Health Committee on April 20th, 2010

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Hershfield.

Dr. Orr.

[Dr. Pamela Orr, Professor, Department of Medicine, Medical Microbiology and Community Health Science, University of Manitoba, As an Individual]

I want to thank the committee for inviting me. I speak as an individual rather than on behalf of any organization.

I have four recommendations.

One, there must be one single unified TB program in each province for both aboriginal and non-aboriginal people. The program must be accountable to and the responsibility of the chief provincial officer of health. The current system of two TB programs, one administered by FNIHB, the other by the provincial department of health, is not only inefficient but counter-productive. TB does not respect boundaries and cannot be controlled by fragmented methods. The responsibility and accountability are opaque in the current system. Cooperation and communication should not depend on personality but should be mandated. People may argue about whether two public health systems, federal and provincial, work for other diseases such as hepatitis, but it clearly does not work for tuberculosis.

Two, there must be clearly articulated objectives, performance targets, and yearly evaluations. These must meet national and international standards. The data must be openly available and shared. This is required in order to expose what is being done and what is not being done in aboriginal TB programs in Canada. Meaningful data are not currently uniformly available. Patients are often blamed, but programs need to take a hard look in the mirror. Confidentiality is often used as an excuse for secrecy; however, it is possible to share information while ensuring patient and community confidentiality. If we had information we would see that some programs succeed and some fail. We see late diagnoses, misdiagnoses, inadequate treatment, failure to contact trace, and failure to employ prevention therapy. The causes of failure include lack of fiscal human resources, insufficient knowledge, insufficient skilled or consistent staff, failure to endorse or follow accepted guidelines, and failure to engage communities. Aboriginal people need to be part of this process. Programs must be accountable to the health authorities but also to aboriginal people.

Three, TB programs must support, nurture, and form a true partnership with those in each community who have capacity. This promotes community ownership of problems and the solutions. TB programs are often so focused on the disease, they fail to use local people. The Navaho have a successful program run by local Navaho people. They are responsible to the Indian Health Service, but their community feels ownership because they see their own faces working the program.

Four, the social determinants of TB, including poor housing and poor nutrition, must be addressed seriously and credibly. There is an unfortunate tendency of TB programs to blame these social determinants for the failure to control TB. However, we have to remember that the fastest decline ever recorded for TB occurred in and among the Inuit from 1960 to 1980, and it was achieved primarily through the medical program.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Orr.

We'll now go on to Dr. Graham.

[Dr. Brian Graham, Chair of the Chronic Disease Policy, Chief Executive Officer of the Lung Association of Saskatchewan, Canadian Lung Association]

Thank you, Madam Chair and members of the committee. I'm pleased to be here on behalf of the Canadian Lung Association, and I wish to thank the committee for recognizing that this is a serious issue that deserves the attention of Parliament.

Rather than repeat a lot of the information that you've already heard this morning, I want to reinforce two points from the lung association's point of view. These are that we do need improved treatment of tuberculosis, and secondly, that we also need to be addressing the social determinants of health.

But there are a couple of other points I'd like to raise. The third point has to do with the nature of the support that's required for tuberculosis. It has to be long-term and sustainable support, and one of the reasons for that is due to the disease itself. Some diseases are dangerous because they grow very quickly and rapidly, but tuberculosis is dangerous because tuberculosis germs grow very slowly. In a society where we appreciate speed, that might be hard to comprehend, but it takes six months or more of taking combinations of drugs to cure a case of tuberculosis. Without intervention, a tuberculosis epidemic can take 200 to 300 years to run its course.

The lung association has been fighting tuberculosis for 110 years; we are here for the long term. Solutions to TB problems in first nations, Métis, and Inuit communities will require long-term programs, with long-term indicators for success, and long-term, sustainable funding. One of the things to consider in looking at these indicators is that if you start improving TB control programs, initially you're probably going to find more tuberculosis. Rates of tuberculosis might even experience an initial increase, and that shouldn't be a reason that one would yank the funding. You have to look at this in the long term.

If we look at where rates are among the aboriginal population right now, it's been about 30 years since rates were that high in the non-aboriginal component of the population. It took 30 years to bring that rate down below one per 100,000. We have better tools now. As Dr. Long has said, a lot of the high risk and high rates of tuberculosis are located in geographically confined communities. We can achieve a faster decline of rates of TB in the aboriginal population, but we still need to build capacity and work with first nations and Métis and Inuit community leaders and champions to make effective TB control a reality.

A couple of programs have worked. The SCRAP-TB program, which was developed in B.C., and the World Health Organization's PAL program appear to have some promise. Both of these programs are based on the notion that there's not one size that fits all.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Graham.

[Dr. Brian Graham]

May I make just one more point on this?

In closing, I think we have tools and expertise, but we need to collaborate with the first nations and Métis communities. As I said before, we all have to be working together on this.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Graham.

We're now going to the Canadian Public Health Association.

I understand, Mr. Chauvin, that you want to say a couple of things before Ms. Randell. If you start within the context of three minutes, as long as you're aware of it....

[James Chauvin, Policy Director, Canadian Public Health Association]

Thank you, Madam Chairman.

I'm going to forgo making an introductory statement, but I would like to thank you on behalf of the Canadian Public Health Association for the opportunity to appear before the committee.

I'd like now to hand over to my colleague, Elaine Randell, registered nurse and communicable disease consultant with the Department of Health and Social Services of Nunavut. She's here as a CPHA member to share with you her first-hand experience of what's happening in the field.

[Elaine Randell, Communicable Disease Consultant, Department of Health and Social Services, Government of Nunavut, Canadian Public Health Association]

Thanks.

To fully understand the pattern of TB in most aboriginal populations in Canada, it's important for us to understand the history of TB among this group, where the epidemic came from, as well as the social determinants of health that significantly contribute to the continuing high rates of infection and disease.

Contact with European merchants and traders in Canada occurred in sequence, beginning with the Atlantic provinces in the 16th century, Ontario and Quebec in the 17th century, the Pacific provinces in the 18th century, the prairies in the 19th century, and the territories in the 20th century. Contact in the territories began in the west in Yukon, and to the east, which is now Nunavut. The subsequent wave of settlement that followed this changed the way that aboriginal populations lived, from small, isolated, mobile groups to large groups living in settlements and stationary.

This social colonization was what provided the vector for the spread of tuberculosis. The earlier the epidemic began, the sooner it reached its peak and began to fall, until the last 15 years or so, as we've heard, which is why we see the pattern of TB rates we have amongst aboriginal populations, the rates being lowest amongst the population where the social colonization occurred earliest and highest in areas such as Nunavut, where it occurred most recently.

Inadequacies in the social determinants of health are key in continuing the cycle of outbreaks and high rates of TB among aboriginal populations. Crowded and inadequately ventilated housing increases transmission. I'm aware of situations in which infectious cases have been recorded in houses with 13 people or more, including young children, who are especially vulnerable. The rate of transmission in these situations is very high. Those without housing move from home to home as guests, thus increasing the number of people who are exposed and infected. Long periods of cold weather and darkness in the north lead to longer periods of time spent indoors in crowded and inadequately ventilated housing. This leads to increased exposure and shared air space and subsequent increase in transmission. Poor nutritional status increases risk of progression from infection to disease. In many remote communities, selection of nutritious foods such as fresh vegetables and fruits is extremely limited and prohibitively expensive. Programs such as food mail that provide access to more nutritious foods are easily accessed by people who have credit cards, but many Inuit don't have credit cards and don't even have bank accounts.

Delayed diagnosis of infectious cases results in prolonged exposure time for contacts. Diagnosis is delayed when regions don't have local diagnostic capabilities and expertise.

Some remote communities lack continuity of health care providers. A successful TB program is dependent on a relationship of trust between the residents in the community and their health care providers. This requires continuity of staff and health care workers who are experienced and trained in early detection of tuberculosis.

Social colonization is the primary root cause of TB among aboriginal populations. Issues related to the social determinants of health, which include crowded and inadequate housing, poor nutritional status, and lack of continuity of health care providers, are the root causes of continued high rates amongst Inuit. TB rates in Europe began to fall even before the introduction of the first medications, with improvements to standards of living. By addressing issues such as poverty, housing, and access to health care and nutritious food, we can expect the same to happen here.

[The Chair, Conservative, Joy Smith]

Thank you so much for your presentation.

We will now go to our second-last presentation, which will be from the Canadian Society for International Health.

Ms. Roberts.

[Janet Hatcher Roberts, Executive Director, Canadian Society for International Health]

Thank you.

As Rosemary Brown has said, “Until all of us have made it, none of us have made it,” and clearly we haven't made it here in Canada yet.

What is stunning, as Dr. Hershfield said, is that the root causes haven't changed. If Dr. Hershfield had déjà vu, I'm sure that Dr. Osler, who in 1900 said that TB is a social disease with a medical aspect and we need to look at housing and nutrition, would clearly be appalled.

The global picture of TB reflects the same inequities we see in first nations in Canada in low-income countries, where poverty and the distribution of poverty is massively inequitable, especially in Africa and South Asia. As well, the expenditure on health care is reflective and inequitable. It has an impact as one of the determinants of health, and thus is one of the determinants of tuberculosis.

There are 370 million indigenous people worldwide. No one knows the prevalence of tuberculosis, because most national tuberculosis programs don't count indigenous people, and there are very significant barriers in access to care.

Canada has made commitments to the world in reducing tuberculosis through a number of initiatives. The millennium development goals include tuberculosis as one of the goals, and there is a call for global partnership to address these issues. We are committed to those millennium development goals, yet here in Canada we have seen an increase in tuberculosis amongst our first nations communities. So while we should be concerned about reaching millennium development goals globally, we should be concerned about our inability to address progress amongst first nations communities. We have committed over $124 million worldwide to tuberculosis, and we will be called upon to reinvest in the global fund next year.

What is needed is a health systems approach, not a health care approach. We've heard this today. We put a little diagram together for you to pull those ideas together. It integrates social determinants and health in all policies; establishes processes for measuring the quality, reach, outcomes, health information systems, surveillance systems, human resources, and evidence-based approaches that are culturally sensitive. It engages communities to allow them to be empowered and accountable, with an ability to interact with governments, researchers, private sector, and other civil society players.

At a global indigenous TB meeting last year, a framework on opportunities for leadership for Canada, in Canada and abroad, brought forward a number of recommendations that we put in our report. They can be considered by this committee.

In closing, it's clear that we need policy coherence. We need to bring together the different policy demands. I suggest an interdepartmental committee be struck to address this issue.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you, Ms. Roberts.

During the questions everyone will be listening very attentively. They will ask you questions, so you will be able to add extra points that you want to put across.

Now we'll go to the University of Alberta and Ms. Fanning, please.

[Dr. Anne Fanning, Professor Emeritus, Faculty of Medicine, University of Alberta]

Thanks very much. I'm going to deviate from my prepared remarks to try to summarize their essence.

It's fantastic that this issue is being addressed by this committee. Congratulations. It is a blot on the conscience of Canadians that the disparity is as profound as it is.

TB control requires a very standard, globalized approach that you've heard about. You find the cases, you cure the cases. You find the contacts, you prevent them, and you do so on an urgent basis for the reasons already described. There's no question about it.

Canada has those standards, but we do not have performance indicators at the regional level to determine whether the standards are being met. These should be measured on an annual basis, and we either pass or fail. We deliver that program in order to save lives, prevent transmission, and to reach elimination strategies.

There is no question that we can do it, because we did it in the fifties when rates were 2,000 to 3,000 per 100,000 people. Now the rate is four per 100,000. But in the north, where a determined Canadian program or policy was put in place—I'm sure at great expense—the rates fell faster than they did anywhere else in the world. They hit their nadir, the bottom, about the mid-eighties.

Since then, they've been rising, because our attention has shifted. We failed to sustain what we were required to do to ensure that we reached the elimination point, and the rates have gone up and up and up in every region of this country, but especially in Nunavut among the Inuit. The rates have gone down in one province, which happens to be Alberta.

I hesitate to brag, but I want to tell you how that program is described. It's described as “pigheaded”, because we are determined to do it. The program works because there is collaboration between the federal and provincial authorities and there are performance indicators measured annually. People talk to each other, and when a case occurs, it is considered an emergency and urgent action emanates as a result. I suggest this happen everywhere.

[The Chair, Conservative, Joy Smith]

Thank you, Ms. Fanning, and thank you for encapsulating your presentation. That was very helpful.

We'll now go into our seven-minute question and answer session. We're going to have shared time between Ms. Neville and Ms. Murray.

Who would like to begin?

[Anita Neville, Liberal, Winnipeg South Centre, MB]

I'm going to start. Thank you.

Ms. Fanning, would you mind tabling your prepared remarks that you deviated from? Would you table them with the chair so we can see the full scope of your comments?

[Dr. Anne Fanning]

I'll try to remember what I said. Thank you.

[Anita Neville, Liberal, Winnipeg South Centre, MB]

No, we would like the prepared ones, not the deviated ones.

I have all kinds of disjointed questions to ask. I was struck when listening to you and the group that was here before by the insanity, I guess, for lack of a better word, of the preponderance, and increasing preponderance, of TB in a country as abundant as ours.

My first question is for Dr. Hershfield. Am I correct that there is a vacancy in the position of director of tuberculosis control in the Province of Manitoba? I wonder if you could speak to that briefly and the impact it's having.

[Dr. Earl Hershfield]

There isn't a vacancy, but the director of tuberculosis control happens to be the chief medical officer, who has 117 other jobs to do. So there isn't a tuberculosis control program as such with a head. That's what the problem is, as I see it, in Manitoba.

The other problem in Manitoba with respect to FNIHB is that they have abdicated their responsibility by contracting out the services on reserve to the Winnipeg Regional Health Authority. The Winnipeg Regional Health Authority, in my view, looks after health in Winnipeg. I have no idea what it's doing on reserve.

So there isn't a regular TB program directed from the top down. That is one of the problems in Manitoba and it is why, as I see it, Manitoba has the highest TB rates in Canada outside of Nunavut.

[Anita Neville, Liberal, Winnipeg South Centre, MB]

You're touching on the other area I wanted to talk about. What we heard from the group today and from the previous group is that there is a lack of coherence, a lack of congruency, in the programming.

Dr. Orr, you mentioned that there should be one organization or one jurisdiction taking the lead. We have a whole array of organizations here. Do the governments, the private sector, and not-for-profit groups speak to each other? What can be done?

Dr. Orr, you had four points. You were cut off at three. If you would like, you can complete your fourth one. Then talk about what's necessary in terms of providing some coherence. We heard Dr. Hershfield speak about Manitoba.

[Dr. Pamela Orr]

On the first point, I would just say that my observation is that in some regions--Alberta is one of them--FNIHB and the province get along very well and work together cooperatively. But in other parts of Canada, that doesn't happen. It's dependent on personality, and it shouldn't be. That's the reason I believe only one unified program can work. Communication shouldn't be dependent on personality.

The second issue is that, basically, improving the social determinants of health must happen at the same time as the medical intervention. That's a question of justice, which Chief Dantouze and Chief Toulouse talked about so eloquently. However, this mustn't be an excuse. The medical program mustn't point a finger at the social determinants. The medical programs have to take a long look in the mirror and fix themselves before they point the finger at the social determinants.

[Anita Neville, Liberal, Winnipeg South Centre, MB]

Does anybody else want to comment? Ms. Roberts? There is no other comment?

Go ahead, Joyce.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Dr. Fanning, I was interested in your comment that Alberta seems to be more successful in reducing TB rates in rural and first nations communities. How would the federal government extend that approach to other provinces without stepping on jurisdiction, in your view? Have you thought about that?

[Dr. Anne Fanning]

That's a difficult question. But I think we have an obligation to deliver the best possible program in every single region. There is no excuse not to. I think the money should follow the authority or the authority follow the money. It should be an obligation to meet the performance indicators we've identified. They're out there, but they're not measured on an annual basis. I think the program could be emulated, but I think that would not sit well with lots of regions. But if every region is measured on an annual basis on their delivery--cases found, cases cured, prevention, action taken....

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Just to understand Alberta's situation, was that methodology and the pigheadedness driven by your provincial medical officer or by the provincial government or by the university and academics? Who has put that forward and is driving it and pushing it?

[Dr. Anne Fanning]

I think it has been a philosophy for 30-plus years. And I think that in spite of some attempts within the province to water it down, the personalities have remained pigheaded and have kept it going. I think it's a mixture of factors, but it clearly works and could be emulated.