THE STANDING SENATE COMMITTEE ON SOCIAL AFFAIRS, SCIENCE AND TECHNOLOGY
EVIDENCE
OTTAWA, Wednesday, October 30, 2024
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:15 p.m. [ET] to study Bill C-284, An Act to establish a national strategy for eye care.
Senator Ratna Omidvar (Chair) in the chair.
[English]
The Chair: Honourable senators, my name is Ratna Omidvar. I am a senator from Ontario and the chair of this committee.
Today we continue our study of Bill C-284, An Act to establish a national strategy for eye care.
Before we begin, I wish to have my colleagues introduce themselves, starting with the deputy chair of the committee
Senator Cordy: Welcome. Thank you, chair, and thank you to each of you for being here today. My name is Jane Cordy, and I am a senator from Nova Scotia.
Senator Osler: I’m Flordeliz (Gigi) Osler, a senator from Manitoba.
Senator Burey: Hello. Sharon Burey, a senator from Ontario.
[Translation]
Senator Cormier: Good afternoon. René Cormier from New Brunswick.
[English]
Senator Bernard: Welcome. I’m Wanda Thomas Bernard, from Mi’kmaw territory, Nova Scotia.
[Translation]
Senator Petitclerc: Good afternoon. Chantal Petitclerc from Quebec.
[English]
Senator Seidman: Good afternoon. Judith Seidman, Montreal, Quebec.
[Translation]
Senator Youance: Good afternoon. Suze Youance from Quebec.
Senator Mégie: Good afternoon. Marie-Françoise Mégie from Quebec.
Senator Boudreau: Good afternoon. Victor Boudreau from New Brunswick.
[English]
The Chair: Thank you, senators.
Joining us today for the first panel, we welcome all of you in person: Mr. Martin Spiro, President; and François Couillard, Chief Executive Officer, from the Canadian Association of Optometrists; from the Canadian Ophthalmological Society, Dr. Nina Ahuja, Chair, Council on Advocacy, Board of Directors; and Elizabeth Fowler, Chief Executive Officer. Thank you all for joining us today.
We will begin with opening remarks by Mr. Spiro, followed by Dr. Ahuja. You have five minutes each for your opening statements. Mr. Spiro, the floor is yours.
Martin Spiro, President, Canadian Association of Optometrists: Thank you, chair, and members of the committee for the invitation to present to you today on Bill C-284.
First, I wish to take this opportunity to thank the bill’s sponsors, MP Judy Sgro and Senator Ravalia, as well as recognize the dedication of the vision stakeholder group, for their efforts to push this bill forward.
Canada is long overdue for a comprehensive national strategy on eye care. As you have heard from the vision community, this is not merely a question of policy, it is a matter of urgency. With an aging population susceptible to eye disease and a generation of children facing an unprecedented rise in myopia, we must take coordinated action.
As an optometrist, I would like to share a recent experience that is a stark reminder of why Bill C-284 is so vital. Recently, a new patient presented to my clinic complaining about a decrease in their vision. Like so many Canadians, he had long felt that, since his vision had been fine, he didn’t need to see an eye doctor. In fact, it had been over ten years since his last eye exam. What he did not realize — and what we discovered during his exam — was that he had advanced glaucoma. By the time he sought care, the damage was significant and irreversible. If this patient had received routine care, this vision loss could likely have been preventable.
Unfortunately, this is not an isolated incident; it is a common and deeply concerning reality. Eye diseases like glaucoma often have no early symptoms, silently stealing vision without warning. Routine eye examinations go beyond ensuring good vision.
Optometrists are the primary eye care providers for vision health and play a pivotal role. We specialize in the examination, diagnosis, treatment, management and prevention of disease and disorders of the visual system, the eye and associated structures.
The Canadian Association of Optometrists represents over 7,000 optometrists and optometry students, as well as thousands of optometric assistants, across Canada. We work closely with both federal and provincial governments on initiatives to enhance eye health outcomes for all Canadians.
This bill is kept purposely at high level. The heavy lifting will occur once it has been adopted. To give you a clearer picture of the potential impact of this legislation, I would like to outline a few key measures.
One key goal of this bill is to identify and address the training and education for those who can play a role in eye health. This includes not only health care practitioners, but also educators, early childhood specialists, caregivers and others who interact with the public. By equipping these groups with the knowledge of the importance of eye exams and the role of vision care professionals, we can ensure they are better prepared to recognize early warning signs and refer individuals for appropriate care.
We also recognize the critical need for research, data collection and vision care. For example, the federal government is responsible for health care of Indigenous peoples, refugees and veterans. These populations face severe barriers, amplified by insufficient research and poor coordination of knowledge exchange when it comes to vision care. Closing the gaps is essential.
We also see an opportunity to improve information knowledge sharing between federal and provincial governments, for instance, identifying shortages of vision care providers in rural and remote areas across provinces and territories. To help address this challenge, the CAO is advocating to the federal government to include optometrists in the student loan forgiveness program which incentivizes professionals to work in rural areas.
Another key aspect of this bill is to accelerate the approval of medical devices and drugs. We must find ways to reduce barriers and costs for introducing new devices and treatments in Canada, all while ensuring patient safety.
Finally, we believe enhanced public education is crucial. The CAO has been actively promoting the importance of comprehensive eye exams and has developed an expertise in this area through a bilingual national public awareness campaign. Federal support from the Public Health Agency of Canada would significantly amplify these efforts.
In conclusion, the Canadian Association of Optometrists strongly supports Bill C-284 as a landmark piece of legislation that will elevate eye health and make a profound difference in the lives of Canadians.
We urge lawmakers to acknowledge the critical importance of eye health and act decisively by passing Bill C-284 without amendments. The CAO is committed to collaborating with all levels of government and stakeholders to make this national strategy a success.
Thank you.
Dr. Nina Ahuja, Chair, Council on Advocacy, Board of Directors, Canadian Ophthalmological Society: Thank you, Madam Chair and senators, for the opportunity to speak about this bill.
I would like to congratulate Mr. Spiro on an excellent presentation. I agree with everything he said. It makes my job easier.
I represent the Canadian Ophthalmological Society here with our CEO, Elizabeth Fowler. We’re thrilled and honoured to be here and to have this opportunity to champion this bill, which will be hugely impactful.
We are at a pivotal point in eye care delivery here in Canada, with an aging population. We have a changing landscape as well in the delivery of eye care with introductions of new technologies which will help streamline our ability to access remote areas and underserved populations as well.
First, as Mr. Spiro said, we’re grateful to The Honourable Judy Sgro and Senator Ravalia for pushing this bill forward for consideration for implementation. It is something that will have a huge impact on vision care for Canadians.
Our goal is to ensure equitable access to essential eye care services for all Canadians, especially those in rural and underserved areas, including our Indigenous population.
There’s often some confusion about the eye care team. I will briefly describe who the different contributors are for health care provision.
Opticians are skilled at fitting and dispensing glasses and contact lenses. They work closely with optometrists.
Orthoptists are specialists in being able to measure and quantify muscle disorders of the eye. They work very closely with ophthalmologists, particularly in paediatric ophthalmology and neuro-ophthalmology.
Optometrists provide essential primary eye care, routine exams and manage common eye conditions, as Mr. Spiro wonderfully outlined.
Ophthalmologists are medical doctors who have gone to medical school and, on top of our medical training, have done an additional five years of specialty training in interventional, surgical and medical management of advanced eye diseases.
Each one of these eye care professionals is extremely important in the tapestry of the care we deliver.
Being at this juncture where we have new technologies coming in, we have opportunities to collaborate even further between ophthalmology and optometry, it is key to have something unifying us from the top. That is where this bill comes into play.
To give an overview of the context, over 1.2 million Canadians are living with vision loss. More than 8 million have one of the top four eye diseases: cataracts, age-related macular degeneration, diabetic retinopathy and glaucoma.
Vision loss has a huge economic impact. A study done by the Canadian Council of the Blind in 2019 revealed an economic loss of $32.9 billion that year. A subsequent study was done that showed each year was anticipated to cause another $560 million loss per year, 2021-23, as a result of the pandemic. That was because of decreased access, not going for follow-ups and longer wait times for procedures. There is no doubt that not addressing vision issues is a significant economic impact.
In terms of the vulnerable populations, we know Indigenous people, seniors and other vulnerable populations are at greater risk due to limited access. Again, that is where the bill really comes in, to ensure we’re providing access to all of these communities in ways we can work collaboratively and optimize the professional services we can provide between all of us.
As I mentioned, the landscape of eye care is evolving. We have advances in technology, including telemedicine as well as AI, and that is going to become a key player as well as we move forward. It is critical that we guarantee access and utilize all of our resources in an organized, structured fashion through a bill like this led from the top that all of us can help support it.
In terms of research, Mr. Spiro gave a wonderful introduction to the research as well. We need to build this framework based on evidence; that is extremely important. I know the University of Waterloo is doing excellent research. Montreal is doing excellent research. In ophthalmology, we have 15 academic centres that are affiliated with medical schools and faculties of health sciences where we are leading cutting-edge research there as well on advanced treatments for eye diseases and conditions.
In terms of this collaborative strategy, collaboration is going to be the key to the success by having leadership from the federal level. We as stakeholders, all of the stakeholders here around the room, are excited and enthusiastic to work together to support the government in terms of bringing something like this forward, including working with the federal government for the Indigenous population and then our provincial counterparts as well.
The impact of passing Bill C-284 would be to reduce preventable blindness by promoting early detection and timely treatment. It would lower the economic burden, again, by having early detection and timely treatment. It would improve the quality of life of Canadians where one of their biggest fears in various surveys is a reported concern about loss of vision.
Together, as an entire team on this side of the table and around the room, we respectfully urge you to pass this as soon as possible so that we can get our feet on the ground and get this moving forward. We are happy to support however we can.
The Chair: Thank you, Dr. Ahuja.
We will move next to questions from my colleagues. Colleagues, we will have four minutes each for the question and the answer.
Senator Cordy: It was a lot of information and some very positive presentations. Thank you for that.
Dr. Ahuja, you spoke about new technologies to access remote areas. When I think about looking at the eye, I think you have to be right there. I understand technologies have improved. Could you give us an idea of how new technologies will work for remote areas? We have many remote areas in Canada. We are a huge country. That would be wonderful.
Dr. Ahuja: Telemedicine plays a large part in that. One nice thing about eye care is that we do rely a lot on visual systems. Photography is a large part of it. Many of our exams are optical‑based technologies. If you can have a remote operator delivering that diagnostic tool or test to patients, that could be transmitted, and then those of us who are able to interpret and guide treatment can do that remotely.
There are a couple of barriers to that. Many remote areas may not have connectivity or the technology available on their side, and those are things that would need to be addressed. However, the ability to be able to transfer images back and forth between where it is being taken to the people who are interpreting, diagnosing and ultimately guiding treatment is something that can be impactful for remote communities.
Senator Cordy: So those pictures you see in your eye doctor’s office would be coming to you from the North. Thank you.
Mr. Spiro, you spoke about eye diseases often not having symptoms, so people do not often realize or recognize they have an eye problem until they go to an optometrist.
You also spoke about training for doctors, teachers and parents. I thought that was important, because you go to the doctor last after having been with those people. Having been an elementary schoolteacher, I know you often see things before. You have the kids sometimes longer waking hours than the parents do.
Could you expand on the training part and the need for getting people in to understand that it should be like a dental appointment where you go twice a year?
Mr. Spiro: Absolutely. Thank you for the question.
Yes. You hit on a couple of great points. Medically, we could see GPs and paediatricians referring their patients for eye exams, routine care, especially given if there is a certain systemic condition like diabetes, which can have an impact on the eye.
Going beyond that to educators and teachers, we are fortunate when a teacher recognizes that if a child is struggling in school, it is hard to learn if we do not see what is going on at the front of the class or if we are having issues seeing what is in front of us. Referring those children for an eye exam is probably the first and foremost important thing to make sure there is no disruption in the visual system that is impeding learning and success for our children.
Senator Seidman: Thank you for your presentations. My question is for both of your organizations.
If I look at the bill and the strategy, clause 2 talks about various forms of eye disease. The strategy must describe various forms of eye disease and include measures. It talks about promoting research and improving data collection on eye disease prevention and treatment, on vision rehabilitation and promote information and knowledge-sharing between the federal government and provincial governments.
I’m zeroing in on that because both of your organizations, in your briefs to us, propose a dedicated vision health desk led by a chief vision health officer within the Ministry of Health. The reason you propose that is in order to help improve research, fostering innovation in treatment and prevention, to standardize vision screening and oversee data collection on national eye health outcomes. I am now combining both of your proposals, because they are very similar.
What I am asking is, what data do we currently have on eye disease, whether it be federal or provincial? How coherent is it? How do you imagine this vision health desk fulfilling that important need? I will let anyone answer the question, as long as I get an answer from both of your organizations.
Dr. Ahuja: That is a great question, especially because we do see this as being an evidence-based strategy.
One of the problems and challenges we have is that there is data out there, but it is often segmented data and not looking at the overall population. The other barrier or challenge with that is that the data collection is inconsistent. The reporting is inconsistent. While we have data, how useful is it in order to put together a national strategy?
The idea of having a chief vision officer is to be able to ensure that there is a coordination between the organizations and research that’s being done between optometry and the centres across Canada for ophthalmology so that we can say what should be standardized in terms of data collection, what parameters should we be looking at, how should we be segregating the data, and how should we do the analysis.
That is why having someone central at the federal level who is driving and overseeing it would be helpful. We could have a central collection where the data goes to CIHI, or whatever that structure looks like, to ensure that it is standardized across both of our organizations and wherever we’re doing research.
Senator Seidman: I will let Mr. Spiro respond, but that is not in this bill. How would you imagine a vision health desk with a chief vision health officer being integrated into the bill?
Mr. Spiro: As my colleague Dr. Ahuja said, often that research can be piecemeal. We’re all working in our clinics. However, optometrists are in a unique position because we generally see patients throughout their lives, from childhood to elderly. We’re often in a place to look at the very early signs of eye disease and disruptions to the visual system. Being able to coordinate that, producing more research on those early signs, is paramount.
Also, Dr. Ahuja mentioned we have great research institutions in Canada. From the optometric position, the University of Waterloo and University of Montreal are doing amazing research, I’m sure many of the other academic institutions as well. How can we embolden and empower the research institutions that already exist to do even more effective research, to compile even more data and to create more clinical evidence that could help Canadian patients as they go through life? That is how we see the advancements on research for this bill taking place.
Senator Seidman: This is critically important. We would all agree sitting here. How do you envision that happening in the current piece of legislation that is proposed?
The Chair: Senator Seidman, thank you for that question. Someone else will pick up on it.
Senator Osler: Thank you to the witnesses for being here.
My question is for both organizations. I will start with the ophthalmologists. You spoke about access. Access to health care, let alone eye care, is not equal across Canada. The bill also does not speak to improving access to eye care, nor does it have funding attached.
I know you are both aware of the Canada Health Act. Administration and delivery mainly fall under provincial and territorial jurisdictions. You also know what eye care services are covered under the Canada Health Act and how access varies depending on your age, health conditions, where you live or whether you have private insurance.
My question is, are there specific and attainable elements to improve access that could be in a national strategy for eye health?
Dr. Ahuja: I believe there are. I believe that comes to leveraging the technologies, and then having metrics that we are following to ensure we are attaining success.
The bill is vague when it comes to research and access because there are many things we can build into it once we understand what direction it is going in and what metrics we want to have. Certain metrics I see are looking at how far-reaching have we gotten in terms of being able to implement that technology to the remote centres?
For example, we could put in a metric of, over three years, have we been able to increase our access to 90%? If we are able to implement and get all the infrastructure in place, and educate how to use the technology from a user perspective in terms of the people doing the diagnostic testing — and also from the patient perspective, so we educate them on how to use the technology — by implementing various strategies like that, I do think we can improve access and reach those remote areas in various ways.
With the education piece as well, that also becomes part of it. Mr. Spiro is talking about educating the caregivers and families, and that is so integral to that, as well as educating the general public so we are addressing those various demographics.
We know that 18 and under is covered for a comprehensive eye exams, as is 65 and over, so it is educating people within those demographics as to what the consequences are of not diagnosing disease and how that plays out in terms of impact to life.
For the working-age group, you are right. There is definitely variability. The coverage varies depending upon the province as well. That is a challenge we need to overcome. Again, through education — and hopefully by collaborating and having this efficient tapestry we can create together through a strategy like this — we can hopefully have an economic impact that frees up resources so we can revisit what type of coverage we can have for those people who are not covered right now.
It is not a short-term game, unfortunately. It is so complex, as we know, and we need to take the silos that are happening in provinces and work together towards coming up with something that is unified.
If we work at it and are open, collaborative and trusting one another that we are all well intended towards the same mission, I think we can accomplish the access issues that we are hoping to, supplemented with the research as well where we lay out the research depending upon what we need to be looking at based on what is rolling out as we move forward.
[Translation]
Senator Mégie: My question is for the Canadian Association of Optometrists. What are the methods of access to optometric care in the different provinces? Since there’s a protest movement among Quebec optometrists who want to withdraw from the Régie de l’assurance maladie du Québec, do you think this national strategy could help rectify the situation?
Mr. Spiro: Thank you for the question. First, according to our surveys, we know that optometric care is covered in Canada because patients have access to an optometrist often quickly and close to home.
In some very rural areas, there are gaps. That’s why we’re raising awareness to include optometrists in the school fee patronage system. We hope to use a national strategy to raise the profile of eye care in Canada, which will show everyone that eye care is important and worth investing in, even in the provinces, especially in systems that don’t provide adequate compensation for eye care currently covered by the public plan.
Senator Mégie: Mr. Couillard, do you have anything to add?
François Couillard, Chief Executive Officer, Canadian Association of Optometrists: I agree with Dr. Spiro. We also saw in Ontario a few years ago that it was a difficult situation. As in Quebec, they had to take measures that weren’t very popular with the public, obviously, but they didn’t even have a model for negotiating with the government. The government had no way of talking with the provincial association to update the fee schedules. As Dr. Spiro mentioned, there is a real hope that this national strategy will give eye care a boost and bring it out into the open to improve things.
We were talking about a “vision desk”. There’s a desk for dental care, but nothing for eyes. There’s no one you can talk to in the federal government who knows anything about eye care. No one has the expertise. So we’re very hopeful that this bill will build momentum and ensure that all these projects across the country, within the provinces and at the national level, can take off. Thank you for your question.
Senator Mégie: Thank you.
The other question has to do with a study that just came out, that was just published in the Canadian Medical Association Journal in relation to the fact that there are studies that show that when First Nations children are assessed, there’s a significant difference in their cranial circumference and that, in fact, all care is based on that difference. Induced macrocephaly or induced microcephaly is diagnosed. For the eyes, is there a study out there that can say that for a given ethnic group, the eyes are a certain way? Have you heard of anything like that?
Mr. Couillard: Not that I know of; I’m not aware of any such study.
Mr. Spiro: I’m not aware of the study that just came out, either.
Mr. Couillard: There’s very little information on Indigenous populations. That’s one of the problems. Access is difficult. There really are gaps, and that’s one of the things…. We were talking about access a little earlier. For us, access, in terms of focusing on those populations and marginalized populations…. Let’s say there’s a lot to be done.
Senator Mégie: Thank you.
[English]
The Chair: Our next panel will focus on eye care within Indigenous communities. That’s a question to hold for them.
[Translation]
Senator Cormier: Welcome. I’m going to ask my questions in French. When I look at the list of issues you raised, data, research, training, the use of new technologies and aging populations, in another study being conducted in another committee on health care in the minority language — in other words, francophones outside Quebec and anglophones in Quebec — we can see that there’s a great lack of information, a lack of data and a lack of adaptation of certain tools to patients’ language.
So my question is this: Do you think Health Canada should systematically take into account the challenges associated with official language communities in its national strategy? In your practice and profession, for instance, is there a way for you to…. Is there a registry or information that allows you to know the language spoken by patients or citizens who use your services? Is there any information on that that could help with data collection for those communities? Who would like to answer?
Mr. Spiro: Thank you. Yes, I also think that in our individual system, yes, when a patient comes to see me, in my electronic medical system, the language spoken is specified. I’m quite comfortable providing care in both languages. I think that many optometrists in Canada are also bilingual. But since we’ve already discussed this, can we bring this information together to better address the issue? I think those discussions will take place as soon as the bill is passed and will develop in due course.
[English]
Dr. Ahuja: To add to that, in my practice as well, I would always make a note in terms of what patients would prefer in how they would like to communicate.
For a national vision strategy, we are obligated and mandated by the federal government, and the federal government is mandated to ensure that all services are provided in both languages. I see the role of artificial intelligence being very helpful here, where we can utilize artificial intelligence to provide translation services in the education materials we are creating.
At the Canadian Ophthalmological Society, any document we put forward, whether it is a position statement, an opinion piece, whatever it is that we are publishing, it is always translated into French. That becomes challenging, though, when you are creating educational materials for the population. This is where I think we can leverage some of those new technologies so we are able to produce video education pieces, as an example, on how to use the technology in a remote area from the patient perspective.
That we can do not just in French, where we would definitely do it in English and French because of the Official Languages Act, but also for other languages because, as we know, we are a multicultural society with multilingual communicators. We can leverage artificial intelligence in a national strategy easily.
Senator Cormier: I understand it is a strong message to Health Canada that they have to take that into account. Thank you.
[Translation]
Senator Petitclerc: We’ve talked a bit about it, but I’d like to come back to the issue of prevention and screening — I don’t know who wants to answer the question, ideally both — especially for children.
I have an impression that may be wrong, but when toddlers have teeth, the family doctor and pediatrician immediately ask the parents if they have made a dental appointment. However, I feel that families aren’t getting the message that they need to have their toddlers’ eye health checked. Am I right in perceiving that? If so, why isn’t it being done? What might the result be? I don’t know if we can quantify the level of prevention that could be achieved if doctors automatically sent families for eye exams very early on.
Mr. Spiro: I think you’ve described very well what we’re trying to achieve in this bill. As you said, it’s an advantage to have a complete eye exam in childhood, and our two associations have worked together to provide guidelines for that. Unfortunately, that’s not always the case, but preventing conditions like amblyopia, which is weakness in one eye, if you can diagnose it early and consider treatment early enough, the prognosis is excellent. After the age of 7 or 8, the prognosis starts to drop, and you risk having a weakness in that eye for life.
Other problems may arise, as I mentioned earlier, such as learning disabilities and major problems for these children, such as their ability to read or see the blackboard well.
Children will normalize their weakness. For example, a six‑year-old who can’t see well from the back of the class will think that all children can’t see well from the back of the class. That child isn’t necessarily going to talk to their teachers or parents. Educating pediatricians, teachers and families about the importance of systematic eye exams in childhood is crucial.
As mentioned in this bill, this requires a good deal of awareness, both among health professionals and the other stakeholders mentioned.
We believe that raising awareness and educating the public and other groups will help us achieve that goal. This undoubtedly how dentists have succeeded.
By examining children, many problems can be prevented, they can be assured success in school and have a good future.
[English]
Dr. Ahuja: I agree with what he said.
The Chair: Let’s carry on if you are agreeing with him. Let me probe a little bit deeper on Senator Petitclerc’s question comparing attitudes and behaviours to eyes and teeth.
My dentist, whether I like it or not, will send me a reminder every six months that I have to come in for an appointment. My optometrist, on the other hand, I have to chase after two years, which is the usual period that elapses between an insurance‑covered eye exam. I don’t get that high-touch care from my optometrist that I do from my dentist. Is this endemic to the system, or is this just my experience? Do optometrists regularly send out a notice that your exam is due?
Mr. Spiro: Yes. It is usually even built into the electronic medical records that we use based on needs. For instance, if somebody needs a follow-up in six months, they’ll receive, by preference — whether it be a phone call, email, text — a reminder, and then generally they’ll book online to do that. But if I could expand, the issue I think that we’re looking at is really that first exam, because it is important to make sure that these children get to see the eye doctor at an early age to ensure that they are ready for school and that there is not disease or an ocular issue that cannot only affect the health of their eye or even systemically, but also impede their success at school as well. It is important, yes, to ensure that patients are getting routine care through touch points and engagement, but also making sure that people are aware to bring them in for that first exam at a very early age.
The Chair: Clearly, I have to change my optometrist.
Mr. Spiro: Maybe check your spam folder.
Senator Bernard: Thank you, chair, for that intervention.
I want to pick up on the question that Senator Osler was asking around access. I want to just go a little deeper with that. Access is often more than geography. For many families, they are not accessing dental care, eye care or any sort of health care for a lot of different reasons, especially those who are living in poverty. Do you see this bill addressing those kinds of challenges, which affect a lot of Canadians?
Dr. Ahuja: Absolutely. In fact, recently, some of our academic ophthalmologists published a study looking at the influx of public funds into the private system and how that impacted access to cataract surgery for socio-economic status and various people in different groups. It actually demonstrated that people who are in a lower socio-economic status actually had lesser access. The study was extremely important, and this is where the research gets really important, to highlight where the well-intended strategies and initiatives that are put forth by the government, with the best of intentions, don’t necessarily play out the way that we want. We’re very cognizant of that in our research at our academic centres across the country, where we’re trying to look at disaggregated data as well to point out socio‑economic factors that are contributing, gender access issues as well, language, and geographic location, of course. That is very much emphasized in the research that we’re conducting at this point in time so that, again, coming to something like a national strategy, we can make informed choices and decisions on what the framework looks like and how it is implemented.
Senator Bernard: We’re really talking about a cultural shift in terms of even how we look at these issues. Will this bill help us get there?
Dr. Ahuja: I think it will. I think that, as Mr. Spiro is saying, we are doing research in optometry. I’m saying “we” because it is a collective “we.” We are doing tremendous research in ophthalmology as well. As you can see, I’m agreeing with what he is saying, and he’s agreeing with what I am saying. There is an effort and intention and energy to collaborate. I think that the more we’re able to streamline something with a national strategy that really pulls us together as professions and then across provinces as well under the umbrella of federal oversight, I think that we can really do something meaningful.
Mr. Spiro: We have done a survey in Canada showing that the number one reason why people delay getting a routine eye exam is because they felt nothing was wrong. Really, that education needs to come in. It’s possible that this education is maybe not being propagated in those types of communities as well, many of which may have coverage either through, in many provinces, social assistance programs or insurance through employers — maybe they are not aware that these coverages do exist, so improving upon that. I think it is really about getting that education out there on the importance of routine eye care, especially being that that’s the biggest barrier for preventing people from going to their optometrist or ophthalmologist regularly.
Senator Burey: Thank you so much for being here. I find this very interesting. I’m a paediatrician, so I could ask you a lot of questions on that.
In May, I gave a statement on our national Vision Health Month which, as you know, came into effect over a decade ago. That was aimed at raising awareness about vision health, the importance of vision health early, exams from birth as recommended by the Canadian Paediatric Society and addressing all the things that you spoke about. I have been hearing a lot that part of this bill is to raise awareness and education. That happened a decade ago.
How do you think this national eye strategy is going to build on that or improve it? Obviously, we haven’t done what we should have been doing. What is different about this strategy that’s going to do it? Obviously, of course, there is no funding attached to it. Can you comment on that? I’m just trying to see how we’re going to move it forward.
Dr. Ahuja: From my perspective and from an ophthalmology perspective, the national Vision Health Month is an excellent way of increasing awareness to the public. Where I see this taking it one step forward is that we are actually engaging as the eye care professional health teams to pull together and see how we can take our respective expertise, knowledge and skills to really build something and intertwine it in a way that will deliver the best care for Canadians, so that we have opportunities to work with optometry where they are supporting us as ophthalmology.
We are, of course, here as a referral base for optometrists to support what they’re doing, but then looking at it from a concrete holistic perspective where we are pulling in not just our professional expertise but also fellow stakeholders. For example, CNIB and the Canadian Council of the Blind and all of the resources and insights that people are bringing to the table with well intentions to bring things to the forefront for people so that vision care is something that is accessible to everyone and impactful for everyone.
I see this as the step further that that didn’t take, and we are going to actually take it and move forward with it in a concrete way.
Mr. Spiro: Those are great points.
I see this bill as being a way to go beyond the public education, which is crucial, as we mentioned in my statement and Dr. Ahuja’s statement and some of the answers to the questions as well. We have emphasized going beyond the public and looking to other health care providers and interventionist who deal with the population at large and all coming together to give that same message on the importance of routine eye care. It is something that you cannot let go of. We will have to keep going. As we go, we will see more results as well. This is something that needs to be constantly worked on. We are willing to collaborate with governments and stakeholders to ensure that can happen.
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Senator Boudreau: Thank you all for being here today for a very important discussion. When a federal government seeks to develop a national strategy in an area of provincial and territorial jurisdiction, it’s always a little more difficult and a little more delicate. You are two national entities that work across the country. You probably have provincial and territorial associations within your organizations. I’d be interested in hearing from both of your associations if you see or foresee any particular obstacles. If we’re going to be successful, it’s important to understand what the obstacles to the goals are. Are there any particular obstacles you see in negotiating with the provinces and territories to develop a national strategy like this?
Mr. Couillard: There are always challenges when it comes to the federal government and the provinces. We’re part of a network that has provincial associations in every province. Our members are members of national associations and provincial associations. The provinces are all on board.
When we started raising awareness of this bill in the House of Commons, I met with the Bloc Québécois health critic. He said to me, “Mr. Couillard, we’re seeing one national strategy project after another.” I thought, “That’s it, we’re done, he’s not happy.” However, he went on to say that this bill is perfect because it doesn’t encroach on our turf at all. It respects federal and provincial jurisdictions. I don’t know if that helps you, but coming from the Bloc, it’s still positive. There are bound to be challenges, but that’s part of working together and discussing things.
Mr. Spiro: The key is to involve our provincial and national associations to work closely with governments in order to ensure success and respect for the jurisdictions of governments and associations, as Mr. Couillard said.
Senator Boudreau: Dr. Spiro, you talked about young people who have a weakness that hasn’t been properly diagnosed. I’m one of those statistics. Do such statistics exist, in terms of how many young people in Canada miss out on an exam every year and don’t have the chance to have these exams at a young age to prevent future illnesses?
Mr. Spiro: There’s some data. There’s data on the incidence of certain diseases too, but we need to go deeper to find out why they wouldn’t have received that care. We have statistics on macular degeneration, myopia, diseases found in older people or children, but we also need to try to understand why exactly these people didn’t have these exams.
More work needs to be done — in some provinces, exams are covered, and the codes could help us determine whether these people had an exam before a certain age, but we could work together to get a comprehensive Canadian overview of these data. That’s one thing that could be considered.
Senator Boudreau: Thank you.
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The Chair: We’ll go to second round.
Senator Osler: Mr. Spiro, I would like to give you time to answer the question about specific and attainable elements to improve access that could be in a national strategy for eye health.
Mr. Spiro: As you know, the federal government is responsible for the care of Indigenous peoples and refugees. One of the ways we see this is to improve access for those populations by making these programs more up-to-date and reducing barriers that patients and practitioners face while using these programs. That is a great start in a way that is within the federal government’s jurisdiction, which involves eye care professionals such as optometrists and ophthalmologists. We need to see improvement where these systems, unfortunately, face barriers on both sides, from the practitioner and the patient points of view.
Senator Osler: You are giving me the lead-in to my follow‑up question, which can be to both of you. Can you speak to the specific populations for whom the federal government is responsible for health care? Eligible First Nations, Inuit, some refugee claimants, serving Canadian Armed Forces members, and inmates in federal penitentiaries. Are you aware of specific examples of inequities in access? On the flipside, are you aware of some best practices and examples of access to eye care in those populations?
Mr. Couillard: Yes. I sit on a working group with Non‑Insured Health Benefits, or NIHB, called the Vision Care Working Group, creative. I’m co-chair with someone from NIHB. We used to meet once a year to discuss challenges and ways to improve. I was able to change the terms of reference. We now meet twice a year. We try to make progress.
I will give you an example. You are keen on telemedicine. We floated the idea of perhaps contemplating telemedicine for Indigenous populations. They won’t. They will not. They feel it is not the gold standard and then Indigenous would be getting less than if they were in person. The problem is that they do not get the same access. Maybe 50% of Indigenous populations get proper access. Access in their communities is very challenging. There’s no common mechanism to get an optometrist to go there, pay them appropriately to get them there and lodge them. An optometrist has to buy their own equipment and bring it with them on the plane or by car and get over there. It is very challenging. We are hoping that this bill would create encouragement for NIHB and their staff to perhaps work a little harder. I do not know if that helps.
Success stories: There is a great success story in B.C. where they do not work within the NIHB model. They have their own Indigenous health authority. Thanks to that, they have been able to organize their own clinics. The British Columbia Association of Optometrists manages clinics in the North, recruits optometrists, makes sure they have enough optometrists and have set up a few clinics up there. It is working well. It is pretty new. It’s only a few years old. It is a good model, but it cannot be extended into the other provinces because the other provinces work under NIHB. They do not have that same flexibility.
There are challenges, but there are also models that could work better.
Senator Osler: Thank you for sharing that. That is under the First Nations Health Authority of British Columbia. Thank you.
The Chair: To clarify, do they bring the optometrists in on a monthly or weekly basis?
Mr. Couillard: It is all over the place. We had a webinar the other day with a few Indigenous optometrists who provide care in the North, and it is typically their own initiative. They contact the northern community, they organize something, and they go on a trip there every three or four months. If they didn’t have the initiative to go and do that, it wouldn’t happen. It is really humanitarian work being done in Canada. It is not systematic.
There are teleoptometry options, but you need someone at the other end. Finding these technologists — we went to the schools on Manitoulin Island in Ontario to try to find a young person at a school that we would train as an assistant who could be at the other end of a teleoptometry lane, and we couldn’t find anyone. We had Indigenous people looking for us. It wasn’t us asking; they were asking their own people, and we were never able to find anyone.
These ideas are very exciting from a technology perspective, but making them work, you need bandwidth, of course, and you need equipment, but you need people on the other end, even if it’s not an optometrist or an ophthalmologist.
The Chair: Senator Seidman, please follow up on your question around a dedicated vision health desk.
Senator Seidman: Thanks. I could perhaps frame it. I might ask you, Dr. Ahuja, because I think you were ready to reply and then we lost time.
I think all of us are expressing that this bill sets up great expectations. We are wondering how they can be realized. If you look at the bill, it talks about consultations, but those who must be consulted are not all described in any way, so how do we guarantee those consultations will happen?
I presume that you’re assuming that in developing the strategy, something like your vision health officer at the vision help desk in the Ministry of Health would come out of the strategy. I’m just guessing now that that’s what you are thinking. All this strategy does is suggest one meeting with the persons referred to in the first clause, which I just said are not very well described. If you could help me understand how you would find your vision health desk, which I think is a great idea given what you are suggesting it would do.
Dr. Ahuja: That’s a great question. I think the key to this is going to be that the chief vision officer is not working in solitude. Those of us who are in the profession understand who the stakeholders are all the way from ophthalmology to optometry to — the four Os, as we mentioned, and then all the other stakeholders, including taking into account the life experience of those people who are suffering from vision loss.
While it’s not specified in the bill, I believe our approach would be a very comprehensive one because we do want to hit this as an overall strategy that, again, is holistic in nature. While it’s not specifically outlined, by supporting the chief vision officer, we would be able to guide and say, “Where are you at? What can we do to support you so that you are getting all perspectives?” Then establishing various touch points along the way, keeping all of the stakeholders in mind.
While this is an overall gestalt of how it would work but not completely detailed, there are elements that I think would flow through if we followed the patient journey through eye care.
Senator Seidman: I don’t see this in the bill. Are you assuming that you will be consulted in developing the strategy? Is that the basic assumption here?
Dr. Ahuja: Yes, that was my assumption. We put forward a draft proposal as a skeleton framework. My assumption and understanding was I think the only way to have an effective strategy is if you engage us. That was my assumption.
Senator Seidman: On the groups that must be consulted, you find yourselves falling under whatever the category — I’m not sure what category it would be. It says here consulting “. . . with the representatives of the provincial governments responsible for health, Indigenous groups and other relevant stakeholders . . .” So you consider yourselves falling within the “other relevant stakeholders” even though you are not described? That’s okay with you?
Dr. Ahuja: That’s okay with me because, to me, respectfully, it seems logical.
Senator Seidman: We hope it’s logical.
Dr. Ahuja: That’s why. It was eye care, so then you’d have the eye care professionals. It just sort of follows. Yes, we would hope.
The Chair: That’s certainly everyone’s expectation, but sometimes government works in ways that —
Senator Seidman: Sometimes you have to spell every detail out.
The Chair: Yes. Thank you so much for spending time with us and for enriching our understanding about the seriousness of the situation with eye care, especially as you are here in person. Thank you for that.
For our next panel, we welcome the following witnesses joining us in person — thank you for doing that — Jennifer Urosevic, President and Chief Executive Officer, Vision Loss Rehabilitation Canada; and Dr. Kourosh Sabri, Founder and Director, Indigenous Children Eye Examination. Thank you both for joining us today.
Jennifer Urosevic, President and Chief Executive Officer, Vision Loss Rehabilitation Canada: Thank you for this opportunity, senators, for us to address you today.
I speak in support of Bill C-284, a vital step forward in addressing the crisis in vision loss impacting millions of Canadians and their families. Today, more than 1.2 million Canadians live with blindness and low vision and, as our population ages, the number is set to double by 2050. Just over 160,000 people access our services. Due to funding restrictions, we are only able to see a fraction of the 1.25 million people living with low vision or blindness who would benefit from our services. The Deloitte report in 2021 commissioned by the Canadian Council of the Blind indicated that vision loss costs to Canadians is $32.9 billion each year.
Vision loss is not life-threatening, but it is life-changing. It affects every aspect of a person’s life, from their physical mobility to mental health and social inclusion. Addressing these areas requires a holistic and integrated approach, which Bill C-284 can help make a reality.
We see firsthand the benefits and positive outcomes in providing necessary rehabilitation services for people with vision loss. Our mission is clear: to provide high quality, integrated, accessible rehabilitation and health care services that enable Canadians impacted by blindness to live the life that they choose. Rehabilitation is not just about adapting; it is about ensuring that individuals can continue to live safely and competently. Existing programs and supports for those living with vision loss are currently unevenly distributed and represent a major barrier in the inclusion and prospering of millions of Canadians.
Vision loss is not an isolated situation; it is overall health, and it intersects with many other aspects of the health care system. For example, people with vision loss are at higher risk of experiencing chronic conditions such as diabetes and mental health. That is why an integrated approach is so essential.
A national strategy for eye care should be prioritized in collaboration with people with lived experience and across health care sectors, including ophthalmology, optometry, primary care, acute care, rehabilitation services and evidence‑based research. Integrated models ensure that patients receive comprehensive support from diagnosis to treatment to rehabilitation and follow-up services.
Last week, you heard from Ian White about technology. Access to technology for Canadians who are blind or who have low vision is vital to supporting independence, productivity and equitable opportunities. Technology has become an essential tool for people with vision loss, enabling safe navigation, independent living and equal participation in educational and professional settings. Without affordable technology, Canadians with vision loss face unnecessary barriers. Inclusive access to adaptive technology leads to higher employment rates, increased community engagement and improved quality of life. However, the cost of these tools and lack of uniform access across Canada places many Canadians at a disadvantage. Technology access is not just a support mechanism but an essential right that allows people with vision loss to fully participate in life and society.
Seventy-five per cent of vision loss is preventable and treatable with early intervention. Regular eye exams and access combined with expanded access to treatment and rehabilitation are essential. Through early detection and timely care, we can prevent many cases of severe vision loss.
Additionally, a national eye care strategy needs to include research and new treatments, especially as we face an increasing prevalence in age-related eye conditions.
We have seen a transformational impact in innovations and technology with our eye health screening initiative, with rapid response to coordinated care to eye examinations in Indigenous communities through our collaboration with our partner, the Indigenous Diabetes Health Circle. This program is now in Ontario, and it is expanding across Canada. We are committed to supporting the research that makes these advancements possible.
In closing, Bill C-284 represents an invaluable opportunity to establish a national framework for eye health that prioritizes research, prevention, timely treatment and comprehensive rehabilitation. It is the pathway for greater independence, dignity and well-being for millions of Canadians with vision loss. By supporting this bill, we can make a Canada where everyone, regardless of age or socio-economic status, can access vision care that they need to thrive.
Thank you for your commitment on this critical issue. I urge you to support Bill C-284.
The Chair: Thank you very much, Ms. Urosevic.
Dr. Kourosh Sabri, Founder and Director, Indigenous Children Eye Examination: Dear committee members, thank you for this opportunity.
Good eyesight is such an important sense. It affects all aspects of our lives, in all phases of our lives. I am delighted that Bill C-284 has come forward before the government, before this committee, because I truly believe that a national eye care strategy can bring eye care and the importance of eye care to the forefront of public health policy-making in this country.
I want to start by acknowledging the Indigenous people of this land, of this country. Over the last several years, I have visited several Indigenous communities in two provinces. I have met probably hundreds of the people in these communities and met with many of their leaders. I have learned much from them, and I learn much from them still every day. Meeting the Indigenous community is probably my biggest honour and privilege since coming to Canada, and it continues to be my honour and my privilege.
There are over 200,000 Indigenous children living on reserves in this country, based on the most recent census data. Most of these children live at least several hundred kilometres away from the nearest eye doctor, and most of these children, as things stand, will probably never see an eye doctor.
ICEE was born when I went for the first time to Hudson Bay in northern Ontario six or seven years ago and saw firsthand the lack of care in the Indigenous communities. ICEE is based on four pillars.
The first pillar is in-person eye clinic visits to the communities. To date, we have developed a great relationship with six First Nation communities along Hudson Bay, Ontario, and two northern Saskatchewan Métis communities. We have visited these communities many times. I am very pleased and proud to say that, to date, despite the two years of COVID when any travelling was prohibited, we have examined almost 1,000 children in person. In some of the communities we visited, they told us that the last time they had an eye doctor come there was ten years ago. One community said 15 years ago.
Alarmingly, only 25% of these 1,000 children that we have seen had normal vision, 75% had reduced vision — somewhere between mild, moderate to severe vision loss — and 75% needed glasses, which we provided. Fifty-one of the children we saw were going to be legally blind in both of their eyes for life had we not seen them in time.
The second pillar of ICEE is training local youth as eye technicians. This is an important pillar because we want to give back in a sustainable way to the community. So far, we have trained one high school graduate out of Attawapiskat in northern Ontario as an eye tech. Over the last few weeks, we recruited a young high school graduate from LaRonge, a Métis community in northern Saskatchewan. She will come to Hamilton next month and be trained as an eye tech for her own community.
The third pillar is telemedicine and expanding the use of virtual eye clinics.
The fourth pillar is to use the most valuable asset of ICEE, of which I am extremely proud, which is the trust and friendship of the communities. We use that trust to develop and facilitate bringing other health care services to the communities. For example, with the First Nation communities along Hudson Bay, where I have known these people for the last six or seven years and consider them my friends, we will now start having plastic surgeons from Hamilton go to those communities and run wound care clinics. Trust is the most important thing here.
I want to emphasize the importance of vision screening as a strategy for all kids across the country, Indigenous or non‑Indigenous, urban or rural. I’ll highlight it with one simple example. A child who loses vision at age 6 has to live with poor vision for the next 60 to 70 years of their life, while an adult who loses vision at 60 or 65 from cataracts, macular degeneration or glaucoma, at most has to live with that poor vision for the next 20 or 30 years. We all know that if you grow up with poor vision, you will do less well socio-economically, you will do less well in school and you will have a much higher incidence of mental health issues such as suicide and depression.
In fact, I would challenge my colleague here, because poor vision is a life-threatening condition. If you have poor vision, you are at a much higher risk of suicide, having accidents and losing your life.
One thing I wanted to mention earlier, which I forgot, is to say that you are not born with vision; we are born blind and we have to learn to see. If vision screening and intervention is not done at an early age, you will not have good vision.
The Indigenous Children Eye Examination, as a project, can bring eye care to all remote parts of our country for Indigenous and non-Indigenous children. We also have many non‑Indigenous people living in this geographically vast country away from eye doctors.
I’ll end by saying that, six or seven years ago, we started another project in Hamilton but which it is not on the information sheets. We go into elementary schools in Hamilton, and we screen all the senior kindergarten kids in the city. That is 140 schools, and we screen 6,000 SK kids in the city every year. It is, hands down, the best public vision screening program in the country, and Hamilton is the only city that has it. We have screened 30,000 or 40,000 kids in partnership with public health.
I will stop there and again commend the will of the government and Senate to bring this bill forward. I believe this will be great as a national eye care strategy, and I believe ICEE has a part to play within this bill. Thank you so much.
The Chair: Thank you very much.
Dr. Sabri, I just want to get some clarification from you. You talked about the wonderful program in Hamilton where children get checked. I forget the numbers, but it is impressive. But under Ontario law, every child has access to an eye exam every year. Do you have any data on whether there is takeup on that?
Dr. Sabri: There is a huge lack of takeup, which is why I am a busy man. For example, I have had colleagues of mine who are cardiac surgeons, published in the New England Journal of Medicine, who have brought their seven-year-old child to me who is legally blind in one eye. They never thought of getting their child’s eye exam done.
One thing I tell all patients and parents: Everybody remembers the teeth and forgets the eyes. A majority of parents, when you ask, go for dental checkups regularly, but they look at the child, who is smiling and has white eyes, and there is no pain, so they assume there is good eyesight. We have a major issue of lack of public health awareness about the importance of vision screening.
The Chair: What is the role for schools?
Dr. Sabri: I trained in the U.K., where, for example, vision screening at schools is done. In Canada, we don’t run that, really. In schools, you have the kids as a captive audience. That’s the best thing. In my opinion, if I were running public health, I would say we check their vision, hearing and teeth in schools because the child is in the class. You don’t have to rely upon the parents remembering to take them.
Even though in Ontario, for example, during Kathleen Wynne’s government, it was written into law that all SK kids should get screened, it was left to each public health jurisdiction to decide how to do it. We published a paper a few years ago. We did a survey of all the public health jurisdictions in Ontario, and less than 50% of the public health jurisdictions were doing it.
The Chair: Thank you.
We’ll go on to our regular line of questions. My apologies, colleagues. The first question goes to the deputy chair of the committee.
Senator Cordy: Chair, this is one of your last meetings; you can do whatever you want to do. We won’t say a word.
Thank you both so much for being here. You have given us a lot of information. I jotted quite a bit of it down.
I’ll start with you, Ms. Urosevic. You spoke about vision loss being life-changing. I think we have all seen that. How do we make health care so it is more of an integrated model? Dr. Sabri is correct. My children and my daughter’s children have been going to the dentist since they have been three years old, but as parents we tend not to think about taking our children to see the eye doctor until maybe they are in school. That would be a positive thing, but we don’t tend to do that. We have heard there is often no pain with vision loss. It is suddenly the case that vision is getting weaker and weaker, and then, suddenly, they can’t see. How do we educate parents, particularly, about the importance of early eye care — meaning, having their children’s eyes checked regularly and starting at an early age?
Ms. Urosevic: It is everyone’s responsibility. When I think about integrated care, I really think about the client — the person, the child, the adult — at the centre of a wheel. To make the wheel turn, all of the people involved in eye care need to work together. That’s how we’re going to get the success of integrated care and reduce some of the barriers I talked about.
One of the other things around promotion — the first panel talked a little bit about this — yes, there is Vision Health Month, which is one month out of the year where everybody is inundated with things around getting your eyes checked, but I think it has to be much more than that. That was a great start; it started 10 years ago. I have been in the field for 27 years, working on the front line. I actually saw Dr. Sabri with one of the clients with whom I worked. Then, as I had my own children, I knew how important it was at the six-month mark and every other year after that to get my children’s eyes checked. As we promote education and we want to integrate, we have to start in the schools. It needs to be a requirement in the schools.
There is a real opportunity with the framework of this bill for the federal responsibility but also at a provincial level so that as we build these policies and laws, then, at the provincial level, there is a consistent way. We’re a national organization. I get the differences. We’re funded both federally, through two programs, and through each of the provinces and territories as well. There are a lot of differences in how we do things, but there are some commonalities in the care that people need when they have that diagnosis and what that lifelong journey looks like.
Senator Cordy: Dr. Sabri, you spoke about telemedicine in the North and in remote areas. How far along are we with telemedicine for eye care? Is it challenging to get people to use telemedicine for eye care?
Dr. Sabri: When COVID happened, what did everybody do in health care? We all had to scramble and figure out how to examine people without actually having them in front of us.
One of the projects that we have been spearheading is developing a particular piece of vision-testing software for children. We certainly now have the capability through ICEE to do vision testing on children remotely. The internet connection can be a challenge, but on the whole, I would say along Hudson Bay, LaRonge — the communities I visit regularly — we have a pretty good connection.
The challenge is training or having someone from — one of the speakers on a previous session mentioned having somebody at the other end, a technician or a nurse in the community who can facilitate that. That’s one of the reasons why we’re looking at training the eye technicians in the communities ourselves. The technology is there. It is more about organizing and training somebody at the community end, and recruiting from the community end. That’s been our challenge. So far, we have trained one person in Attawapiskat. In Saskatchewan, we have been going to the high schools, sending flyers and saying, “Is anybody interested in becoming an eye tech for the community?” By the way, this is something we want to pay that person for. This is not voluntary work. That gets into funding and is another discussion. The challenge is recruiting people at this point.
Senator Cordy: What is the challenge with recruiting?
Dr. Sabri: The challenge is that we have not seen a huge amount of interest amongst the youth in the communities to want to be trained in this. I speak with the community leaders. We sent flyers into the community. First of all, unfortunately, not many of the young people in the communities graduate from high school. Amongst those that do, we haven’t had a lot of traction in terms of interest, even though we sent flyers expressing it could be an interesting position, a stepping stone. We are working with the communities, but there hasn’t been a huge amount of interest so far.
Senator Osler: Thank you to both witnesses for being here today.
My first question is for Vision Loss Rehabilitation Canada. Bill C-284 was amended at second reading in the House of Commons Standing Committee on Health to include a focus on vision rehabilitation. I’m thinking of infants and children born with low to no vision who need vision habilitation, which is maximizing attainment of skills and function because they weren’t born with it. With that specific wording, would rehabilitation, in your opinion, exclude habilitation? Can you share some of the specific challenges in accessing vision rehabilitation services across Canada, and how this bill, a national strategy, could help?
Ms. Urosevic: Sure. I’m so happy you said that, and thank you for the question.
Habilitation is exactly how you described it. It is in our organization name that we call things “rehabilitation,” but to your point, if someone has never had the work, it is a habilitative model. We have specialists that focus on that and that look at the work that we do around sight substitution. The integration of our programs and services is definitely inclusive of that. I don’t think that there will be a problem of that integration. I think where we see differences in access and that unlevel playing field around there is how rehab is funded.
I would go back ten years ago. Rehabilitation and habilitation were the responsibility of a national charity and donor dollars, and that was CNIB. CNIB made a bold statement to separate their health care services and created Vision Loss Rehabilitation Canada so that the provincial governments were accountable for the health care services and that right. I am thankful for that, because through that, we have seen expansions of services. We have seen integrated models of care. But we still have a long way to go.
Recently, over the last year, we are on the list of the Non‑Insured Health Benefits to be prescribers. We do assessments for people who fall under that program as well as an expansion of Veterans Affairs. Now RCMP as well as other veterans who have lost their sight or are losing their sight can now access both rehabilitation or some of our habilitative services.
Senator Osler: For Indigenous Children Eye Examination, Dr. Sabri, your program is a national outreach program where you go into communities, and, when needed, children leave the community and go to the hospital or eye centre. You spoke about the difficulties in recruiting eye technicians. I would like to hear your opinion on whether a national strategy could in some way help to address some of those inequities in access to care. Could it, in some way, help to perhaps empower communities to start developing and taking over the self-determination and control of their own health services?
Dr. Sabri: Thank you. Before I answer those questions, I just want to take the opportunity to make a few important points, if I may.
Often, we get asked, but NIHB covers the costs for children to get on a plane and go to the nearest eye doctor. A child from Attawapiskat will have to get on a plane and fly to Timmins with a parent for two nights in a hotel to get an eye exam. That costs $4,000. Apart from being an expensive way of doing it, most of the children just don’t do that, even though NIHB covers it for Inuit and First Nations children. There is no such coverage for Métis children. They fall between the stools. I just wanted to make that important point. I get asked, “Why are you going? NIHB covers it.” That’s a very cost-ineffective way, and the reality is that most of the kids don’t go. We have the data.
The second point is that the most important obstacle to doctors doing the work that my colleagues and I do is not that they don’t want to go and do it but that they don’t have the time to organize. The organizing is tremendously time-consuming. You wouldn’t believe the amount of organization. We just sent a team of 11 people last weekend. They went 72 hours to Kashechewan, Fort Albany and Peawanuck. We saw 130 kids in 36 hours, and 98% of those kids needed glasses. You will not believe the amount of organization that goes into that.
Going to your point, if we make ICEE a national program that takes the headache of organizing away from the front-line doctors, they will get on the plane. Most of the doctors say, “Dr. Sabri, if you organize a trip, we’ll come, but we can’t be organizing the trip, organizing the communication with the community, organizing the patient list, the travel, the accommodation, the food, the equipment, and then deal with the natural challenges we get.”
A couple of years ago, we were on the plane, mid-air, a team of 13 going to Hudson Bay. Halfway, there was a thunderstorm. It was winter. They called the pilot and said, “Turn around.” We landed in Quebec, had a pizza and went back to Hamilton. That’s reality. One year we were going to Kashechewan, and there was a flood. Everything cancelled. Two years ago, we were going to Peawanuck. It was February, minus 50 on the ground. We were ready to go. The week before we went, there was a house fire and a nine-year-old child died. The community went into mourning. We had to cancel.
Organizing these trips is a phenomenal amount of work, but if we make ICEE a national program, we will have the infrastructure to do that. That’s what we do. We gladly do that, and that’s why we have 15 or so doctors in Ontario who come with us. When we went to the Métis communities in Saskatchewan, we recruited eye doctors from Saskatchewan. But we did all the organizing, so they just hopped on the planes, went to the communities and did the exam.
I’m sorry for not answering your question. Training local youth in the communities. Certainly, we have started it. I think it requires more work. So far, we have trained one, and as I say, we just recruited a high school graduate from La Ronge. There is funding, actually. For example, we’ll bring the high school graduate from La Ronge, Saskatchewan, to Hamilton to train her. We’ll do that free of charge from our end. But the Métis Nation of Saskatchewan has to find funding to pay her a salary, and that’s the obstacle right now. They don’t have the salary part. There needs to be some funding for that, and we can certainly expand that. The core of it all is trust and relationship, which is what we work extremely hard at with the communities.
[Translation]
Senator Mégie: My first question is for Ms. Urosevic.
There are many technological advances in the field of vision rehabilitation aids. What place is there left for Braille writing? Is it obsolete or not used at all? Where does it fit in?
[English]
Ms. Urosevic: Braille is definitely still very viable. It is a literacy tool. It is like your pen and paper, your computer. As people are losing their sight and having reduced vision, they are turning to Braille. It is still a prominent program within our organization and a sought-out skill.
I remember a child who had some functional vision, and I said, “What is your interest in Braille?” People were trying to get him to use the computer all the time. He said, “When my siblings go to bed and all the lights are turned out, I can continue to read.”
[Translation]
Senator Mégie: My second question is for Dr. Sabri. I asked this question earlier to the other panel of witnesses, and I’m going to ask you, since you work with the Indigenous population. Research published in the Canadian Medical Association Journal on October 21, 2024 notes that Inuit children in Nunavut have a larger head circumference than other populations. So the use of the standard tables we have from the WHO in Canada can lead to misdiagnoses, such as overdiagnosis of macrocephaly and underdiagnosis of microcephaly. In the context of eye health, are there standards that are adapted to the population served, or are the standards the same for everyone?
[English]
Dr. Sabri: The striking difference that I find, as someone who has been working in paediatric ophthalmology for 20 years, looking at the Indigenous community compared to non‑Indigenous children, is that there is a much higher percentage of Indigenous children with higher refractive errors. By that, we mean needing glasses. When I compare 100 Indigenous children of a certain age with 100 non‑Indigenous, we find a significantly higher amount of myopia, nearsightedness and astigmatism amongst the Indigenous communities and a much greater need for glasses.
Going back to the comment about the cranium, we find that they require different-sized glasses, so the size of the frames of the glasses. The first time we went to Hudson Bay, Ontario, the optician I brought with me brought the standard frames for kids age six to ten, and none of them were fitting the children because they needed larger frames. So she said, “You know what, I have to go back and come back with a new set.” We find that because of the difference in the cranium size, just the size of the frames needs to be different. That’s not a big deal at all.
But if you like, from an actual ophthalmology point, we find that a much higher percentage need glasses. I don’t know what the reason for that is, but that certainly is what we find. That’s why it is even more important to be in these communities. A much higher percentage of these kids do need glasses.
Senator Bernard: I would like to ask a question about the Indigenous Diabetes Health Circle. I wonder if you could tell us a bit more about that and the connection you are making with that work in terms of this bill.
Ms. Urosevic: Thank you for acknowledging that piece. It is a great partnership that we have here in Ontario. The Diabetes Health Circle is our community partner to provide eye screening with around 20 programs or 20 areas across the province. So it is integrated.
We have a fundus camera that has AI built in it, and in 60 seconds, it will take an image of the back of the eye. That image is uploaded. If there is no access to the internet wherever we are doing our screening days, it can get uploaded later on. Someone from the community is the one that is doing the eye screening, so it is very culturally safe, and it is coordinated through the Diabetes Health Circle. Then it is transferred over to Kingston Health, where our partner in ophthalmology reviews the screen and confirms, just to make sure. We have added in that piece. And we coordinate the care. So whether or not there is travel to see an optometrist or ophthalmologist, we help to coordinate that care. If there are extensions of eye care that are needed, we’ll provide those services, again with our community partners.
It has been, as Dr. Sabri said, a journey of building trust and relationship. We are there to provide the training to the community and then offer any supports that are needed to coordinate that care.
In our first year of this program, we saw 100% of those who did have a test positive on their diabetic screen see an optometrist or an ophthalmologist within six weeks. A lot of these individuals did not have access and had not seen an optometrist in the five years previous to that. The number one that we’re screening for is diabetes.
If you are interested, I can provide more details on some of the outcomes of that program because it was evaluated with the Women’s Hospital of Ontario.
Senator Bernard: I have a personal interest. Thank you.
Ms. Urosevic: You are welcome.
[Translation]
Senator Cormier: My question is for Ms. Urosevic and concerns the accessibility of rehabilitation services.
When I look at your site, I don’t know if there are other organizations that offer the services you do; there are many regions where the population isn’t necessarily served by your services. For example, in New Brunswick, you offer services in Fredericton, Moncton and Beresford, but I imagine there are other regions where people need to travel. It’s the same in Nova Scotia and some other regions.
Given the way the bill is structured, do you think the national strategy will ensure that more remote and rural areas can have full access to these rehabilitation services?
Do you also feel that, in subclause 2(1), where the Minister of Health will consult the stakeholders concerned, the realities of these remote regions could be taken into account? Who should be around this table?
[English]
Ms. Urosevic: Yes, absolutely. Actually, through our provincial funding, we’re not clinic-based. We’re community‑based, so we travel into people’s homes and deliver rehabilitation services.
I actually have an office in Beresford, New Brunswick. Throughout Canada, we have 42 offices, but, really, there are small little hubs, sometimes integrated into hospitals and sometimes integrated into other types of clinics as well.
Our staff actually travel out to provide service because when you have lost your sight, transportation is one of the biggest barriers. Our orientation mobility specialists teach people how to travel, cross streets, navigate transit and travel to where they need to go to.
What I do think that the bill will address — to your point around the stakeholder — we definitely want to be part of the consultation and helping to build with our own lived experience, on how we have experienced the challenges of a rural and remote Canada in the territories as well as in each of the provinces. Every province has a rural area or a remote area. I think one of the greatest challenges that I do hope that the framework will build on is around an investment in the human health resources. We need more people to deliver these services so that we can do better outreach.
The technology is going to help. The first panel talked about the use of AI. I have talked a little bit about the use of some of the telemedicine, telerehabilitation, teleservices. Through the pandemic, we continued to deliver services. We were deemed essential in every single province so could continue to deliver services, and we have maintained around a 35-40% of virtual care to do that outreach. But there are some things that you can’t teach over virtual, like crossing a street and some elements of activities of daily living. That’s where we really want to see an investment. There are only two schools in Canada where you can be trained in this specialized area, so we have had to go south of the border and work in partnership with universities in the U.S. as well as our Canadian universities to deliver this.
There is much more work as the population ages, and we have a recruitment issue, so we are doing a lot of work hiring within communities where we have high populations or where we’re projecting that we will have high populations.
Senator Burey: Thank you so much for the passion and the commitment to this work, which is really from the heart. I’m a paediatrician, so I know what you are talking about, honestly, and the need for infrastructure and for help to do those kinds of things.
Dr. Sabri, you talked about the public health policy implications of this bill. Could you expand on that for us?
Dr. Sabri: As a paediatric ophthalmologist — it hasn’t been stated in so many words in the bill, but I hope this is an opportunity to bring this into it — I truly believe we need to have vision screening for all kids across the country. As I said, school is the best place for this. It is not happening currently, and where it is happening, it is an ad hoc situation.
The reason we took over doing it in Hamilton with public health was because I saw outside for-profit companies coming into Hamilton, and they made a mess of it. They made an absolute mess. We do not have time to go into the details. We went to Hamilton Public Health Services. We said we’d have a program. We are a not-for-profit. We do not make a dime out of doing this. We train McMaster students to go into schools and screen the kids, about 6,000 kids a year.
We need to have a plan for vision screening in schools in the urban areas. It is the best place to do it. It then raises public awareness among the parents, because all the kids we screen will go home with a letter. The child will say, “Mommy, Daddy, look, I have a letter from school. I had a vision test today.” In that screening, if the child fails the test, we say, “Dear mom and dad, your child did so-and-so on the test. You need to take them to the nearest optometrist.” It raises public awareness. For the schools, we need to do it in all urban centres. In the rural areas, the ICEE program is an outreach program that I think works very well, but we need to go out and screen in schools. We do not have anything like that in Canada. Even in Ontario where it is in provincial law, many public health units do not do it. Some who do it, do it badly. That is the reality currently.
I see kids every week who have lost vision permanently and needlessly because no one took them to an eye doctor in time, and that child has to live the rest of their life with one eye. Research shows if you grow up with one seeing eye, you are at three times the risk of losing that eye through accidents because you have less depth perception and peripheral vision. It is an absolute tragedy. It happens every week.
Senator Burey: Thank you.
Did you wish to comment on this, Ms. Urosevic? No. Okay.
I want then to ask you about clause 2 in the bill where it talks about the Minister of Health being able to rapidly approve devices and drugs, circumventing Health Canada. That does take some time. The question is, do you have any data available on Health Canada’s current processing for applications and submissions for devices and drugs for eye care? Do you have any information on that?
Dr. Sabri: I don’t personally, no. I cannot speak to that.
Ms. Urosevic: We are a collaborator and often submit endorsements to some of that cycle. I do not have anything on me right now. We could follow up with some of that information, if it is helpful.
Senator Burey: Thank you.
Do you see any unintended consequences, then, if the minister is just going to circumvent the Health Canada process?
Ms. Urosevic: There still needs to be a process in place.
I was at a conference earlier this year in Seattle. There is technology around AI that has been used for ten-plus years with incredible research that has been approved in the U.K., the United States and other parts of the world. It has not been approved yet here. Those are the pieces where there is evidence that has been existing for a long period of time. That is an area we need to look internationally at some of our global partners and build that collaborative trust. They have done some of that deep diving. I don’t want us to not have the rigour about treatments, and that’s not my area of expertise, but when I look at some of the devices that are becoming available, we need to ensure that they are accessible and affordable and that we want to invest. This could be game changing for a lot of Canadians and for practitioners providing that type of treatment.
Senator Burey: Thank you.
Senator Cordy: Are there countries that have national strategies that you are aware of and that work? Closer to home, are there provinces that do a better job of integrating eye care with other forms of health care so that it becomes more of a routine that when your child is taken to the doctor, the eyes are a part of that?
Dr. Sabri: As far as I know, no province has a good, comprehensive program province-wide.
When we did our publication looking at public health jurisdictions in Ontario, we asked them if they were honouring the vision screening senior kindergarten kids should have, and more than 50% of the jurisdictions said, no, they weren’t doing it. This was published only three or four years ago. No province has it working perfectly. I know some cities where they have something, but no, there isn’t a good program.
For example, I read publications where in some cities in the U.S., they might be encouraging paediatricians, for example, or family physicians to take on the role so that when you are giving the child a vaccine, you also check their vision. The doctors say, “Look, we’re busy enough. We’re doing a million things.” Some companies have made these point-and-shoot devices where you point at the child and press a button, and it will measure if they need glasses. They’re called autorefractors, and they made it for the specific purpose of having paediatricians and GPs use them, but again, they are busy enough.
There isn’t a good program in any one province, I would say. You will find one area will do something and one area won’t. One area sends optometrists into the schools, and one area doesn’t, which is why I believe what we do in Hamilton is the best. We have the data to show it. It works well. We train almost 100 students from the university every year. They go as volunteers into the schools. They screen all the senior kindergarten kids. It’s not for profit. There’s no conflict of interest. We send all the kids who fail to the local optometrists, which is why the optometric community has welcomed it.
Senator Cordy: Your document also gives a lot of information.
Dr. Sabri: Yes, and we have been published in IMACS and journals. We have the data on how it works, its impact and how it raises awareness in the community.
The Chair: Briefly, Dr. Sabri, if you are able to do this with medical students at McMaster University —
Dr. Sabri: Health sciences students, yes.
The Chair: Undergraduates. Why can’t you do it at the University of Toronto?
Dr. Sabri: We can. I’m delighted to be here to share this. We published on this. I hope to organize a conference with the school boards, at least around Toronto, Hamilton and Niagara to share this. This is something we have done in Hamilton. The school boards love it. Public health loves it.
We are doing it ethically. Just to go to that little point I made earlier, the reason I started doing this was I found that when there were some for-profit companies doing it — and I do not have anything against profit — but they were going in schools and failing children who shouldn’t fail just to sell them glasses. When I saw this, we went to public health. We met with the chief public health officer of Hamilton and said this has to stop. We took over doing it. We are transparent. It is a fantastic model. We have run it for six or seven years.
This definitely could be expanded across the country. The students love it. I get a number of emails from McMaster students. They love the idea that they are going to the community, and at McMaster, as of last year, we made this training to be a vision screener a credit course they can take.
[Translation]
Senator Mégie: When we talk about prevention, we’re talking about advertising for the family, the school, teachers, and so on. Are there any data on the effectiveness of these advertising methods? Does it reach the school and teaching staff so that they can put it into practice? Are there any data that tell us that this type of advertising is more successful in reaching this group of people? I don’t know if there’s any data on that.
[English]
Dr. Sabri: Is this a question for me?
[Translation]
Senator Mégie: Yes, or Ms. Urosevic.
[English]
Dr. Sabri: I can certainly speak to the fact that we have the data to show the number of children in Hamilton who had never had an eye exam before. It is a significant number. As to what impact that has on the teachers or educators, I cannot speak to that, but certainly all of the schools welcome us with open arms.
A few years ago, an eight- or nine-year-old was sent to me. He was branded as a difficult, disruptive child. He sat in the chair. I said, “Read the chart.” He said, “What chart?” He was blind in both eyes with cataracts, and he was nine. Certainly through what we do, I can say we also raise awareness amongst the teachers because many a child has been labelled as disruptive or difficult, and they are just blind. That is why they are disruptive and difficult, but no one knew. We are certainly raising awareness amongst teachers as well. I do not have specific data to speak to that, but certainly it raises awareness amongst them too.
[Translation]
Senator Cormier: You mentioned the testimony of Ian White, who was here last week. I was very impressed with the clarity of his testimony.
Mr. White talked a lot about factors other than the medical ones, such as factors of adaptation, integration, the ability to live in society, all the issues that come with this new life of a person who loses their sight, and the variety of realities. There are a whole range of realities for people who lose their sight. It’s not a question of seeing or not seeing.
Does the national strategy take sufficient account of all the social factors that need to be considered, or do you think the Government of Canada intervenes in other ways to take these factors into account?
[English]
Ms. Urosevic: I think there is a way for us to do so. The important piece is that every individual is experiencing life differently. How vision impacts their daily living, impacts their life journey, could look very different. We are a client-centred care. Through our initial intake and client navigation, we have pathways of service and specialists who focus on the clients’ goals. It is goal-focused. People come to us throughout their life journey. They start with us and learn the comprehensive rehab or rehabilitative services that they need. Then they live life. As environment changes, a new subway gets put in, new bus stops, changing in location of your doctor possibly, or your vision changes, you would come back to us. We are with people throughout their lifespan when they need us.
Once they are diagnosed and that treatment happens, our relationship with optometry and ophthalmology and their health care providers is along that entire journey because they are giving us information on some of those changes. Our staff are so adaptable in the techniques that they learn in school to work with each individual client, and they have to pull out many different tools and resources. What works for one person may not work for another.
We have clinical standards and practices. We work globally and internationally with other organizations similar to ours to continue to take a look at and leverage technologies and emerging technologies as well as emerging practices and new ways to deliver services.
Senator Cormier: There is no money attached to this bill. Do you have enough money to do your job? It seems there is a broad —
Ms. Urosevic: There is still a long way to go. Since we are no longer funded from a charitable model and we are fully funded or funded under provincial health and the two federal programs, we are meeting the needs of clients today but not for the future. As people age, as our clients grow and need more services, of course, there are pieces. That is our responsibility as an agency to go back to our provincial health or our federal partners on the new things that are needed. I do not necessarily look at this bill as that is an only avenue but as a way to say we want to have a health care system and eye care is important too. That is what we can leverage to build a future that is important for everyone.
Senator Cormier: Thank you to you both.
The Chair: Thank you to our two witnesses.
I think I speak for my colleagues when I say to both of you that your community-based approach to diagnosing children with vision-care problems is, frankly, exemplary, and I hope many Canadians will read this witness testimony to urge the federal government and, frankly, the provincial governments to do what is right for the eyesight of our children.
Thank you, colleagues. This brings us to the end of our study of Bill C-284. We will proceed to clause-by-clause tomorrow. If you intend to move amendments or observations, you are encouraged — if I may say, you are required, but I am not allowed to — encouraged to share these in advance of the meeting and, please, make sure the translation is absolutely accurate.
(The committee adjourned.)