Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 23 - Evidence for October 8, 2003
OTTAWA, Wednesday, October 8, 2003
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 6:00 p.m. to study the infrastructure and governance of the public health system in Canada, as well as on Canada's ability to respond to public health emergencies arising from outbreaks of infectious disease.
Senator Michael Kirby (Chairman) in the Chair.
[English]
[Editor's Note: The following evidence is a continuation of an informal meeting held prior to the commencement of the public meeting.]
Dr. John Frank, Professor, Department of Public Health Science, Faculty of Medicine, University of Toronto: Senators, you tell me how it would be acceptable, then, for our so-called national system of public health to rely almost entirely, until now, on provincial, territorial and, in Ontario 50 per cent, local municipal tax bases. How could that be right? How could that extremely inegalitarian way of funding public health be expected to leave us with anything but a poor quality of public health services in much of Canada that is remote, northern or poor?
What kind of society would let that happen? Well, it is not deliberate; we were simply not minding the store. We did not think to put public health in the Canada Health Act and so it is not included. Essential public health services are not defined and are not included. I do not need to talk in great detail about the next set of text slides before you because, to be honest, these subjects have been well covered, as of yesterday, by the Naylor report, ``Learning from SARS: Renewal of Public Health in Canada.'' Rather, my job is to tell you that, after reading the report carefully, I cannot disagree with one line. Dr. Naylor has explained the situation incredibly accurately. The diagnosis is right, the prescription looks pretty good to me, but the prognosis for the patient — our system — is guarded.
I welcome your questions, senators.
The Chairman: In respect of your comment on Dr. Naylor's report, where do we begin? One of the difficulties with a prescription that has as many pieces as Dr. Naylor's has, and if we are to begin renewal, is figuring out what the first steps are to be. There is a universal view that something needs to be done quickly, but it is equally true that you cannot do everything quickly. From your perspective, what should we do in 2004?
Dr. Frank: You need to divide your actions into those things that we cannot actually go through the winter without. That means that we need to rapidly increase the capacity of the influenza surveillance system and response system, which has, as you know, been adapted to deal with SARS, about which we have learned a great deal, and we need to rapidly ensure that measures are in place for whatever comes at us in the next three or four months from Asia, because that is where these things originate. That will not be definitive. The definitive action is in the series of recommendations in the Naylor report. The key to his brilliant analysis and the committee's analysis is that you cannot get those jobs done, such as defining the core functions of public health and, therefore, what the performance measures will be and what the human resource and other implications will be, unless you have an agency of people whose job it is to do that assessment and planning work.
The agency is a sine qua non. I think Dr. Naylor got that right. In turn, you cannot have the agency without some enabling legislation, I would assume, although I am not a legal expert. I assume that will take us some time to put in place. I would guess that ``months'' would be a short estimate. How can you get the work done unless you have the enabling legislation? How can you achieve arm's-length, have scientific quality and attract good people to work in the system when they work inside a ministry that is not regarded by people who have academic credentials in research as an independent line of work for professionals?
The Chairman: To pursue that for a moment, there is a way to start the agency and to have the legislation catch up later — by Order in Council. The legislation could be enabled at a later date. I understand your comment on what needs to be done to get us through the winter. Let us suppose we do that by Order in Council before January 2004. What are the priority items that you would want the agency to do after that?
Dr. Frank: The last two slides before you show the set of tasks. If you do not decide on the core functions of public health that need to be executed in every community by public health across Canada, then how can you proceed? You cannot set standards or look for the evidence base for effective interventions and, therefore, you cannot decide on the kind of programs you will fund with federal grant money.
Assuming that we are able to skip point 2 because the legislative work is proceeding, you can determine, for each kind of program, the performance outcomes, and the evaluation measures for local public health services in terms of their through-put, their impact, their costs and their quality of service. If it is restaurant inspection, that should be pretty straightforward because it is a concrete activity. Ontario has done this, although you would probably want to review the evidence base for each of its mandatory programs because they did not have a great deal of scientific, high- level input when they created them with committees of practitioners. All of this will require a mixture of professional work groups, research input, many NGOs, including professional organizations such as those you heard from this afternoon. It is a task that could take one year to do a good job of it.
Luckily, others around the world have amassed the 10,000 to 20,000 scientific papers of reasonable quality that justify most public health core programs. The Americans are spending millions of dollars on it; there is no reason for us to reinvent the wheel.
That takes us to the last bullet on the second last slide: ``Earmarked budget allocations and grants system for public health.'' I side with the Naylor group in concluding that local, provincial and territorial governments are best induced to provide evidence-based programs with money and that the money is to be contingent upon having the program meet evidence-based criteria for content and evaluation. That is why the working groups who set up the core programs must also include the evaluation criteria; otherwise, you cannot write the terms and conditions of the grants.
The new agency is the granting body. You set something up that is not so onerous that poor public health professionals in some rural unit cannot obtain the grant money. You do not want it set up such that the grants are as difficult to obtain as CIHR grants, for example. This is a different kind of grant. However, you do ensure that people get feedback when they do not propose to use evidence-based programming. You do not want them rounding up the fat kids when that is not the way to make an impact on that public health problem. You can also hope that they have had sound advice from local public health professionals or community groups that want to work on the problem and that they are working on it with local public health professionals.
At the top of the next slide, ``Workforce planning and development,'' I state that it must start in parallel. I will not be as polite as the last group. We have dismally failed 90 per cent of the public health workforce — the nurses — in Canada. They did not receive a minimal master's in public health, MPH, level of training. My guesstimate, from being in the field and training people for 20 years in Canada, mostly at the University of Toronto where I ran the largest master's-level program in public health in Canada during the 1980s, is that I would be surprised if 10 per cent of the alleged 12,000 public health nurses in Canada have appropriate public health training in basics at the master's level. Some of them have a master's degree, but not appropriate to public health. They have had to obtain that degree because they were barred from entry because they did not have the right undergraduate degrees. We have all been complicit in this process. We have to ramp up and provide rapid training programs, for which there are good ideas in the Naylor report. You could induce the universities to do this by that wonderful same inducer that we just described for the provinces and territories — that is, money, which is the only thing that will induce universities to do anything, in my experience. That is crucial. Some challenges are outlined well in the Naylor report in respect of physicians, nutritionists and physical education specialists as well. They are all crucial.
Those are the elements that I wanted to emphasize as the first steps.
The Chairman: That is terrific. I cannot resist reminding all of us that the persuader, the inducer — money — was exactly how medicare began. The provinces were offered 50-cent dollars by the federal government, and they could not say no. As some of you will recall, Nova Scotia and Ontario did not buy in during that first year because they were annoyed and did not think they could afford it, although the political pressure from constituents to take the 50-cent bribe was very high.
Senator Morin: I compliment Dr. Frank on his paper in ``The Canadian Journal of Public Health,'' in which he congratulates the authors and Senator Kirby. This committee's work has been noted in a scientific paper and we are hopeful that it will not be lost in the debate.
I am not surprised that Dr. Frank finds this report so remarkable, because he is talking about his boss, Dr. Naylor. We will be certain to tell him that when we see him tomorrow.
For the purpose of those writing the report, could you expand on the influence of the preparedness consortium? I understand this will be the first step for the coming winter. If we decide to include this in our report, we will need the appropriate terms for our wording.
Dr. Frank: I should be pretty modest and say that I no longer work in infectious disease epidemiology; I am not part of the control apparatus. I run the national funding Institute in Population and Public Health Research, so I will not be able to give you everything you require for your report.
Senator Morin: Could you provide us with the exact name?
Dr. Frank: This is not my field and our organization is not involved in that. I am the wrong person to ask, to be honest with you.
Senator Morin: You recommend that we should, in the short term, ensure that this exists and is expanded for any problems that may occur this coming winter. Is that your point?
Dr. Frank: Yes. I would suggest that you search out the five or 10 scientists in Canada who are actually experts in surveillance system design and evaluation.
Senator Morin: I understand that this pandemic influenza organization already exists in Canada.
Dr. Frank: Yes. I think you need to be aware that systems of influenza and other disease surveillance have strengths and weaknesses. You need a mixture of systems because some are slow but valid, and others are less valid but fast. If you do not have a creative mix of surveillance, then you will not have early warnings, which are not very reliable, and later warnings, which are very reliable. You need both early and late warnings.
Senator Morin: My second question deals with research. I know that you are head of the IPPH at the Canadian Institutes of Health Research, CIHR. I note in the Naylor report that there is not adequate basic, fundamental research at Health Canada. How do you see this in parallel with CIHR? The same people, more or less, are involved and funded by the agency and by CIHR for the same research. How do you interpret this? You may be critical of Dr. Naylor.
Dr. Frank: I do not think the Naylor report details a way to foster increased capacity for high-quality research in public health. There are a number of hurdles. One is that you cannot do this by simply giving out grants to university and hospital-institute-based researchers, which is, after all, what CIHR does. CIHR's hands are tied. It cannot, for example, give grants directly to Health Canada scientists. It does so when they have a separate university appointment and are part of a team, but there are many constraints. You need to accept that the capacity in Canada's universities — the hospital institutes, of course, are almost irrelevant to this — to do applied public health research has deteriorated steadily. It was never strong in Canada, but it is minimal now.
We have no schools of public health, so the majority of people are doing academic work in departments within medical schools across the country, such as the Department of Public Health Sciences at the University of Toronto. They are not working collaboratively with public health units. There is no money and no staff for that in public health units. In the 1980s, I was involved in many projects with the public health unit in Toronto to investigate outbreaks and write them up. All those things have disappeared, along with the decline of the teaching health unit — but I will not delve deeper into that now.
Those structures have to be rebuilt, but in the interim you have to build in-house intramural capacity in this new agency. You cannot ramp up people who know about public health in the universities fast enough because there just are not enough of them. You have to take people who have done fieldwork and upgrade their research skills.
Many of them are hungry for it and they would love to analyze some of the data from the SARS outbreak but they have not received the training to do it, as I said earlier. There will be an important role for the CIHR to fund research in the usual way. My institute is committed and has already built bridges between academia and the field, so that we have more partnered — collaborative — activities.
Currently, the field is so dismally weak in its research capacity throughout English Canada — it is quite a bit better in Quebec — that they cannot even collaborate on a grant. Most of them do not write grants; they do not know how to write grants; they do not have time to write grants; and they do not have time to even turn around. Their budgets are cut each year in real dollar terms. Until we fix that, you cannot have integrated applied research that links public health practice to research strengths in the universities.
Senator LeBreton: I will take the bait on a question that you threw out when you talked about one world and no borders. You then talked about your own experience in epidemiology in tropical diseases back in the 1980s. You said that you did not stay in that field and moved on to another field.
If we are into one world, no borders, what happened in our system that would discourage someone like you enough that you would leave an area of work where, obviously, an emerging illness, disease or even biological warfare was merely an airplane of passengers away? How did that happen? How should we fix it? Obviously, this area should have been growing instead of diminishing.
Dr. Frank: The answer is disarmingly simple: the same lack of infrastructure that could use the research that a person produced. If there is no infrastructure to use the research, a person such as an applied researcher loses heart. In other words, publishing papers, which I did in the 1980s in infectious disease and other forms of epidemiology to influence public health practice, fell on deaf ears. As I have already told you, less than 10 per cent of the staff in public health units across the country were able to critically read a scientific paper or were able to find the time to do so. There was no investment in the action arm of public health practice to keep it up to date, provide it with continuing education. People out there were trained 30 or 40 years earlier and did not know even how to do a chi square. How were they to understand my papers about logistic regression? I realized that the gap was hopeless and I may as well move into a field where there was at least a serious effort to apply research to the problems of workplace health. The money for that was coming from the insurer — worker's compensation public insurers — because they knew they needed some advice to fix the problem. You can see how the circularity creates a lack of incentive to go into a field, for applied people.
Senator LeBreton: If we had had a centre for disease control that could actually take information, they would have valued your work in such a structure. What do we do now that we are in this situation and we require this? Do we piggy-back on other world organizations under the theory of the world has no borders? Should we try to reconstruct a system? Other witnesses talked about SARS in November 2002 that did not come to the public attention until March 2003. That is a scary thought. How many other illnesses are out there like a ship lurking offshore with no captain?
In the perfect world where you would be able to correct the situation, what would you do?
Dr. Frank: You have no choice. You have to create an agency that has admirable and desirable career trajectories, just as the Naylor report recommends. I will have a hard time convincing a certain brilliant young Canadian working on his doctorate in informatics, having already attained his master's in epidemiology, to return to Canada. He is a specialist in surveillance and modern software for detecting new patterns of illness or injury in gigantic, routinely collected health insurance databases. How can I get him to return to Canada if the only job available to him is getting grants and writing papers in a university department with no receptor node in an agency that can actually make things happen in the system? How could he want to work in the public health system when many of the jobs in the health branch would be supervised by someone without his level of scientific expertise?
If you work in any of the public health unit positions, you can be fired any time the board disagrees with you. So, you move down the road to the next health unit and start from scratch with the usual gang of 30 to 50 nurses, one nutritionist, four inspectors, three administrators and one person with a master's degree. That is not a career ladder and is not a system. To bring someone with such expertise back to the system, we need to tell him that we need him and that we will provide him with a system in which his research will be put to use to improve the health of Canadians. There must be some serious infrastructure and an agency such as that could provide that infrastructure.
Senator LeBreton: That is an extremely compelling answer. Thank you for that.
Senator Keon: If one were simply to implement the recommendations of Dr. Naylor's report, that would be close to achieving what everyone has been advocating for a long time. There is no question about that.
However, there are a couple of areas where they may have lapsed back to what went on rather than what should go on. Under 12B.11, ``Clinical and Local Public Health Issues,'' of the report, it states, in part, the following:
The CEOs of hospitals and health regions should ensure that there is a formal Regional Infectious Disease Network.
Further on, the report continues as follows:
The CEO of each hospital or health region should ensure that each hospital's protocol for outbreak management incorporates an understanding of the hospital's interrelationships with local and provincial public health authorities.
And that is fine, because they should do that.
In reality, those of us in hospitals when the disease broke out were receiving information from half a dozen places, and no one seemed to be in charge. In respect of the implementation of the ultimate plan and who determines that, Dr. Naylor's report is close and should be supported. We do not need to reinvent the wheel; the ultimate plan has to come from the top. What do you think? I do not think we can depend on goodwill and someone not stepping on someone else's toes.
Dr. Frank: I think you are right. It is widely acknowledged in public health, but uncomfortable to say in public, that the closer you are to a catastrophic emergency the closer you need to be to military chains of command.
You also need to ensure that the people at the top are highly trained and have access to superb advice; there is no question about that. That is the proposal for the chief public health officer of Canada.
However, you have to give that person emergency powers, which were discussed by the CMA, that would allow the individual to do what has been determined in collaboration with advisors, that which is necessary in an extreme circumstance. If the hospital's board objected, then that would be too bad for the board. It is not a popular concept, but I think it is the right one.
Senator Cordy: It has been an interesting dialogue this afternoon. One of my questions concerns vaccination for the control of infectious diseases. You have listed that as a success story of our efforts. Have we become a bit complacent about vaccination? I used to teach elementary school, and many years ago, to gain entry to schools in Nova Scotia, a student had to be vaccinated. Parents had to prove that their children had been vaccinated before they could enter the classroom. Now, however, you may choose to vaccinate or to not vaccinate you children. The schools accept students either way.
For a long time before SARS, we had not had such outbreaks. Has society become complacent in respect of inoculations?
Dr. Frank: I want to distinguish two things: We need to be able to count precisely, and know which ones they are, those children who are not fully vaccinated. We need to do that long before they go to primary school, for the reason I have given. When a measles outbreaks occurs, you need to find them and tell the parents so the they can do the right thing, concerning the cases of those diseases that are directly transmitted.
You may not be aware that no court in the Western World has upheld the state's right to require vaccinations in order to gain entry to schools. However, it is the right of the parents or guardians to have a fully informed, consent- based waiver for religious, medical or conscientious reasons. We explain to people that, because of that status, which is their right, their child will be sent home immediately if there is indication of an outbreak in the environment of the disease against which the child is not vaccinated, such as measles. This has a two-fold effect. First, it provides a mild disincentive; however, more important, it helps to stop the outbreak because the kids who can transmit the disease efficiently are being sent home. That is the way in which we now have to handle these situations.
You have caused me to remember something I did not say, but as an experienced teacher you could corroborate this. There is a problem in the population. Our culture has an increasing minority of people who, for reasons that are not too scientific but are aided and abetted by an enormous amount of non-scientific materials emanating from the United States, almost entirely, believe that vaccines are harmful. They believe that vaccines cause autoimmune disease, which is not true. These people are quite strong in their beliefs and many of them have advanced education. We are doing nothing thoughtful about this in the sense of trying to have an open dialogue with them so that they could at least understand that the tetanus toxoid is not in the same category as a live viral vaccine. It would be important to at least reduce their children's liability, somewhat.
That is an important new problem and it fits with your concerns. It is one area that a good public health system would remain on top of and it is a great reason to make the investment.
Senator Cordy: Dr. Frank, you talked about youth obesity. We have done a great job with some things through the combined efforts of the health care and education systems. Anti-smoking comes to mind as a big one, but obesity is a tough one. I used to notice that many of the kids who most needed the exercise brought notes from their parents every day physical education was on their schedule, to be excused from that class. It is a catch-22 situation, in that they did not want to go to gym class because they could not do it.
My next comment deals with a comment from a previous witness, Mr. Rob Calnan, who said that infection control practices are not necessarily what they have been. Senator Keon said that the rate of infection went down during the SARS crisis. What do we do?
You talked about the training of public health practitioners in general things such as hand-washing machines for cleanliness outside the rooms, or for masks, if need be, or even for the isolation of patients who may have infectious diseases. Do we need to return to the area of training to reinforce those kinds of skills within health care individuals and practitioners?
Dr. Frank: As you may be aware, a large report by the Institute of Medicine in the United States looked carefully at how we reduce injuries to patients because of bad care. We are doing a study in Canada to estimate the rates of so- called ``care-caused'' injury and illness. That report pointed out that you must be sophisticated about the systems required given that to err is human. You cannot expect error-free practice, and this is only one aspect of that. There is always room for improvement in the area of infection control, but doing so is much more than simply educating practitioners. You must have reminder systems in place and extremely accessible and pleasant-to-use washing facilities. You must have incentives and a cultural shift to achieve that. It is no different from preventing medication errors. It is all about the same thing. It is actually the entire field of occupational health and safety, if you want my opinion. It is no different than wanting to prevent accidents in a factory. It is a big, multi-pronged package of elements, and education is one part but not the most important part.
We either get serious about this or else. Dr. Keon's wonderful story illustrates that we could do better. Somehow, people had the fear of God in them and behaved differently, resulting in benefits. We may not have the benefit of the fear of God each day, but let us determine what we could get that would be humane and effective.
The Chairman: I have one last question that senators have been debating around the table. I will arbitrarily pick the number of $200 million, which equates the number in grants and contributions the Population and Public Health Branch now gives.
That money goes to an amazing total number of organizations. There is no recipient over $4 million or $5 million, but there are many under $1 million. From the point of view of maximizing the impact on the health of Canadians, if you had $200 million, would you focus that amount on continuing the current strategy of small bits and pieces to many people or would you focus the amount on one, two or three major issues, thereby allocating the resources in a much more macro way to a limited number of targets?
Dr. Frank: That is a great question. Let us assume for a minute that we will not have other monies in the short run. I do not think you can give out monies in a way that is fundamentally to keep political peace.
The Chairman: We can give out money in such a way, and we do just that.
Dr. Frank: I do not think we can continue to do it.
The Chairman: We should not do that.
Dr. Frank: That is correct, especially when the basic public health core services and programs are in tatters and completely inadequate in much of the country geographically. Let us get that list of core programs that we know, from the literature, are effective when properly executed. Let us use most of the money to put those in place first and then determine what is left over.
Some interventions require community organizations and NGOs so that they will work. A good example of that is the after-school activity program for teens. Now, I am not suggesting that government should do it all; we need to partner. However, if we dribble bits of money to everyone who asks, just to keep them quiet, that is not strategic, because no one would be minding the store around the core of public health services.
The Chairman: I understand the political difficulty of doing it, but the reality is such that my investigations have shown that the money is spent on keeping many people happy, comfortable or off our back; the spending is not strategic.
Dr. Frank: I have not looked at it, but it sounds like what I would expect.
The Chairman: You would be stunned if the spending were the other way around. Thank you, Dr. Frank, for appearing this evening.
Dr. Frank: Good luck with your deliberations.
The committee adjourned.