HESA Committee Report

From H1N1, to the isotopes shortage, and as we have seen now with the elevated rates of tuberculosis infection in First Nations and Inuit Communities, the Conservative Government's response to health issues is to wrap itself in a constitutional cocoon refusing to acknowledge its responsibility and authority for the health of Canadians.

This government's failure to accept any responsibility for the health of Canadians is nothing new. In June 2008 we wrote a dissenting report for the Statutory Parliamentary Review of the 10-year plan to Strengthen Health Care. We noted, "This Conservative government has taken a rigid stance on health care being a provincial responsibility and has therefore refused to participate. The responsibility for the health of Canadians is clearly a shared responsibility across all government departments, across all jurisdictions and across all sectors. There is no partner in Ottawa for Health and Health Care." These same words could be written today.

Every health-related question we ask this government is met with a familiar refrain: "we're working with the provinces and territories"; "the delivery of health care is a provincial and territorial responsibility"; "this is the jurisdiction of the provinces and territories".

If this government were truly working with the provinces and territories, the stakeholders on the ground, and listening to the excellent testimony by the myriad of expert witnesses with years of experience combating tuberculosis, they would hear the pleas for federal leadership. They would also hear that when the federal government does play a role, that is must be one of facilitation and solutions rather than obstruction.

All substantial material presented at the Standing Committee on Health hearing on April 20, if acted upon, would assist in significantly improving prevention and treatment of tuberculosis (TB) in First Nation and Inuit communities in Canada.

Our goal of this report - in the absence of any leadership from the Conservative government - is to ensure that the elevated TB rates are recognized as an urgent problem requiring urgent action (as the rates are, in some cases, comparable to a century ago, and to some Sub-Saharan African rates today), that Inuit and Métis are included in the tuberculosis strategy, and that jurisdictional challenges be clarified so that responsibility is not deflected, and people do not 'fall through the cracks' of the system, and ultimately suffer.

Over the last five years, $42 million was spent on TB programs, yet the rates of infection continued to climb. Going forward, we want to insure that funds are used in the best manner possible - allocated to regions, with real targets, with real accountability.

As we saw with the H1N1 crisis, the 4 C's of David Naylor's Report written in the aftermath of SARS - communication, collaboration, cooperation, and a clarity of who does what when - were not adhered while addressing the issue of tuberculosis infection in First Nations and Inuit Communities.

Jurisdictional disputes are simply inexcusable when they impact a disease as devastating and potentially deadly as tuberculosis - a disease for which Canada has pledged to meet international standards.

Canada has a duty and moral responsibility to work with Aboriginal Canadians to reduce the incidence of TB, particularly when First Nations (with an incidence rate of 26.6 per 100,000) and Inuit (157.5 per 100,000) have a significantly higher rate of a disease than Canadian born non-Aboriginal (0.8 per 100,000).

An example of this dysfunction was evidenced by the testimony of Dr. Earl Hershfield, who stated that Manitoba's regional branch of FNIHB, "abdicated their responsibility by contracting out the services on reserve to the Winnipeg Regional Health Authority. The Winnipeg Regional Health Authority, in my view, looks after health in Winnipeg. I have no idea what it's doing on reserve." He further stated, "there isn't a regular TB program directed from the top down. That is one of the problems in Manitoba and it is why, as I see it, Manitoba has the highest TB rates in Canada outside of Nunavut."

Tuberculosis control is simple and is based on the global standard to find new cases, cure these cases, find infections and prevent progression to active disease and maintain surveillance in high risk groups. The Minister of Health must take responsibility in ensuring a collaborative response is executed among jurisdictions. To ensure collaboration across jurisdictions, we recommend:

• The federal Minister of Health call for an emergency meeting of provincial and territorial ministers of health, as well as leaders of national Aboriginal organizations, to take an honest look at issues of jurisdiction and process that may be behind the current rates of TB in Canadian Aboriginal peoples
• That Provincial and Territorial ministers of Aboriginal affairs, as well as Indian and Northern Affairs Canada, convene a First Ministers' Meeting to address the social determinants of health
• That Federal, Provincial, and Territorial governments include Métis in programs and strategies that address TB in Aboriginal communities
• That one single unified TB program in each province and territory be established for both Aboriginal and non-Aboriginal peoples. The program must be accountable to, and the responsibility of, the Chief Provincial or Territorial Medical Officer of Health (CPMOH), and must be evaluated annually, based on agreed deliverables for which the provinces must be accountable

We believe that the Public Health Network put in place in the aftermath of SARS must be formalized, and be tasked to lead any subsequent public health outbreak. This Public Health network would be run out of the Public Health Agency of Canada, and fall under the leadership of the Chief Public Health Officer for Canada. This new network would be tasked with:

• Revising and renewing the First Nations National TB Elimination Strategy. It is unacceptable that the Canadian Tuberculosis Prevention and Control Strategy - drafted in Winter, 2009 - shows in appendix 9 that the FNIHB TB strategy remains under construction
• Urgently defining a TB control program and strategy - the what, by when, and how - with goals and performance indicators that are measured at the provincial, territorial and regional level in order to determine whether regional branches are delivering the program according to national and international standards in TB prevention and control. Performance must be evaluated on an annual basis.
• Initiating an emergency strategy to immediately send in teams to the epicentre of the TB outbreaks to provide assessments to start addressing the problem
• Engaging First Nations and Inuit communities as full partners in the development of TB programs and strategies
• Ensuring that there are clearly articulated objectives and performance targets, and an evaluation process. These must be based on the agreed upon deliverables and must meet national and international standards. The data from each of the provincial/territorial evaluations must be openly available and shared with all concerned groups (government/nongovernment/academic/clinicians and aboriginal communities and organizations) and be the basis on which changes are made to improve outcomes. A national consensus conference should be convened to define the program goals and performance indicators
• Ensuring that the $47,000 needed to treat each case of tuberculosis - as suggested by the Canadian Tuberculosis Prevention Control Strategy Winter 2009 draft document - is readily available
• Starting TB programs that support, nurture and form a true partnership with those in each community or social group to improve, enhance and build "capacity", in order to promote community ownership of problems and the solutions. Building capacity in partnership with communities will require an investment in training of community health aides, and should reinstitute a cadre of health workers who are well trained, respected, rewarded and sustained.
• Addressing the social determinants of health as part of its overall strategy to reduce the rates of tuberculosis in First Nations and Inuit communities, including poverty, overcrowding, poor housing, poor nutrition, HIV/ AIDS and Diabetes Mellitus amongst others. Ignoring the disparity in social determinants is no longer an option, but delays in improvement cannot be an excuse for failing to deliver strong sustained, measurable TB control programs now

Finally, we would like to address an issue that was not discussed at the Standing Committee: the co-epidemic of HIV/AIDS and TB. Although incidence of HIV has decreased in the Canadian population, HIV rates have steadily increased in First Nations and Inuit populations.

Although Aboriginal people represent only 3.3% of the Canadian population, they have 5-8% of prevalent infections and 6-12% of new HIV infections in Canada in 2002.

People with HIV are up to 50 times more likely to develop TB than HIV-negative people. This is because (1) HIV affects the immune system and increases the likelihood of people acquiring new TB infection; and (2) also promotes the progression of latent TB infection to active disease and relapse of the disease in previously treated patients.

We believe that diagnosis and treatment of HIV/AIDS is a must, as is diagnosis and treatment of TB.

To conclude, we believe that the elevated rates of TB in First Nations and Inuit communities is an urgent problem that needs to be addressed through communication, collaboration, cooperation, with a clarity of who does what and when between all levels of government and First Nations and Inuit Communities themselves. The federal government must stop abdicating its responsibility and play a leadership role in promoting this collaboration through the development of a national strategy to eliminate TB in First Nations and Inuit Communities. Federal leadership cannot be obstruction. These matters are of such urgency that they demand immediate corrective action, and the attention of an interdepartmental committee at the federal level. Formalizing the Public Health Network is a necessary start to this strategy.