Public Accounts Committee on March 10th, 2009

[Dr. David Butler-Jones]

I'm sorry. I missed what you said.

[Luc Desnoyers, Bloc, Rivière-des-Mille-Îles, QC]

What I asked concerns the action plan, which is important. Does the agency need additional money to implement that action plan? If that's the case, has it made a request to the Treasury Board?

[The Chair, Liberal, Shawn Murphy]

Please give a quick response, Dr. Butler-Jones, and then we're going to go to Mr. Weston.

[Dr. David Butler-Jones]

Very quickly, as I was saying, we've had new resources, and we're applying them. If it looks, as we move forward, as though we need additional, then obviously we would be making that request. At the moment, we're able to continue to develop with the capacity that we have.

[The Chair, Liberal, Shawn Murphy]

Merci, Monsieur Desnoyers.

Mr. Weston, you have five minutes.

[John Weston, Conservative, West Vancouver—Sunshine Coast—Sea to Sky Country, BC]

Thank you, Mr. Chair.

In recent weeks we've reviewed interprovincial and federal-provincial transfers and federal-provincial jurisdiction also.

I want to thank you, Dr. Butler-Jones and Mr. Maxwell, for sharing with us infectious diseases.

I would like to take up where Ms. Crombie left off on the international level. I think probably the most terrifying book I can ever remember is the The Andromeda Strain. Bugs have no boundaries. It seems to me that SARS came from China; West Nile came from Africa; AIDS came from Africa; and Ebola came from Congo, I gather. There are twin problems, in that you have no jurisdiction to deal with how things are dealt with in other countries, and secondly, if someone decided to spread a disease as a weapon of war, then you have no control over that.

With that sinister background, I have three questions.

Much of what I read in chapter 5 of the Auditor General's report dealt with the World Health Organization. The first question is wouldn't it be good to expand the membership of the WHO? For various reasons that I don't understand, Taiwan has been excluded. Wouldn't it be good to have Taiwan as a member, and other countries as well?

My second question is how you deal with this. I think I heard you say that other countries are coming to you for reports, which would be a very positive compliment on how we're doing in this area, but how do you deal with the fact that there are all of those other jurisdictions?

My third question is whether there have been lessons learned during your international involvement.

[Dr. David Butler-Jones]

Thanks for the questions.

Post-SARS, one of the developments is the international health regulations, which put some responsibilities on governments.

Under the surveillance system that we operate internationally, as I was saying, the WHO indicates that between 40% and 60% of the notifications to them and then from the country come from us. That's down from 80%. So it is actually changing. Countries are looking harder for these things, partly because they'd rather find something themselves than hear of it from us.

In terms of the World Health Organization, the membership in the organization is a political issue. I will avoid that, but we work with Taiwan, other countries work with Taiwan, and the WHO works with Taiwan. They are resident on committees, etc., and they are part of the world. As you say, from a public health standpoint, we include information sharing, technology exchange, all of those kinds of things, with a range of countries, some of whom are more strategic than others. As I was saying earlier, we have someone based in Beijing because of the risk in that part of the world for emerging new diseases.

The lessons learned generally are that SARS was a wake-up call for all of us. We can never completely eliminate risk. Nature is fundamentally inventive; there will always be surprises. Even during and before SARS, SARS was an atypical pneumonia. At that time, for 60% of the people with atypical pneumonias, we never figured out what the bug was—never—but SARS was one that we figured out because of a concerted effort by our lab and others. But there are many more diseases out there. There will always be surprises, but that's why there's the general preparation that we do, the planning, etc., so we can respond to whatever might come.

The basic lesson beyond the fact that there are always surprises is the connectivity of issues. So those who died of SARS, by and large, were those with underlying chronic disease. So if we don't address the basic health of populations, we'll never even get at infectious diseases effectively.

And there is, post-SARS, a level of.... Again, we're not there, and I don't want to diminish the challenges of intergovernmental work, etc., but the level of willingness to collaborate and work together across countries and within countries—in our case, within our federation—I've never seen in 25 years. That doesn't mean we're there, but it does give me hope about the willingness, and even the relative transparency, of other countries now compared with five years ago. Their willingness to share their failures, not just their successes, is also a hopeful sign.

[John Weston, Conservative, West Vancouver—Sunshine Coast—Sea to Sky Country, BC]

Your report refers to an action plan to be completed by December 2009. Paragraph 5.89 of the Auditor General's report says that “as required by the World Health Organization, the Agency will work with partners to develop a comprehensive action plan by December 2009...”. So it gives me some comfort, in response to Mr. Christopherson's line of questioning, that there is an action plan and that you've specified a date.

One question I have is that I don't see the Centers for Disease Control and Prevention in Atlanta mentioned anywhere in the Auditor General's report or in the other material I reviewed, but I would think it would be a leading agency that you would work with on these things.

[Dr. David Butler-Jones]

Yes, we work with quite a range of countries, some closer than others. We're a key part of the global health security initiative, and the Global Health Security Action Group, as one of the G-7-plus one countries, in terms of planning for a whole range of not just outbreaks and epidemics, but also bioterrorism and other things.

We work very closely with CDC. There are some things they're better at than we are, which we learn from; and there are some things we're better at than they are, which they learn from.

And we share capacity. For example, PulseNet, which looks at characterizing the genetic makeup of bacterial diseases that cause food poisoning, for instance, is a shared system. We and the Americans and the Mexicans now use that. It makes it easier for us to figure out: oh, these five cases in Toronto, these three cases in New York, and these 12 cases in Atlanta are all the same strain, coming from the same place. What are the common factors? Then we can trace those back to figure out where it came from. The listeria outbreak is a good example of that.

[The Chair, Liberal, Shawn Murphy]

Thank you, Mr. Weston.

Thank you, Dr. Butler-Jones.

Mr. Christopherson, for five minutes.

[David Christopherson, NDP, Hamilton Centre, ON]

Thank you, Chair.

On my second round, what I want to come back to is your comment earlier. I thought it was quite interesting that when we were talking about the memorandum of agreement and other standards and things that are not in place, you left the impression with me that we don't need a Dr. David Butler-Jones out there or a senior bureaucrat to manage these issues. What we need is a U.S. General Patton just to go out there and cut through all the nonsense and get to the heart of it. Nobody's ever missed a deadline, we get the job done, and all of that.

There are two ways to look at that. One is that it's absolutely true that there's a lot of useless red tape that's been made up by bureaucrats who are looking for make-work projects. Then there's the other side of it, which is that perhaps the details of reporting mechanisms and agreements and standards and commonalities actually matter in terms of protecting the health of Canadians.

The Auditor General, in her report, and she's very careful about words she uses--she's quite the wordsmith—says:

Surveillance standards ensure that infectious disease occurrences are defined, reported, and recorded uniformly across the country. They are essential for detecting outbreaks quickly and accurately, describing national trends reliably, and planning and evaluating control measures consistently.

She deliberately uses the word “essential”. You deliberately used the words “not essential”--I don't have the exact wording, but I'll stand by the Hansard--when you were talking about the difference between the ultimate goal of information that needs to be gotten and whether the actual details were done.

This stark reality between the Auditor General saying that these are essential and you saying that they are not essential--you used those words--troubles me in terms of whether you're getting where we're coming from or whether this is just a process for you to go through: just write it off as a bad day and go about your regular business.

The Auditor General, in defence of her position, said, in paragraph 5.86: “In its current form, the memorandum is largely a statement of principle and is not sufficient to ensure a complete and timely flow of information between the Agency and the provinces and territories on public health risks and emergencies.”

She goes on to say, in paragraph 5.99:

In the event of a public health emergency, the Agency runs the risk of not obtaining the information needed to do an assessment of the situation within 48 hours, to notify the WHO within 24 hours, and to keep it informed of subsequent events, as required, because information-sharing agreements with the provinces and territories are missing.

The Auditor General says to us, the public accounts committee, that this stuff is essential. You, as the national medical officer of health, have come in and said that it's not essential. Which is it, Doctor?

[Dr. David Butler-Jones]

It's actually somewhere in between. If I wasn't clear when I said it, the most essential thing is to get the information, not the agreement.

The first effort of the agency has been to make sure that we have the relationship with the provinces and territories and others--all our colleagues--so that a phone call will solve it. Rather than that, you can have the regulations in place, you can have a memorandum of understanding, and you can have timelines, and then they wait for 48 hours to send it to you, as opposed to picking up the phone.

We have standard case definitions. You're mixing up a number of things and putting them all under the statement. We do have standard case definitions. We all report on the same things. The issue is that getting the agreements in place takes time. If you think of any FPT agreement, they do take time. We are taking that very seriously. We want them in place. We agree with the Auditor General. We've said so. I'm just talking about the reality.

In the U.S. you have a Surgeon General—I'm the equivalent of the Surgeon General and the head of CDC--and the Surgeon General has no power over the states to order them to do anything.

What you want to ensure is that you have the system working, and we will get the agreements in place to reinforce that. Greater specificity is absolutely essential. I totally agree with that. I'm just speaking to the reality that I want to make sure that I have the information, period. We'll work on the agreements, but I'm not going to spend time working on agreements before I get the information.

[David Christopherson, NDP, Hamilton Centre, ON]

You know what worries me? I remember this distinctly. If my colleagues from city council were here, they would recall this vividly. We had a developer sitting at the table at a committee meeting, and we were advising the developer of certain requirements that he needed to put in place. He got all upset and lost his cool and said, “You know, I've just about had it with the city and all these mamby-pamby rules.” Well, the mamby-pamby rules were the Ontario fire code regulations. And I see your response very similarly, sir.

You're not taking this seriously enough. I understand that you're getting the job done. I'm pleased about that. I hope you have a horse waiting outside your office so you can jump on it and rush to the middle of the scene of the panic so you personally can solve everything. But I have an Auditor General, who knows a hell of a lot more about these things than you or I, telling me that these things are essential. They need to be in place, and you're going on, sir, telling me how unimportant they are, or that they're not as important. I just want to hear you tell me that you agree that these things are essential. You're saying that they're in the middle. That's not good enough.

[The Chair, Liberal, Shawn Murphy]

Okay.

[David Christopherson, NDP, Hamilton Centre, ON]

I want to hear you say they're essential and assure us you're going to do something about it.

[The Chair, Liberal, Shawn Murphy]

David, your time is up.

We'll have a brief response from Dr. Butler-Jones, and then we'll move on to Mr. Shipley.

[Dr. David Butler-Jones]

You're misconstruing. When I was talking about the middle, you had a specific question. Now you're taking that middle to something else.

Let's be very clear. We have responded to the Auditor General. We have agreed we are going to do this.

[David Christopherson, NDP, Hamilton Centre, ON]

You agreed in 1999 and 2002 also, sir.

[The Chair, Liberal, Shawn Murphy]

Go ahead.

[Dr. David Butler-Jones]

Okay. There are practicalities of getting it done. The key elements are whether we get the information we need, whether we have the collaboration we need. That is in place. We will get these agreements done and that will reinforce that.

[The Chair, Liberal, Shawn Murphy]

Thank you very much, Mr. Christopherson.

Thank you, Dr. Butler-Jones.

Mr. Shipley, five minutes.

[Bev Shipley, Conservative, Lambton—Kent—Middlesex, ON]

Thank you.

I just want to appreciate the opportunity to be here with you folks today and to listen. Obviously, it's a concern of a number of folks. We talk about public health; it's always a concern for all of us. You said there will always be surprises. Because of travel, because of global trade that is happening, I suspect surprises will be coming more often. I suspect, because of the poverty and some of the things around the world that are not reflected as much in Canada, that those surprises will not always be as easy to detect, and I appreciate that.

One of the things the Auditor General talks about on page 8, 5.17, is that there are nationally notifiable diseases. The top 60 diseases formed the updated list published in October of 2006, and the provinces and territories have agreed to report cases of these diseases to the agency voluntarily. How is this list monitored? Is it continually updated? Is there a concern in terms of some? We're always concerned when we miss the mark and a disease hasn't been detected. Is there concern that you overreact on something that really isn't an issue but could actually become a national concern?

I'll leave it at that for now.

[Dr. David Butler-Jones]

They are regularly reviewed, because it's a joint project with the provinces and territories and the experts in the area. So they do get periodically reviewed, and that will continue. There are always surprises, but that's also why, for example, in the middle of an outbreak, something we've never seen before, we develop a case definition that day as a working definition, so all jurisdictions can do it, so we know what we're looking for. This is not an infectious disease issue, but with melamine and the children, through our surveillance system that we operate with the Canadian Paediatric Society, they were able to contact all the pediatricians in the country looking for these symptoms and to see if in fact there was any impact in Canada of that from a syndromic surveillance standpoint, before we even knew there was melamine in baby formula in Canada.

That's the kind of stuff we have to do. In all these things there is no disagreement between us and the Auditor General in terms of importance of these things. We will do that. It does take time. I can't speak for the previous two audits. This is the first one I've dealt with. We've made significant progress since the beginning of the agency. We will continue to do it, so when you come back to this again I'm sure you will be happy, for lack of a better term.

[Bev Shipley, Conservative, Lambton—Kent—Middlesex, ON]

I can appreciate that.

You talked about the provinces and you got an agreement. I'm talking now about the implementation. I appreciate the fact that you say it is voluntary and that the cooperation has been good. Is that the same for the responsiveness from the provinces, also in terms of that cooperation?

[Dr. David Butler-Jones]

Absolutely. It works both ways.