Proceedings of the Standing Senate Committee on
Aboriginal Peoples
Issue 13 - Evidence - June 23, 2009
OTTAWA, Tuesday, June 23, 2009
The Standing Senate Committee on Aboriginal Peoples met this day at 9:30 a.m. to study on the federal government's constitutional, treaty, political and legal responsibilities to First Nations, Inuit and Metis peoples; and on other matters generally relating to the Aboriginal Peoples of Canada (topic: update on efforts to address the spread of H1N1 in First Nations communities.)
Senator Gerry St. Germain (Chair) in the chair.
[English]
The Chair: Good morning. I would like to welcome all honourable senators, members of the public and all viewers across the country who are watching these proceedings on CPAC or on the Web.
I am Senator St. Germain, from British Columbia, chair of this committee. Our mandate on this committee is to examine legislation and matters relating to Aboriginal peoples of Canada. Today, the committee is looking for answers. Members have expressed their desire to get an update on the efforts made to address the spread of H1N1 in First Nations communities.
[Translation]
Today, we welcome witnesses from a national First Nations organization, as well as officials; they are going to provide us with an update on the efforts to address the spread of H1N1 influenza in First Nations communities.
[English]
First, let me introduce the members of the committee who are present. On my left is the Deputy Chair, Senator Sibbeston, from the Northwest Territories. Next to Senator Sibbeston is Senator Brazeau from the Province of Quebec. Then we have Senator Lang, from the Yukon; Senator Lovelace Nicholas, from New Brunswick; Senator Dyck, from Saskatchewan; and Senator Hubley, from Prince Edward Island. On my right is Senator Peterson, from Saskatchewan; Senator Campbell, from British Columbia; and next is Senator Watt, from Quebec; and Senator Carstairs, from the Province of Manitoba.
Senators, let me introduce the witness who will address us this morning. First, from the Assembly of First Nations, we have Dr. Kim Barker, Senior Public Health Advisor.
Dr. Barker, we thank you for coming this morning. I know it was on short notice, but thankfully you made it here. If you would be so kind to keep opening remarks as precise and concise as you can to leave time for the senators to ask questions of you.
If you are comfortable and ready, you have the floor.
Dr. Kim Barker, Senior Public Health Advisor, Assembly of First Nations: Thank you very much.
[Translation]
First, I would like to tell you that I will be speaking in English today.
[English]
I would like to thank the Standing Senate Committee on Aboriginal Peoples for providing this opportunity to present on behalf of the Assembly of First Nations. I congratulate the committee for its speed and diligence in addressing this important health issue. As you know, the Assembly of First Nations is the national organization representing First Nation citizens across Canada.
It has become increasingly reported that the H1N1 virus is striking very hard at a growing number of First Nations communities. I think there are three very important points to make immediately about this pandemic. First, H1N1 has thus far resulted in mild symptoms, and there have been few deaths across Canada. In fact, as of last week, the total number of infections in Canada was 6,457, of which 404 have required hospitalization and caused death in 15 cases.
You may have heard some media reporting that H1N1 has caused fewer deaths than normally occur during a regular flu season. It is certainly fortunate that H1N1 was not a more virulent virus because, if it had been, the impact on First Nations communities would have been devastating. I will speak to that a bit more in a moment.
However, I want to raise a second important point: Despite the fact that majority of H1N1 cases have been mild so far, we do have great cause to be concerned about the potential impact of this virus upon First Nations. We need to be concerned about H1N1 because, as the World Health Organization has warned, H1N1 could return in a more virulent form this autumn. If there is no improvement in planning and services, we fear that any increase in the virulence of this virus could have a tragic impact on First Nation communities.
Third, the World Health Organization has been very clear that there is a link between the severity of influenza cases in First Nation communities and pre-existing chronic diseases: living in poor and overcrowded housing, poor access to clean water and substandard health care.
The Senate Subcommittee on Population Health has recently issued an excellent report addressing the impact of social determinants upon health and health outcomes. The impact social determinants have upon health must also be considered during an outbreak of pandemic influenza.
We know that conditions akin to those of the developing world exist in many First Nations communities. This has placed our communities at the highest level of risk in Canada. As Dr. Joel Kettner, Manitoba's Chief Medical Officer of Health, has pointed out, First Nations people are among the most severe cases in his province. From a population and demographic perspective, First Nations are overrepresented in the severe cases.
According to Dr. Kettner's numbers, two-thirds of the 24 Manitobans with H1N1 in intensive care units requiring mechanical ventilation are First Nations peoples. Given that Aboriginal peoples make up only 10 per cent to 15 per cent of the population of the province, two-thirds on mechanical ventilation surely shows an unduly large proportion of illness.
In addition, we know from experience that whether it was the pandemic of 1918 or the frequent outbreaks of tuberculosis in the provinces of Manitoba and Saskatchewan, First Nations have been most vulnerable in the past and present. It is necessary for the federal government to act upon its fiduciary responsibility to First Nations to ensure they enjoy the same level and quality of health care and protection as others in Canada. However, achieving the same level of care is not possible by simply applying pan-Canadian approaches to pandemic preparedness; doing so would not achieve the same results.
A pandemic plan for First Nations must take into account geography, social determinants of health, pre-existing health conditions and the unique cross-jurisdictional arrangements that make up the health care system for First Nations.
I would now like to return to the point I made earlier when I said that it is fortunate that the H1N1 virus was not more virulent because it could have wreaked devastation on First Nation communities.
Knowing already that First Nations are a highly-vulnerable group for a pandemic and knowing the social realities that exist in far too many of our communities, we have further concerns about how the outbreaks have been managed so far. As outbreaks of H1N1 spread through Northern Manitoba and Ontario over the last two months, First Nations communities witnessed delays in receiving urgently-needed medical supplies, breakdown in communication between provincial and federal governments, and a lack in consistency in managing the outbreak between the provinces.
It was also clear that measures aimed at containing the virus were ill-suited to the social realities of First Nations. For example, First Nations were told to avoid contact with others, even though most live in cramped and overcrowded conditions. Similarly, they were told to wash their hands frequently, even though many did not have running water in their homes. This is not an effective approach to dealing with this crisis.
I would like to flag some of our other concerns regarding the Manitoba breakout. In the case of St. Theresa Point, Manitoba, the nursing station in that community with a population of 3,200 people had 1,356 people in the community — more than one third of their population — reporting an illness to that nursing station during the month of May. Five hundred and sixty-seven of the people living in that community reported respiratory-like symptoms.
During that month of May, there was no increase in access to health care services. In fact, other First Nations communities had to sacrifice their own nurses from Norway House, for example, to be able to service other communities that were suffering with these high burdens of illness. Furthermore, no antivirals were sent to the community until June 3, the day it was revealed that 12 residents of St. Theresa's Point had been sent by medevac to Winnipeg and hospitalized with the virus. By this time, hundreds of community members from St. Theresa Point were suffering from flu-like symptoms.
As the outbreak spread to Garden Hill, Manitoba, the response continued to be slow. On June 3, the first H1N1 case was confirmed in Garden Hill. Supplies such as masks, gloves, sanitization equipment and antivirals were ordered for the community. However, they took so long to arrive that the chief himself had to drive hundreds of miles to purchase these supplies. When he came to Ottawa last week and met with the Minister of Health and the Public Health Agency of Canada, he was told masks were not required and therefore he would not be reimbursed for the purchases that he made for his community.
Again, I assert that if H1N1 had been more virulent, these communities would have been devastated.
Let us compare the scenario in Manitoba with the more recent outbreak in Ontario. When 10 cases of H1N1 were confirmed in Sandy Lake First Nation in Northern Ontario on June 13 and 14, a shipment of 500 treatments of Tamiflu, the antiviral drug that combats the flu, was sent immediately. The instructions were to provide the drug to anyone showing signs of illness, forgoing the usual testing to determine if patients indeed had the H1N1 virus.
The Assembly of First Nations does not wish to point fingers at anyone. What we want to highlight to this committee is the lack of consistency in managing these outbreaks and, as important, how crippled the health care system became in Manitoba with only a few communities involved. Let us imagine in fall if there is an increase in the number of communities. How prepared will the Province of Manitoba and other provinces of Canada be to be able to respond appropriately?
However, with sincere respect to the good people working at Health Canada, the Public Health Agency of Canada and in provincial health care systems, we must discover the full facts and identify any gaps or barriers in the system if we are to ensure that First Nations are equally prepared and protected in the event of a more severe outbreak this fall.
For this reason, the Assembly of First Nations is recommending that an independent task force be struck to study the recent outbreaks in Ontario, Manitoba and Saskatchewan and make recommendations to ensure a more seamless service approach. First Nations health experts must also be on this task force for it to produce effective and targeted results. There is also a need for the federal government to review with the provinces and First Nations the inter-agency protocols in place during an outbreak, including the public communication and information sharing components and conduct real-scale simulations to validate these protocols.
There must be an agreed-upon approach and standards to prevent the feeling that varying approaches across the country might create a sense of some regions servicing First Nations more appropriately than in other regions. Further, we would like to recommend that the government work with First Nations to develop and implement national guidelines for emergency health services to First Nations. It is our hope that this work will take place and be implemented by the fall.
Your committee may wish to request an annual state of preparedness report from the federal departments involved until such point that you are assured a plan is in place and simulations have been performed to ensure it will function as planned.
I would now like to turn the committee's attention to Annex B: Influenza Pandemic Planning Considerations in On Reserve First Nations Communities, which I believe was provided to you over the weekend, both in English and French. I would like to say that this is an annex to the Canadian Pandemic Influenza Plan of which the Public Health Agency of Canada has the lead. I would also like to let this committee know that the Assembly of First Nations was involved in the development of this annex and we support it fully.
However, we have concerns regarding this annex that I would like to turn your attention to. We have repeatedly heard over the last few weeks the federal Minister of Health assuring the public that the $1-billion investment into Canada's pandemic plan has resulted in a robust preparedness and several activities across the country. This investment was indeed made. However, it was made and funds were allocated in advance of the development of Annex B. The $1 billion investment has not been allocated to activities of Annex B that is the portion of the Canadian Pandemic Influenza Plan to address outbreaks in First Nations. We know that insufficient numbers of First Nations communities have pandemic plans in place. The majority of communities are unprepared for a pandemic outbreak.
Furthermore, we are gravely concerned that the level of activities listed in Annex B for the provincial, territorial and federal governments are not sufficiently supported in order to implement the guidelines as listed. We are even more concerned because the Assembly of First Nations has been raising the issue with the federal government since the SARS outbreak a few years ago. We had hoped lessons from SARS would have been learned and applied to pandemic planning.
It is our recommendation that immediate investments be made into Annex B to ensure First Nations, federal, provincial and territorial governments can carry out the activities outlined in Annex B.
Finally, we have two other points concerning the annex. First, Annex B does not contain language inclusive of First Nations communities north of 60. It is our hope that governments will work with the Assembly of First Nations to ensure that communities in the Yukon and the Northwest Territories are protected equally. Should an outbreak occur, we do not wish for confusion over the language contained in Annex B to prevent urgently-needed health services from reaching these communities.
Second, we are concerned that the Department of Indian and Northern Affairs may not be prepared for its role as outlined in Annex B. According to Annex B, in preparing for and responding to the threat of an influenza pandemic in on-reserve First Nations communities, INAC is responsible for the following:
Ensuring the continuity of its governance and provision of essential services through implementation of the department's Pandemic Influenza Business Continuity Plan; and
Emergency management on all reserve lands across Canada, except where the responsibility (e.g. public health) falls within the mandate of another federal department (i.e. Health Canada).
To date, we do not know if INAC has plans in place to fulfill its responsibilities. If it does, we have not seen them. It is critical to ensure these plans are established and in place and that funding is available to support them. We recommend that your committee approach INAC to seek clarification on this matter.
The health and success of First Nations peoples, in my opinion, is the single-most important public health goal in Canada. The system must be inclusive, fair and it must also fit the unique needs of First Nations. The Canadian pandemic plan is only as strong as its weakest link. We have all borne witness to that weak link in the last two months.
I would like to thank the Standing Senate Committee on Aboriginal Peoples for this opportunity to speak. I would welcome questions.
Senator Brazeau: Dr. Barker, you cited a few statistics with respect to individuals that have been affected by this disease as well as those who have had respiratory problems. Is this data that the Assembly of First Nations has gathered or is this data already cited in the media?
Dr. Barker: We receive this data daily from the provincial medical officer of health. We have teleconferences with Dr. Joel Kettner.
Senator Brazeau: Could you elaborate on the level of engagement that you have had with both federal and provincial governments and the affected leadership of the First Nations communities in dealing with this issue?
Dr. Barker: We have had daily teleconferences with the Assistant Deputy Minister of Health for FNIP, and occasionally the Public Health Agency of Canada participated in that teleconference. There has been an opportunity for us to raise our concerns and, similarly, for them to attempt to reassure us that everything is under control.
Senator Brazeau: You mentioned the fact that we should not be looking toward a pan-Canadian approach. Can you elaborate on that, please?
Dr. Barker: At the moment, the pandemic plan services all Canadians as though everyone was at the same level of risk. The plan assumes that all Canadians are able to access services within the same level.
Our concern is that having stockpiles of antivirals in Edmonton, for example, and assuming they can be distributed equally and quickly to all communities is probably shortsighted, given the access issues.
We are looking to develop guidelines, and encourage the government to develop guidelines, for remote communities to ensure they are not treated as downtown Edmonton or downtown Toronto.
Senator Brazeau: Obviously, we are dealing with an urgent matter, an important matter. I think every Canadian sees this as being a serious matter. What I have heard this morning is the recommendation to strike a task force; the fact that perhaps some are not happy with language utilized in the preparedness or the strategies that have been put in place; the fact that, in your opinion, the federal government has not properly addressed recommendations following the SARS outbreak — we are talking about responsibilities and jurisdiction, which are important; and the fact that this pan-Canadian approach is not the desired approach.
Is not the most important goal to ensure that Aboriginal peoples have access to the supplies and treatment that they need, first and foremost, before talking about these processes to be set up that would take a longer period of time? Instead of getting to the action, we would be embroiled in processes and a lot of talk and very little action.
Dr. Barker: That is always the concern. However, I think you would agree, senator, that in order for change to happen, there is a process that one must respect. Unfortunately, it tends to be a lengthy bureaucratic process, but that is why we are requesting that this action happen before the fall.
Senator Lang: I just want to put a couple things on the record. I do not know how the nurses' stations run in these small communities. I have not been in these small communities personally. However, I first want to say that for those people that are working on the ground, I think that we should give them accolades for what they do and how they do it. It concerns me that there seems to be a lot of ability to always lay a lot of blame on whomever. Hindsight is 20-20.
From the evidence you have provided us so far, I gather that you are in constant communication with the AFN and Health Canada in respect to this issue.
In May, when this first became known, what advice did you give Health Canada that they could do to help accommodate the situation that obviously came as a surprise to everyone?
Dr. Barker: We were concerned about the lack of nursing in the community and the delay in identifying the outbreak. We suspect that is linked to the rapid turnover of nurses that come in and go within 24 hours. Therefore, our first approach was to suggest an increase the number of permanent health care workers so that they recognize an outbreak much sooner.
With respect to antivirals, we were very concerned about the number of Medevacs. We suggested that antivirals be implemented much earlier in a more aggressive early-treatment approach in the community. However, we were told there was not sufficient scientific evidence to support that implementation.
Senator Lang: You mentioned planning and service, looking ahead in respect to the autumn. I share Senator Brazeau's concern. A committee will not fix this, even in the fall, I suspect.
What have you requested that Health Canada do to meet the situation that these people may face on a day-to-day basis? What can be improved?
Dr. Barker: Senator, I think the biggest success we could hope for is that funding to support the activities listed in Annex B be provided. We have all signed off on it; every Deputy Minister of Health from across the country has signed off on Annex B, and we have approved Annex B from all of our communities.
What we need is financing to support the activities listed. As you can see, there is a ton of activities that provinces are expected to take on. No province will undertake those activities if they do not have a commitment from the federal government that they can keep their receipts and be reimbursed afterwards.
The Chair: I have a quick question. In view of the fact this is possibly affecting First Nations more severely than other communities, it has to be a concern of the provinces and all of us. Unless these communities are put under quarantine, this disease could spread. We know that these people move around and with them the virus.
I can see why we have to focus on the First Nations, but I think all Canadians are concerned. Most of us travel on airplanes continually; and our exposure, as politicians, is most likely greater than most.
I sympathize with your concerns in dealing with the First Nations because that is why we are here this morning. Senator Carstairs suggested this hearing and I think it was the right move, but what I am trying to get through my mind is this must be as important to the provinces and their populations as it is to anyone.
To me, this is important right across the population. What is your reaction to that, Dr. Barker?
Dr. Barker: I think that is a very valid point. The one comment I would make to that is to reassure this group that as a healthy, wealthy group of gentlemen and ladies sitting around this table, the likelihood of you having a severe illness is minimal. We have noticed that mild cases in Canadians tend to be among our healthy and wealthy.
What we do not see is that First Nations, who generally represent a more impoverished group, are having the same reaction to the infection. We are suggesting that we need to identify at-risk populations. Given that, for the most part, First Nations communities are living in poverty, we feel that is what largely puts them at risk — just like the people who live in the Mexican slums.
Senator Carstairs: I was informed that the pandemic plan for Aboriginal communities provides $3,000 for each community. If you live in any of those communities that you mentioned today — St. Theresa Point, Garden Hill — that would amount to taking a maximum of three people out of the community to have any discussions whatsoever.
How are Aboriginal communities supposed to develop, within Annex B, the kind of pandemic planning that is necessary on $3,000 per community?
Dr. Barker: We agree with you and that is an ongoing concern. The point behind Annex B is not that it necessarily needs funding just to First Nations communities, but it needs funding to facilitate greater partnership between regional health authorities and the provinces.
Frankly, if there was to be a widespread outbreak, we cannot expect that Ottawa will be able to service all 633 communities. It is absolutely essential that the regional health authorities and provinces have strong relationships to be able to service communities in a given outbreak.
Similarly, another challenge is that many of these communities have experienced epidemics of suicide, diabetes, and mental health issues. Asking chiefs to make this a priority is difficult when they are struggling with so many other priorities. It is incumbent upon us to ensure that they have the resources, partnerships and facilitated communications to ensure that community members are prepared.
Senator Carstairs: Dr. Allison McGeer, who was on the front line of the SARS epidemic and contacted SARS, has urged the implementation of a pilot program whereby Tamiflu would be used as a prophylactic.
Has there been any discussion with Aboriginal communities, in particular with the AFN, about using Tamiflu in this way to determine whether it might significantly reduce the number of cases within a community?
Dr. Barker: There has been a great deal of discussion, in particular in Ontario where we saw that early aggressive treatment was very effective in reducing the number of severe cases. Certainly, many chiefs came forward and said they would like to be able to identify people with chronic underlying conditions that make them more at risk to go on prophylaxis before they become sick. The chiefs are interested. Unfortunately, there are many other considerations, such as the side effects. Might we potentially cause a mutation within the virus? Might Tamiflu no longer work in the fall when we have a new outbreak? There are many other questions that need to be considered, but I agree that we need to look at prophylactic use as a sincere option.
Senator Carstairs: One of the real problems in communities like Garden Hill and St. Theresa Point, as you said, is that they do not have running water. The need for alcohol-based hand sanitizers became critical but they were not available in the community. As you indicated, Chief Harper had to drive out of the community to obtain hand sanitizers. Meanwhile, empty medevac planes were flying into the communities.
An issue was raised that concerned me greatly. There was some discussion about whether hand sanitizers should be made available because they are alcohol based.
Dr. Barker: I must say that I was equally devastated. I quickly pointed out that it is as easy to get a bottle of Lysol in these communities as anything else. If people think that Purell will be purchased so they can become intoxicated, then that is an outrageous leap to make. We heard that argument and that people were spending days discussing the pros and cons of a non-alcohol-based hand sanitizer versus an alcohol-based sanitizer because of the concerns about addictions in communities. It was absolutely outrageous.
Senator Carstairs: I have many other questions for the second round, if I may.
Senator Stratton: I will follow Senator Carstairs line of questions. I had the good fortune, if you want to call it that, of having a mother-in-law who was a public health nurse on northern reserves for years. I had the experience of visiting most of these communities. I can understand fully the problems that these communities face today.
I will relate anecdotal evidence of Southern Manitoba. I take French language training at St. Boniface College. My French professor looks after special education children in Southern Manitoba communities and small villages. I asked her what the incidence of H1N1 was in the francophone school division and she said that there were very few cases. She explained that in the francophone school divisions, the children wash their hands as soon as they enter the school at nine o'clock in the morning. They wash their hands when they go to recess and when they return. At lunch, they wash their hands and when they come back from lunch, they wash their hands. They wash their hands before leaving for the day. I am not saying that is the complete solution to the problem, but it is part of the procedure in the francophone school divisions. Is that happening in schools in Northern Manitoba? If not, why not?
Dr. Barker: I am not familiar with whether schools are following that routine. Senator, I think that is a good idea, but I have to ask whether the schools have running water.
Senator Stratton: I have been in many schools up North, and they have running water. I would be surprised to learn that they did not have it, at least in any of the schools that I have seen.
Dr. Barker: I have been to a few schools that do not have running water. I agree that it is a terrific public health measure.
Senator Stratton: It accomplishes two things. It teaches the children how critical hand washing is to health, because young children can be walking plagues. I have six grandchildren and know about all the germs they might pick up from other children at school. Surely, we have to try to take the simple measure of keeping those kids' hands as clean as possible.
Dr. Barker: I agree. As well, it highlights another point: Collectively, we are responsible for recognizing the roles that we can play. It is not simply up to the nurses and doctors but up to leadership, schools and even the grocery store manager to ensure that he is stocking nutritious food. Everyone has a role in this issue.
Senator Dyck: Thank you for your clear presentation, Dr. Barker. My question is about the age of the people who have contracted the disease. You were saying that two-thirds are on mechanical ventilation and that chronic disease and social determinants are playing a role. I assume that the people who have been affected most seriously are adults. Is that the case?
Dr. Barker: They are young adults and older youth.
Senator Dyck: In general, the virus seems to have targeted people that are 5 years to 24 years of age. As you well know, 50 per cent of the Aboriginal population is 24 years old and younger. Does this demographic add a greater emphasis to the need to put plans in place?
Dr. Barker: Absolutely, yes. That is a very good point.
Senator Dyck: Presumably that age group is the healthiest in a population.
Dr. Barker: One would presume so, but there are other reasons that a virus would cause more severe symptoms. It can occur when an immune system is not well nourished and overreacts to certain infections, causing greater damage to lungs and so on.
Senator Dyck: How do we identify the most vulnerable, which seems to be the younger-aged group? Perhaps developing a program for use in the school system might help to control the spread of infection there but not necessarily at home. You said that there are 633 First Nations across Canada. Do we have any way of knowing which of these communities would be most vulnerable?
Dr. Barker: The hope is that once we have a vaccine, we will target Canadians at large, beginning with those who are under 40 years of age and children, as well as all Aboriginal Canadians. Our hope is that before we see the next major flu, we will have that vaccine in place for everyone.
Senator Dyck: That would include all 633 First Nations.
Dr. Barker: Yes. I do not think we would try to figure out which one over which other. That would be tricky.
Senator Sibbeston: Dr. Barker, apart from the poverty that exists amongst Aboriginal people, do have any information as to whether the fact that they may be less immune to viruses like H1N1 plays a part in Aboriginal people being more vulnerable to this sickness?
Historically, we know that diseases have ravaged Aboriginal people since their first contact with Europeans. Is there any information to suggest that Aboriginal people are perhaps more vulnerable to these diseases than other people?
Dr. Barker: That is a very good question and one that was raised during our meetings. First, we know that the immune response of First Nations and Inuit people to tuberculosis is completely different to the immune response of non-Aboriginal Canadians.
We also know that the Public Health Agency of Canada has been focusing on H5N1, anticipating we would be looking at chickens from China rather than pigs from Mexico as the cause of the outbreak. Within that, the agency specified that they really did want to ensure they had done studies on serum from First Nations to ensure that their response to the vaccine and to the virus was similar. Of course, our concern is that the vaccine may not actually work on First Nations or may be less effective on First Nations communities because of the way in which the immune system is stimulated.
Now that we are focusing on H1N1 and not H5N1, we hope we will be looking at another opportunity for funding for such studies. You are absolutely right; it is necessary to look at that.
Senator Lovelace Nicholas: Do you think the pandemic would have gone as far as it did if the government and INAC had done their jobs, such as ensuring there is running water and proper housing?
Dr. Barker: I think we would have seen a very different situation if First Nations had proper housing without overcrowded conditions, with running water and proper food security. I think we would have seen a very different situation.
Senator Lovelace Nicholas: They are responsible for essential services in First Nations communities. Why do you think there was a gap in this type of situation? Not every community was as bad as Manitoba and remote places. Why do you think there was such a gap?
Dr. Barker: I think it was just unlucky that communities in Manitoba were struck. If the virus had reached any other location that had similar demographics and similar social determinants, it would have behaved in a similar way.
I think this is a major wakeup call and I hope that Canadians will recognize the need to address the underlying social determinants of health if we are to make any progress in First Nations communities.
Senator Lovelace Nicholas: I have noticed that health care in general has diminished in First Nations. What was covered previously is not covered now. I would like you to explain, if you can, who is responsible for that.
Dr. Barker: That is a very complex question. However, I would say that every one of us who has the power to elect our government is responsible.
Senator Peterson: Thank you, doctor, for your presentation. It is my understanding that there is not enough vaccine to immunize the Canadian population; in fact, it will be available in batches. As a result, the Public Health Agency of Canada is preparing a priority list. Is that list completed and have you seen it?
Dr. Barker: No, we have not seen it and they are busy preparing it.
Senator Peterson: How long will they be preparing it?
Dr. Barker: I have no idea, but we hope it will be on the agenda this Friday, when we will be meeting with them to discuss rural and remote communities.
Senator Campbell: Thank you very much for appearing today. I find myself looking at this and saying, ``We have what we have; this is where we are right now. What will we do?''
I do not see a task force as an answer. We have a situation on our hands where we have an emerging emergency in First Nations and, by the time we get around to a task force, it will be fall before they even figure out who should be on said task force.
You have Annex B and everyone has signed off. There is $1 billion floating around somewhere for something to do with the pandemic. What is the holdup for us getting resources? When I talk about resources, I am talking nurses and, as Senator Stratton said, the basics. I am talking about just having tissues and all that type of stuff.
How do we get this going? This will certainly not be the last we see of this on First Nations, or in other isolated communities. How do we get this moving?
Dr. Barker: The $1 billion is already gone; $657 million went to the Canadian Food Inspection Agency to monitor chickens with H5N1; the remaining $350 million has been allocated and spent. Part of our concern is that part of those dollars was spent in developing Annex B but there is no money left to implement it.
Senator Campbell: Who should we be talking to about getting more money? I will read from Annex B under the First Nations responsibilities. I believe Senator Carstairs brought it up. It is on page 11:
. . . First Nations leadership and health care providers are responsible for the following:
Developing, testing and regularly updating a community influenza pandemic plan in collaboration with the appropriate partners and stakeholders.
It seems to me this is not a tough thing to do. These communities look very much alike and they have many of the same problems. Why are not all of the providers getting together? Why can that not be done? You cannot do it for $3,000 when you have to fly in and out of these remote communities.
All of these communities have commonalities. I do not know why the communities could not be brought together in one spot and develop a plan. Once they have the plan, they could lay down all of the resources and get those resources to where they are needed most. I do not understand the issue. Why does this happen?
Dr. Barker: We do not understand, either.
Senator Campbell: Who is responsible? I hate the term ``responsible'' but who has the task of taking care of this problem?
Dr. Barker: The First Nation and Inuit Health Branch is responsible for ensuring pandemic plans are in place for First Nations communities. Indian and Northern Affairs Canada is responsible for ensuring that emergency preparedness plans are in place. There are overlapping roles and responsibilities that require financial resources that may not be available.
Senator Watt: Welcome, Dr. Barker. I might be a little bit different from the rest of the senators. I will not focus so much on the disease itself but on the condition of the communities.
Does the AFN have an inventory of all the communities right across the country in terms of the condition of the communities?
Dr. Barker: What would be on that inventory list?
Senator Watt: The list could include quality of water, the quality of communities, housing issues, overcrowding and available health services. It is the information necessary to have a community function properly. Do we have an information inventory that has been prepared and brought up to date? Who has that information? Is it the Department of Indian and Northern Affairs or the Assembly of First Nations?
Dr. Barker: The Department of Indian and Northern Affairs would keep a lot of the information. However, it would be in silos. The person responsible for water would have one bit and the person responsible for housing would have another bit and as a result, no one person could give you a total picture of what every community looks like.
Senator Watt: Unless we have a clear idea of what exists in the community itself, this disease, which seems to be warming up, will not improve until we focus on community requirements.
What are we doing here? This is my question. We talk a lot about the disease, but we cannot do anything about the disease unless we have a clean community. That is a big part of it.
At some point, this committee will have to make recommendations to the government. The only thing I can think of is to get the military involved because of the urgency. The virus will spread in those communities. Some of my colleagues have indicated, especially the chair of the committee that it will spread not only within the community itself but it will spread on the outskirts into Aboriginal communities and non-Aboriginal communities.
Dr. Barker: We will all be competing for very few ventilators.
Senator Watt: Exactly.
We talk about people on-reserve. What about the people off-reserve? Some communities are even worse off than the reserves. We need to have that report. Maybe it already exists. With all of this information, this committee must make a decision or a recommendation. We cannot handle it ourselves anymore. It is too big. It will get bigger and bigger.
Senator Hubley: A small paragraph in Annex B refers to ethics. It states, ``There are a variety of ethical principles that guide decision making during any emergency, including an influenza pandemic.''
Does having that paragraph give some protection to our First Nations' communities? Does it bring their conditions to the forefront if we have a plan indicating that we must treat those communities hardest hit during a pandemic? What is your opinion on the ethical principles involved?
Dr. Barker: We felt it was important to include something in the area of ethics. We went across the country speaking to First Nations' communities about pandemic preparedness and use of antivirals.
For example, if elders in the community were not on the Public Health Agency of Canada's list of priority groups in the discussion around decision making, what flexibility might exist within a community who value their elders tremendously to make that decision for themselves? Another issue was around the use of traditional medicine — that its use be respected and ethics around the respect of permitting the use of traditional medicines.
Different ethical issues come out of pandemic planning. We wanted to ensure it was included.
Senator Carstairs: My question has to do with vaccines. There has been some talk that first availability of vaccines would be to Aboriginal communities. Is there such a commitment?
Dr. Barker: This is not a commitment yet; it is a draft in progress. It is important to remember that even once it is written down that Aboriginal people will be getting vaccines first, I would be delighted to see the logistics involved in that.
We saw the delays in getting essential supplies to one community. What will happen when we are trying to get vaccines to 633 communities? The support and logistics will be as important as any commitment to vaccination of a priority population.
Senator Lang: I want to follow up on Senator Watt's observation about the inventory in these communities. I am not familiar with Northern Manitoba. I have not been there. Have you been to all of the communities in Northern Manitoba?
Dr. Barker: I have not been to all of the communities, but I have been to several of them.
Senator Lang: It troubles me with the broad statements made that there are many schools without running water. I would like verification of that statement. In deference to us, it sounds as though there is not a water truck or well or any infrastructure in all of Northern Manitoba. Frankly, I do not believe that statement. It is important that we find out how many communities do not have trucked water, piped water or well water.
Dr. Barker: I certainly did not mean to suggest that none of the schools have water; however, some of the schools I have visited do not.
Senator Lang: I think the committee should have that information.
The Chair: We will try to get that information.
Senator Dyck: Which communities are most vulnerable? You said you needed to identify at-risk communities. That type of information is critical. It could be that the affected communities are the most overcrowded communities without clean drinking water. We must have that information; it is critical to the control of the disease.
We need to know the magnitude of the problems across the country with respect to clean drinking water and overcrowding.
Dr. Barker: Senator, to build on what you are saying, we also have to recognize that this is a new virus. We are still learning who is at risk and what characteristics put an individual or a community at increased risk.
It has been a difficult situation for health care professionals to make difficult decisions in the absence of valid information. Hopefully, with more data and more evaluation over the summer, we will be better able to describe those at-risk populations.
The Chair: Dr. Barker, the chickens are coming home to roost and the lights are going on. This is about all Canadians. It is not a partisan issue. Government after government — provincial and federal — have watched this situation deteriorate. It also includes Aboriginal politics.
Unless we do something different, we will continue to have the same results. We have to do something on First Nations reserves and off-reserve. If we do not, we will have more of these situations. You can blame everyone, but you should not point any fingers. We have created a horror story for First Nations people for the last hundred or more years.
It is time for the AFN and every group — governments, oppositions, whoever — to start working together and to make a difference in the quality of life for our First Nations people. Otherwise, it will victimize all of us.
I want to thank you for being here this morning and for being straightforward and candid. As you point out, we are the healthy and the wealthy. It is up to us to do something.
We now have with us representatives from the federal government to discuss the situation regarding the spread of H1N1 on the reserves in First Nations communities. Ms. Anne-Marie Robinson is the Assistant Deputy Minister, First Nations and Inuit Health Branch. I would presume you have a presentation to make to the committee, Ms. Robinson.
Anne-Marie Robinson, Assistant Deputy Minister, First Nations and Inuit Health Branch, Health Canada: Good morning, honourable chair and senators. I would like to take the opportunity to introduce my colleagues. Dr. Danielle Grondin is the Acting Assistant Deputy Minister, Infectious Disease and Emergency Preparedness Branch. She is here on behalf of the Public Health Agency of Canada. As well, Shelagh Jane Woods is the Director General, Primary Health and Public Health Directorate, First Nations and Inuit Health Branch; and Michelle Kovacevic is the Director General, Strategic Policy, First Nations and Inuit Health Branch. The latter two individuals are from the First Nations and Inuit Health Branch at Health Canada.
I will be providing you with an outline of roles and responsibilities of Health Canada in supporting influenza pandemic preparedness and response in on-reserve First Nations communities.
[Translation]
As you are aware, the Public Health Agency of Canada is the overall federal lead for public health emergency preparedness and response, including influenza pandemic planning.
[English]
Health Canada, through the Public Health Agency of Canada and the First Nations and Inuit Health Care Branch, which I oversee, along with the regions and program branch, are responsible for ensuring that the special concerns and needs of on-reserve First Nations are considered in planning and response activities of provinces and territories. To ensure a comprehensive and coordinated response to public health emergencies, such as an influenza pandemic, Health Canada works closely with the Public Health Agency of Canada, other federal departments, provinces and national and regional First Nations organizations.
[Translation]
Health Canada promotes the delivery of primary care services in approximately 200 remote and isolated on-reserve First Nations communities, where provincial services are not readily available.
[English]
Through these services, Health Canada manages the response to health emergencies in communities following provincial guidelines.
Health Canada's planning and response to influenza is guided by the Canadian Pandemic Influenza Plan for the Health Sector and, in particular, Annex B for on-reserve First Nations communities. As part of our plan, we provide technical expertise and financial support to help on-reserve First Nations communities develop, test and revise community level influenza pandemic plans.
We have also positioned a stockpile of personal protective equipment, such as masks, in many locations, including remote and isolated communities; and we are in the process of procuring additional supplies to meet longer-term needs of health care workers providing health care services on-reserve. We are also collaborating with provinces to distribute and administer antiviral drugs and vaccines, once available, and many other types of supplies, as we have done over the past few weeks to First Nations communities in the North.
Finally, with the Public Health Agency of Canada, we have established a proactive communications plan, including a campaign to raise awareness and increase personal protection against the virus. This campaign includes public health notices sent to First Nation communities in print media reaching First Nations audiences, and to over 1,400 Aboriginal health organizations.
Nevertheless, despite our best plans, there are some key risks and challenges when First Nation communities are faced with a public health emergency. There are multiple jurisdictions and parties involved. This requires timely coordination, which has been done effectively in response to outbreaks in these communities.
The 200 communities in which Health Canada supports the provision of primary care services are remote, isolated and dispersed over a wide geography. This can present a challenge for responding and requires solid planning. We are working with the Public Health Agency of Canada, provinces and territories to develop specific guidelines to address unique challenges as we continue to plan and go forward.
First Nations communities also have higher incidence of respiratory and other chronic diseases. This may make them more vulnerable to complications related to any influenza-like illness, including H1N1.
We also recognize the challenges faced by First Nations communities with respect to overcrowding and safe access to drinking water. In addition to investments in on-reserve housing made in Budget 2009, we continue to coordinate efforts with all levels of government and First Nations leadership to address these challenges.
Finally, any increase in demand on the health care system across the country and on-reserve no doubt stretches everyone's resources. However, to date, we have been able to provide the care needed.
[Translation]
I understand that you have a particular interest in the situation in Manitoba. We are concerned with the current situation in some reserves and continue to closely monitor them.
[English]
Health Canada has sent, over the past month or so, additional health care professionals, as has the province, to the affected communities in Manitoba to enhance existing primary care services. We have distributed personal protective equipment for front line health care workers in communities and pre-positioned these supplies in other locations in the event of further spread. The Public Health Agency of Canada has also provided ventilators to Manitoba.
Antivirals have been long pre-positioned in some communities in Manitoba to ensure rapid access. Health Canada, in collaboration with its partners, has also distributed hand sanitizers in Manitoba communities, including Garden Hill and door-to-door in St. Theresa Point. We will continue to assess the needs of each community to determine what additional resources are required and to provide ongoing education to residents of First Nations communities on prevention and self-care. Health Canada and the Public Health Agency of Canada are also doing epidemiological work to better understand the impact of H1N1 on First Nations on-reserve.
As with all severe cases across Canada, information on risk factors is being collected and analyzed, and guidelines have been adapted. We continue to do that on a daily basis. When this evidence becomes available, we will continue to have better ideas about the role that things like chronic disease, pregnancy and age play in terms of the severity of the illness.
In the meantime, we are doing everything possible to ensure that First Nations people have access to quality health care. Responding to the outbreak of H1N1 is our top priority. We will continue to work with the Public Health Agency of Canada, provincial public health officials and First Nations in monitoring the developments and assessing potential impacts to on-reserve First Nations communities to ensure that First Nations receive the care they need when they need it.
The Chair: Ms. Robinson we have heard in the news that the Garden Hill chief had to come off the reserve to pick up supplies for the community. Was there a breakdown and where did it occur? Do you have an explanation as to why supplies were not made available to that area, given the high concentration of population in these particular reserves in Northeast Manitoba?
Ms. Robinson: I can confirm to the committee that we had all the necessary supplies in our nursing stations for the community in terms of hand sanitizers, masks, personal protective equipment and other medications. There was some confusion, and I would concede that we continue to reach out to all chiefs. We need to continue to speak to them about what, from a public health perspective, is important to have in communities. In that case, I believe there was some confusion about whether we needed to have, for example, N95 masks being used by health care professionals and other surgical masks for people in the waiting room, as recommended in the guidelines, versus whether people needed N95 masks in their homes, which, from a public health perspective, has not been recommended. There was some confusion about what kinds of supplies were needed. I met with the chiefs last week and we sorted it out. I believe we increased the understanding.
As well, the chiefs had asked for hand sanitizers, and those items have been delivered. We had some difficulty procuring those items but we got them into the communities. In addition to that, we are working with communities about other effective ways to deal with the issue. As we heard in the previous testimony, water is a key concern in some of these communities. Some households, not all, have challenges accessing water. We work with communities to ensure that their water supply is functioning. We do that through our partnership with the Department of Indian and Northern Affairs.
Senator Carstairs: We know that the chief from Garden Hill went into Winnipeg on June 12 to pick up supplies. He informed me that the nursing station did not receive an adequate supply until June 15, which was three days after he brought supplies into the community. Given that the first case was diagnosed on June 3, why were supplies not brought up to speed immediately? Why was there not a physician on site until after June 11?
Ms. Robinson: I can confirm that we have had supplies in nursing stations throughout Northern Manitoba in response to preparations for the pandemic. There is generally a shortage of physicians who are able to go to the North, but we have been able to put physicians in the communities to see patients as required. The Province of Manitoba provides physicians and, through our coordination with the province, we prioritize where the physicians go based on the severity of the outbreak.
We did not always have 24-7 coverage of physicians in Garden Hill, but we significantly improved the coverage. During times when a physician is not available, other safeguards are put in place. For example, we use Telehealth so that a nurse can access a physician for a patient as required. Of course, we also have access to medevac services and LifeFlight, which is an air ambulance for Manitoba Health. LifeFlight can medevac critical patients in remote communities to larger hospital facilities.
Senator Carstairs: That is interesting because I am told that the average amount of time to medevac someone out of the community is between 10 hours and 15 hours, and at times it has taken 24 hours. I understand that the medevac service has been turned over to the province of Manitoba without any consultation with First Nations. Why are they flying out of Brandon as opposed to flying out of Winnipeg, which is faster?
Ms. Robinson: We do not operate a medevac service in First Nations and Inuit Health. I am new in my position but it is my understanding that we never operated medevac as they are provincially operated.
I heard the concerns from chiefs about the length of time for medevac services, so I inquired with the province. Even though it is a provincially-run service, we would be concerned about that because we have to ensure that people diagnosed in communities receive timely access. The province shared a report with us. In that report, I saw that in a one-week period at the height of the flu, the medevac response in the St. Theresa Point-Garden Hill area ranged from less than one hour to a maximum of eight hours. The average time was in the range of three to four hours.
With all due respect I was looking at the time it took from the call made by the nursing situation to medevac to the time that it arrived. Perhaps someone else looked at another time period. I am just reporting what I found. I was happy to learn from the province that in critical cases, they have the alternative LifeFlight available to fly people out of the community if they are not in stable condition.
Senator Carstairs: We know that 31 ICU beds in Winnipeg were occupied by H1N1 patients, two thirds of whom were Aboriginals on ventilators. What has been the impact on the usual hospital population as a result of this additional number? It would be rare to have 20 Aboriginal patients in ICU units in Winnipeg. What has the impact been on health services for all other Manitobans as a result? For the committee's information, 65 per cent of all Manitobans live in the city of Winnipeg, where most of the ICU beds are located.
What other alternatives are being considered? I know that First Nations requested a field hospital, which, apparently, was denied. How are we dealing with this emergency in order to find the appropriate level of care?
Ms. Robinson: Senator, the Province of Manitoba would have to answer most of your question. However, we have daily communication with the Province of Manitoba, and I know they went to great effort to extend the capacity of the hospitals in Winnipeg and Brandon to ensure that there was sufficient ICU support. The field hospital request was raised by a few chiefs from the Garden Hill-St. Theresa Point area. As well, it was discussed recently with our tripartite chiefs committee in Manitoba. Our concern with the field hospital is that it is primarily designed to deliver primary care and we have been able to provide adequate primary care support to First Nations people through our nursing stations.
When people are ill with this kind of flu, they tend to be either mildly ill or moderately ill and they are able to stay at home. Alternatively, they might be very, very ill and, in our view, a field hospital would not provide adequate care for them. The priority must remain on getting very ill people flown to the best hospitals in the country. Through the Canadian Pandemic Influenza Plan, if space is not available in local provincial hospitals, the plan is designed so there is support all across the country. I have already seen that happen. I have seen people from other jurisdictions come into hospitals in other provinces.
Senator Lang: I want to follow up on two areas. First of all, on the question of water, once again we are left with the impression that many of these communities have no water, are very poorly serviced by the water they have or whatever. I would ask any one of the witnesses to tell me how many schools in these reserves in Northern Manitoba are without water. I should say I cannot believe that a school could function without water. I would think it would have to be closed down for health reasons.
Ms. Robinson: I do not have the exact answer to the question because I do not know. We work closely with the Department of Indian and Northern Affairs and we do have data on which communities have trouble with water supply in general. In those communities, we are able to work with the community to look at alternatives and, more importantly, ensure what water supply is actually functioning.
If they have cisterns and they need to have water trucked in, then it is critical. It is critical all the time, but it is particularly critical through this outbreak that we ensure water is trucked in.
We have some communities in Ontario, as well, where INAC is working through us and working, of course, with the chief and council. Every community is different, so it is critical that the chief and council play a key role in this planning. In some communities we have taken in bottled water to assist people in terms of personal hygiene with bottled water where other water is not available.
I cannot give you that information today, but I am quite confident that our regional director generals in our communities, who work very closely with INAC, know which communities are vulnerable from a pandemic perspective, not just because of water but because of many other issues.
We have identified those communities and are working with them to figure out what gaps exist and how we can fill those gaps.
Senator Lang: I want to follow up a little further on Senator Stratton's questioning on hygiene. Have you given instructions or worked out agreements with the schools in these communities where there is water — I am assuming there is water — that children wash their hands four times a day so they get in the habit of doing it and may subsequently prevent something from happening?
Ms. Robinson: I cannot confirm that we have given that specific instruction that you have outlined to schools, but we have widely distributed and had meetings with communities and chiefs, providing information about public health. This is to ensure that in addition to schools, public gatherings, festivals, social gatherings, at home, band council meetings, and every kind of event, people continue to use good hygiene.
Shelagh Jane Woods, Director General, Primary Health and Public Health Directorate, First Nations and Inuit Health Branch, Health Canada: One of the key responsibilities of our nurses in the nursing stations is to continue to spread public health messages. For this, we rely on the messages put out by each individual province. Our nursing stations operate as though they were under the jurisdiction of a province. They take all of the public information a province provides to all of its citizens and ensure the appropriate people in the communities have access to that information.
As Ms. Robinson said, we communicate with the Deputy Minister of Health in Manitoba and her staff each day. We are relentlessly reinforcing those messages and ensuring that communication is going forward to the communities.
As I say, the nurses take responsibility, but they then work with all of the allied health workers in the community to ensure that message is going out. Therefore, the home-care nurses get it, the janitors in the schools get it, the leaders in the school get it; everyone is getting those public health messages.
Senator Lang: This is just an observation, but it seems to me that the principals of each school should be giving these instructions to the students. It is not enough to send this message electronically or through the media. The message should come first hand from the principal of the school.
We have 200 remote communities, and I assume that in most cases, the only access is by plane. Have you considered quarantining those communities that have not had any flu symptoms for a period of time, or at least in part, so these communities can stay healthy without people coming in or out until this thing is sorted out?
Dr. Danielle Grondin, Acting Assistant Deputy Minister, Infectious Disease and Emergency Preparedness Branch, Public Health Agency of Canada: It has been very much entrenched in the communities. On the question of quarantine, based on the evidence, there is no benefit to apply quarantine when dealing with respiratory viruses. We are in discussions with provinces, territories, as well as with our partners to review the whole question of ``borders.'' At this point, quarantine and restricting travel are not necessarily the most effective measures.
In short, at this stage, no, there is no quarantine question. Quarantine issues are part of public health measures. It is one of the six key elements of the Canadian Pandemic Influenza Plan. That is one of the key guides we use for public health measures. Although we say that we are not quarantining those communities, quarantine is looked at in terms of whether it will be effective or not.
At this stage, quarantine will likely have no benefit at all. It is more important to go with other measures as explained by Ms. Robinson, and what is being done as well in ensuring people know what to do and practice good hygiene. Particularly people who are ill should stay at home and have access to antiviral medication. That plan has been put in place. Those who are ill are to seek medical care.
Senator Brazeau: Good morning to you all, and thank you for being here.
Earlier there was discussion here about the use of hand sanitizers, and that perhaps one of the reasons they were not distributed was because they were alcohol-based. To your knowledge, have those discussions actually taken place? If you do not know the answer, could you please look into it and get back to the committee?
Ms. Robinson: Yes, I can confirm that those discussions took place, both with chiefs and public health officials. We have had some rare experiences in our communities where we have had theft of hand sanitizers. We are concerned about it. We do have communities where we have large proportions of people who suffer from addiction. We decided on that issue it is best if we work community by community. Everything we do in all 633 communities must be in response to the specific needs of those communities.
We have had a number of people come forward, and some evidence, where this could potentially put people at risk. For the vast majority of people it is not an issue, but that discussion was with the best interests of our clients in mind, and we have now distributed hand sanitizers.
For those communities where we are concerned about having alcohol-based products, we have looked into another product which is not alcohol based. We have some on back order, but unfortunately we have not been able to secure the product in time.
In addition, we think it is most important to ensure a good water supply, not just in those communities, but broadly speaking, so that people also have the option of doing hand cleansing through washing with soap and water.
Senator Brazeau: Were these concerns raised by Health Canada or did leaders in the communities also raise them?
Ms. Robinson: Both have done so over the years.
Senator Brazeau: Today, can you tell this committee if proper basic supplies are in those communities for those who may need to prevent the spread of the disease, or gain treatment, if it is further along?
Ms. Robinson: I can confirm that our communities have adequate supply. Health Canada has a small stockpile of personal protective equipment, such as hand sanitizers and other things, in a warehouse in Edmonton. However, the backbone of our pandemic plan is to work through the provinces. Therefore, our surge capacity is the province. If the province has a shortage of supplies, then the surge capacity for the province is the federal government, which has stockpiles.
So far, we have access to surge capacity by design of the province, and I can say that has worked seamlessly. The Province of Manitoba has been incredibly helpful to us in ensuring that, when we need supplies in communities and when we need support in terms of health care professionals, those professionals have been made available to us.
Senator Brazeau: Therefore, the province has confirmed that they have forwarded adequate supplies to those communities to the federal health department, is that correct?
Ms. Robinson: Yes. Generally, we transport them but we access their stockpile. If there is any issue with their stockpile, then the federal stockpile has been designed as a backup to the provincial stockpiles.
Senator Lovelace Nicholas: You mentioned that Health Canada works closely with the Public Health Agency of Canada, other federal departments, provinces and national and regional First Nations organizations.
If you work so closely together, why did it take so long to deal with this crisis in First Nations communities?
Ms. Robinson: Again, in terms of managing the outbreak, Canada was first notified that there was a flu situation in Mexico on either the April 17 or April 21. From the beginning of this outbreak and this new flu, the First Nations and Inuit Health Care Branch was included in the public health network across the country, which is comprised of medical officers of health from all of the provinces, as well as our own medical officers of health and all the experts on the facts. We were included right from the beginning in terms of planning. As a result of that, we were able to ensure that First Nations communities had supplies. We also put out lots of information to communities, as previously mentioned, about hygiene and protecting individuals.
When we saw the first outbreaks in the communities in Manitoba, like everyone else, we were very concerned about the severity of some of the illnesses in some of those communities. The next thing we did, as soon as we saw that was our first pattern of severe illness in the country, I believe — Dr. Grondin can confirm that, but I am looking at First Nations communities — it was critical at that point to ensure we understood, from an epidemiological perspective, why First Nations communities were being impacted that way.
We immediately sent in epidemiologists from the Public Health Agency. For me, that is the most critical question to understand. We can put supplies into communities and we can ensure that First Nations have access to antivirals. Another crucial question was who should receive first-priority vaccines. The risk factors have to be well understood. Those are the critical questions.
Even with all the supply in the communities, we have still seen a cluster of serious respiratory illness. We need to understand that from an epidemiological perspective. Our primary concern is to ensure we have the most effective response in place so we can identify people who are sick and continue to adapt our strategies vis-à-vis using antivirals and targeting people within populations who are the most vulnerable.
Senator Lovelace Nicholas: I think we know why First Nations are mostly affected. I think most senators here know why. However, I agree with the senator over here that something should be done now in order to end this problem.
Senator Dyck: Thank you for your presentations and welcome. You were saying that the First Nations and Inuit Health Branch is responsible for 20 communities in remote and isolated areas of Canada. How many people does that involve?
Ms. Robinson: We are responsible for 200 isolated communities. The number of people on reserve is in the range of 400,000 to 500,000.
I do not know how many people are in the remote communities. It is approximately one-third of all communities. I would not want to say that it is one-third of that population number.
Ms. Woods: We can certainly get that number for you.
Senator Dyck: I think it would be important to know how many people you are concerned about. If you are trying to stockpile antivirals, thinking about vaccinations or targeting those groups for priority, you should probably know how many people you are dealing with.
That leads me to my next question. Much of what you presented this morning seems to be emphasizing personal protection, such as hand-washing in schools, for example. School is out now so that will not work. It is summer recess.
When do we decide that we have gone past the point of personal protection and we need to take more aggressive action? When do we start giving out those antivirals? When will we start vaccinating and how will we decide who will get priority? Will these remote communities get priority in terms of antiviral protection and vaccinations?
Ms. Robinson: I apologize for not knowing the answer about the number of people because I agree with you it is critical. However, I can assure you that number is well known by our operation and is included in our planning.
Antivirals are available in all of our communities. The physician makes a decision that the patient requires an antiviral. We have had no issue in terms of having antivirals available in communities. The guidelines are evolving as we understand what the risk factors are in the population.
In terms of vaccination, Dr. Grondin may want to comment. However, my understanding is that a vaccination will not be available until the fall.
The critical question now is based on what we are seeing in terms of how this particular flu is impacting the Aboriginal population. We need to feed that information into the process, which is being done as we speak, to ensure that we appropriately prioritize First Nations access to the vaccination. From what we are seeing on the face of it, there are certainly indications that the impact on First Nations communities is severe, which would mean our planning would account for that.
We do have nurses in all of these communities and our nurses are capable and able to deliver vaccines and to give them to the whole population. We do this on a regular basis for children. We have programs in all of these communities where our public health nurses vaccinate Aboriginal children.
Senator Dyck: I think I heard you say the decision as whether to give the antiviral was up to the individual physician, is that correct.
Ms. Robinson: That is correct. Yes, that is the way the public health guidelines are designed. I will ask Dr. Grondin to comment.
Dr. Grondin: The antiviral is not specific to H1N1 flu viruses. It is a medication prescribed for seasonal influenza. There are two of them, Tamiflu and RELENZA. These are medications you can get under prescription. This practice does not change with the H1N1 outbreak.
To decide to give a prescription medication or not is based on the clinical presentation. This does not change; this is part of sound clinical practice in Canada. The reason to prescribe Tamiflu, mainly, or RELENZA is based on a clinical assessment. However, in the context of H1N1, we have put guidelines for health care practitioners on our website. We have also provided explanations to the general public. Guidelines for the prescription of antivirals do not recommend that they be given as prophylaxis. We must understand that we are in a world pandemic. All Canadians are facing this pandemic.
It is very important to note that we now appear to have antivirals that seem effective against H1N1. The last thing we want from a public health perspective is for the virus to develop resistance to the antivirals. It is very important to use the antiviral judiciously. That is the reason prophylactic use is not recommended. The recommendation is for use in treatment. This is the present public health recommendation in Canada and other countries. That is the reason the guidelines were issued in this manner.
As Ms. Robinson has said, we have antiviral stockpiles in Canada to treat all Canadians that need treatment. That includes First Nations, Inuit and Metis populations. The provinces are responsible for health care. They have a supply of the antivirals, which they will distribute. Should the province's supply run out, we also have our own federal emergency supply.
Senator Stratton: Schools in Manitoba are not out yet. It varies across the country. Schools in Manitoba are out June 30.
Senator Peterson: Who is the lead agency on this file?
Ms. Robinson: We have different roles. My responsibility is to ensure that supplies and medical response within reserve boundaries takes effect. The Public Health Agency has a broader public health role in surveillance and guidance on pandemic planning. The province is a key partner in ensuring First Nations people have surge capacity in terms of supply, public health information or guidelines; and in providing hospital care.
I am sure you know that we have primary care facilities in communities where our nurses and physicians work to identify and triage people in terms of understanding their illness. When someone is determined to be seriously ill, he or she has to be flown to provincial hospitals where the province is responsible for his or her care.
Senator Peterson: Would a progress report on how things are going come from your department?
Ms. Robinson: Yes, we would be the focal point in coordinating and ensuring that First Nations have access to appropriate health care.
Senator Peterson: Is the priority list for the vaccine completed?
Ms. Robinson: I am not preparing a priority list.
Dr. Grondin: There is no priority list. There has been a misunderstanding.
Canada has a contract with the company to produce vaccine. We expect to have the vaccine ready in the fall as Ms. Robinson has said. We will have enough vaccine available to immunize all Canadians who wish to receive it, including First Nations, Inuit, Metis and remote communities. Everyone will be able to be vaccinated if they so wish.
Having said that, you can understand there are complex logistics for mass immunization. Who to start with will be based on epidemiological factors and indicators — who is more at risk, how people react, et cetera. It is also based on the severity of the disease and what we are learning. You have to understand that we do not yet know what will happen in the second wave of this disease. We are watching closely to understand what will happen.
We are working closely with other groups including various provinces as well as Ms. Robinson to establish what you call priorities — who we should start with first. Regardless of what will happen, all Canadians that want a vaccine will get it on time within the flu season.
Senator Watt: What is your relationship with the Department of Indian Affairs in coordinating conditions in communities? We are not dealing with heavily populated communities. Everyone seems to know each other in such communities and there is usually good coordination. Do you have a function to make recommendations concerning housing requirements, drinking water and conditions of the communities and things of that nature to the Department of Indian Affairs?
Ms. Robinson: We coordinate with INAC on two levels. First, in terms of logistics with the flu outbreak, INAC has been on standby to help us if we need to store products, to fly things into communities or we need extra personnel.
Second, in the longer term, I take your point about the determinants of health being amongst the most important issues. Things like the water supply and conditions for housing are of critical importance to Health Canada. It is not only for H1N1, but also as we look at communicable diseases generally. Dr. Barker mentioned outbreaks of tuberculosis and the high incidence of chronic disease. We know some of these things are related to living conditions and poverty.
We have a relationship with INAC on an ongoing basis. We do all the testing for water and we ensure that chiefs, council and the Department of Indian affairs have information about the water supply because our interest in delivering good health care is to ensure First Nations have healthy environments.
The same is true for housing. We have environmental inspectors that go into houses and look for things like mould or vermiculite and other serious health issues. It is not critical not only for H1N1. As Dr. Barker said, we may be seeing more severe result in First Nations with this flu, but it is something we see with many other illnesses in communities. We know we must focus on the long-term social determinants in order to mitigate and avoid these kinds of outcomes.
Senator Sibbeston: I am always amazed by government, particularly civil servants. Whereas people in the community think there is a problem, civil servants at your level always give the impression that things are okay. I do not know if this is the result of the fact that you live and work in a place like Ottawa, very far from the communities where things are actually happening.
Have you been in contact with or have you been in those places where the epidemic situations are located? Have you been in touch with Minister Aglukkaq yourself? She is an Inuit and ought to be very concerned about this issue. Has she made any difference in dealing with this problem?
Ms. Robinson: Thank you for that question. It is something I struggle with a lot.
We have a very large and complex system. To ensure we are doing our job properly in managing the response, it is not only about logistics to ensure supplies are in place and people have access. Communications is a huge part of this system. We have a communications plan but it is not always perfect. That is probably the area where we need to continue to dialogue.
I have personally not been in those particular communities during the pandemic, due to my duties here. However, I can assure you that senior people in our department have visited those communities and visit them on an ongoing basis.
I have visited many other communities. I am also a First Nations person so I understand many of the realities these communities face. We have a large number of people working in our regional offices and other areas who are in constant contact with these communities and understand the realities.
We are pleased to have a minister who is Aboriginal. She has made a huge difference in terms of our ability to manage this file because she immediately understands the issues. She grew up in an environment in the North, which is not unlike the environment we are facing.
She has made herself available to us when required. We have had numerous meetings. In fact, I am meeting her again at noon today for her regular update on how the pandemic is being managed and what needs to be done next.
The Chair: Thank you, Ms. Robinson, and your entire panel. I have one quick question. Do you think you have a good handle on the situation? Have you got it under control, yes or no?
Ms. Robinson: I think we have the logistics under control in terms of putting supplies in the communities as needed. We have the cooperation of all the governments involved. The piece that none of us understand is what the virus will do next.
I should say that our planning assumption is that going into the fall, this will be a serious event. Even though we do not know what will happen next, from a planning perspective, we have decided to plan for the worst outcome. That is not to say that is what will happen, but I think that is really our only option.
The Chair: I thank you again, Dr. Grondin, Ms. Robinson, Ms. Woods and Ms. Kovacevic.
Colleagues, a suggestion has been made to me that we have the analysts draft a letter, and the steering committee, which is Senator Sibbeston, Senator Hubley and myself, will look at it. The draft letter will itemize the issues of concern; and on behalf of the committee, we will submit to Health Canada some of the observations that have been discussed here today.
Senator Carstairs: I have no difficulty with that. I think that is a reasonable option, but I would not want it just to go to Health Canada. I would also want it to go to INAC.
The Chair: Fine; very well.
Senator Brazeau: I think we should do the same perhaps with the health officials in the province of Manitoba.
The Chair: Fine. Colleagues, we are running really short of time. I want to thank all the support staff for the support they have given us to this point in time. I know they will continue.
Colleagues, our clerk is taking leave from the committee. She is going on to greater things, so I want to thank Gaëtane Lemay on behalf of all of us for the excellent service she has provided as a clerk of this committee.
There is a question about Inuit schools. Senator Watt, the steering committee has looked at this. I will discuss it with you and we will deal with this.
I wish you all a great summer. If anything urgent comes up, please contact me or Senator Hubley or Senator Sibbeston. Have a great summer.
(The committee adjourned.)