Health Committee on Oct. 2nd, 2018

[The Chair, Liberal, Bill Casey]

Okay, we'll call our meeting to order. Welcome, everybody, to meeting number 113 of the Standing Committee on Health. I would like to welcome all of our guests back for a repeat performance. There will be no votes today, I hope. We are going to continue our study on diabetes strategies. There will be no opening statements. We'll just go directly to questions.

First of all, I want to introduce, from Diabetes Canada, Kimberley Hanson, Director of Federal Affairs, Government Relations and Public Policy; from the Ordres des infermières et infermiers du Québec, Lucie Tremblay, President, and Joël Brodeur, Director of Professional Development and Support; from Diabetes Action Canada, Dr. Catharine Whiteside, Executive Director; and, by video conference, we have from Juvenile Diabetes Research Foundation Canada, Mr. Dave Prowten, President and Chief Executive Officer, and Mr. Patrick Towhill, Director of Government Relations.

I am going to go right to questions.

Ms. Sidhu.

[Sonia Sidhu, Liberal, Brampton South, ON]

Good morning, Chair.

Good morning to everyone. Thank you for being here.

Canada is a very diverse country. As we know, diabetes affects certain communities more than others. For example, South Asians are more likely to develop type 2 diabetes, as are other communities such as the indigenous. What are the unique challenges that Canada faces when trying to develop a diabetes strategy that works for everyone equally? Some communities are facing more challenges than others. What are your thoughts about that?

Dr. Whiteside, perhaps you could start with that.

[Dr. Catharine Whiteside, Executive Director, Diabetes Action Canada]

This is a critically important question for Canada. I draw to your attention a recent publication from the Public Health Agency of Canada. It was published this summer, so it was after our initial meeting and does not appear in the documents we have prepared. This is a document focused on the health determinants based on inequalities in Canada. One of the major items raised in the chapter on diabetes is, in fact, ethnic groups. I draw that to your attention for reference.

Along with a number of determinants of health, including lower socio-economic status and education status, another issue is, in fact, those diverse groups in Canada in which there is a predilection for diabetes. These include East Indians, South Asians and, of course, our indigenous communities. To tackle this issue, one of the opportunities is to understand how to segment populations in Canada into high risk and identify solutions that are community-based particularly in primary care.

[Sonia Sidhu, Liberal, Brampton South, ON]

My riding is Brampton South, and I come from Peel Region. The 5-2-1-0 Healthy Communities Initiative did a report saying that at the present rate, it is expected that one out of every six residents in Peel Region will have diabetes and that the direct costs of medication and supplies range from $1,000 to $15,000 annually, which is a big number.

In July you were there when, on behalf of the health minister, we announced research money of $22.6 million—that was with other partners too—to reduce the incidence of diabetic foot ulcers, one of the most common and feared side effects of diabetes. The amputation rate is very high in Ontario. I know because I worked for 14 years as a health care professional. I ran a diabetes clinic. As a research coordinator, I know how hard it is when somebody loses a limb. There is a big fear of losing a limb. Untreated sores can lead to amputation. How will this funding make a difference in the lives of people living with diabetes?

[Dr. Catharine Whiteside]

Ms. Sidhu is referring to a very important study funded by the Canadian Institutes of Health Research, conducted in Ontario and a number of other provinces, looking at the highest risk individuals with diabetes, and demonstrating the importance of chiropody-led and nursing-led care pathways for individuals to address the issue of the prevention of amputations related to diabetic foot ulcers.

In the care of people with diabetes, complication rates are highest in the highest risk groups. You've just heard us discuss some of those populations at highest risk. In Canada today, we really have a very poor approach to the treatment of diabetic foot ulcers. In Ontario alone, every four hours there is an amputation for untreated diabetic foot ulcers. In Alberta this has been studied, and Alberta Health Services has identified that 85% of these amputations could be prevented.

The study that Ms. Sidhu is presenting is one to identify those care pathways that need to be initiated for the highest risk groups. We believe in a combination of early detection, particularly in the context of primary care, and potentially segmenting those people with highest risk into specific care that is chiropody-led. This doesn't require physicians. It really is a nursing issue. In most provinces, particularly in Ontario today, chiropody care in the community is not paid for. This is one of the biggest barriers to care. Furthermore, medication costs for individuals at high risk may not be covered by current provincial plans.

These are all areas that need to be studied, with evidence to support new pathways for the prevention of diabetic foot ulcers and amputations.

[Sonia Sidhu, Liberal, Brampton South, ON]

My next question is for JDRF.

The Minister of Health announced $7.7 million for type 1 diabetes research, in partnership with the JDRF. The funding will support the clinical trials of groundbreaking therapies in order to accelerate the development of new treatments for people living with type 1 diabetes. How has this investment helped in the fight against diabetes in Canada, especially in the Peel area? How can you help the patients from that area, where there's a high rate of diabetes?

Anybody from JDRF, Patrick or Mr. Prowten, can give the answer.

[Dave Prowten, President and Chief Executive Officer, Juvenile Diabetes Research Foundation Canada]

Can you hear me okay?

[Sonia Sidhu, Liberal, Brampton South, ON]

Yes.

[Dave Prowten]

Some of the trials, MP Sidhu, are based in Ontario and are going to be taking advantage of things like registries and having care provided using telemedicine. In essence, people will be able to access their care when they need it the most. This is actually trying to change the health care system. One of the other trials is actually testing a new therapy that's approved in type 2 diabetes for people with type 1, and that's being led by SickKids. Many of your constituents would be followed by a SickKids doctor. I think these are very important.

Some of these other projects that we're now working on with CIHR are to really understand the genesis or the immunology of type 1 diabetes, because it is an autoimmune disease. I think what you're going to see are advances in treatment and also advances in the understanding of how this disease begins. Ideally, in the future, we'll be able to shut the disease off before it even begins.

[Sonia Sidhu, Liberal, Brampton South, ON]

You have cited that an average of 830 diabetes patients in Ontario die every year because of a lack of access to insulin. If insulin were covered in a national pharmacare program, would this mean that no patient would die due to a lack of insulin? How can we prevent Canadians from a lack of access to medications, especially insulin?

[Dave Prowten]

This is a really important question.

Insulin was discovered in Toronto nearly 100 years ago. It is not available to every person in Canada. We believe that it should be part of a national pharmacare strategy and that all insulin should be available. There have been a lot of advances made, so giving people the most basic of tools to manage their type 1 diabetes, which is insulin, is a very important step that could be taken to prevent the deaths that you're referring to.

[The Chair, Liberal, Bill Casey]

Thanks very much.

Ms. Gladu.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Thank you, Chair, and thank you to the witnesses for appearing today.

Welcome, Ms. Hanson.

Last year there was an issue where people with type 2 diabetes who were receiving the disability tax credit stopped receiving it because the Liberal government changed their policy. Has that been remediated since?

[Kimberley Hanson, Director, Federal Affairs, Government Relations and Public Policy, Diabetes Canada]

We understand that subsequent to their announcement of their intention to do so on December 8, the CRA reviewed about 2,300 cases of people with diabetes who had been disallowed between May and December of 2017.

On review, they approved 58% of them but re-rejected 42%. We've understood from the director general at the CRA that they don't plan to notify the 42% who were re-rejected of their status, so we've recently written a letter to them saying that we really feel that it's important, for the purposes of transparency and equity, that these nearly 1,000 people who were re-rejected be notified of that status. We're hoping they will do so shortly.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Those people who are rejected, that 42%, will also lose any of the retirement disability savings plans that they had. Is that true as well?

[Kimberley Hanson]

That's correct. If a person is rejected from the disability tax credit and they had a registered disability savings plan, they would be required under the law to close that RDSP, and any monies that the government had contributed in the form of grants or bonds to that RDSP would be clawed back.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Yes. That is really unfortunate.

Turning to the rest of you, I've been listening to the testimony and following up on the briefs, and I'd like to hear from everybody on what you think the federal government should do to address this issue. I've heard about about chiropody care, medication costs, including insulin for those who can't afford it, telemedicine and broadening the program for kids.

I'm going to start with you, Dr. Whiteside. Tell me what you think the federal government should do.

[Dr. Catharine Whiteside]

From the perspective of Diabetes Action Canada, we are very much in favour of a national diabetes strategy that would begin to work with the provinces and territories on the standardization of early diagnosis of diabetes complications, on diabetes itself, type 2 diabetes, and on ensuring that the best evidence is brought to bear on solutions for individuals with diabetes, both in the treatment of their diabetes and in the prevention of their complications.

The evidence is available. The technology is available. The question is how to influence the current health system, province by province and in the territories, to ensure that people with diabetes are receiving the most timely and effective care.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

That's excellent.

Monsieur Brodeur.

[Joël Brodeur, Director, Professional Development and Support, Ordre des infirmières et infirmiers du Québec]

Hello,

In Quebec, some specially trained nurses were recently granted powers to prescribe medicine as part of front-line treatment. They can treat wounds prior to medical treatment and offer front-line care in the community. The can also partner with a doctor in more serious cases where the doctor's expertise is essential.

I think measures such as these should be applied more broadly and the right to prescribe medicine should be expanded.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Thank you.

Ms. Tremblay, would you like to add something?

[Lucie Tremblay, President, Ordre des infirmières et infirmiers du Québec]

I have a very serious concern.

Ms. Sidhu was talking earlier about populations that do not receive the care to which they are entitled. We have a very specific situation in Quebec, which we pointed out the last time we were here. It is that nurses' initial training does not prepare them to treat diabetic patients in the community.

As Dr. Whiteside noted earlier, people must have access to care nearby, both prevention and quick treatment. Since not enough nurses receive that training, we fear that access to care could be reduced for all Quebeckers. That means that 8 million people do not have equal access to care to what is available in the rest of Canada. We know that close to 250,000 Quebeckers currently have diabetes and do not know about it.

It is very difficult to access care, yet it is essential for all Canadians to have access to care quickly, regardless of the province they live in. This is a real calamity because people are having amputations which could have been prevented. People are suffering from renal insufficiency which could have been prevented. Something has to be done. Now is the time to act.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Excellent.

I'm going to go to the video conference.

Dave Prowten, we'll start with you. What do you think the government should do?

[Dave Prowten]

I'm going to build on two things.

One would be to create a type 1 diabetes registry. Right now, we actually have very poor data that tracks people who have type 1 or type 2. Actually, they're very different diseases and we need to understand that. That could lead to different models of care for people. That would be a very important initiative and project to undertake.

The second is that we're starting to understand the genesis of this disease. We could have things like screening programs to understand who's going to get this disease and to shut it off before it begins. If we could actually prevent people from getting that disease, that would be incredible.

Two things for us would be a type 1 diabetes registry and a screening program.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Okay.

Mr. Tohill.