Evidence of meeting #10 for Health in the 40th Parliament, 3rd Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was social.

A recording is available from Parliament.

On the agenda

MPs speaking

Also speaking

Shelagh Jane Woods  Director General, Primary Health Care and Public Health Directorate, First Nations and Inuit Health Branch, Department of Health
Angus Toulouse  Regional Chief, Assembly of First Nations
Gail Turner  Chair, National Committee on Health, Inuit Tapiriit Kanatami, and Director of Health Services, Department of Health and Social Development, Government of Nunatsiavut
Joseph Dantouze  Northlands Denesuline First Nation
Richard Long  Professor, University of Alberta, and Director of the Tuberculosis Program, Evaluation and Research Unit, First Nations and Inuit Health, and Immediate Past Medical Officer of Health for Tuberculosis, Province of Alberta
Kimberley Barker  Public Health Advisor, Assembly of First Nations
RoseMarie Ramsingh  Executive Director, Community Medicine, First Nations and Inuit Health Branch, Department of Health
Earl Hershfield  Professor of Medicine, University of Manitoba, Former Director of Tuberculosis, Province of Manitoba, As an Individual
Pamela Orr  Professor, Department of Medicine, Medical Microbiology and Community Health Science, University of Manitoba, As an Individual
Brian Graham  Chair of the Chronic Disease Policy, Chief Executive Officer of the Lung Association of Saskatchewan, Canadian Lung Association
James Chauvin  Policy Director, Canadian Public Health Association
Elaine Randell  Communicable Disease Consultant, Department of Health and Social Services, Government of Nunavut, Canadian Public Health Association
Janet Hatcher Roberts  Executive Director, Canadian Society for International Health
Anne Fanning  Professor Emeritus, Faculty of Medicine, University of Alberta
Clerk of the Committee  Ms. Christine Holke David

9 a.m.

Conservative

The Chair Conservative Joy Smith

Good morning, everybody.

I'd like to start on time. We are a little late.

Before I start, I need to make sure we get our budget....

No, we don't have a quorum for our budget. Okay. We'll do the budget in between witnesses and Q and A.

The orders of the day are pursuant to Standing Order 108(2), the study of elevated rates of tuberculosis infection in first nations and Inuit communities.

We're very pleased to see our witnesses this morning. We're very pleased to be able to hear what you have to say. It's a very important topic.

We have, from the Department of Health, Shelagh Jane Woods. Welcome back, Ms. Woods. We're happy to see you back. And Dr. RoseMarie Ramsingh is here as well. Welcome to you.

From the Assembly of First Nations, we have Chief Angus Toulouse, regional chief. Welcome, Chief. And we have Kimberley Barker, public health advisor. Welcome.

From the Inuit Tapiriit Kanatami, we have Elizabeth Ford, who is a director in the department of health and environment. Thank you for coming. And I think we have Gail Turner. I can't see your name tag, but I think that's who you are. Thank you, Gail. She's from the national Inuit committee on health and she is the director of health services.

From the Northlands Denesuline First Nation, we have Chief Joseph Dantouze. Welcome. We're glad you're here.

We're also going to have a teleconference, so from Edmonton, Alberta, via telephone, we will have Dr. Richard Long. He's director of the tuberculosis program evaluation and research unit, first nations and Inuit health, and the immediate past medical officer of health for tuberculosis with the Province of Alberta.

We are going to begin. Our time is very tight. We want to hear from everybody, so your presentations will be three to five minutes, and I will have to be very tight on the time.

Could we start with Ms. Woods, please?

9 a.m.

Shelagh Jane Woods Director General, Primary Health Care and Public Health Directorate, First Nations and Inuit Health Branch, Department of Health

Good morning, ladies and gentlemen. My name is Shelagh Jane Woods. I am director general of the Primary Health Care and Public Health Directorate in the First Nations and Inuit Health Branch.

On behalf of Health Canada, I would like to thank you for inviting me to speak here today. I am pleased to attend with my colleague, Dr. RoseMarie Ramsingh, the executive director of community medicine at the first nations and Inuit health branch.

Let me begin by emphasizing the fact that Health Canada is working diligently with all of its partners to help close the gap that remains in the overall health status of first nations on reserve and Inuit, including the burden of tuberculosis.

I think it is fair to say that we have helped bring about a significant reduction in TB rates among first nations on reserve and in Inuit communities over the past 30 years. The rates, however, as we all know, remain much higher than among the non-aboriginal population born in Canada and among the overall general population.

During the three-year period from 2005 to 2008, the overall aboriginal TB rate was relatively stable, with an average of 27.3 cases per 100,000 people. This, of course, is much higher than the rate among immigrants to Canada of 13.4 cases per 100,000 in 2008, and the overall rate in the general population, everyone included, of 4.8, which is much lower.

Canada adopted the global stop TB partnership rate reduction target—3.6 cases per 100,000 population by 2015—for the entire Canadian population, including first nations and Inuit. It will take a concerted effort among all partners to get there. We are engaged in a number of activities now toward that goal.

Our mandate at Health Canada is to provide or support the provision of health services in on-reserve first nations communities south of the 60th parallel. In addition, we currently provide funding for TB prevention and control in Nunatsiavut in Labrador. The three northern territories, as you all know, are responsible for all health program service delivery there, and this incorporates TB prevention and control activities for all territorial residents, including the first nations and Inuit. Health Canada and the Public Health Agency of Canada provide funding to support certain health promotion and disease prevention activities in the territories.

The regional offices of the first nations and Inuit health branch work very closely with key partners to ensure the delivery of TB prevention and control services to first nations on reserve, comparable to the services available to those living off reserve. These partnerships exist across each of the regions and include the provinces, local or regional health authorities, and of course, most importantly, the first nations communities themselves.

We support TB reduction through the application of the Canadian tuberculosis standards, which provide the Canadian standard for both public health and clinical management aspects of TB prevention and control.

While each regional office of the first nations and Inuit health branch has its own unique partnerships in place for the delivery of these services, the goal remains the same: to try to ensure equitable access to timely diagnostics, treatment, and follow-up care for those exposed to and diagnosed with TB. Additionally, the provision of TB prevention and education are important components of these programs in every region.

From fiscal year 2004-05 to fiscal year 2009-10, Health Canada invested a total of $42.4 million in our national TB program. The program is currently funded at a rate of $6.6 million a year. In 2009-10, that is, in this last fiscal year, Health Canada invested an additional $3 million to support the delivery of health promotion, TB prevention, and, most importantly, outbreak control services on reserve across Canada. This included support for on-reserve communities to build their own capacity and TB programming. We also supported some project-based work with Inuit Tapiriit Kanatami and the Assembly of First Nations.

In recent years, the first nations and Inuit health branch has reallocated additional funds, particularly to the Manitoba region each year, due to its relatively high incidence of TB, in support of the latter's TB program and to provide the additional funds needed to cover surge capacity and other activities during TB outbreaks. We do this wherever there are outbreaks.

The national TB program at the first nations and Inuit health branch at Health Canada is closely linked to the Public Health Agency's TB program. The agency is currently developing a Canadian tuberculosis prevention and control strategy, and in parallel we are renewing our own first nations national TB elimination strategy, which will be included as a component of the Public Health Agency's strategy.

Our strategy is being renewed through a working group of federal partners, external TB experts, stakeholders and—

9:05 a.m.

Conservative

The Chair Conservative Joy Smith

I'm sorry Ms. Woods, but you are over your time now. I did give you a little extra. Could you just wrap up quickly?

9:05 a.m.

Director General, Primary Health Care and Public Health Directorate, First Nations and Inuit Health Branch, Department of Health

Shelagh Jane Woods

I was just going to say that we're very fortunate to have Dr. Paul Gully working with us on this important file. He wanted to be here today, but he's in Vietnam. He will maintain close links with us on this file.

I'll leave it there to leave lots of time for others.

9:05 a.m.

Conservative

The Chair Conservative Joy Smith

Thank you so much, Ms. Woods.

We'll now go to Chief Toulouse, who is a regional chief in the Assembly of First Nations.

9:05 a.m.

Chief Angus Toulouse Regional Chief, Assembly of First Nations

Thank you.

I'm presenting today on the root causes of the elevated rates of tuberculosis infection in first nations communities. According to information recently released by the Public Health Agency of Canada, in 2008 rates of tuberculosis among members of first nations were 31 times higher than among others born in Canada. It is worth noting that this figure represents a rise in the rate of TB among first nations from only a few years before. It's unconscionable that rates of tuberculosis continue to increase among first nations in a country that otherwise boasts one of the lowest TB rates in the world.

Behind these rising rates are significant disparities between health services available to first nations and those available to other Canadians, as well as disparities in the social determinants of health. If we are to arrest the high rates of TB among first nations, we need to pursue two courses of action.

First, we need to improve the quality of TB control programming within the first nations and Inuit health branch so that it matches standards and resources applied elsewhere in Canada.

Second, we need to address the social determinants of health that contribute to the spread of TB in first nations communities.

Let me expand on the first point, improving the quality of TB control programming within the first nations and Inuit health branch. There is an urgent need to develop consistent program standards that will be followed in all of the first nations and Inuit health regions. These programming standards should be comparable to those that serve other Canadians and may even need to include additional measures to address issues such as latent TB, which, evidence would suggest, continues to persist at higher rates among first nations citizens.

In terms of programming standards, first nations and Inuit health in Ottawa funds its regional branches for TB control. When we examine what is happening in each region, we find there is no consistency in how regions program or monitor for TB in first nations communities. For example, there is no consistency across the region in how to define a TB outbreak. In the absence of an outbreak being declared, there are insufficient resources to control the treatment and spread of the disease. For example, regional health authorities and services are not brought in to assist and chief and council are not notified that persons have TB within their community.

Another example of this inconsistency is in the researching of case contacts, or, in other words, determining who may have come into contact with the disease and who may be at risk. It is left to the first nations and Inuit health regions to determine how many case contacts they will search and when they have searched sufficiently. Again we would suggest there should be national standards.

I also stated earlier that programming within the first nations and Inuit health branch should match standards and resources applied elsewhere in Canada. We looked at the health systems in the provinces and territories. Each sets annual targets related to TB cases, and they report to the Public Health Agency of Canada on the progress they make against these targets. For example, they may look at trying to reduce the number of cases by a certain amount on an annual basis or set a target for expanding their search for contacts.

Within the first nations and Inuit health branch, there are no annual targets for reduction of TB that would enable regions or the federal government to monitor the progress made in addressing TB or reducing rates. In fact, in a recent evaluation of the first nations and Inuit health branch communicable disease cluster, there were tables containing multiple gaps and blanks where there should have been information on a number of cases. This is an important gap that calls for immediate action. Programming and monitoring standards for first nations should be comparable to those that serve other Canadians.

If there is any doubt that programming and monitoring for tuberculosis in first nations falls below the levels serving other Canadians, I would point to data collected by the World Health Organization, which shows that Canada invests on average $47,000 in each case of tuberculosis for non-native patients. However, a report commissioned by the Public Health Agency of Canada reported that the first nations and Inuit health branch invests less than half--only $16,700 per case--in treating first nations citizens, including those in remote communities.

This table is shown as part of the package. Clearly, new investments are critical to closing the gap on standards of care between first nations and other Canadians.

I've also said that additional measures are needed to address issues such as latent TB.

9:10 a.m.

Conservative

The Chair Conservative Joy Smith

Chief, I'm sorry. I've given you extra time. We need to get everybody in. Can you wrap up, please?

9:10 a.m.

Regional Chief, Assembly of First Nations

Chief Angus Toulouse

Sure. Let me just essentially say that overcrowded housing, poor nutrition, and a lack of access to health care contribute to the higher rates of this disease among first nations, and these are the same conditions that were stated in the H1N1 outlook.

9:10 a.m.

Conservative

The Chair Conservative Joy Smith

Thank you, Chief.

We'll now go to Gail Turner.

9:10 a.m.

Gail Turner Chair, National Committee on Health, Inuit Tapiriit Kanatami, and Director of Health Services, Department of Health and Social Development, Government of Nunatsiavut

Good morning.

Current data reveal that the rate of TB for Inuit Nunaat is 185 times that of Canadian-born non-aboriginals. The significance of this cannot be ignored or dismissed. Social research has provided ample evidence that TB is a disease of poverty and social inequality. The same poverty marginalizes communities and threatens health through inadequate housing, food insecurity, and poor access to health care.

Inuit homes are the most crowded in Canada. It is estimated that 53% are overcrowded, a legacy of poverty and the government promise of housing to those who resettled, resulting in a high dependence on social housing, creating true hardship among all four regions, with impacts on psychosocial and physical health. It is estimated that Nunavut alone needs 3,300 housing units to address immediate need.

Inuit have the highest birth rate in Canada, a demographic reality that creates even greater housing need and results in multi-generational overcrowding that can present the perfect milieu for the transmission of reactivated TB from the elderly to the vulnerable young.

Inuit families are seven times more food insecure than other Canadian families. Food security is a complex issue in the north. Rising fuel costs impact immediately on the cost of produce brought in from the south and on the ability to hunt and fish for the country food so essential to optimal health. Weather variations due to climate change have a profound impact on food security, as witnessed this past year with mild temperatures and a lack of sea ice. Ice is essential to transportation and hunting.

The impacts of colonization and resettlement have led to communities in crisis, where coping mechanisms are challenged and addictions and underlying mental health issues are prevalent. These have an impact on wellness and healthy immunity that can make people more vulnerable to TB and can create challenges during treatment with adherence and drug toxicities.

The counselling supports needed for a holistic approach to TB are seriously lacking in many Inuit communities.

In regions with high rates of both latent and active TB, late diagnosis can further increase risk of spread. In many Inuit communities, there is no access to chest X-ray, and people have to fly out for service.

Why are the technologies for TB diagnosis not available where they are needed most? Tuberculosis is a simple medical diagnosis in a complex social situation. It cannot be mentioned without reference to the biological, historical, cultural, political, social, and economic conditions that have contributed, and continue to contribute, to this public health concern.

For Inuit, there appears to be a disconnect between what we know at the community level and what is known at the varying levels of governance and policy about what needs to be put in place to change health outcomes. Is the problem jurisdictional? Is it the lack of clarity around fiscal responsibility for Inuit? Is it the lack of capacity that forces a reliance on southern expertise, who may not have the cultural awareness for the appropriate fit?

Dr. Ellis, manager of TB prevention and control for the Public Health Agency of Canada, describes what is happening with TB among the Inuit as the perfect storm, where the combination of elements, each of which can cause concern, come together to create a serious situation.

Without the right type of intervention, the situation will continue to worsen. To treat TB without addressing the root causes is like using painkillers without looking for the source of pain: it will not go away. There must be a whole-of-government approach to Inuit health, with concrete goals set for immediate and long-term actions to address the social determinants that most impact TB among Inuit: housing, food security, income, and access to health care.

There is a call to consciousness that requires a strong commitment, both human and fiscal, and Inuit must be engaged at every step.

Nakurmiik. Thank you.

9:15 a.m.

Conservative

The Chair Conservative Joy Smith

Thank you very much.

We'll go to Chief Joseph Dantouze, please.

9:15 a.m.

Chief Joseph Dantouze Northlands Denesuline First Nation

Good morning to all.

I wish to thank the committee for inviting me to participate at this meeting. My name is Joe Dantouze. I'm the chief of the Dene people of the Northlands First Nation in Lac Brochet, Manitoba. This is an isolated, fly-in community south of the Nunavut border and 1,009 kilometres north of Winnipeg.

Our community is very familiar with tuberculosis. It has been making our people sick for over 100 years. Our people remember being taken from the community to sanatoria. For many people, we do not know where they are buried. We have rates of TB that are higher than most of the developing countries. From 1994 to 2004, our yearly rate of TB was 636 cases per 1,000 people. TB was an epidemic in our land before this time and it's still with us today.

For my people, tuberculosis is a social issue, a health issue, and a justice issue. All three issues must be addressed at the same time. This is the only way TB can be controlled.

There are social conditions that allow TB to spread in the first nations communities, and there must be immediate action to address these conditions, especially poor housing and a lack of food security. Our community lacks some of the basic things that we need to keep us healthy. In my community, 763 people live in 130 houses. The average homes in my community have 5.2 people in them. The average Canadian house has 2.5. Ventilation systems are absent or non-functional. In more than 80% of our homes, two-thirds of the people report mould in their houses. There are concerns that the mould affects our breathing and immune systems. Windows are damaged, air cannot circulate, and these conditions lead to the spread of TB and more illnesses. Low income and high food prices also mean that it is difficult or even impossible to maintain adequate nutrition, which is so important to prevent not just TB but also diabetes and other diseases.

Addressing TB as a health issue requires serious and proactive programs in partnership with first nations people and communities. People with TB need to be found early and not turned away for months because they are misdiagnosed. People who have been in contact with TB must be found early and treated with prevention therapy. They must not be missed due to poor follow-ups. The workers need to be from our communities, with the knowledge of our culture and the respect of our people. In my community, our nurse is one of our people and she is effective. TB workers need to be true partners in the program and part of the planning, implementation, and evaluation. First nations TB program goals, statistics, and evaluation must be up to national and international standards and they must be openly available. It is a matter of accountability and responsibility. We have met with health officials and Indian and Northern Affairs officials, and both point fingers at each other when we ask for both the social and medical aspects of TB to be addressed together in a coordinated, serious manner.

TB is a justice issue. Health care is a treaty right. Social conditions cause illnesses and steps must be taken. For health care, housing, and human rights, article 25 of the Universal Declaration of Human Rights states:

Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care....

In the Speech from the Throne of March 2010, Prime Minister Harper committed to sign the United Nations Declaration on the Rights of Indigenous Peoples, which confirms the rights of the indigenous people to housing, health, and social security in articles 21, 23, and 24.

We ask for a true partnership fighting this disease. We ask for community-based programs that are accountable.

9:25 a.m.

Conservative

The Chair Conservative Joy Smith

Thank you, Chief. You'll have more time. I've let you go over time, and I need to hear from Dr. Long. So could you just wrap up quickly?

9:25 a.m.

Northlands Denesuline First Nation

Chief Joseph Dantouze

I ask that we be in it together and address it together. We have been waiting too long, and something has to be done for my community of Northlands First Nation.

Thank you very much.

9:25 a.m.

Conservative

The Chair Conservative Joy Smith

Thank you, Chief.

We'll now go to Dr. Long, who will be joining us via phone.

Dr. Long, are you there?

9:25 a.m.

Dr. Richard Long Professor, University of Alberta, and Director of the Tuberculosis Program, Evaluation and Research Unit, First Nations and Inuit Health, and Immediate Past Medical Officer of Health for Tuberculosis, Province of Alberta

Yes. Can you hear me okay?

9:25 a.m.

Conservative

The Chair Conservative Joy Smith

We can hear you very well, Dr. Long. I'm sorry, but I'm going to have to keep you to three minutes. Can you please begin your presentation?

9:25 a.m.

Professor, University of Alberta, and Director of the Tuberculosis Program, Evaluation and Research Unit, First Nations and Inuit Health, and Immediate Past Medical Officer of Health for Tuberculosis, Province of Alberta

Dr. Richard Long

I would first like to thank the committee for the opportunity to speak.

Tuberculosis control programming in Canada is a provincial-territorial responsibility, with the exception of tuberculosis control in first nations communities and selected Inuit communities, largely those in Atlantic Canada and south of the 60th parallel, where tuberculosis control is a shared federal and provincial-territorial responsibility.

One must be careful with respect to tuberculosis incidence rates in aboriginal peoples, as the only two aboriginal groups in which there is reasonably reliable denominator data are status Indians and the Inuit. However, if we put aside denominator data for the moment and include all aboriginal groups, the gravity of the tuberculosis situation in aboriginal peoples is evident in a single observation. The absolute number of tuberculosis cases in aboriginal peoples in Canada has not changed for 15 years or more, while it has been steadily falling in non-aboriginal peoples.

From 2003, the absolute number of cases of tuberculosis in the aboriginal peoples of Canada, who comprise only 4.7% of the Canadian-born population of Canada, has exceeded the number of cases in the remainder of the Canadian-born population. The ignominy of persistent, seemingly intractable tuberculosis in the aboriginal peoples of Canada while rates of tuberculosis in the Canadian-born, non-aboriginal peoples continue to fall and ratios between the two groups continue to rise is not to be borne by people of conscience in a developed country.

I would encourage the federal government to adopt a broader perspective. First, more than ever, aboriginal peoples need to be at the table federally, provincially, and territorially. Historically they have not had a seat at the table. If they are not given a seat, we, the dominant society, will only continue to promote our legacy to aboriginal peoples, a legacy of learned helplessness, which if we are to move forward we must recognize as untenable. Education of both societies with a view to a deeper understanding of our history and commonality are in order.

Second, the bacterium that causes tuberculosis is uniquely well adapted to exploit weakness in the social development of its host. The disease thrives wherever conditions of poverty exist. The unrelenting success of this pathogen inculpates each new generation of its host in its failure to address the basic social needs of all. Attention to the upstream determinants of health, which impact the proximate risk factors for tuberculosis, is urgent. Aboriginal peoples have on average more frequent contact with people with active TB, a higher likelihood of crowded and poorly ventilated living conditions, limited access to safe cooking facilities, more food insecurity, lower levels of awareness and/or less power to act on existing knowledge concerning health behaviour, and limited access to high-quality health care.

Addressing the social determinants of health is a tuberculosis prevention paradigm that is complimentary to the traditional biomedical prevention paradigm of providing preventive therapy to someone who has latent infection. There is a historical and moral imperative for all Canadians to address this socio-economic disparity. This imperative goes far beyond tuberculosis, but tuberculosis as a social disease is like a barometer in measuring the success of our efforts.

With respect to all of the above, government must recognize that public health achievements may well depend on actions outside the health care sector. They must be prepared to work across ministries and in a non-partisan spirit that goes beyond election cycles and pursues social policies aimed to promote equity in health.

I'll stop there.

9:30 a.m.

Conservative

The Chair Conservative Joy Smith

Thank you, Dr. Long.

Dr. Long, we'll keep you very much in mind. I'll refer to you, because visually you can't see the committee and we can't see you. I'll make sure I touch base with you to ask if you want to make comments when the question period comes.

Right before our first round of questions--I could not do this at the beginning of committee--I need to get the budget passed.

It is moved that the proposed operational budget in the amount of $20,600 for the committee's study on elevated rates of tuberculosis infection in first nations and Inuit communities be adopted.

(Motion agreed to)

Thank you.

We'll now go to our questions and answers and to our seven-minute round. I'll be tight on the time to ensure that everybody can get their questions in.

We'll begin with Ms. Murray and Dr. Bennett. Who wants to start?

9:30 a.m.

Liberal

Carolyn Bennett Liberal St. Paul's, ON

I'll start. I have a couple of quick questions.

Ms. Woods, the winter 2009 draft of the Canadian tuberculosis prevention and control strategy, appendix 9, says, “The Inuit TB strategy is under construction and in preparation”. We've heard already today that somehow there isn't a strategy. I think what we are hearing even today is that we don't even have the data to actually do a strategy on what, by when, and how. If you don't have the numbers, then I think TB is a barometer, or almost a measurable sign, of inequity. That is what we're hearing. What I'm hearing is that because it's shared, there are different standards, according to the performance indicators, in every region. Without a strategy, how can we actually do the job? What are the standards? How are we meeting them? Why is it different in different aboriginal communities or across the country?

As we said during estimates, when somehow the medical services branch at CIC gets almost twice the money the first nations and Inuit health branch gets for TB.... Is it resources? Is it a lack of a plan? How can this steadily get worse over these last years as the non-aboriginal population gets better and better and we leave our aboriginal populations behind? I guess at some point the lack of X-ray machines obviously is huge in all these fly-in communities.

I'll leave these other questions. Maybe we'll just let Joyce ask her questions, and then you can all answer them.

What are we doing, obviously, on the social determinants of health, because we're not going to win anywhere without the help of INAC and the other government departments that can help with those things?

9:30 a.m.

Liberal

Joyce Murray Liberal Vancouver Quadra, BC

Thank you for your testimony and for helping us understand the gravity of this inequity and the evidence.

The tuberculosis sub-working group had a resolution, which was to reduce TB incidence to 3.6 per 100,000 among on-reserve first nations and Inuit peoples. I noted in some of the testimony that the rates were stable at 27.3% until 2008. But I also heard that they're rising. What's the current rate? What is the trend? Where are we heading with that? Really, I just want to understand the rates and where they're headed.

Second, is a holistic approach needed, with goals and measures? That seems to be something we've heard, and I presume this is a common view. To what degree is tuberculosis being addressed as part of the whole health of the aboriginal status and Inuit and Métis people as opposed to being treated as a separate disease?

Finally, if it is tied in with the social determinants, which we've heard from everyone it is, what's the role of the federal government in terms of providing leadership and pulling other levels of government together? What's needed to have that actually happen?

9:35 a.m.

Conservative

The Chair Conservative Joy Smith

I'm sorry. You have less than two minutes, and I don't know where you're going to start.

9:35 a.m.

Director General, Primary Health Care and Public Health Directorate, First Nations and Inuit Health Branch, Department of Health

Shelagh Jane Woods

Neither do I, but I'll figure it out as I talk.

9:35 a.m.

Conservative

The Chair Conservative Joy Smith

Ms. Woods, are you starting?

9:35 a.m.

Director General, Primary Health Care and Public Health Directorate, First Nations and Inuit Health Branch, Department of Health