Health Committee on May 28th, 2018

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

I'm going to turn to Ms. Gideon. The numbers with respect to indigenous Canadians are quite shocking, actually. Diabetes Canada has said that 80% of the indigenous population is at risk of getting diabetes. I think you might have said that everybody is at risk in the indigenous population.

It seems that again in the 2013 Auditor General's Report it called for Health Canada to properly measure outcomes of the aboriginal diabetes initiative. In response, Health Canada agreed to:

...enhance...performance measures...to assess the impact of the ADI, ...use these enhanced performance measures...to assess and advance the diabetes activities funded under the ADI; and provide increased support to regions to use data for health status reporting...

I think you testified that the numbers are pretty much static in terms of the indigenous population. Given that, are we making progress with respect to diabetes in the indigenous population, or are we not?

[Valerie Gideon]

I think we made a significant amount of progress with respect to awareness, access to screening, access to treatments and foot care, and so forth. I think that where the work really remains is those underlying risk factors with respect to socio-economic status and food security. I think this is where we really do need to..., and it's a challenge for the country as a whole. It's absolutely accentuated with respect to indigenous peoples, but I do think it has been a significant underlying issue that we need to continue to work on.

We've made some significant access improvements also in terms of access to primary care services, more access to nurse practitioners, more access to diagnostics, and more access to telehealth and a lot of other tools.

[Don Davies, NDP, Vancouver Kingsway, BC]

I'm not going to put words in your mouth. It sounds like what you're saying is that we're having better treatment but that, in terms of the number of people who actually have diabetes, that's not stable.

[Valerie Gideon]

The prevalence continues to remain stable at 19% to 20%.

[Don Davies, NDP, Vancouver Kingsway, BC]

I agree with you very much about the social determinants. You mentioned poverty, food security, and so on. What's being done at the federal government level to address those social determinants, particularly in the indigenous population?

[Valerie Gideon]

The whole mandate of the new department that I'm part of at Indigenous Services Canada is specifically to better address the social determinants of health by breaking through those separations across sectors and across mandates, and bringing common purpose services together in one service strategy. Our minister's commitment is absolutely to develop that.

I have spent my entire career in first nations and Inuit health, and I've already seen a tremendous amount of momentum with respect to drawing the linkages between education, social services, health, and really developing a single window service for communities.

Communities have had the flexibility, for the most part, to be able to do comprehensive community planning and to bring those services and investments together, but the federal government perpetuated this program-by-program and sector-by-sector cycle so that for every program you had a job.

It's hard to break through that in a community to and let go of the sense of ownership that people had. It has been an evolution, but I think a lot of communities have broken through those silos and are working together in a multidisciplinary health team, which is frankly what you need to do in order to ensure that you can follow that individual from birth to death, and actually take them through that full continuum of service.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

[The Vice-Chair, Conservative, Marilyn Gladu]

Now we'll go to Ms. Sidhu for seven minutes.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you all for being here today—all the nurses. I would also like to thank all committee members for voting unanimously for my motion to perform this diabetes study so that we can move forward to address diabetes more effectively in the future.

My question is to Mrs. Gallagher. In the Peel region, where my riding of Brampton South is located, they have had a higher incidence of diabetes than in any other part of Ontario for more than 20 years. This is called the hub of diabetes. How we are measuring the outcomes and inequities? How does Health Canada plan to address the social determinants of health, such as food insecurity and access to culturally relevant cures, as we address the diabetes epidemic? How are the outcomes measured and assessed?

[Gerry Gallagher]

Perhaps I can start and then turn to Alfred.

On the first question about performance measures, we have strengthened our approach to performance measures. We look across our programming from an integrated perspective. A performance measurement framework is in place. It looks at behavioural changes for project participants. It also looks at social and physical environments to support those behavioural changes. We have moved away from awareness only to looking for concrete and measurable health outcomes, and are now starting to look at physiological measures for some of our project programming.

That's the approach. I'm happy to share with you the performance measurement framework that we use for our integrated chronic disease program.

On the second question around inequalities, I spoke earlier about our role in understanding the portrait of health inequalities in Canada, as well as the narrative and the contextual considerations related to that. We've done a lot of work over the last five years related to that. The data tool is one part of that initiative.

The narrative report is a much richer part of the storytelling, in terms of the interaction between broader contextual factors—culture, tradition, interaction—and a lot of other considerations, such as income and education, to name a few, that look at the determinants of health and interaction with actual health behaviours, health status, and health outcomes. That's another role that we play.

As far as the broader work on acting on those determinants is concerned, we are taking steps with our programs to move further upstream. We know that Peel is a leader in this area in terms of looking at builds in social environments, to have the spaces and places where folks make the healthy choice and easier choice, whether that means access to walkability or to affordable food choices within their community.

[Sonia Sidhu, Liberal, Brampton South, ON]

In the pre-budget submission, Diabetes Canada recommended adopting a Canadian strategy for diabetes prevention and management, the “90-90-90 target for diabetes by 2021”. The target means that by 2021, 90% of those at risk of living with diabetes will be aware of their status, 90% of those will be receiving treatment, and 90% of those will have improving health.

We saw success with the 90-90-90 strategy agreement for HIV and AIDS. Do you think we could see the same sort of success if we implement it with diabetes?

I'm asking Health Canada to answer this question.

[Dr. Alfred Aziz]

I do not have an answer for this, but I would like to build on what Ms. Gallagher mentioned regarding Health Canada's role with respect to diabetes.

As I mentioned earlier, Health Canada is responsible for regulating food and health products.

Specifically with diabetes, we regulate medications and drugs that are approved for the treatment of diabetes. We also have a role in providing Canadians with information about food, health, and nutrition so that they can make informed decisions about their health.

In 2016, Health Canada launched the healthy eating strategy. It was put in place to improve the food environment so that the healthier choice becomes the easier choice for Canadians.

We're working along four different themes. We are improving nutrition information through improving Canada's food guide, as well as improving food labels and providing information on the front of the package. We're also building a team around protecting vulnerable subpopulations, including restricting the marketing of unhealthy food and beverages for children, so that they are set up for a better start in life and are prevented from developing these chronic diseases, like diabetes, later in life.

With respect to food security, nutrition north Canada was put in place, and indigenous services are working on that now.

In terms of food security under the food policy for Canada, that is under the leadership of the Department of Agriculture and the Minister of Agriculture.

[Sonia Sidhu, Liberal, Brampton South, ON]

My question is to PHAC.

We know there are a number of countries that have a national diabetes registry, such as Sweden.

Do you think a single national registry both for type 1 and type 2 diabetes is possible in Canada?

[Gerry Gallagher]

I'll turn to Jennette for that.

[Jennette Toews]

I can't speak to it from a care management perspective, but from a national surveillance perspective, we have very good strong data on diabetes in Canada

. We do monitoring through the Canadian chronic disease surveillance system. This is a partnership with all the provinces and territories, using health administrative data. We have information on 97% of Canadians, anyone who is part of the health insurance program.

In terms of a specific registry, I think there would need to be some cost benefit, and it may be more of a provincial-territorial role.

[Sonia Sidhu, Liberal, Brampton South, ON]

Sometimes diabetes goes undiagnosed due to stigma. How will your proposed strategy deal with the stigma? Do you think Diabetes Canada's 90-90-90 strategy is going to be helpful for that?

[Gerry Gallagher]

We do know that the awareness of diabetes and its risks is an important consideration, and our chief public health officer is looking at the issue of stigma across a range of diseases, because we do see this, not only for diabetes, but a lot of other conditions, both chronic as well as infectious. It's something that's very much of interest as it relates to the interaction between mental health and physical health.

As far as comparing the 90-90-90 approach with that of HIV/AIDS, our team is looking at that. There are some considerations from a comparability view. They are two very different conditions. There are some important measurement issues to be considered, so on that one, I would just say that we're looking at that closely.

[The Vice-Chair, Conservative, Marilyn Gladu]

Excellent. That's your time.

I want to thank all of our witnesses for your very informative input to our study. I appreciate it very much. Any comments that you want to make or information that you want to add can be sent to the clerk.

We're going to suspend briefly while we change panels.

[The Vice-Chair, Conservative, Marilyn Gladu]

We're back again, and we are continuing with our study of diabetes strategies in Canada and abroad.

We are happy to have with us today, from the National Aboriginal Diabetes Association, Roslynn Baird, who is the chair, and Dr. Agnes Coutinho, who is the past chair.

We also have Dr. Mélanie Henderson, from the Centre hospitalier universitaire Sainte-Justine, by videoconference, but we are having some video problems. We are going to try again and see what happens.

We're going to start with Roslynn.

You have 10 minutes to share.

[Roslynn Baird, Chair, National Aboriginal Diabetes Association]

Thank you. Good afternoon, bonjour, boozhoo, tansi, sekoh, aaniin.

We thank you for the opportunity to address the Standing Committee on Health. We would like to acknowledge that we are visitors here today on the traditional unceded territories of the Algonquin people.

We are here today to address the Standing Committee on Health to advocate on behalf of the National Aboriginal Diabetes Association, also known as NADA, and all those working with, or who are affected by, diabetes to ensure that this pandemic affecting indigenous peoples in Canada is recognized as a top national health priority.

Type 2, type 1, and gestational diabetes are on the rise, and the complications, such as amputation, blindness, and heart disease, are devastating our communities. According to the Truth and Reconciliation Commission call to action 19, aboriginal health is a direct result of government policies, including residential schools, and it is only through change that the health gap between indigenous and non-indigenous peoples can be closed.

[Dr. Agnes Coutinho, Past Chair, National Aboriginal Diabetes Association]

NADA is a non-profit, member-led organization. It was established in 1995 in a response to the rising and alarming rates of diabetes among indigenous peoples in Canada. NADA is funded by Health Canada, first nations and Inuit health branch. It is a knowledge transfer and networking hub for aboriginal diabetes initiative workers, health care professionals, community diabetes prevention workers, and all first nations, Inuit, and Métis peoples living with diabetes across the nation. NADA's mission is to lead the promotion of healthy environments and to prevent and manage diabetes by working together with people, communities, and organizations.

Our goals are to develop, provide, and facilitate resources for diabetes prevention, management, education, and research; to establish and nurture partnerships and collaboration with people, communities, and organizations; to support people, communities, and organizations in developing and enhancing their ability to promote healthy environments; and to advocate to ensure that the epidemic of diabetes among our peoples and communities is a national health priority.

[Roslynn Baird]

According to a recent study, approximately eight in 10 indigenous young adults will develop type 2 diabetes in their lifetime, compared with five in 10 in the general Canadian population. In fact, diabetes is three to five times higher now in the indigenous population and the onset of this debilitating illness is around the forties, while the rest of society tends to be affected later in life. Alarmingly, diabetes among indigenous peoples is no longer an adult condition, as children as young as five are diagnosed with type 2 diabetes. This disease was almost unknown in the aboriginal communities prior to the 1950s.

There are a number of complex factors contributing to the higher rates of diabetes in the indigenous population. The impact of diabetes varies also between regions and communities, and is highest among the first nations and lowest among the Inuit populations. However, the rates of diabetes are on the rise among the Inuit as well. The causes are rooted in the abrupt and forced socio-cultural changes to our traditional ways over the past several decades.

The first nations regional health survey, referred to as FNRHS, released in 2015-16, provides some of the available data in support of the recommendations that NADA brings forward today. Like many studies on aboriginal Canadians, this does not represent all first nations and does not reflect any Métis or Inuit in the data. The prevalence of diabetes among first nations in this study was an alarming 20% in females and 18% in males. One in 10 children had a mother diagnosed with gestational diabetes, which is diabetes during pregnancy. Seventeen per cent of women were pregnant when first diagnosed with diabetes and 83% of them were told they had diabetes outside of pregnancy. More than half of the first nations adults with diabetes have experienced at least one major complication. Over 25% had complications with neuropathy, retinopathy, and circulation; 21% had complications with lower limbs; and 2.4% of cases resulted in amputation.

Since the Truth and Reconciliation Commission final report released in 2015, our non-indigenous partners are just now realizing the devastating proportion of those affected by diabetes and the severity of complications of diabetes in our communities. However, together with our partners, community-based organizations, and individuals, NADA has been aware of the escalating and devastating impact of diabetes in our communities for over two decades.

Since its inception, NADA has created and implemented a wide range of clinical, health promotion, and support activities aimed at reducing the incidence and prevalence of diabetes and improving the health status of indigenous peoples, families, and communities across the nation. NADA has continually advocated for expansion of our capacity to deliver culturally appropriate and uninterrupted programming through education, prevention, and treatment strategies, as well as research initiatives.

[Dr. Agnes Coutinho]

NADA respectfully recommends that the Government of Canada acknowledge that diabetes among indigenous peoples of Canada is a systemic disease at pandemic levels and requires immediate attention. There is a large and unpredictable gap in the potential health benefits available through our advanced Canadian health system to indigenous peoples with diabetes across the nation and in comparison to non-indigenous groups.

The following points reflect key areas that NADA has identified as having critical impact on the current rate of diabetes and its complications. These are our recommendations.

Support diabetes programs, services, and research to be led by indigenous peoples. Current non-indigenous organizations and efforts focused on diabetes and related chronic conditions do not address the unique cultural needs of indigenous peoples and do not take into account each community's needs, culture, and interests. The growing gap in health outcomes and ability to provide appropriate means to facilitate suitable diabetes management and prevention can only succeed with direct and collaborative consultation with indigenous peoples. Indigenous Canadians must be able to draw upon their own cultural traditions in the design and delivery of programs and research.

NADA requests that funding must reflect the severity of the situation surrounding the current state of health of the indigenous population, especially with regard to diabetes. NADA requests support to continue to lead a collaborative effort to empower its peoples, communities, and partner organizations in order to enhance their ability to foster healthy environments for improved diabetes prevention and management. We reference Truth and Reconciliation Commission call to action 19, which talks about chronic diseases and the availability of appropriate health services.

[Roslynn Baird]

Our second recommendation is to prioritize food sovereignty.

NADA supports culturally competent and safe environments for living, learning, and working, with a focus on promoting healthy environments, for example in food security and mental health. A key priority area in addressing the diabetes pandemic is food sovereignty. It is imperative to recognize that the root causes of the current state of diabetes among indigenous peoples include colonized food systems; reserve systems; erosion of harvesting, trapping, fishing, and hunting rights; erosion of land bases; and access to clean water.

NADA recommends continued and open discussions with government departments and other sectors in identifying cross-sectoral approaches to creating healthy environments through policy and guideline development. We reference the TRC's call to action 18:

We call upon the federal, provincial, territorial, and Aboriginal governments to acknowledge that the current state of Aboriginal health in Canada is a direct result of previous Canadian government policies, including residential schools...

As is our tradition, I want to tell a brief story. I have a couple of interesting documents. The document is from the Indian Office in Brantford, dated August 6, 1920. It's a request to pay $100 to support Norman General, a Six Nation Indian who was going to the Olympic Games in Antwerp, Belgium. The cheque would be payable to the Bank of Toronto in Brantford. In this reference, they “beg to state that General in training” and that the requested amount of money...“is a nice thing to have the Six Nations represented at a meeting of this sort”. Subsequently, this was paid by the Indian trust fund of the Department of Indian Affairs to send Norman General to the Olympics. Norman General led a very long and healthy life as an Olympic runner and did very well at the Olympics. His niece, Helen Dockstader, went to the residential school in Brantford known as the “mush hole”, from the age of three to the age of 15. She passed away from the effects of diabetes, as did most of her children, including her eldest son Andy Baird, my uncle. He was also a runner, but did not make it to the Olympics due to double amputation. We emphasize the direct result of residential schools on indigenous health.

The third recommendation is to provide access to appropriate care and treatment options and to traditional healers and medicines. Despite minimal funding, over the last 20 years, NADA has provided a platform for networking and sharing of traditional and new knowledge and skills, as well as for developing and distributing tools, resources, and services for diabetes management and prevention among aboriginal diabetes initiative and community diabetes prevention workers, health care professionals, and indigenous communities. NADA requests support from the government in building collaborative relationships with non-indigenous health care and industry sectors to establish comprehensive approaches for incorporating traditional healers and medicines, through best-practice sharing of the collective skills and knowledge. Open and respectful collaboration between the communities and external health care teams and authorities encourages trust and promotes continuity and consistency of diabetes care for community members.

[Dr. Agnes Coutinho]

Our fourth recommendation is to raise awareness about gestational diabetes and the rise of diabetes amongst young indigenous women. Currently, indigenous peoples have the highest birth rate in Canada, and 78% of indigenous women will have diabetes in the next five to 10 years. Gestational diabetes, including health complications and higher chance of developing type 2 diabetes later in life, is a major concern not just for the mother, but also for the baby. Collaborating on culturally sensitive approaches in this area is again a huge opportunity to bridge traditional and new knowledge and to close the gaps in health outcomes in maternal, as well as infant and child, health issues.