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

Issue 22 - Evidence for October 1, 2003

OTTAWA, Wednesday, October 1, 2003

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 3:50 p.m. to study the infrastructure and governance of the public health system in Canada, as well as on Canada's ability to respond to public health emergencies arising from outbreaks of infectious disease.

Senator Marjory LeBreton (Deputy Chairman) in the Chair.


The Deputy Chairman: Honourable senators, I welcome our witnesses today from the Canadian Public Health Association, Dr. Christina Mills, and from the University of Ottawa, Dr. Joseph Losos. Dr. Mills, please proceed.

Dr. Christina Mills, President, Canadian Public Health Association: Thank you for inviting me here today to speak on behalf of the Canadian Public Health Association. As you may be aware, the Canadian Public Health Association, CPHA, is a national, non-profit, voluntary organization with a broad membership from many professions and areas of interest. For nearly 100 years, we have been in the forefront of efforts to promote health and prevent disease in Canada. Our members include the public health professionals whose daily work protects and promotes the health of Canadians, ensuring drinking water safety and safe foods, preventing infectious disease through immunization, promoting health through education and advocacy for policy change — seat belt legislation, bicycle helmets, tobacco reduction, et cetera. We work in partnership with individuals and organizations in many sectors. I understand that, tomorrow, you will hear from the Canadian Coalition for Public Health in the 21st century, which was convened by the CPHA.

Among the many achievements of public health in the past century are the eradication of smallpox; elimination of polio; control of the many vaccine-preventable diseases; declines in motor vehicle fatalities, thanks to seat belts and safety seats; and reductions in drinking and driving. However, perhaps we have been a little complacent about some of these successes and in our zeal to cut deficits and protect access to necessary treatment services, we have neglected public health. The just-in-time mentality has left us with empty warehouses in our time of need.

We have neglected public health and are now seeing the consequences in under staffing, lack of surveillance and communication systems and lack of a surge capacity when we see threats such as SARS. The tragedies of SARS, Walkerton and the Battlefords are the wake-up call. We must act to strengthen the public health system as a whole and we must do it now.

There will be no quick fixes for this. Canada cannot prevent SARS or whatever infectious disease outbreak comes next by cherry-picking a few recommendations from among the myriad that you are bound to hear at this table. Prevention is a fundamental precondition of sustainability and unless we pay more attention to prevention, the best treatment system in the world will eventually be overwhelmed by rising demand.

In our written brief, we describe some of benefits of prevention in terms of health outcomes, savings to the treatment system in indirect costs and examples from immunization and chronic disease prevention. I will not speak to that in detail because I want to emphasize now that to realize these benefits, we urgently need to develop system capacity. We need to prepare for the future by planning and investing now with an immediate and substantial investment in the front lines of public health in the current system. To give you an idea of the scope of the gap, we are suggesting $1 billion.

In the mid-term, we would gradually increase the proportion of health spending dedicated to public health so that it doubles over five years from — estimates currently vary from less than 2 per cent up to 4 per cent. The Canadian Institute for Health Information, CIHI, has acknowledged that our systems, which identify the amount spent on public health, are in bad need of an investment.

Part of this increase in public health spending should be directed to a coherent public health human resource strategy, one that would explicitly address training, recruitment and retention needs for a broad range of the disciplines needed for public health. The first ministers recognized the need for a health human resource strategy in the 2000 accord, and again last February, as did the Romanow commission. Public health human resources need to be explicitly addressed within any national health human resource strategy. We have not observed that the needs for public health human resources have been adequately considered in any of the proposals to date.

It is important to note that we would not be starting from zero. We have many existing elements, much strength and a great deal of expertise but we need to consolidate and build and expand on those. We recommend, therefore, the creation of a national, independent public health agency that would be at arm's length from government and report to Parliament through the Minister of Health. Dr. Losos will speak in more detail to the desirable characteristics and advantages of such an agency that would be headed by a national public health officer — a national focal point for public health expertise and leadership — which is so badly needed.

Along with these, we need legislative reform to modernize and harmonize the existing regulatory patchwork that sometimes acts more as a hindrance than help to ordinary public health operations, let alone emergencies such as SARS.

We need new funding and reporting mechanisms to ensure accountability to Canadians for the investment of their tax dollars. The return on their investment would be improved health and well-being. We need surveillance and other information systems to ensure that those who need information for decision-making get that information when they need it and not with the advantage of hindsight. We need communication systems and protocols so that the system acts as a smoothly coordinated whole in critical times.

If we learned anything from the SARS experience, I hope we learned that jurisdictional turf cannot and must not be allowed to block the road to public health. Mr. Romanow heard that message loudly and clearly. Canadians are fed up with federal/provincial/territorial wrangling. They do not care whose job it is, they just want it done.

There is one indisputable role of the federal government in this — leadership. Leadership can be exercised in many ways. For example, it can be accomplished through your own choices about how health decisions are made in the public service workforce and within your ranks. It can be accomplished through using your financial powers in targeting transfers to specific public health functions so that Canadians health is protected in all provinces. It can be accomplished by collaboratively leading a process to develop, together with partners in other jurisdictions and sectors, a comprehensive set of strategies to address the gamut of public health challenges facing Canadians and to ensure a system that can meet the challenges of tomorrow. I think Canadians expect and deserve no less from their federal government.

After Dr. Losos speaks, I will be happy to answer your questions.

The Deputy Chairman: Dr. Losos, please proceed.

Dr. Joseph Losos, Director, Institute of Population Health, University of Ottawa: Thank you, it is an honour to be invited to address these hearings.

Honourable senators, Canada's public health system has evolved over decades of success through immunization programs and numerous disease control and response activities. As a result, Canada's state of health and well-being is among the best in the world — not in all indices, but in very many. However, it is vital to note that our system of human public health and health in general was addressed in the Constitution. It evolved, in large part, as provincial responsibility, shifting gradually over the decades to investment in the health care system, as opposed to public health. The public health system was designed for decades past. Although it is certainly true that adjustments and improvements have been made over time, it is a long-standing system.

The SARS outbreak demonstrated two main issues to us. The dedication of our public health officials and workers was exemplary, and jurisdictions did absolutely the best they could with the machinery they had to work with. The second observation is that our capacity in a globalized world is now too limited in a number of ways. I would like to go into these a little bit.

Globalization dictates that quick travel by anyone in the world can happen within hours. Transmission rates of infection occur beyond our previous comprehension; we saw that in the AIDS epidemic. Global commerce dictates food outbreaks occur from the same source across continents simultaneously, and that has never happened before. Ecosystems have been changed and are degrading, causing everything from Lyme disease to similar types of outbreaks, with the migration north now of vectors of horrible viruses such as West Nile.

Behavioural change: migration into cities and away from rural areas, the mixing of cultures and change in cultural values because of urbanization add to that kind of behavioural change, and changes our very approach to diseases. There is also the evolution of microbial adversaries, such as the emergence of pathogens, as we saw in SARS, and antibiotic resistance, with which we are all too familiar, as it increases.

Public health is an effective, silent sentinel for health, but we cannot remain with 13 largely fragmented jurisdictions. The public expects and demands effective public health, and public health seems to become visible only when things go wrong.

It is not, in my view, that we must be transformative because we have not worked hard enough, or because historically our systems have failed. I do not believe that is true. We must change because we must not try to anticipate and manage 21st century globalized problems, such as SARS, with systems designed decades ago. It really is time for us to upgrade these. We cannot stop at involving only the health sector, but must include other sectors such as agriculture, environment, the Department of National Defence as far as operations are concerned — there is no one more efficient — and other sectors.

Public health by definition is multi-sectoral and we must be multi-sectoral. We cannot rely on one department, one sector, in order to respond. If we do, in my opinion, we will be doomed.

In my written brief to this committee, which is short, I have outlined my vision of what a world-class system needs. I do not know if it has been handed out, but it is a quick read, honourable senators. I believe that we need an agency or a governance position of some kind like that, outside of a direct departmental reporting relationship, because of the flexibility it gives — flexibility in leadership, as Dr. Mills has suggested, in decision making, so that decision making can be quick and not rely on a series or steps of permission giving. Management systems in such a governance model are much more flexible, and one can be much more competitive for the type of scientists that one will need.

Also, for planning purposes, an agency such as this would not be bound to the planning cycles of the government systems that exist, but could plan for longer term risks such as chronic diseases of 15 or 20 years. That is difficult in today's system. An agency would be able to mount a quick response and would be able to coordinate communication as is necessary, and I will come back to that in a second.

It needs primacy of the federal minister. There is no question that this agency must report to Parliament through the Minister of Health — or to the Minister of Health, if that is what this committee recommends. There must be harmonization of legislation and infrastructure with the provinces and other partners. However, at the same time as we do this harmonization, there must be an ability for this commissioner or director, whatever we end up calling it, to act nationally by the power of legislation when that is needed.

With this legislation, there needs to be a flexibility to manage locally. We have excellent institutions in some of the provinces. The National Institute for Public Health in Quebec is exemplary; we have the B.C. Centre for Disease Control, which is a really interesting mix of academia and governmental capacity. We must allow those capacities to be part of a network, or a coordinated system, that is this public health network that we are talking about.

I suggest that the commissioner should be a public health professional, and that that professional run this and lead this agency and be accountable for the performance of this agency to the minister and to Parliament. I was on the scientific advisory board of the National Center for Infectious Diseases of the Centers for Disease Control and Prevention, CDC, for nine years, and health professionals run all of their programs. Throughout the system, they have a lot of MBAs who actually make things work and balance the books and do everything managerial that it takes, but there is no question that the thinking and the direction and leadership comes from health professionals.

We must increase the development of more experts and a surge capacity in Canada so we can respond to greater threats, or multiple threats if they occur. We saw in the SARS epidemic that we were virtually on the edge just with one outbreak. If we would have had two, the people on the front lines tell me we would not have been able to handle it. It is vitally important that we have professional communication coordinated by the commissioner or by this agency for correct, consistent messages for credibility with the public, which is vital; for the professionals, so that the message goes out consistently; and for international partners, who expect this of us constantly.

Honourable senators, at this time I will stop and answer any questions that you may have.

The Chairman: May I say to the witnesses and committee that I was speaking in Niagara Falls this morning to a coalition of four major mental health groups, and the question and answer period went so long I missed my plane, which is why I am here late.

Senator Roche: I thank the witnesses for a very stimulating presentation.

Dr. Mills, you drew our attention, as others have also, to the need for a Canadian public health agency. How do you see the agency being operated in a jurisdictional way? You said, Dr. Mills, that it should report to Parliament. I am wondering how you see it in relation to the provinces. I will leave that as an open-ended question before I pursue some detail.

Ms. Mills: I agree with Dr. Losos that we need a national public health leadership focus. In certain situations it will be necessary to have the legislative underpinning so that there will be sort of a command and control function for a public health emergency. That function would be supported by legislation so that it had the power to actually set into place a train of events to respond to emergencies. I do not think it can be a multi-jurisdictional entity. It must be a national entity, but there also must be agreements and protocols with the provincial jurisdictions so that it functions as a networked system. I do not think Canadians expect or hope for some kind of monolithic thing that will be the be-all and end-all and be able to have every single function brought inside. However, there must be some way of harmonizing and coordinating the elements that we already do have, and adding what is needed. We need sort of a mandated or regulatory glue to hold the system together as a networked, coherent system.

Senator Roche: You talked about harmonizing and coordinating, and I certainly agree, but the history of the relationship between the federal government and the provincial governments is anything but harmonious and coordinating.

I would like to pursue my question by taking up Dr. Losos' points. When you talked about 13 fragmented jurisdictions being incompatible with the needs of globalization in the 21st century, I think you hit it right on. You said that the system that we are operating under was designed decades ago and is not satisfactory to deal with 21st century globalization questions of health. SARS was a dramatic example. You added that the public health agency should be under the primacy of a federal minister.

I want you to know, Dr. Losos, that I agree completely with every word you said, but I come from the province of Alberta and not everyone in Alberta, including important officials of the Government of Alberta, agrees with you and me. We have to figure out a way to get a public health agency that will be satisfactory in the sense that it can deal from a federally led capacity with 21st century globalization, while at the same time we are entrenched in the results of the Constitution a century ago. Will we have to change the Constitution of Canada to adequately deal with the problem of federally led public health supervision in the modern era?

Dr. Losos: The type of governance model that I have been thinking about is represented by the Canadian Institutes of Health Research, CIHR. It is an executive agency of Health Canada, so it is in the orbit of the Minister of Health. It reports to Parliament through the Minister of Health, but it has the flexibility of running the whole academic research machinery according to its own strategic planning and is not taken up by the planning cycles or the time frames of the government.

It is also very important, and CIHR does it, to mobilize the very considerable provincial infrastructure that Dr. Mills alluded to earlier — the B.C. Centre for Disease Control and the public health machinery of the provinces. Where that might be weak, or where that might need supplementation, then I think that it really calls upon a minister with primacy and selected investment to augment that capacity, such as in the Atlantic provinces, perhaps. Whether Alberta is or is not self-sufficient, I am not directly aware nor would I want to comment, but we have in Canada a very sizeable capacity. The problem is that it is not coordinated, and it has been relying on consensus coordination for decades, and that does not work. They may like me today, but tomorrow they might not, and we cannot leave the importance of the public health of Canadians to that level.

I draw your attention to the technical analysis done by the Canadian Medical Association in their brief to the Naylor committee. They actually did a review of the legislation, and they come to the conclusion that without opening the Constitution, which would be, of course, almost a non-starter, there are enough legislative tools on the table that this could happen. You would have local response where that was necessary or logical. However, when it reached a certain level — interprovincial, national, or the potential for national or international spread — that is when the new legislation would come in.

I also draw your attention to the documents that have just been circulated by Health Canada on the consultation on the Health Protection Act, where they have actually added several very important variables. These are excellent documents, in my view. They will consult on whether we should have national surveillance under the legislation that we have. They feel that they can do it without opening the Constitution. Should we have a national research priority setting agenda? They think they can do it. Should we have an emergency response mechanism with the present legislation? They can do it.

Senator Roche: I hope you are right in the expression of your optimism. I do not want to pour cold water on it because I think you are headed in the right direction, but you talked about consensus coordination as the way to move ahead. We now have a pragmatic that we are facing in which Alberta and British Columbia, the governments of those two powerful provinces, are going together in a semi-structural manner to deal with Ottawa on these questions of, inter alia, health. They take the position that because they have the responsibility of spending huge amounts of money on health, they want to have responsibility also in determining how that money is to be spent. That brings us back to this constant conflict we have between Ottawa and the provinces. Our committee recommended a national body, and it cannot get off the ground because of this wrangling. You and Dr. Mills point to the need of this. We know the need of it. However, I am still at a loss to figure out how we will be able to implement a national council to cope with 21st century crises in the present constitutional set-up that we have in Canada at a time when the provinces are escalating their demands for control. This seems to me to bring us into even more conflict. I am not quite sure how it will all play out.

Dr. Losos: I will answer that question directly. I am sorry, senator, but I omitted one part of my answer. I think this entity/agency must have a board that includes the provinces.

Senator Roche: They want majority control on the board.

Dr. Losos: That may have to be the reality because of the capacity that they have and the amount of expenditures.

Senator Roche: If it were a reality, how would the federal minister have primacy of jurisdiction?

Dr. Losos: I would urge a look at the Canadian Medical Association's analysis of the legislation. Once it got to a certain level of risk to the country, then the primacy of the federal minister would have to come into play. The majority of the daily activities would be handled effectively by the local capacities, as they are today. If an issue arose of international import or interprovincial import, then the legislation would kick in. They have a five-tiered response mechanism. The first two tiers are local and then the more serious responses would occur. Without question, the provinces would have to be major players.

Ms. Mills: I would not want to minimize the hurdles for this, but there is a precedent, or at least there is a ray of hope. There is such a thing as a Chief Veterinary Officer for Canada who has certain powers. I do not know if this is a proper legal term but, in certain situations, this office has peremptory powers that span provincial boundaries. If there is a problem with an animal-health outbreak, this Chief Veterinary Officer can put into train actions that have weight with the provinces. The constitutional considerations have not been a barrier to that happening for veterinary health. I do not think we can allow them to be an insuperable barrier to human health.

Senator Roche: If the national agency or, as you call it, the national public health agency, had been operating in force at the time of the SARS outbreak, how would SARS have been handled any differently than it was? Would the creation of such an agency, operated in the manner in which you have described, have alleviated some of the distress over the SARS incident?

Dr. Losos: In my opinion, senator, the data would have been shared automatically because this was an interprovincial and international incident. The commissioner — for lack of a better word and if you would allow me to use that word — would have been in charge. Outbreak investigation teams would have offered to go and perhaps would have been promulgated to go and manage the outbreak in Toronto. They would have helped in Vancouver. The communications would have been far better coordinated, not only within the country but also with the World Health Organization where everyone had different case definitions. The agency and the commissioner would have brought all of this together.

The research capacity of the country would have been much better coordinated. There is no reason why the Canadian Institutes of Health Research, for example, should have to wait for requests for applications two or three months later. With Henry Friesen, the previous president of the Medical Research Council of Canada, the antecedent of Canadian Institutes for Health Research, we actually talked one time about setting up an emergency fund where Health Canada and CIHR, and perhaps a few others, would put in a pot of money, several tens of millions of dollars. The turn-around time for requests for applications would be quick. The questions would be promulgated: We want a screening test on this pathogen and we want a screening test for blood and we want those as soon as you can possibly get it.

That is not the regular daily business of large organizations such as CIHR, but the coordination of the research machinery, either the public health research machinery of departments, the academic research machinery, the National Research Council Canada or even perhaps private industry, could be mobilized under the auspices of an agency like this, brought together and, within a very short period of time, you would have the best shot at an answer that one could have.

In the AIDS epidemic, we waited and waited until LaMontagne or the National Institutes of Health, NIH, one of those two came up with a test. It is still unclear who actually came up with it. We had to wait for that, and there is no reason with the amount of capacity this country has in research capability that we cannot adjust to emergency situations like this.

Senator Morin: Dr. Mills, the Canadian Public Health Association, if I understand correctly, is a voluntary association that would involve most professionals. Do you have within your association people who are not involved in the field or who are not professionals?

Ms. Mills: Definitely. In fact, the past-president of one of our territorial branch associations is a clerk in the Department of the Environment in Whitehorse. I would not say it is a huge proportion of our membership, but, yes, we have people who share the aspirations and values of the association.

Senator Morin: Do you see your association as having a role in engaging the public decision-makers? Since I have been in politics for three years, I realize that excellent causes can exist but if there is no public support and if the decisions-makers are not engaged, excellent decisions cannot be made. We constantly see the Heart and Stroke Foundation and other organizations like that here on the hill. Does your association have something similar to that?

Ms. Mills: Are you referring to a broad outreach strategy to the public?

Senator Morin: Yes, and I refer to decision-makers, whether provincial or federal or municipal.

Ms. Mills: I do not know how much background to give, but our association has some of the same federal- provincial tensions that our government has. Our board consists of nationally elected members and of the presidents of the provincial and territorial branch associations. Those are autonomous associations and their presidents are on our board ex officio. We constantly must balance the big national picture with the needs of the provincial and territorial branch associations who often have much fewer resources.

We usually have a strategy to advocate at the national level to federal bodies, whether health, environment, finance, whatever. We ask our provincial-territorial branch associations to advocate in their own jurisdictions with their own governments and also to educate their own members. We try to help them to build capacity to do that in their own areas so that there is kind of an upward ferment in the provinces as well as a national advocacy approach.

Senator Morin: I do not want to get into the mechanics of it, but public health is an extremely important field that has been neglected over the years; there is no doubt about that. The results are seen with SARS and so on. Some of that neglect is the fault of politicians, but how much is the fault of the people in the field who themselves perhaps did not promote the cause as other organizations have? That is the question. I am not saying that is so but I think your organization should look at that.

I would like to turn to the financial part of your brief and the amount of $1 billion, which is a great deal of money. Where does that money come from at the national level? You based that amount on the CDC's budget, if I understand correctly, at page 9.

Dr. Mills: Yes, it is a rule of thumb to estimate the scope of that.

Senator Morin: How much are we spending at present? The $1 billion that you talk about is not new money and the federal government is already spending some. How much of the recommended amount of $1 billion would be new money?

Dr. Mills: As I alluded to earlier, the Canadian Institute of Health Information, CIHI, has acknowledged that it is difficult to tease out what is actually spent on public health versus the amount that is spent on other health administration. It is not a separate line item in provincial budgets; it is grouped under the general term ``administration.'' The actual amounts are not available to us.

Senator Morin: It is difficult for us to recommend additional resources if we do not know, because you do not know, the division of spending. It is difficult for us to help. That is an important exercise. An amount of $2.5 billion has been floated around as the total amount spent on public health in Canada. The same remark applies to the $1 billion that you recommend at the local level.

As you know, most provinces are unable to spend that. It has been recommended that the federal government should fund this indirectly with flow-through funds. Again, where did you get the figure of 1$ billion?

Dr. Mills: We deliberately chose an amount to get your attention to illustrate the scale of the gap. The figure is not based on an economic study but rather on anecdotal information from people in the provinces about the kinds of challenges they face. A study was done for the conference of deputy ministers of health a few years ago that took almost three years to complete. They did not come up with satisfactory numbers about the total amount of spending. Certainly, with our resources we would not be able to undertake such a study.

Senator Morin: Someone somewhere should be able to provide us with the answer to that. You are recommending additional resources and so we should have a clear idea of what is needed and how much. I think that is important. Perhaps you or someone else could help us with that.

Dr. Losos, I have two short questions. In the last paragraph of your brief you said that in your view, the governance model is more suitable for Canada than a replica CDC. Could you tell us how different this model would be?

Dr. Losos: I will begin with CDC, which I know well. CDC is successful because of its 40 years of credibility. When we have credibility problems in the public's view and in the media, the public goes to the CDC in the United States and asks questions. CDC replies that there is no problem and there is not a word in the media. They have built a lot of credibility over their 40 years; it was not done in a crisis.

CDC is also successful because it has such deep, scientific expertise. It is, in fact, equivalent, in a public health sense, to the NIH in basic research. They pride themselves on the quality of their work. I have some excellent scientists who are global leaders in their fields.

The mass of its capacity is great. The National Center for Infectious Diseases alone employs about 1400 people and its budget is well over $1 billion. It does not have statutory powers over the U.S. any more than we do. However, it does administer certain legislative directives on investment of specifically targeted public health funds for sexually transmitted diseases, ``immunizable'' diseases in the inner cities and for tuberculosis control. That kind of leverage makes it more efficient.

CDC also provides training for the U.S. and places staff there. Officers from the Epidemic Intelligence Service, EIS, are front line in most American states. Whereas CDC has to wait to be invited to an epidemic, the reality is that when there is an outbreak or a possible one, CDC staff is there anyway. They are involved immediately. The tradition in the United States is that they call in the CDC within days. We do not have that tradition in Canada.

The model that I am suggesting relies on the considerable infrastructure that exists in Canada that simply does not work together and that does its own mandate — CIHR, Health Canada, the Canadian Food Inspection Agency, Agricultural and Agri-Food Canada, the National Research Council Canada, et cetera.

If that capacity were brought together to develop national priorities in applied research and if some money were allocated to those applied research priorities under a harmonized legislative framework that did not impose on the provinces, we would be able to match, or come close to, the capacity of CDC and be able to respond as quickly.

Senator Morin: Both cases report to the government and they both have boards of directors. The governance of this agency and CDC is somewhat similar. I understand the capacity, the history, the expertise and the training but the governance between what you are recommending as an agency and what the CDC has is similar.

Dr. Losos: It is similar but they do not have a legislative override over states.

Senator Morin: It is an invitation. That brings me to the last question. No one has addressed this point and I think it is important, from what you are saying.

If I understand correctly, there are two bits of information. One is the new health protection act from Health Canada that is being worked on. The second is the CMA brief and their ideas. Are you familiar with the health protection act? Did you have a chance to go through that? Do you think the existing act would be satisfactory to meet our goals? Should we recommend another layer of legislative process in addition to that? If so, could you give us some advice on how that should be done?

Dr. Losos: I have documents, which certainly the committee could obtain, that show the original target was product safety — health protection, food safety, drug safety, blood, environment, et cetera — when I was Assistant Deputy Minister of Health Protection some years ago. However, to this particular consultation, they have added: Should we have national disease surveillance mandatory? Should we have a research priorization scheme where we bring the groups together? Should we have outbreak response that is coordinated under legislation? Should the minister have emergency powers when that is necessary?

By adding these questions to the Health Protection Act, they have added a layer that says: We, as a country, will do this surveillance on this priority disease or risk, mandatorily.

Senator Morin: Is this in the form of questions or is it in the act?

Dr. Losos: No, these are questions, senator. This is a consultation

Senator Morin: We do not have a proposed bill yet.

Dr. Losos: Not yet.

Senator Morin: In addition to that, or is that included — what is the CMA proposal? We are trying to get some information here in the committee that will help us. Just summarize it.

Dr. Losos: I will leave my copy with the clerk.

Senator Morin: No, just summarize it.

The Chairman: It would be helpful, Dr. Losos, if you summarized it. The CMA will be testifying next Wednesday, and they will deal specifically with this point.

Dr. Losos: The analysis that they had done by their legal department states that under the legislation available to Health Canada — that is the Food and Drug Act and the Department of Health and Welfare Act — there is enough flexibility to add regulations and alter the legislation to, in fact, demand or promulgate national surveillance, national response, prioritization and targeting of applied research and emergency response, not having to use the emergency response powers of the federal government, which stops after the emergency. We do not want it to stop. We want that surveillance to continue.

As ADM of the Health Protection Branch, I could never understand why it was my responsibility under the Criminal Code to make sure that food X was safe, but never have the power to go in and find out why people got sick from that food.

I could never understand that. I still do not understand it. If I have the power over food safety in ensuring that the establishments live up to good manufacturing practices, if there is an outbreak I should be able to move in. I have never understood the difference. Therefore, I think that by harmonizing the legislation, by adding to the legislation as it is, without being overbearing — opening up the Constitution as an example, we can achieve the same ends.

Senator Morin: Coming back to what Senator Roche has raised on the matter of federal provincial relations, I remember you telling me in another life, and that struck me, that in matters dealing with public health and epidemics and so forth, there was remarkable unanimity and lack of conflict between the feds and their provincial counterparts in matters of public health. Is that still true? I remember you telling me this.

Dr. Losos: There is a lot of congruence. There is a lot of agreement on notifiable diseases, on policies, with respect to immunization. However, the ultimate decision on what immunization one gets in province X really relies on the provincial epidemiologist or the chief medical officer of health. It varies from province to province. You can go to one province and go to another one and get two different sets of immunization schedules.

From a national perspective, if we are going to eliminate measles — for awhile, Canada had the highest measles rates in the western hemisphere because the Minister of Health did not have the authority to tell everyone in the country that they will get a second dose of measles. Whereas everyone in the hemisphere — Guatemala, Cuba, you name it — were all giving second doses of measles, and were controlling the outbreaks. Measles is not a minor disease.

Whereas that consensus works much of the time, it does not work all of the time. We have had outbreaks; we have had major policy issues where all 13 jurisdictions went off in all directions, and the international community will not tolerate that. They will want one voice and they will assume that the federal minister is in charge.

Senator Keon: Assuming that you can put together a public health agency and get a commissioner — and frankly, I think you can because something very similar has been done before — I think your biggest problem still will not be addressed. That is the huge holes in the global safety net. We have talked about this before. — at least Dr. Losos has — but I would be interested in Dr. Mills also commenting on this. We have to find a way of dealing with infectious disease so as a country we are not sitting and waiting for it to happen, for it to be imported and this kind of thing. I would like to hear you both comment on how we can participate in the global scene to have some input so that we can have early interventions. For example, as you know very well, there are countries in the world with infectious diseases running absolutely out of control. Canadians go there to visit and come home. There is a little bit of control, but very, very little. I know, Dr. Losos, you have thought about this. I do not know how much you have, Dr. Mills, but I would like to hear you talk about it.

Dr. Losos: WHO's global response and the setting up of global networks for response is reasonably recent. When the plague ``outbreak'' in India occurred, WHO was unready. It did not have a response mechanism. I do not know whether Dr. Chisholm, way back when, had global responses. These things wavered over time but we tried at that time to raise WHO, to find out what was going on in India. It turns out that the debate still goes on whether there was an outbreak of plague in India. At least it stimulated WHO, under David Hayman, an exceptionally good epidemiologist trained out of CDC who worked out of Africa and has set up several mechanisms. One is a global response team that can go anywhere at any time on specific diseases. At one time, they had teams specified for types of diseases. A team for cholera, for example, was based in Switzerland, and these people were ready to go at 24 hours' notice anywhere in the world to investigate a cholera outbreak.

The other thing is they have created a network of agencies that can be called upon in international crises to be part of a global response mechanism — research agencies, public health agencies and the like. They are starting to become a little better at global response. They are nowhere near as capable as one might think as far as response is concerned. Rather, they are trying to rely on agencies, such as centres for disease control, and a new entity in the European Union that seems to be taking shape. If we can get it together in Canada as far as what I have described in bringing together the capacity and give it some muscle, they will let us sit at the table. If we do not, they will never let us sit at the table. They will create their surveillance systems without us. We will get our data later, our information later, because we will not be at the table.

I personally believe that Canada has enough expertise that with the adjustments that we are talking about today, we will be part of the surveillance networks that occur. We are already part of some of them — salmonella networks, these are food-borne bacteria, that we are steadily becoming part of, as far as surveillance is concerned. However, the reality is that someone has to take charge as far as creating international surveillance networks.

WHO was in big trouble until about 10 years ago, maybe even less time than that, when there was a big push by many professional organizations around the world to say that WHO had perhaps outlived its time and was not the coordinator of international response that it should be. The international health regulations are not good enough. No one ever reports on them. They only cover three diseases. They are coming out with a new version shortly.

To answer your question, senator, I think that the surveillance systems not only need to be national in Canada, but we need to bridge and make these international, North America which includes Mexico, hemispheric, or global in other ways. Many people are working on that. We have the informatics. You can go to Trinidad and put your card in and it will give you Trinidad dollars. Why can we not do that in health?

Senator LeBreton: You talked about food contaminants simultaneously going across continents, knowing no borders. I wonder if the same contaminant could have a different reaction in different countries, based on environmental conditions. For instance, does a contaminant on a food from the tropics have a different impact on the population in a colder climate and another impact in another type of climate, or a place with different waters? Is there a system in place that deals with the same contaminant having different results in different countries?

Dr. Losos: Theoretically, the answer to your question is yes. Let us say a food substance is produced in bulk. The distribution systems are so sophisticated now in the commercial sector that you can have these products in various countries within days. Mangoes from Mexico or Costa Rica are good mangoes and no longer green. They have it together as far as distribution is concerned. You could have a contamination of those. There have been examples of these bean sprouts being contaminated. You could have a pathogen or bacterium contaminate these, which one population in Scandinavia might not have any immunity to, and the outbreak there might be worse than in another country where there might be some immunity.

These surveillance systems have to be global. Several years ago, there was a spill of engine oil in Belgium. The Belgian ambassadors will be on the phone to me tonight for sure. I hope the telecast is delayed. This amount of oil, which was not a huge amount but contained PCBs and various other dioxins, which is one of the most carcinogenic chemicals known to man, was poured into this vat which was pooling fats used for all kinds of things — truffles and chocolates and things like that. This stuff was distributed. The person who did it, I believe, did it knowingly. Why, I could not tell you. However, the tracing of this distribution of contaminated oils was almost impossible. We had the U.S. Food and Drug Administration and the European Union looking at it. The Belgians were desperate to trace it and find it. We had to shut down the sale of all Belgian chocolates for some weeks in Canada until we did the analysis. I got to know the Belgian ambassador very well during those two weeks. That is an example of why our surveillance systems have to be global. The private sector understands this as well. They do not want their customers to get sick. They are bringing in, therefore, a much more automated, information-technology-based system to be able to track the lots of their foods that go out. The tracing should be easier, therefore, for the public health agencies involved.

We are at the cusp, as I said before, of having to adjust our systems to the 21st century, because things are so different now

Senator LeBreton: So it is true that bacteria can have different effects on different populations.

Dr. Losos: It can certainly well do, yes. You can have a parasitic contamination — not common, but possible — that would be exposed to a population that has never been exposed to that particular parasite. There would be no resistance, and that would run wild through the population.

Senator Keon: To both of you, as you know, WHO has its severe critics, but I take it from what you have been saying that you are comfortable that they could provide the structure and framework now for the integration of a global network?

Dr. Losos: I think they can, and I think that under the current leadership and the realization that there is no one else, they are trying hard to be that. Canada has been influential in setting up some of these global surveillance systems and the like. I am not sure that everyone believes in that. There is still quite a strong movement in the United States, and there certainly was five or six years ago, that something else needed to replace WHO in global response and global surveillance. WHO has some real strengths in being able to come up with monographs and analyses of professional papers and the like. However, its experience in global surveillance and global response is relatively new. There are some very influential people who believe that other mechanisms could replace them.

Senator Trenholme Counsell: Once again, this is a most interesting and worthwhile presentation. I am a great believer in public health. I more often use the term ``health prevention.''

In the provinces, we do have many people working in public health, often with great frustration. The medical health officers are the people who feel the greatest level of frustration and perhaps a lack of connectedness. There are also public health nurses, nutritionists, and people involved in early childhood development. It is a broad network. How much these people feel connected, I am not sure, but I sense that perhaps they feel alone at times, although they have relationships with Health Canada through their provincial departments of health.

What you are speaking to us about is very important and timely. From my point of view, I am pleased to hear the option being presented of something akin to the Centre for Disease Control. I like to think of prevention as a more positive and modern theme, that is, health prevention. Although public health is an old name, with all due respect to the Canadian Public Health Association, I wonder if that is the best name for the time. For a commissioner or new agency, whatever might be set up, ``population health'' or ``national health'' might be more meaningful.

I do have many concerns about how this would evolve in Canada in the near future if it were to happen with the national health council, which I see as more of a body related to medicare. We need to get a huge drawing board and put the pieces on to see how we will do this in 2003 and beyond. We are talking about a number of things that are national, and health is provincial, so I think the drawing board is very necessary to see how all these pieces fit together.

In addition to the coordination of infectious disease outbreaks such as we have just experienced, and that is what has perhaps made all of these meetings and discussions so relevant, I think one has to took at the great array of non- profit organizations in Canada, all of which are doing wonderful work. I believe there is a lack of coordination amongst government and all those very important and wonderful groups. I know there is a need for coordination with government and with all the national bodies across the land. I think most or all of the agencies have national bodies along with provincial bodies, but I sense that we would do a better job if the work they are doing were coordinated. We all know those groups — heart and stroke, osteoporosis, mental health — the list is very long.

I applaud you for coming forward with this alternative idea. I certainly do not think we could ever do what the Centers for Disease Control and Prevention in Atlanta are doing. That would not be our goal. There is a great deal of research that goes on there.

In that respect, I wonder how this agency would relate to the lab in Winnipeg, which is controlled by Health Canada, I believe. We had a presentation from that lab. They are a player in this whole picture.

Could you elaborate on how you see yourself being perceived at this time while the National Health Council is so much on the drawing board? Is there a relationship or do you see the two organizations as being quite distinct?

Dr. Losos: I had not thought about that at any length, but as a gut reaction, I would see the National Health Council as being pretty well oriented to health care and to ensuring that the principles of the Canada Health Act and the transfers are correct. They should ensure that any upgrades resulting from the Romanow Commission are, in fact, implemented. There needs to be an evaluation and an accountability and a continuum there. I see a public health agency as very separate.

As far as the medical officers of health, nurses and nutritionists, we are totally under-supplied. We have been overwhelmed by what was in reality a moderate outbreak. I know it was a tragedy that 41 people died and so many people were sick. There were probably another few thousand who had a mild disease that remained undetected. However, it was a moderate outbreak and it overwhelmed us. We must mobilize ourselves better and utilize our capacities better.

Here the academic sector comes in. The academic sector is looking at schools of public health and networks of universities that give degrees in operational public health and theoretical public health and everything in between. We must utilize the capacity of the academic sector to increase the human resource capacity to meet our public health system's needs.

Ms. Mills: I want to comment on several things but I do not want to be too long-winded. I want to say something about the ideas of population health and public health. Population health is a conceptual framework, which helps us systematize our thinking about what affects health outcomes, positive and negative. You hear talk about the determinants of health which are broader than the specific behavioural or environmental risk factors.

Public health consists of the tools that we actually use to do something about that situation. Population health is how we think and public health is what we do. We have always worked with a population health conceptual framework in public health because our patient is the society, the community. Some people have said to me, do you not practise? I say, yes, I practise but I do not see individual patients.

On the issue of voluntary agencies, I am happy to tell you that voluntary associations are getting together around many of these issues. Two coalitions exist and I believe both will appear before you. The Coalition for Public Health in the 21st century is, I believe, presenting to you tomorrow. The Chronic Disease Prevention Alliance of Canada started very small, with the Cancer Society, the Heart and Stroke Foundation and the Diabetes Association. They added some risk-factor-based associations who are involved with smoking, physical activity, obesity, and so forth. Now the coalition even includes organizations like the Federation of Canadian Municipalities. They are building a very broad, multi-sectoral constituency. They are pulling together the best thinking from the past few years about what it really takes to influence health on a population basis in Canada, as opposed to depending entirely on clinical approaches.

We do need clinical approaches and not just for treatment. We need to make the best use we can of opportunities for clinical prevention. Using clinical prevention will only ever reach a tiny minority of high-risk people. Population-based approaches can make a substantial difference to the whole distribution of health and disease in the population. I am happy to see broad-based collaborations being formed in the voluntary sector to address all the issues of public health.

We must address not just chronic disease across chronic and infectious diseases. We are seeing more cross-interests in terms of infectious causes of what had been understood to be chronic or non-communicable diseases. There is increased susceptibility to infectious disease in people who suffer from chronic diseases. For example, in a recent study of 29 people admitted to ICU with SARS, every single one had some chronic co-morbid condition, such as diabetes.

Very few people with no other chronic problem became seriously ill from SARS. For healthy people, SARS was a relatively mild infection. For someone with diabetes, heart problems or respiratory problems already, SARS became a serious clinical problem.

There is an interaction between the clinical individual level and the population or public health level of work. We must improve prevention in upstream versus care in downstream but also in clinical and population-based interventions. The theme of the day is integration.

Senator Trenholme Counsell: I do not know whether my province of New Brunswick was unique in this. Our Minister of Health is now called the Minister of Health and Wellness. Perhaps other provinces have made a similar change to focus not just on hospitals and doctors but also on a wellness concept.

To me, it seems ideal, since there is only one pot of money — and we know it is never big enough — to have some national body that could coordinate treatment and prevention and education. Part of that would be infectious disease outbreaks. In a country like ours, that would be the ideal thing. In an ideal world, planning in advance, perhaps a national health council should have two arms, one dealing more or less with medicare and the other with public health. I do not expect that ideal can or will come to pass, but, nonetheless, I compliment you on your presentation. It certainly is what we need to hear.

Senator Callbeck: I have a question for Dr. Mills that stems from your association's brief presented to the National Advisory Committee on SARS and Public Health. You made a number of recommendations and the one that I am interested in concerns improvements in the laboratory systems being accomplished by strengthening connectivity among all laboratory-related sectors — public health and health care.

Now, it is my understanding that there is a national network of public health laboratories that was set up two years ago. I come from a small province and I am concerned about the smaller labs being well connected and having good communication. Is the network effective or is it too soon to know? Do you have recommendations for improvements to the network?

Ms. Mills: I do not have direct knowledge of how well that network is functioning. Perhaps Dr. Losos might know from his experience at Health Canada. My field is chronic disease prevention and not infectious disease, so I am remotely associated with those issues.

Dr. Losos: Senator, there were impressive public health laboratory networks in Canada in the 1940s. There were some leading public health experts globally in the Canadian laboratories at that time. However, the labs were built for the 1940s and in respect of the communications, there was no informatics technology. Mandatory surveillance systems were not in place. Rather, it was a matter of the telephone between the labs. There was no formal, structured, sophisticated, surveillance system. Lab scientists responded as best they could and did a good job. They were world leaders to quite a degree, although they did not have the automaticity that some of the informatics technology can now build, such as thresholds.

If you reach a certain threshold, the bell will ring to indicate that you have found more salmonella than you did last year and so you investigate it. These sophistications were not in place back then but networks of laboratories have, in fact, existed for quite some decades in Canada.

Senator Callbeck: The National Network of Public Health Laboratories is effective. Is that correct?

Dr. Losos: It is getting there. It could certainly be strengthened by help from groups such as Canada Health Infoway, which has the resources for strengthening the informatics — the computer linkages and the data management linkages — between the laboratories. That is still rudimentary in some laboratories. A network of laboratories is actually crucial. Laboratories are the radar rooms of public health. This laboratory is laudable in its creation and it has come up with some terrific guidelines and standards. It could stand to have an infusion by working with some of the capacity around it like Infoway to strengthen it even further.

Senator Cordy: Thank you for an interesting dialogue. I know you both commented on how dedicated health workers are and certainly, members of this committee would agree with you. That was particularly noticeable during the SARS epidemic when health care workers went above and beyond their duties. In some cases, they put themselves and their families at risk of illness.

My question is for Dr. Losos. You made a comment about setting up the agency in respect of amalgamating or developing agreements with various other federal government departments including the Department of National Defence and Agriculture Canada. I assume you mean ``emergency preparedness'' from the Defence Committee.

Dr. Losos: Yes.

Senator Cordy: You used the word ``agreements.'' How do you see the departments working together? Would that be done with written agreements? Would there be interaction?

Who would be in charge if we were to have an emergency situation? Would it be the agency or would it depend on what the emergency was?

Dr. Losos: I know that can be confusing in a crisis situation: who is in charge and is it a health crisis? If it is health, then it should be the Minister of Health, period. The capacity of some of these other departments is incredibly significant in biotechnology. For example, Agriculture Canada and the National Research Council Canada have huge capacities. They should, more systematically, link to and work with the health sector as far as that particular field is concerned. There are numerous others. Health Canada will be working on infectious agents. The immunology centre of the NRC will be looking at infectious agents. They have made some major breakthroughs in infectious diseases but the linkage has not been systematic enough.

Many scientists will make connections with other people in the field because they know who they are and that they will do a good job in networking. My suggestion is that we need to make it systematic.

Senator Cordy: In fact, the linkage would be strengthened more formally. Is that what you are saying?

Dr. Losos: Yes, for example, you could have a standing committee on infectious diseases or any other aspect.

Senator Cordy: An AIDS committee, for example, would have representatives from various government departments.

Dr. Losos: That is right. We have an AIDS committee populated mostly by health professionals. However, AIDS is a zoonotic, SARS is a zoonotic, and mad cow disease is a zoonotic. The veterinarians have very sophisticated surveillance systems. They certainly are first on the wire with 5,000 inspectors across the country, when it comes to some of these problems. Dr. Mills alluded to the chief veterinary officer, who can mobilize 5,000 people in one hour and can close down any farm in Canada.

Senator Cordy: In fact, there is a first step. It is being done informally and you suggest that it should be more formalized.

Dr. Losos: That is right. We defined some of these roles and we cut back the number of committees in an effort to make it more efficient. However, it still ends up being a kind of voluntary, let's-get-together-and-manage-the-situation system, which very often works well. It could work better if it were mandatory.

Senator Léger: I have heard bits of responses to my questions as we have gone along. For public health, you suggested that we would need $1 billion and that is because of the basic consumerism of our society. That is the angle.

I understood you to say that we should create a new agency. Should those efforts — money, human resources and highly trained specialists — be restricted to work in Canada or should there be a connection to the World Health Organization? Would we be creating another system with all the same weaknesses of the previous systems? We have only a certain amount of money and a certain number of specialists. Should we keep them for ourselves again?

Dr. Losos: My opinion is that we should get our house in order first. When we have our house in order, and we are functioning at the level that I believe we are all talking about, then we can help the World Health Organization out in three ways. First, we can fund specific projects — we migrated our global public health intelligence network to them, which is an Internet crawler that found SARS, I believe, three or four months before it actually was picked up by the systems in North America and Europe. We constantly do that, so we can migrate technology to them. Second, we could probably fund targeted activities. We could create an outbreak team that would target a specific area that Canada might have expertise in — meningitis, as an example — and have it at the ready and make it available for global response if there is a meningitis outbreak in sub-Saharan Africa or whatever.

Third, once we have our own human resources picture in order and we have enough people trained in Canada so that we have a surge capacity — so that we are not under-serviced and under-manned in our capacity — we could actually place people with WHO to supplement their expertise, because they are really thin. If you go to Geneva and you actually look at the capacity that they have to respond globally, it is really thin. It is 15, 20 people in their infectious disease group.

Senator Léger: If I understand well, it most interesting. We are in globalization. If we do our part here, it can be part of WHO almost automatically.

Dr. Losos: Yes.

Senator Léger: If the need be.

Dr. Losos: If we get our house in order, we will be asked for participation in global systems, to address Senator Keon's point again. If we have it together, then we will be at the table when international systems will be created. I predict that international systems will have to be created, because it is a globalized world. If we do not do it now, our successors will do it.

Ms. Mills: I agree with Dr. Losos, that the best way to contribute to global public health — both for selfish and altruistic reasons as a developed country — is to create capacity in our own country. When I was at Health Canada, I would get a call from Pan American Health Organization almost yearly, because I happen to speak Spanish, asking if I could go down there and help them with some things. I would have to say no, because we did not have the salary dollars to replace me if I left my position at Health Canada. We need to have capacity to be able to both fulfil our own public health obligations here, and to hold up our moral responsibility to contribute to global health in the broader sense. That requires having some depth to our workforce.

The Chairman: I want to ask two questions. Dr. Losos, what are our international reporting obligations? There was a lot of criticism of China for not reporting the SARS epidemic until several months later. Do we have legal international obligations that require that we inform the rest of the world if something is happening in Canada?

Dr. Losos: Cholera, yellow fever and plague are the only three diseases covered by the international health regulations — none of which, to my knowledge, have we seen for quite awhile, although they get an occasional case of plague in California.

The Chairman: To that extent, if SARS had started here, we would not have been under any international obligation to tell anyone.

Dr. Losos: No, but that is where leadership comes in. A proactive commissioner, a proactive agency, would have contacted WHO and said this is what is happening, this is what we are doing to control it, and I believe that they never would have shut down Toronto.

Senator Morin: We were blaming China without reason. That is a good point.

Dr. Losos: Yes.

The Chairman: Related to that — assume for the moment that we have at least a moral obligation, if not a legal one, to tell the rest of the world — is that the real justification for having essentially a national network of epidemiologists funded by the federal government? It is impossible for us to fulfil our international obligation if we do not have the information, so we have to have the people who can get us the information. Is that right?

Dr. Losos: One of the cornerstones, senator, of the CDC's capacity in the United States, despite their mass and everything I mentioned before, is their Epidemiology Intelligence Service, EIS — their epidemiologists in the States. It is an informal communications network, where one picks up the phone and says I found this, and then the whole system gets triggered. In Canada, we have had field epidemiologists, as we call them, but very few; and when they were put into the provinces, they ended up, at least in the earlier years, doing scut work and adminis-trivia as opposed to doing the outbreak investigation. In my opinion, it is a federal role, and also a human resource development role, to get people of enough seniority and place them with the provinces as outbreak investigation officers, as epidemiologists.

The Chairman: I guess I am asking whether this argument is correct, that in fact that does not constitute the federal government interfering at either the local or the provincial level, because it really constitutes the federal government doing what it has to do to fulfil its international responsibilities?

Dr. Losos: That is right, and the provinces have always been very welcoming to this added capacity.

The Chairman: The head of the British Columbia Centre for Disease Control made that argument.

You talked about the governance of CIHR, the Canadian Institutes of Health Research. Remind me what that is — that board has five provincial representatives and five federal, is that correct?

Dr. Losos: It has a lot of academics on it. I cannot remember the exact number, senator, but it does have provincial and federal representation on it.

The Chairman: One might end up with different numbers, but basically it is the same principle that you have argued for your board.

Dr. Losos: Yes, and to go back to the senator's question over here, I think a board of capacity like I am talking about should include the voluntary sector. There is no reason that the Cancer Society, with the size it is, and the National Cancer Institute that it funds, would not be represented on a board like that. The Heart and Stroke Foundation has $100 million worth of research a year, which may not be as big as CHIR, but is no small pittance. It should have something to say when it comes to the public health of cardiovascular disease.

The Chairman: What is the nature of the board of the Centers for Disease Control and Prevention in Atlanta?

Dr. Losos: Usually, it is made up of deans of medical schools, but they have broadened their look on life just as CIHR has. They have consumer groups, advocacy groups and voluntary organizations.

The Chairman: But no state representatives?

Dr. Losos: To my knowledge, no state representatives.

The Chairman: There are two items I would like you to think about. In politics, selling an idea is often the hardest thing to do, so I would like you to reflect on the following observations.

First, to get back to the discussion that you had, Dr. Losos, with Senator Roche about what the provinces will allow you to do, I would like you to think about the title for your organization, for the following reason. I think if the word ``emergency'' is in there, it is impossible for a provincial government to get upset because at that point you are dealing with a health emergency and no one is going to stand on constitutional nicety. I would like you to reflect on whether there is a way to do that.

The second comment is to Dr. Mills, and it picks up on Senator Trenholme Counsell's point. Outside of the intelligentsia, I can guarantee no one knows what population health means; and I bet you very few people know what public health means. I do not care what you do with the name of your own organization. Can you reflect on a way to describe what you are talking about in your brief, which is old-fashioned public health — not in a derogatory sense? We have to find a way to describe that to the people so that just from the name of the organization, they know what it does. Right now, a commissioner for public health would cause people's eyes to glaze over. If, somehow, what they saw in their mind was an organization responsible for dealing with immunizations which prevent outbreaks, and dealing with emergencies, I think you would get a totally different reaction from the public — and more importantly, from provincial governments.

I ask the two of you to reflect on that and see if you can give us your thoughts on that. I know it sounds odd and not academic, but I mean political in the best sense of the word — the small ``p'' political in selling it to the public. What we call this animal will really matter, and I would like you to reflect on that.

I thank you all for coming.

The committee adjourned.