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 around.

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 Inuit.

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 vaccination clinics.

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 take place.

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 seriously.

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 Nations.

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 their allocations.

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 duly accountable.

My overarching concerns relating to the H1N1 pandemic was that governments were not ultimately addressing the very conditions that make First Nations populations high-risk.

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.]

Thank you.

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 population.

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 administering them.

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 management.

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 than others.

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 statistics.

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 sufficiently prepared.

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 disease occurring.

The Chair: Were these plans deficient in some way, or were they just late?

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 different.

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 Branch.

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 Nation communities.

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. Thank you.

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 communities.

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 emergency.

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 level.

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 issue.

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 supervisor.

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 communities.

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 to communities.

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 urban centres.

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 precedence.

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 population.

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 their families.

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 driver.

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 deserve.

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 not available.

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 impacted.

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 average coverage.

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 resources.

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 Nation communities.

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 Gatherings.

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. Kitty.

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 education.

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 else.

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 collaboration.

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 information?

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 situation.

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 everyone desires.

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.

Thank you very much.

(The committee adjourned.)