Health Committee on May 30th, 2006

[The Chair, Conservative, Rob Merrifield]

I call the meeting to order. Pursuant to Standing Order 108(2), we are studying the new strategy for the prevention of fetal alcohol spectrum disorder.

We have with us today the chief medical officer of the Public Health Agency of Canada, Dr. David Butler-Jones.

Thank you for coming in. You have some assistants with you. Maybe you would introduce them to us; that would work out well.

[Linda Dabros, Director, Office of Drug Strategy Secretariat and Strategic Policy, Department of Health]

Good morning. I'm Linda Dabros from Health Canada.

[Kathy Langlois, Director General, First Nations and Inuit Health Community Programs Directorate, Department of Health]

I'm Kathy Langlois, with the first nations and Inuit health branch in Health Canada.

[Kelly Stone, Director, Childhood and Adolescence Division, Centre for Health Promotion, Public Health Agency of Canada]

I'm Kelly Stone with the Public Health Agency.

[Barbara Beckett, Assistant Director, Institute of Neurosciences, Mental Health and Addiction, Canadian Institutes of Health Research]

I'm Barbara Beckett with the CIHR.

[The Chair, Conservative, Rob Merrifield]

Thank you very much for coming in.

I see that you have a presentation you're going to make. We will ask you to introduce that at this time, and then we'll go forward to questioning.

[Dr. David Butler-Jones, Chief Public Health Officer, Public Health Agency of Canada]

Thank you, Mr. Chairman.

It is a pleasure encore to be with the committee again, this time on a topic that's very important, and not about pandemics. In the context of many people's experience, this is an increasing challenge in Canada, and it has a potential impact on individuals, families, and communities that we think of in other realms as well.

The former standing committee had requested that we return with a vision document to give the committee an opportunity to discuss further the prevention of FASD. I guess it depends on the perspective, but unfortunately, Parliament dissolved, and we're now back with a new committee.

I really am pleased to discuss a vision with you today.

Addressing FASD has been a commitment of the Government of Canada since the mid-nineties. As you know, the term FASD describes a range of lifelong disabilities caused by prenatal exposure to alcohol. It is a leading form of developmental delays in North America and a major cause of preventable birth defects.

The primary disabilities from fetal alcohol create, by the best estimates, somewhere in the neighbourhood of $1.5 million in additional direct costs over the course of an affected individual's lifetime. These costs, we recognize, do not include either the loss of potential of that individual or that of their family or caregivers.

It is in fact a risk for all women of child-bearing age who drink alcohol. Recent studies have shown that drinking even small amounts of alcohol may have a negative impact on the developing fetal brain.

Alcohol-related congenital defects have an impact upon public health, health care, education, ability to work, justice, policing, corrections and child and family welfare systems. Therefore, multiple layers of government must be involved as partners.

While many departments across government have programs and projects to address fetal alcohol issues, the health portfolio is currently the only federal department or portfolio with dedicated resources for fetal alcohol syndrome disorder.

The Public Health Agency of Canada manages the pan-Canadian FASD Initiative with an emphasis on the federal public health role. The Government of Canada is also responsible for providing community-based health programming in First Nations and Inuit communities.

Many provinces and territories have also identified fetal alcohol syndrome as a serious issue for their governments and have developed strategies along this line. They have called upon the Government of Canada to demonstrate leadership and to develop a federal strategy.

In 2003, following consultations with the provinces and territories, as well as with stakeholders across the country, Health Canada released the framework for action to guide the development and implementation of collaborative efforts.

The Framework for Action has become a blueprint for action, and has served as a benchmark for the creation of the Vision. I understand that Committee members have received copies of the Framework document.

The vision is actually based on a three-pronged approach: the promotion of health generally; the prevention of FASD and the reduction of harm by minimizing risk; and thirdly, the early detection and management of FASD and related chronic health and social problems.

Within this approach there are five themes that guide the development of the vision. Under the first theme, the emphasis is on strengthening leadership and coordination to ensure access to tools and knowledge across the country. Stakeholders at all levels are being pressed to work on fetal alcohol problems and related issues as a direct result of growing client needs. Collaboration has let us work more effectively and efficiently and has facilitated joint projects and activities.

The next two themes involve increasing the awareness of the general public and professionals. In 2002 women told us that they felt their health care providers were the most reliable source of information.

They also told us that there is inconsistent messaging about the consumption of alcohol during pregnancy. Other research has told us that many health care providers do not feel comfortable dealing with women who drink alcohol during pregnancy.

In recent years, therefore, the Government of Canada has focused much of its efforts on enhancing health care provider awareness, knowledge, and skills, and the provision of tools and resources for use with their clients.

Large public awareness campaigns are very expensive and require a great deal of research to segment audiences into various population sub-groups within women of childbearing age so that messages are accurately designed according to, for instance, age, socio-economic status, and risk factors.

The health portfolio has collaborated with provinces and territories in establishing the common messaging that no alcohol could be considered safe during pregnancy. Many of the provinces and territories, in collaboration with their liquor control boards, have conducted effective general public awareness campaigns. Part of the challenge, though, is that with limited funds available, the health portfolio has focused on providing the knowledge base for assessing the learning from effective campaigns, helping to make tools and resources available to communities and groups in order to build their capacity to plan, to manage, and to evaluate effective awareness campaigns, which can then be used as part of general health promotion and prevention work.

This continues to be an important element in addressing fetal alcohol syndrome disorder and is bearing some fruit in the improved general awareness of the harm caused by alcohol used during pregnancy, as can be seen from our most recent public opinion tracking. Environics, during March and April of this year, found that there'd been an improvement, in some 11% of the women surveyed, in knowing that any alcohol consumption during pregnancy can harm the baby.

In addition, diagnosis has been an area of focus in recent years and does represent the fourth theme of the vision. Research has shown us that early identification and diagnosis and effective intervention can in fact improve outcomes for those affected as well as their families and caregivers. Many of the costly secondary effects can be prevented through early and effective management of this lifelong disability.

As a result of this research, the Government of Canada facilitated the work of a national expert advisory committee and a wide range of experts and stakeholders to develop and implement the FASD Canadian guidelines for diagnosis.

A common diagnostic approach is critical to being able to move towards national incidence and prevalence data. In the future, an ability to track national incidence and prevalence data will allow us to determine whether FASD awareness and prevention activities are having an impact on reducing alcohol affected births and, consequently, alleviating the individual and societal costs associated with FASD.

This work also appears to be bearing fruit in that the majority of clinics diagnosing in Canada are adopting the new guidelines. This means that we have in fact taken a first step in a common minimum data set on referrals, diagnosis, and common reporting. Central to the vision is the concept that knowledge must be developed and then exchanged to inform and create evidence-based multi-sectoral initiatives.

Knowledge development work includes partnership with the Canadian Institutes for Health Research and other such organizations to develop a common research agenda. The long term goal is to build Canadian knowledge and researcher capacity on FASD.

Finally, it's important to help communities to help themselves. And communities, including communities of practice and front-line workers, do need the capacity to deal effectively with these issues.

Local development and exchange of knowledge and evidence will help communities define effective policies, programs, and practices, and this would include sector-specific as well as intersectoral collaborations.

Local development and exchange of knowledge and evidence will help communities define effective policies, programs and practices. This would include sector-specific and inter-sectoral collaboration.

It should include social work, child welfare, child care, homeless shelters, and education workers, police, lawyers, judges, parole and corrections officers, employers and employment counsellors, and the community really, at the community and regional level.

I am confident, Mr. Chair, that the vision presented to address FASD provides a cohesive way forward and engages, and continues to engage, multiple partners across various sectors as we move forward. Again, as I've often said, on the issues of pandemic, we're not there yet, but we are making progress. Clearly, the Government of Canada has an important leadership role and must work with key partners and stakeholders to promote the health of Canadians and address this issue. Collectively, I think we're on the right road, but there is still much to be done.

Merci.

[The Chair, Conservative, Rob Merrifield]

Okay. I want to thank you for your presentation.

We now move into the question part of our meeting. We'll start with Mr. Szabo; you have 10 minutes.

[Paul Szabo, Liberal, Mississauga South, ON]

Thank you. I may be splitting part of that time. It depends if we can get some answers.

Some time ago, Health Canada collaborated with about 18 other organizations, including the CMA, etc., and one of the things it said in its first principle was that fetal alcohol syndrome was the leading known cause of mental retardation in Canada. That's a very ominous statement, and it's absolutely wrong. Fetal alcohol syndrome is not the cause of anything; it is the result. And way back then, and now, it appears that Health Canada still is not prepared to say the maternal consumption of alcohol during pregnancy is the leading known cause of mental retardation in Canada.

I wanted to make that point because it leads to the same point: I've seen this all before. I think I saw this speech 10 years ago. I'm sorry. I'm disappointed. I haven't seen anything new here. I haven't seen any progress. But it says on page 6 of my report--I don't know where it is in the French--that the health portfolio has collaborated with provinces and territories in establishing the common message: no alcohol is safe during pregnancy.

Dr. Butler-Jones, there is enough medical evidence that the risk to the fetus from maternal alcohol consumption occurs from days 15 to 22, when human facial features are established. And in this statement it says no alcohol is safe during pregnancy. It begs the woman to determine, first of all, am I pregnant? If I'm pregnant, then I'm going to make a decision.

This attitude is fatally flawed, and I don't know why the heck Health Canada still cannot bring itself to understand that the message should be--and I want your comments on this--changed immediately to, "If pregnancy is possible, i.e. you are sexually active, not using protection, and are in your birthing years...." That's what the message should be: "You should not use alcohol if pregnancy is possible." Eliminate the risk.

Can Health Canada adopt that as a new saying and get the provinces and territories to adopt it? And can we take one step forward on this file that has taken no steps in the last decade?

[Dr. David Butler-Jones]

I guess there are a couple of issues there. The first is the suggestion that there's been no progress. In fact there has been progress here. Is it as much as any of us or all of us would have hoped? No. I agree with that. Is there more to be done? Absolutely.

But there's been significant progress in terms of public awareness. There's been significant progress in terms of professional awareness and diagnostic guidelines, etc.

And in terms of the federal role vis-à-vis that of the provinces and territories, that's something for governments to discuss and debate. But within the authorities that we have, we've made significant progress to this point.

On the issue of messaging, the messaging is a complex one, as you can understand, whether it's talking about alcohol and pregnancy or the use of medications during pregnancy or the issue as it relates to other health things and the trade-offs between decisions that people make.

The risk clearly is not uniform throughout the pregnancy. There is risk before women know they are pregnant. That is why the guidance, the public health advice, is different from the common message that all groups are willing to speak to in advertising, etc. What public health speaks to in pre-conception as well as prenatal discussions is that if you think...and this is a general message. I think we can continue to refine what the public messaging is so there is an understanding among the public about the nuance between the issue of dose of alcohol, location of alcohol, and, in this case, pre-conception versus prenatal care and the importance in pre-conception of.... In other words, anybody who has the potential to be pregnant or is thinking about being pregnant should be thinking in the same way as if they are pregnant, not just about alcohol but about the use of over-the-counter medications and other things that may influence the development of that fetus. That is what I was trained in as a physician. That is what public health speaks to. But the message is a bit longer than what you can put on a brochure.

[Paul Szabo, Liberal, Mississauga South, ON]

It's interesting that you submitted what you were trained in. The Canadian Medical Association was opposed to telling women about consumption of alcohol during pregnancy because they were afraid it was going to create spontaneous abortions or somehow victimize women. That's why in that joint statement they had that inclusion there, that it was not recommended to tell women. So I have to tell you, I've never been a strong fan of the CMA when it comes down to fetal alcohol syndrome.

The fact that you've actually mentioned in your comments here that there has been inconsistent messaging on the consumption of alcohol during pregnancy tells me that there hasn't been anything going on. We haven't even made progress on the public education standpoint. When you have a social problem, public education is always part of the solution. We still haven't got that right in terms of the basic messaging.

Dr. Butler-Jones, I have to tell you, I am still going to go on the basis...it's not personal, but it is with regard to Health Canada. Back in January 2000 an Environics survey done for Health Canada showed a tremendous amount of information about the knowledge, and it showed that the knowledge of Canadians, particularly Canadian women, was very poor on this subject matter.

One of the things they did was develop a comprehensive strategy on the ways in which you would communicate with the public. They listed the ways, for these provinces, these areas--because they got right down to it--and one of them was that the most prevalent area of access to information at a critical time was in the doctors' offices. That's where women go when they're in their birthing years and they're wondering about contraception or all these other things.

What has Health Canada done to get the medical association, the family physician, the obstetricians, and all the others involved in the education, promotion, and preparation for pregnancy to show leadership in terms of providing the public with information that is consistent across the country? What has Health Canada done?

[Dr. David Butler-Jones]

I can't speak for Health Canada since it's a separate department from the agency, but in regard to the activities of PHAC that relate to this--and I'll turn it over to the representative from Health Canada after this--in the documents before you is reference to engagement and training of health practitioners in terms of guidelines and advice. So there has been work in that area. To suggest that nothing has gone on is I think really not fair.

I'll ask if Linda or Kathy want to add anything to that.

[Kathy Langlois]

What I could add, from a first nations and Inuit health point of view, is that the Canadian Pediatric Society has a first nations and Inuit health committee. They have issued a position statement in their journal on FASD, and we are currently working with them to update that statement. That is the work we've done in FNIHB.

[Paul Szabo, Liberal, Mississauga South, ON]

Okay.

I have just one last little question, and I gather there are only a few seconds left. The Canadian Centre on Substance Abuse just put out an enormously excellent report on alcohol, tobacco, and drugs. With regard to the alcohol question, they indicated that the deaths from alcohol misuse had gone up significantly relative to drugs and tobacco.

In their report, they mentioned something that you have not mentioned, and I'm wondering why. It has to do with binge drinking. Binge drinking is the worst kind, the most dangerous kind, of drinking for the unborn child. It is different from any other abuse because it's not a cultural thing, it's not a demographic thing; it in fact crosses all demographics. Binge drinking happens in social life. We have not educated Canadians on this important research finding, which has been there for the last decade.

Why hasn't anybody in the Government of Canada--since you're not Health Canada, I assume--said anything to corroborate or to collaborate in or to initiate some sort of project to tell Canadians what binge drinking is and why it is so dangerous to the unborn child?

[Dr. David Butler-Jones]

My point about Health Canada is that we are part of the same portfolio in health and we report to the same minister, but I can't speak for Health Canada programs directly. That was just a point of clarification.

We actually are engaged with the group that you speak about. I certainly have spoken to the issue of binge drinking, as have others. It is part of education around alcohol more generally. Again, whether people pick up, the media pick up, and others pick up the messaging is one issue. The fact that we are speaking to this shows that we are doing it.

Is it enough? Are people all hearing it? Are young people hearing it in their schools, in universities? I see in the media frequent references to this under the issues that universities, provinces, and others are taking on, and we speak to that, as do the institutions we support and collaborate with.

[The Chair, Conservative, Rob Merrifield]

Our time is gone, but if the committee would allow me to just follow up on that, we have Health Canada, we have CIHR, and we have the vision you've laid out. Do Health Canada and maybe CIHR want to respond to how they fit into that vision, because I think that's really the direction of some of the questioning here?

[Linda Dabros]

Health Canada has primary responsibility for Canada's drug strategy and controlled substance program. The responsibilities relating directly to FASD were transferred from Health Canada to the Public Health Agency of Canada when that agency was established a few years ago. We obviously have a lot of links, because part of Canada's drug strategy covers alcohol consumption. We are in the process of leading a national working group to develop a comprehensive Canadian national alcohol strategy, with obvious links with the other partners in the health portfolio, as well as with partners throughout Canada.

So that's the linkage, but in terms of direct responsibility for FASD, Health Canada, except for the first nations and Inuit health branch, doesn't have direct responsibility for that, because they were moved.

I think that might just clarify the responsibilities.

[The Chair, Conservative, Rob Merrifield]

Okay, that adds a whole other group of questions.

Can CIHR respond?

[Barbara Beckett]

CIHR has several mechanisms for funding research in the area of FASD. One of them, and the area where most of the money has actually gone, is our twice-yearly open competition, through which researchers in any area of interest can submit an application and be funded for an operating grant. The other mechanism is through the CIHR institutes. I represent the Institute of Neurosciences, Mental Health, and Addiction, but other institutes that would have an interest in FASD include the Institute of Human Development, Child and Youth Health; the Institute of Aboriginal Peoples' Health; and the Institute of Gender and Health. Each of these institutes has a strategic plan. I don't believe that FASD is listed as a specific high-priority item for any of our institutes, but some of the requests for applications that we have undertaken--for example, early life events was a recent one--could include applications related to FASD. We have in fact funded a couple of team grants related to FASD, through our initiatives.

In terms of collaboration with the Public Health Agency, Health Canada, and other government departments on the issue of FASD, we have within the last year been actively involved in conversations on a research agenda on a very general level, but we have not, to date, had any specific joint programs with other branches of the government.

[The Chair, Conservative, Rob Merrifield]

Thank you.

Madam Gagnon, you have five minutes.

[Christiane Gagnon, Bloc, Québec, QC]

Thank you for being here today. I believe that the issue being raised is one we are aware of.

Bill C-5 respecting the establishment of the Public Health Agency of Canada concerns health in general and your collaboration in establishing initiatives. When we ask questions on an issue under Health Canada's responsibility, the new administrator, Mr. Butler-Jones, says he doesn't have any answers because Health Canada handles it. We don't get the impression these two entities communicate very well, which won't facilitate matters when future initiatives are introduced. Who do we talk to? The new agency or its director, or Health Canada?

Health protection and promotion appear in the preamble of the bill establishing the new agency. If I ask questions on Aboriginal health, for example, I can speak to you and you can give me answers.

Let's take the money that has been invested to fight and prevent fetal alcoholism. In 2001, you invested approximately $25 million, and we don't know what impact that investment has had. Now you want to develop a national plan because, you say, the provinces and territories have asked you to do so.

So it's hard to monitor this new agency and the role it plays in connection with Health Canada and the entire health system in Canada. I don't think Quebec called you in on this issue. For the moment, I won't list all the measures taken by the Government of Quebec to fight fetal alcoholism.

The federal government is responsible for the entire issue of Aboriginal health. And yet, we don't get the impression that a portion of the money invested for Aboriginal health — $17 million at most — was used to fight fetal alcoholism. How much money has been paid to fight this phenomenon? It's quite difficult to see how you will be able to harmonize the strategies put in place by the new agency and by Health Canada management. Who will we talk to? Who will give us the real figures and an accurate picture on changes in alcohol consumption during pregnancy?

[Dr. David Butler-Jones]

The Public Health Agency of Canada, Health Canada and the CIHR are part of the same portfolio, but some aspects are the responsibility of Health Canada and others of the agency. That's not a problem, but it's up to Health Canada to take a position on health in Canada.

The overall budget of the portfolio is $19 million, $3.3 million of which is allocated to the Public Health Agency of Canada for the purposes of the pan-Canadian strategy. The provinces and territories also have programs.

We want to improve collaboration in the various health-related fields that are the federal government's responsibility, in particular, the health of Aboriginal people on reserves, which is the responsibility of Health Canada.

Now I'll turn the floor over to Kathy.

[Kathy Langlois]

I'd be happy to speak to the fact that the first nations and Inuit health branch is a little bit like a province, in that we're responsible for providing those public health promotion services on reserve that a province would provide elsewhere. And we do collaborate with the Public Health Agency; our teams work together, and we ensure that the work we do is consistent with their work. But we also have a special responsibility for community-based programming on reserve. We have developed in that area.

I could speak more on that, Mr. Chair, if you would like me to.

I would say that we are basing all of our programming on evidence that exists in other jurisdictions, and we have in fact based a lot of our mentoring program for women of child-bearing age at risk of consuming alcohol on what's already been done in Manitoba with the Stop FAS program. I could speak at length about our mentoring program.

We're also doing a lot of training in capacity building.

I can tell you that on the awareness piece, we have had significant progress. We have a recent opinion survey that says that 86% of first nations and 75% of Inuit aged 18 to 40 have identified that stopping the use of alcohol is an important factor in having a healthy baby. Similarly, 94% of first nations and 86% of Inuit are aware of FASD, and only a small percentage—less than 10%—think it is okay to consume alcohol during pregnancy.

So we're moving forward in our awareness, but we're also delivering services, which explains why there is a significant level of resources within the first nations and Inuit health branch, because we're actually doing programming on reserve.

[The Chair, Conservative, Rob Merrifield]

Okay, thank you. You might be able to comment further on that as the questioning goes on, but the time has now gone.

We'll ask Mr. Fletcher, who has five minutes.

[Steven Fletcher, Conservative, Charleswood—St. James—Assiniboia, MB]

Mr. Chair, I'm going to yield my time to Mr. Dykstra.