MENTAL HEALTH AND MENTAL ILLNESS: WORKPLAN (PHASE ONE)
The Standing Senate Committee on Social Affairs, Science and Technology
Revised
5 February 2003
A. Definitions
B. Prevalence and Costs
C. Stigma and Discrimination
D. The Need for a National
Action Plan on Mental Health and Mental Illness
SUGGESTED ROUNDTABLES FOR PHASE ONE
A. Roundtable One: Mental Health Problems and Illnesses: Learning from Personal Experiences
B. Roundtable Two: Refresher on Mental Health and Mental Illness
C Roundtable Three: Prevalence and Costs
D Roundtable Four: Mental Health and Addiction
E Roundtable
Five: Mental Health in the
Workplace
F. Roundtable Six: Stigma, Discrimination, Myths and Public Awareness
G. Roundtable Seven: Childhood Disorders
H. Roundtable Eight: Adolescent Disorders
I. Roundtable Nine: Adult Disorders
J. Roundtable Ten: Seniors Disorders
K. Roundtable Eleven: De-Institutionalization and Rehabilitation
L. Roundtable Twelve: Mental Health Promotion, Mental Illness Prevention, Disease Surveillance and Mental Health Services Delivery
M. Roundtable Thirteen: Delivery of Mental Health Services
I. Roundtable Fourteen: Research and Information Dissemination
MENTAL HEALTH AND MENTAL ILLNESS:
WORKPLAN
“There is no health without mental health.”
Ken
Ross, Assistant Deputy Minister
Department
of Health and Wellness, New Brunswick
Brief
to the Committee, 7 June 2001.
On June 7, 2001, the Standing Senate Committee on Social Affairs, Science and Technology held, as part of its multi-phase study on health and health care, a roundtable on mental health and mental illness. This roundtable provided useful information on the prevalence, economic burden, stigma and discrimination associated with mental health problems and mental illnesses in Canada and highlighted the role the federal government could play in the development of a national approach to mental health.([1]) Following the roundtable, the Committee decided to undertake a study on mental health and mental illness in Canada and to release a thematic report on this issue.
This document briefly summarizes the information obtained from the
roundtable on mental health and mental illness, reviews recent provincial and
national reports addressing mental health issues and proposes a set of terms of
reference along with a detailed workplan for the Committee’s upcoming study on
mental health and mental illness.
Mental health is as important as physical health to daily living and is an integral part of health and wellness. The Mental Health Promotion Unit at Health Canada defines mental health as the capacity to feel, think and act in ways that enhance one’s ability to enjoy life and deal with challenges.([2]) Expressed differently, it is how people look at themselves and their lives; relate to other people; handle stress; evaluate the challenges and the problems; explore choices and make decisions.
Good mental health leads to high self-esteem, happiness, interest in life, work satisfaction, mastery and sense of coherence. It is well recognized that, for individuals to realize their full potential and contribute in meaningful ways to our society, good mental health is essential.([3])
At the opposite, mental health problems refer to diminished capacity – either cognitive, social or emotional – that interfere with a person’s enjoyment of life and handling of challenges. Low self-esteem, frustration, burn out, stress and anxiety, depression, distress and cognitive impairment are all indicators of mental health problems.([4]) It is generally acknowledged that, in the course of a lifetime, every individual experiences feelings of isolation, loneliness, emotional distress or disconnections at times. These are usually normal, short-term reactions to difficult situations.
As such, the characteristics of mental health problems – where they are short-term, non-recurrent and do not lead to significant impairment – do not meet the criteria for mental disorders. Mental disorders or illnesses generally refer to clinically significant patterns of behavioural or emotional functioning that are associated with some level of distress, suffering (pain, death), or impairment in one or more areas of functioning (e.g., school, work, social and family interactions).([5])
Mental illnesses can take many forms, just as physical illnesses do. The major mental illnesses include: schizophrenia, mood disorders (depression and bipolar disorders), anxiety disorders (phobias, panic disorder, obsessive-compulsive disorder and post-traumatic stress disorder), eating disorders (anorexia nervosa and bulimia), personality disorders, organic brain disorders (Alzheimer’s disease, AIDS dementia complex and damage from strokes or accidents).([6]) Suicidal behaviour and addictions are often correlated with mental illness. Most major mental illnesses are chronic disorders that require long-term treatment.
A recent report on mental illnesses states that no one is immune and that, at some point in their lives, all Canadians are likely to be affected through a mental illness in a family member, friend or colleague.([7]) Thus, mental health problems and mental illnesses affect people of all genders, ages and cultures, and in all occupations, educational and income levels. However, some population groups have higher incidence of mental illness than others. For example, Canadian Aboriginal communities are plagued with multiple mental health problems and illnesses.
Research also indicates that the Canadian mental health landscape features a combination of substance misuse and mental health problems (“concurrent disorders”). Such combination may result in the disastrous accumulation of three, four or more diagnoses – e.g., HIV, tuberculosis or hepatitis related to intravenous drug use, liver cirrhosis consequent to chronic alcohol use, etc. In addition, the consumption of alcohol during pregnancy and while nursing may cause Fetal Alcohol Syndrome and Fetal Alcohol Effects (FAS/FAE) which are major birth defects leading to permanent brain damage, learning disability and slow growth.
Similarly, research demonstrates a high proportion of mental illness in the growing homeless populations of Canada’s cities.([8]) Moreover, there is evidence of an influx of the mentally ill to jails and high rates of violent criminal victimization of people affected by mental illness. In June 2002, the House of Commons Standing Committee on Justice and Human Rights released a comprehensive review of the provisions of Canadian criminal law that apply to persons found not criminally responsible on account of mental disorder and unfit to stand trial. The House Committee acknowledged that the law is effective and fair, but noted that several areas require reform to improve effectiveness and efficiency and to ensure the appropriate balance between public safety and the rights of accused persons.([9])
Data from the 1994-1995 National Population Health Survey (NPHS) suggest that the majority of Canadians enjoy good mental health. The survey indicated that approximately 31% of Canadians had a high sense of coherence, which means that life is seen as comprehensible, manageable and meaningful. More than half of Canadians (52%) reported high self-esteem, and 23% showed a high sense of mastery or control over their life. Some 74% of Canadians described themselves as being generally happy and interested in life.([10])
If we look at mental health problems and mental illnesses, data from the NPHS found that approximately 29% of Canadians reported high levels of distress; 6% felt depressed; 16% of Canadians reported that their lives was adversely affected by stress; and 9% had some cognitive impairment such as difficulties with thinking and remembering.([11])
Other estimates suggest that about 2.4% of Canadians suffer from severe and chronic mental disorders that can cause serious functional limitations and social and economic impairment. This translates into approximately one in every 33 Canadians over 15 years of age.([12]) Schizophrenia alone affects 1% of Canadians. Depression, a major cause of disability especially among women aged 15 to 44 years worldwide, is expected to become the second leading contributor to the burden of disease in Canada in the year 2020.([13])
Mental stresses and disorders leading to mental illness are unique: they can strike at different periods of life and are characterized by the earliest average age of onset of the major categories of illnesses (although diagnoses are frequently not confirmed in early stages). Autism, behavioural problems and attention deficit disorder most commonly affect children. Adolescence is typical for the onset of eating disorders and schizophrenia. Adulthood is a time when depression may manifest more obviously. Senior years are marred by Alzheimer’s and other types of dementia although depression is also being identified more often in the elderly.
According
to data provided to the Committee, the economic burden of mental health problems
and illnesses was estimated at $14.4 billion in 1998; direct health care costs
amounted to $6.3 billion, while indirect costs related to lost productivity and
premature death totalled $8.1 billion (see Table 1).
In that year, mental health problems and illnesses were the seventh
highest among all diseases in terms of the overall cost of illness in Canada;
they were second only to cardiovascular disease in terms of direct health care
costs. It is also estimated that
mental illness is the second-leading cause of hospital use among those aged 20
to 44, a period of life normally associated with high productivity.([14])
TABLE
1
ECONOMIC
BURDEN OF MENTAL HEALTH PROBLEMS AND
ILLNESSES
IN CANADA, 1998
(In
Millions of Dollars)
|
Direct
Costs (Health Care): §
Medications §
Physicians §
Hospitals §
Other Health Care Institutions §
Non-Publicly Insured Services |
6,257
642
854 3,874
887
278 |
|
Indirect
Costs (Lost Productivity): §
Short Term Disability §
Long Term Disability §
Premature Death |
8,132 6,024 1,708
400 |
|
Total |
14,389 |
Source: Thomas
Stephens and Natacha Joubert, “The Economic Burden of Mental Health
Problems”, Chronic Diseases in Canada, Vol. 22, No. 1, 2001 (http://www.hc-sc.gc.ca/hpb/lcdc/publicat/cdic/cdic221/cd221d_e.html).
Canadian business is increasingly aware of the cost of mental health
problems and illnesses in terms of productivity and profitability. For example, the Global and Economic Roundtable on Addiction
and Mental Health estimated this burden to be equivalent to nearly 14% of the
annual operating profits for all businesses in Canada combined.([15])
In relation to disability insurance, the Commission de la santé et sécurité
au travail (CSST) in Quebec incurred $5.3 million in 2000 in
compensation payments related to work absenteeism caused by depression, anxiety
and other mental health problems. These CSST compensation payments have more than tripled in
the last ten years.([16])
Private insurers face similar trends:
while 18% of compensations by private insurers for long-term disability
were due to mental health problems in 1990, this number is now between 30
and 50%.([17])
It has been suggested that these sharp increases could be the result of a
more stressful and less organized work environment.
The World Health Organization (WHO) stated in 1999 that despite dramatic
improvements in physical health in most countries, “(…) the mental component
of health has not improved over the past 100 years.” A major impediment to mental health promotion, mental illness
prevention and treatment is stigma.
According to the WHO, the stigma and discrimination experienced by people
with a mental illness can be more destructive than the illness itself.
It has a detrimental effect on recovery, ability to find access to
services, the type of treatment and level of support received and acceptance in
the community.([18])
This is very unfortunate because effective treatment exists for almost
all mental illnesses.
Because of stigma, persons suffering from a mental illness are often the
targets of discrimination in the workplace or at school.
According to the WHO, they are denied equal participation to our society,
denied services, opportunities and productive employment.([19])
Loss of employment also has an incidence on the access to treatment
following relapse of their disease. Discrimination
cases based on mental illnesses are difficult to make because of the nature of
the discrimination and the absence of dedicated legal fund to pursue these
cases.([20])
The Committee was told that individual Canadians and society as a whole
would greatly benefit from an informed dialogue that would help separate myth
from reality associated with mental health and mental illness.
D. The Need for a National
Action Plan on Mental Health and Mental Illness
Currently, public policy with respect to mental health and publicly
funded services in the field of mental illnesses and disorders are fragmented.
The Committee was told that a national action plan, a comprehensive
cross-jurisdictional policy framework, is needed and that the federal government
must play a leadership role in facilitating a consensus among all stakeholders
including governments. In this
regard, Dr. John Service, executive director of the Canadian Psychological
Association, stated: “Strong
federal leadership is the key to ensure that Canada is a community where there
is good mental health for all, and that all Canadians with mental illness, their
families and care providers have access to the care, support and respect to
which they are entitled.”([21])
In October 2002, a National Summit on Mental Health and Mental Illness
co-hosted by the Canadian Alliance on Mental Illness and Mental Health (CAMIMH),
the Canadian Medical Association (CMA), the Canadian Psychological Association
and the Canadian Psychiatric Association and involving some 20 national
organizations, agreed on a set of values, principles and elements that should
guide the development and implementation of a national action plan on mental
health and mental illness. The core
elements of such a national action plan should include:
1) national mental health goals; 2) a national policy framework that
includes research, surveillance, education, mental health promotion, and a
health human resources plan; 3) adequate and sustained funding; 4) an
accountability mechanism.([22])
The national action plan reflects the “call for action” made by the
Canadian Alliance on Mental Illness and Mental Health since its creation a few
years ago.([23])
Delegates of the National Summit also agreed that federal leadership is
necessary to move forward this national action plan.
Summary
of Recent National and Provincial Reports on
In recent years, many provincial reports on health care identified
similar issues with respect to mental health and mental illness. These reports pointed out that, currently, mental health
services are not well integrated with the health care system (particularly in
the primary health care sector). This
lack of integration has contributed to a fragmentation of mental health services
with little continuum of care. The
provincial reports also noted a lack of access to appropriate mental health
services, particularly for children and adolescents, seniors and Aboriginal
Canadians. They all raised the
issue of shortages of mental health care providers (like in other areas of the
health workforce). Provincial
reports explained that, as a result of de-institutionalization, many Canadians
suffering from severe and persistent mental disorders often live in the
community without being followed up by the appropriate resources.
Accordingly, they recommended that more mental health services be
delivered in the community (home support, day programs, case management,
respite-relief services, support for socio-occupational reintegration, etc.).
Finally, all reports stressed the need to pursue public awareness
campaigns and mental health promotion initiatives as a means to reduce the
stigma associated with mental illness.([24])
A synthesis of Health Transition Fund (HTF) projects with relevance to
the mental health area provided interesting findings including the following:
the effectiveness of relocating mental health services to primary health
care settings; the need to provide mental health education to health care
providers; the critical shortages of health care human resources in the area of
mental health; the importance of national standardization of mental health
information and communication systems to facilitate benefits and minimize risks;
the importance of effective leadership and collaboration across sectors for
implementing new mental health policy.([25])
In its Volume Two, the Committee reviewed the incidence of illness and
trends in diseases, including mental health problems and illnesses.
The Committee acknowledged the need for enhanced health promotion,
disease prevention, surveillance and research in the field of mental health.
It also suggested that the development of healthy public policy through
population health strategies offers tremendous potential for improving both
physical and mental health outcomes of Canadians.([26])
Many of the recommendations made by the Committee in Volumes Five and Six
are clearly relevant to the field of mental health and mental illness (e.g.:
primary health care, health care human resources, electronic health
records, catastrophic prescription drug coverage, post-hospital home care,
health research, evaluation and accountability).([27])
In its final report, the Commission on the Future of Health Care in
Canada (Roy Romanow, Commissioner) echoed many of the findings and
recommendations made by provincial and Senate reports.
The Commission stated that mental health is the “orphan child” of
health care. It recognized the need
to better integrate mental health services with health care services and
identified mental health as an important part of primary health care reform. The Commission recommended, as part of a new national home
care program, that home mental health case management and intervention services
be brought under the Canada Health Act (at a cost of some $568.1 million
annually). It also recommended
better access to prescription drugs for people with mental illness through a new
catastrophic drug program. Finally,
the Commission raised the possibility of establishing a Centre for Health
Innovation to perform more research on mental health and mental illness.([28])
To
sum up, the reports by provincial commissions and councils, the HTF synthesis
and the reports by the Senate Committee and the Romanow Commission all
acknowledge the multiple problems and challenges related to mental health and
mental illness in Canada and confirm the need to act now.
The development of an action plan, national in scope, would certainly
help provide a supportive environment for maintaining and improving positive
mental health and wellness for the Canadian population.
The terms of reference for the Committee’s study on mental health and
mental illness could read as follows:
That
the Standing Senate Committee on Social Affairs, Science and Technology:
1.
conduct a study on mental health and mental illness in
Canada;
2.
consult broadly with stakeholders, including but not
limited to, federal and provincial departments and agencies, non-governmental
organizations, universities, business sector, professional groups and
individuals;
3.
document the incidence of mental health problems and
mental illnesses by age, sex, region, etc.;
4.
document the economic burden of mental health problems
and illnesses to various sectors of the Canadian society, including businesses,
education and health care systems;
5.
review mental health strategies implemented in other
countries;
6.
consider, and make appropriate recommendations on, the
role of the federal government in the fields of mental health promotion; mental
illness prevention; access to needed mental health services and providers;
support to families and caregivers, and mental health related disease
surveillance and research;
7.
consider, and make appropriate recommendations on, how
mental health services should be integrated into the health care system – for
example primary health care and home care, and
8.
consider, and make appropriate recommendations on, the
development of a national action plan on mental health and mental illness in
Canada.
The terms of reference suggested above are both thorough and complex.
It would be appropriate for the Committee to conduct its study into two
distinctive phases. Phase One of
the Committee study would consist mainly in gathering information, data and
facts on mental health and mental illness.
The phase would also involve public hearings and site visits in Toronto
and Montreal, as well as fact-finding trips in both Eastern and Western Canada.
This first phase would lead to the tabling of a fact-finding report,
which would also discuss myths and realities and highlight the main issues.
In Phase Two, the Committee would address issues raised during Phase One,
review public policy with respect to mental health and mental illness in
selected countries (Australia, New Zealand, Norway, United Kingdom and United
States) and hold hearings designed to consider potential options for Canada,
including the creation of a national action plan on mental health.
Phase Two would lead to a report detailing the Committee’s
recommendations.
The research personnel envisions fourteen (14) distinct roundtables for
Phase One. These roundtables would
be scheduled between February and May 2003.
The fact-based report of Phase One would be tabled with the Senate in
June 2003. The Committee would then
undertake Phase Two in September 2003 with the tabling of a final report in
December 2003.
The fourteen roundtables suggested for Phase One are detailed below. (A
workplan for Phase Two will be prepared and circulated during the summer 2003.)
SUGGESTED ROUNDTABLES FOR PHASE ONE
A. Roundtable One: Mental Health Problems and Illnesses: Learning from Personal Experiences
a)
The impact of mental health problems and illnesses
on patients, families, friends and workplace settings
b)
Discussion of the stigmatization and discrimination related to mental
health problems and illnesses
c)
Experience with respect to access to needed treatment
d)
Sharing information on detection, prevention, treatment and social
reintegration
B. Roundtable Two: Refresher on Mental Health and Mental Illness
a)
Definition of key concepts and background
information on mental health problems and illnesses
b)
Causes (etiology), consequences, co-morbidity, correlation and
interactions between various genetic, social and environmental determinants
c)
Interdependent relationships between physical and
mental health
A.
Roundtable Three: Prevalence
and Costs
a)
Incidence of mental health problems and illnesses by age, sex, region,
etc.
b)
Economic burden of mental health problems and illnesses
c)
Impact on quality of life
B.
Roundtable Four: Mental
Health and Addiction (Concurrent Disorders)
a)
Link between substance use/abuse and mental
illness
b)
Prevalence of concurrent disorders
c)
Specific population issues (e.g.: homeless,
Aboriginal peoples)
d)
Collaborative work between mental health services
and addiction services
e)
Implications for research, policy and treatment
E. Roundtable Five:
Mental Health in the Workplace
a)
Economic burden for business
b)
Loss of productivity and disability
c)
The disability tax credit
d)
Other private disability insurers
e)
2002 Public Service Employee survey (by Statistics Canada on behalf of
the Treasury Board)
f)
Possible
solutions
F. Roundtable Six:
Stigma, Discrimination, Myths and Public Awareness
a)
Stigma and discrimination within the health care system, the education
system and society as a whole
b)
Myths and realities
c)
Public awareness
G. Roundtable Seven: Childhood Disorders
a)
Autism, Attention
Deficit Hyperactivity Disorder, FAS/FAE
b)
Impact of parents with children living with mental disorders
c)
Early diagnosis and intervention, access to and continuity of care,
community services
H. Roundtable Eight:
Adolescent Disorders
a)
Eating disorders, stress, depression, addiction and suicide
b)
Impact of parents with adolescents living with mental disorders
c)
Early diagnosis and intervention, access to and continuity of care,
community services
I. Roundtable Nine: Adult Disorders
a)
Schizophrenia, bipolar disorders, depression, suicide
b)
Concurrent
disorders (addiction and mental health)
c)
Gender differences
d)
Co-morbidity of mental and physical health problems
K. Roundtable Eleven: De-Institutionalization and Rehabilitation
a)
De-institutionalization
b)
Psychiatric rehabilitation
c)
Forensic mental health services
d)
Support to employment, education, and housing
L. Roundtable Twelve:
Mental Health Promotion, Mental Illness Prevention and
a) Role
of federal government
b)
Provincial
perspectives
c)
Non-governmental organizations
M. Roundtable Thirteen: Delivery of Mental Health Services
a) Physicians
and Psychiatrists
b)
Nurses
c) Psychologists
and Social Workers
d)
Hospitals
e)
Community Services
N. Roundtable Fourteen:
Research and Information Dissemination
([1])
Minutes of Proceedings and Evidence of the Standing Senate
Committee on Social Affairs, Science and Technology, 1st Session, 37th
Parliament, Issue 19, 7 June 2001, pp. 19:19 to 19:58.
([2])
Health Canada, Mental Health Promotion Unit, Mental Health
Promotion: Promoting Mental
Health Means Promoting the Best of Ourselves – Frequently Asked Questions.
(http://www.hc-sc.gc.ca/hppb/mentalhealth/mhp/e_faq.html).
([3])
Canadian Alliance on Mental Illness and Mental Health, A Call for
Action – Building Consensus for a National Action Plan on Mental Illness
and Mental Health, Discussion Paper, 2000, p. 7.
([4])
Thomas Stephens et al., “Mental Health of the Canadian
Population: A Comprehensive
Analysis,” Chronic Diseases in Canada, Vol. 20, No. 3, 1999.
([5])
Canadian Psychiatric Association, Youth and Mental Illness,
http://cpa-apc.org/MIAW/pamphlets/Youth.asp
([6])
Canadian Mental Health Association, Mental Illnesses, pamphlet
available on the Internet
(http://www.cmha.ca/english/info_centre/mh_pamphlets/mh_pamphlet_02.htm).
([7])
Health Canada, A Report on Mental Illnesses in Canada, Ottawa,
October 2002, p. 18.
([8])
Elliot M. Goldner, Sharing the Learning – The Health Transition
Fund: Mental Health, Synthesis Series, Health Canada, 2002, pp. 1-2.
([9])
House of Commons Standing Committee on Justice and Human Rights, Review
of the Mental Disorder Provisions of the Criminal Code, 37th Parliament,
1st Session, June 2002.
([10]) Stephens
et al. (1999), op. cit.
([11])
Canadian Alliance on Mental Illness and Mental Health, Brief to the
Committee, June 2001, p. 3.
([13])
Murielle Brazeau, Health Canada, Testimony to the House of
Commons, Standing Committee on Health, Evidence, 2nd Session, 36th
Parliament, 2 May 2000.
([14])
Standing Senate Committee on Social Affairs, Science and Technology, Current
Trends and Future Challenges, Volume Two, January 2002, p. 49.
([15])
For more information, see for example the following two documents:
1) Michael Wilson, Mental Health: Business in the New Economy,
Conference Board of Canada, 2001 Wellness Conference CEO Breakfast, 7 March
2001; 2) Michael Wilson, Russell T. Joffe and Bill Wilkerson, The
Unheralded Business Crisis in Canada, Depression at Work, An Information
Paper for Business, incorporating “12 Steps to a Business Plan to Defeat
Depression,” Global Business and Economic Roundtable on Addiction and
Mental Health, June 2000.
([16]) Ordre
des psychologues du Québec, Violence et santé mentale: prévenir et guérir, Congrès Annuel 2002, Montréal, 31
October to 2 November 2002. Marie-Claude
Malboeuf, “Le
travail rend-il fou?,” La Presse, 1 November 2002.
([17])
Malboeuf (2002), op. cit.
([18])
World Health Organization, The ‘Undefined And Hidden’ Burden
of Mental Health Problems, WHO Information Fact Sheets, no. 218,
November 2001, www.who.int/inf-fs/en/fact218.html
([20])
Phil Upshall, Canadian Alliance on Mental Illness and Mental Health,
personal communication, 8 January 2003.
([21])
Quoted in “Canada Needs a National Action Plan on Mental Illness
and Mental Health,” Press Release, 10 October 2002.
([23])
Canadian Alliance on Mental Illness and Mental Health, A Call for
Action: Building Consensus for
a National Action Plan on Mental Illness and Mental Health, Discussion
Paper, Ottawa, 2000, 36 p. www.cmha.ca/english/research/camimh/call_for_action/index.html.
([24])
Department of Health and Community Services (Newfoundland and
Labrador), Healthier Together – A Strategic Health Plan for
Newfoundland and Labrador, September 2002
(www.gov.nf.ca/health/strategichealthplan);
Premier’s Health Quality Council, Health Renewal, Government of New
Brunswick, January 2002; Premier’s Advisory Council on Health (Right Hon.
Don Mazankowski, Chair), A Framework for Reform, Government of
Alberta, December 2001; Commission on Medicare (Kenneth Fyke, Commissioner),
Caring for Medicare – Sustaining a Good Quality System, Government
of Saskatchewan, April 2001; Commission d’étude sur les services de santé
et les services sociaux (Michel Clair, Commissioner), Emerging Solutions,
Government of Quebec, January 2001.
([25])
Elliot M. Goldner, Sharing the Learning – The Health Transition
Fund: Mental Health,
Synthesis Series, Health Canada, 2002.
([26])
Standing Senate Committee on Social Affairs, Science and Technology
(Senator Michael Kirby, chair), Current Trends and Future Challenges,
Volume Two, the Senate of Canada, January 2002.
([27])
Standing Senate Committee on Social Affairs, Science and Technology, Principles
and Recommendations for Reform – Part One, Volume Five, April 2002,
and Recommendations for Reform, Volume Six, October 2002.