I call this meeting to order.
Welcome, everyone, to meeting number 32 of the House of Commons Standing Committee on Health. Pursuant to the order of reference of May 26, 2020, the committee is resuming its briefing on the Canadian response to the outbreak of the coronavirus.
To ensure an orderly meeting, I would like to outline a few rules to follow. Interpretation in this video conference will work very much like in a regular committee meeting. You have the choice, at the bottom of your screen, of floor, English or French.
As you're speaking, if you plan to alternate from one language to the other, you will also need to switch the interpretation channel so it aligns with the language you're speaking. You may also want to allow for a short pause when switching languages. Before speaking, please wait until you are recognized. When you're ready to speak, you can click on the microphone icon to activate your mike. As a reminder, all comments by members and witnesses should be addressed through the chair. When you're not speaking, your mike should be on mute.
Please note that I will be very strict on time today, given the fact that we have to move in camera later.
I would now like to welcome our first panel of witnesses. Appearing as an individual is Dr. Arjumand Siddiqi, associate professor, Dalla Lana School of Public Health at the University of Toronto. From the Wellesley Institute, we have Dr. Kwame McKenzie, chief executive officer. Welcome to you both.
We'll start with Dr. Siddiqi.
Please go ahead. You have 10 minutes.
Thanks for the opportunity to speak with you today. I come here with a deep sense of gratitude for my parents and all the others who have made this possible, a strong sense of responsibility that comes with my position as a scientist, and a burning desire for my country, Canada, to do right by all its people.
I am associate professor and division head of epidemiology at the University of Toronto's Dalla Lana School of Public Health, where I hold the Canada research chair in population health equity. I am a social epidemiologist and I study health inequities and the social determinants of health, with a particular emphasis on the social policies and other societal factors that are ultimately responsible for giving everyone a chance at health.
Since the gravity of the COVID-19 pandemic became apparent, Canadian officials have assured us that we are all in this together. Indeed, daily briefings have impressed upon us a sense that the overall number of cases and deaths in our cities and provinces is a good proxy for how worried each of us should be about our risk for COVID-19, or how confident we can feel about returning to some of our pre-COVID activities.
However, in late May came a stunning report—if entirely predictable by those of us who study these things and those of us who live them—which suggested that the city-wide numbers we were receiving in briefings from Toronto Public Health concealed enormous differences in the burden and risk of COVID-19 across Toronto neighbourhoods. A similar phenomenon has also been noted for Montreal. Toronto's northwest neighbourhoods, which are heavily black and working class—areas such as Jane and Finch, Rexdale, and Weston—have been hardest hit. The latest figures suggest case rates in excess of 450 per 100,000 in those neighbourhoods.
Meanwhile the downtown core and central areas, which are heavily white and wealthy, have barely been touched. For example, Yonge and Eglinton has a case rate of 14, and Beaches has 15 cases per 100,000.
This means that the overall figures for Toronto have been obfuscating a more than 40 times greater risk of COVID-19 between Toronto's black working-class neighbourhoods compared to its white rich neighbourhoods. While the coronavirus itself does not discriminate, our society unfortunately does. Canada is structured in a way that has placed the burden of risk for COVID-19 squarely on the shoulders and in the lungs of the black working class and to a lesser extent other non-white working-class people.
The spatial distribution of COVID-19 across Toronto neighbourhoods is less a reflection of neighbourhoods themselves being risky, and more a reflection of the fact that the black people in Toronto tend to live in a small set of neighbourhoods, the ones in which they can afford housing and avoid housing discrimination, while rich whites live in a set of neighbourhoods that offer the most convenience and comfort.
Why are we using neighbourhood data if neighbourhoods aren't really the heart of the matter? Unfortunately, those are the best data we have available for understanding the social characteristics—race, income and so on—that carry risk for ill health, including COVID-19. We are effectively using neighbourhood characteristics as proxy for individual characteristics and because Toronto is so starkly and structurally segregated, and people are so clustered by race and income into various neighbourhoods, for now this is sadly a reasonable proxy to make, even if it's imperfect.
My initial plea to you, then, is to think long and hard about better collection of race and socio-economic data whenever we routinely collect data in Canada on health and other matters in our health care system, our schools, the labour market and so on. This is critical for understanding our country and holding our government to account for racial inequity in the same way gender data is used to tackle gender inequity.
If not the neighbourhood itself, what then is creating greater risk for black working-class people? Because the data is lacking, it's difficult to be unequivocal about the answers to this question; however, there is a very large and robust body of research from other countries on which we can draw, as well as indirect evidence from Canada.
The strongest explanation—though there are others I am happy to discuss—is that essential service jobs that have continued during the stay-at-home orders are largely occupied by black and other non-white working class people.
They are our long-term care and personal support workers. They clean our hospitals and shuttle patients around. They stock our grocery stores, drive our delivery trucks and work in the fields to harvest our produce. Conversely, jobs that afford the opportunity to stay home—along with the peace of mind about one's job security and income—are largely occupied by wealthy white people. They are our bankers and financiers, lawyers, and, yes, our professors.
The obvious consequence is that jobs occupied disproportionately by black and other non-white Canadians force them into environments that carry high risk for exposure to COVID-19, while jobs disproportionately occupied by wealthier whites offer protection from exposure to COVID-19.
At the end of the day, knowing that low-wage black and other non-white workers have little choice, we are sacrificing them so that the rest of us can cocoon in the comfort of our homes and wait this thing out.
This racial job sorting is clearly not a function of chance or choice. It is the outcome of a confluence of Canadian policies and systems in which racial discrimination is so persistent and pervasive that it cannot be regarded as an isolated incident or even as an add-on to understanding our system of institutions and policies. Rather, it is an integral part of the systems themselves. Various scholars have used terms such as systemic racism, structural racism, institutional racism and racial capitalism to refer to this deep embedding of racism in our societal policies and systems.
Beyond jobs, systemic racism is more generally the major factor that determines who has economic security, wealth and income. It can be even more powerful than gender in this respect. In turn, economic security is the main predictor of health because it facilitates the everyday living conditions that are foundational for health: jobs that don't expose us to health risks, plenty of money to pay the bills, comfortable housing, lovely neighbourhoods, good food and low stress.
And this is true whether we're talking about COVID-19 or cardiovascular disease, depression or diabetes. At the end of the day, you need economic security to have a good chance at living a healthy life, and that is precisely why economic security is so crucial and it is precisely why racial and health inequalities are so pervasive and so persistent. Racism limits black working-class people's access to wealth, jobs, income and so on. As horrible as it is that we have racial inequities in COVID-19, this is really just another manifestation of a deeply entrenched system of racial inequity.
So it's the root cause—systemic racism—that we really need to fix in order to address COVID-19 inequities. In what follows I will outline what the science tells us are our best options for doing so.
The first is to deal forcefully with racial wealth inequity, inequity in stocks of money and assets.
Economists such as Miles Corak in Canada and William Darity Junior and Darrick Hamilton in the United States have made a jarring discovery about wealth inequity which, as I will explain, is arguably even more critical than income inequality. It turns out that the largest source of racial wealth inequity is not racial differences in education or even in jobs and income. Those things matter but they are the consequences, not the causes of racial wealth inequity.
The biggest source of wealth inequity is what economists refer to as intergenerational transfers and what the rest of us would call gifts from Mom and Dad and Grandma and Grandpa. That's right: the white wealth advantage is not an earned advantage. Gifts are what allow whites to pay for advancing their education and thus income, and what allow them to put down payments on homes early in life.
This is unfair for many reasons, perhaps the greatest of which is the historic injustices that have allowed whites but not others to accumulate wealth over generations.
So it is these wealth transfers that create opportunity for income, rather than income creating opportunity for wealth. That means that black Canadians have already fallen behind at birth. This is unacceptable, and Canada must consider, as the United States is doing, a system of baby bonds or something similar in which young children from black and other groups that have historically faced disadvantage are provided a sum that matures as the child ages and that in adulthood can be used in the same way that family gifts have been used by rich white families. Economists have even calculated how long such a policy would take to create wealth equality.
In addition to resolving wealth inequity, we do need to address income security for every Canadian. We need to design a labour market in which every job is a high-quality job.
We need to ensure the wages, benefits and working conditions of all jobs meet a high minimum standard and that employment discrimination is more rigorously penalized.
We have strong randomized trial data that tell us a very disheartening tale of racial discrimination in the labour market that cannot be accounted for by differences in foreign degrees or lack of Canadian job experience.
We have to stop taking comfort in the fact that people are somehow managing to survive and create the conditions to let them thrive. There are countless examples we can take of ways to implement this. For example, a universal job guarantee would put an end to involuntary unemployment and create good jobs to do important work sorely needed by Canada. It would also put pressure on the private sector to compete on wages and job conditions.
Finally, we must universalize access to basic services that create high quality of life: child care, education, health and pharmacare more broadly defined, elder care, and so on. We can't limit opportunities based on race and economic position any longer. It's so unjust and so unbecoming of a country with so much to offer.
There you have it. There's no half-hearted way out for resolving COVID-19 inequities. Even if we developed band-aid policies, we'd be right back here talking about this or another racial health inequity soon, because that's how it works. Without resolving the fundamental structural issues of systemic racism and its impact on economic security, nothing ever changes. That's simply not fair for any Canadian to be subjected to.
While the policy solutions I've laid out are bold, they are very doable. Many scholars have highlighted how these policies can be designed and paid for. It's our responsibility—
Mr. Chair and honourable members, thank you for inviting me to speak to the standing committee.
I am a physician and also the CEO of Wellesley Institute, a think tank that aims to improve health and health equity through research and policy development focused on the social determinants of health. This morning you should have been given the executive summary of the briefing note we submitted to the standing committee. The executive summary gives more detail on the recommendations I am making today. The full briefing note goes into background and gives references for my comments.
I'd especially like to thank Erica Pereira, the procedural clerk, for getting the executive summary translated so quickly.
Survival for those on the Titanic over a century ago was directly related to their social status: 60% of those in first class lived, while 42% of those in second class and only 24% of those in third class lived. The Titanic’s escape plan was the same for everyone, but third-class passengers were in lower internal berths and had difficulty getting to the lifeboats. The huge death toll was because there was not an adequate plan for them, though they were the passengers most in need.
Fast-forward 108 years to Canada’s COVID response. This has actually been very good. We've done really well. But like the Titanic, we have not developed an adequate plan for our highest-risk populations, such as people living in congregate settings, those with lower incomes, and of course our racialized populations. Our initial response was focused on flattening the curve, not on who was under the curve. If we'd focused on both, we would have had a better response and we'd have saved thousands of lives.
We now need four groups of actions to ensure that our current and future responses to pandemics are equitable and better. First, we need legislation that ensures that our public health responses, our health response and our social policy responses produce equitable outcomes. Second, we need equity-based federal and provincial COVID-19 health and public health plans. Third, we need equity-based social policy and recovery plans that ensure that the most hard-hit populations are served properly. Last, we need data streams, research and capacity building to ensure that we have good socio-demographic, race and ethnicity information on which to build and monitor public health, health and social policy interventions. I'll go through each of those in a little bit more detail.
Recommendation one is for legislation. We've actually seen racial disparities in infection rates and deaths in previous pandemics. During the H1N1 pandemic in Ontario, the Southeast Asian population was three times more likely to be infected, the South Asian population six times more likely to be infected, and the black population 10 times more likely to be infected than anybody else. Despite this, we did not change our systems to collect socio-demographic data. We did not do research or sit with communities to try to find out why the disparities exist. We went into COVID-19 without the surveillance systems or knowledge that would help us identify and deal with racialized health disparities. Then we set up a Titanic response—a one-size-fits-all, colour- and culture-blind pandemic plan that was predictably going to lead to health inequities. Some have argued that this was negligent. I just say that it shouldn't be legal. We have legislation for things we care about. We do not leave them to the largesse of professionals, public servants or politicians. If we want public services to produce equitable responses, we should enshrine this in enforceable law.
Recommendation two is for equity-based federal and provincial COVID-19 health plans. We would have a fairer response if we took a health equity approach to what is left of the first wave, to the second wave and to the recovery. A health equity approach aims to decrease avoidable disparities among groups. It ensures that people with similar needs get the same pandemic response and people with greater needs get a bigger response.
There are lots of evidence-based tools out there such as health equity impact assessments, which could be used to build these sorts of responses, and they have been shown to be effective in public health in Canada. But when we build equitable plans we also have to work with communities to develop strategies that allow them to protect themselves from COVID-19.
Recommendation three is saying let's have those equitable plans, but also let's link to what Dr. Siddiqi was talking about, because health equity recognizes that the risk of illness and the ability to recover are not just linked to health interventions, but also to the social determinants of health.
The Canadian Medical Association has calculated that 85% of our risk of illness is linked to these social determinants such as income, housing, education, racism and access to health care. This offers significant policy opportunities for improving health, because many health disparities are avoidable.
COVID-19 harms health in four ways: through the disease itself, through the side effects of public health response, through health care changes such as cancelled operations, and by the downturn in the economy. These interact with the social determinants of health so that some parts of our population are harder hit than others. As Dr. Siddiqi said, Canada's black populations have been hardest hit by COVID-19.
Our pandemic social policies and recovery plan need to be developed so they decrease inequality and reach the hardest-hit people. Decreasing differential risk linked to social determinants of health is an important intervention here, and probably one of the most important interventions. The idea of a focused recovery plan for the hardest-hit populations would not only improve our response, but would make those populations more resilient to future pandemics and future waves.
The last is numbers and data. I'm a researcher and I'm in a think tank. We think numbers and data are vital, and they have been vital in the fight against COVID. We've relied on the number of cases, the number of deaths, and suddenly everybody understands what an R number is, which I never thought would happen in my lifetime.
Numbers are also useful in indicating whether our interventions are working for everyone, and to do this we need disaggregated data. We desperately need better data streams on race and ethnicity and other social determinants of health for COVID-19, and for health in general. We need similar data, of course, for social policy. These data need to be good quality and there needs to be good data governance and accountability. Communities increasingly want a say in and control of the use of their data.
Wellesley Institute recommends that Canada collect individual-level associated demographic data for COVID-19, including race and ethnicity, and that Canada urgently undertake innovative analysis using existing data to get as accurate a picture of disparities as possible. Also recommended is that Canada develop a strategy for ongoing socio-demographic data collection for health and social policy, including race and ethnicity.
But data is not an end in itself. Data has to be linked to meaningful strategies to decrease disparities. This will mean engagement with communities, research and action to develop equitable public health and social policy interventions.
In conclusion, public health is the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society. Health equity interventions and the concept of social determinants of health are important tools in helping us to organize the best pandemic response. They are also a sound basis for health and social policy.
The one-size-fits-all strategy actually led to a huge death toll on the Titanic, and so far it's led to a significantly increased death toll for some parts of the Canadian population during the COVID-19 pandemic.
If we want a COVID-19 response and health systems to be more fitting for the 21st century, we need legislation that ensures equity; we need equity-based COVID-19 pandemic plans; we need social policy and recovery plans focused on decreasing current inequities and we need data streams and research that allow us to properly identify risk groups, build appropriate interventions and monitor their impact.
If we can put all of these in place, we'll move Canada's good response to being a great response, and we'll save lives.
Thank you very much.
Thanks very much for the question. I'm happy to expand.
I think the way to do better is to understand what caused their vulnerability in the first place. There are two approaches that we could generally think about. One is to mitigate the harm done to vulnerable people, but the first is to ask why people are vulnerable in the first place. What makes us sort people into being vulnerable and not? What we've learned from the literature is that this issue of someone's social and economic position, in particular their race and their social class, creates an inherent vulnerability. Without addressing the fact that life, material conditions, stress, opportunity and so on are fundamentally sorted by race and class, we can't possibly hope to do anything about what the eventual outcomes of that vulnerability are, which are things like COVID-19 inequities, cardiovascular inequities, hypertension inequities, educational inequities, employment inequities and so on.
I think what we can do is take a good, long, hard look at how we structure opportunity in our society and say to ourselves, “We want a society in which the policies and the institutions create opportunity for everybody.” I think, as one of the members eloquently said earlier, it's the distinction between equality and equity in the sense that you want to make sure—knowing that we don't have an equitable society and that it's unfair to some—that we start to look at key policies that would get us to equity and would not just unfold opportunities as if they could be equally taken up.
A great example is that of post-secondary education. You could make an argument that anyone can apply and that this creates some equality. We don't stop anybody from applying. If you make the grades and so on, you can get into school. But that's not actually how it works, because you have to be able to pay for school. You have to have teachers who support you in feeling as though you can make it to that point. You have to have an environment around you that doesn't cause you so much stress that you can't focus on your studies and so on. The same is true for COVID. Yes, we could all shelter ourselves, social distance and technically avoid COVID, but that's not actually how things work. Some of us are more exposed than others are by virtue of our vulnerable position.
I think what I'm suggesting is that, as counterintuitive as it may seem, looking at the fundamental injustices of making some people vulnerable in our society is really the way to tackle the outgrowth of that.
Sure, and thanks very much for the question.
I completely agree with Dr. Siddiqi that we need to go fundamentally towards equality and equity, and that there are these fundamental causes that are driving disparities.
The problem is that a lot of the things you are going to do to try to deal with those fundamental causes are not going to happen during this pandemic in the first wave, second wave or recovery. The question is what can we actually do now and what can we actually do that can practically help this group move towards a more equitable response?
I do believe that we will find, if we have the data, that different jurisdictions have had different levels of success in producing equitable responses. I'm completely sure of that. We know that different jurisdictions have had completely different rates of COVID. If you look at B.C. and compare it to Quebec and Ontario, these are very different outcomes. In fact, if both Quebec and Ontario had the same quality of response that B.C. did, there would have been about 2,000 lives saved in Ontario, and there would have probably been about 4,000 lives saved in Quebec.
There are big differences in the ways we've gone about things. If we could even get to the point of equalizing how well the different provinces have dealt with COVID, we would move towards better outcomes for all.
This idea of legislation is to try to promote equity through legislation, to make sure that provinces actually think about equity when they're thinking about their pandemic plans. At the moment, many don't, and that's why we see some of the disparities. Not all of the disparities would be dealt with by thinking about equity in the pandemic plans, but certainly, because, as Dr. Siddiqi said, there are fundamental causes of these disparities, we could make our response better and more equitable and we could certainly save lives by using a health equity lens.
Then going forward, when we're looking at the recovery, we need to use the opportunity of the recovery to try to decrease some of the fundamental drivers of inequities. I think there are things we can do now, directly in our pandemic plans, and then also in our recovery plan, that will actually make us more equitable and will save lives.
I also think that not having the data is criminal. It's 2020, right?
Thank you, Mr. Desilets.
I would bring you back to some numbers.
If you look at the death rate per 100,000, in Canada it's been about 23 per 100,000. If you look at somewhere like the United Kingdom, it's been 50 per 100,000. In fact, Canada's rate is pretty good compared to that of many high-income countries, so we've done reasonably well.
Obviously if we compare ourselves to Germany, which has a rate of 11 per 100,000, we haven't done as well as Germany. In fact, if we had had a response that was as good as Germany, one analysis has shown we'd have saved 4,528 lives.
We're in the middle of the pack compared to lots of others. We've done very well; it could have gotten a lot worse.
The problem is that, inside that good response, it's worked better for some people than for other people, so my comments are that we have done well but if we had done equally well for everybody, we'd have all been better off and the death rate would have been significantly lower, and the morbidity would have been significantly lower. We would have been in a better place in order to rebound into recovery.
I can tell you what we often hear as the primary reason, and then I can speculate about what might be going on.
We're often told that the reason for withholding this data, for not making it publicly accessible, not collecting it more widely, etc. is really to protect the privacy of Canadians, since there may be some issues particularly with a general release of the data that would compromise the safety and privacy of Canadians were those data able to identify particular Canadians. We have very little reason to believe that is enough of a concern to suppress really valuable information. Is it somehow, through de-identified data, still possible to identify particular Canadians? It almost never is. Maybe there is a slight outside possibility, the way there is with census data for that matter, but not enough for me to believe it's actually a legitimate reason for not collecting this data and not allowing it to be freely, publicly accessible to be analyzed by people like me, Dr. McKenzie and others in order to inform our country about what's happening to us.
That brings me to what I think might be going on. It's unfortunate, but I do think that when we don't collect data, that's at least one way in which we can ignore the evidence. We can equate our own opinions with a claim that those opinions are facts, because the facts simply aren't available to us.
My sense is, as you've pointed out and I've pointed out before, that with data and the ability for independent scientists to analyze that data comes a groundswell of evidence that in one way forces us to at least admit to the facts, to at least have to contend with and confront and recognize the fact that there are empirical evidence sources being put before us, rather than having a situation in which anyone can say virtually anything and we don't really have a good way to contend with or refute what people are saying.
I think that part of the hesitation may be that this actually creates some serious empirical demonstrations of what's happening in our society and that then, as Dr. McKenzie said, that's not the end; it's just the beginning, and that will make us have to move forward with action.
I was lucky to be part of the basic income pilot project as the research and evaluation advisory group chair. I advised directly the running of the basic income pilot and the link between the basic income pilot and the third party evaluators, who were a consortium of academics. In some ways, as you probably remember, I was a translator between the academic language and the bureaucratic language in order to make it work.
The basic income project had two different bits. It had a randomized control trial in two areas, Hamilton and also in Thunder Bay in the north of Ontario, where people were randomized through either the basic income or not the basic income. It then had a saturation study in a different place, Lindsay, with 22,000 people in a predominantly farming area to see whether there would be a change in the economy in that area if all low-income people were offered the basic income. The basic income or essentially the amount of money you got was based on a tax rebate, which worked very well.
We learned loads of things. One, you can do it. Two, people love it. They find it a much more dignified way of getting their social assistance. Three, entrepreneurs take risks and build businesses if they have backing and they know they have at least a basic income. Four, people change their lives and go back to college. They get into better housing and give themselves a fundamental chance in order to move forward if they have a basic income. People move themselves out of poverty if they have a basic income.
It was a travesty, in my mind, that it was stopped. You can't start a research project, say to people that they have three years in order to revolutionize their lives and then take the money away. It's bad for their health. It's bad, obviously, for the country not to have that information. It made us look bad on the world stage, because people all over the world were looking for these results. When there were follow-ups of some of those people, such as in Hamilton, people who'd gotten even one year of basic income had done better than people who hadn't.
For people, I think it's about time that.... There are rights and responsibilities from being a citizen. Maybe there has to be a deal with the citizens that they have rights, and those rights are for a basic level of income that befits a high-income country.
The meeting is now resumed.
Welcome back to meeting number 32 of the House of Commons Standing Committee on Health. We're operating pursuant to the order of reference of March 26, 2020. The committee is resuming its briefing on the Canadian response to the outbreak of the coronavirus.
I would like to make a few comments for the benefit of the new witnesses. Before speaking, please wait until recognized. When you are ready to speak you can click on the microphone icon to activate your mike. I remind you that all comments should be addressed through the chair. Interpretation in this video conference will work very much like in a regular committee meeting. You have the choice at the bottom of your screen of either floor, English or French. If you plan to alternate from one language to the other, you will need to switch the interpretation channel so that it aligns with the language you are speaking. You may want to allow for a very short pause when switching languages. When you are not speaking, your mike should be on mute.
I would like to welcome our witnesses.
We have, from the Canadian Institute for Health Information, CIHI, Ms. Kathleen Morris, vice-president, research and analysis, and Ms. Mélanie Josée Davidson, director, health system performance. From the Department of Public Safety and Emergency Preparedness, we have Ms. Colleen Merchant, director general of national cybersecurity, national and cybersecurity branch. We have Mr. Scott Jones from CSE, head of the Canadian Centre for Cyber Security. We have Chief Superintendent Mark Flynn from the RCMP, director general of financial crime and cybercrime, federal policing criminal operations. From Statistics Canada, we have Ms. Karen Mihorean, director general, social data insights, integration and innovation; Mr. Marc Lachance, acting director general, diversity and populations; and Mr. Jeff Latimer, director general and strategic adviser for health data.
Thank you all for being here. We will start with our statements from witnesses. We will start with the Canadian Institute for Health Information.
Please go ahead. You have 10 minutes.
On behalf of the Canadian Institute for Health Information, thank you for the opportunity to appear before the standing committee.
I am speaking to you today from the traditional territory of the Wendat, the Anishinabek first nation, the Haudenosaunee Confederacy and the Mississaugas of the New Credit. I recognize that this land is now the home of many first nations, Inuit and Métis people.
Since 1994, CIHI, as we're usually called, has been a leader in health data and information. CIHI is a not-for-profit independent body funded by the federal government and all provinces and territories. Our board of directors is made up of deputy ministers of health and other health system leaders, representing all regions of the country. CIHI has signed data-sharing agreements with every province and territory and several federal organizations.
Pan-Canadian health data is a shared responsibility between us and our partners at Statistics Canada, Health Canada and the Public Health Agency. Each organization has a defined role within the health ecosystem, with CIHI's focus on health care systems and their functioning.
For example, CIHI oversees data on hospitals and long-term care, health spending and workforce, and information on health system performance. Data is provided to us voluntarily by the provinces and territories. This allows the data to be aggregated and compared and for health systems to learn from each other. We also work closely with organizations that are international, such as the OECD and the Commonwealth Fund, which enables us to learn from other countries.
CIHI makes the data and information available to policy-makers, health system leaders, researchers and the public. Although we play an integral role in providing relevant and reliable data and analysis to policy-makers, we are neutral and objective in fulfilling our mandate. We neither create policy nor take positions on it. Ultimately, we work to help improve the health care system and the health of Canadians. Maintaining public trust is critical to our success. We're committed to protecting the privacy of Canadians and ensuring the security of their personal health information.
During COVID-19, CIHI's work has focused on three main priorities: first, maintaining the current data supply and looking for opportunities to improve; second, developing analytical products or services that assist with the COVID response; and third, to provide data and information quickly to those who need it.
Let me share one or two examples in each of those three priority areas.
In terms of maintaining and enhancing the data supply, we work closely with our data suppliers to mitigate disruptions to the data. We are pleased to report that hospitals and the majority of long-term care homes were able to complete data collection for the 2019-20 fiscal year within the normal deadlines. We also shared new standards to capture confirmed and suspected COVID cases in care facilities. This information will be critical as we look back at how our hospitals responded to the pandemic. We also created guidelines for race-based data collection in health in an effort to facilitate the collection of high-quality data, which I know was a focus of your earlier discussions.
The second goal is around providing analysis to support decision-making. During the early phases of the pandemic, we received many requests from those who were trying to project the need for hospital beds, for staff and for supplies such as ventilators and personal protective equipment. In response, we developed a tool to help those who are modelling to be able to deliver results at a local level. We also provided advice and facilitated the exchange of information among modelling teams working in different parts of the country. Most recently, we released a report that looked at Canada's pandemic experience in long-term care compared to that of other countries. The report found that early adoption of strict public health measures in long-term care was associated with fewer cases of COVID-19 and lower death rates.
Finally, our third initiative was around responding to requests. In addition, over the past few months CIHI has responded to more than 500 requests for information and data. The topics of these requests have changed over the weeks. Initially, they were very focused on describing the situation: how many cases, how many patients and how many hospitalizations. As time went on, we had more questions around long-term care. Most recently, the questions have focused on the reopening of the health system and ensuring that's done safely, and on the potential consequences of the shutdown on issues such as mental health, substance use and planned surgeries.
As we navigated the pandemic, working closely with our federal partners, it became apparent that there were several gaps in important data flows within and among health care systems in Canada. COVID-19 has highlighted some of these gaps, and we see them falling into one or more of three categories.
The first is gaps in data availability. These are real gaps. The data simply doesn't exist, as the panellists in the first half of this session may have highlighted. The gaps here could include information on supplies and equipment available in the system, or they could be gaps around the characteristics of long-term care homes, such as the number of patients to a room, the ownership models and the staffing ratios. We also saw significant gaps when we tried to examine some parts of the health workforce, such as the number of personal support workers and where they worked.
The second gap involves data that exists but that can't be accessed quickly enough to support decision-making. For example, we needed more timely hospital and emergency room data. This data is collected from hospitals across the country but does not flow in quickly enough to support pandemic-type decisions. To temporarily fill this gap and help the federal government understand whether hospitals were becoming overwhelmed with COVID cases, we created a dashboard report on the supply and use of hospital beds, ICU beds and ventilators. This report is updated manually on a daily basis by key contacts in the provinces and territories as well as CIHI staff.
Finally, some gaps exist because we can't integrate data. Information systems often can't speak to each other, sometimes because they use different standards, but sometimes the data doesn't include personal identifiers that allow this connection. For example, right now we can't follow a patient's full COVID experience from testing through to treatment and, hopefully, to recovery, because public health electronic medical records and health system records are fragmented.
CIHI is always working to enhance the scope and availability of Canada's health system data for analysis and decision-making. While there are many gaps, we recommend focusing on three.
First is comprehensive, timely and integrated health workforce data to support planning and policy.
The collection and analysis of health workforce data is fragmented and incomplete today. We need to capture additional professions in our current systems, such as respiratory technicians and personal support workers, to better understand both the mix of staff who provide front-line care and where they work. We also need to make sure that this data is linkable to data on the use of health services and to financial data systems. This could help identify infection rates in the health workforce, the use of overtime and the longer-term effects of COVID-19 on front-line workers.
The second gap is in the need for more complete and timely data on long-term care homes: the residents, the workforce and the facilities.
While there's excellent information on the clinical profiles of long-term care residents in most parts of the country, there are some significant gaps. We have little information about the residents' quality of life and care experiences before COVID, or how these might have changed during the pandemic. We also have limited information about the facilities themselves, the mix of staff who provide care, and the way infectious outbreaks are dealt with. It's important to recognize that while long-term care treats our most vulnerable seniors, many older Canadians live in a variety of different group care settings for which we have very little information.
The final area is a need for more timely and comprehensive data on hospital-based care and clinic services, both for COVID patients and for patients with other health conditions.
CIHI's hospital data provides deep insight into the number of Canadians treated and the type of care they receive, but this high-quality data is assembled by health information specialists after a patient is discharged from the hospital. To better manage our systems when they're facing emerging issues like COVID-19, but also the seasonal flu or the opioid crisis, we need to automate the flow of hospital data in real or near real time and have more information on patients when they're admitted.
Discussions around these actionable solutions are under way. The groundwork is there, but these solutions require the engagement of health system managers and health care providers, leadership from policy-makers and funding for the development and implementation of information systems.
Today we ask for your commitment and support. Better data allows for better decisions and, ultimately, healthier Canadians.
Thank you for the opportunity to present. I'd be pleased to answer any questions.
Good afternoon and thank you, Mr. Chair and committee members, for the invitation to appear today to discuss cybersecurity during the COVID-19 pandemic.
As mentioned, I'm Scott Jones and I am the head of the Canadian Centre for Cyber Security at the Communications Security Establishment. I'm very pleased to be joined by my colleagues: Chief Superintendent Mark Flynn, director general of financial crime and cybercrime from the RCMP, and Colleen Merchant, director general of national cyber security from the Department of Public Safety.
Our departments have distinct but complementary mandates as they relate to cybersecurity.
The CSE, reporting to the Minister of National Defence, is one of Canada's key intelligence agencies and the country's lead technical authority for cybersecurity. The Canadian Centre for Cyber Security, or as I will refer to it from now on, the cyber centre, is a branch within the CSE. We defend the Government of Canada, we share best practices to prevent compromises, we manage and coordinate incidents of national importance and we work to secure a digital Canada.
Public Safety leads the Government of Canada's cybersecurity policy work. This involves the implementation of the 2018 national cybersecurity strategy and the coordination of government-wide efforts to help secure digital and cyber-assets through strategic-level initiatives. Public Safety also supports critical infrastructure protection and offers assessment tools to provide expert advice to owners and operators on how to improve their cybersecurity and cyber-resilience posture.
RCMP federal policing is responsible for the investigation of attacks against Canada's critical infrastructure—which includes the health care sector—in collaboration with the police of local jurisdiction. Additionally, the RCMP has its national cybercrime coordination unit, which is a national police service that coordinates the response of Canadian police agencies to cybercrime incidents. Together our three departments work with the greater Canadian cybersecurity community to protect Canada and Canadians from potential cyber-threats.
Today I would like to provide an update on what the current cyber-threat environment looks like in the COVID-19 pandemic and also highlight the important work that the CSE, the RCMP and Public Safety are doing to protect the Government of Canada and Canadians specifically in the context of the health sector.
Cyber-threat actors are attempting to take advantage of Canadians' heightened levels of concerns around COVID-19. Prior to, and amplified by, the pandemic, our lives are becoming increasingly reliant on digital communication. Cybercriminals are aware of this digital reliance and are seeking to take advantage of the current situation. More than ever, collaboration for cybersecurity is critical, whether it is for the cyber-infrastructure underlying the Internet of things, connected devices or for the applications supporting digital exposure notification. Designing solutions with cybersecurity in mind is a condition for long-term success.
From a government perspective, the underlying objective must be to protect Canadians online. These efforts are under way and they are significant, with the cyber centre as the lead for the federal government. Among these efforts, cybersecurity and cybercrime remain interconnected and remind us of the importance of pursuing those responsible through the criminal justice system.
Law enforcement remains a critical element of cybersecurity. As such, the RCMP federal policing program investigates the most significant threats to Canada's political, economic and social integrity, including cybercrime that targets the federal government, threatens Canada's critical infrastructure and the health care sector, involves the use of cyber-systems to facilitate or support terrorist activities and threatens key business assets with high economic impact.
The RCMP works with domestic and international law enforcement partners and with other Government of Canada agencies to ensure that the wide array of cyber-threats is not treated in isolation. Appropriate and timely information sharing is essential for investigation, which in turn contributes to improved cybersecurity for Canadians. For example, the cyber centre and the RCMP work together by sharing information about scams to warn Canadians and share indicators of compromise so they can be blocked and prevented. From a public safety perspective, they tackle these questions by engaging with stakeholders and fostering good discussions to identify problems and propose policy solutions.
The cyber centre is working tirelessly to raise public awareness of cyber-threats to health organizations by proactively issuing cyber-threat alerts and providing tailored advice to the health sector, government partners and industry stakeholders. Throughout COVID-19, the cyber centre has worked closely with industry and commercial partners to facilitate the removal of malicious websites, including those that have spoofed Canadian government departments and agencies. The cyber centre has also helped monitor and protect important Government of Canada programs against cyber-threats, including the Canada emergency response benefit web application. We have continued to evaluate cloud applications, including for the Public Health Agency, and enabled cybersecurity monitoring and defence for cloud usage across the government.
Individual Canadians, however, are also at risk. As people and organizations shift to working and learning from home, personal devices and home networks have become attractive targets. In response, the cyber centre has partnered with the Canadian Internet Registration Authority, CIRA, to create and launch the CIRA Canadian shield, a free DNS firewall service, which provides online privacy and security to all Canadians for free.
The cyber centre has also collaborated with the Canadian Anti-Fraud Centre. It is operated by the RCMP, the Ontario Provincial Police and the Competition Bureau, which are are Canada's trusted sources for reporting and mitigating mass-marketing fraud.
The Anti-Fraud Centre's primary goals are prevention through education awareness, the disruption of criminal activities and the dissemination of intelligence that enables law enforcement to identify organized crime involvement in fraud schemes.
Through targeted advice and guidance, the cyber centre is helping to protect Canadians' cybersecurity interests. I encourage all Canadians to visit getcybersafe.gc.ca and all businesses to visit cyber.gc.ca to learn more about our best practices that can be applied to protect you and all Canadians from cyber-threats.
Finally, the cyber centre has assessed that the COVID-19 pandemic presents an elevated level of risk to the cybersecurity of Canadian health organizations involved in the response to the pandemic. Cyber-threat actors know that the health sector is under intense pressure to slow the spread of COVID-19 and to produce medical treatments to prevent new infections and their spread. Hospitals and other front-line medical services are often vulnerable to malicious cyber-threat activity due to limited cybersecurity capacity.
We continue to recommend that Canadian health organizations remain extra vigilant and take the time to ensure they are applying cyber-defence best practices, including increased monitoring of network logs, reminding employees to be alert to suspicious emails and to use secure teleworking practices where applicable, and ensuring that servers in critical systems are patched for all known security vulnerabilities.
To further protect the health sector, Public Safety, in close collaboration with the cyber centre, is developing a Canadian cyber-survey tool to provide health sector organizations such as hospitals, doctors' offices and long-term care facilities, among others, with an easy-to-use tool to assess the cybersecurity of their organization. The survey can be completed in less than an hour and is completely voluntary. It will be used for two main purposes.
The first is to provide the organization with a report detailing any technical and cybersecurity program-related findings that could and should be addressed to enhance their cybersecurity. The second is to identify cybersecurity trends and common challenges in the health sector to help tailor cybersecurity engagements by the Government of Canada to strengthen the cybersecurity posture of the health sector as a whole. Public Safety is aiming to launch this survey tool in the coming weeks and will broaden the application of this tool to all 10 critical infrastructure sectors to examine the cybersecurity of all aspects of supply chains.
It should also be noted that the RCMP's national critical infrastructure team has worked with the Public Health Agency of Canada to share awareness material within the health sector. In addition, they have divisions across the country to continue to develop new partnerships within the health sector, increasing those organizations' situational awareness of the potential threat landscape.
Together, our three departments would like to note that even when all of the possible precautions are taken, if a compromise occurs, it is critical that organizations inform us of any cyber-incident they experience. Cybersecurity is everyone's responsibility, and it will take all of our expertise and collaboration to protect Canada and Canadians. The more we share, the better protected we will all be. If we don't share, then the next person who gets hit will be the next victim.
Thank you for the invitation to appear before you today. We will be happy to answer any questions you may have.
Thank you very much, Mr. Chair.
I'd like to thank you for the opportunity to appear before your committee as a representative of Statistics Canada. As a public servant, I am always grateful for these opportunities. I'm here with my colleagues Karen Mihorean and Marc Lachance. They will answer questions within their areas of expertise if required.
It's clear to us that the pandemic has raised significant concerns about the disproportionate impacts across Canada based upon socio-economic differences. Not all groups have been equally affected, and we have observed such impacts within our data, particularly among seniors living in long-term care facilities, health care workers, racialized communities, indigenous communities and those living in low-income households.
Before presenting a few key examples, it's important to highlight the data collection accountabilities related to COVID-19.
As you probably know, the provincial and territorial public health authorities are responsible for collecting and reporting within their jurisdictions on COVID-19 cases. The Public Health Agency of Canada is responsible for receiving this data from the provinces and territories and reporting at the national level. While Statistics Canada does not collect COVID-19 data directly, we do provide expertise and advice on gaps in existing data and on potential strategies to address such gaps, as well as data collection and data exchange standards.
I'd like to make one last point related to data collection before I provide examples. There are generally two methods: survey data, from a sample the population, and administrative data, typically from a census of all cases. COVID-19 data is collected through administrative data, which often has a number of limitations. In Canada, it is clear these data limitations are creating significant challenges.
First, there is a lack of common data standards and data exchange standards across the country, along with inefficient data processing and data quality concerns. Second, the lack of granularity in the data that is collected related to COVID-19 makes it difficult to answer key policy questions. For example, there is no data collected on such demographic characteristics as race, ethnicity or income, and no data on an individual's underlying health status. In addition, detailed geospatial data is not available to better understand the spread of COVID-19. Finally, and I think most importantly, the data submitted to the federal government does not include identifiers that could facilitate safe and appropriate record linkage with existing Statistics Canada datasets that could potentially fill these gaps.
That said, we have been actively collecting new survey data and analyzing our existing data to shed some light on the potential indirect impacts of COVID-19. During this time of social distancing, for example, 64% of youth are reporting substantial declines in their mental health status, compared with only 35% of seniors. The unemployment rate for students in May of this year was 40%, which is triple the rate reported last year in the same month. A similar pattern was evident among non-student youth as well. More than 70% of seniors in Canada over the age of 80 report at least one pre-existing chronic condition related to severe symptoms of COVID-19, which is more than double the rate among adults under 60.
If we look at the immigrant population, we see that employment losses during COVID-19 have been more than double compared with the Canadian-born population. We also know that before COVID-19, black Canadians were already experiencing unemployment rates twice that of the general population. The wage gap between these groups has been widening in recent years. Among black youth, almost twice as many report experiencing food insecurity as compared with other young Canadians. Visible minority populations, such as Chinese and Korean Canadians, have reported increases in race-based negative incidents over the last few months. One in ten women have reported being concerned about violence in their home during the pandemic.
If we examine the socio-demographic characteristics of long-term care workers, who are currently facing some of the most difficult challenges, we see that they are more likely to be immigrants, they are less likely to work full time, and they are more likely to earn less than the average Canadian. Indigenous men are two and a half times more likely to be unemployed. They earn, on average, 23% less than their non-indigenous counterparts. In almost all indicators, including health status and life expectancy, the indigenous population lags well behind Canadian averages.
The pandemic has shone a glaring light on many of these pre-existing social inequities that Statistics Canada has been tracking for decades. In order to respond to the need for more data, we have launched a number of rapid data collection vehicles, such as web panels and crowdsourcing surveys. The topics have included the impacts of COVID-19 on labour, food insecurity, mental health, perceptions of safety, trust in others and parenting concerns. Statistics Canada finished collection just yesterday, using our crowdsourcing surveys, to better understand the impact on persons with long-term disabilities. This data will be available in early August. It will include information on visible minority status as well as such other demographic markers as gender, immigrant status and indigenous identity. More data on mental health issues will also be made available in the coming weeks. It will provide breakdowns by gender diversity, immigrant status and ethnocultural groups.
In partnership with the provinces and territories, we have also significantly increased the timeliness of death data in Canada so that a clear picture of excess deaths during the pandemic can be estimated. We will be releasing this data publicly next month.
We are also partnering with the Canadian Institute for Health Information to examine in greater detail the issues among health care workers and long-term care facilities.
Finally, we are working with the Public Health Agency of Canada to make detailed preliminary data on the number of confirmed COVID-19 cases available to Canadians and researchers.
I'd like to thank you very much for your time. My colleagues and I are available to answer any questions you may have.
Thank you, Mr. Chair.
Thank you very much for the question.
Researchers are a big customer of CIHI. I spoke of 500 data requests. Many of those were from researchers looking for information to do modelling work to help predict the impacts of the pandemic on the health system as well as to model restarts in terms of beginning elective surgery and other procedures as things started to improve.
One of the things that's particularly helpful with the CIHI data is that it does come with an identifier, so we can follow patients across datasets in terms of the prescription drugs they've been prescribed, whether they are in long-term care, in hospital settings or, in some cases, in primary care. We can follow them across.
That's particularly helpful in looking at health system performance measures such as readmissions or repeat emergency department visits, and it's very helpful at following the complications that might happen over time. For example, with COVID, it would be very interesting to know whether there are any long-term health consequences for patients who test positive that we could follow over the course of their lifetimes.
However, you're correct that there are data gaps. Some of them relate to the timeliness of the data. The data that CIHI collects has been built to facilitate benchmarking across long-term care facilities, hospitals and health regions, and the benchmarking supports improved health system performance. The data is complete, it's comparable, it uses common standards, and it provides very good information on care, but things like readmissions or pain levels in long-term care or worsening pressure ulcers are all things that don't change from day to day, typically, and the improvement efforts are okay if you can provide that information on a quarterly basis or an annual basis.