Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 20 - Evidence for September 17, 2003
OTTAWA, Wednesday, September 17, 2003
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 3:53 p.m. to study the infrastructure and governance of the public health system in Canada, as well as Canada's ability to respond to public health emergencies arising from outbreaks of infectious disease.
Senator Michael Kirby (Chairman) in the Chair.
The Chairman: Senators, we are here today for the first of a compressed set of hearings to deal with what the public would call the SARS issue and what we would call the issue of the appropriate role of the federal government with respect to handling infectious disease epidemics. We are not here to look at the full scale and scope of public health. As you know, we have already indicated that when we finish our report on mental health, we may well decide to turn to that, but we are here with a very focused study. We intend to conclude and table our report before the middle of November in the hope that, in a Speech from the Throne that appears to be at least reasonably likely for the beginning of February, the government will have the advice of this committee in deciding what, if anything, to say about the follow-up to the SARS issue in that Speech from the Throne and in any subsequent budget.
We are delighted to begin today with witnesses from the Government of Canada. Our purpose today is to understand the current situation. We will, over the next four weeks, have a lengthy set of hearings. For the information of colleagues, I believe we will distribute today the witness list as approved by the steering committee. We will do all of this by the third week of October in order to be able to table a report by the middle of November. I lay that out as much for witnesses in government who will be interested in following what we do as for the television audience and my colleagues around the table.
We are here, then, to begin by giving the committee a background in terms of understanding the current situation with respect to the existing infrastructure for responding to significant public health emergencies from outbreaks. We have before us the Assistant Deputy Minister and the Director General from the Office of Critical Infrastructure Protection and Emergency Preparedness. We also have a number of officials from Health Canada, beginning with Scott Broughton, Assistant Deputy Minister for the Population and Public Health Branch. Dr. Paul Gully, aside from having become a TV star during the SARS outbreak and probably getting more coverage than any federal politician on the issue, is the Senior Director General of the Population and Public Health Branch. We also have David Mowat, the Director General of the Centre for Surveillance Coordination, and Ron St. John, the Director General for the Centre for Emergency Preparedness and Response.
I thank all of you for coming. We thought that the best way to begin was to have all of you, who represent different elements, if you like, of the infrastructure within the federal government for responding to public health emergencies, provide an overview. We will ask that two of you, Mr. Harlick and Mr. Broughton, begin with presentations, and then we will turn to comments and questions from the committee as a whole. I would urge the panel, when we do get to the questions and answers, that even if a question is directed to someone else, if there is something you want to add, if there is an additional point you would like to make, please feel free to chime in. We would like that part to be as informative and yet informal as possible.
Mr. James Harlick, Assistant Deputy Minister, Office of Critical Infrastructure Protection and Emergency Preparedness: Thank you for the invitation to appear today and to outline for you the role of our office in emergencies and then to try to relate it to your study on infrastructure and governance of the public health system in Canada.
Mr. Gary O'Bright, our Director General of Operations, joins me today. I will give you an overview of our mandate, some of the things that the office does when an emergency occurs and identify the legislative foundation or framework within which we operate.
The mandate of the office is set out in the Prime Minister's press release of February 2001 that created this new organization. It has a twofold mandate. The first is to provide national leadership on a modern and comprehensive approach to protecting Canada's critical infrastructure, and the second is to act as the government's primary agency for promoting national civil emergency preparedness — those two items, of course, being represented by the words in the overly long title of our organization.
We fulfil these mandates by working closely with key federal, provincial and private sector players during major emergencies, in which we are responsible for coordinating federal support to provincial and other orders of government involved in a particular emergency, and I emphasize coordinating and delivering that support through the provincial emergency management organization.
That is our primary interface at the provincial level.
The Emergency Preparedness Act assigns certain responsibilities to the minister responsible, and that for a number of decades now has been the Minister of National Defence. The act, I would note, does not refer to our organization, it refers only to the minister and assigns responsibilities to him or her.
At the present time, Mr. McCallum is responsible to develop policies and programs to achieve an appropriate state of national civil emergency preparedness in Canada, to encourage and support civil preparedness at the provincial level, to establish arrangements for ensuring the continuity of constitutional government during an emergency, and, with respect to implementation, to monitor and report to his colleagues on potential or actual emergencies, what should be done about them, and to coordinate with provincial governments in similar situations. I would also note he has the authority to provide financial assistance to a province when it is properly authorized. We support the minister responsible for emergency preparedness in the exercise of these responsibilities.
I would also note that all federal ministers under the act have responsibility to develop plans within their areas of accountability to respond to any type of emergency. That is an overarching responsibility of all members of the administration.
OCIPEP, in meeting these monitoring and response responsibilities, has developed a federal support plan than establishes a response structure allowing for the coordination of federal aid to affected provinces or territories in major emergencies. We call this the National Support Plan and it brings together all federal departments that can find, obtain or deliver resources to the affected area, and thus facilitates the overall coordination of the federal response with provincial and territorial colleagues.
In addition to the act, in 1995, the government approved a ``Federal Policy for Emergencies,'' which in particular, and perhaps relevant to your considerations today, details the lead minister or lead department concept and outlines the emerging responsibilities of individual departments in an emergency situation.
Health-related emergencies fall under the purview of the Minister of Health at the federal level, and for emergencies in which no particular individual lead minister mandate may be engaged, perhaps such as an earthquake, a flood or an ice storm, then OCIPEP and the Minister of National Defence would likely assume the lead federal role.
Once this lead minister has been established, the relevant department becomes the lead organization in support of that minister, and we would assume, since we would not be in the lead role, a supporting agency role to the lead minister and department. We would be there to assist this lead department in its response to the emergency by ensuring that a reliable link to other government departments federally and to the provincial emergency measures organizations is made.
In these emergency situations, we engage in the production of national situation reports, in which we try to summarize all relevant factual information in a single, concise, all-source document. These are disseminated to all government departments, as well as to our regional offices and the provinces, and are prepared at a frequency required or warranted by the elements of the various emergencies.
We also have 10 regional offices, one in each province, and they play a crucial role in linking us with the provincial emergency measures organizations, as well as with the private sector in that given jurisdiction.
For example, during the SARS outbreak, which was predominantly centred in the Greater Toronto area, OCIPEP worked closely with Health Canada officials as a supporting federal agency. As the situation grew more complex, Health Canada augmented its own departmental emergency operation centre capability as it monitored the outbreak. We followed suit, increasing the staffing in our own Government Emergency Operations Coordination Centre so that we could support, as required, Health Canada in its dealings with the provinces, territories and other government departments in coordinating its overall response to the outbreak.
Through our regional director in Toronto, we maintained a direct link with the provincial emergency operations centre in Toronto. We also placed liaison officers with Health Canada's emergency operations centre here. We ensured that federal departments and key stakeholders were fully aware of the situation in order to relieve some of this burden from the municipal, provincial and other federal operations centres, which were focused on other response and intervention aspects of the emergency.
As many of you know, most emergencies tend to be of what is called the ``public welfare'' variety. They directly engage the provinces in responding to emergencies here, and they are often caused by natural or climatic phenomena. The Red River floods, the ice storm and, more recently, the B.C. fires, would be very good and pertinent examples of that.
The first level of response to emergencies in Canada is the municipal level, and you have seen that actually in the examples I have cited. A municipality may declare an emergency to acquire extra powers to deal with it. If the municipality is in need of assistance, it goes to the provincial level. That province has the primary responsibility under the Constitution to handle emergency situations within its jurisdiction. If it in fact needs additional assistance from the federal government, then it does make requests of us and we use our provincial office link to coordinate the federal government's response to the emergency needs of the province dealing with the tornado, the ice storm, the flood or the fire.
Our regional directors strengthen our support capability by ensuring that lead federal departments are updated on regional operations, provincial management decisions in a crisis or emergency, the provincial/public communications arrangements, and the requests for information and assistance from the province and affected municipality, as well as keeping an eye on and reporting on the status of other federal department activities in the particular province or region. In the opposite direction, decisions and arrangements of the federal government are conveyed to the province via its provincial operations centre and via our regional director.
Using the recent power outage in Ontario as an example, OCIPEP played a significant role in providing other government departments with timely information on the overall situation of the power outage, while working closely with key provincial, federal and private sector stakeholders to ensure that the resulting consequences were adequately addressed at all levels of government.
I made reference earlier to financial assistance. In wrapping up, I will touch on that. There are things called the ``disaster financial assistance arrangements'', which is a federal set of arrangements to assist provinces that are suffering under a financial burden as a result of responding to significant emergencies. Since 1970, when the DFAA first came into force, there have been over 100 natural disasters or emergencies.
The Chairman: Not only are acronyms impossible for those around the table, they are absolutely impossible for anyone watching on television, so can you tell us what is the DFAA?
Mr. Harlick: The DFAA is a document. The disaster financial assistance arrangements is a set of provisions, you might call it a program, which is the basis on which the federal government provides financial assistance to a province to compensate it for some of the expenditures it has made in dealing with an emergency.
For example, after the Saguenay flood, the Red River flood and the ice storm, disaster financial assistance arrangement payments were made to the impacted provinces to compensate them, in part, for the expenditures they had made in dealing with the emergency. The federal government therefore does not directly provide funds to affected individuals, but does provide the funds to the provinces.
The federal government, in these arrangements, has defined a minimum threshold for provincial-territorial expenditure that must be met to trigger the arrangements provisions. These funds are intended, and the program is intended, to help restore public works and essential property of Canadians and small businesses to their condition prior to the emergency. It also helps to compensate provinces for the extraordinary expenditures they have made on the emergency response itself. It is not an insurance program, it is not a 100 per cent compensation program, it does not indemnify against all losses, but is there to assist the provinces in bearing the burden of these extraordinary events. As I indicated at the beginning, since 1970, over 100 individual emergencies have seen disaster financial assistance arrangements compensation.
The provinces provide the bills to the federal government. Those bills are audited. Expenditures are then authorized and payments are made to the provinces.
In closing, I wish to assure this committee that OCIPEP is committed to continuing to build, nurture and strengthen its working relationships with its key colleagues and partner departments in the federal government and in other levels of government in the provinces and territories, as well as in the private sector, the latter being particularly important in the area of critical infrastructure protection.
The Chairman: This is not the time for questions, but I would like to ask you to clarify one point particularly before Mr. Broughton begins.
You were very clear on the financial side, also very clear on your role with respect to what I would call ``natural'' emergencies. You talked about the blackout, the Saguenay floods, the B.C. forest fires and so on. It seems that an infectious epidemic is of quite a different character. It is difficult to envision how sending troops in to deal with the outbreak would be terribly helpful, whereas one can understand how it would be very helpful in the forest fires, floods and power blackouts.
Can you tell us precisely what your role is in the event of a public health emergency, particularly an infectious disease outbreak, rather than a natural emergency?
Mr. Harlick: Certainly. I will address the financial side as well as the handling of events.
In regard to the SARS situation, in all likelihood, the Minister of Health, supported by Health Canada officials, my colleagues on my left, would take the lead on behalf of the Government of Canada to provide health-related advice. Obviously, something as significant as an infectious disease outbreak, just as we saw with SARS, has other kinds of impacts, thus engaging other walks of life, sectors and requirements.
OCIPEP, acting in support of Health Canada, would be working with the provincial emergency measures organization to try to address any requirements the province has to effectively enable it to handle that outbreak of infectious disease.
The Chairman: The non-health aspects; is that correct?
Mr. Harlick: That is right. At the provincial level, in all likelihood, you would have the provincial health ministry in the lead on the health issues and dealing with colleagues from Health Canada, but the emergency measures organization will try to pull together the other areas where emergency assistance is needed: Evacuation, quarantine, transportation and so forth.
The Chairman: That is helpful, thank you.
Mr. Scott Broughton, Assistant Deputy Minister, Population and Public Health Branch, Health Canada: Honourable senators, with the permission of the chair I would like to share my opening comments with my colleagues. We will be brief. Each of us would just like to take a minute or two to make a couple of salient points.
I would like to provide a context for public health, and while appreciating the chair's comments that your focus is on infectious diseases and SARS, we still think it is helpful to position much of that discussion in a broader public health context. I will do that quickly. We do have a slide deck, which you have been given. We will not read it, but we would like to walk through it quickly. My colleagues will touch on some particular points more related to SARS.
Moving to the second page, it is noteworthy that while Canada ranks high internationally using many health indicators, we do need to be aware of the continuing threats of infectious diseases and the increased burden of non- communicable diseases.
On the third slide, we display health systems within a broad health sector, but it is critical to note that these systems and the actual health settings are obviously interrelated.
You will see on the fourth slide that our definition of ``public health'' is extremely broad. It cuts across communicable and non-communicable diseases. Importantly, it focuses on the whole population or sub-populations, rather than on specific individuals, which tends to be more the case in primary and acute care settings.
The fifth slide obviously highlights the fact that the determinants of health cut a wide swath through all sectors of our society, touching on the discussion that the chair just had with my colleague, in terms of who might be involved in public health circumstances.
The sixth slide focuses on what many people refer to as the three ``Ps'': prevention, promotion and protection. There is a general consensus that an effective public health system writ large has and/or needs a balance across all three, in other words, preventive actions, solid promotion and, obviously, protection.
In terms of the seventh slide, the most significant point to be made is that most individuals and organizations — and this includes governments, non-governmental organizations, the voluntary sector and the private sector — either already have come or are coming to the conclusion and understanding that to have an effective public health system in Canada, we must have, for both communicable and non-communicable diseases, a combination of individual and integrated strategies.
The eighth and ninth slides try to describe at a broad level the roles of various players, focusing on governmental sectors at the federal, provincial and territorial level. The significant point for us is that the challenge to all public health officials and organizations is to find delivery systems that are both effective and integrated.
On that note, I will turn it over to Dr. Gully, who will head into the specific discussion of SARS.
Dr. Paul Gully, Senior Director General, Population and Public Health Branch, Health Canada: Honourable senators, I will begin at slide 11, which portrays a limited assessment of our experience with SARS.
The public health system and the acute and primary care system did weather a major challenge and governments did respond in a variety of ways to prevention; in particular, from the Government of Canada point of view, with screening at points of entry, and that screen does continue.
In regard to control and containment, Health Canada did deploy public health officials, particularly in Ontario, and developed tests. Of particular note is that this disease, severe acute respiratory syndrome, was primarily transmitted in hospitals or in the health care sector, to health care workers, families and visitors, and only in a few cases actually to the community. It was spread and controlled in the health care sector.
We managed this issue through the use of infrastructure at the pandemic influenza committee, which had been developed already and was actually a good basis for our cooperation and collaboration with the provinces and territories. As honourable senators will know, there were a number of lessons learned, including those to be outlined by the Naylor committee.
Slide 12 indicates that gaps in public health had already been noted prior to SARS. There is the work of the Auditor General's office, and a capacity study related to surveillance was presented to the conference of deputy ministers. The suggestion there was that there should be an emergency preparedness and response network in place and that is being developed.
SARS highlighted more issues, such as the need for better coordination capacity. The epidemiological capacity is the capacity to investigate outbreaks, collect and analyze information and then make decisions.
Turning to the subject of the need to strengthen communications across all jurisdictions, the ability to be able to contain, but also to critically analyze, control measures such as quarantine, was a challenge and continues to be a challenge. Here I refer not only to communication with the public, but also to communication with organizations outside this country, other countries and the World Health Organization.
Slide 13 shows that similar issues could happen again and it could be worse. There are various factors that increase the likelihood of the spread of an outbreak, in particular, travel and our mobile population.
It is important to note that diseases such as this can arrive suddenly and without notice. We have to have prior preparedness. The threats are changing, and may in the future relate to climate change, more indiscriminate use of antibiotics and an increasing likelihood of diseases spreading from animals to humans, as is thought to have been the case with SARS.
Slide 14 examines how the public health system was strained in responding to SARS. SARS was likely derived from close contact between animals and humans and spread through rapid travel. This factor has been pointed out in the past in regard to the U.S. and Canada. Also, SARS demonstrated how a public health emergency in one province may have an impact elsewhere.
The assessment by Dr. Naylor has been aided by opinions from the Canadian Public Health Association and the Canadian Medical Association.
Finally, the overall response was that to improve preparedness, we do need a national surge capacity to investigate and carry out public health functions — an ability to consistently collect information related to outbreaks in a usable and shareable form that we can analyze easily. We need public health leadership that spreads across the system, including the hospital sector, at all levels.
Many of these gaps in public health capacity apply to our ability to deal with immediate communicable disease issues, but also point to gaps in dealing with more long-term issues in non-communicable diseases.
Dr. David Mowat, Director General, Centre for Surveillance Coordination, Health Canada: The next slide, entitled ``Information,'' provides a brief overview of the types of information that we are concerned with in a rather theoretical fashion, and reminds us that the collection of information and its interpretation is not an end in itself, but is there to inform better decision-making.
A lot of the attention has been on surveillance. Surveillance tells us what is going on at a particular time, and is information with a particular emphasis on timeliness. However, we must also accumulate and synthesize that evidence, as we learn more about an outbreak such as SARS, so that we develop a base of knowledge; and that base tells us what to do about a particular question. Then we need to know about the context — for example, how many people are moving through airports — and there is also a need for operational information systems to manage the thousands of people who may be going into and out of quarantine.
The next slide just touches briefly upon some of the work we have been doing at Health Canada, recognizing that surveillance at the national level depends critically upon the capacity at provincial, territorial and local levels, because that is where most of the data originate. We have been working with our provincial and territorial colleagues; we mention here the public health information system that we have developed with British Columbia and which is now being rolled out across several provinces. Of interest is the fact that we are now working with Ontario on improvements to the outbreak management module for that information system, which would provide the ability to better manage quarantine in the future. The laboratory data management system reminds us that there is a need to move information between types of providers — hospitals, physicians, public health people, laboratories — because people who need to take action on outbreaks such as SARS will not all be present at the same place. Therefore, we need to move information around in a comprehensive and comprehensible fashion.
The mention of the CIPHS collaborative points out that we have developed a collaborative arrangement, which includes all of the representatives from all the provinces and territories, to work on further developing these information systems, initially around communicable diseases and immunization, so that we will have an enhanced ability to pass information not only within a province, but between provinces and to the national level.
We do this, according to the next bullet, ``Architecture,'' by ensuring that we have in place standards and systems of information management that will ensure that there is interoperability of the systems, not only for public health but also, in the longer term, between public health and projects and initiatives such as the electronic health record, which is a very long-term project.
There is clearly a need to continue to improve the human resources and the skills in these areas. However good information systems are, there will continue to be a need for highly skilled persons who can analyze and interpret these data. Health Canada has been active in this area for a long time and has recently expanded its activities.
Finally, on chronic diseases and injuries, a reminder that the activity and investment in this area of information benefit not only dealing with the immediate concern around communicable disease, but the same infrastructure serves also to improve our information and our knowledge and the way we manage chronic diseases and injuries also.
Dr. Ron St. John, Director General, Centre for Emergency Preparedness and Response, Health Canada: On slide 18, we outline some of the basic principles and premises on which the Centre for Emergency Preparedness and Response works. Mr. Harlick has already explained and described what we call the ``cascade'' of response and assistance, from local, to provincial and territorial, to federal. I would draw your attention to the fact that the local resources have to be prepared to respond first, because the event is always local initially. Our commitment to the country is to provide all of our federal resources in health to anywhere in the country within 24 hours of a request for assistance.
It is important also to note that infectious disease outbreaks can be either natural or human caused. SARS was a natural event; anthrax could be either natural or human caused; and smallpox will always be human caused, because we have eradicated that disease.
At the federal level, Health Canada's Centre for Emergency Preparedness and Response provides a platform to address any one of those possibilities. For example, just this week, in Cranbrook, B.C., we provided a mobile hospital to a fire camp where there was an outbreak of gastrointestinal illness among firefighters. That was provided and deployed immediately upon request, and well over 100 people were treated in that mobile hospital.
On the next slide, again, Mr. Harlick has described the Government of Canada Emergency Preparedness and Response framework. I would draw your attention to the federal-provincial-territorial network for emergency preparedness and response, established in June 2002 by deputy ministers. After 9/11, the deputy ministers established this special task force to examine gaps in our response capacity across the country. In June 2002, when the task force finished its work, it was replaced with a network of chief medical officers of health, emergency health services personnel, emergency social services personnel at the provincial and territorial levels, and ourselves at the federal level.
The network has been tasked with implementing the 31 recommendations from the task force and preparing a seamless, coordinated emergency preparedness and response capacity in health across all jurisdictions in Canada.
As noted on the slide, approximately 55 per cent of the recommendations have been completed. All recommendations are being addressed by the network at this time.
The Chairman: May I thank all of you for that comprehensive overview, which nevertheless raises a considerable number of questions in my colleagues' minds. I would like to turn to our list of questioners. Before I do so, may I welcome, on behalf of the committee, Senator Trenholme Counsell, who was just appointed yesterday. Thank you for jumping into this right off the bat; and I will say to the witnesses that our new colleague not only served as a minister for community services in the New Brunswick government, she is also a physician. She brings to this issue some not insignificant background in terms of understanding where we are going. Welcome. Thank you for joining us.
Senator Keon: Thank you all for coming before us here today. It seems to me that what came out of the SARS incident was considerable criticism of what we have in place. It seemed that from every corner there were calls for a national coordinating system that would work better than last time around. Indeed, some of the more severe critics said that dealing with the SARS epidemic became almost dependent on an old boys' network.
I would like to hear from you collectively. Mr. Harlick could start, but then the others could join in. We have heard about the cascade of authority and so forth, when Toronto, for example, declared a medical emergency.
The consensus is that things did not go very smoothly. Perhaps you could lead us through what did transpire and how the system works when a state of emergency in health is declared. I know you tried to address it, Mr. Harlick, and Mr. St. John, but drill down a little further and tell us just what happened.
Mr. Harlick: I will approach it at a general level. Mr. Broughton will then pick up on the actual instance of SARS in Toronto.
The crucial concept of lead minister and lead department is the central operational fulcrum, if you will, for how the federal government organizes its emergency preparedness responsibilities and how it executes them in implementation. For example, in a health situation, it is quite logical for the Minister of Health to take the lead on behalf of the government to address the problem if it is a health policy issue. In the case of an emergency, that minister has the best advice, skilled people, assets, and inherent response capacity, which is in the centre operated by Dr. St. John, for mobilizing the health advice and resources of the federal government to apply to the given instance. In this case, SARS.
That lead minister concept is key. The key to making the system work is to ensure that there is an early, confirmed identification of the appropriate lead minister, which then allows that person to be very clear about the responsibility. Their officials know to support them. The rest of the town organizes itself in support of that lead.
Obviously, also, these complex emergencies, which seemingly are more prevalent than in the past — and SARS being one — impact people not only through the means of their own illness, but in their modes as restaurant goers or providers of service. It had impacts in other areas of the world, including the economy and various sectors such as transportation. We know that from what we saw collectively in Toronto.
The system also has to have the ability to organize or bring together, at the given level of government, the federal level and those other interests in a concerted way, so that there is no gap between the health concerns and health advice and these other areas that are being impacted by the nature of the health emergency, and for which federal assistance and federal information also must be brought together.
Mr. Broughton could layer in how the health department exercised that lead role.
Senator Keon: I will just take a moment before we go to Mr. Broughton. I take it that if the state of health emergency is declared in Metro Toronto, the cascade that has been described lands on your desk. Is that correct?
Mr. Harlick: No, it would not. In this case, it landed on Health Canada's desk.
Senator Keon: I see.
Mr. Harlick: I am talking about a health emergency.
Senator Keon: How was the decision made to put it on Health Canada's desk as opposed to yours?
Mr. Harlick: It would be invoked by the lead minister concept at the federal level, that this is a health problem and the most appropriate minister to deal with it, not exclusively, but in the lead, is the health minister.
Senator Keon: Who made the decision that it was a health problem and not an emergency?
Mr. Harlick: Mr. Broughton, would you help me on that one.
Mr. Broughton: I think through the process of the discussions that happened from the federal point of view, it was evident to everyone that there was complete consensus across the system that the lead minister should be the Minister of Health on the federal scene.
Senator Keon: How did you communicate with each other and come to that decision?
Mr. Broughton: There are committees of officials within the federal system. There are existing groups of people who would come together and have those discussions. Obviously, the ministers have their own forums where they meet, cabinet committees and other places.
We do have existing mechanisms to meet on a regular basis. Those were called together fairly quickly, and we worked our way through the issues.
Senator Keon: Thank you.
Mr. Broughton: I look to my colleague to help me out, but I can give you a broad perspective from the Health Canada point of view. We have two perspectives. One is the one that my colleague has described within the federal system, so it is necessary for us to make the determination of which minister and which department would be presented with the lead. In cases of natural disasters, it is more likely to stay with OCIPEP. When you move into the health domain —
The Chairman: Just to clarify, on that basis, the lead minister would be the Minister of Defence. Is that correct?
Mr. Broughton: Correct.
The health dynamic is a little different. People do tend to use the notion of an emergency, particularly when talking of an infectious disease. As important and urgent as it is, it is not an emergency in the same sense as some of the natural disasters.
The system looks to Health Canada. We all understood that our minister would then be the lead minister and we, as officials, would support her in that process.
The second dynamic, which is where most of the discussion plays out, is what happens within the country. Mr. Harlick and Dr. St. John were explaining that when an event occurs it starts locally, works up to the provincial or territorial level and then comes to the federal level. That is the second dynamic with which we were working.
The way SARS developed, it never did evolve into a national emergency in the sense of it being across the entire country. Most of what happened around SARS, as we all know, was focused on Toronto.
It was a national issue because it was also an international issue in terms of the spread of the disease and relationships with the World Health Organization and others. There was clearly a significant role for the federal government, but the event, in and of itself, stayed fairly contained. There were obviously issues in British Columbia, but they were much smaller.
In terms of the invoking of legislation or the invoking of any emergency action on anyone's part, it was initially contained in Toronto. The province then stepped in and invoked its emergencies legislation. The federal government did not decide to declare any use of any emergency legislation.
Throughout the entire SARS event, the majority of what needed to be done was actually being handled on the ground by a combination of local and provincial officials. The federal role, of course, was significant in terms of advice, sending in resources and dealing with an international perspective.
We recognize one major challenge now and are trying to work through it. With the help of this committee, and other things, perhaps we can.
There is the challenge if something does become national in scope. We would need to figure out, in the case of an infectious disease, how many cities and locations within the country would require moving the coordination and actual authority beyond a local or a provincial and territorial perspective.
Mr. Gully: The request for assistance, for an investigation, occurred before the declaration of emergency in Ontario. We often send individuals to assist an investigation. We have officials located across the country already. During that first week, we did send epidemiologists to assist Ontario before that particular state was declared.
Senator Callbeck: Thank you for coming this afternoon.
I am still not clear as to who establishes the lead minister. You may have a disaster that affects three departments. Who determines who the lead minister will be?
Mr. Harlick: In that case, senator, I would suggest that the Prime Minister would confirm a decision of officials on who would be the lead and who would take the chair of the interdepartmental coordination process.
Obviously, the Prime Minister takes advice from the Privy Council Office, PCO. They become intimately engaged in these kinds of events and can be involved quite significantly in coordination or lead capacity.
Senator Callbeck: Is there nothing in legislation, or somewhere, that determines who the lead minister would be?
Mr. Harlick: I cannot quote from the federal policy on emergencies but it does make a reference to the lead minister and department. I would be surprised if there were not a reference to the PCO providing advice on behalf of the Prime Minister and confirming the suitability of that choice. As you know, a certain emergency could occur that affected three or four issue areas or sectors and a choice would have to be made. If I were to go back to the days of Mr. Mulroney and the Edmonton tornado, it was the Deputy Prime Minister of the day, Mr. Don Mazankowski, who was the lead minister to handle the federal response. He was the regional minister located there and a member of cabinet — it worked that way. The Prime Minister can make choices in accordance with his or her appreciation of the situation. There is no cookie-cutter approach. In fact, the flexibility allows the best choice to be made in a given situation.
Senator Trenholme Counsell: Mr. Harlick, I am interested in your answer to Senator Callbeck's question. I was assuming that because the Emergency Preparedness Act is under the Minister of National Defence, that minister would immediately assume responsibility, probably in consultation with the Prime Minister, and designate, if he or she were not to do it, the lead minister. Is it not that clear? I thought it was clear in the act.
The Chairman: It appears that it is not clear.
Mr. Harlick: That is correct. I can confirm that there is no reference to the lead minister concept in the Emergency Preparedness Act. It is covered in the ``Federal Policy for Emergencies'' that came out in 1995. For example, a flood, or other general emergency, engages the provincial emergency preparedness organization, which is our natural partner. The presumption would be that the minister responsible for emergency preparedness, the Minister of National Defence, would be the lead minister in that emergency. In fact, the power outage is the most current example of where that occurred. If there is a health crisis, as Mr. Broughton has indicated, it is natural to look to the Minister of Health.
Those things are subject to confirmation by the Prime Minister or by the Privy Council Office, as required. There could be, however, a very complex emergency. Let us factor in the terrorist example. That immediately brings in the Solicitor General, who is responsible for the National Counter-Terrorism Plan. An act by terrorists that has some kind of health impact on the population, as well as a more general emergency impact such as the dislocation of people, immediately puts up an interesting scenario as to who should be the lead minister. That is when a deliberate choice would have to be made quickly by PCO and the Prime Minister. The system would organize itself to handle that. In fact, it is even conceivable, in the course of an emergency, for the lead to shift as the focus of the effort may shift during an extended or prolonged emergency.
Senator Morin: I might say, while I have a chance, that we truly appreciated the efforts you made during the SARS epidemic to inform parliamentarians. I know that Mr. Broughton and Dr. Gully came at least three times to the Hill during an extremely busy schedule. We appreciate the effort you made to inform us. You answered all of our questions and it was extremely useful for us.
We may not see you again before the committee, I understand, so I would like to get back immediately to the future. I do not know who mentioned that the public health system during the SARS epidemic was strained. I think it was more than strained. According to the Ontario Minister of Health, it was close to the breaking point. Had there been another public health issue at the same time, the whole thing would have broken down. Had this epidemic occurred in a smaller province, it also would have been a complete disaster.
The situation in Canada is such that all public health issues, with a few exceptions such as immigration, fall under the responsibility of the provinces, where the resources are. If there is a major emergency, it is extremely difficult, as was shown during the SARS epidemic in Toronto, to mobilize all these provincial resources.
Mr. Harlick, you referred to the future as involving a national surge capacity with coordination between the provinces. I think we should take it one step further and have cooperation between the provinces. I think the provinces would agree that we should have complete integration of public health resources in the face of a major disaster or epidemic, whether it is a local or a national emergency. SARS was a local emergency of near-disaster proportions.
Both the CMA and the Naylor report, from what we have read in The Globe and Mail, strongly recommend a national agency that would integrate the public health resources of the provinces, would have a responsibility for surveillance and information, and, especially, would have the capacity to respond in the case of a major crisis by mobilizing the resources. Finally, there are relatively few resources at the federal level; and I realize that. There is expertise and a potential to react but there is very little to mobilize there.
Now, most countries have gone this way. Of course, the CDC, as it is today, is relatively recent.
The Chairman: The CDC is the Center for Disease Control in Atlanta.
Senator Morin: Yes, it is in the United States.
The U.K. has just set up a health protection agency precisely for this same issue — to mobilize resources and for surveillance in the area of infectious disease, also poison and so forth. Australia has done the same. Every country is faced with the same problem and the same solution — setting up an agency that is, with apologies, not bureaucratic but prepared to immediately respond to crises with scientific leadership, inclusion of the provinces, and a responsibility for public health.
I know you may not be prepared for this, but I am bringing this up today because we may not see one another again. This is on everyone's mind after reading what the CMA stated in its public submission to the Naylor commission. You know clearly what I am talking about — an independent agency, led by a scientific director who reports directly to the minister, to integrate the resources at the national level, while prepared to act anywhere at a moment's notice in the face of an emergency or a serious public health problem.
Mr. Broughton: One of the issues around surge capacity that is important to understand is why we link communicable and non-communicable diseases. It is done in the context of which people are available to help when you are facing extraordinary circumstances. Many people like to use the analogy of a fire department. Most people think that those hired by a fire department are there to put out the fires.
Thankfully, those do not happen on a regular basis. Therefore, over time, those people have been deployed to do other things around prevention and promotion. In a country as big as Canada, a lot of the thinking that a lot of us are doing these days is around a similar model, in terms of the non-communicable diseases, of having people at whatever level of government or organization working on promotion and prevention on a regular basis. However, when you get yourself into a crisis situation such as SARS, that is when those people might be available and deployable across the system. That is not dissimilar from what they do in the United States with the CDC.
In reacting to the kinds of models that exist, what we discovered through SARS is that there is a need for a model that allows people to react across the whole country. Many models have been put on the table. There are those who understand that within the federal government, you could use Health Canada. In some of our moments, the four people that you have here from Health Canada, plus the two who will speak to you next week — our two lab directors, Frank Plummer and Mohamed Karmali — are, in essence, the current Health Canada version of the CDC. All of the activities — in terms of surveillance, laboratories, infectious disease and so on — sit within that process.
That is one model that people can use. There are those that would argue that it is the resources that need to be there. Our minister and others have obviously expressed a clear interest in looking at how the CDC is functioning. The CDC has a level of independence. Some of it is more perceived than real. They are part of the health department within the United States, although they do work through the system. They do have a reputation, and they do have the resources that allow them to react quickly across the system — so there is that model. It is closely aligned with the states in the way their funding arrangements work. In fact, in many ways, the relationship they have with the states is not dissimilar to what we have with the provinces and territories.
When you hear in the media of the CDC coming in with their teams to save the day, or however it is described, that is always at the request of a state. They do not go in on their own.
There is the model of using the existing bureaucracy; there is the model of having something more independent, with an agency or centre perspective; and there are others who would create some kind of a model that is, to use your words, national rather than federal. I think a lot of the efforts our minister has made with her health colleagues in the recent past have been around those discussions. What is the nature of the way we are organized in Canada for public health writ large, but specifically for these infectious diseases, that would allow us to handle the circumstances differently?
Senator Morin: Would you have a preference for one model over the other? In other words, had we had a completely independent model — independent but reporting to the minister, and with more integration of provincial resources — would it have been different?
Mr. Broughton: That is a challenging question for us. I think you will get views out of committee reports like the Naylor report, and you will draw your own conclusions. I think the best answer you could get from us is that a number of factors would have had to be different. I think we would be hard pressed to say that simply changing an organizational model would be the answer, simply adding resources would be the answer, simply having better communications. A scenario like this has shown us that you have to look at all the factors that go into making it work. Many people would argue that there is some merit in a different organizational model.
We in the bureaucracy — and the advice we would give to our minister — would suggest that if that is all you do, the effect will be pretty limited unless you look at everything that happened. Unless, given the way our federation works, you have federal, provincial and territorial players, plus others, willing to sort through what kind of integration, communications and systems we need in place — the things that Dr. Mowat spoke about in terms of information systems — an organizational change will be only part of the answer. That would be our assessment; I think my colleagues would agree.
Senator Morin: Thank you for the answer.
The Chairman: I am glad you answered for your colleagues, but I would not mind if they actually answered for themselves. I am not being pejorative here, but it does seem to me that nuances matter. Could I ask each of your three colleagues from the department whether there are nuances to Mr. Broughton's answer that might help us explore the alternatives?
Dr. Gully: Whether it would have made a difference this time is a challenging question. SARS was different in terms of the magnitude of the issue being dealt with. There were a relatively limited number of cases of this disease, but in terms of how it affected the health care system, how it was responded to in terms of isolation and quarantine — as you know, at any one time there were maybe 8,000 or 10,000 people in quarantine — meant a huge stress on a system. Even if it had been differently organized, there just was not the capacity in the public health system to deal with an issue that was in the hospital system — and there have been questions about the capacity of the infection control system in hospitals — in addition to what was in the community.
I think the present capacity to respond to it, even if it were a combined federal, provincial and territorial effort, would still have been challenged. It does come down, in part, to the resources available. As you will find out when you do a comparison, the Centers for Disease Control and Prevention do have large resources available to them that they can deploy, and states and local health departments can access those to improve their capacity.
Dr. St. John: If I could add to that, senators, I was a CDC employee for 18 years and a commissioned officer in the U.S. Public Health Service for 20 years — 18 with CDC and two years with health and human services at headquarters — before I came to Canada.
It would be my opinion that it would not have made that much of a difference, for some of the reasons that were given by my colleagues. The problem is not with reorganizing or changing; the problem is systemic and structural at many different levels.
The Chairman: Can you enlarge on what you mean by that?
Dr. St. John: The capacity at local and provincial levels is highly variable across the country. We look at it strictly from an emergency preparedness and response point of view. We see a lot of variability across the country in resources and personnel, training and retention of personnel. There are many issues of a systemic nature that would not, in my opinion, have changed much if there had been a so-called ``CDC North''.
Dr. Mowat: I perceive a consensus among the public health community on the need to provide the kind of surge capacity that we were able to provide to some extent during SARS, and a consensus that it needs to be further strengthened. There is also a consensus that there are opportunities to strengthen the infrastructure at the local and provincial levels — in terms of things like people, information systems, training — to provide the capacity to respond. There is, I believe, a lot more thinking to be done on the issue of agencies and possible models. For example, to talk about a national versus a federal agency gets us into constitutional territory and the existing legislation, because the provinces all have their own public health legislation. Unfortunately, they are all very different.
It would take some considerable time to work through that, in a federal-provincial-territorial partnership, and decide what to do. It is not up to any one party to come up with the definitive model. I believe it is early days to be thinking about models.
The Chairman: I have two supplementary questions on that. Number one, who is doing that thinking? Secondly, I understand that for any public problem, one immediately looks for a solution that one can explain to people in easy terms and that sounds plausible. I am always reminded of the H.L. Mencken comment, that for every public problem there is always a solution that is easy, plausible and wrong. I raise the question in the context of the CDC.
Everyone in Canada has heard of the CDC. It is easy to say that we need a Canadian CDC. My point to you, Dr. Mowat, in light of the comments you made, is that surely there must be other models elsewhere in the world in which the kind of thinking about which you are talking goes on. I would like to know who is doing it. Does that kind of thinking include going beyond the CDC model or is there a tendency to simply jump on the one solution that we know?
Mr. Broughton: We all want to answer this one. I will start. There are a couple of questions there.
It is fair to say that we are looking at a variety of models. We are looking at the U.K. and Australia. Those are countries to which we tend to look because there are some similarities.
We are looking at other models. Many people are convinced that there does need to be a focus on the American model, if for no other reason than the proximity.
The Chairman: The one thing that this committee learned in a two-and-a-half-year study of the health care system is that there is absolutely nothing that you can learn in the Canadian context from the American health care system. We were not looking at it in this context, but if we had one basic rule that underlay all our conclusions, that was it. It is important that we look at some other models.
Mr. Broughton: We definitely are doing that. I made reference to the Americans partly because, especially on the infectious side, on communicable diseases, you are talking about something that is international. From that point of view, things start to take effect in a North American context. It is not necessarily that their model is perfect, but we have to have some way to make it fit because much of what happens on the continent, especially with infectious diseases spreading, is significant.
Regarding who is looking at things, our minister obviously is playing a key role with her colleagues on the provincial/territorial side. The ministers of health have given much direction to their deputy ministers and, therefore, to people like me, and others on the various advisory committees, to look at public health and what is happening around SARS. Obviously, our minister engaged Dr. Naylor to do the report. She will be looking to that to provide some advice and guidance.
Within our own communities in Health Canada, we are putting a lot of time and energy into our entire system and looking at the kinds of things that we could do better or differently to be prepared, in the short term, for the upcoming flu season and the possibility of a re-emergence of SARS, but also on a longer-term basis.
The four of us who are here, our colleagues in the labs and numerous other people are looking at everything, from the laboratory network, how we are doing the testing, to what the surveillance system looks like, how ready we are on emergency preparedness and all the infection control guidelines. Health Canada sponsored a meeting in mid- September, which was played out in the press, trying to get at some of the issues. There is much time and energy spent at a variety of places tackling the issue.
Senator Morin: The matter of resources is extremely important, either resources that remain at the federal level or that flow through the federal level. The additional advantage of an agency is that resources could flow through the federal level to the provinces.
It is easy to say that provinces do not have the infrastructure and the resources, but some just cannot afford it. There is a need for federal resources that would flow through conditionally to the provinces to help them set up public supports.
Incidentally, the CDC has a remarkable record in training public health officers in the States, something we have never done at the federal level. This is one advantage of an agency that can do all sorts of things, like training and research, which a bureaucracy has less flexibility to do.
Dr. Gully: There are models in the U.K., Australia and U.S. Europe is now proposing a central agency. They all wish to take advantage of expertise that exists outside of a federal or other form of government. That would be true here, too.
We would wish, in any kind of model, to work very closely with the British Columbia Centre for Disease Control and the Quebec Institut national de la santé publique. There are other such centres within provincial/territorial governments and in academia. We would want to collaborate with those organizations.
I would like to echo Mr. Broughton's remark about the U.S. We have a close working relationship with the CDC. That is important because of our continental situation. Therefore, we would want to work towards trying to develop surveillance systems that were compatible.
Infectious diseases certainly do not respect borders. Therefore, we want to find some way of sharing information and expertise across those borders because certainly there have been outbreaks in the past across both countries.
Dr. Mowat: First, I could give Senator Morin additional information about training epidemiology officers. You are correct to say that the U.S. does this. It was the first such program in the world. Canada's was the second program in the world. We have been training epidemiology officers for 27 years now at Health Canada.
It is a two-year course. They are placed at Health Canada or in the provinces to provide assistance. They are our first responders when we are asked for assistance in investigating outbreaks.
On the issue of models elsewhere, there are models we could look at in the U.K., Norway, Sweden, the European Community and New Zealand, in addition to the United States. We are a federation and not all of those countries are. Even if you compare our system with Australia, there are differences. The context is different. It is unlikely that we would find an off-the-shelf kind of answer. All of these need to be looked at and then the debate has to proceed within this country as to what our solution would be.
Senator Keon: I want you to comment on ramping this up a notch. It is one thing to look at what exists in other countries. One of the big areas of confusion this time, which hopefully will not occur again, was the difference in statements between the World Health Organization and our authorities in Canada.
Hopefully, what would evolve out of this is our contribution to the global safety net, with integration of whatever comes with the rest of the world. Some of you can address that as the other questions come forward.
Senator LeBreton: Thank you very much for appearing today.
My question goes back to an intervention that the Chair made at the beginning and also to Dr. Keon's interventions. It is in regards to public health and natural disasters. It is easy for people to get their heads around natural disasters — fires, floods and ice storms. In this case, it was a public health issue.
It was concentrated in the Greater Toronto area, but how do you sort all this out? This had implications for the economy and the hospitality industry. People lost their jobs. The Ontario government had laid out a lot of extra money for extra health care. How do you sort this out?
You mentioned the DFAA, the disaster financial assistance agreement. Does that apply in the case of what happened in Toronto? Who sorts it out? Who puts a dollar value on it? Is there anyway to determine the magnitude of the financial disaster as well as a public health disaster? How do you sort out how these various claims against the government for compensation are ever paid out?
What is happening now in the Toronto context? What stage are we at in terms of sorting it out and negotiating?
Mr. Harlick: I will take it as two parts. The first part relates to a complex emergency and how all the various strands of the emergency are managed, especially when they can interact with and impact on each other. Senator, you used SARS as the example and, indeed, we have all read about it in the media and perhaps some here have experienced that kind of impact.
The way in which the government tackles that issue is to try to determine the factors in play. There could be health issues; there could be general emergency response issues; there could be economic development issues, such as effects on the tourism sector; there could be unemployment issues, such as individuals in the entertainment or restaurant industries perhaps on reduced hours or laid off pending resumption.
All of those issues can be identified at the federal level as being of interest to, or the responsibility of, one or another government department or agency. The health issues would fall under Health Canada; tourism issues would fall under the Tourism Commission and Industry Canada; and the unemployment issues would fall under Human Resources Development Canada. It would be divided in such a way. You put together an interdepartmental process with which, from your former life, you will be well familiar and bring those departmental representatives under the leadership of the lead department. That could be Health Canada or, because of the variety of departmental interests engaged, it could be the Privy Council Office, which often takes that role in these and other circumstances.
What is the impact? Are there other issues? What could the federal government do? What should the federal government do in these areas? One initiates a dialogue and discussion; shares out work, examinations and work-up of proposals; and they are brought back for discussion and for the shaping of an approach. That happens whether it is for a policy issue, policy development, or an emergency.
That is a standard response on the part of public servants and it varies according to the nature of the occurrence.
The second part is disaster financial assistance arrangements. They did not apply in the case of SARS in Toronto, as you well know.
The Chairman: Why did they not apply?
Mr. Harlick: Ministers looked at the situation in Toronto, in Ontario, and at what the disaster financial assistance arrangements were originally created for: natural disasters, physical devastation and severe impact on emergency resources. In fact, yesterday in the Senate, Senator Carstairs, in response to a question on this point, drew the attention of senators to the fact that the disaster financial assistance arrangements are rather blunt instruments in dealing with things other than climatically induced natural disasters such as floods, ice storms, tornados, et cetera. Those financial assistance arrangements are easy to determine and have been many times.
We cannot speak for them here but, when the ministers made their decisions, they thought that the best approach was for the federal government to offer considerable financial assistance to the Province of Ontario. My minister and the health minister were involved, spoke about it publicly and talked about it to their counterparts in the legislature. The best solution was for the federal government to offer to help them bear the cost of the effects of SARS. As you know, Ms. MacLellan and Mr. McCallum were involved, along with other aspects of the government decision-making system. That offer is still before Ontario but it has not been accepted.
Senator LeBreton: Again, there is the confusion over who takes charge. There has been some finger pointing on that issue. I know that politics enters into it and there will be finger pointing back and forth — that somehow or other the federal government is not turning over the money, while the federal government says that the province has not applied for it. That is why the public is confused. I can understand, in the case of SARS, why it would not fit the terms of the DFAA. Would the Department of Finance be brought in because of the economic impact? Would that be left to evolve for assessment at a later date?
Mr. Harlick: Certainly, the Department of Finance would have been involved in looking at and contributing to this interdepartmental process on the economic impact of SARS in Toronto. They are one of the pre-eminent economic modeling organizations in the federal government so they would have been involved. Finance would be a player and, as you may well recall, the Minister of Finance is a fairly pervasive and ubiquitous player in the halls of government. Yes, the department would have been there as well as other departments. I have articulated the health interest, the emergency response interest, Industry Canada's tourism interest, the Department of Intergovernmental Affairs' interest and HRDC's interest. A range of interests is brought to bear at the table when one makes a significant governmental decision. Those would be put into play.
Mr. Broughton: Perhaps I could add a completely different perspective and I am hoping that it will help you with the deliberations. This might be an oversimplification, but from a health perspective, there are roughly three categories of significant or emergency kinds of situations or crises. First, those that tend to be natural, such as floods, tornadoes and ice storms, are an immediate threat to health. They are usually contained in a very short period of time. It is easy for most of the systems to figure out what the impact as been, in the unfortunate cases of loss of life, although people will need time to sort out the economic impact.
The second category is a little more protracted, like infectious diseases such as SARS. That is much more challenging because of the threat to life; how many people are impacted; and how long it will last, whether a couple of weeks or a couple of months or, in fact, years. In that context, it is an emergency at a particular time, but it is not as easy to grapple with from either a health point of view or from a financial point of view in such an immediate and shortened period of time. The third category is what we would typically refer to as the chronic diseases. People tend to use similar kinds of words about the burden there — the emergency situation of obesity or diabetes or any number of things. Those obviously happen over decades. Therefore, in terms of their impact on society, what we do about them and the financial and economic impacts, this category raises a much different kind of discussion. At either end of the spectrum, society seems to have found a way to deal with them. If it is very short term, one day or one week, or over many decades, we talk about the kinds of things we do. SARS falls in the middle category because it has a mixture of the immediate, which people react to, and an undetermined element. Speaking less from a DFAA point of view and more from a health point of view, it is one challenge that we face in being precise with respect to these kinds of things. I leave that with you.
The Chairman: Mr. Harlick, I want to know if I am correct in saying that the disaster financial assistance arrangements are essentially based on a formula that has historically been applied in so-called ``natural'' disasters.
Mr. Harlick: Virtually all of the 100-plus cases were natural disasters, by which we mean climatically induced.
The Chairman: They were included under the act because when they occurred, someone somewhere — a Governor in Council or someone — declared them to be a national disaster. Is that right? That triggers the act?
Mr. Harlick: There is a requirement now in the act to have a Governor in Council authority by an Order in Council to formally decide that the event is eligible for DFAA application.
The Chairman: The eligibility occurs because it is deemed by cabinet to be a national disaster. Is that correct?
Mr. Harlick: No. The word ``national'' does not apply.
The Chairman: Okay. The basic difference then between SARS and forest fires in British Columbia is that first, there are precedents for dealing with forest fires and second, the cost associated with a public health epidemic is much harder to measure than the cost of burned out houses and the need to pay for firefighters. Part of the problem was measuring the cost. Is that the answer?
Mr. Harlick: In part, yes. It is not because they were unmeasurable with enough effort and data, but you must also recall that the disaster financial assistance arrangements have never been applied to a public health emergency.
The Chairman: I assume you are not a lawyer. However, you remind me of the classic lawyer's problem, or what one often hears in government circles, which is that there is no precedent. The problem is that, in the absence of accepting the notion that you have to have a first time, there never would be a precedent for anything. I have always found the absence of a precedent a difficult concept. What is troubling me, and I am not being critical, is the fact that it had never been done before and therefore was not done this time. It says to me that the next time there is a public health emergency of some kind, there will still be no precedents because it was not done this time. The issue will be that there is no precedent. Therefore, we will not have any way of dealing with a reasonable allocation of the financial costs. How will we get around that problem, if the defence for not handling it this way is that there is no precedent?
Mr. Harlick: I must confess to you that I do have a law degree.
The Chairman: You have my condolences.
Mr. Harlick: However, I am not a qualified lawyer.
The Chairman: I regard it as one of my better attributes that I am not a lawyer.
Mr. Harlick: To complete my thought about it not having been applied previously, it is not because it has not been applied in the precedent sense. It is because of the question of knowing how to apply it. Why would one necessarily think something that has been applied 100 times to floods, fires, tornadoes, et cetera, would work as it would be intended to work in those situations in a public health emergency? This is the most major, and I will defer to my colleagues here, public health emergency that has occurred in Canada in terms of impact, costs to the province, et cetera. To arbitrarily say, ``Yes, it should apply, and we will work out how to do it later,'' raises some serious questions.
The Chairman: That argues there is a critical methodological issue that needs to be addressed, which is how to measure the cost. That has not come up yet today. We have talked about organizational structure, but am I missing something? That is clearly an issue that needs to be addressed so we do not get into this question of how much you really owe on future issues.
Mr. Harlick: I would suggest that there is a broader public policy issue here, in light of some of the factors that are in the Health Canada deck, and we certainly agree on the increasing risk environment that we all have experienced. That environment, in part, drove the creation of this office in 2001, and in the future we will have to ensure that there is appropriate disaster financial assistance capacity, capability and program authority for a federal government to look at areas which perhaps hitherto have never required federal financial assistance. I do not single out Health Canada, but it is an obvious one.
In the agricultural area, there was BSE, for which there was no application of DFAA. They came up with a program that the federal Minister of Agriculture and his provincial colleagues agreed was a good and appropriate approach to handling that particular problem. They did it sui generis. I think the point would be that, whether we think of environmental disasters, public health disasters, agricultural disasters or whatever, the increasingly severe risk environment which we collectively face here because of globalization, terrorism and other factors is requiring all national governments to ensure that they have that kind of capacity available. That is something well appreciated by the federal government today.
The Chairman: I would strongly agree with that. I just think it ought not to be an ad hoc decision. The people receiving the money should not be left in the position of feeling they are simply the supplicants for an amount that will be determined by the federal government on a whim. This is perfect, because the next questioner is Senator Callbeck, a former Premier of Prince Edward Island. I would submit to you that Prince Edward Island, had this occurred in Charlottetown, could not have absorbed the percentage of the costs that in fact we are asking a richer province and the biggest city in the country to absorb. I think that inevitably creates a sense of arbitrariness. I am not arguing about whether the number is right; I am saying that it just creates a sense of arbitrariness and it seems to me everyone would be better off with an understanding that it is not really an ad hoc amount, that there are at least some guidelines. I would agree with you; I just think we need guidelines as well.
Senator Callbeck: How much money is set aside for the DFAA reserve fund?
Mr. Harlick: Effectively, there is no money set aside. It is not a funded program, because you cannot predict in any given year what the total cost of disaster assistance will be. There is provision, just for purposes of financial management in the government, for a couple of hundred million dollars to be put into the national defence department's budget. It makes it easier to get the cheques out. As opposed to having go back through parliamentary process, it is provided up front through the Main Estimates. However, there is no program. It is a direct draw on the federal fiscal framework, that is, the Department of Finance and the Minister of Finance, when the decision is made that this is the amount owed.
Senator Callbeck: Do I understand correctly that there really are no guidelines or criteria?
Mr. Harlick: No, that is completely incorrect, senator. The guidelines exist. They are on our Web site, in fact, and are the basis on which the claims of the provinces and the bills they submit to us are audited and verified and the totals are calculated and cheques are issued.
Senator Callbeck: At what point does a public health threat become a national emergency?
Mr. Broughton: As I alluded to earlier, that was one of the big issues that were highlighted by SARS. A public health issue like SARS will always be national, in the sense that we have an international responsibility. Even if it is one person in one town in one place in the country, because it involves infectious disease, particularly coming from another country, it clearly becomes a national issue. We, as the federal government, are responsible for international dealings. There is no question of that in that context, and in that sense, that was where we were working with the World Health Organization and others. I think the bigger challenge that people are discussing and working on now is the actual coordination of the effort throughout the country to ``solve the problem.'' To take decisions about what you do in hospital settings, what you do with the population at large, what you do within cities or across provinces, is the challenge before us. Many of us would have known pre-SARS, but it was brought to our full attention through SARS, that we do not have the mechanisms to make that exact determination.
Because so much of what happens takes place within a provincial or local setting, most of the resources and the decision-making sit with that jurisdiction. In the case of Toronto, it was a combination of local officials in Toronto and the Province of Ontario that were left with the decision-making because that is where the bulk of the problems were. No one has offered a precise definition as to how many cities, provinces, people need to be affected to raise it to another level. That then takes you to the questions that Senator Morin and others were asking earlier, of ``Assuming you can do that, then what is the entity or process that you would use to handle that accordingly?'' Within this federation, we do have issues of authority and, as we were pointing out earlier, even in the States, the CDC does not come on board out of any federal authority. It comes on board and provides assistance at the request of the state.
There are two issues there. The first is that the definition does not exist. That is the answer to your question; there is not a precise one. The second is that once you reach a definition, the mechanisms, which I think our minister and others have expressed an interest in sorting out across the federation, need to be resolved.
Senator Morin: You are putting your finger on the issue. This is a personal comment. He is putting his finger on the issue right now; this is exactly it.
Senator Callbeck: There is one other area I wanted to ask about. Mr. O'Bright, you are the director general of the Office of Critical Infrastructure Protection and Emergency Preparedness. You mentioned you had people in all provinces, so if an emergency was to develop in my province of Prince Edward Island, what role would your office play?
Mr. Gary O'Bright, Director General of Operations, Office of Critical Infrastructure Protection and Emergency Preparedness: Our office has a regional director in Charlottetown. His job is to work with your emergency measures organization. He would be in a position to coordinate the response of federal resources in the province, if an event occurs that requires such. That happens in all other provinces and territories in the same way.
Senator Cordy: Thank you very much to all of you for appearing before us today. I will follow up on Senator Callbeck's question.
OCIPEP has someone in each province. When an emergency occurs, the municipal or the local people are the first to deal with it. How are they made aware of the personnel and medical supply resources that are available to them?
You spoke earlier about a hospital that was set up somewhere. Are all the municipalities in Canada aware of exactly what is available to them?
Mr. Harlick: They should be. They can be made so aware.
They would request help via their provincial emergency measures organizations, if they needed resources outside of their own municipality but in the rest of the province, or resources in other provinces. The provinces have, or are developing, mutual aid agreements by which, for example, Manitoba can provide these kinds of people and this asset to Ontario in certain circumstances, and vice versa.
There is a very good network of information flow among the provinces themselves and thus through the provinces to the municipalities. There are some municipal level associations and organizations, such as the Federation of Canadian Municipalities, that become involved in a range of issues and would therefore be cognizant of this area.
Senator Cordy: Not every region would have an emergency mobile hospital that they could set up. Those things would be shared across the provinces, with the federal government taking responsibility?
Mr. Harlick: There would be sharing between the provinces of provincial assets. I will speculate, and Mr. Broughton may correct me, that the provision of the hospital was done through a request from a provincial level to the federal level at Health Canada. Perhaps Dr. St. John could expand on that point.
Mr. St. John: We work very closely with chief medical officers of health, the emergency health managers in the ministries of health and emergency social services at the provincial level. We have a national forum every year on emergency preparedness and response at which those three groups are brought together. We talk about our level of preparedness and our national emergency stockpile system.
All three groups are made very well aware of what is in our $300-million national emergency stockpile system. We have seven federal depots strategically placed across the country and 1,600 caches of medical and health supplies that are jointly managed by the provinces to be readily deployable within 24 hours to anywhere in the country.
There is a system already in place whereby these people know how, whom and when to call and what is available.
Senator Cordy: Are medical supplies updated?
Mr. St. John: We have an annual program of refurbishing all of these supplies. We have 165 200-bed hospitals strategically placed around the country. There is at least one in every province. We have many clinics, rescue units and first aid treatment packages. There is a long list of resources that are available to the local authorities to help them manage any kind of a disaster.
Senator Cordy: You highlighted some of the gaps that were evident in dealing with SARS in the document that you gave to us. I assume that you are working on correcting them. Who is taking the lead role? Is it Health Canada or OCIPEP? Who is looking after what went wrong over SARS so the same types of things do not happen again?
Mr. Broughton: Our minister in Health Canada is taking the lead from a federal perspective. We are spending much time worrying about these kinds of things. Our minister is engaged with her provincial and territorial colleagues. The provincial and territorial colleagues met recently in Halifax — and meet on a regular basis — to have these discussions. They are all engaged. I would say that the Minister of Health for Canada is in the lead, but the responsibility is shared with the provinces and territories.
We would obviously work with OCIPEP and a variety of other federal players on what needs to be changed or fixed over time.
Senator Cordy: Senator Kirby made mention of a medical emergency, similar to SARS, happening in a small area that financially could not deal with it. Small cities and towns, or even small provinces, could not deal with it in the way Toronto dealt with it. You have suggested that there were gaps even there.
In a small town, patients could not be transferred to another hospital. There would not be the staff. I know that staff was stretched in Toronto. They certainly went above and beyond the call of duty. There would not even be the staff in a small area.
Are you also looking at the effect of an outbreak of a disease in a small province and a small community?
Mr. Broughton: We are. You have touched on a few issues. One is this notion of surge capacity. Most people have come to the conclusion regarding gaps across the system that we need to worry about where we go to get the resources that are needed in an emergency situation.
The second issue is that when you have that kind of a circumstance, you have a huge impact beyond the public health system. You are into the health care system. That in and of itself means that all the jurisdictions need to worry about how to handle the circumstances. The specifics of what they are doing in an individual town or province obviously rests with those jurisdictions. The local regional health authorities, however they are organized, plus the provinces, are the main players who figure out what they would do in any immediate disaster. We are trying to look at it from a national perspective.
Mr. Gully: Every infectious disease is different. In some ways, the fact it occurred in Toronto was more of a problem because of the complexity of the health care system. The movement of patients and staff among hospitals and the large number of institutions meant that it spread through the Greater Toronto area.
One thinks of Walkerton, for example. It was a large issue for that small town. There were a large number of cases, but it did not spread beyond the boundaries. In fact, if SARS had occurred in a small town, it would probably have been easier to limit it, albeit with assistance from the outside.
That has often been the case with highly infectious diseases in the past that have occurred, not in our environment, but in less developed countries. The disease was a problem for local populations but was limited to that population.
The Chairman: Can I ask you to expand on that, Dr. Gully? I understand why the complexity of the health care delivery system in Toronto was a complicating factor. On the other hand, the impression was that doing things like closing emergency rooms and so on were an important element of the containment strategy. How do you do that in a place like Charlottetown, St. John's or Halifax, with effectively only one hospital? You have to have a completely different strategy because some of the techniques used in Toronto are not applicable. You cannot shut the system down.
Mr. Gully: I go back to my point about critical analysis of the effectiveness of the strategies that were used. One could look at other countries. Singapore, for example, put all their cases of SARS in one hospital. They had a large number of cases. They did not quarantine all the staff in the hospital. They quarantined individuals who were in close contact with cases.
Hindsight is easy, and I am not criticizing what was done in Toronto, but I think the capacity to analyze, perhaps on the fly, during an outbreak how it is managed is illustrated by SARS. Perhaps in certain situations, certain actions do not need to be taken, but still the matter can be controlled.
The Chairman: A modified strategy would have been required for practical purposes. Nevertheless, you are suggesting it might have been just as effective?
Mr. Gully: Perhaps.
Senator Léger: You started by saying coordination is an issue and there are many subdivisions. With the experience that you have had, you hope to create unity. Hopefully, those subdivisions will ameliorate, and not complicate, the process of getting to the lead minister.
In the World Health Organization, what was Canada's rating for the response to this crisis of SARS?
Dr. Gully: I seek clarification. Do you mean the rating of us by the World Health Organization, or our rating of the World Health Organization?
Senator Léger: The World Health Organization rating of the work Canada did.
Dr. Gully: First point, senator, we are making a diplomatic connection with WHO to have further discussions with them to clarify the World Health Organization's role in this circumstance.
One of our challenges was demonstrating our competence to deal with this. In fact, it was controlled. Unfortunately, the challenges about which we talked about before, such as data sharing and the ability to analyze and demonstrate what we did, meant that the World Health Organization made a less good assessment of us than they did of other countries, such as Singapore, for example.
We did have regular communications with the World Health Organization. In fact, we believe that they did a very good job in terms of the laboratory and epidemiological networks. We assisted the World Health Organization in a global outbreak response in Hong Kong.
However, I do believe that they were not as able as they might have been to assess what we were doing because of some of the difficulties and challenges that we had in terms of demonstrating and analyzing what we were doing.
Mr. Broughton: When you look at the cascade of organizations from international to domestic, they formed a part of this entire scenario and dilemma. People saw the provinces and territories, us and other countries trying to react on the fly to the impact of SARS and the case definition and potential impact. In fairness to everyone, the World Health Organization was doing exactly the same thing. It is easier for the higher-ranking organization, that is, the international one, to pass judgment on others. We have all concluded that the entire system, including the WHO, had their equal share of challenges in trying to sort out the circumstances.
That is perhaps less diplomatic than Mr. Gully's answer but it gives some perspective on it.
Senator Léger: We do not care about the money until the life-and-death question has been controlled, and I imagine that you must face that. We will see the bill later.
As an ordinary citizen, I was very proud of what Canada did. All of a sudden, though, the World Health Organization made Singapore sound better than us. We then looked at it in new ways. I hope the new subdivisions will not complicate things. That is a danger.
Senator Morin: Senator Léger is raising a very important point. At some point, we should look retrospectively at the travel advisory that hurt Toronto so much. It was unfair as far as we are concerned, although we do not have the facts. Was it in fact advisable to issue a travel advisory at that point or was it a mistake? A year later, we should know.
Airport screening was another issue raised at the time. Were we doing the right thing, giving out these little pink slips while other countries had sophisticated technology? We did not look very good with those little slips, but maybe in retrospect that was the thing to do.
We should have that information within a year on these two specific points that were raised, as you probably remember, at the time. It does not need to be made public.
Senator Cook: Thank you for several compelling hours. I come from the province of Newfoundland. What would happen if the unknown came to my area, if someone stepped off a plane from somewhere with a disease? We have only one tertiary care hospital.
I wrestle with a more compelling thing. I know that the provinces deliver health care and I know a little about the federal system. When we did our report, we allocated a fair amount of money to public health because we thought that it was underfunded. That which has happened in the intervening time dwarfs that in comparison.
We talked about structures, and we talked about systems, but we have not talked about the preparedness of the human element to deal with it. We have not talked about training people or cross-training all the health professionals. Is there a public health school in this nation today? Is there curriculum support? Is there sufficient training for people to deal with the unknown — because that is what we are doing?
Health care is the responsibility of the provinces, but somehow, somewhere, the federal system has to take some responsibility. The provinces regionalize services. Public health is always low on the totem pole because it is seen as education in schools or nice little cosy things like weight control or whatever.
We thought in the 1970s that we had it licked — that communicable diseases were controlled. Here we are in 2003 and we are into a new round. In our preparedness, we need to look at the human element of who takes care of the people who are affected by this. No one this afternoon has talked about that.
The Chairman: I should add, to emphasize the point that Senator Cook just made, that I have used in speeches a number of times lately the wonderful quote from the official in the Ontario government who explained why two or three years ago it was okay to lay off their last public health researcher. The explanation that was given to the media at the time was that it was because there were really no new diseases that would ever again come to Canada in general, and Ontario in particular.
I merely use that as an illustration of the point that I think Senator Cook is trying to make. It is a wonderful quote for posterity.
Mr. Broughton: Senator, please ensure that the record shows that that was not a Health Canada person.
The Chairman: It was someone in the Ontario government. It was not a minister. It was some official in Ontario.
Dr. Gully: I would like to make two comments. One relates to health care workers in general during SARS. I was at a meeting at the University of Toronto this morning and every speaker paid tribute to health care workers across the board, including public health workers, laboratory workers and so forth, in terms of how they responded. In fact, the public responded hugely well to this. It is in recognition of their input that we have to be critically analyzing what we did, so that in fact we can do a better job next time.
The ``public health capacity'', which we have referred to in the presentation, is shorthand for improving capacity across the board in public health. We must improve our ability to do surveillance, ongoing investigation and analysis and develop programs for communicable and non-communicable diseases.
However, we would certainly recognize that that capacity building has to take place across the country, because there is not a large capacity for academic training in public health. There is not a school of public health in Canada. There is some discussion among universities that there might be in the future, but certainly there is no current one. There is limited training for physicians in public health outside Quebec. Quebec does a good job.
Outside of Quebec, there are not many physicians and very few nurses, even in positions as public health nurses, who have a lot of training in public health. What we say about bolstering public health capacity includes all those things. It includes the recognition that those individuals are needed in every province and territory, so there is a first line of defence for acute issues, as well as chronic issues in the long term.
Dr. Mowat: If I can just add, in response to Senator Cook, some more information about training and health human resources for public health. There are provisions of various kinds across the country, particularly through the 16 schools of medicine, for the supply of public health professionals, including physicians, nurses and others. There is some concern about a number of issues that are in some sense no different from elsewhere in the health care system, such as an aging workforce and the ability to replace those who might retire. If anything is a national issue, this is it. Of course, medical training and the post-graduate training is a provincial responsibility, yet that capacity and that human resource is transferable among the various provinces and territories.
This has concerned federal and provincial ministers and deputy ministers. There is now a federal-provincial- territorial advisory committee on population health and health security, which will be looking at a number of health infrastructure issues, including matters of health human resources. It will involve the federal government, provincial governments and representatives of universities and the health professions. We have a vision of everyone getting together to look at this in the longer term.
Senator Trenholme Counsell: We have moved into this whole issue of human resources. I want to say that one was very struck by the compassionate concern about the patients and their families. However, I think the nurses in those hospitals bore an enormous burden. When I compare it to what firefighters do in the case of an emergency, knowing they are perhaps risking their lives, be it in New York or B.C. or wherever, I do not know whether one needs to talk to nurses' associations or whether there could have been more support. This does not really deal with education of public health personnel. This deals with trying to realize who is under the most stress. Of course, patients' families come first; however, I think the next would have been the nurses. I felt as I watched and listened that the nurses at those hospitals were at the breaking point. I am not being critical at all, but if this was a first, in a sense, I wonder whether there could have been more help for the nurses to alleviate the stress on them and their families. There must be a lot of post-stress syndrome among those nurses and a very lasting impact.
I think that is something that one has to perhaps be aware of through the nurses' and nursing aides' associations.
The Chairman: To pick up on Senator Trenholme Counsell's point, is anyone looking at the impact on the people who were on the firing line?
Dr. Gully: I do not know, senator. We can find that out from the head of nursing policy in Health Canada, who was very much involved in assisting Ontario in finding nursing resources.
The Chairman: Would you mind talking to her about that? She has been a witness here before.
May I just say to the assistant deputy ministers, I think it would be helpful to us, but I also believe it would be helpful to you, if a member of each of your organizations were to monitor these hearings, for two reasons. As we go along, there may well be specific questions where, if someone is here, they do not need to answer on the record, but at least we can be sure we get an answer quickly. It may also be, when we get to the end of the process, that we would like to call this group back again. In that case, having had someone monitor hearings would make that discussion substantially more efficient. If you could do that, that would be great.
I thank all of you for coming. I know we imposed on your time, but it has been a good start.
I have one five-second piece of business. We need a motion in the committee, which was approved by the steering committee yesterday, for a small budget of $9,000 related to this study. It went through Senator LeBreton and me yesterday. Senator Keon can move it.
We will take that as done. Thank you very much.
The committee adjourned.