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

Issue 66 - Evidence - September 10 (Afternoon)

OTTAWA, Tuesday, September 10, 2002

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 2:07 p.m. to examine the document entitled ``Santé en français — Pour un meilleur accès à des services de santé en français.''

Senator Yves Morin (Acting Chair) in the Chair.


The Acting Chair: We continue our examination of the document entitled ``Santé en français — Pour un meilleur accès à des services de santé en français.'' This afternoon, we welcome, among others, Ms Arsenault, from the Centre communautaire Évangéline. She has previously appeared before our committee, and Mr. Romanow has cited her publicly as one of the models to follow. We also have Dr. John Joanisse, of Montfort Hospital, Ms Suzanne Nicolas from the Centre de santé de Saint-Boniface, and Dr. Denis Vincent, of the Comité consultatif des communautés francophones en situation minoritaire.

We welcome you and thank you for coming. I would remind you that you have approximately six or seven minutes to make your presentation, and that will be followed by a question period. The question period is always too brief. We always have questions we would like to ask and time prevents us from doing so. So I would ask you to make your answers as brief as possible. You have submitted documents to us which we are going to read carefully. I now give you the floor.

Ms Élise Arsenault, Director, Centre communautaire Évangéline: It's good to be able to make a presentation a second time, and it's even more pleasant to be able to do it in my language.

First, thank you for your invitation, and I would like to congratulate you for undertaking an in-depth study of the issue of health in French. I'm going to speak briefly about the Centre de santé communautaire Évangéline as a place of welcome and a model for minority health care delivery.

The Centre de santé communautaire offers a program of Services communautaires de Santé Prince-Est, one of the four health administrative regions of Prince Edward Island. We operate in partnership with the community to promote the health and welfare of individuals, families and the community. We serve a population of approximately 3,000 inhabitants, more than half of whom are of Acadian and francophone origin.

On our multidisciplinary team, we have a public health nurse, a speech therapist, a mental health consultant, a part- time occupational therapist, a secretary-receptionist and a coordinator. In little time, the Centre de santé Évangéline has become a community service hub where people can get information about their health and be referred to professional health care.

In a survey conducted in 2000, the Centre's clients confirmed how important it was for them to receive services in French, particularly in a language respectful of the culture of the region's Acadians. ``We're comfortable, we're at home, these are our people,'' one client told us. The comments heard in the interview highlighted the cultural component of health-related activities. Certain clients said they wanted health professionals who not only speak French, but who can also understand their regional expressions and their deepest values.

Others said they had to feel secure in order to talk about their health problems and that it was difficult for them to do so with caseworkers whose vocabulary was beyond them.

Before the Centre de santé was established in the region, francophones did not know how to access services. The number and nature of information requests we currently receive at the Centre reflects this situation. On the other hand, the Régie de santé had very little knowledge of the needs of the region's individuals and families, which made it more difficult to plan and deliver programs and services. The opening of the Centre de santé contributed to a new energy. Closer relations developed between the community and the formal system. Now service delivery is based on needs, and access to first-line care has vastly improved. In the past, people often went without services because there were none in their language.

For example, if a unilingual anglophone public health nurse has to assess the overall development of a four-year-old child who does not speak English and part of the assessment includes language evaluation, the parent is of course asked to act as a translator. So the question arises: is that assessment a valid assessment? The same problem arises with the other services such as speech therapy. How can a unilingual anglophone speech therapist help a francophone child who has language problems? As you can understand, it is important to have services in French when you're talking about accessibility.

Early intervention is really very important, and we must absolutely ensure that francophone children in this country are not deprived of the services they need to grow and develop.

Our experience at the Centre de santé communautaire Évangéline confirms the findings of the study on the importance of language in the effectiveness of care provided. It is true that the language barrier reduces demand for preventive service, and increases consultation time and the number of diagnostic tests. The likelihood of error in diagnosis and treatment affects the quality of services provided, reduces the probability of compliance with treatments and lowers satisfaction with care received by users.

We very much believe in the community development philosophy and in our approach to health promotion and disease.

Community partnerships are very important to the Centre's success. In working closely with the community, we can start to attack the root causes that negatively affect health determinants. The Centre's caseworkers work closely with the school system so that students can receive the interventions they need to perform at their highest level. By working as part of the multidisciplinary team, caseworkers are able to monitor the child's overall development in the pre-school years and begin therapy as soon as possible.

The Centre is also currently involved with other partners in developing a self-esteem kit. We are working to produce and present sketches depicting situations in which children's self-esteem can be increased or broken down. We very much believe in public education as a tool to prevention.

We are also very much involved in crime prevention issues and are working to reduce violence and poverty in our communities. The Centre de santé communautaire Évangéline has become a very important player on the community scene. We have carved out a position and are helping to provide health care to the community. People in the community feel that the Centre belongs to them and that they control it, unlike other health services in the district. They tell us their needs and ask us to help in improving residents' health.

The opening of the Centre de santé communautaire had an impact on the entire question of supply and demand. The province's francophones now request more services in French, and the government of Prince Edward Island has undertaken to improve access to health services in French.

The community now wants the federal government to assume a leadership role in this regard by providing financial support to the provinces that wish to offer more health services in French and to include a sixth principle in the Canada Health Act.

The Acting Chair: Thank you very much, Ms Arsenault. I now give the floor to Dr. John Joanisse, Vice-President, Academic Affairs, Montfort Hospital.

Dr. John Joanisse, Vice-President, Academic Affairs, Montfort Hospital: It is an honour and a privilege to speak to you on behalf of the ACFA, as a humble representative of that proud francophone institution, the Hôpital Montfort. In recent years, the name of Montfort has become synonymous with the courage and tenacity of all Canadians of French language and culture who desperately want to preserve their language and culture. The powerful symbol that Montfort has become for all francophones in the country over the past five years of struggle for its survival goes beyond the health care field. In fact, that symbol goes to the very heart of our conception of Canada, of our history, of our national values and, without question, of our Constitution.

I am a Franco-Ontarian. I have three degrees from the University of Ottawa. I've been a doctor for 30 years. I have been Vice-President of Academic Affairs at Montfort Hospital of Ottawa for two years now, having been, before that, chief of staff at that hospital, in fact during the worst crisis Montfort and the Franco-Ontarian community have known.

As you know, Montfort Hospital is still open and its administration, which I represent as vice-president, is here before you today and able to appear before you as a result of an all-out fight by the population of Canadian francophone patients from the 10 Canadian provinces. Montfort Hospital managed to resist the threat of closure over five long years and ultimately triumphed in the name of the francophone minorities and won its case before the Ontario Court of Appeal and the province's political authorities.

It would be a good idea to acknowledge the reasons why the public fought so hard were the same as those the Court ultimately recognized as right and valid in its decision in December 2001. The possibility of receiving health care in one's language was acknowledged as a constitutional right, as important and fundamental as the right to education for francophone minorities.

Even the Health Services Restructuring Commission of Ontario, an agent of the provincial government, could not revoke those rights. The commission acted in good faith and in the name of efficiency and cost rationalization, at a time when it was necessary to do more with less. However, we invite you, in your report, to avoid the efficiency trap and solutions that apply to the anglophone majority.

The Court readily acknowledged that those considerations were secondary to the rights of Canada's francophone minorities. The Ontario Court of Appeal went further in asserting that Canada would not exist without this fundamental principle.

In the Montfort decision, the Court of Appeal wrote:

The protections accorded linguistic and religious minorities are an essential feature of the original 1867 Constitution without which Confederation would not have occurred.

The court cites a 1932 Supreme Court reference:

It is important to keep in mind that the preservation of the rights of minorities was a condition on which such minorities entered into the federation, and the foundation upon which the whole structure was subsequently erected.

Lastly, in 2001, the Court of Appeal categorically held: ``The protection of linguistic minorities is essential to our country.''

As we often repeated during the Montfort crisis, Canada makes no sense if we cannot even preserve a single francophone teaching hospital in all of Ontario, in all of Canada west of Quebec. The Ontario government had attempted to take everything back to Bill 8, which concerned the protection of our rights. The court went much further in its judgment, and it would be wise for you to consider that in the report you issue.

Why attach so much importance to the rights of francophone minorities in the health field?

Others will talk to you about the fact that patients, particularly when ill, always revert back to their mother tongue. Perhaps I could elaborate on this idea. For patients or their families to be able to make decisions concerning their health needs, they must understand the full impact of the decision.

We are talking here about an entirely fundamental ethical question, informed decisions. If I become ill in a foreign country such as China, for example, I will definitely hope to obtain the best possible care and will be content with a physician who speaks only Chinese. In Canada, however, let us understand this once and for all. I am at home here, francophones are at home, in the country our ancestors helped to found, under a confederate agreement that guarantees our language rights.

Although very much involved in the French-language training and management of the French-language training of medical and health sciences students, I am above all a family physician. My career took many turns before focusing on the care of elderly patients. Among others, I treat patients who are coming to the end of their lives and, together, we face difficult situations and crucial decisions.

These patients are often suffering from multiple diseases and serious illnesses. They are confused and they are afraid. In some instances, they have lost their minds, and their families and friends must attempt to speak and act in their stead. I cannot conceive of how I could provide the same care, secure the full participation of patients and their families without being able to communicate information and without understanding the subtler aspects of their questions. Consequently, language is an essential tool for me.

Non-verbal language is all well and good, but there are limits. How do you effectively and respectfully transfer to a patient the information on which decisions are based if the language used is not the patient's language? This simple fact is important in all dealings between patients and health professionals, particularly when we're talking about primary care.

The many reforms proposed in the primary care sector have not taken into account communication in the patient's language. It is essential that senators be aware of this in their proceedings on the very important question of primary care.

The question of the training of health professionals in the patient's language will be addressed very eloquently by other persons appearing before the committee. However, we should also mention that Montfort Hospital triggered a very strong reaction among people. That was due in large part to the fact that what we were threatened with was not just the loss of an institution that could take care of people in French, but also of an institution responsible for training professionals who could provide those services elsewhere than here at home, that is to say in communities where francophones represent an even smaller minority than here in the National Capital.

The Court of Appeal acknowledged that we must not compromise health professionals, the teachers capable of training students in French with patients at an institution managed in French. Otherwise it was inconceivable to expect young francophone students — the next generation of health professionals — to be able to serve their communities in reasonable fashion, that is to say in the language of their future patients.

Francophone minorities can no longer afford to be bypassed by the initiatives, policies and decisions of all of Canada's government authorities. Lack of respect for the rights of francophone minorities, which are one of the fundamental values of the Constitution of 1867, has hurt Canadian francophones to the point where the extent of their assimilation suggests they could eventually disappear.

Now more than ever, francophones need this constitutional protection, and government authorities now more than ever have a duty and responsibility to respect it and ensure it is respected. In closing, I would once again like to encourage this committee to acknowledge what patients have demanded and what the Court of Appeal has granted the francophone public: the right to receive care in their language, now and in the future.

The Acting Chair: I would like to clarify one point. The committee you are addressing is not the one that will develop the Kirby report on the federal government's role in health care, but rather a committee that was struck as a result of the Senate's decision to examine the report entitled ``Santé en français — Pour un meilleur accès à des services de santé en français,'' submitted two years ago. The two are related of course, but the report we present will address the distribution of care. The committee is currently considering comments on that document, which is somewhat different.

I give the floor to Ms Suzanne Nicolas, Director General of the Centre de santé de Saint-Boniface.

Ms Suzanne Nicolas, Director General, Centre de santé de Saint-Boniface: I would like to thank the committee members for allowing me to testify. Three years ago, on July 2, 1999, the Franco-Manitoban community witnessed the birth of the Centre de santé de Saint-Boniface. It was a great day.

The Centre de santé Saint-Boniface is the first francophone community centre in Manitoba. It has brought together, for the first time, a team of francophone primary health care professionals. The team's mandate is to serve the francophone population of the City of Winnipeg.

How did the francophone community manage to start this project? I believe there are a few key factors here that should be mentioned in order to show what can be done when a community mobilizes and close cooperation exists between key partners. The turning point for the francophone community of Winnipeg came after the study conducted in 1994 for the regions of Saint-Boniface and Saint-Vital. The findings of that study clearly showed that there was a shortage of health and social services in French. There was also a desire among francophones to be served in their mother tongue.

The francophone community then mobilized and played an important role on a working committee established by certain managers and health professionals interested in the question. The Collège universitaire de Saint-Boniface, the Société franco-manitobaine and the Sœurs-Grises du Manitoba jointed forces with the working committee to establish and consolidate the initiative, thus enabling francophone communities to govern and manage primary care services in French.

Manitoba benefited from the political will of the time to advance the question of health services in French. Despite the Centre's great success, we still face major challenges. In Manitoba, only 4.5 percent of the population is francophone, approximately 50,000 inhabitants. Those people are spread over a vast area, with a core of approximately 25,000 francophones in Saint-Boniface itself.

So it is a perpetual struggle to secure French-language services for our Franco-Manitoban community. The Centre de santé cannot serve the rural francophone population because its mandate limits access to francophones in the City of Winnipeg. It should be noted that many francophones in rural Manitoba want access to the centre's French health services and are prepared to travel hundreds of kilometers to get there. However, the services are not available to them.

Eighty percent of the centre's staff are francophone and 40 percent of those francophones come from across the City of Winnipeg and travel long distances to obtain services in French. Surveys conducted at the centre show that the main reason people go to the centre is to receive services in French.

Once again, the francophones of the City of Winnipeg are viewed as privileged, and the centre is even being accused of discrimination because we can't accept francophones from rural Manitoba. Wouldn't it be possible one day for francophones from rural Manitoba to have access to health and social services in French without being forced to travel very long distances?

Would it not be possible for people from rural areas to have access to the centre's services that can meet some of their needs? We acknowledge that different regions have different needs.

As a result of the provincial government's great openness and privileged treatment of us, we were very pleased to see the centre created. However, very few resources are allocated to promotional and prevention activities, treatment of health problems and reinforcing community capabilities.

I would dare say that we're working miracles with what little we have. And yet we've barely scratched the surface. How can we improve the health of the Franco-Manitoban population and its appropriation of health services when we only have a minimum of resources at our disposal? The centre's experience shows that, if we make the service available and accessible, people will come and will come in large numbers. We have long waiting lists.

Francophones in the Winnipeg area criticized the fact that we can't give priority to francophones since our mandate also calls for us to serve anglophones in the St. Boniface area in an equitable manner.

We have created expectations in our community, and the community now wants results. It is increasingly demanding health and social services in French, and we are limited in what we can offer them.

We talk a lot about our clientele, the clientele of the centre and others as being recipients of primary care services. However, allow me to focus on the internal clientele, that is to say the employees. All the centre's employees have come to work at the centre in order to have the opportunity to work in French. The place where they are received is not only extremely important for the external clientele, but for the internal clientele as well.

Our employees, our health professionals need a place where work is done in French in order to promote the language among the staff and with the clientele.

We realize that a number of health professionals work in an anglophone environment and that we need to create not only a place where we can bring them together, but also a network of francophone professionals so that they can provide each other with mutual support and continue growing and developing in their work in French.

The Centre de santé is currently self-governed and self-administered. This enables the francophone community to take charge of itself and make decisions that meet the needs of their community. However, I can assure you that this is not an established fact. This fundamental question is being extensively debated. We are a very small core surrounded by a critical mass of anglophones continually attempting to invade and assimilate us.

History clearly shows us that, when health services are governed and administered by anglophones, there is no guarantee that francophones will be served fairly. The only way to ensure continuity of top-quality services in French is for governance and administration to be assumed by and for francophones.

What more do we want in Manitoba? We are a very small francophone health centre which serves a very few francophones in the City of Winnipeg. The Centre is currently self-governed and self-administered. We have managed to recruit a certain number of bilingual professionals. We are able to meet certain needs of the francophone clientele. What more then do we need to deliver health and social services?

We need the federal government's support in making health care accessible to francophones, not only those in Manitoba, but also those living in a minority situation in Canada.

Our provincial governments need to give this question greater priority, and they need the federal government's support to achieve their objectives. Our provincial governments need to agree clearly that the federal government will give priority to the delivery and development of health and social services in French.

We who are working and making major efforts to develop strategies, initiatives and action plans, we need a concrete commitment from the provincial government. We need to be reassured that the provincial government will not let us down and push us aside. We need resources to implement the strategy, initiatives and action plans that will improve the health of French-language minority Canadians.

The Acting Chair: It is unfortunate that there are not more people in the room to hear you; you are convincing. A question regarding a detail: Saint-Boniface is part of Winnipeg, is it not?

Ms Nicolas: That's correct.

Dr. Denis Vincent, Comité consultatif des communautés francophones en situation minoritaire: I have been a family doctor for 13 years. For 10 years, I worked in the francophone rural area of Peace River, 500 kilometers north of Edmonton, and I have been back in Edmonton for three years. Although Franco-Albertans represent only 2.5 percent of the population of Alberta, there are nevertheless 65,000 of us. As a result of family ties and friendships and contacts in the school and professional spheres, people know each other well.

In Edmonton, for example, francophones really form a village within a city. I have an office with another francophone doctor in the francophone community centre in Edmonton's francophone neighbourhood.

I work in the same neighbourhood where I grew up. I very often care for people who have always been around me, school friends, their families and relatives, my former school teachers, friends of my parents and people from the parish. I meet new arrivals to Alberta, of course, Acadians and Quebecers, but also Africans, French and Belgians. This francophone community is a fascinating one.

In addition, as a result of the energizing impact of French-language schools, the Albertan francophone community has experienced a remarkable renaissance and optimism over the past 15 years.

However, as is the case of many minority cultural communities, when we talk about health, our community perceives itself as being outside the present system. Our participation is not sought out. Our specific needs are not considered. We are told that, if authorities had to concern themselves with the specific characteristics of one group, they would have to do the same thing for all other groups, as though that were a bad thing.

In the recent periods of restructuring and cuts, our health system has become too focused on itself. Attention is fixed on the system's efficiency and rationalization. Care management is centralized. Care is generic and delivered to everyone in the same way. And yet, of course, everyone claims that the health reform should be based on the patient.

Who supports those patients? Who sees them every day? Who can better understand their family situation, their support network, while still being aware of their culture and language? Who can better help patients take responsibility for themselves, take charge of their own health, support them in the progress they make? It's of course their family, friends, the people in their neighbourhood and their cultural community.

The fact of the matter remains that, outside my office, there are few resources to which I can refer my patients. There is no home care in French, no extended care centre for francophones who are losing their independence, no dietetic service, no program in French for diabetics of cardiac rehabilitation, no prenatal courses, no early childhood intervention program and so on.

In the past two years, I have sat on a minority francophone community advisory committee. Our community can see the growing energy and enthusiasm of francophones outside Quebec for the health sector. Although there is definitely an aspect of claiming minority rights, I contend that the primary motivation is the desire to be able to better help our people, to provide better care to them, with compassion, kindness and respect.

Francophones outside Quebec do not merely want to be recipients of services. We don't just want to be outside the system so that we can receive services. We want to take part in the supply of those services; we want to contribute actively as an integral part of the health system.

We think we can help the health system better achieve its objectives. There is ample evidence that the services provided in the patient's language of choice and in a cultural context are more effective, less costly and result in greater satisfaction for patients and caseworkers. In fact, in our case, who could better help our people than us? That's our challenge. How can we help our people to stay in the best health?

So there is room for a new health resources management model that ensures the minority communities take part, a model based, of course, on patients, but through the communities that support them. This participation is not limited to consultation, but must include the administration and delivery of health care, from networks and primary care clinics to home care and hospitals, from perinatal health to health at school, and from early childhood to long-term care.

I refer again to the example of the human wealth that has blossomed in our communities with the growth and development of French-language education. Today we have thousands of teachers in the francophone and immersion schools. These people are making an invaluable contribution to shaping the Canadian society of the future. All Canadians benefit from this.

For us francophones, the health sector presents an equally exciting challenge. Health represents not only care for our people, but also jobs for our young people, economic strength for our community, a means of integration for new French-speaking Canadians, and a way for our community to grow and develop within a diversified society. We believe that all Canadians will benefit from this project.

The Acting Chair: Do any colleagues wish to put questions to our witnesses?

Senator Pépin has a particular interest in the health field. She was a nurse and was enormously involved in the question of women's health. So it is in a twofold capacity that she will ask you questions.

Senator Pépin: Ms Arsenault, you spoke about primary care and child assessment. This is one of the first times we have heard talk about care that might reach children. You spoke about assessment of a four-year-old child by someone who does not speak that child's language, and about the need for accessibility in this area. You have managed to establish an accessible program for people in your city.

To be able to help and make general recommendations for people who would like to do something in this field, what are the most important things with regard to doctors and social workers? What are the points, the personalities, the people needed in order to start? What minimum do we need to ensure success?

Ms Arsenault: In Prince Edward Island, it is public health nurses who have the role of immunizing children. The nurses go see pregnant women, do prenatal education, then visit them at home once the baby is born and do the two- month, four-month and six-month visits. The nurses thus see all the young children in our community.

In working very closely with other health professionals such as speech therapists, occupational therapists, mental health consultants, nurses are in a much better position to detect the problems that a child might have. It is by working as part of a multidisciplinary team that a person is able to ensure that the assessment tools are adequate.

Senator Pépin: Are they nurse practitioners?

Ms Arsenault: In our case, they are not nurse practitioners. They are public health nurses who, among other things, see to the immunization of children and language assessment.

It is important that all professionals be at the same level, as specialists in each of the fields. We have realized that isolated professionals tend to refer patients to another office, but do not know whether the choice of office they have made is the right one. However, a professional who works very closely with his or her colleagues, becomes much more capable of referring children very early to the appropriate office.

A child may have a speech therapist, for example, from the age of nine months; the same thing is true for twins who have language problems. So we can intervene early, and that's somewhat the beauty of working as part of a multidisciplinary team.

We are also discovering other aspects. For example, we have been able to put an occupational therapy professional on the team. We always want to expand the team. In early childhood, it would be important to have a family doctor, for example, but it's difficult to take the next steps. We can do a lot when we work as a team.

To give you an idea of the impact of professionals who work together, consider the example of a four-year-old girl who spoke with a loud, thick voice. The public health nurse had a lot of trouble understanding her. So she was immediately referred to the speech therapist. An appointment was made within a week. The assessment showed that the girl had a language problem because her parents were divorcing, and the girl had retained a great deal of rage in her voice, as a result of which she had developed large nodules.

We immediately referred her to a mental health consultant, and, in the space of six months, she was no longer being followed by the speech therapist. A year later, she was no longer being following by the mental health consultant. She would normally have been sent to a doctor, who would have referred her to a surgeon.

So it is important to go to the root cause of the problem.

Senator Pépin: You spoke about a partnership with the school system.

Ms Arsenault: Our centre is concerned with prenatal health: that is with everything concerning sexuality, menopause and pregnancy. We deal with the health of children from birth to six years of age in a school and community health context.

In the school health context, we work very closely with caseworkers and teachers in the school system. We are part of a team and we try to detect problems in children, again as part of a multidisciplinary team with school professionals. We work not only with students, but also with the teaching staff. For example, we organize health clinics for system teachers because, if the teachers aren't well, that's going to affect the quality of teaching.

We also address situations in a comprehensive manner.

Senator Pépin: When I was a young girl, we had health unit nurses who did exactly what you just described. There is probably still a great deal of room for nurses in the field.

Senator Losier-Cool: Congratulations to the Évangéline region.

Where are your staff and all these specialists trained? Can they get training in Prince Edward Island? Are they people from the Évangéline region or from the outside?

Ms Arsenault: There are currently 10 of us on the team, including the occupational therapist, who is part time. Four are from the region. They went to study in Moncton or to Charlottetown to study English. The speech therapist studied off the island, but came back. They worked in the health system, but not together. They often worked in the health system, but people did not know they were francophone. It was really by bringing people together that a core was created. All those who enter the centre can receive health services in French.

Senator Losier-Cool: Provided by people from the region?

Ms Arsenault: Yes, but one day we hope to be able to train people in French in Prince Edward Island.

Senator Pépin: Ms Nicolas, there is something I do not understand very well. You explained how things operated at Saint-Boniface. Why don't rural people have access to your service? Is that a condition set by the government or is it because you cannot afford to provide the services?

Ms Nicolas: It is largely because of the mandate we received from the Department of Health. That mandate is limited to the city. We are called upon to serve a population of 100,000 inhabitants. Of that number, there are approximately 70,000 francophones or French-speaking persons. The department believes that, to be able to serve people from the city and to do it well, they had to limit the clientele to people from the city. That was the mandate. It was in the form of a pilot project for the first three years. We are starting dialogue to see whether we can expand the mandate.

Senator Pépin: Couldn't a team trained by your organization open another centre?

Ms Nicolas: That is definitely part of the discussions we're having. However, our resources are limited. If we spread ourselves too thinly, we'll become ineffective and be unable to provide high-quality service.

Senator Pépin: My next question is for Dr. Vincent. It is interesting to hear that you received your training in French, that you set up outside Edmonton and that you returned there.

It is one thing to attract francophones so that they can receive training in French in the health field, but it's quite another thing to convince them to return and work in their province or city. They may come and study in Ottawa, Sherbrooke and so on, but, following training, how do you encourage them to return to their region?

Dr. Vincent: There are two situations in Alberta. There are young people who come from the rural areas, who can't wait to get out of there and never return. And there are young people who live in Edmonton for whom it is quite simply easier to live with their parents than to go and study in French in the east, which would cost more money. You have to boost young people's pride and enthusiasm for them to go and study in francophone schools. I see that the francophone school has done a great deal in our community to increase that pride. Our young people are more likely to leave and study, then return and contribute to the community they love.

Senator Pépin: You mean in their region.

Dr. Vincent: Yes, to go home. What limits us are the opportunities for studying in French. It is all well and good to believe that you can go and study in Ottawa, Moncton or Quebec City, but it's not easy if you don't have the opportunity to go home to do work terms and rebuild ties with the community. In that case, you're less likely to go back.

If students could do work terms in their community, it would be even better. I realize that this may not be possible everywhere, but there is potential all across the country, from British Columbia to the Maritimes. If we invest a lot in training, we'll be able to create better opportunities for our young people. For the moment, our choices are limited. It's probably easier to study in English because that's not as expensive. If we want to send young people across the country to do work terms, we must set up a good scholarship and travel program to enable them to travel.

Senator Pépin: The important thing would be to have training in French everywhere.

Dr. Vincent: If you know there is an opportunity to work in French, that's promising. If a young person perceives that professional life will simply happen in English, why would he go study in French?

Senator Pépin: Dr. Joanisse, Montfort Hospital is now a jewel, but I'm going to leave the legal questions to Senator Morin. It's an institution that has opened its doors to other francophone communities across the country, and it has been established that French is a constitutional right, like English. This morning, we talked about various institutions in New Brunswick, the University of Sherbrooke and the University of Ottawa, which provide training in French. Do you think there could be other postsecondary institutions that could provide training in French to health professionals? The federal government will definitely be asked to grant other moneys in this field.

Dr. Joanisse: That is a very good question. This is important, without a doubt. It also goes back to what Dr. Vincent was saying, not to focus everything on the big city, on Ottawa or on Montfort. It's a problem we're dealing with at the National Training Centre, a federal initiative that provides money for training. You've no doubt already heard about it.

The problems Dr. Vincent has raised are really very important. First, how to kindle the interest of young francophones, who traditionally have not contemplated the possibility of being a doctor or nurse? What's a nurse practitioner? We don't know. The National Centre's first mandate is to raise interest. That's the kind of thing that's already being done at the University of Ottawa through the Bureau des affaires francophones. I'm talking about medicine.

Second, we have to see how we can train young people in French in a non- francophone environment. That's very difficult. That's why we have chosen to concentrate a large number of activities in Ottawa, for example. We would like to do more in Saint-Boniface; we're already doing a lot in Moncton.

However, if we take young people out of their communities, first of all, it's costly and, second, how do you get them to go back? The solution is to make sure they do a lot of work terms in their home community. We partly addressed the problem through telesupervision. It's all well and good to send people to their villages, but you also have to control the quality of instruction.

It's becoming mandatory to telesupervise not only the students, but also the preceptor.

Distance training is an important component. However, if you put people in Montfort to train them, there is a shortage of patients and teachers. I believe we've tried to develop non-traditional francophone training environments. I'll speak from personal experience. With my partner, a nurse practitioner, in ``cooperative'' practice, at a long-term care residence, we train a number of disciplines at the same time. We have students, family medicine residents, nurse practitioner students and nursing students, all francophones, some of whom are at a 200-bed long-term care residence at the University of Ottawa and others at the Cité collégiale. It's the kind of thing that must be studied, non-traditional training environments. We have a geriatric population that is entirely suited to being approached by students, and we're doing ``cooperative'' training in the same way we take care of patients. That's understood. For example, patient approach training, taking personal histories, is still better done by a nurse practitioner than by a doctor, even a family doctor with 30 years' experience.

This type of approach is very important because we have so few teaching resources that we have to maximize the way in which all these people are used. I'm a doctor, but that doesn't mean that I won't be training in physiotherapy tomorrow.

It is important for francophones to aim for a new teaching model and to really stress the multidisciplinary side. If these young people return to their communities, they won't have the full range of francophone participants. Perhaps there will be a francophone occupational therapist. If there isn't, the doctor or nurse practitioner will have to take care of that. They'll have to be more flexible than our anglophone colleagues.

Senator Losier-Cool: The witnesses we heard this morning advocated a certain health program similar to that which exists in the official languages and education program. I'm thinking of the Centre communautaire Évangéline and the one you spoke of in Saint-Boniface. Dr. Vincent, you are no doubt aware of other centres currently in existence. If a new federal program were established, would you be afraid a certain amount of your independence was being taken away or would that supplement your work? What are your impressions regarding the recommendation that there be a number of francophone groups?

Ms Arsenault: I entirely agree with that approach. That will take away nothing from the health centre. We are prepared to react. We're currently serving part of our population. We're not touching the whole question of home care of the elderly. We have a building that is 34 feet by 50 feet.

This kind of program can get us moving. When we started talking about the advisory committee's report, the province got interested in it, as did the federal Deputy Minister of Health. They want to sit down at the table and talk with francophones. It is important that this dynamic process continue. Every time the federal government makes a decision, the province tends to want to move more quickly. That works very much to our advantage in the communities. The community is ready. We are serving only part of the population. Francophones in Charlottetown don't have the same services as people in the Évangéline region. Mr. Romanow's visit may have caused a little bit of jealousy. People contend that francophones cannot have better service than anglophones. We do not have better service; we are doing things differently. Service is delivered in a different way, based on people's needs. This kind of program would help a great deal.

We are highly disadvantaged with regard to health. I believe we won't have to fight for services and that programs will soon be put in place to enable us to move forward and answer people's health questions.

Senator Losier-Cool: Do you feel that the government of Prince Edward Island shows a political will to work with the federal government?

Ms Arsenault: And the community?

Senator Losier-Cool: At all levels. This morning we heard representatives from various provinces, but those from Prince Edward Island were not there.

Ms Arsenault: The province has already opened discussions. We have already prepared a frame of reference. A network will be established between government representatives and each of the health administrative regions, people from the Health Department, people from the community, from the education system and from the postsecondary education system who handle training. They are interested in the advisory committee's document and recommendation.

Senator Pépin: The report will be published by the end of September.

Senator Losier-Cool: Dr. Vincent, would you say that there is that same political will in Alberta?

Dr. Vincent: Yes, absolutely. When I was in the Peace River region, through Heritage Canada, we signed a 50/50 cooperation agreement with the Department of Health and Heritage Canada for a French-language health project in Peace River. We spent a great deal of time negotiating because we didn't know how it would work. It's still working. If managers can find effective ways to do things and to allocate funds, francophones will be ready. If there were a program, francophones would no longer be beggars who come with their pockets empty asking for services. We would have funds to get them ourselves, and health authorities would be prepared to offer them if we were prepared to pay our share. Partnerships could work. Anglophones are not opposed to francophones. They have to manage a big system. There have been cuts left and right. If we showed up with solutions rather than problems, they would be more open.

Ms Nicolas: I would like to emphasize that the federal government has not just been parachuted into the provinces without consultation or communication. Exactly the opposite. The federal government offers certain funds for initiatives, and that's always done through dialogue with the province and the community. We are very much involved, very much aware of those funds. In Manitoba, we are mobilizing as a community to gain access to those funds. The federal initiatives are very important for us. Our provincial government is very open and prepared to take action.

Senator Léger: My breath has been taken away. This afternoon, you mentioned the words ``initiative'' and ``dialogue.'' Not once did I hear that it was the federal government's fault or, vice versa, that it was the provincial government's fault.

Community development must be done from the bottom up. That's the only way to do it, to arrive at the top. Montfort Hospital has served as a model and it has been copied in Moncton for the George-Dumont Hospital.

Ms Nicolas mentioned the words ``by and for francophones,'' as though that were natural. You say that no one is against it and you request the federal government's support and commitment. Dr. Vincent spoke about the emphasis that is placed on efficiency rather than on the patient. There is growing enthusiasm; that's what I've sensed in the testimony this afternoon.

Senator Pépin: When we talk about home care, we often talk about palliative care. Someone said that there was no accessible care in French in a number of regions. They say you should be able to die in your language. Do you see any solution?

Apart from the money question, is there a door no one has knocked on? I sat on the Senate Special Committee on Palliative Care. The government is committed, but it is still difficult in certain regions. When we say there is no home care, that means there is no palliative care and people cannot die at home.

Ms Arsenault: Precisely, we see people who receive palliative care and who say that the health workers are all anglophones. Some people even say they are required to pray in English. That really shows just how important the home care question is. And yet very little funding is allocated to community care.

Francophones should have levers to enable them to enjoy palliative care in their mother tongue. That wouldn't be something the province would finance right away — at least not for francophones — since funding that care for anglophones is already difficult.

Let's not forget that there is the entire question of the $250-million transition fund. And we're part of that population.

Dr. Vincent: In Edmonton, we're talking about establishing an extended care centre. Because there are a few of us, we know we have to consider innovative solutions, find new models, and we're discussing palliative and home care.

What would prevent home care from being provided from an extended care centre? You also have to think about integrating funeral services at the extended care centre. When we can propose these kinds of solutions, managers are surprised because they have never seen this before. This clearly shows how important it is to give our opinion because we too can come up with good solutions.

Ms Nicolas: There are other very creative options in the area of technology which could enable us to provide home care, palliative or other kinds of care. For example, the Centre de santé de Saint-Boniface is in partnership with the CLSC d'Orléans in Quebec City. We're going to move on to the tele-home-care experimentation phase. That will promote the francophone clientele and put telecare tools at their disposal, at home. Data will be transmitted electronically to home care recipients.

We may not be able to reach an isolated region and to have francophones serving that clientele. However, we can have a francophone service provider who can sit in front of a screen and assess a client who may be 400 kilometers away. This highly innovative project is the first major project in the tele-home-care field in Canada. It must be said that IPOLC has given us a great deal of help in enabling Manitoba to take part in the project.

We have opportunities to maintain partnership relations with people from Quebec and Moncton. A francophone call centre would also be an option. I believe the ideas are there, the strategy is in place, and we have to take advantage of this and continue to move forward. I also believe that technology is to a large degree the answer.

The Acting Chair: I would like to emphasize that the CLSC Orléans project was funded by the federal government. And one of the conditions of federal funding was that assistance be provided to the francophone communities outside Quebec. That initiative deserves to be singled out.

I got interested in the project and I'm pleased to see that the initiative of helping the francophone communities outside Quebec is beginning to produce results.

Ms Nicolas: The $80 million comes from the Canadian Health Info-Structure project.

Senator Pépin: Once a year, we update all the recommendations and check to see how they are being implemented. We also look at where new technology stands in the field because that's important. Do you have anything to add on that point?

Dr. Joanisse: No, not really. Instead I'd like to come back to the fact that we need to be innovative. As Dr. Vincent said, we have to find specific answers adapted to our society, to our culture and to our resources. It's not always necessarily in a major city that we'll find answers, and it's not always doctors who can dictate the solutions.

Senator Pépin: You need to be very resourceful.


Senator Keon: Dr. Vincent and Ms Nicolas, how successful have you been in establishing networks in the hospital system, in the chronic care system and so forth? I make contacts with French nurses and French doctors who can care for unilingual francophones.

Dr. Vincent: When I went back to Edmonton, I set up my office in the francophone community. I figured it was a start. At one point we will get a network of services. It has helped.

I have privileges at the Grey Nuns Hospital & Health Centre. I am known to be a French-speaking doctor, so when specialists want to refer patients to a French-speaking doctor, they refer them to me.

I have had trouble getting other services in French. In Edmonton, there are three psychiatrists, three orthopaedic specialists and a couple of cardiologists who all speak French. I know personally a number of colleagues with whom I can work and who receive my patients readily.

I have trouble with the paramedical services. There are two French-speaking nurses who offer prenatal courses in Edmonton. However, given the way the system is organized, they do not have the budget to teach prenatal courses in French. In the past year, I had eight franco-dominant mothers who have not been able to get any prenatal courses. It is a glitch in the system, and we can find a way to make it work.

Home care has been centralized to the point where a different home care nurse calls me each time. I never see them. None of them speak French, although I know there is a francophone who works at the other end of the city. It is a big nebulous system, and we cannot get in touch with each other easily.

Among physicians, I can usually get services from colleagues. However, I have had much difficulty in the rest of the health care system.

Ms Nicolas: Our physicians must have admission privileges to the facility that has been designated to offer services in the French language. They have admitting privileges. These physicians follow through with their clients as they are admitted to hospital. That provides continuity.

St. Boniface General Hospital has 4,000 employees, 10 per cent of whom are French speaking. A great majority of them are found in support services. It becomes problematic to have hands-on care at the patient level in French, although there has been improvement.

With respect to long-term care, we do not have much of a partnership in terms of direct client services, but we do have a support services partnership in the areas of finance, payroll and human resources, for example.

As Dr. Vincent has mentioned, home care is problematic. There are about 2,000 employees in home care. It is a centralized program. It is extremely difficult to access French-speaking providers to provide the continuity of services. We have established partnerships, but many times we must communicate in English and our clients must receive services in English.

Senator Keon: Given my experience in Ottawa, I feel that this is a more powerful force than anything else we can do bureaucratically. The doctors develop a network and they develop knowledge of who can provide a francophone service. They use that network, and it really works quite well in many cases.

Recently a document came out by Michael Decter dealing with the tremendous shortage of nurses presently in Canada. When I read it a couple of days ago, I noticed that there was nothing in it about the French problem. I am sure that was just oversight.

This is an opportunity. If incentives could be offered to young people choosing the nursing profession that would allow them to deliver francophone services when they graduate, it might assist them. In addition, if they knew where the opportunities were — for example, in Edmonton or Winnipeg — they could target them.

Do you think that be would be a worthwhile endeavour? If you do, I would encourage you to make representations in that regard, and we could too, perhaps.

Dr. Vincent: There is a crying shortage of nurses, and we know it. There is a lot of potential for opening up programs across the country.

In Edmonton, the Dean of Faculté Saint-Jean is very interested in this matter. She has been looking at ways to open up a nursing program in Edmonton.

We always have trouble dealing with our university because it is new territory and people are afraid of change. We know that there will be a big peanut scramble when we put up all of these positions for nursing students.

We would like to participate in training and teaching nurses as well. The consortium of post-secondary institutions across the country would be ready.

We are worried about the timing and missing our chance to open up programs. We would be ready to have nursing students in Edmonton.

Ms Nicolas: We are extremely privileged in Winnipeg in that we are in our second year of an RN program in partnership with University of Ottawa. That program is being offered in French at the Collège universitaire de Saint- Boniface. The first class had 18 or 20 people enrolled. The last I heard, 30 were enrolled for the September class.

There is definitely an interest. Again, if we provide the service, the French-speaking people will come. It is definitely worth pursuing.

Dr. Joanisse: We must stimulate the interest and not rip these people out of their home towns, especially francophones. At a time when there is a shortage of nurses, what are the chances that we would attract a nurse from the city, train her in French and then have her go to a small community outside of where she was born to practice in French? The chances are not great.

Therefore, it is back to that which Dr. Vincent said in his presentation. We must get potential nurses from their community, where they are most likely to return, and somehow train them in French and maintain that attachment to whence they came. It is not easy, especially when it is a buyers' market.

My thing is non-traditional teaching. The distance-learning program that Ms Nicolas mentioned is through the national training centre. It is distance teaching by a consortium of two or three institutions, one being in Manitoba and the other in Ottawa. Laurentian in Sudbury is also part of it.

In this approach, you can have a virtual critical mass as opposed to having a critical mass as we have in Ottawa. Even then, we are at some risk. Technology is one of the ways to link the small communities across the country, but it does not beat hands-on, in-person meetings. We have to get to know each other by visiting.

Dr. Vincent speaks of Faculté Saint-Jean. I have been there and it is impressive. A nursing course there would be just great. To get started, they would need only minimal support from the francophone areas inside or outside Quebec. They could then obtain funding from the province.


The Acting Chair: Before closing, I would like to come back to the report because the committee's purpose was to study that report.

Dr. Vincent, I would like to come back to the problem we're always dealing with when we talk about care intended for minorities. When you talk about levels of care, levels of service, you talk about minimum levels, base levels, levels relative to population density. What we're constantly asked is whether francophones who live in a town of 10,000 inhabitants will be entitled to all the care and services to which the rest of the population is entitled.

You mentioned 60,000 inhabitants. I would like you to tell us about services relative to population density, but especially what you consider is a minimum level. In general, people have trouble understanding what services those who live in regions with low population density can expect to receive.

I would also like to have your opinion on level of care. We can start with Dr. Vincent. Since he signed the report, he may be responsible for it, but I also ask the others to comment on the level of care because that's an objection you must have heard and that we often encounter in relation to care for low density populations.

Dr. Vincent: The health system is not like the education system. In the education system, you have to fill a school with francophone students. You have to create an entirely French atmosphere, and the integrity of that atmosphere must be respected. In the health system, it's one on one: a care provider and a client.

Nearly one-third of my clientele is anglophone; they are anglophones from our neighbourhood. When they enter the francophone community centre — they are proud to have the centre in their neighbourhood — they see posters in French in the waiting rooms and, for them, it's also a process of sensitization to the French fact.

When I leave a room talking to a patient in French, respecting that person's dignity and needs, there is nothing preventing me from going to the next room and speaking English with the next patient and thus respecting that person's dignity and needs.

Community health, home care, should not involve services that are hard to deliver. As for dietetic services, physiotherapy and so on, we should find ways of delivering those services without building a hospital.

In Edmonton, we are able to have networks of primary care, outpatient services, home services, extended care services, and, I know, we will never have a hospital. That would be inconceivable. My work, for example, is to prepare my patients well in order to send them to a heart surgeon. If I prepare my patients well and do a good job of explaining things clearly to them, the surgeon will respect me for it. If I do my job well, the surgeon will not need to speak French.

The Acting Chair: Does someone else wish to answer?

Ms Nicolas: Technology can deliver care where the client is, with basic services such as a call centre, a francophone call centre which provides service 24 hours a day, seven days a week, in French. Let's talk too about home care, for example, about the technology for telehome care. With these services, I believe we can reach these people.

You have to get away from thinking about health care solely in terms of care that must be given or delivered by a doctor. There is a whole range of health professionals who can also provide the necessary services in highly innovative ways.

The Acting Chair: I am surprised that you emphasize this question of health information, of call lines, when, as far as I know — someone may correct me — there is no mention of this in the report.

You can have a telephone number where you can press 1 for service in French, 2 for service in English, in making a hotel reservation, for example. In general, health lines are not available in both languages, and you are right in saying that this is a service that saves a lot of trips to the emergency room and which is economical.

Ms Arsenault: We cannot really look at the question of population density since there are very few of us. There are 6,000 persons of ethnic origin in the province, and we represent 4.5 percent of the population. However, we are still able to do a lot of things with a small group. If we look at the health administrative region, we have 1,200 employees. There are five of us working at the centre, and we can still meet a lot of needs. Obviously, we cannot meet them all, but, with the turnover we currently have in the professions, openings continually occur. It is possible to add health professionals to our team because people are already supposed to serve our population in any case. When positions become vacant, we act on a proactive basis and staff those positions with bilingual people. We group them together and, when a person appears and requests service, he or she is immediately directed to the French-language service.

I was a social worker in a bilingual position for a year, but I didn't have any francophone clients because no one in the place knew I spoke French. No one told patients that there was a French-language service.

At the health centre, however, we are grouped together. Everyone knows that the professionals there are francophones, and, within the centre, we know the francophones in the system. That's what makes the difference. Sometimes it's not the number that makes the difference.

Senator Losier-Cool: According to your study, since we're talking about the report, are francophones in better health, sicker, in poor health, or less sick than anglophones? Did you find a significant difference regarding living conditions or the lives that francophones lead; I mean more sedentary life, differences in food habits? You don't know?

Ms Nicolas: In the study conducted in Manitoba, that question was not looked at. First, we don't have the resources to consider conducting those studies to determine whether francophones are in equally good health, in poorer health or in better health.

Health is linked to the determining factors of health. We know that the francophone population is aging at a faster rate, has less education and that fewer of them are in the labour market. Incomes and social status are lower than in the anglophone population. We might therefore observe, and certain studies show this, that health determinants are directly related to state of health.

One might conclude that francophones are in poor health. However, we have not conducted the studies. We have had little opportunity to conduct the studies identifying the health needs of francophones. Needs differ from region to region.

This touches on the question Senator Pépin asked at the very start, that is to say how we identify the professionals who will be put in place. Often people are put in place before anyone has determined the needs in the community.

We have to change our way of doings things, to consult the community and ask them what their needs are, and, from there, build a multidisciplinary team that will be able to provide services to that clientele.

Perhaps in regions with lower population density, if we have the resources, we could train mobile teams that would go into the more isolated regions once a week to provide multi-disciplinary services.

Dr. Joanisse: This is a fundamental question at the national health training centre, which had originally included a research component in its funding application. That was precisely in order to seek out that information since preliminary research has concluded what Denis whispered, that is that we don't know. However, no funding was granted, except in training for the second phase, which will start in April 2003.

There is a research component that will answer that question, questions such as those you asked, particularly regarding prevention. How to do prevention if we don't know what we're going to prevent? Prevention has a lot to do with the question of oral, cultural and inter-disciplinary interaction. If we do prevention, we have to have supporting figures, but we don't have them.

I have two particular concerns. One is tobacco prevention, the other fetal alcohol syndrome. In Western Canada, this is a frequent phenomenon. Research and prevention exist. But from the moment you get to the Ottawa River, there's none.

Is the approach to preventing that syndrome the same among anglophones and francophones? Is there a significant cultural aspect to the prevention and subsequent treatment of disease. I sit on an advisory committee for the federal minister, and that's a question that must be answered. We have trouble raising interest among francophones and are nearly told, ``Don't go there!'' It's a very particular situation.

We recognized that there was some interest in Acadia. Once again, is the problem the same there as it is elsewhere? We don't know. The cultural aspect is important in a number of respects such as post-cardiac rehabilitation, for example, for women's health. Are the approaches the same in minority French Canadian culture as in Quebec? These are very important questions.

Senator Losier-Cool: Some diseases are culture-related. For example, the Japanese or Asians have a lower incidence of breast cancer than Americans.

Dr. Joanisse: The national centre organized a research day at the University of Ottawa for francophone researchers from a number of disciplines. People were there from the health sciences, geography, the arts and so on.

The conclusion was that we don't really know how to raise funds or who the funding agencies are. We don't know what affects francophones or how to interpret results and treatments, and we turned to the University of Ottawa and Montfort Hospital. We asked them whether they could establish an institute that could take charge of this research because it is not recognized by the traditional institutes of the federal government.

Ms Arsenault: We regularly produce reports on the health of Canadians. In one of those reports, I asked whether it was possible to get a handle on the issue of francophones' health, as we did with Aboriginal people. I was told that, in terms of numbers, that was not posible. In Prince Edward Island, there are more Acadians than Aboriginals. And yet it's possible to do it for Aboriginal people. I would like to raise this question. The federal government must play a role that could without a doubt support our requests.

The Acting Chair: There are a million francophones outside Quebec. Surely that number is sufficient.

Senator Pépin: Following our sixth report, a committee will examine the health of Aboriginal people and women from a francophone perspective.

The Acting Chair: I would like to thank you on the committee's behalf. Your testimony has truly informed us and made us aware of the specific and real problems of francophones outside Quebec.

I congratulate you on your very real commitment to thewell-being of your fellow citizens. It is at times moving. You work in extremely difficult conditions. We don't always realize that it's a constant fight. I thank you and congratulate you.

The Acting Chair: We're going to hear Ms Andrée Lortie, who is part of the training component of our study. She is the President of the Cité collégiale in Ottawa and she's going to talk to us about college-level training in French.

Ms Andrée Lortie, President, Cité Collégiale: Thank you for inviting me, and I thank Senator Gauthier for bringing to my attention the fact that you were sitting on this subject.

The study recommendations were the result of quite extensive reflection by colleges and groups that provide college- level training in French outside Quebec. francophone colleges believe they are able to make a major contribution to achieving the objectives put forward in the study.

You'll excuse me if, in the course of my presentation, I often cite examples from the Cité collégiale, but it's a situation I know very well. However, it should be said that there are a lot of college-level activities right across Canada.

I would like to introduce Mr. Pierre Bergeron, who is the director general of the network of colleges and cegeps of Canada. You probably know him as the publisher of the newspaper Le Droit. He is also responsible for the organization that governs colleges and cegeps.

First, I would like to talk to you about francophone colleges. The francophone colleges outside Quebec are often poorly known. They were established to provide minority francophones with postsecondary education. The francophone colleges offering numerous one-, two- and three-year programs in the health field.

Since 1990, we at the Cité collégiale have trained more than 2,700 students in the health fields. I'm talking about the Cité collégiale, but I could also talk about the Collège Boréal in northern Ontario, about Campbellton, New Brunswick, or the Collège de l'Acadie in Nova Scotia.

The programs currently offered by francophone colleges provide training in the physical health sectors (paramedical care, mental health, support for social reintegration) and public health (palliative care, social work and dental hygiene). Training is also offered in specialized institutional care (nursing, institutional care, respiratory therapy), personal care and peer counselling (social work, gerontology, special education) and community care, as well as home care.

We also offer training in the primary, secondary and tertiary sectors. In the primary sector: personnel support employees, physical-therapy aids. In the secondary sector: paramedical care. In the tertiary sector: respiratory therapy and nursing care. These health programs are offered at various levels in all regions of Canada. Ontario is quite privileged because it has two college-level institutions: the Cité collégiale and the Collège Boréal. The Cité collégiale offers some 15 health programs, the Collège Boréal about 10. The Collège Boréal is located in Sudbury. In New Brunswick, the Campbellton campus offers six health programs: health care aid, nursing care assistant, community service intervention techniques and so on. In Nova Scotia, the Collège de l'Acadie offers programs in ambulance and paramedical care, health and continuing care services.

Of course, in the West, when one considers what's going on in the health field, be it in Manitoba, Alberta, Saskatchewan or British Columbia, college-level programs do not currently exist, although there are college-level activities. There's a great shortage in this area.

Our francophone colleges train health professionals in partnership with our communities. When you say ``community college,'' ``community'' means working with the community, living in the community. In most cases, that also means that there is a significant partnership component in that community.

Consider, for example, the places where technology and radiology work terms take place. In technology, in medical laboratories, training is given at George-Dumont Hospital in Moncton to students of the Collège communautaire du Nouveau-Brunswick. Dr. Joanisse briefly mentioned the number of partnerships created with Montfort Hospital. The community colleges providing health programs must also have advisory committees composed of people from the public and private sectors and community agencies. They advise institutions on the type of training they should provide. The community colleges are thus truly integrated into their communities and work in partnership with the colleges and universities. I cite the Cité collégiale as an example because we have developed the following programs with the University of Ottawa: social work, gerontology and nursing. The world we live in is increasingly concerned with continuing training. People don't necessarily stop their training after their first diploma. When we talk about solutions, about access to health services, colleges are used to working together and are increasingly doing do. I mentioned the Collège de l'Acadie, which offers a course in ambulance care. The Cité collégiale has worked with the Collège de l'Acadie. The programs and teaching material were already developed. A relationship has been created and the Collège de l'Acadie now offers this program in its community.

The colleges increasingly want to work together to adopt a common vision. Education may be seen as a cohabitation of various silos. Many institutions implement programs and do not always cooperate among themselves. At the college level, you can no longer reinvent the wheel. In health training, greater cooperation must be promoted. The network of colleges and cegeps of Canada plays the role of catalyst in leading these institutions to work together.

Francophone colleges outside Quebec must be part of the solution to the problems experienced with regard to access to health care services. As regards the national health training centre, the colleges have prepared a proposal which they have submitted to the consortium. That proposal was well received by the consortium, but required a significant amount of organization and assembly work. I see that the colleges, at round tables, have now recognized regional differences: Ontario is not New Brunswick or British Columbia; it's something else. We must adapt to different situations, not reinvent the wheel or fail to cooperate. We were talking about the size of supply that creates demand. When the Cité collégiale was established in 1990, it was thought that it would be the worst failure in the world and that francophones wouldn't send their children to francophone institutions since the labour market was bilingual. We started out with 1,800 students and now have 3,500. It wasn't supposed to work. The supply was there; demand came afterward.

Francophones constitute a minority; at the college level, we will not be able to advance unless we build on what we have: who has done what, how and where? How do we adapt? How do we build on it? Our challenge is to realize the importance of managing francophone institutions by and for francophones. In Ontario, we saw that francophone training at the college level was not developing. Francophones didn't seem to be interested in it. The day francophones were told that they had to take responsibility for it and that it had to work, they said to themselves that, instead of convincing anglophones that certain things had to be done differently, they had to set to work in an effort to succeed. What strategies would be adopted and how would they organize themselves? That's why we have achieved some success. People decided to take a positive direction.

An effort has to be made to identify needs. Reference is made in the report to the importance of identifying health training needs, even in the West. I will use the example of a group in British Columbia, Éducacentre, which made an effort to identify needs for nursing assistant care, ambulance care, personal support services and palliative care.

Les Entreprises EFE (enseignement, formation, emploi) in Alberta, which joined forces with NATE, and with which we are currently working, identified needs for training in special education techniques (student assistant, speech therapy assistant, personal support services attendant, palliative care attendant and so on). In Saskatchewan, the francophone adult training service has identified training needs in programs related to prevention, screening, primary care, rehabilitation, palliative care and gerontological care. Small, very active and energetic groups are doing good work which all too often goes unnoticed.

The college-level teaching sector outside Quebec is prepared to get organized and coordinated by creating ties between regions. Paramedical care will be provided in the Halifax area. In British Columbia, the same need has been expressed and teams are working with these people. At the college level, we want to offer decentralized training structures. Earlier you mentioned an important matter, keeping health professionals in the regions. Students who have to travel to Ottawa or Montreal to continue their training do not always return to their regions once that training is complete. We must develop on-the-job training sessions and afford students the opportunity to take theoretical courses in the appropriate places and to be exposed to non-traditional training models. If a student is moved for one or two years, for example, what are those models? This does not augur well in certain sectors. On October 3 and 4, we will be holding a working session with community colleges to discuss models that should be established and to attack this retention issue. We will also examine new delivery methods.

The Collège Boréal in Sudbury is an important player in distance training. We are already offering certain programs, but we have to go further by not assuming that this is the solution to everything because direct intervention with the student is important in health. We are training people who must acquire attitudes and ways to do things.

There's also the question of new training programs. College training is provided in French, and I believe you have understood from this presentation that there are a lot of programs. However, a number of programs are not offered at the college level — in French, once again. In fact, the community care attendant and dietetics technology programs are not offered in French.

When we refer to access to services in French, the community colleges are currently in a good position to be part of the solution. In health, there are skills, expertise, infrastructures and partnerships. There are also new technologies being used and, especially, the will and leadership. This is fundamental.

You can have a lot of people and good infrastructures, but, if the desire, leadership and will to work together are missing, we will not succeed. We are well placed to make a contribution, but we are nevertheless facing fairly significant challenges. First of all, we must expand the range of college services and programs offered in French. Many programs are currently being offered, but we are far from having a full slate of programs.

For college-level training, there's also the question of recruiting francophones. In the nursing field, much remains to be done, particularly as a result of what has happened to the reputation of nurses in recent years. In addition, certain health sectors are not known at all.

Guidance counsellors and parents who are not aware of these sectors must be sensitized to them. Adults who feel the need to retrain should also be made aware of them.

There is another challenge as well, networking, which consists in promoting cooperation between people from Eastern Canada, Ontario and Western Canada. However, the process has begun, and, when we talk about networking, we're talking about people who are getting to know each other and who can appreciate their differences. This takes time, resources and energy.

We must also implement delivery and retention methods that will enable francophones to stay in their regions. These challenges are very great and, to meet them, colleges need human, material and financial resources. I believe that college-level institutions are ready and well placed to do this because they provide training to professionals.

However, it's also a question of resources, and assistance need not be enormous to set the process under way. The study refers to major levers, and I believe that one of the essential levers in ensuring access to health services in French is college-level training in French.

I would like to thank you for inviting me to talk to you about this situation, which is full of energy and expertise and which augurs well for the future.

The Acting Chair: Thank you, Ms Lortie. Mr. Bergeron, would you like to add anything? Tell me, Mr. Bergeron, what is your title?

Mr. Bergeron: I am President of the Réseau des cégeps et des collèges francophones du Canada, an organization representing some 50 college-level institutions and, in provinces where there are no colleges, teaching associations. The Réseau currently has members in nine of the 10 provinces.

I concur in what the President of the Cité collégiale has so eloquently said.

The Acting Chair: Both eloquently and enthusiastically.

Mr. Bergeron: Enthusiasm is in the college sector's genes.

The Acting Chair: Are there any questions or comments regarding Ms Lortie's presentation?

Senator Pépin: As I listened, I said to myself that we only need to press the button for everything to start working. Ms Lortie, you say you only need a little help?

Ms Lortie: Currently, things are being done even without resources. With regard to assistance in starting up paramedical programs in Acadia, it was the people from the health sector in our region who decided to pitch in.

I'm afraid that the people in place are often very tired, that they are limited, that they are doing all that because they believe in their mission. They feel that francophones must get organized because there absolutely have to be health services in French.

Ms Linda Butcher-Assad, the sector's director, only manages the programs at the Cité collégiale and she has a lot of work to do. In spite of that, she is full of energy and always prepared to say that, if someone wants to start up a program somewhere else, it's possible to do that.

How can people help? My fear is that it can only be done in a preliminary way. If there were resources for organizing and creating a network, we could then implement training models and work at a much faster pace. There is a shortage of resources in the health field.

The placement rate for our health students is more than 92 per cent. Everyone finds a job very quickly because they are bilingual. And yet we soon realize we cannot meet the demand and the many existing needs. To do this, we must increase the number of professionals in the health sector programs, the number of students and the number of types of programs.

We must also establish a network that can accommodate students from isolated regions. By creating various training models, we would ensure that the isolated regions do not completely lose their students because they come to study in Ottawa.

The desire to act is there and the players are ready to do so. We simply need to lend a hand and say: ``Present us a program, here are the resources and go ahead and set your objectives.''

In the context of the national health centre, a new proposal has been submitted to the minister. In the first phase, the universities were essentially the main actors, and that's entirely legitimate. In the second phase, the colleges got organized at the last minute to present a proposal.

The Cité collégiale very much appreciates receiving support in this regard because we often tend to forget that the college level trains a lot of health professionals such as nursing assistants, health care attendants and people who work in palliative care. Those people are very close to the patients. If the federal government decided to allocate funding for health, it would have to support the program.

Senator Pépin: That's in cooperation with what department?

Ms Lortie: With the Department of Health, which is currently studying the possibility of adding a second phase to its program. The colleges are included in the context of the national centre and we are part of the proposal.

The Acting Chair: I would like to discuss two points with you. On the list of professions for which you provide training, I see some professions are much more specialized such as electrophysiology and radio-oncology. These professions may not apply to the specific needs of francophones outside Quebec, particularly if the emphasis is being placed on community services.

There are also other professions such as community care attendants, palliative care attendants, we spoke about earlier, nursing assistants and so on. In your wish to meet the needs of the francophone communities, do you draw a distinction between those various professions?

Ms Lortie: Yes, in our planning work in the various regions, we're focusing first on primary care. When we study the needs of British Columbia, Saskatchewan and Alberta, what is apparent in all the health care sectors is the need for palliative care attendants because that's a priority. In an order of priorities, social work and rehabilitation care are the top priorities at the college level. In the proposal we submitted to the national health centre, we attach priority to that sector.

I spoke about it with Ms Assad-Butcher, who is here and who can definitely give a better answer than I can. I made exactly the same comment as you about certain programs such as respiratory therapy, wondering whether that should not be set aside because it's a lower priority sector, in view of the fact that there is less contact with the patient. Ms Assad-Butcher, perhaps you can repeat what you told me.

Ms Linda Assad-Butcher, Director, Health and Community Services, Cité collégiale: Because of the shortage of professionals in all health sectors, we have applications coming from everywhere. In the spring, when our new graduates complete their training, we have people coming from Saskatchewan and Alberta to take respiratory therapy programs because they want to offer that service to their patients in French. These are very costly programs, like radio- oncology technologies, but even though we know that this technology is not offered in French outside Quebec, patients nevertheless need to receive care in French. Radio-oncology technologists administer radiation, anti-cancer drugs and so on. They are therefore in constant contact with the patient.

The Acting Chair: Then, as is the case for cardiac surgeons, there is always a need. Could you establish a certain order of priority in which oral contact in electrophysiology and radio-oncology is much less important? Language is an oral contact and it is less important for radio-oncology and electrophysiology than it may be in palliative care or nursing.

Is there federal financial support for access to training in French? This committee is examining access to health care in French for francophones outside Quebec. That's a different thing and equally useful. Access for young francophones to stimulating and interesting professions is another thing. That's not really the subject of our study. There is a danger that we may want to confuse the two objectives.

Ms Lortie: At a meeting with the people from Western Canada and New Brunswick, we established an order of priority. In the proposal submitted to the national health centre, the favoured option is priority to all matters pertaining to primary care, not to introduce respiratory therapy programs or much more specialized programs such as biotechnology, for example. Obviously, all that is consistent with the desire to provide better service to francophones outside Quebec and opportunities for contact and needs are much greater when you work directly with patients. In the proposal put forward, we attach priority to the primary sector.

The Acting Chair: Does the report also concern the question of college-level institutions?

Ms Lortie: No. That's one of the reasons why I wanted to meet with you today. Often we say to ourselves that health means doctors and nurses, although, in some provinces, as you are aware, nurses are training at the college level. That's not the case in Ontario, where they are trained in accordance with agreements. There is nevertheless an entire range of programs provided in the health sector. That was the reason for our presentation today.

The Acting Chair: We can therefore tell Dr. Vincent that that's a deficiency!

Ms Lortie: A great deficiency...

Senator Pépin: We support the work you are doing and especially the objectives you are pursuing.

Ms Lortie: Objectives which are very consistent with the content of the report. It's really an important lever if we want to obtain results; that should not be forgotten.

The Acting Chair: The message we want to transmit to you is that, with regard to the training component, in addition to the university training component for doctors and nurses, we must also consider the college component, which comprises the first-line professions, in sectors where we see there are significant deficiencies. In geographical terms, it must be recognized that, west of Ontario, it's a complete desert. No training is given.

Ms Lortie: Precisely.

The Acting Chair: It remains for me to thank you, Ms Lortie and Mr. Bergeron. I congratulate you once again. You're doing extremely important work. We will definitely refer to college-level instruction in our report. There's no doubt about that.

The committee adjourned.