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Kelley Bush
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Kelley Bush
2015-06-18 16:07
Good afternoon. My name is Kelley Bush, and I am the head of radon education and awareness under Health Canada's national radon program.
Thank you, Mr. Chair and members of the committee, for inviting me to be here today to discuss radon as a cause of lung cancer and to highlight the work of the Canadian – National Radon Proficiency Program.
Through the ongoing activities of this program, Health Canada is committed to informing Canadians about the health risk of radon, better understanding the methods and technologies available for reducing radon exposure, and giving Canadians the tools to take action to reduce their exposure.
Radon is a colourless, odourless radioactive gas that is formed naturally in the environment. It comes from the breakdown of uranium in soil and rock. When radon is released from the ground in outdoor air, it gets diluted and is not a concern. However, when radon enters an indoor space, such as a home, it can accumulate to high levels and become a serious health risk. Radon naturally breaks down into other radioactive substances called progeny. Radon gas and radon progeny in the air can be breathed into the lungs, where they break down further and emit alpha particles. These alpha particles release small bursts of energy, which are absorbed by the nearby lung tissue and lead to lung cell death or damage. When lung cells are damaged, they have the potential to result in cancer when they reproduce.
The lung cancer risk associated with radon is well recognized internationally. As noted by the World Health Organization, a recent study on indoor radon and lung cancer in North America, Europe, and Asia provided strong evidence that radon causes a substantial number of lung cancers in the general population. It's recognized around the world that radon is the second leading cause of lung cancer after smoking, and that smokers also exposed to high levels of radon have a significantly increased risk of developing lung cancer.
Based on the latest data from Health Canada, 16% of lung cancers are radon-induced, resulting in more than 3,200 deaths in Canada each year. To manage these risks, in 2007 the federal government in collaboration with provinces and territories lowered the federal guideline from 800 to 200 becquerels per cubic metre. Our guideline of 200 becquerels per cubic metre is amongst the lowest radon action levels internationally, and aligns with the World Health Organization's recommended range of 100 to 300 becquerels per cubic metre.
All homes and buildings have some level of radon. It's not a question of “if” you have radon in your house; you do. The only question is how much, and the only way to know is to test. Health Canada recommends that all homeowners test their home and that if the levels are high, above our Canadian guideline, you take action to reduce.
The national radon program was launched in 2007 to support the implementation of the new federal guideline. Funding for this program is provided under the Government of Canada's clean air regulatory agenda. Our national radon program budget is $30.5 million over five years.
Since its creation, the program has had direct and measurable impacts on increasing public awareness, increasing radon testing in homes and public buildings, and reducing radon exposure. This has been accomplished through research to characterize the radon problem in Canada, as well as through measures to protect Canadians by increasing their awareness and giving them tools to take action on radon.
The national radon program includes important research to characterize radon risk in Canada. Two large-scale, cross-Canada residential surveys have been completed, using long-term radon test kits in over 17,000 homes. The surveys have provided us with a much better understanding of radon levels across the country. This data is used by Health Canada and our stakeholder partners to further define radon risk, to effectively target radon outreach, to raise awareness, and to promote action. For example, Public Health Ontario used this data in its radon burden of illness study. The Province of British Columbia used the data to inform its 2014 changes to their provincial building codes, which made radon reduction codes more stringent in radon-prone areas based on the results of our cross-Canada surveys. The CBC used the data to develop a special health investigative report and interactive radon map.
The national radon program also conducts research on radon mitigation, including evaluating the effectiveness of mitigation methods, conducting mitigation action follow-up studies, and analyzing the effects of energy retrofits on radon levels in buildings. For example, in partnership with the National Research Council, the national radon program conducted research on the efficacy of common radon mitigation systems in our beautiful Canadian climatic conditions. It is also working with the Toronto Atmospheric Fund to incorporate radon testing in a study they're doing that looks at community housing retrofits and the impacts on indoor air quality.
This work supports the development of national codes and standards on radon mitigation. The national radon program led changes to the 2010 national building codes. We are currently working on the development of two national mitigation standards, one for existing homes and one for new construction.
The program has developed an extensive outreach program to inform Canadians about the risk from radon and encourage action to reduce exposure. This outreach is conducted through multiple platforms targeting the general public, key stakeholder groups, as well as populations most at risk such as smokers and communities known to have high radon.
Many of the successes we've achieved so far under this program have been accomplished as a result of collaboration and partnership with a broad range of stakeholder partners. Our partners include provincial and municipal governments, non-governmental organizations, health professional organizations, the building industry, the real estate industry, and many more. By working with these stakeholders, the program is able to strengthen the credibility of the messages we're sending out and extend the reach and impact of our outreach efforts. We are very grateful for their ongoing engagement and support.
In November 2013 the New Brunswick Lung Association, the Ontario Lung Association, Summerhill Impact, and Health Canada launched the very first national radon action month. This annual national campaign is promoted through outreach events, website content, social media, public service announcements, and media exposure. It raises awareness about radon and encourages Canadians to take action. In 2014 the campaign grew in the number of stakeholders and organizations that participate in raising awareness. It also included the release of a public service announcement with television personality Mike Holmes, who encouraged all Canadians to test their home for radon.
To give Canadians access to the tools to take action, extensive guidance documents have been developed on radon measurement and mitigation. Heath Canada also supported the development of a Canadian national radon proficiency program, which is a certification program designed to establish guidelines for training professionals in radon services. This program ensures that quality measurement and mitigation services are available to Canadians.
The Ontario College of Family Physicians as well as McMaster University, with the support of Health Canada, have developed an accredited continuing medical education course on radon. This course is designed to help health professionals—a key stakeholder group—answer patients' questions about the health risks of radon and the need to test their homes and reduce their families' exposure.
The national radon program also includes outreach targeted to at-risk populations. For example, Erica already mentioned the three-point home safety checklist that we've supported in partnership with CPCHE. As well, to reach smokers, we have a fact sheet entitled “Radon—Another Reason to Quit”. This is sent out to doctors' offices across Canada to be distributed to patients. Since the distribution of those fact sheets began, the requests from doctors offices have increased quite significantly. It began with about 5,000 fact sheets ordered a month, and we're up to about 30,000 fact sheets ordered a month and delivered across Canada.
In recognition of the significant health risk posed by radon, Health Canada's national radon program continues to undertake a range of activities to increase public awareness of the risk from radon and to provide Canadians with the tools they need to take action. We are pleased to conduct this work in collaboration with many partners across the country.
Thank you for your attention. I look forward to any questions the committee members might have.
Tom Kosatsky
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Tom Kosatsky
2015-06-18 16:43
You know, anyway, that smoking causes lung cancer in smokers. You probably also know that to a degree it causes lung cancer in people who live with smokers. I won't really talk about either of those things, but if you can get to the slide that's marked “Lung Cancer in Lifelong Non-Smokers”, you'll see that there is a new thing that's been described only over the last, about, 10 years, which is lung cancer in lifelong non-smokers, something which, before this committee invited me to speak with you, I didn't know much about. It turns out that it's a whole other disease. It has some similarities to smokers' lung cancer but some very important differences.
The geography is different. It's a huge phenomenon in Asia and in Asians in Canada. It has a female predominance, so there are far more lung cancers in female non-smokers than in male non-smokers. The age distribution is different, so it tends to present itself at a much younger age than smokers' lung cancers do. The cell types, the cancer types are different. The typical small cell squamous lung cancer that you see in smokers, you don't get in non-smokers. You get a whole different cell type and cell shape. The genetics are different, so there is some family relationship. It's not very strong, but there's a very strong genetic relationship based on genetic analysis. You can almost predict who's going to get it, which is a really important thing. Further, it tends to be much more symptomatic at diagnosis than is lung cancer in smokers. The five-year survival, oddly, is better, even though it presents later, for non-smokers' lung cancer than for smokers' lung cancer. In many ways it's a different disease.
Radon-related lung cancer is somewhere intermediate, because, as I'm going to say, most radon-related lung cancers occur in smokers. The question of whether it is more cost-efficient to stop smoking was right on the mark.
The next one is called “Principal risk factors (excluding occupational exposure)”, only because you asked. There are a number of conditions, including radon exposure, that are associated with non-smokers' lung cancer, like the history in your family. It's associated with hormone use in women. It's associated with environmental tobacco smoke. It's associated, to a degree, with air pollution. It's associated with cooking-oil fumes, so indoor cooking over a long period of time. It's associated in Asia and Africa with domestic heating by wood and wood products in the home. Those are also associated with lung cancer. Something that I didn't know much about before is that it's associated with lung infections like tuberculosis and other lung infections over a long period of time. It's also, like so many of the other bad things in life, associated with being poor. Getting lung cancer is associated with being poor, even if you eliminate all the other stuff. To a degree it's mitigated or prevented by a diet high in fruits and vegetables, so eat your leafy greens, eat your fruit, and you're less likely to get lung cancer no matter what else you do.
The next one is an American slide. It has a little American flag, and it looks at the attributable percentage of lung cancer by cause. For active smoking, it's 90%. For radon exposure in the U.S., it is between 9% and 15%, and in Canada it's estimated at 15%. For workplace carcinogen exposure, it's 10%. For air pollution, it's 1% to 2%. That adds up to more than 100% because, as you'll see, some of those causes add to or multiply each other. If you're exposed to radon, don't smoke. If you smoke, don't be exposed to radon.
Non-smokers' lung cancer is a really important cause of lung cancer. It's about number six in terms of all the causes. Radon-related lung cancer—this is U.S. data but for Canada it would be the same—is number eight. How could that be? It could be because smoking and radon exposure are interactive, so one multiplies or adds to the effect of the other. That leads, in any case, to non-smokers' lung cancer being a very bad issue.
Any radon exposure is bad news, not just at over 200. An artificial limit, no matter what it is, is not very useful for lowering the whole population's exposure. It would be better if we were all exposed to less radon rather than picking one area, maybe for convenience, or one level. It may be good for convenience, but it's not a really useful population health measure. For the whole population, it would be better if we were all exposed to less radon. It's a linear relationship. The more radon you're exposed to and the longer you're exposed, the more likely you are to get lung cancer.
The other thing is that, as I was saying, the more you smoke the more it interacts. On the last slide, which I made up using Canadian data, most radon-associated lung cancers occur in smokers. If you've never smoked, as you get up to high levels, like interior B.C. levels, of radon about 36 people out of 1,000 exposed to those levels would get lung cancer. On the other hand if there was no radon exposure and you did smoke, about 100 people would get lung cancer. If you add the two together, you're exposed to a high level of radon and you smoke, 270 people exposed to those two for their whole lives, smoking and radon, will get lung cancer. It's 270 out of 1,000 people; that's tremendous.
How can you lower it? The number one way to lower it is to stop smoking or to never have smoked. The number two way to lower it is to lower your radon exposure, and you'll do that for everybody in the population. The less smoking there is, the less radon there is, the less lung cancer there will be, to the point that as we lower the level of smoking exposure, radon will become a more important cause of lung cancer. But there will be a lot less lung cancer. If we eliminate smoking, there will be less lung cancer in general, but all of these other causes other than smoking will increase in focus. The big issue is the interaction, the doubling, tripling, quadrupling, or really octupling effect, because it's an eight-time effect, of smoking and radon will go away.
What's been the Canadian public health stance on radon? Before the year 2007, it was pretty passive and largely seen as a private issue. Health Canada was helpful. They gave advice when people asked for it. That was at the time of the 800 becquerels per metre cubed, or 800 disintegrations per second per metre cubed level, which is what a becquerel is. Then when the level was lowered a more active stance was taken. Health Canada was involved with large-scale testing across the country to establish a radon profile across the country so that we knew what our levels were likely to be. They were much more active in terms of giving advice, and with this lower guideline, they promoted it and they encouraged “test and remediate”. Test and remediate to me is not the way to go. The way to go is to build it out in the first place.
If you look at this complicated Ontario slide, Ontario looked at levels of radon across the province and how many cases of lung cancer could be saved by doing something for those above 200 becquerels per metre cubed, by adopting 100 becquerels per metre cubed, by adopting 50 becquerels per metre cubed—all of which are attainable—or by going to as low a level possible and getting close to outdoor air levels, which are relatively benign. At 200 becquerels per metre cubed, if every Ontario resident got their house from that point down to outdoor levels, 2% of all the lung cancers in Ontario would be averted. If you got down from current levels above 200, if everybody tested and remediated and they successfully got their house down to background or no radon, it would avert 2% of all lung cancers. If all houses in Ontario with any level of radon in them could get down to outdoor levels, we'd get rid of 13% of all Ontario lung cancer deaths. If there were a way to do it, why not do that? Why not get it down lower?
The next slide looks at the change in levels of radon over time. This is Dutch data. Canada would be the same. Yes, as we've made our buildings tighter, radon levels have increased. This is even more reason to look at the joint effects of building changes on radon.
Sarah Henderson
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Sarah Henderson
2015-06-18 16:55
Good afternoon.
There is a slide deck for me as well. The first page of that slide deck should say, “Radon risk areas and lung cancer mortality trends in British Columbia”. I hope that you all have it. I will try to speak to the slides as I go along for those who don't have them.
I want to start by saying thank you so much for inviting me to be here. It's a real honour.
My title at the BC Centre for Disease Control is senior scientist, and I'm really a research scientist. The mandate of my role is to conduct applied public health research in support of good environmental health policy for the province, and that's how I first became interested in radon in British Columbia.
I'm going to show you some real, hard numbers today that come directly from the population data for British Columbia, and that's a bit different from what everybody else has been talking about so far.
If you move to the first slide, it's just a recap of the current guideline values for radon in Canada. We've heard about the number 200 all day, and any concentration lower than that is below the Health Canada guideline. Then if you measure your home and the concentration is between 200 and 600 becquerels per metre cubed, Health Canada currently recommends that you try to remediate that within the next couple of years, whereas if your measurement if over 600 becquerels per metre cubed, they really recommend that you remediate right away. That is the high-danger area for radon.
We've used these values in British Columbia to sort of break up the province into areas that we consider to be low, moderate, and high radon areas. If you are not seeing this in colour, the darkest areas there are coloured in red, and those are the high radon areas.
We're very lucky right now in British Columbia. We have a database of over 4,000 residential radon measurements, including measurements from Health Canada national surveys as well as from a bunch of surveys that have happened in the province, so we were really able to use the data that we have observed in the province to break things up this way. These geographic regions are called local health areas. They're the smallest health geographic unit that we use in British Columbia. We are able to look at deaths that have occurred in this province at this geographic scale, which is why we've used this geographic scale.
We did something quite simple, but I hope you'll agree, also quite effective. We looked at the province by those regions, and over the course of 25 years we summed up all of the deaths attributed to lung cancer in the low, moderate and high regions, and all deaths attributed to all natural causes, and then we divided the number of lung cancer deaths by the number of deaths from all natural causes, and in general, we expect about 7% of all deaths in B.C. to be attributed to lung cancer, which is probably true for most of Canada.
Slide number 4 shows the hypothetical situation. If there were no lung carcinogens in the world other than radon, we would expect lung cancer to be high and steady in the higher radon areas, somewhat lower and steady over time in the moderate radon areas, and then lower still and steady over time in the low radon areas. That's the framework I want you to think about when we go to this next slide.
When we looked at all deaths in British Columbia, we saw something quite different from what one would expect to see under that hypothetical scenario. The bottom line there shows the low radon areas. You might not be able to see that if you're not looking at it in colour. The middle line, which is just a little bit higher than the bottom line, shows the moderate radon areas. Then that line that is sloping upward over time and is quite distinct from the low and moderate lines is the lung cancer mortality proportion that we see in high radon areas over the past 25 years in British Columbia.
We don't have a lot of data about these people. We're doing this with only administrative data. We don't know whether or not they smoked. We don't know whether or not they lived their entire lives in those high radon areas. There are a whole lot of limitations here that we simply can't speak to.
When we split up these data by the higher and lower smoking regions of the province—we know that smoking rates can be up to 30% in some areas and down to 12% in some areas of B.C.—we still see these same persistent trends. It does seem to be that radon is an important factor here.
Another important distinction, and I think it's probably why I was asked to be here today, is what we see when we look at the trends for men versus women.
To look at men, the low line shown on the slide is the low radon areas, the middle line is the moderate radon areas, and the top line is the high radon areas. There's not as big a difference among those three lines as there was when we were looking at everybody together. In general, the lung cancer rates are going down. That's what we expect as the population stops smoking. When we go ahead and look at women, as shown on the next slide, we see the low and moderate lines towards the bottom there, and then the line for women is just taking off and is quite divergent from the other regions.
We're seeing a pretty big difference with respect to the two sexes here when we split up these data. Speaking anecdotally, it's not very scientific, but those of us who are interested in radon in British Columbia hear so many stories from people who say, “My wife died of lung cancer and she never smoked a day in her life.” This matches up with what we hear anecdotally, although that's not very scientific.
Somebody asked about the burden of radon-related lung cancer in high- and low-risk areas according to the current Health Canada guidelines. On this next slide, what we see is from data published by Jing Chen from Health Canada. There's an estimate of 6% of the housing stock currently being over the 200 becquerels value, and that's related to 28% of lung cancers in Canada, versus 94% of the housing stock being under the guideline value and 72% of all radon-related lung cancers being attributable to homes in that range. The bulk of the burden really remains below what we're currently talking about in terms of the Health Canada guideline.
This very point is something that we've addressed in a new paper. I want to make it clear that this work has not been published yet. It's currently under review, but it's not in the scientific literature and it has not been peer-reviewed. We looked at a bunch of different threshold values. It's really just a line in the sand that we're drawing when we say that 200 is the level or 100 is the level. We took that line in the sand and drew it at 600, 500, 400, 200, 100, and 50 becquerels to see whether or not we could still see a clear distinction between high and low radon areas in B.C. with respect to lung cancer mortality trends when we drew that line in the sand in different places.
Indeed, if you look at the far right-hand side, that top plot shows you lung cancer mortality trends in men and in women at a threshold value of 50 becquerels per metre cubed, and you can see that the trends are still distinct from one another. We still see that sharp increase in lung cancer mortality in women in the high radon areas.
In the final slide, the key message again is that these are very limited administrative data. This is something we've done as a surveillance exercise. It was really an exercise we undertook because a lot of the evidence we use in Canada to build our policy comes from places other than Canada. We're pulling together studies that have happened in Europe, the U.S., and elsewhere. We really wanted to show some hard-hitting data from the Canadian context.
Again, most radon-related lung cancers in Canada happen below the current guideline of 200 becquerels per metre cubed. We see clear temporal trends by radon risk areas of British Columbia. We have not repeated similar analyses elsewhere in Canada, but I wouldn't be surprised to see similar results. The trends that we see at 200 becquerels per metre cubed persist when we drop that threshold to 50 becquerels per metre cubed. This is really supportive of that idea of ALARA, or “as low as reasonably achievable”. As Tom said, the way to pursue ALARA in Canada is really through widespread changes to our national building code to protect the population into the future.
We have estimated that it would take about 75 years to turn over the entire residential building stock in Canada, or most of it, but at the end of that 75 years, you would have a radon-resistant building stock and a population that was well protected.
Finally, there does appear to be a difference between men and women in terms of risk.
Thank you very much for your time.
Sony Perron
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Sony Perron
2015-06-01 15:39
I would like to thank the committee chair and the rest of the committee members for the invitation to appear here today.
I, and other officials at Health Canada, have reviewed the Auditor General's 2015 Report, and we have paid a great deal of attention to his recommendations. We take the findings seriously and are addressing each of them through an action plan. This plan will continue to be refined and defined in collaboration with first nations. Indeed, as you know, we work in cooperation with first nations. This plan can therefore only be completed with an additional commitment by our first nations partners.
The health care system serving first nations is highly complex. Provincial health systems do not directly extend to first nations reserves. To support first nations, Health Canada provides the delivery of a range of effective, sustainable and culturally appropriate programs and services. We work with first nations to increase their control of health services and collaborate with provinces to increase access and promote system integration.
We also support programs that address first nations health priorities in the areas of mental health, chronic disease, maternal and child health, and health benefits providing coverage for prescription drugs, dental care, vision care, mental crisis intervention, and medical supplies and equipment.
Most of the community-based programs have been transferred in varying degrees to over 400 first nation communities. This number does not include British Columbia, where in 2013 Health Canada transferred its role in the design, management, and delivery of first nations health programming in British Columbia to the new First Nations Health Authority.
Health Canada provides funding to first nations to deliver clinical care in 27 remote and isolated communities, again, outside British Columbia. In an additional 53 remote and isolated first nation communities, Health Canada continues to deliver clinical care. The delivery model varies based on the specifics of each province and geographic conditions. The clinical care teams are located in nursing stations, along with community health workers delivering other programs.
Because of the importance of these services, it is imperative that Health Canada ensure that remote communities have access to clinical and client care, that nursing stations are staffed with registered nurses, and that nurses work in a safe environment, have access to physicians to support them, and have access to tools.
Registered nurses and nurse practitioners are predominantly the first point of contact in isolated communities and are highly educated and qualified individuals. To ensure that our nurses are prepared for the unique demands of working in remote stations, a mandatory training requirement has been defined and is now part of the national education policy.
I can report that we currently have an 88% compliance rate on Health Canada's nursing education model for controlled substances in first nations health facilities, while advanced cardiac life support is at 63%, trauma support is at 59%, pediatric advanced life support is at 64%, and immunization is at 61%. The overall compliance rate is at 46% as of the end of April 2015. We still have work to do, and we are doing it while ensuring that we have resources in place to backfill these important positions while incumbents are in training.
Health Canada is committed to ensuring that nurses working in remote first nations communities meet established public service requirements on top of these workers' already robust credentials.
Remote and isolated practice environments sometimes require nurses to respond immediately to life-threatening or emergency situations. Nurses therefore need appropriate mechanisms to perform these important duties.
Clinical practice guidelines assist nurses to address clinical care situations and provide instruction on whether and when consultation with a physician or a nurse practitioner is required. There are arrangements in place for all nursing stations to access physicians when physicians are not located in the community. We also continue to collaborate on region-specific solutions with provinces to advance access to health services and with regulatory bodies to support nurses practising within their scope of practice.
A key challenge is the need for more nurses. Health Canada has implemented a nurse recruitment and retention strategy, which involves a number of initiatives: a nursing recruitment marketing plan, a nursing development program, a student outreach program, and an onboarding program.
Since its February launch, we have received over 500 nursing applications, with 200 of these moving to the next level of screening. As well, the strategy aims to increase the number of nurse practitioners, which will provide greater stability in the clinical teams, assist in meeting training objectives, and enhance the level of services available at the community level.
Nurses and other community health professionals require facilities to conduct their work. Currently, we invest approximately $30 million annually for repairs, renovation, and construction of health facilities, plus an additional $44 million for maintenance and operations. The nursing stations are owned by first nations communities, and we collaborate with them to support their operation.
We work with first nations communities to ensure buildings are inspected and deficiencies are addressed. In response to the audit, we are implementing a more robust tracking system to capture this work. We will also enhance our process in order to use facility condition reports as a tool to better plan maintenance and renovation work with the owners.
In addition, to ensure new nursing stations are built to code, we have updated our requirements for attestations and have communicated the change to facility management staff. The audit rightly noted that the requirements, such as the station as defined currently, did not provide the necessary level of assurance.
Another area reported on was the management of medical transportation; medical transportation that provides coverage to support access to insured health services. Health Canada spends over $300 million on medical transportation per year, and approximately 60% of that is in remote and isolated communities. The main reasons for transportation are emergencies, at 24%, hospital services, at 10%, appointments with general practitioners, at 7%, and dental services, at 5%.
The program provides coverage for transportation to the nearest appropriate professional or facility that takes place when the needed service is not locally available. Our goal is to provide timely coverage for medical transportation to avoid an undue burden for clients and health care professionals. Decisions are based on a national program framework and are made with a solid understanding of the health services available and the transportation options at the regional level.
In response to the audit observations, the program has already modified and disseminated guidelines to resolve discrepancies observed between our practices and the medical transportation framework in terms of the level of documentation required.
Regarding the transportation of children who are not registered, Health Canada has a long practice of allowing coverage for a child up to one year of age to be covered for medical transportation under the registration number of their parents. Health Canada will continue its efforts with partners to inform parents and make available registration material in nursing stations and health centres.
Health Canada and the Assembly of First Nations are undertaking a joint review of the non-insured health benefits program, of which medical transportation is a component, and I am pleased to report that the work is well under way. It will identify strengths, weaknesses, including inefficiencies in administration, and recommendations for action.
Given that the geographic location, the size of the community, and the need to ensure cultural safety influence the range of programs and services funded or provided by Health Canada, comparing one community to the other is not always possible or the best approach. Community health planning, investing in the integration of services with provincial systems, and the development of community programs and capacity have proven to be more effective and more responsive to community needs over time.
As indicated earlier, Health Canada funds a number of community programs aimed at addressing specific needs and working as a complement to the clinical and client care program. These programs are funded to support community health needs and mostly managed by the communities themselves. In response to the audit, we will improve our support to community health planning to enhance integration of the community-based programs and clinical services where these services are delivered by Health Canada. We will also engage with the communities to review the current service delivery model and clinical care resource allocations.
The last area I would like to discuss is coordination among health system jurisdictions.
We work closely with partners to build health service delivery models that take into account community needs.
We have made significant progress with health service integration over the last 10 years. We see examples in various regions where there are more physicians' visits, provincial services are being extended on reserve, and there are more collaborative arrangements between community health services and regional health authorities. Co-management and trilateral tables exist in most regions to formally engage with provincial and first nations partners to advance common practices and resolve systemic issues. We will formally engage these tables in order to make progress on the important issues raised in the report.
Health Canada will continue to collaborate with our partners to develop and implement other models of first nations-led health systems across the country, as we have celebrated in B.C. We have presented an overview of our action plan, which requires further engagement and collaboration with first nation partners. We believe the next update will be more comprehensive as it will benefit from our partners' input.
In closing, we are working on a number of actions in response to the audit, and we will continue to do so.
I would note that I am accompanied today by three senior officials from Health Canada's first nations and Inuit health branch: Valerie Gideon, assistant deputy minister, regional operations; Robin Buckland, executive director, office of primary health care; and Scott Doidge, acting director general, non-insured health benefits.
We would be pleased to answer your questions. Thank you.
Robin Buckland
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Robin Buckland
2015-06-01 16:04
Thanks, Sony.
I am a registered nurse, and I have been for the last 27 years. To become a registered nurse, you have to complete a nursing program. In the vast majority of the country, it's at the baccalaureate level; you have to have a degree in nursing. In Quebec, the entry to practise is actually a diploma, so you can obtain a nursing diploma from the CEGEP in Quebec. Basically, through nursing school, you obtain the core competencies that are required to function as a registered nurse.
Generally speaking, nurses come out of nursing school and they are generalists. They're able to practise in a wide variety of areas.
In remote and isolated locations, there are additional competencies that are required. As the report indicated, they are often the only provider in the community and they are the first point of contact for the patient. They need to be able to respond to what comes in the door. If it's an emergency, a trauma, they need to have the competencies to deal with it. That is why Health Canada has identified advanced cardiac life support, pediatric life support, trauma, and the other courses you'd see listed as our five courses. Those are the key competencies that RNs will require to meet the needs of the community, in addition to so much more.
Valerie Gideon
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Valerie Gideon
2015-06-01 16:27
Very quickly, we have a trilateral table in Ontario with the Ontario Ministry of Health and Long-Term Care. We also have a specific northern table that the northern first nations have asked for, and in that table, which has just started this year, we do anticipate that we're going to be talking quite a bit about clinical and client care and medical transportation and engaging them in terms of our follow-up actions on that plan.
In Manitoba, we've had a committee for several years that was at a more junior officials level. We've now bumped it up to an assistant deputy minister level, with the Province of Manitoba, the Grand Chief of the Assembly of Manitoba Chiefs, and me. As well, we will be using that table to engage first nations in Manitoba with respect to our actions on this report to ensure that we're also monitoring progress and partnership of first nations.
Those are just two examples that are more relevant to this audit, but there are many more across the country. We also have national partnership agreements with the Assembly of First Nations and the Inuit Tapiriit Kanatami, which we signed this year.
Sony Perron
View Sony Perron Profile
Sony Perron
2015-05-12 15:38
Thank you, Mr. Chair, for the opportunity to provide an overview of the programs and services supported by Health Canada in the area of mental health and wellness for first nations and the Inuit.
Health Canada recognizes that addressing mental health and addictions issues are important health priorities for First Nations and Inuit. Consequently, the department is investing more than $300 million this year on a suite of mental wellness programs and services.
Programming includes mental health promotion, addictions and suicide prevention, other crisis response services, treatment and after-care services, and supports to eligible former students of Indian residential schools and their families.
Health Canada is working with partners so that efforts to support individuals, families and communities around mental health care are coordinated and include family support, employment and training, education and social services.
Building on best practices, we know that efforts to support individuals, families and communities should be culturally safe and community-driven. We can find lasting solutions only if we work together with our partners, including First Nations and Inuit organizations and, most importantly, the communities themselves.
Mental health promotion and suicide prevention research emphasizes the need for comprehensive and multi-layered interventions across a continuum of wellness. Interventions at each of the individual, family, and community, and federal, provincial, and territorial levels have been found to be most effective.
We have worked with the Assembly of First Nations and mental wellness leaders to develop the first nations mental wellness continuum framework. Through this process, communities were engaged and brought their ideas to the table.
From these discussions, culture emerged as a foundational component. Community innovation, partnerships across government, collaboration and coordination across sectors, and linkages between programs and services were also identified as being crucial for moving forward.
This framework has been ratified by the Assembly of First Nations' chiefs of assembly and was released by the AFN in January 2015. We are now working with the Inuit Tapiriit Kanatami to develop a mental wellness continuum for the Inuit.
Health Canada is a partner in implementing the first nations mental wellness continuum framework, which calls for integrated models of service delivery that focus on community strengths and indigenous knowledge.
Moving forward, we will look at ways to strengthen the federal mental wellness programming with our partners to meet community-specific needs, such as moving away from siloed program approaches toward more coordinated and effective approaches, and through closer integration between federal, provincial, and territorial programs.
We are also supporting mental wellness teams, which provide specialized treatment to a group of First Nations communities facing mental health issues. These teams seek to increase access to a range of mental wellness services including outreach, assessment, treatment, counselling, case management, referral and aftercare.
Through the National Aboriginal Youth Suicide Prevention Strategy we support screening for depression in schools; education and training for front-line workers to reduce stigma and increase community awareness; referral and intervention training; crisis services; follow-up and support for at-risk youth; and cultural and traditional activities to promote protective factors and to reduce risk factors.
Since 2008, we have supported a range of services to former students of Indian residential school and their families so they may safely address emotional health and wellness issues related to the disclosure of childhood abuse. For example, in 2013-14 alone, Health Canada supported approximately 630,000 emotional and cultural support services to former students and their families, and 47,000 professional mental health counselling sessions.
On February 20, 2015, Minister Ambrose announced an investment to prevent, detect, and combat family violence and child abuse. Health Canada's investment will support enhanced access to mental health counselling for first nations victims of violence who are in contact with shelters, and will support the improvement of services to first nations and Inuit victims of violence so that services are better coordinated, more trauma informed, and culturally appropriate.
Thank you for your attention. I am pleased to take your questions afterward.
View Rona Ambrose Profile
CPC (AB)
Thank you very much, Mr. Chair, and thank you to the committee. I want to thank all of you for the work you do on the health committee. I know many of you are passionate about the issues of health, and I thank you for your commitment to that.
I'm joined by Simon Kennedy, Health Canada's new deputy minister; Krista Outhwaite, our newly appointed president of the Public Health Agency of Canada; and Dr. Gregory Taylor, whom you've met before, Canada's chief public health officer. I know he'll be here for the second half. You might want to ask him about his trip to Guinea and Sierra Leone to visit our troops and others who are working on the front dealing with Ebola. I'm sure he'll have some great things to share with you.
Michel Perron is here on behalf of the Canadian Institutes of Health Research. He's also new. Last time I know you met Dr. Alain Beaudet.
We also have Dr. Bruce Archibald, who's the president of the Canadian Food Inspection Agency. I think you've met Bruce as well.
Mr. Chair, I'd like to start by sharing an update on some of the key issues that we've been working on recently. I'll begin by talking about Canada's health care system, the pressures it's facing, and the opportunities for improvement through innovation. I will then highlight some recent activities on priority issues such as family violence and the safety of drugs in food.
According to the Canadian Institute for Health Information, Canada spent around $215 billion on health care just in 2014. Provinces and territories, which are responsible for the delivery of health care to Canadians, are working very hard to ensure their systems continue to meet the needs of Canadians, but with an aging population, chronic disease, and economic uncertainty, the job of financing and delivering quality care is not getting easier.
Our government continues to be a strong partner for the provinces and territories when it comes to record transfer dollars. Since 2006, federal health transfers have increased by almost 70% and are on track to increase from $34 billion this year to more than $40 billion annually by the end of the decade—an all-time high.
This ongoing federal investment in healthcare is providing provinces and territories with the financial predictability and flexibility they need to respond to the priorities and pressures within their jurisdictions.
In addition of course, federal support for health research through the CIHR as well as targeted investments in areas such as mental health, cancer prevention, and patient safety are helping to improve the accessibility and quality of health care for Canadians.
But to build on the record transfers and the targeted investments I just mentioned, we're also taking a number of other measures to improve the health of Canadians and reduce pressure on the health care system. To date we've leveraged over $27 million in private sector investments to advance healthy living partnerships. I'm very pleased with the momentum we've seen across Canada.
Last year we launched the play exchange, in collaboration with Canadian Tire, LIFT Philanthropy Partners, and the CBC, to find the best ideas that would encourage Canadians to live healthier and active lives. We announced the winning idea in January: the Canadian Cancer Society of Quebec and their idea called “trottibus”, which is a walking school bus. This is an innovative program that gives elementary schoolchildren a safe and fun way to get to school while being active. Trottibus is going to receive $1 million in funding from the federal government to launch their great idea across the country.
Other social innovation projects are encouraging all children to get active early in life so that we can make some real headway in terms of preventing chronic diseases, obesity, and other health issues. We're also supporting health care innovation through investments from the Canadian Institutes of Health Research. In fact our government now is the single-largest contributor to health research in Canada, investing roughly $1 billion every year.
Since its launch in 2011, the strategy for patient-oriented research has been working to bring improvements from the latest research straight to the bedsides of patients. I was pleased to see that budget 2015 provided additional funds so that we can build on this success, including an important partnership with the Canadian Foundation for Healthcare Improvement.
Canadians benefit from a health system that provides access to high-quality care and supports good health outcomes, but we can't afford to be complacent in the face of an aging society, changing technology, and new economic and fiscal realities. That is why we have been committed to supporting innovation that improves the quality and affordability of health care.
As you know, the advisory panel on health care innovation that I launched last June has spent the last 10 months exploring the top areas of innovation in Canada and abroad with the goal of identifying how the federal government can support those ideas that hold the greatest promise. The panel has now met with more than 500 individuals including patients, families, business leaders, economists, and researchers. As we speak, the panel is busy analyzing what they've heard, and I look forward to receiving their final report in June.
I'd also like to talk about another issue. It's one that does not receive the attention that it deserves as a pressing public health concern, and that's family violence. Family violence has undeniable impacts on the health of the women, children, and even men, who are victimized. There are also very significant impacts on our health care and justice systems.
Family violence can lead to chronic pain and disease, substance abuse, depression, anxiety, self-harm, and many other serious and lifelong afflictions for its victims. That's why this past winter I was pleased to announce a federal investment of $100 million over 10 years to help address family violence and support the health of victims of violence. This investment will support health professionals and community organizations in improving the physical and mental health of victims of violence, and help stop intergenerational cycles of violence.
In addition to our efforts to address family violence and support innovation to improve the sustainability of the health care system, we have made significant progress on a number of key drug safety issues. Canadians want and deserve to depend on and trust the care they receive. To that end, I'd like to thank the committee for its thoughtful study of our government's signature patient safety legislation, Vanessa's Law. Building on the consultations that we held with Canadians prior to its introduction, this committee's careful review of Vanessa's Law, including the helpful amendments that were brought forward by MP Young, served to strengthen the bill and will improve the transparency that Canadians expect.
Vanessa's Law, as you know, introduces the most significant improvements to drug safety in Canada in more than 50 years. It allows me, as minister, to recall unsafe drugs and to impose tough new penalties, including jail time and fines up to $5 million per day, instead of what is the current $5,000 a day. It also compels drug companies to do further testing and revise labels in plain language to clearly reflect health risk information, including updates for health warnings for children. It will also enhance surveillance by requiring mandatory adverse drug reaction reporting by health care institutions, and requires new transparency for Health Canada's regulatory decisions about drug approvals.
To ensure the new transparency powers are providing the kind of information that Canadian families and researchers are looking for, we've also just launched further consultations asking about the types of information that are most useful to improve drug safety. Beyond the improvements in Vanessa's Law, we're making great progress and increasing transparency through Health Canada's regulatory transparency and openness framework. In addition to posting summaries of drug safety reviews that patients and medical professionals can use to make informed decisions, we are now also publishing more detailed inspection information on companies and facilities that make drugs. This includes inspection dates, licence status, types of risks observed, and measures that are taken by Health Canada. Patients can also check Health Canada's clinical trials database to determine if a trial they are interested in has met regulatory requirements.
Another priority of mine is tackling the issue of drug abuse and addiction in Canada. There's no question that addiction to dangerous drugs has a devastating and widespread impact on Canadian families and communities. In line with recommendations from this committee, I am pleased that the marketing campaign launched last fall by Health Canada is helping parents talk with their teenagers about the dangers of smoking marijuana and prescription drug abuse. The campaign addresses both of those things, because too many of our young people are abusing drugs that are meant to heal them.
Our government also recognizes that those struggling with drug addictions need help to recover a drug-free life. From a federal perspective, of course, we provide assistance for prevention and treatment projects under our national anti-drug strategy. We've now committed over $44 million to expand the strategy to include prescription drug abuse and are continuing to work with the provinces to improve drug treatment.
I've now met and will continue to meet with physicians, pharmacists, first nations, law enforcement, addictions specialists, medical experts, and of course parents to discuss how we can collectively tackle prescription drug abuse.
Finally, our government continues to make very real investments to strengthen our food safety system. As only the latest example, I recently announced a five-year investment of more than $30 million in the CFIA's new food safety information network. Through this modern network, food safety experts will be better connected, and laboratories will be able to share urgently needed surveillance information and food safety data, using a secure web platform. This will put us in an even better position to protect Canadians from food safety risk by improving our ability to actually anticipate, detect, and then effectively deal with food safety issues. This investment will continue to build on the record levels of funding we've already provided, as well as the improved powers such as tougher penalties, enhanced controls on E. coli, new meat labelling requirements, and improved inspection oversight.
In conclusion, those are just some of the priorities that will be supported through the funding our government has allocated to the Health portfolio. This year's main estimates, notably, include investments for first nations health, for our ongoing contribution to the international response to the Ebola outbreak in West Africa, and the key research and food safety investments that I have already mentioned.
I'll leave it at that. If committee members have any questions, my officials and I would be very pleased to answer them. Thank you.
View Murray Rankin Profile
NDP (BC)
View Murray Rankin Profile
2015-05-07 15:46
I appreciate that.
As you speak of transparency, that takes me to Vanessa's Law, to which you made reference earlier.
Toronto doctor, Nav Persaud, made an information request to Health Canada to get clinical trials on a pregnancy drug, an anti-nausea drug called Diclectin. He tried that three and a half years ago. He finally got 359 pages, 212 of which were completely redacted or censored.
In March, after Vanessa's Law came in, he resubmitted the request for all of the 359 pages, and so far has been given nothing. I got that as recently as two days ago in a letter. The clinical trial data was something that was to be made available, as I understood it, under Vanessa's Law. His experience has been entirely frustrating.
View Rona Ambrose Profile
CPC (AB)
I sympathize with his experience.
Under Vanessa's Law, the intention is to make clinical trial information available, but still to some extent—and for legal reasons obviously—protect confidential business information. Our intention under Vanessa's Law—and it's my belief—is that we should be sharing as much as we possibly can.
On that specific one, I think that's still under way, but I know Simon is working on that.
Simon Kennedy
View Simon Kennedy Profile
Simon Kennedy
2015-05-07 15:48
Thanks, Minister.
On this particular case, the original submission was made under the access to information rules. The ministry is obliged to apply the access law, which does require a number of exemptions for business information and so on.
With new authorities under Vanessa's Law, there is this other avenue we can use to make information available where there is a health or safety threat. We've spoken to the researcher in question, and we sent him a fairly detailed letter to explain the process to make an application under Vanessa's Law. That conversation is going on and our hope would be to be able to move through that avenue to deal with the issue.
View David Wilks Profile
CPC (BC)
Thanks, Chair.
I just have a couple of questions both related to the same topic, one for Health Canada officials and then one to CIHR. They both are with regard to electronic cigarettes. As you know, this committee carried out a study of electronic cigarettes and made a number of recommendations on which the minister is moving forward, including that the Government of Canada establish a new legislative framework for regulating electronic cigarettes and related devices.
Has any of the $26.5 million in planned spending for the tobacco program been identified for developing a legislative framework toward this initiative?
Simon Kennedy
View Simon Kennedy Profile
Simon Kennedy
2015-05-07 17:06
Mr. Chair, on the issue of electronic cigarettes, this is something the department is looking at quite carefully. We're grateful actually for the work of the committee and all of the consultations that were done and the recommendations. We've been examining those quite carefully.
At this point I would say we have not dedicated specific funds to that work because we have policy staff, and analysts and so on, who are busy doing that work, but there hasn't been a necessity of, for example, hiring additional staff or setting up a dedicated office. We have specialists who look at these kinds of issues all the time who are actually doing that work.
Depending on the ultimate decision of the government in terms of how to move forward on this, it's entirely possible we would need to make budget decisions to reallocate resources. But when it comes to the policy development work, and the assessment of the work of this committee, and to develop a government response, that doesn't require the movement of money budgetarily. We're able to handle that within our existing resources.
Simon Kennedy
View Simon Kennedy Profile
Simon Kennedy
2015-05-07 17:07
I want to assure the member there's a lot of work going on to come back with a response.
View Colin Carrie Profile
CPC (ON)
View Colin Carrie Profile
2015-05-07 17:17
Thank you very much.
I'd like to split my time with Mr. Young. First, I wanted to express my appreciation to Health Canada for all the work you've done over the years for natural health products and the world-class regulatory system.
As you may know, I still work as the minister's...part of the committee for traditional Chinese medicine. With many more Canadians today coming from Asia, looking to have the traditional Chinese medicines they're used to taking, could you explain the work you're doing with traditional Chinese medicine? What approach are you taking with traditional Chinese medicine and what kinds of innovations are you working with to make these products available to Canadians?
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