[Recorded by Electronic Apparatus]
Tuesday, October 22, 2996
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[English]
The Chairman: Good afternoon, ladies and gentlemen. I will now bring this meeting to order. Pursuant to Standing Order 108(2), we will carry on with the introduction of our witness, Mr. Paul Cochrane, Assistant Deputy Minister, Health Canada.
Mr. Cochrane, would you like to introduce the people you have with you and proceed with your presentation? After that, we will have a question and answer period.
Mr. Paul Cochrane (Assistant Deputy Minister, Medical Services Branch, Department of Health): Thank you, Mr. Chairman. Gweneth Gowanlock, who is with the HIV/AIDS program within our health programs and promotion branch, will speak first this afternoon. Mr. Earl Nowgesic is the HIV/AIDS consultant within the medical services branch. I am the assistant deputy minister of the medical services branch of Health Canada, with primary responsibility for status Indians on reserve. Dr. Sutherland is with the HIV/AIDS directorate of the laboratory centre for disease control within the health protection branch. Dr. Sutherland will speak second this afternoon in terms of incidence and risks associated with the HIV/AIDS virus.
Mr. Chairman, on your behalf, I will ask Gweneth Gowanlock to speak first.
Ms Gweneth Gowanlock (Director, Population Health Directorate, HIV/AIDS Policy and Coordination Programs Division, Department of Health): Thank you, Mr. Chairman and members of the committee. I am pleased to be part of the Health Canada delegation to appear before you today on the important aspect of poverty and discrimination as it concerns HIV and AIDS.
In Health Canada we believe that AIDS is a challenge we all must address. It has significant impacts on public health, human rights and costs for our economy and our health and social service systems.
Before saying anything further in my brief presentation, Mr. Chairman, I want to say that I know the committee is aware of the eleventh international conference that took place in Vancouver. You had representation there. I think it's important for all of us to note that by all accounts the eleventh international conference on HIV/AIDS was a success. Fourteen thousand people came from 130 countries and addressed all aspects of this issue. Canada fared well in demonstrating that it contributed well domestically and internationally in the fight against AIDS. The conference organizers, I believe, have sent information to all members of Parliament pointing out, in their own way, the successes of the conference.
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Underlying that, the scientific presentations and the clinical findings in research on the virus and on drugs were showing some progress. They also showed that some of the ongoing challenges in developed countries such as Canada need to be centred on largely marginalized groups. Those groups may not seek assistance or access to support, and that goes to the heart of what you're studying here today in terms of poverty and discrimination.
The national AIDS strategy has provided the federal government with the means to show leadership in the fight against HIV/AIDS and has been key to Canada's overall response. There is some agreement in the field that it has helped to advance the issues in the fight against AIDS.
The strategy's goals remain: to stop the infection; to search for vaccines, drugs and therapies; and to care for and provide support for people infected with HIV and for their caregivers, friends and families.
The focus of the committee's work is very much in harmony with the goals of the strategy. Important parts of the national AIDS strategy are: addressing circumstances that place people at risk for HIV, enhancing the ability of people living with HIV to cope with their illness and to delay the onset of symptoms through healthy lifestyle choices, and improving access to services, treatment, care and support.
The strategy also aims to increase public participation in matters of health, to reduce discrimination, and to strengthen social and community networks and services. Through its policies and programs at the community-based level, creating supportive social environments is an integral part of the strategy.
The community action part of the AIDS strategy focuses on prevention education activities for groups that are not reached by ordinary, general, HIV/AIDS information and that, by definition, are more vulnerable to HIV risk, such as street-involved youth, gay youth, injection drug users and their sexual partners, marginalized women, prison populations, some ethnocultural groups and some aboriginal peoples.
On the subject of discrimination, ten years ago when we first began to learn more about HIV/AIDS, our experiences demonstrated that social, economic, racial, sexual and gender inequalities play a large part in driving those HIV/AIDS epidemics. This means that prevention, treatment and a balanced social response are all that more difficult to achieve.
AIDS does disproportionately affect Canadians who are marginalized by poverty, injection drug use and sexual orientation. Society has made progress in this area, but some of that stigma persists. There has always been an issue of discrimination against gay men. It's been present since the beginning of the epidemic. In its policies and programs, the department has emphasized the need to create positive social environments to address the issue.
Over the years, Health Canada has also emphasized that other socially and economically marginalized groups are at increased risk of contracting HIV, such as prisoners, injection drug users and others.
In the broad response to the epidemic, the department has focused on the determinants of health and on the link between human rights and health and has fostered intersectoral and multidisciplinary approaches.
The national AIDS strategy recognizes that poverty is a significant concern for those persons living with HIV/AIDS. The issue is twofold. Some people living in impoverished circumstances are more susceptible to being infected with HIV, and people living with HIV are more vulnerable to falling into poverty. Basic necessities such as adequate food, nutrition and housing, along with medication costs, are beyond the financial means of many people living with HIV/AIDS.
Finally, Mr. Chairman, I just want to touch on the fact that aboriginal peoples are one of the target groups encompassed within the national AIDS strategy. Regular funding programs of the strategy are accessible to aboriginal peoples who live off-reserve. Activities have been undertaken that are culturally sensitive and appropriate for the needs of this population. There are special funds for on-reserve populations, and Mr. Cochrane will speak to that.
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Mr. Chairman and members of the committee, my comments are meant only as a highlight of the strategy and of how issues of poverty and discrimination are underlying components of the strategy and are focused upon by it, and are intended to note that aboriginal people are one of our priority target areas. My colleagues Dr. Sutherland and Mr. Cochrane will speak to the other issues.
Thank you.
The Chairman: Thank you very much.
Dr. Sutherland.
Dr. Donald Sutherland (Director, Bureau of HIV/AIDS, Department of Health): Thank you.
I believe you have copies of these slides in front of you, so I'll just speak to what you have.
Our mandate at the Laboratory Centre for Disease Control, as part of the national AIDS strategy, is to develop the laboratory science methodologies to track the epidemic, and to do surveillance and targeted HIV research. The evidence I'm going to present today is some of the work we have pulled together to indicate the situation in the aboriginal community in Canada.
On this slide, there are two main messages. Information made public some time ago says that the trend in AIDS - that is, the late stage of this HIV infection - amongst the general population, as illustrated by the yellow line, has been levelling off. This has been expected and relates to the overall change in behaviour in the epidemic in the mid-1980s. The pattern within the aboriginal peoples of Canada unfortunately does not show this levelling off phenomenon. And I would also point out, on the bottom of the slide, that in 40% of the AIDS case reports that we get, ethnicity status is not indicated. So these numbers would be the minimal number of known AIDS cases amongst aboriginal peoples in Canada.
I would point out that the scale on this end of the graph is obviously very different from what it is for the total population. This relates to the original numbers, and this relates to the overall population numbers. So the question is what we can learn about the difference between how AIDS presents itself, in terms of risks, between aboriginal peoples of Canada and the non-aboriginal population.
Basically, we see a difference in sex ratio. In proportion, there are a lot more aboriginal women infected by AIDS. For age, you can see that one-third of the AIDS cases occur at age 30 or less in aboriginal populations, as compared to 19% for non-aboriginals. With respect to risk categories, two-thirds of aboriginal cases are seen amongst homosexual or bisexual men. In the non-aboriginal population, this is at 80%. And you'll also see that more of the AIDS cases relate to injection drug use in the aboriginal community than amongst the non-aboriginal community. This is particularly true amongst women, where injection drug use for aboriginal women is indeed a much higher proportion of the risk.
So that relates to AIDS cases that tell the story of infections that occurred, on average, ten years ago. It's more important to be aware of the current situation and to look at HIV infections rather than AIDS cases. As you can see, aboriginal AIDS cases have represented 2.3% of all AIDS cases in Canada. If you look at HIV information, however, 5% to 11% of HIV-positive individuals under clinical care are aboriginals. And the range is there because we looked at different sites across Canada. More recently, if you look at the period of 1993 to 1996, this ranges from 12% to 26%. So we know there are more AIDS cases coming for persons of aboriginal origin in Canada.
If we now take a look at what we know about risk behaviours or situations in which risk may occur, it was already mentioned that aboriginals are overrepresented in some populations that seem to be at greater risk for HIV. The figures are there: 14% of federal inmates are aboriginals, and in some provinces it may be as high as 40%. Between 25% and 75% of inner-city service clientele are aboriginals, and 7% of those clients going to sexually transmitted disease clinics in urban areas are aboriginal. And in looking at STD rates as an indication of unprotected sexual risk, as you know, they are much higher - and we look at the Yukon and Northwest Territories. So there is evidence that the aboriginal population is more at risk.
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We had a chance to look at details of risk in one particular situation, and I thought it was useful to share this with you. We looked at the injection drug use outbreak in B.C., which is recent. We found that 33% of the injection drug users were aboriginal. The risk factors for getting human immunodeficiency virus were the frequency of needle sharing, the frequency of injection, and - important for this committee's consideration - living in unstable housing. Being aboriginal itself was not the risk factor that was significant. It was the other risk factors related to behaviours or housing conditions that seemed to be associated with HIV infection - and that's what that final point is about.
One other piece of evidence that I'll mention, because it just occurs to me that it's relevant today, is that after a person is infected and is coming under care, we know their chances of survival, the length of survival, and the quality of life during that period relate to their social and economic network support. So this is an economic and social support factor that relates to prognosis after the infection with AIDS. Even with the same treatment, these social and economic networks seem to make a significant difference.
Thank you.
The Chairman: Mr. Cochrane.
Mr. Cochrane: Thank you, Dr. Sutherland.
Mr. Chairman, when you speak of poverty and discrimination, certainly these are issues all too familiar to the clients we serve - first nations citizens on reserve and the Inuit peoples of Canada. For example, 64% of on-reserve first nations citizens earn less than $10,000 a year, 42% of all first nations citizens are on social assistance, and 25% of first nations communities have inadequate infrastructure such as clean, safe water. All of these health determinants contribute to the risk of first nations health. Some of you, I know, have witnessed this first-hand during visits to aboriginal communities. Similar problems can be found among the off-reserve and Métis communities, which fall under the mandate of our health promotion and programs branch.
Today I will focus on the education and prevention efforts of our department, and first nations and Inuit communities in the relentless fight against the spread of HIV infection and AIDS. Gweneth Gowanlock has provided an outline of the goals for the national AIDS strategy, and medical services branch expands upon these goals to meet the specific needs of on-reserve first nations and Inuit.Dr. Sutherland has included an outline of HIV/AIDS among aboriginal communities, and from that it is clear that there are unique differences between aboriginal and non-aboriginal populations.
The differences include cultural issues, which have resulted in a reluctance to openly accept and discuss the problem in the past, and has resulted in an underreporting of aboriginal AIDS cases; language and culture, which have complicated the use of mainstream promotional and educational material and activities; and a young, highly mobile client base that often engages in high-risk behaviours that put individuals and, in turn, communities at risk. These high-risk behaviours often include unprotected sex and injection drug use. For example, sexually transmitted disease rates among the age group of 15 to 24 are among the highest in Canada. Many young people find themselves returning to their home communities for support once infected. These factors all heighten and contribute to the spread and prevalence of AIDS within aboriginal populations.
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Recognizing the threat of HIV infection and AIDS to the first nations and Inuit population, Health Canada has been providing education and prevention resources since 1989, targeted to these communities.
The three key principles that guide our response to HIV infection and AIDS in first nations and Inuit communities include the following. First, community development and health promotion must be at the basis of the program. Second, close partnerships with first nations and Inuit communities in the planning and implementation of the programs is essential. Third, first nations and Inuit ownership of and responsibility for the activities and resources are essential.
These three key principles are directly linked as well to the branch strategy, which is to transfer health resources and programs, including HIV/AIDS programming, to first nations communities and organizations. Through the medical services branch, $12 million has been directed over five years to meet the needs of first nations and Inuit peoples in addressing HIV/AIDS. This funding will remain at the $2.5 million level for each of the final years of the strategy.
Activities that are supported through these funds include culturally appropriate education and prevention programs; community-based research; initiatives targeting persons with HIV/AIDS; AIDS curriculum, for example for students in grades 7 to 12 in first nations schools across the country; and workshops and conferences addressed at high-profile issues.
Another interesting initiative is the in-service training that has been carried out to increase the AIDS knowledge and skills inventory of nurses and other primary health care workers in communities. This is targeted at a better understanding of the issues and hence better understanding of how to deal with individuals.
At the national level, action is directed toward the support of national first nations and Inuit groups such as the Assembly of First Nations, Pauktuutit and the Canadian Aboriginal AIDS Network. Specific activities include the HIV/AIDS Focus Group, consisting of Health Canada officials and aboriginal representatives from each province, who meet twice a year to address HIV/AIDS among first nations and discuss emerging trends and promotional activities.
Through the departmental aboriginal AIDS committee, we work in partnership with the Correctional Service, as an example, to address HIV/AIDS issues affecting the aboriginal inmate population. This year we have provided support to the British Columbia correctional facilities for aboriginal HIV surveillance projects, and a report will be upcoming at the end of this fiscal year as a result of that survey.
The department has also provided support to aboriginal AIDS service organizations to provide networking and workshops across the country. However, more than 80% of our funding is targeted towards support for community-based AIDS projects. These projects are many and varied. Given that most of our funding is used for community-based projects, I would like to end my presentation by providing specific examples of some of these initiatives.
Health Canada funded the Indigenous Peoples' Working Group to organize a satellite conference at the eleventh international conference on AIDS in Vancouver. This was to ensure aboriginal participation, and was open to both congress delegates and aboriginal and non-aboriginal populations. This initiative allowed more than 200 indigenous peoples from various countries to exchange HIV/AIDS information and participate in various events.
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In partnership with our other branches in Health Canada and the Department of Indian and Northern Affairs, we are co-funding the fourth Canadian aboriginal conference on HIV/AIDS and related issues. This conference will be held in Halifax later this year. The focus of this conference will be to improve communications, influence future programming and address determinants of health issues such as poverty and discrimination.
In Alberta this year, a three-year initiative was developed, and a strategy and a comprehensive plan for HIV prevention was launched with the department of health in Alberta. This plan will assist all aboriginal communities in developing the capacity to care for and support those affected by HIV. This unique three-year initiative takes essential steps toward a more coordinated, comprehensive approach between federal and provincial governments in dealing with the aboriginal population in Alberta.
In Manitoba, a coalition of first nations and Métis communities called the Manitoba Regional AIDS Steering Committee was established to address the issues among aboriginal communities, both in rural and urban settings in Manitoba. This strategy, called Together We Can Stop AIDS, involved federal, provincial and aboriginal governments in actively addressing interjurisdictional barriers to AIDS and AIDS access for promotional material in Manitoba.
All these community-based initiatives are supported by the national AIDS strategy and demonstrate firstly that there is an increased awareness of AIDS in first nations and Inuit communities. They also demonstrate that in trying to deal with this issue, there is an increased discussion among all interested parties, including caregivers, those infected and governments.
There is a better base of information and better collection of data, as Dr. Sutherland has shown us. These will enable us and first nations communities to target their efforts. I feel they also demonstrate a close partnership between all levels of government and the aboriginal communities themselves.
The challenge now will be to use this increased awareness and better information reporting to continue to support first nations in their efforts to address AIDS in their communities.
Due to the high-risk nature of this client group, the Indian and Inuit health services funding envelope will ensure funding remains available over the years to respond to program priorities of first nations, including HIV- and AIDS-related issues.
Mr. Chairman, members of the committee, thank you for your attention. We will be pleased to respond to any questions you may have.
The Chairman: Thank you very much, Mr. Cochrane.
Mr. Nowgesic, do you have any comments to make?
Mr. Earl Nowgesic (Program Officer, Health Program Support, Department of Health): Mr. Chairman, I am here supporting Paul Cochrane.
The Chairman: Good. Thank you very much.
We will then go to our question section, in which we allow a 10-minute question round. Then we go to 5-minute questions. We allow latitude in the answers, but not to the questioners, so if we cut someone off it won't be you. It will be the members here.
Traditionally we start with the opposition. Mr. Ménard.
[Translation]
Mr. Ménard (Hochelaga - Maisonneuve): Mr. Chairman, I join you in welcoming our witnesses. I would like to go from the general to the particular. We know, as members of this committee, that when the AIDS epidemic and its terrible damages were discovered in the early eighties, the median age of HIV infection was around 30 years.
Canadian scientists I met in Vancouver alerted us to the fact that nowadays HIV infection occurs early in the twenties and that we are now faced with a situation where the epidemic is practically out of control. Besides, the Canadian AIDS Society informed us that the number of infected people is expected to double within the next five years in Canada. It means that not only is the epidemic out of control, but people are getting infected younger and younger.
That suggests that the patterns of behaviours must be reviewed. I am aware that there are people in your department who provide funding for programs and make research into the causes of HIV transmission and the way to influence attitudes and behaviours. The situation is rather worrying, don't you think? Can you elaborate on that? How is it that in spite of our strategy, we're heading towards phase III? I am, indeed, of those who feel that we are going to have a phase III.
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How come do the young continue to get infected, how come is the disease still far from being controlled and how come do we have the feeling that our efforts in order to change the patterns of behaviour have failed?
How do you interpret that in Health Canada?
[English]
Dr. Sutherland: Thank you, Mr. Ménard, for the question. You're correct about the median age. It has changed dramatically since the beginning of the epidemic. The epidemic in the early 1980s did affect a broad spectrum of ages, but in the later part of the 1980s the median age dropped to 23 years, which means that half the new infections are occurring at the age 23 of or less. This has really important implications for prevention programs.
With respect to the trend in HIV infections, the last period for which we have made an estimate was 1989 to 1994. We estimated that during that period, there were 2,500 to 3,000 new infections on average per year, but it's very difficult to know how many infections are occurring in the current year, because there isn't a way to know that unless all Canadians were tested every year, which is clearly impossible.
So the recent trends overall in the infection are much harder to estimate. We have seen some changes in pattern. Within the injection drug use community, there is evidence of a fairly rapid rise recently. We've also seen that in the homosexual community it is among the young that the new infections are occurring. We've seen a slow increase in women who are getting HIV infection, and even the heterosexual epidemic has been slowly rising. But the overall question of whether it's rising or not is very difficult to determine. Our last estimate was that there were between 2,500 and 3,000 new infections on average per year.
[Translation]
Mr. Ménard: Thank you. You could be very helpful to our committee in sending us regularly the estimates released by your Service concerning the epidemic. I know that there was an update issued last June, and I think that we should be on your mailing list.
I know that it is difficult to analyse those trends in details, but our committee is very mindful of two unmistakable basic data, namely that in Canada and in Australia, contrarily to other countries, the target clientele in HIV/AIDS transmission is the gay community and that the incidence of the disease among young people is serious.
That being said, you are surely aware that for over one year our committee is making constant efforts to try to understand the reality of AIDS. Now, we want to develop a more in-depth expertise about the link between poverty and AIDS. Is there a map available in Health Canada which could be helpful to us? You told us a lot concerning aboriginal people. It is known that they account for 2,3 % of cumulative reported cases of AIDS.
How could we direct our action to make sure that the funds intended be used for the implementation of that strategy can actually serve the clientele which is considered at risk, in addition to being poor? Do you have any geographical data, for example? Is there a correlation? There certainly is a correlation between poverty and the risk of getting infected, but can you elaborate? Do you make comparisons between the reports regularly issued by the Canadian Council on Social Development and those released by your own services? It could give us some indications about the incidence of the disease in the poorest cities, the clienteles who are more at risk, and the fact that people living in disadvantaged communities might be less inclined to protect themselves due to the lack of information?
There is also the issue of self-esteem. Personally, I do believe that there is a way to explain that phenomenon among the youth. When a young discovers, around the age of 16, 17 or 18, that he is a gay, he then gets a very negative message from the society in which he feels he does not really fit, and this obviously does not prompt him to protect himself. There must certainly be a link between the two. Could we try to explore with you the correlation which exists between the life in big cities, poverty and AIDS?
[English]
Dr. Sutherland: You've covered quite a lot of ground with that comment. Certainly we're prepared to share whatever data we have. That's in fact the purpose of our collecting the data. It's so that decision-makers and program planners will use it. We work in close collaboration with other parts of Health Canada to give them that information as soon as it's available.
So we can either give you the general information or we can try to answer specific kinds of questions that you in fact have posed.
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There are some data available already that relate poverty - there's one such study in Montreal - to the prevalence of HIV. There are a few other pieces. It's not only what we saw in Vancouver, but elsewhere.
I think this targeting of the work is possible now because we've been able to determine the locale of the new trends far more. Consider the urban-rural situation. There are more infections occurring not in urban areas. It is important for prevention programs and other types of programs to extend beyond urban centres. The data related to that are certainly available.
With respect to the determinants of specific behaviours, there is a research strategy being carried out in the HPPB part of Health Canada to look at that. I'll ask Ms Gowanlock to speak to that particular issue.
Ms Gowanlock: Before speaking to that, it is important to mention that in the the strategy of trying to balance the resources in a variety of directions - there's research, prevention, community action, care and support - the issues you have raised are targeted programs at the community level through the AIDS community action programs. There are a lot of programs that pay particular attention to that year after year. As the funding goes on, the adjustments are made each year on how the moneys are spent.
At the national level, Dr. Sutherland is talking about research projects that are under way, which deal with prevention strategies and how well they are are working. We don't have all of the results in, but in terms of targeting two specific high-risk groups, that is part of the direction.
Behavioural research is particularly important. What kinds of factors enter into the attitudes and behaviours of people who are still getting infected? If that's the younger group, yes indeed, that's very much of concern.
[Translation]
Mr. Ménard: In trying to look at poverty, we must obviously understand what is being done by community groups, given the fact that it is probably easier to get services from community groups than from traditional institutional networks, since they are nearer to people and have broader freedom of action.
I know that within the national strategy, if we want to look at the links which are established with community groups, it's primarily through the AIDS community action program that the support is provided. I think it would be useful to our committee to get a fairly complete list of the projects which were funded during the last year through the ACAP. It would help us to have a good understanding of the directions you are taking.
Members of this committee might submit some proposals about new directions for funding, since it is an extremely important tool for those groups. I know that evaluation is of paramount importance for Health Canada and the Secretariat. We would not want these funds to be allocated and not be in a position to assess the relation between the monies made available to the groups and their concrete results in terms of the way services are provided.
When we want to look at communities, we need to know what is being done through the ACAP. Therefore, I would ask, with the agreement of the chair, that the relevant authorities send us the complete list of those projects before our next meeting so that we can understand well the ACAP's orientations.
I guess my time is over. I will come back at the second round.
[English]
Mr. Cochrane: In terms of targeting, 90% of our funding is targeted to on-reserve community activities, which supports your hypothesis, to a degree, such that we want to get as much of our funding as possible into the hands of the communities so that people can access support systems right at the community level. That's also a function of a lot of aboriginal communities, our rural, semi-isolated, or isolated communities. So it makes sense to get the project funding there, and we can certainly provide you with the list.
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The other comment to make about targeting in the aboriginal population is that even though the numbers demonstrate an upward trend, from a statistical basis, 196 reported cases is statistically very hard to deal with when it comes to a master strategy as to who, where and what the targeting should be. So our general approach has been to put the resources in the community. We know the reporting on a regional basis, but the numbers are so small that to draw substantive conclusions would be dangerous.
The Chairman: Thank you very much.
Mr. Szabo.
Mr. Szabo (Mississauga South): I'd like to refer you to this chart where it talks about aboriginal AIDS cases, sex, ratio and age, particularly age.
It says here that 31% of aboriginal cases are in individuals less than 30 years of age, compared to only 19% among non-aboriginals. If my memory serves me correctly, the distribution of age in the aboriginal community is significantly different from the non-aboriginal community, which makes this a misleading statement to make, I believe. Could you advise the committee of in fact how many young people are under age 30 in the aboriginal community as a percent of the total population and how that is compared to the non-aboriginal?
Mr. Cochrane: As a percent of the total aboriginal population, almost 50% of the aboriginal population is age 30 and under. So you're correct in that if you took two distribution models of the population you would find a significantly larger number of aboriginal people under the age of 30 than you would in the general population.
Mr. Szabo: So you can't compare the 31% to 19%.
Mr. Cochrane: I'll let Dr. Sutherland speak to that piece of the equation.
Dr. Sutherland: I think there's something in what you say. On the other hand, the purpose of this is to describe amongst AIDS cases what's different about the aboriginal AIDS cases. I guess the point is really that the need to target prevention programs at the young in the aboriginal population is even more important than in other populations. That's perhaps the take-away message from that.
Mr. Szabo: Do you have the percentage of non-aboriginals who are under 30 years of age?
Mr. Cochrane: I'm sorry, I don't.
Mr. Szabo: I think it's about half the number.
Mr. Cochrane: I don't know what the distribution is.
Mr. Szabo: About 25% of our population is under 30. When you think of 50%, it's a very young population, and there are very few seniors in the aboriginal community as well.
Mr. Cochrane: That's right.
Mr. Szabo: We studied that on the health committee.
An hon. member: They took good notes.
Mr. Cochrane: Sometimes, you know, we learn the odd thing.
The Chairman: Mr. Szabo is a CA; he's a numbers man.
Mr. Szabo: I'm not sure if it applies a lot and I do have others than aboriginals, but in some communities off-reserve represents 75% of the population. I think we saw there were some examples out in the east coast.
Mr. Cochrane: Yes, you probably would find it there.
Mr. Szabo: So do these figures include off-reserve people as part of aboriginal peoples as a whole?
Mr. Cochrane: Yes, they do, and across the country the split is about 55-45; about 55% of the status population is on reserve, and 45% off.
When you go to the broader aboriginal population, which represents close to 2 million Canadians, then you will find that the figure is the reverse. For the total aboriginal population in Canada, in other words those people of aboriginal ancestry, it's probably 75% off reserve and 25% on reserve.
Mr. Szabo: It's a little bit different if you're in Rigolet verses a Micmac outside of Halifax.
Mr. Cochrane: Exactly...or if you're in northern Manitoba, or if you're in Sioux Valley in Manitoba.
Mr. Szabo: They have a better community centre in the Micmac community than I have in my own community.
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The $10,000 average income you mentioned - again, I'm trying to identify the figures, because we have to use them carefully. As disposable income, $10,000 is not too bad comparatively, because you can't compare aboriginal disposable income and non-aboriginal, I don't think, because so many of the basic necessities of life are provided without cost to the aboriginal community. You would have to normalize or eliminate the differences in the funding of life because of the amount of moneys that are contributed to the aboriginal communities for health care, housing, food, you name it.
Mr. Cochrane: The statistic is that 64% earn less than $10,000. That's 64% of the population -
Mr. Szabo: But if I don't pay for my housing, it's not a good comparison.
Mr. Cochrane: - in receipt of an income of less than $10,000. It doesn't build in if someone is in receipt of social...but the $10,000 would include their social assistance benefit if they received one, and it would include their housing benefit if they received one.
I agree it would have to be normalized, to a degree. But we're not talking about a factor of two here. It might represent the equivalent of $12,000 or $13,000 in an off-reserve setting.
Mr. Szabo: I understand the economic disparities. The numbers, however, are probably stretching the point. They might detract from the message. I just raise these three examples to show that figures can be used very liberally. Anyway, I want to get off the aboriginal thing, because I think we have a sensitivity there.
At the Vancouver conference I watched an awful lot of media reports and some of the CPAC reporting. One of the doctors presenting was talking about the homosexual community, because over 80% of new cases of AIDS are contracted in the homosexual community. She made a statement that floored me. It was that you have to understand there are ``moments of forgetfulness'' that are experienced and there's nothing you can do about it. I wish I had been there. I would like to find out who that was.
I don't know if you recall that quote. It was rationalizing behaviour on the basis of ``moments of forgetfulness''. It has burned into my mind, because if health experts presenting at that conference are rationalizing behaviour on the basis of emotional whims when in fact the reality is we're getting very close to the situation where promiscuous homosexual activity is like playing Russian roulette with a bullet in every chamber... You are choosing to die; it's getting that bad. I want to be comforted that somehow those kinds of messages and rationalizations are going to be challenged, because it's not good enough to say, oh well, in the heat of the moment the emotion..., etc.
Mr. Ménard mentioned a very similar thing about not being accepted in the community; if you are uncomfortable, you have a tendency not to protect yourself. As a layperson, I need to understand how it is that the imminence of pain, suffering, and death is not as readily impressed on that person as the self-esteem issue of being accepted in a community. How is it that death is not as important as having self-esteem?
I would ask you if that's a theme you've heard before and if you could help me find out who that person was with the speech, and secondly, I ask you about this issue of not caring about a life because of the self-esteem issue.
Mr. Cochrane: I certainly can't provide you with the name of the speaker. Maybe Gweneth can research it and get back to you.
Ms Gowanlock: There were so many presentations I don't know which one it was.
Rather than commenting on the speaker's comment, one of the things in our programs of prevention... The studies we have undertaken in Health Canada on the determinants of behaviour have pointed out how very difficult and complex it is to understand people's knowledge, attitudes, and behaviour. We call some of the earlier studies the KAB studies - studies on knowledge, attitudes and behaviour - because quite often, even though people have the knowledge and their attitudes may be appropriately sympathetic, behaviour doesn't always follow. That's in all communities, men and women, young and old. It is an ongoing issue in the prevention strategies not only in our country but also in many other countries. It's very much a concern.
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I didn't hear, of course, the reference you were making to the speaker. I would be interested to know if the speaker was saying not to worry, therefore, or to please acknowledge that these things are part of being human and it's something prevention programs have to take into account.
Dr. Sutherland: I have a couple of comments about evidence in terms of what you mentioned. First of all, not only in the gay or homosexual community is self-esteem an issue. We know that the likelihood of developing a sexually transmitted disease or HIV relates to personal self-esteem, whether it's heterosexual transmission or any other. So we know from other research that this already exists.
But with respect to behaviours and trends, one of the things presented at the Vancouver conference that I think was very important is that although the young take more risks than us older fellows, the amount of risk being taken now as compared with ten years ago is less. So there's some comfort in the fact that behaviours have changed, even though the young still take risks, which has been universal for a long time.
The Chairman: Can I ask where the bisexual numbers fall in this? You've split your evidence between homosexuals and heterosexuals, but I'm not sure where bisexual numbers fall.
Dr. Sutherland: We would include bisexual in homosexual, because that is presumed the most likely route of transmission.
The Chairman: Mr. Ringma.
Mr. Ringma (Nanaimo - Cowichan): Thank you for your presentations.
I too would like to zero in on the Vancouver conference, hearing from Ms Gowanlock about the size and diversity of representation there. I must assume that a substantial element was directing their concern at the same thing this subcommittee is - specifically, what are the effects of poverty and discrimination on the whole scene?
Since they're aiming at the same thing we are, I'm looking to see if we can profit by asking you if all of the results of presentations have come out from that. Have they been collated? Have they been put together? Could we then as a committee get from whatever source a summary saying what are the presentations and the findings in those areas of poverty and discrimination?
Ms Gowanlock: Because the conference was so big there was a book of abstracts of the various presentations. In ordinary conferences you have one book of abstracts. Vancouver was so big they had two of them. The abstracts are a boiled-down version of the presentation, whatever it was.
I believe the committee would have direct access to those abstracts. They're indexed, so one could look up the issues presented on poverty and discrimination. They would be there in bite-sized capsules. I think it would be your most immediate means.
Your point is well taken. If good evidence was presented, the committee would benefit from seeing it and not having to look for it.
Mr. Ringma: At a previous meeting we went through that as a committee, wondering if in the next couple of months we were going to have a repetition over and over of the same groups saying the same things. We're trying to get as much diversity and total representation as we can.
I guess we can follow up on this.
Ms Gowanlock: If the committee did have representation, I think the abstract books are your best bet.
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The Chairman: I can give you a Windows version or a CD-ROM version, so it can all be done on the computer. I'll get that to you, if you like.
Mr. Ringma: I'll leave that to the chair, then, and he'll let us know about its availability. Thank you very much.
The second question is totally different and it reveals my relative ignorance in this whole field. You state that 80% of your effort goes into community efforts, and it's essentially preventive education, I gather, and necessarily so. I would like to ask specifically how much is being spent in two other areas, first on drugs or palliatives or experimental things. I understand some things are available to HIV sufferers, some of which are endorsed by the government, some of which are not. I'd like to get some sort of a snapshot of what is going on there. The second area I'm curious about is how much we as a country are spending on research and development on this whole thing.
Ms Gowanlock: The strategy is broken down into various slices. There are actually twelve areas in which the resources are spent. Some of them very clearly do fall in the areas you are questioning about, drugs and care.
One way to slice it is that about $5.5 million in each year's expenditures is spent on care, treatment, and support issues related to development of resources for professionals so they are better able to know what the latest trends are in treatment modalities. Also, some of the research money spent under the national AIDS strategy goes very clearly into developing treatments, and some of them are non-traditional treatments. Some projects funded under the strategy have looked at non-traditional therapies to see if more could be learned about them and what could be learned to make them effective.
In general terms, another way of slicing the resources is that of the strategy, nearly half the resources of $40 million a year is spent on research and epidemiological monitoring. Some of that research, research into care and drugs, is there as well.
There's also a whole area in Health Canada that deals with drug research funded under the regular programs of Health Canada and it is not part of the AIDS strategy that is part of our health protection branch. So quite a lot of resources are focused in that area.
The final thing I would say is that two major projects are funded under the strategy. One is the National Clinical Trials Network. It's centred in Vancouver and it has links all across the country. That particular infrastructure is funded to a little more than $2 million a year, in order to facilitate the clinical trials of new drugs for the benefit of individuals who have HIV.
The other one is the Treatment Information Service, out of Toronto. It provides information on treatment modalities through 1-800 numbers and produces information that goes out. It's also about $2 million a year. Those are resources that are national, they're targeted across the country, but they're centred in one area.
Mr. Ringma: I think it would be helpful to me and perhaps to the whole committee to have a budget statement of some sort just to pin down what it is that you've given as an answer. If we could have a two-pager that says, here it is, this is what we're spending on what, it would be helpful.
Mr. Cochrane: Yes, we can do that.
.1635
When you talk about how much is spent on drugs and drug therapy, a lot of those costs are within the insured health systems in the provinces. So there is a lot of money spent on drug therapy that doesn't come out of the strategy but that certainly sufferers have access to.
That's equally true in the first nations population, where under our own drug program for status Indians, we provide medications and supplements in addition to what the provinces would provide.
So if you try to get at the drug cost, the therapy cost, it's a very difficult audit trail to follow, because the expenditures are in many different pockets of the health care system across Canada.
Dr. Sutherland: Mr. Ringma, for your information, of course all treatments that are given in Canada have to receive approval. All drugs that are used have to receive health protection branch approval saying they've been tested for safety.
As you know, the AIDS drugs are on a quick-release program based on the needs and based on everyone understanding that we do our best to make them available as soon as possible, taking the approach that it's more important to make these available as soon as we can, rushing through the safety assessments and so on. We don't do less safety assessment. We just prioritize these drugs for the benefit...
So all treatments that are given in Canada under provincial government drug programs and so on have to be approved, as other drugs do.
Also perhaps useful, the last estimate that was done about direct medical care costs was about $100,000 per AIDS case, and that would include hospitalizations and other diagnostic tests, besides the drugs involved.
Mr. Ringma: Thank you.
The Chairman: Thank you. That's your 10 minutes, Mr. Ringma.
We'll now go to Mr. Volpe for 10 minutes.
Mr. Volpe (Eglinton - Lawrence): I won't take the 10 minutes, Mr. Chairman, but I thank you very much.
I want to thank our witnesses for coming today and being so thorough. I couldn't help but think while Mr. Cochrane was speaking that a lot of the programs he's enunciated really address the issues that the subcommittee was supposed to address in this third phase of its study.
While all of those programs appear to be directed to at least one of the social sectors we were looking at, I'm wondering what will happen to those programs or to funding for AIDS study and research in the aboriginal community once the national AIDS strategy funding sunsets in 1998.
Mr. Cochrane: The moneys we direct to the status population on reserve, and in some cases the money we target off reserve when we partner with people, will remain available through the Indian health envelope. When the major strategy sunsets, the part we primarily target to status Indians will remain available. Should first nations indicate a willingness and a priority to have those particular programs continue, we will be able to continue those beyond the sunsetting of the strategy.
Mr. Volpe: Only if there's a partnership inclination on the part of those communities.
Mr. Cochrane: Certainly. The dollars will remain available to the communities, and if they want to continue the initiatives, we are in a position to be able to fund them to continue, but the choice will rest with the communities in making that determination.
Mr. Volpe: That's an important consideration for the subcommittee inasmuch as our main focus of interest, as I said a moment ago, is to see how any of the strategy would apply to those communities that appear to be at greater risk than others. Dr. Sutherland has given us some indication, at least from a statistical point of view, that this community, perhaps more than others, appears to be at greater risk.
I want to draw your attention to another set of data we received from our researchers from the Library of Parliament in preparation for this briefing. It provides a series of data from Health Canada's quarterly surveillance update, AIDS in Canada, dated July 1996. As of June 1996, 73.8% of all AIDS cases in Canada was due to homosexual activity.
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In the United States, data from the Centres for Disease Control and Prevention show that a proportion of new cases reported among homosexual/bisexual men decreased from 47.3% to 43.3% in 1994.
Dr. Sutherland: You're probably asking why is this guy actually surprised - can't he read?
Mr. Volpe: We're going from 73.8% to 43.3%. There's a substantial difference.
Dr. Sutherland: I think the problem is we're not talking about comparable kinds of figures. One was the proportion of AIDS cases in the current year, and the 73% - I'm not sure if that was reported for within that year...
I know that the proportion of the epidemic in Canada amongst homosexuals has been dropping steadily, and I believe the most recent figures are even under 70%. Of course this reflects the infections that occurred 10 years ago, on average, so we're still looking at the historical epidemic.
In proportions, you have to look at what is coming up, and the American epidemic has always been different from the Canadian epidemic. Its epidemic among injection drug users was quite a bit higher than ours from the beginning, so its proportions have been a little different.
If you look at British Columbia, for example, the epidemic out there initially was almost entirely amongst men who had sex with men. But in the HIV testing program being carried out in British Columbia right now, the number of newly found HIV positives amongst injection drug users is now actually higher than amongst men who have sex with men.
The shape of the epidemic and the proportions are definitely changing in Canada as well. I can get you the exact comparable figures to relate to those.
Mr. Volpe: But it's still a very large percentage difference. We're looking at 30%.
Dr. Sutherland: I'm not comfortable that those are the right comparable numbers. You may be correct, but I'd like to have another look at them. I could send you back the information for the committee's benefit.
Mr. Volpe: I would appreciate it, because it will give us an opportunity to match that up against the work that came out of the Library of Parliament, so we can have figures in the proper dimension.
[Translation]
Mr. Ménard: You know that our committee made a report on compassionate access, an issue which is of great concern to me.
I know that there is a link between poverty, income, and the capacity to get drugs. Are you aware of some findings or data which could help us in addressing the whole issue of compassionate access? Instead of waiting an average of 180 days until the Health Protection Branch approves a drug, even when the fast-track process is engaged, would it be possible to force or at least to convince the big pharmaceutical companies to give infected people, especially those terminally ill, access to some drugs which have not got approval yet? Do you have data concerning that issue?
Second, one of the highlights of the national strategy is the needle exchange program. If I'm not mistaken, it is primarily through federal funding that it was possible to establish in various communities that kind of program which, hopefully, will contribute to reduce the risks of contamination for the next generation of people, especially for the injection drug users for whom communities have been prompted to identify very specific points where they can go to take their used needles back and get new ones in exchange. They are even given one additional needle.
At this committee's first meeting, and I think Ms Gowanlock will recall it, Health Canada's people placed much hope, I think, on that way of proceeding, that is on trying to prompt communities to develop needle exchange programs. Drug addiction is closely related to poverty. Can you comment on that?
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Third, Mr. Ringma referred to the whole issue of research. It seems that there has never been any real national research policy in Canada. Anyhow, there was certainly no consistent and well- structured framework. Some funds have been set aside for research, namely 18 million dollars. The Medical Research Council of Canada had also committed 3 million dollars, but Health Canada asked Dr. Cohen to develop a strategic framework for research. I know that a first draft of that strategy was tabled in Vancouver and that it was Health Canada's intention to make us know about it afterwards. Could you tell us were we are at now in that regard? It involves not only research related to drugs, but the overall sector of research, for which funding will finally amount to approximately 21 million dollars, including the Medical Research Council's contribution.
Fourth, and I am going to end my remarks with that point, there is an extremely interesting research project, funded through the National Health Research and Development Program, which is called Cohort Omega.
I have been said that, right from the moment when the epidemic first broke out, the Australians were smart enough to have studies undertaken on the issue and to make long-term follow-up of hundreds of people to try to understand how they got infected. In Canada, for all kinds of reasons, that was not done, but Health Canada funded a first project in Montreal, Cohort Omega.
I am proud of that project because I am a member of Parliament from Montreal. Even though that project is not in my constituency, it's something I'm interested in. That kind of project seems useful, since it could help us to get a better understanding of poverty, of behavioural patterns and of the way people get infected.
Those are my four questions. Let's start with the issue of compassionate access, about which I am going to table a private bill which, I guess, will be supported by the Liberals. That's a scoop,Mr. Volpe!
[English]
Mr. Volpe: The provisional stuff didn't last very long.
The Chairman: We never comment on something we haven't read. Anyway, go ahead.
[Translation]
Mr. Ménard: I know your cautiousness, sir.
[English]
Dr. Sutherland: [Inaudible - Editor]
The Chairman: We allow you all the latitude to answer and take your time. The five minutes is only so we can get Mr. Ménard and other members to ask their questions.
Dr. Sutherland: Thank you. I'm not clear about the exact information regarding compassionate access that you're looking for. I think the whole question of access to treatment is an important research one that needs to be looked at with respect to Canadian population. Included in that would be access to drugs and therapies.
This is particularly important in light of the fact that the evidence that's out now suggests that treatments could well be offered much earlier in HIV disease. So I think this is an ongoing question of access to testing, care and perhaps compassionate access drugs.
Perhaps those questions need to be formulated more clearly and would advise us on the research we should be trying to do in the future.
I'll jump to number four for the moment. With respect to cohorts, you're absolutely right, they are the best way to track all the risk factors and trends for many of the research questions, but they are extremely expensive things to do. Some of the best information Canada received early in the epidemic came out of the cohort studies that were done in Toronto and Vancouver. To some extent, the cohort in Montreal contributed important science.
I would like to mention that two more cohorts have been started. The Vancouver study in a sense was reopened because of the need to get new information from the affected communities. There is also a very important cohort study that's being undertaken now in Quebec amongst men who have sex with men. There are associated cohort studies of women with HIV looking at other diseases. So I think you're correct that this is an important component. They are the most expensive way to get the answers to these questions, however.
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Ms Gowanlock: I'll go back to question one and just add to what Dr. Sutherland has said. I know that in our care treatment and support program we have some studies under way that talk about the economic impact of HIV/AIDS. That takes into account various things: questions of income, questions of housing, and questions of treatment, if they were costly. There are a number of studies under way with the Canadian Policy Research Network that are going to have some results available fairly soon on the economic impact and the economic costs of HIV, and some of them go to those areas that you mentioned about poverty and drugs and the costs.
I'm not sure I can answer further about the compassionate access. I know the report has come out, and there will be a response from Health Canada in due course on that particular report.
On the needle exchange program - the second question - I would just say, to correct a little bit, that Health Canada never funded the actual needle exchange programs but did fund, in partnership with the provinces, the evaluation component of those very successful programs across the country in the early part of the epidemic. Needle exchange programs have continued and some new ones have been started in provinces to the present time and are ongoing.
With the third question, I would start by asking for some assistance from my colleagues. I'm not quite sure of the paradox, Mr. Ménard, that you are talking about with respect to the national framework for research. I'm not familiar with that particular... Maybe Dr. Sutherland can answer.
Dr. Sutherland: I think what Mr. Ménard is referring to is the process that Theo de Bruyn was heading up, which is the forum for research where all the researchers across Canada were consulted by Health Canada to come up with a research strategy plan for the future.
Perhaps now that you know what it is, Gweneth, I'll hand it back to you.
[Translation]
Mr. Ménard: There is no master research plan in Canada, and the scientific community complained about that. Health Canada asked Dr. Cohen to organize a forum and then make proposals. I think that Dr. Cohen, together with six other medical doctors, including Ms Catherine Hankins, the former president of the Canadian Association for HIV Research, submitted a report to Health Canada. That report was presented in a very selective way at the Vancouver conference, and we were supposed to be told afterwards about the follow-up that Health Canada intended to give to that report.
But the scientific community asked that an agreement be made about research orientations. Given the fact that there is not enough funding for research, we ought at least to target a number of concerns. It must be recognized, Ms Gowanlock, that there is really a paradox. The situation used to be somewhat anarchic in the area of research on AIDS. It doesn't mean that there was not any good research initiative, but there was no master plan, and the consistency of orientations was rather questionable. That issue is in fact Dr. Cohen's responsibility.
[English]
Ms Gowanlock: I do believe, as Dr. Sutherland is suggesting, it probably is the national research forum process that has been under way for a year and a half, and there was a report tabled for discussion in Vancouver. The department has supported the process of making a better-coordinated approach to research in Canada, not so much a priorization of the type of research but a better-coordinated approach, which is not only basic science research but social science research, and a whole range. A good many people - very important experts from across the country - participated in that.
It's still with us; that particular plan has been receiving comments up to this fall, and it will be further dealt with. It's under way. It is I think a successful venture that involved not only government but quite a number of people outside of government. The approach, as well as recommendations so far in the plan for coordinated research, doesn't turn its attention entirely to governments but says the research community has a responsibility, government has a responsibility, and private organizations have some too, in this area. That was one of its successes.
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The Chairman: Mr. Ringma, you have a short question.
Mr. Ringma: Just a short observation.
Mr. Cochrane, in your response to my earlier question you pointed out some of the difficulties in being precise about what's being spent on this and that because there is an overlapping of provincial and federal programs. I would like to offer the philosophical or editorial comment that it's not unique to the health field or anything else, it's a problem we have with Confederation. Therefore I take it on myself for all of us to say that in every area we're in, whether it's justice, health, immigration, or you name it, we all have to bear that in mind and take the extra effort to say, can we overcome this and do whatever we can?
I'm not directing this at you, I'm directing it at myself, at my fellow committee members, at Parliament as a whole and all the committees, in saying it's part of the problem we have. There's a division of responsibility across the board in every area you can think of and we have to bear it in mind in trying to resolve the problems we have.
The Chairman: Thank you very much, Mr. Ringma. I believe there is no answer to that question. Maybe the assistant deputy minister would want to answer it; I don't know.
I want first of all to take this opportunity to thank you very much for your information and for taking the time to inform the committee. It was very informative, well done. I hope you will come back to see us again.
Before we wrap up, I want to ask the members to stay for one minute after the witnesses leave so we can deal with our next two meetings, if that's acceptable.
Mr. Szabo: Can we ask Health Canada to comment on recommendations or suggestions for appropriate witnesses or whatever, or are we going to?
The Chairman: No, that's what our research team is for.
[Proceedings continue in camera]