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

Issue 15 - Evidence - October 27, 2010


OTTAWA, Thursday, October 27, 2010

The Standing Senate Committee on Social Affairs, Science and Technology is meeting today at 4:16 p.m. to study Canada's pandemic preparedness.

Senator Art Eggleton (Chair) in the chair.

[Translation]

The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.

[English]

Today we continue with our study on pandemic preparedness and response. We are looking specifically at emerging issues in research and ethics.

We have two panels today. For the first hour and 15 minutes, we will have two witnesses with us and another two in the second panel from 5:30 to 6:45.

On the first panel we have Dr. Alain Beaudet, President of the Canadian Institutes of Health Research, CIHR. Not only does he hold that distinguished position, but he has also built a distinguished career at the world-renowned Montreal Neurological Institute and Hospital.

We also have Dr. Bhagirath Singh, Director for the Centre for Human Immunology at the University of Western Ontario. From 2001 to 2009, he served as the founding scientific director of the CIHR Institute of Infection and Immunity. He was responsible for providing a rapid research response to the threat posed by severe acute respiratory syndrome, SARS, in 2003 by creating the Canadian SARS Research Consortium. Since 2006, he has coordinated the pandemic influenza research through the formation of CIHR Pandemic Preparedness Strategic Research Initiative, but he is here on his own today, having recently left CIHR.

Welcome to both of you. Dr. Beaudet, you can start, about seven minutes each.

Dr. Alain Beaudet, President, Canadian Institutes of Health Research: I thank the Standing Senate Committee on Social Affairs, Science and Technology for this opportunity to discuss the role of research and the Canadian Institutes of Health Research in planning for pandemics.

As indicated by previous witnesses who appeared before this committee, Canada's coordinated response to the 2009 H1N1 pandemic would not have happened without years of planning and investment in pandemic preparedness research. The impact of the 2009 H1N1 influenza pandemic could have been much worse without these years of planning.

[Translation]

Since 2006, the Government of Canada has invested $21.5 million in research, and that money has helped us acquire essential knowledge in preparing for a pandemic. These investments, along with an additional $24.2 million in matching funds donated by public and private partners, have enabled the Canadian Institutes of Health Research to pour large amounts of money into influenza research. We focused our efforts on developing effective influenza vaccines, on understanding the biology of the virus better, on developing rapid diagnostic tests, on preventing the spread of the virus, on developing new approaches and treatments, and on implementing an ethics, legal and social contract.

As you can see on the chart you were given, the number of Canadian publications on the H1N1 flu and on pandemics has doubled since 2006. The investments have also enabled Canada to develop a research infrastructure that played a key role in helping us respond to the risks of an H1N1 pandemic quickly and effectively. The investments have also enabled us to set up, in record time, an influenza research network that is overseen jointly by the CIHR and the Public Health Agency of Canada, who are working in close collaboration.

[English]

In 2009, this PHAC-CIHR Influenza Research Network was a key element in the development and testing of methodologies related to the evaluation of influenza vaccines as they pertain to safety, effectiveness, and program implementation and evaluation. Because of this network, Canada was able to run four separate trials to assess rapidly the safety and immunogenicity of the H1N1 pandemic vaccines in various at-risk populations. Other trials were also conducted successfully to examine various strategies for deploying mass immunization programs, for the improvement of vaccine coverage, for ensuring vaccine safety in children with egg allergies, and for improving the effectiveness of the vaccine in preventing hospitalization and serious outcomes.

In addition to these numerous clinical trial activities, the PHAC-CIHR Influenza Research Network also established an extensive archive of biological samples and reagents, which can be accessed by public and academic investigators to address questions related to influenza vaccination programs.

In conclusion, I reiterate that part of Canada's readiness to face global threats such as SARS and H1N1 resides in our capacity to mobilize rapidly our world-class researchers. Thanks to the Influenza Research Network, which now includes over 90 investigators at 30 institutions across Canada, and has the ability to set up and carry out clinical research trials rapidly, our research community is well poised and sufficiently nimble to mount an immediate effort to identify infectious agents and develop preventive and treatment strategies to combat various infectious threats.

Furthermore, even in the absence of immediate threats, it provides a unique ongoing research capacity for assessing the safety and efficacy of vaccines against seasonal flu, which is responsible for the death of up to 8,000 people a year in Canada alone.

The funding that CIHR received for the Pandemic Preparedness Strategic Research Initiative to implement projects such as the PHAC-CIHR Influenza Research Network ends in March 2011. Dismantling this network, which proved so important for implementing a coordinated response to the 2009 H1N1 pandemic, could compromise Canada's ability to respond rapidly and efficiently not only to threats linked to new mutated forms of the influenza virus, but also to new emerging pandemic threats such as the West Nile virus, Lyme disease, multi-resistant bacteria, or other unknowns that are likely to arise in this era of increased travel, increased trade and climate change.

Finally, I inform your committee that Marc Ouellette, the scientific director of the CIHR Institute of Infection and Immunity, and his team are organizing a large research conference on Canadian pandemic preparedness that will focus on the outcomes, impacts and lessons learned from the Canadian pandemic preparedness initiative. This meeting is to be held in Montreal on November 12 and 13, 2010, and I know that Dr. Ouellette would be delighted to appear before this committee to discuss the conclusions of this important meeting.

Bhagirath Singh, Director, Centre for Human Immunology, University of Western Ontario, as an individual: Honourable members of the Standing Senate Committee on Social Affairs, Science and Technology, I thank the committee for the invitation to provide my personal reflections and experiences dealing with the matter under consideration by your committee.

My comments reflect my personal knowledge of the research in this area and my own research in immunology over the last 30 years. The creation of CIHR in 2000 and the Public Health Agency of Canada, following the SARS outbreak in 2003, led to seminal changes in how we perceive research in this country, particularly in dealing with pandemics and infectious diseases.

While the CIHR investment in knowledge creation and translation is the basic foundation of future research and how we use this research in the public health arena, the Public Health Agency involvement in the monitoring and strengthening of the health care system is paramount in how they function.

Between these two agencies, as Dr. Beaudet pointed out, we had an effective collaboration, which started many years ago and continues. Following the 2003 outbreak of SARS, it was clear that Canada cannot respond to pandemics, large or small. The creation of the Public Health Agency and, in Ontario, the Ontario Agency for Health Promotion and Protection, are the new directions in which we are heading in facing the many challenges posed by infectious diseases.

After SARS, West Nile virus, C. difficile, mad cow disease and avian influenza, the threats continue to come. Every year we see many new types of challenges arise in the field of infectious diseases.

Influenza comes around every year whether we are ready for it or not. It kills on average 4,000 Canadians, thousands become sick, and the cost to our health care system is enormous.

Pandemic influenza, on the other hand, comes every 30 to 40 years and kills millions around the world. There is a connection between these two influenza outbreaks. We have to be prepared for seasonal influenza because it informs how we will respond to pandemics. Given that challenge in 2005, CIHR and the Public Health Agency jointly put together a conference to consult with stakeholders, which led to joint pandemic preparedness initiatives.

It is clear that Canada and the U.S. both made major investments in pandemics around that time, 2005-06, and I can tell you that research was one of the major areas in which the Canadian Parliament has invested funding. Unfortunately, the amounts dedicated to research were about 2 per cent, or $21.5 million, of the $1 billion commitment. Despite that small investment, when I was the director of the CIHR institute that Dr. Beaudet mentioned, we launched, along with various funding partners and other agencies, a major research initiative, the Pandemic Preparedness Strategic Research Initiative. This became the foundation for research response, in 2006, to prepare for the forthcoming pandemic.

The collaborative nature of the initiative increased that $21.5 million in research funding to over $43 million through efforts in which our staff and I were involved in a major way. This five-year funding will come to an end on March 2011. This situation will not, in the end, attract or retain people who work in this area. They will probably leave or move into other areas of research. This is definitely an opportunity lost.

Have we really addressed the challenges of future pandemics? Will the funding always be there when we need it? We need to think about some of these challenges as we move forward. There is always a challenge. When we have a pandemic, everyone is thinking of how we respond to it. We cannot work towards a research agenda in the middle of a pandemic, so preparedness becomes the key in how we respond to these challenges as and when they arise.

We faced the challenge of H1N1 when it arrived following our preparations that began in 2006. The numbers are there, and I have circulated the paper, ``Research preparedness paves the way to respond to pandemic H1N1 2009 influenza virus.'' The paper is a factual document that details what we did, how we did it and how we responded to the challenge.

We also held several meetings, which were funded from our program. These meetings informed the research community and the stakeholders of the progress and the challenges. They allowed everyone to work in coordination so as to address the issues that arise in a pandemic.

I have three recommendations for you to consider. First, we should continue to have dedicated funding. CIHR and other funding agencies receive a fair bit of funding for research. However, unless the funding is dedicated, it usually does not pan out into a detailed, long-term commitment in a particular area of research. To meet the ever-changing challenges of infectious diseases, pandemic research must be supported through federal research initiatives, whether through CIHR or other venues, but the initiatives have to be there. Funding should be flexible so that we are able to use it when it is needed instead of simply spending the money.

Second, the health research and funding programs outlined have built research capacity, as we did for pandemics in the last four years. This capacity has set us apart, compared to many other countries in the world. Canada was the leader in developing the pandemic plan, and dedicated research funding was the key for how we succeeded in putting it in place.

Finally, we also need to think of a rapid research response team. Since my initial work with SARS, it has become clear that we need a free-standing rapid response team like our Disaster Assistance Reponse Team, DART, which is ready when we need it so that the best minds can be brought together on short notice to respond. Research is not simply surveillance and developing product, but it is the way we solve problems. Both for SARS and for the H1N1 pandemic, Canada was the leader in sequencing the virus. We were the first country to sequence because we had the technology platform and we were able to respond by using the research to develop diagnostic tools.

We have shown that research pays off. It is the way to face challenges. Simply accepting the fact that things will happen, and we cannot respond, is not the right way to go.

I thank the Canadian Parliament for funding the pandemic initiative. It has paid off. As the current funding comes to an end, we have an opportunity to rethink that issue and consider that Canada must be a leader in this field. The only way we can provide that leadership is by having dedicated support for our researchers who have dedicated their time and effort to build the networks that were mentioned.

The Chair: I will start. I have a question for Dr. Beaudet and then one for Dr. Singh.

Dr. Beaudet, you raised the matter of funding running out next year. How does that situation affect a couple of things that we have heard at this committee that would be of some value in terms of research? Do you have any involvement in these two areas? Will this funding affect them?

First, we heard that we lack sufficient capacity, in terms of electronic systems, for collecting, managing and disseminating clinical and epidemiological data. Is CIHR involved in creating or maintaining such infrastructure?

The second one we heard about was new vaccine technology that might be developed, including cell-based and DNA- based technology, which may result in vaccine production methods that produce vaccine faster than the traditional technology that uses eggs.

Can you comment on whether you are involved with that research, what the current state of the research is, and whether this funding that you are talking about ending in this fiscal year will affect those areas?

Dr. Beaudet: This funding has allowed us to do two things. First, it has allowed us to build capacity, that is, to interest some of the best minds in the land in infectious disease and research. You saw the result here; it worked. Obviously, these people were excellent researchers in this country, but they shift their interest, and that is good news when it comes to being prepared to respond to a crisis. It is also good news in that these researchers will then have their students and post-doctoral trainees work on projects that are linked to influenza. We are preparing the next generation of researchers.

The second advantage is that we have built an infrastructure. In science, it is difficult to have scientists working together. Science is naturally competitive; researchers are naturally competitive. However, they will work together for the common good. That is exactly what the pandemic preparedness initiative allowed us to do, namely, to bring them together to work together, and to work together in such a way that, when the pandemic arrived, we could rapidly launch Requests for Applications.

We then received excellent applications from excellent researchers that could be reviewed and carried out in a short time period — much shorter than we usually do things. It is not that we do not want to go fast, but you know how these things are. The response is clearly yes. Funding is critical not only to building capacity but also to maintaining an infrastructure that will be critical.

To address your two points more specifically, there is broadly in this country a need to create and access electronically data banks and records better. We are aware of that need and we have several programs that are geared towards improving that area. One is the Drug Safety and Effectiveness Network, DSEN. One of the avowed aims of this network is to improve access to electronic data banks, and particularly to enable the different data banks in different provinces to talk to each other, or at least to have ways to merge the data so that we can better use the fabulous data produced by our universal health care system that we do not use sufficiently.

More generally, also, is the need for the production of electronic records. I will not go there. I think you know exactly what I mean. We are not there yet. That capacity will make a huge difference. Also, more broadly, is the need for infrastructure in clinical research in this country. CIHR is fully aware of that need and has launched a Strategy on Patient-Oriented Research. CIHR has developed the strategy with partners — with the provinces, with the private sector and with non-governmental organizations, NGOs — to improve the infrastructure, the communication, the means to support clinical research in general and the means to support several networks of that type in the country, because we need networks to develop clinical trials in other areas.

As for the vaccine and the technical aspects of vaccine production, I will refer to Dr. Singh. He is more competent to address that area than I am.

Mr. Singh: There is no question that vaccine technology has not moved as rapidly as we thought it would. Given the technology of developing vaccines in eggs, it goes back almost 60 years. The technology to produce egg-free vaccines in tissue cultures is there, but to scale it up so that the companies actually produce it is expensive. It is not the technical issue of having the technology, but the issue of adapting and producing it by manufacturers. That is where the gaps are. Those gaps are huge, because the investment that the private sector will have to make is to change the way the private sector conduct their current business. That is where we face hurdles.

The Chair: The research is ongoing, then?

Mr. Singh: The research is ongoing. It is global.

The Chair: Will the funding to CIHR that will be cut next spring affect that research, or is it being conducted in the private sector?

Mr. Singh: There is no question that the basic research is needed to continue to improve this technology so that we remove the hurdles that may be there in vaccine development. Without research, we cannot make progress.

The Chair: Let me ask you one other quick question, Dr. Singh. You have proposed a Canadian rapid research response team, CRRRT. We have found out in the course of our hearings that there is an alphabet soup of plans, committees, networks and you name it. We have asked for a list so we can sort them all out. Do you see this team replacing some of them?

Mr. Singh: No; research is not in any of those programs. All the federal agencies have different rapid response mechanisms, surveillance, diagnostics, but not research.

We propose that we do not need another agency. CIHR can create the team, but it must have a dedicated focus and funding like that for HIV or hepatitis C. As well, there must be linkages with the provinces and maybe with international agencies. However, it must be managed as a research network.

Senator Eaton: I will look at this issue from another perspective. SARS came to Canada off a plane, I think; someone got off a plane in Toronto from Hong Kong or China with SARS. At St. Michael's Hospital they are presently conducting research on a computer program where, if someone got off the plane in Montreal from Paris with influenza, in an epidemic they could track where it would go next.

Is that something that you do as well, or have you heard of that tracking device? They can predict where it will go next across the country, or even in the world. I saw this technology illustrated and it is interesting.

Mr. Singh: It is a fascinating idea; however, practically, can we do it? If someone develops an infection, there is an incubation period, which could be a few days. To predict that someone who got off the plane had the flu is one thing, but if that person develops the flu after arriving home, we are looking at a different scenario of how it evolves.

Models are a beautiful way to predict how things will go, but in the practical sense there are limitations because human nature is different from what mathematical models predict.

Senator Eaton: This is being developed by doctors. I might put them in touch with you so you can argue back and forth as one expert to another.

As part of your pandemic planning, if a pandemic starts in a school, what would you do to try to track it and predict where it might go?

Mr. Singh: The modelling has been created. You are absolutely right; there are models that beautifully demonstrate this tracking. However, in a practical sense, there are limitations on how it will work. The Public Health Agency of Canada is aware of that approach. Surveillance is under their jurisdiction and they do use that approach.

Dr. Beaudet: You are absolutely right in that it is critical to be able to determine where a pandemic originates from. We were pretty sure that the next pandemic would come from Asia; and, surprise, it came from Mexico. No one foresaw this origin. It was important to be able to track rapidly the pandemic back to Mexico so that the Mexican authorities could take measures, which they did.

Senator Eaton: Once the pandemic arrived here, you had no way of predicting how fast it would travel and to what cities it would travel, based on the number of people coming from Mexico or going back and forth, et cetera?

Dr. Beaudet: We are funding a group that is creating that type of modelling to follow the patterns of spread of the pandemic in this country.

Senator Eaton: That information might be useful to hospitals, schools and communications.

Dr. Beaudet: Yes, which is why I mention it.

Senator Callbeck: Thank you for coming here today.

You spoke about funding. I notice that the institute funded five research projects on H1N1 over two years. Are those projects still ongoing or are they completed? Can you give us an overview as to what they were?

Mr. Singh: Several projects are funded. Close to 70 projects were funded in the last five years. Some were shorter term, some longer term. They all will end as of this coming March. The results of some of that research are available now, but others eventually will have to end.

Senator Callbeck: It says here that there were five new projects on H1N1. Have those projects been completed?

Mr. Singh: There are more than five; perhaps five team grants. They are ongoing currently.

Senator Callbeck: In the Canadian Pandemic Influenza Plan for the Health Sector, it says that your institute was involved only in surveillance. Do you agree? If not, what exactly was your role?

Dr. Beaudet: No; it is the Public Health Agency of Canada that is involved in surveillance. The institute is the Institute of Infection and Immunity of the Canadian Institutes of Health Research, which is one of the 13 institutes that were intimately involved. This is the area of expertise of the institute, and it was responsible for supporting research in this area, for rapidly launching calls for proposal, which they did — amazingly so — and for ensuring the quality of the research that we support; that is, for selecting the best project, as always using a peer-review process.

Senator Callbeck: Your role should be revised within that plan, then. According to this document, it says that CIHR is involved only in surveillance.

Dr. Beaudet: I am not sure what document you are referring to. Clearly, the role of CIHR is to support health research, and surveillance is the responsibility of the Public Health Agency of Canada. We are both in the same portfolio, in the health portfolio, but we have different agendas. Having said that, we work together closely. The network that I was talking about is a joint network. One is responsible for public health issues, and we are responsible for the health research issues.

Senator Callbeck: This information came from the Canadian Pandemic Influenza Plan for the Health Sector.

Dr. Beaudet: The two agencies were involved. That is probably the confusion. Both agencies were involved in responding: Public Health, on the one hand; and we, on the other hand, responsible for the research response.

Senator Ogilvie: My first question is more out of interest and to clarify in my mind something that arose as a question.

In the early 1980s we had the emergence of human immunodeficiency virus, HIV. Was it identified at that time as a pandemic?

Dr. Beaudet: I was too young; I do not remember.

Mr. Singh: HIV was not designated a pandemic, but you saw what happened; it became a pandemic.

Senator Ogilvie: I rarely have seen the term ``pandemic'' associated with it, but when I look at the definitions of ``epidemic'' followed by ``pandemic,'' it is surprising to me that HIV was not identified or treated in that fashion. That is a general question.

Dr. Beaudet: It took time to be identified as an entity, as a disease. That situation already was different from influenza.

Senator Ogilvie: Dr. Singh, you gave an initial answer to this question and I want to pursue it further, the possibility of a DNA culture-based vaccine. I agree with the quick explanation you gave in the summary, and I will explain my reason for wanting to delve into it more in a moment.

Can you go back over that explanation a little more slowly and give your personal professional opinion as to the likelihood of being able, with current technology, to develop a DNA-based vaccine for a newly emerging strain of influenza virus, if it occurs by spring of next year, let us say?

Mr. Singh: Developing the vaccine takes research effort. It could be six months, a year or two years. If we identify what the virus is, can we then go back and say what part of that virus will make a good vaccine? A virus produces all kinds of things. There are two ways to make a vaccine. We can take the whole bug, kill the bug and use it as a vaccine. The other way is to take parts of the bug that will produce a strong immune response so that the body can produce an immune response. Those approaches are two different things. How they approach the actual vaccine development is an important challenge.

Second, the adjuvants — and I am sure you have heard about them — increase the efficacy of the vaccine. Even if they identify a piece of a virus which would be a good target for the vaccine, can they obtain a good immune response? That is the challenge where they have to do a lot of research to produce and manufacture the vaccine. You can see that the time window between research and the actual vaccine production can be large or small depending on the nature of the virus.

Senator Ogilvie: Let me tell you why I asked the question. At one of our earlier sessions, a witness enthusiastically said that if we had used a DNA approach to this issue, we would have had the vaccine some two or three months earlier. His enthusiastic approach was that if we were to take that approach to a next pandemic possibility, it would be a piece of cake — he did not use the term ``piece of cake''; that is my interpretation of what he meant — to quickly develop the vaccine and to have it in large quantity.

When I expressed some doubt about that solution as a practical reality, his enthusiasm was undiminished and he felt that it was something that was at hand. I was not aware that we were anywhere near that capability, especially with new emerging infectious agents. In fact, my sentiment would be exactly along the lines that you so well expressed.

Can I conclude, then, that you have said that yes, potentially the DNA vaccine is a possibility as an alternative but you have expressed two aspects to it? One is the reality of the research that identifies the potential basis for the vaccine. Then in your earlier answer, you clearly identified that scaling up the research to being able to produce hundreds of millions of doses is not yet a practical possibility?

Mr. Singh: If it were a simple thing, we would have a vaccine for HIV. I do not have to go any further than that.

Dr. Beaudet: You raised an important point.

I am now talking about the scientific community in general. I think we have been complacent in our approach to vaccines. It worked so easily. Pasteur had it work immediately. It worked on eggs and then, all of a sudden, came acquired immunodeficiency syndrome, AIDS, and we realized that we were misunderstanding the basic human function. We had not spent the necessary money, time and efforts to better understand and look for other ways to better understand the immune system, the human immune system, and look at other approaches to make vaccines. We believe that effort is something we now must make.

I believe that some of the work that we are funding on the vaccine production of AIDS, some jointly with the Gates Foundation, is something that will help us devise other vaccines for other types of viruses. You make an important point here.

Senator Ogilvie: I thank you both because this point is important. If we have senior bureaucrats or others who feel that the exercise is a simple one, then we are in a serious situation. I used HIV as an alternate example because everyone is focused on H1N1 as if the only possible pandemic is an influenza virus, when potentially the most serious situation we can face is some other agent. We have HIV as an example. As you correctly pointed out, if this exercise was trivial, with all the studies on the genetic composition of the virus, we would have had that vaccine by now. Your answers are extremely important for the record. Thank you very much.

Mr. Singh: We have spent $20 billion or more on the HIV vaccine and you can see that we are not there yet. That is why I have taken the challenge now to run a centre for human immunology. We need to understand human immunology and we have to go back to the fundamentals. That is what I am doing now in my next life.

Senator Braley: Senator Callbeck started my questioning because I wanted to ask about the role of CIHR and what it should be. That is now clarified. However, who is responsible for identifying the virus or what is wrong? Who is responsible for ensuring that the vaccine is safe? Who is responsible in the line and reporting to whom? On the communications front, whether it is new or otherwise, there is some confusion. When I first read the information, I had the same confusion as Senator Callbeck with regard to who is in charge.

Dr. Beaudet: As you saw during the H1N1 crisis, the regulatory role is the Public Health Agency of Canada, which was created for that role after the SARS pandemic.

Our role is a support role to provide evidence to the Public Health Agency of Canada and to Health Canada. It is to provide the second type of information that you are mentioning, for instance, to carry out the clinical trials that will give us information on the safety and effectiveness of vaccines, and whether we should have an adjuvant with the vaccine. We are responsible for the research part that provides the scientific evidence. The regulatory aspect and the decision aspect are the responsibility of the Public Health Agency of Canada.

Senator Braley: To extend that answer further, you do not have the people on staff. Obviously, you must use the researchers at the various hospitals or universities, and tie them together.

Dr. Beaudet: That is correct.

Senator Braley: Was that program excellent in the cooperation?

Dr. Beaudet: Yes, excellent.

Senator Braley: Did everything work the way it should?

Dr. Beaudet: It really did. That is why we are so worried about losing it. We have built a network. By that, we have brought together close to 90 scientists across the land, the top scientists in that field, to work together and to collaborate. We do that by giving them the money to support that network and to support the human infrastructure that is needed to maintain it. We created that infrastructure to be able to have the resources to carry out the research when the need arises because we do not have staff. That is exactly what happened; they were there. We want to ensure that we maintain that infrastructure for the next pandemic.

Senator Braley: You talked about money. I understood that. That was my next question, whether you paid them. Are there enough evidence-based trials and so on? When you are creating these things so quickly and trying to bring things down, who makes the call on whether the trial is three months, six months or nine months? Are the decisions under your jurisdiction?

Dr. Beaudet: It is our jurisdiction. All the proposals for trials are reviewed by experts. They tell us whether the proposed duration makes sense, whether the number of patients enrolled is sufficient to gather data that will be statistically significant, et cetera. That is us.

Mr. Singh: Usually, there are people who are experts and we bring in international experts, not only people from local communities. The process is a peer-reviewed process.

Senator Braley: Do you go to other countries also?

Mr. Singh: Absolutely.

Dr. Beaudet: Absolutely; we bring in experts.

Mr. Singh: When we started in 2003-04, there were probably about five people in the country working on flu research. Now we have close to —

Senator Braley: The general public, like customer service, must have that feeling of comfort with the information and everything.

Mr. Singh: Absolutely; however, without funding we cannot make that happen.

Dr. Beaudet: Canada ranks number one in the world for the quality and impact of its publications in clinical research.

Senator Braley: I am aware of that.

Senator Cordy: Thank you both very much for being here today and for the wonderful work that you are doing, and that the CIHR is doing, not only in this field but in many other fields.

I want to talk about the whole issue of human resources. We heard witnesses who appeared before us talk about clinical researchers and epidemiologists who were particularly stretched during the pandemic crisis. They were working seven days a week. They had challenges in terms of having the human resources to deal with a pandemic in a time of crisis.

They talked to us and said that people were seconded for two or three weeks at a time. Every time someone new came in, they had to be trained, not in the whole field of epidemiology but to give them a sense of what you were doing and where you were going.

How are we to deal with this issue? It is easy to schedule the research in times like now, when we are preparing for the next pandemic, than it is from the time period of last April until Christmas, for example, when you were, I do not want to use the term ``on the fly,'' but you were trying to keep things going 24 hours a day.

What will we do in Canada in terms of having the human resources to do these things?

Dr. Beaudet: The issue is a critical one. As I said, in terms of pandemic preparedness, at least we have a network now of people who have the necessary infrastructure, and we think it is important to maintain it. You raise a huge problem in all areas of clinical research, for a variety of reasons. We have fewer and fewer health professionals who are interested in entering research, or have the time to enter into research; the demands on the clinical side are such that it is becoming extraordinarily difficult for them to spend time conducting clinical research. The same is true for doctors and nurses.

In planning human resources clinically, you have to remember that health clinicians who conduct research are essential for the clinical research enterprise. We have to train these people, protect the time of these people, compensate them properly, and give them the infrastructure that will allow them to continue this extraordinarily important work, for which, as I said, Canada is renowned.

That is something we have realized, that we have come to grips with, where we are investing money and where we need more money to invest. That issue is central to our strategy on patient-oriented research; to ensure that the health professionals who conduct research have the means to conduct it, and to ensure that we have attractive career paths for health professionals who conduct research. They are essential in the chain of clinical research. They are the ones who conduct the research with patients.

Mr. Singh: It is also the responsibility of universities and hospitals to protect the time of people for conducting research, because it is not only funding agencies that can dictate; it is also the local environment. The universities have to take the responsibility to build the cadre of people who will be resourced; otherwise we will not have the future clinical researchers in this country.

Senator Cordy: That is unfortunate, but hopefully we can start working on it now.

Dr. Beaudet: There are solutions.

Senator Cordy: I like the term, ``patient-oriented research.'' That is a great way to phrase it.

I want to talk about what you do with the information and the data that you collect. We have heard many witnesses before you talk, which is why I am returning to these areas, about the electronic systems for collecting and distributing the data. Does CIHR have the capability for collection and distribution of the data? To whom does your data go, or does it depend on what you are researching? You spoke earlier about the Public Health Agency being involved, but who else has access to the data?

Dr. Beaudet: First, the data eventually are published and there is open access to these publications because they are funded by public money.

Second, there is end-of-grant reporting at CIHR, which is entirely electronic, whereby recipients of grants, at the end of the granting period, have to report on the results they have obtained. That report is also made public, so that information is accessible. It is important for us also to be able to use that information to identify the gaps, the needs, and whether what we funded worked.

In addition, conferences play an extremely important role for information exchange and dissemination. Hence, we are holding a conference in Montreal next month specifically on this topic so that researchers who worked on the H1N1 preparedness and response to the pandemic can come together, exchange their views, show their results and prepare, frankly, for the next one, which we are not in a hurry for.

Senator Cordy: We have to prepare.

Dr. Beaudet: It will happen. The question is when, but it will happen.

The Chair: I have several more questions.

Dr. Singh, is the rapid research response team also an answer — this is follows up on what Senator Cordy asked — to what we heard earlier in testimony, that there are not enough epidemiologists and methodologists for research? Would this kind of vehicle be able to access those resources better, and to co-opt people?

Mr. Singh: When we build teams, the teams will be multidisciplinary — epidemiologists, basic researchers and clinical researchers — because the goal of the team is to bring the best minds together and put them to work, not simply to work on one thing. The team can divide the work. Having a team is critical, because one hand does not know what the other hand is doing. That will be the key for building these teams.

I gave you this document. It has a list of how we put the team together. People from the Public Health Agency, from universities and from industry all came together and we were able to build the network and set what the priorities should be for the next few years and how we should move forward. That is when we were preparing, but if there is a new virus today, how do we respond? We need to bring the team together that has people from biology to genetics to vaccines, to decide how to address this virus. That is the goal of the team.

The Chair: To Dr. Beaudet or both of you, are there any aspects of CIHR's influenza and pandemic influenza research that have included an ethical component? Can you tell me about that area?

Mr. Singh: One of the witnesses you will hear later today, Dr. Ross Upshur, was a member of our team who was also connected to the World Health Organization. He was at the forefront of Canadian ethical issues around pandemics. Of the 70 programs we have funded that I mentioned, at least 4 or 5 of them relate to ethical issues; social consequences and issues around obtaining approval such as how to obtain the approval rapidly for, say, vaccine. The vaccine network you heard, based in Halifax, had to deal with this issue, because to conduct a trial, they need approval. I am sure patient-oriented research is a perfect example. We cannot conduct that research without addressing the ethical issues.

Dr. Beaudet: Every single clinical trial needs formal approval from an ethics review board. These clinical trials were no exception.

Mr. Singh: As well, for human research, researchers need ethical approval.

The Chair: Do you have any particular recommendations for us in this area going forward?

Mr. Singh: This area is difficult. If they want ethical approval in Halifax, will the people in Vancouver accept it? For 27 universities, they must have ethical approval. You can imagine if we have a pandemic outbreak, having to gather approvals. It will be the responsibility of the rapid research response team to have those protocols in place before these things come along.

Dr. Beaudet: It is an important and difficult aspect of clinical research in this country. The ethics approval is under the responsibility of ethics review boards that are in each institution in the country. When we are talking about multi- site trials, we are talking about multiple ethics approval. What we are looking at, and trying to encourage, is to have a less cumbersome system, a more efficient system, while at the same time ensuring that the patient is fully protected. That system would involve having fewer ethical review boards, or at least for multi-centre projects, the projects would be approved by one board or one board per province, let us say, but all the other institutions would accept the review of that single board. It would be an accreditation process, if you will.

The issue is complex but critical if we want to be able to respond rapidly, and also in terms of maintaining our competitiveness in clinical research in this country because the approval for a given trial can take a long time to go through all these separate boards. That issue is something we have recognized, and are working on with the provinces.

The Chair: That point is an introduction to the next panel, which will deal with that issue. If there are no other questions, then I thank our witnesses for helping us in this matter and providing their contribution to our dialogue.

The second panel of this meeting involves ethical and legal considerations. We have two people to help us through these issues.

Dr. Ross Upshur is Director at the University of Toronto Joint Centre for Bioethics. Dr. Upshur has designed and taught courses in the graduate, postgraduate and undergraduate curriculum in ethics, epidemiology and the philosophy of medicine. He has been active on advisory boards for the International Joint Commission, Doctors without Borders, the Science and Development Network — SciDev.Net — and several medical journals. He has consulted with the World Health Organization and the Grand Challenges in Global Health initiative.

Professor Françoise Baylis is in the Department of Bioethics at Dalhousie University. Her current research interests are in a wide range of things: novel technologies, assisted human reproduction, research involving women, stem cell research, women's health, public health and feminist ethics.

Currently, Professor Baylis is a member of the board of directors of the Canadian Centre for Ethics in Sport, and is a member of the Canadian commission of the UNESCO Sectoral Commission on the Natural, Social and Human Sciences.

Welcome to both of you. We will start with Dr. Upshur.

Dr. Ross Upshur, Director, University of Toronto Joint Centre for Bioethics, as an individual: I have to start with an apology to the committee. I was asked to provide a written submission, but that request was buried in the first email I received and there was uncertainty as to whether I would be able to make it. I apologize for not putting anything in writing.

The kind of work we do, which is applied ethics, and the papers we write may be accessible to this committee in ways that the genomic sequencing of the influenza virus may not be. I will be happy to forward some of those papers to the committee, particularly on some of the ethical issues and citizen stakeholder engagement. I will send them to the clerk.

I will take this opportunity to thank the Canadian Institutes of Health Research, being preceded by Dr. Singh and Dr. Beaudet, both of whom have supported some of the research I have conducted over the past seven to ten years, looking at ethical issues involved in responding to a variety of different pathogenic threats — first, SARS; and second, influenza and pandemic influenza.

My narrative goes back to SARS, and I will continue from there. Keeping in the same vein of some of the discussions I caught at the tail end of the previous panel, Canada rightfully should be proud of some of the contributions its scholars have made to understanding the ethical issues raised by pandemic response. Dr. Jaro Kotalik at Lakehead University wrote one of the first papers in an influential journal called Bioethics. My colleague to my left from Dalhousie University, along with Professor Kenny and Professor Sherwin, is doing some of the most essential fundamental work on how we rethink our obligations in terms of pandemics. Professor Alfieri at the University of Montreal has been influential in informing the Canadian Pandemic Influenza Plan for the Health Sector.

My own team and group has had its impact as well. We released a white paper on ethical issues in pandemic preparedness in 2005, which served as the basis for a global consultation in ethical issues by the World Health Organization. I was privileged to chair one of those working groups, particularly with respect to health care workers' obligations in situations where in the delivery of care, they may put themselves at risk and how to draw the line on those risks.

In that white paper document, Stand on Guard for Thee, we identified four major issues. These are legacies of SARS. They are not exhaustive, but they are important for consideration.

One of them has to do with the use of restrictive measures, such as quarantine and isolation, for the control of communicable diseases. We learned in SARS — and I was recruited out of my happy avuncular role as a family physician to be the quarantine officer for York Region Public Health — and I can assure you that telling people they are quarantined for 10 days and if they step out of that quarantine, they will face serious consequences, is not a pleasant role to play.

Taking that role seriously, we went on to address these issues in more fundamental ways, thinking through what are the ethical issues that are entailed in the suspension of a person's individual rights and liberties for the good of public health.

Another issue that I alluded to already was the duty and obligations of care of health care providers in conduct of their duty. With SARS, we noted that health care workers were disproportionately affected. Issues around health care worker obligations and where to draw the line in risk became pertinent in SARS. We followed up on those issues.

One area that is of immense importance to understanding some of the ethical complexities of pandemic response is resource allocation and priority setting; that is, how we utilize and conceive who will receive which scarce resources and under what criteria. There are still many unresolved issues there. That was an issue in H1N1 too, particularly when we started to talk about who is on the priority list on one day, but not on the list on another day. Parenthetically, as a family physician, a lot of the lists made no sense. When families came in with four kids in tow and a mother and father, and only one was on the priority list, it seemed exceedingly cruel to say, ``You can have the vaccine today and the rest of you can come back when you are on a priority list.''

It makes no sense. When we have frail, elderly people, and Monday is the day they are on the priority list but they are there on a Friday, it seems to be a cruel and unusual punishment to ask them to come back, particularly given the extortion of parking fees at hospitals these days.

A fourth area of concern relates to Canada's role as a global citizen, global governance and what we can contribute as one of the wealthier best-resourced countries in the world to assist and aid those of lesser fortune. As Margaret Chan likes to say, and as we have argued, a pandemic illustrates our universal vulnerability as humans. We are all in the same boat, so why does a border makes a huge amount of difference? The virus does not respect that border. How do we aid and assist? What is Canada's role in assisting and doing well in a pandemic?

From our white paper, we have conducted two further studies that are germane. It is one thing to say there are ethical issues; it is another to hear what citizens think are the issues, and whether the values and principles that we thought were important as academics and clinicians resonate with people across Canada.

We conducted deliberative town halls in three different cities where we brought in people — not selected people — for a day to work through scenarios that touched on those four areas to reflect on the ethical issues. It was a brilliantly transforming experience to see people engaged. They came out and said, ``I wish we could do that on every topic.'' We have undertaken survey work as well, which might be germane to your deliberations. People trust public health and their physicians. Those people are the ones they look to for advice and guidance.

Finally, our current project is the Canadian Program of Research on Ethics in a Pandemic. In this group, we engaged citizens and entered into some thinking on the ethical issues, perhaps not as deep, consistent and coherent as it should have been. You probably have heard this point in your testimony, and what I have read so far attests to it. We noticed a jumble of different organizations and acronyms are all trying to coordinate a response.

We saw three people: policy-makers; implementers, namely, physicians, nurses and health care providers; and affected populations. I will not call them ``vulnerable'' because when we said they were vulnerable populations, they did not like that label. We will call them ``special needs populations.'' In this grant, we brought them together to talk about how they were planning, how they were coordinating together and what their concerns were going forward. We had policy representatives from the Public Health Agency of Canada, the World Health Organization and the Ontario Agency for Health Protection and Promotion. We brought together the regulatory bodies of health professionals, namely, nursing, medicine, pharmacy, occupational health and physiotherapy, and representatives from seniors groups, First Nations communities, rehabilitation populations and other groups that work in homeless shelters to bring the issues to the surface. In the midst of this preparedness grant, H1N1 hit, and we went into response mode.

Some issues we dealt with were the issues of data sharing between organizations and sample sharing. We did a reasonable job, but we could do better. There was the issue of research ethics. I hope we can spend time picking up on what Dr. Beaudet and Mr. Singh said about multi-site review. There are solutions out there that are promising.

In May, we brought all these groups of people together again after the pandemic to ask about the lessons learned. How did we do well, and how did we not do well? Three issues came up.

One has been mentioned by everyone that has testified before this committee, namely, communication was suboptimal and we need to enhance communication.

The second issue is how we set priorities; by what grounds and means and how we communicate that information. We can do a better job of that communication. Communities love to be engaged and want their input heard at the policy tables. Policy makers welcome hearing from the public about this subject. It is imperfect; sometimes special interests can get in there. However, it can be done.

Finally, risk communication is important. Most important of all is trust. Trust, to me, is one of the most fascinating concepts in ethics in human life because few people can tell us what it is and how we get it, but virtually everyone knows when it is not there. How agencies, clinicians and groups can act in a trustworthy manner and build trust with the communities they serve is one of the overarching issues.

I will stop there and hope to have more time to answer questions.

The Chair: Thank you very much. Professor Baylis is next.

Françoise Baylis, Professor, Department of Bioethics, Dalhousie University, as an individual: You will hear overlap in what I have to say, which is good because it suggests we have hit on the right things for you to hear.

My work in this area is recent and dates back only two or three years ago, when a colleague of mine at Dalhousie University, Sister Nuala Kenny, received a grant from CIHR on pandemic planning. We were anxious when we submitted the grant proposal because the call was for something on pandemic planning, and our proposal was to say, we cannot plan for an epidemic unless we step back and do foundational work on public health ethics. If we do not understand, and do not have a plan for, public health, our plan for a pandemic will not work. That foundational work was the project we wanted to do. We thought we would take our chances. Either they will fund us or they only want to fund work on pandemics.

We were funded, and the work I share with you today comes from that funding.

I will address four issues briefly, but I hope they spark your interest. I will be happy to expand on any of those issues and many others.

One has to do with the issue of governance. It focuses on the overarching importance of public trust, which has been referred to.

The second issue concerns the need for effective communication in building and maintaining that trust.

The third issue concerns priority setting, with particular attention to vaccine sequencing. You have heard about that issue, and I will try to expand on it.

The fourth issue, dear to my heart, concerns the issue of equity. Here, I want to focus on the disproportionate burden of illness borne by our First Nations communities. For the record, I have a strong interest in our international obligations in outbreaks of global significance, something that has been mentioned. I will not address that issue in my brief remarks. I have provided you with a copy of two brief editorials that address some of those issues.

Let me start with public trust and the 2009 pandemic.

Governments on both the federal and provincial level clearly wanted people to choose to be vaccinated. They wanted this vaccination to happen in a way that would meet the health needs of those most at risk first; hence, there was an attempt to develop a sequencing plan. To develop that plan, however, we need public trust. In turn, for there to be public trust, Canadians need to know at least two things: one, that the vaccine is safe and effective; and, two, that the sequencing plan is fair.

Instead, I suggest to you that the public received confusing messages about the safety of the adjuvanted vaccine, especially following the flip-flop on what should or should not happen with pregnant women. Furthermore, the public could hardly have confidence in the sequencing plan when this plan, supposedly based on the latest scientific and epidemiological evidence and legal and ethical considerations — that is, what we were told by Public Health Agency of Canada — varied on the basis of geography.

The virus did not change as it swept across the country, but the order in which Canadians were provided with access to the vaccines did. Public trust was thereby placed at risk and, in turn, public health goals were imperilled.

Let me mention something briefly about effective communication. Again, the Public Health Agency of Canada and other public health authorities, from my perspective, did a poor job of communicating effectively with the general public. The public was confused, and in many cases, rightly so. I participated in a lot of radio interviews at that time, and I was surprised at what filled my email box when I came in. In some cases, comments were, ``Thank you. I finally understand something.''

I am an ethicist. I should not have had to answer questions that were about basic issues at a level that I could explain but were the business of someone else to explain.

One strategy that might have helped would have been a plan that started with basic vaccine education. In my opinion, a carefully staged public education campaign should have begun in the summer of 2009, long before there was any stress, shall we say, well in advance of the H1N1 influenza pandemic in Canada. Initially, it should have focused on the basics: What is a vaccine? I can tell you that prior to this pandemic, many Canadians could not have answered that question. How do vaccines work? Canadians did not understand that process. Why do we routinely vaccinate newborns and children? Why do the elderly receive a vaccine for seasonal influenza? We could have answered these questions and then built on that basic knowledge in terms of what should or should not happen with respect to H1N1.

Beyond this issue, generally for the next time, more work is needed in terms of improving the timing and content of public communications; more work is needed on effectively using social networking tools. I am beyond that generation by a long shot but they are important. Third, it is important to develop partnerships with trusted key opinion leaders and with the media. I cannot insist enough on this last point and I will be happy to expand on it later.

My third brief comment concerns sequencing. It is probably something you have heard lots about but I want to add a comment. While other countries around the globe identified priority groups to receive the vaccine, the Government of Canada made a commitment to provide vaccine for all Canadians who needed or wanted to be vaccinated. However, all vaccine was not available on day one, and even if it was available on day one, it could not have been delivered to all Canadians on day one, so everyone knew there had to be some kind of distribution plan.

The plan was not first-come-first-served. It was supposed to be about early access for those most at risk. Two groups or clusters, if you will, were identified, and I have put that information on two slides. The first group was those who would most benefit from immunization and the second group was others who would benefit from immunization.

You might want to quarrel with the list, but that is not my intention. I want to defer to the expertise of those who developed the lists. My quarrel is with the fact that the lists were only recommendations and the provinces and territories could or could not follow them. Not all provinces and territories followed those lists, and as a result, there was no uniformity across the country.

If you look at the next two slides, you will see what it should have looked like in terms of moving through those priority groups that were identified. That is this particular picture here, and thank you to one of my graduate students who did this work. The second, because it had to do with my graduate student's work in the area of obstetrics and gynecology, we tracked what happened with respect to access for pregnant women in my little part of the world, the Maritime provinces. You can see here quickly that nothing is consistent. We ended up having to close clinics and reopen them. Vaccination was open to the general public and then was not, and I could say much more about that situation.

The point is, you had a plan that you did not follow, so you cannot expect people to trust that the plan was a good one in the first place if you did not think it was worth following when it came time to make decisions. The situation was confusing; it was frustrating, and more than that, I argue that it could have been risky for Canadians if the virus had been more virulent.

I realize that I am wading into complex and contested constitutional waters because health is a provincial responsibility, but there is an issue that needs to be addressed in a timely fashion. In my view, there needs to be a harmonized response to pandemic. I suggest that perhaps uniform statutes could be developed through the Uniform Law Conference of Canada. Through this process, considerable harmonization has been achieved in others areas that have to do with health, and I have included a few examples: Health Care Directives Act, the Human Tissue Donation Act, the Medical Consent of Minors Act, et cetera.

However, beyond this issue, and this is where we really start to become contentious, careful thought must be given now, not in a future crisis situation, to when we believe as Canadians, and you as part of government, that pandemic has more to do with ``peace, order and good government'' than it has to do with health such that a federal intervention may be not only warranted but called for. That challenge needs to be addressed in a timely fashion. Imagine that the H1N1 virus had been more virulent, that thousands upon thousands of Canadians were dying and emergency measures needed to be invoked. What would have happened?

Let me end with a brief comment on relational public heath ethics, which is the foundational work we have been doing at Dalhousie. I want to apply it in a practical way to address the uneven burden of illness for our First Nations.

Our approach to pandemic planning is nested purposely in relationship public health ethics. Our approach aims to promote population and community health, and reduce health inequalities. This approach, which focuses on relational personhood, autonomy, social justice and solidarity could have informed pandemic planning usefully.

An important feature of relational ethics is the recognition of mutual but not equal vulnerability. We are not, as Canadians, equally situated or affected by public health concerns and policies. We have to attend to the needs of the disadvantaged and ensure their fair access to social goods. This reasoning informs the belief that governments — federal, provincial and territorial — in Canada failed to meet their ethical obligations to First Nations individuals, families and communities in the years, months and weeks leading up to the H1N1 influenza pandemic in Canada.

This pandemic disproportionately affected First Nations both on- and off-reserve. That data is now available. We could have anticipated this burden of illness if a relational public health ethics approach had been used because this approach would have focused our attention on issues of social justice and on the historical as well as contemporary political, economic and social marginalization of First Nations.

A relational public framework suggests that there are possible responses to pandemic that draw our attention away from emergency response, away from things like the vaccination, away from critical care triage protocols, et cetera. Instead, we focused on an emergency response with insufficient attention to public health.

If we had looked at the influenza pandemic through the lens of relational theory, and carefully considered this situation, what might we have seen differently? Among other things, we would have seen that these communities already have disproportionately more underlying health conditions than the average health population, primarily related to long-standing issues of poverty, inadequate housing, unemployment and access to ongoing economic development opportunities. If we had truly opened our eyes wide, we might also have seen our collective failure to correct these underlying threats to public health, coupled with the more specific failures to put into place appropriate emergency response measures.

The Chair: You have given us a lot of food for thought here. We will have questions now.

First, I want to ask about something that neither one of you mentioned. I am curious to know how we relate to the World Health Organization's guidelines and the question of ethics. The WHO put out a document entitled Ethical considerations in developing a public health response to pandemic influenza covering everything from balancing rights, interests and values; the evidence for public health measures; transparency; public engagement and social mobilization; information; education; communications; and resource constraints.

How did Canada fare in confronting the H1N1 pandemic in terms of the WHO document? Both of you have told us where you think further work is needed. You were clear about that area. Is there anything about that plan that we need to address further?

Ms. Baylis: Early on, WHO called on many countries to donate vaccine to the developing world as part of an overall global response. I believed then, and I still believe, that Canada failed miserably in responding to that call. Our government initially said it would not make a contribution, and that at a time when the United States, the United Kingdom and a number of other jurisdictions said they would commit. The original response was that, if we had any excess vaccine, we would give it back to the company and, because GlaxoSmithKline and others had also made commitments already to donate to the developing world, the company could choose to add that vaccine to their pool, but at that time, we would not make any kind of contribution. There was a change of plans at a later date.

I have said on the record that I was ashamed at that in time, and not only because of what I took to be foolish decision making. If you understand how the virus works, it makes no sense to think of it in terms of geography. That point has already been well made. That is not what my country stands for or what I stand for as a Canadian. That is the most important thing that I thought with respect to that response.

The document makes a number of important contributions. It says a lot with respect to issues of process. I have no quarrel with it on a big picture scale, but that was the first time that there was a public call for us to stand up, along with others, and we did not.

The Chair: We subsequently provided vaccine though, did we not?

Dr. Upshur: We sent some to Mexico.

Senator Cordy: However, Mexico did not need it. Dr. Butler-Jones said that we sent 5 million doses, but at that time, Mexico did not need it. The Canadian International Development Agency also received 5 million, but I think it was too late.

Dr. Upshur: The document itself is strongly influenced by, and modeled on, work done in Canada. Canadian representatives were at the global consultation and there was a Canadian chair of one of the working groups. The summary document and recommendations were written by Alex Capron, an American who at the time was the head of the ethics office at the WHO. We can be proud of having influence on the global stage and in the actual framing.

As to whether we had the framing right, I am more and more persuaded by the Dalhousie group's thinking about relational ways of responding to a pandemic. I call them the gluey principles in my off-the-cuff way of thinking. Principles of ethics that recognize our mutuality and our interdependence are important in times of a pandemic. Also, about the point that Professor Baylis made about the differential impact of that vulnerability remains an important one, and I want to endorse her statement around First Nations. We had them at the table of our stakeholder forums and have heard loud and clear about how we failed them historically as well as presently with the H1N1 response.

We performed much better this time than we did with SARS. Let me reinforce that point. I was a field epidemiologist during SARS. We saw the bench scientists sequence the gene while we were still working with sticky notes trying to figure out who had what, and to harmonize line listings for follow-up. We performed much better in that regard.

We also saw unprecedented global collaboration. The nations shared and communicated information. We started to see some of the benefits of social networking technology. One of my colleagues at the University of Toronto is interested in looking at the messages that are going out through YouTube, Facebook, Twitter and all the other social networking media about influenza and vaccines.

We had an unprecedented look at the evolution of a virus in human populations in real time because we were able to sequence viruses and find out where resistances were arising. We must remember that it is still going on today. We are not finished with H1N1.

Professor Baylis wants to step back and go to fundamentals about ethics. Let us step back and go to fundamentals about viruses. The 1968 pandemic virus became the regular seasonal virus. The amount of morbidity and mortality from 1968 to 2010 associated with H3N2 was substantial. It rivals and surpasses the 1919 influenza pandemic.

People are saying that H1N1 is now becoming only a seasonal flu. My early research showed an absolute increase in morbidity and mortality, particularly in seniors, associated with regular seasonal flu. We have had 40 dress rehearsals for the pandemic with seasonal flu and we have done little in terms of preparation by using what happens with the seasonal flu as a dry run for a surge associated with a new virus.

Influenza viruses are well sequestered through many mammal species. Canada has probably the richest reservoir of influenza viruses in the world because they are reservoired in aquatic birds. The Canadian Shield in the summer, when all the ducks are there, is a gold mine for all the influenza viruses. It is reasserting and we will see it again. To say that we got off easy with H1N1 and to fold up shop would be a huge mistake.

The Chair: Professor Baylis, you suggest that the federal government should use the peace, order and good government provision to impose sequencing of vaccine priority groups. Are you suggesting that the federal government make the decision or would the federal government work it out with the provinces?

Ms. Baylis: I think that if you are serious about it, you start working with the provinces now and come to an understanding, and hopefully you arrive at that understanding in a cooperative context. The goal is not for one or the other party to assert authority. The goal is to recognize that there may come a time when certain values have to come to the fore, and that the most effective way to proceed in pursuit of the interests of Canadians will be to have a uniform national response.

An option is to sit back and say that, it being health, there is nothing we can do, that the provinces will decide; we can make general recommendations and beg them to follow them but that at the end of the day it is their decision. However, we have certain mechanisms that allow the federal government rightfully to step in. Let us have a collaborative conversation now with the provinces and see if we can come to an agreement to ensure that we all understand the rules of the game. Provincially, they can do what they are doing to a certain point.

I do not know where the line is, but surely there must be one. It cannot be the case that Canadians would expect their federal government to sit back and say that there is nothing they can do. Given that we can anticipate that there may be criteria on the basis of which it would be appropriate to intervene, let us try to figure out those criteria now so that if and when the time comes that the federal government needs or wants to act, it was anticipated.

The worst thing we could do at that point is to start a constitutional challenge. Do we want a legal debate when we are in the midst of a pandemic? Good work can be done now with the right minds around the table, respecting the Constitution, to figure out when it is appropriate to insist on a common response.

The Chair: You talked about a basic vaccine education. That involves more than H1N1.

Ms. Baylis: That is right.

The Chair: It is basic vaccine education, period. It covers a pandemic situation where vaccines are needed.

Do you suggest the same there, or is that something that will be left to the provinces?

Ms. Baylis: Education is a complex issue because we cannot impose it on the recipients that we want to have more information. However, we are in a period of transition where we need to learn how to use new media in partnership. The news media is in a period of transition. They are figuring out new roles for themselves in terms of how much is entertainment, how much is education, how much is investigative journalism, et cetera. There are ways in which both sets of interests can be pursued in a creative way. Much of the media attention could have been directed more positively if the common goal was how to help Canadians. That was not the common goal, and that, again, requires a certain kind of exploration.

Early in the summer I tried hard to have CBC put on a town hall. Part of my suggestion was, let us have Canadian experts and let us have the audience be all those people across Canada who think they have authority in terms of how they will manage things. Let us have Canadians tell the experts what it is Canadians need to know, what will make them trust their government and when they would or would not want to come forward for vaccine. Governments had hopes and plans. Yes, there was consultation, but there are ways in which that consultation could have happened in an instructive public way, where there could have been ripple effects in terms of learning.

Senator Callbeck: Thank you both for coming here today.

You talked about communication. Dr. Upshur, you said we have to enhance communication. Professor Baylis, you spoke about causing confusion in the minds of the public at times. We have heard this point from many witnesses.

Professor, you spoke about basic education early on. You said you believe work needs to be done. You then listed three things. I want to hear you elaborate on each of these things. The first was improving the timing and contact of public communication.

Ms. Baylis: Basically, we saw public announcements on television. We saw David Butler-Jones encouraging people to become vaccinated, and I am sure other provinces had other kinds of public announcements. I would rather have had public education happen much earlier, and in a way that was not necessarily focused on H1N1. There was news about H1N1 because it was not a Canadian phenomenon. We could have been reading on the Internet what was or was not happening, for example, in Australia. I think there is a way that we could have had a staged, well-planned process that did not assume knowledge. The interesting thing is, yes, in the context of educating Canadians, they had to learn about what was an adjuvanted and unadjuvanted vaccine. Most Canadians would not have known about that difference prior to H1N1.

The issue became contentious, but the flip-flopping may not have happened if there had been proper education way back when, rather than what we saw as a series of events where the media made an issue about this difference, where people became concerned, and where the population we are talking about, namely pregnant women, typically do not even come forward for seasonal vaccine. It has been recommended in both Canada and the United States at least since the 1960s that pregnant women receive seasonal influenza vaccine. Right now, 15 per cent of pregnant women wilfully come forward for that vaccine.

Here is an at-risk group that has all kinds of reasons not to come forward and historically has not come forward, and the messaging to them is not well-thought-out and not consistent. None of that confusion needed to happen.

Dr. Upshur: We have had several years of seasonal vaccine to improve understanding amongst pregnant women, for example, and enhance their willingness to be vaccinated before the H1N1 outbreak. As Dr. Baylis rightly points out, it has been a recommendation that pregnant women or women who are pregnant during influenza season be vaccinated. Uptake levels are low. There was a lot of opportunity to improve that uptake before an influenza outbreak. It is the same thing now. We are going into a seasonal pattern of influenza. Let us work on some of these basic building blocks of understanding and communication so we do not have to reinvent the wheel the next time a new virus comes around.

Ms. Baylis: In my province — and I hear and read about this subject in the media, so I assume discussion is happening across the country — there is a lot of interest in lessons learned. When I raise the issue of communication locally with our public health officer, there is total resistance to even hearing the kinds of criticisms that people are trying to make in a constructive way. That resistance is another thing that is compounding a particular problem with respect to this issue. Maybe there are people who feel a little bruised. I have spent a lot of time saying that, on the ground, people were working hard, but this issue is a big-picture issue that is not about any one person. It is about having a strategy to educate more than 30 million people. We cannot educate them haphazardly.

Senator Callbeck: You mentioned effectively using social networking tools. Can you elaborate, please?

Ms. Baylis: Different mechanisms are available from simple things. For example, I live at a university. When you walk into many of our buildings, we now have TV screens with announcements and things like that. There are ways in which the university can deliver messages to a large community of people. We then must have behind those mechanisms a real plan in terms of the availability of clinics, et cetera. That is where we had problems. The communication also depends on what you know that you have to communicate? Part of my concern is with the mechanisms being used. The examples I gave are two simple ones that are not sophisticated. They are about things happening on Facebook and Twitter, and all the things I do not pretend to know much about, but those mechanisms are what my kids use. That is where the messaging is happening. If they think something is important, it flies quickly. I am not the right person to answer that question. My daughter who is 16 could do a better job telling you how to use those mechanisms.

Dr. Upshur: There has been active research looking at how these new social network media have been used to communicate messages, both beneficial and harmful, regarding H1N1, vaccines, antivirals, et cetera. A couple of people at the University of Toronto and someone here at the University of Ottawa have conducted that research, and they will present in November at the Pandemic Preparedness Strategic Research Initiative meeting, which is all the research that has been conducted on pandemics in Canada. I think it is important.

The Chair: That meeting is in November, you said?

Dr. Upshur: Yes, November 11 to 13.

The Chair: Is any information available from those people now?

Dr. Upshur: If you contact Dr. Singh's successor, Professor Marc Ouellette, the program is being put together and it should be available soon. It is on the web.

Senator Callbeck: Your third point was the partnerships with the media.

Ms. Baylis: The partnerships issue is that many individual people who have public roles have relationships with the media. They can call the media and ask if they want to write a story on this issue. There are ways that information can be delivered institutionally and structurally so that it is not only about getting a good story. Much of what happened in the early days of H1N1 was looking for controversy within a particular way of framing and understanding one's job in the media. There might have been ways — again they would have required a lot of preplanning — to develop a partnership and relationship, which does not stop the media playing its investigative role, asking hard questions, et cetera. The media wanted to play an educational role. Almost all of them had questions and answers. They have questions and answers on the PHAC website, on CTV, CBC and every major newspaper. They are not all saying the same thing. If we look at who identified which questions as being important and where they ended up, that is where, again, a partnership with Canadians would have been beneficial. They could have identified what questions were important to them, as opposed to someone else with an academic, scientific or political perspective deciding that these things were what people needed to know.

That is what I mean by partnerships, namely, finding out what people need to know; bringing that information together; making it accessible at the right level, which we hear now is grade 8; and trying to see if there are ways to have consistent information that people are willing to use commonly instead of the diversity that happened. I am not saying we can stop that diversity. I am saying there are conversations and negotiations that could have been tried. They may not have been successful, but I think the media wanted to play more roles than only the investigative reporter looking for the scoop and the big story, whether it was someone cheating and jumping the queue, someone failing to be vaccinated, or someone being turned away.

Dr. Upshur: I think there were also great examples of accomplished journalism. In particular, Helen Branswell and André Picard come to mind for their excellent reporting on H1N1 and influenza in general.

Senator Callbeck: There is no doubt that the information caused a lot of confusion in the public. It is difficult, because the media usually want to cover something from all angles. This is what caused so much confusion out there with people.

Ms. Baylis: The government must own part of the confusion. One simple example is the flip-flopping around the adjuvanted and unadjuvanted vaccine. If we look at the data and the science, there was no reason for that flip-flop. If we look at other countries, they tried different things. The United States went with the unadjuvanted vaccine. Britain went with an adjuvanted vaccine. Neither of them flip-flopped. The science was there to defend the initial decision that the government made with respect to adjuvanted vaccine. There was no reason for that flip-flop.

However, that decision undermined public trust in a tremendous way: If that vaccine is not good enough for pregnant women, is it really good enough for me? To this day, I do not understand why that issue was not managed differently. If we look at the advice that was given by the Public Health Agency, it does not map one to one with the advice given by the Society of Obstetricians and Gynaecologists of Canada. If you talk to people who were on the ground, physicians or specialists in OB/GYN, they were looking to figure out what to do, and every day they went to the website to try to find out what is happening.

Then there was different information around the demarcation line of 20 weeks, where they decided if someone was above or below 20 weeks. Again, I do not think that information was helpful in terms of giving confidence either to that population or to Canadians writ large. I think that situation was an example of something we could have done differently.

Senator Eaton: These are fascinating subjects.

Ms. Baylis, you said it would be good if the government had an instrument to override in a health emergency and that they should talk about this instrument now. Are you talking about something like a War Measures Act, but instead a health measures act? If the government declared a pandemic or a health emergency, they will have worked out ahead of time with the provinces that they would decide who and in what order people received whatever allocated resources the provinces had; they would decide if schools are closed; they would decide whether the army moves in; or whatever. Are you advocating something along those lines?

Ms. Baylis: I think I am advocating something along those lines. I hope we do not end up having to draw the analogy to the War Measures Act, for all kinds of reasons.

Senator Eaton: Something that, in an emergency, worked. Whether we agree with it or not — and I was in Quebec at the time and I felt much more comfortable, but that is another discussion.

Ms. Baylis: What I want to say is, possible. Let us imagine a scenario where one part of the country is particularly hard hit. Let us imagine that the resources we need — whether they be people, personnel, critical care beds, vaccines or whatever — are somewhere else. I am putting it in those kinds of stark terms, but somewhere else in Canada.

Are we then going to sit down and have long, bilateral conversations between two provinces about whether one province would, could or should help?

Senator Eaton: I agree with you. In Toronto, there was confusion because some schools were closed, and on other days the schools were reopening, there were three kids in that school over there, and we shut all the schools in the surrounding area. It was confusing.

Ms. Baylis: Some work was done around SARS. Perhaps Dr. Upshur can speak to this point. The report David Naylor put out addresses this issue as well, where they look at some of the ethical and legal issues. They refer again to ``peace, order and good government,'' which the lawyers refer to as POG. The mechanism exists. At this point, I do not have any insights into the particularities of how it might work. I believe it is a priority to bring the right people around the table to start figuring out how that mechanism can be used.

The beauty of doing it now is that they would not do it off the cuff in an emergency, in a crisis. They would try hard to say: Let us come to an agreement; let us exercise our moral imagination; let us think about these kinds of scenarios that could go wrong; and this is when we think it would be reasonable. Hopefully, there is an understanding and an agreement such that if that power is used, it is used in a context where at least nobody is surprised. They may not be happy or may not agree, but there were efforts in advance to lay the groundwork.

Senator Eaton: However, people had signed on and if supplies have to be allocated from one area of the country to another, someone in Ottawa is breaking down the silos, looking at the big picture and making the decisions.

Dr. Upshur: To pick up on that point, I think it was Professor Choudhury at the University of Toronto who wrote the section on what kind of law reform would be required. That section was a submission to the Naylor Commission on SARS.

Has Professor Kumanan Wilson come to speak to this committee? He is here in Ottawa. He is the Canada Research Chair in Public Health Policy.

The Chair: He was asked, but he could not make it.

Dr. Upshur: I will put a fire under him. He understands federal-provincial public health laws and has written papers on what reforms or instruments are available to serve some of these ends.

The Chair: It would be helpful if he could send us something on this area.

Dr. Upshur: I will have him send his papers. He is part of our research team. As the principal investigator, I will implore him to be a good citizen and send his work, which I think would be illuminating to this committee.

Senator Eaton: We have heard about communications over and over again. Something I did not understand, but I have been made to understand a little more, is that when I heard the word ``pandemic,'' I assumed hundreds and thousands of people were sick. Then I slowly figured out that the World Health Organization was looking at a map and saying: It is in South Africa, it is here, it is there, so therefore it is a pandemic.

Should we create, when we are not in a pandemic situation, our own standard words that Canadians can understand, maybe not referring to geographic areas but more to the intensity or the numbers of people who are sick? I think there was a misunderstanding, not only mine. The word ``pandemic,'' we thought it was an influenza of the early 20th century. I think we can work on words and definitions more, and tell the Canadian public, yes, there are 500 people sick, not 500,000 people.

Dr. Upshur: ``Pandemic'' is a term from communicable disease epidemiology. It has a lovely Greek ancestry of ``pan,'' meaning ``all,'' and ``demos,'' meaning ``people.''

One of the criteria for a pandemic influenza virus is that it is a newly identified strain of virus that has rapid global spread. It is a geographic descriptor, not a severity descriptor. I completely agree; going forward, we will have to uncouple geographic distribution of disease with severity. The levels of pandemic declaration by the World Health Organization — which, from where they sit in Geneva, where they have the whole world under their concern — can be fierce and virulent in local areas like it was originally in Mexico, but mild elsewhere. There is both the severity and the geographic dispersion. I think you will see action, movement and changes on that approach.

Senator Eaton: I hope so, even if it is only a colour chart. When we talk about trust, it gives people a greater sense of trust, because they do not feel the government is exaggerating. I think many people at the end of H1N1 thought, ``What was that all about?''

Dr. Upshur: It is a bit odd that people were disappointed that not enough people died.

Senator Eaton: Expectations were built up.

The Chair: The pandemic was a big thing.

Dr. Upshur: It was, and a lot of people were sick around the world. Let us not forget about that. My view is that a pandemic never ends. We are not finished yet.

Senator Eaton: I am not saying that. As Ms. Baylis said, to establish a degree of trust, we have to use the right words.

Ms. Baylis: The thing we also need to be wary of is we cannot invent words that will work only in a Canadian context because of the global context we are living in. People will know and hear. What we need to see is an uncoupling of the issue of distribution versus severity.

For example, that kind of thing could have been talked about in the summer, when there was not any immediate health crisis or perception of health crisis in a Canadian context. Part of the story could be that there is a pandemic now. What does pandemic mean? That is what I meant when I said we needed basic education such that when things happen in a particular context, there is a frame of reference.

We do that with kids for other things. We teach them sex education, and I think my son was eight years old at the time. The idea is that we are trying to have them understand words and concepts long before they need to act on them and use them.

Senator Eaton: I still think we have to come up with a vocabulary that indicates severity as well as geographic mass.

Dr. Upshur: The World Health Organization has learned that lesson, but it takes time. You have worked in government. It is slow to see change sometimes. With all the member states at the World Health Organization, it has to go to the World Health Assembly. Perhaps by 2015, we might have something. I am only kidding.

Senator Cordy: My concern is that because, fortunately, the pandemic was not as severe as people thought it would be, when the next pandemic arrives, people will become much more complacent and ho-hum, and think, ``Maybe I will not have a vaccination,'' et cetera.

My question is about the priority groups. I would not want to determine what the priority groups are — who goes first and second. We had witnesses from a nurses union, the Canadian Teachers' Federation, police and firefighters and everyone cannot be in the priority group.

One thing that stands out for me was when we had the First Nations Aboriginal panel before us. Regarding the development of the priorities, they spoke about the lack of attention, or the seeming lack of attention, paid to cultural aspects.

Later, I sat down with them after the panel was over and asked if they could expand on that point. Two of them said they would never be vaccinated before the elders in their community were vaccinated, no matter what anyone in Ottawa or anywhere else said. That was one issue they raised.

Another issue relates not only to First Nations peoples but those living in remote areas that Dr. Upshur made reference to earlier. They drive 20 miles with their children, and only one child can be vaccinated. Therefore, they have to come back on another day for their other child. Then they come back on yet another day and take their parents with you. That approach does not make sense.

Professor Baylis, you made reference to the living conditions of Aboriginals. With three generations living together, overcrowding and poor sanitary conditions, what is the advantage to having one person in the household vaccinated? If one person catches the pandemic virus, they will all catch it.

In developing priorities, there is so much we have to take into account. I agree with you, Professor Baylis: We cannot develop priorities in the midst of a pandemic. What do we do?

Ms. Baylis: I will offer two comments. When Dr. Upshur made his comment, he said this approach was cruel. I wrote down that it was not only cruel but wrong.

Dr. Upshur: It was dumb.

Ms. Baylis: It is stupid, too; it is cruel, crazy and dumb. There is nothing to defend that approach. I want to use that example of where I think our work on relational theory would have had an impact.

Part of what is foundational about that work is that it recognizes that people live in families and communities. It is within that context where they learn who they are, what their priorities are and what it means to be supportive. With that kind of philosophical perspective, they would never have ended up with this kind of list, which looked narrowly at an individual in isolation as though a baby somehow lives in the world by itself and shows up by itself to be vaccinated.

That concrete example is where, if they had started with a theory that said people are embedded in families, they would have had a philosophy that would have allowed for greater related inclusion. It would have said that, even if we had some kind of priority list, if they made it onto the list, anyone who comes with them is vaccinated at the same time.

People have pushed back and said, people will cheat. Yes, they will. There are places around the world where they manage to have transit that works on an honour system. For the few that might try to game the system, they do not set up an entire infrastructure to police. They spend a lot of time educating.

Around this issue, I spent a lot of time trying to explain to people why waiting their turn was a good thing to do from a moral point of view, and a smart thing to do. We wanted them to understand it as a communal risk and to ensure that everyone who was vaccinated before them was helping protect them. That was a basic concept again that I think could have been worked on beforehand. That is the first thing I want to say.

The second thing is with respect to the living conditions that made it already difficult from a public health point of view. We are conducting research now where we are looking at water quality across Canada. It is shocking to find out how many of our First Nations communities cannot rely on clean water. Here we have the Public Health Agency of Canada telling people to wash their hands, and sanitizers popping up all over the place; they will not disappear. We walk into not only the hospital but the bank and the sanitizers are there.

Then we hear that certain First Nations communities cannot even obtain hand sanitizers, never mind clean water, because we are concerned they are alcohol-based. I can only think, ``You want people to feel they are part of this community and that you care for them; did you think through anything; did you have a plan?''

These things are basic. However, when we see them happen in multiple ways and at various times, we ask what the strategy is, and whether people are paying attention to the underlying problems, cultural context or priorities.

That is why I wanted to say strongly here: We needed to think about this issue from a public health point of view and we needed to think about it years ago. The unevenness of our vulnerability is an important thing to recognize at the same time that we recognize that we are all vulnerable.

Dr. Upshur: If I had one message to the committee to take forward and make recommendations on, it is around investing in appropriate priority setting and resource allocation methods. It is difficult to do well. It is contentious and it is incredibly important.

We have argued for this kind of a lesson right from the beginning. When the emergency rooms are filling up is not the time to have the arguments about who goes first. We need to have a principled public discussion about which values will animate the decisions. South of the border, there have been influential arguments that are variations on fair innings or efficiency — that investment in vaccines, life-saving drugs and technology should go to those who have more potential years of life than those who are older. Some people will argue the opposite, as in the example you gave where they would never think of not caring for their elders first. We need to have that discussion about which principles will animate our priority sequencing.

There was a good object lesson during Hurricane Katrina. Water was flooding into a hospital and all the electricity was out. The clinicians wanted to take out the sickest people, the firefighters wanted to take out the walking wounded and the helicopters were only interested in taking pregnant women. I submit that when the water is rising and the levees are broken is not the time to have an argument about first principles of philosophy.

We can do a better job by having a broad public discussion on priorities. We have the methodology; we have engaged people on how they think these discussions should go. I am happy to share that data with you.

However, going forward, it is one of the most important things. We cannot leave it latent and tacit, and say we will base it on the belief that the science is there to inform us in a timely fashion. I can assure you, it almost never is, which is why ethics are important. Often, we are left with the values and goals we are trying to achieve with our public health response. We can wait for the technical information to come in, but it is hard won and takes time. We often have to take the decisions in advance. We have time before the next pandemic to do a better job in priority setting.

Senator Cordy: People tend not to think rationally if someone in their children's school has H1N1.

Dr. Upshur: A good example is where seniors are placed on the priority list. If we, by fiat, put them at the bottom, we might have resistance. If we ask, we have a different story. There are lovely studies showing that older people would willingly cede their place in a queue for coronary artery surgery if they are asked, listened to and respected as having a say in that choice.

It is easy to say we will communicate with the public but it is hard to listen to, and to take seriously what we hear, as I have learned. If we ask people, we might receive heterogeneous responses. Some would be willing and some would not. However, if we are to be person-centred, as was talked about before, and relational, we need to think about how people think about themselves and relationships, who and what they value and adjust to that view.

Senator Cordy: My other question follows up on a question Senator Eaton asked. Should the federal government ever have the mandate to force vaccines on groups at risk? Is there ever a situation where you can see that happening?

Dr. Upshur: No.

Senator Cordy: Is vaccination always voluntary? I do not know the answer. I am curious.

Dr. Upshur: As long as there is a concern with human rights and exercise of conscience, you will have a hard time. People talk about mandatory vaccination, but it is not forcible. One of the interesting paradoxes is south of the border in the land of the free and home of the brave. Jacobson v. Massachusetts said it was not a constitutional infringement upon the integrity of the human body to forcibly vaccinate someone against the smallpox.

We have a completely different legal framework in Canada. Conscientious objection as a legal term came from refusal to vaccinate against smallpox in the U.K., and we adapted that. We would have to evacuate a lot of legal tradition to evacuate conscience clauses in a refusal to vaccinate and make it forcible or mandatory. It did not work out well.

Ms. Baylis: We are continuing to look at that issue with some of the legal scholars involved in the research I am working on now with respect to the question of mandatory vaccination for health care providers narrowly. That work is not completed in terms of the legal analysis.

In the interim, not necessarily with H1N1 but with seasonal vaccine, we are working with the public health agency in our province to look at this concept of declination. The idea there, of course, is that people have to consent, but we have a philosophy within our health care institutions that they do not have a right to kill a kid and his grandma.

The reality is, at least in the children's hospital where I do some of my work, that if they come in and bring a virus, they are putting someone at risk. We use the example of the kid and the grandmother as the two populations at risk. They may have a right not to be vaccinated, but it does not translate into a right to then put other people at risk. We are then looking at the implications if they are asked or required to stay home by virtue of having made a choice. We are looking at the parallels between, ``I have the right not to be scanned, but then they do not have to let me on the plane.''

We have introduced this notion of a declination, which is the opposite of consent. Interestingly, people are allowed to decline, and they do. At this point, we have not gone beyond requiring them to sign that they do not wish to be vaccinated. A signature requires them, nonetheless, to show up. In that context, they are offered education about what it means for them to make this choice. Several of them change their minds.

I should not offer a percentage because I am sure I will get it wrong. We still have a percentage of our health care workers that choose not to be vaccinated. We have not done anything with that choice at this point, but we are trying, through education and requiring them to make a serious commitment in terms of signing, to ensure that they have been educated about this issue and refuse to be vaccinated. I think there is still more work to be done around that issue.

Dr. Upshur: That is an elegant solution because they are not derogating anyone's right to refuse a therapy they do not want to have, but they are retaining correlative powers to exclude that person from the community, should they be a risk to others.

The Chair: Or to be removed from their health care job.

Dr. Upshur: Yes, to be reallocated or work somewhere else. It is complicated, but I do not think forcible vaccination is anywhere near a reality. There is a strong moral argument for health care providers to be vaccinated, and we have written papers to that extent as well.

Senator Seidman: Thank you for being here tonight. I have a question, but I first want a brief follow-up on the issue that Senator Cordy put forward.

While no doubt there were many socio-demographic factors that made the Aboriginal communities extremely high risk, I want to make a couple of observations here for the record, and remind us of some of the facts that we heard in previous meetings.

For example, the Aboriginal communities had some of the highest vaccine uptake rates going. The second point we heard is that the pandemic planning and preparedness plan work began on that community in 2006, so there was a sense of trying to prepare.

I make those points for the record, to put forward what we have heard from other witnesses.

I will come to my main question, which concerns first, access to the vaccine, not in the sense we have been talking about but, rather, who in workplaces should be vaccinated because of exposure. On the surface, it seems like an easy question to answer because, as we know, we started to say that all health care workers should be vaccinated immediately because they are exposed. The question becomes: should their families be vaccinated; should other staff who work in the hospital system be vaccinated; should the police be vaccinated; and should people who run our food supply be vaccinated? It becomes a complicated issue. Do you have thoughts on this area from an ethics point of view?

Ms. Baylis: I have a number of quick comments. With respect to the high uptake rate amongst Aboriginal peoples, that is true in certain parts of the country. That uptake rate is because there was a different plan in certain parts of the country responding to local and geographical differences whereby the public health nurses went out to the community in a way that they were not expected to come into clinics, et cetera. There were some differences in terms of delivery that accounted for that difference.

If we look at the data from Winnipeg, that population is disproportionately represented relative to what they represent in the population in terms of what happens when they catch the virus, land in critical care and die. There are interesting summaries of that work in the Canadian Medical Association Journal, and the data is striking.

With respect to the fact that work was completed regarding public health that dates back to 2006, that is true, but it has been hard to track that money. We can find millions of dollars committed, but it is not clear how much is new money and how it is being used. As I said, the project we are working on now is tracking clean water, something completely separate from what we thought the pandemic might have been about. That issue turns out to be an important one, and we did not see major changes in this same time frame.

I think the issue is complicated; I am not pretending it is not. I would be happy if we paid attention to it.

With respect to the issue of who makes it on the list, one of the things I was pleased to see in a Canadian context, was the list, and given some of my cynicism these days, I might not have thought that would happen. In other places, for example, France, big business made it on the list. If they are running a big company, it is part of the economy, they cannot have this company go down, so the company made it on the list. Other people made it on the list elsewhere that maybe should not have been on list. When we think about our health care workers, should we have understood that this group included emergency? For some people it did; for others it did not in terms of how we understand that term.

There are different ways of responding to a priority list. I will leave it to Dr. Upshur if he wants to add anything about what we came up with in a Canadian context.

In my remarks, I was careful to say that at this point, I am not in a position to second-guess that list. I do not know enough about it from a science point of view, but I want to believe that the people who made it had access to that information in terms of truly understanding where the greatest risk was from a health point of view for populations and subpopulations.

If I can take a bit of time, I draw your attention to this point. I have an opportunity to explain what this one slide means. I think this is a microcosm of what happened in Canada. We do not have the resources to do it in Canada, but if someone did, I am confident you will see something like this replicated.

We read all the newspapers every day, in both languages in the three provinces. We chose newspapers. Why; because we could not obtain the information from the public health agencies in the provinces, not because they did not want to give it to us, but because they did not have any kind of consistent paperwork. You will be surprised when you try to find out what was tracked. You almost want to ask who the note-taker was.

More importantly, we also thought from a process point of view, what did Canadians know? They did not know what was in the press release. They knew what made it into a public medium for them to have access to information.

What I want you to see here is that in some cases, health care workers had earlier access. A plan was started somewhere to ensure that access happened. Then we see that the general public had access. There is nowhere in any of this plan that the general public, writ large, should have had access.

What happened, at least in our parts of the world? That is what that lovely finger means saying, ``Hello, we have a problem here?'' People were asked politely, ``We think we are running out of vaccine; could you step back?'' When they did not do so willingly, we ended up having to close clinics.

What is interesting is we also see the difference that happened with respect to pregnant women, and you will notice that sometimes the area on the chart is dark and sometimes it is gray.

The dark ones are when all the pregnant women were supposed to show up, and the gray ones are when the pregnant women less than 20 weeks were supposed to show up. This chart tracked only one population that we were particularly interested in. If we go across this country and track every population, it is so different that, at one point, it makes me wonder whether it was worth all the time, effort and energy of, I hope, talented people to develop a sequencing list. Is it worth our time, effort and energy to fix it if we do not think it was right? The answer is yes, but only if we follow it. If we have no intention of following it, then I wonder about the effort put into it. I assume most of us think it is worth trying to figure it out right, but we cannot do that without the other piece, which is we need confidence that it will be used.

Senator Seidman: Do you have a response, doctor?

Dr. Upshur: Considerable thought at the international, national and local level has gone into first access, or who receives vaccine first. Universally, across the board, it is accepted that first access includes health care providers, but, as you rightly point out, how far does that access extend? How far is the first response? I think people settled on critical infrastructure, so people involved in water supply, sewage, the chain of people who are critical to the function of society.

Again, this point leads back to the point about severity. In a severe pandemic, with high morbidity and mortality that might threaten the function of society, we need to have a much broader notion of who the first access people are to ensure that we have critical supply lines — food supply, water, sanitation, et cetera. It goes back to understanding the dynamics of an influenza outbreak, pandemic or otherwise. Outbreaks reach their peak in intensity for about six weeks. It is not that once a pandemic comes, we are in there forever. Outbreaks are short and intense at their peak. The duration of illness is three to five days for those who recover. Even in the worst case scenario, about 95 per cent or 99 per cent of people will survive and recover. Only they will be very sick.

In the preparation, you can see and plan what you absolutely, by necessity, need to have in place to keep society running in a severe pandemic and where you could have a second and third tier. There is a lot of literature where people have given it thought. We have public input on who they think should be the first, second and third tier. There is some thought, and I will forward that information. I do not want to make up numbers on the spot, because we have precise estimates.

Senator Seidman: That is good.

For example, in the health care workplace, in hospitals, there was an attempt to make vaccination mandatory. If they did not take their vaccine, they would be fined or if they became sick they would lose their pay. Do you have some response to those attempts?

Dr. Upshur: It strikes me that there is probably a lot more work that can be done upstream before we go to more Draconian measures. I think most health care providers do not want to be a vector of illness to their patients.

One study by one of my colleagues was that work culture and organizational culture influence vaccine uptake rates. There are many ways of influencing uptake to make it fun. They can have competitions amongst wards and make it seem like it is part of being a good citizen. There are many ways of being Draconian that will get people's backs up and further workplace dysfunction and labour management stress. We can be much more creative and supportive before we are heavy handed about uptake, but always with a firm message that there is a strong obligation on behalf of health care providers not to infect their patients.

Senator Seidman: Thank you. I appreciate that.

Senator Callbeck: I have a brief question on that chart. Let us take Prince Edward Island, for example. On October 30, I take it there were vaccine shortages because you have ``closed'' here.

Ms. Baylis: Yes.

Senator Callbeck: Above that, it says all pregnant women, and below, health care workers. What took place?

Ms. Baylis: The symbols there represent that they were identified as an eligible group to show up at the clinic. In this particular grid, we were tracking when pregnant women were identified as eligible to come forward. They remained eligible to come forward. There was no vaccine at the time.

Senator Callbeck: Fine; thank you.

The Chair: That brings us to the close of this session. We thank you for coming here and giving us your thoughts, many recommendations and suggestions for improvement. It is appreciated.

(The committee adjourned.)