Good afternoon, Mr. Chair and committee members. I'm pleased to have the opportunity to appear before you today to discuss issues related to the federal population of women offenders.
In my brief opening remarks, I don't want to repeat what the previous deputy commissioner for women related to you at her appearance last November. I'll instead use my time to bring you up to date on a number of developments in the women offender file over the past five months.
First of all, I understand that the committee had the opportunity to visit a number of our institutions late last year, including Okimaw Ohci, our aboriginal healing lodge, and the regional psychiatric centre in Saskatoon, where we have the Churchill unit dedicated to the treatment of women offenders who require intensive mental health care. As such, you were able to see two very different approaches to managing our complex and diverse women offender population. If the committee members intend to visit one of the five regional facilities for women to expand your knowledge of how we manage the majority of incarcerated women offenders in our care, I would certainly be pleased to organize that for you.
The area of mental health continues to challenge us. We are committed to look for new strategies that will work for everyone: the women offenders, CSC staff, and the general public. To this end, we are working with our research branch, particularly in a project to develop a national profile of the mental health needs of women offenders. This will help us to better target our interventions and provide more effective counselling and programming to the women in our custody and in the community.
We are also examining how we manage women who pose a high risk to other offenders and CSC staff. We are currently using a system called the management protocol. It has come under criticism from the Office of the Correctional Investigator and the Canadian Association of Elizabeth Fry Societies, among others. CSC agrees that the approach is not ideal and we are currently reviewing our strategy to move away from the management protocol. We have been engaged in national consultations with various stakeholders and experts over the past few months. I expect to receive a report of their findings in the near future, which will help guide the development of an alternative and more comprehensive approach that is more in line with a fully integrated correctional plan.
As part of CSC's transformation agenda, we are now in the final stages of implementing a community framework for women offenders that will provide more support and opportunities for these offenders when they're conditionally released into the community. Over half of the federally sentenced women are in the community. This framework will affect most of the women under our care. I am exceptionally proud of this new model that will enhance the continuum of care for federally sentenced women, better support their transition into the community, and help to achieve greater public safety results for all Canadians.
I continue to work closely with my colleagues in health services, the Office of the Correctional Investigator, and our other partners to ensure we exchange information and best practices on how to effectively manage our more complex cases. To this end, I hold teleconferences and face-to-face meetings on a regular basis with the wardens of women's institutions and other officials as needed.
I would like to state in closing that I'm delighted with the challenges this new job entails. I'm very excited to be part of the group of CSC staff who work every day to improve the lives of our women offenders and help them return to the community as law-abiding citizens.
Ms. Thompson and I are pleased to appear here before you to discuss issues related to the opiate substitution program for the offender population within the Correctional Service of Canada. The commissioner, Mr. Don Head, and the assistant commissioner of health services, Ms. Leslie MacLean, appeared before you in June 2009 and provided with you with information about the mental health strategies and initiatives within CSC. Today we will brief you on the CSC's opiate substitution program.
Injection drug use, primarily the practice of sharing injection equipment, is a major risk in the transmission of infectious diseases such as HIV and hepatitis C. Substance abuse is also a factor contributing to the commission of many crimes. Providing an opiate substitution treatment program to federal offenders helps to reduce the demand for drugs, thus improving our ability to contribute to public safety.
Research has shown that active participation in opiate substitution therapy is associated with positive release outcomes for offenders. Johnson et al. (2001) found that offenders who had participated in a methadone maintenance treatment program while incarcerated were 28% less likely to be returned to custody after release to the community than offenders who had not.
l'II provide you with the background on the program. Originally called the national methadone maintenance treatment program, it was implemented in two phases. In 1997, phase one allowed opiate-addicted offenders who were in a community methadone program prior to being sentenced to be considered for continuation of methadone treatment. Phase two, announced in May 2002, increased CSC's capacity to initiate treatment of opiate-addicted offenders requesting methadone if such treatment was deemed medically appropriate.
In December 2008 the methadone program was renamed the national opiate substitution treatment program because of the addition of an alternative opiate substitute medication called Suboxone.
When used in conjunction with cognitive programming, intensive monitoring, and support, opiate substitution has been found to be extremely helpful for opiate-dependent persons. These medications can help free the opiate-dependent person from the continuous cycle of withdrawal and opiate use. Stabilization on opiate substitutes allows offenders to concentrate in school and participate in programming and work, thus increasing their ability to actively engage in their correctional plan.
Prior to initiation of treatment, a detailed health and mental health assessment is conducted with each offender to determine whether the offender meets the necessary criteria, such as whether the offender has received from a physician a diagnosis of dependency to opiates. Congruent with community practice, the assessment process includes a review of the rules of the program outlined in a treatment agreement between the offender and care providers, outlining what each commits to, including the requirement for ongoing monitoring.
In 2009-10 the cost of CSC's opiate substitution program was over $12 million. As of January 2010, there were 701 offenders on opiate substitution therapy across the country, of whom 55 were women offenders. Due to offender flow-through, over 1,000 offenders are managed on the program by CSC every year. CSC's opiate substitution program is managed in a multi-disciplinary team approach, with involvement from case management, programs, and health services, and in accordance with national guidelines.
In 2009, of the 512 offenders who were admitted to the CSC opiate substitution program from the community, most were received from provincial correctional facilities. The majority of these facilities provide treatment to offenders who are already on methadone in the community. For those offenders entering CSC already on methadone, CSC maintains their treatment while they undergo assessment to ensure they meet the program criteria.
To ensure safety and security, offenders are observed for 20 minutes after taking their methadone, which reduces the risk that offenders will divert the medications. A nurse provides each dose directly to the offender and watches the offender swallow the medication. The offenders are observed for 20 minutes to ensure that most of the medication is absorbed.
All offenders in treatment are expected to participate in regular substance abuse programs, which are specifically geared to opiate dependence and delivered by trained program delivery officers. An offender's progress is monitored and reviewed on a regular basis through meetings with their individualized intervention team.
The opiate substitution program is subject to regular medical and institutional reviews to provide early identification of areas of concern, tailor educational training sessions for staff, and modify procedural policies.
Extensive preparation is done for any offender being released to the community on opiate substitution to ensure the transition is smooth and continuity of care is maintained. This process starts at the onset of initiation into the program. The availability of a community provider is reviewed and confirmed six months prior to release.
The last sentence of the quote--and I'm sorry, I didn't mean to hold this back, but I think it's important--said:
|These findings were confirmed in prison needle exchange review of the evidence, a 2006 review by the Public Health Agency of Canada undertaken at the request of Correctional Services Canada.
Are you familiar with that report? Okay.
The reason I ask is that we're opposed to drugs in prison, but we have methadone, and methadone is an opiate. We are opposed to sex between inmates in prison, yet we have dental dams and condoms. We are opposed to having paraphernalia in prison, but we supply bleach. This committee saw a rig, a very grotesque homemade piece, that was shared by inmates, passed among the inmates.
I'm just wondering, does it not make sense to go that final step, if drug use is going to happen in prison, to ensure that at the very least we're not spreading the disease? As pointed out by my colleague, it's something that will spill into the general population and become a public health issue as well. Is that not a logical conclusion?
I'll try to be efficient with my comments, but I would be remiss if I didn't begin by saying thank you to this committee for the privilege of coming to Ottawa from Manitoba to address my government.
You have had just a brief moment to see an untranslated picture of my family, and you would have seen that four of our children are Ethiopian, first-generation Canadians, and they're very proud of this country and the privilege that I have today to serve in some small way.
The reason I'm here today--and that brings me to my second thank you--is that Shelly Glover was in our offices a few weeks ago to present to Momentum Healthware a certificate recognizing Momentum Healthware as an innovation leader in Canada. That certificate also came with the recognition that you, our government, have invested in Momentum Healthware over the last number of years. Most recently you have spent $111,000 of National Research Council money to invest in the development of a mental health module for Momentum Healthware's health IT solution. That was recognized at a press conference. I want to thank you for that investment in our research and development and I want to give you at least some feedback on the effectiveness of that investment. We are now already moving into the pilot stage in Manitoba with our community mental health module. We've had expressions of interest from a number of other provinces, as well as New Zealand, for possible deployment of that module as well. So I think it speaks for itself that the National Research Council has invested well.
Canada is a country that has many jurisdictions in it. I recognize, as a health IT executive, that my job is in fact a very, very simple job compared to the role that you have and that the executives who sat in these chairs before me have, in terms of forming policy and respecting the incredibly complementary but sometimes conflicting values that come from the different jurisdictions we are made up of. As an IT solution provider, I have often found in my experience in the health IT sector that as I come into different sectors of health care--Momentum Healthware's solutions span long-term care, home care, community care, community mental health, palliative care--in each of these sectors of care and each of these forums of care, the health care providers use a different language to describe their activities. They use different processes to provide care to their clients. One of the things that we've done with the software solutions is we've really focused on trying to abstract that or reduce that down to what things are common across the different health care sectors, and create a solution that is highly translatable. It's translatable among sectors of health care and it's also translatable among different languages in order to be able to provide a single repository for health information to the multiple health care providers.
As a citizen of Canada, it's something I'm very conscious of. At the same time, I'm also a citizen of Manitoba. In my early years as a child growing up, I was educated on the God's River First Nation, so I also have both an allegiance and interest in the first nations communities of Canada. Each of those communities will treat me as a stakeholder to some extent. The work that you're doing with Corrections Canada also deals with, again, those same citizens. For them, you also represent an important stakeholder in their health care.
What we try to do with the software solutions that we've developed--and I want to really treat this as general information available to you--is really highlight the fact that information technology is a determinant of health care. There are so many different things that you have the opportunity to review as determinants of health care, and I would submit to you that this information is perhaps one of the greatest determinants of health care.
If you were to ask health care providers in any sector of care whether they would appreciate or benefit from or whether the care of their clients would benefit from the knowledge of the other health care providers in the continuum of care, whether they are federal or provincial or whether they work for an aboriginal healing centre or within a correctional facility or a parole centre, every health care provider would understand that the care they provide would be better, more informed, and more effective if they were able to have access to the information that was provided by the other health care providers who are caring for that same client.
I'm reminded of an Indian fable--and in this case I mean Indian as in India--a story about six blind men who discover an elephant and seek to define it. One of them defines it as being very much like a tree because he has come across the leg of the elephant. One of them describes it as being very much like a wall because he has come across the side of the elephant. One of them describes it as a spear because he has a tusk in his hand. One of them describes it as a rope because he has encountered the tail. They then get into heated debates about what exactly an elephant is. Is it more like a spear or more like a tree? None of them is capable of seeing the whole elephant, and it blunts their ability to have an effective discussion about elephants.
I want to offer my services to you this afternoon to inform your discussion about how health information technology could serve to bridge the gap between federal correctional institutions and community mental health.
We have developed a software solution that has the capacity to model the health care delivery system in any form of care. I did go through the effort to develop some slides for you that demonstrate the ability to deliver care within a correctional facility. It's not necessary for the purposes of the discussion to simply understand that the same client can be seen in different forms of care and can be treated by different teams of providers. He or she can have selective information appropriately shared through the privacy and the security you define--or negotiate with the other health-care-providing constituents--to deliver the most effective care and to be able to most effectively understand what the elephant is that you're trying to understand in each individual case.
I'll limit my comments to that and make myself available to any questions.
Mr. Penner, welcome.
I was born and raised in The Pas, Manitoba, so it's good to see a fellow Manitoban here.
I understand you're a health information services provider. Have you formed any opinions about the availability of information, the degree to which integration is available within federal corrections? You said you had some slides, but we didn't see them.
Some of the preceding witnesses were talking about aspects of the problem, and the specific thing we're looking at is addictions and mental health, to what degree there is knowledge of the problems, to what degree there is action about it, obviously what is effective and what isn't, specifically methadone and other drug treatments. There are also public safety concerns as well as individual concerns. I think there seem to be some missing pieces.
Have you been able to come to any understanding about what goes on in corrections in terms of the work you have done on your own software?
I was paying rapt attention to the previous witnesses and took some statistics from their conversation, like the statistic that 24% of the women in their particular form of care had significant mental health issues. I recognize that the 24% of that population are likely or ultimately going to be released back into the community or into residential care facilities within the community.
I certainly have done no assessment of the quality of information systems within the correctional system. In terms of my assessment, I am aware, again from the previous witnesses, that they have developed standardized assessments and are finding them to be very effective when women are being taken into the process. Obviously information technology is just a tool, but it is a great tool for taking standardized assessments, collecting information in a way that can easily be shared where appropriate, and then informing future decisions as you start to try to understand the impact of assessment, recovery planning, and outcomes.
I'm not well informed in the area of how much information technology has taken hold in the correction system. Anecdotally, it seems to be limited, but I haven't researched it.
There was a pledge in the 2008 budget of about $500 million to develop the Health Infoway, which I'm sure you're versed in and at least somewhat oriented to, whether provincially or nationally. That money has yet to flow, for a variety of reasons.
What can you tell us about the development within Manitoba? Because provincial health systems often make their own decisions independently of that federal funding. Is there an idea about what the plan looks like? Have you heard nationally how that fits with Manitoba's system? Again, I'm not trying to pigeonhole you just because you're from Manitoba, but it may be a health system you're more familiar with. Nonetheless, from whatever purview, what is that federal money going to be used for? How effective can it be? Can it help us with the problem we're looking at today? You touched on that in a general way.
In the private sector, in the community helping to develop these various potential solutions, what is the anticipation and knowledge of where that $500 million—a fair bit of money—needs to be, and when will it be available?
I want to welcome you here today, Mr. Penner. Thank you very much for taking part in these discussions. I was quite impressed with the presentation. I actually got to see the presentation, which brought to my mind what's been repeated in this study continually, and that is continuum of care.
To me it was significant to have been able to see the slides showing that not only can you capture, retain, and track the health treatments and the proposals that have been made by different health officials, and what's worked and hasn't worked, but also to have been able to see that we can track information from places like the correctional service, the police, and other inter-agencies that will be functioning in tandem because they care about the individual suffering from mental illness.
I believe in trying to find solutions to problems. We've heard a number of times here from witnesses that they're still using paper files. Of course, in corrections, it's very difficult to get a paper file from one jurisdiction to another or to track someone effectively and quickly. That's why I believe that electronic records are something that ought to be considered so we can quickly get that information, which might lead to our better serving someone who is suffering from mental illness.
We just heard one of the deputy commissioners indicate that they must do an assessment in the prison system, which can be time-consuming. In your system, I believe that will reduce the time taken, because you're going to have access to previous treatment, what did and didn't work, and the diagnosis, of course, which will obviously help them treat that person more quickly.
Am I assessing your program correctly?
Thank you, Mr. Chair and members of the standing committee, for giving us the opportunity to share some of our research on prison and HIV/AIDS.
I'm a senior policy analyst with the Canadian HIV/AIDS Legal Network. We're a human rights organization based in Toronto. We're a national organization that promotes the human rights of people living with and affected by HIV/AIDS. We do this through research and education, legal and policy analysis, education, and community mobilization.
We've studied the issue of HIV in prisons for many years now. More recently, we've focused on the issue of prison-based needle and syringe programs. In 2006, we released what was the most comprehensive international report on the evidence from prison-based needle and syringe programs around the world.
What the research demonstrates, as one of the last witnesses from CSC reinforced, is that there is no prison in the world where drugs do not exist. In spite of the many efforts of prison systems to prevent drugs from entering, drugs do come into prisons, and people use them. In our interviews with people who were formerly incarcerated, they often mentioned the availability of drugs and the fact that in some prisons, there are more drugs inside than what they have witnessed on the street. There's rampant addiction inside prisons. People inject drugs in prison, and they share needles because of the scarcity of sterile needles and syringes inside.
In 1995, CSC conducted a survey of drug use inside federal institutions. Thirty-eight percent of the people interviewed reported having used a drug since entering the institution, and 11% reported injecting a drug. This is quite an old study, as you can see. It's from 1995. We believe that the evidence today probably would indicate a much higher rate of injection drug use and needle sharing, given our interviews with people in prison. It's unfortunate. A 2007 study undertaken by CSC looked at risk behaviours and HIV and hepatitis C prevalence in federal prisons. It's about to be released in a week or so. If we were to have that information before us, I'm sure that it would reveal much higher rates of hepatitis C, HIV, and injection drug use.
As in many other countries, the rate of HIV and hepatitis C is much higher in Canadian prisons than it is in the population as a whole. I know that you've already heard from other witnesses that the HIV rate is at least ten times higher in the federal prison system. Hepatitis C is at least 30, close to 40, times higher in federal prisons than it is in the population as a whole. That rate has increased significantly in the last ten years. In 1999, the reported hepatitis C rate was 20%, and now it's close to 30%.
We studied prison needle and syringe programs around the world to see what the evidence would reveal, how they were working, and whether they were effective in reducing syringe sharing and infectious diseases.
These programs were first instituted in 1992 in a prison in Switzerland. They exist in over 60 prisons in at least 11 countries around the world. Most recently, in January 2010, Kyrgyzstan announced a pilot program.
These prisons are in western Europe, in Asia, and in well-resourced and less well-resourced systems. They're operating in civilian prison systems and in military systems, in women's and men's prisons, in prisons of all security classifications and sizes, and in institutions with drastically different physical arrangements.
They've used various methods to distribute syringes. Some prisons use automated dispensing machines, where you have a one-to-one exchange with the machine. Some use health care units to distribute the syringes and needles through either the prison nurse or the physician. In some cases, peer health workers distribute them in a one-to-one exchange. And in some cases, external NGOs or external practitioners--health professionals--distribute the needles and syringes inside the prison.
Based on the programs that exist around the world, there have been a number of systematic evaluations of these programs, including by the Public Health Agency of Canada in 2006, as a member previously mentioned. What this evidence shows is that these programs reduce risk behaviour and disease, do not increase drug consumption or injecting, and do not endanger staff or prisoner safety. In fact, there's been no single case of a needle or syringe from these programs being used to attack a staff member--not a single case since 1992, when these programs were instituted. They have other positive outcomes for people in prison, including referrals to drug addiction treatment programs.
What's interesting, as well, is that in spite of resistance from correctional officers in some of these countries--Germany and Switzerland, specifically--they have come to learn that their own security is protected when these programs are instituted, because they're less likely to come across a needle that's been hidden in a prisoner's cell and be accidentally pricked. If they are accidentally pricked, for whatever reason, it's less likely that the needle has been distributed among many people and is infected with HIV or hepatitis C.
We feel that by refusing to implement prison needle and syringe programs, CSC is unnecessarily placing those individuals with the most severe drug dependence at risk of severe HIV and hepatitis C infection. Needle and syringe programs have been operating in the community for many years now. In 2001 there were 200 needle and syringe programs operating in Canada, with support from all levels of government--municipal, provincial, territorial, and federal. Many of the people who are entering prison are realistic. They are using these needle and syringe programs in the community, and when they're entering prison suddenly they're denied access to them.
Denying prison needle and syringe programs also discriminates against people in prison who embody many of the characteristics upon which discrimination is prohibited. We've heard, I think, from previous witnesses for the standing committee about the disproportionate representation of aboriginal people in prisons. They're disproportionately represented in federal prisons, disproportionately represented in the community among injection drug users and as people living with HIV.
It also has a disproportionate impact on women. I guess the last witness mentioned the fact that many women entering the federal system have a history of injection drug use, more so than the men incarcerated. They come with a history of trauma. A history of injection drug use is consistently found more frequently among women than men in Canadian prisons. The Canadian Human Rights Commission actually recognizes this, and I provide a quote from them, which reads:
|| Although sharing dirty needles poses risks for any inmate, the impact on women is greater because of the higher rate of drug use and HIV infection in this population. This impact may be particularly acute for federally sentenced Aboriginal women.
Conversely, prison needle and syringe programs benefit not only the people who use drugs in prison, but also other prisoners, prison staff, and the public as a whole. With increasing rates of HIV and hepatitis C, society bears the cost of treatment for those who are infected. According to CSC, treating one person in prison for hepatitis C costs $22,000 and treating one person with HIV in prison costs $29,000 a year. So this is a lifetime cost. It is far more effective to provide sterile needles and syringes than to treat someone for HIV and hepatitis C infection.
I'm going to conclude with another statistic from CSC. In 2006 over 2,000 people were released into the community with hepatitis C and over 200 people were released into the community with HIV. Prison health is public health. There is no reason to treat prisoners who are struggling with addiction differently from people in the community who have access to needle and syringe programs. By reducing the risk of HIV and hepatitis C infection among people who use drugs in prison, all Canadians face fewer risks of becoming infected with HIV and hepatitis C.
That's my presentation. I'll take questions now. Thank you.