Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology

Issue 15 - Evidence - October 29, 2010

OTTAWA, Friday, October 29, 2010

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 8:01 a.m. to study Canada's pandemic preparedness.

Senator Art Eggleton (Chair) in the chair.


The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.


Today we continue with our study of pandemic preparedness and response, and we are pleased to welcome the Minister of Health, the Honourable Leona Aglukkaq, who was the person that initiated our examination of this matter, by a letter she wrote to us back in June asking us to look at the issues involved here, the experiences, and to make recommendations as to future pandemic planning.

Minister, this is our final hearing, and it comes after some nine hearings and 60 witnesses. Later, we will have a round table to wrap up our discussions on the matter before we head towards putting a report together with recommendations to go to you by the end of the year.

Welcome. Thank you for your confidence in asking us to conduct this study. We were pleased to take it on. This committee loves policy development and has a long history in that area. The floor is yours.

Hon. Leona Aglukkaq, P.C., M.P., Minister of Health: First, I want to thank committee members for inviting me this morning. It is a pleasure to be here. Over the past few weeks, you have heard from many people on a wide range of topics related to pandemic preparedness and our response. I know many witnesses from the health portfolio have also discussed the topics in detail with you, and I understand they will continue those discussions later today.

Your interest in this important subject is helpful to us as we incorporate the lessons we have learned from the H1N1 pandemic into our ongoing pandemic planning. For this reason, I am pleased to be here with Glenda Yeates, Dr. David Butler-Jones and Dr. Paul Gully, who are with me to be part of the final hearings. Other officials are also here in attendance.

On April 17, 2009, the Public Health Agency of Canada first became aware of a severe respiratory illness outbreak in Mexico. The Mexican authorities contacted the agency requesting laboratory support. Within days, laboratory samples from Mexico had arrived at the agency's national microbiology laboratory for testing and identification.

The Public Health Agency of Canada and the national microbiology lab were able to isolate and identify the virus quickly. By April 26, the Public Health Agency of Canada had confirmed within our own borders six cases of H1N1. We immediately triggered our comprehensive Canadian Pandemic Influenza Plan.

By April 30, we were at a level 4 emergency on a 24/7 schedule, adjusting daily in real time, collaborating in lock- step with our partners. The strength of our existing partnership with Mexico, the World Health Organization and other partners allowed us to move quickly and helped us to deal with changing circumstances.

Canada played a leadership role in global pandemic preparedness and response efforts. We maintained and shared information from our world-class influenza surveillance system, FluWatch. We assisted with virus testing and analysis, and we were the first to submit the entire genomic sequence of the virus. We continually provided rapid support and information to our international partners.

Manufacturers and regulators were able to develop a seed strain quickly, refine it and test it for safety, and Canada was able to order vaccine through a unique supplier arrangement.

It was one year ago today that my colleagues and I were preparing for our thirty-fifth news conference on the H1N1 virus and our third pandemic briefing to the health committee. We were entering the usual flu season and the second wave of H1N1.

The H1N1 vaccine had recently been approved and the roll-out of the largest immunization campaign in Canada's history had begun. Dr. Butler-Jones and I had completed a cross-country consultation the week before. The long hard work preparing the Canadian Pandemic Influenza Plan was essential to our response to the H1N1 influenza pandemic.

The overall success of Canada's response to the H1N1 influenza pandemic shows that the plan worked. Approved in 2006, the plan was built on lessons learned from severe acute respiratory syndrome, SARS, in 2003, and from previous pandemics.

It ensured that we were ready, that players knew their roles and responsibilities and that our efforts would be coordinated. It demonstrated the value of the arrangements for information sharing that we had in place. It highlighted the value of our partnerships, coordinated outreach and public education at all levels.

Provincial and territorial governments have responsibilities for pandemic planning for their residents, including Inuit. For this reason, as the federal Minister of Health, I supported the decision of my provincial and territorial counterparts not to develop an Inuit-specific pandemic plan. I raise this with you, as I was advised that there was a presentation on this very issue.

As you have heard, Canadians had access to the H1N1 vaccine sooner, in greater volume and at a lower cost than almost any other country. Federal, provincial and territorial governments worked together. Thanks to years of planning with partners, and to the response of Canadians, we successfully completed the largest immunization effort in Canadian history. Every step of the way, we made decisions based on the best available scientific evidence and reflected the views of public health experts in Canada and around the world.

Canada worked with its partners to share information on trends, surveillance, vaccine safety and effectiveness. Aboriginal leaders helped us respond to the unique needs of First Nations communities and, similar to the general population, their take-up of vaccine through mass clinics in their communities was positive.

Internationally, Canadian scientists at our National Microbiology Laboratory played a key role in assisting Mexico with its response efforts. Canadians helped protect themselves by taking many precautions through effective prevention, including being immunized with the H1N1 vaccine. The plan helped us to get there.

However, no plan can anticipate every possible challenge we will encounter, and we dealt with many. Scientific evidence evolved; unexpected issues arose. Nature is, after all, unpredictable, but we adapted and responded to each of the new challenges.

While the level of planning, coordination and collaboration was unprecedented, there is always room for improvement. Pandemics are unpredictable, and H1N1 was no exception.

We continue to act on the lessons we have learned from this experience, including a full review of the pandemic plan. It is clear that we need to develop ways to communicate knowledge of science to the general public to provide individuals with the information and the tools they need to make informed personal health decisions.

It is also clear that we must improve our surveillance abilities to track and report better on the national spread of disease. These tools will help improve public health activities and response across jurisdictions, not only in times of emergency.

We look forward to releasing the joint Health Canada and Public Health Agency of Canada report on the H1N1 lessons learned in the near future.

Three central recommendations from the review are as follows: we need to continue to build federal, provincial and territorial capacity and coordination to respond to future influenza; we must continue to clarify, communicate and practice federal emergency management roles, responsibilities and mechanisms; and we must improve the health portfolio's ability to communicate science.

We are always looking for ways to improve our processes, including evaluations, Auditor General reports and internal audits. These management tools help to strengthen the health portfolio's capacity to respond. This committee's report will also form an important part of improving our response capacity in the future.

I will follow up with my officials on progress to implement the improvements identified in your report. I will also take this opportunity to thank all the members of this committee, as well as the witnesses who have appeared, for your insight into Canada's pandemic planning. I also want to thank all the public servants who worked along with me and had an important role in Canada's response for their dedication and tireless work during the pandemic.

I welcome any questions at this point.

The Chair: Thank you, minister.

Minister, you mentioned in your comments a joint review by the Public Health Agency of Canada and Health Canada. Officials said when they were before us earlier that the report would be completed by the end of this month, which is only a couple of days away. We are anxious to see that report because we want to see how the direction we are going in corresponds with the direction they are going in. We thought the report would be helpful. Can we still have that by the end of this month?

Ms. Aglukkaq: As soon as it is completed, I will be happy to share it with you.

The Chair: We are reaching the wrap-up stage here, so the sooner, the better.

Ms. Aglukkaq: The idea was that we would conduct an internal evaluation of how we performed and this committee would conduct the external evaluation, so both of those reports will be valuable, I agree.

The Chair: Hopefully, we will have their report before we wrap up here.

In the course of our hearings, we found that in 2005, the federal government set aside a pandemic preparedness budget for a sunset period of five years. This period will be up at the end of March of the coming year, 2011. Will this budget be renewed? What will be the situation? I am sure you would agree that a lot of work still needs to be done in this area. What will happen with this money? Will it be renewed?

Ms. Aglukkaq: When we approved the pandemic plan in 2006 at the federal-provincial-territorial meeting in New Brunswick, we set aside funding in a central pool to support that work and we will continue to renew that funding.

To position our government to be able to respond to pandemic is important, and resources are part of that positioning. Identifying what resources will be necessary to stock up again, if I can use that term, will be an important step that we will take.

The Chair: It will not run out suddenly at the end of March 2011; it will be ongoing?

Ms. Aglukkaq: It will be work-in-progress. We set aside that funding in 2006 in anticipation of a pandemic so the resources were there when we kick-started the pandemic influenza plan. We were able to access those resources immediately. A similar approach will be taken to replenish the resources needed to implement a pandemic plan.

The Chair: In the course of our hearings, we heard from several national organizations, including the Canadian Teachers' Federation and the Federation of Canadian Municipalities. They felt we should have a national pandemic influenza plan, not one only for the health care sector but one that will take into consideration these other sectors that will be vitally affected by a future pandemic, particularly anything more severe than the one we had. Obviously, the school system and teachers are involved. The Canadian Federation of Municipalities has responsibility for first responders, such as firefighters, paramedics, et cetera. They felt that the plan needs to be broader in scope, so they called it a national plan. Is that something you foresee as a possibility? How can we broaden this consultation to take into account these various sectors that are a vital part of implementing a plan?

Ms. Aglukkaq: In rolling out the plan, the only way I can describe what was happening behind the scenes in simple terms is that a number of wheels were all spinning at the same time, whether they were the provincial and territorial governments, us, vaccine international development, the World Health Organization, WHO, the Pan American Health Organization, PAHO, or municipalities. These initiatives were all happening at the same time. The challenge we had was to communicate as a snapshot every day all those wheels turning to communicate to Canadians what we were doing. Each organization had a role, but in this planning, it is important to continue to strengthen those relationships in the case of a pandemic, whether the organizations be airlines, borders, schools, communities and so on.

Municipalities were engaged in the process of developing the 2006 pandemic plan.

Having said that, we can do more, I agree, which is part of the reason we asked for this report. I survived the outbreak of severe acute respiratory syndrome, SARS. I was health minister in the territory when that happened. My experience there was that there was no communication with provincial health ministries at a federal level. It was night and day. There was confusion and no information. It was a scary time because we did not know what was happening with SARS. There was no plan. If there was a plan, it was not well communicated.

Shortly thereafter, health ministers said we need to have this plan, and the 2006 plan was approved. I was intimately knowledgeable about the provincial and territorial side of it, and not so much about the national side because the national side was run by Minister Clement at the time. If I can compare what happened in SARS to today, it is night and day.

Having said that, the lessons that we have learned through H1N1 and how we can improve upon that response will be important to adapt in this new plan. I agree that we can improve our relationships with municipalities. If there are ways we can work with municipalities better, then we will adapt those ways as well — not only with schools but with other agencies as well. We will continue to improve.

The Chair: I will now go to my colleagues. We have about five to seven minutes each. We will start with Senator Seidman from Quebec.

Senator Seidman: Thank you, minister, for coming here at this early hour on a Friday morning. One issue that has arisen with great frequency during our hearings is the importance of surveillance producing almost real-time data and the value of well-coordinated, standardized electronic systems that will capture new cases, hospital cases, adverse events, deaths, and other things. In your remarks this morning you referred to this issue. You said that it is clear we must improve our surveillance abilities to track and report on the spread of disease better. You also talk about coordination among federal-provincial-territorial governments, which is a big issue in trying to capture anything in a standardized way across the country.

Might you give us highlights of how we performed and how we are performing from the point of view of a national surveillance system, and an electronic system at that?

Ms. Aglukkaq: Compared to other jurisdictions, the surveillance system in Canada is one of the best models I have seen in terms of how we collect data. Every day, we were asked questions such as how much of the vaccine have we put into the arms of people, for example. Surveillance data comes from a variety of sources, including doctors' offices, remote stations, hospitals, labs, pharmacies and other resources. The challenge of collecting that data everyday requires a 24/7 approach during the pandemic.

Once we have all the data, then we have to analyze it at the local, provincial and territorial levels. Capacities and processes do work, and they vary across Canada, but the interpretation of information and so on is a huge undertaking.

In terms of going forward, an effective pan-Canadian strategy would define clearly how we prioritize and recognize the roles of federal-provincial-territorial governments in conducting public health surveillance. Provinces and territories are also evaluating those roles in terms of how we can improve the surveillance processes in Canada. Again, that work is in progress. It takes time. The provinces and territories are all updating their plans and adjusting how they can do better. The National Microbiology Laboratory and the Public Health Agency are also working with medical officers across the country in those areas. That work is part of the process. We can establish the infrastructure needed to improve our surveillance systems better by identifying some of the gaps.

Senator Seidman: Will we look, for example, at examples of other countries? Yesterday, we met with Dr. Harper of the U.K. He discussed their surveillance system and electronic reporting, which sounded thorough and advanced. However, I am not sure if that is the case. Are we looking at examples of other countries that may already be doing this kind of thing?

Dr. David Butler-Jones, Chief Public Health Officer, Public Health Agency of Canada: We are always looking at other systems. The federal government funded the development of a system called Panorama with Canada Health Infoway. The system is in the process of implementation. It is a tool not only for surveillance but also for case management. For those jurisdictions that have chosen to adopt it, the system will allow a rapid collection of information and the appropriate sharing of information, at least in terms of the data that we collectively need. Others have systems, and it is ensuring that those systems link in. We have a number of systems in place but they are not all coordinated yet and in place. Over the next couple of years, we hope to see our ability improve further to collect that data rapidly.

With that said, we have one of the best hospital surveillance systems in the world. Surveillance does not identify everything, however. When we look at the institutes of health information data, looking at hospitalizations for flu, the surveillance probably picked up less than a third of hospitalizations. The number we used for hospitalizations was at least three times that number. Surveillance will not pick up everything, but it will show us the trends and patterns, which is the key role for surveillance. Afterwards, when we look at the mortality data, we will not know how many people died from this pandemic until we have the mortality data from Statistics Canada, and compare that data to normal years.

It gives us enough information to manage what we need to know at the time to understand what is going on and to identify early when there are problems, but it does not give us the full and complete picture. That is why the ongoing research will be important to have a more fulsome understanding of what happened during the pandemic.

Senator Seidman: Are you finding that there is cooperation across the country in the various provinces and territories? Of course, it is critical to have that kind of cooperation and to want to contribute to a national system.

Ms. Aglukkaq: The working relationship during the 10 or 11 months with the provinces and territories was extraordinary. I had daily contact with the ministers on what we were doing, providing information to them in real- time. Everyone was on the same page in terms of reporting facts on science and not on hypothesis. The working relationship was extraordinary. The success of rolling out this plan was dependent on the jurisdictions that actually delivered health care. It was important to work together through the coordinating that we undertook across the country, including from the Public Health Agency medical officers. It was phenomenal, in my view, how they were able to work with us in communicating. We had our glitches and challenges, but, all in all, the working relationship was good.

The Chair: Now we have Senator Ogilvie from Nova Scotia, who is also the deputy chair of the committee.

Senator Ogilvie: Thank you, minister, for being here. First, as a member of the committee, I have found this pandemic review that you initiated a good experience. I thank you for initiating it because we have had the opportunity to look at a complex situation. To be frank with you, I am impressed with how Canada fared relative to the rest of the world. In fact, we have heard from officials from two countries, the U.K. and Mexico, that extolled not only the calibre of Canadian science, which was critical to this situation; but also the willingness and speed with which we were able to respond at that level, the degree of communication we kept up with them, and our willingness to share excess — and it turned out we had excess — vaccine in those cases. It has been satisfying from that point of view, as well as learning the complexity of the situation.

The first issue I want to deal with follows on Senator Seidman's area of questions. When we look at legislation from our initial act of Confederation through to today, the system of authorities in the area of health, for example, with the responsibilities and so on, is incredibly complex. My cursory looking suggests that some legislation can be interpreted in two completely different ways when we look at the issue of authority.

I think that the summary you mentioned — the issue that arose with SARS and then the willingness of these various jurisdictions in Canada that have rights under formal legislation to come together over that period of time and to evolve a plan together that was able to operate with little apparent friction of the political or other type at a public level during an emergence and outbreak of a pandemic — that response shows a number of things, including the ability of the various jurisdictions to learn from a serious issue, the SARS issue, and then begin to evolve.

Second, it is clear that as we look back on the situation, many people seem to have forgotten the time frame in which all of this situation arose, and the fact that right up until very late there were even questions as to whether we would be able to identify a vaccine that would be effective and whether we could produce it, distribute it and so on. People forget those time frames when they think back on the situation. However, we learned a great deal.

As we enter into this subsequent year, where we know that the virus has been identified as mutating to some degree in certain countries, and it is now merging with the normal flu preparation, I want to direct my question specifically to the issue of cooperation among the jurisdictions.

Do you see that the cooperation that evolved — and more important, the attitudes that influenced cooperation — has that attitude of positive cooperation continued to evolve as we look at this year and as we build our plan even more robustly for the future?

Ms. Aglukkaq: In terms of how the situation has evolved since SARS, having gone through that experience and having worked through the provincial and territorial jurisdictions — because I have been in the health file now for over five years, which is a long time in this country — I was able to bring in the experience from SARS with other provincial-territorial ministers who were new to the table since that time. What also worked, in my view, is to have been intimately involved in the development of the 2006 plan, and to bring jurisdictions up to par in communicating some of the rollout of a pandemic plan and sticking to it.

The other part of the discussions, which involved meetings with provincial and territorial ministers in September in Winnipeg, was to agree to the mutual aid agreements. Should we see a huge outbreak in one jurisdiction, the mutual aid would allow us to work together in assisting jurisdictions to respond to the population outbreak. Mutual aid is important in that when we are dealing with a public health crisis, there is no time to build infrastructure, to hire, to train people or to hire more students coming out of university. Recognizing that situation, we needed a mutual aid agreement across the country on how we would support each other.

Also, we recognized that each jurisdiction was responding to the H1N1 pandemic at different times. In the North, we did not see any of what we saw happening in Manitoba until later. Jurisdictions were responding to the pandemic plan at different times. We were able to work through some of that difference. Recognizing the differences and the challenges that each jurisdiction was exposed to was critical, and to offer support through that process. The federal role behind the scenes of surveillance and vaccine development was all happening as we were trying to respond to support jurisdictions and dealing with issues as they arose in real time.

In terms of the relationship with the jurisdictions, for the first time we were testing how we would work together within the 2006 updated pandemic plan. That area was a real test, and the response was phenomenal. The cooperation was extraordinary, not only from the minister's point of view but from the point of view of the Public Health Agency, First Nations communities, and so on. During the SARS outbreak, we did not have those relationships defined. In updating this plan, it will be important to further those relationships.

The second part is our recognition that perhaps we could do more testing of the pandemic plan by jurisdictions to clarify further the public health and municipality roles. We should probably have done more testing since 2006 within the pandemic plan itself. These roles have completely evolved to a different relationship. The years of planning have benefited us in a big way.

Senator Ogilvie: Minister, my time is rapidly expiring. I will ask you one quick question.

We recognize the federal responsibility in the area of native people, the Inuit and other specific jurisdictions. There has been some misunderstanding of how the Inuit are dealt with, because they are, in many cases, a different people and a different organizational structure than First Nations.

Can you help us understand how they were dealt with and informed during the pandemic?

Ms. Aglukkaq: Within the pandemic plan itself, there is an annex for First Nations people. There is also an annex for all the provinces and territories. The reason there is an annex for First Nations people within the pandemic plan is that First Nations on reserve are a federal responsibility. Each jurisdiction has its plan, but this population is strictly within the federal role, as is the delivery of health care.

Often the Inuit are mixed in with that group. However, the Inuit of the Northwest Territories, Nunavut, Northern Quebec and Newfoundland are part of the public health care system. Because Inuit do not live on reserves, they are part of the general population in the pandemic plan itself.

There were requests from my good friend Mary Simon of the Inuit Tapirisat of Canada to look at developing an annex specifically for Inuit. I mentioned that the model is different for Inuit in the delivery of health care. It is a provincial-territorial responsibility. I presented her requests to the provinces and territories at the time, in September, and the response was: No, we cannot have a separate annex for people with different ethnic backgrounds in responding to a pandemic; when we are dealing with a patient, which plan do we pull out?

With all due respect to the organization's request, the provinces said that it would only add to the confusion; that our provincial-territorial plan is for everyone, and we will adapt that plan. The provinces are responsible for the delivery of health care to Inuit, so I have to work with them, and I respected their decision.

Senator Cordy: Thank you, minister, for being here today. Thank you for asking this committee to prepare a review of what happened during H1N1. This committee also prepared a review of SARS, and some of the lessons learned were put in place for H1N1. It is a great idea to look at this issue, because as soon as one pandemic is over, we are indeed planning for the next pandemic; it is not, if the pandemic comes, but when it comes.

I wanted to ask the question about Mary Simon's comments before the committee, but you have addressed that question.

One thing we heard repeatedly was the issue of communication. We saw you, minister, as well as Dr. Butler-Jones on television or radio on numerous occasions. We heard from top officials in the provinces that they were being provided with communication frequently and that they were pleased by that communication; however, it never seemed to filter down to the general public. Associations who appeared before us corroborated that information. We did not need to have associations appear before us. We live in our communities. We know there was mixed messaging and we know there was confusion among the people.

One example was pregnant women and whether they should receive adjuvanted or unadjuvanted vaccine. Then there was a change — a ``flip-flop'' was the term we heard — in terms of what vaccine pregnant women should receive.

To give an example of some of the suggestions we heard, Dr. Harper from the U.K. said that they had a call-centre type of thing where people could call in. We also had a suggestion that there be televised town-hall kinds of meetings where, not the top scientific kinds of questions be asked, but, more simply, what is bothering the person who lives in your neighbourhood.

Today in your comments you talked about improving the general public's knowledge of the scientific aspects of a pandemic. One suggestion that we also heard was that during the regular flu season, like the fall, is probably a good time to educate the public about the advantages of being vaccinated for a regular flu shot, not even taking into consideration a pandemic, because when the pandemic hits people become nervous. They hear about someone they work with that had H1N1, and what will they do about it.

Are you working on plans now so that we can educate people about vaccination, educate people now about, as you said, the public's knowledge of science, without the fear of a pandemic being upon us? Are you looking at those kinds of things?

Ms. Aglukkaq: First, one of the most challenging aspects of managing the pandemic was the communications piece, hence our efforts to try to provide information to the population — what we were dealing with in real time — as we dealt with the situation. Communication was a huge challenge.

The other part of the challenge was managing the media and the misinformation out there. I will use one example. We were educating Canadians to wash hands and cough into sleeves, and then one article said, do not wash your hands. That is an example of those kinds of mixed messages. Probably the most frustrating part of trying to provide the right information to Canadians in a public health crisis was the misinformation. I believe the media has a huge role to play in educating the population in a public health crisis. What did not help was the misinformation. Canadians need to ask themselves, what is the role of the general population and media outlets in a public health crisis.

In terms of rolling out communication, it was always real time. We communicated what we learned about the science, and that whole process was relayed as we learned about H1N1, how it spread, who was more vulnerable, and the whole issue involving pregnant women and the adjuvanted versus unadjuvanted vaccine, et cetera.

Not only was it a challenge to communicate in Canada, but we were also receiving information from WHO and PAHO about who should receive adjuvanted or unadjuvanted vaccine. The lessons we learned were that we should have gone with the adjuvanted vaccine in the first place and this vaccine would have been less of a challenge, but now we know that.

In terms of communicating with Canadians now on the prevention issue, that initiative is an ongoing public health initiative through the provinces and territories. We recently produced a YouTube video on the regular flu, describing what to do to keep healthy and that the best way to avoid becoming ill is to have a flu shot. Those videos are rolling out across the country.

On the public health message during H1N1 about washing hands and coughing into sleeves, the comments I received from jurisdictions were that it prevented other illnesses that we usually see, but this simple practice of keeping hands clean and coughing into a sleeve has prevented the spread of other things. That is success in itself, I think.

I do not know if you want elaboration on that, but it is ongoing.

Senator Cordy: There is one thing I am a little nervous about. The good news was that H1N1 was not as serious as people thought it would be, but one becomes a little nervous that maybe that situation will lead to complacency for the next pandemic. We must be aware of that possibility. The good news, as I said, is that the pandemic was not as severe as one would have thought, but, then I hear people say, well, it was not that bad; next time I will not bother being vaccinated. That complacency will be almost a double-whammy in dealing with the next pandemic. How do you deal with the complacency aspect?

Ms. Aglukkaq: All the efforts we put into preventing the spread of H1N1 paid off. Had we done nothing, it would have been a crisis.

Senator Cordy: I agree with you.

Ms. Aglukkaq: The other thing is, if you look at, and talk to, people who were seriously ill, I think that is a different story. We have lost Canadians, and one death is too many. Perfectly healthy people, within days, died. It is how we measure this impact. Every individual will make their own decision about whether they want the vaccine, as an example, but I can say that, had we done nothing, it would have been far worse. All our efforts that we made across the country paid off in that we were able to prevent the spread of H1N1.

In my view, it was a successful roll-out of the largest immunization campaign in this country: 40 per cent of Canadians received the vaccine. In jurisdictions like Newfoundland and Labrador, almost 80 per cent of the population received the vaccine. In the North, it was 65 per cent to 70 per cent.

I think people recognized the need for the vaccine, and there are some who will make their own choices not to be vaccinated. We must be respectful of that choice, but we will continue to communicate to Canadians the importance of preventing illness in the first place.

Senator Merchant: Good morning, minister, and thank you for coming.

I, too, want to say that we, I think, fared well as a country. I wonder, though, about the changes that we have made in relation to this year. I had the flu shot last week in Regina because I will be traveling out of the country. Included in that vaccine was the H1N1 strain, but have the provinces already ordered their vaccine? You said 40 per cent of Canadians received the vaccine, and I think that number was about 11 million doses.

Ms. Aglukkaq: It was 16 million doses, so 45 per cent.

Senator Merchant: For this year, what has changed? What are the provinces doing?

You made such a big effort to put together a system and to communicate with them and to make things a little easier for this year. Following on some of the other questions, what concrete steps have taken place? What are the things that you are doing this year already — people are already starting to receive the shots — to communicate to people? Also, what are the provinces themselves doing?

Ms. Aglukkaq: Thank you for that question. Every year, every jurisdiction rolls out their regular flu vaccination programs, and those are happening now across the provinces and territories, which is why you received your shot. This program is the normal initiative of every jurisdiction.

The timing of the pandemic was before the flu season. We were hit with a pandemic and had to make decisions on vaccine and regular flu vaccine development. There were lessons learned in how we managed the production of the regular vaccine versus the new vaccine required for H1N1. That was a difference when dealing with the pandemic for 10 months.

In terms of communication, these initiatives are regular public health initiatives through jurisdictions. As we deal with updating the pandemic plan, the challenge will be how to improve the response to a pandemic in a regular flu season and the implications to vaccine production, as an example.

That whole process is being evaluated now on how we can prepare better for the next time, because we were dealing with two regular flu viruses and the pandemic at the same time last year.

Do you want to add anything, Dr. Butler-Jones?

Dr. Butler-Jones: I will save the time for the minister now because I can address it when we have the round table.

Senator Merchant: The concept of emotional epidemiology, or emotional reactions, I think had something to do with people's fear. They did not understand exactly what was happening, so sometimes people make decisions on an emotional basis rather than a factual basis. Do you have some insight on how that reaction impeded the delivery? How can you change the mindset of people in the way they react to something like a pandemic?

Ms. Aglukkaq: From the beginning when we discovered that we were dealing with possible pandemic, we were in the office on a Sunday morning making phone calls to provinces and territories that this is what we are dealing with. One of the first things I said, and not only to the provincial and territorial health ministers, was that communication will be based on facts; communication will not be hypothetical. As soon as we start to manage hypothetical situations in a pandemic, we have lost management of the situation. We are no longer managing evidence; we are no longer managing science and information that is scientifically based, and we have lost control. It was important to be factual from the beginning.

Second, I contacted all my critics. I told them we were in a public health crisis and it was not a political issue and that we needed to work together to ensure that the information we were dealing with was shared, and I made it a priority to keep the politics out of my responses. I think, as a Canadian, I would want that of my leaders.

I learned about some of the unnecessary fear mongering that resulted in a lot of fear, particularly with First Nations people. ``Ten percenter'' flyers went to First Nations with the body bags, as an example. That was completely unacceptable. I was disappointed in some of my colleagues for those tactics. In responding to a public health crisis, there is no time for that fear mongering. Yes, there was fear out there because of some of those tactics. As the Minister of Health for Canada and a former territorial minister, I found that situation to be one where I was most disappointed in how some people dealt with the file.

I could not get into that type of discussion and debate but tried again to make contacts to reduce that fear. I had a great working relationship with the Assembly of Manitoba Chiefs. Grand Chief Ron Evans, I believe, appeared before House of Commons Standing Committee on Health and said, Stop using Aboriginal people as your political punching bags and let us deal with the facts here.

I thought it was unnecessary, but that act added to public health fear and reluctance to be vaccinated perhaps and whatnot, but in my view, it was one of the most disappointing things we had to deal with during the time we responded to the pandemic.

The Chair: We have only five minutes left and two senators who wish to question the minister.

Senator Champagne: Minister, I will talk again about those mixed messages. I know you and Dr. Butler-Jones held many press conferences. We saw you on television many times on whatever television network in whatever language. I listened to both. Whenever they had one of you or a local doctor tell us of the importance of being vaccinated, you would think they were in a political campaign, an election campaign. They felt obliged to present someone else who would say, ``H1N1 is not that complicated; you might be sicker with the vaccine.''

There needs to be a law. We should talk to our colleagues in the other committee about keeping that from happening. I think it is outrageous.

I want to touch on another subject. I had a conversation recently with a nurse who worked in the Toronto area during the SARS problem and who is now teaching nursing at Ryerson University. One of her concerns was nurses who come from agencies instead of the hospital. One day they work in one hospital and the next day, or the day after, they are in another hospital. They may have been in contact with someone. I do not know under whose jurisdiction this issue falls, but there should be something so that if there is a pandemic of some kind these people automatically should not be allowed to go from one hospital to the other perhaps carrying something. They become a carrier but without symptoms and they may still communicate the disease. Is that something that you and your people have thought about? Whichever one wants to answer, I think the point is an important one.

Ms. Aglukkaq: Thank you. That is an interesting and important point. I do not know what discussions Dr. Butler-Jones has had with the provincial-territorial counterparts, but agency nurses fall under provincial hiring practices. It is something we probably can raise and have further discussions on, unless Dr. Butler-Jones already has.

Dr. Butler-Jones: It is a discussion. There are practical realities, but in the midst of — certainly during SARS — it is often us, the doctors and nurses, who share the diseases with our patients, particularly if we do not wash hands. The level of handwashing was impressive, and we saw reductions in Clostridium difficile and other problems in hospitals because people were more attentive to infection control. During a crisis like SARS, in terms of infection control, minimizing movement of patients and staff reduces the risk of spreading the infection, so it is part of that general understanding. It is something coming out of this crisis that we will continue to focus on even more, so your point is well taken.

Senator Lang: I want to say to the minister that we are fortunate that we had someone like you in charge of the department when this pandemic occurred, primarily because of your territorial-provincial background and then being thrust onto the national scene. I think that background allowed the provinces, territories and national government to work together, and you should be commended for that.

One area I find alarming is the fact that only 40 per cent of Canadians were vaccinated. The prime concern, or one of the prime concerns, around this table should be why that figure was not higher. To make a couple of observations from where I sit, in talking to some segments of the population, there is fear out there from the point of view of vaccines — forget what kind of vaccine. We are fortunate that we have gone through a number of generations where we have not experienced significant health problems compared to the 1800s when they had the plague, as they called it, and various other things. Therefore, we have no fear of that situation and then we receive — I think Senator Champagne talked about this — mixed messages where misinformation is going out to the population and then it is a personal decision and the situation becomes, ``Do I take that decision; the last person I heard said that I should not take it so I will not.''

Every year, we have flu shots so there is a window here that all governments can use. Why are we not exploring the area of social media further, with Facebook, tweeting, blogging and utilizing all those vehicles for communications of why we should be vaccinated and what it does for us, so the science gets out and is as widely distributed as possible?

What further steps are being taken on that so that we progressively communicate the information year over year, and more people become informed?

Ms. Aglukkaq: I had said earlier that the most challenging part of managing a pandemic was the communications aspect, particularly today because we have so many different means to communicate, for example, the social media such as YouTube, Twitter, emails and so forth. Managing the right information is a task in itself.

The information Dr. Butler-Jones and I provided to Canadians was factual. Then it rolled out and we managed that roll-out. Sometimes the communication becomes not factual, which is why we go back the next day to correct some of it, not only through television but also through social media, and to provide information even on how we produce vaccine. That is part of the ongoing information package we will continue to distribute to Canadians, which is important.

This communication on how we can do better is probably the one that will take up most time in how we can improve the delivery, based on this pandemic. There are lessons learned through H1N1.

In terms of the number of people that received the vaccine, it will vary by jurisdiction. In the Yukon, I believe it was 60 per cent, and it was 80 per cent in Newfoundland and Labrador. Overall, it was 45 per cent, so some jurisdictions did much better than others. We will continue to do some of that.

Dr. Butler-Jones: We can learn a great deal. The alternate message is out there, and we will talk more about it when we have the panel.

One thing was striking. Some of you may have seen the YouTube video with the young woman who said she had the vaccine and could only walk backwards. That went through all the campuses. I heard from students across the country that it was circulating around campuses, and people said, ``I will not take that vaccine, even if it is a rare complication.''

The reality was that CNN, I believe, was smart enough to videotape this person who was perfectly normal. It was a hoax, but that was not part of the news. I only found out about that recently. We all thought this situation was an unfortunate coincidence, when it was not a coincidence at all; it was a hoax. It did a lot of damage in terms of people's trust in the system. We were constantly responding to many things like that videotape.

As the minister said, we used Twitter and social media. No matter how much we communicate, we have discovered there is always more. In the current information age, there is always someone with an alternate view, even if it is rare.

The Chair: That brings this session to a close. I want to thank you, minister, for being here, and for giving us your insights into this matter.

Our final session with respect to pandemic preparedness is the round table. Rather than have me introduce everyone, let us all introduce ourselves so that everyone around the table knows who is here. I will start with myself. I am Art Eggleton, a senator from Toronto and chair of this committee.

Jessica Richardson, Clerk of the Committee: I am Jessica Richardson, and I am the clerk of the committee.

Senator Ogilvie: I am Kelvin Ogilvie, from Nova Scotia.

Dr. Perry Kendall, Provincial Health Officer, Province of British Columbia: I am Perry Kendall, Provincial Health Officer for British Columbia.

Senator Seidman: I am Judith Seidman, from Montreal, Quebec.

Dr. Todd Hatchette, Associate Professor, Department of Pathology, Dalhousie University, as an individual: I am Todd Hatchette, a medical microbiologist from Halifax, Nova Scotia.

Senator Merchant: I am Pana Merchant, a senator from Saskatchewan.

Meena Ballantyne, Assistant Deputy Minister, Health Products and Food Branch, Health Canada: I am Meena Ballantyne from the Health Products and Food Branch of Health Canada.

Dr. Paul Gully, Senior Medical Advisor, Health Canada: I am Paul Gully from Health Canada.

Glenda Yeates, Deputy Minister, Health Canada: I am Glenda Yeates, Deputy Minister of Health Canada.

Dr. Butler-Jones: I am David Butler-Jones, Chief Public Health Officer for Canada and the deputy responsible for the Public Health Agency.

Dr. Frank Plummer, Scientific Director General, National Microbiology Laboratory, Public Health Agency of Canada: I am Frank Plummer, Public Health Agency of Canada.


Elaine Chatigny, Director General, Communications, Public Health Agency of Canada: Mr. Chair, my name is Elaine Chatigny, Director General of Communications for the Public Health Agency of Canada.

Senator Champagne: Good morning, I am Andrée Champagne, a senator from Quebec.


Senator Cordy: I am Jane Cordy, and I am a senator from Nova Scotia.

Senator Fairbairn: I am Joyce Fairbairn, and I am a senator from Southern Alberta.

Suzanne Kiraly, Executive Vice-President, Government Relations, Canadian Standards Association: I am Suzanne Kiraly, representing the Canadian Standards Association.

Senator Martin: I am Yonah Martin, a senator from British Columbia.

Dr. Maura Ricketts, Director, Office of Public Health, Canadian Medical Association: I am Maura Ricketts, the senior public health adviser for the Canadian Medical Association.


Odette Madore, Researcher, Library of Parliament: I am Odette Madore from the Library of Parliament.


The Chair: During the committee's study on pandemic preparedness and response, we have had nine hearings, ten if we count the minister earlier today. We have heard from 60 witnesses who discussed their role during the pandemic, or their organization's role. They complimented the strengths of Canada's response, outlined the weaknesses of the response and suggested recommendations to strengthen Canada's pandemic preparedness for the future.

The purpose of today's round table discussion is to address some of the issues and concerns that the committee heard during those sessions and to have an open and frank discussion on how we can improve the state of preparedness for the next public health emergency.

How will we do all of that with roughly 20 people around the table? First, we will need to keep our interventions short and sharp. Second, if you want the floor, please let the clerk know. Give her a signal and she will put you on the list. Third, I propose to divide the discussion up on the basis of the issues paper that was previously distributed. I hope everyone has it. It is divided into seven categories, starting with communications and messaging, on into vaccines and antivirals, et cetera. That will be our agenda or the script we will follow. We will deal with each one of them.

Subsequent to that document being prepared by the researchers, another session was held on Wednesday on the topic of research and ethics, so we can add it as a further topic for discussion today. We may need a final wrap-up session if we have not covered the first eight subjects.

That is an awful lot to do in the time we have, so I will stop talking and get on with it. We might have 20 to 30 minutes for each of topic. Some will take longer, and others will be shorter. Let us get into it and see what we can do.

Let us start with communications and messaging. This is an issue that was most frequently mentioned by witnesses. They talked about the need for consistent messaging and to avoid contradictory statements, particularly as the messages worked their way down the levels of government and out to the public. The committee heard that public awareness campaigns during the inter-pandemic period — that is, between the two parts of the H1N1 pandemic — would help to increase confidence in both the public health system and safety of vaccines. Several witnesses have urged that health professionals be consulted and included in the communications strategy. We also had a suggestion about a basic vaccine education program. I do not know whether that will come into play here or in the next section.

On communications and messaging, I will start with the officials at the other end of the table because in addition to giving suggestions about the way forward they may also want to talk about responses they might have to the hearings that we have had.

Please begin, Dr. Butler-Jones.

Dr. Butler-Jones: The first point to make is that the coordination of communications occurred in a way that had never occurred before — close collaboration, sharing messages, sharing information, good transparency at the provincial and territorial level that we had not seen in the same way previously. The challenge was getting the messages down to the front lines and to individuals. As identified earlier, there was a mix of so many messages out there, and people were quite happy to speculate, to make comment or to critique. The media was looking for alternative views. Messages had to be transmitted to the coal face for local workers. The challenge, in my view, was to prepare people for the reality of what might happen. Throughout the pandemic, I kept asking professionals and others to listen to their local medical officer. They are the ones who know the local situation and know what is going on. They are connected back up into the system. The message was that while there might be one or two different views than everyone else in the world, take that into account if what you are hearing is one exceptional view and everything else is the other view. You have to make a judgment call.

As clinicians, we always have to deal with competing messages in how we manage patients, even with guidelines. Do not forget that in the pandemic we saw talented clinicians who, because it was an H1N1pandemic, were going to the provincial medical officer and asking, ``How do I manage this?'' The reply was, ``It is influenza. How do you normally manage an influenza case? This is what we know, and this is how you do it.'' It is important to prepare people to not forget everything they have learned over their last 20 years of practice and to strengthen relationships locally so they can get the most accurate information that is appropriate to their situation. We can reinforce that through professional associations, as we did, but preparing people's mindsets and having that focus will make things more efficient.

Senator Merchant: I read in the paper yesterday that a doctor in Manitoba has put out a booklet about washing hands. He has written a little text along the lines of Dr. Seuss. He has included pictures and has paid for this from his own money because there is no way this can be done quickly if you have to make a request for funds to put something out like this.

Have you thought of doing something catchy? Perhaps a good place to start is with children.

Dr. Butler-Jones: There were some items published during the early days of the pandemic; school-based materials on hand washing, for example. The minister in Manitoba and I went to a school and witnessed how it was being applied. There are materials out there.

Senator Merchant: I taught school and I know about children.

Dr. Butler-Jones: We did see kids and they were teaching their parents about washing hands, so that serves to reinforce the practice.

Dr. Kendall: On that point, senator, a program has been running for several years between B.C. and Alberta called ``Do Bugs Need Drugs.'' It is targeted at reducing the use of antibiotics in viral illnesses. The program focuses on pharmacists and physicians to educate them, but it also focuses on kindergarten children and children in grade 1 and 2 about hand washing, cough etiquette and basic information. That has been evaluated, peer reviewed and published. It is quite effective.

There are materials out there. The challenge is to get people to click on the right website that has the program in place.

Senator Martin: A few sessions ago we heard a recommendation to connect other professional health organizations and associations to the communications plan. Pharmacists, for instance, are in direct contact with the public, as are physiotherapists and various health networks. That in itself could multiply the number of health professionals who are saying the same thing. That is something you will be strengthening for the next time.

Dr. Butler-Jones: That certainly was part of the strategy. We worked with the professional associations nationally, but also with the distributers, the major pharmacy collection, to make sure they had the right materials. You are right; that can continue to strengthen.

One of the things we have learned is there is a great desire to cooperate and collaborate. Through the process, we improved the mechanisms, and now I think the will is there to be even better prepared next time.

Ms. Kiraly: On the communications front, we heard similar comments from front-line workers that they wanted to be further engaged. We talked about YouTube and other techniques, but we need to go to the people in the community that we trust, whether it is the educators, the firefighters or the nurses. When someone goes to a walk-in clinic, we need to ensure they have the same message on a real-time basis.

Dr. Ricketts: On the matter of communications, obviously an awful lot worked very well. However, we are facing right now an opportunity to massively improve our response to the next pandemic if we can get our heads around how we will communicate to the front-line clinicians.

I represent the Canadian Medical Association, so I will speak about physicians. I do not know the others that well, but I know that other important clinicians are involved.

We saw that information was collected, analyzed, reviewed, synthesized and put out in the format of large documents completely unsuitable for clinical use. We need to keep in mind that in responding to the pandemic we had some 75,000 physicians out there waiting to hear what was going on, and they did not receive the information in a timely fashion.

I hold in front of me the results of a survey we connected at the Canadian Medical Association. In looking at the comment section, we see the phrases ``too many'' and ``too much'' repeated for over half a page. Yes, indeed, getting information from your local health unit is a great idea, but you cannot wait for the information to trickle down through the controlling process that takes place. There needs to be recognition at the national level that physicians are a specific communications target. It is not good enough for us to get our information from André Picard, which is how I got most of my information during this pandemic.

I do not think that is such a hard thing to do because we saw that it worked well in some provinces. We saw good results and excellent action out of the agency on a couple of matters — for instance, an algorithm that was prepared jointly with the Canadian Collaborative Antiviral Task Group.

We also have other specific advice, and I must remind you that physicians need quite different information than does the general public.

I also need to remind you that one of the public messages was that this was not the flu as usual. When the public message is ``not the flu as usual,'' you cannot actually expect physicians to ignore it. That is the message they have been getting.

I have here some quotes: ``Direct, simple clinical questions that needed to be responded to; unclear whether H1N1 vaccination and seasonal flu can be given at the same time.'' These are simple practical matters. The inclusion of practising clinicians is important, not the tertiary care, hospital infectious disease experts who have billions of years of experience in this area and know how to do everything. It is a completely different matter for the average family practitioner who tends to be female, with children at home, and runs a small practice but not full time. That person needs different information. This is one of the best places where we can do some work.

I would like to point out that Dr. Pat Huston is sitting behind us here. She was wonderful during the pandemic, talking to us directly and providing us with a large amount of information. We need to gear up those processes and do them nationally because a doctor cannot wait for filtering and provincial alterations of information.

I do apologize for going on a bit, but I feel so passionately about this matter. There is no explanation on the planet for why give clinical treatment would be different in Prince Edward Island or in B.C. That is indefensible. As a clinician, if something goes wrong and you have to explain to your insurer why you did something different than what someone did in another province where things went well, you are legally liable. There have to be national guidelines, and they have to be brought in early so that clinicians can actually make use of them.

I hope that is one area in which the committee will make strong recommendations, that is, how to reach out to them. For example, Dr. Vyta Senikas of the Society of Obstetricians and Gynaecologists of Canada went straight to the agency. The agency provided her and her organization with money to come up with guidelines.

Dr. Butler-Jones: We did that a lot. I believe we can do more next time, and quicker, and have more in place in advance than we did. Again, over the last number of years we have been ticking these off. Then the pandemic came and we did not have all the boxes ticked. I think we will be in a better position next time.

As far as comments about the importance of engaging, we absolutely agree but we need to do that together.

As an aside, one of the things that both the medical association and the College of Family Physicians has identified is the need to better interface public health with clinical practice at the local level in this country. Some places do it very well, other places do not. When it does not happen well, there are problems. We all have an interest in finding ways to better improve that.

Senator Seidman: With the understanding of the importance of a consistent message to the public, which you all emphasize, is there some way that we can enlist the help of the media?

I believe it was Dr. Harper from the U.K. who yesterday said that the chief medical officer was the one person who went out to give the same consistent message over and over again, but they used the media. Somehow they got the media on their side and used the media to help get a correct message out to the public. One of the problems we had here was that the media was consistently picking apart our message and trying to find holes in it. They were interviewing people who were not experts in the field and who only had contrary opinions to offer. Is there some way we can work proactively on that?

Dr. Butler-Jones: I will start and then I will turn it over to Elaine Chatigny, who is instrumental in the whole risk communications strategy.

As a for-instance, there were certain media outlets that were more challenging. As we had done during bird flu, we went around the country and met with editorial boards and the media to give them basically Pandemic 101. We saw an improvement in reporting, but even with meeting with the editorial boards and pointing out the errors, et cetera, although it was better for a little while, they then went back to looking for alternate views.

I am not sure in a democracy what difference there is, but post-SARS, all the national media outlets had people specifically assigned, and they were all looking for the big scoop. In order to do that, you have to find something different.

The Chair: Maybe Ms. Chatigny knows how to control the media.

Ms. Chatigny: Having been a journalist for many years, I can tell you that that is not possible, because we do not let it happen to ourselves as a matter of principle, or we try not to anyway.

You have raised some key issues. Dr. Butler-Jones alluded to the fact that prior to the pandemic, years of planning led to a series of workshops across the country with chief medical officers of health. It was a joint Public Health Agency of Canada and provincial-territorial exercise where we had workshops and invited media. We were deliberate in who we were inviting. We did not want just to talk to the health reporter who we knew had a fairly good baseline of knowledge. We wanted to get to the editorial desk editors who would have to edit copy. They do not know what they are talking about and make mistakes when they edit copy. We wanted to get to assignment editors and the second stringers who would inevitably get assigned to cover pandemic because it would be all hands on deck. We knew they would not have basic information on science, what influenza is, what a vaccine is, et cetera.

We did that. We were very deliberate and purposeful in our interaction with the media as a key stakeholder prior to the pandemic. However, news is not news if it is not bad, and news is not news if it becomes routine. As long as there was avian influenza in Southeast Asia and people were dying, the media in Canada had an interest because they could see a potential risk for Canada. We were able to engage with them and they were interested in coming to our workshops and learning, but the moment that the avian influenza waned in Southeast Asia, they lost interest in interacting with us on issues around pandemic and avian influenza. It was a hard sell. Desk editors would say, ``We are too busy; we do not have enough staff, and it is not news.''

That said, we made that effort. During the pandemic, we had a system called detect and correct. I will talk about the proactive media relations, but in terms of responding to inappropriate media coverage and wrong information, we had a team of media relations officers who would pick up the phone and/or email back, and when we had to bump it up right to the desk editor because we were seeing consistent misinformation, we would ramp it up and aggressively manage that interaction to try to get appropriate reporting out there.

As a matter of principle, the storytelling technique is always one of antagonist-protagonist. You cannot have just the Chief Public Health Officer, as credible as he is in the eyes of the media and Canadians. Journalists do not feel that they are doing their job if they do not have a counterpoint. That counterpoint can be ill-informed, and we saw that, but what do you do? When we saw a trend around who the go-to third-party spokespeople were, we gathered them around; we started bringing them into the tent by having technical briefings with them prior to major announcements, so that at least when the media went to them as the go-to third-party spokespeople, they were better informed about the decisions we made and why we made them.

There were a number of activities like that during the pandemic to try to correct the information that was out there through the media.

Senator Seidman: That is the point. I am not talking about controlling the media but about producing evidence, data, information, which of course goes back to surveillance and monitoring so that we have that information, and if you did daily bulletins indicating the situation in the country, province-by-province, and the number of cases, you keep producing facts.

Ms. Chatigny: That is what we did.

Senator Seidman: The facts speak for themselves — end of story.

Ms. Chatigny: We updated our websites on a daily basis, as did provincial and territorial colleagues. We had a one- stop shop for Canadians that we populated jurisdictionally called We also had all the right surveillance information that we were publishing regularly. We directed media to those websites and to every day at every opportunity.

The efforts were there. The activities were right. Did we catch everything? Did we interact with key reporters as many times a day as we would have liked? We probably did not, but there were many more of them than there are of us in terms of the volume and number of reporters covering the story and our ability to have that kind of close relationship with those reporters to be able maybe to shape the stories they were telling.

When looking at our media analysis and reporting trends, on balance the reporting was neutral. We had to correct some misinformation, but for the most part it was appropriate. What I think led to the sense of confusion and misinformation was the media's over-amplification of certain problems in the rollout of the vaccine. The information was very accurate around infection prevention behaviours, around the characteristics of the virus, and eventually around the composition of the vaccine itself, when they started getting it right around what an adjuvant is and what the difference is between adjuvanted and unadjuvanted. What led to a sense of chaos among Canadians were the images of people waiting in line, and the stories of a healthy 14-year-old playing hockey one day and dying the next. That amplification led to a sense of, ``What is going on here?'' Of course, Dr. Butler-Jones, the minister, Dr. Kendall and other respected public health figures were out there talking then, trying to instill confidence but also to ensure that people had the right information so that that natural human emotional reaction to a death and to concerns of what is going on were counterbalanced with this appropriate information.

Senator Martin: I have a comment on the communications. It sounds like you did a lot of work on this one-stop website It is a very challenging situation to get this out to Canadians. The people on the ground may not necessarily know that this is a one-stop website, so we need to convey that through a public campaign to make people aware.

As a former teacher, I know that schools are one of the most captive audiences, and if the kids are well informed and information is going out through the schools, the parents will receive that information because they receive it on a regular basis, such as through amber alerts. Much emergency preparedness is done in the schools. That would be one area to target for getting the information to the public.

Dr. Hatchette: I would like to approach Dr. Ricketts' comments about clinical guidelines. I was a member of the clinical care antiviral task group. The clinical care guidelines had their origins in the pandemic influenza preparedness document. They were basically generated by flu experts, as you said. One issue was that we did not bring other clinical groups into the fold quickly enough so that the guidelines could be done in a more expedient fashion. Part of that was that there was confusion about the role of PHAC in clinical care. We had many discussions, and I was quite vocal saying the clinicians expect the federal government to provide some leadership on consistent clinical care guidelines. As Dr. Butler-Jones said, influenza is influenza, but people do get the message that this is somewhat different.

We were told the mandate is that PHAC is a public health agency and legally is not allowed to comment on clinic care guidelines, to the point where we had arguments as to whether we could call the algorithm an algorithm. Once that role was defined, that the agency would facilitate the development of guidelines through the appropriate groups like the obstetrics group and the family physician groups, things went much more smoothly. The problem was that that happened too late in the game. At that point, in some places, such as Nova Scotia, we had developed our own clinical care guidelines and disseminated them to the front-line physicians. The learning point from that is that defining the role early and bringing the right people in will make that happen much more quickly.

Senator Cordy: I have a follow-up to comments made by Senator Seidman and Dr. Ricketts. We have different audiences. They have to get the same message but not necessarily in the same way.

Going back to the partnerships with the media, Ms. Chatigny, you explained that very well; thank you. Is it possible to develop these partnerships when it is not a news story, in times like right now? That is always a challenge. Not all the media were trying to find their story. Some were trying to disseminate the information in a worthwhile way. There would be many good partnerships there.

Also, going back to what Dr. Ricketts said, we heard about medical practitioners getting enormous volumes of information. You are dealing with a pandemic, so you are already working extremely long hours. You sit down at your computer and have 75 messages from the federal, provincial and municipal levels, in addition to other organizations. Someone who came before us said that we should have used the health professional associations in a better way for communicating to other health professionals.

Senator Champagne: I have a brief comment on what I was saying earlier today. I wish the television networks would not have considered the H1N1 problem as an election campaign. If they presented someone from one party, freedom of speech forced them to bring in someone from the other side. That organized mixed messages.

What did you do to encourage pharmacists to help? I go to my pharmacy almost as often as I go to my food store. Some pharmacies are now like department stores; you go there often. I had a conversation with the pharmacist next to my house. I said, ``You say, `Come to my pharmacy and you may win a trip to Hawaii.' I wish you would have said, `But if you get H1N1 you may not be alive to go to Hawaii.''' With the amount of money the drugstores spend to buy a whole page in the newspaper or an ad on radio or on television telling me that I might win something, they could use this media to tell people that they must have the vaccine; it is important. I want to ask Dr. Butler-Jones and Dr. Chatigny about this.


Ms. Chatigny, have you asked pharmacists to help to promote the importance of getting vaccinated?

Ms. Chatigny: Briefly put, no. No campaign has been developed jointly with pharmacists to promote the importance of getting the H1N1 vaccine. In other instances, yes, campaigns have been launched, for children's vaccines, for example, but not for the H1N1 shot.

As Dr. Butler-Jones said earlier, we had a very busy agenda and our agency was fairly new. We have accomplished many things, including social marketing campaigns amounting to $30 million, and advertising campaigns for TV, radio and bus shelters, but not for pharmacies.

I am glad you brought this up. People are likely to see pharmacists to avoid long wait times at the busy doctor's office or just because they do not have a doctor. It is a good idea.

Senator Champagne: Please know that I was not trying to criticize you, but I simply wanted to point out to you that pharmacists are respected by the public at large. We believe them and we listen to them.

Ms. Chatigny: They have credibility.

Senator Champagne: They have credibility and, if they say that it is important to get vaccinated, it is definitely a plus. That is all I was trying to say.

Ms. Chatigny: I agree with you. It would also be worthwhile to think of other non-traditional resources. If we really think about it, we can most probably come up with other stakeholders who have as much credibility as pharmacists with the public. That is worth looking into.

Senator Champagne: Going back to pharmacists, I feel they could help us more by contributing to this type of advertising campaign than by giving us a chance to win a trip to Hawaii.


Ms. Kiraly: The Canadian Standards Association, CSA, produces emergency preparedness and business continuity standards. As part of our activity, we held a round table of front-line workers. Everyone can criticize communication and talk about improving it, but one thing from the firefighters, nurses and emergency physicians was that they needed not only communication coming from the provinces and from the federal level but also a way to bring their information back so that there were more opportunities for two-way communication. The recommendation that came out of our round table was that there needed to be a special communication network to which front-line workers would have access to get their information and to get it in a way that suited them, and also where they could come back with their questions, concerns and issues that would help shape the communication that was coming from the various sources. Again, they were complimentary about the effort put into communication. This is a comment aimed at continuous improvement.

The Chair: It is good to get some response from the officials.

Dr. Kendall: In regards to communication, there is only so much that the federal government can do. If the provincial and territorial governments are not engaged fully, then that will not work. We are the level of government that has the ongoing relationships around licensing, negotiations, funding, et cetera, with physicians, pharmacists, nursing, the ambulance service, the police, the school boards and municipal associations. Speaking for B.C., we try to engage those existing relationships to push the information out, both in the inter-pandemic period, with communications and presentations; and during the pandemic period, when we work with the professional associations to develop a go-to website. There was one website where as soon as we had guidelines produced, they were put online for pharmacists, nurses and physicians. You can do so much at the federal level, but unless the provinces and territories are really engaged, the message will not go out.

The Chair: Some people suggested that the federal level should have the biggest control on the communications end of things. Some people suggested that having one voice was valuable, too.

Dr. Kendall: Creating the single message is important. I have always thought many voices, one message was more practical.

The Chair: Many voices, one message; okay.

Senator Fairbairn: This is an extremely important discussion around communication and how it should be used. There is no doubt that in our last period some excellent things were done. However, I want to remind everyone of something. When we talk about communications, I cannot say strongly enough that we must remember that within our country we have a large number of people who cannot read. Literacy is nonexistent in their home and in their concerns. I think it is impossible for many people to connect unless there is some kind of vocal person or group that can explain to those who cannot read. That is particularly important for people with children. If their parents cannot give them the help, then somehow the rest of us must have some kind of group across this country that will get out and work on this, if necessary, in a literacy way of doing things. Many people cannot read. In a situation like this, it is overwhelming. I think this is one time when television also can be used to help people, particularly parents with their children.

The Chair: That is a good point. Now I will give a final say to the federal officials.

Dr. Butler-Jones: Those are all good comments. In relation to this, the next pandemic may be in 5 years or 40 years. If it is 40 years, none of us will still be in decision-making positions. Therefore, capturing these lessons of the ways we did well but also the ways we can improve is important and much appreciated, from all the different reviews that are being done. As for the communications network, we need to find better ways to connect people back and forth.

With regard to the jurisdictional issue and Dr. Kendall's point about one consistent message that we all agree to and that comes from many voices, that is important. The connections are local. The minister talked about circles, reinforcing the connections locally, and a common source of information that we all share. There is a tension between wanting someone to be clear and, at the same time, wanting to engage. These are often conflicting. Getting everyone engaged takes time, and then you have multiple messages. Through the public health network, and through Ms. Yeates', Dr. Ricketts' and my engagement at the deputy level, we can do better at striking that balance. Certainly this is not something we have seen done previously.

We had planned with Canada Post to have materials ready to go, so we were able to get into every household in the country. That does not address the literacy issue, but we also had posters and other media that do not require literacy, as well as radio and television. These are all important, and I do not want to lose the importance of that.

A bigger issue, not just around pandemics, is the issue of clinical guidelines in this country. Public health has often been looked to in order to coordinate and facilitate that. We have done that with a number of groups, such as stroke or cardiovascular guidelines, diabetes, infection control. Dr. Hatchette's point is accurate. There is no structure in this country to do that in a consistent and coherent way across a range of disciplines. We have tended to fill in the gaps.

Early on, as Dr. Hatchette said, the legal advice was not to go there, that you are basically entering into the realm of medical practice and you have no right or jurisdiction to do that; and if you do that, you risk the federal government. In response, I said that we have to find a way to do it, because there is no one else in the country to do it. That is where we worked out the accommodation with the professional associations and that we would support that effort and share in it and, respecting the legal advice, still do it.

As we move forward, we need to have better ways of addressing this, not just around pandemics but more generally. That is again a lesson learned. We got there, but next time let us do it faster, please.

Ms. Yeates: I would make one comment about specialized communications to particular groups. One area where we learned quite a bit about doing things differently is communications with First Nations. Early on, there were particular viral campaigns.

I remember meeting with some chiefs in Northern Ontario. They asked whether we were getting the vaccine. We heard these kinds of stories about the vaccine and we were able to speak specifically. This raised the challenge of reaching that community through specific partnerships with the Assembly of First Nations — for example, the Virtual Summit — and providing thoughtful ways of reaching a group of people who felt quite vulnerable, given the remote and isolated nature of many of their communities.

The community leadership and the relationships with those individuals facilitated this. For example, the vaccination rates for First Nations were higher than for the population as a whole. There are lessons to learn from that experience about targeting a specific vulnerable population.

The Chair: This has been a productive discussion on communications and messaging. Thank you for that.

We will move on to vaccines and antivirals. Several witnesses raised concerns in our hearings about vaccine supply, production problems, packaging, distribution, and prioritization lists. Others mentioned the need for clear national clinical guidelines, including the issue of mass vaccination clinics, as well as the need to develop new vaccine technologies. Yesterday we heard about the possibility of a broad-spectrum vaccine that could be developed and delivered prior to the emergence of a pandemic virus.

On vaccines and antivirals, perhaps we could have the federal officials start and finish in each case. You are all sort of separate from everyone else here; you did not intermingle.

Dr. Butler-Jones: I heard that we would be mixed in, and then we ended up this way. Hopefully that is not reflective of the relationship.

We have never actually watched a vaccine being developed during a pandemic or seen the challenges in the vaccine production. While we had a number of measures in place — such as the regulator doing a lot of pre-work, which allowed them to do their work in an efficient way to ensure there was in fact a safe product — we also faced decisions in the spring for a vaccine in the fall, such as whether to follow WHO's advice to finish off the seasonal vaccine, and we saw seasonal strains and others circulating at the same time, and we saw a young woman in Winnipeg in the intensive care unit, ICU, with seasonal H1, not pandemic H1, in the spring.

At the time, it made sense to continue to finish off the seasonal vaccine and then start with the pandemic H1. Next time we would be more skeptical of that and maybe think about other ways of dealing with seasonal risk in the face of a pandemic, and perhaps we would actually plan not to finish off the seasonal run and maybe have tighter guidelines around the use of seasonal vaccine. We recognize that will put us in a difficult situation when we do face the fall, should this transpire, if we are still seeing seasonal strains circulating and telling some people: ``You usually get the vaccine, but you are lower risk this time, and there is no vaccine for you.''

Again, these will not be easy decisions. We now have experience with adjuvanted vaccine and pregnancy, so that potential concern will not be a concern next time. Both of these situations will contribute to more and faster production. As for the future pandemic supply, we are working in a way that will give us more vaccine, more efficiently. That will all help.

There were lessons learned at the local level, as well as sharing across jurisdictions as to what really worked. As Ms. Chatigny said, at the outset there were lineups. Two weeks previously, the view was that we would be lucky to get 30 per cent of the population immunized, and suddenly there were sad and unfortunate deaths of great visibility and everyone lined up. The media take on that was not, ``Good for you to line up,'' like it is a sale at Future Shop. Rather, the take was, ``How unfortunate and terrible it is.'' However, within days, the system adjusted and was able to manage the lineups. The lineups were more orderly and planned and essentially went away. However, what remained in the public eye were the challenges of the lineups.

Moving forward, assuming we have a vaccine that works, there will be new technologies and access to these new technologies as they develop over the next five to ten years. However, there will not be a quick and ready fix in a totally new vaccine. For example, the cell-based vaccines had challenges. Baxter's vaccine had challenges around actually getting production of vaccine at all. We cannot count on any one vaccine, and that is part of the reason we keep adding to our options, diversifying the stockpile of antivirals and thinking about the different issues moving forward, and the same with vaccines. A critical element will be to not put all our eggs in one basket.

I do not think I mentioned this last time, but many countries were purchasing H5 vaccine on the supposition that H5 would be the next pandemic and that even though the vaccine would not work, maybe giving it could give some priming.

Canada negotiated with the company to have the adjuvant separate from the actual antigen so that we could have adjuvant on hand and substitute whatever the appropriate antigen was, again hedging our bets and not counting on any one solution or trying to guess what nature will do, since that is fraught with challenges.

I will stop now, because I know you want to get to the discussion.

Ms. Ballantyne: I want to talk about the safety of the vaccine and some of the issues that came up around whether we moved too fast or too slowly. I said at this table earlier that making a vaccine is a hugely complex and global process that begins with WHO-certified labs actually identifying the virus. You actually have to wait for the pandemic or the seasonal flu viruses to be there so that you can extract the virus, isolate it in these WHO-certified labs, and then send it out to the manufacturers. All the vaccine manufacturers in the world then get this virus; they develop the strains and the reagents, and then production begins.

In this particular case, as Dr. Butler-Jones said, back in 2006, as part of the pandemic preparedness, the global community thought it was going to be H5N1, so everyone started working on that. We inspected facilities, good manufacturing facilities, and made sure the vaccine manufacturers had those. We looked at clinical trials related to this mock vaccine, as we called it.

In 2006, we tested the same adjuvant used last year, which had already been tested in clinical trial data. As a regulator, you cannot begin to look at the safety, quality and efficacy until the product starts coming off the production line.

We were with GlaxoSmithKline in this particular case, and we looked at the quality of the chemistry in manufacturing. We looked at animal data, ferret data, which is usually used in flu vaccines. Then we looked at clinical trials.

In Canada we required small clinical trials in Canada and North America. We were fortunate enough to use the clinical trial data from countries such as Australia, which had already gone through the pandemic period.

To actually approve the vaccine, we had to assess, as we do for any kind of drug, whether the benefits of the vaccine outweigh the risk of the H1N1 and the risk of the vaccine itself. Then we authorized it, but we also had post-market conditions built in, such as surveillance that carries on to look at whether there are adverse reactions or not, and then also commitments for the manufacturer to provide us with data on an ongoing basis.

Senator Ogilvie: I want to address both the vaccine and the antiviral issue. First, Dr. Butler-Jones, I think it really is a great tribute to Canadian science and Canadian medical science the rapidity with which the laboratories were able to identify the viral genetic characteristic, to be able to provide that information to other countries and to be in a position to cooperate with other countries to the degree that they did.

I am not concerned about the great success we had, but I am a little concerned about how it is sometimes presented. To give you a background to my comment, we identify a cystic fibrosis gene one day and we convey to the public the next that there will be a diagnostic, that the day after that there will be a treatment and two days after that there will be a cure. Those of us who heard that at the time and understood something about this knew that we were perhaps even a light year away from a cure and some considerable distance away from even a diagnostic.

What has happened is that even many informed people seem to think that the minute we know a little bit of DNA today, we are able to deal with the disease completely. In fact, in response to an observation I made at one of our hearings, a witness indicated that if only we had used DNA as a basis of developing the vaccine, we might have had it three months earlier. The implication was that we would virtually have these things off the shelf.

That was not my understanding of the capability and potential, although there is enormous potential in knowing the DNA of an organism. This week we heard clearly from scientific experts what the real situation is and were able to get on the record that this is not automatic.

I think it is a real concern if officials with some expertise believe that the identification of DNA will give us a vaccine very rapidly. As in the communication issue we heard about earlier, we will hear this kind of possibility and perhaps additional challenge to you with regard to dealing with these issues and how we respond to vaccine. That is an observation.

Parenthetically I will say that during much of my career I have been interested in how we have dealt historically with organisms and in the evolution of our understandings, all the way up to vaccines. Even today, as you pointed out moments ago, I think it was remarkable that we had the vaccine as quickly as we did. I will make that clear.

I have an observation with regard to the antiviral. Again, as a result of an answer to one of my questions, I dug into it a lot, and I will not get into the reasons for that. In looking at this particular antiviral, I found that there are many inventers who would like to have approval of a 50-million dose antiviral with little clear indication that it is absolutely effective, as I seem to be able to gather from this.

What I will say, however, is that I believe it is an important part of your arsenal for many reasons. I have no difficulty with the idea that it was in our arsenal, but I think the reason for it is part of how we are able to generally respond to disease, public attitude, their sense of confidence in the system and so on. It may also be with great difficulty, because of the nature of the influenza viruses, that effective antivirals will be off the shelf. Those are just observations.

The Chair: I would be interested in your response to that, but save it up.

Dr. Ricketts: It has been said already that the process of producing a vaccine is much more complicated than almost everyone on the planet understands. I used to say this about surveillance all the time, but I will say it applying to vaccine production as well. If you think it is easy to produce a vaccine, you must think it is easy to play a flute; blow in one end and move your fingers over the holes. It is extremely difficult to do, and kudos to the agency and their international recognition in this area.

Problems arose here, and there are comments about the problems. Some of these comments that came from the Canadian Medical Association really were happening at the front-line level. In some provinces they came up with new ways of distributing the vaccine during the course of this outbreak. As a result, they could not operate that quickly. There might be a comment about changing course in midstream, or perhaps one might say that if you are going to test these resources you should test them down to the application level, not simply at a higher government level or as tabletop exercises.

I wanted to make a specific comment on the reporting of adverse reactions and the need for electronic medical systems that would support that process. Indeed, this was a great problem for clinicians. They could not find out whether there were adverse events. In fact, I used to look for these things online and was unable to find them myself. I had the occasion to work with biologics people in the federal government for a period of time, and thought I would be able to get the information easily.

The clinical practice guidelines also included complex forms that needed to be completed by clinicians. I do not know what the solution is to this. It is just mystifying and difficult.

The other thing I would like to mention is the antivirals, and I would remind the committee that we were lucky in a way to have a spring pandemic. Since we had the outbreak in the spring, we had some hint of what the virus was, which gave this breathing period during the summertime when people are dispersed, when they are not together, when they are not spreading — the calm period — and then we had the resurgence in the fall with the larger second wave.

Keep in mind that in a fall epidemic, the role of a vaccine might be substantially less. Indeed, modelling demonstrates that the roles of antivirals would be greater in preventing death and reducing the amount of disease. Keeping that in mind, I am honestly not sure how easy it will be to communicate this to the public. I find it quite bewildering and must recognize the numbers and types of skills that are required to make these vaccine programs and the antiviral programs successful.

Senator Merchant: Have you gained some insight as to why there was that disparity and certain provinces did so well? We heard this morning that in some populations, 90 per cent of the population received the vaccine. Since we have landed at a level of 45 per cent, there were obviously some places, more in the urban areas, I believe, where there was a difficulty in getting people to go out and get vaccinated.

What have you learned, and how will we do this differently? Are there perhaps certain ethnic groups that are averse to being vaccinated? In the large centres, such as Toronto, there are many people from different parts of the world, more than we have in Saskatchewan. We are a little more homogenous in Saskatchewan. I am just wondering whether certain populations are fearful or do not believe in getting a vaccine.

The Chair: That is good question, but save the answer.

Senator Merchant: Maybe this is not the moment.

The Chair: It is the moment. It is okay. The federal officials will start and they will also finish. They will have many things to answer including your question. Is there anyone else? I have Senator Ogilvie for another one. I have Ms. Kiraly.

Ms. Kiraly: To echo Dr. Butler-Jones, what our stakeholders told us particularly around vaccines and antivirals is looking for a consistent approach. For example, why are front-line health care workers not a priority? How do we decide consistently who gets what and when to use what? Let us have a discussion before the next round about those guidelines and standards.

Senator Martin: I wanted to add to what Senator Merchant said. In Vancouver, where I am from, many of the cultural communities may not be watching the same news. They will get their news from their ethnic papers and media, so language is one of the issues as well.

Senator Ogilvie: On this issue, I want to state briefly that I am not concerned that not everyone gets vaccinated in the situation we had. We have to remember that we live in a democratic society with a range of individual and ethnic views on a whole range of subjects. I would be concerned if we did not have it within our authority under emergency measures if there is an absolute proven need that we can go in and deal with situations under those circumstances. We need to remember that there were highly educated and informed people who did not get vaccinated in this situation.

Rather than looking at it that 40 per cent overall was not a high number, I consider it quite a high number, under the circumstances, where once we got past some of the initial shock potential with regard to young people, the situation settled very quickly again, due to the leadership in the medical and health communities across the board. Communities were not panicked beyond the initial children issue and some local panic.

I just want to add a slightly different voice to the issue of whether 40 per cent is good or not. In fact, we saw that in communities where there was a clear, articulated higher risk, there was a higher percentage of response by the public on its own to the possibility of vaccination. I would like to think that that will continue to be the case, that when a given public is clearly convinced of the need for the access, it will respond. It is our role to ensure that the appropriate information is disseminated. That is another observation with regard to the response.

The Chair: I will cut the list off where I have two people, Dr. Kendall and Senator Cordy.

Dr. Kendall: I have a provincial reflection on the delivery of antivirals and vaccines. Unless there is a way of rapidly getting vaccines off the shelf, and I think I agree with you that there is not, antivirals will be critical as long as they remain effective. We did a lot of work in the inter-pandemic period with stakeholder engagement and ethical reviews to determine whether they should be used for prophylaxis or for treatment or for both. We ended up recommending for treatment. The system across Canada worked well with that.

We did not do as well with vaccines in a delivery system provincially because we were not as well organized as we ought to have been. We had a whole range of problems that we did not anticipate. One of the problems with the vaccine is timeliness. If you always get it well into a second wave or after people have had a long experience of what turns out to be a mild outbreak, the receptivity or the desire to get the vaccine goes down.

However, having said that, although on average our uptake in B.C. was 40 per cent, we actually did very well targeting pregnant women, health care workers and people with chronic conditions where the coverage was between 66 per cent and 75 per cent, depending on the group you looked at.

With risk targeting, the limited supplies worked very well. With the First Nations, because of the arrangements we just talked about, we had 75 per cent to 130 per cent coverage in those communities. We will go back and learn a lot more about vaccine delivery at the local level.

Senator Cordy: I would like to follow up with the priority lists. I would never want to be the one determining what the priority lists are because many witnesses before us presented valid cases as to why they should be on the first priority list, but we cannot have everyone on the first priority list. Someone must make the decision.

One of the challenges when you have a priority list and you have those under the age of 60, not over, and different age groups and pregnant women is that when you get to remote and rural areas, a family has to drive for 20 miles or 40 miles to have one child or two children vaccinated, and then they have to go back the next week so they can be vaccinated, and then they have to go back perhaps four weeks later to take their parents to be vaccinated. Logistically, that does not make sense. It seems to me that if one person in the family needs to be vaccinated, to make things simple the whole family should be vaccinated.

Going back to lessons learned in Newfoundland and Labrador, we wonder what they did well in order to get 80 per cent of the population vaccinated. Aboriginal people and First Nations had 75 per cent vaccination rates, which is good, but we did good things like bring people into the communities to vaccinate, which worked out well. Maybe we could do that in rural areas as well, looking at lessons learned.

When we had the panel of Aboriginal and First Nation and Inuit peoples before us, we learned there was no way to identify the Aboriginal and First Nation people who were or were not vaccinated because apparently there was nowhere on the form to indicate it. Of course the numbers of urban Aboriginal people are extremely high now, but there was no way to follow up regarding what percentage of them were vaccinated.

The Chair: I will get a quick question in from Senator Seidman, and then I will charge the jury, as they say, and tell them a few other things to respond to, and they will respond.

Senator Seidman: I wanted to ask a question about first access and who should be vaccinated immediately because they need to maintain the smooth functioning of daily living. We talked about vaccinating the health care providers, and we talked about maybe even their families, other staff in the hospital, police and key business people to maintain the food chain and things like that. It seemed obvious to start with, but as it started to filter down, the list grew longer and longer. Is there some way to think about that?

The Chair: We will go to the end of the table. I want to mention a couple of other things here. Packaging was mentioned at some of our hearings. It seemed local physicians were excluded in a great many cases because of the packaging size. Could you comment on that?

Dr. Ricketts covered adverse reactions. We did not hear about what happened there, so we would like to hear more.

Is this prospect of a DNA- or cell-based technology real, or is it just a fantasy and hope for the future? Where does that stand in consideration for developing future vaccines?

Again I will raise the question of a basic vaccine education because perhaps much of the reluctance to get the H1N1 vaccine is borne out of something that has long existed in that person's mind or in their family's mind. If we helped to overcome that, maybe the next time there is a pandemic it would be easier to get a higher percentage.

Finally, going on what Senator Ogilvie talked about, we first heard 40 per cent. My reaction was that was not very good, but then you came and told us that was better than anywhere else. How do we improve the vaccination rate? It is hard to justify the 40 per cent as being good when you hear that Newfoundland and Labrador vaccinated 80 per cent. It was so uneven across the country. How do we get it more even? Sorry to throw those in addition to the other questions you have had, but over to you.

Dr. Butler-Jones: I will walk through them and look to both sides of me to supplement. I know Dr. Plummer has comments around some of the scientific and antiviral issues.

I will start with your questions, Senator Eggleton. The packaging we have addressed. It is recognized that 500 in a package is too many. It creates problems for people to repackage. No one thought much about it in advance, so next time there will be smaller packages.

With regard to adverse reactions, a lot of thought went into ensuring that we have good monitoring ongoing from both Health Canada and ourselves. Again, having electronic records in the future will help and facilitate that. We did see adverse reactions other than the issue of a sore arm with the adjuvanted vaccine, the general reactions typical for vaccines, and not by and large severe.

Vaccine education is a huge challenge. We could spend a lot of time on that, and that might be worth a longer discussion. When I was a kid, hospitals were full of kids with vaccine-preventable diseases, from polio to complications with measles. We do not see that much anymore in this part of the world.

The advent of alternate views — ``You cannot trust your doctor or big pharmaceuticals, all these people, but I have this product that will save you'' — feeds into a mythology. Vaccines by and large are given in early childhood at the same time other things, such as birth trauma, are starting to manifest. It is a bit like saying umbrellas cause rain, but the cause of a problem might well be pablum or ice cream for the hot weather.

Being able to communicate science is an issue, and it is a long-term project, whether in schools or whatever we do.

Looking at the prospect of new vaccine technologies, there is a huge renaissance in vaccines as we are starting to use vaccines not only for infectious disease and public health problems but also for clinical problems, cancer treatments, et cetera. The next decades will see tremendous advancements. What that would mean ultimately in terms of a compressed time frame is hard to say, but even with the compressed time frame, we still have to ensure the new vaccine is safe. It will take some time to do that kind of research. We are hopeful and will keep looking for better alternatives, and time will tell.

There are all kinds of reasons for the variability in vaccine rates. We are trying to do some research to understand why people were or were not immunized. It is almost like reasons for quitting smoking — everyone has a reason. One reason was timing — they went once and did not get it. Southern B.C. was hit earlier in the fall, so by the time the vaccine was broadly available people thought perhaps they did not need to worry about it. There is all the mythology. There are so many reasons, and we could spend a long time talking about it, but we are trying to look at that and understand how that will help us to address that more in the future.

Regarding prioritization, a lot of work was done in advance, and that will continue, including ethical considerations. The plan has an ethics section that looks at trying to minimize the impact of the disease in terms of severe illness and death and from social disruption. That is where you saw the focus on getting the vaccine to those most likely to get severely ill or die and those who have to care for them.

In the spring we saw that the public structures, such as water, police and fire, were not disrupted. Because the antivirals worked, that early treatment was able to get people through that and back to work quickly, and so the priority was those who were more likely to die. A fireman with underlying asthma would be in the priority group. However, a fireman who was perfectly healthy then got sick would go get treated but otherwise go about his job.

Dr. Kendall's point is true as is Senator Ogilvie's. It actually worked. We did not know in advance of the pandemic how many people you need to immunize in order to get a herd. Basically we saw that within a couple of months the pandemic in Canada was essentially over, and we had the shortest flu season in history. With the combination of the 15 per cent or 20 per cent who were ill and then immune and the 45 per cent or so — and much higher rates particularly in high-risk groups — who were immune from immunization, we stopped the spread of the pandemic. It was in fact a very successful campaign, and now we know, at least for that virus, that that rate of immunization was sufficient to stop the spread.

I will stop there. We hedge our bets. One thing we did for the national stockpile was to purchase proportionally more Relenza, another antiviral, in case Tamiflu did not work. We were fortunate that Tamiflu did work, as well as Amantadine, and as new antivirals became available, we were impressed with how well the antivirals did work. They worked much better in severe disease than we were expecting them to, and that was fortunate because there was a good chance the thousands of young people who were in the ICU might not have survived, and we would have had thousands of deaths rather than the hundreds we saw.

Dr. Plummer: I will speak to the DNA questions raised. We can now rapidly determine the genetic sequence of any organism, which gives us the ability to diagnosis that organism quickly; within a couple of days of determining a genetic sequence, the provincial labs across the country were able to diagnosis it. It does not give us a treatment right away, but it does tell us that the treatment will work, because we know from the sequence that the virus will be susceptible to Tamiflu, for instance.

A lot of research is being done around the world on new vaccine technologies, including the use of DNA for vaccines. It is interesting that naked DNA will be taken up by cells, and you can produce an immune response in mice and sometimes in people. DNA is being tried as a vaccine strategy for many different organisms. None of them are anywhere close to being commercially available as approved products, and it will be decades before they are.

At the same time, there is a lot of research going on around the world on different vaccine technologies. The one we have is quite old. It is really from the 1950s. Cell-based is one. It may be that you can use DNA. It may be that you can discover how to make a more universal influenza vaccine. A lot of research is being done within the agency on these types of approaches, and we have developed about five or six different vaccine candidates. That was done within a couple of months of the pandemic's emergence, but the process of getting them into clinical use takes many years.

Ms. Yeates: I thought I would pick up on four of the points that were raised in the questions.

The first is the question on rural and remote and how we took the priority groups and how that made sense in rural communities. Precisely as was mentioned, we thought it did not make sense for families to drive long distances repeatedly or for health workers to send out immunization teams repeatedly. There was an early decision that in the rural and remote communities it would be a whole-of-community approach.

Certainly in the First Nations communities, that was the approach we took in the remote areas. It was one reason that the three territories got all of the vaccine for their populations rather than just for the priority groups, and that was agreed to by everyone. There was a recognition that we had to meld practicality with the priority sequencing.

As a federal, provincial and territorial table we have discussed how we learned from the provincial and territorial variances. There is a desire to follow up and learn as each jurisdiction does its own lessons learned about what worked well. We have talked as deputies about the need to share that and understand that through the public health network and at the deputies' table. There is a sense that we do need to learn from that experience.

On building the understanding, we talked a bit about the challenges of vaccines generally. I know PHAC has done some work there. As the regulator, we have tried to build an understanding of how we do vaccine testing, because there are many concerns about the safety of what we approve, particularly in a pandemic. The sense is that it seems to have been approved more quickly: Does that mean it is safe? The pamphlet that has been handed out talks about the development of a seasonal flu, but it is meant to educate the public in that less frenetic or less pressed time about that issue.

Finally, on the point made about what we learn from this going forward, on the regulatory side we have learned that we can work very differently with international regulators. This kind of working internationally was unprecedented, having daily calls or certainly frequent calls with regulators across the world, saying what we are finding and sharing data. That experience was built on relationships and planning beforehand, but it is one we will be able to build on going forward.

Dr. Gully: I would like to add one or two more points. On sequencing and prioritization, there seems to have been criticism about certain provinces doing things slightly differently than the nationally agreed guidelines. I do not have a problem with that. We should recognize that certain jurisdictions have certain different pragmatic requirements given their populations, current situation, and perhaps even the epidemiology of the disease going on at a particular time. Those variations were slight. In particular, perhaps First Nations were prioritized in some jurisdictions and not others, but that was probably pragmatic and practical for those jurisdictions.

We were discussing communications, and we realize that we do not have a very good idea locally of where people seek information. This applies perhaps to First Nations, rural and remote communities and then urban communities as well. It is a question of not only what we put out but also actually where people go, and this applies to all of us. Do we get information from the web? Do we get information, as well as opinion, from The Globe and Mail or national newspapers? Again, that is quite local. Local public health authorities have to tailor their messages to where people locally get their information.

In the First Nation communities we talked to, the chief, the chief and council and the health committees essentially said, ``This is what we think is right for the community.'' In certain communities where individuals arrived preaching an anti-vaccine message, the community said, ``Go away, because this is actually what we feel we should do.'' It was very much community-based. This is where the information came from.

The urban Aboriginal population is challenging. However, local health authorities were encouraged to use immunization clinics in Aboriginal friendship centres. Again, that would be pragmatic because the people going there would be First Nations. Also, we felt in the sequencing that probably the majority of First Nations in urban centres would have other risk factors, such as chronic diseases, and therefore they would be included.

The Chair: Our next section is surveillance, data collection and analysis. The committee frequently heard in our hearings that surveillance needs to be enhanced and consistent across the country. We heard that Canada needs a more robust system to collect and analyze data, convert it into policy and communicate the policy to all levels in real time. Such a robust system requires more expertise, such as laboratory, epidemiological and methodological personnel. To further enable this, some witnesses urged that electronic tracking systems be developed and implemented across the country, including, for example, the tracking system already in use for the over-the-counter and prescription flu medication.

Would you like to start with an initial thought on that?

Dr. Butler-Jones: On this one particularly I will be very brief and just say yes. While those things were far better than we ever had before, if we had had a few more years they would have been even better. The practical lessons of the reason, which reinforced the reason for where we are going and ways that we can refine that, are important.

Dr. Hatchette: I was critical of the robustness of the surveillance system. Certainly there were many things where the system did work, and we do have FluWatch, which has been in place for a long time. We could say that flu was here and not there, and we could look at the trends, but it did not have the capacity for real-time risk assessment, and it is all about risk assessment nowadays.

Part of that is the infrastructure or the lack thereof. That is my perception, but I am not an epidemiologist and I do not work for the government. However, I was co-chair of the surveillance epidemiology lab task group.

There seemed to be a lack of infrastructure for the surveillance of respiratory viruses in particular. I know that the public health network is undergoing a complete overhaul. The Pandemic Preparedness Oversight Committee had recommended a discussion forum on enhancing respiratory virus surveillance, and we had that in August. They recommended that public health surveillance be championed effectively at the public health network level. That is a very important statement because it is not just for flu but for any type of illness, whether infectious or non-infectious. You need a strong surveillance group that can not only define and track what is going on but also actually provide the risk assessment and have the expertise to do the special studies and things that will answer the questions that will inform the policy.

How do we use our antivirals? If we are in short supply you will have to target those who are sick. How do you find that out? You find that out through surveillance. Similarly, with vaccines, if you have an idea of who is at risk for most severe disease and you have a prioritization scheme, you need that information.

I will give a plug for the labs as well because not only is epidemiology important but lab surveillance is equally important. They are the two sides of the surveillance coin. Often the lab data comes first because very often symptomatic illness is non-specific, and it is the targeting of a pathogen that makes you worry about something. Alternatively, you can have clusters of unusual cases and the lab then has to look further to try to identify the pathogen, like SARS.

If I could suggest a recommendation, it would be that there be enhanced surveillance capacity at the national level and that there be effective co-integration of both lab and epidemiology in a co-leadership model. If this public health network restructuring is occurring, you want to ensure that that is occurring, because the labs and the epidemiologists have to talk to one another so we understand each other's language and better interpret the data.

An non-flu example would be sexually transmitted infections. The epidemiologists look at the rates and see that our chlamydia rates are going up every year, but what they do not understand is that we have more sensitive tests; we have better ways to sample; we are testing more people because the sampling is much easier. Not having that nuance makes it difficult and sometimes is disconnecting with the two systems, so it really does have to occur, and not only at the national level but also at the provincial level.

I was lucky in Nova Scotia to have great working relationships with our epidemiologists at the provincial level. There are other good examples. The British Columbia Centre for Disease Control would be one, where there is a bricks and mortar relationship where both laboratory people and epidemiologists are in the same building and have a relationship. Those pre-existing relationships only facilitate the ability to respond in emergency situations.

That was not always the case in some of the other provinces; the labs and the epidemiologists were quite disconnected, which made it more difficult to share even simple information. Without that connection and without that integration, you will not have the ability to tap into the potential to answer the necessary questions that will inform policy.

Dr. Ricketts: I could not agree with Dr. Hatchette more strongly. Everything he has said is right on the mark in regard to public health surveillance, so I will limit my comments to draw your attention to the fact that surveillance is not just public health surveillance. As Dr. Butler-Jones stated, you get your information and use it to decide what is happening at the national, provincial and local levels, but in fact the surveillance systems are actually missing down at the clinical level. The integration of clinically relevant surveillance is also a big gap.

It will not be easy to do these things. Surveillance systems are enormously complex. However, it is part of why the Canadian Medical Association is pushing so hard for electronic medical records. For example, at the local level, we know of one large primary care clinic that had electronic records for all of its patients. Staff were able to identify all the pregnant women in their setting and phone them and tell them they need to get a vaccine. There is nothing to improve your vaccine rates like having your doctor phone you and say you really need your vaccine. As Dr. Kendall pointed out earlier, it is more important to measure that the high-risk populations got their vaccine than perhaps to pay too much attention to the general vaccination rates.

I should perhaps mention that I spent most of my professional career in the development of surveillance systems, designed and ran the AIDS case reporting surveillance system, and designed and ran a research surveillance system for Creutzfeldt-Jakob disease. Talk about finding needles in a haystack.

It is considered the poor sister of epidemiology and there is often not as much attention paid to it as there should be. There should be more investment at all levels in this area, but I also believe strongly that good surveillance systems work best when the information that is collected is useful to the provider of the information. Again, to comment about that need to move down below or to one side — let us not set ups and downs — of the public health relevant information, keep in mind the importance of having clinically relevant information. This speaks to the response, so that at the local level you are seeing the response to the epidemic wave moving in and out of the area.

At the local level, you are finding out about the adverse reactions and any problems arising with antivirals or resistance. Clinically relevant information will always be relevant at a higher level, although not all that will be collected. It is very complicated, but I would like to draw some attention to that area.

Senator Seidman: I probably already put forward in the previous session my interest in surveillance issues and an electronic system that would facilitate those.

In this period of listening to witnesses we have heard a lot about the need for epidemiologists, or the lack of them. From my perspective, the most interesting thing when thinking about this is that it is probably not epidemiologists in general that we are looking for but infectious disease epidemiologists, because one of the biggest problems is that when we wiped out the most serious infectious diseases it was no longer trendy to be an infectious disease epidemiologist. Everyone went into chronic disease epidemiology. We had AIDS, and now we have other issues coming up. It is something to think about in a larger perspective. How we deal with that is a matter for education.

The third point I want to make has to do with an interesting development over the last 10 years in the Netherlands, where primary care physicians have been enrolled into teams to use electronic recording in their practices. It is on a national scale so that whenever there are serious medical issues they have private practices to tap into. It is sort of a ready-made research or surveillance tool. I am not sure whether you are aware of this, but it is quite impressive.

The Chair: In addition to commenting on the comments or questions that you have heard, let me say that again I would like to know what steps are being taken to improve Canada's surveillance capacity in preparation for the next pandemic. Again, I want to raise adverse reactions. How do the reports of adverse reactions to H1N1 vaccine compare to the adverse reactions usually reported for the seasonal flu vaccine?

Dr. Butler-Jones: Other than a sore arm, the adverse reactions have a very similar pattern to seasonal vaccines. An interesting part of the research going on during the pandemic was the concern raised about 1976, and some people alluded to that, when the U.S. mounted an immunization campaign against a swine flu that never came. The rate of Guillain-Barré syndrome, which was higher than in the general population but lower than during an influenza outbreak, did create a challenge around immunization. Therefore the study of that came up with two major conclusions. One is to separate the decision between producing a vaccine and delivering a vaccine; in other words, make sure you have something to deliver it against. The second is that you do not just go willy-nilly on technical advice because at that point basically those working in the area of influenza were concerned about the next pandemic, and they drove the agenda that we have to immunize everyone because otherwise it will be 1918 all over again, as opposed to a more tempered public health thinking of all the risks and balances.

I think we learned from that, and we did break it down into issues of risk, et cetera. Panorama is a surveillance system and also a case management tool. That will assist us in the future, both in public health practice and in getting quicker information. It is with the laboratory network, among public health laboratories, but again we have to make sure that hospital labs and others are linked back into that so that the public health authorities know what is happening. As I said earlier when the minister was here, it looks now like we picked up only a fraction in the overall surveillance of the actual hospitalizations, because hospitals would do a test and say it is influenza. We know it was all H1 at that time. It may not even have been reported as such. We need better linkages with those systems.

As well, we do use sentinel physicians, much like you were describing, and sentinel hospitals, so again we can get more detailed information and the pharmacological data around what is going out to pharmacists so that we get the signal of whether it is diarrhea medication or others.

I want to comment on a distinction between surveillance and research, because sometimes that gets confused. Surveillance will give us signals of issues; it will give us clues as to what questions to ask, but it will not necessarily tell us that this is the true relationship. For example, if surveillance picks up that pregnant women are at greater risk than their counterparts, we need then to understand why that is. We would still, in the midst of a crisis, tell them to get on the list for vaccine, but we then need to study it, which requires specific research. That is the value of having had the research network already established in advance, so that researchers across the country could start taking on some of the very practical questions. For example, are N95 masks better than regular masks for protecting nurses and other health care workers? As it turns out, in most settings, there is no different. That research is an important and practical thing to do.

There is a long list of questions that need research, but the surveillance for early detection, recognizing patterns, knowing when things are going funny, et cetera, is absolutely critical. We totally agree with the comments made and ways in which we can move that forward.

To reinforce Dr. Ricketts' point that for good information to be collected in surveillance or in research it has to be relevant to the person collecting it, we must find ways to close those loops so that clinicians, nurses and others see that by contributing this information on behalf of their patients they actually are better able to serve their patients. That is a critical piece to the loop, and we have not always done that well. We can and should do that better.

Dr. Gully: In relation to Dr. Butler-Jones' point about 1976, there is a very readable report called The Swine Flu Affair, published by the Institute of Medicine, which is a fascinating analysis of how government makes decisions around an issue like this.

In terms of surveillance and then clinical investigation, information that came out of Manitoba relating to First Nations, which was rapidly collected and analyzed and which was the result of a very close collaboration between the federal government, the provincial government, clinicians in Manitoba and the laboratory in Manitoba, allowed the situation in Manitoba relating to First Nations to be widely publicized and to be useful to other communities across the country. They were then aware of the unfortunate events in Northern Manitoba. The rapid analysis, in particular the relationship to the utility of treatment with antivirals, was available relatively quickly. I think that is a positive.

The other point about research is that we are asking questions about why some communities have a higher rate of immunization than others. It is not surveillance, but if we want to talk about First Nations, other Aboriginal communities and maybe other communities, we have to involve them in research. We do not have research as a question here. Planning ahead for what I would describe as participatory research so that we are able to ask those questions fairly rapidly will have to involve members of the community and planning ahead of time.

Ms. Ballantyne: To add to adverse reaction monitoring, not only did we not have intense surveillance mechanisms in Canada under the leadership of Dr. Butler-Jones and the PHAC, but we were also having surveillance done globally. For example, after the vaccine was authorized, we continued our weekly calls with our regulatory partners to ask whether they were picking up any kind of adverse reactions in different countries. Even that information was shared on a real-time basis. That was the unprecedented international cooperation that Ms. Yeates talked about.

GlaxoSmithKline Inc., GSK, the manufacturer, is required to send us data. If they notice any serious adverse reactions, they send information to both PHAC and Health Canada as the regulator. Therefore, this was monitoring internationally in a sustained manner even after this, and it is continuing now as well.

Dr. Kendall: The only thing that Dr. Butler-Jones did not mention about increasing our capacity was the work that PHAC was doing in reaching out to the existing agencies, such as the BC Centre for Disease Control, BCCDC; Institut national de santé publique du Québec, INSPQ; and the Ontario Agency for Health Protection and Promotion, OAHPP, to formalize some of the future linkages that can be put in place so that when he and I are no longer around, there is a mechanism to bring them in.

Dr. Ricketts: I have one comment about the adverse events surveillance system, which I know a little about, but I am not highly familiar with it. It is a passive surveillance system; that is, if you know something has happened, then you can report it if you wish to do so. That is probably part of the reason why we are not perfectly sure of the exact number and kind of adverse events. You obviously assume that the most severe ones will be reported, but maybe not the less severe ones.

It would be nice if we had an opportunity to move toward active surveillance. Again, in the presence of electronic medical records that actually inquire for this information, you can send out little messages that ask the electronic database if there have been any reactions, and then collect that information out.

This is not simple. All kinds of regulations exist to do with the Personal Information and Electronic Documents Act, PIPEDA, and computers. Dr. Plummer knows about this. I want to make sure that we understand the difference between ``active'' and ``passive'' surveillance systems. We would like to see a push toward active surveillance systems and the two- way communication systems that Ms. Kiraly mentioned as well; that is, where the communication comes back not just to the regulators. It is great to have the conversations — and I have been fortunate to be involved with Health Canada and in communication of information — but information needs to go down to our clinicians so that they know that this truly is not a problem.

Dr. Butler-Jones: To elaborate on the active surveillance or passive surveillance, it is much more effective when people have their attention. For example, in a situation where a large number of people are being immunized, and it is in the media, the chances of picking up a signal are much greater because people are paying attention as opposed to otherwise.

The other piece is the link to research. Whether it is active or passive, you pick up signals. It does not give you answers as to whether it is a true bill or not. During the pandemic, we did active research in following people who were immunized, for example, First Nations. In other words, if there are genetic variables, and given their risk situation, would they be more likely to have adverse events? Would they be more likely to develop immunity or not? There was active research happening during the pandemic. A large number of people were part of that study and volunteered. To supplement that, we were picking up signals from elsewhere. That combination is important. It is not as though one strategy will give us the kind of information we need.

The Chair: I will move on to the next issue, which is capacity.

The committee heard frequently that the H1N1 pandemic stretched Canada's resources to the limit. I think we heard that early on from you, Dr. Butler-Jones. Many witnesses called for greater surge capacity. Some offered that the scope of practice of some health professionals should be expanded in this regard. Others suggested the creation of linkages between the health care system, starting with acute care and the public health system, would be beneficial. We had one witness who indicated that we were talking something of a magnitude of five to ten times worse. That would be challenging to cope with.

Maybe we can talk about these capacity issues now. Do you want to start on that, Dr. Butler-Jones?

Dr. Butler-Jones: Sure. First — and the minister alluded to this — it would have been much worse if not for all the things we already had in place. If people had not learned the lesson early on about antiviral treatment at any stage and early pre-positioning of antivirals in communities, the experience of St. Theresa Point in 1820 of many vaccines in a short period of time would have been repeated in many communities in this country. The application of lessons learned meant that we did not hit the wall in quite the same way.

Having said that, the advantage alluded more to the fact that the spring event allowed us to the summer to prepare. Hospitals were able to tune up their plans and could look at what beds they could use. We were able to purchase additional ventilators, et cetera, to ensure that should we push the margins, we would be in a better position to stockpile additional medications. Again, because of the nature of how these people had to be ventilated, in the space of a month, Winnipeg used some of the medications in the ICU that they would normally not use in a year. They were able to pre-position those kinds of things.

Planning for surge is important. At the same time, you cannot have many people sitting around. We have been looking across the system at how better to engage. For example, you saw B.C. giving pharmacists the ability to dispense antivirals. Those are the questions that people need to be thinking about and anticipating for another event, as well as how we can better engage people that are retired and have some expertise. For example, in public health, we have more people with a basic understanding of epidemiology and public health 101. The more people know some of the basics, the more they are then in a position if not to contribute directly then to be more relevant to what needs to happen. I think we can do much more there in using professionals more widely.

Another the challenge is people's comfort levels. Although many jurisdictions were told that they could hire people who were retired and trained, their comfort level in doing that was not there. We need to think that through. Why did it not happen? Where did it happen? We need to ensure that is in place.

A point was made about the local level connections. One of the nice aspects of pandemic planning and where it took place was that it introduced new relationships, and people started to see other things that they could work on together. In the midst of a pandemic or another emergency is not the time for the local medical officer to meet the chief of police, the fire chief or the hospital administrator for the first time.

I practiced north of Toronto as a medical officer in Simcoe County. Back in the 1980s, I set up infection control committees in all the hospitals, nursing homes and homes for the aged. They all had public health on board. All of the institutes had protocols so that if they saw two diarrhea episodes that they were not expecting, or whatever, they knew what to do. There were close connections between public health and the institutions. Fast forward to the SARS outbreak a decade later, and in Toronto there was no connection between the hospitals and public health. Where that is lacking, we need to bring those together so that we can respond effectively as a system, not simply as a hospital versus public health or primary care.

I will leave those as my comments at this point, and then I will have an opportunity later.

Ms. Yeates: The only thing I would add is what we concluded at the FPT deputies table. I think you heard from other witnesses how frequently we were talking and meeting. We moved to a command structure to oversee the development and approval of all these many guidance documents and other things that were happening so quickly. We came to the conclusion partway through that process that we needed to have a body that looked at what I believe was called health services and logistics. We had a sense of, if we needed to move respirators or ICU capacity, how to be able to coordinate that. In the end, we did not need to be able to do that, but we created that capacity.

One of the lessons learned in the FPT sense is that we need to have that sharing mechanism, the ability to share information about the health services capacity, in place right from the beginning. That is key.

Dr. Ricketts: I would like to support Dr. Butler-Jones and Ms. Yeates strongly in their comments. They commented on important issues. It is always hard to deal with health services because of the division between federal and provincial roles in our health care system. Nonetheless, this needs to be done. We need to remember that we are trying to protect the Canadian public from a problem, even if it is disruptive to bureaucratic processes and unfamiliar to us at the time. It is important to establish these processes in advance. As Dr. Butler-Jones has described, based on his enormous amount of experience, once you have those processes in place, you do not do anything different; you just do it more quickly.

One issue that arose is particularly with respect to clinicians. I realize now that I am the only person at the table who is actually representing clinicians and physicians. Perhaps I will extend a bit into my understanding of the pharmacies. I dare not talk about nursing because I have not worked with nurses in the same way as I have with pharmacists.

The issue around how to compensate small-business owners when they contribute to the pandemic process was left a little long and ended up indeed in the sense of a conflict instead of a partnership, which was unfortunate. Small- practice family physicians are small businesses. They have to pay insurance for their building and for their personal insurance. They have to pay for their secretary, anyone else working in their office, all of their rent, et cetera. If they leave their office for a period of time, it costs them money. I do not think anyone would suggest that Shoppers Drug Mart would volunteer the time of its pharmacists, but it certainly could afford to do so. However, small family practices certainly could not.

There was some unfortunate apparent conflict. I would like to remind everyone about how Dr. Turnbull addressed a question related to this, in saying that physicians are fully committed to doing this work and that it should not be the issue of billing that arises during this time period but rather how we will roll out these services in the most relevant way possible. It is great that at least some of this work has been done in many of the provinces. I appreciate the opportunity to mention that again.

I have only one suggestion in this area. It occurred to me that we see these capacity exercises done for situations such as airplane crashes, where people get dressed up and they actually have them come and go. It is very real-time and very physical. I have had the opportunity to participate in some round-table exercises. One recommendation that could be made is that these capacity-testing exercises roll down to the level of clinicians.

In addition, if anyone does decide to talk about using retired health care workers, the training required to do these jobs is not insignificant. Please do not underestimate how important it will be to give those people the opportunity to learn what their new jobs will be, especially if they have been out of the workforce for a period of time, even for a pharmacist to provide a vaccine.

I was in the United States recently. I happened to be at the airport, and there was a nurse sitting at a booth next to the lady selling Visa cards. The booth said, ``Get your vaccine, $35.'' Maybe we do not need to make this too complicated, but I am glad I do not live in the United States for these kinds of things. Those are the extent of my comments.

Ms. Kiraly: When we talk about capacity and planning, certainly our stakeholders said that having the federal plan for influenza planning was wonderful. What they looked for was a little more guidance in developing, training and planning their own emergency plans, particularly in hospital settings. They were looking for standardized approaches. Five hospitals in the same area all had the basic framework, but they took different approaches to collect it.

Now that the pandemic has passed, we have talked about moving on and how to get people's attention. We need to ensure that health care facilities, which are all required to have emergency plans as part of their accreditation, have a section in that emergency plan on pandemic planning and that they have a consistent approach so that hospitals have the opportunity to learn, absorb the information, reflect on that, update their plans, look at training and capacity and put a new plan in place. That is something that some will do.

It is important to have the benefit of all the knowledge that sits at PHAC, Health Canada and in the provinces to have the ability to assist. At CSA we have been talking to the Council of Health Emergency Management Directors, CHEMD, and they are supportive of the idea of improving the planning for pandemics in emergency planning and looking at linking hospital accreditation to that. Again, we would advocate a standardized approach where we take the lessons learned, incorporate those into existing emergency plans and build for the future.

Dr. Butler-Jones: While no one would have wished for SARS, there was a silver lining: Canada recognized that we had neglected public health for some time and that there were serious capacity issues and a need for a different way of working. Whether in the establishment of the various agencies, the resources that came, the pandemic planning or the Pan-Canadian Public Health Network, this put Canada in a better position to deal with pandemics, taking the lessons from SARS and applying them.

During the bird flu, people would ask me if we are ready. Every month we were more ready, and we are more ready today than we were a year and a half ago. We need to continue to build and understand the capacities we need in order to do this work.

It is gratifying to see progress at the ministerial level, with deputies across the country. At the last ministers' meeting, and at FPT deputies' meetings, public health is a regular part of the agenda. Ministers across this country endorsed a declaration on prevention and a framework on tackling childhood obesity. Five years ago, one might never have imagined all the jurisdictions coming together. That bodes well into the future, but we cannot lose sight of the appropriate capacities that allow us to do this.

I want to pick up on Senator Seidman's reference around infectious disease epidemiology, and epidemiology more generally. There is a clear shortage of good epidemiologists. It is not just about epidemiologists but about people who have had experience dealing with these types of events and outbreaks. We are trying, not just for the agency but more broadly, to find ways that people can get experience. As Dr. Kendall said, now that there are three provincial public health agencies, as well as ourselves, we need to collectively leverage that capacity.

As you may know, we have field epidemiology training and a number of things in place, but that is a small piece of it. We could work the system so that more people can shadow, get experience, and, as we send Canadian teams overseas, maybe others can come along to learn so that they bring that experience back into their local settings. We are considering a number of things, and it is critical to have the people to backup, as well as flexibility.

One of your witnesses talked about the unique skills of someone dealing specifically with influenza, but also some good generic skills are necessary. One of the things we saw during the pandemic was bringing chronic disease epidemiologists and others to work alongside. They may not have the specific expertise but they know how to analyze and understand data and how to develop logical and rational explanations for it.

Again, finding ways to assist people to be part of that process will be important, moving forward.

Ms. Yeates: There was reference to the MOU on mutual aid. I was a provincial deputy of health in Saskatchewan during SARS. Since that was so concentrated in Ontario, I recall the calls we had then. No easy mechanism existed to even send people who were currently in the workforce to help. We could send some epidemiologists and others, but the licensing arrangements are complex for health professionals, as the committee knows.

The ability to have that arrangement not only between provinces and territories but with the licensing bodies in each jurisdiction is important. Again, we did not need to use that in large measure in this pandemic, but given the comments people have made, pandemics tend to hit different areas at different times. There are different experiences from which one can learn. The ability to ensure that we have the frameworks sorted out to the best of our ability in advance, not only between governments but between professional organizations, to move people who are willing to help out in urgent situations is key.

The Chair: Let me move on to collaboration and consultation. The agency's collaboration and cooperation with provincial and territorial governments as well as other jurisdictions globally, such as Mexico, was commended by witnesses.

To further improve it, however, the committee heard that there should be greater integration of the resources available within the public health agencies of Ontario, Quebec and British Columbia. It also heard that there should be greater awareness of how policy decisions at the federal level present logistical challenges on the front lines.

On the question of collaboration and consultation, do you have an opening salvo on that?

Dr. Butler-Jones: A couple of things, and some earlier commentary addressed a little of it.

Having been around these issues for quite a while, the level of collaboration and cooperation was unprecedented. I have never seen anything like the willingness of people to engage and to drop down their normal walls to facilitate a common objective. That part was gratifying.

In advance of that, we had a number of things in place. For example, we had the private sector working group. Under the federal deputies that I co-chaired, there were a number of working groups, including the private sector, the major infrastructure and industry groups from across the country.

One of the things that came out through that was that even with that in place, whether it is the Federation of Canadian Municipalities or others, there is a need to go even further, to particularly directly engage the federation, at least at the federal level, around things. When you have 30 industry groups, for example, you can deal with it at this level. However, when it comes to other things, you need to deal with the truckers' association specific to the transportation of goods, et cetera; and you need to deal with municipalities around emergency services more generally, et cetera. We are progressing in how we actually best develop those relationships and continue to refine the plans moving forward.

It is the same as what Dr. Kendall said earlier about the provincial associations, but not just the existing provincial agencies. There is also that capacity in Nova Scotia, Dr. Hatchette's group and others, and with academics.

Again, it worked better than it ever has before, but we think we can continue to improve that. I will leave it at that as a setup.

The Chair: Does anyone else have a comment on collaboration and consultation?

Dr. Gully: I just realized that, when I was at WHO and the UN, I participated in regular calls of financial regulators globally, which included Canada. There are other networks out there as well of groups that have an interest in what is happening with the pandemic and preparing and responding with which perhaps we do not normally have interactions, but they actually do exist. As I said, the finance sector is an example.

Dr. Butler-Jones: In advance of this, we were in partnerships with the Bank of Canada and others.

Dr. Hatchette: I want to make a comment, and this will speak to the experience I had with the epidemiology group. I think collaborations are essential, and many people in the country have specific expertise that will only enhance what we can do.

However, you cannot rely on collaborations alone because those individuals will have as many demands on them as would be requested of them by their federal partners. We saw that with our group.

We invited provinces that have specific interest and experience in influenza and have very experienced epidemiologists to participate in the group, but the participation was very limited because they were overwhelmed by the necessary activities that they had to do in their own provinces. They just did not have the time to participate at the federal level.

While collaborations are important, it is really more than that; you have to build the resources and the capacity at the home centres to allow this extension to occur.

Dr. Ricketts: I want to restrict my comments to the health professionals who are actually working in the field because I know we have heard about other professional organizations. I will repeat something I mentioned earlier about some 75,000 physicians in active clinical practice who were trying to do their work during this time period. I am not quite sure of the number, but I think it is approximately 50,000 family practitioners — it could be lower than that. I would like to emphasize their particularly important role. I thank Dr. Butler-Jones for a phone call he made not very long ago, as a matter of fact, where we had a conversation about this.

Having worked at the federal level and also at WHO for a long time, we need to keep in mind that the job is not done just because the FPT process is working. It is very awkward in Canada, with the FPT relationships and with the way that clinicians are involved in this, but it is essential that we design systems. Dr. Hatchette was referring to designing systems that you can put in place.

I already mentioned how successfully it was working with, for instance, the Society of Obstetricians and Gynaecologists of Canada, SOGC. Maybe we need, in advance, a system of twigging the relevant professional organizations to ensure that they will be able to pull the people together and to provide them with small amounts of necessary funding. Most of the time these physicians volunteer their time to be on these groups, but it would be nice if the travel and conference room costs would be covered, maybe a little secretariat support. Some of the professional medical organizations are quite wealthy and some are not. There are those who would need help with research. Establishing that in advance would be quite useful.

To return to a comment made earlier as well, the clinicians in Canada, physicians in particular, are looking for a national response when it comes to clinical matters. I believe it is important to emphasize that that includes not just facilitating professional organizations to support them but also bypassing some of the FPT processes. That must be addressed. It does not mean excluding FPT processes but rather bypassing so that you do not end up with guidelines coming out in September and October, while people were thinking about other things.

The physicians are quite capable of working directly with public health experts, and there is huge expertise in this country. However, to get the information that they need from them in an atmosphere of trust and respect so they can design the guidelines would be a very important step forward and a very worthy outcome that might have implications in other areas as well.

I hope that the agency and the provincial and territorial public health groups will get the infrastructure funding that they need to facilitate this sort of activity.

Senator Cordy: Dr. Ricketts certainly talked a lot about the professional organizations, so I would like to talk about consultation with the private sector because I think that large organizations particularly can be very effective in communicating messaging to their staff.

One unfortunate occurrence within the private sector — this sort of ties over to priority groups and communication — was the frustration people felt when they saw professional sports teams, or even in Halifax the Quebec Major Junior Hockey League, immunized far ahead of many of the priority groups in the province. People wondered why that was happening. I guess you would call those people the private sector.

How do you deal with that? People were upset by that, but going ahead with collaboration with the private sector is extremely important, particularly with messaging, and is a very effective way of getting people to find out the latest information on what is happening.

The Chair: I want to reiterate something I asked the minister earlier. The Federation of Canadian Municipalities and the Canadian Teachers' Federation said that we should have a national pandemic influenza plan, and they meant not just one for the health care system but rather a plan that incorporated the first responders and all the other entities. Does that suggestion have merit?

Dr. Butler-Jones: I remember when I was doing local pandemic planning; as part of it, one thing I would say and still agree with, is that pandemic planning is part of emergency planning. It is not just about pandemics in isolation. It is a little different than dealing with an earthquake or a tsunami or whatever because it is ongoing; it is not an event that goes away. It keeps happening for weeks and months and maybe comes back again.

It has to be part of municipal planning, provincial-territorial planning, national planning for emergencies, and there is a pandemic component to it because it relates to antivirals, health care facilities, et cetera, and cannot be done in isolation of the other.

My support is for ensuring that it is part of the ongoing planning. As part of that, in advance of the pandemic, setting the private sector working group that included the Canadian Chamber of Commerce and others and looking for tools was what prompted us to fund the International Centre for Infectious Diseases, ICID, to develop tools for small business, et cetera. We found that large companies — Canadian Tire, the banks — coming out of 9/11 had great contingency plans in place, but that was not the case with small businesses, mom-and-pop shops. Now that those tools are developed, it will make it easier for the next time around.

It also struck me how quickly certain measures were adopted, such as hand sanitizers and information in washrooms on washing of hands and application. Even for groups with plans in place, we discovered that many plans were so specific that people said, ``We do not do anything, but then at this level of pandemic when it goes to level six, suddenly we are doing this, this and this.'' It pointed out the need for those plans to be much more flexible, and we were able, through labour organizations and others, to provide advice on how to interpret them. However, in the planning going forward, I think everyone will need to introduce more flexibility in their plans to articulate up front the need to adapt to the situation and not presume that simply because it is level five or six, all this falls into place.

That takes us back to communications and planning and the importance of that moving forward. At the end of the day, while it is local and may be 1,000 localities at once, if we can get the local connections right, then every other level will be reinforcing and supporting, and we can focus on getting those things we need to know in common, and then producing the actions locally.

I cannot stress enough the importance of having those connections in place and having plans in place, whether it is clinicians with medical officers, local businesses with the municipality or whatever the connection may be. That will assist us greatly for a range of issues, not only pandemics.

Ms. Yeates: I would add to the question of coordination that there was a Government of Canada coordination effort that was quite unprecedented in what we did. Initially it was the Privy Council Office, and then the lead switched to Health Canada to pull together a Government of Canada response so that whether it was the questions that were coming up at the border, the transport questions, or whether it was the labour department, for example, that was getting questions from businesses, we were able to ensure that the same information was going out everywhere.

We did try to reach out through that mechanism to the people who would normally contact the departments of labour or transport, for example, if they were in that industry, to ensure the same guidance, the same work we were working on with the provincial and territorial governments and other health stakeholders, was put through those mechanisms. That was one mechanism that can no doubt be improved but something we tried to do to cover off a broader range of stakeholders.

Dr. Butler-Jones: For example, on the labour side, we at the federal level as deputies were meeting regularly, and then had other committees under that to coordinate, as Ms. Yeates said. However, in addition, labour had a network with their provincial and territorial counterparts so that they could feed information and have common interpretations across the country when it came to challenges around the right to work or refusal to work, et cetera. Huge amounts of cooperation allowed that to happen. Instead of people saying, ``Oh, this is my jurisdiction,'' they were asking what is the issue; how can we address it together; and how can we bring science to bear to address it.

The Chair: Do you feel you need any new mechanisms for consultation processes amongst all the various groups you are talking about?

Dr. Butler-Jones: Certainly the Pan-Canadian Public Health Network and the network of deputies proved their utility, et cetera. That is being revised as we speak or being looked at in terms of how the structures can be better in the future. It really is about more specific connections with municipalities, et cetera.

At the federal level, they must be conscious of the jurisdictional respect, and it is for good reason that each level is able to make those connections, and we can reinforce them nationally. However, we cannot do it for everyone, nor should we because they know their situation best.

As every jurisdiction looks at their lessons learned, they are coming up with very similar comments. We have learned from the past and applied that. We have learned more from this event, and if we apply that, we will be even better in the future.

I do not think there is a structural different response to that. It is really working with the structures we have in an even better way.

The Chair: I will move on to Aboriginal issues or, as you have it on your agenda, First Nations and Inuit. During its session on Aboriginal issues, the committee heard, in addition to many of the issues we have talked about already, that there should be permanent Aboriginal representation on the Pan-Canadian Public Health Network, that the social determinants of health must be also addressed to reduce the vulnerability in the face of a pandemic and that not all aspects of the response that were made on H1N1 were culturally appropriate.

Dr. Butler-Jones: I would certainly agree that not everything was culturally appropriate for all cultures. That is a challenge. One of the advantages — and challenges at the same time — of public health is being local and being able to respond and adapt to their communities, recognizing, as the minister said, from the federal level at a point in time that we are trying to capture the diversity of this country and the diversity of responses that are needed. You will never be, quite honestly, completely adequate in that. However, for the first time, in a way that I have, again, never seen, we saw the desire and effort to have resources, information and materials that respect language as well as engage and respect culture. For example, if you look at the posters that were developed, the materials across Nunavut were developed locally with our support, allowing communities to see themselves expressed. It was not perfect, and we can always do better on that.

The public health network itself is a jurisdictional relationship between the provinces, territories and federal government in terms of how we deal with our management of public health in the country where it makes sense collectively. Under that is a range of expert committees, et cetera, where not just Aboriginal perspectives are reflected but others as well. It is important that, at the jurisdictional level, we are sensitive to that and sensitive to the difference in relationships. As the minister said, in Nunavut, 85 per cent of the people are of Inuit descent, which is very different from the Yukon and Ontario. There is the jurisdictional aspect to it, and also the aspect of how to gather and engage the various communities in this country, particularly given the challenges and relationships that Europeans and others have with the first peoples of this country and how to best engage that so there is actually an active discussion of how to improve that.

We have, for example, the national collaborating centres. The agency funds a number of national collaborating centres, one of which is on Aboriginal peoples' health, and that reflects a range of opinions. How can we better engage them in the conversations to bring to the policy and programmatic dialogue as well as others? We are looking very actively at how to do that and focusing on what we are trying to accomplish by that, which is ensuring that we do have the right inputs and processes, et cetera, but also respecting that a jurisdictional conversation needs to take place. We have not quite got it yet, but we are sensitive to that issue moving forward.

Others might want to speak to that in terms of the services side, because the First Nations and Inuit Health Branch, FNIHB, actually delivers services on reserves, for example.

Dr. Kendall: I agree. As a member of the network and its co-chair for the first five years, we have been striving to come up with a way of engaging Aboriginal and Inuit input. We are a cross-jurisdictional thing, creatures of deputy ministers of health, so our structures are somewhat dependent upon the political realities across the country and how that works with First Nations and Inuit. It has proved challenging. We all agree that we need a First Nations or Inuit lens, but we are still struggling with how to get that. Having said that, I am not sure it would have made much of a difference to the response on the ground for First Nations or Inuit experiences.

I can only speak for B.C., where I think we have good relationships over a number of years in a tripartite table where FNIHB sits down with the provincial government and the representatives of the five political First Nations organizations to work out a transformative health accord. We have been working with them on health goals. That was a table at which we were able to come together and create a detailed plan for not only First Nations communities but also rural and remote communities. That does not quite address even the issue of who provides services or how you engage planning for the First Nations people who are off-reserve or for the Métis Nation British Columbia. Those were separate engagement tables.

I cannot see how the public health network or engagement of it would have helped us deal with the issues on the ground. It is an important issue, but the outcome of the future planning really needs to engage locally. We do have the federal engagement, but it is a local federal engagement within B.C., which is doing something quite different from what is happening in other jurisdictions.

Dr. Gully: I did come into this file relatively recently, but I have realized the complexities of arrangements at the community level for First Nations on-reserve. There are either not transferred, or if they are transferred, there are various levels of transfer, and their relationship to the provincial governments are various. Therefore, I think that to try to systematize that in any way in terms of planning will not work. Again, as Dr. Kendall says, we have The Canadian Pandemic Influenza Plan for the Health Sector, and an annex relating to First Nations on-reserve. However, the actual application, planning and preparedness are dependent on the community, the leadership in the community and the relationship with the province and the local health authorities.

We can work through that, as I think we did. I remember talking to one leader in Northern Manitoba who said, ``I could not get interest in pandemic preparedness in my community. I tried, but there are many other issues going on.'' Some communities were better than others, and they were well aware of the need to do it, but they are continuing to face other challenges as well. It was expressed that we need to continue to support, communicate with and collaborate with those communities at that level to then enable their response and their ability to take up and take advantage of such things as the immunization vaccine and also the antivirals and other services.

The Chair: You do not think the idea of a permanent Aboriginal representative on the public health network is the answer, is what I am hearing from all of you. However, you need to still improve the communication and collaboration with people in the Aboriginal communities. Is there another mechanism you are suggesting, or do you think you have a good handle on that now?

Dr. Gully: I am sure we can continue to improve that. During the pandemic, there was continual communication with the national Aboriginal groups. Again, it is also recognizing that the First Nations, Metis and Inuit are different communities, different across the country, and therefore it is very local because relationships in Manitoba are different from relationships in British Columbia, et cetera. We can do it nationally, but it has also has to be done locally.

Dr. Butler-Jones: Building on that, it is again the importance of the connection at all levels, at the interjurisdictional level, ensuring that there are input perspectives. There are a number of ways to do that — on our committees, in direct consultation, in the work that we, Health Canada and others do with the national Aboriginal organizations — so there is a constant flow of information and consultation occurring. How to structurally do that with the public health network is a struggle, but it does not change the fact in terms of the issues of engagement. There were many examples across country, and the lesson for me is ensuring it works at the local level because, as I looked at where things worked well and where they did not, the solution is different in different jurisdiction.

In Saskatchewan, I did it by having medical officers cross-appointed long before this. Therefore, whether they were working for the National Aboriginal Health Organization, FNIHB or a regional health authority, they were all cross- appointed so that they could cross-cover for each other. They all met together on a regular basis. They could work on- or off-reserve and could share information. The planning around pandemics and emergencies engaged local band councils as well as municipalities. When it came to the pandemic, they were able to look at it very smoothly. At the House of Commons Standing Committee on Health, HESA, some of the chiefs from the North said that they saw their people as people, not whether they were on-reserve or off-reserve. They had planned and prepared to deal with people living in their communities and to deliver the vaccine or antivirals and ensure they received appropriate care. That is what you need to see at the end of the day, in my view, which then can be reinforced and supported provincially or territorially and nationally.

Senator Fairbairn: I am close to the Kainai Nation, and they have that now. It has made a tremendous difference, not just for the people at the top but in every part of that organization, every part of the people on the ground. They are doing it well. It would be wonderful if that could happen everywhere in Canada because it has changed all sorts of things. In addition to being ill or not, it has made quite a difference to that group. I do not know whether you have had anything to do with them.

Dr. Butler-Jones: I have not had any involvement with that specific community, but it is reflected in many communities across the country and where the connections are not there, it was a much bigger struggle for the communities and those around them.

Senator Fairbairn: Previously, anyone who had difficulty would have to go across to Lethbridge, or the town that was closest, and now they have the opportunity to do it themselves and it is fine.

The Chair: I will now move on to roles and responsibilities in public health. We know it is a shared responsibility for the FTP levels of government. The committee heard, though, that some people felt it should be a stronger federal role, that it was good to have Dr. Butler-Jones out there as the father figure or the chief doctor being able to help convince the population of what needed to be done and to calm the population. On the other side of the coin, Dr. Kendall used the phrase ``many voices but one message.''

Is there need for any shift here in these responsibilities? I guess communication with the public becomes one of the key parts of that, but what do you think about this?

Dr. Butler-Jones: This is a question we periodically revisit, whether it was with listeria or the formation of the agency, the legislation that created the agency, or coming out of SARS, where we need more thorough authority to tell people what they need to do and make the provinces do what they need to do, et cetera.

On the other hand, we have a federation, and with all its warts, it generally works. In my view, it works best because we can find a common interest, where we respect each other's roles; we can come to what Dr. Kendall refers to as many voices with one message. While the approaches may vary, they vary for a reason, and the more we communicate and connect, the better we articulate that reason. However, it is not a nice 10-second sound bite unfortunately.

Having sat on both sides of the table, I keep going back to the fact that public health is local. People get sick locally; they stay well locally; and they face emergencies locally, even if it is 1,000 localities at the same time. I keep asking, within our organization and more broadly at each level, what is our value added. What can we do to bring that together so that no matter where you are in the country, the capacity to address issues of public health is available at some point if needed?

The public health network has been a very helpful mechanism where Dr. Kendall and I, as the first co-chairs, can have those conversations on a range of issues so that we can, to the extent that we can within this diverse federation, move in concert on the things that make sense to do so. Quite honestly, when I was on the other side and even on this side, I would not want someone in Ottawa trying to manage every issue across the country. We can facilitate coordination, bring capacity, bring resources and do many things to make it work better.

I remember the debates around water. This was when I was on the other side and before there was an agency. There was a concern about water in Saskatchewan and in communities, et cetera; and surely we need the federal government to take this over. At that point, I could only point to the fact that the federal government does have some responsibility on- reserve for water. I am not sure that is what we would all like to see. In fact, the reality is that the further removed we are from the issue, the more difficult it is to manage those issues. It is a fine balance that we always struggle with between local authorities, accountabilities, the responsibility to those communities, the knowledge of those communities and then what at each level we can value add.

In the federation, that is an ongoing discussion as to what we can contribute as a federal entity, what can be contributed at the provincial level and what can be done locally. I will leave Dr. Kendall and others to speak to that. I have seen tremendous progress in that in the last six years, compared to what we saw with SARS and before. This is another learning experience, not just the Senate's work but this whole exercise in helping to move that forward on a range of issues, not just in dealing with pandemics.

Ms. Chatigny: If where you were going with that comment, or as a result of what witnesses' suggestions of one voice, was to suggest one spokesperson for an entire country in an event, I would strongly dissuade that for the simple reason, as was alluded to by Dr. Butler-Jones, that in eight months Dr. Butler-Jones conducted 50 news conferences, 100 interviews and was on the airwaves and in people's homes on television screens multiple times a night on the 30-second spots. All of that takes time and energy. It was almost superhuman what he was able to do as the chief public health officer in that period of time but certainly not at great risk to individual health and sustainability.

If the notion is, if you only had the one voice, the one spokesperson, you would not have had all the noise and all the contradictory messages and that is somehow a solution, I would suggest that to have chief medical officers, such as Dr. Kendall, in provinces to reinforce Dr. Butler-Jones' message was powerful. You have to repeat the message many times in many different venues. If you are not watching the six o'clock news, and you missed Dr. Butler-Jones, is that it? If you miss your window of opportunity, will you not get the information? You have to repeat; you have to be everywhere in a coordinated fashion.

If you go back and look at the messages that public health officials disseminated at all those levels — federal, provincial, territorial and local — when it came to infection prevention behaviours there were no contradictions. Never did we pick up on any contradictory messages.

When we look at analysis of messaging around adjuvanted versus unadjuvanted, everyone was saying the same thing in terms of who should get it, in terms of general high-level messaging. Of course, at the local level, if everyone agrees that the actual response is local, it stands to reason you need local people to speak to the issues, such as your mayor, your public health officer, your high school principal and your pastor — the people who you know, trust and respect.

The national strategy was a coherent, coordinated strategy of cascading information. I hear the point that it did not come back up, but it went perhaps one-way down too often. I hear that. However, to suggest a completely different strategic approach to risk communications in an event such as this I cannot see being sustainable.

Dr. Kendall: Going back to Dr. Butler-Jones' comments, I basically agree with his analysis of the situation. I know, for example, some organizations such as the Canadian Medical Association, CMA, have suggested there should be additional federal powers if you reach a certain critical piece of a pandemic or a national emergency.

I am not sure that the federal government sees it that way, and I am pretty sure the provinces and territories do not from having sat at their tables for a while.

Additional federal dollars are always welcome, as a leadership. From having sat at provincial and territorial tables I feel safe saying that. However, when you get to the end of the day with the guidelines, the process we had through the public health network is that if we had an ongoing disagreement that they could not be public health network guidelines because not every jurisdiction would sign off on them. We had an agreement that they would be the Public Health Agency of Canada guidelines, as put out by Dr. David Butler-Jones, and then it was up to provinces or territories to adopt them or adapt them as they felt appropriate. That seemed to work for us.

Dr. Ricketts: I am unaware of the extra federal powers requested or the details post-SARS. I believe we were writing those in the context of SARS, and we were quite keen to see the Public Health Agency of Canada form. The CMA at that time wanted the Chief Public Health Officer of Canada to have powers that were more like those in the United States. That is true. I was getting confused about that.

When I hear the responses coming from around the table, everything makes sense to me. I can appreciate where they are coming from. I would like to see the committee make a direct comment on the role of the front line in public health emergencies and some endeavour to solidify the opportunity for front-line professionals to do their work.

I feel like a broken record on this, and I apologize for saying the same thing so many times, but it is important. We are quite happy to work with the agency, of course, with the provinces — because we do have the provincial and territorial medical associations, PTMAs as well — and with our sister organizations to come up with reasonable and practical tools that can be used in a time of public health emergencies. That work should start now. The benefits will fall out at a number of levels as a result of that.

As Dr. Butler-Jones alluded to earlier, the primary care public health interface strengthening is something we really need to see. It is invigorating to hear some of the information, referred to by Dr. Butler-Jones earlier, about the federal- provincial-territorial agreements on health promotion and disease prevention. These things are very inspiring. If we are to have a sustainable health care system, we need to think in terms of how we will have our partnerships across all of these boundaries.

I applaud any recommendations that would ensure support for those actions.

The Chair: To clarify, when we are talking about front-line workers, we are talking about health workers as opposed to first responders, such as firefighters?

Dr. Ricketts: They are also very important. The first rule of outbreak response is to take care of the ill. It is the number one rule of outbreak response. It is in the public health rules. That is what I was trained in. It is a five-year postgraduate specialty in public health. Epidemic response requires that you take care of the ill. The people who do that are nurse practitioners and physicians, for the most part. Obviously, nurses, technicians and all these other people have a role, but when it comes to the decision making on how to care for these people, they need to be informed correctly. Finding a way to engage them will not be easy, but we should work toward that and come up with a systematic response so that we can have national clinical guidelines.

I have to emphasize that I am talking about clinical guidelines, not the other kinds of responses that have to be localized. It is this one area of clinical practice.

Dr. Gully: Dr. Harper from the U.K. referred to England's chief medical officer in his testimony yesterday. There is also one for Scotland and one for Wales. There is not one voice for England, Scotland, Wales and Northern Ireland, so in some ways the way we work in terms of a federation works well.

Senator Seidman: Can I clarify one point? I do not want to be misunderstood. He did indeed say England, and there were chief spokesmen in Wales, Scotland and Northern Ireland.

The Chair: We are past our time so we need to wrap up soon. We will have one wrap-up session now.

Two additional issues came out on Wednesday afternoon. We had first a panel on research, and then a panel on ethics. On the panel on research, we had the head of the Canadian Institutes of Health Research, CIHR, as well as Dr. Singh, who was formerly with CIHR. He proposed that Canada should establish a rapid research response team with a dedicated budget. He actually compared it to the Disaster Assistance Response Team, DART. He said that that would be a way to deal with research on an emergency basis.

CIHR was concerned about the funding that stops at the end of March. We went from there into an ethics panel with respect to public trusts, prioritization lists for vaccine, communications and the leadership role of the federal government. Therefore, we have talked about some of those aspects already, but they were also framed within ethical parameters.

I will put those on the table. As well, if there is anything we have not already covered, this is the time to bring it out. Do you want to respond at least to the research and ethical areas at this point? If anyone else wants their name down to cover those issues or anything else, that is fine.

Dr. Butler-Jones: I will also have Dr. Plummer comment as well.

On research and ethics, we were fortunate because in following on from SARS, the recognition of a need for a group who could actually do rapid research was recognized. We were just establishing that research network before the actual pandemic, with resourcing from ourselves, CIHR, et cetera. That was important in addressing a number of questions during the pandemic. That is something that we would hope to see continue.

With respect to Dr. Singh referring to the value of having rapid research, depending on what we are facing, that may change. The mechanisms with which we can address research quickly, provide the funding, et cetera, and develop appropriate protocols still need work. That is something for Health Canada, CIHR and other organizations. When you think of it, it is not just about CIHR and health funding but also about Social Sciences and Humanities Research Council of Canada, SSHRC; Natural Sciences and Engineering Research Council of Canada, NSERC; Environment Canada and others and the ability to do rapid research and get those findings out quickly. There is work to be done. It is important to do, and I appreciate comments on that.

There is a section in the pandemic plan on ethics and ethical considerations. The principles have been long thought about and debated among ethicists, practitioners and others as well. We need to continue to bring that issue to bear. As a society, it is interesting that we come to our understanding of ethics by contemplating them, debating them and arguing them. That is important.

What was helpful in advance of the pandemic with the antivirals — Dr. Kendall made a brief reference to this — was that we did an active public engagement around prioritization, should there be a pandemic, for who receives antivirals, whether or not we should do prophylaxis, et cetera. Again, that was informative and helpful. In that process of deliberative dialogue — and this is my experience in other things as well — when the public actually has good information, they come up with similar conclusions to the experts. It is how much better to have us all involved in that conversation than simply the experts trying to defend it after the fact. Again, there were very valuable lessons there.

Dr. Plummer: I would certainly agree with the assessment that research is critical to respond to these events, and you absolutely need to have robust research capacity. In some ways, the National Microbiology Laboratory, which is part of PHAC, is set up like that. We have scientists who ordinarily work on diseases that are not particularly important in Canada, who can drop tools to respond to something such as H1N1 or SARS. That is essentially the way we are set up. We have part of that kind of rapid research and response team.

On the clinical and epidemiology part of it, having a standing team is a little more difficult because you have to have people on the ground locally with right licensing and connections with organizations. You could have some supplement to that in terms of additional federal capacity, but I do not think you can have a team that you could send in that would be able to do all the work.

Dr. Hatchette: I could not agree more with Dr. Plummer that having this rapid research team to be deployed across the country is almost impossible. You need to have the infrastructure in place beforehand. The research network was designed to get rapid clinical trials based on a structure of researchers interested in the area. That is certainly the way to go. Also, building a solid surveillance capacity from the ground up and engaging your front line, whatever that might be, whether emergency room physicians or family physicians, as a potential resource so that you can then parachute in people who can ask direct questions and get them involved at the base is important.

For the Canadian Institutes of Health Research, rapid funding is important because it comes down to having money to conduct this sort of thing in addition to the infrastructure.

Once the research is done, you then need a knowledge translation aspect, which is also lacking. The U.S. has the Morbidity and Mortality Weekly Report, MMWR, which can rapidly release research data. It does not affect the author's ability to publish that in a peer reviewed journal, but it gets the information out there in the public eye or on the public record much more quickly. We did not have that during this pandemic. The Purple Paper was created, which was an overview of topical things that were discussed, but we did not have an MMWR, which may have facilitated some of the discussions, for example, about whether we should have been vaccinating for seasonal influenza. There was data out there that might have influenced that decision that could not be released to a broader audience.

I think the translation aspect needs to be worked on as well. CCDR — the Canada Communicable Disease Report — does exist, but I believe its capacity is limited. During the pandemic, the stuff coming from CCDR was rates for gonorrhoea. No one is interested in that in a pandemic. People wanted to know specifically about transmissibility and so on. There was data that we could not get.

You must remember that in order for this to occur you must have not only rapid funding but also ethical approval. If you have a streamlined ethical approval process that allows these studies to get done, it is another hurdle that you do not have to go over. If you have a multilateral and collaborative study, which you often need to answer some of these large questions, then each of the jurisdictions has to undergo an ethical review. You then have these cascading ethical reviews that become cumbersome. If we could streamline an ethical review process, that would be helpful.

Collaborative research processes become difficult when it comes to data ownership. To get researchers to participate in actively releasing information or the data they are collecting, you need to ensure that they will not get scooped. That concern has been voiced in the past by our researchers. That is important. Data ownership is important for more than just research, at least in my perception. We had issues in the surveillance group of analyzing the First Nations data because there were data ownership issues. The First Nations owned that data. They were not too keen on giving that to the federal surveillance group to analyze it. This collaborative process needs to occur from that perspective as well.

The Chair: Are there any other subjects that we have not touched that you want to get out on the table? Dr. Butler- Jones, you can finish it off, then, and respond to some of the comments.

Dr. Butler-Jones: I think the comments are all very apt. We had a pretty robust agenda to go through before the pandemic ever occurred in terms of pandemic planning. We actually covered off much of that list but added to it as well. I look forward to that work. Hopefully, it will not be me. Actually, I have mixed feelings about that. Not that we want another pandemic, but I would like to be able to apply the lessons learned the next time around to see if we can do even better.

First, I want to say a very sincere thank you to the committee. The diligence of your process will contribute to the body of evidence and understanding around the pandemic. Thank you for the respect you showed your witnesses and for the calibre of the questions and issues that you pursued. I think that will help us all. That is not sucking up; that is a true statement. It has always been a pleasure for me to appear before this committee, even when you have challenging issues for me.

It was for me, and I think for all of us, a tremendous privilege to be even a small part of this study dealing with pandemic preparedness. I want to have it on the record that Canadians did an amazing job. It was not about any one of us; it was about the fact that collectively people stood up to the plate, dropped the armour, if that is what was needed, and made it happen.

The last thing I wanted to say was alluded to in capacity. One of the key lessons learned in this is the need to ensure that we look after our people — not just the public but the people who are actually mounting the response and who are able to engage, whether they are front-line providers or first responders, or whomever, in an honest and intelligent way in terms of addressing the concerns. Everyone is very dedicated. They work long into the night. We see that. Working in emergency departments, we know that the most toxic thing is that combination of fatigue and adrenaline. People want to make a difference; they want to be there; and they want to keep helping. However, we reach a point where we are so exhausted that we are not thinking clearly. We need to ensure we look out for our people. We need to ensure that they get the rest they need and that we have backups and systems in place to ensure there is coverage so that they do not feel that they have to stay when they need rest and recovery.

In the comment that I made earlier about this pandemic continuing longer, the point I was making was that by December everyone was feeling incredibly stretched trying to deal with the immunization campaign and with all the issues, the media and everything else. If it had continued much longer, people would have lost energy. I want to stress the importance of looking after our people and ensuring that we have ways to support them and their families. With SARS, one of the critical issues was not the workers in the hospitals but their concern about whether or not their families were looked after if something happened. Again, that is something we do not want to lose as we move forward. I wanted to raise that as a last point.

The Chair: We are at the end of the meeting. I thank all of you very much. All of you have been with the committee on this issue during our various hearings, so we got the best to come back again and help us out in this round table. I appreciate all of you being here, particularly some of you who travelled some distance to make it here. It has been very beneficial and is a good way to wrap up our hearings on the matter. We will be moving from here into considering recommendations and our report, all of which we intend to have out by the end of the year.

Thank you again. Have a good weekend.

(The committee adjourned.)

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