Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 7 - Evidence - October 26 meeting
OTTAWA, Thursday, October 26, 2006
The Standing Senate Committee on Social Affairs, Science and Technology, to which was referred Bill C-5, respecting the establishment of the Public Health Agency of Canada and amending certain acts, met this day at 10:48 a.m. to give consideration to the bill.
Senator Art Eggleton (Chairman) in the chair.
[English]
The Chairman: I call to order this meeting of the Standing Senate Committee on Social Affairs, Science and Technology. We are continuing this morning with hearings with respect to Bill C-5, respecting the establishment of the Public Health Agency of Canada and amending certain acts.
Before I welcome our witnesses, I want to note that our colleague Senator Watt, no stranger to the North, is with us today. I also want to note the presence of two members of the House of Commons who are with us and who are familiar with these issues and with the witnesses speaking today. Nancy Karetak-Lindell is the member for Nunavut, and Tina Keeper, who is the member for Churchill, is with us today.
With us today is Dr. Kim Barker, a public health adviser to the Assembly of First Nations. Dr. Barker previously worked for the Ontario Ministry of Health for long-term care as a physician manager in the public health division. Before that, she spent six years in East Africa as a medical consultant to UNICEF. Her work for the Assembly of First Nations focuses on developing a framework for public health for First Nations, with a strong emphasis on disease surveillance issues.
With Dr. Barker is Dr. Valerie Gideon, who is a member of the Mi'kmaq Nation. Dr. Gideon holds the position of senior director of health and social development at the Assembly of First Nations in Ottawa. Dr. Gideon previously held the position of director of the First Nations Centre at the National Aboriginal Health Organization. She was named chair of the Aboriginal Peoples Health Research Peer Review Committee of the Canadian Institute of Health Research in 2004. She is a graduate of McGill University; in 2000, she received a Ph.D., and previously completed a Master of Arts at the university. She is a founding member of the Canadian Society of Telehealth.
Representing Inuit Tapiriit Kanatami, is its President Mary Simon. She is no stranger to many of us here. Ms. Simon has had a very distinguished public record. She has devoted her life's work toward gaining further recognition of Aboriginal rights and promoting the study of northern affairs.
Ms. Simon started out with the CBC as a northern service producer and announcer. She has gone on to serve in many capacities, but perhaps the most noted is as the first Ambassador for Circumpolar Affairs between 1994 and 2003. She was also Canadian Ambassador to Denmark. I remember meeting with her in Denmark. Ms. Simon was also a member of the Joint Public Advisory Committee of NAFTA's Commission for Environmental Cooperation. She was formerly a Chancellor of Trent University. In 2001, she was appointed counsel for the International Council for Conflict Resolution with the Carter Center. She has had a broad range of experience and made many contributions both in this country and internationally.
Ms. Simon was also one of the senior Inuit negotiators during the repatriation of the Canadian Constitution. She has received many awards, including the Order of Canada, the National Order of Quebec, and recognition from Greenland and other organizations.
We are pleased to have Mary Simon with us today.
Mary Simon, President, Inuit Tapiriit Kanatami: Good morning. I am pleased to be here today to speak to this committee. I wish to extend my thanks to you, Mr. Chairman, for the opportunity to do so.
As many of you probably know, ITK is the national voice for Inuit in Canada, representing approximately 55,000 Inuit living in various parts of Inuit Nunaat, which is what we call the different regions of the Arctic, which means the land of the Inuit. There are 53 Inuit communities located in the Canadian Arctic, an expanse we commonly refer to, as I said, Inuit Nunaat.
Fifty-one of those 53 communities are located along the Arctic coastline. There are four Inuit regions within Inuit Nunaat represented by the four Inuit land claims organizations. They are the Inuvialuit Regional Corporation in Nunarput in the Northwest Territories, Nunavut Tunngavik Incorporated in Nunavut, Makivik Corporation in Nunavik in northern Quebec, and the government of the Nunatsiavut, which is the newly formed government in Newfoundland and Labrador. ITK works closely with these member organizations and others to protect the rights and interests of Inuit and to ensure that our important place in the fabric of Canada is considered in processes impacting the people we collectively represent.
ITK has a long history of approaching federal matters in a non-partisan manner. ITK aims to work collaboratively and develop solutions that are Inuit-specific and thus best serve our distinctive needs and circumstances. This approach extends to today's proceedings.
With respect to developing Inuit-specific solutions, ITK is advocating for the inclusion of appropriate references and mechanisms for Inuit in different federal acts, regulations, policies and programs that address health and other issues in Canada at the national level.
Inuit are faced with an incomplete national health framework which has a number of challenging gaps and weaknesses. For example, the Auditor General of Canada, dating back to 1993, has on a number of occasions pointed out the problems and risks that result from the lack of a legislative base for the non-insured health benefits program that operates for Inuit and other Aboriginal people.
Particularly with respect to ensuring financial accountability and a clear, coherent base for provisions of the necessary range of benefits to Inuit, the NIHB program lacks definition of purpose, expected results and anticipated outcomes. In fact, the same observation holds true for the complete range of health programs provided by Health Canada to Inuit. Both the department and Inuit, in my view, would benefit from a sound legislative base defining the nature and scope of programs to be provided to Inuit.
Inuit had a great interest in public health at the national, regional and community levels. We are very supportive of sustaining and enhancing the public health dimensions of overall health care. Public health represents a component of the health care system that targets prevention and promotion. Preventing disease and promoting health in a population rather than focusing solely on treatment is a vital front-end investment in health.
Further, public health considers population health and the determinants of health, those various factors that have enormous impact on the health of a population such as employment, housing, education and mental wellness. This approach is very much consistent with an Inuit world view of health as it is holistic in nature.
Given the range and scope of public health concerns that Inuit are facing, it is likely that Inuit needs in the area of public health are unique in comparison to that of the general Canadian population. Further, Inuit are much more vulnerable to both positive and negative consequences that can flow from legislative policy and resource allocation decisions that are made in the public health field.
I would like to give you some examples of how underlying public health problems are experienced in our communities across Inuit Nunaat. The incidents of meningitis among Aboriginal peoples and Inuit in the Northwest Territories is 7 per cent in the first eight years of life, some 200 times that of the general Canadian population. The territory of Nunavut experienced its first recorded death linked to HTLV-1 or human T-cell lymphotropic virus type 1, in 2005. This communicable disease can be sexually transmitted. It is an area of great concern, as sexually transmitted infection rates in Nunavut are generally higher than the Canadian population. For example, chlamydia rates in Nunavut are 2,500 per 100,000 compared to 188 per 100,000 in Canada generally. That is more than 13 times the Canadian average.
Tuberculosis remains a concern for all Inuit even though advances have been made in immunization. Recently, one of our communities faced a serious resurgence of this preventable disease and those working in public health were faced with great challenges due to communication gaps across the system. The system did respond, but we must learn from this experience so that it informs future responses.
Today, Inuit rates for tuberculosis are 71 cases per 100,000 whereas for the general Canadian population it is five per 100,000 — that is 14 times the Canadian average.
These are just representative examples. I can summarize by saying that no informed health observer would challenge that Inuit in Canada face a range and depth of public health problems that exceed almost all other Canadians.
There are a number of factors that contribute to the particular sensitivity and/or exposure of Inuit to public health problems. These include demographic factors and pressures including a young population, lower health status, lower levels of education and high incidence of poverty, as well as jurisdictional coordination and communication issues. Inuit live in a number of provinces and territories under various land claims agreements with health services provided to them at the community, regional and federal levels. This context makes it difficult to provide a seamless comprehensive health service on the ground.
As well, with regard to human resources, there is a lack of trained personnel to work in the health care system. There is rapid staff turnover with attendant recruitment and relocation difficulties and linguistic and cultural barriers that result from a lack of sufficiently trained Inuit personnel, as well as isolation and high cost factors.
Inuit Nunaat is vast. Our communities are geographically isolated and often served by small nursing stations. Specialized care and treatment is only available in larger centres at great distance and expense. Infrastructure costs, capital and maintenance, are also very high.
These factors contribute to there being little slack or give in the public health regime in Inuit Nunaat. In the event of a public-health crisis such as a pandemic, Inuit are likely to face challenges beyond anything experienced in Southern Canada.
This bill gives parliamentarians a rare opportunity to shape federal law in relation to public health. It is an important opportunity to acknowledge the specific circumstances, needs and views of Inuit. Inuit support the objectives and substance of this bill and congratulate those who have worked on its development. We believe that the same logic and motivation that forms Bill C-5 for Canada as a whole could very usefully and effectively be replicated at a smaller yet efficient and effective scale to meet federal government responsibilities in relation to Inuit public health.
As you are likely aware, Health Canada has been given the primary mandate to provide health services to Inuit at the federal level through the First Nations and Inuit Health Branch. There are other pan-Aboriginal health organizations such as the National Aboriginal Health Organization.
These do not substitute for a more focused approach to Inuit public health issues for the following reasons: They are not defined around or focused on public health. They are not legislated and therefore lack security of purpose and maximum transparency and accountability. They are not sufficiently Inuit-specific or Inuit-oriented and they are only marginally aimed at bridging disparities through interjurisdictional collaboration. I am not in any way contesting that these organizations all do valuable work, but none is in a position to provide a complete and comprehensive Inuit health service operating at the national level.
By way of conclusion, Mr. Chairman, ITK proposes that Bill C-5 be amended in three particular respects. First, the inclusion within the Public Health Agency of Canada of a chief Inuit public health officer, reporting to the Chief Public Health Officer of Canada. The officer should be of adequate seniority within the agency. The holder of the office should have an understanding of Inuit, our regions and respective jurisdictions, and have professional qualifications in the field of public health. Second, a requirement that the Minister of Health consult with Inuit representatives when establishing various advisory and other committees under section 14 of the bill with a view to finding and acting on the best way to secure appropriate Inuit participation and input into such committees. Finally, a requirement that an Inuit public health section be added to the annual report on the state of public health in Canada to be provided to Parliament by the agency.
It is worth noting that the proposed chief Inuit public health officer would serve a vital role in communicating and identifying mechanisms to address Inuit-specific public health issues at a federal level. Closing gaps in Inuit health status is fundamental, and public health has an important role to play.
There might also be an amendment to the bill's recitals to provide explicit reference to the importance and relevant responsibilities at the national level associated with Inuit public health issues. ITK has not drafted these amendments for the purpose of this presentation, but would be willing to collaborate in doing so if that were requested by this committee.
I would be pleased to take questions if you have them, and I thank you for the opportunity to appear before you. I have with me Mr. John Merritt who may be able to answer some technical questions that I may not be able to answer.
The Chairman: Thank you very much. Welcome to John Merritt as well. He is here as legal counsel to ITK.
Before I go to the Assembly of First Nations presentation I want to note that our speaker of last week is back with us today, Dr. David Butler-Jones, the Chief Public Health Officer. If you are agreeable I will ask him to say a few words at the end to respond to the presentations we have heard today.
Valerie Gideon, Director of Health, Assembly of First Nations: Thank you for the opportunity to speak to you this morning. I would like to express regrets from the National Chief, Phil Fontaine, who is on his way back from Australia today. As well, I thank you for the opportunity to speak a year ago on the mental wellness report, and also for the fact that our input was well considered by the committee and reflected in the report. I want to express my appreciation, since this is my first opportunity to do so.
Today I will quickly address some of the specifics about the bill, but similar to President Simon I want to talk about the broader public health context for First Nations, which is an area of direct federal responsibility.
The Assembly of First Nations is the national representative organization for approximately 750,000 First Nations living in reserves, also off reserve and in northern territories. While we understand that this is mainly a machinery bill, we would like to speak to specific proposed sections of it, as we believe these sections would have impacts on First Nations governments. In terms of the broader public health context, there is a lack of jurisdictional clarity and accountability among federal, provincial, territorial and First Nations governments in terms of their areas of responsibility.
First Nations governments must also be recognized as having inherent Aboriginal and treaty rights and bylaw- making capacity in the area of protecting the public health and safety of their membership. It is quite important to recognize these particular rights in the context of this bill.
Treaty 6 has a medicine-chest clause in the bill, which is certainly the foundation for First Nations expression of the need to recognize the treaty right to health. Currently, the federal government does not recognize this particular right but maintains a role in providing health services to First Nations directly as a matter of policy. First Nations maintain that the federal Crown has a responsibility under its fiduciary obligation to provide health care to First Nations regardless of where they live. Irrespective of federal responsibility, public health services for First Nations are organized in a manner that promotes more fragmented delivery, jurisdictional ambiguity and continued poor health.
As part of the public health context, it is important to note that the majority of First Nations governments have negotiated health transfer agreements, which means they have a direct responsibility for providing health services and programs to their membership.
As noted also by President Simon, there is a lack of federal government legislative authority in the area of public health. For example, medical officers of health that are currently employed by the First Nations and Inuit health branch of Health Canada are not recognized in the majority by provincial public health acts, which limits their ability to act in the context of outbreaks.
There is also the phenomenon of First Nations populations moving in and out of their communities and crossing jurisdictional boundaries in the area of health care. Furthermore, there is a lack of multi-jurisdictional agreements to clarify roles and responsibilities in that particular context with respect to First Nations public health.
Another key factor in public health service delivery to First Nations is the chronic underfunding of the federal First Nations health-funding envelope, which is capped at 3 per cent annual growth rate, which compares to the 6.6 per cent growth rate of the Canadian health and social transfers. This means we face annual shortfalls because we cannot keep up with the basic cost drivers of population growth and inflation. I have included in the package some background information on the fiscal imbalance we are currently facing, so I will not go into further detail now.
Our vision for an improved public health system for First Nations is simple: It is a vision that means an organized approach would drive the delivery of public health services to our populations and would overcome the current legislative and jurisdictional hurdles. The approach must respect the diversity of First Nations communities and their inherent jurisdiction as governments. We must ensure that there is an adequate and equitable standard of care that is offered to First Nations regardless of where they live, regardless of which province or territory provides their secondary and tertiary levels of services.
Public health services must extend to First Nations who live away from reserves by increasing their access to current provincial and territorial programming. We must ensure that provincial, territorial and even pan-Canadian public health surveillance systems protect the interests of First Nations in terms of their collective privacy rights as governments.
Over the past 18 months, we have been developing a comprehensive public health framework for First Nations. Such a framework has never been undertaken before; the document will be published next month. The vision, of course, is simple. It focuses on the need for common standards, equitable capacity and clear authorities. The exact components are included in the graph in the presentation. It is slide seven, I believe.
The public health system for First Nations does not need to be a separate system. When we are talking about a First Nations public health framework, we are not talking about setting up 633 different First Nations public health systems; we are talking about the need to have separate recognition of First Nations jurisdiction, but certainly interaction, harmonization, integration toward a common purpose that makes sense and will see the closing of the current gap in terms of health disparities among our populations.
We need to have a collaborative and coordinated infrastructure, which means sharing resources and information. We need to determine on what core functions federal, provincial, territorial and First Nations governments would agree to collaborate.
Our framework is not intended to be prescriptive. We offer six options for First Nations to be able to exercise their jurisdiction, either inherent or delegated, through bylaw making authority under section 81.1 of the Indian Act. There will be different ways in which First Nations communities will be ready to express and exercise this jurisdiction. I will not go through all the options, but I want to raise the importance of also recognizing self-governing First Nations, particularly in the North, that are excluded from many current federal health care programs.
In the public health framework, we recommend the development of a public health act for First Nations. The objectives of this act would be to clarify the roles and responsibilities of the various players in the system. This would be particularly important, for example, in the areas of emergency preparedness or pandemic influenza planning. We wish to enable flexible governance and implementation options for First Nations governments.
Another objective is to set up some economies of scale in terms of health commissions or secretariats that could support First Nations at a regional or a sub- regional level, for example a treaty level. This could encompass environmental health and help to support regulations in the areas of safe drinking water.
The act would also compel federal-provincial-territorial governments to in some manner share First Nations data that they currently hold with First Nations governments, which is not currently the case. We do not have access to our existing data that is held by these governments at this time, be it data held within electronic health records surveillance systems or even administrative databases. As noted earlier, the act would ensure the protection of the collective privacy interests of First Nations governments.
Speaking specifically to Bill C-5, we wish to note that there has not been a specific process of inclusion or consultation of First Nations in the development of the bill. In fact, this is our first opportunity to be officially consulted.
The bill should honour the federal fiduciary obligation to First Nations, and there are several ways in which that could be done. The bill does not clarify authorities of First Nations and Inuit health branch medical officers of health who are employed by Health Canada at this time. It does not address current jurisdictional gaps in First Nations public health roles and responsibilities. It does not ensure that the minister reports to Parliament specifically on his or her performance regarding First Nations public health, again despite the fact that this is a direct federal responsibility. It does not provide capacity for the Public Health Agency of Canada to compel provinces and territories to share that health data, which for our purposes would include First Nations data.
There are specific sections of the bill that I would like to bring to your attention in which we feel that our interests could be better represented and the potential impacts on First Nations governments and citizens could be addressed. Under clause 12 the Chief Public Health Officer is to report to the minister every six months. This could include First Nations public health issues. As well, the bill does not have a provision for consultation with First Nations governments. This could be included within the context of the bill today. Under clause 14, the minister can strike advisory committees. There is no requirement to include First Nations on any of those committees. In clause 15, the minister has regulatory powers over public health information. Clause 15(b) should recognize and include the collective privacy rights of First Nations when collecting information and distributing it, particularly when it has a First Nations focus or implication, and penalties for contravention of the violation of collective privacy right to First Nations should be specified.
In conclusion, if clauses 12 and 14 of the bill do not specifically refer to First Nations public health interests, this could be done through the development of policy frameworks, that is, regulations that would guide the bill's implementation, but First Nations would need to be meaningfully engaged at the outset of the development of those policy frameworks or regulations. Clause 15 could be amended by adding a subsection (c), which we have drafted to read, ``the protection of information of a First Nation, group of First Nations or self-governing First Nations.''
Finally, a commitment should be made by Health Canada and the Public Health Agency of Canada to work with the Assembly of First Nations and First Nations governments in the development of a public health act for First Nations that would address the gaps that the bill cannot currently address as a machinery bill. We would pursue amendment of Bill C-5 to accommodate any requirements for adjustments based on the Public Health Act that we would develop jointly.
Thank you for your time this morning. We will be pleased to answer any questions.
The Chairman: Thank you very much for your input.
I have a procedural question. I am puzzled as to why, at what might be considered the eleventh hour of the consideration of Bill C-5, this representation is being made for the first time. You did not appear before the House of Commons committee on Bill C-5. Bill C-5 was introduced in the last Parliament, known as Bill C-75. The Public Health Agency of Canada has been around since the Order-in-Council of 2004, so it is two years old.
Has either of your organizations made representations to the minister, the Public Health Agency or Health Canada? Is this the first time you have had an opportunity to say any of these things?
Ms. Gideon: This is our first opportunity. We brought forward some of the issues we have with Bill C-5 with the Public Health Agency directly. At the beginning of the development of the health protection legislative renewal piece, which is probably almost a decade old — although I am not an expert on its history — there was a round of consultations where Health Canada recognized the need to discuss the implications of the legislative renewal package with First Nations. On March 31, 2003, one-day session was convened, and to my knowledge, that was the only other time we were engaged in the discussions concerning the overall scope of the proposed public health legislation package. I believe that Bill C-5 is a parcelling out of the Public Health Agency's authorities within that particular package. No, we did not have an opportunity to speak to the House of Commons standing committee on the bill.
Ms. Simon: Mr. Chairman, I was elected in July, so I do not have a lot of previous information. Onalee Randall, director of the health department in ITK, is here with me and I will ask her to answer your question.
Onalee Randall, Director of Health, Inuit Tapiriit Kanatami: We were not approached. We had discussions with the Public Health Agency of Canada and we provided a written submission on the overarching legislation in 2004. The input provided to that overarching bill was similar to what we presented today, but we have not given specific input on Bill C-5 until today.
Senator Callbeck: Thank you for your input here this morning. I was going to ask whether you had been approached and whether you had any input into Bill C-5; obviously you did not.
With these advisory committees, I take it there is nothing in the legislation that says that you will have input into any of them.
Ms. Gideon: That is correct.
Senator Callbeck: How are you supposed to get your input into this? What is the process?
Ms. Gideon: We have approached Dr. David Butler-Jones to see if we can participate in the public health network that the Public Health Agency has been currently developing. I am assuming that will be mainly the advisory committee structure implemented under this bill. Of course, I cannot confirm that.
We have received a proposal for how we may become involved in the process. The only way to do it would be for us to push the bureaucracy and hope for a positive reception. There is nothing that would obligate the agency to do it. I am not saying they would not do it, but it is a struggle for us. It would be better to be recognized in the legislation in order to guarantee a long-term commitment.
Senator Callbeck: You say you have received a proposal from the Public Health Agency as to how this would work?
Ms. Gideon: We have submitted one proposal and they are responding back, yes. It is just very recently, within the last few days.
Senator Callbeck: So you have not had time to look at it to know if you are happy with it or not?
Ms. Gideon: No; but it is in the context of expert groups, so it does not give us a decision-making role over Public Health Agency initiatives. We would just be providing feedback; we would not be on a governing council level.
Ms. Simon: The same thing holds for us. As I was saying in my presentation, one way of addressing that issue is to create, within the Public Health Agency, a chief Inuit public health officer who would work with the Chief Public Health Officer of Canada. That way, we would be assured of our involvement and input into this area. We made some very specific recommendations to address that.
Senator Cordy: Those of us who have been on the committee for a while understand the dismal state of health care within the First Nations community. We have learned that through our first study on the health care system overall, and then certainly when we did mental health, mental illness and addictions.
I am very interested in your point about ensuring the minister reports to Parliament regarding First Nations public health. Is there any reporting that goes on right now? I cannot remember anything coming to us in the Senate, but perhaps it has.
Ms. Gideon: The department files its annual reports in the same manner as all other federal departments. It also produces an annual statistical profile on First Nations in Canada. That is not a requirement that the First Nations and Inuit health branch has, but it is something they have done over the last three or four years to be able to demonstrate whether or not there is any health status improvements. However, it does not relate back to their performance in any way with respect to the services that they are obligated to provide.
Senator Cordy: As I understand, it does not include whether or not things are working.
Ms. Gideon: No, it does not. It gives the infant mortality rate or the rates of tuberculosis and so forth. In fact, the department itself — I am speaking to the First Nations and Inuit health branch because the Public Health Agency is new — has set goals in terms of strategy, such as the elimination of tuberculosis. When that objective was not met, it just changed the objective in the strategy and changed it on its website without reporting back on why it could not achieve that objective.
A lot of these things are subjective targets included within Treasury Board submissions. Beyond annual reports, there is no public reporting on what it is they do.
Senator Cordy: We are getting statistics, but not the stories behind them, is that right?
Ms. Gideon: That is correct.
Ms. Randall: I would just add, regarding the federal reporting that FNIB does, ITK has been advocating strongly for the past four years and, as Ms. Gideon said, it now comes out as a First Nations report. It previously came out as a First Nations and Inuit report with no Inuit data. There is very limited Inuit data available on public health. From the information provided by President Simon, most of that is territorial data and it is certainly not consistent, although we believe it is representative of the Inuit population.
Senator Cordy: I think you both mentioned protection of First Nations privacy rights. Would that be in addition to what is currently available to all Canadian citizens? I am not sure what you mean by that statement. Can we collect data and not make it public or can we not collect data — if we are looking at public health in terms of determining what avenues we should take to make the health care system better for First Nations people?
Ms. Gideon: That is a complex question. Essentially, in the same way that the federal government understands that the provincial government has jurisdiction over its information — and that you would respect that in the development of this particular federal legislation — similarly, First Nations governments have jurisdiction over their information. However, their rights to that information or their rights to the protection of that information are not recognized.
Essentially, yes, you could extract First Nations data from databases and report on it. Generally, it is understood within the federal government that First Nations will react very negatively politically if they use their information and publish it without their collective permission. There is nothing that really entrenches that responsibility of the federal government to protect that information.
Senator Cordy: It is happening now but it is not enshrined in legislation. Is that correct?
Ms. Gideon: That is correct. It is not even enshrined in a policy. Right now, it is the fear of political fallout.
Ms. Simon: Historically, when health issues were addressed with Inuit, there was no consent asked for any kind of information that went public. People were not aware of it. We are trying to change that situation. We are not suggesting we are going to be outside the system, but we need to have a process where there has been a lack of any kind of consent. When information goes public, people must be informed what kind of information is going public concerning their health.
Senator Cordy: Would that also include being made aware beforehand that information will be collected?
Ms. Simon: Yes.
Senator Trenholme Counsell: This is a very important presentation. I think it points to glaring gaps in some of the consultation and the problems with the initial consultation that went on in the initial preparation of the bill. However, that is history.
Perhaps you saw me going through pages. I am trying to understand the composition of the governing council. Dr. David Butler-Jones can fill us in on that.
I am addressing, on page 5, your first point with regard to a chief Inuit public health officer reporting to the chief public health officer of Canada. I will give you a comment and ask you to respond. I think of Canada as all of us, and I cannot see that within that agency, you could have two chiefs.
What is the composition of the council? If it is not there now, whether at a high level within the council reporting to the Chief Public Health Officer of Canada, there could be better and, from your point of view, satisfactory representation of the Inuit First Nations on this governing council, rather than having two chiefs — which I think we all know does not always work well.
Ms. Simon: We talked about that question. We wanted to be able to explain it to you when we were here today — how this chief Inuit public health officer would fit into the present mechanisms that are in place with the Public Health Agency of Canada.
In our view, the chief Inuit public health officer would take on a facilitated role, specifically in the area of policy, interjurisdictional coordination and facilitate those necessary discussions that need to happen between Inuit, provinces, territories and federal government in developing approaches to address disparities in public health.
We acknowledge that the Chief Public Health Officer for all of Canada works with the relevant chief medical officers from the provinces and territories, but this arrangement does not mean Inuit participation and input into public health matters is happening. I outlined previously in my presentation some specific situations that impact on Inuit that are distinctive and unlike that of any other Aboriginal group. This warrants, in our view, an Inuit approach. That is why we were proposing that this recommendation be put forward.
Senator Trenholme Counsell: You are bringing very important insight and information to our attention. If the input from the Inuit, from First Nations or any province or territory is inadequate, it behoves us, as members of the Parliament of Canada, as members of this committee, to ask why and to do what we can to ensure your input is adequate. I see that as falling short of another chief.
On the other hand, I think we must take a very hard look at this. What you are telling us today is exceedingly important. This is not just public health; it is health. Everything to do with children, mothers, families and water; all of these things are not always handled well. You do not want to be at the end of the line; you want to be equal with every other Canadian. How we can make that happen, a level playing field for all Canadians?
Ms. Simon: I appreciate your comments, because what you are saying is very accurate. No matter what health area you are looking at, the information that we are getting and the statistics that we are getting in terms of the numbers compared to other Canadians is very dramatic. The level of suicide rates in the Arctic do not compare to any other parts of Canada. There is a reason for that. They are related to other issues such as health factors and social conditions. We need to close that gap that we often find ourselves in.
Senator Trenholme Counsell: Mr. Chairman, the input from our distinguished colleague Senator Keon yesterday went to this very point. We were talking about population health. If Canada is going to do better on the world index and population health, we need to know where to start.
This presentation this morning is exceedingly important for the committee. We must ensure this inadequacy and misrepresentation is corrected.
[Translation]
Senator Champagne: On reading your recommendations, I noted that for a variety of reasons, technical and otherwise, in sections 12 and 14, no direct reference is made to First Nations. You would be reassured somewhat if there was a reference to First Nations from the very beginning of the regulations. Agreed?
Ms. Gideon: Certainly it would be better than what we now have. We would prefer to see this entrenched in the law. If not, we are prepared to work on developing the regulations. I understand that for some sections, there will not be any regulations at all. That decision will be left in the hands of the bureaucrats when the time comes to formulate certain policies. This will leave us in a less secure position, but if this is included in public regulations to assist with the implementation of a bill, then it is feasible.
Senator Champagne: As the Chair was saying, the 11th hour is truly upon us. It is indeed very unfortunate that you did not take part in the study of this bill when it was before the House of Commons. We understand your concerns clearly and we will have to find some way to reassure you. However, it is important that the bill moves forward and not be sent back to the House of Commons with amendments. That is my view at the present time. But I would not want you to leave here saying that we do not care about the outcome, because that is not at all the case.
[English]
The Chairman: That is an important point for the committee to consider. Are we going to deal with the issues I think most of you said were legitimate through amendment, or deal with them through observations that can find their way either into policy or into regulations?
I am sensing from the witnesses that the first choice is to carve it in stone and put it in the legislation. It is interesting to hear their comments about the other alternative, because we will have to consider that when we finish with our presentations this morning.
Ms. Gideon: It is important to look at the precedent this could set for us. The reason we are here at the 11th hour is because there is no entrenchment of responsibility or process that enables us to be assured that we will participate. It is very difficult for us to access these fora. That is why I thanked the committee on the mental wellness report, because that set an important precedent for us. It was important for us to have a specific session on First Nations and Inuit interests, and you see it in the report. This will hopefully assure we are part of the commission once it is established.
There is no precedent for our inclusion in the health care legislation, even to the extent of a mention or a specific reporting of the minister to Parliament. I understand the decision the committee needs to take, but I want to stress how important this is to us. We need that first step. We need that first precedent.
Ms. Simon: It is very important to ensure that when you talk about Aboriginal people that it is specific to both First Nations and Inuit. We find ourselves many times in any legislation or policy or program announcements that if Inuit are not specifically mentioned, everybody assumes we are included in the First Nations. There is nothing we say against that, we just want to have a clear understanding that Inuit have very specific issues and priorities also. Anything you do, we want to ensure Inuit-specific issues are recognized also.
Senator Champagne: I stand corrected.
[Translation]
Senator Pépin: If I understand correctly, being involved in the drafting of the regulations — if there are in fact some in the bill — remains a priority for you. You want to be in control when decisions affecting First Nations and Inuit are made.
You also talked about wanting to be involved in a specific report, as well as about the need to educate First Nations on program participation. Otherwise, you say that they might feel they are being targeted in the report and might feel different than others.
Ms. Gideon: It is clear that in the past, information was not used consistently or in a manner that was in our best interest. Information was used against us. Therefore, it is very important for us to have some control over information.
Senator Pépin: At all levels of the decision-making process.
Ms. Gideon: Basically, yes.
[English]
Senator Fairbairn: My question follows on the comments that all of my colleagues have made. We have an opportunity, short of amendment, to make statements when moving this bill back into the Senate.
I know there is a difference between Inuit people and other Aboriginal groups. You have a problem with getting information from the government and health agencies in the manner you wish to. You also have a difficulty in that there is no person or group to whom you can express your concerns and views in such a way as to get action rather than simply passing on thoughts.
Where would you see that connecting link? What kind of position would you want a person in to speak on your behalf?
Ms. Gideon: The fact that the First Nations and Inuit Health Branch is not recognized as a health system creates difficulty for us. It is a branch of Health Canada, a federal department subject to all rules, procedures and policies of all departments. Those are not adapted to the fact that FNIHB is our health system. It is like the Alberta health department or the Quebec health department. That creates many barriers to the system being responsive and effective.
I think you are talking about an ombudsman-type role. It is not something we have considered specifically for health. It is a concept that would be interesting, but overall I think First Nations want their own jurisdiction in the area of health care recognized and to have the health system that is intended to support them recognized as a health system.
That is a broader issue that would need to be considered in the context of the public health act for First Nations that we are proposing. We would need to consider what the appropriate mechanism would be, whether it would be national, or even regional, which would allow for a better working relationship with provincial and territorial health systems, which carry all the secondary and tertiary levels of care for our population.
I am not specifically answering your question, but it would be interesting to think about it from the context of the public health agency, if there were a specific individual responsible for First Nations public health in the context of the agency's functioning. The role would not necessarily be public health, because the provinces, territories and First Nations governments have a role in that, but that would be an interesting proposal.
The Chairman: Do you see the framework for public health about which you are speaking as a separate entity altogether? How do you see it relating to the public health agency of Canada?
Ms. Gideon: The public framework lays out all the parameters relevant to public health for First Nations. The public health agency has a defined role and functions, but the provincial and territorial governments also have a role with respect to public health service delivery to First Nations, and First Nations governments have jurisdiction over public health. Our framework lays out those roles and responsibilities and provides options for improving the current system in terms of creating a better continuum — that is, harmonization.
An example of an enabling mechanism is multi-jurisdictional agreements. In the context of pandemic-influenza planning, there would be an agreement laying out the responsibilities of the Ontario government, Ontario First Nations, the First Nations and Inuit Health Branch and the public health agency. The framework talks about all the foundational components, so it is bigger than Bill C-5.
Senator Fairbairn: I am troubled by this because this is a major part of our country. It is also a group that, over time, has had severe difficulties with health issues.
The fact that you were not part of the of the development of this bill or of addressing it before it was passed by the House of Commons indicates that you need to have a connecting link to the government. There is a process of some sort here, but oddly enough you are not part of it.
Where is your place, in an advisory capacity, in the system? At this point, it does not seem that there is a connecting place, and there should be in order for you to be part of one of the important issues, in addition to literacy and education.
This is a foundation issue with your people. There must be a presence from you within the national picture. Where is that most likely to be helpful to you?
Ms. Simon: What you have said is very important, as are the other comments made by senators. How do we link our people to the government? That is always a big question on many levels, but it is particularly important on health.
I said earlier that we would like the creation of an Inuit public health officer that would help facilitate this process and the link you are talking about. However that is set up, it is important that the person or people who will create this link have professional qualifications in the field of public health. It is important to ensure not only that those people are sensitive to our culture and way of life but also that they have the required professional capacity.
The third recommendation that we made, which relates to the fact that we think the Inuit public health section be added to the annual report that is provided to Parliament by the agency on the state of public health in Canada, would help to bring those issues forward, specifically about our issues.
In addition, this is a process of many other levels that we are working on regarding health issues. One of the things we also have been exploring within ITK — we wanted to separate the two because this is very specific to Bill C-5 — is looking into discussing with the Government of Canada a health act for Inuit. We have had these discussions for some time now. We will be pursuing that further in the future. In fact, I have a meeting with the Minister of Health to talk about that.
I want Mr. Merritt to elaborate a bit more on that.
John Merritt, Legal Counsel, Nunavut Tunngavik Incorporated, Inuit Tapiriit Kanatami: I have two points to raise. President Simon mentioned the broader need for wider Inuit health legislation. I know a couple of senators earlier talked about privacy considerations, as did the Assembly of First Nations.
When the First Nations Inuit health program a couple of years ago was dealing with the impact of new privacy legislation — electronic data legislation — the consequence of that was that Inuit and First Nations people were confronted with an expectation that they would sign elaborate consent forms to try to regulate the use of information.
We had the example in the Inuit world where, effectively, monolingual, Inuktitut-speaking senior citizens were going to be asked, with the help of a public health nurse, to decipher and sign a four-page English legal document as to the use of personal health data. ITK's position at that time was that this was absurd, that wherever this goes into terms of societal balancing of principles, to ask little old ladies in small communities to sign a document in a foreign language to govern the use of health data is a system gone wild.
That is a perfect example that, wherever the balancing is, this should take place in a public law — either that or in the context of the professional ethics of the health professionals administering these things. However, it is absurd to get to the point where you are investing the resources, the time, the money, the use of health professionals, who are already very much stretched to provide basic health care, to turn them into people who have to interpret complex legal propositions.
We said we need legislation to deal with this. If there has to be a balancing act between privacy issues and use of data for public health services, we expect to see that in the context of a well thought out statute. That is an example where privacy issues bring home the consequences of there being what amounts to a total gap in the delivery of very important health services to First Nations and Inuit people.
Second, a number of senators talked about the possibility of there being regulations to backfill on some of these issues, short of amending the act. I appreciate that the committee gets its legal advice from the Law Clerk, and appropriately so. I would invite you to consider that section 15 of the bill at the moment is very narrow. The regulation-making section in the bill at the moment would not, it appears to me, allow you to make the kind of changes through regulation that ITK has suggested you make by amending the bill itself.
I appreciate that is an issue of legal interpretation. However, I listened with interest to the AFN's proposals and I think some of them would be difficult to fit in within the regulations as well. Obviously, it would be a more secure legal result to amend the bill itself.
Senator Watt: I have not participated in this committee before. I appreciate the fact that Dr. Simon has invited me to hear what she has to say, along with the First Nations.
As the chairman said, he was quite surprised to learn that this is your first participating in the formulation of this bill. It is at a very late stage; it is already at second reading.
If this bill is passed — and I imagine there is no hesitation by committee members to allow it to do so, if it is satisfactory and can be worked out — you are not in there. I think the Constitution explicitly states that you have to be consulted before the government makes any move in any field.
Taking that into account, if the committee made recommendations before third reading to suspend this until such time as the other matters are taken care of, the issues you have raised, would that be satisfactory to you? Or would you recommend to the committee to allow this bill to deal with the issues you have raised after the fact? What does that mean? Could you elaborate on that?
Ms. Gideon: If the bill goes through as is, essentially what it means is that I will have to constantly rely on bureaucratic goodwill to ensure that First Nations interests are secured in the context of the Public Health Agency's work. That is a risky business, but it is my business.
It means that the status quo will continue and that we have to continue to struggle and raise awareness and work through political mechanisms to be able to have our feedback included. That is what it means.
It also means that we might be able to secure some expert representation on the public health network's various groups. However, that is difficult for us to do because there are several dozens of expert groups and we do not have the capacity to participate in all of those effectively.
Going back to Senator Fairbairn's point, being represented at the governing council level would allow us more security than having a specific secretariat within the agency, with a bureaucratic lead who is subject to the governing council's direction. That would be the most effective process for us. It also would be the most feasible because of our capacity challenges.
Ms. Simon: As you know, in our own society, there are a lot of issues that we are faced with in terms of health services. We have many barriers to overcome. Trying to deal with this after the fact will likely be very difficult.
I support what Dr. Gideon is saying in terms of her perception and her understanding. If we can start the process, at least in terms of our participation through this committee hearing, that would be good. I am not sure how you, as a Senate committee, would address our concerns. If it proceeds with no changes, it will be an uphill battle for us.
Senator Watt: Mr. Merritt indicated that there might be a way of dealing with it, if I understood correctly, even though it would be hard to make an amendment to the regulations. I should like to get his reaction on whether he feels you have enough time to put forward a possible amendment that both the Inuit and First Nations would be happy to live with? We do not have much time.
Mr. Merritt: As President Simon said, the amendments that Inuit are suggesting here are actually pretty short amendments, in terms of their drafting requirements. As a consequence, we would be happy to draft those.
Our perception was that this is a very short bill; and the real issue is whether senators would want to put those changes in, in the context of whatever other decisions you have to make by way of process, precedent and what have you.
We do not see the drafting of those as being complicated. We would be confident that the Law Clerk of the Senate could convert our suggestions into text readily. We would be happy to work with him and the committee if people wanted to make the decision to entertain those specific amendments.
We would be happy to work with Assembly of First Nations as well because I think there was overlap between some of the things the ITK suggested and AFN.
Senator Watt: I am not a member of the committee and I have no voting rights as such. I can only try to speak to each individual senator in an effort to persuade them. I can help as much as I can. It is up to members of the committee to decide what they will do with this bill.
The Chairman: You can join us if you want. We need more men.
Senator Watt: I can participate but not vote.
Senator Callbeck: I have a question in a different area, and it concerns funding. Dr. Gideon, in one of those points you made you talked about the chronic underfunding and fiscal imbalance of First Nations.
You said there is a cap on the Indian health envelope of 3 per cent, whereas you mentioned that the social transfer average is 6.6 per cent. That envelope would include a lot of other programs and transfers besides that social transfer. In order to compare apples to apples, what is the average increase for all the programs that go to the provinces contained in that envelope?
Ms. Gideon: I am relying on the 2004 first ministers' health accord, which has been honoured in budgets 2005 and 2006, in terms of the breakdown. In terms of First Nations specifically targeted programs within the Canada Health and Social Transfer, we do not have that information because the provinces are not required to report, despite the fact that First Nations populations are included in the overall population numbers on which the CHST is calculated. Provinces are not required to report on the programs or services they deliver specifically to First Nations, nor could the majority of provinces do that right now because First Nations are not identified in their provincial health care databases.
While First Nations do access secondary and tertiary care provided by provinces, there is data that demonstrates that their access is poorer and the quality of care is poorer because provinces do not plan their health care services with respect to First Nations communities because they see those as federal responsibility.
Ms. Simon: Figures are almost impossible to track. For example, the Health Canada First Nations and Inuit Health Branch report on Non-Insured Health Benefits Program has been unable to report on dollar amounts that are Inuit- specific. Of additional importance, neither is there mapping of Inuit-specific expenditures done at the federal level. This was acknowledged last year as a problematic area. A commitment was made at the Kelowna meeting that there would be mapping for overall expenditures, but we do not have that. It is hard therefore to tell you exactly how much money is spent on health issues related to Inuit.
The Chairman: I should like to ask the Chief Public Health Officer, Dr. David Butler-Jones, to join us at the table and to give us his thoughts about the presentations that have been made this morning.
Welcome back.
Dr. David Butler-Jones, Chief Public Health Officer, Public Health Agency Canada: The issues that have been raised are clearly important to ones that we share, and the challenges faced by First Nations and Inuit communities are real.
The bill before you is a machinery bill, not a public health act. Perhaps in describing what is being done and planned, it might help to address some of the questions that senators have and some of the issues raised by the representatives here.
This proposed legislation was a bill in the last Parliament but it died on the Order Paper. It was in the public realm for seven months. In advance of that, it was a cabinet document. There have been no formal consultations with anyone, other than the parliamentary process. Provinces and territories have not had a formal consultation; there have been informal consultations.
I have met a couple of times with the Grand Chief. There have been conversations between the people in the agency and the national Aboriginal health organizations about it, and opportunities to speak to this and raise issues. What we kept coming back to, both with the provinces and territories and others, is that this is a machinery bill to establish the agency. There was an open invitation in the legislative committee, but no one came forward to make representations to that.
Most people say that they do not want to face an event like SARS without having this in a legislative frame. Many of the issues being raised cannot be addressed in this bill; there are other processes to do that. Proposed legislation such as is before the committee will require some discussion and work, which we would be pleased to engage in that.
The provision of public health services on reserve is part of First Nations and Inuit Health delivery. What we provide are connections across the system. We are responsible for facilitating the public health network, which is the federal, provincial, territorial network providing oversight to all public health components.
In that network, there is a council with federal, provincial and territorial representatives, one example of which is the chief medical officer in Nunavut who speaks eloquently and frequently on the issues that are unique and challenging for Inuit peoples. That council then reports to the conference of deputy ministers, where I sit, and then reports to the conference of ministers. Within the network, there is a series of expert and other committees that we have made a commitment to. I recognize the challenge in terms of availability, which is why we have had consultations with the national Aboriginal health organizations around what would be appropriate representation within the network to ensure that we have that expertise reflected in those tables and issues. That is moving forward.
There have been conversations and a recent proposal back, and we are committed to that. We do not control the council — it is federal-provincial-territorial. There are 14 representatives around the table, of which we are one. I co- chair that council, but it really is a collaborative process and there is a clear commitment that there will be Aboriginal expertise.
From my view, it is essential that we have an Aboriginal health committee as part of the network or advisory to me that looks at all the pieces that may help to address Dr. Gideon's concerns and others about how to impact on these things.
In terms of the consultation at this point, it is informal. Then there are the legislative process and committee structures where, at the legislative levels, no witnesses came forward.
The only regulatory authorities in the act are around protection of individual privacy. The provisions in here do not allow the public health agency to extract information. It does not allow us to compel either First Nations or Inuit or provinces or territories to give us the information. All it does is allow us, when they give it to us, to hold it and use it for public health care purposes and share it appropriately.
The privacy provisions and regulations will ensure that with respect to whatever we do receive, that people have given us permission to have, protection is in place. In terms of some of the concerns around that, it is a bigger issue.
In terms of a public health act for First Nations and Inuit peoples, that is a very important conversation that we want to engage in.
I have talked about the expertise, the committee, privacy and public health act. We are interested in trying to identify what it would accomplish and what would we need to do. However, there is far more conversation needed about that.
As an agency, we provide to the territories and the provinces specialized expertise and laboratory services. For example, concerning the issue of the HTLV outbreak, the public health agency was working with territorial health authorities to help with the investigation, understanding and appropriate testing to get a better handle on these issues. We provide those kinds of supports.
There is clearly a challenge in the country, which is part of reason we now have the agency and why provinces and territories are continuing to try to invest in public health. There is a capacity issue. There are just not enough people to go around. One of our jobs in the network is to ensure that those are matched appropriately.
That is where we are at. Clearly, our intent is to address these issues. I am not sure you can address them in legislation, given the nature of this piece of legislation. I am concerned that if we try to do it in legislation there will be further delay. Who knows, there may be another election, and then a year and a half down the road we will be coming back to establish the agency, the authorities in legislation and the role of the CPHO having its dual position and mandate.
That is where we are at. We are in conversation. From my perspective, obviously, some things could move faster. However, we are absolutely committed to making it work.
The Chairman: From the representations that have been made today, how would you see improving upon the understanding and the coordination with these two organizations and who they represent? Can you see some changes you would like to make now? Are you saying that you feel that all these changes can be made by you in a policy context as opposed to a legislative or regulatory context?
Dr. Butler-Jones: Because the focus of this bill is simply to establish the agency, that is difficult to address. Other than general provisions around fostering cooperation with governments, interested persons and organizations, there is not even explicit reference to provinces and territories having a seat at a table. There is no reference to the public health network being composed of certain people or organizations.
Those are part of the frame in the development and the agreements in terms of moving forward. It would be a challenge to start naming all these things that need to be in it. Since it is not a public health act, it would be a challenge to try to deal with some of the other things. There is, however, the ability to create committees, and there is the public health network, which is a mechanism by which we can pull these things together.
The other point is around the establishment of the relationship and the continuing development of that relationship. It is absolutely essential to move forward on that. I do not see anything in this legislation that will address that.
The bill sets out provisions for an annual report that I must prepare, as well as other reports when appropriate. Consultation with First Nations, Inuit groups and others, as appropriate, will occur depending on the nature of the report because it may or may not have relevance. I think we would need to have an ongoing conversation about that.
Clearly, a report that deals with issues and does not make specific reference to address some of the issues faced by First Nations and Inuit people would be inadequate. At the end of the day, at least the way it is phrased, it is a report of the Chief Public Health Officer and not a report of the minister or any particular sector.
The Chairman: It is presented to the minister, after which it becomes a public document, is that right?
Dr. Butler-Jones: Yes.
Senator Trenholme Counsell: Dr. Butler-Jones, I am sure you heard me wondering about the composition of the governing council. I note that clause 14 provides:
The Minister may establish advisory and other committees in relation to public health and provide for their membership...
Can you give us any idea of your structure of operation right now and how Canadians are represented?
Dr. Butler-Jones: This reference is a reference to the ability of the minister to establish a ministerial committee. Such a committee does not currently exist. Clause 14 provides the minister with the authority to establish committees for that purpose.
The public health network is a federal-provincial-territorial creature. The representation on that is a mix of expertise in the committees, and the council of the network is the FPT. All the jurisdictions — provincial, territorial and federal — are represented at that council table that reports to the conference of deputy ministers.
This provision is not about the public health network or about the function and activity of public health. It provides the minister with the ability to establish a committee.
Senator Trenholme Counsell: Can you elucidate for us as to how the Department of Indian Affairs and Northern Development is included? How does there representation come into this?
Dr. Butler-Jones: If we talk about the FPT and the expert structures, it depends to what extent they either engage bureaucratically or in terms of expertise. The FNIHB is our link, because they are the lead on Aboriginal, First Nations and Inuit health issues.
Senator Trenholme Counsell: Yet there is no direct representation from that branch to you.
Dr. Butler-Jones: That is right.
Senator Trenholme Counsell: Do you see that as something that might happen?
Dr. Butler-Jones: That is part of a question of whether you have it formally or informally, and whether or not it is issue-based. We are open to advice on how that takes place.
Senator Fairbairn: In listening to our witnesses today, it seems that the core of their difficulty is that they do not have a formal and continuing connection with the important area that others have. If it is not legislative, if it is something that should be part of a system now, after this hearing today, I hope that there will be a seat at the table for the people who are in a position of leadership concerning the health issues of their people.
Dr. Butler-Jones: There are a number of tables.
Senator Fairbairn: They should be at every table.
Dr. Butler-Jones: The offer is there. The one table over which we do not have control is the FPT. Their decision in establishing the public health network as an FPT network was that each jurisdiction — federal, provincial and territorial — would have one representative. If it is the desire of the Senate, then we would have to take it back to the ministers of health across the country. If they wished to have an Aboriginal-First Nations-Inuit representative on the council of the network, they could do that.
We have been involved in negotiations to find out the best way to do that, given the challenges of personnel, et cetera. We need that kind of expertise. I have also committed that there will be an Aboriginal health committee of some sort — although we are not sure structurally where it will fit — that will help to bring that together in terms of Aboriginal health expertise. That is something I can actually do. In this proposed legislation, we cannot compel an FPT mechanism to have certain representation.
Senator Fairbairn: You do what you can in your area.
The Chairman: Ms. Simon has asked to make a comment at this point.
Ms. Simon: In my presentation, we proposed some amendments to Bill C-5. I want to point out that they are all machinery amendments and not related to anything other than changing some of the machinery. I want to highlight one in particular because, as Dr. Gideon was saying about setting a precedent, this would be very important for us because of the difficulties that we have had. We have explained those to you.
That would fall under the second amendment we propose, which is that, in establishing various advisory and other committees under section 14 of the proposed act, the Minister of Health should consult with Inuit representatives with a view to finding and acting on the best way to secure appropriate Inuit participation and input into such committees.
Dr. Butler-Jones: Just to clarify, that proposed section only refers to a ministerial committee. I am sure the minister would want to consult with a number of groups in terms of the composition of that committee. Senators have expressed some interest in ensuring some aspects of that. It is a ministerial committee, not the FTP process over which we are one player in that process. It is a more narrow focus, and it has more than one committee, but it may be one committee, depending on the desire of the minister and the government.
The Chairman: I think that brings to a conclusion our hearing of witnesses. I thank all of them for their input today. I excuse you as witnesses, but you are invited to stay in the room, if you wish, for the next portion of our deliberations on Bill C-5. Thank you very much to Dr. Gideon, Dr. Butler-Jones, Ms. Simon, Mr. Merritt and Dr. Barker.
Honourable senators, we will now resume our deliberations on the matter. Let me outline some of the options I think we have here. I am a fairly new chair, so I may not get them all right.
The normal thing to do, as is noted on our agenda, is to go to clause-by-clause consideration. We can do that now. We have to do that in public session, by the way. If you want to contemplate amendments, you must consider whether you are ready with specific wording of amendments at this point or whether you need time for amendments to be fashioned.
The other option is to deal with observations, which can include recommendations to the minister or to the Public Health Agency and can be in the form of suggested regulations or suggested policy, or both. By my understanding of the rules, observations are an in-camera discussion.
In terms of the order, we can decide to do clause-by-clause consideration now in public, if you do not feel we are going to make amendments, and then we can go in camera for discussions about observations, which could involve recommendations relevant to what we heard this morning. We can also do the observations first, going in camera now, and do clause-by-clause in public afterwards.
It is now 12:25 p.m. Our normal timing is to be finished by 12:45 p.m. However, we brought in lunch, so we could extend it to 1:15, which means we would have 15 minutes to get to the Senate chamber. We could go as far as 1:15 if you think we can finish it today. If not, we can come back next week to do more work on it.
In any event, we should have a discussion in camera; according to the rules, those are the options.
Senator Pépin: I think we should go in camera right now and discuss what we want to say. We can do clause-by- clause after, but I think we should sit down and be able to talk to each other.
Senator Trenholme Counsell: I have to leave to chair a committee at one o'clock. It seems to me, especially after listening to Dr. Butler-Jones, that the concerns that came up today are outside this bill. The governing structure is not defined in the bill. Staff can correct me if I am wrong.
Without some major changes to the bill, I do not think it is appropriate to say this group or that group needs representation or needs a report or needs committees. Both the Canada Health Act and the Public Health Act are significant issues in our health care system, and the more I listened to the Chief Public Health Officer of Canada, I am not sure things can be resolved with amendments to this bill.
The Chairman: If there is a quick answer, that is fine. Otherwise, that can be discussed in the in camera session. The answer is not an easy one. Are there any other suggestions on procedure? Senator Pépin has suggested we go in camera at this point in time to discuss observations. Is that agreed?
Hon. Senators: Agreed.
The Chairman: Thank you very much. If senators agree, senators' staff can stay.
The committee continued in camera.