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

Issue 12 - Evidence


OTTAWA, Wednesday, March 23, 2005

The Standing Senate Committee on Social Affairs, Science and Technology, to which was referred Bill C-12, to prevent the introduction and spread of communicable diseases, met this day at 3:54 p.m. to give consideration to the bill.

Senator Wilbert J. Keon (Deputy Chairman) in the chair.

[English]

The Chairman: Minister Bennett, Mr. St John and honourable senators, we do not have quorum but the rules allow us to proceed with the hearing. Our meeting will be interrupted because there is a vote at 4:40, which nobody expected and which has caused some senators to have to remain in the chamber at this point in time.

Thank you so much, Minister Bennett, for coming. Please proceed.

The Honourable Carolyn Bennett, Minister of State (Public Health): I would like to begin by thanking this committee for all the important work you have done to date, which has really contributed extraordinarily positively to the need for improvement in a true public health system for Canada. The recommendations in your 2003 report play a very large role in shaping our efforts to create the new Public Health Agency of Canada and the role of the Chief Public Health Officer.

[Translation]

In the Speech from the Throne, the Government of Canada committed to the modernization of health protection legislation. To date, Canadians have been well served by the health protection system. However, the time has come to update our legislation to ensure effective intervention capability in order to meet the public health challenges of the 21st century.

[English]

The SARS crisis was a stark reminder that times have changed, that in a globalized world, emerging and re- emerging diseases can spread rapidly throughout populations with no respect for borders.

The need for a comprehensive public health system, equipped with modern tools, is critical to mitigating the socio- economic consequences and the geopolitical implications of future health emergencies, a consideration put forward by Dr. David Naylor and this Senate committee as a result of the lessons learned from SARS.

From this experience, the Government of Canada had to face the fact that our current health protection legislation is outdated. The existing Quarantine Act, one of Canada's oldest pieces of legislation, has remained largely unchanged since 1872. From a pan-Canadian perspective, the need to modernize existing quarantine powers is paramount in preventing the introduction and spread of communicable diseases arriving into or departing from Canada.

Not too long ago, this government made a commitment to Canadians to enhance public health protection. This is why we are moving forward quickly with Bill C-12, new quarantine legislation.

[Translation]

Updating the Quarantine Act is the first step in a series of initiatives such as the new Public Health Agency of Canada Act that the Government of Canada plans to take to strengthen our public health system.

[English]

The modernized legislation we are proposing complements our previous efforts in strengthening public health, namely the creation of the new Public Health Agency of Canada and the appointment of our first Chief Public Health Officer. Bill C-12 becomes an important instrument for the agency in managing disease outbreaks. It is a very powerful piece of legislation that requires due diligence when administered.

[Translation]

The scope of the proposed Quarantine Act is limited to ensuring that communicable diseases are prevented from entering Canada or being spread to other countries.

[English]

It will not affect interprovincial movement but complements existing provincial public health legislation, recognizing the need for ongoing collaboration with our partners in public health. It also underscores Canada's commitment to the International Health Regulations. As we know, public health protection is a global effort.

With a new emphasis on migration health-related consequences, the newly proposed Quarantine Act is focused on airline travel, the new mode of global disease transmission. It offers enhanced protection at Canadian points of entry, by outfitting the Minister of Health with additional authorities to ensure rapid and decisive action to stem the spread of disease. New quarantine legislation will enable the Minister of Health to divert aircraft to an alternate landing site and to establish quarantine facilities at any location in Canada, if it becomes necessary to contain and isolate at-risk travellers. Further, it provides flexibility, enabling the minister to compensate the owner of a facility in a manner consistent with responsible and prudent government spending.

Bill C-12 also contains a provision to enable the minister to close Canadian border points, in the event of a public health emergency of international concern. It prohibits carriers from other countries to enter Canada, if such an arrival threatens the public health of Canadians.

The proposed act also lists many more communicable diseases for which Canadian officials can detain departing passengers. It also ensures that the administration of quarantine powers is carried out by qualified professionals and that entry and exit control measures are tailored to the presenting circumstances.

In the event of a public health emergency, the Quarantine Act would place temporary restrictions on individual liberty rights for the greater collective good. That is the essence of protecting public health.

I want to assure the committee that privacy rights are guaranteed. While the updated act authorizes the collection and sharing of personal health information, the authorization to do so is limited to what is required to protect the health and safety of Canadians. This was reaffirmed and supported by the Office of the Privacy Commissioner.

In the spirit of collaboration, it is my hope that committee members will find merit in the work previously undertaken by the House of Commons and demonstrate continued support for this very important initiative for public health protection. With that said, I remain confident that contributions by the Standing Senate Committee on Social Affairs, Science and Technology will further enhance and strengthen Bill C-12 and serve the Canadian public well.

[Translation]

The updated Quarantine Act will add an additional lawyer of protection by providing strong, flexible, up to date legislative tools that will allow us to respond more effectively to current and future health threats, while ensuring at the same time that human rights are adequately protected.

[English]

To this end, I wish to express my support for Bill C-12, a modernized Quarantine Act. Your input into this legislative process will help pave the way for enhanced uniformity in the management of public health, providing the agency with a modern legislative tool to enable an effective response capacity in the event of a future public health crisis.

The Deputy Chairman: Thank you, Minister Bennett, for that presentation and for being here. This is complex legislation. When one considers the interval of time between this Quarantine Act and the last one, there is little doubt that it must be complex.

How do you see this act interfacing with what I suspect will be the Canada health protection act, the legislation that will be necessary to allow Dr. Butler-Jones to do his job and get the system up and running? I was a little surprised that this act came out in isolation, although perhaps that is the best way to proceed. At least we now know what is in it, and the other act can deal with that. Have you any thoughts about how these acts will interface?

Ms. Bennett: Health protection renewal is a suite of approaches. As you have alluded to, the matter is so complex and it has taken so long to get to this point that we need this one now. No ones wants us to go through what we went through with SARS without this specific tool. We want to get this tool and then we will move forward on getting an integrated approach to health protection. This act is something that we could not work without.

[Translation]

Senator Pépin: What are the roles and responsibilities of each level of government? We know the provincial government plays a very special role. What responsibilities will be set out in the new legislation for each order of government?

Will the provisions of the bill help us to deal with outbreaks such as SARS? I know that these legislative provisions have been strengthened. With everything that has happened, we are confident that another outbreak of this nature will not occur. What are the responsibilities of each level of government? Do you foresee any jurisdictional problems arising further to the enactment of this legislation? Will we end up tripping over each at some point?

Ms. Bennett: The role of the federal government is truly international. Relations with our new network of provincial and territorial medical officers of health have been developed by David Naylor who advocated the four Cs, namely collaboration, cooperation, communication and clarity. Who does what, and when, has been spelled out clearly.

[English]

Health and health care is the responsibility of the provinces and territories. The federal government cannot take over in a province in a public health emergency. That does not work. The approach has to be bottom up and it has to be about relations. In Toronto, Sheila Basrur knew what was going on and whom to call. However, the federal government can supplement provincial and territorial resources with whatever extra services are required.

Perhaps Dr. St John can talk about health emergencies. We will have some Health Emergency Response Teams that can be deployed, but it is a matter of invitation. As well, we must coordinate the international reality with this new tiny planet. We must deal with the World Health Organization in Geneva, the Centers for Disease Control and Prevention in Atlanta and with Hong Kong and Vietnam. We need to have an alert system whereby we know what is going on and can alert the provinces and territories of what we think is coming.

In Canada, we have the exciting Global Public Health Intelligence Network that works for the WHO. It combs media press releases from around the world in six languages and lets people know when there is an alert in any country in the world. We have those eyes and ears outside the country and the fabulous new relationship between the chief medical officers of health and Dr. David Butler-Jones.

We are gradually implementing all the recommendations of your report and the Naylor report.

In response to your specific question, this bill is clear that our responsibility is for people coming to and leaving Canada.

Senator Fairbairn: To continue on the line of Senator Pépin's question, will having this jurisdictional relationship require provinces to pass legislation regarding jurisdiction in connection to this bill?

Ms. Bennett: Perhaps Dr. St John can address the inter-provincial aspect.

Dr. Ron St John, Director General, Centre for Emergency Preparedness and Response, Health Canada: The Quarantine Act is one of the oldest pieces of legislation in Canada. From the very early days of the confederation, authority for people coming into Canada was ceded by the provinces to the federal government. This Quarantine Act has been in existence for just about 150 years. The authority, as Minister Bennett said, is for people coming into and out of Canada. There is no need for any additional provincial legislation.

The question that came up after SARS, and the legislative gap that was identified, is that there is currently no legislative process in Canada for the movement of people between provinces. Provinces have legislation to control the movement of people within their provinces under various pieces of public health legislation, but there is no legislation anywhere about people moving from one province to another.

The provinces asked us, after SARS, about the possibility of extending the Quarantine Act, which operates only at the point of entry, to a domestic situation to govern the movement of people between provinces. That is still a subject for discussion. There is a possibility that, at some future date, we will come back after extensive discussion with the provinces and territories to amend this bill to include domestic authority, but that is still very much a discussion point.

Senator Fairbairn: Therefore, in the case of Alberta, where I am from, this bill would affect people coming across the Montana border, where we used to have cattle coming across, though we do not do that any more. However, going from Alberta to Saskatchewan or to B.C. would have to be covered by another phase of this bill, if it were believed to be necessary. Is that correct?

Dr. St John: Just to be perfectly clear, if you are travelling from Beijing, China, to Toronto, and you disembark in Vancouver to change airplanes, at that point, if you were sick, you would be subject to the federal quarantine law, but if there is no reason to detain you at that point and you then moved from Vancouver to Toronto, you are now on a domestic flight, and if you got sick on that flight, there is no quarantine authority at the Toronto airport to do anything about you because you have moved from an international flight to a domestic flight.

Senator Fairbairn: That is not in this bill.

Dr. St John: That is not in this bill. It is a subject of discussion with the provinces.

Senator Fairbairn: You may have another round to do this?

Dr. St John: Yes.

[Translation]

Senator Chaput: What are the specific responsibilities of each level of government should an outbreak occur or an alert be issued?

[English]

Who does what, who starts what, and how do they do it? I do not really understand how it will work out. In a crisis, which government acts first? Is it the federal government?

Ms. Bennett: It depends on who finds out first. This act will be for people coming to Canada and leaving Canada. As we learned during SARS, sometimes it would be a matter of stopping someone leaving Canada whom the local public health officer thought was sick. Because of our reputation as a country, we do not want a person with a serious illness leaving and landing somewhere else and infecting another country; this goes both ways.

If we hear that someone very sick is on a plane coming into Vancouver or Toronto, then we are the first ones to hear, and we would act and notify the local authorities of where that plane is. We would work with them on containment and whatever that meant. Also, if they alert us about someone they are worried about whom they think should not be leaving the country, then we can detain that person.

Dr. St John: May I give you a real life example? We were notified by Ontario public health officials that there was a person with very serious and severe tuberculosis who was recalcitrant and refused to take treatment. This person, a Canadian citizen, decided to leave Canada to go back to his country of origin. Unfortunately, we were not able to intercept him when he left, but we were able to put out a quarantine detention order in case he decided to come back. In fact, the person decided to come back on Christmas Eve when he suspected there would not be much vigilance. However, we intercepted him and turned him over to the Ontario authorities. We said that you can either accept treatment or you can be quarantined for as long as you want to stay in quarantine, but you are not going to be allowed to walk around and spread the disease. That is exactly how it works.

Senator Trenholme Counsell: I regret that I was not here for the beginning, so I may have missed certain things. Obviously this is a very important, detailed, long piece of work. I wanted to ask about the quarantine schedule on page 33. It says 2004-2005 schedule. Is that the schedule of diseases for the new act?

Ms. Bennett: In the bill, yes.

Senator Trenholme Counsell: I have not given this enough study, but I wondered about avian flu. Is it there under some name I do not recognize? I know that under section 63 you can add, delete or change the name of any communicable disease. I would have thought that avian flu would be included. Is it not there?

Dr. St John: It is there indirectly. There is influenza, type A, pandemic.

Senator Trenholme Counsell: Avian flu is not a type A.

Dr. St John: It is not a disease of people either.

Ms. Bennett: Avian flu is a disease of chickens. Only if it combines with an influenza would become infectious to humans; you have to have the mutation with a human flu.

Senator Trenholme Counsell: So it is basically included here.

Dr. St John: Yes. As soon as it becomes a human disease, it is automatically included.

Senator Trenholme Counsell: There are two types of measles. I find it a little worrisome that a child coming in with a parent may be in the last stages of measles. The doctor perhaps can answer that. Chicken pox is not included. Why would measles be included and chicken pox not?

Dr. St John: Measles is essentially almost eradicated. It is eliminated in Canada, and there is a worldwide effort to eliminate measles. This list is not intended to be all-inclusive or exhaustive, but we feel that measles is an important disease of childhood and that it should be on the list.

The question of chicken pox is a good one. At the moment, although chicken pox is a very discomforting disease, it is not considered to be a candidate for worldwide elimination and is not felt to be serious in terms of mortality for children.

Senator Trenholme Counsell: I disagree. I think chicken pox is quite a serious disease.

Ms. Bennett: The point is whether you would quarantine someone for it or divert a plane for it.

Senator Trenholme Counsell: I was surprised to see measles there and chicken pox not.

The Deputy Chairman: For the record, Senator Trenholme Counsell is a long-time practising family physician.

Ms. Bennett: It is interesting. Another way of looking at it, senator, is the case of tularemia that everyone was laughing about. In Dr. David Butler-Jones' first week on the job, hamsters infected with tularemia actually ended up having to be dealt with. It precipitated his first take-off on Air Farce doing a red, orange and green alert on tularemia in hamsters.

Even diseases we think are long gone seem to have surfaced. Because the hamsters were being exported to the U.S. from Manitoba, it was viewed to be a big deal. I am not sure the act is intended to quarantine hamsters, but it is interesting how, with the diseases we thought were gone, everything old is new again.

Senator Trenholme Counsell: I would respectfully submit that perhaps this list should be reviewed. We are limiting influenza to one type there, and measles is either rubella or rubeola, as we know; perhaps the list should be more explicit and carefully reviewed.

I was anxious to see who the screening officers are, but it says anyone deemed competent would be a screening officer. I think there is enough guarantee in here as to whom you would designate, and there is some flexibility in that, is there not? Can you elaborate on who would be designated at an airport, for instance, to be a screening officer?

Ms. Bennett: In airports, the quarantine officers have been the chief customs officers. The act is worded generally because you do not want to designate that it has to be a certain profession in case you have to train people in a hurry if you need other kinds of health professionals in the event of a big problem.

Dr. St John: If I may, minister and senator, there are 1300 border crossings between the U.S. and Canada that are manned by personnel. It would not be particularly efficient or effective to put a quarantine officer at every one. However, every one of them has a chief customs officer; if the border crossing has only one person, that person is the chief customs officer.

The law allows us to designate that chief customs officer temporarily as a quarantine officer. If there is a need to detain a person or cargo, goods or conveyance at that border crossing, the customs officer can do so on a temporary basis, backed up by a full quarantine officer, including our medical staff at the Public Health Agency of Canada, who then will help resolve the situation with that customs officer.

Senator Trenholme Counsell: In the case of a major crisis in public health, what would happen with all these small border crossing places?

Dr. St John: We have a very close working relationship with the quarantine division at the U.S. Centers for Disease Control and Prevention, and we have been talking at some length about what are the major border crossings, what are the minor ones, and whether or not we can have confidence in each other's quarantine service to draw a ring around the two countries, rather than through the middle. That way, there would be less concern, if any, about the movement of people across the common Canadian-U.S. border, but more concern about people coming into the two countries from outside.

Ms. Bennett: I feel a bit better at the moment that attention is paid all the time at major entry points like Toronto or Vancouver.

Dr. St John: We now have 28 quarantine officers in the field at the eight international airports in Canada that receive 94 per cent of all international air travellers. Also, they cover the four major seaports — Vancouver, Toronto, Montreal and Halifax.

We do not cover every single international airport because Transport Canada designates 128 international airports in Canada. If you take a small two-seater plane from Duluth, Minnesota, to Red Deer, that is an international flight, but it is not one of importance. We have targeted what we call the high-risk areas for the possible importation of disease into Canada.

Senator Cook: I will take you to the place I know best, my island province of Newfoundland, where there is a transatlantic flight twice a day. There is enough time crossing the Atlantic to get sick and to be identified.

Once this bill comes into being, what measures will the federal government take in cooperation with the provinces regarding the human resources infrastructure, that is, nurses and general practitioners? I know that it is not realistic to have a full-scale facility on my island, but we are a port of entry. The other thing is that the tourist trade is very much involved in my province; people come in from all parts of the world.

I would like to see the federal government be proactive in making sure that the necessary infrastructure is put in place to manage this. Measures such as training are needed, especially given the workload for the nurses in my province. I would hope that there would be good collaboration.

Ms. Bennett: We have felt over the last 20 years that the public health infrastructure in this country really was frayed, and we have begun to build it back. The $100 million that we had in last year's budget, which the provinces could draw down specifically for public health infrastructure, is a small first step.

The other piece is the ongoing training. Dr. David Mowat at the Public Health Agency of Canada has been very involved, and not only in creating modules for nurses and on-line ways of getting people's skills up. I was very worried, as you were, at the round table we did in St. John's to hear that even 40 per cent of the medical officers of health in your province had no training in public health at all. They were conscripted family doctors. How do we make sure that training is ongoing, whether it is in reading an epi curve or something else?

I feel great about having a chief public health officer for Canada because that has created a network; there is an excellent relationship among the chief medical officers of health for each of the provinces and the territories. They are a fantastic group of people who know their provinces well and who have great working relationships with one another, both with their neighbouring provinces and with the Chief Public Health Officer for Canada. As a result, we have a beginning network of infrastructure for public health, including collaboration, cooperation, communication and clarity around what would happen if something occurred in Newfoundland and the way that we could deploy help from province to province. There have been many positive steps post-SARS — the memoranda of understanding, helping with nurses and doctors and licences and all the things that were serious irritants during the SARS problem.

Senator Cook: I see an opportunity here for the federal government to become involved in training and infrastructure with your new agency, particularly enhancing the role of the nurse practitioner. There is an opportunity here for a nurse practitioner: nurses need help — they are getting older, raising families, and so on. It would be wonderful if the federal government could offer a program through its Public Health Agency to include that piece. We have nurse practitioners working with primary care for mental problems. This is a good opportunity to fit that in to what you have created.

Ms. Bennett: Dr. Butler-Jones is keen, as I am, on the interface between primary care and public health. Primary care reform should consider the specific needs of a community and build a health care team customized for that community, depending on the physician capacity needed and the need, for instance, for a mental health nurse or a community health nurse.

We have put a little money away for bursaries, scholarships and community-based apprenticeships. We hope that the federal government can help fulfil the health human resources requirements and have nurses dedicated to this. In our school health consortium we are looking at a proposal from the deputy ministers of health and education for a school health coordinator for each school. With schools being a hub in a community, we know we would get better results, not only on the disastrous infectious disease piece, but regarding the broadest definition of public health.

Senator Cook: You may be interested in knowing that the nurse practitioner program in my province is being enhanced with new protocols. I see this as an opportunity to further enhance it.

Ms. Bennett: When I was at the University College of the Cariboo in Kamloops, it was very interesting meeting with the nursing students. Many are women with a second career. The number of them interested in community health and public health was really inspiring; that is how they see nursing now.

Senator Cook: If you think it cannot happen there, I would ask you to cast your mind to 9/11, where every plane that came across the Atlantic dropped itself on the ramps of Newfoundland.

The Deputy Chairman: We have a predicament, which I do not like at all as chair, but that is life. There is a vote at 4:40 so we have to suspend the committee, go vote, and then come back.

When we come back we will hear from Dr. Patricia Huston, the Associate Medical Officer of Health in Ottawa. We will have an opportunity to see the problems of the hands-on application of this act. It will be very interesting indeed.

The committee suspended.

The committee resumed.

The Deputy Chairman: We are delighted to Dr. Patricia Huston, Associate Medical Officer of Health for Ottawa, here. It should be very interesting because this will be an application at the city level of the federal-provincial problems we were talking about earlier.

Dr. Huston, thank you for staying despite the break for the vote. We would appreciate hearing from you now.

Dr. Patricia Huston, Associate Medical Officer of Health and Manager of the Surveillance, Emerging Issues, Education and Research Division of Ottawa Public Health, City of Ottawa: I have come today to offer the perspective of a local public health authority regarding controlling the spread of communicable disease. I would like to take the specific case of pandemic influenza to illustrate some of the challenges involved in organizing a local response to this potential international public health emergency.

Local public health officials have been identified in the Canadian Pandemic Influenza Plan and in the Ontario Health Pandemic Influenza Plan as being responsible for local planning and coordination for pandemic preparedness.

I am chair of the Ottawa Pandemic Steering Committee and have recently drafted Ottawa's inter-agency pandemic plan. I sit on the Provincial Public Health Subcommittee for pandemic planning and was invited this fall to participate in a joint Health Canada/World Health Organization initiative to increase national emergency preparedness capacity.

As a public health physician working on pandemic preparedness and who witnessed SARS and its aftermath in Canada, I fully support the intent and provisions of Bill C-12. That being said, communicable diseases are notoriously difficult to eradicate. Despite all our knowledge about disease transmission, risk factors and treatments, many old diseases that we consider history, such as leprosy and syphilis, are with us today. The World Health Organization has called for all countries to step up their preparedness in case there is a genetic change in avian influenza to become a pandemic. If this occurs, the measures enacted by the Quarantine Act could delay, but likely will not be sufficient to prevent, pandemic influenza from entering Canada.

There have been stunning accomplishments in pandemic planning at international, national and provincial levels. Although this was necessary and laudable, my biggest concern is that the local health care system is really not ready. It is the local health care system that will need to take care of tens of thousands of infectious patients each week, for an estimated eight to 12 weeks. This lack of preparedness is not from lack of due diligence, but from structural challenges that still need to be overcome. I would like to take the next few minutes to give you some examples of those gaps and those challenges that we are experiencing at a local level.

Ottawa may have close to a best-case scenario for pandemic planning in Ontario. We have sought and received guidance from national pandemic planning experts here in town, and we are well-linked with provincial planning initiatives. We have an excellent inter-agency relationship with the hospitals, with home care, with the paramedics, with many other health services, and we have worked together, held case studies or table top exercises and so on. Despite the progress, many questions remain, and here are a few examples.

First, surveillance: You may remember that during the SARS outbreak the focus was on the number of cases, and whether that number was increasing or decreasing. Collecting surveillance information is critical to knowing whether we are at the beginning, middle or end of an outbreak. Specifically, we must collect statistics on laboratory-confirmed cases. It is important that these statistics are gathered in a uniform way, so that we know whether we are better or worse off than others. Yet, to date, there is no answer to the relevant local question: whom do I test for influenza and how do I get the sample to the provincial laboratory? Despite direct contact with the provincial pandemic working group on surveillance and thorough knowledge of local, provincial and national plans, I still do not have an answer to that question. This is a basic building block of pandemic influenza surveillance that is not yet in place.

Second, assessment strategies: It is not clear how we will be able to prevent the spread of pandemic influenza in the waiting rooms of emergency departments and family physicians' offices. Although we want to keep potentially infectious patients away from non-infectious patients, it is not at all clear operationally how we will do that. There are no guidelines out there right now to direct it.

Third, alternative care sites: Alternative care sites will be needed for influenza patients when hospitals become overwhelmed. As you know, many hospitals are already at 100 per cent capacity, so to have a case of pandemic influenza will seriously strain the hospital systems. The Ontario plan identifies the setting up of these alternative care centres as a local responsibility, but it does not identify whose responsibility it is, and this was not an oversight. It is simply not established.

Local discussions have not found a definitive answer either. Ottawa hospitals did not initially see this as their responsibility, and they have recently been informed of major budget cuts, so to ask them to think about opening up extra centres was counterintuitive. No family physician, group of family physicians, community health care centre or home care service has come forward to offer to organize this. Ottawa Public Health and the City of Ottawa have offered to provide the sites, but we do not provide clinical care services so we could not staff these centres.

Health care services are scrambling to meet staffing needs now. The idea of trying to provide surge capacity when health care professionals may be off due to illness has evoked many quizzical looks. People just do not see how they will do it.

There are some jurisdictional challenges. The challenge locally is that although local public health authorities have been charged with the local pandemic planning, we have no legal authority over family physicians, hospitals, paramedics, home care services or community health centres. No one has explicit responsibility to provide surge capacity. There is no legislative imperative for hospitals to coordinate their services. In Ottawa, none of the hospitals has written plans for providing surge capacity outside the confines of their own physical premises.

In other provinces, this is less of a problem. In Alberta, for example, there are district health authorities where all public health, hospital, paramedic, home care and community health services report to a single board of directors. However, to my knowledge, no province integrates family physicians into such a district health care model.

Therefore, one of the major challenges is the lack of integration of primary care. Recently, the top story of a local CBC station was that family physicians are not prepared for pandemic influenza. That is true. That is true despite the fact that Ottawa has probably done more to prepare family physicians for a pandemic than most municipalities in Canada. The rub is that few family physicians have actually participated in these preparedness activities because many physicians are simply too busy. They are in chronic information overload. Many are paid on a fee-for-service basis, so to come to an all-day case study or table top exercise would mean they would lose a day's wages. Perhaps most importantly, the majority of family physicians are independent professionals who are under no obligation to coordinate their efforts with other health care providers or with public health authorities.

I believe one of the biggest challenges in local pandemic preparedness is that there is no existing mechanism to coordinate the efforts of public health, hospital and community-based care. Trying to integrate family physicians into pandemic planning and response is particularly challenging. Who can legitimately represent family physicians at the local planning table? How can any decision taken there be binding?

There is also a problem of imperfect knowledge transfer. Again, David Naylor talks about the gap between ``is'' and ``ought.'' One of the ways that this relates to pandemic preparedness is around the use of alcohol-based hand cleaners. The U.S. Centers for Disease Control and Prevention has developed programs for respiratory infection control that promote the use of hand cleaners, at work, at home and at school. Evidence shows that they are 99 per cent effective in killing viruses, including influenza virus. That is an incredibly good news story. However, it has not really been integrated into pandemic planning. Planning for pandemic and for emergency preparedness in general has been incredibly decentralized.

This fall, when I was working on the Health Canada-WHO project, a WHO official asked me, ``What are the chances that your public health emergency preparedness plan will be identical to a comparable city in another province?'' My response was, ``Approaching nil, because we are all doing it independently.'' He found that astounding, considering that most countries do not have as highly decentralized a health care system as we do in Canada. One has to wonder about the efficiency of such a system.

Local plans for pandemic influenza vary widely. Furthermore, there is no mechanism for coordinating the neighbouring local responses, be it interprovincially or intraprovincially. For example, across the river from Ottawa in Gatineau, there is a completely separate pandemic planning process in place, although we have had some informal contacts to share notes. However, there is no mechanism; it is only working now because of relationships and goodwill.

We are currently conducting a scan of pandemic preparedness materials for the public. We have already found both gaps and huge redundancies. It reminds me of the spring of 2003 during SARS when public information sheets were prepared by Health Canada, the provincial ministries of health, local health units and other health care organizations. It reminds me of the summer of 2004 when West Nile virus was on the rise and public information sheets were developed by Health Canada, by the provincial ministries of health, by local health units and other health care organizations. In contrast, during those times, a similar scenario did not occur in the United States. Everyone simply went to the CDC website to download information. Surely Canada must begin to work towards a less disjointed and overlapping response.

To ramp up on the Ottawa case study, I am confident that when pandemic influenza hits Ottawa, we will be prepared to meet the challenges it brings. That will be due in part to important international, federal and provincial initiatives that are in place or in progress. It will also be due in part to the sheer ingenuity of incredibly dedicated people to overcome the gaps and structural challenges. These gaps and challenges may not be equally well addressed in other localities across Canada. Such an inevitably varied and patchwork response begs the larger question of how we could fill the gaps earlier and build a better structure.

In conclusion, I would like to say that great strides have been made in developing the public health care system in Canada, including augmented legislative powers that would be enabled by Bill C-12.

In order to optimize our emergency preparedness capacity and our ability to prevent the spread of communicable disease, we need to question Canada's decentralized health care system. An optimal local response would be well coordinated among the different health care providers and well connected with provincial, national and international efforts. We need mechanisms to better integrate public health, hospitals and community-based care. We need further integration of local, provincial, national and international public health initiatives.

The Deputy Chairman: Thank you very much, Dr. Huston. That was a truly wonderful presentation. Actually, it answered so many of the questions we have been wondering about that some of the questions are not going to be necessary.

I have sat in on the hearings for various health studies over the last couple of years, and one thing that is becoming very worrisome is the lack of organization of our primary care and the lack of integration of our primary care into community services and public health and emergency preparedness.

As you pointed out so well, if there is a pandemic and you send two or three patients to a large hospital, you close the hospital. We need to build basic infrastructure at the community level.

Senator Trenholme Counsell: Dr. Keon just summarized what I was going to say. Hospitals most certainly have to have a plan, and in the end they are the most likely ones to have a plan. The plan we really need is on the ground in the communities, because, except for those whose respiratory systems become really compromised, we do not want people with the flu in hospitals.

I am saddened by what you have said because I thought we were further along the road of developing these plans, but it is important that you have said what you have. Most of us have been involved in one way or another in emergency preparedness, where communities actually have a plan that they develop, practice and are ready to execute. That is what must happen and it must involve many players.

The hospitals, of course, are almost the refuge of last resort when it comes to the flu.

It is fine to hear glowing words from Parliament Hill, but it is better to hear from people like you who are in greater touch with reality. We heard about the terrible state of affairs in Toronto and about how bravely and heroically the outbreak was handled. It was very challenging and almost overwhelming for them.

Dr. Huston: I have tremendous respect for the work that Health Canada has done. The Canadian Pandemic Influenza Plan is truly a landmark document. A few years ago, people were wondering if we could even talk about a health care system in Canada, because it was so fragmented. It was extremely important to lay out the federal responsibilities, the provincial responsibilities and the local responsibilities at each phase of the pandemic plan. The Canadian plan came out a year before the plan in the U.K. It was a truly remarkable and seminal document that gave people a vision of how the different levels of public health could work together.

I do not want to say that locally we have been left in the breeze. Huge advances have been made at the federal level. SARS and now a possible pandemic have become a great motivator to address some of these issues. We have to consider where we were starting from in 2003.

Senator Fairbairn: I was getting worried when we were talking about the need to have special agreements for crossing the border into Canada, and then we were getting into the issue of crossing provincial borders within Canada, which opens up the almost scary thought of the negotiations that always take place between the federal government and the provinces. Those negotiations are never easy. On this issue, demanding though it is, they would still not be easy. You have taken us to another level entirely, reminding us that if we do not have the collaboration that you are talking about, we do not have much.

You mentioned the Province of Alberta, from whence I come. There has been an effort in Alberta to implement district organizations and to build the kind of system you were talking about. However, I can tell you, having had to work with this system through family, that there is another level yet underneath, and that is the education of the public, particularly older people, on how to access this quite well-developed system.

Dr. Huston: Yes.

Senator Fairbairn: Public education, especially in the case of an epidemic, may end up being among the most critical factors. I do not think we are quite there yet, even in Alberta. It is hard for a member of the public to know the language that has created the new district system in Alberta, or even to know where to look in the phone book. Home care is not called that any more, for example.

When all is said and done, probably each one of us needs an advocate. If we are not our own advocate, we need someone who is. Never would that be more important than in a case of great anxiety and perhaps panic.

The medical profession at all levels has to consider the awareness of the patient and the patient's family and make that connection so that the patient and family know how to access the very good things that you are doing here in Ottawa and that are being done across the country. That piece of the puzzle is difficult but necessary but communities large and small do not think about it much.

Dr. Huston: I agree with you. One of the exercises we did was to pretend we were the public and there was an outbreak in Vietnam and then an outbreak in Vancouver. We thought about what we would be asking for.

It was an interesting exercise. We wanted to know where to call, what to do and how to help. This started to become the focus of our efforts. We have a community engagement committee now developing educational materials on how to look after your loved ones at home without getting sick and how to get information. That is a huge piece of the puzzle. The public needs to be informed.

The two goals of pandemic preparedness are to minimize morbidity and mortality — illness and death — and to minimize societal disruption. We have been focused on the health care system, but we must also focus on decreasing societal disruption, getting the public prepared and getting business continuity plans in place.

Senator Cook: While I understand the context of your presentation, it is worrisome. You are from Ottawa Public Health. Is that a municipal jurisdiction or a provincial jurisdiction?

Dr. Huston: We are part of the City of Ottawa, a municipal jurisdiction. Fifty per cent of our funding comes from the province and we do have a provincially legislated mandate through the Health Protection and Promotion Act, but our borders are the City of Ottawa.

Senator Cook: The legislation before us is designed to put all the right bits and pieces in place. I share your concern. I have had sleepless nights about this, and you have just confirmed my worries. We live in a global village, so we need a global protocol.

There are three clauses in the bill that provide for the establishment of quarantine facilities, but the details — location, design, construction and operation — will be provided in regulations.

I understand what you are saying. With each crisis will come the opportunity to reach that goal. I understand that we have a rocky road ahead. Many people know how to achieve the goal, but we have not been able to get linkages in place. The legislation is an opportunity for us and for this committee to ensure that there is seamless delivery, if you will forgive the phrase, and to see that the infrastructure is there.

I come from Newfoundland. It is a small island with 350,000 people. Do not put me into Toronto and expect me to understand the consequences of a pandemic in the Greater Toronto Area. The numbers are overwhelming.

Unless we have a seamless protocol through all levels from the individual health boards on up, I do not see how, even with all the goodwill and the knowledge we have, we will be able to deliver what we are capable of delivering. I would like your response to that. I would also like you to help us see how we can get there.

Dr. Huston: The bill will help prevent the introduction or will delay the introduction of communicable diseases. My experience is that it may not do as much for the spread of communicable diseases.

Senator Cook: The Public Health Agency of Canada is struggling to be born, I would say. That is where our best options lie for making a strong federal agency that everything would feed into, that would not be restrictive, and that would be connected to at least parts of the whole, right to the nurse on the floor.

Dr. Huston: Absolutely.

Senator Cook: I do not know where we would go for extra people in my province. They would have to be flown in from the Maritime provinces. My province is at risk as much as the Greater Toronto Area. Planes drop in every day; tourist ships come during the season. We are just as vulnerable, but we have only that wonderful group of people that you are talking about; they have their own case scenario all ready in the event of a disaster, but they are not connected. That is worrisome.

Sooner or later we will have to have one seamless delivery that everyone understands. Can you offer any suggestions or help with that? Does anything in this bill address that problem? The first ministers meet annually. I am trying to see where we are.

Dr. Huston: My local perspective cannot inform much on this question. This is a very significant act, but it is important to realize that it is just one piece. I was very encouraged to hear about the renewed health protection bill that is coming, as well as the other pieces that are coming. From a local perspective, this bill alone will not do it.

Senator Cook: That is why, Mr. Chairman, I think the regulations will be critical. I thank you very much for that information.

Senator Chaput: I will be repeating what Senator Cook said.

I am from Manitoba. Listening to your great presentation, I was worried. I know that they are not ready at home. I was on the regional authority board before becoming a senator. Had we heard such a message on that board, I am sure that all the board members would have worked together to see what could be done.

What do you think can be done? Who should be going to those regional authority boards and to the municipalities to tell them that they are not ready and that they must get ready? Board members would be open to such a suggestion, if they only knew. Sometimes when you are not connected at the federal level, as I was not before, you do not really grasp the extent to which you are not ready at the local level. What can be done in regard to telling us to get ready? I do agree with you that this bill is but one piece. Do you have any suggestions or ideas?

Dr. Huston: What we are doing locally is really a result of having gone through case studies in a tabletop exercise where you try to visualize the situation — a disease is in Vancouver, for example, now in Toronto, now here. Everyone who could be involved in that situation was invited to the table. The result was an agreement to set up a pandemic clinical care committee that would include hospital representatives, family physicians, home care people, paramedics. All the people involved in clinical care need to be at the table. Once again, pandemic is the great motivator. We have to put our heads together and come up with solutions.

Through dialogue and understanding the different perspectives, we start to find the solutions, and then we need to compare notes. I understand that a medical officer of health in Alberta, though I am not sure if it was the provincial or a municipal officer, had a meeting several weeks ago to which he invited local health units from across the country to share the kinds of solutions they have started to work out.

Having talked to quite a few people about this, I understand that the biggest problem is surge capacity. We have hospitals that are at 100 per cent capacity already, bursting at the seams now. People cannot get their heads around the idea of having staff off sick and yet needing to increase capacity.

Senator Pépin: Who will be responsible for finding the special hospital or the special place where those patients will be kept?

You spoke about Ottawa and Gatineau. The two are very close, just across the river. What would be important to communicate and to share or exchange between the provinces? What plans should be put in place? We can look at the number of doctors. Also, the rules from one province to another have to be quite similar.

Dr. Jean-Pierre Legault, Head, Quarantine and Travel Migration Health Program, Public Health Agency, Health Canada: It gets complicated very quickly. We have set up a web portal where everyone can go to find out what we are doing on pandemic planning. That is one form of communication.

In the last case study we worked on the idea of a daily schedule of teleconference calls. During an emergency, you spend half your time on the phone scrambling. It would be much more efficient to know that every day at nine o'clock the CEOs of the hospitals, the emergency operation centre at the city and the public health people would all have a chance to put our heads together. The head of the Département de santé communautaire could also join that teleconference meeting. Then we could start to share.

The Deputy Chairman: Thank you again, Dr. Huston. Your brief is invaluable to us. It will get careful attention in the chamber at third reading. I can assure you that you have made a tremendous contribution. It will be particularly important as everyone works their way through the health protection act, because it will give us an opportunity to deal with some of the holes you were talking about.

Dr. Huston: Thank you very much for the opportunity to speak to you.

The Deputy Chairman: Honourable senators, we will now proceed to clause-by-clause consideration of the bill, with your permission.

We have two amendments by Senator Pépin. They are straightforward. They are circulated to you and we can deal with them as we walk through the clause-by-clause consideration.

They are amendments by the committee, which I think is better than letting the bill go to the floor. I think our committee can agree on the amendments. However, if you have concerns and prefer not to do it this way, we can defer the amendments and get amendments on the floor at third reading.

Everyone can take a minute to read the amendments. They are well laid out; in fact, all they do is demand recognition of the work of the Senate in the process, rather than just the House of Commons.

Senator Trenholme Counsell: May I ask, since I am new here, whether regulations are always handled this way?

Senator Pépin: They always go to the House and to the Senate. Also, Senator Joyal introduced a special bill, S-8, to make sure that it is always mentioned in every piece of legislation that regulations go to both the House and the Senate. That is not new. This is a mistake and therefore must be corrected.

The Deputy Chairman: The amendments are to clauses 62.1 and 62.2, and we will deal with them when we get there. Are you comfortable in proceeding?

Is it agreed, honourable senators, that the committee move to clause-by-clause consideration of Bill C-12, to prevent the introduction and spread of communicable disease, the Quarantine Act?

Hon. Senators: Agreed.

The Deputy Chairman: Shall the title stand postponed?

Hon. Senators: Agreed.

The Deputy Chairman: Shall clause 1 stand postponed?

Hon. Senators: Agreed.

The Deputy Chairman: Shall clause 2 carry?

Hon. Senators: Agreed.

The Deputy Chairman: Shall clause 3 carry?

Hon. Senators: Agreed.

The Deputy Chairman: Shall clause 4 carry?

Hon. Senators: Agreed.

The Deputy Chairman: Shall clauses 5 to 11 carry?

Hon. Senators: Agreed.

The Deputy Chairman: Shall clauses 12 to 33.1 carry?

Hon. Senators: Agreed.

The Deputy Chairman: If I am I moving too fast, slow me down.

Are all of the senators comfortable?

Hon. Senators: Yes.

The Deputy Chairman: Shall clauses 34 to 43 carry?

Hon. Senators: Agreed.

The Deputy Chairman: Shall clauses 44 to 46 carry?

Hon. Senators: Agreed.

The Deputy Chairman: Shall clauses 47 to 53 carry?

Hon. Senators: Agreed.

The Deputy Chairman: Shall clauses 54 to 57 carry?

Hon. Senators: Agreed.

The Deputy Chairman: Shall clauses 58 to 61 carry?

Hon. Senators: Agreed.

The Deputy Chairman: Shall clause 62 carry?

Senator Pépin: I have an amendment.

The Deputy Chairman: Yes, it is coming. Shall clause 62.1 carry? Do you wish to speak on this, Senator Pépin?

Senator Pépin: We have distributed the amendment that we would like to have accepted. It has already been stated that regulations should go before the two Houses. We state the following:

[Translation]

(2) A proposed regulation that is laid before a House of Parliament is deemed to be automatically referred to the appropriate committee of that House, as determined by the rules of that House, and the committee may conduct inquiries or public hearings with respect to the proposed regulation and report its findings to that House.

(3) The Governor in Council may make a regulation under section 62 only if:

(a) neither House has concurred in any report from its committee respecting the proposed regulation before the end of 30 sitting days or 160 calendar days, whichever is earlier, after the day on which the proposed regulation was laid before that House, in which case the regulation may be made only in the form laid; or

(b) both Houses have concurred in reports from their committees approving the proposed regulation or a version of it amended to the same effect, in which case the regulation may be made only in the form concurred in.

(4) For the purpose of this section, ``sitting day'' means a day on which the House in question sits.

I move that Bill C-12 in clause 62.2 be amended.

[English]

The Deputy Chairman: We will hold clause 62.2.

It is moved by the Honourable Senator Pépin that the bill be amended as presented to clause 62.1. Is it your pleasure, honourable senators to adopt the motion?

Hon. Senators: Agreed.

The Deputy Chairman: I declare the motion carried.

We move to clause 62.2.

[Translation]

Senator Pépin: The clause reads as follows:

(2) A proposed regulation that is laid before the House of Commons shall be referred to the Standing Committee on Health, or, in the event that there is not a Standing Committee on Health, the appropriate committee of the House, and it may review the proposed regulation and report its findings to the House.

We are proposing that Bill C-12, in Clause 62.2, be amended by replacing lines 25 and 26 on page 26 with the following:

``before each House of Parliament, the Minister shall cause to be laid before each House a statement of the''.

[English]

The Deputy Chairman: It was moved by the Honourable Senator Pépin that the bill be amended as read. Is it your pleasure, honourable senators, to adopt the motion?

Hon. Senators: Agreed.

The Deputy Chairman: I declare the motion carried. Shall clause 62.2, as amended, carry?

Hon. Senators: Agreed.

The Deputy Chairman: Shall clause 63 carry?

Hon. Senators: Agreed.

The Deputy Chairman: Shall clause 64 carry?

Hon. Senators: Agreed.

The Deputy Chairman: Shall clauses 65 to 72 carry?

Hon. Senators: Agreed.

The Deputy Chairman: Shall clauses 73 to 80 carry?

Hon. Senators: Agreed.

The Deputy Chairman: Shall clause 81 carry?

Hon. Senators: Agreed.

The Deputy Chairman: Shall clause 82 carry?

Hon. Senators: Agreed.

The Deputy Chairman: Shall clause 83 carry?

Hon. Senators: Agreed.

The Deputy Chairman: Shall clause 84 carry?

Senator Trenholme Counsell: May I ask a question on clause 84? I must admit I have not read the bill as carefully as Senator Pépin. Were those the only two places where you found this inconsistency?

Senator Pépin: Yes.

Senator Trenholme Counsell: Okay.

The Deputy Chairman: Yes, that is correct.

Shall clause 84 carry?

Hon. Senators: Agreed.

The Deputy Chairman: Shall the schedule carry?

Hon. Senators: Agreed.

Senator Trenholme Counsell: I had doubts about the schedule, and I raised those with the minister. I did ask them to review it carefully, because I do not feel it is as good as it should be. Do we have to pass the schedule? It is not part of the bill.

The Deputy Chairman: Yes, we have to pass the schedule. It is part of the bill.

Senator Trenholme Counsell: Is there some way that we can ask that it be reviewed? Can we pass the bill with an advisory? I am not sure how one does that.

The Deputy Chairman: You can speak to this on third reading in the chamber and have it read into the record.

Senator Trenholme Counsell: If I may ask you, chair, what did you think about, for instance, limiting influenza to type A? You have been in medicine much more recently than I have.

The Deputy Chairman: Actually, I do not know as much about it as you do because it is quite a long way from the heart.

I was comfortable with the answer that the minister and her expert gave on it. They felt they had it covered.

Would some of the officials care to speak to that to clarify the situation to increase the comfort level of Senator Trenholme Counsell?

Mr. Dennis Brodie, Legislative and Regulatory Policy Advisor, Centre for Emergency Preparedness and Response, Health Canada: There is a bit of confusion about this schedule, I must admit. The act requires travellers to report to a quarantine officer when they are arriving in Canada if they feel they have a communicable disease or have been in close proximity to someone who has. This list is intended to provide them with what Canada feels are the most important diseases from a public health standpoint. It is not an exhaustive list. It is there for travellers and for conveyance operators, who also must report. Therefore it is not intended to be exhaustive, and it can be amended from time to time.

The Deputy Chairman: It was my understanding that it will be amended if something surfaces in Uganda that is not on that list. It will be added to the list immediately.

Mr. Brodie: Yes.

Senator Chaput: From clause 63 my understanding is that the minister may amend the schedule, and she may make regulations to amend the schedule by adding, deleting or amending the name of any disease.

Mr. Brodie: That is correct.

Senator Chaput: If something comes up the minister can add to the list; is that correct?

Mr. Brodie: Exactly. That is by regulation.

Senator Chaput: How long does that take?

Mr. Brodie: If it is an emergency, I believe it can take a matter of days depending on the time of the year and so forth. It can be done quite quickly.

The Deputy Chairman: Senator Trenholme Counsell, did you have something more?

Mr. Brodie: I would like to add also that this does not mean that we could not deal with an unknown disease at the border, because the definition of a communicable disease is broad enough that we deal with anything coming across the border, even if it is not a scheduled disease or is not yet named, like SARS in its time; under this new act we could take action.

The Deputy Chairman: I understood that when a new virus appears you can name it immediately.

Mr. Brodie: Yes.

Senator Trenholme Counsell: Could you tell me what viruses were included in the vaccine in 2004-05 that the public received?

Dr. Legault: I cannot, no. I am the chief of operations of quarantine. I could not list that just right now.

Senator Trenholme Counsell: I do have trouble with the idea of limiting the influenza virus to one type, but perhaps I could speak to that. Certainly there is a clause whereby that can be modified. Since most of the diseases are correctly identified here, we should not just have measles. Maybe that is what is used commonly, but that is not what doctors talk about. They talk about rubella and rubeola. I do not think the list is as good as it could be.

Mr. Brodie: As you pointed out, it can be amended, but remember that this is only for reporting purposes. If I am coming back from somewhere overseas and I believe I have one of these diseases, then I am required by law to report that to the quarantine officer. That is the purpose of the schedule.

Senator Trenholme Counsell: I think there is a level of comfort in the bill.

The Deputy Chairman: Your point is well made and well taken, Senator Trenholme Counsell. I do think it is important that you raise this at third reading and it will get attention there.

Shall the schedule carry?

Hon. Senators: Agreed.

The Deputy Chairman: Shall clause 1 carry?

Hon. Senators: Agreed.

The Deputy Chairman: Shall the title carry?

Hon. Senators: Agreed.

The Deputy Chairman: Is it agreed that this bill be adopted with amendments?

Hon. Senators: Agreed.

The Deputy Chairman: Is it agreed that the chair report this bill as amended at the next sitting of the Senate?

Hon. Senators: Agreed.

Senator Trenholme Counsell: Could we ask that the officials get us a bit more information on viruses that are under surveillance and observation in Health Canada and the makeup of the most recent virus that was issued publicly in the vaccine of 2004-05?

Mr. Brodie: I will commit to that, Mr. Chairman.

The Deputy Chairman: You will be in direct contact with Senator Trenholme Counsell, Mr. Brodie, will you?

Mr. Brodie: Yes.

The Deputy Chairman: Thank you very much indeed.

The committee adjourned.