Health Committee on April 20th, 2010

[The Chair, Conservative, Joy Smith]

Okay, thanks.

[Shelagh Jane Woods]

Thank you for the questions. Those are very complex questions. I'll try to give a very quick answer.

The first nations and Inuit health branch strategy is under renewal. We've had a strategy for a long time, but we haven't renewed it in a very long time.

I wouldn't say there are different standards; as you know from other testimony from many other people here, our regional offices tend to follow the clinical care guidelines, the practices, and the standards of the provinces in which they find themselves, and those standards do not differ markedly. There may be different approaches, but the standards are all pretty well the same. I don't think there is a lack of a plan. As I say, we are updating the plan. That's important work that we have to do with our partners.

I'm not sure it's lack of money, but that's one of the things that renewal of the strategy will tell us. We are always able to find the money to cover the outbreaks when they occur, which is not necessarily a sign of good planning, but at least it's a good response.

I'll try to do justice to the social determinants of health. Yes, we understand how important it is. We've spent a number of years working with our partners at the Department of Indian and Northern Affairs, for example. There is a much greater recognition of the importance of the social determinants of health to their work, not just to ours. I think we can make some breakthroughs with them, but it's going to take a concerted effort.

On housing, I agree with the things people have said. Of course, overcrowding is a very big issue. We obviously have to do a lot of work with the Assembly of First Nations and then at the regional level with first nations organizations and with the communities themselves. That's exactly how we're doing the renewal of this strategy and all the other activities that take place.

I'm sorry about the shortness of time. We definitely are trying to treat tuberculosis not as just a separate disease but more as a bellwether of the social determinants of health. That's definitely the approach we're trying to take.

[The Chair, Conservative, Joy Smith]

Thank you so much, Ms. Woods.

We'll now go to Monsieur Malo. You have seven minutes.

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

Thank you for being here.

I am going to continue along the lines you were discussing, Ms. Woods. In this present situation, we see that the same elements lacking in all the problems that affect aboriginal populations are factors here too: housing, nutrition, all the social determinants of health are involved.

I saw you taking notes as the witnesses were testifying. So I suppose that you were writing down the answers you wanted to give to all the questions that people asked: are there intermediate targets; why are we spending less on the treatment of tuberculosis in aboriginal society than in non-aboriginal society; why are there problems in diagnosis; why are aboriginal communities not more involved in the entire process of treating disease? I would like to add one more question: how will you reach the target of 3.6% by 2015? According to the infection numbers we have been given, that seems to me to be a very bold target, to say the least.

[Shelagh Jane Woods]

Are those your questions? Yes, I agree that the elements are the same in all the determinants of health. I am not sure that we are spending less. That was a—

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

—a question from Chief Toulouse.

[Shelagh Jane Woods]

Yes, and it was exactly why I was taking notes. It interests me a good deal and I am probably going to work on it with my colleague Dr. Barker.

There are a lot of things that have to go into the renewal of our strategy. With every one of the elements you touched on, we have to know what the factors are underlying the differences in expenditures. I don't know about those, so I can't really comment on them at this point.

It's audacious and bold to set a target of 3.6 by 2015. I cannot see how we could say 3.6 is good for the overall Canadian population, but we are not even going to try for the aboriginal population. I honestly believe that between 2010 and 2015, if we get it right, if we have the active and willing partnership of the first nations, and if we support them well in this, it is something we can achieve.

I cannot imagine that we could settle on a less ambitious target for first nations and Inuit. That's not fair or right.

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

Chief Toulouse is asking you for intermediate targets. Is that something he is going to get?

[Shelagh Jane Woods]

That is exactly why I was so interested. I am of the same opinion: it would be very useful to have them, but we have to develop them together. Because, for sure

it's not up to the first nations and Inuit health branch to try to do this by ourselves. We must work with our partners on this.

[Dr. Kimberley Barker, Public Health Advisor, Assembly of First Nations]

Thank you.

I think one of the limitations the federal government has in all of this is that the accountability of the FNI regions is nil. Money is given to each of the FNI regions to support their TB programs, but there is no accountability and no expectation that these regions are accountable for the dollars they are reporting on an annual basis. In fact, we rely on the provinces and territories to determine who the first nations and Inuit cases are, and we only get this data through the Public Health Agency; we don't get this through FNIHB.

The report we referred to on the evaluation of the cluster demonstrates that even FNIHB doesn't know the number of cases and the amount of money that's being spent, because of their lack of control over the region. That's how the structure is in place. It's certainly not their fault, but it does mean that the vulnerability of the communities is not what Ottawa decides but what each of the FNI regions decide. Somehow there will have to be some changes within the strategy that demands a level of accountability by the FNI regions on these programs.

[Dr. RoseMarie Ramsingh, Executive Director, Community Medicine, First Nations and Inuit Health Branch, Department of Health]

I just want to say that the FNI regions don't operate in isolation. They are very closely tied to the provincial TB directors. So the TB services that are supplied to everybody in the province are the same services that coordinate that in most of the provinces as well.

There is a tripartite type of relationship in most of those places.

[Dr. Kimberley Barker]

I look forward to hearing from our provincial experts in the next round at 10 o'clock, where they will deem that actually is not happening.

[The Chair, Conservative, Joy Smith]

You have another minute.

[Luc Malo, Bloc, Verchères—Les Patriotes, QC]

Do other people want to say anything?

[The Chair, Conservative, Joy Smith]

Ms. Turner.

[Gail Turner]

As someone who lives in an Inuit region in a province within an Atlantic FNIHB region, there is a serious disconnect. The people most disconnected are we, the Inuit, who are engaged with FNIHB but not engaged with the province, which has responsibility for our public health. That's a real challenge.

In fact, if you read the document on TB control for Canada, there's no clarity around who is responsible for Inuit. It contradicts itself, and again today I've heard another contradiction, particularly for Nunavik and Nunatsiavut in Quebec and in the Province of Newfoundland and Labrador.

I suggest that's part of the problem. The Canadian Tuberculosis Standards has only one paragraph that addresses special concerns for remote and isolated communities. For those of us looking for guidance on practice, it doesn't fit. In that paragraph on page 266 it suggests there are particular challenges, and perhaps extra mobile test units need to be brought to a community. If they are not, who do you then hold responsible?

[The Chair, Conservative, Joy Smith]

Thank you, Ms. Turner.

We'll now go to Ms. Wasylycia-Leis.

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

Thank you, Madam Chair.

Thank you very much for being here today, on what I think is clearly a national emergency. I'm not sure we're hearing today from the Government of Canada a response that is commensurate with the urgency of the situation.

I'm not here to criticize Shelagh Jane Woods. I am here to say that I don't think a strategy developed in 1992, which is only now under review and sitting as a blank page on the Health Canada web page, is appropriate. We're almost at the same rates we were at in 1992. I think the real question here today is, what the heck has the government been doing? What has FNIHB been doing? What has Health Canada been doing? What has the Public Health Agency of Canada been doing?

In fact, we are at earth-shattering numbers. As many have said, rates of tuberculosis are higher than in third world countries like Bangladesh. We're here today because of the groundbreaking research of someone like Jen Skerritt and the Winnipeg Free Press, who went up to Lac Brochet, talked to Chief Dantouze and others, found the grave of Catherine Moise, and helped to focus our attention on the human issues involved. We're hoping today to get some answers. I don't hear much from the government except that the strategy is under review.

I would like to know from all of you what we can do to get this government working for all of us with standards of care and a focus on the determinants of health. As Chief Toulouse said, look at the money being spent on a per individual basis for an Inuit or a first nation person. It's $17,000, compared to $47,000 for a non-first nation or a non-Inuit person. There's a huge gap. Somebody is not doing their job. I think it's time we get a strategy in place to address it.

First of all, Kimberly Barker, you have told me in the past, and so has Chief Toulouse, that when first nations have requested assistance from Health Canada or FNIHB in terms of something as simple as a mobile X-ray unit to test people, in fact, you can't even get that. I want you to use that as a jumping-off point, and then I would also ask you, as well as Gail Turner, Chief Toulouse, and Chief Dantouze, for other recommendations.

[Dr. Kimberley Barker]

Thank you.

There are a number of communities—probably only five or six, actually—that seem to be the epicentre of the outbreak. These communities in the past have asked FNIHB to do entire community screenings. That's not an unreasonable request by international standards. If there are high rates of TB and frequent outbreaks within a community, one is encouraged to screen the entire community, looking for latent TB cases.

In Garden Hill, for example, when Chief Harper came to Ottawa in 2006 and asked FNIHB to support the entire community screening, he was told there was insufficient evidence to suggest this would be required. Not only that, it would require nursing staff around the clock for at least a year. With the nursing shortages, nobody had nurses, and there would not be sufficient funds to be able to support one community having 3,000 people screened. If you ask the TB experts who are in the room today, asking for community screening at that level is not an unreasonable request.

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

Do you think there's any possibility that the federal government refuses to do that kind of screening and help with that screening, bring in the mobile X-ray units, because they don't want to know the actual numbers, because it would be too embarrassing nationally and internationally?

[Dr. Kimberley Barker]

Perhaps, but I think it's an issue of resources. I think it's largely that you're going to end up robbing Peter to pay Paul. They will end up saying, which nurse do you want to take out of which community to do all that screening for you?

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

Let me ask Gail Turner a question. When we had the minister before us and asked her about the fact that the rate among Inuit is 185 times the rest of the population, she basically said you've got to go to the provinces and territories to get solutions.

Can you tell me what you think the federal government should be doing? What should Health Canada and the Public Health Agency of Canada be doing to help at least coordinate services and bring some measure of high-priority strategy to this whole critical issue?

[Gail Turner]

I think first and foremost there really needs to be a clarification about who is responsible for Inuit. We don't have a piece of legislation in the same way that our brothers in first nations do. That creates some challenges.

I think there also has to be recognition that given the geography and culture of the Inuit, we will require a separate strategy. Our rates are extremely high; in fact, we have communities with rates as high as 500 for 100,000. The Inuit must be engaged. We know what the solutions can be, but people don't talk to us, and the solutions will still be made for us and they won't work.

I also think we really have to look at access to health care. I have a very short story to bring this home. In one of my communities last October, we had a case of TB. One of the contacts who tested positive—and for people in the room, they'll know we're probably looking at latent TB—is terrified of flying. She refuses to leave that community to go for a chest X-ray, which is critical to finalizing her diagnosis, until the ice goes out and the ships start sailing in June.

[Dr. Kimberley Barker]

What I really want to emphasize to a group that may not feel they have the medical expertise to fully understand this is that this is not a complicated disease. This is curable, treatable, easy, cheap. It's not rocket science. It doesn't require a wizard to be at the steering wheel. It simply requires dedicated resources, ongoing monitoring, and a decent program with acceptable standards.

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

Is there any point in setting targets if there is no strategy behind those targets? It seems that we talk big about following the World Health Organization's strategy to stop TB, but there's nothing on paper and there's nothing that has a plan of action to say we are going to conquer this.

Can you tell me what we put in our report to Parliament to call on the health minister to do after the end of this session, because we only have one little session on this national emergency?