureate and know that they can go on to a master's of public health, then do a PhD in epidemiology and enter one of the public health agencies such as a major municipal agency or the B.C. Centre for Disease Control — one hopes there might be a new one in Ontario — the Quebec national institute or any equivalent public health branch, and then move back and forth very comfortably with the Canadian agency for public health. That would give a sense of an ability to gain a breadth of experience, to carry your seniority with you, to grow and to always have continuing education opportunities. We need those career paths for all public health personnel, but it is particularly weak for nursing, in part because we do not have enough master's degrees in public health that are practically oriented in this country. One is then left with doing a baccalaureate degree in nursing, entering the public health system and learning on the job. Add to that the general shortage of nurses, and it is not the most propitious set of circumstances in which to staff and revitalize this renewed system. We have work to do.
Senator Cook: On a personal note, it does not make one comfortable to look at the news and hear about the new surveillance equipment in airports, particularly Pearson, where there are options for screening purposes. How can we defuse that? I hear that the iris is the test, and then they cut the long line-ups at Pearson. Surely, it does not do the public any good to hear those kinds of things. My final question: Is it realistic for me to expect that there would be a provincial centre of excellence in my province, or could it be like the spokes of a wheel, with a centre of excellence in one of the other provinces that would bring my province in? We have to start somewhere, I know; but I do not think it would be a short-term realization to have one in every province. Could we build in that way — with one in the Maritimes where three or four provinces could feed into it? Would that be adequate?
Dr. Naylor: Those are two very important questions. First, I will deal with the airport-screening question. Airport screening is a very difficult area. Screening systems build public confidence. While the Health Canada study suggests a high degree of compliance with the various screening systems that were in play, if you talk to passengers — friends, family, neighbours — they all tell you stories about how they sailed through customs and no one collected their cards, or no one filled in the forms and so on. The committee members have had some difficulty aligning these two views — the formal studies and the anecdotes.
We also have had some difficulty, more fundamentally, in getting too concerned about it. We are not sure that even if the compliance were 100 per cent, these systems were ever likely to be very effective.
Thermal scanning has the obvious deficiency that it picks up fevers from all causes; and people brewing a virus like SARS have several days when they have no symptoms. What you need is a pre-symptomatic, non-invasive way of testing for the virus. Someone walks past a screen and it says, ``Will develop SARS in five days.'' We do not have that.
Absent that, you have to focus on two things. One is information. You have to put masses of information in the hands of people. Assuming that most people are good, well intentioned and want to do the right thing, they will bring themselves to public notice quickly if they have suspicious symptoms and have been travelling. Second, you need a strong, local public health infrastructure so that when someone phones and says, ``I have this information packet, I was just in wherever and I have the symptoms that match, I am worried that I may have X or Y,'' there is an instant response. Someone is at the house in 30 minutes. They get the information about what to do on the phone. They are transported, with appropriate precautions, to an emergency room that has an isolation area. They go into hospital, if need be, and into a negative pressure room, if that is required. There must be a local system that knows how to respond to the traveller who has concerns or suspicious symptoms.
We believe, and we have recommended, as I think honourable senators will have read, that there is a need for a multilateral, international process to reconsider travel screening; but also that we need in Canada to take a sober and critical look at the results of our screening activities. Millions of people went through thermal scanners and card systems with no cases detected. Let us have a critical look at it and decide what we need to do as a country in terms of information for travellers and screening. Quarantine officers are another issue that has been covered in the report in some detail. We need a proper set of quarantine officers at all ports. This is all there.
Let me turn to the really difficult question of how you would imagine a national network for communicable disease control functioning. In the best of all worlds, there would be a combination of some provincial and regional centres of excellence. When we look at the firepower in the British Columbia Centre for Disease Control, again, a lot of the money moves out of the provincial centre to municipalities to deal with vaccines and so on. The actual staffing is modest. You do not need a vast number of experts; they just have to be really good and well connected to the systems.
In that sense, it may be difficult for smaller provinces to build the critical mass to make this work. Thus, as a committee, we felt strongly that there would have to be discussion at the provincial and territorial level about setting up hub-and-spoke models in some areas. We would not want to prejudge, but one could imagine that there might be an Atlantic CDC run on a network basis. Certainly B.C. has an agency in operation that is exemplary in many ways. Quebec has a strong agency. Ontario, I am sure, will be discussing creating stronger capacity after SARS; and with the change of government, this may well be on their radar screen, too, as a tangible contribution early in the mandate.
The Prairies will be a difficult debate because of size and firepower. There is the National Microbiology Laboratory, which will be a magnet for Manitoba in co-locating some provincial capacity. There will be some head scratching in multiple provincial capitals and in the territories about how to make this work.
We believe firmly that we must make it work. There must be a network of agencies. It is not for us to say how it is constructed.
Senator Roche: Mr. Chairman, I would like to read into the record the last recommendation that Dr. Naylor made under the section ``Preparing for the Respiratory Virus Season.'' I will read from page 214. I suggest that we highlight this because of the urgency that it will come to. In his recommendations, Dr. Naylor states:
Health Canada should coordinate an open scientific meeting late in the Fall, with objectives that include: updating Canadians on the science of SARS, discussing plans for SARS surveillance for the winter season, and reviewing the roles of travel advisories and passenger screening.
I quickly point out that there are several other recommendations in this section. Surely Health Canada ought to be able to move immediately on such a campaign to inform people about what is happening. I want to refer Dr. Naylor to what the head of the World Health Organization, Dr. Lee Jong-Wook, said yesterday to the European Parliament in Brussels. He said:
Our working assumption is that SARS will come back...in the coming winter, if SARS is mixed with the common cold and flu this will cause a lot of problems.
My point is that there is a significant degree of public nervousness, and when we hear that SARS may return in forms that are unclear to us, then that ought to be addressed quickly by Health Canada. I would like to have Dr. Naylor's view on that.
Connected to that question, Dr. Naylor, did I hear in your opening comment that you feared a threat of a pandemic influenza? I believe those were the words you used. Do I infer correctly that you were speaking of something extraordinary on the way, as distinct from the normal flu season? If I am correct in that, then you, too, are warning us, along with the head of the World Health Organization, that we will have to ready ourselves for something big in the winter ahead. That highlights the need for some public education. Would you care to comment on the way in which I have characterized this sense of urgency in respect of the road ahead?
Dr. Naylor: The views are that we move on with preparations for the winter cold and flu season. I do not whether SARS will be back; and no one knows. We can only be sure that there will be false alarms. We do not have a rapid, non-invasive test whereby people who turn up with suspicious symptoms will be immediately reassured, as will their families and the providers who give care to them, that they do not have SARS. The tests take time and there will be confusion. We do need to be prepared and there is much to be done.
I want to be very clear about pandemic influenza. I am assuredly not saying that pandemic flu will happen this winter. No one knows when there will be a major flu outbreak such as the one we had back in the early years of this century, and which caused such havoc and suffering worldwide.
I can say that experts in infectious disease and epidemiology have been in preparation for such an outbreak for multiple reasons. First, there is a working assumption that we have had a variety of virulent flu strains appear over the last few decades. Fortunately, none of them have been on the scope and scale of the killer influenza of 1918. However, there is a worry that one of them could be and we have to be prepared.
Second, the preparation for pandemic influenza is preparation for an outbreak such as SARS. It has the same set of principles. Some of the federal response to SARS was facilitated by the existence of the pandemic influenza planning process. Planning was already underway. People were trying to be prepared for pandemic flu. Those same processes were quickly shifted over to the SARS processes.
We are talking about a set of systems that will be as good for SARS as they are for pandemic flu. Personally, I hope that we never see pandemic flu. I make the point simply to highlight that we are no longer in a world where we can assume that a new virus will simply emerge and burn itself out in some remote country, while we watch the newspapers for accounts on page 8 and say, ``Oh, is that not too bad?'' That is not the way it will be. Rather, the new virus will be with us within hours because we are a global community and travel is a huge issue now. We have millions of arrivals in Canada each year, and viruses and bacteria will get to us quickly. This has changed the playing field. It has made the WHO much more important than it used to be. That is why we have said that whatever the frustration and reservations about the travel advisory, we must be in a position to work credibly with the WHO and to be citizens in a global public health community. That takes an agency and some leadership.
Senator Roche: The global nature of viruses brings me to my second question. In your opening, you highlighted the creation of a Canadian agency for public health, which would have, as you have expressed it, a clear focal point to interact with the global community. I certainly want to stand strongly behind that recommendation. You are reflecting the 21st century reality of globalization by applying that to the area of infectious disease control.
You said that a chief public health officer reporting to the federal Minister of Health would head the agency you envision. The thrust of the agency that you recommend would reach outward into the world. I understand and certainly want that. However, we are still trapped in 19th century constitutional constraints such that the provinces are competing with the federal government on virtually every decision in the health care field. They take the view that because they are spending the bulk of the money, they should be in the driver's seat.
Did you mean to be exhaustive when you said that the chief public health officer would report to the federal Minister of Health? Did you mean to exclude the provinces or did you just not get around to that in your comment? In that context, what is your view about the efficacy of the agency that you envision in reaching outward when it will have to take into account the competing interests of the provinces?
Dr. Naylor: On constitutional issues, the committee saw a set of dysfunctional relationships among all the levels of government. It was disappointing to live through it, as a physician and an administrator, in Toronto during the SARS outbreak. It was sobering but not surprising to have our perceptions confirmed as we talked to a variety of people who were directly involved.
We have highlighted repeatedly that there needs to be a change in ethos. We refer in the conclusion to the need for public health to be a constructive engagement zone. We know there will be tensions between various governments — federal, provincial and territorial — at times. The view is that the funds should flow through an agency rather than the usual sort of federal-provincial-territorial venues. That would help to depoliticize these issues and take away some of the jurisdictional tensions.
You would have public health professionals with greater experience than ministers and deputies, who have had a lamentably short time in health over the last decade or so, debating how to get the job done. These people would not be driven by the vicissitudes of re-election and could a take a longer-term view of how to get the job done.
None of this will change the fact that there is an essential tension in the Canadian Constitution. I am carrying coals to Newcastle in telling this group what it is. We saw it very clearly. Spending power and revenue generation power is concentrated in the hands of the federal government, and administrative authority for the growing portfolio of health and social programs is concentrated in the hands of the provinces and territories. This is an essential tension. It is a built-in recipe for conflict.
However, what was so encouraging is that there are similar provisions in Australia and in the U.S. The U.S. Centers for Disease Control has to be invited to the table by the states. It is invited early and often because it flows funds to the states to support their work and helps train their people, because individuals move back and forth between the state public health agency and the CDC. It is a common culture. It has firepower people respect. It is seen to be helpful rather than another lumbering bureaucracy that is working at the behest of a minister who may have recently had a spat with a provincial colleague.
It is not a perfect fix. There is still tension at times, but it does change the dynamic.
Australia, intriguingly, even without an agency, brings together the health ministers and the deputy ministers. The federal government accounts for about 50 per cent of public health spending, but it does it in an interesting way. Of that 50 per cent, half is funding that flows to the states and territories in Australia on a very strategic basis and is broken up into programs in the same way that we are recommending. About half is services provided in kind. You have federal employees, if you will, working in states and territories to provide services on a sort of secondment system that changes the dynamic again.
The CDC does much of this. You will find CDC employees in the state public health agencies running the surveillance system for the U.S. Those data flow from the state to the CDC officials and on to headquarters in Atlanta. There are many ways to skin the cat, to create a different culture and a sense of collaboration.
I want to deal briefly with the question of the Canadian chief public health officer reporting to the provinces versus the federal government. We scratched our heads about the national public health board and how it should be structured. One of our key recommendations is that there should be a board of credible individuals.
On the one hand, if you have a governing body for the institute that is controlled by a majority of provincial and territorial representatives, you create some confusion in accountability. You would have a chief public health officer dealing with a board with very strong provincial and territorial direct representation yet accountable to the federal minister. We could see benefits in terms of trying to create collaboration. We also saw the possibility that that individual would be in his or her job for approximately 32 days before psychiatric help was required.
The approach instead was to have a body that really is more advisory than governing, because the individual must report to the federal Minister of Health. That national public health board would include experts nominated by the provinces and territories, but we would not want people who were in line positions in a province. You do not want to have the chief public health officer of Newfoundland on that board and then the next week negotiating with the person on whose board they sit about how much money they will get. It would just not work.
Therefore, that national public health board will not strictly govern, but will have a very good influence in providing a national perspective, especially if there are people drawn from across the country and there is a sense that the provinces and territories have had some say in who is included.
To come back to your point about how the chief public health officer would interact with the provinces, it is crucial that they sit down time after time with the public health officer for Nova Scotia, Saskatchewan or British Columbia and hammer out how they will do business. Currently, we do have a council of chief public health officers, on which Paul Gully sits representing the federal government.
This would be a different creature if we had a Canadian agency with a chief public officer flowing funds to the chief public health officers of the different provinces. The dynamic would be different. They would be strategizing about how to achieve national health goals and how to get the funds out to maximize the impact. There would be a collective consciousness about health protection and disease prevention that would be different.
Let us get these people together. That is a separate table from the advisory board that we imagined.
Senator Fairbairn: Thank you, Dr. Naylor. This has been a tremendously interesting discussion today. As all my colleagues have said, and I totally agree, it is a brilliant report that will hopefully be given the attention and the action that it deserves.
I have been listening carefully to you today, but from the very beginning, one of the issues involving SARS that puzzled and alarmed me was in the area of communications. There appeared to be a lack of a distant early warning system internationally, not just in Canada.
Could you perhaps lead me through how this could be improved? You talked to Senator Roche about dysfunctional relationships among all levels of government, but there may be dysfunction problems within government, including the federal government.
When SARS was first mentioned in Ontario, I had a niece in Hanoi, Vietnam, who has been there for six years working in the international aid community, primarily with families and children. I sent her an e-mail because Toronto is her hometown. She responded to me immediately with an essay, practically, about the situation in Vietnam and the doctor who had identified the virus from China and had started treating people and segregating them in the hospital in Hanoi. It seemed to me odd that throughout the beginning of the SARS situation in Canada there seemed to be a disconnection between information for the people in the field and the Ontario government. People did not have the advantage of knowing ahead of time that something was coming our way, given our open border.
Something was coming our way, and the disconnection continued throughout the process, even in the World Health Organization. The information was slow in coming and confusing in the way that it was disseminated.
You are obviously very concerned about how to get the information out so that everything gets done and the signal is clear so that everyone knows when to jump into action.
Could you give us a more detailed understanding of how this connection would be made in the midst of an outbreak? Certainly it would not be entirely up to Health Canada or DFAIT. The federal government effort would perhaps have to be broader than we currently realize, because without the tip-off, all the expertise and good organization in the world will not be able to respond.
Dr. Naylor: I can only respond, senator, in generalities, but thank you for the kind comments about the report and for your question.
Right now, Health Canada operates a Web crawler system called the Global Public Health Intelligence Network that continually trolls for reports of disease outbreaks. There are various e-mail systems that infectious disease specialists and public health people use to send messages on a list serve, worldwide, to advise on outbreak X or disease Y; or we have A or we have B. In this highly connected electronic global village, systems are in play to try to pick up information to determine whether we have a new outbreak — a new disease.
All of these systems are critically dependent on local surveillance and detection. If you simply have an informal e- mail system and an outbreak starts in a village that does not have anyone on the list serve, you will not pick it up until it has spread. Someone from that location may have travelled somewhere else and the disease eventually winds up in Canada. Similarly, with the Global Public Health Intelligence Network, GPHIN, which the WHO uses — it is a Health Canada triumph — it is crawling through the Web, but unless the information is entered, it will not be picked up.
The cornerstone of required intelligence is much stronger surveillance everywhere and it has to be organized. It has to come from the caregivers and the health system. If we think about how outbreaks have been detected through the years, there will be an alert nurse on a ward who connects the dots and a doctor in an emergency room who realizes that he saw it three days earlier, and they question the connection. Those individuals have to be trained, respected and taken seriously when they raise an alarm. There has to be a system that draws the information from those individuals, amalgamates it and makes the connection between hospitals or cities. It needs to travel up the chain quickly to national capitals and on to a clearinghouse.
This is clearly the direction that the World Health Organization would like member states to take. They are talking about international health regulations that put more emphasis on surveillance. The drawback to that is the creation of non-funded mandates — the emergence of a new transnational government — dedicated to health. It is not completely straightforward. In some ways, we are yielding areas of sovereignty.
Ultimately, I believe that is the way in which we must move this forward. Every nation must have a multi-tiered surveillance system so that the information flows up through a clearinghouse and returns. That must happen overnight — quickly — instead of trying to deal with all of the disconnections that we have now.
There was confusion at the time of SARS. There was a case of avian or chicken flu in Hong Kong. There was uncertainty about whether this was simply another form of flu. It was initially thought it was due to something other than a virus. There was a false alarm about SARS being due to chlamydia, simply another form of community- acquired pneumonia. Much confusion existed as this was percolating through the system.
If the right surveillance system with the right filters were in place, it would have been much better. I will say a word about filters before I wrap up.
Remember, this is about signals and noise. Just as we do not want false alarms in the winter flu and cold season, by the same token, we do not want false alarms when we are looking at global alert systems. We do not want a country to go on alert, squander resources, put stress on public health and health care workers and make the public anxious about nothing. There is a balance between sensitivity and specificity.
Senator LeBreton: On that point, part of the problem was the communication system, public confusion and the issue of probable cases and actual cases. That helped to contribute to the public's hysteria over it because some people chose to look at the probable cases. There were conflicting signals from this end and from the World Health Organization.
Dr. Naylor: I agree, senator. I emphasize, as Dr. Keon and Dr. Morin know, that I am a cardiovascular person. I was asked to participate here as the neutral scribe rather than the content expert. As cardiovascular people, we spend considerable effort trying to clarify taxonomy. Who has what? What is the definition? That is so we can be precise about it. I was taken aback by some of the confusion. It only emerged in June that different countries were using somewhat variant definitions of SARS and the WHO was okay with that. If you tweak the definition one way, you will have more cases, and if you tweak it the other way, you will have fewer cases. How can we have a global health system if this country is vulnerable to a travel advisory for being obsessive, careful and erring on the side of over-reporting, and another is spared a travel advisory because it wants a restrictive case definition. The WHO needs to get its act together in this area.
Senator Keon: I was pleased to see that you went with the WHO in your report, because there have been severe criticisms of it, as you know. Some Americans and some from the EU have suggested that it may be time for another agency, that they do not have the resources and, particularly, that they do not have the intellectual power to be doing what they are doing.
However, it is nice to see that put to bed and discussions begin on how we could reinforce the WHO rather than trying to reinvent the wheel.
In that context, how do you see the connection between our national agency and the WHO being able to make a contribution to the WHO and overcome some of these difficulties? Will it mean that we have to provide revenues? Will it mean we will have to lend them personnel? Does it mean we have to give them access to what leading-edge research information we have in the country, give them access to some of our better research labs or give them collaborative power with CIHR? How do you see all this?
Dr. Naylor: I think, senator, that you have covered in your question, in a very insightful way, many potential options for how we would reinforce the WHO. I agree completely that rather than simply criticizing the WHO, we need to get on with enhancing the way they do business and being effective collaborators and leaders with them. We said in the report that Health Canada's own travel advisories were not based on much firmer evidence than those issued by the WHO — and this is a generalized issue — despite our understandable national frustration and anger about what happened.
I think secondments of personnel are important. The agency needs to have an effective liaison function of multiple dimensions with the WHO. It takes us back to this vision of how careers might unfold, so that public health nurses do a baccalaureate, get that master's in public health, do some outbreak fighting and front-line public health work, come back and do a PhD in public health policy, work for the Canadian agency for public health, and are sent to Geneva to be a liaison on building capacity for public health nursing in developing countries — or surveillance systems.
We need to develop a sense of the ability of these skilled personnel to have a choice of a career in one location, as part of the community, or as global citizens — I hope always with the maple leaf stitched on their backpack — moving from Toronto to Moose Jaw to Geneva.
We did see the WHO play an effective leadership role in coordinating some of the laboratory activity. They have their own outbreak response network that helped in investigating the outbreak in Hong Kong, which included people from our National Microbiology Laboratory.
We need to be at the table, part of the networks, part of the response teams. We recommended that the Government of Canada take seriously our role in outreach to build capacity in the infectious disease and research area. These things do move across borders so quickly. As a form of international capacity building, sending excellent people in public health to work with other nations that have less capacity, under the WHO rubric, would be a terrific way for us to participate in the creation of that kind of global surveillance system to deal with the other senator's issue — and that is what do you do about the fact that the information may never get to the national capital in another country, let alone to us here in Canada? This is now an international set of concerns. Public health is global, and we have to act as members of a global family.
Senator Trenholme Counsell: I want to echo the words that this is a brilliant report. It made me proud as an alumnus of your faculty to receive this report and watch you today. This was an extremely acute crisis in our country. The fact that you have prepared this report in four months is amazing. It is an acute response — and when I heard that you were a cardiovascular person, I could understand how you work.
Our government must respond to this in the way that you have prepared it. There are so many things in front of the government right now, but I think Canadians would want this to go to the top of the pile. You have pointed out the urgency of it. I hope that we, as the Senate, can play a part in ensuring this gets the kind of urgent attention it deserves, because you prepared it in such an excellent way. It is an inspiration. I think the front-page attention it got in the media was excellent, and that was exciting. I wanted to say that, and congratulate you.
You have dealt with the constitutional part of it, but I put a question mark beside this. You said that no specific dollars are transferred now to the provinces for public health, and probably what you are envisaging would require dollars for the provinces, specifically to build up their capacity.
Having worked in a provincial context, I could see the lights going on in the heads of all the ministers of health from the provinces, and a real hassle at a federal-provincial meeting by designating health dollars for one thing. That is one of the challenges in all of this. It has been constitutionally addressed subsequent to my putting an asterisk by this. However, it will represent a real problem if the federal government moves toward designating dollars out of that global health budget for public health. That will have to be addressed. There is not time to deal with that, but it certainly will be an issue.
I liked what you said about nurses taking public health master's programs. That is happening. I know it happens at the University of New Brunswick. I believe that there are nurse practitioners who do their master's in a subject relevant to public health, and it is very important and exciting for the nursing profession.
I hope that you can use your influence — and I think you have an enormous influence and a strong voice right now — to ensure this gets treated as something acute should be treated.
Dr. Naylor: Thank you.
The Chairman: I should say to you that Senator Trenholme Counsell began her professional life in public health. She was a graduate of the University of Toronto medical school and practised as a family practioner in New Brunswick for nearly three decades. Her background, and passion for these issues, is quite clear.
Senator Cordy: I would like to echo what my colleagues have stated. For somebody with a non-medical background, to receive a medical document that is easy reading is laudable.
I would like to ask about the national immunization strategy. Certainly we all know that immunization has been a proven preventive health measure. However, we have a couple of problems. One is the absence of registries in most jurisdictions.
You talk in your report about improving the information system. Does that mean that all provinces would have to keep a record of those who have been immunized? No matter what wonderful vaccines we have, if people are not vaccinated, it does not do any good. How do we persuade people to get vaccinated?
In my province of Nova Scotia, the pharmacists have started a program where they offer immunization at local pharmacies. It is just a trial project, but the province is actually paying for the vaccine and sending it to the pharmacies. The pharmacies are doing it as a goodwill gesture.
What types of things can we do to ensure that people do become immunized?
Dr. Naylor: Yes, we definitely envisage that all provinces would keep, ideally, a coherent set of immunization and vaccination records; and that this would be rolled up into a set of reports that would give us a sense of our degree of coverage nationally. Again, consistent with an accountability approach to the use of the funds, we would try to ensure that we know that we are getting optimal coverage. We believe the information systems must be enhanced.
I want to emphasize that even this amount of money is modest.
The national immunization strategy, as it rolled out from the FPT tables, was slated to be about $200 million for the vaccine purchase alone, plus information systems. We are counting on this as money that would go a meaningful distance toward helping provinces purchase vaccines, knowing that some provinces have moved ahead and others have not. Again, we are trying to be consistent with the Social Union Framework Agreement strategy here and not penalizing those that have moved ahead. This is actually a modest investment, especially given the payoffs from it.
On the question of trying to ensure that people are vaccinated, obviously when you deal with children in the school system there is a series of provisions; you get a notice and are not allowed to go back to school unless you are protected. There are mechanisms in place in terms of some of the required vaccines that tend to track individuals and create compliance. As you get into issues like influenza, obviously you would love to see vaccines more widely available. We have mentioned that pharmacies might play a role in a crisis. Is there a way for pharmacies to play a role during business as usual? I know the Canadian Pharmacists Association raised this in their submission to our committee. We thought about the immunization strategy as being not just about purchasing and systems, but ideally, drawing people together in this field to decide how do we get out there, what is the battle plan, what are the strategies that work? We do not have a magic bullet for changing human nature.
The story of public health is that people do not value prevention. There is a natural instinct to buy too little insurance, to be chagrined if you do not need it when you should be relieved, and to put off that immunization or not bother to change lifestyles or do whatever we need to do to prevent illness and maintain health. Immunization falls into the same category sometimes.
Senator Léger: The general public, or at least in my case, were extremely moved when we heard that a doctor and the nurses who were caring for the hospitalized SARS patients died. With globalization, travel and screening, I began thinking of the mosquitoes that came in swarms this summer. We had to be very careful because of the West Nile disease. Is there a danger, with all these precautions that must be taken, of crying wolf?
At the same time, you must warn us and we must be ready. That is the medical side of it; parallel to that, could judgment come into it? Is there as much energy put in to avoiding false alarms that scare people?
How long does it take for the commercial interests to get involved? I was still worrying about SARS, the disease, but other people were already worrying that it was affecting business. The focus was somewhere else. For me, it was the illness. When you give your warnings, they are about the illness, but the other issues arise very quickly.
Dr. Naylor: I appreciate the expression of sympathy about the health care workers who were affected. One doctor and two nurses died of SARS. Scores of others were sick, some very seriously.
It is hard for me to convey the stress that this put on colleagues. I will not get into all of the detailed anecdotes, but I will tell you that this was an extremely harrowing time in Toronto in the health care system.
I agree that there is a danger of crying wolf. This is a real teeter-totter in terms of preparedness and communication. We rode that teeter-totter in SARS. We went from being hugely alarmed and alarmist, and then when the WHO slapped us with a travel advisory, to suddenly saying, ``What are you talking about? Everything is fine.'' It was not the most credible performance.
In finding the balance so that we get people to be prepared without being alarmed, we understand that there are concerns and that it is okay to be anxious, but most of us are healthy most of the time and getting on with our lives and this will not necessarily sweep through the country tomorrow. That has been a challenge with SARS. You hear people say, ``Only 44 people died.'' For the 44 families, it is a huge tragedy and the damage to the health care system was enormous. At the same time, you can understand why some people would say: ``Well, influenza kills hundreds every winter; 44 people is the number we lose in this country on the roads on a long weekend.'' Where is the balance?
It is important to understand that there is a need for balance. There are things we can do to prevent these outbreaks, to contain them better and limit the harm so that we do not have 44 deaths and hundreds of people sick next time. That is not trivial. It is a huge issue in this country. At the same time, we should not cry wolf, as you say, and lose sight of all of the other issues.
One of the things that happened is we were so consumed with fighting SARS that virtually all other public health functions stopped. One does wonder what harm was done. The health care system in parts of Ontario was paralyzed for weeks. It is estimated there were thousands of surgical cases delayed or backlogged. There was huge harm from that, too. We have to get it right. We cannot be on the teeter-totter going up and down, either overreacting or being blasé or trivializing things that cause huge harm. Finding the right balance is where we have to go from here.
Senator Fairbairn: My question is, in a way, connected to what Senator Léger asked, and I ask it of you because it is been asked of me in the area where I am from, Alberta. You mentioned BSE. You mentioned West Nile. We have SARS. We are very close to the state of Montana in the southwest corner. The question that I have been asked repeatedly is what happened in the United States? Here we were under the international spotlight. We obviously had people in deep distress, it was all very public and people were curious as to whether the United States escaped this same issue even though they have open borders and obviously many travellers from around the world. We never heard much about that. Are you aware of the situation?
Dr. Naylor: There is speculation of all kinds about why there were not more cases in the U.S. To give you a flavour, and I repeat it not to endorse it, because I think it is purely speculative, I have heard one colleague argue that the traffic back and forth with Asia was reduced as a result of the Iraq war and the climate of tourism and interaction with the U.S.
My response is that there is no way the traffic was less in absolute terms than ours. That makes no sense to me. Another colleague said that the case definitions were more restrictive. Yes, you can have state-to-state variation and they have some of the same problems that we have with surveillance and case definitions. However, the CDC is very influential, and if there were any systematic under-reporting, could we imagine that the New York Times or The Washington Post would not be all over this?
One hears that perhaps there has been a jump in cases of non-specific community-acquired pneumonia. Perhaps it was misclassified. I have not seen a significant amount of evidence for that either.
There are all kinds of speculation in the public health and infectious disease community about why the States had fewer cases. We should stop speculating. Do the international-lessons-learned exercises and find out why they had fewer cases or why Japan had virtually none. Let us look at our neighbours to the south and other countries and figure out the factors that meant that some countries had lots of SARS cases and others did not. We will be in better shape to prevent the next outbreak once we know that.
That kind of international lessons exercise has yet to happen. Hong Kong did one recently. I am sure Singapore will do one. We have a couple underway in Ontario. Our panel has reported.
We really need to draw together all the international threads and figure out what is happening. For now, the answer to the question is that I have no idea why the U.S. had so few cases. I am glad for them that they did not face an outbreak like ours. I hope we will understand on a global scale why some countries were relatively spared.
The Chairman: Dr. Naylor, on behalf of the committee, I wish to thank you for, first, allowing us to prevail upon your time for substantially longer than I told you we would. That is not unusual with this committee, by the way.
I thank you for your extremely articulate responses to our questions. They will be very helpful to us in preparing our final report.
On behalf of all the committee, accept our congratulations on such an outstanding piece of work.
The committee adjourned.