THE STANDING SENATE COMMITTEE ON SOCIAL AFFAIRS, SCIENCE AND TECHNOLOGY
EVIDENCE
OTTAWA, Wednesday, May 20, 2020
The Standing Senate Committee on Social Affairs, Science and Technology met by videoconference this day at 11:30 a.m. [ET] to study the government’s response to the COVID-19 pandemic.
Senator Chantal Petitclerc (Chair) in the chair.
[English]
The Chair: Honourable senators, before we begin officially, I would like to remind you of a few items.
Senators are asked to have their microphones muted at all times unless recognized by name by the chair, and they will be responsible for turning their microphones on and off during the meeting. Before speaking, please wait until you are recognized by name. Once you have been recognized, please pause for a few seconds to let the audio signal catch up to you. When speaking, please speak slowly and have the microphone close to your mouth.
If you have chosen an interpretation channel, I also ask that members speak only in the language of the channel. Should any technical challenges arise, particularly in relation to interpretation, please signal this to the chair, and the technical team will work to resolve the issue. If you experience other technical challenges, please contact the committee clerk with the technical assistance number that was provided to you.
Finally, please note that if the committee decides to go in camera, the use of online platforms does not guarantee speech privacy or that eavesdropping will not be conducted. As such, all participants should be aware of such limitations and restrict the possible disclosure of sensitive, private and privileged Senate information. Participants should know to do so in a private area and be mindful of their surroundings so they do not inadvertently share any personal information or information that could be used to identify their location.
Good morning. Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[Translation]
My name is Chantal Petitclerc, a senator from Quebec. It is a pleasure and a privilege to preside over this virtual meeting.
[English]
Before giving the floor to our witnesses, I would like to introduce the senators who are participating in this meeting. We are pleased to have with us Senator Diane Griffin, Senator Julie Miville-Dechêne, Senator Kim Pate, Senator Patti LaBoucane-Benson, Senator Donna Dasko, Senator Jim Munson, Senator Josée Forest-Niesing, Senator Judith Seidman, Senator Ratna Omidvar, Senator Rose-May Poirier, Senator Rosemary Moodie and Senator Stan Kutcher.
Today we continue the committee’s study on the government’s response to the COVID-19 pandemic.
[Translation]
It is not a coincidence that, after hearing from government representatives last week, we are starting today’s meeting by looking into issues essential health care workers are facing.
Since the beginning of this pandemic we are going through, they have answered the call and are on the front lines leading daily battles without respite, in conditions we know are risky and difficult. To each and every one of you, we say thank you.
Without further ado, I will introduce our first panel of witnesses for today: Dr. Sandy Buchman, President of the Canadian Medical Association; Claire Betker, President of the Canadian Nurses Association; Dr. Cornelia Wieman, President of the Indigenous Physicians Association of Canada.
[English]
I do want to remind our witnesses that you have five minutes for your opening remarks. We will begin today with Dr. Buchman, followed by Dr. Betker and Dr. Wieman.
Dr. Buchman, you may begin your opening statement.
Dr. Sandy Buchman, President, Canadian Medical Association: Thank you, Madam Chair, and good morning everyone.
Today I appear before the committee as president of the Canadian Medical Association, with the honour of speaking for our members — the front-line physicians. My name is Dr. Sandy Buchman. I have almost 40 years of experience practising comprehensive family medicine, with academic interests in primary care, cancer care and palliative care, HIV/AIDS, global health, and the social accountability of the medical profession. I currently practise home-based palliative care, including palliative care for the homeless in Toronto.
Since 1867, the CMA has championed improving the health of Canadians and strengthening the health care system. We represent dedicated physicians who are fighting COVID-19 alongside other health care providers.
Physicians and other health care workers represented here today are leading the health response, caring for those afflicted by COVID-19 and keeping our health care system running along the way. As we all know, health care workers face greater risk of contracting COVID-19 than the general population. They have put their health and that of their families at risk to care for others. As we look to lift public restrictions, we must ensure that the health of our front line is not outweighed by efforts to support the health of the bottom line. An economy cannot thrive while its health care system remains sick.
Our health care system has been sick for some time. The shortcomings we witnessed before COVID-19 are now glaringly obvious: our stifled access to care, our weakened primary care networks, the dire state of our seniors care, insufficient and inadequate mental health services. Long before COVID-19, too many Canadians were falling through the cracks. Too many physicians and other health professionals were stressed to the breaking point. These cracks have only grown; they have become crevasses.
The health care system pre-COVID was a patchwork of uncoordinated services, and this patchwork contributed to our lack of preparedness. It is clear that there is an urgent need to strengthen our public health capacity to ensure preparedness and response in public health emergencies. We cannot consider ourselves civilized if we continue this way.
Madam Chair, this presentation is five minutes. It has an end. The pandemic is not something that will simply end. This is not temporary, nor do we have the liberty of retrenching old ways. Physicians and other health care workers continue to put their lives on the line. Going back is not an option. “Normal” will assume a new meaning. We will learn to address this terrible virus, but we must seize the opportunity to act on what we’ve learned to create a healthier tomorrow.
We’ve learned that we can all benefit from telemedicine and virtual health care. We’ve learned that it can work. It can enable the equitable delivery of health services to Canadians. The pandemic has irrefutably demonstrated the important role that virtual care can play in the delivery of medical care in Canada.
Our population is aging. With more than half the deaths from the virus occurring in long-term care homes, it’s time to renew the discussion of a coordinated national seniors care strategy. So much more is needed to appropriately care for and protect our elderly.
We need to take care of those who care for Canadians. Our front-line workers face unprecedented circumstances. The personal protective equipment supply is still in critical shortage. This is an unfortunate fact. Physicians continue to express grave concerns about the lack of supply of PPE. They are being told to ration and reuse in some cases, and that the supplies are substandard. This, combined with relentless hours, is increasing anxiety levels. Additional measures that acknowledge the risks and the financial burden they have taken on are sorely needed. Financial loss has no place amongst the myriad hardships already experienced by our front-line workers.
In conclusion, Madam Chair, if we don’t support our front-line workers with the armour, the technological infrastructure, policies and additional measures that they require to help Canadians, we will revert to our perilous perch before this transformational time. And no one can afford that. Thank you, meegwetch.
The Chair: Thank you. Dr. Betker.
Dr. Claire Betker, President, Canadian Nurses Association: Thank you for the opportunity and the invitation to appear today.
I speak to you from my home near Winnipeg, Manitoba. I acknowledge that I am on Treaty 1 territory, the traditional lands of the Anishinaabeg, Cree, Oji-Cree, Dakota and Dene Peoples, and the homeland of the Métis Nation.
I am a registered nurse. I have spent my entire career in the community, most of it in public health. I am here today as the president of the Canadian Nurses Association.
There are more than 431,000 regulated nurses in Canada, the largest group of health care providers across our health systems. The Canadian Nurses Association is the national and global professional voice of Canadian nursing. We represent 135,000 members, including licensed practical nurses, registered psychiatric nurses, nurse practitioners and registered nurses.
In the past few months, the impact of the coronavirus on our country, our work, our economy and on our lives has been far-reaching and staggering. The health and safety of the people and the nation’s health care workers are uppermost in all of our minds.
The Canadian Nurses Association appreciates the measures taken by all levels of government to minimize the spread of COVID-19, respond to the pandemic and anticipate our recovery. We have benefited from the leadership of our public health officers across Canada. We are supportive of the strong communication from the Chief Public Health Officer, Dr. Theresa Tam and her team, and we’ve had good communication with Health Canada, including the Minister of Health. We thank them all.
I will quickly highlight eight key areas that we keep hearing from nurses.
First, three months into the pandemic, the consistent, reliable and adequate supply of personal protective equipment remains an issue. Decisions about the use of PPE must be driven by evidence, not availability or fear of shortages. Health care workers need clear guidance for their use of this equipment and access to it.
Second, disseminating consistent information and guidance is a challenge in a federation across thousands of employers in many sectors of health care. This requires greater collaboration to reduce confusion caused by different guidelines and directives across jurisdictions and practice settings.
Third, the World Health Organization is urging large-scale testing, but Canada falls behind other nations. Nurses are concerned that without this data to contribute to public health surveillance, prevention, further mitigation and recovery efforts will not be evidence-informed.
Fourth, prior to COVID-19, nurses were reporting high levels of fatigue. Nurses now face significant challenges to their mental and emotional well-being. Rapid access to tailored no-cost mental health supports need to be here in the pandemic and long after.
Fifth, we are working with the Canadian Medical Association and the Canadian Institute for Health Information to determine the impact of COVID-19 on the health of health care workers. But we need to know who they are and where they are. We urge governments to fund systems to track this most important data. This is a long-standing issue.
Sixth, nurses worry about populations who are at higher risk for COVID-19, including Indigenous peoples. Other vulnerable populations include the homeless, those in congregate settings like prisons and shelters. These populations require strategic and ongoing supports.
Seventh, given the lessons of history, we urge an evidence-informed and cautious reopening of services across society. We are concerned that the virus is still very much alive, still spreading and not well understood.
Finally, to the issue of long-term care, the pandemic has laid bare the crippling lack of standardization, funding, leadership, appropriate staffing, proper training and equipping of the people who deliver services in our long-term care sectors. These vulnerabilities are well documented.
We must reimagine aging in this country, including support at home, institutional long-term care and end-of-life care, and put in place the bold changes that are needed.
We meet today in the global Year of the Nurse and the Midwife 2020, and nurses across the country have answered the call of this pandemic very ably. On behalf of nurses of Canada, I ask you to place nurses in leading roles in the analyses of the COVID-19 response that lie ahead. Listen to them, bring them to the table and know that they and we will deliver the best evidence to help governments and health system decision makers reimagine and develop systems and implement the required change. Thank you.
The Chair: The floor is yours, Dr. Wieman.
Dr. Cornelia Wieman, President, Indigenous Physicians Association of Canada: I would like to thank the chair, deputy chair and members of the Standing Senate Committee on Social Affairs for the invitation to appear before you. My name is Dr. Cornelia Wieman. I am originally from Little Grand Rapids First Nation in Manitoba. I am a psychiatrist by training, and I currently work as the Acting Deputy Chief Medical Officer at the First Nations Health Authority in British Columbia. I am Anishinaabe, not on my ancestral territory, and I respectfully acknowledge the land on which I work, live and play is the traditional ancestral and unceded territory of the Coast Salish Peoples, the Musqueam, the Squamish and the Tseil-Waututh Nations.
I want to acknowledge the Indigenous Physicians Association of Canada membership, my Indigenous physician colleagues working on the front lines and those working in specialties such as public health, the Indigenous residents and medical students who have had their training delayed, interrupted or otherwise disrupted by the pandemic.
Some of the key messages that the Indigenous Physicians Association of Canada would like to convey are: There has been a great deal of variability between communities, regions and provinces and territories in the incidence and prevalence of COVID-19. Some First Nations communities in B.C. and in northern Saskatchewan have experienced outbreaks. Some First Nations communities have only had one to two cases or very few, while some communities have had none at all.
While there have been instances where the response to COVID-19 in communities is going well, this is not always the case. Some of our IPAC members have been meeting regularly with the minister of Crown-Indigenous Relations and Northern Affairs to discuss the challenges that they are facing during this pandemic. Some communities are still having difficulty acquiring adequate supplies to address the risk of COVID-19. This would include PPE, including masks and gowns and other essentials such as hand sanitizer.
Indigenous and First Nations people have and continue to experience racism in the health care system, and we as Indigenous physicians continue to work towards achieving cultural safety for our family members and community members within the wider health care system.
Because First Nations and Indigenous people continue to experience disparities in the social determinants of health, there are significant gaps in our health and mental health status, higher rates of chronic diseases such as diabetes, heart disease, lung disease and some mental health conditions, including chronic complex post-traumatic stress disorder. These pre-existing physical and emotional conditions put us at increased risk of poor outcomes should we contract COVID-19.
Our experiences of complex trauma — historical, intergenerational and contemporary — challenge our levels of emotional distress and ability to cope during this pandemic, which will continue for some time to come. This emotional distress is related to things such as mental health issues, including acute suicidality, substance use, including alcohol, and domestic violence.
We believe that credit for keeping the virus out of our communities for the most part should go to the communities themselves. Self-determining measures that have been taken are reducing the virus transmission. The vast majority of our community members recognize the risks to their communities, especially to our elders, who are our knowledge, language and culture keepers.
As our various provinces and territories start the initial phases of opening up, again we need to remember that in our rural and remote communities, our curves are somewhat lagging behind the provincial and territorial curves, meaning we must remain vigilant and adhere to recommended public health measures. Communities will also have to consider how they want to manage potential movement of people in or near their territories, once provinces and territories proceed through their phases of reopening.
Communities are to be congratulated for doing the best they can under all circumstances and to remain ready for any upsurge in cases or a possible second wave.
The Indigenous Physicians Association of Canada is creating a national public messaging campaign that is currently in development and will feature Indigenous physicians from across the country sharing words of advice, reassurance and encouragement during these challenging times.
In closing, as Indigenous physicians, residents and medical students, we are also members of our Indigenous communities. We want to acknowledge our collective strengths and resilience across the country. We continue to serve on the front lines and in other capacities to ensure that Indigenous communities emerge from this pandemic healthy and well, from a place of strength, not just surviving but thriving. Thank you, meegwetch.
The Chair: Thank you all for your opening statements and for being here with us today to help us with this study.
Before we proceed with the questions from senators, I do want to remind each of you that we have five minutes for questions and that includes the answers.
Last week, for our first meeting, I did allow a fair bit of flexibility, but it does come at a cost and does not always allow for a second round, which I know are very valuable questions. So let’s try to stay to the point, and that goes for the witnesses as well. We like to have your answers in a precise manner in order to be able to ask more questions.
If you do wish to ask a question, please use the blue raised hand function in Zoom. We will add you to the list and we will lower your hand once the question is answered.
Senator Poirier: Thank you to the witnesses for being here today and for your presentations. It’s greatly appreciated.
My first question is for the Canadian Medical Association representative. In your latest memory survey, a third of the physicians in community practice said they had less than two days’ worth of the key PPE. Yet on May 3, almost two months after the self-isolation measures began, the government created a new COVID-19 supply council to do, among other things, “ordering ahead in bulk on behalf of provinces and territories.”
It is difficult to order ahead when you’re already in a crisis. So I’m asking your opinion on how the COVID-19 supply council will help Canadian physicians get the PPE they needed two days ago, and how can they help other physicians and nurses when they’re not given a seat on the council?
Dr. Buchman: Thank you very much for the question. I think that the best way the council will be able to help secure PPE and help health care professionals is by coordinating the actual procurement of the PPE, creating a domestic supply, including the standard or the quality of the PPE that is imported meets Canadian standards, and providing consistent, coordinated information to health care providers, to regional health administrators, et cetera, who are then able to deploy the equipment in a coordinated and socially just manner to the places in the country where it’s needed the most at this time. I think they will have an important role in advocating for and coordinating the supply of the PPE.
It’s late. The government has been working very hard during the whole crisis in trying to obtain PPE, procure it and retool our current manufacturing facilities to provide a domestic supply. It’s a challenge. We shouldn’t be in this position of scrambling for PPE at this time. That speaks to an earlier question about pandemic response, and I am hopeful that what the council may be able to do is help us prepare later on, more long-term, once we’re through the major part of this crisis.
Senator Poirier: Again to the medical association, a past experience with influenza pandemic suggests that recurrent waves of COVID-19 are a strong possibility. Right now we seem to be nearing the end of the first wave, but in your opinion has the government put in place what is needed for a medical professional to be ready for a second or third wave, and if not what should the government do differently?
Dr. Buchman: In my opinion, we’re not fully prepared for a second wave. We don’t have adequate diagnostic testing, so original testing — disease testing for people who have the disease, and we are doing insufficient contact tracing. When we do adequate testing of cases, as well as contact tracing, we can better prepare to see if the health care system would be overwhelmed. We would get a much better picture of what we should do. In addition, we haven’t undertaken serological testing. That actually assesses the immunity within the population.
We have insufficient information as to what’s out there and we can’t make really good, evidence-informed decisions about opening up the health care system, for example, the number of elective surgeries, getting primary care back up, all the things we do ordinarily, and we are unable to reopen the economy and schools, et cetera, in an evidence-informed way, so we’re gambling by reopening.
We understand the challenges of having an economy and a business and a society where people have these restrictions. There are huge health consequences to maintaining the restrictions. There is intimate-partner violence, of course, there are ongoing mental health problems, there’s poverty, there are people not getting primary care, they’re not looking after their hypertension and cardiovascular diseases, they’re not doing cancer screening. All this is really important, but we need the contact testing, we need the tracing and we need the serological testing in order to make decisions about what to do next.
Senator Poirier: Thank you very much.
Senator Seidman: Thank you for being with us today in this virtual fashion. My question is for you, Dr. Buchman, and it is about virtual care.
The Virtual Care Task Force, led by the Canadian Medical Association and the College of Family Physicians and the Royal College of Physicians and Surgeons of Canada was created — [Technical difficulties] — that’s the reason why health care has fallen behind other industries in providing — [Technical difficulties] — digital services. In a report released in February 2020 — very timely — it concluded:
While consumer demand and the drive to improve access will probably make virtual care more common in the Canadian health care system, a pan-Canadian framework is needed to establish excellence in virtual care that upholds quality health service and supports continuity of care among care teams. Without such a framework there is a risk that a series of fragmented virtual care services will be established that detract from continuity and potentially lead to quality of care issues.
And that’s the end of the quote.
What I would like to know from you at this timely moment is this: Could you expand on what risks the report is referring to, and what gaps must be addressed in order to scale up virtual care in order to make it more accessible to Canadians? In fact, are we learning something from this pandemic that will be important post-pandemic as far as virtual care is concerned?
Dr. Buchman: Thank you very much for the question and thank you for referencing the Virtual Care Task Force report. Again, it was very timely, and we’ve been working on it a long time.
It’s clear that during the pandemic, when virtual care got up so quickly, virtually everywhere across the country, it wasn’t the technology that was the problem. The technology has been there for a long time. What has been missing, one of the gaps; it’s about policy. It’s about regulation. It’s about governance. It’s about privacy and safety.
Virtual care has the potential to make far more equitable health care across the country, particularly for remote and rural populations. But one of the serious risks is that it also has the potential to make care more inequitable for vulnerable populations, for those living in remote and rural communities, for our Indigenous populations, our homeless populations and those of lower socio-economic status who can’t access the technology to provide the care. So we have to be very careful about that risk.
The inclusion of the private sector into virtual care — because they’ve taken up the gaps — is also a potential risk. Who is monitoring the quality of that care and ensuring the privacy?
How can we prevent episodic walk-in care? I think people are aware that one of the most important things in primary care is the relationship between the provider and the patient. We could be turning virtual care into virtual walk-in clinics where there isn’t that continuity of care, so essential in chronic disease management, et cetera.
I have highlighted some of the gaps. We need to make sure care is equitable. We need to make sure it’s safe, that it’s continuous, that it’s of high quality and that privacy issues are protected.
Another thing we would like to see national licensure for physicians and other providers, so that as a physician in Ontario, I would be able to provide care to people in northern Manitoba, Northwest Territories or Nunavut. It’s very important that we iron that out so that we can actually improve access and back each other up at the same time.
The Chair: Thank you.
[Translation]
Senator Mégie: I have two questions. They are for Ms. Betker and Dr. Buchman.
My first question is about the devastation caused by COVID-19 in long-term care centres. I have learned in the media that, in British Columbia, they found a way to contain the pandemic when all this began. I think that is the only province that has not had many cases. Do you know what methods they used? Those methods could be used by others. Unfortunately, it is a bit late, but you never know.
My second question is about individual protective equipment that, according to the Quebec Minister of Health, was available in the national strategic stockpile, but in insufficient quantities. Ms. McCann said that insufficient equipment should not be the only explanation for the management of the crisis. Where do you think we could get that equipment if not in the national stockpile, or how could we enhance the stockpile to prevent this from happening again?
The Chair: Senator Mégie, whom are your questions for?
Senator Mégie: They are for Dr. Buchman and Ms. Betker.
[English]
Dr. Betker: Thank you for the question. In terms of the personal protective equipment, there’s often a long space, if you will, between where that supply is and where those providers, those health care workers, are. It’s a big country. Geography is an issue. Deployment of that equipment is an issue. And there are multiple different settings where not only health care workers but social services workers are working in very close human contact.
There have been tremendous efforts on the personal protective equipment side in terms of procuring it and having an adequate supply, but its deployment across the country and through the provinces and territories, out to those settings, is still an issue. That is what we’re hearing from nurses.
Another priority is where that equipment ends up. I think Dr. Buchman talked about using the principles of social justice as well, within that deployment, and being very just and equitable in how we make those decisions. In terms of PPE, that would be my answer there.
In terms of the long-term care facilities, we’ve known about many of these issues for a very long time. There is a lot of research both in the nursing field and the health system field in terms of long-term care facilities. I really think this situation warrants a good, hard look and some really concrete action. B.C., as you’ve said, stepped in early and had some good outcomes. Others maybe didn’t. But I think it’s a really important time to take a very hard look at this part of our system, and really look at it from a population perspective — seniors, aging population in Canada — and build a system to meet those needs now and into the future.
The Chair: Dr. Buchman, did you want to add something to that briefly?
Dr. Buchman: Sure. I can add something briefly. I agree with Dr. Betker. I would like to emphasize, with regard to PPE, that transparency and coordination between the federal and provincial and territorial governments is key. One of the reasons for the high anxiety amongst physicians and other health care workers is the lack of information about when that equipment is coming and what is coming. Are we going to have enough? We get reports that physicians, for example, only have one or two days’ worth, and it’s particularly worse in the community as opposed to hospitals. The information is not getting down to the front-line provider, so that is causing a huge amount of anxiety. And that information will in itself relieve the strain.
With regard to the long-term care issue, yes, British Columbia jumped on it and provided their solutions. What did they do? For example, they recognized that personal support workers were underpaid. In order to cobble together a full-time job, they were working at multiple institutions. The province recognized many aspects of their care.
We are seeing a catastrophe now in long-term care, and I use that word very deliberately. What has happened in long-term care, where over 80% of deaths from COVID have occurred? It means it’s not just the biological vulnerability of older Canadians. There are system issues which go everywhere from infrastructure to the understaffing, underfunding, that require these workers to visit many homes. It’s very clear that we need a whole revamp and re-analysis of long-term care.
We have a health care system that was designed in the 1960s and 1970s for acute care of a younger population without co-morbidities. As people have aged and have developed ongoing co-morbid conditions, they are much more vulnerable to the effects of the virus, of course. And the long-term care system has been a poor cousin of acute care. We need to have a national conversation on whether we need to revamp the whole system. Should the Canada Health Act be reopened to examine this issue? Those are the reflective questions that we’re considering at this time.
The Chair: Thank you very much.
Senator Munson: I want to thank the witnesses this morning very much. I have three statements to Dr. Buchman: We shouldn’t be scrambling for PPE. We aren’t fully prepared for a second wave. We are gambling on reopening.
Back a few months ago, a number of doctors — [Technical difficulties] — that the Chinese government, through various emissaries, was scrambling to get personal protective equipment, i.e., masks, from ordinary doctors in Ottawa and across the country. And there was pressure. From the Canadian Medical Association’s point of view, do you have stories from that particular time when there was panicking taking place in China, that they were actually moving masks and requests were taking place — [Technical difficulties] — ordinary doctors across the country, and masks were moved out of this country to China?
Dr. Buchman: Senator Munson, I had some difficulty hearing the question. There are some feedback and echo. If you could just repeat the specific question?
Senator Munson: The basic question is, there is a shortage in this country of personal protective equipment.
In January, when everything was taking place in Wuhan, the Chinese government, through emissaries, were going after PPE, personal protective equipment, i.e., masks, but ordinary doctors, you name it, in this country, to have these masks moved to China. Is the CMA aware of that?
The Chair: Did you understand the question? It is a little challenging.
Dr. Buchman: Yes. Are you able to repeat it, senator? I think I’m getting it, regarding was the CMA aware of the situation in Wuhan, and the fact that doctors here in Canada were, of course, anxious about that. Were we aware of the situation? Or can you clarify?
Senator Munson: No, that there was an orchestrated campaign to move hundreds of thousands of masks from this country, that the Chinese government was calling up doctors in this country and asking them if they had excess or surplus supplies and could these contribute to this.
Dr. Buchman: I see; I’m sorry. Thank you.
Personally, and from the CMA, I was not aware of that particular issue. So I don’t think I can comment further on that. I wish I could, and we certainly can look into that further and provide you with information subsequent to this meeting.
Senator Munson: Okay. I’ll ask a gentler question, then. Doctor, you talked about — I hope you can hear me on this — telemedicine and virtual health care.
Dr. Buchman: Yes.
Senator Munson: Again, I’m startled by your statement where you say our health care system has been sick for some time. Is virtual health care and telemedicine available in every corner of this country? If not, why not?
Dr. Buchman: Thank you, because that actually allows me to expand on my previous answer on certain gaps. Telemedicine and virtual care are not available in an equitable and equal way across this country. It’s much different between urban and rural populations. I can provide you with statistics later, but it’s somewhere like 80% of the urban population has access to high-speed broadband internet, and it’s something like 50% or so of people in more rural communities. The further afield you go, the more challenging it gets. We have inadequate infrastructure in many large areas of the country, for example in Nunavut, where we do not have the adequate broadband, high-speed infrastructure in order to be able to carry out telemedicine in a significant way.
So I think the disparities are urban-rural, and again even more in remote areas. We need large-scale investment in the infrastructure right across the country in order to be able to achieve the equitable access to care.
Senator Munson: Briefly, chair, because it was breaking up earlier. One quick question. We talked about nursing homes and what is taking place. Nursing homes were built so long ago that they shouldn’t even be there today. That’s one of the reasons we have a major problem in nursing homes. Is it the view of any of the doctors on the line that the Government of Canada should use its massive amount of billion-dollar infrastructure money to build brand new nursing homes across this country?
Dr. Buchman: Because I’m on here, I will answer quickly. The answer is yes. The infrastructure that is in many of our long-term care facilities, which are some built in the 1960s and 1970s, have four people to a room, for example, sharing one washroom. We aren’t able to achieve the quality care that we need without improvement. As well, I think, as Dr. Betker indicated earlier, we need to focus more on maintaining elderly seniors at home with adequate personal support care, adequate home care. This is key to dealing with the long-term care issue. I will defer to my colleagues.
Senator Dasko: First, thanks to the witnesses today for your very interesting presentations. My questions today are for Dr. Buchman. I have to say, I was taken aback by your description of the health care system as a sick system, however, I don’t want to go there especially.
I want to say, first of all, that the mandate of this committee is as follows: to examine and report on the government’s response to the COVID pandemic. So I’d like to ask you, from your point of view, how have they responded? Can you tell me if you think any of the responses have been good or adequate? If so, which responses have been good or adequate?
Second, can you tell me which of their responses have been poor or inadequate? And if everything is poor or inadequate that they have done, perhaps you can rank the worst things that they have done to the least-worst things.
Let me just put it that way, and if you could take a stab at that, thank you. And then I have other questions if there’s time.
Dr. Buchman: Thank you for the challenging question; I will try to get it all in two or three minutes.
I’m going to start with what’s good that the government has been doing. In exceptional circumstances, in unprecedented circumstances — so I think it’s very important to understand the context of this — that their willingness to, from a health care system point of view, to advocate and try to develop a supply chain of personal protective equipment has been exemplary. But, as I said before, we shouldn’t have been scrambling. There are many things pre-pandemic that our provincial, territorial and federal governments have neglected to do.
I think they have been wise to put their faith in our Public Health Agency of Canada and its leadership. I think our leadership has been going on the best available evidence to them at any point in time. It’s always easy in retrospect to go back and criticize, oh, we should all be wearing masks, for example. We have to do it carefully, and there’s a balance. I think our public health leadership has been exemplary in trying to get that balance. So that’s what’s very good.
What hasn’t been so good, again, is the inability to procure that equipment, to have the domestic supply, to retool our manufacturing facilities, to import standard equipment, but we’re in the midst of global competition for that. So getting that equipment out to the front line. They have not been good in providing consistent and transparent information about what’s coming, what’s in the pipeline, how are we getting it out to the right providers, how do we know those areas of the country that need it most will get it? They haven’t been good at alleviating that anxiety.
So in terms of supporting the testing, I’m not even sure of the reasons why we haven’t had more of the testing that you’re referring to, and the contact tracing. I know that’s within a provincial jurisdiction, but why hasn’t that happened? Why haven’t we got coordinated responses and support for these? I am really at a loss to explain why we haven’t been able to scale it up and get it going much faster than we have now.
Senator Dasko: Let me follow up on the contact tracing comments, just in terms of how you think it is working from the physicians’ point of view? Is it a process that’s effective or is it quite faulty? What is your opinion about the use of mobile devices as a way to facilitate this process a little bit better?
Dr. Buchman: When we compare our methodical, manual contact tracing methods, yes, they work. But to get it to adequate numbers and the speed with which we need to do it, and the responses that we have, have been lacking for sure. We’re able to compare ourselves to other countries that have initiated the sort of technological contact tracing. Of course, I think Canadians are somewhat different in terms of our appreciation of privacy. I think we don’t know enough from Canadians whether they would accept this kind of contact tracing. We don’t understand fully the privacy implications of this yet.
We need to do a better job of figuring that out and figuring that out soon, because there’s no doubt that using technology, cellphones, credit card information, what have you, to improve contact tracing would go a long way. I think that’s a really important question to focus on right now.
Senator Moodie: Thank you for joining us today, doctors. I’ll start with full disclosure. I’m a front-line position too.
As you noted in your statement, our health care workers have operated in stressful and precarious conditions before this pandemic. I absolutely agree with that, in a health care system that in many ways is fractured.
This pandemic has obviously made working conditions much more difficult, and we’ve seen in different instances, physicians, nurses and other front-line workers voicing their concerns. We are many weeks now into this pandemic, and we continue to hear the same voices voicing their concerns. We hear about failures in procurement and distribution, failures in communication, failures to address the needs of our front-line providers. My question takes you back a little bit to a higher level.
I’d like to ask two things. What do you think of the government’s efforts to protect health care workers? By that, I want you to please be very specific, because we have different levels of government and we are all aware that the accountability for health care sits not necessarily fully at the federal level but mostly at the provincial level. What do you think of your provincial governments’ level to protect health care workers?
The second part of this question is: How are front-line workers feeling now about continuing to work in an environment that they are considering unsafe, that they’re voicing their fear of continuing to work in, under conditions of a pandemic, and in many cases across the country, emergency conditions where they are being mandated to go to — they have to turn up?
Dr. Buchman: Thank you. You’re asking me really what I think of our governments’ efforts to protect health care workers on two major fronts. One that we’ve been talking about, of course, is the PPE front. Because of our lack of preparedness and the fact that we’ve had to scramble, I think we have put front-line health care workers in harm’s way. Not only have we put the workers in harm’s way, one of the things that doctors, nurses and others worry about is that they will infect their patients and their loved ones. So we haven’t had adequate support of that, although we’ve had recognition and acknowledgement of that. But because we’re scrambling, because of the difficulties we’ve encountered, we haven’t actually protected them.
Doctors, nurses and other health care workers, from respiratory therapists to PSWs, have a strong duty to care — an ethical obligation to care for their patients. But do they have that duty of care putting themselves in harm’s way and those of their loved ones? I think there are limitations to our rights. We need to have adequate protection in order to do that. We would never permit a firefighter to go into a burning building without adequate protection. We can’t expect our front-line health care workers to put themselves in harm’s way, and those of others may I add.
This causes significant moral distress. We have the evidence in many of our surveys up to now. Doctors are sometimes questioning their obligation to go in if they’re not adequately protected. That’s a health care system breaking down. As a result, the moral distress they feel if they can’t help their patients, if we were to run out of equipment like ventilators and who gets the ventilator — the mental health challenges have not been adequately resourced. It’s our own professions that have been helping deal with the mental health issues, and I think further funding needs to be made.
The governments have an obligation, a reciprocity to provide that protection, and as well, the mental health resources to assist front-line workers in getting through this pandemic. Down the road for the second and third waves, we’re going to have big problems in depression, substance use, maybe some PTSD. That’s all going to happen. We need to intervene now.
Dr. Betker: I would agree with all of what my colleague said. I’d add one thing to the PPE, remembering these are professionals and they can make an assessment of risk and should be encouraged to do that, and then be able to have the equipment and protection that they deem is required, both for themselves as well as the patients. It’s not just about guidelines and protocols and those kinds of things. You need to realize these people are well educated, they have an enormous capacity to use the evidence around them, and they need to be listened to at that front line and point of care. So I would add that.
In terms of the moral distress and the ethical dilemmas they’re facing, those are across the system. In some ways, they’re both within the COVID-19 response, but also within what’s been left behind as a result of deploying all the resources towards that effort when there are many other really serious issues going on within the system and within our communities. I’m sure Dr. Wieman has some excellent examples in terms of remote First Nations communities where those issues will continue to grow and develop while we’re focused on COVID-19. It plays into that moral distress, not to leave behind those people who were already vulnerable and struggling and burdened. We need to be thinking about that as well — about the whole system.
Dr. Wieman: I do agree with my two colleagues who just spoke. I would make the point that some of the issues they’ve identified are only amplified for different Indigenous groups across the country. I know that people tend to have this visual in their head that we’re only talking about Indigenous or First Nations people who live on reserve communities, but that is not the case.
According to the census, about half of us live in urban settings as well. Some of these needs or vulnerabilities that have been identified, if you want to call them that, also exist for many people living in urban centres, as well as rural communities that are close to urban centres. For example, when we talked about the long-term care situation that has become unmasked, so to speak, during this COVID crisis, one of the needs we would see as Indigenous physicians is to advocate for more training for all Indigenous health care workers in a variety of capacities, who can provide health care services, including in long-term care settings and in communities where people are located.
Senator Forest-Niesing: Let me first start by thanking our panellists and, through them, thanking all of their members for the tremendous level of courage and dedication that they are demonstrating, which, of course, reassures all Canadians, not only those already affected by the virus, but all those who fear infection.
It is certainly nice to know that we have courageous front-line workers on the job.
That being said, I’d like to expand a little further along the same lines that we just discussed, delving a little deeper into the consequences potentially affecting the mental health of health care practitioners. My question is addressed to each of the associations on the panel.
Given the level of uncertainty and anxiety that are the obvious consequences of this virus, particularly and evermore present in the medical environment, I’d like to hear more from our panelists with respect to the system that is in place for managing and monitoring the mental health problems that are being experienced by their members due to the crisis. I’m also interested in learning a little more about your point of view with respect to concrete measures that are already in place and bringing much-needed relief, but certainly what additional measures need to be brought in response to that very unfortunate consequence.
Dr. Betker: I can start on that, and I will start with the nurses themselves. I think we need to talk to them, and we need to tailor those kinds of resources that they need and that would be helpful to them.
What’s interesting is that we’ve been in conversation with our board but also with nurses on a weekly basis over the last few months, and we did a session on mental health. One of the questions we asked in a poll was how many people had benefits and had access to counselling or therapy or whatever. Then the other question was how many were using it, even though they were expressing the issues around mental health and emotional well-being. Many had benefits and the vast majority were not using them.
I think we’re not used to acknowledging the stress and the impact of the stress, so it needs to be done with full engagement and collaboration with our members and our teams. It might look different in different parts of the country, and I don’t think it’s the same as what might be needed for society at large. We certainly encourage nurses to access what is available to society at large.
I also caution us to think that when the COVID-19 pandemic calms down and we come to some sense of normal, there is a long recovery period after that, so not to stop then but continue to pay attention to the mental health and the emotional well-being of nurses.
I will also mention, we put out a call out — not us, the CNA, but different jurisdictions put a call out around retired nurses — and many put their hands up. One of our hypotheses is they know the stress that was already there before COVID and the pandemic occurred. As I said in my comments, nurses were reporting being fatigued. Complexity, as Dr. Buchman talked about, in terms of not only people’s health but the social conditions that they are living in, and what that does in terms of their health and well-being. It was an issue before, and it has been amplified as a result of COVID-19. I think we need to really pay attention to that.
[Translation]
Senator Forest-Niesing: I have a second question. Provincial health care networks are under exceptional pressure caused by COVID-19. Medical services intended for patients with illnesses other than the virus are different. Those patients’ needs are also different. However, the care intended for them is being postponed or cancelled, except, of course, in emergency situations. I am especially interested in knowing one thing: What do you think are the less obvious consequences of postponing or cancelling those interventions and those treatments? How much longer do you think the medical system could keep this up?
[English]
Dr. Buchman: Thank you for the question in addressing non-COVID issues.
First of all, with regard to elective surgical procedures, we see that in the press all the time. These things aren’t truly elective. It’s only described as elective because there was some flexibility in determining the time at which these surgeries are scheduled. We’re not referring to cosmetic surgeries or surgeries of choice. We are referring to medically necessary procedures, and that can be anything from cardiac surgery to cancer surgery to drug replacement surgery.
The consequences of the delay are immense, and we have to now, as we get back into the system, determine the priority of when patients can resume surgeries. We can’t double the number of surgeons to get in, for example. We can’t double their workload. We don’t have time. We have to assess them in terms of their acuity and establish the priority or urgency.
There have already been consequences from the delays in surgeries. We don’t have a really good handle on it, but anecdotally, I’ve heard of mortality associated, for example, with delaying cancer and cardiovascular surgeries. There are consequences of people with ongoing, severe pain who require joint replacement surgery, and the decreasing function and quality of life. There is, might I add, a delay in managing the usual conditions in primary care, such as cardiovascular disease, hypertension, diabetes, asthma and chronic obstructive lung disease. The delay in these will have significant consequences later on.
I think it’s really important to look at some of the innovative models that are being developed, for example, to deal with the surgical things, such as single-entry models where people are assessed by a team and then assigned to the next available surgeon. We need to get more virtual care going, as has been happening for primary care. There are many innovative solutions. It’s a big question.
The Chair: Thank you, Dr. Buchman. We may want to continue on that line of questioning in the second round. For now I believe Senator Omidvar has a question.
Senator Omidvar: Thank you to all our witnesses. It is a particular delight to have witnesses who actually answer the questions. Sometimes that can become a challenge in committee, but I appreciate your direct answers to our questions.
I have three questions. I hope I can get through them. The first is to Dr. Buchman.
Dr. Buchman, you have talked about the stress on the system. There is also stress on the supply and demand of health care professionals in the system, with shortages of front-line staff, primary care staff and physicians. I refer to an available but latent resource, which is qualified international medical professionals. I know it’s a complicated arena, with provinces being responsible for health care and regulating bodies being responsible for who gets to practise or not.
In the current crisis, B.C. and Ontario have made some tiny changes, not very big. When I look at what other nation states are doing, like Spain, Ireland, Germany, France, Peru, Colombia and Argentina, they are being far more proactive in embracing the talent that is there, to deploy it in the crisis.
Do you believe that the central government should do more in the current crisis to open up pathways, in cooperation with the provincial governments and licensing bodies? I think particularly of the crisis of care in long-term care homes. Is there not an opportunity here to meet the needs of our senior citizens and to deploy the talent that is already here and underutilized?
Dr. Buchman: Thank you for the question. It is a question that has been simmering and that we have been dealing with at the Canadian Medical Association. I want to first state that the group of physicians that we’re referring to are international medical graduates, so graduates that have received their training. Canada is — we wouldn’t even have a health care system or provide the good care that we do provide without the contribution of international medical graduates. These are often very well-trained physicians who are willing to go out to rural and remote areas in order to be able to serve the Canadian public and get integrated into the system.
Having said that, and the fact that we were able to flatten the curve during COVID-19, the actual surge in demand that was anticipated to overcome our health care system’s capacity to deal with this didn’t fully materialize, and that was due to good public health measures, physical distancing, et cetera. We have been approached by international medical graduates who clearly want to help and want to make a contribution. We’ve deferred to the Federation of Medical Regulatory Authorities of Canada, FMRAC, who are the ones that are looking over all medical regulatory authorities, and so far, they haven’t seen the need that has been pressing other countries to get enough IMGs certified to be able to practise at this time.
I think the problem, though, goes deeper. I think it relates to our whole lack of national health human resource planning in Canada: physicians, nurses, nurse practitioners, pharmacists, social workers, OTs, et cetera. We don’t have any national entity that looks at what we need, particularly as you referred to long-term care and seniors. We have no concept of how many geriatricians we need for the future. Looking 10 or 20 years hence, we have no ability to plan for that. We have about 10 times the number of pediatricians graduating now compared to geriatricians.
This becomes a much bigger complex issue. I think, based on what FMRAC says to us, that just licensing enough international medical graduates at the present time wouldn’t actually solve the problem, their feeling — and they should be consulted — is that we need to ensure that all the IMGs are competent and capable within our culture. It’s worth a national discussion for sure. I don’t think there are simple answers. There’s a much bigger picture.
Senator Omidvar: Thank you very much. My second question is for Dr. Wieman. You appropriately noted that Indigenous peoples live not just in rural settings but also in urban centres of Canada. Sadly, too many of them live in prisons. Can you give us a microcosm of what they are experiencing due to the crisis, and whether the government’s response to individuals who are in the Correctional Service Canada has been, in your view, appropriate?
Dr. Wieman: Thank you, Senator Omidvar, for that question. I will have to base my answer on my experience here in British Columbia, which as you know, experienced an outbreak in one of the federal institutions here. I would say, as a start, the short answer was that people, I believe, in my opinion, were not prepared in the correctional institutions for COVID-19, and so that resulted in the outbreak that happened. Since, however, that time, I think what it has forced people to do is to scramble to rely on existing partnerships that have happened, for example, with the provincial health authorities here in British Columbia, with other organizations here in the province, to come up with a more comprehensive plan to deal with reducing the transmission and hopefully preventing the transmission.
There are many issues, not just for the inmates, of which Indigenous people are overrepresented, but also for the staff in those institutions. Right now, our experience, at least with the federal system, is we have here at First Nations Health Authority where I work, we have established through our existing partnerships, and building on those partnerships, we have established different pathways, for example, to appropriately plan for discharge because there’s a great deal of concern that an individual who is released, either serving to the expiration of their warrant or on parole, will still, for example, travel to a rural or remote community and thereby potentially bring the risk of transmission with them.
That has taken some time. I would say that now we are probably in a better place than we were a month or two ago, but we weren’t prepared, I don’t think, initially. Of course, as I mentioned, there are situations in both provincial and federal corrections where, because we are overrepresented in that population, we stand to experience the majority of the negative outcomes that could potentially happen.
I would add, because it’s kind of related to this question — that what was not mentioned by Dr. Buchman in a previous question around the consequences of other things going on at the same time in addition to COVID-19 — that in different places across this country, we here in British Columbia we are dealing with dual public health emergencies: the opioid crisis and the COVID-19 pandemic. But the opioid crisis is also taking place in different places across the country, in large urban settings as an example. But we are also noticing unintended consequences of a negative sort in terms of a trend of increasing overdoses and overdose events and deaths here in British Columbia, again in which Indigenous people are, unfortunately, disproportionately represented. So there is a great deal of work that still needs to be done.
Senator Omidvar: Thank you.
The Chair: Thank you, Dr. Wieman. Before we move to our next witnesses — and we will have time for a second round of questioning — allow me to ask a question to you, Dr. Betker, because this morning or last night in my home province of Quebec, I was reading that the Quebec Nurses’ Association was making aware that the nurses, after so many weeks of working overtime and under extremely stressful conditions, are saying that, with the summer coming they will want to have some well-deserved vacation. I am wondering if this is something that you are hearing across the country, and I’m wondering if it is something that we prepare for or are we going to be reacting to it, or is this already planned to make sure that it does not have a negative impact?
Dr. Betker: Thank you for that question. What I will do is hearken back to the mental health question. Those nurses, members of those interdisciplinary teams, need their vacation. And remember that they are also members of families, so kids are out of school. They have senior parents and other family members they are also looking after and communities that they are part of, and have responsibilities and obligations there. I think discouraging them from taking their vacation would not be a wise move because they need it. They need the break from the physical — it’s tough work — so from the physicality of their work. But, yes, every year that brings that cycle, through vacation time, of shortages upon shortages, so we certainly need to be looking at that.
I think also in terms of what Dr. Wieman said. There are all of these other things that are going on as well, so I think about flu in the fall where annually there is the flu season, which puts pressure on the health system. We’re in springtime but fall will come fast, so we’ll see that compounding effect. So vacations, definitely those kinds of things compounded as well.
The Chair: Thank you. Hopefully we will be ready to support them, but also make sure that we keep being able to respond to this pandemic.
Senator LaBoucane-Benson: Thank you.
This question is for Dr. Wieman. You said in your statement that there has been a real range of response by the government in the distribution of PPE for health care workers in Indigenous communities, and front-line operations and organizations. Can you describe this range for us and tell us why some communities and agencies have gotten so little and others have received so much?
Dr. Wieman: Thank you for the question. I’m not exactly sure why there is the variability, because it does vary across provinces and territories, but I know for example here in British Columbia, through the First Nations Health Authority, we are the only First Nations provincial health authority of its kind across the country and, of course, we work on behalf of our B.C. First Nations communities and are strong advocates.
So we have a process in place to procure, to receive, to distribute PPE across the province, however, if you speak to one of my colleagues, Dr. Lana Potts, who is an Indigenous physician in Alberta, she has also spoken to the media about her experience of working part-time in downtown Calgary, where there does not seem to be an issue with acquiring PPE. However, in the work she does with the Siksika First Nation, in their medical clinic, they have had difficulties.
So I can’t speak to the Alberta experience, except this is what our members are reporting across the country. There has been a variability in response. Sometimes I have heard there is actual delay in people, for example in the federal government, responding to requests for PPE. Sometimes people have sent emails or made phone calls and are waiting for days and even longer to receive a response in general. I couldn’t pinpoint it necessarily to specific things, except to identify that’s an issue, the variability across the provinces and territories.
Senator LaBoucane-Benson: Thank you very much.
[Translation]
Senator Miville-Dechêne: Before I ask my question, I would first like to say that, like all my colleagues, I really admire the work our health care workers are doing during this crisis. Thank you.
COVID-19 is highlighting the glaring lack of home-based palliative care, especially in Quebec. The fact that doctors are not providing that service, in Quebec more particularly, explains in part why our institutions are overcrowded, despite the fact that seniors would prefer to live out their last years at home. My question is somewhat critical because I am saddened by the fact that resistance is coming mainly from colleges of physicians and medical doctors’ unions. This is not just a systemic problem that exists outside the medical profession.
In light of this crisis, Dr. Buchman, should there not be some soul searching done to determine whether medical professionals need to get away from institutions and go to patients?
[English]
Dr. Buchman: Thank you very much for the question. This is an issue close to my heart. For the last 15 years, all I have done exclusively is look after people at home, as well as our homeless population, as a palliative care physician.
The medical associations, to my knowledge, are not against this at all. There may be systemic reasons for the lack in particular provincial jurisdictions as to why this hasn’t happened. It has not been adequately remunerated or funded to a sufficient extent to make it efficient and able to do home visiting, whereas now we see virtual care can be done in so many things.
We do need to break down the walls of our institutions. Care can be provided adequately. My group provides 24/7 care in the home. This can be easily done. We can cut down on emergency hospital admissions. It is extremely cost effective. We have that data. Patients and families appreciate this. It is patient-centric. We need to put a much larger amount into palliative care in this country and doing it at home. We need to implement a palliative care approach into our long-term care institutions. We need to have the goals-of-care discussions of what a patient values in their life, and the evidence that speaks to a particular intervention, like hospital admissions.
The majority of people, when they understand what palliative care can offer and what advance care planning these goals-of-care discussions can have, they actually very much agree to it. We can focus on providing effective care that isn’t oriented towards futile interventions. We certainly have the Canadian Medical Association behind increasing access to palliative care, particularly for those that choose to remain at home.
Senator Miville-Dechêne: I understand your commitment. However, there doesn’t seem to be a commitment of all the corporations and doctors. Are you seeing resistance? Because tariffs can be negotiated. One of the problems is some of your colleagues — and I’m not speaking of you — prefer to work in hospitals and offices than go towards the patient. So we have a real problem. How can we break that resistance?
Dr. Buchman: Part of the answer and some resistance to it may be that when physicians are out in the community, they are not able to see and meet the demands of the volume of patients that are required. In other words, they have too much to do. Seeing people in the home, making these visits, whether it’s remote and rural with long distances or weather challenges — even in a big metropolis like Toronto with traffic issues — it is not time effective and time efficient.
Being that the demands are elsewhere in terms of the number of people, I agree there may be resistance that certain physicians may have. We can overcome these with proper tariff negotiation, virtual care and using a team-based approach, where physicians, nurses, nurse practitioners, social workers — the whole interprofessional team — is the way to go. This can be done in a very cost-effective and time-effective way.
So you have a strong advocate for this, and we do have to get those messages out. This problem can be solved.
Senator Kutcher: Thank you so much everyone. I have a few questions. During this pandemic, the director general of the World Health Organization stated that we are also facing an infodemic; an abundance of false and misleading health information related to COVID-19.
What needs to be done by health organizations and by the government to effectively counter this infodemic?
Dr. Wieman: Thank you, Senator Kutcher, for that question. I will take 20 seconds to say I think you were my Royal College examiner, so it feels a bit like that again. It has been 22 years.
I agree with you. The information and misinformation out there can not only be distracting, but it can actually be dangerous, as we have seen in many of the popular media. For the Indigenous Physicians Association of Canada and First Nations Health Authority, we have made it a point since the beginning of the pandemic to work together in order to provide clear, to-the-point, culturally safe and relevant public health messaging to our communities. With the Indigenous Physicians in the upcoming messaging campaign, we are planning to add to the information that’s already there.
It is hard to attract people to the daily news briefing that takes place by Dr. Theresa Tam and some of the other public health officers, although what we are seeing, here in British Columbia, is this is really the time for public health physicians to shine.
What we have done here is to provide culturally relevant and correct information, because we know there’s a lot of fear out there within our communities. We know there are a lot of people who talk amongst each other, word gets spread person to person, and that can perpetuate stigma in a variety of different ways. One of the issues we’ve talked about in our First Nations communities is that some people may have difficulty or reluctance to come forward to be tested because they fear the stigma or blaming they may experience in their communities, that they brought the virus into their communities.
There is a lot to be said for trying to put out quality, relevant, and in our case, culturally safe and relevant information to our communities. One of the things we have done here in British Columbia is we, at First Nations Health Authority, have shown ourselves to be leaders in this messaging that is going out, as our messages have been used across the country, and even by some of our brother and sister communities in the United States, for example, the Navajo Nation. There is a need for that, and that needs to continue. Obviously, there needs to be funding to do that type of messaging properly. Thank you. Meegwetch
Dr. Betker: I agree with what my colleague Dr. Wieman has said, especially around cultural safety, but I want to take you back to that systems level.
Public health, the system; part of their responsibility is risk communication, and they’re good at it. We’ve seen those public health officials, the physicians in particular, shine in that. Dr. Theresa Tam has shown outstanding leadership in that risk communication.
Nurses also are seen as reliable and trusted sources of information in families, communities and the organizations in which they work. We’ve been trying to make sure that that good, solid, consistent information is with them, and they also are using it to inform, whether it’s the people they’re working with or in their communities, and really encouraging everyone to stay informed as part of their responsibility in this societal response.
Thank you for the question. It is an important question. Being a good risk communicator is a high level of skill. It requires practice, and not just during urgent and emergent situations, but really using our voice all the way along in many different situations.
Senator Kutcher: Thank you. In a recent Nature, article it was demonstrated that the anti-vaccine movement is actually growing during the pandemic, and many people are now saying they will not take a COVID vaccine when one becomes available, including in the study done by Senator Moodie. What should be done now by the government and your organizations to address these concerns at this moment?
Dr. Buchman: Thank you, Senator Kutcher. That has always been brewing in the background, whether the anti-vaxxers would actually take a vaccine for COVID-19. It’s going to be critical to sit down and have communication and dialogue. There’s a strong moral commitment to protect each other in this country. When I put on my mask, I don’t put it on for myself. I put it on to protect you, and you put your mask on to protect me. I think the vaccine controversy can be approached in a similar way.
Will we ever have mandatory vaccination in this country? I don’t think so. That’s not something we even do for our normal primary immunizations. We need to have the discussion. We can’t pretend it doesn’t exist. We can’t dismiss this segment of the population — that they’re just a fringe group. These are important public health measures, and our organizations can all work together and collaborate with government to take on this challenging issue.
Senator Pate: I also want to thank [Technical difficulties] join colleagues and also recognize Dr. Wieman as the first Indigenous woman psychiatrist in the country. Congratulations. I didn’t realize it has already been 22 years.
I wanted to [Technical difficulties]. There are concerns that have been raised by doctors. It seems their advice has not been followed. A number of doctors wrote to the federal [Technical difficulties] pick up on Senator Omidvar’s question. [Technical difficulties] concern about prisons as vectors for the virus in ways that both the health care systems in local communities could be overwhelmed, but also ways the virus could be prolonged unnecessarily.
First, the recommendation of health professionals was to depopulate the prisons, to reduce the number so that hygiene measures could be followed, as well as the method of allowing people to come through the virus, or not contract it, would not be just through the use of solitary confinement. I’m curious as to your comments on that.
You mentioned in Mission, B.C., your knowledge of that, Dr. Wieman, but I know this has been happening across the country as well, and some provinces have taken more progressive approaches than the federal corrections system.
Second, I received a letter this morning, from 160 health [Technical difficulties] indicating that the largest single determinant of health and their [Technical difficulties] with the organization, and [Technical difficulties] base income initiative, particularly in light of the evidence that addressing poverty, in the context of the MINCOME project in Manitoba and the Basic Income Pilot Project in Ontario, resulted in an 8.5% reduction [Technical difficulties] health care [Technical difficulties]. If we discovered a drug that reduced hospitalizations by 8.5%, we’d put it in the water.
I’m interested in the comments of all three of you on those particular areas in terms of, particularly, vulnerable populations. Thank you.
The Chair: Dr. Wieman, I hope you understood the question correctly. We had some challenges with the sound. Go ahead if you feel comfortable.
Dr. Wieman: Thank you. I will say that the question was a little broken up, so it was hard for me to understand everything that Senator Pate said, but I will also say a big hello to her as well.
Thank you very much for those questions. There is a lot there to unpack. I think what you’re hitting on, at least my interpretation of both of those questions, is that there are basic inequalities that Canadians experience, such as poverty or other social determinants of health that put them at a special risk of poor or negative, more severe, outcomes during this pandemic. That is only layered on top of all of the challenges that they faced, both pre-pandemic and as we move forward perhaps into a lower rate of pandemic, but we won’t be back to normal, so to speak. It highlights those significant differences and challenges that people have, such as poverty.
For example, when you were talking about people having a basic income, for many Indigenous people who live in, as an example, rural and remote places, if they didn’t already have that adequate income to start with, feeling that they are able to meet the needs of themselves and their families during this pandemic has been an incredible stress, for example, with regard to food security. That has forced people to rely on other ways of achieving food security, relying on care packages delivered to the community, or going out on to the land to hunt for their own food.
I won’t take up too much time from the other two respondents, but I also want to take this time to make the point that some of the solutions to some of these challenges aren’t necessarily just based on Western medical models of delivering care, or in our social service agencies, of trying to help people with some of these challenges. We also have our own systems, our own traditional systems of medicine, people, traditions, ceremonies, et cetera, and we have encouraged people through our public health messaging to rely on these places as well. That’s what we call out here a two-eyed seeing approach. I feel that’s very important to make that distinction when we’re talking about the challenges that are faced in corrections and, as Senator Pate also asked, with the social determinants of health. Thank you very much.
Dr. Betker: Thank you, Dr. Wieman, for that very eloquent answer and thank you for the question. Just a couple of observations.
It’s been interesting to see that things that have been advocated for and championed, and for which there is a strong evidence base, like income, housing, food security, discrimination and stigma, racism, those kinds of things, especially around policy work, so for food security, housing and income, where we’ve been able, as a whole-of-government, to put those solutions in place in a very short period of time.
I would hope that we take a close look at that and don’t move back on that, because those inequities do drive health issues and those health issues then drive that health system. I would certainly be highly recommending those inter-sectoral, whole-of-government approaches to these issues, and staying the course on some of the things we’ve been able to do quickly as a country.
The Chair: Dr. Buchman, I know you’re signalling that you’d like to add something to that. I would ask that you do it very quickly. I want to make sure we have some time for second questions.
Dr. Buchman: Thank you, Madam Chair. I’ll be very brief. It is most unfortunate that the Dauphin, Manitoba, experiment that you referred to in the 1970s regarding basic income guarantee was not followed up recently in Ontario, for example — that it was cancelled. We know that income status is the most important social determinant of health. It would be very important for the federal government to support further basic income studies.
The 8.5% decrease in health care was fine. We also didn’t see more unemployment. The only unemployed group we saw were new mothers. So it is very important to be able to follow up on this study. I think, as we can see with CERB and everything done, that it’s critical to support Canadians. We can improve health just by doing that, and might I put in a plug for adequate housing. Our vulnerable populations that are homeless need housing. More than anything, that will contribute to their overall health and well-being.
The Chair: We do have time for a second round of questions, although it’s only 15 minutes and we need to stop at 1:30 for technical reasons. I will urge my colleagues to ask one brief question to one witness, providing one brief answer, if that is possible.
Senator Poirier: My question is a follow-up to Dr. Buchman’s answer earlier. As you answered earlier, we’re not ready for the second or third wave that could possibly be coming, due to lack of testing and contact tracing. I saw an article earlier saying we are behind in testing compared to other nations. My question is: Why are we falling behind in testing at a time when the government should be expanding that testing?
Dr. Buchman: I do not know the answer to that. What is it, we lack supply for adequate testing? Is it lack of trained workers who can go out and do the contact tracing? Being just manual does put us behind. We could be hiring many more contact tracers and train them easily to do this. This question needs investigation. Right now, I do not have an answer as to why we’re so behind compared to other nations. I wish I did.
Senator Poirier: Thank you. Maybe we could follow up.
Senator Seidman: I’m sorry, by the way, Dr. Buchman, because the sound cut out when you were answering my question about virtual care, so I’m going to go back and try to listen to it in the system later. I’d like to ask you another question, if I might.
Following the H1N1 pandemic in 2009, the health minister asked this particular committee, Social Affairs, Science and Technology, to undertake a review of Canada’s response, and in fact this committee submitted their report in 2010. In that report, there were serious issues raised even then about health human resources and its capacity to increase a surge capacity. Despite the mild severity associated with the H1N1 pandemic, many witnesses testified that Canada’s resources were pushed to their limit. Many witnesses mentioned that there needs to be more focus on public health generally. This would bring about the needed change to public health infrastructure that would, in turn, increase our capacity to respond to health care emergencies.
So one of our recommendations was that the Public Health Agency of Canada implement regular and rigorous testing of the revised Canadian pandemic plan for the health sector specifically, and that active participation of all the stakeholders, namely, the health professionals, would be involved.
I’d like to know if indeed this happened following the H1N1 and that report.
Dr. Buchman: To my knowledge, no, not to the degree that it should have. Over the intervening years, I think many other health issues have taken our attention away. As human beings, we tend to move on, we tend to neglect and we often deal with what is at hand. So we have the public health crisis of the opioid crisis, as an example, and that takes attention, but the similar issues that contribute there — the systemic racism, the social determinants of health, everything that contributes, the lack of mental health access and addiction treatments — all those contribute. Our attention gets diverted and we move on. So there has been inadequate public health funding over time.
The lessons there and the health human resource planning, et cetera, are all relevant to today and we need to begin, from this committee now, to resume those kinds of discussions. It’s the COVID crisis, if there’s a silver lining, that may be one of them, to bring forth those previous recommendations, and now people are listening and we should get those into action and not neglect this anymore.
Senator Seidman: Thank you. Good lesson.
Senator Forest-Niesing: My question is along the same lines. A second wave and possibly even a third wave are expected. I’m particularly interested in knowing what lessons we’ve learned. It seems to me that your members are in the privileged position because they possess the knowledge, they have had the experience. They can and should be able to share that knowledge and inform the preparedness for the future expected waves.
I’m wondering specifically what mechanisms already exist for the flow of information and for the sharing of that knowledge. And if no mechanisms are in place or insufficient mechanisms are in place, what additional measures can and should be taken to ensure the flow of that knowledge to inform the preparedness for future responses?
From Dr. Wieman, if I could also inquire about how we capture the experience flowing from the two-eyed seeing approach.
Dr. Buchman: Thank you for the question. It’s really looking for what mechanisms are available for input and information from those front-line workers who have the experience and knowledge to address preparedness, if that’s correct.
Certainly I’ll speak for the Canadian Medical Association, but I know our provincial and territorial medical associations have portals. We undertake surveys. We have regional member forums. We have round tables. We are seeking information all the time from our membership to have input as to the preparedness, and we are doing so now.
The information I provided earlier about mental health concerns, et cetera, comes from our recent surveys about PPE, et cetera. I think we’re doing a good job. We are seeking that information all the time and we are always willing. We have regular contact with the government, with the Public Health Agency of Canada, in order to provide them with the information from the front line.
Dr. Betker: The Canadian Nurses Association has the same mechanisms. Much of what I said came from our members. We also have the connection to the Public Health Agency of Canada, Health Canada, our provincial and territorial jurisdictional members and their governments. We also work very collaboratively with CMA, the Canadian Association of Social Workers and pharmacists and other disciplines. We’re well connected and well networked, and I know our members would welcome being asked what the issues are, but also what the solutions are, because they are very practical people, and they know and have those solutions.
Dr. Wieman: Thank you. I can only echo and agree with the comments of my two colleagues who went before me.
In order to capture the experience or to learn more, in order to prepare for either future waves or future pandemics, I do think it’s extremely critical that we continue to have sessions such as these that focus on the experience of Indigenous people. For example, my suggestion would be, respectfully, that a different session would include, for example, the Indigenous physicians but also the Canadian Indigenous Nurses Association and other front-line workers who are working in our communities, both rural, remote and urban.
How we capture that experience; this is too large a subject to open in a brief question, but there’s been a lot in the media you may have seen around data, how data is collected and how it affects our populations, and that includes both narrative and quantitative data.
I can only suggest that hopefully we have an opportunity to discuss this further. There’s a lot of information still to be gleaned in terms of how we use that information and prepare for future waves or future pandemics.
Senator Moodie: My question has to do with public health agencies and their role in pandemics and in general across Canada. Are you seeing a difference, a variability in the resourcing of public health agencies across Canada? What has that impact potentially been on how individual regions have been able to manage and play their part in managing the response to COVID?
The ability to trace effectively and the ability to test and ramp up testing has been linked to the available resources and the infrastructure that exists regionally. Can you comment on who has done well and make the link for us in terms of resourcing across Canada? Have we seen a significant gutting of public health resources in certain regions? What impact may this have had on the ability to respond?
Dr. Betker: I’m going to take a shot at answering that first. I’m going to follow on what Dr. Wieman said. I suggest there is a conversation or a meeting such as this where you actually look at the public health system across the country.
I was in public health during SARS, and we have seen some improvements, absolutely. The Public Health Agency of Canada, the establishment of some of the structures around the public health network council and others, have really helped the communication. But really focusing on that capacity within each province and territory, and within each one of those organizations that’s responsible for the delivery of public health services, that really hasn’t been looked at. There has been a drift away from that upstream, preventive, health-promotion perspective.
From a nursing perspective, more than half of that staff are nurses. That’s who’s doing the case and contact tracing, or were. That’s who’s doing the follow-up, that is who’s out there in the community. Your question is outstanding and I would really encourage you to take a look at the public health system writ large across this country.
Dr. Buchman: Just to add to what Dr. Betker said, we have seen cutbacks. I can’t comment on the resourcing, but we’ve seen cutbacks. I’m Ontario-based. We saw it in Walkerton, where inspection of water treatment facilities was cut back. We’ve seen it now in long-term care, where the assessments of quality of care provided to residents of long-term care has been cut back drastically. Again it’s just financial. Therefore, in terms of resources. I can’t discern what the resources are. I agree 100% that this absolutely needs further study and we need to achieve federal standards.
Senator Munson: Dr. Buchman, do you have any idea what the second wave will look like? How will we cope with it this time? You said at the very beginning of this two hours that we’re not prepared. What do we have to do specifically to be prepared? Do you have any idea at all what a second wave will look like?
Dr. Buchman: Second waves can often be worse than the first. We have public health measures, the physical distancing, shutting down our economy, et cetera. As we reopen, and if we don’t practise these public health measures, in the absence of a vaccine and adequate diagnostic testing, adequate contact tracing, adequate serological testing, we will likely be opening too quickly.
We will see a cycle of opening and closing, which can be very difficult. So I think the importance of ongoing public health measures will be there, and we still have to be prepared for surges in the health care system and all the issues we were anticipating with the first wave. We have shown that these public health measures are effective, and we will have to find a balance. Everything from wearing masks to adequate contact tracing is going to make a difference, and hopefully won’t impact the health care system’s ability to manage during a second wave.
Senator Omidvar: Let me quickly ask my question of Dr. Buchman. Would the collection of data based on race help in the treatment of the crisis?
Dr. Buchman: I will answer quickly. The answer is absolutely yes. There is a disproportionate burden of the disease based on people’s status. Racism has contributed greatly to the disproportionate experience say, in the Black communities in urban centres. That kind of thing is coming forth.
We need to be able to get race-based data in order to be able to do the things we were talking about earlier, such as the right contact tracing, protecting these populations that are way more susceptible. Certain populations are very much at risk. Health care workers — often women of colour who are subjected to increased risk with a lack of adequate PPE — is an example. So the bottom line is yes, absolutely yes.
The Chair: Dr. Wieman, did you want to add your perspective on that specific question?
Dr. Wieman: Thank you. The only thing I will add is that we as Indigenous people are very interested in having sovereignty over our own data. So yes, I agree the data needs to be collected, but we need to do it for ourselves, by ourselves. That is a principle that is running through much of the health care research happening across the country, through the Canadian Institutes of Health Research and the Institute of Indigenous Peoples’ Health.
Senator Dasko: Thank you. Some activists, with respect to seniors’ care, are in fact calling for the federal government to take on a more active role — the same type of role it takes on with respect to the Canada Health Act, i.e., using federal spending power to spend and to regulate in this sector.
Dr. Buchman, you alluded to this earlier in your comments. I know that the situation with Indigenous communities is different, so my question goes to Dr. Buchman and Dr. Betker. Have your organizations actually called for this model?
Dr. Buchman: The answer is we’re in the process. We’re actually convening an expert advisory committee to begin looking at these questions and examining these issues. It’s too early right now to answer your questions, but we’re in the process of trying to come to some answer about that.
Dr. Betker: We are, within the Canadian Nurses Association, in the process of writing a paper as well. We are also probably suggesting a commission of inquiry on aging, looking at the population. Not just long-term care but the whole population.
Senator Dasko: My question was about the federal role.
Dr. Betker: Federal role, yes.
Senator Dasko: Thank you.
Senator Kutcher: Is the general hospital, as we know it, no longer a tenable health care delivery institution? We’ve had H1N1, SARS, MERS, not Ebola here but Ebola, now COVID. Each time, the hospitals shut down.
Is there a different way we can deliver health care? Is our reliance on the general hospital finished?
Dr. Buchman: I think these pandemics, and most recently in the midst of COVID, of course, reveal many of the gaps within our health care system. For example, we need a far greater emphasis on primary care as the foundation of the health care system. So much can be done out of a hospital environment. Five million Canadians lack a family doctor or access to an interprovincial health care team. We have, of course, a maldistribution problem across the country with regard to care.
We talked earlier about the ability to provide home care and breaking down the walls of the institutions. We can do much more innovative models, from virtual care to what they’re doing at Women’s College Hospital in Toronto, which is an ambulatory outpatient hospital.
In answer to your question, this is part of the review of the whole health care system that needs to be undertaken as we leave the COVID crisis.
[Translation]
The Chair: Thank you, Senator Kutcher. Thank you to everyone — our colleagues and our guests — as well as our witnesses for the quality and the accuracy of their answers. We really appreciate it.
We are continuing with our next panel of witnesses: Dr. Margaret Tromp, President of the Society of Rural Physicians of Canada; Dr. Barry Power, Senior Director, Digital Content, and Dr. Shelita Dattani, Director, Practice Development and Knowledge Translation, from the Canadian Pharmacists Association; and Pierre Poirier, Executive Director of the Paramedic Association of Canada.
[English]
We will begin with Dr. Tromp, followed by Dr. Power, Dr. Dattani and then Mr. Poirier.
The floor is yours, Dr. Tromp.
Dr. Margaret Tromp, President, Society of Rural Physicians of Canada: Thank you very much. And thank you for the opportunity to witness the experience of rural communities through the COVID-19 pandemic.
We who work in rural communities have a saying that “once you’ve seen one rural community, you’ve seen one rural community.” This is to emphasize that each rural community is unique, with its own strengths and challenges. I would like to be a witness to two different and unique rural communities today.
I work in Picton, which is a community of 4,000 in southern Ontario. We are in Prince Edward County, a tourist destination with the famous Sandbanks Provincial Park. Our population swells in the summer and attracts tourists from both Ontario and Quebec.
The WHO declared the pandemic on March 11, a Wednesday. By Friday, it became clear that we would have to stop seeing non-urgent patients in the office. We spent part of the weekend phoning patients who were booked to see us on Monday and had phone visits with them. We also made changes in our office to isolate our staff from patients with barriers. We took the toys and the magazines out of the waiting room and separated the chairs so they were six feet apart. Now we see only pregnant women, infants who need immunization, patients who need injected medication, and patients with potential urgent problems like cancer scares.
We developed a COVID parking lot assessment cart so we could assess patients in the parking lot for respiratory issues, so they would not have to come into the office building. Then we started developing a COVID assessment centre in the arena that happens to be next to our offices and hospital, and were up and running as of April 2.
The emergency visits in our hospital dropped dramatically and this gave the emergency physicians time to do a lot of COVID-19 education, including practice resuscitation scenarios. At present, the Hastings and Prince Edward Public Health Unit has the lowest number of COVID positive cases in all of southern Ontario. However, tourist season is upon us and as tourists arrive from urban areas of Ontario and Quebec, we are concerned that they may bring the virus with them.
I would now like to move across the country to La Loche, Saskatchewan. La Loche is a Métis and Dene village in the north of the province, close to the Alberta border. It is 200 kilometres by road to Fort McMurray. Like most northern public health departments, the Northern Saskatchewan Population Health Unit has been very concerned about the possibility of isolated northern communities being exposed to COVID-19. These communities have challenges with crowded housing and other social determinants of health.
The population health unit also works closely with the uranium mining camps, where workers live in close quarters. There were two cases where health professionals returning to the north contracted COVID-19 while out of the community or country. These cases were identified and isolated and there was no community spread. Then a La Loche resident, who worked in the oil patch in Alberta, contracted COVID-19 and returned home to his crowded living situation. COVID began spreading through the community.
Access between and the north and the south of the province was severely restricted, and northern residents wondered why these restrictions were only put into place after there was a breakout in the north. Food choices became even more limited. Many residents who needed to self-isolate had no place to live, so ATCO and vacation trailers were brought in. Residents received some money as a result of various programs at the community, provincial and federal level. Several of these amounts were received at about the same time, and they were followed by increases in the incidence of alcohol-related domestic and other violence.
The community leaders worked closely with the population health unit and closed the liquor store, and a monitored alcohol program was started for residents who needed to self-isolate but were alcohol-dependent. These residents received delivery of alcohol to their isolation locations three times per day.
There have been two COVID-19 deaths in the long-term care in La Loche, and some patients had to be transferred south for care. Reflective of the demographics of the community, which has an average age of 20, many of the residents who contracted COVID-19 were young and have not become severely ill. At present, the northern population health unit has by far the most number of active COVID-19 cases in Saskatchewan.
The COVID-19 pandemic has brought to light the social inequalities across the country. There is a need for funding of more research related to health disparities and the best ways to deliver health care that responds to the unique circumstances of each community.
We need better intraprovincial cooperation, especially for communities near provincial borders. Limited resources like PPE and swabs should be coordinated on a national level. We need to be aware that rural communities feel that their health services are constantly stretched, and that the inflow of tourists who may need health services is a significant concern.
I’m happy to discuss these issues further. Thank you for the opportunity to speak with you.
The Chair: Thank you, Dr. Tromp, for bringing this unique perspective from the rural communities to us.
Dr. Shelita Dattani, Director, Practice Development and Knowledge Translation, Canadian Pharmacists Association: I will be giving remarks on my behalf, and on Dr. Power’s behalf, for the Canadian Pharmacists Association, and we’ll be happy to take questions together.
Good afternoon and thank you for inviting us to appear today. We are here today representing Canada’s 42,000 pharmacists and Canada’s 10,000 community pharmacies that have remained open to Canadians during this crisis.
In times of national emergencies, pharmacies are considered essential services, which means that they stay open when others are closed. This pandemic has been no exception. Pharmacies have adapted considerably to continue to serve their patients safely, and so they can access their life-saving medications. This includes providing more delivery services for seniors and other vulnerable patients, dedicating special opening hours for seniors, and putting into place protective measures like plexiglass barriers to minimize the risk of contamination, just to name a few.
Community pharmacists are also a key source of COVID-19 information for the public. In a recent survey that we did, over half of pharmacists across Canada indicated that they’re providing COVID-19-related information to five or more patients per day.
While pharmacists have been grateful to do their part, it has not been without added pressure and stress. When we surveyed our pharmacists in April, there were two major areas of concern that stood out: the increased difficulty in managing our drug supply and being able to protect pharmacy staff.
Drug shortages are not new in Canada but the pandemic certainly added a layer of pressure and complexity to managing our drug supply. As concerns about COVID-19 started to grow in Canada in late February and in early March, we saw a huge spike in demand for many products such as toilet paper, masks, hand sanitizers and medications. In fact, the demand for prescription medications went up 200%, putting a significant strain on the drug supply chain across the country. Our job as pharmacists is to ensure that our patients get the right medications at the right time, meaning that we need to make sure that we can distribute medications equitably to all of our patients, and why we felt at the time that the only responsible course of action was to recommend limiting dispensing to 30 days’ supply.
The limits on dispensing helped stabilize the supply of drugs, and while we must continue to carefully manage drug inventories, we are in reality in a much better situation than two months ago. However, as the pandemic continues to progress, we know that there will be an increased demand for many medications that are being used to treat COVID-19 or symptoms associated with COVID-19.
Health Canada has developed a list of over 70 medications that are currently being used in the context of COVID-19. The availability of these drugs is being closely monitored. We are also concerned that disruptions in manufacturing in countries like China and India will have a downstream impact on shortages in the upcoming months. As a result, we feel that we must remain vigilant so that we can adapt to whatever comes next.
We hope that the Government of Canada will continue to prioritize this issue, and to work with us to look at those longer-term impacts.
The second issue that we wanted to touch on is the ongoing lack of personal protective equipment for health professionals and essential workers. You’ve heard much of this from the colleague who just spoke now and also from the colleagues who spoke this morning from the Canadian Medical Association and the Canadian Nurses Association. We won’t repeat their observations except to say that pharmacists have found it equally difficult to access the protective equipment that they need on the front lines and as front-line health care workers. We believe there is an important role for the federal government to assist health care providers and essential workers in this respect.
Last, we feel it’s important that we start looking forward to the fall and a possible second wave. Specifically, it will be particularly important that we have an even more ambitious influenza strategy campaign this year to ensure we don’t add additional burden to our health care system. This means that we must start planning now by ensuring that we have sufficient vaccine to deal with increased demand, and proper access to PPE for all of the providers who provide flu shots in our communities, including pharmacists who deliver over a third of flu shots to Canadians every year.
We’ve seen in the southern hemisphere, in countries such as Australia where they are already in their flu season, that the demand for flu shots has increased but that access to vaccines was somewhat erratic. A coordinated approach is necessary to ensure that all Canadians, regardless of where they live, can access flu shots conveniently and safely. This is why we have to prepare now.
Thank you very much. My colleague and I will be happy to take your questions.
[Translation]
Pierre Poirier, Executive Director, Paramedic Association of Canada: Good afternoon, honourable senators.
[English]
Welcome and thank you very much for the opportunity to speak to you today. My name is Pierre Poirier. I am the executive director of the Paramedic Association of Canada. We’re not a union. We’re the professional association that represents the interests of the profession as a whole.
There are over 40,000 paramedics in the country who have done incredible work during COVID-19 and continue to do so. Just to highlight some of the items: Paramedics recently have been engaged in the swabbing in long-term care homes, of note here in Ottawa and several places across the country. Our contribution has been significant. That leads into my next point: We actually feel we are part of the health care system. That is an important facet and an important point to deliver.
If I look at the macro issue here — and I’ve spoken about this before — it is probably time for Canada to revisit the Canada Health Act. For example, if you take an ambulance with paramedic care in Saskatchewan, you may receive a $400 bill for that trip to the hospital. Worse, with COVID-19, some people are choosing not to go to the hospital, resulting in higher acuity of patients and a greater number of patients who are dying at home.
I think there is time now to look at the Canada Health Act in two phases. One is to look at it from the front end, recognizing that when somebody calls 911 for help, that should be the start. At the back end, our seniors and most vulnerable populations in long-term care facilities and in retirement homes also deserve our care and respect. They should also be included appropriately within the construct. And the federal government absolutely has a role to protect all the citizens in this country. That’s the front-end piece.
There has been discussion on PPE, personal protective equipment. Paramedics across this country have struggled. They have been told they should only use the appropriate PPE if it’s absolutely necessary. They have been asked to ration. They’ve had poor access to N95 masks. This is truly a sad, sad situation for what is considered a First World country.
Unfortunately, this rolls back to the federal government in some way, with respect to Canada’s National Emergency Strategic Stockpile, or NESS, as it is known. Through different events, including SARS, H1N1 and other events, there has been a commitment to rejuvenate, replenish, resupply and to manage. Here we are in 2020 and, somehow, some way, we are unable to provide the appropriate PPE, not just to paramedics but to health care workers across the spectrum. This is sad for the country. It’s not just that the federal government has the sole responsibility; it is a shared responsibility within the construct of the Canadian context with provinces. But it starts with the federal government that we continue, as of today, not to have N95 masks available to paramedics across the country.
That is the most important point we have to establish. It’s not just the N95s but also gowns that are now in short supply. There is a perception that people should only use the appropriate gear when they believe it is absolutely necessary, as opposed to the information that’s first provided determining what the level of personal protective equipment should be.
Paramedics continue to provide service across this country. They’re doing incredible things. They’ve changed the way they have delivered care. You hear a lot more about home care. You hear a lot more about how they have been able to assist the hospital infrastructure in taking care of long-term care facilities and retirement homes. We will continue to do so.
Once again, thank you for the opportunity to speak on behalf of paramedics today.
[Translation]
I thank all the senators.
The Chair: Thank you all for your presentations.
[English]
It is now time to proceed with questions from the senators. I remind senators that you have five minutes for questions, and that includes the answers. If you wish to ask a question, use the raised-hand feature on Zoom. We will add you to that list which is filling already. When asking a question, I kindly remind you to direct your question to a specific witness. That really helps the process. We will begin with the deputy chair of this committee, Senator Poirier.
Senator Poirier: My first question is for the Society of Rural Physicians of Canada.
We have heard of multiple reports about the lack of PPE across the country. For rural and remote communities, could you elaborate on what the current situation is for personal supply and for testing? Do you have easy access to testing kits and contact tracing for the rural and remote communities?
Dr. Tromp: What happened with the PPE is it was a bit of a moving target. Pre-COVID, in an emergency department, I would use an average of zero masks per day, maybe one or two a week. Then you get into a situation where you would use a fresh mask for every single patient encounter. That is how we are supposed to ideally do it, because if you encounter one patient and they breathe on you, they could put the virus on your mask, and then, when you talk to the next patient, the virus from your mask could be transmitted to the other patient. So in an ideal world you would change your mask for every patient encounter.
In my emergency department, we see between 60 and 100 patients per day. So that means, in the ideal world, we would need 60 to 100 masks per day. That increases your need for a mask to approximately 1,000 times what you used to previously need.
How do we decide when we have enough? Now, instead of changing your mask for every patient, you get one mask at the beginning of every shift and you are encouraged to use that mask for the entire shift. If it gets soiled, you get a second mask. As I said, we have not had a lot of COVID-19 in our community, so I think generally as people work in the emergency department they are not high-anxiety about this. But if you’re in a community like La Loche, where you’re told to use the same mask all day, that would be a whole different anxiety level.
One of the issues that people have expressed to me is this real emotional turmoil about having to do things that, pre-COVID, would have been considered malpractice, or poor nursing or medical care. You would never wear the same mask from one patient to another patient. If you did, you would be reprimanded for bad practice. Now you’re instructed to do this, and this causes the emotional turmoil to people.
For example, I had a woman in my office who works for a home care company, and it is her job to schedule — she wasn’t in my office, but we talked on the phone — PSWs to go into people’s homes. She said, “I know this is not right. They have to use the same mask for the entire day going from home to home to home.” She was in tears telling me about this. She said, “I can’t do it. It is so wrong. We’ve been told that this is not what you do, and this is what we have to do.”
With us all using the same PPE, the same mask for the day, we’re not short. There has been no day that I have gone to work and someone has said to me, “We don’t have a mask for you today.” There is always one for me every day, but at the hospital and in my private office I provide my own. At the hospital they always have them, but that’s because we are using them at a level that, in pre-COVID-19 times, would have been considered to be against public health recommendations.
So it is similar in all the rural communities like that.
Senator Poirier: From your perspective, is the government doing enough to address the mental health issues that have developed as a result of the pandemic and the subsequent social distancing measures for rural communities? What more can be done?
Dr. Tromp: The mental health issues come out a bit later. Initially you have social isolation. You’ve probably seen the curves that people show about the initial wave that goes up, and then you have the post-wave when some people went home and then got sick again. Then you have the chronic care wave where people who should have care, but aren’t getting care, get sick. Then you have the mental health wave that is more gradual and comes later. So the major mental health effects appear after weeks to months.
For the first week or two, people aren’t doing too badly, but then they get more and more stressed as they become more isolated. How do we address these issues? For many of us, we’re not even yet aware of what the mental health effects are, because these patients are not presenting to us because they have this message — not given by me, because I’ve written my patients messages and said you phone and do this and this — but there are many patients who are reluctant to call or come unless they think they are literally dying. So they don’t come with stress and mental health concerns at this point, but I think they will be coming down the road.
Right now, I don’t have that many people making phone appointments with me to discuss mental health concerns. Most of the people I’ve seen with this problem have had pre-existing stressors in their life and maybe it is coming to a head, but they are not people that I would have been totally surprised if they would have come to me with mental health concerns outside the pandemic.
The Chair: Thank you, Dr. Tromp. You paint a very stressful environment.
Senator Griffin: I would like to thank our panelists. This has been very interesting.
My first question is for Dr. Tromp. I’m from Prince Edward Island. We’re a tourist industry province and, of course, cottages are a big part of that, both by residents but also a lot from people who would come in from out of province, and they own or rent a cottage here. I guess that is easy for us. We can close them off at the bridge to the mainland.
However, in a larger province, how much more difficult is this? People are coming from a larger city to a rural area. What are the major issues if we don’t act carefully in easing the restrictions?
Dr. Tromp: Yes. Generally in the rural population there’s some consensus, but not complete agreement on this issue. Many rural populations really want to restrict tourism quite a bit. Some rural communities have requested that people not come to their cottage at all this year and stay away for the year.
I personally feel that we maybe do not have to be that restrictive. If people socially isolate at their cottage, I don’t think the risk is super high, but we are concerned.
There are different levels of tourism. There is the tourism where 500 people go to the beach and talk on top of each other, and there is tourism where someone has a cottage in the woods.
I think this is a problem and I don’t think we have resolved what we should do about it. In communities where there are cottagers, we know economically that people who own cottages pay a lot of tax. The tax rates are high for waterfront property and their tax money is significantly contributing to the local economy. So how do you find a balance between that? We have to have more discussion about this and work on it and reach some consensus.
I do not feel as strongly that we have to keep all tourists away for the entire tourist season. I’m hoping there is some sort of physical distancing solution that we can have. If I lived on the 23rd floor of a condo in downtown Toronto and had to take an elevator with a group of people coughing and sneezing on me, I would want to go to my cottage.
Senator Griffin: Thank you very much. Those are the same issues we have here except we don’t have 23-storey high buildings.
My second question is for Dr. Dattani. It was mentioned previously that it’s really important not to forget we have other issues going on. For instance, people are staying away from emergency rooms and whatnot, out of fear. But we’ll also have a flu season coming up next year, as we do every year. Is there a good level of collaboration between the various levels of government in terms of preparation for such a thing as the next flu season?
Dr. Dattani: Thank you very much. I think that’s a really good question. I just got off a call about an hour ago with the Chief Public Health Officer Health Professional Forum, and we talked about this a little bit, and we highlighted the importance of excellent coordination between national and provincial levels of public health, because a lot of this is coordinated provincially but rolled up from the national level. So we definitely discussed the value and importance of that, the understanding there’s going to be a very big demand that we anticipate this year, and what I mentioned earlier in my remarks around even experiences from Australia having some challenges with erratic drug supply. We will need that coordinated at all levels of government.
I think there’s a sense of awareness, but I think we need to continue to discuss how important that is going to be and that the preparedness strategy really has to start happening now, when we’re talking about procuring not just vaccines, but syringes and alcohol swabs and masks and all of the other supplies that providers — all of the providers, including pharmacists, but others, nurses and physicians— need to make sure that we meet the preventive needs of Canadians who will want them more than ever this year.
Senator Griffin: Thank you.
Senator Moodie: Welcome to the speakers today. Thank you for all your hard work and facing the challenges as you do every day to help Canadians, all Canadians.
My question is directed to the pharmacists, Dr. Dattani and Dr. Power. The Government of Canada tells us it’s actively monitoring the supply of prescription and over-the-counter drugs, and they’ve also warned that there may be supply disruptions due to COVID-19. Can you identify for us which specific drugs have experienced disruptions, shortages of critical or essential medications?
I’d also like you to, if you can, tell us how you’re managing the drugs that are restricted. What partnership do you have existing with the federal or provincial governments around how this shortage is being managed, and who has the absolute say on which drugs get used and how they’re distributed?
The final part of my question is: Did we prepare appropriately for this? Were drugs that were expected to be in short supply stockpiled appropriately?
Dr. Barry Power, Senior Director, Digital Content, Canadian Pharmacists Association: Thank you for the question, Senator Moodie. You raise a number of excellent points. Health Canada has identified 17 or 18 medications that they have on a Tier 3 shortage list, which means that they’re actively managing the supply. Several of the more high-profile ones are an inhaler that contains a medication called salbutamol. It sometimes goes by the brand name Ventolin. It’s used by people with respiratory problems, whether it’s asthma or COPD. It is in fairly serious short supply at the moment. Health Canada has worked with a number of manufacturers to bring in supplies from the United Kingdom and from, I believe, Latin America, to augment the supplies that are in existence in Canada.
Part of the reason for the shortage of salbutamol was a change in policy in hospitals to try to reduce the spread of COVID-19. Hospitals began using the inhaler that’s typically used in the community setting instead of a different form of the same medication. That was a last-minute shift.
Another medication that has received a bit of profile is hydroxychloroquine. It, as you all know, gained a bit of popularity due to some statements from one of our neighbours. It typically would not be considered in the top 100 drugs. It’s used by a relatively small number of people, typically with rheumatoid arthritis, lupus, some other conditions. Again, Health Canada has, through their drug shortages unit, worked very closely with a number of the manufacturers to try to augment the supply. They’ve been quite successful with hydroxychloroquine, to the point where it is no longer on the Tier 3 shortage list. It has dropped down to Tier 2.
Most of the other medications that are on the Tier 3 shortage list are used in either intubation or sedation of patients in the ICU. They’ve been flagged as in critical supply.
It’s one of those situations where I think Mr. Poirier brought up the idea of the national emergency stockpile. It’s one of those things where nothing has happened, so people tend to forget about it. I’m sure everybody on the call has forgotten to change the oil in their car at some point and then has run into problems. It’s a similar situation where, if there’s nothing wrong, you might tend to try to stretch a supply, similar with all the protective equipment.
Senator Moodie: Sorry to interrupt you, Dr. Power, but would it be possible for you to comment on critical care drugs as well, please?
Dr. Power: Sure. A lot of the critical care drugs — some of the neuromuscular blockers, a lot of the sedative agents, fentanyl, a number of other opioids that are used to sedate people during intubation or prolonged stays in the ICU setting — are in fairly serious supply. They’re being managed and rationed quite well, I would say. But they are the focus of a lot of work that’s being done through hospitals. The hospital pharmacists have been doing a tremendous amount of work, trying to procure appropriate supplies, and there has been a lot of collaboration across hospitals and wholesalers to try to make sure the supplies are used.
One of the issues that this has raised is that a lot of surgeries have been postponed because many of the medications that are needed in the ICU setting would also be used by anesthesiologists during surgery. They are taking similar steps to source medications from other countries. There’s a sedative called propofol which is being imported from an international supply to help augment that. So there are a number of steps being taken for the critical-supply medications as well as the medications that are used in ambulatory settings.
As far as who has the ultimate say in what medications are used, ideally it would be the physician treating the patient who would say we need this drug, this drug and this drug. But the situation we’re in is that there are a lot of restrictions. Many of the sedation medications are used through protocols that are established through the institution as well. The final say at this point is often going to be the institution, and it’s going to be based on what is available to them at any given point in time.
Senator Seidman: Thank you very much for being with us and indeed, as previous colleagues have said, for all the work that your members are doing on the front lines at this serious time.
My question is probably going to be addressed to Dr. Dattani of the Pharmacists Association and Mr. Poirier of the Paramedic Association.
In 2010, the Minister of Health requested that this committee, the Standing Senate Committee on Social Affairs, Science and Technology, undertake a review of Canada’s response to the 2009 H1N1 influenza pandemic.
One of the findings of our committee — and, in fact, I was fortunate enough to be on the committee at the time — was that innovative approaches to health care service delivery need to be considered in order to increase surge capacity. Witnesses suggested that greater use could be made of health care providers outside of those traditionally called upon during health emergencies. The committee heard from both the paramedics, who felt they were an untapped resource during the H1N1 pandemic, and the pharmacists, who explained how some jurisdictions expanded their scope of practice in order to mitigate the strain on human resources.
My question to both of you, the pharmacists and the paramedics, is: In what ways have your role changed in order to serve the public during the current health crisis? I think both of you addressed some of that in your presentations. I’d like to give you the opportunity to expand on it.
I know, Mr. Poirier, you were very adamant and enthusiastic about that particular aspect of the paramedics’ role. And I’d like to know, specifically for the paramedics, are you currently considered a health care resource in other than the more traditional ways? What is the uptake like during this pandemic for those roles?
To the Pharmacists Association, in what way has your typical role changed in order to provide patient care? For example, has your staff experienced cross-training in hospitals or been asked to interact with patients through virtual platforms?
Finally, what does all this mean for the future, in the way you might see your roles change permanently? I do have to tell you that the recommendation in this committee’s report in 2010 was very much to expand the role of paramedics and pharmacists, especially during pandemics.
Dr. Dattani: I’m not sure who wants to go first. Maybe I’ll chime in. Speaking on behalf of pharmacists, thank you very much for those comments and some of the recommendations from the 2009 report.
In terms of scope of practice for pharmacists, there has been some growth in terms of what pharmacists are able to do across the country. Unfortunately, some of our challenges that remain are the lack of harmonization, so it’s still a little bit of a fragmented system, as it often is in this country. But unlike some other health care providers, patients do not enjoy getting the same level of care from their pharmacist, depending on where they live. A patient living in New Brunswick is not able to benefit from the broader scopes of practice that a patient living in Alberta, for example, may experience, where pharmacists can fully prescribe all medications, outside of opioids and controlled substances.
I spoke in my remarks a little bit about immunization and really how pharmacists have broadened widespread access to influenza and other immunizations. There’s a lot of data supporting that that has really changed the game in terms of preventive care and public health access, with respect to immunizations and injections.
There are other areas, though, where pharmacists have the knowledge, skills and training, yet don’t have the ability to provide the same harmonized care across the country. For example, in the treatment and assessment of minor ailments, like urinary tract infections or reflux disease, in some provinces pharmacists have the ability to assess and treat for these, so we could potentially keep patients out of emergency departments or walk-in clinics, or leave physicians in the primary care environments to deal with the more complex patients they need to deal with. Pharmacists could provide help to those patients in a very convenient and accessible way, because most pharmacies are open seven days a week, several hours a day.
I think we still have challenges with respect to harmonization, and we believe that the scope of practice should be harmonized across the country, and that every patient should be able to access the same care from their pharmacist, whether they live in Newfoundland or British Columbia.
The second question you asked us was around utilization of virtual platforms. I think that has been a really interesting and growing discussion. We know that physician and nursing colleagues have been using virtual platforms in various ways, and have a sort of hybrid now in terms of the care they provide to patients.
Pharmacists in provinces where they are able to prescribe — for example, the province of Nova Scotia — immediately with the pandemic they were able to deliver those services virtually, which I think was very helpful. Virtual care has taken off in some of those areas.
In other areas, there are some services, like medication assessments, that are starting to be delivered virtually. As with others, privacy concerns and making sure the patient provides consent, and is looking for the right platform, is still kind of a growing area, but there are platforms out there that provide that.
So while pharmacies remain open and accessible, I think it’s also important for patients and the public to know they can also get, whether it’s counselling needs or prescribing or medication assessment, there is an opportunity to do so virtually.
Senator Seidman: Thank you. Sorry to interrupt you, but I hope I have a few seconds for Mr. Poirier to respond as well.
The Chair: We will take a minute for a response from Mr. Poirier.
Mr. Poirier: Thank you for the question, and 2010 was an important year in terms of the recognition of the contribution paramedics can make to health care. At that time, there was a real shift in the evolution of paramedic care. When I grew up as a paramedic several years ago, it was all about the neurovascular, the respiratory and the cardiovascular, and it was all about urgent care.
In the mid-2000s, there was a significant change to recognize health promotion and the prevention of disease. The competency profile for paramedics evolved to start to include the social determinants of health and a comprehensive understanding of everything from pediatric care to geriatric care.
You saw in 2010 and thereabouts, with H1N1, paramedics starting to give immunizations. Following that, the evolution of the community paramedic is now kind of across the country, where it’s not about urgent care, it’s about health promotion and disease prevention, such as providing foot care for diabetics, providing information on slips, trips and falls, and going into the homes and actually doing house calls. You see that very much, even today in Renfrew County, just outside of Ottawa here, where they have a significant program where they’re taking care of the community as a whole.
It is a fantastic evolution, even to the point of remote patient monitoring, where you have paramedics engaged, where individuals or patients at home may take their vitals daily and they’re recorded in a central location. Based on those vital signs, it may trigger whether or not a paramedic goes to see them. That is the evolution of health care that is evolving. I don’t think it’s fast enough, but we are getting there.
The last point you make, which I think is significant — as much as we’re doing this in different locations across the country, it doesn’t have a coordinated approach. Part of that is due to, I think, your last statement with respect to paramedics being included as part of a health care practitioner, for us to be included in the decision tables. That’s what we’re struggling with, admittedly, but we continue to work with that. These presentations and your support absolutely help us, inch by inch, move forward to provide better care across the country.
In many respects, going back to 2010 and even today, we continue to believe — not that we’re not busy — we continue to be an untapped resource to provide that continuum of care.
[Translation]
Senator Forest-Niesing: As I did for the panel of witnesses we heard from earlier this morning, I want to sincerely thank the witnesses we are hearing from now, not only for today’s testimony, but also for the front-line work they are doing for all Canadians. We are counting on you, and we are very happy that you have risen to the occasion.
My first question is for the Paramedic Association of Canada, and it concerns data reliability. I would like to better understand the policy implemented when a team of paramedics is called to the bedside of someone who potentially has COVID-19.
Are patients tested for the virus if their symptoms are similar to those attributable to it? If someone dies, what measures are taken to ensure that the cause of death is correctly attributed to the virus? Are there many cases where the stated cause of death remains pneumonia, breathing difficulties, cardiac arrest, without the paramedics checking whether there is a link to the virus?
Mr. Poirier: Thank you for your question. When it comes to the way paramedics behave with patients, they never know whether someone has the virus. That is why, if someone has a cough, does not feel well or is having breathing difficulties, appropriate individual protection equipment should be used, such as the N95 mask or something similar. That is always an element paramedics must take into consideration when they go to a home, and they must be able to adapt their behaviour, as they don’t really know what the patient’s condition is.
Concerning potential death, we, the paramedics, have since recently been able to know whether the patient or the individual who died had COVID-19. Paramedics across the country have had access to that information for about four to six weeks. I think that, even though that information is private, it is important for paramedics to know whether the patient has COVID-19.
Can you repeat your last question?
Senator Forest-Niesing: I wanted to know whether the cause of death could sometimes be wrongly attributed to pneumonia or to another cause, without it being possible to ensure that it was not related to COVID-19.
Mr. Poirier: I don’t think we know the answer to that question. There were many deaths related to cardiac and respiratory issues that paramedics were talking about amongst themselves, and they were thinking the deaths were perhaps related to COVID-19. That was in January and February. More recently, testing for COVID-19 has occurred more frequently. We are confident about knowing the cause of death.
It is very important for paramedics to have information on the death of a patient with COVID-19, and we have had access to that information over the past four to six weeks.
Senator Forest-Niesing: Do I have a bit of time left?
The Chair: You have about 45 seconds, and I would ask that you not exceed that.
Senator Forest-Niesing: I will continue in the same vein, but I will now talk about data consistency.
When we look at websites that provide information on the number of deaths across the country, and especially when we look at major cities, we see a fairly worrisome discrepancy in terms of the number of deaths. For example, in the city of Montreal, which has a lower population than the city of Toronto, the rate of death is three times higher than that in Toronto.
Do directives on recording or documenting the causes of death vary from one province to another? This is somewhat related to the point I raised in my first question. Could this be one of the explanations for that discrepancy?
Mr. Poirier: I don’t think that is the reason for the discrepancy between Toronto and Montreal. I think all that rather has to do with the fact that spring break was in early March for Quebec residents and one week later for Ontario residents. That is one of the reasons that could explain that difference.
Another reason for that discrepancy could have to do with retirement homes and the way they operate. It is not that they operate much better in Ontario, but perhaps, when it comes to information, data and ways to manage patients or residents in retirement homes, the two provinces do not operate in the same way.
The Chair: Thank you for your answer. Thank you, Senator Forest-Niesing. We are continuing with Senator Omidvar.
[English]
Senator Omidvar: Thank you to all our witnesses for being with us and for doing everything you do to keep us safe. My question is for Mr. Poirier and Dr. Tromp. Both of you said in your remarks today, and we’ve heard from earlier witnesses as well, the desire to have a new look at the federal role in the health care paradigm. This is, of course, difficult because health care and the provision of health care services is provincial; it’s choppy waters. I’m forgetting if it was you, Dr. Tromp, but we did hear today about the need for a national health care human resources plan. I think you talked about securing the supply and distribution of PPE.
Mr. Poirier, you wanted to open up the Canada Health Act. I wonder if you can tell me: What should the government do now to ensure these recommendations for a more articulated federal role, in order to ensure that we are ready for the next pandemic without any of these differences in power and jurisdiction getting in the way of health care protection for Canadians?
Mr. Poirier: I’ll start and I’ll be brief. The easier one is for the federal government to manage the NESS, the National Emergency Strategic Stockpile, well. It isn’t just about gurneys and bandages. It is also about pharmaceuticals and personal protective equipment. So I think there really is an important role for the federal government on the NESS file. Part of that would be to ensure that the Public Health Agency of Canada is speaking with Public Safety Canada, so that we do understand what our vulnerabilities and risks are, and that we can adjust the stockpile to meet the needs within an all-hazards approach. I think that’s the easy one to do, if anything is easy in government.
The second item would be that I think it’s time for us to have that dialogue. Sometimes in a disaster, opportunity presents. It really is a significant event — the number of people in long-term care and retirement facilities that have passed away. I think it is time for us to take a national look at the Canada Health Act and how we can really serve our older generation much better. We deserve to start that discussion. Thanks for that.
Dr. Tromp: I’ll make a comment about an issue that comes in the Society of Rural Physicians a lot. We find that doctors who especially work in northern areas of every province and other health care workers have much more similarity in their needs with other doctors who work in the North than with their colleagues in the South. So health is delivered on a provincial basis.
The doctors in northern Ontario are working with the doctors in southern Ontario, but the doctors in northern Ontario have much more in common with the doctors in northern Manitoba and northern Saskatchewan, because they’re training and what they need to learn is much more. So we talk a lot about this in the Society of Rural Physicians.
I’m not a parliamentarian. I don’t really know the Canada Health Act and how it affects the Constitution, but I think there are things like the stockpile, which is very important. It seems to me that if there were things that were out of date three years ago and were not replaced, you have to not let it get into your subconscious. As people were saying before, if you forget to change your oil or replace the battery in your smoke detector, you have to have a way of reviewing that regularly.
We don’t have all the answers, but this is a good opportunity to look at what the problems were and see how we can help with the issues that have now been identified, not having the answers yet.
For rural doctors, there are many rural areas that are in isolated areas of one province but close to a tertiary care centre in another province. For example, people in southeastern British Columbia are a couple of hours’ drive to Calgary, but if they have a sick pediatric patient, they have to send the patient to Vancouver, which is an airplane ride, or a 16-hour drive when the parents have to drive the child home. Is there some way we could coordinate some of these things, especially the provincial barriers, to help with that?
What we have more of is lots of questions for discussion and sorting out. I don’t think we have the answers yet, but these are some of the things that we have to start discussing.
Senator Omidvar: Thank you. All of you represent major stakeholder groups in the health care professions: the pharmacists, paramedics and rural physicians. We heard this morning from the CMA and the Canadian Nurses Association. Are you putting your minds and best ideas together to make recommendations, not individually as associations but collectively as a group of significant stakeholders, to help the government understand what the priorities are and what they should be doing, or are you just working in your own silos?
Dr. Tromp: No. There is an organization called the Canadian Medical Forum. It is sort of physician-based, so I will apologize for that. As an example, the CMA, our society, the College of Family Physicians, the Royal College, the educational bodies sit together on that. I believe there are 11 organizations that work together, and we try to come up with recommendations.
We did put out two statements since the start of COVID. The first was a recommendation about access to PPE, which is very important. The second one was a recommendation in support of our resident learners, that they be recognized, and if there were any financial incentives and hazard pay, that it be given to the resident learners as well, as they are the very front line in these health situations.
Obviously, we have to work together even more, and we have to be more multidisciplinary in our approach, but the Canadian Medical Forum is one group that is actively working together right now on some of these issues.
Senator Omidvar: Could we get a copy of those two recommendations for our committee?
Dr. Tromp: You certainly can.
Senator Omidvar: Thank you.
The Chair: Thank you. That would be appreciated.
Dr. Dattani: May I add to that very briefly? There are other interdisciplinary forums we participate in nationally. As I mentioned earlier, the Public Health Agency of Canada’s chief public officer has a health care professional association forum. We have talked about many issues that are provider agnostic, including virtual care, PPE and others that people have mentioned. We have done joint statements and looked at responsible prescribing and dispensing together, in the context of drug shortages and other issues, so those forums have been working quite well in terms of collaborating on an interdisciplinary level.
The Chair: Thank you for those answers, and thank you for the question. Every member of Social Affairs and senators, for years, every time we have committees on health issues, the silo challenges are always apparent, even more so in times like these. Thank you for putting this on the record.
Senator Kutcher: Thank you to the witnesses. We appreciate you taking the time to help us through this.
I have two questions to the pharmacists. First, we are all aware of the presence of legitimate online pharmacies and the role they play, but we have seen during this COVID time a plethora of irregular, fraudulent, online pharmacies. They are selling all sorts of products that could be harmful to the health of Canadians. What role have your organizations played in trying to address this, and what role has the federal government played, and do you think it has been sufficient?
Dr. Dattani: I can start by taking that. We — not me specifically but my colleagues — have been involved in some organizations that have been looking at the safety and concerns with online pharmacies, and ensuring that Canadians receive safe and legitimate health care, health care delivery and prescriptions. We have been actively involved with that. We have been involved with our U.S. counterparts in engaging in discussions about that as well.
Senator Kutcher: Has that been successful in terms of dealing with these online? I’ve heard somewhere that approximately 28,000 have been shut down over the course of the COVID pandemic, but they keep coming. It’s like whack-a-mole. Is enough being done?
Dr. Dattani: We’ve engaged in quite a bit of this. It’s hard to say whether we successfully shut them all down, but there is a voice and a presence, and it’s something we continue to watch.
Senator Kutcher: Thank you. My second question goes back to the vaccines issue. I am pleased to hear you’re preparing for the flu season, but I have a concern that is slightly different than being prepared, although it’s essential that we are.
In many provinces, less than 30% of the population gets vaccinated for the flu. It’s sad to say, but in many health organizations such as hospitals, fewer than 70%, sometimes 50% of the health care providers, get vaccinated. What work is being done and should be done to improve vaccination rates, at least of health care providers?
Dr. Dattani: I agree with you. The population that gets vaccinated most are the seniors, which we want them to do because they are vulnerable to the complications and risks of influenza, but there is a significant proportion of the population that doesn’t get vaccinated for lots of different reasons.
Vaccine hesitancy is something that is on a spectrum. I know that pharmacists have made a significant contribution, and need to continue to do so in their role as immunizers. It’s not just about the technical aspect of providing the vaccine. It’s having the time to spend with patients in their communities, to educate, coach and understand those reasons for vaccine hesitancy. Often it is the health care workers who are, in some circumstances, even more reticent. I think utilizing pharmacists, as well as other providers, to have those conversations and understand why there is vaccine hesitancy, and help coach people towards better preventive care is an important role to invest in, outside of just delivering the vaccine itself. As many health care providers as we can get to engage in those conversations with our communities and the public, the better off we’ll be as a society.
Mr. Poirier: In the paramedic community in Ontario, it is legislatively mandated, so the compliance number is in the mid-90s. The only exceptions are those who can demonstrate an allergy or possibly a religious reason. The number for paramedics is quite high and has been for several years.
Dr. Tromp: Likewise for physicians. If you have hospital privileges you are not required, but if you are not vaccinated and there’s an influenza outbreak, you are not allowed to work.
Senator Kutcher: Can I make an observation?
I have been listening to people talking about the importance of having information, that when there is personal protective equipment that’s outdated, someone acts on it. I wanted to observe that my car tells me when it needs an oil change.
The Chair: Good point.
Senator Munson: Thanks very much for being here this afternoon. This has been revealing testimony all day long. We’re hearing hope, and yet we have a lot of questions of worry of a second wave.
There was a tremendous sigh of relief in this country yesterday when it was announced on both sides of the border that it would remain closed until June 21. That is a really big deal, because talk about having clusters and having people moving. Dr. Tromp, you talked about trying to find a balance. I’m still trying to figure out where that balance is locally. You talk about Picton for example, how the beaches will be packed with people. We’ve seen pictures recently of not-so-social distancing and yet, if you own a cottage and you’re a taxpayer, you can go to your cottage and you can self-isolate. What’s the point of going if you will be in your home for two weeks looking at maybe not a virtual body of water, but a real body of water?
I’m trying to figure out, where is that balance? I live in Ontario. I do want to go to our cottage in northern New Brunswick, but I’m willing to bite the bullet and pay the price that we should pay, which is a good price, which is about saving lives. If the others want to get involved in this — I don’t know where the balance is unless we have discipline.
Dr. Tromp: We can’t put the balance at a specific location because so much of this is based on personal and community values, and personal and community values are not clear cut right or wrong. There are many shades of grey.
If we go back to the vaccination question that people talked about, some people make a conscious decision not to vaccinate because they don’t want to over medicalize their life. There’s a certain value system in our life in Canada that not everyone necessarily agrees with, that the more medical care you get the better, the more you medicalize your life the better, and the longer you live the better, and you must put everything towards these aims. But not everyone has that value system.
My family has a cottage on the Ottawa River. We go there and we go canoeing. We have not gone there this year. But we could go there. We go out on the river. We can swim. That’s basically what we do when we go there. We don’t go to cafés and whatever. We go to the cottage to go outdoors when we’re there. There are a lot of people who go to their cottage to enjoy the outdoors more so than to mingle with other human beings.
The difference with something like a pandemic is that obviously your decisions affect the people around you, so it’s different than saying, do I want to take my blood pressure pill or not, because if you don’t take your pill, that’s your decision, and you’re the only one directly affected.
If you go to your cottage, maybe other people can be affected. So we must have community discussion about these things. There is a big line of various shades of grey, and we have to decide along that line where we want to be. If we decide no cottages ever, then as a community we can decide that. But I don’t think that’s the only reasonable decision that could be made. There are other reasonable decisions that could also be made.
Senator Munson: Thank you very much for that.
Dr. Power, we have not had too many questions to you. Those of us who may take a pill from time to time just take it for granted. Where does it come from? Who is responsible for it? Is there a procurement program? Are these blood pressure pills — or you name it — there was talk of a shortage and there was a worry, especially at the beginning of all this, when people weren’t just hoarding toilet paper, but were going and getting prescriptions pushed ahead because they were worried about a shortage. How does that whole process work, that we as Canadians take for granted? How do we know the efficacy, and the idea that would be good for us, and it is being done properly? Who is involved in that? It’s a mystery to me.
Dr. Power: It’s a mystery to a lot of people.
The supply chain in Canada is fairly complex. Between 50% to 80% of medications are either produced in China or India, or have an active ingredient or a significant ingredient that comes from China or India. Part of the concern with COVID-19 is that, with the shut down in China in January and then the subsequent shut down in India, we didn’t have a good sense of what the shipments of medications into Canada were like.
We know that in the first couple of weeks in March, the number of prescription medications being filled doubled. So in a system where we already have a lot of fragility and there are frequent drug shortages, having the supply chain disrupted by increased demand was a problem.
There is a series of steps. Manufacturers develop their medications. They’re brought into the country if they’re not produced here. They are then sold from the manufacturer to a wholesaler and then to a pharmacy. There are a number of steps along the way. Pretty much everyone has put some type of rationing in place along the supply chain at this point.
We do feel it has been stabilized. Pharmacists have reported that blood pressure medications are one they are having trouble getting. But they are still able to get it, and we have been able to see that very few people have gone without their medications for the vast majority of medications out there.
In terms of the supply chain and the consumer, as with many consumer goods, most people just know they go to the pharmacy and it’s there for them. That’s the system we want to get back.
We need to look at some of the problems that exist with the globalization of the supply chain. There is a hard-working group at Health Canada working on drug shortages. We’re on a committee with them. That’s part of the problem that needs to be addressed.
Then with the national stockpiles, we need to make sure there is an ebb and flow, in and out, so that the medications come in. They’re not expired, but they can be used in other parts of the health system.
The Chair: Thank you for those questions.
[Translation]
Senator Mégie: My question was just asked by the senator who spoke before me. However, one minor aspect was missing. Are we mainly talking about commonly used drugs, such as blood pressure or diabetes medication people pick up at the pharmacy? Was there a fear of running out of specific types of medications? Finally, what lesson should be learned from this going forward?
[English]
Dr. Power: Thank you for the question. In March, people were filling all their medications, but there was particular focus on medications for breathing difficulties. Salbutamol, which I mentioned earlier, or Ventolin is the brand name; people were trying to get large quantities of it because people in Canada knew it was a respiratory virus and shortness of breath was one of the common symptoms. That was one in particular focus.
There were other ones where we know there was a lot of demand but no resulting shortages. People with diabetes were trying to get large quantities of insulin and other diabetes medications, and people with pretty much all chronic medication, so cholesterol, heart disease, high blood pressure, pretty much everything. So it wasn’t really a targeted demand, it was just system wide.
Senator R. Black: This question could go to the three speakers, and thinking about rural, remote and northern communities, in your view what measures need to be taken to help build human capacity within these areas to respond to this pandemic and future outbreaks?
My second question would be around the idea of agricultural producers or farmers. Are you seeing different numbers with respect to farmers coming in, being impacted by the pandemic or in need of your services?
Dr. Tromp: I will answer the second one first because there are farmers in my community.
I have not seen — [Technical difficulties] — for any particular services beyond any other group. I would say on average our requests for services have gone down and it has been pretty well across the board. I’m seeing my patients mostly on the phone, and I am seeing one third to one half the number of patients per day as I would normally see. Some weeks are busier, some not, but I would say on average it’s in that range and I have not noticed a difference in the farm population.
When you ask how we respond to this pandemic, what is the care we need — the challenge is we need something that is flexible. For example, I was talking to Dr. James Irvine, who is the medical officer of health in the area of La Loche, Saskatchewan, and I asked him about having all these people with COVID and what he needed. He said it wasn’t doctors and nurses they needed. They needed public health people, they needed people to do the contact tracing and to phone everyone. He said they had lots of public health people in La Loche, and then our regional office is in La Ronge, and they had to get lots of people in there and get lots of people in Saskatoon working for them.
When it hits, what you will need is so variable from community to community that you need to have a very flexible system in some way, and that’s what makes it particularly challenging. Where I live, we’ve had no increased medical needs because we have not had an outbreak, and there are a lot of people who partially laid off their staff because their offices are less busy, and so we don’t need front-line workers in our community, but there are other communities who do, and for some people it’s not front-line workers. It might be another — [Technical difficulties] — health professional. They might need pharmacists in some areas, or paramedics or nurses. As you go into the northern communities, as you’re probably aware, a lot of the northern Indigenous communities are staffed by nurses in nursing stations. That might be a need in certain communities too. If you get an outbreak in one of these communities, you will need a lot of extra nurses to help you out.
The needs are unpredictable, and to be nimble enough to fill those needs as they come up is the real challenge.
Dr. Dattani: I will add to what Dr. Tromp said. She made a good point about the need to be nimble. In most rural and remote communities across Canada, there is a pharmacy that often — and I heard someone say it this morning — is the only pharmacy, and sometimes it almost functions like an emergency department in their community. They do as much for their patients as they can.
Enablers to that capacity could be things like expanding the scope of practice. We have examples from previous pandemics, like the wildfires in Alberta where pharmacists were prescribing medications for people and delivering them, and managing for two or three weeks because they had the ability and the flexibility with expanded scope, and because they had access by being in those communities.
There are similar examples from the snowstorm earlier this year in Newfoundland, where things shut down and pharmacists were enabled through their access, and also through some scope expansions, to be able to quickly build capacity and serve patients, particularly in remote areas.
The idea of being nimble and also the idea of preparedness planning and building capacity, and learning from this and other pandemics, to be able to prepare for either the next phase or the next pandemic, is something we need to think about now in terms of leveraging the value that each of the health care providers can offer to patients in these communities.
Mr. Poirier: I will offer a comment on that one. Thank you for the question, senator.
Probably about four years ago we started working with the Minister of Health, and then the Minister of Indigenous Services, with respect to the idea that the Indigenous communities and their health is the responsibility of the federal government. Our challenge has been to get paramedics into rural and remote Indigenous communities, and that has been a long-term piece of work. Currently, we have an individual working with the First Nations and Inuit Health Branch here in Ottawa, and we’ve been laying all the groundwork and we’re in negotiation with NAN, the Indigenous group in northwestern Ontario, to bring paramedics into those communities.
That’s an example of how we’re trying to extend the value of paramedics to the federal government, and working through the details to ensure paramedics can support, and not take over what the nurses do in the nursing stage, but actually bring value to those communities. That’s why it has been so important that we’ve been working with FNIHB and with the NAN group.
Senator R. Black: I will say thanks to Dr. Tromp for her very first line: “Once you’ve seen one rural community, you’ve seen one rural community,” and I fully agree. Thank you very much.
The Chair: I do have a question that has been on my mind, Mr. Poirier, ever since you first spoke, so I want to ask you this question. In this study, we are really conscious of the different jurisdictions and decisions that are provincial, and we are studying this government response to a pandemic that covers all Canada. Earlier, you said in some provinces, calling the paramedics might come at a high cost and some individuals may choose not do it because they can’t. That strongly resonated with me because of the consequences we know it can have.
This government, in its response to COVID-19, has strongly committed to connect with the provinces and to help, even in the jurisdictions that are provincial. I’m trying to get a sense if your organization, and maybe Dr. Tromp, feel that this connection and this help is happening, and maybe give us some examples that this response to the provinces is actually felt by your different organizations.
Mr. Poirier: It is an excellent question. There is data already out of New York City where the number of cardiac arrests have gone up as a consequence of people not paying attention to chest pain, and we’re starting to see that anecdotally across the country in larger urban municipalities, where people are choosing not to, for fear of COVID-19 at the hospital, which is a very strange thought, but is something within society at present. I believe there is a real concern about that. The other piece I mentioned earlier was about the cost across the country.
It has always had this nuanced impact on people. In Ontario, an individual through the health insurance may pay no more than $50 for the paramedics to provide service, whereas in Alberta, Saskatchewan and New Brunswick you can be paying hundreds of dollars, depending on how far you’ve been transported. I recognize it’s a provincial responsibility, but it is one of those inequities in health care that I think is inappropriate.
Dr. Tromp: I don’t work in Prince Edward Island, but I’ve been told that the drug plan for Prince Edward Island is really quite minimal. In Ontario, once you’re above 65, you get the majority of your prescriptions paid for, but a colleague told me that is not the case in Prince Edward Island. This particular worker, I believe she was a nurse, said she spent the majority of her days trying to figure out how to get people’s medication paid for. Dr. Dattani probably knows this more than I, whether that’s true.
So there are these wide disparities. How do we find the balance between having provincial responsibility but having some consistency from province to province? Again, I guess that is a constitutional challenge how we figure that out.
The Society of Rural Physicians has been working with the licensing bodies about the possibility of having portable licences, so that if I’m licensed in Ontario and there is a great need for physicians in La Loche, Saskatchewan, which there is not right now, that I could go and help there. But I don’t have a Saskatchewan licence. All the licences are provincial.
I want to say something about Indigenous Services Canada because we have worked with them and I think people feel generally quite positive. Tom Wong seems to be doing a great job. He has been making surge plans for Indigenous communities. If they get a big outbreak, he has lists of people across the country who have volunteered to help out. He’s done that through the various disciplines. I’ve been working primarily for physicians, but I know he also has people of other disciplines who have volunteered for that. At this point he has to get them from the same province. He can’t take someone from Ontario to work in Saskatchewan. That is also a bit of a challenge.
Some of the licensing bodies are making it easier during the pandemic to move across. For example, the Northwest Territories lightened things up, but they only made it for Alberta physicians. I had a colleague from B.C. who wanted to go to the Northwest Territories. He couldn’t because he was from B.C. and not from Alberta.
I want to say very briefly that I am very supportive of multidisciplinary care and what everyone can contribute. One of the challenges I find is the communication. I’m very supportive that a pharmacist can see my patient and do things, but I don’t necessarily get a communication of what was done. So then I see the patient the next time and I’m trying to figure it out.
As we get this multidisciplinary care going, which is great, we have to work on how we communicate among ourselves, so we all understand what the other person is doing. That’s a big challenge.
Dr. Dattani: I was going to say I agree. We need our electronic health records to help us with that. But communication and documentation are important for all of us.
Senator Pate: Thank you to all of you for all your work and your presentations. I have two questions. One may be a simple answer, but the first one may not.
You’ve all talked about variations. Many of us have experienced that in terms of, not just during this pandemic, but if someone moves from province to province. A number of gaps in services have shown up during this pandemic. Is there anywhere a good description of what is covered from province to province, in a compilation that would be easy for senators to look at as a group? If there isn’t, that’s obviously a need-to-have.
My second question is one of the things that Minister Hajdu said — and I believe I quoted her last week or the week before — about the fact that in this crisis many have come together and created important vital health care guidelines, and has speculated that perhaps we need to be looking at those as national standards moving forward.
Is that a sentiment that each of you would share?
Dr. Tromp: I would say that we have to be a titch careful about the use of a guideline versus a standard because there’s always a judgment. The standard or the guideline might say that everybody has to have their blood pressure below 140 over 90, but you have this patient in front of you who has these issues — maybe poverty, maybe just has other priorities in their life or whatever — so we have to leave open personal choice and values. When you call it a national standard, I’m not sure what “standard” means. These things have to be adjustable for the community.
In rural communities, what might be considered the standard or the guideline for a large urban centre will not apply. There is a health professional called a respiratory technician or technologist, an RT, who runs the ventilators and helps with intubation and sets all that up. There is virtually no rural community in Canada that has an RT working in their hospital.
If you have a guideline about how to intubate, and this is what the doctor and the RT and the nurse does, it obviously has to be adjusted for rural communities who don’t have RTs. That’s just an example.
We have to be really careful about our wording. Guidelines or standards or whatever word we’re going to be using have to be adaptable to the needs of the local community and the workforce of the local community. As we’ve talked about multidisciplinary care, in certain communities you might say: I’ve got this person to help me, they’re such-and-such professional and they would be great to help me out and I’m going to get them to help me. In another place it might not be so appropriate.
How do we do standards and still leave the appropriate adaptability?
Dr. Dattani: If I can add to Dr. Tromp’s point. I agree with many of the points she mentioned. We have to be careful, particularly in the area of this pandemic, using words like “standards” and “guidelines.” In fact, we’re really in a situation where we have a virus we have never seen before and everything is very fluid in terms of how we practise. I think it’s a bit more in terms of expert consensus, and taking an interdisciplinary approach to expert consensus.
For example, we’ve developed what we feel are best practice, expert consensus papers for the use of PPE in community pharmacies, because if we had waited for public health guidance nationally — we’re still waiting for those specifics. We have to use what we think is best and take some of the experts out there, including physicians and nurses and others that work in this way, and come up with some expert consensus and be ready for living documents that are continuing to be fluid, and accept that they will adapt and change because we are in an unprecedented time.
I think that also applies with working interdisciplinarily to leverage other scopes of practice even though there might not be a randomized control trial saying I have impacted patient mortality with respect to opioid use disorder. To your point, Dr. Tromp, the need is to be nimble and work together as a health care provider community, where we feel there can be help from many health care providers. So on a practice level and more on an expert consensus level.
The Chair: Thank you very much for these questions. We do have time for a next round of questions. You will notice that Mr. Poirier had to leave us, but our other witnesses are with us and staying for the next 20 minutes, until we conclude this meeting.
In this next round of questions, I would ask my colleagues to focus on one question and one answer by one witness. In this way, we can maximize our chances to have everybody asking their question.
Senator Poirier: My question was for Mr. Poirier, and he has just left. So I will leave it at that, but thank you, Madam Chair.
[Translation]
The Chair: Thank you very much. If you want to send your question in writing, we will make sure to get an answer and share it.
[English]
Senator Forest-Niesing: My question is addressed to the Canadian Pharmacists Association, Dr. Dattani and perhaps Dr. Power.
Researchers around the world are working hard to find a vaccine. That, of course, is part of the response of governments around the world. Once the vaccine has been discovered and becomes available, the global demand will be exponential, and I’m concerned about how prepared Canada is for the vaccine. Once it becomes available, how can we ensure it’s going to be made available everywhere, in sufficient quantity and rapidly?
Perhaps, as a secondary point, what’s the role of the pharmacists in relation to the availability?
Dr. Dattani: Sure. I can start. With respect to availability of a vaccine coming rapidly to fruition, we don’t have direct involvement. But, certainly indirectly, as you’re probably aware, there are rapid-fire clinical trials going on across the world. There is international funding happening. A large study is happening now in our own country at Dalhousie University, in phase one and phase two clinical trials. That’s exciting that we are also seeing some national drug development here within our own country. I think that provides us with some hope that we will not be waiting 18 months, hopefully, for a vaccine, but that some time next year we will see one. The science is moving very quickly on that, as I’m sure you know.
I agree with you that there will be a demand for this. I think there will be a change in looking at all immunizations. Based on the precedents of influenza with respect to the role of pharmacists, as I previously described, pharmacists really were able to change the way Canadians access their preventive care through vaccinating 30% of all people who got flu vaccines. Again, with the accessibility and the convenience and the ability to go to a pharmacy seven days a week, I don’t see the COVID vaccine as being any different.
It’s important to recognize — as we talked about earlier with respect to one of the senator’s comments about vaccine hesitancy — as important as it is to administer the vaccine, the education and the public health role that pharmacists can play in that role should not be under-represented either. Particularly with their accessibility and their long-term relationships with patients, they will have a big role to play there also.
Senator Omidvar: My question was for Mr. Poirier, but I will shift it to Dr. Dattani and Dr. Power. I hope they have a response.
The question is about the virus and race. We know from other jurisdictions that the virus is not blind to race. In the U.S., we know that the Black community has been severely impacted. We don’t collect this data in Canada.
My question to you is, anecdotally — because your members face the customers, Dr. Power and Dr. Dattani — can you confirm whether this phenomenon has been observed? And if we did collect data, how would it help your members?
Dr. Dattani: That’s a very good question. You’re right, it’s difficult to speculate without data. So we don’t have the data in Canada in terms of how demographics, racial determinants, social determinants of health affect the impacts of this virus. But, as you say, it doesn’t appear to be blind to race. We know the information from the U.S. is suggesting that the African-American community doesn’t do as well.
I would not say this from my personal practice but just from my anecdotal discussions with colleagues across the globe. I have seen and heard from pharmacist colleagues in countries like Italy and the U.K. We’ve seen a tremendous impact on Italian communities, even on my own South Asian community in the U.K. You could speculate that some of that could be due to the intergenerational families commonly living together, and the challenges that may be associated with that. But, again, for me that would just be speculation. There have also been health care providers that have been affected. It’s difficult to know, unless you have that data, what some of the racial or genotypic differences might be.
Senator Omidvar: If we had this data, would it help your members across the country?
Dr. Dattani: I think it could help with a sense of understanding how to educate patients. There are even different ways that people metabolize drugs based on genotype, and phenotype differences based on race. It could help in some of those aspects as well. Unfortunately, we don’t have the information.
Senator Omidvar: Do I have time for a second question, Senator Petitclerc?
The Chair: I will put you on a third round if you’re fine with that.
Senator Dasko: I had a number of questions, but my colleagues have asked most of them. I do have one question for Dr. Tromp. I know we’ve talked about this cottage thing back and forth, but I just want to attack it one more time, if you don’t mind.
I am a Torontonian. I have several friends who left for their country houses or cottages the moment this crisis hit. The premier here in Ontario said to us, “You shouldn’t go to the cottage because rural hospitals would be overcome with people going there.”
From what you’ve said so far, I would conclude that possibly not even one rural hospital has been overcome with these kinds of cases. I know you spoke about your own personal experience in your hospital. Have any hospitals in Ontario been overcome? I’m looking for evidence here.
Dr. Tromp: Yes. I think we’ve done quite well. I’m not aware of any hospitals in Ontario that have been overcome.
Maybe La Loche is feeling a little bit overcome, in Saskatchewan. I don’t know. We know that there are specific areas that had great outcomes in the long-term care, like Bobcaygeon and Hagersville. I haven’t heard specifically from those that are hospitals. With long-term care, a lot of those patients choose not to go to the hospital because of their level of care. I have not heard that those have been overcome.
The difficulty in a pandemic is that we don’t know. Who said the trouble with the future is it’s so darn hard to predict? We don’t know for sure what’s going to happen. It’s always fine in the balance, but as someone said, if we do a really good job and there’s no major outbreak, everyone will say we overdid it — we put in far too many measures. If we don’t do enough and we get an outbreak, then we’ll say we underdid it. Again, it’s a value judgment. I do this a lot with patients. Do you want to take this medication just in case it might help you prevent a heart attack, but the chance it’s going to help is 1 out of 100? We’re making similar decisions now on a societal level and we have to have the society as a whole involved in these decisions. So do we want to shut down the cottages because there’s a chance that if we let the tourists come, there will be an outbreak?
The difference between this situation and telling people about their blood pressure pills is that I actually have some evidence, and it’s a bit based on studies, so I can probably say the chance it will help you is 1 out of 100 or 3 out of 100 or something like that. I do not have a number that I can give society as a whole of what the chance is that people coming to the cottages are going to cause an outbreak.
Senator Dasko: I appreciate that. I think you’ve answered my question. By the way, I always felt that these friends of mine who ran off to their cottages, the moment they would have gotten sick, they would have headed right back to Toronto as fast as they could to see their personal physician. So I had a sense that it could never happen. Anyway, you are the professional, so thank you.
Senator Munson: It’s getting towards the end of this conversation, Dr. Tromp. When you first spoke to us about two hours ago, you were quite emotional, and you’re very emotional about rural medicine. You have an opportunity now to tell the government what they must do in terms of rural medicine. We heard about telemedicine and the whole idea and what’s lacking in rural Canada, that people in rural Canada don’t have the same access. There’s been talk for years and years about broadband and making sure Canada is connected. In terms of communications, we feel that we are connected, but we’re not.
So what do you have to say to the federal government at this moment to connect rural Canada, to spend some money and to get it done? For the life of me, I don’t know what the holdup is.
Dr. Tromp: What is the holdup? Yes. I think rural Canada includes, as we say, many different communities. I will be honest. I think there’s a little bit of, like with the northern, isolated, Indigenous communities, I am concerned that there is a little bit of judgment going on there. I believe, and I think this is true, that one of the reasons we have northern, isolated Indigenous communities — if we say this is our territory, we have to claim our territory by having people live on it. I believe that’s why they put a whole bunch of people in Grise Fjord where there’s nothing to do. They moved Indigenous people from northern Quebec to Grise Fjord because they want to have people living on the land to claim the territory from the Russians. If it is important to have people there, we have to provide them with the services. If we need the farmers to grow our food, we have to provide them with the services.
At the same time, I will say on behalf of my rural medical communities, if you have a well-functioning rural community, you are probably getting better service than you would get in a lot of urban centres. It’s a bit variable, but you get some communities that work very cohesively together. They have a great group of health care workers of various disciplines who work great together. I honestly believe that in many rural communities you are getting better care. But there are also some rural communities where there are no family doctors, there are very few nurses, there are no health care workers. So the variability is much greater in rural communities. I think we have to recognize and applaud the communities that are doing a great job, and we have to learn from them and say, how can we take those things and bring them to the communities that are struggling?
I think broadband is important. I’m not presently working in the very North, but I’m in the process of moving up to Moose Factory. I did spend a few weeks there last year and the internet was fine. We have our EMR going from the hospital to all the peripheral communities, and it works pretty well. We didn’t have the internet going down. We didn’t have the EMR going down. That doesn’t mean all the communities are like that.
I think, again, we have to celebrate the communities that are doing well and we have to help the ones that are struggling, and internet is one thing. I don’t think it’s the most important thing. I’ve always said the most important virtual care tool that I have is the good old telephone, invented in 19 whatever it was. The fact that you can get on the phone and talk to a specialist in a big city or talk to a patient is your most important virtual care tool. And internet is better, but —
The Chair: Thank you, Dr. Tromp.
Senator Kutcher: For pharmacy: We’ve had welcome changes in widening of the scope of practice for many health professionals, health providers, including pharmacists, and this is focusing on mental health scope of practice from pharmacists. Has there been any effort during this time of COVID to enhance the uptake of evidence-based mental health interventions specifically developed for pharmacists, such as the Bloom Program created by Drs. David Gardner and Andrea Murphy?
Dr. Dattani: I remember you’re from Nova Scotia so you know about the Bloom Program. It’s fantastic. Just to clarify, Dr. Kutcher, mental health for patients, correct?
Senator Kutcher: Yes. It’s the scope of practice of pharmacists.
Dr. Dattani: That’s right. Pharmacists, now even within their current scope of practice — and you know this through your knowledge of the Bloom Program and through the relationships that they have with their patients, because they see them seven to eight more times for chronic conditions, more than they often see their family physician — they have the ability through their current scope of practice to provide some of the care that is described in the Bloom Program. It is an area that I think pharmacists can provide tremendous capacity in. It’s like other areas right now. I think Dr. Tromp spoke of this earlier. It’s probably not getting the current attention that it needs because of all the acute crises, but I believe like of all the chronic conditions out there, there’s a tremendous opportunity for pharmacists to help patients.
It’s going to be really important to understand whether there’s going to be things like post-traumatic stress disorder, and acute and chronic mental health challenges, for both patients and health care providers for that matter, after this. I think the role of primary care providers in supporting patients and their mental health needs is going to be invaluable, including pharmacists.
There have been no immediate scope of practice changes in terms of the ability to prescribe more broadly for mental health conditions, if that’s what you mean. But I think even with current scope, there’s certainly the ability. It’s just having the capacity to focus on some of those things right now, as all of us providers in general are challenged with. But it can’t be undervalued. Your point is well taken.
Senator Forest-Niesing: Thank you. I didn’t expect to have an opportunity for a third round. Thank you so much, Madam Chair.
The question has been partially answered, but if you can expand perhaps, Dr. Tromp, on the new reliance that we’ll have on remote video medical appointments, virtual appointments and the need for access to the internet. You’ve talked about Moose Factory and the experience you had there. I was pleased to hear you say that the dependence on the internet can be mitigated by greater and better use of telephone communication, but you were cut off just at the point where you were going to expand on how the internet is better. Given the obvious advantages of having a potential face-to-face and an opportunity to interact in real time, in your opinion, what is the challenge for communities? To your knowledge, what is the percentage of communities that are not sufficiently well served with internet access?
Dr. Tromp: I don’t know the percentage, but I would say the only communities that don’t have good internet are pretty remote. Moose Factory is moderately remote. They have Kashechewan and Attawapiskat and those places that are fly-in, and I had no trouble connecting with the electronic medical record and talking to the nurses.
I had this great experience where they had something called virtual ICUs. I had a patient in critical condition who came into a nursing station. The nurses phoned me and we did the initial stuff, and then they said, “Why don’t we get the virtual critical care?” Then we had a three-way teleconference going with the critical care specialist in Sudbury, myself in Moose Factory and the nurses at one of the nursing stations, with a view of the patient in front of us. We discussed the management.
Where I really see a need or a good use of virtual care is — in those acute situations it’s useful, but I think it can also be very useful for chronic disease management. In Moose Factory, they have an airplane that flies back and forth between Moose Factory and Kingston, which is their tertiary care centre. It goes back and forth every day and has 35 seats, I believe, and it just brings patients back and forth for medical appointments. These are patients who can obviously sit in a regular airplane, so they’re not in critical care, not on a stretcher and don’t have an IV. They’re going to see someone to follow up about their heart, rheumatoid arthritis, kidney failure and that type of thing.
I think that is a great area we need to focus on, to start doing a lot of those appointments by teleconference, and doing three-way teleconferences with the patient in their home community, the family doctor in Moose Factory and the specialist in Kingston all seeing the patient at the same time, asking questions of each other. Some patients like to travel to the big city every once in a while, but a lot of people, if they have to go over and over again, it gets a bit monotonous and becomes quite difficult.
I would like to see virtual care expanded to increase access to specialist services in isolated communities. I think that’s a big thing that we need to do next.
Senator Forest-Niesing: It’s interesting the example you used was one that included Sudbury. Sudbury is where I’m actually speaking to you from today.
Dr. Tromp: Very good. Well, your critical care physicians are supporting northeastern Ontario.
The Chair: Thank you very much. Before we conclude, Senator Omidvar, I want to give you an opportunity because I know you might have another question in the last round, and we can certainly take a few minutes for it, if you so wish.
Senator Omidvar: Thank you. I am going to not ask my question.
The Chair: Thank you. We’ll conclude this very informative and productive meeting. I want to warmly thank our witnesses. It was a long meeting with some very detailed questions, and we thank you for being here and sharing with us your expertise. It has been very helpful for this study.
(The committee adjourned.)