Health Committee on Oct. 28th, 2009

[The Chair, Conservative, Joy Smith]

Good afternoon, ladies and gentlemen. I'm going to have to ask all of you as committee members to please take your seats.

We're going to have to change the times a little bit today because the bells will ring at 5:15 for votes. So we'll have our first round of witnesses from 3:30 to 4:45, and the H1N1 briefing from 4:45 to 5:15. When the bells ring, I have to suspend the meeting. We have to go for votes, and then we'll come back for our subcommittee on neurological disorders.

Also, committee, I have a motion that the proposed supplementary operational budget request in the amount of $32,000 in relation to the committee's study on the H1N1 preparedness and response be adopted. Would the committee adopt that, please?

(Motion agreed to)

[The Chair, Conservative, Joy Smith]

Thank you.

Thank you to the witnesses for coming today. We're so pleased you all could make it.

We have with us the Grand Chief of Manitoba, Ron Evans. Welcome. Glen Sanderson, senior policy analyst, welcome to our meeting. We also have the Indigenous Physicians Association of Canada, Dr. Marcia Anderson, president; the Society of Rural Physicians of Canada, Dr. John Wootton, president-elect; and Cecelia Li, medical student, McGill University. Welcome.

We will have a 10-minute presentation, and following that we will have the questions and answers. We will start with Grand Chief Ron Evans, please.

[Grand Chief Ron Evans, Grand Chief, Assembly of Manitoba Chiefs]

Thank you, Madam Chair.

I want to thank the House of Commons Standing Committee on Health for the invitation to appear once again before this committee to discuss our H1N1 preparedness and our response in Manitoba and to provide an update to our last visit to this committee.

As I stated in August, the Manitoba first nations are affected by the H1N1 virus disproportionately in comparison to the general public. In our initial analysis of the first wave, we identified a host of contributing factors, including overcrowded living conditions, poverty, lack of access to medical supplies and services, conflicting information, and a lack of access to running water, which all combine to make an ideal breeding ground for H1N1.

In the interest of time, I will outline our priorities and accomplishments in beating back this flu.

In June, under the direction of the Assembly of Manitoba Chiefs executive council, I requested all Manitoba first nations to declare a state of emergency on the H1N1 pandemic in order to hold the federal government responsible and accountable to fulfill their fiduciary responsibility towards first nations.

The Manitoba first nations set out the building blocks for the Manitoba first nations incident command system to respond to emergencies. We initiated an aggressive educational campaign where we printed and distributed H1N1 posters to approximately 16,500 first nations homes and businesses in Manitoba. We aired radio commercials targeted at H1N1 prevention strategies. We put a priority on H1N1 updates and aired them weekly on the Assembly of Manitoba Chiefs' half-hour NCI FM radio show. The network has 140,000 listeners, including all 64 first nations communities and every major centre in Manitoba, including the city of Winnipeg.

In July we completed preliminary training of personnel from every first nation for the incident command system, and we built on our advocacy initiatives for pandemic preparedness.

In August the chiefs and assembly passed a resolution at Nisichawayasihk Cree Nation, which is Nelson House Cree Nation, that directed me, as the grand chief, and the health staff to advocate for Manitoba first nations to be the first priority for the H1N1 pandemic vaccination. We've done that.

In September there were shocked northern chiefs who revealed publicly that Wasagamack First Nation received body bags in shipments of medical supplies. In response, the health minister called for an investigation. In the end, the investigation raised questions about the government's ability to coordinate communications to respond effectively to a national health emergency. It also demonstrated that first nations have a right to be consulted regularly about preparations for their survival in the midst of a pandemic.

In October the health minister publicly released the findings. Headquarters in Ottawa had advised nursing stations “to order big” on pandemic supplies. And nurses took that directive to mean stockpiling three to four months' supplies, which included body bags.

From the beginning I have said that this crisis is about people, not politics. I was distressed to see some feedback that used our people, even our children, like props in a political theatre.

We are the most vulnerable living in conditions of poverty. It's not helpful for our people to be given this kind of information, with pictures of our children being used as props, and body bags, especially when we're trying to convince and encourage them to get vaccinations. We feel as first nations communities that we should be working together to encourage all our citizens to get vaccinated. We should not be using people as pawns for political gain. This is a collective responsibility we have as leaders, as elected people, to make sure the Canadian population is vaccinated. We find it very disgusting and unacceptable that our people are used for this purpose. We ask that we all take collective responsibility to ensure that everyone is vaccinated, not frighten people or discourage them from being vaccinated.

I want to give you an update. In Cross Lake, one of the largest first nation communities in Manitoba, 2,000 people were vaccinated just yesterday, and maybe the whole community will be vaccinated today.

There are some hockey players who have come in contact with the H1N1 virus. This is a very serious issue, and we should all be supporting each other in combatting this virus.

We also designed flu kits. We designed them as a first line of defence against H1N1. They were delivered with the help of the province and generous private sponsors. All 15,500 of them have been delivered to every home on every first nation in Manitoba. Then last week, federal approval of the H1N1 vaccine turned a welcome corner and we started moving ahead to protect people, not argue about politics.

As first nations and aboriginal leaders in Manitoba, we were among the first to take the vaccination so we could lead the way and give our people the confidence and comfort they need to get the H1N1 vaccine shot.

The federal government worked with the province and the first nations to organize a series of mass vaccination clinics, which are taking place. Thirty-seven communities will have clinics set up this week, 25 will be next week, I believe, and the balance will be the week after.

The first week of a four-week campaign rolled out just the other day, on Monday. Today, the province's northern medical unit stands ready to support northern nursing stations with staff and medical supplies, and we are in better shape to face the future.

We have in excess of 50,000 first nations people with health centres that do not provide any primary care. Without transportation, there is no access to emergency medical care for our people. Too many of our communities are remote, rampant with poverty, poorly equipped, and with little infrastructure and even less health care. In my last appearance I requested that the Government of Canada fund annex B, the government's own pandemic preparedness plan. I'm pleased to say that we have made partial progress in implementing annex B.

My overarching concern remains that we are not ultimately addressing the very conditions that make first nations populations high risk. I continue to advocate for the political will. We work hard to reverse the impoverished conditions of our people, and we expect nothing less from all political representatives. We have an opportunity to address the pervasive issue of living conditions among first nations communities. H1N1 is a wake-up call for us to do that.

Thank you very much, ekosani, meegwetch, wopida, mahsi cho. Those are the five languages of the Manitoba first nations.

Thank you very much. Merci beaucoup.

[The Chair, Conservative, Joy Smith]

Thank you very much, Grand Chief.

We'll now go to Dr. Marcia Anderson from the Indigenous Physicians Association.

[Dr. Marcia Anderson, President, Indigenous Physicians Association of Canada]

I would like to begin by thanking the members of the Standing Committee on Health for the opportunity to stand on Algonquin territory and speak to you today about H1N1 in first nations communities.

My name is Marcia Anderson, and I'm Cree-Saulteaux from Manitoba, with clinical training in internal medicine and public health. l've been the president of the Indigenous Physicians Association of Canada for the past three years. As an organization of physicians and medical students who hold the vision of healthy and vibrant indigenous nations, communities, families, and individuals, we have been watching with great concern as H1N1 has circulated the globe.

At this point, we are all aware of how H1N1 disproportionately affected first nations people in the first wave, which was particularly striking in Manitoba, where 37% of all cases and 60% of those admitted to the ICU with H1N1 were first nations people. According to PHAC data, first nations were also disproportionately represented among pregnant women who were infected with H1N1. This should not have surprised us, given that in past epidemics of influenza there have been mortality rates four to seven times higher in indigenous peoples, and that each year first nations people are hospitalized for seasonal influenza at four to five times the rate of the general population. Further, we now know from Australia's experience with H1N1 that aboriginal and Torres Strait Islander people were hospitalized and died at ten and seven times the rate of the general population, respectively.

I consider it a success that aboriginal ancestry has been defined as a characteristic that makes people eligible for priority group one vaccination in Manitoba. I find it concerning that the federal government has not clearly identified all first nations people as higher risk for severe illness, as evidence has shown that urban first nations people are also disproportionately affected. There has been a lack of targeted and focused communications on the risk of H1N1 illness for first nations people that explains, at a literacy appropriate level, why the risk is higher and what to do. This is particularly striking as it pertains to pregnant first nations women. I cannot help but wonder if, had this been clearly recognized as a risk factor, more resources would have been made available to mitigate that risk.

First nations organizations in Manitoba have been setting up command centres at the community and regional level to support first nations communities in their H1N1 planning and response. I commend them for this, and I am aware that a proposal has been submitted for the support required to establish these systems and to ensure that the individuals are appropriately trained. It is my belief they should receive an equitable level of financial resources to support this new role for these representative organizations. They have done an excellent job in representing and advocating for their communities, filling gaps in communication pathways, and identifying the logistic and operational realities that many who work in the provincial public health system were not familiar with.

I also believe we need to provide an equitable level of public health expertise to the first nations incident command system as exists to national, provincial, and regional incident command systems. In Manitoba there is a single federal regional medical officer of health to serve 64 widespread communities, and that is simply inadequate even at the best of times. Perhaps consideration should be given to providing resources for the Assembly of Manitoba Chiefs to contract one to two public health professionals who can assist with finalizing the plans in the communities that have not finished them, and implementing them across the province as we are entering this second wave.

I will finish with two suggestions for addressing the risk of H1N1 in first nations communities.

First of all, an independent evaluation of the health care system response to the first wave of H1N1 in first nations contexts that can identify the effectiveness of different elements of the response, including adequacy of resourcing, communications, working structures, and working relationships, and clinical care, should be done. This is absolutely necessary to understand how to improve the health care system response, particularly inasmuch as we don't know if we as a system contributed to increasing the risk of severe illness or mitigated that risk. I will note that on a CBC The National interview, with respect to the health system response to H1N1 in aboriginal and Torres Strait Islander peoples, a senior Australian health official stated that he didn't feel they should have done anything differently, that the gap was only 10 times. It could be considered a successful outcome, because if they had not done so well the gap would have been wider. I hope that none of us would consider such a significant inequity acceptable and evidence of a job well done.

Second, the elevated risk for respiratory infections, including H1N1, is chronic and well known, and evidence shows that reasons for this include poverty, overcrowded and inadequate housing, higher rates of non-traditional tobacco use, and underlying medical conditions, which themselves are also due to underlying socio-economic inequalities. We must see a commitment to addressing these underlying social and structural inequities if we want to see a different outcome. I have heard Sir Michael Marmot, chair of the WHO commission on the social determinants of health, remind us that there is plenty of money to address underlying inequalities in social conditions. We saw the clear evidence of this with responses to the economic crisis. We have chosen to bail out banks and car manufacturers and have chosen not to ensure that all have access to appropriate shelter and to a safe and potable water supply.

If we truly want to see the gaps in health close for first nations communities, whether we are talking about H1N1, seasonal influenza, tuberculosis, diabetes, or heart disease, we must choose differently. We must have an explicit goal of health equity for indigenous peoples in Canada, and we must ensure that every policy and program decision is evaluated for how it will impact the gap in health for first nations, Inuit, and Métis people.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you very much.

Now we'll go to the Society of Rural Physicians and Dr. John Wootton.

[Dr. John Wootton, President-elect, Society of Rural Physicians of Canada]

Thank you, Madam Chair.

I appreciate the opportunity of appearing before you. I have Cecelia Li with me, whom I dragged into this. She's a medical student who's currently doing a rural rotation in Shawville, just down the road. She's part of the group that is the relief, the cavalry coming over the horizon, and we hope to interest her in rural practice. She brings a fresh set of eyes to the problems.

I've been in rural practice for 25 years. I'm the president-elect of the Society of Rural Physicians, and there are other members, colleagues of mine, across the country. When I got the the invitation to come to speak to you, I put out a call to my colleagues to give me some front-of-the-line reaction to the question of preparedness in their communities. This is unavoidably a bit anecdotal, since we haven't done a scientific survey. But I heard from people working in first nations communities and from health care teams in more southern rural communities. I'll list them for your interest. I heard from people in Lacombe, Alberta; La Loche and Wynyard, Saskatchewan; Sioux Lookout, Haileybury, and Smiths Falls, Ontario; Invermere, the Queen Charlotte Islands, Fort St. John, and Golden, B.C.; Glenwood and Freeport in Nova Scotia; and Goose Bay, Labrador.

As a general impression, what I heard was that there are preparations being made. Nevertheless, they are being added to from the shortages that already occur, and these are mostly human resources shortages of nurses, physicians, and other health care providers. In some places, it's going to make a difficult situation worse.

The one that worries people is that if the pandemic, as it has in the first wave in some communities, produces large numbers of people who require intensive care, transport, and facilities to care for them, things will become very difficult. This is why the Society of Rural Physicians has for many years lobbied for increased education of physicians who intend to practise in rural areas. We favour dedicated rural streams so that the skills required to look after patients close to their home communities can be strengthened. This way, when difficult times arise, particularly difficult times when everybody's in the same boat, some of those skills can be applied where the people live.

One of the other comments that I got from rural communities is that we shouldn't lose perspective on this pandemic. Many public health experts are still not sure what the severity of H1N1 will end up being. Communities that have a lot of other essential services to provide need to be able to continue to provide them. Physicians are also telling me that it's a wake-up call. We haven't been paying attention to infectious diseases in other years in the way we should have. It's well known that seasonal influenza also causes a lot of morbidity and mortality among slightly different demographic groups. But because these epidemics are not so widely publicized, not as much effort is put into combatting them. I think they are saying yes, H1N1 is a significant problem and we have to respond to it now, but let's not pack that experience away into a suitcase afterwards; let's learn from what we've had to do to combat this one.

Another possible perspective of interest to committee members is the federal-provincial one. As you know, health is a provincial responsibility, so all the provinces have rolled out slightly different pandemic plans, slightly different vaccination strategies, and slightly different target groups. For people who live on borders and for physicians who communicate amongst themselves across borders, that produces a fairly confusing picture. I work in Shawville, which is just up the river from here in Quebec, and my patients are very confused, because the news they hear is about the Ontario program, which is vaccinating with a different vaccine for the seasonal flu, and at a different time than Quebec has chosen. I'm not here to debate who's right; I'm here to assert that the plethora of different programs is guaranteed to cause confusion, both in health care providers' minds as well as in patients' minds.

I'd make the comment that the need to do all of this province by province must in the analysis have led to a great deal of wasted—or not wasted, but certainly duplicated—effort. Perhaps there's a lesson to be learned from this about a more coordinated planning process.

I mentioned the worst-case scenario, the concerns about there being a lot of people requiring ICU care. Already in Quebec they're talking about 200% to 300% of ICU capacity being reached. That's going to stress rural physicians with limited resources and limited backup, if we come to that point.

Looking into the future, there are some things that the Society of Rural Physicians is very interested in pursuing. One is ensuring that at times like these there are adequate human resources in rural areas. It's an ongoing issue. We've worked very hard to make the case that the quality of care provided in rural Canada should not be different from the quality of care provided elsewhere, but only organized differently; and that the providers of that care need to be educated differently, and that we need a presence in the universities and in the residency programs and in our teaching communities to ensure that this happens.

Finally, I think I can guarantee for you that rural physicians have community connections second to none and that they will step up to the plate and do whatever is required under the circumstances. Hopefully, we'll come out of this stronger than before.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you very much.

We'll now go to our first round of questions, with seven minutes for questions and answers.

I'm going to be strict with the time, so don't bother to ask me whether you can have extra time; it won't work. We want to cover as many questions and comments as we can today.

I understand, Monsieur Oliphant, that Dr. Duncan is going to share your time, so I'll give you a signal when you're halfway through.

Mr. Oliphant, would you begin, please.

[Rob Oliphant, Liberal, Don Valley West, ON]

Thank you.

Thank you all for coming and for taking time at an important point in your careers to be here today. Having been a patient at Pontiac Hospital years ago, I am particularly glad that you're here, Dr. Wootton.

Also, Grand Chief Evans, I want to begin by saying that if the paper you held up has come from our party, I want to first of all extend apologies if it is in any way offensive to you or to anyone. I had not seen it until you just held it up now, and I heard the concern in your voice. I take it seriously. If it was done by our party, I want to assure you that I am convinced it was done to try to raise attention to the dire needs of vulnerable communities, particularly in our first nations and Inuit communities. It was, I hope, done with the best intentions, and I hope you will accept that apology, if indeed we did that.

That being said, I have a question. Technically, the most important thing I've heard so far is from Dr. Anderson: the concept of evaluation and the sure-and-steadiness of an evaluation from the first wave of H1N1, and how we have perhaps failed in doing one.

If there is advice you can give further, I'd like you to elaborate a bit more. If you have an intuitive evaluation already that is not yet scientific, that would be helpful for us. And can you address how we may advise our government about how to do a more appropriate evaluation of what we did?

[Dr. Marcia Anderson]

Thank you for that question.

I have worked with the public health system in Manitoba, because in part of my day job I am a provincial public health employee. I have a unique relationship, I think, with some of the different people, because I am a western-trained public health physician, but possibly because of my background and my interests and my previous research experience with first nations, I feel that I've developed a trust relationship with a number of the different representatives who have sat at our tables. Also, when I received the invitation to come here, I e-mailed them to ask them for any feedback I could represent on their behalf.

As far as the evaluation goes, the feedback I've had in the past and what I've witnessed myself is that there are many tables designed to provide a forum for communication. But on the first nations representation side, there has been a lot of frustration, because merely having the forum hasn't necessarily led to meaningful discussions or to resolutions of the issues. Things seem to have to come up again and again prior to there being any satisfactory resolution, if there is one.

What I've seen and heard more broadly from my own family members, friends, and community members indicates a significant lack of trust in the public health system as well.

Intuitively, I think we have had some wins. I mentioned one before: the aboriginal ancestry being recognized as a risk factor in Manitoba. So I think there would be positive findings also, but I think there was a lot that could have and should have gone better.

In terms of how an evaluation could be done, my suggestion would be that we consider an approach at arm's length from government. A professional organization such as ours would be willing and could consider leading some type of organization. The second most common specialty among physicians in our organization after family medicine is actually public health. We have a number of physicians who work in different federal and provincial public health systems with the requisite expertise as well as a number of very highly qualified researchers and appropriate international links that could help develop a really solid scientific methodology.

I think it could use a combination of standard epidemiological techniques, really getting to those rates, which would require open access to the data that PHAC and the provinces hold. It would also need to include other methodologies to collect information about the quality of working relationships, such as key informant interviews. Obviously a key factor would also be the organization of response structures and some feedback from the first nations on how they feel they were represented in those response structures, so that we could build better linkages and better representation among those.

[Rob Oliphant, Liberal, Don Valley West, ON]

It would be as part of a system, I know.

[Dr. Marcia Anderson]

Yes, it would be really a system-level evaluation.

[The Chair, Conservative, Joy Smith]

You have seven minutes left, Dr. Duncan.

[Rob Oliphant, Liberal, Don Valley West, ON]

Can I respond to that?

[The Chair, Conservative, Joy Smith]

Yes, absolutely.

[Rob Oliphant, Liberal, Don Valley West, ON]

Thank you.

[Grand Chief Ron Evans]

I want to express why this is very disturbing. It talks about body bags and flow kits. The investigation was done and the information was put out there--what happened with the shipping of the body bags. I want to believe that everyone here has read the report, and we accept the findings of the investigation.

The other misinformation is that a question is put: were the Conservatives wrong to ship body bags instead of flow kits to first nations? The flow kits were shipped by us, the Assembly of Manitoba Chiefs, with the help of the provincial government, so it's wrong information as well. If this came after the investigation, then we need that clarified. It has Dr. Carolyn Bennett's name on it.

I don't know when you sent these out to your communities.

[Carolyn Bennett, Liberal, St. Paul's, ON]

It was before.

[Grand Chief Ron Evans]

I just hope they were sent before all these things happened. We just shipped our flow kits in the last couple of weeks. Obviously our experience tells us that these things went out after the investigation was revealed, and that's what's troubling. Then it appears our children are being used for the wrong purposes, although we do appreciate any help we can get to raise our issues. We'd like that to be done in a good way. That's why we need to raise that. It's really troubling to our people with the--

[Rob Oliphant, Liberal, Don Valley West, ON]

We'd like you to know that the printing and mailing timelines in this place are unbelievably slow. If they arrived on doorsteps you can rest assured they were done about two months ago. That's the reality of what we live with here. Yours are much faster.

[The Chair, Conservative, Joy Smith]

Thank you very much.

We'll now go to Monsieur Dufour.

[Nicolas Dufour, Bloc, Repentigny, QC]

Thank you very much, Madam Chair.

Time is running out. No?

[The Chair, Conservative, Joy Smith]

No. I give you every benefit, Monsieur Dufour.

[Nicolas Dufour, Bloc, Repentigny, QC]

Thank you very much.

[The Chair, Conservative, Joy Smith]

There are no presents today.