Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 14 - Evidence - October 21, 2010
OTTAWA, Thursday, October 21, 2010
The Standing Senate Committee on Social Affairs, Science and Technology met
this day at 10:30 a.m. to study Canada's pandemic preparedness.
Senator Art Eggleton (Chair) in the chair.
The Chair: Good morning, and welcome to the Standing Senate Committee
on Social Affairs, Science and Technology.
We continue our study on pandemic preparedness and response, and today we
focus particularly on on-reserve First Nations and Inuit communities.
We have two panels. The first panel will run from now until 11:30 a.m., and
then we will pick up on the second panel. On the first panel, we have Dr. Isaac
Sobol, Chief Medical Officer of Health for the Government of Nunavut; Ron Evans,
Grand Chief of the Assembly of Manitoba Chiefs; Shelagh Jane Woods, Director
General, Primary Health Care and Public Health Directorate, First Nations and
Inuit Health Branch for Health Canada. That is a lot to put on a business card.
We also have someone we have seen before, Dr. Paul Gully, Senior Medical Advisor
at Health Canada.
I will take you in that order, unless you have a preference for switching it
Welcome to Dr. Sobol, from Nunavut.
Dr. Isaac Sobol, Chief Medical Officer of Health, Government of Nunavut:
Good morning, and thank you. I am giving you a perspective from Nunavut, which,
as I am sure you know, has an 85 per cent Inuit population base. Basically I
want to speak about some positive aspects of the H1N1 response for Nunavut and
some cautions with respect to the national response for First Nations, Metis and
I do not know if you have received the notes that I sent out in advance.
The Chair: Yes, we did.
Dr. Sobol: Then it will be very simple. Nunavut had, I felt, a very
positive response to H1N1, and we received help when we asked for it. Health
Canada sent in communications staff. We only have one person in communications
in our whole department. The Public Health Agency of Canada, PHAC, assisted us
with pandemic planning and developing an incident command structure.
SAC is the Special Advisory Committee on H1N1, which you have probably heard
about before. That communication with Nunavut provided a pan-Canadian forum for
discussion and information exchange, which was extremely valuable. Guidelines
were developed, in terms of responding to H1N1, to be modified or used as seen
fit by provinces and territories, and these were developed by expert groups and
made available via the PHAC and the Special Advisory Committee on H1N1. They
were extremely useful in helping us respond to the pandemic.
Nunavut received all of its H1N1 vaccine right away. All of our communities
were designated as isolated, and it was decided that isolated, rural and remote
communities would be given their allocation of vaccine. We did not have to do
any prioritization with different parts of the population.
Our department itself was able to mobilize resources and focus our efforts on
response to H1N1. We did a very positive response. I do not know if you saw the
background material that I sent about the waves of the epidemic in Nunavut. I
sent another background paper that showed the first wave and the second wave in
Nunavut versus Canada. We had the highest rates of hospitalization in Canada in
the first wave, but we actually avoided a second wave of H1N1 with our mass
I sent a presentation that was given to the Canadian Public Health
Association, CPHA, in June that had a detailed description of our response. I
was told that might have been made available to you.
From the Nunavut perspective, I felt that we had a lot of support. The
response was very positive, but there were some challenges, I felt. I represent
Nunavut on the Pan-Canadian Public Health Network Council. I also sit on the
advisory board for the National Collaborating Centre for Aboriginal Health,
NCCAH; and the advisory board for the Institute of Aboriginal Peoples' Health of
CIHR — Canadian Institutes of Health Research. I have worked for 20 years in
Aboriginal health, so my whole medical career has been working with and for
Aboriginal people, First Nations, Metis and Inuit.
I felt there were some challenges, and our deputy minister and I reviewed
this, so this is a Nunavut perspective. Requests for guidelines for Aboriginal
populations were not responded to in an efficient manner. This is through the
national public health forum. No guidelines were developed specifically for
First Nations, Metis or Inuit. Instead, a task group was developed on rural,
remote and isolated communities. Attendance at the teleconferences for that task
group was not possible for a majority of the calls. There were just too many
demands being put on jurisdictions.
The guidelines that were eventually developed by this task group were not
available in a timely manner. Therefore, I know that Nunavut was not able to use
them; and I do not want to speak for another jurisdiction, but the Chief Medical
Officer of Health for the Northwest Territories said that she also did not have
a chance to use them because they came in so late.
There was, at one point in the discussion of the Public Health Network
Council, the report that an expert group found that Aboriginal people,
regardless of place of residence or socio-economic status, were more vulnerable
to adverse outcomes from H1N1 than other population groups. This was not really
addressed by the special advisory committee.
Finally, there was a request in that forum from the chief medical officers of
health to have a meeting to discuss the impact of H1N1 specifically in
Aboriginal communities. That request was not supported, and the meeting did not
Finally, on a more global perspective, at present, still, no mechanism exists
for formal, ongoing First Nations, Metis or Inuit participation in public health
issues or pandemic planning within the structure of the public health network.
Requests for special assistance for First Nations committees during H1N1 were
seen as being political at the special advisory committee, and they were
reluctant to respond to what they saw as political requests.
Thank you for letting me give you these brief remarks today.
The Chair: Thank you very much.
Let me move to the Grand Chief of the Assembly of Manitoba Chiefs, Ron Evans.
Ron Evans, Grand Chief, Assembly of Manitoba Chiefs: Thank you very
much, and good morning. I am Grand Chief of the Assembly of Manitoba Chiefs,
AMC. I would like to thank the Standing Senate Committee on Social Affairs,
Science and Technology for inviting me here today to speak on issues concerning
Canada's past pandemic preparedness and lessons learned from Canada's response
to the 2009 H1N1 pandemic virus. This is a very critical issue that had
significant impact on the First Nations of Manitoba.
I was about to introduce to you Chief David McDougall, but I do not know if
he has arrived. He has accompanied me, and perhaps he will be here before I
finish my presentation. He is the chief whose community was gravely affected by
the H1N1 pandemic and sounded the alarm for all Manitobans to take this pandemic
The H1N1 virus was a world health threat that affected Manitoba First Nations
at a rate disproportionate to the general public. This was due to a number of
factors present in our First Nations, including poverty, lack of access to
health care, overcrowded housing and access to those essential elements related
to acceptable standards of living, such as access to water and sewer, along with
other services that the rest of Canada enjoys.
Living conditions in many of Manitoba's First Nations communities places our
residents at much greater risk than the general public and facilitated a rapid
spread of the H1N1 virus. With any pandemic, such as we learned from H1N1,
immediate action and ongoing preparedness is necessary to respond and provide
critical tools, supplies and health services to our people. During the pandemic,
Manitoba First Nations, using the organizational structure of the Assembly of
Manitoba Chiefs, together with a tripartite working committee, prepared for the
potential pandemic by establishing the First Nations critical incident
management system. Together, we developed a four-month work plan to deal with
the anticipated second wave of the influenza, the core of which was the delivery
of a training program on the First Nations critical incident management system,
designed to train local health officials from Manitoba First Nations to set up
incident command centres in each First Nation community.
These command centres acted as nerve centres on each First Nation to respond
to local emergencies around the pandemic to prepare for the fall flu season and
assist the communities in preparing their respective pandemic plans.
On June 24, 2009, with the support of the AMC executive council, and on
behalf of all Manitoba First Nations, I announced a state of emergency on the
H1N1 pandemic, designed to ensure the safety of all First Nation citizens during
this upcoming crisis and to hold governments responsible and accountable for
taking the necessary measures to fulfill their fiduciary responsibility to First
During the first wave of the influenza outbreak, we know we were ill-prepared
to deal with the impacts of a second surge, given that nursing stations in the
North reached surge capacity almost immediately. We encountered a number of
serious challenges and obstacles. Let me share these challenges and obstacles
with you, since they are absolutely key in dealing with this and other similar
issues facing First Nations.
The first are jurisdictional issues. Realizing the complexity of providing
health services to First Nations communities, we began our interventions by
establishing the tripartite working committee with the governments of Manitoba
and Canada. As we completed our scanning and environmental analysis, designed
and implemented the First Nation critical incident management system and the
very necessary training programs for critical incident managers at the First
Nation community level, we continually bumped up against the constitutionally
prescribed roles of government and assigned roles of government agencies.
Adherence to these jurisdictional roles seriously delayed our progress in
implementing our initiatives. It took extensive discussions and continual
interventions at many different government levels to determine precisely who and
what agency had the respective jurisdictional responsibility and, in some cases,
the simple willingness to act in these important matters.
Second was the issue of decision-making capacity related to the
jurisdictional issue, as you may expect, with the capacity and the complexity of
making key decisions, particularly with reference to financial resources and
Frequently, after identifying the necessary actions affecting the individual
First Nation at the community level, and after also coming to a decision on
jurisdiction, we were unable to obtain the decision on the availability of the
financial resources to proceed with the necessary action. This was particularly
the case with Government of Canada agencies.
Third was vaccine availability, the prioritization and implementation plan.
As with all jurisdictions in Canada and, for that matter, the world, we awaited
the availability of a vaccine but were concerned that the predicted incidence of
the flu virus might well occur before the vaccine was widely available. We also
feared that our most vulnerable community members would not have access to the
vaccine as distribution and prioritization plans were simply not fully
articulated. Along with most other similar jurisdictions in Canada, it is
somewhat surprising that these plans were not yet in place at the time of the
outbreak. As we participated in the tripartite working committee, held briefing
sessions with our communities and trained local persons for the incident command
structure, we were constantly faced with a growing perception that the potential
for a pandemic of serious proportions was imminent. We came to the conclusion
that our best preparations would not have been sufficient for what was required
to deal with an extensive pandemic, particularly because of our unique situation
where many of our communities are small, many are remote and most are not well
equipped with the necessary medical facilities.
We had serious concerns that we might be facing a pandemic that would exceed
our available and accessible resources. The Government of Canada had a
well-developed plan for dealing with the unique situation of First Nation
communities. It was Annex B, entitled ``Influenza Pandemic Planning
Considerations in On Reserve First Nations Communities'' and was part of a
larger document. We are quite puzzled that the government chose not to implement
that plan. Our operating principles include collaboration, cooperation and
mutual respect in a context of problem- solving, recognizing that we have a
treaty relationship with the Government of Canada, to whom these officials are
My overarching concerns relating to the H1N1 pandemic was that governments
were not ultimately addressing the very conditions that make First Nations
Our ongoing advocacy to address these conditions includes the following. As
an economic matter, it is widely recognized that the maintenance of good health
is more affordable over both the short and long term than dealing with a chronic
illness. Prevention is key. Therefore, why is it that First Nations continue to
face the substandard community realities that have long been identified and so
well documented? Why are we not dealing with the physical conditions that simply
continue to worsen, further increasing the risks of this particular pandemic,
not to mention the already present high-risk factors of illnesses such as
diabetes and obesity? What better opportunity is there to finally address the
pervasive issue of substandard living conditions in First Nation communities
than by addressing such a serious health issue?
In conclusion, it is entirely clear to me that the costs of dealing with
these identified conditions of risk in a proactive manner would be an excellent
investment in the present and future health of First Nations. This investment
would also address, once and for all, the treaty responsibilities of the
Government of Canada with respect to the very unequal living conditions of First
Nations and ensure equality of access and resources over the long term. It is
important, however, to reflect on this experience and provide feedback on what
we have all learned from the first outbreak and in dealing with the potential
second wave of H1N1 to be better prepared in the event that we face a pandemic
in the future.
First and foremost, we, as First Nations, must lead the way when dealing with
issues affecting our people and our communities. We must be the driving force,
as we best understand the challenges our communities face. Only we can make the
necessary recommendations, decisions and plans for our communities. We must lead
on initiatives that directly impact our communities, but we need the support of
all governments to address the health needs of our people and ensure that the
necessary resources are secured.
In meeting with Minister Aglukkaq last week, we had the opportunity to
reflect on the H1N1 pandemic a year later. Pandemic preparedness is beyond
complex. It involves a web of individuals, organizations, agencies, federal and
provincial departments, scientists, experts, doctors, nurses, researchers,
technicians, leaders and front-line workers from around the world. Information
is constantly changing amongst each of these respective groups and authorities
at a rate faster than you can blink your eyes.
The sharing and transmission of information amongst this web is circling
cities, provinces, countries and continents. At the same time, the media is
paying close attention to the work of this web as a collective and individually
reporting to the public the information that they gather. The point of our
discussion is that this is a very serious concern that has wrapped the globe and
has had devastating impacts on communities, groups and individuals.
We learned that we must all work together in a coordinated, unified manner
and provide consistent messaging to the public. We must be honest, direct and
timely with our messaging. We need to be organized and work collaboratively to
provide the necessary information and tools to protect communities. We must work
together as leaders to provide the public with the necessary resources for
prevention and preparedness.
I would like to thank Minister Aglukkaq, our federal Minister of Health, and
Minister Theresa Oswald, Manitoba's provincial Minister of Health, for
demonstrating true leadership, compassion and understanding of the health care
needs of Canadians, Manitobans and the First Nations of this country. They
listened to our concerns and embraced us in true partnerships, a partnership of
respect, trust and cooperation so critical when dealing with issues that have
severe impacts on our communities as a whole. Both ministers made themselves
available for regular phone calls and meetings, ensured follow-up on issues and
instructed bureaucratics to act on a direction based on mutual decision making.
It is these sincere partnerships that allow us to work together to ensure
sustainable and accessible health care for First Nations people, Manitobans and
Canadians. It is these sincere partnerships that allow us to move forward and
develop solid plans and strategies to ensure the safety, health and well-being
of all citizens.
[ Mr. Evans spoke in his native language.]
The Chair: Thank you very much. Ms. Woods will speak for Health
Canada. Mr. Gully is here to answer questions subsequently.
Shelagh Jane Woods, Director General, Primary Health Care and Public
Health Directorate, First Nations and Inuit Health Branch, Health Canada: I
would like to take this opportunity today to provide you with a description of
some of Health Canada's key activities in pandemic preparedness and response in
on-reserve First Nation communities during the H1N1 pandemic. I will cover the
topics of planning, supplies, medications, immunization and communications.
First, let me start by describing some of the important work that occurred
before the pandemic, and it was work that laid the foundation for the response
efforts during H1N1.
For a number of years now, the First Nations and Inuit Health Branch of
Health Canada has been working closely with the Public Health Agency of Canada
to align our preparedness and response activities for on-reserve First Nation
communities with the overall Canadian planning strategy.
Since 2006, the branch has been working with communities on emergency
preparedness, planning, training, and integration with provinces and regional
and local health authorities.
Before the start of the pandemic, approximately 80 per cent of First Nation
communities already had a pandemic plan in place.
First Nations and Inuit Health Branch also developed Annex B: ``Influenza
Pandemic Planning Considerations in On Reserve First Nations Communities,''
which Chief Evans mentioned, the Canadian pandemic influenza plan for the health
sector in collaboration with PHAC, the Assembly of First Nations — AFN — and
others, and we actually updated it during H1N1.
In 2008, we established a three-year work plan on pandemic preparedness and
response with the AFN and PHAC. We feel that the long-standing relationships
that were developed through collaboration with First Nations local leadership,
with national Aboriginal organizations and with regional, provincial and federal
partners proved to be instrumental during the H1N1 pandemic.
The H1N1 virus was present very early on in some First Nation communities,
and, as Chief Evans noted, especially in some of the remote and isolated
communities in Manitoba. The severity of many cases was very worrisome.
In wave one, Aboriginal people — including First Nations, Metis and Inuit —
regardless of their place of residence, so beyond just the reserves, were very
disproportionately represented in hospitalized cases in Manitoba, in people
admitted to intensive care units and in death.
Aboriginal people accounted for fewer severe cases during the second wave.
However, they continued to be overrepresented compared to the general
The Manitoba experience that Chief Evans talked about during the first wave
of the H1N1 pandemic proved to be valuable lessons from which our regional
office in Winnipeg — and in all of our regional offices across the country —
First Nations and health authorities learned. They were able to adjust their
actions in light of these lessons. At the same time, there were some success
stories to help guide clinical and public health interventions as the disease
progressed over the summer.
For example, the Province of Manitoba, in collaboration with our regional
office, pre-positioned antivirals in a select number of First Nation communities
that were experiencing H1N1 soon after the serious cases began to appear. This
strategy was implemented by other provinces and territories shortly after.
With respect to personal protective equipment, PPE, for front-line health
care providers, Health Canada, as any other employer, is responsible for the
purchase of such supplies for its health care workers providing health care
services in on- reserve First Nation communities. At the onset of H1N1, we
pre-positioned the modest PPE stockpile in many on-reserve First Nation
community nursing stations and other health facilities to supplement the routine
PPE supplies that are already available. Then we made further purchases to
ensure we had adequate supplies that would last, no matter how severe the
disease would turn out to be.
With respect to the antivirals, our non-insured health benefits program took
steps, on April 27, 2009, to cover prescription costs for antiviral medications
on a case-by-case basis before provinces had released antivirals from provincial
stockpiles to deal with outbreaks. This was because we did not want any delays
in getting antivirals to people because it is necessary to administer them
quickly for them to work.
As I mentioned earlier, learning from the outbreaks of H1N1 in Manitoba
during the months of June and July, the First Nations and Inuit health regions
of Health Canada worked with provinces to pre-position antiviral medications in
all of the remote and isolated on-reserve First Nation communities, and then
followed the provincial clinical care guidelines for dispensing and
We organized and held mass immunization clinics, a complementary activity, in
most First Nation communities, beginning as early as October 26, when the
vaccine was first available in some regions, following the provincial leads. The
coverage rate amongst on-reserve First Nations overall for the vaccine was 64
per cent, which was significantly higher than the general population of Canada.
The rates were particularly high in many of the northern communities, where
access to timely medical care for acute illness can be very challenging.
This success can be attributed to the hard work of all levels of government,
First Nations leadership and First Nation communities themselves. It relied, in
many places, on long-standing arrangements with provinces around vaccine
We participated in all of the federal-provincial-territorial task groups
under the pandemic coordinating committee to ensure that First Nation
considerations were brought up and integrated at all levels of planning
activities. We were members of the Special Advisory Committee on H1N1 that Dr.
Sobol referenced in his remarks. We actually co- chaired the Remote and Isolated
Communities Task Group, which Dr. Sobol also referenced.
With broad federal, provincial, territorial and Aboriginal representation, we
produced public health guidance to address the unique challenges facing remote
and isolated communities, many of which are First Nations. Like others, we were
hard pressed to do this in a timely way, as Dr. Sobol noted, although I would
add that it has left many useful products and information for the future.
On the communications side, we learned that consistency in communications to
all stakeholders and partners, and particularly to the First Nations leadership
and on-reserve First Nation communities, is critical.
For that reason, the federal Minister of Health, along with other Health
Canada and PHAC officials, made several visits to First Nation communities to
discuss the impact of H1N1 in those communities and other H1N1 related issues,
such as vaccine rollout.
Our regional offices communicated regularly with First Nation communities,
either via information letters, regular teleconferences and visits, of course,
to keep those communities abreast of new information. We also developed a
communications protocol with Indian and Northern Affairs Canada, INAC, which is
one important part of our two departments' collaborative efforts.
As a result of H1N1, I would say that the level of preparedness on-reserve
has significantly increased. Despite that, however, we recognize that it is
important to continue to help First Nation communities to prepare for future
pandemics or, for that matter, for any other public health emergencies.
Since the pandemic, we have participated in several activities to review and
learn from the H1N1 experience. We have already identified important lessons,
and I think many of them relate to some of what Chief Evans said.
We must continue to work with partners and stakeholders to clarify roles and
responsibilities at all levels of government pertaining to services provided to
First Nations consistent with recommendations from the World Health Organization
— WHO — and PHAC. We must continue to work to ensure that plans at all levels
are adaptable and scalable to the different pandemic scenarios — mild, moderate
and severe. Of course, like others, we had only one scenario.
We also must encourage communities to address business continuity in their
community-level pandemic plans to promote the communities' self-sustainability,
and we have to support the communities to do so. In collaboration with our
partners at INAC, we will work toward the integration of pandemic plans into
larger all-hazards emergency preparedness plans.
In summary, we understand that we must continue to work with our partners and
stakeholders, through forums such as this, to target areas of improvement that
have been identified and that are still being identified as a result of H1N1 to
ensure that First Nation communities are better prepared for any future
pandemics or other public health emergencies. We will also build on the
successes from our collective H1N1 experiences and apply them to our day-to- day
public health initiatives.
The Chair: Thank you very much.
I have a two-part question. It is really to Ms. Woods, but others may jump in
with any responses. First, you have made reference, and Chief Evans made
reference, to Annex B, to the plan. Chief Evans said that they were quite
puzzled that the government chose not to implement that plan.
Can you clarify where the plan stands? Who is included in the plan? Are Inuit
included in this plan, or just First Nations?
Second, you have cited a number of statistics, as has Mr. Gully previously,
that indicate that many plans were in place — 80 per cent or even more — in
First Nation communities. In addition, the vaccination rate was higher than the
general population, 64 per rather than 41 per cent, yet we had higher incidences
of hospitalization, ICU admissions and death among the Aboriginal population
What happened there? Could you comment on that?
Ms. Woods: I will ask Mr. Gully to address your second question.
Annex B is an annex to The Canadian Pandemic Influenza Plan for the Health
Sector. We had developed it several years ago in anticipation of a pandemic
as part of the development of The Canadian Pandemic Influenza Plan for the
Health Sector. We had done that, as I noted, in collaboration with the AFN,
many other stakeholders and provinces and territories.
I am not quite sure how to answer whether or not we implemented it. I think
we did most of the things it said. Annex B does not just apply to us or First
Nations; it also applies to provinces and territories. It is a question of how
useful they found as guidance when dealing with a pandemic. Like every other
part of The Canadian Pandemic Influenza Plan for the Health Sector, this
was a first try.
Going into it, we recognized that some gaps and deficiencies existed, and
some pieces of it had not been completed. That was why we started doing an
accelerated revamp of the plan, which was finally signed off by provinces and
territories about mid-June 2009.
The Chair: Therefore, it does have official status; it is used.
Ms. Woods: Yes, definitely. It is part of The Canadian Pandemic
Influenza Plan for the Health Sector.
The Chair: What about the Inuit population?
Ms. Woods: The Inuit are not included in that one.
The Chair: How do you deal with the Inuit?
Ms. Woods: Dr. Sobol will tell you how they deal with the Inuit and
Nunavut. A discussion is happening about whether something specific is needed
for the Inuit.
The Chair: My second question is about the contradiction in the
Paul Gully, Senior Medical Advisor, Health Canada: There is a paradox
here. In general, we got the impression that this was mild or moderately severe,
as described by WHO. However, globally, good evidence shows that populations
that are disadvantaged in terms of socio-economic status, are younger, have
higher rates of pregnancy and higher rates of chronic disease also have higher
rates of illness, severe illness and mortality.
Those risk factors combined with the situation that Grand Chief Evans
describes of poor housing meant that when the virus arrived in a situation such
as Northern Manitoba, it spread very quickly. Therefore, it was not surprising
that with the high rates of disease, severe illness and mortality, the situation
required a response, which we did give but for which we perhaps were not all
The province, the federal government and First Nations worked together on
issues such as medical transportation. However, it is well known that in
Manitoba, for example, there was pressure on ICU beds as a result partially of
what happened in the North. Therefore, we all had to respond.
As you heard perhaps from Dr. King, other provinces responded more
aggressively with the use of utilization of antivirals to try to prevent severe
The Chair: Were these plans deficient in some way, or were they just
Mr. Gully: The individual plans were there. They were sufficient for
dealing with immunization, perhaps. I am not sure that they were sufficient
initially to deal with the high rates of disease and severe disease, which
occurred particularly in Manitoba. In the other provinces, given the experience
in Manitoba, lessons were learned, and the response was much quicker and
Ms. Woods: The experience across Canada, not just in First Nation
communities but with municipalities and other entities that had plans, we were
often not quite sure when the plan should actually be activated. It is a tough
decision. The longer the plan has existed, the less fresh it is, so that is
sometimes an issue.
Dr. Sobol: I have several points in reply.
Nunavut is not included in the service delivery aspect from First Nations and
Inuit Health Branch. We do have programs that come from First Nations and Inuit
Health Branch that the Nunavut government administers. However, with respect to,
for example, the response to H1N1, that is a territorial response. Therefore, we
did not have active engagement at that point from First Nations and Inuit Health
With respect to plans being in place, as with many other jurisdictions,
Nunavut found that our pandemic plan was based on the premise that the pandemic
would be severe, that we would have many deaths and many people hospitalized. As
the response to H1N1 progressed, we realized that we needed a more flexible
pandemic plan, so we have been working on that. As Ms. Woods said, all the
pandemic plans assumed the worst. This was a pandemic that was not the worst,
thankfully. Therefore, we are modifying our plan as we speak.
With respect to the paradox between the number of First Nations, Metis and
Inuit hospitalized versus the high immunization rate, we had the highest rate of
hospitalization in the country in Inuit per population. However, that all
occurred before the vaccine became available. After that, we had no second wave.
If you look at the epidemic curve that is in the background document I showed
you, most of Canada had hospitalization rates and deaths much higher during the
second wave than during the first wave. In Nunavut, we experienced almost all of
our hospitalizations and our one death in that first wave.
I would like to return to an issue that has to come to the table, which Chief
Evans alluded to and both Ms. Woods and Mr. Gully spoke to also: Why were First
Nations, Metis and Inuit so vulnerable to the adverse effects of H1N1?
In public health, we always talk about the socio-economic determinants of
health. If you have a population of persons living in overcrowded housing and
whose communities are living with poverty, as in the case of Nunavut where 70
per cent of preschool children live in homes that are food-insecure, then it is
a cauldron for rapid dissemination of communicable disease. We see this every
day and every week in Nunavut. From January 1 to October 1, we have had 90 new
cases of active tuberculosis. We feel this is partly a result of the
socio-economic situation in which Nunavummiut live.
Speaking personally, I feel it is shameful for Canada to have accepted the
status quo of this type of living standard for First Nations, Metis and Inuit in
general. To respond to H1N1 appropriately really would have meant responding to
the current living situation of First Nations, Metis and Inuit in Canada many
years before the outbreak.
I am sure that is old news to all of you, but I am always distressed to see
the lack of urgency and the lack of priority placed by Canada on this, I think,
shameful blot on our country.
Mr. Evans: Referring to Annex B, it is important for you to understand
the plans the leadership had. You have the remote communities, but you also have
the communities in the South. Communities in the South were prepared to do what
was necessary to ensure that they protected their people. It comes down to
underfunding, where communities were ready to order food — lots of beef to store
— and refrigeration units.
What happens if there is mass death? Where do you store the bodies? You have
to build temporary facilities. What happens if the water and the sewage truck
drivers are ill and cannot provide water and sewerage to the communities? All
this has a cost. The plans do not include the financial resources to implement
these necessities. Yes, the plans might be in place, but there are no fiscal
resources to support that. Without that, the communities are out there exposed
to any virus. That was the concern.
The other concern was that one of our communities went ahead and did all the
plans, and they took whatever they had from their resources. Hopefully, they
will get reimbursed because they did not want to risk the lives of their people.
Those are the issues that the community leadership dealt with in the First
Senator Seidman: Chief Evans, you have presented a complex and serious
picture of issues related to the H1N1 events of 2009-10, and, in fact, the more
general state of health and living conditions in the First Nation communities.
You have mentioned that you met with Minister Aglukkaq, last week, in fact,
and had the opportunity to reflect on the H1N1 pandemic, now one year later.
Could you give us, if possible, some more details about this discussion and
whether you came up with ideas to address some of these issues and problems?
Mr. Evans: I will go back to the statement. We talked about the number
of people involved and the different organizations, the behind-the-scenes stuff
that we did not see. What we saw was what was played out in the media. The
minster shared with me all the different organizations, the scientists, the
researchers, how the information kept changing, and she explained how it was
moving at the time. That is what we shared and talked about. It was important
that I understood that and shared that information with those whom I represent
so we are better prepared next time.
We are fortunate that we had that relationship with the minister's
department, as well as the provincial health minister, and that we were able to
deal with the pandemic. I thank the Creator for sparing us from what was
predicted to be severe.
That is the information, the behind-the-scenes stuff and the things that were
happening, such as the vaccine, all that was happening at the time. We were
talking about how she was just beginning her role as health minister and how
things were moving so fast. I commended her on how she was able to come through
that period in her new role as minister.
Senator Seidman: Some of the issues that you have presented — the
gaps, lack of ability of various levels of government to move together, lack of
decision making — were some of these addressed with the minister?
Mr. Evans: Yes. That is what happened with the incident management
team that we put together with the province and with ourselves. We had daily
communication with both levels of government. That is what allowed us to deal
with the pandemic the way that we did. That is what it will take. It will take
the participation of the First Nations leadership to be there working with
governments, dealing with the issues that are impacting and affecting our
people. No decisions were being made without our presence. That was important.
Senator Seidman: Do you feel that is indeed now the case?
Mr. Evans: That should be the case. We should always be included and
involved. We are the best ones able to bring that information and the solutions
for how we deal with those issues.
Senator Cordy: I would like to return to the jurisdictional aspects.
The challenges of wondering who will pay for what must have been frustrating
while in the middle of a pandemic, deciding whether it is provincial, federal,
or band. You said that the availability of financial resources was particularly
challenging when you looked at the federal government.
That surprised me because I look at the federal government as having the
responsibility for the health care of the First Nations people.
Are discussions taking place right now to firm up plans for the next
pandemic? We hope it is a long way off, but we know we are always planning for
the next pandemic. Are discussions taking place to ensure that the guidelines
are clearly set out so that, while the federal government ultimately is
responsible, we do not worry about that during a pandemic? Let us get what we
need, and the federal government will be the insurer or the guarantee that the
bills will be paid.
Mr. Evans: I want to again commend the provincial health minister. We
sent out a flu kit to each First Nation community in Manitoba. It contained all
the necessities to deal with the symptoms. That cost, I believe, over $1
million. The minister went ahead and gave it to us so that we could order the
kits. We were about to fund raise so that we could provide those to our
communities. Because of the minister's compassion and the urgent need for these
flu kits, the province provided the resources for us to do that.
This goes back to the jurisdictional issues about who pays for what. That is
something that we would like to develop with the province, so that anything that
happens to our people, the province will be there with us. At the end of the
day, we hope we will continue to strengthen that partnership in approaching the
federal government to provide what should have been their responsibility.
This refers back to Jordan's Principle, the child-first principle. Let us not
fight over jurisdictional issues when someone needs medical attention.
Jurisdictional issues and who pays for what can be dealt with afterwards. I hope
we can develop those types of arrangements.
Dr. Sobol: Nunavut does not have the same scenario as First Nations
on-reserve with respect to who is funding. However, we did have a strong support
during the H1N1 response from our Minister of Health, Tagak Curley, and Deputy
Minister Alex Campbell. Their directive was that they were there to protect the
health of the population.
We spent funds that were not in our budget, and we continue to have an
outstanding deficit as a result. Our deputy minister is still concerned about
that outstanding deficit and, in an overwhelming national situation such as an
H1N1 pandemic, whether there is any discussion or plan to have the federal
government bear some responsibility for funding. As far as I know, that
discussion, at least between Nunavut and the federal government, is not
occurring on an active level. I think you have posed a very pertinent question.
Ms. Woods: On the question of ongoing discussions, it is interesting
to note that the people who had been so intensely involved in the pandemic
planning, all the jurisdictions and the federal government, of course, agreed
that it was absolutely necessary to continue and not to just drop everything and
say, ``We will see you before the next pandemic, we hope.''
In fact, we have now reorganized ourselves. An inter-jurisdictional set of
committees will continue to move forward on all of these issues. Many of these
issues are being brought up through the various lessons-learned exercises that
are taking place at all levels in all provinces and our regional offices. We
have done it nationally. PHAC has done it as well, which I think you heard about
in some of the previous testimony. We continue to be involved in these forums
where we can raise those issues.
I am struck by what Dr. Sobol said about not having funds in the budget. We
more or less took the same approach. I was lucky enough to be the person who had
the job of being the point person at the beginning. My regional offices asked
what they should do and whether there would be enough money. I told them to just
spend it, and we would find it.
That was money for our regional offices. I am sorry; we do not deliver the
health services in Nunavut, nor do we deliver them in the provinces. This was
for on-reserve needs for the continuity of health care to deal with the H1N1
cases that were coming up. We never short-changed our regions, and they
certainly did not short-change the First Nations.
In terms of our prescribed care, I agree with Chief Evans and Dr. Sobol that
it is necessary to keep on with those broader discussions and keep finding the
forums. As I say, we were careful not to put a damper on spending, hiring extra
nurses, ensuring they had enough pandemic supplies, keeping the nursing station
open beyond regular hours and that kind of thing. That was critically important.
Senator Callbeck: Thank you very much for coming this morning.
Ms. Woods, I want to ask you about the commitment that the federal government
made four years ago, in 2006. They committed to $6.5 million, over five years,
to strengthen public health capacity and surge capacity in First Nation
How much of that money has been disbursed to date?
Ms. Woods: All of it has been disbursed.
Senator Callbeck: What was that spent on?
Ms. Woods: Much of it was spent on assistance to organizations —
largely to Aboriginal organizations — to deal with First Nation communities in
developing their plans. It was also to build some capacity in our regional
offices. You noted that it is for public health capacity and pandemic planning.
We have spent it largely on assistance. Early on, Chief Evans will remember,
the decision was that the best method was not to go individually to communities
— you can do the mathematics; that is not very much money — but rather to go to
larger organizations, such as the Assembly of Manitoba Chiefs. I think at one
time they had arrangements with the Manitoba Association of Native Fire
Fighters, Inc. because they are cognizant of emergency planning.
The focus of that was to achieve some basic planning, which happened in most
communities, and to strengthen our own public health capacity.
Senator Callbeck: Have the goals you set for that money been achieved?
Ms. Woods: Yes. However, they were overwhelmed by H1N1. Mr. Gully has
reminded me that that was where we got some of our pandemic supplies. That money
came out of the lessons from severe acute respiratory syndrome, SARS: Our branch
went ahead and purchased additional PPE supplies for any such public health
We met the goals in that we moved forward in the readiness of communities to
deal with pandemics. However, like other jurisdictions, corporations, entities
and municipalities, we have learned along the way that you are never quite as
ready as you think you are. The lessons-learned exercises have been so important
to us because they show us where we have to put our focus.
Chief Evans is correct: We cannot do this without First Nations leadership.
We were utterly dependent on the willingness of the First Nations leadership to
engage and to engage with their communities. We will put even more focus on that
as we move forward.
Senator Dyck: Thank you for your presentations. I will continue along
the line of the jurisdictional issues, as it seems to be a critically important
issue. It is disturbing to hear that something such as this can create such a
problem for people's individual health and well-being.
I suspect that it is actually more than just a money issue. I wonder what
role bureaucratic systems play in jurisdictional issues; for example, the forms
you have to fill out, whom you report to and the responsibility at the local
I will ask a naive question. In serious incidents such as a pandemic, could
you not just say that the province is responsible for everything, and we will
sort it out later if there are bills to be paid?
Mr. Gully: If we could do that, yes, it would seem logical. I am not
sure that we are in a position to do that. Having said that, in Manitoba there
was a close working relationship between the province, the federal government
and First Nations.
There was a willingness to spend money, as well. Some challenges existed.
Where the federal government, for example, wished to spend money — at the
community level or the tribal council level — was different from where the
requests came from, sometimes from political organizations. Therefore, a
difference existed in terms of who was asking for the money.
Second, the tripartite community, to which Chief Evans referred, was not new.
It had been in existence for some time. However, it met more often and actually
responded to that initial wave, which, as I said, happened over a very short
space of time and, although it was not a surprise retrospectively, was a
surprise when it happened. We were all involved in the immediate response as
opposed to then further advancing the planning.
Ms. Woods: I think you would be pleased to know that as H1N1 hit, we
knew instantly that our usual bureaucratic processes would not do. The federal
government collectively put together much quicker ordering systems, so there was
never a question of having to fill out another hundred forms and sending them to
32 people, for example, for the approvals process. It was quick; namely, we
needed to buy masks, so we had the authority to purchase masks. We did move
quickly in that sense.
Mr. Evans: As what happened in Dr. Sobol's territory, in the event
that such a pandemic should occur in the future, if there is any spending that
First Nations have to make decisions on for the safety and health of their
people, then that is something that should be set aside. Hopefully, no harm is
brought to the community because of a decision they made in the best interests
of their people. Something should be in place for that in the future.
Dr. Sobol: I have a brief comment on the question of public health
capacity. In addition to public health capacity for First Nations communities,
it is my reflection that during H1N1, the total Canadian public health capacity
was stretched to its limit. We learned much having to deal with an event of this
magnitude. From the Public Health Agency of Canada through all the provincial
and territorial jurisdictions, we had more than we could do to maintain our
response to this pandemic. There is not much slack whatsoever in our capacity.
Therefore, as you consider Canada's response to First Nations, Metis and
Inuit, please put it in the perspective of Canada's response in general and
recognize that our resources are in need of enhancement.
The Chair: Thank you.
On that note, we have come to the end of our time with this panel, but I want
to thank our panellists for contributing to the dialogue on this important
Honourable senators, let me mention that we do have Senator Poirier with us
today from New Brunswick. Welcome, and thank you for joining us in this
significant discussion about pandemic preparation.
We have five people at the end of the table, four speakers altogether. First
is Angus Toulouse, Regional Chief for Ontario for the Assembly of First Nations.
He was born and raised in Sagamok Anishnabek First Nation in Northeastern
Ontario. Regional Chief Toulouse has been an elected member of the AFN executive
committee since June of 2005. Welcome, chief.
Dr. Darlene Kitty, Board Member for Indigenous Physicians Association of
Canada, IPAC. She is also a member of the Society of Rural Physicians of Canada,
SRPC. She works as a family physician in Northern Quebec and has been actively
involved in rural medicine and Aboriginal health, giving various workshops on
important medical issues that affect Aboriginal people. Welcome, Dr. Kitty.
Mary Simon is no stranger to us. She is the president of Inuit Tapiriit
Kanatami, ITK. She was elected national Inuit leader in 2006, and of course she
has been the Ambassador for Circumpolar Affairs for Canada as well as a past
ambassador to Denmark. She is assisted today by Elizabeth Ford, who is from ITK.
Rosella Kinoshameg, is the president of the Aboriginal Nurses Association of
Canada. She is an Anishnawbe-kwe, Odawa-Ojibway, who is fluent in her language
and lives in a traditional lifestyle in her community on Manitoulin Island,
Ontario. She spent 15 years working with First Nations communities in the
diverse capacities of community health nurse, manager, educator and nursing
Welcome to all of you. If we could try to keep the presentations to about
five minutes each, I would appreciate it.
Angus Toulouse, Regional Chief, Assembly of First Nations: Thank you
for having me here this morning.
Let me start by saying that it is important to understand that First Nation
communities need to prepare, and that these preparations must consider factors
in pandemic planning beyond those of other Canadian communities, including
distinctiveness of culture, value systems, jurisdictional differences, economics
and community infrastructure relative to the rest of the Canadian population.
Also, remoteness and lack of access to supplies affect response capacities
and make communities even more vulnerable. I have provided the PowerPoint
presentation that you have before you. In some of the activities that we
covered, many different agencies were involved in responding to the H1N1 at a
national level. Among them are the Health Canada First Nations and Inuit Health
Branch — or FNIHB — PHAC, INAC and AFN.
Fortunately, AFN, FNIHB and PHAC had been working together on a trilateral
First Nations pandemic committee and working group before H1N1 appeared. This
collaboration greatly improved the coordination of the response efforts leading
to the holding of a virtual summit with the participation of First Nation
community representatives, provincial and territorial organizations, federal
ministers of health, FNIHB and PHAC.
Positive results came from the summit. Also an influenza-like illness
surveillance tool and guide was developed in a very short time by the
collaboration of the three partners and distributed to over 1,000 schools to
improve our surveillance and early outbreak detection system. Posters and other
information materials were also generated and distributed to First Nation
Some of the lessons learned include where tripartite working groups existed,
the coordination and response was more fluid and effective, as was the case with
the British Columbia tripartite in which B.C.'s First Nations Health Council;
Health Canada's FNIHB B.C.; B.C.'s Ministry of Healthy Living and Sport; and the
BC Centre for Disease Control were working together.
Other examples include the AFN-FNIHB public health pilot sites in Ontario,
Manitoba and Saskatchewan, where federal, provincial and community members sat
at the same table. Even though emergency and pandemic plans existed, the crisis
highlighted many gaps, specifically jurisdictional differences, responsibilities
and non-flexible funding policies. There needs to be more dialogue on the
emergency preparedness and response agreement between the province and INAC in
the provision of emergency services.
First Nation disease surveillance is fragmented. Different organizations —
FNIHB, PHAC, provincial, regional, national level — gather different levels of
information without proper complementation and sharing. Cultural
misunderstanding and a lack of culturally sensitive language and practices
delayed the onset of many activities in many regions. Communities should be
approached through their leaders and the information given should be consistent
in a culturally appropriate language and format.
The pre-positioning of antivirals and supplies was effective in distribution.
Again, contrary to concentration in urban areas, some regions had issues
accessing therapy because the nearest distribution centres were located in the
urban areas, and the same for the initial vaccine distribution.
A successful example was in B.C. where the drugs were distributed by the BC
Centre for Disease Control, which had experience distributing tuberculosis drugs
The following are some of our recommendations: Each community must work to
develop their own plans regionally, involving counterparts from provincial and
federal Health Canada levels — this cooperation should extend beyond pandemic
planning; cultural practices need to be considered when defining ``priority
groups'' for vaccination and service delivery; a plan is needed to optimize use
of resources — having few resources in remote locations means that appropriate
planning will offer greater benefits than simply an influx of many inappropriate
ones; and we recommend the creation of infrastructure capable of coping with the
required basic services — the lack of support infrastructure capable of
providing screening, vaccination and primary care hindered many efforts of
caring for the communities.
Just as a closing statement, First Nation communities can deal with crises
such as H1N1 with competency, resiliency and dignity as long as they have the
appropriate levels of capacity and resourcing.
Dr. Darlene Kitty, Board Member, Indigenous Physicians Association of
Canada: I would like to thank the committee for inviting the Indigenous
Physicians Association of Canada, IPAC, to participate. I would also like to
acknowledge the Algonquin people of the Ottawa area as I stand before you today.
Since the 2009 pandemic, there have been many difficult situations and
lessons learned from indigenous communities across Canada, including First
Nations, Inuit and Metis populations in not only rural and remote areas but also
The effects and responses to seasonal influenza and H1N1 have been variable
in indigenous communities, and this is dependent on many factors, such as the
poor quality of housing, overcrowded living conditions, sanitation and water
quality problems, poverty and socio-economic inequalities, unemployment and
lower level and quality of education.
These and other social determinants of health, as well as the lingering
effects of colonization, have significantly augmented the prevalence of acute
and chronic diseases such as H1N1, diabetes, obesity, heart disease and
respiratory illnesses. Human and material resources affect the ability of
indigenous communities to effectively deal with intermittent threats, and thus
this population is particularly vulnerable to bearing an unequal impact from
pandemics in the past, present and likely the future.
Past influenza epidemics have historically demonstrated higher prevalence of
infections, with hospitalization rates four to five times higher and mortality
four to seven times higher in First Nations than that of the general population.
The elderly, pregnant women, infants and young children have been and
continue to be particularly susceptible to serious influenza infections and
complications. Once again, the factors previously mentioned have played an
important role in these outcomes.
The first wave was strongly felt across Canada and the world. Disturbing
events occurred in First Nations communities in Northern Manitoba and
Northwestern Ontario that made national headlines. The supply and training of
physicians, nurses and other workers and the lack of knowledge of administrators
and politicians, compounded by the challenges already faced by these
communities, likely contributed to the alarming incidents, which must be
examined and addressed.
For the Crees of Northern Quebec, the first-wave hospitalization rate was 33
times and ICU admissions 15 times that of the Quebec rate respectively. In
Northwestern Ontario many First Nations communities were hit hard, requiring
many medevacs, and protective equipment and antiviral medications were urgently
needed as they tried to cope with this.
For Manitoba, 37 per cent of all H1N1 cases were Aboriginal, and 60 per cent
of those cases needed ICU admissions. Access to care in tertiary centre
hospitals and ICUs was a significant factor. The First Nation communities in
British Columbia experienced a delayed first wave with lower hospitalization
rates that were still higher than that of the general population. Metis and
non-status populations have been similarly affected, and notably the Inuit
experience was even worse.
The data collection for H1N1 in indigenous populations has not been ideally
and consistently collected. In fact, it is very likely that prevalence rates of
influenza-like illness are actually higher than calculated due to
under-reporting, inaccuracies in filling surveillance forms and lack of
appropriate identifiers. Urban populations also need to be considered in
addition to rural and remote Aboriginal groups. Future assessments must include
accurate methods, including appropriate parameters and reporting systems.
In the second wave, many Aboriginal communities prepared for this by training
their health care staff; instituting infection control measures; supplying
gowns, gloves and masks to their nursing outposts and sanitizers out in the
communities; and promoting public education.
Indigenous communities became mobilized, involved in their health care,
motivated to help themselves and protect the healthy, showing leadership,
resiliency and advocacy. Public health education strategies became an important
tool. For indigenous communities, radio messages, meetings and posters were
important avenues of communication.
Provincial updates and training programs for all health care workers were
instituted in most provinces, notably Ontario and Quebec. Despite this, the
federal government should lead preparatory and training efforts, and coordinate
and evaluate for consistency across Canada, particularly for high-priority
groups such as indigenous populations.
Probably the most successful strategy to deal with the H1N1 pandemic was the
expeditious production and dispensing of the H1N1 vaccine. What helped soften
the impact of the second wave was the prioritized urgent vaccination of
indigenous populations in rural and remote areas. Unfortunately, urban
Aboriginal groups face the same challenges as those in remote communities but
did not receive the same high priority for vaccination in all provinces. H1N1
immunization and public education were key elements in the second wave that
helped to reduce the prevalence of H1N1 cases.
Vaccination rates were high in remote communities. For example, the Crees of
Northern Quebec had a vaccination rate of 84 per cent and lower rates of
hospitalization and ICU admissions in the second wave as compared to the first.
Similarly, Northwestern Ontario, Northern Manitoba and B.C. also had high
vaccination rates. IPAC encourages the government to more thoroughly examine
statistics from various regions of Canada, including urban Aboriginal
populations. This will enable further evaluation of outcomes of the 2009
pandemic to help plan an improved response to future pandemics of influenza.
In the future, pandemic planning bodies must place a high priority on First
Nations, Inuit and Metis people who live in remote and rural communities, but
not exclusive of urban centres. We strongly recommend that indigenous health
organizations be partners in their own health care, as we know the realities of
our communities and are ready, willing and able to brainstorm, help and
strategize in national pandemic planning. The social responsibility of medical
schools, health boards, provincial ministries of health and federal departments
must be upheld and mandated to work in indigenous communities as needed in a
culturally competent and safe manner. Improving communication at all levels —
local, regional, provincial and federal — and coordinated efforts must take
Finally, addressing the underlying social determinants of health that have
chronically resulted and continue to result in the unequal health of Aboriginal
peoples will help not only in limiting the influence of a future influenza but
also in improving their health in general.
The Indigenous Physicians Association of Canada upholds the vision of healthy
and vibrant indigenous nations, communities, families and individuals. In this
spirit, we thank you for the opportunity to speak to the committee today.
The Chair: Thank you very much, Dr. Kitty. Next we go to Mary Simon.
Mary Simon, President, Inuit Tapiriit Kanatami: Ulakuut, Mr.
Chair, and to the members of the committee.
Thank you for the invitation to speak to you this morning on the topic of
pandemic preparedness. It has been a little over a year since our organization
appeared before the House of Commons Standing Committee on Health to speak about
the issue of H1N1 and its effect on Inuit.
At that time, the highest rate of H1N1 infection in the country was being
experienced in Nunavut, where case numbers approached 600 — 5 per cent of the
Inuit weathered last year's pandemic with experience borne of previous
outbreaks. In the early 1900s, the Spanish flu wiped out entire Inuit
communities in a matter of days. This time we were lucky. Canadians were lucky,
but we may not be so lucky next time, so I call on the members of this house and
on all parliamentarians to support Inuit as we prepare ourselves for the next
one. In that regard, I have a few key recommendations.
First, support the creation of an Inuit-specific process for pandemic
planning. Health Minister Leona Aglukkaq introduced the idea of an
Inuit-specific annex to the Canadian pandemic plan to her provincial and
territorial colleagues last year. They turned her down. We feel they were wrong.
I do not lay the blame for this situation on this current government and
certainly not on our health minister. This deplorable situation has been decades
in the making. Inuit are very proud to work with Minister Aglukkaq because we
know that she understands the health conditions and the needs of Arctic peoples
and is trying to make a difference for us.
Nevertheless, in its current form, the Canadian pandemic plan does not
address issues unique to Inuit communities. A year and a half after the first
cases were diagnosed in Inuit regions, there is nothing in our national pandemic
planning document to address gaps in the rollout of the H1N1 prevention program
in Inuit communities and prepare us for the next pandemic.
As many of you know, most Inuit communities have no roads, hospitals, doctors
or pharmacies. Many have health clinics, which are staffed by nurses. Doctors
fly in and out on a regular basis in most communities. Staff turnover is high.
In the case of a pandemic, these people may also choose to leave and return to
Community-based health care may not be seen as an essential service in most
parts of the country, but in our communities, they are our only access to
treatment. In some cases, the maintenance person may also be the ambulance
We are dependent on air travel and, in turn, on the weather. Some years ago,
a representative from the Public Health Agency of Canada told a group of meeting
participants that antivirals could be sent to any community in Canada within 12
hours. If you have ever been to the High Arctic, then you know that that is
simply not true.
We need an Inuit-specific approach to Canadian pandemic planning, and we need
it to be prepared with us and not for us. It must reflect our realities and
include what we have learned from our journey with H1N1. It must be a meaningful
plan, able to guide us in the future to the level of preparedness that we
Second, begin the very serious work of addressing the social determinants of
health. Inuit live in some of the most crowded living conditions in Canada. In
2006, about 15,000 — or more than 30 per cent of Inuit — lived in crowded homes.
This includes 40 per cent of children aged 14 and under. For most regions, this
represents a decline from the previous decade, but in Nunavik, where I am from,
which is in Arctic Quebec, crowding has actually increased to nearly 50 per
cent. Clearly we have more work to do.
Overcrowded housing allows infectious respiratory diseases to spread
uncontrolled and hinders our ability to reduce the risk to others. The poor
general health of our population, the result of poverty and food insecurity,
also facilitates the spread and severity of disease. The Human Development
Index, which measures life expectancy, standard of living and education, ranks
Canada at fifth place in the world, yet Inuit communities would stand at
ninety-eighth place of 177 countries in the same ranking.
Access to health care is a great concern at the best of times and even
greater during a pandemic. We lack the equipment, resources and services that
patients require. X-rays and other diagnostic tools and treatments are simply
We need expanded access to home and community care. Existing resources are
already compromised by limited funding, a shortage of health professionals and
the inability of communities to provide more specialized services.
The life expectancy of Inuit should be rising, not continuing to fall. At the
end of the day, Canada will be judged on the efforts made to improve the health
of all Canadians.
I look forward to your questions.
The Chair: Thank you very much, and finally we have Rosella
Kinoshameg, President of the Aboriginal Nurses Association of Canada.
Rosella Kinoshameg, President, Aboriginal Nurses Association of Canada:
Good morning. I thank you for the invitation to present on the issue of pandemic
preparedness. The Aboriginal Nurses Association of Canada, ANAC, is the only
Aboriginal professional nursing organization in Canada formally established in
1975 out of the recognition that Aboriginal people's health needs could be best
met and understood by health professionals of a similar cultural background. Our
vision is wellness of Aboriginal people by supporting Aboriginal nurses across
Canada, many of whom work in First Nations communities in various capacities.
Besides being the president of ANAC, I worked full-time as a health director
in a First Nations community up until October 2009, retired briefly, then went
to work in another community to assist with the H1N1 activities. Based on my
experiences, I speak from both perspectives.
In regard to the issues concerning Canada's past pandemic preparedness, in
the spring of 2009, we heard from the media about how the H1N1 was spreading
rapidly, and from attending teleconferences with First Nations and Inuit health
officials, we learned how several First Nations communities were being severely
These are the well-known factors that have already been quoted.
The following are some statistics from the Public Health Agency of Canada: In
wave one, at least 20 per cent of all hospitalized cases were Aboriginal peoples
and 11.7 per cent of deaths. In wave two, at least 4.6 per cent of the
hospitalized cases were Aboriginal peoples and 6.1 per cent of deaths.
On a positive note, 95 per cent of Canada's First Nations communities had a
pandemic plan in place. The Chiefs of Ontario in their report to First Nations
communities in Ontario said, ``Ontario is the first province in Canada to
develop an influenza pandemic plan specifically dedicated to First Nations
people.'' The planning started in Ontario in 2004, when the Ontario Health Plan
for an Influenza Pandemic, OHPIP — a First Nations technical working group — was
formed. Also the Chiefs of Ontario had added, ``The comprehensive pandemic plans
that have already been developed give us a degree of confidence that we will be
able to cope with the H1N1 flu in First Nations communities in Ontario and in
the rest of Canada.''
I attended a pandemic preparedness round table in June hosted by the Canadian
Federation of Nurses Unions, and a presenter there said that the level of
preparedness on reserves has increased significantly as a result of H1N1. Today,
close to 98 per cent of First Nations communities have a community pandemic
plan. Furthermore, during H1N1, there was a 64 per cent vaccine coverage rate in
First Nations communities, which was 20 per cent higher than the national
Many lessons learned from the response to the 2009 pandemic virus have been
presented. Dr. Arlene King, Ontario's Chief Medical Officer of Health, gave a
report in June 2010 on how well Ontario responded to the H1N1 pandemic but said
that greater coordination and standardization was needed for future health
emergencies. The report recommended that the current spirit of collaboration be
built on to ensure the province continues to be ready for future emergencies.
The Registered Nurses Association of Ontario, RNAO, in their feedback
applauded ``the government's efforts to remedy the response to SARS'' and
expressed the feeling that ``the province was much better prepared to respond to
the pH1N1 influenza outbreak.''
Dr. Annalee Yassi, who had also presented on lessons learned, highlighted the
need to take a proactive rather than a reactive approach. She said that there
was confusion with PPE use, low levels of supplies, inadequate levels of
staffing, excessive workloads, conflicting and confusing information and that
the vaccination campaigns targeting health care workers failed.
The Aboriginal Nurses Association of Canada in the feedback documented to
PHAC and Health Canada provided their perspectives on PHAC and Health Canada's
interaction with the organization during the period of April 2009 to January
2010. ANAC's role was to provide input to the Aboriginal relations and strategic
relations PHAC committee. It was also a frequent and timely two-way conduit of
information between ANAC and PHAC through sharing of information, raising issues
at the teleconference briefings and doing a quick dissemination of the
information to its members. Members found this absolutely timely and ahead of
information shared from local health authorities, hospitals or local infection
control personnel. Regular email updates were considered a phenomenal way to
educate, and the links provided quick reference.
PHAC was the primary source of information that was found to be useful,
accurate and accessible. Some members accessed their website directly for useful
With respect to the roles of all levels of government in pandemic
preparedness, Health Canada has a major role in its networks with First Nation
communities. INAC is responsible for emergency management. AFN also works with
First Nation communities. The Ontario Ministry of Health and Long-Term Care
collaborated with provincial and municipal governments, public health units and
health care stakeholders and worked closely with the Chiefs of Ontario and First
Nations leadership. On their website, they posted Guidance on Public Health
Measures for the Pandemic H1N1 Influenza Virus in First Nation Communities.
The Chiefs of Ontario had a role to notify the community's leadership and also
the regional chief.
Many recommendations were made. Many of them had to do with the PPE needs,
staffing needs and improving communication and organization. Recommendations
also included establishing lines of communication and collaboration, human
resource capacity, recruitment and retention, some structural changes and
greater powers for Ontario's Chief Medical Officer of Health, CMOH.
The processes related to pandemic preparedness deal with the planning needs
and the coordinated response to the possible risks, hazards and vulnerabilities;
identify resources; continue to plan and prepare; and be involved.
The Canadian Pandemic Influenza Plan for the Health Sector listed
helpful information in all of their annexes, from A to P. The Workplace Safety
and Insurance Board of Ontario, WSIB, had a pandemic preparedness checklist, and
many organizations offered considerations on the promotion of best practices,
such as the RNAO and the Canadian Nurses Association, CNA.
With respect to the ethical issues related to pandemic preparedness, PHAC
listed some ethical considerations that can be found under ``Background,''
section 6.0, ``Ethics and Pandemic Planning,'' and also lists Annex D, G and H.
CNA also listed several things such as the ``Code of Ethics for Registered
Nurses,'' nurses' ethical considerations in a pandemic or other emergency and a
position statement on emergency preparedness and response.
The University of Toronto also published some discussion papers, and one was
on ethical issues and H1N1 swine flu pandemic, including the topics of duty to
care, priority setting, H1N1 vaccinations, restrictive measures, global ethics,
risk communications and vulnerability.
The Government of Ontario's Ontario Health Plan for an Influenza Pandemic,
Chapter 2, outlines ethical decision- making frameworks.
The Canadian Federation of Nurses Unions, CFNU, had an interesting
presentation by Dr. Cecile Bensimon. She said that because issues related to
pandemic planning and responses have ethical underpinnings, she proposed that an
ethical framework be used to guide such decision making and consider values we
use in emergency decision making before another crisis happens.
From my own comments and observations, many government organizations have
worked together in collaboration and partnerships over the years in pandemic
planning. Many guidelines have been developed and updated, and now there is so
much information on many websites. Many organizations have provided responses to
lessons learned, and it would be good if all those could be combined together to
look at what did not work well, what did work well and what needs to be improved
for future pandemic preparedness.
ANAC members highlighted that Health Canada, in collaboration with PHAC,
should be the first choice for accessing information with respect to First
It was interesting to read that 95 per cent of First Nation communities had a
pandemic plan. These plans were tested during the pandemic period and issues
surfaced, such as confusion in messaging. Therefore, better communication and
improved leadership relationships and a national lead and voice are needed.
Other issues include a bombardment of information from every source — too much
at times; frequent teleconferences for updates versus media coverage for public
awareness; changes in priorities; vaccine supply and rationing by public health
units; and inadequate staffing.
PHAC had requested ANAC to let retired nurses know that if they were
interested in helping with H1N1 support, they should contact regional First
Nations and Inuit health offices or friendship centres if living in urban areas,
to be connected to their efforts for surge response. However, no plans were in
place yet, and people were bounced around.
Most helpful, but after the fact, were the following documents: A First
Nations Wholistic Approach to Pandemic Planning: A Lesson for Emergency Planning,
which was completed in 2007; Guidance on Public Health Measures for the
Pandemic H1N1 Influenza Virus in First Nation Communities. The most helpful
websites were PHAC, which had Annex B: ``Influenza Pandemic Planning
Considerations in On Reserve First Nations Communities,'' and information found
on the Ontario First Nations Pandemic website that had the latest H1N1 virus and
situational updates and posters. Again, I found that out later, after the fact.
There was also a report entitled First Nations Risk Assessment Tool for Large
The Canadian Nurses Association was another good site for nursing information
on ethics. ANAC provided H1N1 updates with a long list of useful PHAC
information guides, printable handouts and tools that were much appreciated.
The Chair: Thanks to all of you. I have a quick question for Dr.
You have brought something else in here that perhaps should be apparent to
all of us. We have been talking about all of the plans, a high number of plans,
in rural and remote areas and First Nations areas, but you have also brought in
the question of the social determinants of health, something this committee is
familiar with, having done a study on it. You have mentioned the poor quality of
housing, overcrowded living conditions, sanitation, poverty, unemployment and
Tell me more about how you feel the different orders of government need to
work together to deal with these issues as a means of also dealing with pandemic
preparedness. These issues are still outstanding. Will we still have a difficult
time having overrepresentation amongst those who suffer from the pandemics, the
influenza, when they happen?
Dr. Kitty: The social determinants of health are a priority for our
indigenous health care workers because we see that every community is affected
by poor infrastructure. Building quality is not good. The challenges of weather
and the environment affect that and so do the social aspects, such as 15 people
living in a house. How can you prevent people from passing the influenza to each
other without having clean water, good hygiene, et cetera?
It is a priority for indigenous health, not only H1N1 pandemic planning.
Ms. Simon: That is a critical issue because it touches on other
determinants that relate to respiratory illness. For instance, babies and young
children have a high incidence of respiratory illness in our Inuit communities.
That has an impact on any disease that comes into our communities.
We are not talking about other communicable diseases right now, but currently
in the Canadian Arctic, we have tuberculosis in our communities, and that is a
highly contagious disease. We do not have the infrastructure and the capacity to
address that issue properly. We thought if we called this particular H1N1
process the ``H1TB initiative,'' it would perhaps receive the level of attention
that we would like on the tuberculosis issue as well. These are interconnected,
as you said, with the living conditions. We were lucky this time, but we might
not be so lucky next time.
Mr. Toulouse: I want to re-emphasize the social determinants, namely,
the housing conditions, lack of infrastructure, water and so on in many of the
First Nation communities. There is willingness on the part of these communities
to have the best infrastructure, but without the cooperation and willingness of
INAC in our communities to, first, address the fundamental issues of better
infrastructure. The effects of these strains of viruses continuing to have a
much greater impact on our community than on anyone else is not what we expect
in this day and age, especially when we see the services available to everyone
The bottom line is the ongoing poor housing. It underlies many of the issues
that we continue to discuss.
Senator Martin: I want to thank all of you for your compelling
presentations. From what we have heard to date, as well as from the two panels
today, it seems that we have the key pieces in place. As you say, Chief
Toulouse, it is a matter of optimizing those resources and continual
Ms. Simon, you spoke about having a minister who in terms of her commitment
and cultural understanding has lived it, and she will continue to be committed
to ensuring that we are better prepared for the next pandemic.
Chief Toulouse, you spoke about cultural practices needing consideration, the
cultural misunderstanding, and how that must be a two-way communication. As much
as we try to understand the cultural sensitivities and the practices that are in
place, how much more can we do, and how can we most effectively for the next
time make sure that cultural practices and values are considered? You have not
given the specifics, but you talk about the priority groups for vaccination and
service delivery. Is that information being clearly shared with the provinces
and the federal government? Was that information already made known? That is a
very important gap for any of the groups in Canada, and that cultural
sensitivity is one of the keys to bridging the gaps that may exist and be at the
centre of many of the issues we are discussing.
Could you speak about the cultural misunderstanding and the continual
education that must take place and be considered for the next plan?
Mr. Toulouse: Without initially having any working relationship with
the community, the chief or the health people, misunderstandings will happen
immediately if there is no input or engagement or sharing of information. As an
example, in many of the communities that received the body bags, the initial
reaction was ``Holy smokes! We have a government who wants to put us in a body
bag, and away we go.''
Let us talk about the real issues, our culture and what we believe are our
values and principles. We believe that, like anyone else, we need to have a
healthy environment. We must have an infrastructure that works. It is not
culturally acceptable that three generations of families live in one house. That
is not our cultural norm. As a result of the lack of resources and recognition
of the needs of our communities, we have these situations. Then it creates a
total misunderstanding that government is only interested in wanting to minimize
the liability and not deal with the people and our issues in terms of the social
determinants of health. We have had regional health surveys asking what would
create a much healthier individual, community and family.
Many times it is a lack of recognition of the governance and the community
and the understanding that the First Nations need that recognition for their
governance, their structures and how they need to function. Many times, as much
as they know what it is that they want and need, no capacity is consistently
there to ensure that the safety and health of the citizens in the community will
be met. That makes up much of the problem that I have seen.
Senator Martin: Can that be addressed? For instance, you have a forum
where you come together to speak about the issues, and ongoing dialogue and
collaboration will happen to plan for the next pandemic. You have all expressed
that you are pleased with that process in which you will be engaging in
preparation for the next pandemic.
Mr. Toulouse: We need to expand it so much more.
Ms. Simon: Except for the Inuit — we are not part of the pandemic
plan. For First Nations, there is an annex, but for the Inuit, there is not.
Therefore, we are asking to become part of the national pandemic plan.
Dr. Kitty: On your question about cultural sensitivity and cultural
competency, efforts are taking place now for health care programs, such as
nursing and medicine, to train their students. Once they go into practice, they
will learn about different cultures and become competent in the knowledge,
skills and attitudes of a different culture and work with that population. To
extend that further, cultural safety is now the big buzzword. This is an
extension basically recognizing the power differential between non-Native health
care workers and Native patients. If you bring the two people to the same page,
that will benefit collaboration and moving forward with the health care agenda.
Senator Martin: I absolutely agree with that. Thank you.
Senator Cordy: My first question has to do with the statistics on how
many people were inoculated on reserves. Dr. Kitty made reference to the lack of
information particularly about those living in urban areas. Do we have an
accumulation of data on whether Aboriginal peoples, First Nations and Inuit
living in urban areas actually contracted H1N1 and any information on the
percentages of those people in urban areas who actually received the
vaccination? We are seeing all the information about on-reserve, but large
pockets of people who are on their own live in urban areas. Do we have
Second, earlier Chief Evans talked about nursing stations being at full
capacity during H1N1. Ms. Simon mentioned it, and others have mentioned that the
next pandemic could be worse. If they were at full capacity during H1N1, what
happens if the next pandemic is worse?
Ms. Kinoshameg, you mentioned the efforts to have retired nurses help out and
give their names to either friendship centres in the urban areas or to Inuit or
First Nations offices, but they were being bumped around. Nothing is worse than
volunteering to help, and then standing around doing nothing.
Ms. Kinoshameg: On the statistics for urban areas, I do not know if
that is being captured anywhere, unless it is voluntary, but there is nothing
that would capture those statistics. Probably 50 per cent of our people live in
urban areas. In my own community, the total population is 6,000, with 3,000
living on-reserve, so the other 3,000 are somewhere else. We do not know what
their statistics were in pandemic planning.
With the nurses volunteering, I was lucky; I did not go to First Nations
Inuit health or a friendship centre to give my name. I knew of one First Nations
community, and they contacted me to help them out in the planning and
immunizations for H1N1.
Dr. Kitty: From the 2006 Census, we know that over 60 per cent of
Aboriginal people live in urban centres now. Also, when they are collecting data
for H1N1 specifically, there was no tick-the-box kind of form to be filled out.
The data is collected basically from what nurses collect in the emergency
departments, and they do not really know the ethnicity of the patient coming in.
In urban centres, that information is lost, so we do not actually know.
Some of my colleagues have informally mentioned that Aboriginal people in
urban centres had much lower H1N1 vaccination rates, for whatever reason. I am
not sure because the general public also did not receive as high vaccination
rates as they did in indigenous communities. We can better capture that
population by having more comprehensive data collection.
Senator Eaton: Ms. Simon, you said that the territories and provinces
were against the Inuit having their own health annex. What were their
objections? Why did they turn you down when you asked for it?
Ms. Simon: Because the Inuit live within the province, such as in
Quebec and Newfoundland, we deal directly with the provinces in this type of
Senator Eaton: Did they not feel you were isolated or special enough
to give you your own pandemic plan?
Ms. Simon: We do not know the real rationale behind it, except that
they did not see a need. With First Nations who live on reserves, there is a
direct link with the federal responsibility, and in the case of Inuit living in
provinces, it is the province. That was part of the reason, but we argue that
that is not a realistic plan. If we had another pandemic in Nunavik, Northern
Quebec, for instance, which is very likely, and our health care workers, who are
mostly from the South, wanted to be with their families, our capacity would go
right down. If the province felt that they could not actually deliver the
service to our region, no federal plan exists. This is one of the reasons we see
the need for an overall plan that relates to all Aboriginal peoples.
Senator Eaton: A plan is needed for specifically isolated
communities, especially those in the North.
Ms. Simon: Yes. We cannot drive into any of our communities.
Senator Eaton: You are a long way away; I know that. I am sympathetic.
When we do the report, this is certainly a recommendation. If you have stronger
reasons, or if you gave the clerk a sheet of reasons, we could perhaps consider
them when we do our report.
Mr. Toulouse, having gone through the access-to-higher-education exercise and
now with this exercise, does the Indian Act need revamping or throwing out,
looking at it again? It is housing, health, access to education, Aboriginal
people or First Nations moving into cities. There seem to be so many issues, and
it is always the same refrain. Are we fighting against a barrier, in other
words, the Indian Act, that should be re-examined?
Mr. Toulouse: A fair amount of approaches and discussion have occurred
in the past. The Assembly of First Nations took a recent approach to get
recognition and implementation of First Nation governments. The Indian Act is a
piece of legislation that everyone knows has been around since 1876 and has not
had many revisions. The tinkering of it, such as some of the legislation we are
seeing now in the McIvor decision and matrimonial real property, MRP, is
not addressing the need to have those First Nation governments recognized in
terms of the jurisdiction that they are exercising and want to continue to
exercise in many areas, including matrimonial real property. However, that is
not the priority for many of the First Nation communities; the priority is
ensuring that the basic services and infrastructure are there — water, sewer,
roads and houses.
Yes, absolutely the Indian Act needs to be revised. Approaches have been
taken by many organizations that want to address this in a self-government
approach. In many of the cases in Ontario when they were negotiating self-
government, we found the current inherent rights policy that is there does not
allow for what we consider the recognition of First Nation governance.
It is really limiting their administrative abilities, if you will. We need to
recognize that much of the time all the Indian Act does is give resources to
administer programs and services when the work is much more in the area of
ensuring that the laws and policy within the administration and within the
community are in place and understood and there for everyone's benefit and to be
fair and to ensure that everyone receives the same opportunity and services that
On some of the priorities and approaches that need to be taken, yes, there is
a need to have that discussion and to look at the ways forward. There have been
a number of approaches. Accountability for results was an approach that talked
about bringing in the Auditor General, Treasury Board, INAC and First Nation
leaders to talk about the best way forward and what agenda we can have in common
that would ensure that at the end of the day we would have certainty around such
things as input into pandemic planning.
The Chair: Thank you very much for that answer and for all your
answers and participation in this. We have come to the end of our meeting. Thank
you for being with us and for your input.
Colleagues, that brings this meeting to an end, but we are back tomorrow
morning at 8:00 a.m. We will see you then.