Health Committee on April 20th, 2010

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Ms. Roberts, what can we take from other countries? Are there other countries that have dealt with the specific kinds of challenges we have with the Inuit and with the historical changes, which Ms. Randell explained, that you would advise this committee to study? Are there particular regions?

[Janet Hatcher Roberts]

First of all, the idea of imposing versus emulating I think is an important distinction. The idea would be that those are best practices. If everybody is tasked with a report card, then they're going to have to come up with those best practices. It isn't imposing; it's adoption and emulating. So I don't think we have to be so concerned about jurisdiction. Certainly internationally we have some wonderful examples of tuberculosis control, exactly as Dr. Hershfield has said.

[The Chair, Conservative, Joy Smith]

Thank you, Ms. Roberts.

[Janet Hatcher Roberts]

If you follow along with those steps, it will happen.

[The Chair, Conservative, Joy Smith]

Monsieur Dufour.

[Nicolas Dufour, Bloc, Repentigny, QC]

Thank you, Madam Chair.

First of all, I would like to ask Ms. Hatcher Roberts a question.

Before exploring some matters in depth, I too would like to know what is being done internationally. How is Canada viewed internationally when it comes to tuberculosis in aboriginal populations? I know that, a little earlier, you told us that, in some developed countries, national programs do not necessarily include the aboriginal population. Do we have comparative figures to see how well Canada is doing internationally? And are there good practices that we could import?

[Janet Hatcher Roberts]

When we implement programs, we bring people like Dr. Fanning and Dr. Hershfield in to actually deliver those national TB programs. So we use the best practices that have been used here in Canada, that have been tested out, that have been proven to work. Exactly what Dr. Hershfield said—and I'm sure Dr. Fanning can elaborate—those are the steps.

We work with national TB programs to not only adopt those steps but to build the capacity and involve communities. I think somebody else was talking about this. If you involve communities and train them, they don't all have to be doctors, but we do have to involve an interdisciplinary team to approach that: laboratories, nurses, doctors, and community health workers. And it works, but it has to be a comprehensive investment.

Perhaps Dr. Fanning or Dr. Hershfield could comment, but one of the examples is Guyana, where I worked with Dr. Hershfield. I know the Canadian Lung Association has done considerable work in Ecuador, and Dr. Fanning has worked elsewhere.

If you go in with that approach, it does work, but it requires continued investment. You can see in Canada what the result was when that didn't happen.

[Dr. Anne Fanning]

I've just recently looked at Australia, New Zealand, the U.S., and Greenland, because they have disaggregated data on aboriginals. In aboriginal communities in each of these countries, the rates are higher by factors ranging from 1.5 in the U.S., to ours, which is the highest.

In all of the countries but the U.S., the rates are going up in indigenous peoples, not as dramatically as in Canada, except in Greenland.

Greenland had the same Inuit experience in the 1950s. Their rates went way down because of an excellent program. It bottomed out in 1987 and their rates are now higher than the Inuit of Canada.

It is related to program delivery in a sustained, committed, well-funded, participatory fashion, engaging communities and making sure the capacity exists in those communities with the kind of health professionals who know the circumstances of those communities.

I might add why it works in the U.S., just to say that they have program indicators, and every state reports every year on their performance.

[The Chair, Conservative, Joy Smith]

Dr. Hershfield, did you want to make a comment on that?

[Dr. Earl Hershfield]

Yes.

One of the problems in Canada is that we do not have a national TB program. We have provincial programs that can do as they like at any time, but we do not have a national program. That's the trouble in trying to compare Canada with other countries.

One of the things that I would hope would come out of a committee like this is that there should be a national program. It can be administered by the provinces for those individuals who have federal responsibility.

The problem is that each province must have a distinctive TB program. It can vary from province to province, but how you carry it out is simple, easy, straightforward, and it has been done for 50 years.

[The Chair, Conservative, Joy Smith]

You have two more minutes.

[Nicolas Dufour, Bloc, Repentigny, QC]

You were talking about a national program. Of course, the provinces will not just have to be consulted, they will have to take the operational lead.

We also have the problem of a lack of communication that we heard about earlier. There seems to be some vagueness; we do not know exactly who should be dealing with the problem and how it should be handled. Ms. Turner told us that, not only was there just one paragraph, but also that it was very vague. There are no specifics about who should be dealing with the problem. How do you see it? The question is for all the witnesses.

[Dr. Earl Hershfield]

I go back to what I said previously: each province has to have a vertical tuberculosis control program. This is frowned on by some people in public health. It isn't to say that the director of tuberculosis control is a world unto him or herself, and in fact they should be responsible to the chief medical officer, but the tuberculosis control program in each province must be single, vertical. It can be horizontal at the community level, and should be horizontal at the community level, but the control and the decision-making and the program itself must be a vertical program. That's anathema to some public health individuals, I understand that, but it's the only way TB is going to come under control in Canada.

[The Chair, Conservative, Joy Smith]

Is that the end of your questioning, Mr. Dufour? You've only got about 30 seconds.

[Nicolas Dufour, Bloc, Repentigny, QC]

A little earlier, Mr. Graham told us that it has taken 30 years for the rate of tuberculosis in non-aboriginal populations to fall to 30 cases per 100,000. The government has set a goal of bringing the rate down to 3.6 cases per 100,000 by 2015. Do you really think that is realistic?

[Dr. Brian Graham]

Yes, I do. I think some of the reasons for this are that in the Canadian population as a whole we were dealing with a whole country, and it's one of the things Dr. Long has pointed out, and especially from our experience in Saskatchewan, where we've seen, as he's pointed out, that there are may be six or seven communities that have the highest burden of tuberculosis. So it's not a whole stretch in that regard. We also have better tools than we had before. We have better ways of diagnosing tuberculosis and recognizing and treating latent tuberculosis.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Graham.

We'll go to Ms. Wasylycia-Leis.

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

Thank you, Madam Chairperson, and thanks very much to all of you for coming to talk about a national emergency.

I want to just begin by noting that Dr. Fanning's comments were much appreciated. She is not here just as an expert and a doctor and a professor, but she is also a winner of the Order of Canada for her work on tuberculosis. I think we need to take very seriously her very straightforward recommendation, and I hope we can put that directly into a report that goes to Parliament and that will then be acted on by the government.

I want to say, sitting here and listening to all of this, I feel so embarrassed to be a Canadian when I hear what you're saying, which is so basic and so possible and not being done, either because of lack of political will or just sheer inability--or maybe incompetence--to coordinate folks across this country according to one national standard that is monitored annually, and if the targets aren't met and if the performance isn't met, then action is taken. What can be more straightforward than that?

I want to know a couple of things. According to the department, she said today, we spent $42 million in the last five years on TB and all the while the numbers are going up. What's clear is that the money is being spent, allocated to regions, with no targets, no performance criteria, so we don't even know where that money goes. Maybe it's all going into pollsters. Who knows? And maybe what we should be doing, Madam Chairperson, is having the Auditor General in to look at this fund and find out where the heck that money is being spent and why it's not going to where it should.

I want to ask Dr. Orr something, and I don't know if this is okay with you, Dr. Orr. As I understand it, you were the director of TB control in Manitoba, and you got frustrated and quit your job, partly I think because of the absolute inability to coordinate anything with FNIHB. I don't want to put words in your mouth--I'd love for you to tell your story--but what I'd like to know from you is, how do we get FNIHB and the Public Health Agency of Canada to do what you recommended today, to take this seriously, to kick-start this issue and start putting the resources and standards in place to deal with an absolutely ballooning number of TB cases in a supposedly civil society that is not a third world country?

[Dr. Pamela Orr]

I want to say that I've seen a great deal of leadership on this issue from Dr. Ed Ellis from the Public Health Agency of Canada, and he's a hero of this process. I would just say that when you have a TB program, let alone an HIV or hepatitis or cancer program, in which there are different leaderships, jurisdictions, you are going to get fragmentation, and that may be okay for hepatitis or cancer--I don't think it is--but not for tuberculosis. One has to have a single program in each province, and the medical officer of health will then have to answer for what goes on in his or her region according to the performance targets. To do otherwise is to allow for the variance between some areas of Canada, where personalities are pigheaded and effective and they get along, they cooperate, and other areas where there's a disconnect and non-communication.

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

You're right about Dr. Ellis. And we should mention that he put out a report on January 20 of this year, which said, “The TB situation in Canada, Forgotten by most, but not gone: a new TB case in Canada every 6 hours”, and a death every two weeks. He actually identifies a number of the problems, from the rise among aboriginal peoples, including delayed suspicion of disease by health care providers, delayed diagnosis due to time required to obtain sputum and X-ray data results...all of which are under the jurisdiction of the federal government and are not being done. That's why I'm so embarrassed.

I was in Dhaka, Bangladesh, and I saw the sputum tests being done in a little tent in little rural villages of enormous poverty. They were sent off, and if X-rays were needed they were followed up and medicines were provided. Volunteer nurses were making sure that the medicines were taken. They're conquering it by that. We're not even doing that in Canada.

My question is this. Would it not make sense to at least have Health Canada and the FNIHB, with public health agencies, send in special teams to those hot spots in this country, like Lac Brochet, where they can't even get a team in to do the X-rays, where there are only 750 people but where they expect there is widespread tuberculosis in that community? Why couldn't they at least say, “We will do that today, we will send in a special team to those 10 to 15 hot spots in this country and get to the bottom of it”? At least get the accurate numbers, get the prevention, get the drugs in place, and start to work on it.

[The Chair, Conservative, Joy Smith]

Dr. Hershfield.

[Dr. Earl Hershfield]

It's a jurisdictional problem. The federal government--I don't think--comes to the Province of Manitoba and says, “I'm going to do this in Lac Brochet”, without consultation, at least, with the provincial program.

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

Okay, but what I understood, first of all, is that it is federal jurisdiction that we're talking about--reserves.

Secondly, it seems to me, based on what I've heard from others and from you, there is in fact a lack of any kind of performance standards and will by the--

[The Chair, Conservative, Joy Smith]

Ms. Wasylycia-Leis, with all due respect, do you want to keep talking, or do you want him to answer?

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

I just want him to address it from the point of view of--