Health Committee on Oct. 5th, 2009

[Judy Wasylycia-Leis, NDP, Winnipeg North, MB]

What's UL?

[Dr. Mary L'Abbé]

That's the upper level, the 2,300.

That would mean a significant reduction in sodium intake by the Canadian population. And we feel that although that might--

[Judy Wasylycia-Leis, NDP, Winnipeg North, MB]

Significant enough to achieve some instant reduction in some of these numbers that are killing people?

[Dr. Mary L'Abbé]

The experience in a number of countries is that even.... We discussed things like 5% per year; those would translate into significant lives lost. I think Dr. Campbell is a better expert at doing the calculations, but the feeling is that that gradual, sustained, continuous change in the food supply over time is the approach to take. And that is the approach that has been used, for example, in the U.K. system. The working group has borrowed very heavily on its experience to develop the targets for Canada, or draft targets at this point.

[Judy Wasylycia-Leis, NDP, Winnipeg North, MB]

I'd love to hear from Dr. Campbell.

While you answer that, maybe you could also answer the question of a voluntary versus a regulatory approach, because I think we've learned from the trans fat experience that voluntary only takes you so far. At some point, industry starts to feel the pain of a system that has some complying and others not, and that causes serious concerns in terms of the food and restaurant association, I'm sure. So wouldn't it be better to get right to it and set some definitive targets?

[Dr. Norman Campbell]

We've been a while setting the targets. The ultimate target is to get us down to between the adequate intake level, which is 1,500 milligrams for an adult of average age, but is considerably lower for a younger or an older individual, and the upper limit target is likely going to be around 2,020.

It was felt that it was important to get an interim target that was feasible and could be achieved. That's 2,300 milligrams in 2016, and that requires about 5% per year. In Finland, that achieved 40% reductions. It took them about 20 years to achieve that. In the U.K., they're achieving somewhat over 2% per year. So it's a fairly substantive effort that Canada is trying to achieve.

It's important. Each year, as you know, we're estimating that 11,500 people have a cardiovascular event while we're waiting to achieve these targets. So from my own perspective, it's quite urgent that we do so, but we must do so in a way that we're actually able to achieve. I think that's going to require very strong government oversight, with voluntarism.

There will be good corporate citizens that toe the line. There will be companies that try to avoid the issue, potentially to gain a commercial leg up on some of their competitors. If that's a substantive problem, I'm guessing that our good corporations will be advocating for regulations.

I'm told that's actually starting to be the case in the U.K., where a number of companies really have made substantive reductions and are looking at some of their confreres who haven't. Some companies are requesting regulation.

In Finland, there were a number of regulations introduced, including high-sodium warnings on food. In Portugal, the amount of sodium in bread products was regulated, and that was the highest source of sodium there.

The advantage to regulations is that there is a very rapid change, but sometimes regulations can take considerable time. The model we're looking at, which currently is probably the most defensible one in the world, is the U.K. model, where it is voluntarism, but voluntarism with strong government oversight and with the threat of regulations should there be failure to comply.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Campbell.

We'll now go to Dr. Carrie.

[Colin Carrie, Conservative, Oshawa, ON]

Thank you very much, Madam Chair.

First of all, I want to thank the witnesses for being here.

I want you to know that we as a committee are committed to studying healthy food. It's one of the things that was brought up as one of our priorities, but personally, I'd like to admit first that I am a recovering saltaholic. I love the stuff, but I'm okay now. When the salt shaker's passed, I do get some shakes, but overall I think I'm doing much better.

I was shocked, Dr. L'Abbé, by one of your handouts. I look at some of the food on there and see that the numbers are really high. I am aware that the industry is taking this seriously. I have been visited by one of the major potato chip manufacturers, another product that I love, and they've taken a lot of action already to lower the amount of sodium.

But I am concerned. My colleague brought up World Action on Salt and Health, and sodium levels in selected products internationally, and bran flakes were mentioned. In Canada, the stated number was 861 milligrams for a serving, but in the U.S. it's only 258. Onion rings, another favourite of mine, in Canada are at 681, while in the U.K. it's down to 159. Popcorn chicken in Canada is at 908 and even Malaysia has it at 560 milligrams.

When I look at these differences internationally, I think there's an obvious question. How does Canada compare to other countries with respect to sodium intake? I was wondering if you have a hypothesis for why. Is it cultural reasons? Is it historic reasons? When I see numbers like that for the amount of sodium we have in products, that looks to me like the average MP's diet.

[Voices]

Oh, oh!

[Colin Carrie, Conservative, Oshawa, ON]

Why the big difference? How does Canada compare? Could you comment, please?

[The Chair, Conservative, Joy Smith]

Who would like to answer that?

[Phyllis Tanaka]

As we're a trade association, I obviously can't speak on behalf of individual companies, but yes, it is known that there are differences between products in different parts of the world, and it can be on both sides of the fence. There will be some products in Canada that are lower in sodium than they are in the U.K., for instance.

But you did point out that you wondered how we compared to other countries with respect to our population's sodium intake. In fact, in Canada, while we are high at 3,100 milligrams per day, if we compare that to the U.K., their population's sodium intake when they started out was much higher. Looking at individual products doesn't give a full picture of all the elements that shape the population health status of different countries.

[Colin Carrie, Conservative, Oshawa, ON]

Dr. Campbell.

[Dr. Norman Campbell]

Both the Stroke Network and Blood Pressure Canada collaborated on the World Action on Salt and Health survey, but we went into that enthusiastically, thinking Canada would look very good because we had had two to three years of widespread publicity around the issue, and we thought Canadian companies would respond. I think most of us were totally shocked when the results of the survey came out, and it was very disheartening. I think it indicates that a lot of companies have the exact same product in a different country that's very low in sodium, and it speaks favourably for impacts that we could have.

Notably, high sodium is not an issue for just Canada, it's a world issue. Sodium is added to food around the world. It's one of the priorities of the World Health Organization. Very recently the Pan American Health Organization struck a sodium committee to try to develop policy recommendations for reducing sodium in the countries of the Americas, some of which have very high rates. Notably, stroke rates around the world correlate very closely to sodium intake, and that's because they are associated with high blood pressure, but also some other health issues such as gastric cancer. High dietary sodium is also a procarcinogen and has other potential adverse health effects.

[Colin Carrie, Conservative, Oshawa, ON]

We are trying to send a message to the average Canadian that eating well and staying active is really important for a “healthier you”. I was wondering if you could give the committee an opinion on why sodium is such a high-priority issue when we have other things like fat--we talked about trans fat--and sugar. Why is sodium such a big priority relative to other things?

[Dr. Norman Campbell]

Just recently I was invited down to the Centers for Disease Control and Prevention in the United States, where they're restructuring how they deal with their health system and they're looking at the major risks to health in their population and how feasible it is to deal with them.

Number one, increased blood pressure is the leading risk for death in the world. That's from complex analyses done by the World Health Organization, and it relates to the fact that blood vessels are everywhere in your body and that increased blood pressure damages them.

The leading causes of death in our country are stroke and heart disease, and high blood pressure accounts for about 66% of strokes and about half of heart disease. The increase in blood pressure that we experience in our society is not experienced in primitive societies where they eat unprocessed foods, are lean, and are physically active. When we look at the different reasons for increased blood pressure, we see they relate to a number of dietary factors--high caloric intake, saturated fats, low calcium, low magnesium, low fibre--but in a large proportion, high dietary sodium is one of those big contributors.

As I indicated earlier, about 30% of hypertension in Canada, the clinical diagnosis, would be associated with high dietary sodium. When it's examined how much you're going to pay for how much you're going to get out of it, again, international analyses have suggested the most cost-effective way to improve the health of the population is to reduce dietary sodium. This includes reduction in tobacco smoking, which is viewed as highly cost effective. But reducing dietary sodium will get you more bang for your buck. That's why there's a focus on it.

That's not to suggest that other health issues are not critically important and shouldn't be dealt with. We do have Canada's guide to healthy eating, which indicates what we should be eating. Perhaps we need an overarching strategy on how we can get the Canadian population to eat that way, as opposed to just putting it out as a nice handout.

[Colin Carrie, Conservative, Oshawa, ON]

Madam Chair, just briefly, can we ask if anybody else has an opinion on that, or does everybody agree with Dr. Campbell?

[The Chair, Conservative, Joy Smith]

We'll have to wrap up with Mr. Jeffery. I'm sorry, Monsieur Malo, we've run out of time.

Briefly, Mr. Jeffery.

[Bill Jeffery]

With regard to the nutrients you identified, trans fat and sodium, excess sodium intake is responsible for about four times as many deaths as trans fat by some estimates. However, we're still talking about thousands of premature deaths per year. The World Health Organization, in May of this year, issued a scientific update on trans fat, indicating that the scientific case is even stronger for getting it out of the food supply. But we still have this voluntary program, and we're waiting to find out if the Minister of Health is going to make good on Health Canada's call for regulations in the absence of strong action from industry.

There are other factors to consider too. Canadians get inadequate intakes of fruits and vegetables and whole grains and legumes, and those are all important risk factors. They're just not as well studied in terms of the actual population level implications in terms of premature deaths, but they are important too.

[The Chair, Conservative, Joy Smith]

Thank you, Mr. Jeffery.

We're going to have to bring this to a close. Perhaps we can have this topic on another day. It's very interesting and I think more questions are pending.

I want to thank you very much for being here.

I would like to ask now that we suspend for two minutes to allow our next guests to come to the table.

[The Chair, Conservative, Joy Smith]

I will ask all members to come to the table, please.

I would also like to ask all witnesses to come and take their places. We're quite looking forward to your presentations today.

We're now going into the second hour, which will be the H1N1 preparedness and response.

We have four organizations represented today. Starting with the Canadian Nurses Association, Rachel Bard is the chief executive officer. Welcome, Rachel. And we have Della Faulkner, nurse consultant, public policy.

We have five-minute presentations today, Ms. Bard. We have a lot of presentations and we want to make sure there's an opportunity to ask questions as well. When you see this light on red, I need you to wrap up before very long.

Welcome, and we look forward to listening to your presentation.

[Rachel Bard, Chief Executive Officer, Canadian Nurses Association]

Bonjour.

I am certainly pleased, as the chief executive officer of the Canadian Nurses Association representing registered nurses from across the country, to have the opportunity to present. Thank you very much for the opportunity to present nurses' solutions to successfully managing the H1N1 influenza pandemic.

Our analysis of the implementation of the pandemic plan to date reveals several improvements since the last public health crisis--namely, SARS--but also several areas that require action. Let me begin with the strengths.

First, we commend Minister Aglukkaq and our Chief Public Health Officer for their regular communication with the public and health professionals. CNA appreciates the regular opportunities for communication with officials at the Public Health Agency and the minister's outreach to Canada's nurses.

Second, consultation with the health professionals has been fairly extensive. CNA and other national health professional groups have been consulted on a number of policy documents, including PHAC's guidance on the sequencing of vaccine delivery and the development of an online course for health professionals.

Third, we support PHAC's efforts to provide an evidence-based approach to the pandemic, using data and information from around the world to inform our implementation.

This is not to say that there isn't room for improvement. Coordination is a challenge, especially as it relates to communication. Canada's registered nurses tell us that they are receiving communications from multiple sources, and not all of the messages are consistent. They receive information from PHAC, their provincial or territorial government, their local public health unit, their employer, and the media, and I could go on.

While we recognize the responsibilities of various governments and stakeholders, we need to find a way to coordinate and streamline our communications. We urge the federal government to lead this effort by ensuring consistent and timely messages, policies, and implementation. Without this, we will confuse health professionals and the public and erode trust in our public health system and governments.

Health professionals are inundated with information that is critical to their practice. From the very onset of this pandemic, CNA has called on the federal government to produce for health professionals factual and consistent guidelines that are user-friendly and easy to access. Given that health professionals may be operating under difficult conditions, it is imperative that they be able to quickly refer to a definitive source of information that focuses on essential facts. This information must be available in both paper-based and electronic formats in order to reach nurses and other health professionals in all corners of the country.

Our second concern is for protecting the health and availability of nurses during this pandemic. Nurses tell us that some employers have not offered fit testing for N95 masks, or that N95 masks are not available. Imagine how the health system will fare if the largest group of health professionals, that being nurses, fall ill and can't report to work. We need your help to ensure that Canada's nurses are protected.

Third, the electronic health record is an essential component in the real-time tracking and reporting of patient information during public health emergencies. Continued investment in e-health is critical. We therefore urge the federal government to release the $500 million announced in the federal budget for Infoway to continue implementation of the electronic health record.

Finally, we believe this pandemic points to the need for better research to observe and evaluate the allocation of nursing research. Lessons learned will inform our action this time around, help us improve our level of emergency preparedness, and benefit all Canadians in the future.

Canada's registered nurses and CNA are ready and willing to work with governments to minimize the effects of this pandemic. RNs have the skills and knowledge to play a number of key roles.

In fact, CNA's provincial and territorial members have been working with their governments to expedite registration for recently retired nurses so that they can take an active role in dealing with the crisis.

Canada's registered nurses are partners with government in this pandemic.

Merci beaucoup.

[The Chair, Conservative, Joy Smith]

Thank you very much, Ms. Bard.

We'll now go to the Canadian Federation of Nurses Unions.

Welcome to Linda Silas, the president.

[Linda Silas, President, Canadian Federation of Nurses Unions]

Thank you.

My remarks will focus specifically on infection prevention and safety in the health care system.

It appears that, with the exception of Ontario, the provinces and territories are set to follow the Canadian pandemic guidelines, which are based on occupational health and hygiene, not safety. If the federal government releases and accepts these as they are currently drafted, and the provinces and territories accept them verbatim, a nurse in Ontario will be better protected than the other nurses across our country. This is not the message our members or the public want to hear. They want to know that all levels of government are taking all possible precautions to eliminate, and where that is not possible, to minimize, the risk to health care workers.

Let me remind the committee, and I'll quote from its website, that the Public Health Agency of Canada was created for “clear federal leadership on issues concerning public health”. As a nurses' union, we think the Public Health Agency of Canada is setting a gold standard for public health concerns generally. We need the same clear leadership in annex F, which is on employee personal protection. If PHAC cannot provide this leadership because of so-called jurisdictional issues around workplace occupational health and safety, we believe that silence from the federal government would be better than the lowest common denominator.

We feel strongly that the use of occupational health and hygiene as opposed to occupational health and safety downplays the legitimate work and concern in the field of occupational health and safety, that is, workplace and employee-focused safety. If safety standards are used for firefighters, miners, and police officers, they must also be the standards used for nurses and other health care workers. As reported by the SARS Commission, the precautionary principle generally impacts worker safety.

We can have a battle of words, and let me tell you, we've been having it--researcher X said this and researcher Y said that--but what we all agree on is that the evidence is not clear. What we have learned from SARS is that it's too dangerous to wait for conclusive science before deciding on protective measures. Therefore, while scientific debates persist, we have to exercise the precautionary principle: be safe, not sorry.

Another example of our disbelief in the direction PHAC is taking in annex F are the tools suggested to determine that a health care worker is at risk. An employee is required to navigate through four separate tables, which is very confusing and inefficient. If we simply applied the precautionary principle, we would have health care workers equipped with N95 respirators when in a room or in an area with a patient who has an influenza-like illness during the pandemic. There's no need to navigate through a maze of confusing guidelines. There's no need to place that on a nurse who will be working at 4 a.m., when most everyone in Ottawa will be sleeping. She will be there to defend her own safety and the safety of her patient. We will not accept this.

This doesn't mean that everyone in a hospital needs to wear an N95. Let's be clear. We can determine who actually needs respirators by conducting risk assessments.

Let me remind you that of the 251 probable cases of SARS in Canada in 2003, 247 were from Ontario. Of these probable cases, 77% were exposed in the health care sector. Two of our members died there. Health care workers made up half of these cases.

Ontario has incorporated the precautionary principle in occupational health and safety in its pandemic influenza plan. We urge you to protect health care workers and to make SARS the lesson for national lessons. If PHAC won't do it, nurses will.

Merci beaucoup.

[The Chair, Conservative, Joy Smith]

Thank you.

We'll now go to Dr. Doig from the Canadian Medical Association.