Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 26 - Exhibit 5900-S2-SS-5-9-2, Transcript of Fact-finding meeting
OTTAWA, Wednesday, September 24, 2003
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:00 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.
[English]
The Chairman: Today we will continue our study of the infrastructure and governance of the public health system with a particular focus on infectious disease epidemics. Our witnesses today are from the Canadian Food Inspection Agency and from Health Canada.
Consistent with our usual procedure, we will begin with both sets of witnesses making their presentations, after which we will have questions from the committee.
Before you proceed with your presentation, Dr. Plummer, please explain the word "zoonose," in respect of Mr. Karmali's laboratory focus.
Mr. Frank Plummer, Scientific Director, National Microbiology Laboratory, Health Canada: I would like to introduce Dr. Mohamed Karmali who is the Director for Foodborne Zoonoses in Guelph, Ontario, a sister lab to the national microbiology lab at Health Canada. Zoonotic diseases spread from animals to humans. That is why it is so relevant to have the Canadian Food Inspection Agency, CFIA, and Health Canada appear before the committee together. Many emerging infectious diseases, such as West Nile virus, Severe Acute Respiratory Syndrome, SARS, Bovine Spongiform Encephalopathy, BSE, and variant CreutzfeldtJakob Disease, vCJD, are zoonotics they pass from animals to humans.
The Chairman: Are you based in Winnipeg?
Mr. Plummer: Yes I am, but I am also in charge of a directorate in Ottawa.
The Chairman: Your microbiology lab is commonly referred to as "the Winnipeg lab" by the media. Is that correct?
Mr. Plummer: That is correct. Senators should have before them a copy of the material that I will speak to today. I will try to pick up on comments that my colleagues from the public health branch made last week when they testified before you.
The public health system is the totality of the organized efforts that a society puts in place to protect and promote the health of the population. The system is focused on the health of the population rather than on the health of individuals.
It is a complex system that crosses many different government departments and many jurisdictions. Public health systems are, obviously, interdependent and only as strong as the weakest link.
Laboratories constitute a key resource in the infectious disease component of the public health system. They also play a lesser role in the public health of chronic diseases. Laboratories contribute to the public health system by the diagnosis of infectious disease reference microbiology and quality assurance, or crosschecking each other's results. Laboratories provide support to epidemiological surveillance and epidemic investigation. There is almost no infectious disease surveillance that does not involve a lab test at some time.
Laboratories are also key in surveillance systems. We have a key role to play in preparedness for biological threats such as bio-terrorism, BSE, West Nile virus, et cetera. We do applied and fundamental research and development, particularly on diagnostic tests. We play a key role in international linkages to other laboratories around the world. Increasingly, at Health Canada, we are trying to develop strong links with universities to enhance research.
In order to effectively respond to emergencies, laboratories need a strong foundation for daytoday operations the infrastructure, the people, the facilities and the equipment and strong linkages to other laboratories in other public health organizations. It is important to note that there needs to be integration between laboratory science and epidemiological and public health sciences so that can happen. One without the other integration would not be sufficient.
In Canada there are generally four levels of laboratories. Local and hospital laboratories provide patient testing and receive test materials from doctors.
Provincial public health laboratories are in all provinces except New Brunswick, where two different hospital laboratories deliver that function. Provincial facilities function as reference labs for the local labs within their jurisdictions. They do some primary diagnoses, often for viral diseases, and they provide some national services as part of national networks. However, they have a relatively limited role in research and development. That capacity has been eroded over the years.
At the national level, laboratories for infectious diseases are primarily based within the population of the public health branch. We provide multiple functions and have advanced scientific testing capacity that is generally more sophisticated than that available in provincial laboratories.
At the national level, we are involved in a number of different international laboratory networks that are key in respect of our response to infectious disease threats. For instance, the Winnipeg lab is a member of the CDCled Laboratory Response Network in the United States. We are also currently chairing two important groups: the international high security laboratory network and the laboratory network of the G7 countries in Mexico called the Global Health Security Network. Within that system, research laboratories based in academic institutions supplement the research done in government labs on behalf of public health.
On page 6 you will see the list of Population and Public Health Branch, Health Canada, labs for Canada. They are: the National Microbiology Laboratory, NML, in Winnipeg; the Laboratory for Foodborne Zoonoses, LFZ, in Guelph, Ontario, in Saint-Hyacinth, Quebec, and in Lethbridge, Alberta; and the National Laboratory for HIV and Retroviruses in Ottawa. Overall, these PPHB labs have a staff of 330, about 50 of whom are medical, veterinary or Ph.Dtrained scientists. They have a combined budget of $23 million for the current fiscal year and receive an additionl $9 million in external funding from a variety of resources, including the CIHR.
The Chairman: I was under the impression that there was a lab facility in Vancouver.
Mr. Plummer: There are Health Canada laboratories in Vancouver. There is also the B.C. Centre for Disease Control. The Province of British Columbia runs a combined epidemiology-laboratory program.
The Chairman: The B.C. Centre for Disease Control is a provinciallyowned facility.
Mr. Plummer: Yes.
Senator Callbeck: What about Nova Scotia?
Mr. Plummer: There are no Health Canada lab facilities in Halifax, although a provincial laboratory is in the Queen Elizabeth Hospital. It is a combined hospitalprovincial laboratory.
On page 7 we deal with the National Microbiology Laboratory located in the Canadian Science Centre for Human and Animal Health in Winnipeg. We cohabit the building with our colleagues from the National Centre for Foreign Animal Diseases, which is a CFIA lab. Our functions are surveillance and epidemic investigation. We run a number of important research programs. We have a training program for scientists, of which we are proud. We have a training grant from the Canadian Institutes of Health Research for graduate students that is matched by the Province of Manitoba and totals approximately $.5 million per year, for student salaries alone. We currently have 30 graduate students, or postdoctoral fellows, in our training programs. We also have a number of important international activities, some formal and many informal linkages.
On slide eight we have listed some of the features of the National Microbiology Laboratory, NML. We have the only health bio-safety lab in the country, but it is not correct to say that it is the only level four bio-safety lab in the country, because Dr. Kitching has one at the National Centre for Foreign Animal Diseases.
The National Microbiology Laboratory is designed to accommodate the most basic and most deadly infectious agents in the world. Another key function of the National Microbiology Laboratory is to provide the secretariat for a national network of public health laboratories. Over the last two years, we established the Canadian Public Health Laboratory Network, which is a new structure, to try to get provincial and federal laboratories working together in concert collaboratively to solve collective problems.
I would also mention that, in addition to the activities that are based in Winnipeg, the National Microbiology Laboratory also funds provincial laboratories to develop expertise in certain areas. For instance, most of the work for streptococcal diseases is done at the Alberta provincial laboratory.
I will turn to slide 10 to talk about the Laboratory for Foodborne Zoonoses. This lab, directed by Mr. Karmali, was originally part of Agriculture Canada and came to Health Canada in 1996. Its main focus of activities is on bacteria such as E. coli, campylobacter and salmonella, which arise from food animals and cause gastrointestinal illness in humans. They have excellent links with McMaster University and the University of Guelph, and are colocated with the University of Guelph. Their satellite labs in Saint-Hyacinthe and Lethbridge have developed relationships with the universities of Montreal and Calgary. It works closely with the Food Inspection Agency and Agriculture and AgriFoods Canada.
We are making efforts within Health Canada to integrate the different laboratory activities and all infectious disease activities through the Infectious Disease Program Steering Committee.
The LFZ program areas include integrated enteric pathogen surveillance, research on population and environmental determinants of foodborne zoonoses, the microbial and host determinants of disease, as well significant work on antimicrobial resistance, health risk modeling, and food safety policy research.
How do Canadian laboratories compare to international labs? In some areas we compare extremely well. In at least a couple of areas at the national level, our laboratories are as good or better than those elsewhere. On average, particularly with the National Microbiology Laboratory, we have greater basic science strength than most public health laboratories around the world. Between what we are doing in Winnipeg and what we are doing in Guelph, I think we are better integrated with research universities than would be the case in most other countries.
We do have some world class and unique resources. Specifically, I would mention the Canadian Science Centre for Human and Animal Health in Winnipeg. It cost the Government of Canada about $180 million to build, and its replacement value, according to the architects, would currently be about $500 million.
In the past, the laboratory system in Health Canada suffered from poor integration with epidemiology and surveillance. I mentioned at the outset that that is key in being able to respond effectively. Since the reorganization of Health Canada in 2000, a major goal within the PPHB has been integration. It is significant, I think, that I am now the director general of the Centre for Infectious Disease Prevention and Control in Ottawa, as well as the head of the lab at Winnipeg, which allows that integration to occur.
We do have some significant challenges. Our labbased surveillance systems lag significantly behind those of the U.S. There are possibilities for real time electronic surveillance based out of labs, such as the U.S. system, PulseNet. We have been trying to put that in place for several years and are getting closer, but it is taking longer than I would have liked.
I would now ask Mr. Karmali for comments.
Senator Morin: Mr. Plummer, what is your other title, apart from being director of the Winnipeg lab?
Mr. Plummer: I am scientific director of the Winnipeg lab and director general of the Centre for Infectious Disease Prevention and Control in Ottawa.
Senator Morin: This would imply surveillance and so forth.
Mr. Plummer: Epidemiology surveillance.
The Chairman: Mr. Karmali, is there anything you would like to add?
Mr. Mohamed Karmali, Director General, Laboratory for Foodborne Zoonoses, Population and Public Health Branch, Health Canada: Compared to the almost $150 million budget that Mr. Plummer controls, my program has a budget of $5 million. I should be regarded as, perhaps, the Prince Edward Island population in the public health branch.
Mr. Plummer rightly pointed out the frontline work that the Winnipeg lab does in terms of controlling outbreaks and epidemics. Our psyche has been shaped a bit by the recent SARS epidemic, so we tend to focus on emergency control, and so on. After we have put out the flames, however, and dealt with the aftermath, we must ask questions such as: Where did this epidemic originate? What caused it to arise? How can we prevent it in the future?
While our program is not in the front lines dousing the flames, we are asking the critical questions of: How do some of these infections arise? Where do they come from? How can we prevent them in the future, and so on?
Since our work focuses mostly on zoonotic diseases that is, diseases transmitted from animals to humans we must, naturally, work closely with CFIA. We especially have close interactions with Ms. Bossé in CFIA.
I will stop there. I hope I have given you a perspective of how we fit into the scheme of things.
[Translation]
Ms. Judith Bossé, Vice-President, Science, Canadian Food Inspection Agency: Mr. Chairman, I would like to introduce Dr. Paul Kitching, Director of the National Centre for Foreign Animal Disease in Winnipeg. I want to thank you for the opportunity to appear before this committee and to outline the Agency's activities in the area of public health.
The mandate of the CFIA is to safeguard Canada's food supply and the plants and animals upon which safe food depends. The Agency is the key player in providing protection to the public from preventable health risks.
The CFIA contributes through programs and activities designed to identify and manage food safety risks, respond to food safety and animal disease emergencies, carry out emergency food recalls and prevent the spread of animal diseases to humans.
Integral to the CFIA delivering its mandate to Canadians are the application of sound science to Agency activities, the delivery of effective inspection services and the fostering of strong partnerships.
The Agency has extensive scientific expertise and close association with federal, provincial, university, international and other partners in areas such as risk assessment, surveillance, laboratory science and the development of science- based inspection strategies.
The Agency's national mandate, extensive laboratory network and inspection capacity allow the CFIA to act rapidly and effectively in the event of a threat to public safety or agri-food security. In addition, the CFIA's ongoing surveillance and emergency planning activities allow it to anticipate and prepare for potential problems before they occur.
[English]
Food safety risks managed by CFIA include foodborne pathogens such as salmonella and E. coli. In addition, the agency addresses existing and emerging public health threats from human infectious disease agents linked to animals. These include the socalled zoonotic diseases such as bovine tuberculosis, brucellosis, anthrax, rabies, bovine spongiform encephalopathy and others, which fall under the CFIA mandate as reportable diseases under the Health of Animals Act.
The CFIA is able to apply sound science to its mandated activities thanks, in large part, to the scientific expertise within its own laboratory system. The agency has laboratory facilities on some 21 sites across Canada. Scientific and technical experts in these facilities are engaged in a variety of activities related to CFIA's mandate that directly support the protection of public health, including laboratory testing services, research, methods development and the provision of scientific advice in support of food safety and animal health. For example, the CFIA is confirming human suspected cases of rabies.
[Translation]
Many CFIA laboratory facilities are designed to permit work with infectious animal disease agents posing high risk to humans. The National Centre for Foreign Animal Disease located at the Canadian Science Centre for Human and Animal Health in Winnipeg is co-located with Health Canada's National Microbiology Laboratory. This has fostered a close relationship between the CFIA and HC and has facilitated collaboration on testing and research for exotic zoonoses and emerging diseases.
Examples from the recent past include diseases such as SARS, West Nile Virus, Nipah virus, a disease that has struck in Asia, but not in Canada, BSE and avian influenza.
Currently a Memorandum of Understanding is being drawn up between HC and the CFIA to further strengthen this productive relationship for the benefit of public health in Canada.
Besides the NCFAD, there are high-level biocontainment facilities operated by the CFIA in each of the West, Ontario and Atlantic areas. These facilities are unique in Canada in that they are equipped to house and handle livestock infected with high risk, domestic zoonotic agents such as bovine tuberculosis and brucellosis. Biocontainment protects public health by allowing scientists to conduct research, testing and waste disposal in a safe manner.
Many of the CFIA facilities house Centres of Expertise recognized as World Reference Laboratories by the World Organization for Animal Health, for example, rabies, brucella and anthrax.
The CFIA has developed agreements with provincial agencies on the sharing of animal disease information. The Agency continues to develop management systems to enhance disease intelligence, implement targeted surveillance programs, and cooperate with Health Canada in evaluating human health implications.
The CFIA's extensive diagnostic capabilities and unique scientific expertise allow it to be a key contributor to the federal government's efforts to strengthen Canada's preparedness for, and response to, potential terrorist threats.
Agency expertise and resources are used to address biological threats to humans which may occur through the deliberate contamination of the environment, or food or water supplies. For example, the CFIA, in association with Health Canada and the National Research Council, and with funding from National Defence, leads in developing and evaluating new test methods for several high-threat zoonotic disease agents.
[English]
The CFIA, operating within the current governance framework in partnership with Health Canada and others, is well prepared to contribute within its mandate to the protection of public health in Canada. The agency and its partners are able to act rapidly and effectively in response to public health emergencies in Canada, whether caused by accidental or intentional events.
The CFIA continues to strive for better ways to improve the system. It is therefore pleased to be able to appear before the committee.
We look forward to the final report.
Dr. Paul Kitching, Director, Winnipeg Laboratory (Arlington), Canadian Food Inspection Agency: Thank you, I have nothing to add.
The Chairman: We have a minor technical problem. Technically, under our rules a committee of the Senate is not supposed to sit when the Senate is sitting unless it has received permission. Senator LeBreton and I, the Chair and cochair, were told by our respective house leaders that permission would be granted, which is why we embarked upon this meeting. Apparently, an independent senator objected, so the committee was not granted permission to sit.
The evidence is on the record. I suggest that, at this point, we continue but not as an official committee meeting. We will simply continue, as we are allowed to do, as a group of senators having a meeting with a group of people who have been kind enough to come in from out of town.
In that sense, the official committee meeting has stopped, and we will, therefore, go into an unofficial committee meeting. We will continue to ask questions and have translation as we usually do.
Senator Morin: Will we have reporting?
The Chairman: I am looking at the clerk, but we probably will not be able to continue with Hansard. You understand our dilemma. We have stretched the rule as far as we can.
In fairness, both Senator LeBreton did not think that this was an issue but, under the circumstances, we cannot blatantly go against the rules.
Senator Morin: Do we know how long the Senate will sit?
The Chairman: It will be a long session tonight.
Senator Morin: Will someone be taking notes?
The Chairman: We will do that.
Senator Morin: I expect it to be taken verbatim.
The Chairman: You people have been around long enough to understand that it is a good thing we are not running a business?
Senator LeBreton: Dr. Plummer, I would like you to take us through the process that you and your people went through when we had the SARS outbreak in Canada. How did you find out about it? What processes did you go through to try to control it, and what cooperation did you receive from the Centre for Disease Control in Atlanta and the World Health Organization? I know this is a multifaceted question. I believe the outbreak started in China. It took some time for them to admit that they had an epidemic there. How did you get control of it, and how long did it take before you gathered all the information that was required to kind of get a handle on it?
Mr. Plummer: Just for clarification, are you talking about from a laboratory perspective or a Health Canada perspective?
Senator LeBreton: I suppose from both.
The Chairman: I am not being critical when I say this, but the fact that you wear two hats is immaterial to us. We are interested in trying to understand what happened. Since you are in charge of epidemiology and surveillance, I assume at some point it fell on your desk.
Mr. Plummer: Correct. Putting together what happened takes us back to November of 2002 when there were rumours out of China about a severe respiratory illness and a lot of information suggesting it was influenza or chlamydia. It was quite unclear.
In February 2003 there began to be more substantive reports of a severe respiratory illness of uncertain etiology and, in mid-February, Health Canada sent out alerts to its provincial partners about this illness. On March 12 or 13 the World Health Organization issued its first alert about severe acute respiratory syndrome. It was clear at that point that this was probably not influenza or some other known agent, and that it was severe. Health Canada sent out an alert across the country within a few hours of receiving the WHO alert, but, by that time, we had already had eight cases in the country. There were seven cases in Toronto and one in Vancouver.
I followed these alerts, but we first learned that there were cases in Canada on Friday, March 14. It so happened that I was at a meeting of the Canadian Public Health Laboratory Network, a meeting between ourselves at the National Epidemiology Laboratory and provincial lab directors when I was called away to an urgent conference call when I learned of this problem. It was fortunate that it was Friday and not Saturday and we were able to call back to the lab in Winnipeg, ask people to come in the following day and begin to order things that we thought we might need to control this epidemic.
We first received specimens from Toronto and Vancouver on Saturday morning. We worked through the weekend, around the clock and, by late Sunday, early Monday we knew that this was not something we had dealt with before. We ruled out virtually all the known respiratory virus agents, and then we began work on trying to understand what was causing this.
The other parts of Health Canada were working with the provinces to understand what was going on, to try to provide them assistance in terms of epidemiology. Managing an epidemic is always a provincial or local matter. At the federal level you can only supplement what is happening. Health Canada could not, from both a jurisdictional and practical point of view, send a team into Toronto to manage the whole epidemic. It just would not work. We would not know who to call, how the systems worked, et cetera.
What we can do from a federal level is manage the national dimensions, and that was done through something called the pandemic influenza committee. It is a federal-provincial group that has been working for several years to plan for pandemic influenza, and that structure was used to respond to SARS. For the most part, at the federal level, it worked fairly well.
The other aspect at the national level was managing interactions with the World Health Organization and the CDC. There are a number of different points of contact. I was part of the laboratory network that the World Health Organization pulled together, that included laboratories in affected countries, plus some other laboratories. That was a key factor in making rapid advances in the science. This was an unknown agent on March 14 and by April 14 we had the whole genome of the virus sequenced, so there was some pretty amazing progress.
Have I answered the question yet?
Senator LeBreton: You talked about the rapid advances you made. Were you just fortunate in your research? Did you have some sense that it had originated in China in November of 2002? Rather than considering all possibilities, did you focus on a certain specific area that led you to get the information so quickly?
Mr. Plummer: No. In the laboratory, we use some standard, old, tried and true techniques, from a biological point of view. We also use some sophisticated, cutting-edge and state-of-the-art types of approaches. It turned out that this was a pretty easy virus to grow. It just grew in tissue culture, which is a standard technique.
The people in Hong Kong found it first, then the CDC was next, and we found it about a day or so after them. Having in place the scientific capacities to be able to deal with that situation was important. The laboratory was well prepared.
Senator LeBreton: Did the three of you find it independently or were you sharing information?
Mr. Plummer: We were sharing information, but the answer to that is it was both.
The Chairman: May I ask a follow-up question which troubles me, Dr. Plummer? I am not being critical. I am trying to understand the process.
I do not care whether it is a health crisis or military or business crisis, in any crisis you must have one person in charge. A crisis cannot be managed by a body of people because, in the end, you have to short-circuit normal decision- making processes, and intergovernmental processes are very complicated. You must be able to short-circuit the process and have somebody in a position where he or she can call the shots. Obviously, there would be a group of advisors, but somebody has to be in charge.
As I listened to you, I was not at all sure that any one person was in charge. Correct me if I am wrong on the impression I have that, on the research side, you and your colleagues across the country and around the world were working on this problem. As well, somebody in Toronto was trying to decide how to handle the situation on the ground, so to speak. Is my impression correct?
Would you agree that somebody has to be in charge, that somebody has to decide what the researchers are going to do, how the various players will coordinate their efforts and so on?
From my experience, traditional intergovernmental coordinating mechanisms are an unmitigated disaster. How would you get around that?
Mr. Plummer: I would agree with you completely that command and control are very important in managing crises. Clearly there must be leadership. Normal structures and normal ways of working together are ineffective in a crisis, so you must alter them.
That is a lesson that we took from the early days of SARS. Within the national microbiological laboratory we collapsed the bureaucracy completely and I was selected to be the leader. That also happened within the population of the Public Health Branch and within Health Canada. The normal structures were wiped out and new procedures put in place.
The Chairman: Dr. Gully I believe was probably the head person.
Mr. Plummer: Mr. Broughton and Dr. Gully. I am not sure to what extent that happened in Ontario. When you have our major city with a tremendous epidemic, the challenge becomes, how do you handle that. I do not have an answer. It is both a national problem and a local problem. There has to be local leadership and provincial leadership but there also needs to be national leadership.
The Chairman: You say you have a pandemic committee. Have they not addressed this question directly? To me it is a central question of management. Surely you cannot draw the conclusion that a committee will manage it when it involves three levels of government. For all the same reasons you collapsed the decision-making mechanisms within the laboratory system and within the department, surely the same thing has to happen in this kind of situation. I am not arguing that the commander in chief needs to be from the federal government. I am only arguing that it has got to be somebody.
Mr. Plummer: I completely agree with that. I think an epidemic has to be managed at the lowest level possible within the different tiers of government. I could not from Winnipeg manage the epidemic in Toronto. It would not be possible. It has to be done in Toronto. Other levels of government can supplement and help, particularly the federal level.
The Chairman: We will probably want to come back on that. If at any time any of you want to pitch in to either help Dr. Plummer or to tell me you have a different view, feel perfectly free to do so. This is designed to be a general discussion.
Senator Morin: We should look to the future. A door was opened and we, unfortunately, did not have all the information we wanted. It is very important for us to have all the information that is available.
Was there no federal presence in Toronto?
Mr. Plummer: Yes, there was a federal presence in Toronto.
Senator Morin: Were those people sitting in hotel rooms waiting for calls to come in?
Mr. Plummer: No, we seconded epidemiologists to the Province of Ontario and they were then deployed, first, at Toronto Public Health and later deployed at the Ministry of Health.
Senator Morin: As you know a number of criticisms were published. I can summarize them. It was said that there was a failure by officials to identify SARS clusters; an archaic paper-based tracking system; people at risk were not called; a complete lack of leadership; conflict; confusion; and a refusal of health ministries at both levels to share key information with the SARS centre. The ones I have cited were from an article in the Toronto Star.
The federal government has some of the expertise and does respond to some of these problems. The article deals mainly with provincial responsibilities but as you read it, you no mention of the supplementary roles that the federal government should have taken, especially in view of the pandemic nature of this disease. I believe there is an understanding among the provinces that the federal government should take a leadership role if there were an influenza pandemic equivalent. Is that correct?
Mr. Plummer: Yes, there is a federal leadership role in pandemic influenza but it is a leadership role regarding coordination. That is because pandemic influenza requires a multifaceted response. Much of the delivery will involve vaccinating people and dispensing drugs, and the federal government is not in a position to do that. You must have effective working relationships between different levels of government.
To come back to the SARS outbreak in Toronto, I think a large part of the problem was the interface between different levels of government, between different jurisdictions and between local public health and hospitals. Those connections did not work well.
Senator Morin: I think it is important is to look to the future.
My question concerns the number of lab scientists and epidemiologists, surveillance people, let us say, in the infectious field. Did I understand you to say that you had 50 persons or more in your lab?
Mr. Plummer: That includes Dr. Karmali was well.
Senator Morin: That would be 50 scientists. How many epidemiologists do you have?
Mr. Plummer: I have 12 medical epidemiologists and nine PhD. epidemiologists.
Senator Morin: That is a total of 21 epidemiologists.
Mr. Plummer: That is just within my centre for infectious disease control.
Senator Morin: I realize that. Do you think that combined number of 50 and 21 is sufficient? In a way we are lucky this happened in Toronto and not in Fredericton or a smaller city. I do not expect you to give me an exact number, but should we double it or should we increase it by, say, 10? Do we have sufficient number of scientists, experts within your branch, within your doctorate, to deal with another SARS outbreak or a new disease that could happen next year?
Mr. Plummer: The capacity within the Centre for Infectious Disease Prevention and Control was stretched to the limit to deal with SARS, which was an epidemic of some 400 cases. Having 21 epidemiologists with senior qualifications, to me, is obviously not enough. I do not know the appropriate number.
Senator Morin: Could you give us some idea? We would like to make concrete recommendations in our report. That is what we did in our last report and I think people appreciated it. If you cannot give us the answer today, perhaps you could send that information to us. It would assist us if you could be specific about the further resources you require. If we were to manage a further epidemic in the way we should, I think the resources should be federal because they can be mobilized. This is where the new resources should be, if we run into a problem next year.
Mr. Plummer: I would think that double the number of epidemiologists be needed.
Senator Morin: Are you satisfied with the number in the lab?
Mr. Plummer: No, I am not satisfied, but I think there is less of a problem there.
Senator Morin: Less of a problem with epidemiology. This would permit us to mobilize epidemiologists and send them to an area, if we had an epidemic of that type; is that fair?
Mr. Plummer: Yes, I think so.
Senator Morin: Are you in a position to mobilize provincial resources? Let us say that there were no cases in Quebec, is there any possibility of mobilizing the epidemiologists and transporting them to Toronto?
Do you know who these people are? Do you know where these resources are, and is it within your responsibility to ask for, say, five more epidemiologists from a certain location?
Mr. Plummer: No, it is not part of my immediate responsibility. This was done by Health Canada. Specifically, the office of nursing policy undertook that task.
Senator Morin: Did they have a data bank on that?
Mr. Plummer: I am not be the right person to comment on that. However, in response to the first part of your question, would doubling the number of people give us a capacity to better supplement what is happening at the provincial level in an epidemic, I would say that, yes, it would.
Work is also going on to set up health emergency and response teams. That is being done by the Centre for Emergency Preparedness Response. It is to put in place a reserve of individuals, health professionals who will be trained and organized into deployable teams that would be able to respond to many different kinds of health crises, including infectious disease crises. They would normally be employed as doctors, nurses and other types of health care professionals, but would be spread across the country.
The Chairman: In some sense, if I use the military analogy, they are part of the reserve.
Mr. Plummer: Yes.
Senator Morin: I should have started out by saying that our experts from Health Canada are world-renowned scientists. Dr. Plummer has done extraordinary work in the field of global health and AIDS, and AIDS in Africa; and Dr. Karmali is the one who made the very important discovery that Ecoli is viral toxigenic, which means that it affects the kidneys. That is the Ecoli in hamburger disease that is so toxic. Dr. Karmali made this discovery while he was working at the Hospital for Sick Children in Toronto. Both of you have experience in global health.
We are talking about the importance of increasing the efficiency and resources of our Canadian public health system to meet Canadian needs. If we increased our capacity and our resources in that field, would there be any consequence at the global, international level? I do not know if both of you deal with this.
Mr. Karmali: I will make a couple of observations. One is that microbes do not recognize national boundaries and so infectious diseases is an international global problem, and we do now live in a new world of globalization. Individual nation states will have to readjust their perspective on how they relate to this new global infectious disease challenge.
As to the discussions about coordinating national responses to infectious disease threats, it is critical to recognize that, unless we get our own house in order in Canada, we will not be able to play an effective role in the emerging global environment in infectious diseases.
The second observation is that Canada has played a prominent role internationally in peacekeeping, but peacekeeping is now becoming regionalized and Europe will look after its own backyard, Africa will look after its own back yard, and so on. However, in the area of public health, Canada probably has a very good opportunity to play an important role internationally. Obviously, the CDC in the U.S. is a dominant global centre, but not everybody likes the United States, and some people prefer to work with countries like Canada.
Apart from globalization, incredible changes are taking place in science and technology. If we are to prevent infectious diseases, we must understand the enemy a bit more, that is, these microbes, their lifestyles and preferences. Unfortunately, they speak neither English nor French, so they will not tell us whether they prefer an aisle seat or a window seat.
A change is taking place because now there is a universal code, which is the genome. Genomes are being sequenced. We all know about the human genome project and so on. With genomic development we will learn a lot more about the lifestyles of microbes and we will study better ways to control them.
Unfortunately advances in genomics will not happen overnight, nor will they happen without significant investment, especially in public health. The United States is probably the leader overall in genomics, but in the public health area, the British and the French are way ahead of everybody, especially the French at the Pasteur Institute.
I think that Canada should have a prominent place internationally in this area. We should not be seen as just dabblers but, rather, as significant players. However, that will require some thought and investment.
Those are just general observations. Dr. Plummer spent 20 years in Kenya, so he can probably talk a lot more than I can on global issues.
Mr. Plummer: I would just add that the front line in the battle against emerging infectious diseases is off our shores. We cannot protect our borders from the importation of these diseases. In the last couple of years, we have seen the introduction of the West Nile virus, SARS and BSE, major events that we have not been able to keep out.
The other part of the front line is our surveillance systems, whether those are food inspection, local public health or surveillance in hospitals. Those are the systems that we need to have in place, and they should be strong ones, to protect ourselves.
Senator Morin: I would apologize to Dr. Kitching. The only reason I did not quote his scientific accomplishments is out of ignorance. I am sure that if I had your CV, it would read as impressively as that of Dr. Plummer and Dr. Karmali.
The Chairman: May I go back on your constant reference, Dr. Plummer, to local resources; the people on the ground? There may well be a lot of people on the ground in Toronto. I would suspect that, if you come from Charlottetown where Senator Callbeck is from, or Halifax or many other places in this country, the local resources would range from nothing to meager. Tell me if I am wrong on that. When you talk about roughly doubling the number of epidemiologists, to be effective, would a number of those not have to be located in Ottawa or your lab in Winnipeg but in fact be located out in the field?
The sense I have is that, if something goes wrong in Toronto, we are probably bound to hear about it because there are a lot of good people there, but if something goes wrong in 90 per cent of the geographical area of this country, we will probably not hear about it. If one of the roles of the federal government, at least to fulfil its international responsibilities, is to be able to tell the rest of the world when we have a problem, do we not need an intelligence system on the ground with our federal people supplementing whatever it being done on the ground by others?
Mr. Plummer: I agree that we need capacity all across the country. It is not enough to have a strong lab in Winnipeg and a strong program in Ottawa or a few strong programs. We need capacity all across the country. I am not sure exactly how you provide that, but one way would be have federal resources, supplementing resources at the provincial and local levels.
The Chairman: Do you know of anybody who is considering doing that?
Mr. Plummer: I am not aware of any ongoing discussions about doing that. There are some things going on in certain limited areas. For instance, part of the HIV AIDS surveillance programme for the country involves field surveillance officers who are placed at the provincial level to collect surveillance data on HIV and AIDS.
The Chairman: Are they federal employees?
Mr. Plummer: Yes. They report to the HIV AIDS division, which reports to me.
The Chairman: There are federal employees scattered across the country.
Mr. Plummer: Yes.
The Chairman: To get back to the assumption that I made, which is that, in a number of smaller centres, you would not have the epidemiological support or other scientific support that you have in Toronto. Is that assumption correct?
Mr. Plummer: I am not an expert on that but I would think so, yes.
Senator Callbeck: Dr. Plummer, in your presentation at page 8 you talk about structure. A few years ago a technical advisory committee, made up of provincial laboratory directors and representatives of many other labs, used to meet and I understand that they all kept well informed. There was a formal structure. That was disbanded and I believe that caused some problems for smaller labs. Does this Canadian Public Health Laboratory Network take the place of the technical advisory committee?
Mr. Plummer: Yes, you are correct that, for a number of years, there was something called the technical advisory committee. Directors of the provincial laboratories were advisory to what is now the National Microbiology Laboratory. They they fulfilled an advisory role. The committee, prior to my coming to Health Canada, had become quite dysfunctional. Most provincial laboratory directors felt it was not working well.
In consultation with the provincial laboratory directors, we came up with the idea of a federal-provincial laboratory network, a table of equals that was chaired by the director of the provincial lab in Saskatchewan. We work together on common problems.
It is not necessarily the federal lab that does the spade work on a given issue. It may well be that a provincial laboratory takes the lead on developing the laboratory capacity in a given area. For instance, Alberta as I mentioned has a lead in the streptococcal area; British Columbia is taking a lead in food and water safety; and Halifax has until recently — or still has, but it is under negotiation — taken a lead in enteroviruses, so there have been a number of different leads.
Perhaps Dr. Karmali wants to comment on that.
Mr. Karmali: Yes, I do. It is probably difficult for Dr. Plummer to articulate this effectively, but the fact is that the technical advisory committee was incredibly dysfunctional, and it just fell into a mire of federal and provincial distrust.
The Canadian Public Health Laboratory Network, which is an incredible achievement, with credit to Dr. Plummer, has changed the climate. It works very well and I would say that, even though the chair is the provincial lab director of Saskatchewan, I would say the de facto leader, if not the de jure leader, is Dr. Plummer. He has been effective, in part, by channelling federal monies into the provincial labs, which are cash poor. As part of the downsizing of the health systems in the provinces they let the provincial laboratories go to some extent.
Dr. Plummer has been able to provide some infusion of cash to ensure that advanced equipment is present in all the provincial labs so that they can all talk the same language. That is a major accomplishment. In one form or another, this development could form the basis of whatever it is that we want to develop in the future, perhaps as a new agency or whatever.
Public health and microbes do not recognize national or even provincial boundaries, and if we are to have a strong national system that can complete internationally, the federal government has to play a strong role. It could be a nation-building role. Infusing funds at the federal level to play a leadership role at the provincial, regional and municipal levels is absolutely vital.
Senator Callbeck: How long has this been in existence?
Mr. Plummer: It is approximately two or two and a half years.
The Chairman: Dr. Karmali, you emphasized your desire for a federal leadership role. Can you detail that statement for me? If I asked you to tell me the two, three or five things that the feds ought to do that they are not doing now, what would be your response? By the way, if you do not have the answer off the top of your head, I would be quite happy to have you drop me a note on it.
One of the things that distinguished our report from the Romanow report is that our recommendations were concrete. I mean our recommendations included numbers and specific steps. We did not just refer to statements of principle. I view the statement that there should be strong federal leadership as a statement of principle. My question is: "All right, wise guy, what do I do now?"
Mr. Karmali: I can only talk in terms of principles. The fact is that, if we are to have a national enterprise as opposed to a provincial or regional one, the federal government is the only act in town. In that sense the federal government has to provide leadership.
Having said that, the head honcho of this new organization does not have to be a federal government employee. That can be dealt with in a number of ways. Unless the federal government is going to put money in for a national enterprise, I do not think it will happen.
Exactly what the structure of this entity should be is obviously open to debate. However, I feel very strongly that a component of this new structure must be the recognition that the nature of infectious diseases is changing, with new, emerging infectious diseases, infections crossing the border, globalization, advances in science and technology and so on.
One of the areas where I do not think we do a very good job, at least as well as we should, is in the area of public health research. Arguments have been made about how health has tremendous implications for our biotech industry and so on and so forth; and those are very valid arguments. However, I believe that we need a very strong public health research infrastructure because, ultimately, that is how we innovate to deal with infectious diseases. That will give us a stronger standing internationally. As well, the SARS epidemic showed us that there was an incredible impact on the economy in the Province of Ontario and Toronto. There can be a huge economic fallout if things are not orchestrated and, as far as I am concerned, research is fundamental to progress.
Universities do not have a mandate to do public health research. Since Dr. Plummer and I have come to Health Canada, we have tried to change the dynamics of research. I think the environment could be optimized into a virtual CIHR — a public health research infrastructure which could work in parallel or be part of CIHR. If we are to become important players internationally and get our act together nationally, if the federal government invested in a public health research infrastructure, that would be a good start in getting a national enterprise together.
As far as the operational side is concerned, I do not think that top-down management is the best way to do things. Yes, there are command and control issues, but what you need at a command and control level is a vision you must set down certain rules that people at a decentralized level follow, rather than having people at different decentralized levels making up their own rules so that the orchestra is not playing in tune. Someone at the federal level, or funded by the federal government, should be the conductor of the orchestra, if that gives you the concept.
The Chairman: That is a very good analogy, Dr. Plummer
Mr. Plummer: From my point of view, there are three ways you can lead. First you must have the authority to lead. That does not necessarily mean you have good leadership skills, but you have the authority, the law to provide leadership. We currently do not have that. Second, you can also provide leadership if you are the source of important information, knowledge or training. Third, you can provide leadership if you have money to get people to do what you want them to do. There are three possible ways of doing it. To have the authority to do it, I do not think we need change the laws in Canada. We are at the point where the federal government has that. I think we could build excellent systems where we do science that provides leadership so that other people follow. The third is financial.
The Chairman: Just to pick up on a point that Dr. Karmali mentioned, does CIHR currently fund any public health research?
Mr. Plummer: Yes, it does.
The Chairman: Does it fund much?
Mr. Plummer: More than the MRC did, but I do not think it is at the point where it is optimal yet. Some of that is about the absorptive capacity.
Senator Morin: We will be hearing the director of the institute of public health.
The Chairman: Dr. Plummer, can you send us a brief description of how the field officers in AIDS function? How do they coordinate with people in the provinces and municipalities, and how do they report to Ottawa? I do not need the answer now, but, if you have a description of how they function, I would appreciate it if you would send it to us.
Mr. Plummer: I do not have the answer now, but I will provide that to you. I will also provide some documents on the Canadian Public Health Laboratory Network.
Senator Robertson: A couple of concerns that automatically arise from this discussion. I come back to what Senator Kirby talked about, and that is the coordination of the resources that we have. What sort of cooperation and coordination is there among the federal agencies? Then, what sort of cooperation and coordination do those agencies have with the provincial agencies?
I do not know whether the constitutional responsibilities of health that the provinces have make this more difficult or not. I should like to know if real efforts have been made to achieve coordination, not only with the federal agencies but also with the provincial agencies.
You indicated to Senator Kirby that there was a problem in getting information. You told us that everyone wants to protect what they are doing, which is terribly destructive to progress. Could you make recommendations to us of how to get that cooperation? I do not know if the federal minister of health has discussed this at any great length with the provinces or not.
Coming from a small province it scares me to death to think how we would deal with an outbreak. I would also be concerned about native reserves. How would we pool the resourceful people we would require? I listened carefully as you identified what is being done, but I am not comforted. It may work in Toronto and Montreal but I am not comforted that the smaller provinces, or native reserves, or islands would be accommodated in a satisfactory manner.
Having said all that and listened to what you referred to before, it would be excellent if we could get from these specialists, some sort of a model that they think might work.
The Chairman: That is a good idea.
Senator Robertson: You could point out things that just do not work. There are areas where it breaks down. If you could give us something that would tie it all together that would be tremendously helpful. I do not expect you to give me an answer on that today. Perhaps the staff could work with these witnesses to develop something like that.
I have a couple of other concerns. Do not be easy on yourselves and do not be easy on your difficult partners. If there is someone who is not cooperating, we want to know who it is.
The provinces are standing aside and saying that this is their responsibility. However, we want to know what is going on because, one of these days, they will call for help, and we do not know what kind of help they need. I am sure you understand my concern.
When considering a model to break down barriers, surely we can learn from other countries that have better coordination structures. We do not always have to reinvent the wheel. Perhaps you would share what information you have about other models. That would be very helpful to this committee.
What is your definition of an epidemic?
The Chairman: As the witnesses prepare to answer the questions, I would tell you and our CPAC television audience that Senator Robertson was, for nearly a decade, the Minister of Health in New Brunswick, so it is a subject that she understands from the perspective of one of the smaller provinces.
Mr. Plummer: I would answer the last question first. An epidemic is an increase in the frequency of disease beyond what is normal. An epidemic can be one case or it can be many thousands.
Senator Robertson: Is the West Nile virus considered to be an epidemic or something else?
Mr. Plummer: Technically it is an epidemic. However, "epidemic" is a scary word, so some people do not often use it.
Senator Robertson: We should not be afraid of West Nile. Is that what you are saying?
Mr. Plummer: No, I am not saying that. I am saying that people do not use the word "epidemic" often because it has scary connotations. They use other words like "outbreak" or "cluster."
Senator Robertson: It does not hurt to scare people once in a while
Mr. Plummer: We try not to do that in public health. We try to reassure.
There are obviously challenges with regard to coordination. My personal observation on the issues that arose with SARS is that coordination among different levels of government, different jurisdictions, different types of agencies, hospitals verses local public health, was at the heart of many of the problems. It was not just a lack of federal and provincial coordination.
There are obstacles to better coordination and cooperation, such as privacy legislation in the provinces that does not allow or apparently does not allow the sharing of certain kinds of information that we need to have on a national basis.
We need to work on those issues. It is challenging, but I think it is possible to work better using our current structures. The lab network has gone rapidly from having very dysfunctional relationships to one that has quite constructive relationships. It is not that we are not critical of each other, but we are critical in a positive way, and we work towards trying to find a better way to do it. I think we have collective goals.
We can do that in the epidemiology and public health spheres as well. We have taken steps — and the Minister of Health has allocated some resources — to create the equivalent of the Canadian Public Health Laboratory Network in epidemiology and public health. We are just beginning to do that.
Studies have been done by Health Canada and discussion papers have been written about public health care structures in other countries. There are many different models. The U.K. model is often looked to, but the U.K. is not a federal state like Canada, so it is easier for them in some ways.
The United States has a federation that is in some ways similar to ours. They face some of the same challenges in interaction between the states and the centres for disease control. They are not perfect. However, the CDC does have the spending power. When a problem arises, congress will often vote the CDC a lot of money. That money is to flow it through to the states to implement particular programs, so they have emerging infectious disease funds, or bio- terrorism funds or influenza funds that congress votes for that specific purpose. Those funds go to the state laboratories or the state public health agencies and they are used for those purposes.
The Chairman: What does Australia do? Australia is often viewed as not a bad analogy to the Canadian context?
Mr. Plummer: I am not familiar with Australia, but we can provide a discussion paper on it.
The Chairman: It would be interesting to know that.
Mr. Plummer: We can certainly provide the Health Canada discussion paper.
Senator Cook: I come from Newfoundland, and I have been preoccupied with the issue of SARS and West Nile or whatever disease may come into my province, where we have one tertiary care hospital. I searched for answers and I found them in the most unlikely place last Friday night. I attended a women's network dinner. After dinner, two public health nurses approached me and asked to speak with me. When I asked them what it was about, they told me that they were looking for money. I told them that I was pleased that they had approached me, and I told them of my preoccupation with SARS and the like, and what would happen if it hit our province. They beamed and told me that they had met with the AMOs, the firemen, the police, and that they had a plan of action to deal with whatever is thrown at us, but, they said, "The problem is it needs funding." They were aggressive to a point, but this initiative had come from the public health nurses in the system who saw what needed to be done and sat down with their resources and drew up a plan of their needs. I was encouraged.
They agreed that I could sit down with their group and they would give me a briefing. I saw it was a wonderful good news story. All this was from two public health nurses. You, however, are at the top of the pyramid. Basic human needs have been considered by those people who meet the challenge of meeting our needs at the care level. You talked about jurisdictions and linkages. I think I met the basic link last Friday night. Would you care to comment on that.
Mr. Plummer: That is very interesting. It is the front-line public health care workers who were the heroes of the SARS response, particularly in Ontario. They did an amazing job.
Senator Cook: They were confident in their plan. They admitted that it needs funding and an infusion of some other things, but they were confident in their own abilities to manage anything that could come at them.
Mr. Karmali: Any system works well if you empower the people who are going to do the work to come up with ideas and innovation.
One of the benefits of having some sort of a national system is that it allows people to share their experiences at a national level so that people from all across Canada can learn from how different people in different provinces, regions or municipalities are coping. Somehow all of this has to be orchestrated from a national level. Funding can be channelled through the national level.
Dr. Plummer mentioned, and I would emphasize, is that, in the United States, Congress votes money to CDC. That money then flows to the states and so on. The adage that "He who pays the piper calls the tune," is a very important one, and the role for federal leadership in orchestrating a national enterprise has to involve funding to support this kind of a system.
Your observation is very important. That is the type of thing we should be encouraging, but it has to be coordinated within a national framework.
Senator Cook: Paramount is the training of the people. Capacity building is important, but there must be training all along the spectrum. All the dedication and the goodwill in the world will not help if the people do not have the training. Mr. Chairman, being part Newfoundlander, I know that we got skinned in public health in 1970. We did not think there would be any more epidemics. How wrong we were. Public health does need an infusion of a number of things, but money is probably the most important.
Senator Trenholme Counsell: I was most impressed by the way SARS was handled, and I know you gentlemen played a big role in that. I wanted to ask a question specifically regarding education. You made the statement that Canada is weak in public health research. In the last few days, somebody said to me that there was a diminution, if not major changes, in the school of public health at the University of Toronto, and that perhaps we were not training enough people in Canada in public health. That remark caused me some concern.
I was in public health for six years all together, three in New Brunswick and three in Ontario, before going into medicine. We looked to the school of public health at the University of Toronto.
What is the state of public health education in Canada in our two official languages? What is happening in the various centres and medical schools?
Mr. Plummer: I do not have specific information in that regard, but we will find out what we can. Since I have no personal knowledge of it, I cannot comment on the Toronto situation.
It is fair to say that we do have a crisis in public health human resources in this country similar to what is being faced in other areas. We are not training enough community health specialists, and we are not training enough people with masters and PhD degrees in public health. As well, for the most part, people are not adequately trained in the management of epidemics. There are significant human health resource challenges. We can provide the committee with some numbers, but I do not have them at hand.
Senator Trenholme Counsell: Where are we training people in public health? Are certain medical schools doing it?
Mr. Plummer: I think every medical school has a residency program in community health sciences, and most students would have graduate degrees in community health sciences, masters degrees or PhDs.
Senator Robertson: Do we have a school of public health in Canada?
Mr. Plummer: We do not have schools of public health, per say. The United States has many schools of public health, and those exist in a parallel system with the medical schools. Canada did not go that route.
Senator Morin: What is your opinion on that Dr. Plummer?
Mr. Plummer: I think there are advantages and disadvantages. The fact is that the U.S., at the turn of the century before the last century, the 1900s, created schools of public health across the country. That was championed by John D. Rockefeller. The U.S. has many strong schools of public health that turn out a lot of well-trained epidemiologists and public health specialists who do very good epidemiology. However, it has caused a kind of rivalry for attention between themselves and the medical schools, so there is a dysfunctional kind of relationship.
I am not sure that is the best model there is. There may be other ways of doing it.
The Chairman: Just to follow up on Senator Trenholme Counsell's comment, it certainly seemed to me, from watching from afar, that a huge amount of the work done in the SARS outbreak in Toronto was done by nurses. As we noted in our last report, there are two tendencies in the health care system that are troubling. One is the desire of the medical profession to always have a "doctorcentric" system. The second is the general credential creep, which is having professions ratchet up their requirements and thereby ratchet up their income, even if the requirements are not necessary.
That brings me back in a circle to the comment about nurses. Do you know the extent to which public health nurses become doctors? Senator Trenholme Counsell said she began her professional career as a public health care nurse before going on to become a doctor. Am I correct on that?
Senator Trenholme Counsell: I am a nutritionist.
The Chairman: I think it is possible to overly concentrate on training PhDs and not enough ground level workers. Does anyone know what we are doing in ground level training?
Mr. Plummer: I am not well placed to comment on that, but I can say that public health nurses are the front-line workers in public health.
The Chairman: The impression I have is that they are a rare commodity.
Senator Cook: In my province a new nurse practitioner will often specialize in either in the area of mental health or public health. As I see it, there is no other training or learning process for nurses.
Senator Morin: That is an important issue on which we should hear some evidence. We should have more information on human resources in public health, either those under training or those who are already public health care nurses, epidemiologists, PhDs or MDs.
The Chairman: We will be hearing from the Canadian Nurses Association and from the Canadian Medical Association on this.
Are there any other questions?
I thank the witnesses for coming and apologize for our late start. We appreciate your assistance.
If you have any information on some of the issues that we left with you, please send that to us.
The committee adjourned.