The Canadian Medical Association (CMA) is pleased to make submissions on Bill S-4. CMA has followed the history of PIPEDA and participated in the studies of various Standing Committees, most notably and recently in 2007 to the House of Commons Standing Committee on Access to Information, Privacy and Ethics. CMA is pleased that amendments to PIPEDA are once again being considered.
The Canadian Medical Association represents over 80,000 physicians in Canada. Privacy is an important value to physicians and the patients to whom they serve. This is reflected in our Code of Ethics and policies, in particular, Principles for the Protection of Patients' Personal Health Information and Statement of Principles: The Sale and Use of Data on Individual Physicians' Prescribing. Physicians are also required to abide by privacy and confidentiality standards of practice. Thus, the CMA has a strong interest and valuable insights into the topic of personal information and privacy with respect to health information.
We thank the Standing Committee for the opportunity to comment on the proposed amendments to PIPEDA. Our key comments are outlined below:
CMA supports the existing legislative framework on the collection, use and disclosure of personal information produced by an individual in the course of their employment, business or profession ("work product") and suggests further amendments focus on strengthening it further.
CMA supports the current standing of work products, that work products are considered to be personal information. That is, we support the framework defining personal information as information about an identifiable individual and that there is no carved out definition or exemption for "work product".
CMA supports the position of the Office of Privacy Commissioner's following its 2007 investigation on work products, that they should not be exempted for two main reasons:
* The exemption is not needed, and it would be inconsistent with the balanced approach in the current definition of personal information. The current definition of personal information and the approach to deciding issues based on that definition have worked well. They have promoted a level of privacy protection that balances the right of privacy in personal information with the needs of organizations for the reasonable and appropriate collection, use and disclosure of personal information. ...Because the concept of "work product" is ambiguous, excluding it from the definition of personal information could have unpredictable consequences that would diminish privacy unnecessarily.
It is the CMA's position that work products should be considered personal information and given the section 7 amendments, work products should only be collected, used or disclosed without consent only if it is consistent with the purposes for which the information was produced.
In the case of physicians, a prime example of a physician's work product is prescribing information. Prescribing information is a synthesis of assessing patients - by probing into their health, familial, social and sometimes financial background - infused with medical knowledge, skill and competencies resulting in a diagnosis and treatment plan, which often includes prescribing a medication or test. Not only is the physician's prescribing information a product of physicians' work but would not exist but for a trusting physician-patient relationship wherein the patient's private and personal information are shared under circumstances of vulnerability and trust. The outcome is that this is personal information. Prescribing information is about an individual: it includes the name of the patient, the name of the prescribing physician, and the drug name, dosage, amount and frequency; giving major clues as to what the patient's health issue(s) are.
For further clarity, however, CMA recommends that physician information, and physician work products, should be specifically recognized within the legislation as personal information. To this end, we would propose that the following addition be made to the definition section under personal health information:
Section 2.(1) "personal health information", with respect to an individual, whether living or deceased, means .....(d) information that is collected or is the outcome of collecting information in the course of providing health services to the individual;
CMA supports the amendments to subsections 7(1)-(3) of the Act that any subsequent collection, use and disclosure of work products without consent must be related to the original purpose (of collection, use and disclosure). This relationship reflects the government's understanding and faithfulness to privacy principles. This is particularly critical when dealing with health information, and is even more critical in today's world given the ease of linking information through advancements in technology. In the absence of a causal relationship, personal information should not be used for system performance, commercial enterprise, data brokering, research, assessment or other purposes.
CMA recommends that the legislation should go further and allow persons who believe that protection cannot be afforded under the legislation that they have the authority to refuse to communicate the information. This is the conceptual approach taken in Quebec's Act Respecting the Protection of Personal Information in the Private Sector wherein persons have an opportunity to refuse that professional information (as defined therein) be used for commercial purposes. Physicians are constantly writing prescriptions and such information should only be used for other purposes in the interests of patients and the health care system, and not to serve commercial interests or marketing strategies. If physicians do not feel that such protection is afforded patients, then they should be permitted to refuse that such information be collected, used or disclosed. Patient privacy should be primary.
And finally, addressing work products in legislation clears up past differences of interpretation by Privacy Commissioners thus, providing certainty and clarity to the public.
That Section 2. (1) "personal health information", be amended to read as follows: "personal health information", with respect to an individual, whether living or deceased, means .....(d) information that is collected or is the outcome of collecting information in the course of providing health services to the individual;
CMA is pleased to see a section on breaches of security safeguards and recommends greater specificity.
As noted above, physicians have responsibilities as data stewards and custodians of health information. As such, CMA supports breach notification measures that would enhance and protect patient privacy. In principle, we support the proposed amendments of breach disclosures to the Privacy Commissioner, to individuals and to organizations.
However, CMA is concerned that meeting the requirements may be confusing. For example, in the health care context, it is easy to surmise that all health information is "sensitive". A far more difficult matter is determining whether the risk reaches the threshold of "significant harm" and the "probability" that the information "will be misused". The result being that incidental disclosures will be reported causing unnecessary concern and confusion in the patient population. Further specificity is recommended and we suggest something akin to Ontario's Personal Health Information Protection Act, 2004 (PHIPA).
The PHIPA is an act specifically dealing with personal health information. One of its purposes is "to establish rules for the collection, use and disclosure of personal health information about individuals that protect the confidentiality of that information and the privacy of individuals with respect to that information, while facilitating the effective provision of health care" (section 1a ). The PHIPA notification provision states that the individual shall be notified "...at the first reasonable opportunity if the information is stolen, lost or accessed by unauthorized persons", [section 12(2)]. CMA is unaware of any concerns with this approach.
The language of PIPIEDA is one of reasonable belief of real risk of significant harm to an individual. The issue is the test for required notification of patients for incidental inadvertent breaches and decreasing "notification fatigue". To illustrate the issue, if physicians were told today that patient data could be retrieved from the drums of discarded photocopiers and printers, it would be inappropriate for legislation to suggest that the entire patient population during the life of the photocopier or printer be notified. To this end, we recommend that there be acknowledgement that in some circumstances notification may not be required. The probability of misuse under PIPEDA is more ambiguous than the PHIPA test. Under PHIPA, the approach is more objective in that the data must be stolen, lost or accessed by unauthorized persons. To our knowledge, the Ontario model has been in place for almost a decade with no significant issues and thus we submit is one that works.
In other jurisdictions (eg., Newfoundland and Labrador, Nova Scotia, New Brunswick) with health privacy legislation, there is acknowledgement of trying to balance notification and those breaches unlikely to result in harm by directly indicating when notification is not required.
CMA recommends that the statute move towards a more objective test and acknowledge that there are situations when notice is not required.
CMA supports disclosure without consent under limited circumstances, but finds the current list of disclosures overly inclusive.
Health information is considered highly sensitive information and is initially collected for the purpose of individual patient health care. It should only be disclosed with consent and in only some exceptions without consent. The PIPEDA amendments for disclosure without consent have been broadened.
Privacy, confidentiality and trust are the foundations of the patient-physician relationship. Without these fundamental values in play, open and honest communications cannot occur and patients would not receive the care they require. Both the patient and the physician have significant investment in the relationship. CMA respects the requirements to disclose information without consent under certain premises, such as required by court order or statute. However, any kind of activity requiring physicians to disclose patient's information without consent for the purposes of advancing a government or institution's goal could jeopardize the relationship.
Both the patient's consent and the physician's consent should be required if there is potential to disturb this relationship. The physician is fiduciary of the relationship and is appropriately situated to assess and determine whether disclosure will disturb the relationship.
While CMA acknowledges that certain situations may require that disclosure occur without consent (eg. purposes of investigating fraud, national security, abuse or as legally required), disclosure for less malicious activities (e.g., breaches of an agreement, insurance claims) ought to require a court order or warrant. For example, under the proposed section 7(3)(d.1) if a physician were in default of a contract with a technology company supplying electronic medical record software or app to his/her clinic, the company could disclose health information without consent for the "purposes of investigating a breach of an agreement". While we appreciate that there is a caveat that disclosure without advising the patient can only occur if there is a reasonable expectation that the disclosure would compromise the investigation, we submit that leaving the determination of what is "reasonable" to an interested party to the breach is unfair to all. Another example, if a physician is a witness to a dispute between an employer and union representing an employee for denial of long term disability by an insurance company, and has filed a witness statement which includes a medical report he/she wrote to the employer's insurance company, under the proposed section 7(3)(e.1) disclosure of health information without consent is permitted in order to assess, process or settle an insurance claim.
CMA is concerned that the disclosure amendments are overly broad and do not differentiate sufficiently between highly time sensitive or grossly malicious situations, and those where it is merely expedient or an administrative encumbrance to seek consent.
In addition, the disclosure requirements are framed in permissive (ie., may) and not mandatory language (ie., shall). This is very problematic when the "organization" is a physicians' clinic unless the physician's own consent is made as a pre-condition. CMA believes this suggestion is a progressive one in keeping with the broadened disclosure amendments. Physicians are in a relationship of trust and take seriously the protection of patient privacy and confidentiality, for which they are trained and are ethically and legally required to protect.
To place physicians in a position which might entail breaching this trust may impact the confidence of the physician and the patient in the patient-physician relationship which is required to properly formulate appropriate treatment plans; thus, negatively impacting the health of Canadians.
That disclosures of health information without consent require a warrant or subpoena or court order. Furthermore, disclosures of health information require the physician's consent that in his/her opinion the disclosure does not harm the patient-physician relationship. And, finally any broadened disclosure situations be restricted to criminal activity or that impacting national security.
Once again, CMA appreciates the opportunity to provide comment as part of the committee's study of Bill S-4. CMA is prepared to work with Parliament, governments, health professionals and the public in ensuring legislative frameworks for the collection, usage and disclosure of personal information for legitimate and reasonable purposes.
The Canadian Medical Association (CMA) provides this brief for consideration as part of House of Commons Standing Committee on Public Safety and National Security's study of Bill C-2, An Act to amend the Controlled Drugs and Substances Act (Respect for Communities Act).1
Prior to a discussion on CMA's position regarding the substance of Bill C-2, the CMA firstly recommends that legislation pertaining to harm reduction services requires study by parliamentary committees responsible for health or social matters in addition to public safety.
Bill C-2 (formerly Bill C-65) is subsequent to the 2011 unanimous ruling of the Supreme Court of Canada2 that recognized the significant evidence on the benefits of Insite, Vancouver's supervised injection site. The Supreme Court ordered that the federal government grant the exemption for medical and scientific purposes to Insite.
The ruling left decisions regarding future applications for exemptions to the Controlled Drugs and Substances Act (CDSA) for Insite and other potential supervised injection sites up to the discretion of the Minister of Health, with the provision that the Minister seek to strike the appropriate balance between the public health and public safety goals, and suggests the decision be based on five elements: "evidence, if any, on the impact of such a facility on crime rates, the local conditions indicating a need for such a supervised injection site, the regulatory structure in place to support the facility, the resources available to support its maintenance and expressions of community support or opposition." 3
In response, the Minister of Health proposed Bill C-2, which amends the CDSA to include section 56.1, and provides a federal regulatory framework for supervised consumption sites.*
CMA is deeply concerned with the proposed legislation, as it has the potential to create unnecessary obstacles and burdens that would ultimately deter the creation of new supervised consumption sites, even in municipalities where the need and cost-effectiveness has been well researched and the health and safety benefits clearly established. Moreover, it does not strike the appropriate balance between public health and public safety, as is the spirit and intent of the Supreme Court of Canada ruling on Insite. This will make the renewal of exemptions for Insite, the very facility which the Supreme Court ruled "saves lives", very difficult.
Public health approach to addiction
Addiction should be recognized and treated as a serious, chronic and relapsing medical condition for which there are effective treatments. The CMA has long called for a comprehensive national drug strategy that addresses addiction, and includes prevention, treatment, harm reduction and enforcement components.
Public health objectives in addressing addictions will vary depending upon the circumstances: preventing drug use in those who have not initiated use (e.g. pre-teens); avoiding use in circumstances associated with a risk of adverse outcomes (e.g. drug use and driving motor vehicle); assisting those who wish to stop using drugs (e.g. treatment, rehabilitation); and assisting those who continue to use drugs to do so in such a manner as to reduce the risk of adverse effects (e.g. needle distribution program).
Despite drug use being primarily a health and social issue, the focus of the federal National Anti-Drug Strategy is heavily skewed towards a criminal justice approach, as evidenced by a recent evaluation.4 This approach does not address the determinants of drug use, treat addictions, or reduce the harms associated with drug use. Other models are more effective in achieving the desired objectives and more investments need to be made in prevention, harm reduction and treatment, keeping individuals out of the criminal justice system.5
Drug use is a complex issue, and collaboration among health and public safety professionals, and society at large, is essential.
Harm reduction is part of health practice
Harm reduction is not restricted to services for people who use drugs; it is an approach that is adopted routinely in every health and social program. For example, seat belts, air bags and helmets are encouraged and even mandated to reduce some of the possible harmful consequences of driving or cycling - regardless of who is at fault. Many medications do not cure diseases, and are essential to prevent complications. An example is the use of insulin by people with diabetes.6 There are many programs created to reduce the harms created by alcohol, a legal substance that contributes to a significant burden of disease, disability and deaths. Examples include low risk drinking guidelines, designated driver or alternate driver programs for drinkers, graduated licenses and changes in the hours of liquor stores to reduce the use of non-beverage alcohol.7 While the risk is still present, this approach reduces harms.
Harm reduction related to psychoactive substances, "refers to policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction benefits people who use drugs, their families and the community".8 They are part of a comprehensive approach which also includes abstinence-based programs.
The CMA fully supports harm reduction strategies as they aim to reduce mortality and morbidity even in the face of continued exposure to a potentially harmful substance. Addiction is an illness, and harm reduction is a clinically mandated and ethical method of care and treatment. Physicians must treat patients as a matter of good medical practice and ethical obligation, whether the patient is believed to contribute to his or her injury or not. Section 31 of CMA's Code of Ethics provides that all physicians must "recognize the responsibility of physicians to promote fair access to health care resources".9
Harm reduction information, services and interventions are respectful and non-judgmental, and have the purpose of promoting health and safety. These strategies were developed in response to critical situations and high costs to the health, social and criminal justice systems. Harm reduction approaches are evidence-based, cost effective and have a high impact on individual and community health. Such programs for injection drug users are now well established within every province and territory in Canada, in the form of needle and syringe distribution programs, methadone maintenance and the provision of sterilized equipment.10
Supervised Consumption Sites are evidence-based
Supervised consumption sites, within a comprehensive drug strategy, are another example of a harm reduction program. They were developed to reduce the harms of Injection drug use, which are an increased incidence and prevalence of infectious diseases including HIV/AIDS, Hepatitis C, and skin- and blood-borne infections; frequent drug overdoses resulting in significant morbidity and mortality; and increased hospital and emergency service utilization. Many of these health problems are not due to the drugs themselves, but to the injection method and equipment.
Supervised consumption sites are "specialized facilities that provide injection drug users with a clean, safe, unhurried environment. Sterile injection equipment is provided and health care and social service professionals are available to deal with health issues, provide counselling, and facilitate access to detoxification and treatment programs. Supervision is provided by health professionals trained in low-risk injection techniques and overdose intervention."11 The drugs are acquired elsewhere, and they are located in areas of concentrated and highly visible drug scenes. Such services have existed for many years in many countries, and there are over 90 sites operating in countries such as Australia, Germany, Luxembourg, the Netherlands, Norway, Spain and Switzerland.12
Clients of these sites have complex histories of trauma, mental illness and drug use, and live at the margins of society, unreached by traditional health and social services. Supervised consumption sites are developed as low threshold services for hard-to-reach populations which are experiencing unacceptable levels of deaths and diseases. Existing outreach and treatment programs are insufficient to meet the needs of this population, and these sites are a point of entry into health and social services.
Insite, the first supervised injection site in North America, operates in Vancouver's downtown east side as part of the 'four pillars' drug strategy: prevention, treatment, harm reduction, and enforcement.13 14 In 2012, Insite had an average of 1028 visits per day. There were 497 overdose incidents with no fatalities and 3418 clinical treatment interventions. Insite staff made 4564 referrals for further health care, housing and social supports, and the vast majority was for detox and addiction treatment.15
Insite has been one of the most researched public health interventions to date.16 Research was conducted by the BC Centre for Excellence on HIV/AIDS, funded partially by Health Canada, and there are over 30 publications in leading peer-reviewed scientific and medical journals.17 18The evidence shows that there has been:
* A reduction in the overall rate of needle sharing in the area;19
* A reduction in deaths due to overdose in the area, with no overdose deaths in the facility;20 21
* Increased access to addiction counseling and increased enrolment in detox programs;22 23
* Opportunities for HIV prevention through education, and increased links between patients and HIV treatment and services;24
* Improvements in measures of public order including reduced public drug injections and publicly discarded syringes;25 and
* No increase in levels of drug dealing or other drug related crime in the area in which the facility is located. 26
* Cost savings to health and social systems, reducing risks of infectious diseases, intervening early when there are issues, and reducing the need for emergency care.27 28
Reports from other countries show similar results.29 30 However, "research evidence, even if it meets rigorous academic standards, might be insufficient to sway opinions among those who hold a firm view of addiction as a moral failure."31 Assertions that supervised consumption sites will not reduce disease transmission, exacerbate crime, encourage drug use, have destructive effects on local businesses and residents are not based on evidence.
Physicians believe that medical decisions must be based on evidence, not ideology or public opinion, and the evidence shows that supervised injection reduces the spread of infectious diseases, decreases the incidence of overdose and death and increases access to much needed services, without increasing problems with public safety.
Significantly, the Court accepted the evidence that "Insite has saved lives and improved health without increasing the incidence of drug use and crime in the surrounding area."32 It also stated that Insite is supported by the Vancouver police, the city and provincial governments. Supervised consumption rooms aim to address problems of specific, high-risk populations of people who use drugs, particularly those who consume in public and other high risk situations. They seek to meet the needs of those who use drugs, but also of the communities that are struggling with a crisis situation.
The CMA has the following concerns with Bill C-2:
1. Bill C-2 does not strike a balance between the public health and public safety goals of the CDSA. As written, Bill C-2 disregards the strong evidence of important positive impacts on public health and public safety and giving undue emphasis on public opinion, which might not be fully informed or experienced. Although public opinion might initially be against the introduction of such facilities, public acceptance of supervised consumption sites is considerably high in most of the locations where they have been established, in both Vancouver sites (Insite and the Dr Peter Centre) and in European countries. "Health problems have been reduced, and law and order have been improved. Communities, neighbourhoods and local authorities are usually involved in the good functioning of the facilities through cooperation and communication."33 The Supreme Court states that there has been "no discernible negative impact on the public safety and health objectives of Canada during its [Insite's] eight years of operation."
2. Bill C-2 contradicts the spirit and intent of the unanimous decision of the 2011 Supreme Court of Canada regarding Insite which states that "the potential denial of health services and the correlative increase in the risk of death and disease to injection drug users outweigh any benefit that might be derived from maintaining an absolute prohibition on possession of illegal drugs".34 Bill C-2 does not acknowledge the extensive evidence that exists regarding supervised consumption sites both internationally and in Canada, as discussed previously. Passing Bill C-2 in its current form could potentially prevent the renewal of the exemption to Section 56 of the CDSA for Insite. A likely consequence will be further costly litigation.
3. Bill C-2 would impose multiple and significant barriers that providers of health services to obtain an exemption to section 56 of the CDSA. From five criteria in the Supreme Court decision concerning Insite, Bill C-2 lists 27 requirements (Section 56(1)(3)), which include demographic and scientific data, letters of opinions from representatives of local police and local and provincial governments, information about proposed staff, descriptions of planned procedures and reports from community consultations. Such evidence could require extensive resources and funding by local public health units and community agencies. Some of the data required may only be available in the context of a research project. The data is not only influenced by the existence or not of a supervised consumption site, but by many other factors, such as poverty, enforcement resources and others. Community opinion of supervised consumption sites can also change to be significantly positive after experiencing months of its operation. Finally, Bill C-2 does not address how the Minister is to weigh the information submitted, to guarantee impartiality, or even if he or she must consider an application. Even after meeting all those requirements, the Minister has the sole discretion to decide whether a site can open, and the preamble states that exemptions will only be granted in "exceptional circumstances".
4. Bill C-2 did not involve consultation with provincial and territorial ministries of health, community agencies and professional associations, such as the CMA. Public health authorities and particularly health professionals, who work with people with addictions on a daily basis, recognize the dire need for complementary approaches to substance use that address different needs. The exemption to section 56 is for medical purposes, and public health agencies have the competency to determine when there is a need.
It is the CMA's ultimate position that Bill C-2, the Respect for Communities Act must be withdrawn, and that it be replaced with legislation that recognizes the unequivocal evidence of benefits of supervised consumption sites, that was accepted by the Supreme Court. Legislation would enhance access to health services, which include prevention, harm reduction and treatment services in communities where the evidence has shown they would benefit from such health services.
* "Supervised consumption site" is the term used in Bill C-2, section 56.1, and defined as "a location specified in the terms and conditions of an exemption, granted by the Minister under subsection (2) for a medical purpose, that allows any person or class of persons described in the exemption to engage in certain activities in relation to an illicit substance within a supervised and controlled environment." The Supreme Court of Canada and other documents use terms such as "supervised injection site" "supervised injection services", "drug consumption rooms" or "safer injection site". In the literature, supervised consumption sites could also include supervised inhalation services.
1 Bill C-2: An Act to amend the Controlled Drugs and Substances Act. 2nd Session, 41st Parliament. Retrieved from: http://www.parl.gc.ca/HousePublications/Publication.aspx?Language=E&Mode=1&DocId=6256959&File=4
2 Supreme Court of Canada (2011) Canada (A.G.) v. PHS Comm. Serv. Soc. Retrieved from: http://scc-csc.lexum.com/scc-csc/scc-csc/en/item/7960/index.do
3 Supreme Court of Canada (2011) Canada (A.G.) v. PHS Comm. Serv. Soc. supra. p.192-3
4 Department of Justice (2013) National Anti-Drug Strategy Evaluation. Retrieved from: http://www.justice.gc.ca/eng/rp-pr/cp-pm/eval/rep-rap/12/nas-sna/p1.html#sec23
5 Day, Brian (2008) "Ottawa's bad prescription on addiction." Toronto Star, Sunday June 8, 2008. Retrieved from: http://www.thestar.com/comment/article/438967
6 Canadian Centre on Substance Abuse (2008) Harm reduction: what's in a name? Retrieved from: http://www.ccsa.ca/Resource%20Library/ccsa0115302008e.pdf
7 National Alcohol Strategy Working Group (2007) Reducing Alcohol-Related Harm in Canada: toward a culture of moderation. Recommendations for a National Alcohol Strategy. Retrieved from: http://ccsa.ca/Resource%20Library/ccsa-023876-2007.pdf
8 International Harm Reduction Association (2010) Harm Reduction: A position statement from the International Harm Reduction Association. IHRA Briefing. Retrieved from: http://www.ihra.net/files/2010/08/10/Briefing_What_is_HR_English.pdf
9 Canadian Medical Association (2010) Factum of the Intervener. Supreme Court of Canada (Appeal from the British Columbia Court of Appeal) between the Attorney General of Canada and Minister of Health for Canada and PHS Community Services Society, Dean Edward Wilson and Shelly Tomic, Vancouver Area Network of Drug Users. Retrieved from: https://www.cma.ca/Assets/assets-library/document/en/advocacy/CMA-Factum_filed14April2011.pdf
10 Canadian Centre on Substance Abuse (2008) Harm reduction: what's in a name? Retrieved from: http://www.ccsa.ca/Resource%20Library/ccsa0115302008e.pdf
11 Canadian Centre on Substance Abuse (2008) Harm reduction: what's in a name? Retrieved from: http://www.ccsa.ca/Resource%20Library/ccsa0115302008e.pdf
12 Schatz, E. & Nougier, M. (2012) Drug consumption rooms: evidence and practice. International Drug Policy Consortium Briefing Paper. Retrieved from: http://www.drugsandalcohol.ie/17898/1/IDPC-Briefing-Paper_Drug-consumption-rooms.pdf
13 City of Vancouver Four Pillars Drug Strategy (2008) Limiting the harms of drug use. Retrieved from: http://vancouver.ca/fourpillars/harmReduction/limitHarmDrugUse.htm
14 Vancouver Coastal Health. Supervised Injection Site (N.D.) Services. Accessed September 19, 2014 at: http://supervisedinjection.vch.ca/services/services
15 Vancouver Coastal Health. Supervised Injection Site (N.D.). Accessed September 19, 2014 at: http://supervisedinjection.vch.ca/research/supporting_research/user_statistics
16 Urban Health Research Initiative (2010). Insight into Insite. Retrieved from: http://www.cfenet.ubc.ca/sites/default/files/uploads/publications/insight_into_insite.pdf
17 Health Canada. Vancouver's Insite service and other supervised injection sites: what has been learned from Research? Final Report of the Expert Advisory Committee. Ottawa: Health Canada, 2008. Prepared for the Hon. Tony Clement, Minister of Health, Government of Canada. Retrieved from: http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php
18 Wood, E. et al. (2006) Summary of findings from the evaluation of a pilot medically supervised safer injecting facility. Canadian Medical Association J, 175(11): 1399-1404.
19 Kerr, T. et al. (2005) Safer injection facility use and syringe sharing in injection drug users. The Lancet 366: 316-18.
20 Milloy M.J., Kerr, T., Tyndall, M., Montaner, J., & Wood E. (2008) Estimated drug overdose deaths averted by North America's first medically-supervised safer injection facility. PLoS ONE 3(10):e3351.
21 Marshall B. D. L., Milloy, M.-J., Wood, E., Montaner, J. S. G., & Kerr, T. (2011). Reduction in overdose mortality after the opening of North America's first medically supervised safer injecting facility: A retrospective population-based study. Lancet. Published online April 18, 2011. doi: 10.1016/S0140-6736(10)62353-7.
22 Wood, E. et al. (2007) Rate of detoxification service use and its impact among a cohort of supervised injecting facility users. Addiction 102: 916-919.
23 Tyndall, M.W. et al. (2005) Attendance, drug use patterns, and referrals made from North America's first supervised injection facility. Drug and Alcohol Dependence.
24 Tyndall, M.W. et al. (2006) HIV seroprevalence among participants at a medically supervised injection facility in Vancouver Canada: Implications for prevention, care and treatment. Harm Reduction J 3:36.
25 Wood, E. et al. (2004) "Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users." Canadian Medical Association J 171(7): 731-34.
26 Health Canada. Vancouver's Insite service and other supervised injection sites: what has been learned from Research? Final Report of the Expert Advisory Committee. Ottawa: Health Canada, 2008. Prepared for the Hon. Tony Clement, Minister of Health, Government of Canada. Retrieved from: http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php
27 Andresen, M.A. & Boyd, N. (2010) A cost-benefit and cost-effectiveness analysis of Vancouver's supervised injection facility. Int.J.DrugPolicy 21(1): 70-76.
28 Pinkerton, S.D. (2010) Is Vancouver Canada's supervised injection facility cost-saving? Addiction 105(8): 1429-36.
29 Schatz, E. & Nougier, M. (2012) Drug consumption rooms: evidence and practice. International Drug Policy Consortium Briefing Paper.
30 Hedrich, D. (2004) European report on drug consumption rooms. Report prepared for the European Monitoring Centre on Drugs and Drug Addiction.
31 Watson, T.M. et al. (2012) Police Perceptions of Supervised Consumption Sites (SCSs): A Qualitative Study. Substance Use & Misuse, 47:364-374.
32 Supreme Court of Canada (2011) Canada (A.G.) v. PHS Comm. Serv. Soc. supra. p. 136
33 Schatz, E. & Nougier, M. (2012) Drug consumption rooms: evidence and practice. International Drug Policy Consortium Briefing Paper. (p.20)
34 Supreme Court of Canada (2011) Canada (A.G.) v. PHS Comm. Serv. Soc. supra (p.188).
The Canadian Medical Association (CMA) is pleased to present this brief to the House of Commons Standing Committee on Health for consideration as part of its study of Bill C-17, Protecting Canadians from Unsafe Drugs Act, which proposes amendments to the Food and Drugs Act.
The CMA has over 80,000 physician-members. Its mission is to serve and unite the physicians of Canada and to be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care.
Prescription medication has a very important role as part of a high-quality, patient-centred and cost-effective health care system. Prescription medication can prevent serious disease, reduce the need for hospital stays, replace surgical treatment and improve a patient's capacity to function productively in the community. As such, the CMA has developed a substantial body of policy on pharmaceutical issues, including on the post-approval surveillance of prescription medication. Over the last several years, the CMA has prepared several briefs and reports on pharmaceutical medication and prescribing-related issues.1 It is a priority to physicians that all Canadians have access to medically-necessary drugs that are safe, effective, affordable, appropriately prescribed and administered, as part of a comprehensive, patient-centered health care and treatment plan.
The CMA supports a robust legislative framework and unbiased, evidence-based system for the oversight of pharmaceutical products. As outlined below, the CMA has identified opportunities to strengthen elements of Bill C-17 toward this end.
1) Clarify ministerial authority and responsibility
The current legislative limit to the health minister's authorities is troubling. The CMA, along with many other stakeholders, has long called for an expansion of ministerial authorities related to the pharmaceutical legislative framework, including both pre- and post-approval, in support of patient safety.
The CMA supports the underlying intent to expand the authority of the health minister to require the submission of information, modify the label or replace the package, to order a recall or relocation of a product. However, the CMA has two concerns regarding the limitations to this expanded authority (section 3, proposed new FDA sections 21.1, 21.2 and 21.3):
* Firstly, that the threshold for the new authorities in section 3 (new proposed section 21.1, 21.2, and 21.3 of the FDA) may be too high. The term "serious risk of injury to health" will be the standard for these new ministerial powers and may limit the authority of the minister to take action when the concern may be serious, but not necessarily permanently debilitating or life threatening.
* Secondly, that the minister is not required to take any of the actions proposed in Bill C-17 even if the threshold is met (these sections specify that the minister "may" take the specified action, rather than the minister "shall"). While seemingly minor, the difference between "may" and "shall" is the difference between having the authority to take action and being responsible to take this action. This difference is critical to a robust legislative framework for patient safety.
In order to clarify the health minister's authority to take appropriate measures to protect patient safety, the CMA recommends that the standard "a serious risk of injury to human health" in section 3 proposed new FDA section 21.1 and "serious or imminent risk of injury to health" in section 3 proposed new FDA section 21.3 be amended to ensure an appropriate threshold that does not constrain ministerial authority.
Recommendation 2: To ensure that the health minister has the clear responsibility to take appropriate measures to protect patient safety, the CMA recommends that the word "may" is replaced with "shall" in section 3, proposed new FDA sections 21.1, 21.2 and 21.3.
2) Oversight of natural health products
The extensive use of natural health products, such as vitamins and herbal medicines, is partially due to a belief that such products are "natural" and thus low risk. Increasingly, it has become clear that these products can have adverse effects, including drug interactions. However, relatively little is known about the adverse effects associated with natural health products due to its limited legislative and regulatory requirements, including reporting.
To ensure that patient safety risks associated with natural health products are addressed, these products should be included in the new patient safety legislation, as proposed in the previous iteration of this legislation in 2008, Bill C-51 An act respecting foods, therapeutic products and cosmetics. The CMA encourages the Health Committee to include natural health products within the scope of Bill C-17, as a first step toward ensuring that natural health products are subject to the same regulatory requirements and oversight as are prescription and over-the-counter pharmaceuticals in order to promote patient safety.
Recommendation 3: The ministerial authorities and measures proposed in Bill C-17 should be extended to include natural health products and, as such, CMA recommends that the definition of "therapeutic product" in section 2(3), be amended to include natural health products.
3) Comprehensive post-market surveillance and response system
The CMA has advocated for significant improvements to Health Canada's post-market surveillance and response system in light of significant shortcomings.
A) Increasing accountability and public transparency
Robust accountability and transparency are important elements in the legislative framework governing the post-market surveillance and response system. The 2011 report of the Office of the Auditor General of Canada (OAG) highlighted significant concerns regarding this system, not least of which being Health Canada's failure to meet its own benchmarks in reviewing and responding to pharmaceutical safety issues. While there was no assessment of the benchmarks themselves, as is typical with an audit, the OAG report highlighted a number of issues with Health Canada's approach to measuring its performance against its benchmarks.
Following the publication of the OAG audit report, Health Canada's 2013-14 Main Estimates and Report of Plans and Priorities2 shows cuts in both budget and staff allocation for health products (which includes drug oversight). The 2011 OAG report states that "Canada's small population reduces the likelihood of serious, rare adverse drug reactions being identified in this country; therefore, the capacity to search and analyze foreign reports electronically would contribute to more comprehensive safety monitoring."3 Of note, the audit found that Health Canada "does not take timely action in its regulatory activities" (...). "In particular, the Department is slow to assess potential safety issues. It can take more than two years to complete an assessment of potential safety issues and to provide Canadians with new safety information."4
Despite Health Canada's March 2013 update on its efforts to address the OAG recommendations5 the status of the improvements to the reporting tools, timeliness of information or quality of information provided to practitioners and patients remains unclear.
The preceding paragraphs capture a number of issues pertaining to the post-approval surveillance and response system; it is imperative that Health Canada not only address these issues, but that Health Canada has adequate resources to do so. This is paramount prior to any consideration of expanding the input of reporting data.
Recommendation 4: The CMA recommends that Bill C-17 be amended to require Health Canada undertake public consultations in establishing its performance benchmarks related to adverse drug reaction reporting, analysis and response communication.
Recommendation 5: The CMA recommends that Bill C-17 be amended to establish a new public reporting requirement of its performance in meeting its performance benchmarks.
B) Improving the reporting and communication system
The CMA cautions against the advancement of new legislative authority with respect to mandatory reporting of serious adverse drug reactions prior to the improvement of the system and model currently in place.
Information gathering does not in itself constitute post-market surveillance. In our opinion, the most important element of the process is the monitoring and analysis that occurs once an adverse drug reaction report has been received. Monitoring capacity requires rigorous data analysis and, to be useful in preventing further adverse events, it must be timely. As well, it should also provide information about a drug's efficacy and effectiveness.
When new information is uncovered about a prescription drug, it is important that health professionals are made aware of it as quickly and efficiently as possible. Therefore, post-approval surveillance requires a system for communicating timely, reliable and objective information in a manner that allows them to incorporate it into their everyday practice. Ideally, this communication would report not the safety problem alone but also its implications for their patients and practice: for example, whether some patients are particularly at risk, or whether therapeutic alternatives are available. Such feedback will encourage further reporting.
In order to improve patient safety, the CMA recommends that Health Canada's establish a model that includes:
* Making it easier for physicians and other health professionals to report adverse drug reactions by making the reporting system user-friendly and easy to incorporate into a practitioner's busy schedule. Currently the existing system imposes an unnecessary administrative burden that comes at the expense of time dedicated to patient care.
* Making the reporting process even more efficient by incorporating it directly into the Electronic Health Record systems. Health Canada has improved the process by introducing online reporting, which may have contributed to the significant increase in the number of reports over the past 10 years, but being able to connect patient information with drugs they are taking, reporting of adverse drug reactions and safety information would improve care on the front line.
* Augmenting spontaneous reports with information gathered through other, more systematic means. These could include formal post-market studies of specific drugs, or recruitment of "sentinel" groups of health care providers who would contract to report adverse drug reactions in detail, and who would be committed to assiduous reporting.
* Linking to international post-approval surveillance systems, thus increasing the body of data at researchers' disposal, as well as the capacity for meaningful analysis.
Health Canada should take a leadership role in ensuring that the public has access to appropriate information on drugs and drug safety, engaging civil society at the appropriate phases of the process. In providing this information, Health Canada should consider the management and communication of risk, and take into account the diversity of Canada's population. Access to accurate, unbiased information allows people to make decisions regarding their own health.
In addition to ensuring a comprehensive model is in place, it is essential that there be more clarity in Bill C-17 regarding what constitutes a "prescribed health care institution". There are very different changes to the system that would need to be in place should it refer to tertiary care hospitals, community hospitals, clinics or doctors in family practice. Bill C-17 must not place an unnecessary administrative burden, which would ultimately fall on health professionals. Further, it is unclear whether a cost assessment of the proposed new requirements for health care institutions with respect to provincial/territorial resources has been undertaken. Only those health care institutions that are best positioned to improve the quantity and quality of reporting should be required to report.
Another term that requires clarification in the legislation is "serious adverse drug reaction". It should be clear whether it means adverse drug reactions that require visits to emergency departments or hospitalization, or whether there are other criteria to define it.
Recommendation 6: The CMA recommends that Bill C-17 be amended to require that Health Canada implement comprehensive post-surveillance monitoring and reporting model that includes:
* Accessible, comprehensive and user-friendly reporting tools that are clinically relevant and linked to electronic health records;
* Rigorous and timely analysis of reports for the early identification and response to emerging drug safety threats; and
* Communication of timely, user-friendly and clinically-relevant information to health care practitioners and the public.
Recommendation 7: The CMA recommends amendment of Bill C-17 section 5, proposed new FDA section 21.8, to require that an assessment by the minister for reporting regulations be undertaken following a prescribed period after this new model is established; that this assessment precede the coming into force of expanded mandatory reporting.
Recommendation 8: The CMA recommends that essential terminology be defined in Bill C-17, including (a) "serious adverse drug reaction" and (b) "health care institution".
Canada's physicians are prepared to work with governments, health professionals and the public in strengthening Canada's post-approval surveillance system, to ensure that the prescription drugs Canadians receive are safe and effective.
1 Canadian Medical Association (2005) Building a Comprehensive Post-Market Surveillance System. CMA's Response to Health Canada's Discussion Paper 'Designing a Mandatory System for Reporting Serious Adverse Reactions'. CMA. Retrieved from: http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Submissions/2005/English/Mandatory_Response.pdf
Canadian Medical Association (2014) Federal levers to address unintended consequences of prescription pharmaceuticals and support public health, quality care, and patient safety. CMA Submission to the Senate Committee on Social Affairs, Science and Technology. CMA. Retrieved from: http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Submissions/2014/SOCI_BriefEnglish-Final.pdf
Canadian Medical Association (2008) Post-Market Surveillance of Pharmaceutical Products. CMA Submission to the House of Commons Standing Committee on Health. CMA. Retrieved from: https://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Submissions/2008/brief-drug-en-08.pdf
Canadian Medical Association (2012) Prescription Drugs: Clinical Trials and Approval. CMA Presentation to the Senate Standing Committee on Social Affairs, Science and Technology. CMA. Retrieved from: https://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Submissions/2012/Senate-ClinicalTrials_en.pdf
Canadian Medical Association (2012) Prescription Pharmaceuticals in Canada: The Post-Approval Monitoring of Prescription Pharmaceuticals. CMA Submission to the Senate Committee on Social Affairs, Science and Technology. CMA. Retrieved from: http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Submissions/2012/Senate-Pharmaceuticals-Oct2012_en.pdf
Canadian Medical Association (2014) Review of Controlled Drugs and Substances Act. Submission to Health Canada in response to the consultation on the Controlled Drugs and Substances Act and its regulations. CMA. Retrieved from: http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Submissions/2014/CMA_SubmissiontoHealthCanada-CDSA_Modernization.pdf
Canadian Medical Association (2013) The need for a national strategy to address abuse and misuse of prescription drugs in Canada. CMA Submission to the House of Commons Standing Committee on Health. CMA. Retrieved from: http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Submissions/2013/Prescription-Drug-Abuse_en.pdf
2 Health Canada (2013) 2013-14 Report on Plans and Priorities. Government of Canada.
http://www.hc-sc.gc.ca/ahc-asc/alt_formats/pdf/performance/estim-previs/plans-prior/2013-2014/report-rapport-eng.pdf (pg 30)
3 Office of the Auditor General of Canada (2011) Chapter 4 Regulating Pharmaceutical Drugs - Health Canada. 2011 Fall Report of the Auditor General of Canada. Government of Canada. Retrieved from: http://www.oag-bvg.gc.ca/internet/docs/parl_oag_201111_04_e.pdf (pg 21)
4 Office of the Auditor General of Canada (2011) Chapter 4 Regulating Pharmaceutical Drugs - Health Canada. 2011 Fall Report of the Auditor General of Canada. Government of Canada. Retrieved from: http://www.oag-bvg.gc.ca/internet/docs/parl_oag_201111_04_e.pdf (pg 2)
5 Health Canada (2013) Update and response to OAG recommendations for the regulation of pharmaceutical drugs in Fall 2011. Government of Canada. Retrieved from:
The Canadian Medical Association is pleased to present this submission to the House of Commons Standing Committee on Health regarding Bill C-422, National Lyme disease strategy.
The Canadian Medical Association (CMA) is the national organization representing over 80,000 physicians in Canada; its mission is to serve and unite the physicians of Canada and to be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care.
Lyme disease is a growing problem in Canada. According to the Public Health Agency of Canada (PHAC) there were 315 cases of Lyme disease reported in Canada in 2012 -two and one-half times more cases than the 128 reported in 2009, the year that it became a reportable disease. In the Ottawa area, cases have increased almost 8 fold from 6 in 2009 to 47 in 2013. The PHAC surveillance indicates that established populations of blacklegged ticks are spreading their geographic scope, and are increasing in number, in much of southern Canada. In 2013 the US Center for Disease Control and Prevention released new estimates of Lyme disease that was 10 times higher than the previous yearly reported number of 30,000 reported cases.1 This highlights the difficulty in establishing the true burden of illness from Lyme disease.
Why this matters to Canada's physicians
The Canadian Medical Association supports the implementation of a national strategy that can address the breath of public health and medical issues surrounding the spread of Lyme disease in Canada. As with any new infectious disease threat, Canada needs to ensure that we are prepared to address the impact of Lyme disease on Canadians.
CMA's policy on climate change and human health notes that changes in the range of some infectious disease vectors such as blacklegged ticks, are a possible consequence of climate change in Canada. Research has suggested that the tick vector of Lyme disease has been expanding into southeastern Canada which can lead to increased disease risk for those living in areas with tick populations.2
In this policy, CMA recommends that the federal government report diseases that emerge in relation to global climate change, and participate in field investigations, as with outbreaks of infectious diseases like Lyme disease, and develop and expand surveillance systems to include diseases caused by global climate change.
The World Medical Association Declaration of Delhi on Health and Climate Change urges colleges and universities to develop locally appropriate continuing medical and public health education on the clinical signs, diagnosis and treatment of new diseases that are introduced into communities as a result of climate change. Diagnosis of Lyme disease can be difficult, as signs and symptoms can be non-specific and found in other conditions. 3 If Lyme disease is not recognized during the early stages, patients may suffer seriously debilitating disease, which may be more difficult to treat.4 Given the increasing incidence of Lyme disease in Canada, continuing education for health care and public health professionals and a national standard of care would improve identification, treatment and management of Lyme disease. Greater awareness of where blacklegged ticks are endemic in Canada, as well as information on the disease and prevention measures, can help Canadians protect themselves from infection.
The CMA supports a national Lyme disease strategy which includes the federal, provincial and territorial governments and the medical and patient communities. This strategy must address concerns around research, surveillance, diagnosis, treatment and management of the disease and public health prevention measures will advance our current knowledge base, and improve the care and treatment of those suffering from Lyme disease.
Once again, CMA is pleased to provide this brief to the Standing Committee on Health as part of its study on this important issue. Canada's physicians recognize the importance of monitoring all emerging infectious diseases in Canada. In addition, Canada's physicians recognize the importance of developing strategies to treat, manage, and prevent Lyme disease in Canada.
1 CDC provides estimate of Americans diagnosed with Lyme disease each year, media release August 19, 2013 Accessed at http://www.cdc.gov/media/releases/2013/p0819-lyme-disease.html on Feb 21, 2014.
2 Ogden, N., L. Lindsay, and P. Leighton. 2013. Predicting the rate of invasion of the agent of Lyme disease Borrelia burgdorferi. Journal of Applied Ecology. April, 2013. 50(2):510-518.
3 Mayo Clinic, accessed at http://www.mayoclinic.org/diseases-conditions/lyme-disease/basics/tests-diagnosis/con-20019701 on Feb 21, 2014.
4 Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006;43: 1089-134.
The Canadian Medical Association (CMA) is pleased to present this brief to the House of Commons Standing Committee on Finance regarding Bill C-462 Disability Tax Credit Promoters Restrictions Act.
The Canadian Medical Association represents 78,000 physicians in Canada; its mission is to serve and unite the physicians of Canada and to be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care.
The CMA is pleased that the House of Commons has made Bill C-462 a priority. This bill is an important step toward addressing the unintended consequences that have emerged from the Disability Tax Credit since 2005.
Part 2: Issues to be addressed
In 2005, the Disability Tax Credit was expanded to allow individuals to back-file for up to 10 years. While this was a welcome tax measure for individuals with disabilities, the CMA has been urging the Canada Revenue Agency to address the numerous unintended consequences that have emerged. Central among these has been the emergence of a "cottage industry" of third-party companies engaged in a number of over-reaching tactics. The practices of these companies have included aggressive promotional activities to seek and encourage individuals to file the Disability Tax Credit. The primary driver behind these tactics is profit; some companies are charging fees of up to 40 per cent of an individual's refund when the tax credit is approved.
Further to targeting a vulnerable population, these activities have yielded an increase in the quantity of Disability Tax Credit forms in physician offices and contributed to red tape in the health sector. In some cases, third parties have placed physicians in an adversarial position with their patients. We are pleased that this bill attempts to address the concerns we have raised.
The CMA supports Bill C-462 as a necessary measure to address the issues that have emerged since the changes to the Disability Tax Credit in 2005. However, to avoid additional unintended consequences, the CMA recommends that the Finance Committee address three issues prior to advancing Bill C-462.
First, as currently written, Bill C-462 proposes to apply the same requirements to physicians as to third-party companies if physicians apply a fee for form completion, a typical practice for uninsured physician services. Such fees are subject to guidelines and oversight by provincial and territorial medical regulatory colleges (see Appendix 1: CMA Policy on Third Party Forms: The Physician Role).
The CMA recommends that the Finance Committee:
* Amend the definition of "promoters" under section 2 to exclude "a health care practitioner duly licensed under the applicable regulatory authority who provides health care and treatment."
* If the committee imports the term "person" from the Income Tax Act, then the applicable section of Bill C-462 should be amended to specify that, for the purposes of the act, "Person does not include a health care practitioner duly licensed under the applicable regulatory authority who provides health care and treatment."
Second, the CMA is concerned that one of the reasons individuals may be engaging the services of third-party companies is a lack of awareness of the purpose and benefits of the Disability Tax Credit. Additional efforts are required to ensure that the Disability Tax Credit form (Form T2201) be more informative and user-friendly for patients. Form T2201 should explain more clearly to patients the reason behind the tax credit, and explicitly indicate there is no need to use third-party companies to submit the claim to the CRA.
The CMA recommends that the Finance Committee:
* Recommend that the Canada Revenue Agency undertake additional efforts to ensure that the Disability Tax Credit form is more informative, accessible and user-friendly for patients.
Finally, the CMA recommends that a privacy assessment be undertaken before the bill moves forward in the legislative process. It appears that, as written, Bill C-462 would authorize the inter-departmental sharing of personal information. The CMA raises this issue for consideration because protecting the privacy of patient information is a key duty of a physician under the CMA Code of Ethics.
Part 3: Closing
The CMA encourages the Finance Committee to address these issues to ensure that Bill C-462 resolves existing problems with the Disability Tax Credit while not introducing new ones. The CMA appreciates the opportunity to provide input to the Finance Committee's study of this bill and, with the amendments outlined herein, supports its passage.
Summary of Recommendations
The definition of "promoters" under section 2 of Bill C-462 should be amended to exclude "a health care practitioner duly licensed under the applicable regulatory authority who provides health care and treatment."
If the Committee imports the definition of "persons" from the Income Tax Act, the applicable section of Bill C-462 should be amended to specify that, for the purposes of the act, "Person does not include a health care practitioner duly licensed under the applicable regulatory authority who provides health care and treatment."
The Canada Revenue Agency should undertake additional efforts to ensure that the Disability Tax Credit form is informative, accessible and user-friendly.
Prior to advancing in the legislative process, Bill C-462 should undergo a privacy assessment.
In 2010, physician delegates to the CMA's annual General Council voted in favour of a ban on mixed martial arts prize fighting matches in Canada. The CMA's complete policy on head injury and sport, the central concern of physicians with respect to mixed martial arts, is attached as an appendix to this brief. A key recommendation in this policy is that physicians discourage participation in sports in which intentional trauma to the head and body is the objective of the sport, as is the case with mixed martial arts (MMA).
MMA prize fighting, like commercial boxing, is distinct from healthy sport because the basic tenet is to win by deliberately incapacitating one's opponent through violent bodily assault. Professional fighters train in different martial arts disciplines in order to develop the widest possible set of fighting techniques. Blows delivered by hands, feet, elbows and knees are entirely permissible.1 "Bouts" are won in a number of ways that include deliberate head injury such as knockout (KO) and technical knockout (TKO). Physician and referee stoppage are recognized as a necessary option for the declaration of a winner in order to prevent continued violence.4; 5
Despite the introduction of rules and regulations meant to ensure fighter safety, MMA is a violent sport with a high risk of injury. Publications seem to indicate that the overall injury rate in professional MMA competitions ranges approximately from 23 to 28 injuries per 100 fight participations, which is similar to that found in other combat sports involving striking, including boxing.1; 5; 7 Organizers support the rules because they realize that prize fighting can't be sustained as a business if the fighters are unable to return to the ring.
The injuries vary in severity but include many types of head injury: ocular injuries, such as rupture of the bony orbit or of the eye itself; facial injuries including fractures; spine injuries; concussion; and tympanic membrane ruptures.2, 6, 7
Most sanctioned matches end in a submission, judge's decision or referee/physician stoppage, as opposed to KO or TKO. It is important to note that the overall risk of critical injury, defined as a persistent acquired brain injury, permanent blindness, permanent functional loss of limb or paralysis, appears to be low. The ability of referees to intercede and for fighters to voluntarily concede victory to their opponents, as well as the presence of physicians at the ringside, are all thought to play a role in minimizing the risk of critical injury.7
The risk of traumatic brain injury and concussion nevertheless remains one of the chief concerns with respect to MMA. KO rates are thought to be lower in professional MMA events than in similar boxing competitions, but it is not clear why. It is well known that knockouts are the result of brain injury4 and at least one study reported that blunt trauma to the head was a common reason for match stoppage. One study reported a severe concussion rate of 16.5 per 100 fighter participations (3.3% of all matches). 6 Regrettably, as in other combat sports, long-term follow-up of players is insufficient to measure how often head injury leads to permanent brain damage.1, 3
Whether you defend or condemn MMA, the true nature and rate of severe brain injuries is speculative.6 Similarly, the absence of longitudinal studies means that the true long-term health implications of MMA fighting can only be surmised.
Risk factors for injury
Unsurprisingly, losing fighters are at a considerably greater risk for sustaining injury. It is notable that fighters losing by KO or TKO appear to have a higher overall incidence of injury.4 An increased duration of fighting is associated with an increased incidence of injury.3, 5 However, it remains unclear how age and fight experience contribute to the risk for sustaining injury.2, 3, 4 It appears that fighters with head injury continue to fight and sustain further injury, head injury being more clearly associated with injury than are either inexperience or age.
Despite the sport's growing popularity, professional MMA competitions are currently illegal in Canada. Indeed, section 83(2) of the Criminal Code of Canada states that only boxing matches, where only fists are used, are legal. However, the governments of Nova Scotia, Quebec, Ontario, Manitoba and Northwest Territories have regulated/licensed MMA through athletic governing commissions, effectively circumventing the Criminal Code. The legality of the sport in New Brunswick, Alberta and British Columbia currently varies by municipality.
The CMA recommends that Section 83(2) of the Criminal Code, the ban on mixed martial arts, be maintained in its current form.
The CMA recommends that the federal government undertake further research on head injuries and concussion in Canada, including expanding current surveillance tools for the incidence of these injuries.
1. Bledsoe, G. H. (2009). Mixed martial arts. In R. Kordi, N. Maffulli, R. R. Wroble, & W. A. Angus (Eds.), Combat Sports Medicine (1st ed., pp. 323-330). London: Springer.
2. Buse, G. J. (2006). No holds barred sport fighting: A 10 year review of mixed martial arts competition. British Journal of Sports Medicine, 40(2),169-172.
3. Bledsoe, G. H., Hsu, E. B., Grabowski, J. G., Brill, J. D., & Li, G. (2006). Incidence of injury in professional mixed martial arts competitions. Journal of Sports Science and Medicine, 5(Combat Sports Special Issue), 136-142.
4. Walrod, B. (2011). Current review of injuries sustained in mixed martial arts competition. Current Sports Medicine Reports, 10(5), 288-289.
5. Unified Fighting Championship. (n.d.). Unified rules and other important regulations of mixed martial arts. Retrieved May 28, 2012, from http://www.ufc.com/discover/sport/rules-and-regulations
6. Ngai, K. M., Levy, F., & Hsu, E. B. (2008). Injury trends in sanctioned mixed martial arts competition: A 5-year review from 2002 to 2007. British Journal of Sports Medicine, 42(8), 686-689.
7. Scoggin III, J. F., Brusovanik, G., Pi, M., Izuka, B., Pang, P., Tokomura, S. et al. (2010). Assessment of injuries sustained in mixed martial arts competition. American Journal of Orthopedics, 39(5), 247-251.
The Canadian Medical Association is pleased to present its views to the House of Commons Standing Committee on Finance regarding income inequality in Canada.
The Canadian Medical Association represents 78,000 physicians in Canada; its mission is to serve and unite the physicians of Canada and to be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care.
Income inequality is a growing problem in Canada. According to a Conference Board of Canada report, high income Canadians have seen their share of income increase since 1990 while the poorest and even the middle-income groups have lost income share. In 2010 the top quintile of earners accounted for 39.1% of Canadian income while the bottom quintile only accounted for 7.3%. These numbers led to a ranking for Canada of 12 out of 17 among other high income countries in terms of income inequality.1 Research by the Organization for Economic Co-operation and Development has largely confirmed these results.2
Part 2: Why Income Inequality Matters to Canadian Physicians
The issue of income inequality is an important one for Canada's physicians. As physicians, we are not the experts in housing, in early childhood development, income equality and so on. But we are the experts in recognizing the impact of these factors on the health of our patients.
Hundreds of research papers have confirmed that people in the lowest socio-economic groups carry the greatest burden of illness.3 In 2001, people in the neighbourhoods with the highest 20% income lived about three years longer than those in the poorest 20% neighbourhoods.4 Mental health is affected as well. Suicide rates in the lowest income neighbourhoods are almost twice as high as in the wealthiest neighbourhoods.5
Studies suggest that adverse socio-economic conditions in childhood can be a greater predictor of cardiovascular disease and diabetes in adults than later life circumstances and behavioural choices.6
Finally, the countries reporting the highest population health status are those with the greatest income equality, not the greatest wealth.7
These differences in health outcomes have an impact on the health care system. Most major diseases including heart disease and mental illness follow a social gradient with those in lowest socio-economic groups having the greatest burden of illness.8 Those within the lowest socio-economic status groups are 1.4 times more likely to have a chronic disease, and 1.9 times more likely to be hospitalized for care of that disease.9
Income plays a role in access to appropriate health care as well. Individuals living in lower income neighbourhoods, younger adults and men are less likely to have primary care physicians than their counterparts.10 Women and men from low-income neighbourhoods are more likely to report difficulties making appointments with their family doctors for urgent non-emergent health problems. They were also more likely to report unmet health care needs.11
People with lower socio-economic status are more likely to be hospitalized for ambulatory care sensitive conditions and mental health12, admissions which could potentially be avoided with appropriate primary care.13
Those with higher socio-economic status are more likely to have access to and utilize specialist services.14 Utilization of diagnostic imaging services is greater among those in higher socio-economic groups.15 Access to preventive and screening programs such as pap smears and mammography are lower among disadvantaged groups.16
It is not just access to insured services that is a problem. Researchers have reported that those in the lowest income groups are three times less likely to fill prescriptions, and 60% less able to get needed tests because of cost.17 Services such as physiotherapy and occupational therapy to name two are often not covered unless they are provided in-hospital or to people on certain disability support programs.18 Access to psychologists is largely limited to people who can pay for them, through private insurance or out of their own pockets.19 Similar access challenges exist for long-term care, home care and end-of-life care.
There is a financial cost to this disparity. According to a 2011 report, low-income residents in Saskatoon alone consume an additional $179 million in health care costs than middle income earners.20 A 2010 study by CIHI found increased costs for avoidable hospitalizations for ambulatory care sensitive conditions were $89 million for males and $71 million for females with an additional $248 million in extra costs related to excess hospitalizations for mental health reasons.21
The societal cost of poor health extends beyond the cost to the health care system: healthier people lose fewer days of work and contribute to overall economic productivity.22 According to data in the U.K., those living in the most disadvantaged neighbourhoods experience almost 20 years less disability-free life than those in the highest income neighbourhoods. These individuals will become disabled before they are eligible for old age services, striking two blows to the economy: they will no longer be able to contribute through productive work, and their disability will consume a great deal of health care services.23
The reasons for this inequitable access are multifaceted and include patient specific barriers as well as challenges within the health care system itself. CMA recognizes the need for physicians to work to address the system related barriers. However, one of the biggest challenges for patients themselves remains economic. Having a low-income can prevent access through lack of transportation options, an inability to get time off work, and the inability to pay for services that are not covered by government insurance.
Health equity is increasingly recognized as a necessary means by which we will make gains in the health status of all Canadians and retain a sustainable publicly funded health care system. Addressing inequalities in health is a pillar of CMA's Health Care Transformation initiative.
Part 3: Ensuring adequate income for all Canadians
"The rates of family and child poverty are unacceptably high taking into account Canada's high quality of living standard."
2010 Report of the Committee on Human Resources, Skills and Social Development and the Status of Persons with Disability
One reason income is so critical to individual health is that it is so closely linked to many of the other social determinants of health. These include but are not limited to: education, employment, early childhood development, housing, social exclusion, and physical environment.
The CMA and its members are concerned that adequate consideration during the decision-making process is not being given to the social and economic determinants of health, factors such as income and housing that have a major impact on health outcomes.
Recent decisions such as changes to the qualifying age for Old Age Security, and new rules for Employment Insurance, among others, will have far reaching consequences on the income of individuals, especially those in vulnerable populations. We remind the government that every action that has a negative effect on health will lead to more costs to society down the road.
One method to ensure that these unintentional consequences do not occur is to consider the health impact of decisions as part of the policy development and decision-making process.
A Health Impact Assessment (HIA) is a systematic process for making evidence-based judgments on the health impacts of any given policy and to identify and recommend strategies to protect and promote health. The HIA is used in several countries, including Australia, New Zealand, the United Kingdom, and increasingly the United States.
The HIA can ensure that government departments consider the health impacts of their policies and programs by anticipating possible unintended consequences and taking appropriate corrective action. The use of HIA will allow the federal government to demonstrate leadership in health care in Canada and provide greater accountability to all Canadians.
The CMA recommends that:
1. The federal government recognize the importance of the social and economic determinants of health to the health of Canadians and the demands on the health care system; and
2. The federal government requires a health impact assessment as part of Cabinet decision-making.
We are hearing about the need to address the poverty and income security of Canadians from stakeholders across the country. We have conducted a series of town halls with Canadians asking them questions about how the social and economic conditions of their communities affect their health. From Winnipeg, to Hamilton to Charlottetown we have heard how poverty and a lack of income is undermining Canadians' health.
This public response is not surprising. According to the Conference Board of Canada, more than one in seven children in Canada live in poverty.24 This poverty will severely limit the ability of these children to achieve good health in the future.
There are systemic barriers that contribute to this poverty. The annual welfare income in Canada varies between $3,247 for a single person to $21,213 for a couple with two children. The 'best' of Canadian programs provides an income within only 80% of the poverty line. The lowest income is barely 30% of that needed to 'achieve' poverty.25
It is not just people on social assistance, however, that are facing poverty. Data from 2008 indicates that one in three (33%) of children living in poverty had a parent that was employed. Based a review conducted in 2010, one in 10 workers still earned less than $10 an hour in 2009, with 19% paid less than $12. The same study found that roughly 400,000 full-time adult workers, aged 25+, were making less than $10/hr. and therefore paid less than poverty line wages.26
Some physicians are working directly with patients to try and address the income inadequacy which is undermining their health. Physicians from Health Providers Against Poverty in Ontario have developed a tool for physicians to use in screening their patients for poverty and linking them with provincial/territorial and/or federal programs that might help mitigate the health effects of their poverty. This group is also involved in training health care providers to support this work. While this program and others like it are serving as a 'band aid' solution for some living in poverty, the CMA feels that physicians and their patients should not be placed in this position.
As part of its study on income inequality, the CMA encourages the Finance Committee to review two recent reports from Parliamentary committees on the same topic. The first and most recent is the report of the House of Commons Committee on Human Resources, Skills and Social Development and the Status of Persons with Disability, Federal Poverty Reduction Plan: Working in Partnership Towards Reducing Poverty in Canada.27 The second is the report of the Senate Committee on Social Affairs, Science and Technology In From the Margins: A Call to Action on Poverty, Housing and Homelessness.28
The Committee on Human Resources, Skills and Social Development and the Status of Persons with Disability, noted that the federal government's efforts to address poverty among Canadian seniors "is generally recognized as one of Canada's most notable achievements of the past 30 years."
The report of the Senate Committee made a number of significant observations, two bear repeating:
* "[W]hen all the programs are working, when the individual gets all possible income and social supports, the resulting income too often still maintains people in poverty, rather than lifting them into a life of full participation in the economic and social life of their communities."
* "[A]t their worst, the existing policies and programs entrap people in poverty, creating unintended perverse effects which make it virtually impossible for too many people to escape reliance on income security programs and even homeless shelters."
The public policy debate on addressing income inequality in Canada is not new. For instance, the 1971 report of the Special Senate Committee on Poverty recommended that a guaranteed annual income financed and administered by the federal government be established. In consideration of this concept, from 1974 to 1979, the Governments of Canada and Manitoba funded the Manitoba Basic Guarantee Annual Income Experiment (referred to as "Mincome"). While this was initially designed to be a labour market study, the results were also relevant from a health perspective. A recent study of this data concluded that hospitalizations declined by 8.5 per cent for the Mincome subjects.29
The CMA recommends that:
3. The federal government gives top priority to the development of strategies to minimize poverty in Canada.
Part 4: Addressing access barriers in the health sector
Access to services not covered by provincial health plans remain a large barrier for Canadians. Those with low incomes are less likely to be able to access needed pharmaceuticals and services due to this barrier. One in 10 Canadians can not afford the medications that they are prescribed.30 This further exacerbates the income inequality that exists. While we urge the federal government to take action on reducing poverty among Canadians, at the minimum action needs to be taken to ensure universal access to needed medical care.
The CMA recommends that:
4. Governments, in consultation with the life and health insurance industry and the public, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies;
5. Governments examine methods to ensure that low-income Canadians have greater access to needed medical interventions such as rehabilitation services, mental health, home care, and end-of-life care; and
6. Governments explore options to provide funding for long-term care services for all Canadians. This could include public insurance schemes or registered savings plans allowing Canadians to save for their future long-term care needs.
Finally, there is a need to recognize the effect on income related to providing care to family members who are ill. Many Canadians take time off work to care for their children or parents. Without adequate long-term care resources and supports for home care, Canadians may be forced to take a leave from the workforce to provide this unpaid care. Research suggests that more than one third of parents (38.4%) who care for children with a disability are required to work fewer hours to care for their children.31 While the 2011 federal budget provided some relief in the form of a Family Caregiver Tax Credit of up to $300, it is not enough. A 2004 Canadian study placed the value of a caregiver's time at market rates from $5,221 to $13,374 depending on the community of residence.32 This is a significant amount of unpaid work and may further add to income inequalities. Expanding the tax credit available to these individuals would help but there is a need to provide further supports to family caregivers.
The CMA recommends that:
7. The federal government expands the relief programs for informal caregivers to provide guaranteed access to respite services for people dealing with emergency situations, as well as increase the Family Caregiver Tax Credit to better reflect the annual cost of family caregivers' time at market rates.
Part 5: Conclusion
Once again, we commend the Standing Committee on Finance for agreeing to study this important issue. Canada's physicians see the examples of income inequality in their practices on a daily basis. Tackling this important social issue will contribute to not only reducing the burden of disease in Canada but to providing Canadians with the necessary financial resources to achieve good health.
Summary of Recommendations
The federal government recognizes the importance of the social and economic determinants of health to the health of Canadians and the demands on the health care system
The federal government requires a health impact assessment as part of Cabinet decision-making.
The federal government gives top priority to the development of strategies to minimize poverty in Canada.
Governments, in consultation with the life and health insurance industry and the public, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies.
Governments examine methods to ensure that low-income Canadians have greater access to needed medical interventions such as rehabilitation services, mental health, home care, and end-of-life care; and
Governments explore options to provide funding for long-term care services for all Canadians. This could include public insurance schemes or registered savings plans allowing Canadians to save for their future long-term care needs.
The federal government expand the relief programs for informal caregivers to provide guaranteed access to respite services for people dealing with emergency situations, as well as increase the Family Caregiver Tax Credit to better reflect the annual cost of family caregivers' time at market rates.
1 Conference Board of Canada. How Canada Performs: Income Inequality. Ottawa (ON); 2013. Available: http://www.conferenceboard.ca/hcp/details/society/income-inequality.aspx (accessed 2013 Apr 11).
2 Organisation for Economic Co-operation and Development. Divided We Stand: Why Inequality Keeps Rising: An Overview of Growing Income Inequalities in OECD Countries: Main Findings. Paris (FR); 2011. Available: http://www.oecd.org/els/soc/49499779.pdf (accessed 2013 Apr 11).
3 Dunn JR. The Health Determinants Partnership Making Connections Project: Are Widening Income Inequalities Making Canada Less Healthy? Toronto (ON); 2002. Available: http://www.opha.on.ca/our_voice/collaborations/makeconnxn/HDP-proj-full.pdf (accessed 2011 March 15)
4 Wilkins R, Berthelot JM and Ng E. Trends in Mortality by Neighbourhood Income in Urban Canada from 1971 to 1996. Statistics Canada, Ottawa (ON); 2002. Health Reports 13 [Supplement]: pp. 45-71
5 Marmot, M. Fair Society Healthy Lives: The Marmot Review: Executive Summary. London (UK): 2010. Available: http://www.marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLivesExecSummary.pdf (accessed 2011 Jan 25); Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts. Toronto (ON); 2010. Available: http://www.thecanadianfacts.org/The_Canadian_Facts.pdf (accessed 2011 Jan 14)
6 Raphael D. Addressing The Social Determinants of Health In Canada: Bridging The Gap Between Research Findings and Public Policy. Policy Options. March 2003 pp.35-40.
7 Hofrichter R ed. Tackling Health Inequities Through Public Health Practice: A Handbook for Action. The National Association of County and City Health Officials & The Ingham County Health Department. Lansing (USA); 2006. Available: http://www.acphd.org/axbycz/admin/datareports/ood_naccho_handbook.pdf accessed (2012 Mar 16).
8 Dunn, James R. (2002) The Health Determinants Partnership...
9 Canadian Population Health Initiative. Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions. Canadian Institute for Health Information, Ottawa (ON); 2012. Available: http://secure.cihi.ca/cihiweb/products/PHC_Experiences_AiB2012_E.pdf(accessed 2012 Jan 25).
10 Bierman AS, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7. Toronto (ON) Project for and Ontario Women's Health Evidence-Based Report; 2010. Available: http://powerstudy.ca/wp-content/uploads/downloads/2012/10/Chapter7-AccesstoHealthCareServices.pdf (accessed 2012 Dec 10).
11 Bierman AS, Johns A, Hyndman B, et al. Ontario Women's Health Equity Report: Social Determinants of Health & Populations at Risk: Chapter 12. Toronto (ON) Project for and Ontario Women's Health Evidence-Based Report; 2010. Available: http://powerstudy.ca/wp-content/uploads/downloads/2012/10/Chapter12-SDOHandPopsatRisk.pdf (accessed 2012 Dec 10...; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences with health-related services: Implications for health care reform. Health Policy 2006; 76:106-121.
12 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status for Males and Females. Ottawa(ON); 2010. Available: https://secure.cihi.ca/free_products/disparities_in_hospitalization_by_sex2010_e.pdf (accessed 2013 Feb 6)
13 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status...;Roos LL, Walld R, Uhanova J, et al. Physician Visits, Hospitalizations, and Socioeconomic Status: Ambulatory Care Sensitive Conditions in a Canadian Setting. HSR 2005; 40(4): 1167-1185.
14 Allin S. Does Equity in Healthcare Use Vary across Canadian Provinces? Healthc Policy 2008; 3(4): 83-99.;Frolich N, Fransoo R, Roos N. Health Service Use in the Winnipeg Regional Health Authority: Variations Across Areas in Relation to Health and Socioeconomic status. Winnipeg (MB) Manitoba Centre for Health Policy. Available: http://mchp-appserv.cpe.umanitoba.ca/teaching/pdfs/hcm_forum_nf.pdf (accessed 2013 Feb 6); McGrail K. Income-related inequities: Cross-sectional analyses of the use of medicare services in British Columbia in 1992 and 2002. Open Medicine 2008; 2(4): E3-10; Van Doorslaer E, Masseria C. Income-Related Inequality in the Use of Medical Care in 21 OECD Countries. Paris(FR) OECD; 2004. Available: http://www.oecd.org/els/health-systems/31743034.pdf (accessed 2013 Feb 6).;Veugelers PJ, Yip AM. Socioeconomic disparities in health care use: Does universal coverage reduce inequalities in health? J Epidemiol Community Health 2003; 57:424-428.
15 Bierman AS, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services...Demeter S, Reed M, Lix L, et al. Socioeconomic status and the utilization of diagnostic imaging in an urban setting. CMAJ 2005; 173(10): 1173-1177.
16 Bierman AS, Johns A, Hyndman B, et al. Ontario Women's Health Equity Report: Social Determinants of Health & Populations at Risk: Chapter 12...); Frolich N, Fransoo R, Roos N. Health Service Use in the Winnipeg... Wang L, Nie JX, Ross EG. Determining use of preventive health care in Ontario. Can Fam Physician 2009; 55: 178-179.e1-5; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences with health-related services...
17 Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts....
18 Barnes S, Dolan LA, Gardner B, et al. Equitable Access to Rehabilitation : Realizing Potential, Promising Practices, and Policy Directions. Toronto (ON) Wellesley Institute; 2012. Available : http://www.wellesleyinstitute.com/wp-content/uploads/2012/06/Equitable-Access-to-Rehabilitation-Discussion-Paper1.pdf (accessed 2013 Feb 6).
19 Kirby M, Goldbloom D, Bradley L. Changing Directions, Changing Lives: The Mental Health Strategy for Canada.Ottawa (ON): Mental Health Commission of Canada; 2012. Available: http://strategy.mentalhealthcommission.ca/pdf/strategy-text-en.pdf (accessed 2013 Mar 12).
20 Saskatoon Poverty Reduction Partnership. From poverty to possibility...and prosperity: A Preview to the Saskatoon Community Action Plan to Reduce Poverty. Saskatoon (SK): Saskatoon Poverty Reduction Partnership; 2011.Available: http://www.saskatoonpoverty2possibility.ca/pdf/SPRP%20Possibilities%20Doc_Nov%202011.pdf (accessed 2012 Mar 13)
21 Canadian Institute for Health Information. Hospitalization Disparities by Socio-economic status...
22 Munro D. Healthy People, Healthy Performance, Healthy Profits: The Case for Business Action on the Socio-Economic Determinants of Health. The Conference Board of Canada, Ottawa (ON); 2008. Available: http://www.conferenceboard.ca/Libraries/NETWORK_PUBLIC/dec2008_report_healthypeople.sflb (accessed 2012 Mar 26).
23 Marmot Sir M. Achieving Improvements in Health in a Changing Environment. Presentation to the World Medical Association, Vancouver (BC); 2010.
24 Conference Board of Canada. How Canada Performs: Child Poverty. Ottawa (ON); 2013. Available: http://www.conferenceboard.ca/hcp/details/society/child-poverty.aspx (accessed 2013 Apr 11).
25 National Council of Welfare. Poverty Trends in Canada: Solving Poverty Information Kit. Her Majesty the Queen in the Right of Canada. Ottawa (ON); 2007. Available: http://www.ncw.gc.ca/l.3bd.2t.1ils@-eng.jsp?lid=140 (accessed 2012 Jan 25).
26 Campaign 2000. 2010 Report Card on Child and Family Poverty in Canada: 1989 - 2010. Toronto (ON); 2010. Available: http://www.campaign2000.ca/reportCards/national/2010EnglishC2000NationalReportCard.pdf (accessed 2013 Apr 11).
27 Hoeppner C, Chair. Federal Poverty Reduction Plan: Working in Partnership Towards Reducing Poverty in Canada. House of Commons Canada. Ottawa (ON); 2010. Available: http://www.parl.gc.ca/content/hoc/Committee/403/HUMA/Reports/RP4770921/humarp07/humarp07-e.pdf (accessed 2013 Apr 17).
28 Eggleton A, Segal H. In From the Margins: A Call TO Action On Poverty, Housing and Homelessness. The Standing Senate Committee on Social Affairs, Science and Technology. Ottawa(ON);2009. Available: http://www.parl.gc.ca/Content/SEN/Committee/402/citi/rep/rep02dec09-e.pdf (accessed 2013 Apr 17).
29 Forget, Evelyn L. The town with no poverty: the health effects of a Canadian Guaranteed Annual Income Field Experiment. University of Toronto Press. Canadian Public Policy 37(3), 283-305.
30 Law MR, Cheng L, Dhala IA et al. The effect of cost adherence to prescription medications in Canada. CMAJ February 21, 2012 vol. 184 no.3.
31 Campaign 2000. 2010 Report Card on Child and Family Poverty...
32 Chappell NL, Dlitt BH, Hollander JA et al. Comparative Costs of Home Care and Residential Care. The Gerontologist 44(3): 389-400.
The Canadian Medical Association (CMA) is pleased to provide this submission in response to Health Canada's Notice of proposed order to amend the schedule to the Tobacco Act1, from October 14, 2014, on the restriction of the use of additives.
Canada's physicians have been working for decades toward the goal of a smoke-free Canada. The CMA issued its first public warning concerning the hazards of tobacco in 1954 and has continued to advocate for the strongest possible measures to control its use.
Flavoured tobacco products include candy or fruit flavoured products including cigarillos, water pipe tobacco, smokeless tobacco and blunt wraps. They come in flavours that are appealing to youth such as chocolate, mint, cherry, peach, or strawberry. Flavouring makes the tobacco products more palatable to youth and young adult smokers because they have a lower tolerance for irritation and an underdeveloped taste for tobacco smoke.2 Menthol is a long standing and common flavour used in cigarettes and is used to reduce the harshness of cigarette smoke. It is the most popular flavour among youth. Almost three out of 10 Canadian youth who smoked cigarettes in the last 30 days (29 per cent) reported smoking menthol cigarettes.3
Tobacco Use and Youth
While tobacco use has declined in Canada we must remain vigilant in our efforts to reduce smoking rates. Today 16 per cent of Canadians continue to smoke on a regular basis and physicians are particularly concerned about the smoking prevalence among young adults and youth with 20 per cent of those aged 20-24, and 11 per cent of youth aged 15-19 currently smoking on a regular basis. 4
Flavoured tobacco products, with their appeal to young Canadians are a major threat to the health and well-being of our youth. A recent report, Flavoured Tobacco Use: Evidence from Canadian Youth based on the 2012/13 Youth Smoking Survey, shows that young people are using flavoured tobacco products at high levels. Results show that 50 per cent of high school students in Canada who used tobacco products in the previous 30 days used flavoured tobacco products.5
Previous Amendments Regarding Flavouring Agents
The CMA supported efforts of the federal government in 2009 to limit the addition of flavouring agents to tobacco products through the 2010 Act to Amend the Tobacco Act. But the Act did not cover all tobacco products and it excluded menthol as a flavouring agent. Manufacturers have been able to modify the weight and packaging of their products to technically comply with the Act while they continue to market flavoured products.
It is the CMA's position that the federal government has an important role in smoking cessation and prevention among youth. The CMA supports the proposed extension of the prohibitions on the use of certain flavouring additives in relation to the manufacture and sale of little cigars to cigars weighing more than 1.4 g but less than 6 g.
The CMA remains very concerned that these amendments do not ban menthol flavouring in tobacco products. To that end, the CMA recommends that Health Canada extend its prohibition on flavouring additives to include a ban on the addition of menthol in all tobacco products.
1 Health Canada. Notice of proposed order to amend the schedule to the Tobacco Act. October 14, 2014. Accessed at: http://www.hc-sc.gc.ca/hc-ps/consult/_2014/tobacco-act-loi-tabac/index-eng.php
2 Carpenter CM, Wayne GF, Pauly JL, Koh HK, Connolly GN. New cigarette brands with flavors that appeal to youth: Tobacco marketing strategies: Tobacco industry documents reveal a deliberate strategy to add flavors known to appeal to younger people. Health Affairs 2005;24(6):1601-1610.
3 Manske SR, Rynard VL, Minaker LM. 2014 (September). Flavoured Tobacco Use among Canadian Youth: Evidence from Canada's 2012/2013 Youth Smoking Survey. Waterloo: Propel Centre for Population Health Impact, 1-18. cstads.ca/reports.
4 Canadian Tobacco Use Monitoring Survey 2012 , accessed at http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/research-recherche/stat/ctums-esutc_2012-eng.php.
5 Manske SR, Rynard VL, Minaker LM. 2014 (September). Flavoured Tobacco Use among Canadian Youth: Evidence from Canada's 2012/2013 Youth Smoking Survey. Waterloo: Propel Centre for Population Health Impact, 1-18. cstads.ca/reports.
Minaker L, Manske S, Rynard VL, Reid JL & Hammond D. Tobacco Use in Canada: Patterns and Trends, 2014 Edition - Special Supplement: Flavoured Tobacco Use. Waterloo, ON: Propel Centre for Population Health Impact, University of Waterloo.
Canadian Medical Association 2
November 10, 2014
On behalf of its more than 82,000 members and the Canadian public, CMA performs a wide variety of functions. Key functions include advocating for health promotion and disease prevention policies and strategies, advocating for access to quality health care, facilitating change within the medical profession, and providing leadership and guidance to physicians to help them influence, manage and adapt to changes in health care delivery.
The CMA is a voluntary professional organization representing the majority of Canada's physicians and comprising 12 provincial and territorial divisions and 51 national medical organizations.
The Canadian Medical Association (CMA) is pleased to provide this submission to the House of Commons Health Committee for its study on e-cigarettes.
Electronic cigarettes, or e-cigarettes, which replicate the act and taste of smoking, but do not contain tobacco, are growing rapidly in popularity. The tube of an e-cigarette contains heat-producing batteries and a chamber holding liquid, mainly propylene glycol. When heated, the liquid is turned into vapour which is drawn into the lungs. Ingredients vary by brand but many contain nicotine. Flavourings are also added with the intention of boosting their appeal to young people. Issues have been identified with labelling of e-cigarettes, where upon inspection, there have been contaminants, and nicotine has been detected in products labeled without nicotine.1 Users are generally able to modify the contents of e-cigarettes, with the addition of other substances, including marijuana.
Originally most e-cigarette manufacturers were small entrepreneurial companies; now, however, all major transnational tobacco companies are also producing e-cigarettes and competing for a share in the market.
There are little data on Canadian use. In the U.S., one in five adult smokers has tried them, according to the Centers for Disease Control and Prevention2.
Current Regulatory Status
Health Canada issued a warning in 20093 about the potential dangers and the fact that e-cigarettes had not been fully evaluated for safety, quality and efficacy. The sale of e-cigarettes containing nicotine is currently illegal in Canada under the Food and Drugs Act regulations4 though they can still be purchased in the US or over the Internet. However, those that do not make any health claim and do not contain nicotine may legally be sold in Canada under the same regulation. Health Canada is considering additional regulatory measures but none have yet been introduced. Some municipal jurisdictions are also considering regulation changes.
Internationally, regulation of e-cigarettes is just beginning, and approaches vary. A few countries - such as Brazil, Norway and Singapore - have banned them outright. France plans to regulate e-cigarettes in the same way as tobacco products, and the US Food and Drug Administration is considering a similar approach. On the other hand, Britain will regulate e-cigarettes as non-prescription drugs starting in 2016.5
Current evidence is insufficient to estimate the health effects of e-cigarettes. There are both defenders and opponents, though their arguments are based largely on opinion since e-cigarettes are only beginning to undergo rigorous clinical testing.6
Proponents, including some health officials and groups, say they are safer than tobacco cigarettes since they do not contain the tar and other toxic ingredients that are the cause of tobacco related disease.7 Some believe they serve a useful purpose as a harm reduction tool or cessation aid, although marketing them as such is not permitted since that claim has never been approved by Health Canada.
Opponents are concerned that the nicotine delivered via e-cigarettes is addictive and that the e-cigarettes may contain other toxic ingredients such as nitrosamines, a carcinogen. Also, they worry that acceptance of e-cigarettes will undermine efforts to de-normalize smoking, and that they may be a gateway to use of tobacco by people who might otherwise have remained smoke-free.8 The use of flavouring agents and attractive packaging could entice children and youth, and survey data in some countries has shown that teens are increasingly experimenting with e-cigarettes.
There has also been a dramatic increase in cases of nicotine overdose by ingestion or through dermal contact, particularly in children.9 The number of these incidents seems to be rising in countries that monitor poisonings.
The World Health Organization recently released a report on the health impacts of electronic nicotine delivery systems (ENDS) use which incorporates the 2013 deliberations and scientific recommendations by the WHO Study Group on Tobacco Product Regulation. It concludes that "ENDS use poses serious threats to adolescents and fetuses. In addition, it increases exposure of non-smokers and bystanders to nicotine and a number of toxicants." The report says that it is possibly less toxic for the smoker than conventional cigarettes but it is unknown by how much.10 This report suggests that governments should have the following regulatory objectives:
* impede the promotion and uptake of e-cigarettes with nicotine by non-smokers, pregnant women and youth;
* minimize potential health risks to e-cigarette users and non-users;
* prohibit unproven health claims from being made about e-cigarettes; and
* protect existing tobacco-control efforts from commercial and other vested interests of the tobacco industry.11
Given the absence of solid evidence of harms or benefits, CMA recommends that:
1. E-cigarettes containing nicotine should not be authorized for sale in Canada.
2. The sale of all e-cigarettes should be prohibited to Canadians younger than the minimum age for tobacco consumption in their province or territory.
3. Smoke-free policies should be expanded to include a ban on the use of e-cigarettes in areas where smoking is prohibited.
4. Research on the potential harms and benefits of electronic cigarette use should be supported.
1 Institut national de santé publique du Québec (INSPQ). (Mai 2013). La cigarette électronique: état de situation. Available : http://www.inspq.qc.ca/pdf/publications/1691_CigarElectro_EtatSituation.pdf
2 Centers for Disease Control and Prevention. About one in five U.S. adult cigarette smokers have tried an electronic cigarette. Centers for Disease Control and Prevention Press Release. February 28, 2013 Available: http://www.cdc.gov/media/releases/2013/p0228_electronic_cigarettes.html (accessed October 31, 2014)
3 Health Canada. Health Canada Advises Canadians Not to Use Electronic Cigarettes (archived). Available: http://www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2009/13373a-eng.php (accessed October 31, 2014)
4 Health Canada. Notice - To All Persons Interested in Importing, Advertising or Selling Electronic Smoking Products in Canada. Available: http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-demande/pol/notice_avis_e-cig-eng.php (accessed October 31, 2014)
5 Kelland, K. & Hirschler, B. Insight - No smoke, plenty of fire fuels e-cigarettes. Reuters. June 13, 2013. http://uk.reuters.com/article/2013/06/13/uk-ecigarettes-insight-idUKBRE95C0F720130613 (accessed October 31, 2014)
6 Non-Smokers Rights Association. Product Regulation: The Buzz on E-Cigarettes. Available: http://www.nsra-adnf.ca/cms/page1385.cfm (accessed October 31, 2014)
7 Weeks, C. Could e-cigarettes save smokers' lives? Some health advocates think so. The Globe and Mail April 29, 2013. Retrieved from http://www.theglobeandmail.com/life/health-and-fitness/health/could-e-cigarettes-save-smokers-lives-some-health-advocates-think-so/article11583353/?cmpid=rss1
8 Toronto Public Health. E-cigarettes in Toronto. Staff report to the Toronto Board of Health. August 1, 2014. Available: http://www.toronto.ca/legdocs/mmis/2014/hl/bgrd/backgroundfile-72510.pdf (accessed October 31, 2014).
9 Centers for Disease Control and Prevention. Notes from the Field: Calls to Poison Centers for Exposures to Electronic Cigarettes - United States, September 2010-February 2014. Morbidity and Mortality Weekly Report, 63(13): 292-293. April 4, 2014. Available: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6313a4.htm?s_cid=mm6313a4_w (accessed October 31, 2014).
10 World Health Organization. Electronic nicotine delivery systems. Conference of the Parties to the WHO Framework Convention on Tobacco Control. Sixth session Moscow, Russian Federation, 13-18 October 2014. Provisional agenda item 4.4.2. Available: http://apps.who.int/gb/fctc/PDF/cop6/FCTC_COP6_10-en.pdf?ua=1
The Canadian Medical Association (CMA) welcomes the opportunity to provide input to the Standing Senate Committee on Banking, Trade and Commerce study of Bill C-31 the Budget Implementation Bill, in particular the section concerned with tobacco taxation.
Tobacco use is still the number one cause of preventable disease and death in Canada, claiming 37,000 or more Canadians' lives every year. It is a major risk factor for the chronic diseases that burden Canadians and their health care system, and it costs the country over $17 billion per year for medical treatment, social assistance, lost productivity and reduced quality of life. While progress has been made in lowering smoking rates and changing attitudes towards smoking much work remains - nearly 4.6 million Canadians still smoke.
Physicians have been warning of the dangers of smoking for over 50 years. Canada's doctors treat the harmful effects of tobacco use every day in their offices, and see first-hand the devastation it causes to patients and their families. The CMA has consistently recommended tough legislative and regulatory measures to control tobacco use. Comprehensive tobacco control efforts must include legislation, regulation, together with public education and smoking cessation programs.
Impact of Price on Smoking
Research has shown that an increase in cigarette prices has an impact on reducing both the number of cigarettes smoked and smoking prevalence rates. Permanent, inflation-adjusted increases in cigarette prices, which could be achieved by increasing cigarette taxes, will contribute to reducing cigarette smoking rates in Canada. Youth are up to three times more sensitive to price than adults, with a 10 per cent price increase estimated to reduce youth smoking prevalence by 5 per cent or more and also to reduce cigarette consumption among continuing young smokersi
With the current smoking rate of 20 per cent among Canadian young adults, higher than the smoking rate for the rest of Canada which is 16 per cent, additional initiatives to reduce smoking in this population are urgently required.
Research has also shown that persons of low socioeconomic status are more responsive to price than the general population but it is less clear on the impact on long-term heavy smokers and aboriginal smokersii
Estimates imply that the long-run effect of a permanent price increase is approximately double the short-run impact. Thus, a 10 per cent increase in cigarette price is expected to reduce the prevalence of cigarette smoking by approximately 8 per cent in the long run.iii
Excise Tax Adjustments
The current proposal to adjust the domestic rate of excise duty on tobacco products to account for inflation and eliminate the preferential excise duty treatment of tobacco products available through duty free markets will increase the cost of cigarettes and other tobacco products like fine-cut tobacco for use in roll-your-own cigarettes, chewing tobacco and cigars. For example, the government has stated that the excise "duty free" rate for cigarettes will increase from $15.00 to $21.03 per carton of 200 cigarettes. The commitment to make an automatic inflation adjustment every 5 years is a means to ensure that tobacco tax rates retain their real value in the future.
The CMA recommends passage of the proposal under Part 3 of Bill C-31 to increase the domestic rate of excise duty, accounting for inflation and eliminating the preferential excise duty treatment of tobacco products. This proposal represents a positive step toward the development of a federal integrated tobacco tax strategy for both domestic and imported products, and speaks to the importance of the relationship between health policy and tax policy.
There is a risk that a rise in tobacco taxes with the resultant rise in the cost of smoking will lead to an increase in the smuggling of lower-cost cigarettes. To avoid potential unintended consequences, such as smuggling, the CMA recommends that the federal government work with other countries to ensure that tobacco prices are harmonized across national borders. In addition, all levels of government should take the most stringent measures possible to control the sale and distribution of contraband tobacco, on their own and in cooperation with other affected jurisdictions.
Investing Tobacco Taxes in Health Promotion
The Minister of Finance has estimated that increasing tobacco taxes, including excise taxes on tobacco products, will increase federal tax revenues by $96 million in 2013-14, 685 million in 2014-15 and $660 million in 2015-16.
The CMA recommends that the revenue from increased taxation should be directed towards strengthening Canada's tobacco control strategy.
The CMA recommends that tobacco taxation policy should be used in conjunction with other strategies for promoting healthy public policy, such as public education programs to reduce tobacco use. The federal government should place a high priority for funding tobacco prevention and evidence-based cessation programs for young Canadians as early as primary school age. For these, substantial and sustainable funding is required.
A portion of these tobacco taxes should also be used to defray the costs of tobacco interventions, including physician-based clinical tobacco intervention services and up to 12 weeks stop-smoking medication annually per smoker. We encourage the government to focus their efforts on "high-risk" and "hard-to-reach" populations.
For Canada's Tobacco Control strategy to continue to reduce smoking rates in Canada we must continue to assess evolving best practices in smoking cessation programs, and conduct research on the impact of policies on high risk populations.
The CMA recommends that a portion of the revenues from tobacco taxes can be directed towards supporting evidence-based action to reduce tobacco use. This evidence comes from surveying Canadians on smoking behavior, conducting research and evaluation, and keeping track of trends and emerging issues.
The CMA supports increasing the excise duty on tobacco products. An increase in the excise duty tax on tobacco products is long overdue and a welcome contribution to efforts already underway to further reduce smoking rates in Canada.
Summary of Recommendations
The CMA recommends passage of the proposal under Part 3 of Bill C-31 to increase the domestic rate of excise duty, accounting for inflation and eliminating the preferential excise duty treatment of tobacco products.
The CMA recommends that the federal government work with other countries to ensure that tobacco prices are harmonized across national borders to avoid potential unintended consequences, such as smuggling.
The CMA recommends that the revenue from increased taxation should be directed towards strengthening Canada's tobacco control strategy.
The CMA recommends that tobacco taxation policy should be used in conjunction with other strategies for promoting healthy public policy, such as public education programs to reduce tobacco use.
The CMA recommends that a portion of the revenues from tobacco taxes can be directed towards supporting evidence-based action to reduce tobacco use.
i The Impact of Price on Youth Tobacco Use, Tobacco Control Monograph NO. 14
Frank J. Chaloupka, Rosalie Liccardo Pacula
ii Effects of Tobacco Taxation and Pricing on Smoking Behavior in High Risk Populations: A Knowledge Synthesis
Pearl Bader, David Boisclair, Roberta Ferrence
Int J Environ Res Public Health. 2011 November; 8(11): 4118-4139. Published online 2011 October 26. doi: 10.3390/ijerph8114118
iii The Impact of Price on Youth Tobacco Use, Tobacco Control Monograph NO. 14
Frank J. Chaloupka, Rosalie Liccardo Pacula