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

Issue 23 - Evidence - Afternoon Meeting


MONTREAL, Tuesday, June 21, 2005

The Standing Senate Committee on Social Affairs, Science and Technology, met this day at 1:11 p.m. to examine issues concerning mental health and mental illness.

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

[English]

The Deputy Chairman: Honourable senators, we will begin our hearings this afternoon with Dr. Louise Nasmith.

[Translation]

Dr. Louise Nasmith, President Elect and Chair of the Board of Directors, College of Family Physicians of Canada: Mr. Deputy Chairman, I would like to thank you on behalf of the College of Family Physicians of Canada for this opportunity to make a presentation this afternoon. Dr. Alain Pavilanis, the President of the College, was unfortunately unable to be here today. He asked me to appear in my capacity as President Elect and Chair of the Board of Directors.

I should say that I have also been a family physician for twenty years and that I have carried out most of my practice here in Montreal. For three years now, I have been working in Toronto as Director of the Department of Family and Community Medicine at the University of Toronto.

[English]

The college would like to congratulate the committee on the reports that you have prepared. You did receive briefs, I believe, both in English and in French that were couriered yesterday, so I will not go over that in detail. I just wanted to draw out a few points.

It is always difficult to present on behalf of an organization when one may have one's own biases, so I will declare that up front. Certainly the college does believe that all Canadians, and particularly those who have mental health and addictions problems, should have access to a family physician to provide comprehensive and ongoing care. You cannot divorce the mental from the physical. We know that many of our patients who have mental illness have severe physical illnesses as well.

If you look across the country at primary care reform or renewal, whatever you wish to call it, many of the models being put forward do indeed speak about population health, understanding the needs of our patient or client population, and building multi-professional teams to address their needs. Hence, there is a process of transformation in the system that should be feeding into that particular issue. If we can start from our own patient or client population, understand needs, and then look at the local context, we could probably build interesting models from the standpoint of linking, either within similar walls or in a virtual way, with the kinds of services that are required for patients who have mental health and addictions problems.

Tied to that, clearly, are models of funding for all the health professionals, not just the physicians. It is interesting, if you look at what is happening with family health teams in Ontario as we are now rolling these out, people are not at all clear about how other health professionals will be paid in these new teams, who will be paying, employer-employee relationships, all that; and that has to be worked out. You cannot expect it to work if you do not deal with those kinds of issues.

The access issue and these models feed into the question of health human resource planning. The kinds of models, frameworks and forecasts that are being used have not begun to take into account the inter-professional issue, and that will be mandatory. If we start with population need and then build forecasting models, hopefully we will have a chance to do something meaningful.

My concern is that each province is doing its own thing, and how can we get beyond the silos at that level and feed it into the federal level to be shared across the country.

In your documents, you speak about special populations with their own needs, whether it is children and adolescents, our Aboriginal communities, or our seniors and the caregivers who provide them with day-to-day care. As a practising physician, I can tell you that those are indeed special populations that need attention. How do you set priorities among them? I am not sure. Certainly if we want to do prevention, we have to start with children and adolescents. Adolescents are known never to seek health care, so being able to reach out into schools and other kinds of community agencies will be the key to bringing them to get help.

I would hope that this initiative will be able to influence some of the projects that will be funded through the new Aboriginal monies that the federal government has announced. It is a fair amount of funding, and I cannot remember what that particular pot of money is called, but clearly this group should be able to influence some of that.

I will turn now to the issue of stigma and discrimination. As a family doctor, I do not know how often I speak to my patients who suffer mental illness to try to tell them, ``It is no different from if you had an ulcer,'' but they cannot talk about it. They cannot go to their employers and divulge it; it remains a major problem. This is nothing new; it is like Uncle So-and-So chained to the bed 100 years ago. People still feel that notion of shame, which they should not.

This may be an interesting way to link up with public health to do some public education around this and get the messages out, to get people talking and more accepting.

My last point refers to your comments about creation of databases and the role of government. There are a number of projects going on across the country. I believe you received a brief from the Canadian Collaborative Mental Health Initiative. Our college is a member of that Primary Health Care Transition Fund project, which has done a stellar job of creating an inventory of many different models of care across the country. One would hope that we are linking into them and that they can link into the creation of a database. I have been around long enough to have seen all these wonderful projects, but they stay out there and we do not bring them together. We do not capitalize on them.

I am on the National Expert Committee for Interprofessional Education for Collaborative Patient-Centred Practice — the IECPCP — a Health Canada initiative. We are just starting to bring in all the players so we are actually talking to each other, and that has to be done.

The CMA, the CPA, the CPS and our college have recommended the creation of an institute for mental health and addictions. One interesting thought would be whether that could that be placed in the public health agency. Would that be a natural home for it, where we could bring together some of the issues around public education, reaching into schools, and others? It is a thought.

My last point is that governments are silos in and of themselves within departments, across departments, across provinces. It is appalling, as somebody from the outside who is now working fairly closely with our Ministry of Health in Ontario, to see that one department down the hall has no clue what the other department is doing. If we cannot get beyond that, how do you expect those of us in the trenches to be able to do it?

That was not in our brief; it is my personal note.

However, to turn this around, I think the time is right for us to capitalize on everything that is starting to happen. The stars are aligning — I am not an astrologist, but I think things are starting to come together. The key here is to bring those players together, and then I do believe that we can move things forward. I thank you for your time.

The Deputy Chairman: Thank you very much.

Dr. Sidney Kennedy, Psychiatrist in Chief, University Health Network: Good afternoon. I appreciate this opportunity. I am presenting as a psychiatrist, currently the Chief Psychiatrist at the University Health Network in Toronto; as the founding Chair of the Canadian Network for Mood and Anxiety Treatments; and also the recent past President of the Canadian College of Neuropsychopharmacology.

I have taken counsel from colleagues across each of these groups, but I am essentially speaking in terms of my own review of the documents, and I focused more on the issue of depression, which is one of the areas that I am most involved in. The spectrum of concerns that relate to the mortality and morbidity, the economic impact, the actual structural brain changes that happen in people with depression, the nature of the illness in terms of relapse and recurrence, are all critical issues. For example, the deaths, not just from suicide, but from increased mortality through heart disease, cancer, the work that would suggest depression is a systemic illness, support some of the issues that Dr. Nasmith raised.

I wanted to comment on the document as it spoke to service delivery. Obviously, we recognize the importance of language and culture in a city like Toronto — we are certainly aware of the emerging immigrant populations, the programs that have been developing language-specific mental health services, but it also illustrates the importance of making sure that you bring the content-specific level up as well as delivering services in local languages. The case for communication and integration has been made, the importance of collaborative health care, and psychiatry and family practice have taken promising first steps in a number of areas, but we would like to see this develop a lot further.

On the issue of specific population groups, for example, in the area of children and adolescents, the question of early detection seems to be important. However, unless we have resources to deliver the interventions, and, indeed, evidence that the interventions make a difference over the long term, it can be a major issue.

We look today at the issue of suicide in young people. The figures show that suicide rates have declined in the last decade, yet if we take the concept of ``suicidality,'' or, sometimes, suicidal behaviour with some treatments, there is a suggestion that it might even have increased. We clearly need to make sure that these are better integrated and delivered.

There are many issues in terms of seniors, such as lack of information on age-specific outcomes when we transfer knowledge from middle life to later life, specific treatment interventions that have not necessarily been developed and tested in other populations. There is a major need to address the complex populations, the individuals with addictions, schizophrenia and medical illness concurrently.

I have commented on suicide. I was also impressed by your work on the workplace, and again, it relates to the stigma issues. There is a need to integrate the workplace employee assistance programs, the work done by insurance companies, with the medical system, with specialty areas and so on. I applaud some of the recent CIHR initiatives that have looked at this, and also the round table on work.

On human resource issues, greater emphasis on specialist primary care and shared-care interventions is really pivotal in much of what psychiatry can do. I also agree that there are major difficulties in coordinating some of the physician/ non-physician teams, how they are funded, how well they are integrated. We are in an evolving payment system review in our academic health science centres, certainly in Ontario, and our alternative funding plans. It is important to be able to factor in how the non-physician and physician groups can be truly integrated.

In terms of partnerships, both for research and for service delivery, the question of protected federal dollars for mental health would be important to consider. If you look at the impact of mental health, we are underfunded in our research dollars, in the overall health care delivery, and certainly in many of our organizations.

I will confine my remarks to those.

The Deputy Chairman: Dr. Charbonneau?

[Translation]

Dr. Manon Charbonneau, Psychiatrist, Social Services Centre of Sept-Îles: Mr. Deputy Chairman, I would like to thank the Senate Committee for its invitation. I intend to speak French because I am more comfortable speaking that language. I want to thank Senator Keon and all the other senators for being here today.

I have prepared a brief in both French and English which addresses all the aspects of practising in a remote region. I am a psychiatrist. I have been practising for some fifteen years in the North Shore region of Quebec.

I am a member of the Executive of the Quebec Psychiatric Association as well as the Canadian Psychiatric Association. I am here today to discuss my clinical experience as a professional psychiatrist, and especially as someone with a rural practice that involves one of the populations that I believe to be the most affected and the most disadvantaged in terms of access to mental health and addiction treatment services.

The brief that was tabled with you provides an overview of various geographic, demographic and clinical characteristics, as well as organizational characteristics proposed as a way of optimizing access and ensuring better quality care and services in rural areas.

There is no universal model that can be applied to all areas. But we believe that our recommendations may help respond to some of the Senate Committee's questions with respect to mental health, mental illness and addiction.

Working in remote regions raises specific issues in Canada, as well as internationally. Many other countries with similar geographic characteristics are dealing with the same kinds of issues with respect to access to specialized care.

For example, 21 per cent of all Americans do not have access to specialized psychiatric services. The province of Quebec is currently suffering from a shortage of psychiatric personnel. Quebec now needs some 200 additional psychiatrists.

In my opinion, a national and interprovincial health action plan would be one of the healthiest interventions to advocate and facilitate with a view to ensuring greater consistency of service for the most disadvantaged members of the population — and I would even add that this is primarily the case in such areas as child psychiatry, psychogeriatrics and treatment for the Aboriginal population.

This requires an integrated approach to providing comprehensive health care with very limited resources. Fluidity or flexibility of administrative structures, allowing for a certain structural decompartmentalization, is essential in my opinion to arriving at win-win solutions and serving as a catalyst in ensuring the continuity of care.

Working in remote regions has inevitably meant that we have had to centralize requests for service so as to priorize quick access to care in the right place, for the right patient, at the right time, and by the right caregiver.

We not only concur with the Senate Committee's perspective on the patient/client relationship, but the overall organization of our services is based on this fundamental objective, which serves as our guiding principle in making what are sometimes difficult administrative or clinical decisions.

As regards the concept of emergency or accessibility, there is no doubt that these concepts are seen more broadly. In this context, the importance of proper training of staff and compensation for caregivers providing services in the area.

One example of an integrated approach that reflects clinical, socio-demographic and cultural issues is when a patient in the area presents with an acute problem. It is very important to understand what the patient's point of entry to the system is and his/her geographic location.

For example, in a small community with a population of only 2,000 or 3,000 people, a patient suffering from acute schizophrenia may present with such symptoms as agitation and aggression. The only person on site available to provide care is a nun who is a nurse or a social worker. Thus the point of entry into the system is the dispensary.

Naturally, no medical resources are available on site. This is therefore the resource person whose education and training will be key in ensuring prevention and very quickly detecting signs of dangerous behaviour or suicidal tendencies.

Within the community, we also identify the informal caregiver able to make contact with the responder or practitioner. We assist and empower that individual so that he/she can quickly identify the needs of the beneficiary or patient. That person then contacts a member of the medical profession, either a family doctor or psychiatrist practising in the area.

Very often, I am the only one available on the North Shore, and through family physicians, they can contact me.

In every institution or organization, whether it is a dispensary or health centre, it is useful to have one individual designated as the clinical or health care coordinator and to have all requests and messages pass through that simple and easily accessed route of entry.

The North Shore region extends as far as Blanc-Sablon, along approximately 1,000 kilometers of coastline. It covers hundreds of kilometers and has a population of some 120,000.

As a general rule, there are only one or two permanent psychiatrists available to cover the entire region. Most villages are accessible by boat or by air, and sometimes by snowmobile in winter.

In the area, care is provided at three hospitals, including the Centre hospitalier régional de Sept-Îles (the CHRSI) which is the regional centre. It also serves as the referral centre for specialized care.

In our hospital Psychiatric Section, we have 21 patient beds, an out-patient clinic, a day centre, and intensive follow- up in the community.

This way of working greatly supports our approach to, and management of, psychiatric treatment and emergencies. Transfers between dispensaries and the hospital are not carried out according to the usual, top-down method from one doctor to another.

We have to conduct our practice differently, meaning that we have to accept transfers that may come from a social worker or in a medical emergency.

Some procedures are also carried out over the telephone or through video-conference through a service called telepsychiatry. This is extremely helpful when dealing with emergencies, in cases where patients cannot be brought to a hospital.

In terms of the rural population, here are some basic characteristics: it makes less of a distinction between the concepts of physical and mental health. People living in rural areas therefore make much greater use of front line physical medicine as a preferred method of seeking assistance with mental health issues.

Practitioners starting up a practice in a remote region rarely possess the prerequisites needed to assume the different roles they will be called upon to play in the region. The lack of adequate prior qualifications also applies to paramedical workers. There are different reasons for this: the lack of theoretical model, the lack of a clinical model, a lack of preparation for the workload and the specific nature of the work to be performed, a lack of training or exposure prior or subsequent to becoming a doctor.

Workers and clinicians are also part of the community. They have a social role to play, whether they want to or not. That sometimes causes problems with respect to confidentiality.

And here is a example of the type of flexibility that is required: the treatment plan tailored to the patient's needs is possible through the designation of a senior or central case manager. That person is responsible for coordinating and liaising with various medical and community services.

The designation of the senior case manager is the responsibility of an interdisciplinary team involved in treating the patient based on priority needs at the time. The case manager is responsible for the patient, and so there is an element of accountability involved in the management of the patient's care. This person may be an educator, a social worker or may also be a physician. However, a physician is always assigned to the case manager and on call to provide assistance.

Providing general training for case managers is fundamentally important as a prerequisite to providing excellent mental health care. More standardized legal frameworks would also be of great assistance for the clinical application of certain measures.

There are two false premises related to remote areas or limited resources in the region. The first: developing regions so that they can become fully self-sufficient. The second false premise: bringing all residents into urban centres for the purposes of receiving treatment.

First of all, it is utopic to talk about self-sufficiency given the limited resources available in all areas — and that is not likely to change. We are equally sharing staff shortages.

The other idea of bringing all people into urban regions for treatment fails to meet their specific needs, and goes well beyond what they need in terms of clinical treatment.

There are five important factors to consider with respect to the organization of services: flexibility, access to the full range of telecommunication tools, training, integration and affiliation. I will conclude with a brief comment about affiliation.

Our hospital's affiliation with a university in an urban region has made it possible to enhance and expedite access to highly specialized services, has contributed to appropriate training of medical and paramedical staff, and has made it possible to ensure ongoing professional development.

Affiliation has also helped to boost staff levels and provide a regional training internship under university auspices, thereby supporting possible recruitment efforts. University affiliation has reduced the sense of isolation among professionals and has helped to ensure universal sharing of scientific data through the use of video-conferencing. Through virtual means, it has reduced geographic distances, thereby enhancing real access to care.

In conclusion, teamwork is important in order to have a clear understanding of the regional community's structure and dynamics, to organize services as efficiently as possible from the standpoint of the patient, to meet the need for professional training and development, and to educate the population. It is also important for the purposes of working with informal caregivers, and in order to carry out the necessary research and evaluation that make it possible to develop theoretical models.

Work in the regions thus offers an unparalleled opportunity to optimize our skill sets for the greater benefit of our patients and the next generation.

The Deputy Chair: Thank you, Dr. Charbonneau.

[English]

The Deputy Chairman: How were you recruited into the position of working alone as a psychiatrist and being the kingpin of the North Shore?

[Translation]

Dr. Charbonneau: In 1982, the Government of Quebec cut the number of residency positions for medical specializations. So, during the first round, I was admitted to the specialization program, but all of a sudden, right after it began, I was told I was now first on the waiting list. There were five fewer positions.

So, I was offered an opportunity to do my residency in psychiatry in exchange for practising for four years in a remote area. I was going to be able to do four years of residency in psychiatry. My spouse, who is an anaesthesiologist, decided to leave with me to share in the experience, and we have never returned. We are free.

[English]

The Deputy Chairman: Louise, with respect to your presentation on the need for community-based resources in psychiatry, we will be addressing that in our report. We have heard that over and over, that patients are begging for more community-based facilities that provide primary care integrated with social services, so they have one-stop shopping, a home to go to, peer reinforcement and all of the things that go with it.

I know there are a couple of these springing up in Toronto, because Minister Smitherman told me that he wants Senator Kirby and me to come down and see them. How many of these community-based clinics and facilities are up and running in Toronto now?

Dr. Nasmith: Certainly not a sufficient number. It is always an interesting balance between creating new structures versus using what you have and integrating them better. We have to be careful not to create yet more silos out there, because the reality is that there is such a prevalence of mental health problems that run the gamut from somebody who is very severely ill with schizophrenia, to somebody who is struggling with depression.

The reality is that most of these individuals will probably still, at some point, come to a family medicine centre or a family doctor's office, and so long as that continues to happen — which I think it will, by default — you will not be able to build these kinds of structures that you are describing. We need to be able to hook into them and work with them.

There are a lot of community agencies doing terrific work around the University Health Network, where I happen to do my clinical work. I keep hearing about these little jewels of things that are happening, but we are not aware of them and we are not able to facilitate shared care for our patients.

There are potentially these separate units that will maybe deal with some of the severely ill patients in the community, but we need to also look at the linking up, and at other patients who will not necessarily be using those. Yes, go and see them, but we need to learn some lessons from how they work and then how to broaden it out.

I think it works better in the rural areas because they have to make it work. It is not perfect and there is still a lack of resources, but you can function much better. As soon as you get into a big city, everything just falls apart in terms of coordinating care.

That is as much as I can say.

The Deputy Chairman: We learned something very interesting this morning from McGill, that fundamentally, the students of McGill get much better psychiatric care than the normal population. The reason is there is a private health care delivery system at McGill for psychiatry and student services.

The witness also alluded to the fact that it is similar in Toronto, but did not go any further. I would be interested in what you have to say, because he presented the ideal mental health medical-social team that is in place for the students, but not, of course, for the normal population in Quebec.

Tell me about the contrast between the University Health Network and Spadina Avenue.

Dr. Kennedy: I think you are asking about the university health services that would be available to students, obviously, from beyond Ontario. They do have an integrated health team that includes psychiatrists, family doctors and non-physicians, including a fairly decent number of psychotherapists, master's level psychologists, or Ph.D. psychologists. The service has relatively short waiting lists, and the majority of students who access it are in what you might call crisis mode, so they are given short, focused psychotherapy interventions.

A number of people who worked in our hospital settings have left the hospital to work in that group, and I think they find it very rewarding to see rapid turnaround of crisis mental episodes, if you like.

I cannot say much about its funding, other than I think students pay a modest amount per month, which gives them the equivalent of, I think they call it the University Health Insurance Plan rather than the Ontario Health Insurance Plan.

Dr. Nasmith: It is the UHIP system, right, rather than OHIP. The interesting part is the rapid turnaround for a student in crisis — and I know McGill has the same thing. Pierre Tellier, who runs student services, was one of my colleagues, and they have an excellent system. However, it is contained and insurance pays for it.

The Deputy Chairman: We all get so uptight when we talk about private insurance, but here is a classic example in both our major cities. Of course, Workers' Compensation is the same idea.

Dr. Kennedy: Yes.

[Translation]

Senator Pépin: Dr. Nasmith, you made quite a few references in your presentation to education, and what should be done in faculties of medicine. I have to say we have heard a number of presentations where witnesses said that general practitioners were not adequately trained.

On page 4 of your brief, you make a number of suggestions with respect to medical schools, saying that they should modify their admission criteria, and there are a number of other points as well. We will certainly want to consider that because, according to Mr. Couillard's report tabled yesterday, physicians are to become the point of access for patients with mental problems.

So, there is room for improvement. Based on what I see here in your recommendations, that is extremely important.

You also talked about silos and what happens from one region to the next. If I understood you correctly, you were saying that there are silos between the different provinces and that what happens in one province does not necessarily happen in the next.

Do you have any suggestions to make as to how we might minimize these silos?

Dr. Nasmith: No, I do not have any suggestions because I wasn't really familiar with the term ``FPT'' until I began working with Health Canada. Now I understand that it is, unfortunately, extremely complicated and highly political.

Sometimes we come forward with very specific projects — and mental health may be one — and we succeed in bringing down existing barriers. We are focusing on a vulnerable client group that we feel very strongly about, and people are prepared to work towards this.

As a committee, you may have an opportunity to make suggestions that will help us to go further. Because the fact is it really is not easy, based on my understanding. I do not want to be too naive and believe that this can easily be accomplished.

Senator Pépin: If we were capable of removing the stigma attached to this and carrying out a really effective public awareness campaign, that would certainly help. We have noticed that from one province to another, there are silos. Perhaps if that happens, we will be able to negotiate our way around them.

When you look at the situation in the urban areas, there are a lot of professionals available there, compared to the regions. That is another problem. With new admission criteria, it would be easier to access well-trained general practitioners in every area.

[English]

Dr. Kennedy, you spoke about the workplace and insurance. Perhaps you could develop that concept a little further.

Dr. Kennedy: My visual presentation had a model that really highlighted the problems of people in the workplace — the term being ``presenteeism,'' people who are physically at work, but are often underperforming, under-functioning, and the delay before there is detection and a referral. Indeed, people often receive partial treatment and return to the same adverse work circumstances, so the problem is perpetuated. Again, it speaks to the public-private integration, whereby many people in the workplace receive employee assistance program help, which is adequate for some, like the university students in crisis, but not for those who have serious mental illness. There is not a good link from the health system within the workplace to other aspects of health care, and that is what I was saying needs to be developed.

Senator Pépin: We know also that some insurance companies will not insure people if they know that they had a nervous breakdown or something else, and the accessibility then for them is very difficult because often they cannot afford to see a psychiatrist.

[Translation]

Dr. Charbonneau, you said that self-sufficiency is utopic. I am referring here to certain proposals brought forward last week for the creation of frontline teams made up of practising physicians, social workers, nurses and psychologist.

Working in the region, your team is able to communicate with you and you can then tell them what service should be provided and where.

What do you think the ideal team would look like in terms of numbers? Would it include the same professionals? What do you see as absolutely critical?

Dr. Charbonneau: I guess you are referring to the clinical plan tabled in Quebec?

Senator Pépin: Yes, that has just been tabled.

Dr. Charbonneau: With health centres divided up into areas?

Senator Pépin: Yes.

Dr. Charbonneau: I agree with most of what is proposed. I think it is an excellent initiative. What I would not like to see forgotten and that I see no mention of in the report is the need for linkages between urban centres and universities.

I see an initial structure in the form of a health centre, but with linkages between regional poles and universities in every area, whether it be clinical considerations, training, supervision, or decentralization of specialized training.

Senator Pépin: When you have a patient with a serious psychological disorder, are you able to bring him in to a university centre to be treated and hospitalized?

Dr. Charbonneau: Yes, through our university affiliations. The administrators have made interfacility commitments. When there is a need for a clinical transfer for the purposes of receiving highly specialized care, the existence of these agreements greatly facilitates things. Because the centres know there is an administrative link in place already, that is extremely helpful. In that respect, there are no problems. That can be the case with Pinel, for patients that are highly dangerous or where there is a need for child psychiatry because we have no in-house unit able to provide that specialized care. As a result, we have to transfer the patient for extended hospitalization — in other words, more than seven days.

Senator Pépin: We were also told this morning that another factor is the kind of leadership parents give their children — both the parents and grandparents, the support network being extremely important. And yet that support is less and less evident, since we see a great many adolescents with psychiatric problems.

There was a lot of emphasis on the need for good parent-child relationships, something that is rarer nowadays because of the number of broken families. Do you see that in the regions as well?

Dr. Charbonneau: We do know that as a general rule, children tend to live at home with their parents longer. We work a lot with families that act as informal caregivers. As we were explaining earlier, we have a model in place that is defined according to needs. We can certainly say that this model is working well.

Senator Pépin: In your region?

Dr. Charbonneau: Yes. And patients are satisfied. The concept of confidentiality and working one on one is more prevalent among certain users or administrations that have some reservations with respect to confidentiality.

However, as a general rule, the patients themselves are extremely satisfied with the idea of other family members being involved or there being contact with other system partners. That is not really an issue for the patients.

[English]

Senator Trenholme Counsell: I found myself this morning defending the training of physicians in mental health. I said that I think medical schools are getting a bad rap, because perhaps there is a limited amount of time for all students in training to become medical doctors, to get that first degree. Then they will go in 60 directions afterwards; I used that number out of my head. I said I believe that in family practice training, which lasts two years, there is a much better preparation in terms of mental illness and mental health. I wonder, Dr. Nasmith, how you would reply to that, whether I was speaking out of turn? We would be interested to hear the emphasis of the college in terms of that preparation.

Dr. Nasmith: Certainly it is one of the requirements for accreditation that all of our residents in family medicine get good, solid training in issues related to mental health. I would say that generally speaking, the grounding in mental health issues, particularly around depression and anxiety is good — perhaps less so on schizophrenia. We have so many of our own patients, as well as when they do their psychiatry rotations, they are quite comfortable in diagnosing and, I think, in treating. I am quite taken with the level of comfort that our residents have.

In the area of addictions, it is another story. I was looking at some of the data that have just been released from the National Physicians Survey of 2004 that also surveyed medical students and second-year residents across the country, and there were questions about whether certain things are important in training. They were asked whether they get certain kinds of training and whether it should it be mandatory. One of the questions had to do with addictions, and only a small number of residents felt that it was an important part of their training, which quite shocked me, given the extent of the problem. An equally small number felt that training in Aboriginal health was important.

That is a message to us that not only do we have to bring it into the curriculum more forcefully, we have to show our young people that these are important parts of their future practice.

I am not sure if that answers your question.

Senator Trenholme Counsell: Yes, it does.

I became interested in early childhood development largely because of my experiences as a family physician, and I am wondering how well you think our new family physicians are being sensitized to early detection, diagnosis, suspicion, whatever, and intervention in the case of children, whether it is attention deficit or a multitude of things. There are just so many things. I do not like to use the word ``adequate'' because it is never enough, but do you think there is good attention to this? Family physicians are on the ground there, and I believe that they and public health nurses have a great responsibility for the early detection, shall we say, rather than diagnosis, at least of vulnerabilities. What do you think about that?

Dr. Nasmith: I certainly agree that this should be done. I would say that we are probably not doing a great job. Part of it has to do with just getting adequate exposure. We have to cover a lot in two years. There are a certain number of children seen in our family medicine centres, but usually the percentage is not terribly high, so the chances of seeing a lot of children who have either developmental problems or some of the other issues you are talking about is limited. They might get it during their pediatrics rotation and again in their ambulatory work, but it is unlikely in the case of in- patients. I would have to say that I do not think we are doing a good enough job, and our young ones coming out do not feel comfortable.

They might have an index of suspicion, but they do not know what to do with it. If you do not know what to do with something, as someone said earlier, you tend to ignore it. I think there is work to be done there.

Senator Trenholme Counsell: I know we are not supposed to be telling you things, we are supposed to be listening, but I would hope that with this great emphasis across the land, and internationally, of course, on early childhood development, that the college would be looking at that to see how they could better prepare physicians for this role. The days when we had mother and baby programs are gone, and then we had Dr. Spock, but I do not think anyone is giving out Dr. Spock any more and saying to read it; not that it is still not a good resource. It is all important, because we have unique opportunities right from the beginning, and prenatally, of course.

This is a new era in early childhood development, and I would hope that the college is reconsidering the amount of time spent on it and how that is handled. Have you talked about that as a college?

Dr. Nasmith: Alain Pavilanis is our current president. Every year the president has a theme, and his is child and adolescent health. I will certainly bring this back to our executive. I also sit on the accreditation committee and will take it to them as well.

Senator Trenholme Counsell: Dr. Kennedy, we had some discussion this morning — we have it almost everywhere — about drugs, and it comes up repeatedly that physicians are not adequately informed about and skilled in drug prescribing; that they are, in the case of mental illness — this was said, so I will try to repeat it — being unduly influenced by the pharmaceutical companies. I believe there is a rating, a check-off sheet. Is the person depressed or not? Maybe there are a lot of other check-off sheets for family physicians to use. That is a question with a number of angles to it, but maybe you could just respond.

Dr. Kennedy: The first question is about detection and the use of self-reporting tools, and of course they are not diagnostic, but they can be used for screening. Obviously, with screening instruments, you hope for more false positives than false negatives, so more detection is, in fact, good.

The second point is what do you do when you detect a problem? I can speak for the University of Toronto and for others, and, I think, those in the pharmaceutical industry as well. A series of guidelines and standards of practice have been put in place that I believe clearly define the interaction in a positive way. People are aware of some of the concerns. The real question is how do we get the information out in our own residency training for psychiatrists? When we ask residents how satisfied they are with various aspects of their training, often the pharmacotherapy is felt to be inadequate. We have, as you know, tricyclic antidepressants that have a 50-year history, and then we have a series of newer agents. If I ask the average resident after four years what experience they have had with some of the older agents, many will have had none.

Senator Trenholme Counsell: Because they are using the new drugs?

Dr. Kennedy: Because they are only using the newer agents. I think we can certainly do a better job in training. Frankly, because in our profession we have not taken the time to develop the educational programs ourselves, industry has often stepped into the vacuum. I think the next step will be much better — if you want to call it ``policed partnerships'' — where the information is delivered in an unbiased way. Unfortunately, there is not the money to do the training without partnerships with industry, and that is often how the information is delivered.

Senator Trenholme Counsell: I interned at the Toronto General, the old hospital, and I felt I had quite an immersion in mental illness because of the people who came there. I would like to know, with the University Health Network, is that outpatient clinic still serving the mentally ill, mentally distressed, the deranged and so on, in downtown Toronto? You do not have family practice residents there now, do you?

Dr. Kennedy: We do.

Senator Trenholme Counsell: Oh, you do?

Dr. Kennedy: Yes.

Senator Trenholme Counsell: You still have a family practice unit?

Dr. Kennedy: We have Toronto General Hospital, Toronto Western Hospital, and Princess Margaret Hospital in our three-hospital group.

Senator Trenholme Counsell: Is the Toronto General still where it was?

Dr. Kennedy: Absolutely.

Senator Trenholme Counsell: That is good to know.

Dr. Kennedy: With a few new buildings beside it.

Senator Trenholme Counsell: It does not look like its old self.

That must give you quite a good indication of what is happening in the city in terms of the walk-ins of mentally ill? Is it going up, staying the same, or is it worse or better?

Dr. Kennedy: We are in discussions at the moment of an alliance among Mount Sinai Hospital, the University Health Network, St. Michael's Hospital, St. Joseph's Hospital and the Centre for Addiction and Mental Health to look at how best to serve our walk-in emergency psychiatry population. For example, by having some what we might call comprehensive sites, and then some supportive sites, and a better integration of the assessments and the beds.

In some of the hospitals we have also developed programs and teams with the police, where psychiatric personnel go out in the squad cars and see people who are felt to be —

Senator Trenholme Counsell: Mobile crisis.

Dr. Kennedy: Mobile crisis teams. We are trying to improve the efficiency.

The actual volume of people coming in fluctuates. For example, in the last year it has not gone up, but it often depends on where ambulances will actually take people.

As we talk about the community investment, one of my concerns would be if we did to the mentally ill what was done 100 years ago, in that they were walled off from the other aspects of medicine, particularly at a time when we see more and more the physical basis of a number of mental illnesses. Clearly, it is important to build the community programming, but to my way of thinking, it would be doing a great disservice if we made it more difficult for somebody with schizophrenia or bipolar illness to be treated in a medical model. We need the best of both models.

The Deputy Chairman: If I may intervene there, because it is most important.

We heard that universally from the patient population.

Dr. Kennedy: Good.

The Deputy Chairman: They want to be part of the big picture. They do not want to go to somewhere with a sign saying, ``Toronto Bipolar Institute.'' The other thing that we heard from the patients is the flip side of what is happening in Toronto. They said they do not want to go to the big medical centres. They want community centres, with primary care in those centres. They are happy to go to the Toronto Hospital, or whatever, when they need the expertise of a psychiatrist, but they rightly pointed out, ``We do not need a psychiatrist very often, and we do not want to go there unless we do. We want to go to our community centres and see our family physician, our guidance counsellor, the lady who gives us the cheque to pay the rent, the lady who gives us the cheque to buy the food, all in one place.'' I think that is important.

[Translation]

Senator Trenholme Counsell: I listened to your presentation in French, which is always a challenge for me, but I believe you did refer to telemedicine, did you not?

Dr. Charbonneau: Yes.

Senator Trenholme Counsell: I would be interested in hearing your opinion of this new technology and the options it gives you in your region, indeed in all rural areas.

Dr. Charbonneau: I am very pleased to have an opportunity to talk to you about telepsychiatry. I am mandated by the Quebec Psychiatry Association to implement the telepsychiatry system in Quebec, and so you will understand why this is something I feel very strongly about.

I have been involved in telepsychiatry for seven years now and have found it extremely useful, although it cannot replace regional staff. And there is no doubt that it in no way replaces psychiatrists themselves. However, telepsychiatry can improve care and provide quicker access to care.

Perhaps I could just explain. Telepsychiatry can be useful in the clinical setting when you need a second opinion. It means you don't have to send a patient somewhere else, and you can be with him. And we get a second opinion. Telepsychiatry is very quick, effective and inexpensive.

There is also the matter of treatment for patients living in rural areas. For two years now, we have even been providing group therapy via telemedicine. The way it works is that patients who may be living in Blanc-Sablon, say, come in for the first of ten group therapy sessions. For the following sessions, they attend via video-conferencing with other local patients. They then complete their group therapy at a final session with psychologists present.

It is a way of increasingly broadening horizons. The other very important aspect in terms of regional involvement, both from a clinical and administrative standpoint, is the fact that physicians from all over, and at different administrative or policy levels, can take part via video-conferencing. Telemedicine makes it easier to get people involved.

And there is one last very important point, which has to do with the training of staff and other individuals. Several times a week, we have a chance to participate in academic conferences that we receive live online via video-conference, and thus we are able to interact with the University of Montreal every week. We are not isolated. We are up to date and we take part in academic life. We also collaborate by teaching students in residence on site.

So, I am in favour of partnerships. I do not agree with operating in silos, and believe instead we should be promoting partnerships at all levels between the regions and the major urban centres.

Senator Trenholme Counsell: Can telemedicine or telepsychiatry be used for all age groups, even older people, or is it particularly suitable for young people?

Dr. Charbonneau: There are two things with respect to clinical use. As a general rule, there are very few problems with adult clients, except in special cases, such as with highly paranoid patients. Sometimes this particular technique cannot be used with such patients.

With children, however, it can be extremely useful because as you know, children living in remote areas do not have access to child psychiatry services. I find that quite incredible and I deplore the fact that these services are not available. We're doing whatever we can, because there is no child psychiatry team available in the region.

Telepsychiatry can therefore be extremely useful for pedopsychiatry, because it allows us to receive assessments from pedopsychiatrists in the major centres. One of the problems we encounter is using this with small children who are only two or three years old, because they do not understand that they may be too close to the television. When they are too close to the screen, the pedopsychiatrist no longer sees them on camera.

With older people, it is also extremely useful. We are even considering developing ``homebase'' models for the purposes of making assessments, so that seniors are not required to travel. There are some models available already, and I believe that they have already begun to use that particular model in the rest of Canada.

With older people, there can be hearing limitations. From what I have read, hearing and sensory problems can sometimes make things more difficult, but it is generally a very useful tool.

Senator Trenholme Counsell: Are you comfortable with that practice? And do you use it often?

Dr. Charbonneau: Yes, we use video-conferencing every week.

Senator Gill: Dr. Charbonneau, I would say you are both a physical and a psychological athlete because anybody who knows the Lower North Shore area knows that it is very large. As you were saying earlier, it is 1,000 kilometers of coast, 600 kilometers to Schefferville and the Labrador boundary, 1,000 kilometers from Montreal, and 800 kilometers from Quebec City.

I know that you have contact with people all over the place. You work with anglophones and with francophones. You work with the Montagnais and the Innu. You also have Naskapi. How do you manage to deal with all of that?

Senator Pépin: She does not want to move. She wants to stay there.

Senator Gill: On top of all that! And as you were saying earlier: a lot of places do not have roads, so you can only access them by plane or boat, and in some cases, by plane or train, to get to Schefferville, for example. How do you manage it?

Dr. Charbonneau: I do the best I can. But I absolutely love the area. I have to say I have learned a great deal by working in the region. After five years of practising there, I went to one of the universities in Montreal to talk about my experience and the fact that we aren't trained to work in remote areas.

We encountered a number of clinical situations but had no experience handling them. So, we had to be very creative. That is when I was told to forget about the possibility of training in the region.

On the other hand, I'm very happy because for seven years now, we have been training residents and family physicians. We have a teaching unit on site.

Senator Gill: In Sept-Îles itself?

Dr. Charbonneau: Yes, in Sept-Îles at the Regional Centre, in the family medicine unit and the psychiatry department. It gives us a chance to demystify life in the regions and teaches people how different it is. We do not reproduce an academic model, obviously, and we are not there to tell them the same things or to give them the same kind of training. They are different practice settings.

I guess it is kind of a vocation for me and that is why I take such pleasure in being able to tell others about the kind of experiences that motivate me.

Senator Gill: Are you in contact with other regions of Quebec?

Dr. Charbonneau: Yes.

Senator Gill: But I imagine you are the only one with no roads in most cases.

Dr. Charbonneau: Yes.

Senator Gill: There is also the James Bay area.

Dr. Charbonneau: Yes. We have been involved in some very interesting training opportunities all across Quebec, with the Saguenay/Lac Saint-Jean area, the North Shore, and the Gaspé. Every two years, we have a regional psychiatry convention which is developed around assessments of requirements among family physicians and others working in the field.

We build our convention around very specific training requirements in the regions, because training needs are very different from one area to the next. Sometimes we focus on legal issues, other times, it is pedopsychiatry. And we bring everyone together for these sessions.

There are even administrators, pharmacists, and social workers, but there are practically no psychiatrists, given that there are none in the area. However, there are family physicians. We bring all these people together and it is a way of building a network; that facilitates subsequent contact and patient management.

People learn to get to know each other. It is really all about communication. When that communication is there, it makes things much easier.

Senator Gill: If you were in our position, what recommendations would you make with respect to the regions? Because in the urban areas, there are already relatively effective organizations in place, compared to the rural areas. What would your take on this be? And what would you say in that regard? And what would your priorities be for improving your working conditions in the area of mental health, addiction treatment or suicide prevention?

Dr. Charbonneau: I would say that one of the major imperatives is funding for on-site multidisciplinary teams, for so-called frontline workers; 80 per cent of patients consult a responder or a family physician for mental health problems. And they are also the ones who have to detect the mental health problem or treat addictions.

As regards our Aboriginal clientele, what I see, first of all, is a very high rate of suicide, and Aboriginal responders have not received the proper training to be able to deal with these problems and provide an appropriate response.

So, I do think increased funding would help.

Senator Gill: Mr. Deputy Chairman, I still have a little bit of time left, say two minutes, do I not? In terms of the Aboriginal population, I imagine you do not have time to go down to the Lower North Shore every day.

Dr. Charbonneau: No.

Senator Gill: In terms of patients referred to you for mental illness or psychological disorders, do you see a significant difference between the remote Aboriginal communities, for example, Saint-Augustin or La Romaine, and more urban communities, such as Maliotenam?

Dr. Charbonneau: Directly in Sept-Îles, you mean?

Senator Gill: Yes, in Sept-Îles, or Washat.

Dr. Charbonneau: Yes. In terms of access to care, it is important that there be proper trained responders within the community so that they can respond in time. By the time patients come to us, it is often too late; the individual has already committed suicide. But no assistance was requested.

We know that when people are over 60 miles away, they tend not to want to travel to receive treatment. All the more reason to provide proper training to responders in the communities so that they can get in touch with us and be a reference point.

Senator Gill: Yes, but is the community able to care for individuals who are mentally imbalanced? Do remote communities have more options on site, which would mean that you would see fewer patients, compared to the major urban centres?

Dr. Charbonneau: It is very difficult. From what I can see, it is a very tricky situation. Once they have received psychiatric care, when they return to their community, they are pretty severely ostracized. Reintegration is difficult. So, we have to be very careful in terms of our response.

Senator Gill: I understand. But there are Aboriginal physicians, you know. There is Dr. Stanley Vollant who is practising in Chicoutimi now, but who belongs to the Betsiamites band.

Dr. Charbonneau: Yes.

Senator Gill: There is also Johanne Philippe, from my community, which is Mashteviatsh. Do you have any contact with these Aboriginal physicians, even though they are not psychiatrists?

Dr. Charbonneau: Yes.

Senator Gill: You do have contact with them occasionally?

Dr. Charbonneau: I have had contact with them, but not on a professional level. I know these individuals well.

Senator Gill: I see. But not on a professional level?

Dr. Charbonneau: No.

Senator Gill: I mention this in connection to possible collaboration in terms of treatment to be provided in the communities.

[English]

Senator Callbeck: I come from a small province, a rural area.

The Deputy Chairman: If I may interrupt, Senator Callbeck comes from a small province, but she owned it. She was the Premier and a Minister of Health.

Senator Callbeck: Thank you, Mr. Chairman.

I wanted to ask you about telepsychiatry. When you talked about the pluses, you said it is not costly. Now, the last time I brought this up in another province, they said the opposite, that it was extremely costly. You do not feel it is?

[Translation]

Dr. Charbonneau: I believe the initial investment is inadequate, especially when it comes to introducing certain bandwidths in specific places, which can require an investment of several million dollars.

On the other hand, studies do show that when the costs are shared among different specializations, that greatly reduces the initial outlay. In the remote areas, we calculated how much it would cost to transfer patients by plane with an escort, dangerous patients, to wait for that patient, and return the next day, and we determined that it costs far less, when the equipment is in place, to use telepsychiatry.

Initially, the cost may be very high — say for the first two or three years. But after three years of use, you start seeing the cost effectiveness of this method. A number of authors have done cost analyses of this type of service.

Senator Gill: Just one question, if I may.

Senator Callbeck: Go ahead.

Senator Gill: Drs. Nasmith and Kennedy, this morning we heard from Dr. Hoffman of McGill University, who told us that there are ten or more psychiatrists providing care to students and other individuals at McGill University.

Considering how few psychiatrists there are in outlying regions and in other institutions, I would be interested in knowing what it's like in your facility? Are you as spoiled as Dr. Hoffman? And if so, how do you go about sharing the services with others? We have heard all kinds of stories, in St. John,s, Newfoundland, and all across the country, and there really is a serious problem in Canada because of the shortage of psychiatrists.

[English]

Dr. Kennedy: I think you are speaking about the uneven distribution, and I suppose the telemedicine is one aspect. In Toronto we now have a number of links in our outreach programs, and of course with a new medical school in Northern Ontario, there are more local students being trained. There is a distribution. Many psychiatrists at my hospital spend one to two weeks every two months in Northern Ontario. They love it, they take residents, they teach, and in fact, many will say it is the variety in their year that keeps them going in doing some of the more day-to-day work in the hospital. I think that is a positive thing.

I have learned from this discussion; I was impressed by some of the discussions around the telemedicine psychotherapy, and I think that we could be doing more of these communications now with Internet technology.

The Deputy Chairman: Thank you very much, all three of you. This has been a wonderful session.

Senators, our next witness will be Valérie Gideon from the Assembly of First Nations.

Dr. Valérie Gideon, Director of Health and Social Development, Assembly of First Nations: Good afternoon, and thank you very much for the opportunity to speak with you today. My name is Dr. Valérie Gideon and I am the Director of Health and Social Development at the Assembly of First Nations in Ottawa.

This is the first opportunity for the Assembly of First Nations to address the committee on the mental health issue and your interim report, so I appreciate this very much. Since it was rather short notice for us, I will be referring to my notes, although I do like to be more spontaneous at times.

Coincidentally, today is National Aboriginal Day, and I would like to wish my colleagues in the room who are of Aboriginal descent a happy day. Although we should all be off enjoying ourselves, we are here because we are dedicated and working hard for the interests of our people.

Back in Ottawa yesterday, a group of Youth Suicide Prevention Walkers, First Nations, Metis and Inuit, arrived from their annual walk. They walked from Duncan, British Columbia, to Ottawa, and met with the Minister of Health yesterday to relate their personal stories and their courageous journey to bring national attention to the alarming suicide rate among First Nations and Aboriginal peoples, which is, as you know, up to six times higher than the national average.

They were quite pleased, however, this year, to find out that there has been a new investment of $65 million to develop a national Aboriginal youth suicide prevention strategy, but certainly they are also aware that that would not be sufficient to address the needs of all First Nations and Aboriginal peoples.

For example, this past March, an eight-year-old boy from the Gods Lake First Nation in Manitoba committed suicide by hanging himself, and his 11-year-old brother had committed suicide three years earlier. I am sure you would agree with me that children this young should not know what suicide is, let alone contemplate it.

Some mental health experts have diagnosed First Nations as suffering from low-grade levels of post-traumatic stress disorder as a result of living in poverty and despair. Without a doubt, First Nations are among those who we believe would benefit most from a national action plan for mental health.

Your interim report references many times, and I am quoting:

...that a national action plan for mental health, mental illness and addiction can only be developed out of the collaboration among federal government, provincial and territorial jurisdictions, NGOs and other stakeholders, together with individuals with mental illness/addictions.

On this note, the AFN wishes to highlight that First Nations constitute a unique and another level of jurisdiction that must be recognized in light of our historical relationship with the Crown, as recently recognized in the political accord signed between the Government of Canada and our national chief at the May 31 cabinet policy retreat.

The AFN is concerned about the suggestion that harmonization of federal mental health-related funding with that of provinces and territories would be the most effective solution. In your report you state:

Finally, some provinces have integrated Aboriginal issues with their province-wide mental health strategies. In those circumstances, federal programs for Aboriginal mental health on or off reserve should be harmonized with the provincial mental health plans and implementation strategies.

It is our opinion that this could be misconstrued as an off-loading of federal responsibility, certainly something that has often been communicated to us by our regions and our communities. This is especially alarming in the absence of a comprehensive federal program for First Nations mental wellness.

We certainly concur with your findings that limitations on non-insured health benefits and fragmented programming do little to systematically address the needs of First Nations individuals and communities.

We have recently completed action plans in the areas of non-insured health benefits, continuing care and health research information, of which I have provided copies this afternoon. These are action plans that we have been preparing for the first ministers' meeting in November of 2005.

While integration and harmonization are important, this cannot be done in the absence of a comprehensive mental wellness program for First Nations both on and off reserve. Provincial and territorial governments are already responsible for providing mental health services off reserve to First Nations, as you have pointed out.

If we take as an example the largest jurisdiction, Ontario, we must underline that the Centre for Mental Health and Addictions, which receives the bulk of funding from the province, does very little to adapt and extend its services to First Nations.

The Royal Commission on Aboriginal Peoples and the Romanow commission have pointed to the need for more targeted and consolidated funding for First Nations health, and more specifically, the royal commission proposed a system of healing centres and lodges under First Nations' control to bridge jurisdictions and individual ministries, and to pool health and social resources from all sources — this idea of block funding. However, the AFN maintains that such efforts will only be acceptable and effective under First Nations' control.

The majority of First Nations governments currently deliver health services to their members both on and off reserve, and this has been underlined in a September 2004 joint communiqué signed by all Aboriginal leaders and all first ministers. The communiqué also highlighted the importance of clarifying roles and responsibilities across all levels of government. Hence, the increased transfer of dollars to First Nations communities to develop and maintain their own mental health services with strategic linkages to provincial and territorial jurisdictions would be more aligned with recognition of the nation-to-nation relationship and First Nations jurisdiction in health.

Furthermore, health research has demonstrated a clear link between self-determination and cultural continuity and improved health outcomes, and you noted that as well in your reference to Chandler and Lalonde.

Unless First Nations have a sense of ownership and control over a comprehensive mental wellness program, any new investment or initiative would be working against itself.

We also recommend that your report take note of the collaborative mental health framework developed by the AFN, the Inuit Tapiriit Kanatami and Health Canada's First Nations and Inuit Health Branch in 2002, where we defined mental wellness as:

a lifelong journey to achieve wellness and balance of body, mind and spirit. Mental wellness includes self-esteem, personal dignity, cultural identity, and connectedness in the presence of a harmonious physical, emotional, mental and spiritual wellness. Mental wellness must be defined in terms of the values and beliefs of Inuit and First Nations people.

I have also shared copies of that framework with you.

It is our position that any development of a Canada-wide mental health or wellness strategy must reflect the integrity of this work, which was passed by a resolution of our chiefs in assembly in 2001 and was quite a high-profile initiative for First Nations leadership.

An additional concern that I wish to relay from our analysis of your report is that it would be important to take into account relevant findings of the First Nations Regional Longitudinal Health Survey, the first phase of which was completed in 1999 and the second phase just recently. National reports will be made available in the fall. There is a lot of rich information about First Nations adults, children and youth living on reserve in that survey.

Reference would also need to be made to the valuable work undertaken by the National Indian and Inuit Community Health Representatives Organization, the National Native Addictions Partnership Foundation, and, of course, the Aboriginal Healing Foundation — represented here today — particularly their work related to training, capacity building and best practices.

In terms of the pieces in the report on research and ethical considerations, it would also be important to capture the valuable work that we have completed with our First Nations Information Governance Committee and the National Aboriginal Health Organization's First Nations Centre with respect to the principles of ownership, control, access and possession — or OCAP — of First Nations data and information.

We have also completed, as I noted, an action plan on First Nations health research and information that gives you a sense of our positions with respect to undertaking collaborative research, public health surveillance and other types of information management activities. We also highlight our interests in the area of telehealth and electronic health records, particularly in our development of a client registry, and in the area of tele-mental health, a key project undertaken by Keewaytinook Okimakanak, our K-Net in the Sioux Lookout Zone. I am not sure if you have heard from those people yet.

I wanted to also indicate that we have been excluded from several pan-Canadian developments of late, including the Healthy Living Strategy, the Healthy Schools Initiative and the Catastrophic Drug Coverage, all initiatives you mentioned in your report.

I think Gail will mention the number of First Nations who have been impacted by or diagnosed with fetal alcohol syndrome and mental illness, and the lack of facilities and limited funding available to First Nations communities to respond to the specialized needs of those children.

Continuing care is a key area, and I have shared with you our action plan for continuing care, in which we estimate that an additional investment of $264 million per year would be required to address the gaps. Of course, some of the unmet needs are for residential care and residential facilities for First Nations impacted by mental disorders, and I am sure that Jules will be sharing a story with you relating to Quebec's experiences in this regard.

In terms of the report's discussion of the effects of stigma and discrimination on those who are experiencing mental health and addictions, I believe it would be important for the report to outline the exacerbating impacts of colonization, such as Indian residential schools and racism, on First Nations. Again, I am glad that Gail is here, because I am sure she will be talking about the Aboriginal Healing Foundation's wonderful work in that area.

The lower levels of research funding, particularly to support community-based First Nations research, lessens opportunities for knowledge translation of First Nations mental health, leaving both the medical community and program administrators in the dark with respect to the cultural relevance and competence of research and resulting programs.

In terms of accountability and fragmented federal funding and programming, I wish to point to the newly formed First Nations and Inuit Mental Wellness Advisory Committee, which represents an opportunity to develop a comprehensive First Nations and Inuit wellness strategy as a collaborative effort between Health Canada, the AFN and the Inuit Tapiriit Kanatami.

In looking at my notes, I want to emphasize again the need to include us at the outset in the development of any pan-Canadian or national strategy in this area, particularly since we have been excluded, as I have noted earlier, from any component relating to Aboriginal peoples for the Healthy Living, Healthy Schools and Catastrophic Drug Coverage initiatives. This has been a major gap, and our advocacy efforts with the Public Health Agency of Canada to be included in those initiatives not been successful, despite support from the First Nations and Inuit Health Branch of Health Canada.

Therefore, we are looking for your support in recognizing the need for a joint action plan and wellness strategy between federal and First Nations leadership that would immediately address this crisis in a collaborative, comprehensive and culturally relevant manner. We see as critical to the success of such a strategy the renewal of the Aboriginal Healing Foundation, whose momentous work over the past several years will be leveraged to expand and sustain community healing projects.

The Deputy Chairman: Thank you very much, Valérie. I will come back to the national strategies, because I do realize that they are a problem and we do not quite understand the mechanisms to make them fit. However, we will first hear from the rest of the panel.

Dr. Gail Valaskakis, Director of Research, Aboriginal Healing Foundation: Good afternoon. I am a former professor and dean at Concordia University. It may be of interest that I sit also as Co-Director of the Network for Aboriginal Mental Health Research and as a member of the advisory board of the Institute of Aboriginal Peoples' Health. I am Director of Research at the Aboriginal Healing Foundation. I am grateful for this opportunity to speak this afternoon, to say a few words about the foundation's work and what we have learned in the process of that work.

The Aboriginal Healing Foundation, you will remember, was established in 1998 in response to RCAP and the statement of reconciliation made by Jane Stewart, then Minister of Indian Affairs. It was established with a 10-year mandate, one year to set up, four years to allocate, on a multi-year level, $350 million, plus interest, five years to evaluate the effectiveness of that project, and close.

We are now in the seventh year. The funding will end in 2007 and we will close in 2008 under the current mandate.

The Aboriginal Healing Foundation was established to address issues of physical and sexual abuse related to residential schools. As you know, those are greatly related to trauma and to mental health in Aboriginal people. It has to do with the loss that people who attended residential schools suffered in regard to language, to culture, to family, to nation, and with the impact that had on Aboriginal communities with respect to a cycle of abuse over a long period of time; in regard to the lack of parenting skills that related to their experience in residential schools and historical trauma — something we have learned a great deal about lately — with regard to the grief and loss that Aboriginal people have felt over many years of displacement, loss of culture, loss of language and death in their own communities.

It was established as the first national Aboriginal organization, with 17 board members who represent the five national organizations, as well as Inuit, Metis and First Nations; it includes the national women's group, status and non-status; it includes two government organizations, INAC and Health Canada, both of whom are represented by Aboriginal members of the board. It is the first organization to work on a community-based, holistic healing project on a national level that is Aboriginal initiated and implemented, and that has had an impact in regard to Aboriginal peoples' mental health.

To date, the Aboriginal Healing Foundation has invested $437 million in community-based projects, ranging in type from awareness and prevention to actual healing services, including long-term healing services in residential treatment in trauma centres and programs for addiction.

We have given out about 1,339 grants to First Nations, Inuit and Metis. In the first wave of take-up of the projects that we funded, First Nations came in great numbers, particularly in the West, starting with British Columbia and Saskatchewan, and following with other Western provinces.

In the second wave, First Nations across the rest of the country came in, although Quebec is still underserved.

In the third wave, Inuit took up this project in greater numbers.

We think the fourth wave, should the Aboriginal Healing Foundation continue, would be Metis, who are underrepresented as well. The northern waves have been much smaller.

We have done three national surveys over the last several years; we have done a best practices survey; we have done 13 case studies of different types of projects, and six in-depth case studies through the Network for Aboriginal Mental Health Research. We have also done an extensive file search and have had six focus groups. A final report that will be published in January 2006, the first volume of which is being authored by Marlene Brandt Castellano, the co-director of research for the royal commission. The second volume is being authored by the evaluator, Kim Scott; the third volume by someone who has worked in best practices for many years and has taken that up with us, Linda Archibald.

We have found that if you extrapolate the figures on the basis of those national surveys, 204,564 people have been involved in healing projects in the time we have been operating; 49,095 have been involved in training projects over that period; and 27,855 people have special needs. Those special needs are extreme trauma, suicidal behaviour and life- threatening addictions. Those people have often not had attention before. We found in our survey that less than 10 per cent of the people who have addressed healing needs through our projects had ever addressed healing before; they have never received any services. Therefore, 90 per cent of the people that we are reaching are being reached for the first time.

Our findings show that 94 per cent say they feel more secure and safe on the basis of what they have done through their healing projects; 72 per cent say they are better prepared for other difficulties; 71 per cent say they are resolving past trauma; and 69 per cent say they are securing support and feel that they can better resolve future trauma on the basis of what they have gone through.

What has helped? It is interesting. You will see in the handout that I have left for you that learning about residential schools helped, in part because people who attended them have been very reticent to speak about their experience with their children or grandchildren. Intergenerationally impacted people in our communities do not know what that experience was like and they do not understand, so that has been extremely important.

Cultural celebration, identity issues, working with others and connecting to others helped. If you look at the graphs in the document, you will see that the largest number of people, in regard to healing services, access and participation, rated traditional activities at the top of the scale. Traditional activities means talking to elders, working in healing circles, cultural celebration, working with others on cultural projects, going out on the land; those activities are at the top, and at the bottom of the graph is Western therapies.

That has to do with two aspects; one is accessing services, and the second is the rating of the effectiveness of those services by those who accessed them. Those are extremely important graphs with respect to what Aboriginal initiated and implemented community-based holistic healing projects are telling us all about healing, particularly in regard to mental health and trauma.

We have also employed over 5,000 people in the communities, and most of those are either survivors or intergenerationally impacted, with few exceptions. We have established a great many partnerships, the largest partner being Aboriginal governments themselves. It may be no surprise to you, but it great surprise to us, we did not expect that. We found in our best practices survey that over two thirds of all the therapies involved the use traditional activities — again, elders, healing circles, cultural activities.

We have done a great deal of research, not only in regard to evaluation, but in regard to issues that we do not understand very well in terms of Aboriginal communities, particularly as they relate to residential schools.

Dr. Gideon mentioned the study we have done on fetal alcohol syndrome. I will leave this with you and would be happy to have it delivered to all of the committee members, should you wish. It is an excellent study on fetal alcohol syndrome, and it does show that people in the Aboriginal communities are under-diagnosed. More importantly, it shows that they are often not diagnosed at all. There is no way to diagnose them in most Aboriginal communities, and we assume a great deal in regard to the kind of impact fetal alcohol syndrome is having.

I brought a mental health profile study by two professors from Simon Fraser University on British Columbia's Aboriginal survivors of the residential school system. It is the only empirical research there is.

I have also brought a study by Dr. Cynthia Wesley-Esquimaux on historical trauma and Aboriginal healing. Historical trauma is an extremely important issue that we all should understand much better than we do.

Finally, I have brought Reclaiming Connections. This was done by one of the groups we funded, the Wabano Centre for Aboriginal Health, and is a manual on understanding the impact of trauma on mental health. I have also brought the third interim evaluation report.

We have many more published research projects and many more under way that I think are important to the work we have been doing.

Let me close by saying that we are in our final years of funding. Our funds are now fully committed. All project funding will cease on March 31, 2007, and the Aboriginal Healing Foundation, as I mentioned, will close in 2008. It will have a tremendous impact on government services because of the numbers of people who have been involved in healing in Aboriginal communities across the country. Health Canada will surely feel the impact, Corrections Canada will feel the impact, and many other government agencies will too.

What we will do with regard to ending the Aboriginal healing project will have a remarkable impact on the mental health of Aboriginal people across this country in terms of projects that we have, through empirical evidence, found to be effective in addressing mental health issues for Aboriginal people.

I thank you once again for this opportunity and I would be pleased to answer any questions.

The Deputy Chairman: Thank you very much.

We will now hear from Jules Picard.

[Translation]

Mr. Jules Picard, Social Services Coordinator, First Nations of Quebec and Labrador Health and Social Services Commission: Thank you, Mr. Deputy Chairman. I and the people with me today would like to wish Senator Gill a happy National Aboriginal Day.

I work for the Quebec and Labrador Health and Social Services Commission. This is an organization that was created by the Quebec Assembly of Chiefs, with specific mandates in terms of health and social services.

There is no doubt that in the time that I have been with the commission, not only for us but for the government, mental health has not been a priority. However, we consider the Senate committee's reports to be good reports. It is clear that the commission will not reject out of hand the comments and suggestions you make in your report.

We recognize there are significant gaps at the present time in terms of access, delivery and quality of mental health services all across the country. We also know that the First Nations are facing specific and complex issues.

Senator Gill referred earlier to the communities of Paquashipé and La Romaine, which are located in remote areas. There is also the community of Schefferville, which is going through an extremely trying time both economically and socially. Of course, this situation affects families, individuals and young people, in terms of their mental health. I will come back to this a little later in my presentation.

In general, there seems to be no recognition of the fact that political and decision-making bodies within First Nations can be partners on the same level as both provincial and territorial government decision-makers, when it comes to mental health and treatment of addictions.

Over the last three years, the First Nations and the commission have clearly made mental health, crisis situations and suicide in the communities a top priority. However, the machinery of government doesn't seem to want to move in that direction.

Of course, there are committees such as yours that are working. Agreements were signed last September with respect to the health care system as a whole. In Quebec, I believe that two communities in particular have experienced some major crises in the last six months: Schefferville, for one, as well as Manouane and Weymontachie.

Last March, there were three suicides in those two communities. And there have been several attempted suicides. We were called upon to respond in those two communities. When a death occurs, no matter who is involved, the community mourns.

And when a death occurs as a result of suicide, the community not only mourns, it is in crisis. Ms. Wood had to go in to work with responders, political authorities, counsellors, and of course, the families.

The report recommends that an individual experiencing mental health and addiction problems be at the centre of the health care system, rather than just in terms of services. We are recommending that individuals experiencing these kinds of problems be given priority.

And this must occur in keeping with the First Nations' holistic vision. Families and communities must also be the focus of our concern, not only for the First Nations, but for all governments, both federal and provincial.

We could list the concerns or problems the commission has noted. Social conditions within these communities are deteriorating in a way that can only be described as extremely alarming.

The issues surrounding mental health crises are very concentrated and are affecting these populations. As I said earlier, a number of communities are experiencing major social crises and are having a lot of trouble trying to stabilize the situation.

At the present time, the First Nations have very few means of taking ownership of their mental health, their wellness and their social and overall development. Of course, there is a strong desire to do so.

Without going into detail, I know there are significant issues in terms of both federal/provincial jurisdiction, something that has a direct impact on individuals, families, and of course, on their communities.

I would like to refer to a specific situation. I believe there are several such cases of this across the country. In our community of Pointe-Bleue, there are people with mental health problems. In terms of federal/provincial jurisdiction, there is currently a young schizophrenic living there who is in trouble with the law. And he has to be stabilized with medication.

What we seem to be hearing now is that Health Canada cannot pay for that young person's medication because he is the responsibility of the provincial prison system. Therefore it is up to the provincial prison system to pay those costs.

And yet in order to protect both this young person and society, that medication is necessary. He is in his early twenties, and I knew him when I worked as a social worker there. He is in need of a lot of care and specialized services.

So, when it comes to jurisdictional issues, we don't want to see the authorities playing tennis the way they are in Wimbledon right now: forever putting the ball into the other guy's court.

There is tremendous concern in terms of the growing number of children. On the weekend, we had a working session with the Walgwan Treatment Centre. That treatment centre handles young people aged 12 to 18. The mission of the Walgwan Centre is to treat young people with addiction problems.

The director of the Centre was telling us that over the last two or three years, many of the young people aged 12 to 18 that are coming to the Centre have mental health problems, as opposed to addiction problems.

This treatment centre, which was mandated to treat addiction problems, is not mandated to treat mental health cases. And that does not only apply to this particular treatment centre; it also is the case with child welfare authorities in First Nations.

Young people experiencing behavioural problems are protected, as provided under the Youth Protection Act. Here I am referring specifically to the communities, but I could also talk about the Quebec system, where others have made the same observation.

A young person experiencing behavioural problems is reported and protected. Yet today, fewer than 50 per cent of the young people reported for behavioural problems are experiencing mental health problems.

That legislation that says young people experiencing mental health problems must be protected has a piece missing. The fact is those young people don't need to be protected, they need to be treated.

That is what we are seeing in terms of these resources. I believe the problem is becoming more and more of a concern. I have been on the Board of Directors of the Walgwan Treatment Centre for two years now. At the beginning, they talked about addiction problems, but for some two years now, there have been more mental health problems.

What can we do now to provide immediate, practical support to the communities that currently find themselves in crisis?

There is no doubt that the damage that has been done is very significant and relevant to all Canadians. And there is no doubt that the recommendations made by your Senate Committee on Mental Health will not immediately be followed by an action plan; that will take some time.

Before the government machinery has a chance to digest all of that and before all the departmental machinery comes up with some action plans, we are talking about at least 18 to 24 months.

Senator Gill: Three or four years.

Mr. Picard: I believe it will take a certain amount of time before these recommendations can be implemented and action plans developed. In the meantime, however, what are we supposed to do?

I believe that interim measures should be recommended, to both provincial governments and First Nation organizations — at least as regards youth and children.

I think we will have to take a very serious look at interim measures because there is damage there and there are things happening in the communities.

As I said earlier, we want to avoid administrative and financial jurisdictional duality across different governments and departments. That constant duality revolves around: who pays the bill? Does this concern Indian Affairs, Health Canada or the province?

That is what must be avoided. Because while that is going on, the young person is waiting for his medication and the consequences are serious.

We need to provide the same level of services in mental health and addiction treatment to First Nations people as we do in the rest of Canada. But let's not delude ourselves: there is currently an imbalance in terms of the services provided in the communities.

Programs and policies, as well as action plans with respect to service organizations, should be developed in cooperation with the First Nations, both in Quebec and the other provinces. They should be considered equal partners. We may not have money, but we can implement certain components of these programs with the cooperation of governments.

Of course, this partnership should be based on mutual respect and recognition. There is a need to recognize that integrated and lasting community development is a fundamental condition for improving mental health and wellness among First Nations. I don't think we should only be taking initiatives that are fleeting in nature.

We should be thinking of lasting initiatives and programs. Too often the DJSPI develops initiatives, but three years later, the initiatives are dropped and then nothing else comes along to replace them. That happens very often at the DJSPI.

The First Nations have to be given the appropriate levers to take ownership of these issues by defining their own priorities. We say that mental health should be at the same level as physical health. I believe you refer to this as well in your third report: develop measures tailored to their needs; ensure implementation of the actions determined to be necessary, and not only for the First Nations, but also with governments.

There are lots of public awareness campaigns across Canada dealing with mental health; often you see the posters. But within the governments themselves, could we also engage in some awareness raising so that they have a better understanding of these issues?

I called the Regional Office this morning and I asked someone to provide me with some figures with respect to mental health. I doubt that our Regional Office deals with mental health. However, I do believe that a certain percentage of the money is paid directly through agreements between band councils. But it's a minimal percentage — around 1 or 2 per cent of the total amount of the agreement.

So, there is a need to raise awareness among departmental officials so that they have a better understanding of the issues, and not only in terms of what is going on in the communities.

Senator Gill: When you refer to the Regional Office, do you mean the Regional Office of Indian Affairs?

Mr. Picard: No.

Senator Gill: Health Canada.

Mr. Picard: Health Canada.

Senator Gill: National Health.

Mr. Picard: And among professionals as well, so that they are able to receive specific training regarding realities in First Nations communities. A better understanding would certainly help to reduce the discrimination and stigma that First Nations people, particularly those experiencing mental health problems, are often subject to.

Dr. Charbonneau, who appeared before us, said that when people go back to the communities, they are identified. I think we need to take action to address those aspects of the problem. There is a need to provide specific funding to the First Nations so that they can develop and implement prevention services for children and their families.

Finally, your Committee will certainly go forward with a number of recommendations. It might be worthwhile bringing together a group of people, including Canadians and First Nations people and others from different backgrounds — to work on drafting those recommendations and setting priorities so that one day, we could have some decision-making power.

It's important to give First Nations the opportunity to tell you what their priorities are and to convey their recommendations. We need to find a way to work together and implement those recommendations.

Ms. Isabelle Wood, Social Crisis Issues Technical Coordinator, First Nations of Quebec and Labrador Health and Social Services Commission: Mr. Deputy Chairman, I am the Social Crisis Issues Technical Coordinator for the First Nations Health and Social Services Commission.

Jules is my supervisor, my boss. I worked for three years in the community — specifically the community of Weymontachie — which has been hit very hard by a number of social crises and suicides. Over a period of three years, there were almost ten suicides in the community. That is a huge number for a community with a population of only 1,200.

In your reports, and particularly the ``Issues and Options'' document, there is a lot of discussion of the individual, the family, and so on. In terms of the First Nations communities, it will be important to talk about the specific issues facing responders and front-line workers who every day, and sometimes several times a day, have to deal with individual or family crises. These responders have to deal with these crises as they arise and find themselves completely exhausted and overwhelmed, such that they no longer know how to address the problem or what the solution is.

People develop very meaningful bonds of trust with these responders. They often go to the same responder when they need help. The responder ends up being completely exhausted, with no way of leaving the community.

You referred to the community of Schefferville earlier, and the fact is that you cannot leave that community when you like; you have to wait for a plane or a train, and be able to afford this kind of travel.

So, there is a need to be concerned about the health of responders and those people working on the front line in First Nations communities.

Senator Gill: Dr. Valaskakis, I want to begin by thanking you for your presentation, which is extremely pertinent and covers the whole gamut of situations that can occur in this country. As I said earlier, we heard from a number of witnesses in Manitoba. I think the main ideas are emerging from every region of the country.

There is certainly a common view with respect to Aboriginal communities and mental health programs. I want to express my sincere thanks to you for your presentation. I also want to point out that Gail and I have known each other for a long time. I am sure you remember that we worked together on the Collège Manitou file, so the battle continues. I want to congratulate you.

And Valérie, I knew your father very well a number of years ago. I watched Jules grow up. And Isabelle and I also know each other now.

So I want to say thank you and commend you for what you're doing, because it is difficult work. My mandate relates to the Aboriginal peoples and I can tell you that I have been working hard in this area on a daily basis for many years now.

Senator Pépin: We can certainly testify to that.

Senator Gill: I also want to commend my colleagues for their openness. In past years, there have been a lot of problems in terms of achieving that kind of openness, understanding and desire to listen. However, now I can certainly say that most of my colleagues in the Senate want to take action and help First Nations people and others to move forward and secure the services that best meet their needs.

On the other hand, I would say there is still a lack of information. The fact that there is not enough information getting out there may be partly our fault, as First Nations people. It's information that we see as very basic, but it is important nonetheless.

Valérie was saying earlier that the First Nations were meeting and that within the First Nations, there are structures in place. I don't think people realize that the Assembly of First Nations represents all the chiefs in all the provinces.

What can be confusing — and I think it is important to mention this — is that at the government level, First Nations are referred to by the communities themselves. And yet the communities only represent part of the First Nations; they are not the First Nations per se.

But because they do not have accurate information, people become concerned and have a tendency to say: What are we going to do to meet the needs of some 630 First Nations all across the country? But the fact is that there are not 630 nations. As far as the Innu are concerned, our nation includes the Lower North Shore and Mashteviatsh. The nation has about 12,000 to 15,000 members. So, we're not talking about nine or ten First Nations there.

It is also important to help people understand the difference between nations and communities. As nations, we can provide services. But it is very difficult to provide all services to the community. On the other hand, we can pool our resources.

The same thing applies to the province. Nations in Quebec — for example, the Confederation of Indians of Quebec — can certainly provide services that others are unable to offer at the community level. I think it's important to mention that.

I also want to ask you, and this goes back to what Jules was saying earlier, to play a role with respect to our recommendations and findings. In fact, the Committee Chairman, Senator Kirby — and I believe that he has also discussed this with Senator Keon — has asked me to participate in developing the recommendations and findings to be presented in the report.

I would therefore like to bring some people together to help me draft that report, and then discuss our conclusions with the other senators. My intention is to do this with people with national responsibilities, such as Valérie Gideon and Dr. Gail Valaskakis. As for Quebec, I intend to proceed in exactly the same manner, if possible, in order to clearly articulate our ideas.

My intention, Mr. Chairman, is to put together a small group of people to assist in formulating recommendations and conclusions. I could then discuss this with the other senators who sit on the Committee who are interested in hearing these recommendations.

In terms of recommendations, I imagine it is a repetition of the ERI program. The recommendation coming from the First Nations, the Inuit, the Metis and others was to be given the funding and have control. I would be interested in hearing your comments in that regard, if you feel it's appropriate to respond.

Dr. Gideon: Thank you very much. Yes, the Assembly of First Nations has a very well established structure in terms of health and social development, and we could certainly participate in a very effective manner and include all the First Nations regions.

As you mentioned, the First Nations of Quebec and Labrador Health and Social Services Commission is one of our regional organizations.

We have ten regional chiefs who sit on the Executive Committee. The Chairman of our Committee, Phil Fontaine, is the National Chief, as I am sure you know.

In terms of health and social services, we work with a network of technicians who are in the employ of these various regional organizations, and it is in cooperation with them that we develop our recommendations. They set my mandate as director, as well as that of my team in Ottawa. So, it is not what could be called a top-down system; it truly is bottom-up. The ideas flow from the communities and the regions, and we then set about implementing them at the national level.

So, we can work with the network of technical coordinators. We also have a committee of chiefs with responsibility for health issues and a committee of chiefs with responsibility for social development; this is a similar type of group working through the same network, except that it operates at the chiefs' level as opposed to the technicians' level.

We have these two structures which are well established. We meet several times a year and communicate regularly via conference call. So our structure does allow us to keep abreast of everything that's going on across the country. It's really not that complicated.

Health Canada, specifically the First Nations and Inuit Health Branch, works with us on a regular basis and within our technical coordinator and committee chiefs structure. So, we have a very good relationship in place there.

As I mentioned in my presentation, we recently set up a committee with Health Canada, the Inuit leadership and the Assembly of First Nations, for the purposes of following up on the mental health conceptual framework that I discussed with you. However, there has never really been any follow-up or implementation of those preliminary ideas. So we also have those structures.

We would obviously be very open to the idea of working with the Healing Foundation. This is an organization I see as absolutely fundamental as regards our future and the possibility of improving the mental health of First Nations people.

Senator Gill: I just wanted to have a better idea of the structure of your organization. Here in Ottawa, people often do not think of the Aboriginal nations as being well organized. They imagine that it's the way it used to be, even though things have changed considerably.

[English]

The Deputy Chairman: This is tremendously important, because you mentioned, Dr. Gideon, that some of the national programs that should be getting to First Nations are not. It seems to me, from what I am hearing, that there are so many options for the flow of federal money into First Nations health; some flows directly and you are getting some services from the provinces that are covered by the transfer payments. The reality is that in many areas, the federal government is not capable of providing adequate services because they do not have the critical mass of health professionals to do the job.

It seems to me that First Nations need to become the fund-holders for health, and they can buy the services wherever they wish, up to a given quality at a given price. Most of them would be purchased from the provinces because they have the experts to deliver the services. However, some will have to come from the federal government because of our public health system and so forth. Even in the public health system, when it comes down to the delivery systems, if we want to vaccinate a large number of children, for example, we are again dependent on the provincial public health resources to get the job done. It would be interesting if we could find a way to sort through this massive confusion and suggest a structural framework that would work.

Senator Kirby and I have discussed what would work best with some of the provincial ministers. I do not have to tell you what they would like to do. They would like the federal government to give them the money and they would supply it —

Senator Gill: Then we have to fight it.

The Deputy Chairman: Yes. This is not acceptable; it is a non-starter.

Having said that, I think the time has come to try to evolve a structural framework that would work. When we write the report — and all we senators will take the credit — we have to come up with some suggestion for a structure for mental health services for First Nations.

We will not solve this today, but we need more dialogue on it.

Senator Gill: There was some experience in the past where money was given to the provincial governments. I can name the governments. The Government of Newfoundland and Labrador is one. The money was given to them, and then they had to manage services for the Aboriginal people. We studied that, and not even half of the money went where it was supposed to. That is why I think it is important that the money goes to the people who are responsible, and then they decide about the services, where they should buy the services. I think that has to be part of our recommendation.

[Translation]

Mr. Picard: Along the lines of what Senator Gill was saying, there is already some experience with this in Quebec, particularly as regards social services, whereby money is given to the band councils which then sign agreements directly with the Youth Centres for the purpose of obtaining specific services either from the Youth Protection Branch, institutions or foster families.

They agree on the services to be provided to the community and there is a sharing of responsibility. At the present time, there is experience with this not only in Quebec, but in the other provinces as well.

Ms. Wood: If I could just add something, in addition to transferring money directly to the nations or the communities for the purposes of purchasing services through the provincial systems, the idea is also to allow First Nations and communities to develop their own mental health services, because we're talking about expertise within these networks.

I can tell you there is quite some expertise within the communities themselves. Whether we're talking about responders, the political decision-making authorities in health and social services or other workers, there are many people who have been working in this area for a long time and have developed real expertise in terms of a holistic approach, and the appropriate distribution of various services and therapies that involve the natural environment.

The communities and First Nations need to be given a chance to develop their own mental health services.

[English]

Dr. Gideon: Senator, I just wanted to echo that there are models that any recommendations could build on. We are going through a massive exercise now that I am sure you have heard about, the blueprint on Aboriginal health that has to be delivered to first ministers in November. Our fingers are crossed that that will be a success, but I do not have a crystal ball. I am responsible for coordinating that at the national level for First Nations. It is been a daunting task. However, I think that at the end of it there will be some quite concrete recommendations for an overall new way of working across the jurisdictions, but also a new way of flowing funds to First Nations communities after what we have learned from the last several years of the health transfer and some of its limitations. Block funding is given to a community, but it is still a fixed funding envelope. There are still some stovepipe-type program frameworks at the national level that communities have to fit within, and there are new programs that are not eligible for transfer that have created fragmented administrative mechanisms.

There are a lot of reasons the potential for the RCAP and Romanow recommendations around the targeted consolidated funding have not been fully achieved. I would be happy to provide the health transfer report recommendations to you so you could take a look at that as well.

If there was a more flexible funding approach around wellness, for example, where communities could invest in areas of health determinants that contribute to poor mental health, I think that it would be highly successful. I would also agree that while some communities would purchase provincial services, or maybe even university-type services, if you look at research in the surveillance area, they would also establish centres of expertise among themselves, particularly in the area of traditional healing, and building on some of what the Aboriginal Healing Foundation has been able to provide in terms of capacity.

I do think the options are there and that the blueprint will help us in informing the future agenda for health services overall in First Nations country.

Dr. Valaskakis: If I may just add that I do think we have had a tremendous amount of experience in Aboriginal communities now with the development of services and capacity building through the Aboriginal Healing Foundation, and it will be a great loss to the projects. Many of them are closing, many of them have closed, many more will close in the next few months and years and everything will be finished in 2007. That is a huge loss to the communities.

The Deputy Chairman: Does that have to occur?

Dr. Valaskakis: It has to occur unless the Aboriginal Healing Foundation is refunded, with a new mandate, which is something that the Assembly of First Nations has spoken forcefully for through Chief Phil Fontaine. That has not happened to date, and so given the current mandate, the Aboriginal Healing Foundation will close.

There was a small amount of bridge funding given in the last budget, $40 million; that does not even fund the projects we have now that will close. Therefore, we are not putting out a new call for applications, we are extending by one year the projects that have proven themselves in the past and were to close earlier than 2007.

That does not include all the projects that are currently funded, because, of course, we actually went out into the communities with community support workers, with gatherings right across the country, with grants that would allow people to write proposals, and finally got people involved in this process. It takes time, and so we will lose that as well when we close. We are now at the peak of our participation, which will then fall off, and we will end in 2007.

Given that we are at the peak, we could not fund all the projects with the $40 million, and that is breaking down very quickly.

The Deputy Chairman: Was there ever a plan for transitional funding to convert so-called pilot projects to operational projects?

Dr. Valaskakis: Not in terms of the Aboriginal Healing Foundation, which just had a clear 10-year mandate, with one year to establish itself, and all the money had to be committed within a four-year process. After the commitment of that money, we were allowed to do an evaluation and then close down. That is what we are in the process of doing now. There was no long-term mandate.

The Deputy Chairman: There is something wrong there. The entire reason for the existence of a pilot project is to create something.

Dr. Valaskakis: I am not sure it was thought of as a pilot project so much, as a response to the Royal Commission on Aboriginal Peoples and the awareness that Phil Fontaine and others brought to residential schools. It was one response to that on the part of the government, and a very short-term one.

Senator Gill: I think Jules mentioned that for pilot projects for Aboriginal people, no follow-up study is done with respect to the results. Some of them get good results, but there is no repeat and it all falls apart. That is why we have to be insistent.

Dr. Valaskakis: We do have a tremendous amount of research to show the results.

The Deputy Chairman: I know.

Dr. Valaskakis: We have so many research projects to look at, and the national evaluations, so it is really important.

The Deputy Chairman: I think we should give some serious consideration, honourable senators, to a recommendation in that area, but we need some help. This is an absolute minefield, trying to sort through this at this time. My own surgical mind simplifies it quickly — give the money to the fund holders of the Aboriginal peoples and let them buy the services they need from whomever.

[Translation]

Ms. Wood: The issue raised by Dr. Valaskakis is a very important one, in the sense that because project funding is not recurring, that has a tendency to perpetuate the acute social crises being experienced by these communities. The fact is we're always responding to a crisis.

Senator Pépin: Right.

Ms. Wood: What constantly happens is, if we develop a project, we receive funding for a few months — a year at most. So it becomes very difficult to develop effective prevention and promotion programs aimed at the longer term that would enable the community to get back on its feet, as well as allowing for earlier detection and intervention with children and youth.

The lack of recurring funding for projects developed by and for First Nations and Aboriginal peoples results in multidimensional issues that are very complex.

Senator Pépin: So, there is no continuity whatsoever?

Ms. Wood: There is no continuity. It's very difficult.

[English]

Senator Gill: Dr. Gideon, I want to mention that the chairman of our committee would like to make some strong recommendations on Aboriginal health. The report has to be produced. I do not know if we will have time when we come back in September to have a meeting with the people concerned, but we can all make good recommendations that will serve the people.

The Deputy Chairman: Senator Kirby and I have discussed this dilemma at some length. The big problem that I see here is how to get a simplified flow of funding to Aboriginal fund holders. Believe me, the provincial ministers of health do not want to hear about that, but I do not think the problems we are talking about will ever be overcome until that happens.

On the other hand, you are highly dependent now on services that the provinces provide, and then get reimbursed for in some willy-nilly fashion.

Senator Gill: There is no simple solution; it is always a bit complicated. It is easy for the federal government to give the money to the provincial governments, but the most important thing is to make sure that the people are receiving services. Believe me, that is not always the case. It is not that I do not believe in the provincial governments, but the situation is so different that it is difficult for the provincial governments to get all the money and all the services to the people.

Provincial governments are already receiving money through this system to provide services to Aboriginal people, yet look at the situation. We have to change the current situation, which means that the provincial ministers may have to apply some pressure, but that is not the way we should go.

The Deputy Chairman: No. They are absolutely convinced that they can take care of all the services for the Aboriginal people if the federal government would just give them the money.

Senator Trenholme Counsell: It varies from province to province, I think.

Senator Gill: It varies, yes, but we should ask the people who are receiving services elsewhere in other provinces if they are satisfied.

The Deputy Chairman: Well, we had good presentations, particularly from Saskatchewan and Manitoba.

Senator Gill: In Winnipeg, yes.

Ms. Gideon: I would suggest that it is not an all-or-nothing proposal. There has been a real openness in the context of the blueprint process to airing some of the issues with respect to clarifying roles and responsibilities in different areas. I am very aware of the tensions there. The new committee that First Nations and Inuit Health Branch organized does have representatives from the FPT advisory committees, the Canadian Mental Health Association and other people who appear to be supportive of listening to what would make sense and would work better.

In 2003, the first ministers agreed to report back on their performance with respect to Aboriginal health through the Aboriginal Health Reporting Framework, and that is another mechanism through which they feel that there needs to be better accountability for the monies that they already receive. The idea of establishing some strategic linkages between First Nations organizations and communities that would hold the funding remains the AFN's recommendation, obviously. I do think that that is possible, for the benefit of all jurisdictions involved, and to improve the overall quality and health status outcomes of First Nations.

If the prevention services are not effective at a community level, the provinces will just incur more expenditure down the road for individuals who have severe, acute problems or require hospitalization and so forth.

There is an interest for everyone involved here in terms of improving the quality of care. I believe that there can be a resolution and some common understanding.

During the blueprint process, it was established that there needed to be three separate streams — First Nations, Inuit and Metis. The leaders of all of those agree that that is the only way it can work because of the uniqueness of each of the peoples, but also because of the different settings and jurisdictional issues.

For example, although I do not want to speak on behalf of Metis, they currently only receive services from the provincial levels of government. Therefore, the kind of issue that they would be raising would be different from the kind of position that I would be putting forward. If you wish to organize a meeting to formulate recommendations, we would be very interested in helping, in providing any kind of assistance, and, of course, participating. The recommendations would be more effective and practical if they were unique to each of the First Nations, Inuit and Metis groups.

The Deputy Chairman: In Manitoba and Saskatchewan the native populations off reserve are quickly outgrowing the non-native population, so there is another situation. Their health care is paid for out of the provincial budget if they are off the reserve?

Dr. Gideon: The Federation of Saskatchewan Indian Nations, as an example, provides services to off-reserve members. First Nations governments are responsible for extending services to their members living both on and off reserve. The difficulty is that they are not resourced for that purpose in most cases, so they have to make some decisions.

For example, in post-secondary education funding, they have to have a list of priorities, and so the band councils have to make decisions based on those. They are not resourced to look after their entire population, particularly in the area of health.

First Nations governments are ready and willing to deliver services to their off-reserve membership, and some do. Some communities and organizations can actually accomplish that now.

Senator Gill: I think we have to consider the fact that the old policies led to a kind of integration or assimilation, so more people are moving off the reserves. The government was really pushing that; we have to admit it. They were pushing that to reduce the population on reserves, but it creates a lot of problems.

The Deputy Chairman: Currently, in Saskatoon and Winnipeg, as I understand it, if an Aboriginal person requires health care, the individual simply goes to the medical centre and it is paid for by the province, period. Am I right or wrong?

Dr. Gideon: It depends, because tribal councils also deliver health and social services in Saskatoon. Again, if you were Metis, it would be different, and there may be an Inuit person living in Saskatoon, I do not know. However, if you were a First Nations person, you would probably go to the Saskatoon Tribal Council, to their health and social services department.

The Deputy Chairman: If First Nations had their way, would they cover all the health needs of the people in Saskatchewan and Manitoba, rather than maintain the mix that exists now?

Dr. Gideon: I would say the great majority would. Some of them are not as ready as others to carry it out at that level. I think that there need to be, as Jules was saying, provisional types of arrangements for some of those communities and organizations that may never have played that kind of role before. I would say more than half would be ready tomorrow, but they would need flexibility in allocating funding to where the needs are, the proper infrastructure, both capital and information-wise, and technology. They would need the kind of technological infrastructure that would allow them to have the proper systems in place for monitoring and so forth. It would need some openness from the provincial level so that they could negotiate those linkages.

There are a lot of things that they currently do not have that they would need to really be effective. They would need to fill out less than a thousand reports a year around administration and finances.

Senator Gill: Most of the time, the bands obtain financing on the basis of people living on reserve. Those who are living off reserve on a permanent basis have their Indian status, they are part of a band and they have their number. However, the government does not cover them. That is another problem. We have to make a distinction between the Metis people and the status Indians living outside the reserve. It is complicated.

The Deputy Chairman: We have really laboured on this point, but it is something we are having trouble clarifying in our minds, at least Senator Kirby and I. This has been very helpful.

Senator Callbeck: I wanted to come back to the Aboriginal Healing Foundation. I believe you said that before it started, less than 10 per cent had ever gotten any healing services. Now, obviously this has had a tremendously positive impact on the community, but I see here there is a 36 per cent waiting list. Is that 36 per cent of the projects, or 36 per cent of what?

Dr. Valaskakis: That is 36 per cent above those who are currently being served. This information comes from a national survey, and the first piece comes from individual participant questionnaires, of which we have about 1,500, and they were asked whether or not they had ever accessed healing services before.

Your second question refers to the national surveys. We asked whether the projects that we fund had waiting lists, and to what extent they could serve others, were they funded to do so. You have to realize that given the funding we had and the needs, we did not fund on the basis of need, but on the basis of the money we could allocate. Many of these projects would have worked with many more people if they had had the funding to do so, and that is where that number comes from.

Senator Callbeck: You say the funds are fully committed now?

Dr. Valaskakis: The funds are fully committed.

Senator Callbeck: But a lot of people were left out?

Dr. Valaskakis: A great many people were left out, very sad people, calling us often. I remind you that this issue is well understood by our board and our chair. The chair of our board and our CEO is George Erasmus, the Co-Chair of the Royal Commission on Aboriginal Peoples; and our executive director is Dr. Mike Desgagné, who has worked in Health Canada and in addictions for many years. They are very informed, and if either of them could be helpful with regard to your mandate, I am sure they would be very pleased to do so.

Senator Callbeck: Valerie, you talked about telehealth, that you have three projects under way. Could you talk a little about those, and are you getting good results?

Dr. Gideon: Just to clarify, the only tele-mental health project that I am aware of in First Nations communities is in Keewaytinook Okimakanak, our K-Net, which was a pilot project funded by Health Canada, and it also received some provincial dollars through Ontario's NORTH Network. They did a preliminary evaluation, which is on their website, and I can send that to you. It was quite qualitative in nature because they have only been operating for a couple of years, and there are no good evaluation models for telehealth to begin with, so it is challenging.

There are very few telehealth projects in First Nations communities because there is no program to fund telehealth at the federal level, so they are dependent on whether a province is willing to include them in their networks, and that is the case only in Manitoba, which has started to extend their service, and Alberta, and I understand New Brunswick has a strategic plan in place to do so.

Again, it is based on whatever the provincial network is, and it might not serve the needs of First Nations communities. They do not have the option of specifying the basket of services they would like to receive, and there is no sustainable funding in those cases either.

There is a large network of First Nations telehealth sites in Alberta, which again is a pilot project and could end at any time. There are not a lot of tele-mental health experiences, certainly that I am aware of. We are trying to work with Canada Health Infoway. However, I do not know if you are aware that we are also excluded from Canada Health Infoway. There is absolutely no funding from Infoway that has gone or can go to the federal government, and therefore to First Nations. They are looking at a mechanism to fund First Nations directly, but even though we have been lobbying them just like everybody else for the last several years, since their establishment, we have not yet been successful.

They have identified First Nations as a priority in their telehealth plan, but we have had to push and push, and we are having our first meeting with them tomorrow to discuss what that could mean. It is very difficult, when we are not recognized at the outset of a national initiative such as that, to be visible and able to access funding.

Senator Callbeck: Jules, you talked about the centre for youth, 12 to 18, that was set up to deal with youth with drug problems, and now they are finding a lot of mental health problems.

Are you saying that the mental health problems are increasing, or were a lot of them just never recognized before?

[Translation]

Mr. Picard: Over the last two years, the Treatment Centre's mental health clientele has increased. They are obliged to treat these cases as a priority. Even though they are not mandated to treat these problems, youth are referred to the Centre for help with mental health issues.

The funding which allows the Treatment Centre to keep operating comes from Health Canada. It is a First Nations Treatment Centre, and the rise in mental health cases is of tremendous concern to us.

Senator Pépin: Senator Callbeck asked the following question: Are we talking about cases that existed previously but had not been detected? Are we talking about a detection issue, in the sense that these were deemed to be cases involving drug use?

Mr. Picard: There is no doubt that in terms of detection, it is in the process of carrying out case studies that they realize that a youth is experiencing a mental health problem that is clearly linked to drug addiction and vice versa.

But as I was saying, it is not only at the Treatment Centres, but across the child protection system and within the communities as well. Someone was telling me that a large percentage of youths reported for behavioural problems are actually experiencing mental health problems.

They realize this when they carry out their assessment. These young people are obviously referred. But there is shared jurisdiction in this area. The ministry pays for social services. When a youth is experiencing mental health problems and a treatment is prescribed, the Ministry steps back, because it only pays for things related to social problems.

That means we have to go after Health Canada for the authorization to treat this youth. There again, it is a case of medication.

Ms. Wood: The real issue is early detection, which is something that is practically impossible to do. As I was saying, youths and even adults receive emergency assistance, but not when the problem first appears; rather when it is most acute.

That results in the need for high levels of services within the communities. And that eventually affects the health and social services system. It becomes very difficult to control and manage.

I had one case involving a youth who showed signs of schizophrenia. He was going to be 18 in a few months. Nobody wanted to pay for him to receive rehabilitation services, and he needed help over the long term.

One month of therapy was not enough for that youth to deal with his addiction and mental health problems. No one wanted to pay for him. We fought with Health Canada and with the insurance company. The provincial ministry did not want to have anything to do with it either, which made things very difficult.

So, we are talking about jurisdictional issues as regards the systems and organizations in place. That has repercussions for the individuals and families that are having trouble looking after their youth or family members experiencing these problems.

The committee is adjourned.