Evidence of meeting #10 for Health in the 40th Parliament, 3rd Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was social.
A recording is available from Parliament.
Conservative
The Chair Conservative Joy Smith
Who would like to answer that question? We only have a very short time.
Professor, University of Alberta, and Director of the Tuberculosis Program, Evaluation and Research Unit, First Nations and Inuit Health, and Immediate Past Medical Officer of Health for Tuberculosis, Province of Alberta
I'll make a few comments to try to answer that.
I did raise a couple of points that I really think the federal government should think seriously about. They're big picture points. There is a set of standards for tuberculosis control, but they are applied differently across regions. There's no question about that.
Just as there needs to be a recognition of the interdependence of social determinants and risk factors, there needs to be a recognition that tuberculosis control in aboriginal peoples is a fragmented exercise with jurisdictional issues that confound control unless they are properly addressed. As an example, precipitating this hearing are events in Manitoba and Saskatchewan. With respect to those two provinces, which along with the territories are the last major strongholds of tuberculosis in aboriginal peoples, the endemic tuberculosis is largely restricted to maybe 10% to 15% of 192 reserve communities.
Conservative
The Chair Conservative Joy Smith
Dr. Long, I'm going to have to go on to the next person. Thank you.
Ms. Davidson.
Conservative
Patricia Davidson Conservative Sarnia—Lambton, ON
Thanks very much, Madam Chair.
And thanks very much to our presenters here this morning.
Certainly we've heard a great deal about this issue. I would like to address some of my comments to begin with, to Ms. Woods, please. I'm going to refer to some of the things you said in your opening remarks.
You said that Health Canada is working diligently to help close the gap between the first nations on reserve and the Inuit. You said there had been a significant reduction in TB rates over the past 30 years but they still remain much higher than in the non-aboriginal population. My first question would be, how and what you are doing to close the gap specifically?
Then you talked about adopting the global stop TB rate reduction target. I'm wondering if you could talk a little more about that, because I don't think you were able to explain too much of it in your opening remarks. Could you tell us how that's going to work and how you are going to try to attain that target?
One of the other things you talked about was the $3 million of additional funding in 2009-10. I'm wondering what that was specifically put towards and if we have seen any results or any feedback from that additional funding.
Director General, Primary Health Care and Public Health Directorate, First Nations and Inuit Health Branch, Department of Health
Okay. Thank you for those questions. That's a lot to cover.
Let me start with the last one. The additional $3 million last year was money that we scraped together. A lot of it went to outbreak control in Manitoba, but it was spread more broadly than that. I think that accounted for maybe half of it. It went to enhance a whole lot of activities in various regions, but largely it was in Manitoba and Saskatchewan last year.
You're asking how we intend to get to the global reduction target. I won't have a good answer to that question until we finish re-examining the national strategy, because within the national strategy there will be a number of targeted approaches to the key areas. As Dr. Barker said, there is an epicentre; what we now have to do is make sure our focus is squarely on the epicentre and on finding out the things that are going to work. That will require working very closely with the communities, with Dr. Barker, and with other people at the table to ensure that we have approaches that will work, community by community.
There are jurisdictional complications, without doubt, as I believe a number of people have said, most notably Dr. Long. There are confounding jurisdictional issues. It's evident we have to rise above them. We have to get beyond them. We have to sit down with our partners.
I am hearing a lot about disconnects; we're going to have to work with our regional offices on this issue to make sure we have a better understanding of what's going on. I will take exception to Dr. Barker's statement that they are not at all accountable; of course they're accountable, but perhaps just not in the way she would like to see. Again, we can sit down and work on this aspect to see where we can set realistic evidence-based interim targets so that we can achieve something, instead of sitting here every year explaining why we haven't made any progress.
Conservative
Patricia Davidson Conservative Sarnia—Lambton, ON
Are there others who need to be at the table but aren't?
Director General, Primary Health Care and Public Health Directorate, First Nations and Inuit Health Branch, Department of Health
Yes, I think eventually you're going to want to talk to people from the Department of Indian Affairs. You'll remember that in the budget there was a lot more money for housing. We're really hopeful that there will be.... As I said at the beginning, there is a greater understanding of the importance of the social determinants of health across all federal departments. It's not our domain; it's a federal domain, and there is a much greater understanding, certainly at the Department of Indian Affairs, about the importance of it, so there is much more of a shift towards taking not just an economic view of housing but a very social view.
There are a number of initiatives broader than what we have here. You may want to talk to my colleague, Kathy Langlois, about efforts on food security, since that has come up in what everybody has said. Those are important initiatives to understand.
As I said earlier, this issue is broader than just tuberculosis, and perhaps we have erred in focusing a little too closely just on the disease of TB itself. We are now certainly aware that it's much broader than just TB.
Conservative
Conservative
Conservative
Cathy McLeod Conservative Kamloops—Thompson—Cariboo, BC
I will focus on the health service component as opposed to the very important social determinants.
I'm having a bit of déjà vu here. I might be dating myself, but back in the 1980s we had mobile chest X-rays that went into every community. We had BCGs, we had a very systematic process around sputum samples, we had people observing therapy, and it didn't seem to get us anywhere. Is that accurate, or did we move away from that type of process in a way? Do you have some general comments there? That used to be how things were in the 1980s, as I recall.
Executive Director, Community Medicine, First Nations and Inuit Health Branch, Department of Health
Could you just clarify? Are you asking if the process that was there in the 1980s is still in place at this time?
Conservative
Cathy McLeod Conservative Kamloops—Thompson—Cariboo, BC
We were hearing about mobile X-ray units. That used to be the way it was, and BCGs for infants used to be the way it was, but after all these years they're asking for those things again. Didn't they seem to make a difference? Maybe you could describe the trends in what we've done.
Executive Director, Community Medicine, First Nations and Inuit Health Branch, Department of Health
Okay.
Well, I'll just say really quickly--then maybe I'll pass it to you--that we do follow the Canadian tuberculosis standards. They have evolved over time in terms of what's included and what's recommended based on the evidence. Richard Long is actually one of the editors of the last version of them. Some things that were done in the eighties are probably dropped off. We've taken up some new technologies and different ways of doing things.
So we try to keep up with the latest guidelines.
Conservative
The Chair Conservative Joy Smith
Thank you so much.
I'm going to suspend the committee for only two minutes.
I'm going to ask that you not come over to the committee members and talk with them. If you want to speak with them, just go outside the door and they'll speak with you.
I am going to ask our next panel to quickly come and take their seats.
Two minutes: thank you.
Conservative
The Chair Conservative Joy Smith
We will begin.
I want to welcome our witnesses. Thank you very much.
I would ask everybody to welcome our witnesses to committee.
Dr. Earl Hershfield, professor of medicine, University of Manitoba, welcome. I'm glad to see you here.
Dr. Pamela Orr, professor, department of medicine as well, is here from the University of Manitoba. Welcome to you. I always like to see people from my home province.
We also have, from the Canadian Lung Association, Dr. Brian Graham, chair of the chronic disease policy. Welcome, Dr. Graham. I'm very happy to see you here.
From the Canadian Public Health Association, we have Elaine Randell, communicable disease consultant from Nunavut. Thank you so much for joining us, Elaine.
We have James Chauvin, policy director with the Canadian Public Health Association. Thank you for joining us as well, James.
From the Canadian Society for International Health, we have Janet Hatcher Roberts, executive director. Welcome.
And from the University of Alberta, we welcome Dr. Anne Fanning, professor emeritus, faculty of medicine.
We feel very honoured and very privileged to have you here. We're going to keep our presentations to three to five minutes. I'm sorry, but I will have to watch the time; I can't have one person or one committee member monopolizing it. We need to be able to get in all the questions and all the presentations.
Thank you for being patient.
Dr. Hershfield.
Dr. Earl Hershfield Professor of Medicine, University of Manitoba, Former Director of Tuberculosis, Province of Manitoba, As an Individual
Thank you, Madam Chair.
For me, this is a reminder of what Yogi Berra said, “It's déjà vu all over again.” I've been to a number of these meetings over the years.
What I want to talk briefly about is what I consider a proper tuberculosis control program. We can discuss later whether it is being applied across the country.
Tuberculosis, as previous speakers have said, is easy to control, and it has four or five elements to it. You have to find the cases, especially infectious cases. You have to register those cases. You have to get all the details that are necessary to get a picture of that case. You have to put the patient on treatment, and it doesn't matter what regimen you put them on—it could be an old regimen or a new regimen—it's a matter of whether the patients take their pills for the proper length of time. So regimens are not an important aspect of the treatment control program. And you have to find the contacts.
Each infectious case is said to infect four to 20 people over a year. If you say there are 100 cases in a particular jurisdiction and you're looking at 10 contacts, it's a lot of work for the public health system to look after the cases, to diagnose those cases, to trace the contacts, to put the contacts on a treatment program or watch them, and it's cumulative over the years. So tuberculosis control, though easy, can be administratively cumbersome.
Some of the ancillary issues are that all positive cultures must have TB sensitivities done. All the provinces have labs that do anti-TB sensitivities. All TB cases must be HIV tested, since HIV is the strongest ancillary problem with tuberculosis patients, especially in Africa.
All cases of TB should have a diagnosis investigation of diabetes. Diabetes is the second most common worldwide associated condition with tuberculosis, and in Canada, amongst the first nations people, it is probably the most important ancillary condition. Somewhere along the line, these two diseases have to be melded in order to deal with the problem, because we'll not deal with it unless diabetes is looked at.
All anti-TB drugs must be free to the patient. You may think that's a given, but in many countries of the world, the patients have to pay for their drugs. We must keep a situation in Canada where all drugs to the patients are free.
All AIDS patients, HIV-positive patients, should be TB tested in order to determine which of the patients who are HIV-positive have been affected by the TB germ. There are priorities in prevention. A jurisdiction has to decide whether they want to treat their positive patients with drugs. The most important priorities are contacts, converts, HIV-positive patients, and immunosuppression.
Unfortunately, tuberculosis is not a single disease in the sense that it can be looked at in isolation. There are multi-factoral, socio-economic determinants: substance abuse, overcrowding, poor housing, malnutrition, lack of fresh water, sewage problems, and difficulty interfacing with the established health care system, which in Manitoba, in my experience, has been a great problem amongst first nations persons interfacing with white man's medicine. They just won't come forward many times, and there are many other problems as well.
Professor of Medicine, University of Manitoba, Former Director of Tuberculosis, Province of Manitoba, As an Individual
I have one more statement, if I might.
Professor of Medicine, University of Manitoba, Former Director of Tuberculosis, Province of Manitoba, As an Individual
Too rapid a diminution or discontinuation of a public health program often leads to resurgence of the problem that appeared to be under control. It's a public health maxim and it has been shown in the literature over and over again. If you dismantle a program—
