The public health system in Canada lies at the heart of our community values. It is the quintessential “public good” and is central to the continued good health of our population. When the public health system is working well, few are even aware that it is at work! Only when something goes terribly wrong — like the Walkerton tragedy or when we are faced with a new threat like SARS — is the integral, ongoing role of public health really recognized.
The Canadian Medical Association (CMA) has been warning that our public health system is stretched to capacity in dealing with everyday demands, let alone responding to the latest crises. Canada’s physicians have repeatedly called for governments to enhance public health capacity and strengthen the public health infrastructure throughout Canada.
Our public health system is the first — and often the only — line of defence against emerging and ongoing infectious and noninfectious threats to the health of Canadians. But we are only as strong as the weakest link in the emergency response chain of survival. As most health threats know no boundaries, our public health armaments must be in a constant state of “battle readiness.” In today’s climate of SARS, West Nile Virus, mad cow disease and monkey pox, even the thought that the public health system may be stretched beyond capacity strikes fear into the hearts of Canadians.
Physicians have always been an integral part of the public health system serving as medical officers of health, community health specialists and other related roles. Indeed public health cannot successfully fulfill its mandate without the cooperation and commitment of front-line clinicians.
In this submission, we reflect on the lessons to be learned from our recent experience with SARS and reflect on the longer-term needs of the public health system as a whole. The objectives of the pan-Canadian Public Health Action Plan proposed by the CMA are, first to realize a clearer alignment of authority and accountability in times of extraordinary health emergencies; and, second, to enhance the system’s capacity to respond to public health threats across the country (see recommendations, below, and Appendix 1).
To achieve these twin objectives, three broad strategies are presented for immediate attention. They are legislative reform; capacity enhancement; and research, surveillance and communications.
Legislative reform (see recommendations 1–3)
The country’s response to SARS has brought into stark relief the urgent need for national leadership and coordination of public health activity across the country, especially during a health crisis. The apparent reluctance to act quickly to institute screening at airports, the delay in unifying the practice community for a concerted response and the appalling communications confusion worked against optimum handling of the outbreak — despite the best efforts of health care professionals.
This is a wake-up call that highlights the need for comprehensive legislative reform to clarify the roles of governments with respect to the management of public health threats. A renewed and enhanced national commitment to public health should be anchored in new federal legislation to be negotiated with the provinces and territories.
Specifically, the CMA recommends an Emergency Health Measures Act, to deal with emergent situations in tandem with the creation of a Canadian public health agency headed by a Chief Public Health Officer of Canada.
Capacity enhancement (see recommendations 4–7)
The SARS crisis has demonstrated the diminished capacity within the public health system. The Greater Toronto Area (GTA), with one of Canada’s most sophisticated public and acute health systems, has not been able to manage the SARS crisis adequately and carry on other health programs. The acute care system virtually ground to a halt in dealing with SARS. There was little or no surge capacity in Canada’s largest city. We should be grateful that SARS did not first strike a smaller centre in a far less-advantaged region of Canada.
A critical element of the public health system is its workforce and the health professionals within the acute care system, such as hospital-based infectious disease specialists and emergency physicians who are the front-line interface. Let there be no doubt that the ongoing efforts of the GTA front-line providers are nothing short of heroic. However, the lack of coordinated contingency planning of hospital and community-based disease control efforts was striking. The overall shortage of critical care professionals and the inability of governments to quickly deploy the required professionals to areas of need contributed to the enormous strain on the public and health care system.
Considering the importance of the public health system and its clearly limited capacity to protect and promote the health of Canadians, it is incomprehensible that we do not know how much is actually spent on the system. It is imperative that public health expenditures and capacity, in terms of both physical and human resources, be tracked and reported publicly.
The CMA recommends a $1-billion, 5-year capacity-enhancement program to be coordinated with and through the new Canadian public health agency.
Research, surveillance and communications (see recommendations 8–10)
Canada’s ability to respond to public health threats and acute events, such as SARS, and to maintain its effective public health planning and program development depends on sound research, surveillance and rapid, real-time communications.
A concerted pan-Canadian effort is required to take full advantage of our capacity for interdisciplinary research on public health, including infectious disease prevention and control measures. New-millennium challenges require moving beyond old-millennium responses. Enhanced surveillance is an overdue and integral part of public health, performing an essential function in early detection and response to threats of infectious diseases. Mandatory national reporting of identified diseases by all provinces and territories is critical for national and international surveillance.
During times of crisis, rapid communication to the public, public health staff and front-line clinicians is of critical importance, but in many jurisdictions impossible. We tested our systems during the SARS outbreak and they came up short.
The CMA recommends a one-time federal investment to enhance technical capacity to allow for real-time communication.
The CMA believes that its proposed three-pronged strategy, as set out in the attached recommendations, will go a long way toward addressing shortfalls of the Canadian public health system. Action now will help to ensure that Canadians can once again be confident that they are protected from any future threat of new infectious diseases. Action now will help Canada regain its position as a leader in public health.
We wish the advisory committee well in its deliberations and offer the CMA’s assistance at any time in clarifying the strategies set out in our submission.
Recommendations to the National Advisory Committee on SARS and Public Health
Legislative reform ($20 million / 5 years*)
1. The enactment of a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation, allowing for a more rapid national response, in cooperation with the provinces and territories, based on a graduated, systematic approach, to health emergencies that pose an acute and imminent threat to human health and safety across Canada.
2. The creation of a Canadian Office for Disease Surveillance and Control (CODSC) as the lead Canadian agency in public health, operating at arm’s length from government.
3. The appointment of a Chief Public Health Officer of Canada to act as the lead scientific voice for public health in Canada; to head the Canadian Office for Disease Surveillance and Control; and to work with provinces and territories to develop and implement a pan-Canadian public health action plan.
Capacity enhancement ( $1.2 billion / 5 years*)
4. The creation of a Canadian Centre of Excellence for Public Health, under the auspices of the CODSC, to invest in multidisciplinary training programs in public health, establish and disseminate best practices among public health professionals.
5. The establishment of a Canadian Public Health Emergency Response Service, under the auspices of the CODSC, to provide for the rapid deployment of human resources (e.g., emergency pan-Canadian locum programs) during health emergencies.
6. Tracking and public reporting of public health expenditures and capacity (both physical and human resources) by the Canadian Institute for Health Information and Statistics Canada, on behalf of the proposed Canadian Office for Disease Surveillance and Control.
7. Federal government funding in the amount of $1 Billion over 5 years to build adequate and consistent surge capacity across Canada and improve coordination among federal, provincial/territorial and municipal authorities to fulfill essential public health functions.
Research, surveillance and communications ($310 million / 5 years*)
8. An immediate, sequestered grant of $200 million over 5 years to the Canadian Institutes of Health Research to initiate an enhanced conjoint program of research with the Institute of Population and Public Health and the Institute of Infection and Immunity that will expand capacity for interdisciplinary research on public health, including infectious disease prevention and control measures.
9. The mandatory reporting by provinces and territories of identified infectious diseases to the newly established Chief Public Health Officer of Canada to enable appropriate communications, analyses and intervention.
10. The one-time infusion of $100 million, with an additional $2 million a year, for a “REAL” (rapid, effective, accessible and linked) Health Communication and Coordination Initiative to improve technical capacity to communicate with front line public health providers in real time during health emergencies.
*See Appendix 2: Estimated cost of implementing recommendations.
The CMA prepared this submission in response to an invitation from Dr. Naylor to provide input to the National Advisory Committee on SARS and Public Health.
We applaud this initiative and welcome the opportunity to present the views of Canada’s medical community to the committee. The CMA’s basic message is that our health protection laws are woefully outdated and the public health system is stretched beyond capacity. This submission draws on our long history of engagement in public health in Canada and our experience both post-September 11, 2001 and with SARS. It builds on the knowledge and experience of our members, national specialist affiliated societies and provincial and territorial divisions. (We acknowledge, in particular, the outstanding efforts of the Ontario Medical Association and the Canadian Association of Emergency Physicians in battling SARS.)
In this submission, we examine the lessons to be learned from our experience with the SARS outbreak and reflect on both the immediate and longer-term needs of the public health system as a whole. The objectives of the public health action plan proposed by the CMA are, first, to realize a clearer alignment of authority and accountability in times of extraordinary health emergencies and, second, to enhance the system’s capacity to respond to public health threats across the country, including those posed by preventable chronic disease.
The public health system in Canada lies at the heart of our community values. It is the quintessential “public good” and is central to the continued good health of the population. When the public health system is working well, few are even aware that it is at work! Only when something goes terribly wrong — like the contamination of the blood supply in the 1980s, the Walkerton tragedy or SARS — is the integral, ongoing role of public health recognized.
Our public health system is the first — and often the only — line of defence against emerging and ongoing infectious and noninfectious threats to the health of Canadians. But we are only as strong as the weakest link in the emergency response chain of survival. As most health threats know no boundaries, our public health system must be in a constant state of “battle readiness.” We can ill afford any weakness in our public health preparedness. In today’s climate of SARS, West Nile Virus, mad cow disease and monkey pox, the mere thought that the public health system may be stretched beyond capacity strikes fear into the hearts of Canadians.
Physicians have always been an integral part of the public health system serving as medical officers of health, specialists in infectious disease and community medicine (who will not remember the stalwart efforts of Dr. Donald Low on SARS?) and in other related roles. Indeed, public health cannot successfully fulfill its mandate without the cooperation and commitment of front-line clinicians.
The CMA has been warning for some time that our system is stretched to capacity in dealing with everyday demands, let alone responding to crises. Canada’s physicians have repeatedly called for governments to enhance public health capacity and strengthen the public health infrastructure throughout Canada. For example, the CMA’s submission to the House of Commons Standing Committee on Finance’s prebudget consultations on October 22, 2001 called for substantial investments in public health and emergency response as a first step to improve the public health system infrastructure and its surge capacity.
This submission not only reiterates our previous recommendations, but also outlines specific actions that the CMA believes must be taken to ensure a strong public health system in Canada.
The Enduring Impact of Severe Acute Respiratory Syndrome
SARS (Severe Acute Respiratory Syndrome): in February 2003, these four letters sent massive shock waves around the world, causing widespread fear and confusion among health care officials and citizens of many countries. The “fear factor” extended across Canada as people realized the full threat of SARS.
Since SARS was first identified in a patient in Toronto in March 2003, 438 probable or suspected cases have been reported to Health Canada and 38 people have died (as of June 23, 2003). However, these numbers do not reflect the full impact of the outbreak. The number of indirect deaths due to system shutdown will never be known.
Local public health authorities across the country went on high alert. Those in the Greater Toronto Area (GTA) as well as their provincial counterparts diverted almost all of their resources to respond to the crisis.
Acute care services were adversely affected as stringent infection-control and screening measures were put into place to control the spread of SARS. In the GTA, the health system — acute and public — was brought to its knees. Over half of the reported SARS cases involved front-line providers as the outbreak largely affected health care settings. Approximately 20 physicians in Ontario contracted SARS and close to 1000 were quarantined. Thousands of nurses and other health care workers also faced quarantine, some more than once.
Institutions closed their doors, limiting access to emergency departments, clinics and physicians’ offices. Intensive care units were full and surgeries were cancelled. Front-line health care professionals involved in critical care were stretched to their physical and mental limits. Others found themselves underutilized due to the impact of the infection-control measures on their practice settings. Feast and famine co-existed.
Although the outbreak was mainly confined to health care settings, the entire GTA felt the effects. Upwards of 20,000 people entered voluntary quarantine. Businesses were affected. The tourism industry is still reeling. The disruption that SARS caused continues to reverberate through health care systems and economies.
In response to urgent requests from both the Ontario Medical Association and Health Canada, the CMA mobilized its membership and assisted in the country’s response to SARS. Everything that could be done was done to facilitate bringing in qualified personnel to relieve those on the front line and make appropriate information available in real time. The CMA has learned its own lessons, both positive and negative. A full chronology of CMA activity is attached as Appendix 3.
It has become abundantly clear that Canada’s public health system was ill prepared to deal with the SARS outbreak. If not for the heroic efforts of public health officials, health care providers and research scientists, Canada’s experience would have been much worse.
Public health in Canada
Public health is the science and art of protecting and promoting health, preventing disease and injury, and prolonging life. It complements the health care system, which focuses primarily on treatment and rehabilitation, sharing the same goal of maximizing the health of Canadians. However, the public health system is distinct from other parts of the health system in two key respects: its primary emphasis is on preventing disease and disability and its focus is on the health needs of populations rather than those of specific individuals.
Public health is the systematic response to infectious diseases. It also ensures access to clean drinking water, good sanitation and the control of pests and other disease vectors. Further, it is immunization clinics and programs promoting healthy lifestyles. But it is also there to protect Canadians when they face a public health crisis like SARS. If the public health system is fully prepared to carry out essential services, then communities across the country will be better protected from acute health events.
The reality in Canada today is that a strong, consistently and equitably resourced and integrated public health system does not exist. Public health systems across Canada are fragmented — a patchwork of programs, services and resources across the county. In reality, it is a group of multiple systems with varying roles, strengths and linkages.
Each province has its own public health legislation. Most legislation focuses on the control of communicable diseases. Public health services are funded through a variable mix of provincial and municipal funding formulae, with inconsistent overall strategies and results, and with virtually no meaningful role for input from health professionals via organizations such as the CMA, or the federal level, in terms of strategic direction or resources.
Federal legislation is limited to the blunt instrument of the Quarantine Act and a variety of health protection-related acts. (e.g., Food and Drugs Act, Hazardous Products Act, Controlled Drugs and Substances Act, Radiation Emitting Devices Act) Some of the laws, such as the Quarantine Act, date back to the late 19th century. Taken as a whole, the legislation does not clearly identify the public health mandate, roles and responsibilities of the different levels of government. In many cases, the assignment of authorities and accountabilities is anachronistic.
Moreover, there is little information available on the functioning and financing of Canada’s public health system. There is no “one-stop shopping” for authoritative information on public health issues.
In 2001, a working group of the Federal, Provincial and Territorial Advisory Committee on Population Health assessed the capacity of the public health system through a series of key informant interviews and literature reviews. The consistent finding was that public health had experienced a loss of resources and there was concern for the resiliency of the system infrastructure to respond consistently and proactively to the demands placed on it. Significant disparities were observed between “have” and “have-not” provinces and regions in their capacity to address public health issues.
The report’s findings are consistent with previous assessments by the Krever Commission and the Auditor General of Canada. In 1999, the Auditor General said that Health Canada was unprepared to fulfill its responsibilities in public health; communication between multiple agencies was poor; and weaknesses in the key surveillance system impeded the effective monitoring of injuries and communicable and non-communicable diseases. In 1997, Justice Horace Krever reported that the “public health departments in many parts of Canada do not have sufficient resources to carry out their duties.”
The Challenges Ahead
The 21st century brings with it an awesome array of new public health risks and ancient foes. Not all of them can be identified at the present time. New diseases (e.g., SARS, West Nile Virus) will likely continue to emerge. Dr. Alan Bernstein, President of the Canadian Institutes of Health Research, recently noted that SARS is here to stay. Old threats, such as contamination of a community water supply (e.g., Walkerton), can strike quickly if vigilance is relaxed or delegated to third parties. This century will likely bring greater focus on threats from the physical environment. Our social environment is also a source of illness as shown by the recent epidemic trends in obesity and type 2 diabetes mellitus. A substantial minority of Canadians continue to smoke. In short, there is no lack of public health threats to Canadians.
Although for each of these issues, there is a clear role for clinical care, it is the public health system that will identify and monitor health threats and provide interventions to prevent disease and injury and improve health. The system will also be at the front lines in any response to a biological, chemical or nuclear event. The public health system must have the infrastructure to respond to a range of threats to health, including emergencies. The experience with SARS has reaffirmed that we do not have the system flexibility to respond to these events after they have occurred. It is vital that we take steps now “to embrace not just the essential elements of disease protection and surveillance but also new strategies and tactics capable of addressing global challenges.”<1>
CMA’S PROPOSED PUBLIC HEALTH ACTION PLAN
No one policy instrument can possibly address the multiple factors involved in meeting the public health challenge head on. Similarly, no one level of government or constituency (e.g., community medicine) can or should shoulder all of the responsibilities.
Although we need to restore public confidence quickly, we must also do what it takes to get it right. Accordingly, the CMA is proffering a three-pronged approach to meet the challenge:
* A legislative reform strategy
* A capacity enhancement strategy
* A research, surveillance and communication strategy.
These three broad strategies make up the CMA’s proposed 10-point Public Health Action Plan. Taken together, the CMA believes the Plan, if adopted, will serve us very well in the future.
Our experience with SARS — and the seeming lack of coordination between international, federal, provincial and local system levels — should be a massive wake-up call. It highlights the need for legislative reform to clarify the roles of governments with respect to the management of public health issues and threats.
Four years ago, national consultations on renewing federal health protection legislation<2> resulted in a recommendation that
* “The federal government must be given, either through legislation or through memoranda of understanding among provincial and territorial governments, the authority it needs to effectively address any outbreak of a communicable disease, where the health risk extends beyond provincial borders.
* “Federal health protection legislation should be amended to give Health Canada authority to act quickly and decisively in the event of a national health emergency... if it poses a serious threat to public health; affects particularly vulnerable segments of the population; exceeds the capacity of local authorities to deal with the risk; and involves pathogens that could be rapidly transmitted across national and international borders.”
Such legislative reform is consistent with the federal government’s well-recognized responsibility to act to protect public health and safety. It fits well with Health Minister McLellan’s recently announced plans to act now to review and update health protection legislation. The SARS outbreak has provided further experience to support these, and in our view, even stronger recommendations.
There is ample historical evidence to support the federal government’s role in the management of communicable disease, a role that dates back to the time of confederation. The quarantine power was the initial manifestation of this authority in 1867 under Section 91 of the British North America Act and it gave the federal government the responsibility for ensuring the containment of infectious diseases. The outbreak of the Spanish Flu epidemic in 1918 further highlighted the need for coordinated national efforts and (at the urging of the CMA and others) resulted in the creation of the federal Department of Health in 1919. It would be reasonable to assume that legislators at the time had an expansive view of the need for centralized authority to deal with pan-Canadian health threats.
One hundred and thirty-five years after confederation, we have a highly mobile global community. This mobility and the attendant devastating speed with which diseases can spread demand a national response. Currently, there is tremendous variation in public health system capacity among the various provinces and territories and, more particularly, among municipalities and local authorities. Inconsistencies in provincial approaches to public health matters have resulted in significant disparities between and within the provinces.<3>
Health Canada’s mandate as set out in its enabling legislation states that “[t]he powers, duties and functions of the Minister extend to and include all matters over which Parliament has jurisdiction relating to the promotion and preservation of the health of the people of Canada.” The CMA believes that it is time for the federal government to take responsibility for public health matters that touch the lives of all Canadians.
The legal staffs at CMA, in consultation with external experts, have conducted a detailed review of existing legislation. We have concluded, as Health Minister McLellan recently announced, that there is a long overdue need to consolidate and rationalize current related laws. We also believe there is now public support and a demonstrable need to enhance the powers afforded the federal government. We recognize that the government has put forward Bill C-17, the Public Safety Act and a review of health protection legislation is underway.
We believe that amending and updating existing legislation is necessary but not sufficient to address today’s public health challenges. The CMA is calling for the enhancement of the federal government’s “command and control” powers in times of national health emergencies. Specifically we are recommending a three-pronged legislative approach.
1. The CMA recommends
The enactment of a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation, allowing for a more rapid national response, in cooperation with the provinces and territories, based on a graduated, systematic approach, to health emergencies that pose an acute and imminent threat to human health and safety across Canada.
The existing Emergencies Act gives the federal government the authority to become involved in public welfare emergencies when regions of the country are faced with “an emergency that is caused by a real or imminent... disease in human beings... that results or may result in a danger to life or property... so serious as to be a national emergency.” However, to use this power, the federal government must declare a “national emergency,” which itself has political and economic ramifications, particularly from an international perspective, and mitigates against its use. The CMA believes that this all-or-nothing approach is not in the public’s best interest. The concept of emergency in the context of public health requires a different response from governments in the future.
Although we recognize that provincial and municipal governments currently have preplanned sets of responses to health threats, the CMA is proposing new legislation to allow for a rapid federal response to public health emergencies. The proposed Emergency Health Measures Act clarifies the roles and authority of governments and ensures a consistent and appropriate response with sufficient human and financial resources to protect Canadians faced with a public health emergency. Of utmost importance, all Canadians, regardless of their location, can be assured that the response to a health emergency will be delivered systematically by experts who can sustain the effort as needed.
The proposed legislation would be founded on a graduated approach that would give the federal government the powers necessary to deal with a crisis, in an appropriately measured way, as it escalates. As the emergency grows, the government could implement stronger measures as required to meet the challenge — in principle, akin to the Unites States’ homeland security levels, which increase as the level of threat increases (see Appendix 4 for a description of the Canadian Emergency Health Alert System).
The CMA strongly believes that the federal government must have jurisdiction to act when the ability of the provinces to respond to public health emergencies is so disparate. The inability of one province to stop the spread of virulent disease would have serious implications for the health of residents in the rest of the country. The federal government and the provinces must work together to ensure the safety of all our citizens.
2. The CMA recommends
The creation of a Canadian Office for Disease Surveillance and Control (CODSC) as the lead Canadian agency in public health, operating at arm’s length from government.
Although some provinces have established centres of public health expertise, considering the breadth of public health issues, the relative population sizes and differences in wealth, it will never be feasible to have comprehensive centres of public health expertise for each province and territory.
Even if one achieved this, there would increasingly be issues of economies of scale and unnecessary duplication among centres. This issue is not unique to Canada.1 The CMA is proposing the development of a Canadian Office for Disease Surveillance and Control (CODSC) operating at arm’s length from any level of government. CODSC would have overall responsibility for protecting the health of Canadians.
The Office would provide credible information to enhance health decisions and promote health by developing and applying disease prevention and control, environmental health and health promotion and education activities.
CODSC would enable a consistent and coordinated approach to public health emergencies as well as play a key role in the prevention and control of chronic diseases and injuries. It would provide national health surveillance, apolitical scientific expertise, system development including standards and guideline development, development and dissemination of an evidence base for public health interventions, skills training and transfer of expertise (i.e., through secondment of staff) and resources, including funding for core programs, to other levels of the system (e.g., provincial and local).
3. The CMA recommends
The appointment of a Chief Public Health Officer of Canada to act as the lead scientific voice for public health in Canada; to head the Canadian Office for Disease Surveillance and Control; and to work with provinces and territories to develop and implement a pan-Canadian public health action plan.
Many national or federal–provincial–territorial committees play an important role in recommending public health strategies or actions. The National Advisory Committee on Immunization and the Federal, Provincial and Territorial Advisory Committee on Population Health are two excellent examples. But there is currently no single credible public health authority in whom is vested, through legislation or federal–provincial–territorial agreement, the overall responsibility for pan-Canadian public health issues.
Therefore, the CMA is recommending the appointment of a Chief Public Health Officer of Canada. Potential roles for this officer may include:
* Serve as the head of the Canadian Office for Disease Surveillance and Control
* Serve as the national spokesperson for public health with the independence to comment on critical public health issues
* Report annually on the health of the population
* Develop, implement and report independently to parliament on public health system performance measures
* Lead processes to identify and address gaps in the nation’s public health system.
The public health system infrastructure is the foundation that supports the planning, delivery and evaluation of public health activities. In March 2001, the Federal, Provincial and Territorial Advisory Committee on Public Health<3> reported,
In the view of respondents the system ‘is lacking in depth.’ This means that a sustained crisis would seriously compromise other programming. While the research does not indicate that the public health system in Canada is strained beyond capacity, there does appear to be agreement that there is a capacity to manage just one crisis at a time.
However, just 2 years later, the GTA, an area with one of Canada’s most sophisticated public and acute care health systems, was not able to manage the SARS crisis and carry on any other programs. The Ontario government recognized this state of affairs when, on 12 June, Ontario’s Health Minister Tony Clement said, “I was concerned that if we had one additional large-scale crisis, that the system would crash.”
Important public health issues ranging from immunization to suicide prevention went virtually unaddressed, as the public health capacity in Toronto was overwhelmed. In the absence of a mechanism to share resources within the system and a general lack of overall system surge capacity, the city of Toronto and the province competed with each other to recruit trained staff from other health departments. The SARS outbreak has shown there is no surge capacity in Canada’s largest city. The acute care system in Toronto virtually ground to a halt in dealing with SARS. We must ask ourselves what would have happened if SARS had struck first in a smaller centre in a far less-advantaged region of Canada.
Clearly Canada is not fully prepared. We should not have needed a crisis to tell us this. The CMA sees several components to rebuilding the capacity of the public health system.
Public health human resources
For the essential functions of the public health system to be realized, public health agencies need a workforce with appropriate and constantly updated skills. Canada’s public health workforce is extremely thin. There appear to be too few graduate-level public health professionals (i.e., those holding a master’s degree and physicians who are certified specialists in community medicine); those who do exist are not distributed equitably across jurisdictions. The scarcity of hospital-based infection control practitioners and emergency physicians within the acute care system and the lack of integration of hospital and community-based disease control efforts have been particularly striking during the SARS outbreak.
The knowledge and skills required for effective public health practice are not static. They continually evolve as new evidence is identified. However, continuing education programming for public health practitioners is woefully underdeveloped in Canada. Health Canada has made some limited progress in this area, but the issue needs to be addressed much more substantively.
4. The CMA recommends
The creation of a Canadian Centre of Excellence for Public Health, under the auspices of the CODSC, to invest in multidisciplinary training programs in public health, establish and disseminate best practices among public health professionals.
Canada has world-class expertise in public health. However, it does not have the depth of other countries, partly because we do not have a national multidisciplinary school of public health of the calibre of Harvard in Boston, Johns Hopkins in Baltimore and the School of Hygiene and Tropical Medicine in London.
A national school of public health, which might be based on a virtual network of centres nationwide, could
* Develop a plan to assess and address the substantial educational needs of new and existing public health staff
* Address the coordination of the various academic training programs to meet the needs of the field
* Ensure self-sufficiency of our public health workforce.
5. The CMA recommends
The establishment of a Canadian Public Health Emergency Response Service, under the auspices of the CODSC, to provide for the rapid deployment of human resources (e.g., emergency pan-Canadian locum programs) during health emergencies.
The SARS outbreak clearly demonstrated the need for a pre-planned approach to supporting and augmenting the public health and acute care workforce during a crisis. When health professionals in the GTA were overwhelmed, we were ill prepared to move health professionals in from other jurisdictions to help. Health professional associations like the CMA took the first steps in investigating and overcoming obstacles regarding licensure and insurance. We were taken aback when we found that the Ontario government had unilaterally awarded an exclusive contract to a for-profit company to arrange for emergency relief. The further delay caused by concerns about privacy, confidentiality and harmonizing fees hampered relief efforts. The deployment of health professionals during health emergencies is too important to be left in the hands of for-profit organizations as it was during the SARS experience.
An established Canadian Public Health Emergency Response Service, operating on a non-profit basis, would
* Maintain a “reserve” of public health professionals who are fully trained and could be deployed to areas of need during times of crisis
* Co-ordinate the logistics of issues such as portable licensing, malpractice and disability insurance
* Identify funding for staff training and a more equitable distribution of numbers and skills among jurisdictions.
Investment in public health
Considering the importance of the public health system and its capacity to protect and promote the health of Canadians, it is amazing that we have no reliable or comprehensive information about how much money is actually spent on the system or what public health human resources are available across Canada. This is partially due to the lack of uniform definitions, service delivery mechanisms and accounting practices. Even in the absence of reliable data on public health expenditures, there is ample evidence that the public health system continues to operate under serious resource constraints across Canada.
6. The CMA recommends
Tracking and public reporting of public health expenditures and capacity (both physical and human resources) by the Canadian Institute for Health Information and Statistics Canada, on behalf of the Canadian Office for Disease Surveillance and Control.
In its latest report on health system expenditures, the CIHI states that 6% of total expenditures in 2000 were spent on “public health and administration.”<4> The inclusion of administrative costs in this figure means that public health funding is substantially less than 6% of health system expenditures.2
Federal Government Estimates report that Health Canada allocated $433 million in 2003–2004 for health promotion and prevention activities with spending scheduled to decrease to $308 million by 2005–2006 or by almost 30%. This decrease in spending exemplifies a decade that has seen tremendous fluctuations in spending on public health activities.
The situation is alarming when looked at from a current-dollar basis; there was an 8.8% decrease in funding of public health activities between 1994–1995 and 1997–1998. In fact, federal spending on public health on a constant dollar basis did not regain its 1994–1995 level until 2000–2001.
Although the late 1990s saw some reinvestment in public health initiatives, the most recent 2003–2004 estimates suggest that, once again, federal investment in public health will decrease dramatically over the next few years. Indeed, public health continues to represent only a small fraction of total federal direct spending on health (9.7% in 2002–2003).
At the provincial level, although we cannot distance public health from administration, we know that it fell victim to the brutal climate of fiscal retrenchment of the 1990s, when in real terms provincial–territorial per capita health spending declined for 5 consecutive years after 1991–1992.
During this period, public health was further destabilized by regionalization. According to the Survey of Public Health Capacity in Canada most provincial and territorial officials reported reductions in programming as a result of the transfer of funding and responsibility to regional structures. Although Ontario did not regionalize, in 1997 public health funding was downloaded to municipalities, which left public health departments scrambling to find funds to meet existing programs as well as new services that were mandated by the provincial Health Protection and Promotion Act.
Whether talking about federal or provincial–territorial jurisdictions, we can no longer afford to have funding for health and safety subject to the vagaries of financial cycles.
However, what perhaps is most alarming is the potentially large economic impact of underinvestment in this area. Although the net cost of the SARS outbreak in Ontario is not yet known, recent estimates suggest that it could be as high as $2.1 billion.3 Given this, the proverbial ounce of prevention that is worth a pound of cure comes to mind suggesting that a relatively modest increase in funding for public health could potentially result in substantial savings in the longer term.
7. The CMA recommends
Federal government funding in the amount of $1 billion over 5 years to build adequate and consistent surge capacity across Canada and improve coordination among federal, provincial/territorial and municipal authorities to fulfill essential public health functions.
The best way to ensure that the public health system is capable of addressing the range of public health threats, including emergencies, is to significantly increase investment in its capacity. This investment must assist all levels of the system to fulfill essential public health functions, with particular attention to local and regional agencies. The strategic national leadership that we are calling for includes the development of new mechanisms for federal cost sharing of basic public health services and the guarantee of a basic core set of local programs serving everyone in Canada, regardless of where they live.
The system also needs to receive targeted funds so that it can do its work smarter and more effectively. Priority areas for this targeted funding should include development of an integrated information system and staff training.
Research, surveillance and communications
Canada’s ability to respond to emerging public health threats and acute events, such as the SARS outbreak, and to maintain its effective public health planning and program development depends on sound research, surveillance and rapid, real-time communications.
8. The CMA recommends
An immediate sequestered grant of $200 million over 5 years to the Canadian Institutes of Health Research to initiate an enhanced conjoint program of research with the Institute of Population and Public Health and the Institute of Infection and Immunity that will expand capacity for interdisciplinary research on public health, including infectious disease prevention and control measures.
Similar to the efforts in clinical care to support the use of evidence-based practices, interventions in public health must be based on research, evidence and best practices. A national effort should be undertaken to develop and make widely available, on an ongoing basis, a comprehensive and up-to-date review of the evidence base for public health programs. This information would support effective practice, enhance public health research capacity and support other infrastructure elements (e.g., minimum programs and services, performance measurement, system funding). It could also reduce unnecessary duplication of efforts by different public health agencies.
We applaud the tremendous work of the unique trans-Canada partnership of 4 CIHR-funded research teams who, in just 11 weeks, discovered the complete DNA sequence of the coronavirus associated with SARS. This is a perfect example of what can be accomplished when our talented research teams work together. The recent announcement by the CIHR of an integrated national strategy for research on SARS reflects the intent of this recommendation for other public health challenges.
9. The CMA recommends
The mandatory reporting by provinces and territories of identified infectious diseases to the newly established Chief Public Health Officer of Canada to enable appropriate communications, analyses and interventions.
Public health surveillance is defined as the ongoing, systematic collection, analysis and interpretation of health data necessary for designing implementing and evaluating public health programs. It is an integral part of the public health system and performs an essential function in early detection and response to threats to human health.
Current surveillance systems for communicable and noncommunicable diseases are inadequate to allow public health professionals to detect and react to major health issues. For effective public health management, surveillance must be a continuous process covering a range of integrated data sources to provide useful and timely information.
10. The CMA recommends
The one-time infusion of $100 million, with an additional $2 million a year, for a “REAL” (rapid, effective, accessible and linked) Health Communication and Coordination Initiative to improve technical capacity to communicate with front line public health providers in real time during health emergencies.
In today’s world, international travel, business and migration can move infectious diseases around the world at jet speed. But during the SARS experience, governments and public health authorities were unable to communicate in real time with health professionals on the front lines. Gaps in the basic communication infrastructure prevent public health agencies from talking with each other in real time, and also hinder exchanges between public health staff, private clinicians and other sources of information about emerging new diseases.
In response to requests from both the Ontario Medical Association and Health Canada, the CMA mobilized its communication networks to provide physicians with critical information about public health management of SARS. In less than 48 hours, via email and fax, we reached over 45,000 physicians with authoritative information. Through the good offices of the Canadian Council of Health Services Accreditation, this information was also made available to over 1500 accredited health facilities across Canada.
Although necessity caused the limits of the system to be tested, SARS highlighted the fact that we do not have information systems in place to facilitate real-time communication with health professionals. Information is the key to effective response during times of emergency. Information in real time is also essential for effective day-to-day health care to provide, for example, information on adverse drug reactions.
SARS brought out the best in Canada and Canadians’ commitment to one another. It also turned a bright, sometimes uncomfortable spotlight on the ability of this country’s health care system to respond to a crisis, be it an emerging disease, a terrorist attack, a natural disaster or a large-scale accident. We must learn from the SARS experience and quickly move to rebuild the infrastructure of a strong public health system.
The CMA believes that this 10-point Public Health Action Plan will go a long way toward addressing shortfalls in the Canadian public health system. Action now will help to ensure that Canadians can be confident once again that their governments are doing all they can to protect them from the threat of new infectious diseases.
We wish the advisory committee well in its deliberations and offer the CMA’s assistance at any time in clarifying the strategies set out in our submission.
APPENDIX 1: THE CMA’S PUBLIC HEALTH ACTION PLAN
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APPENDIX 2: ESTIMATED COST OF IMPLEMENTING THE RECOMMENDATIONS
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Estimated cost over 5 years
Legislative and institutional reform
1. Canada Emergency Health Measures Act
2. Canadian Office for Disease Surveillance and Control (CODSC)
3. Chief Public Health Officer of Canada
4. Canadian Centre of Excellence for Public Health
5. Canadian Public Health Emergency Response Service
6. Canadian Institute for Health Information and Statistics Canada
7. Surge capacity
Research, surveillance and communications
8. Canadian Institutes of Health Research
9. Mandatory reporting
Included under 2 and 3 above
10. Enhanced reporting
a. Work is currently underway to break-out public health from the current category of “public health and administration.”
b. This is an incremental investment in addition to funding currently available under Health Canada’s Health Promotion and Prevention Strategic Outcome area.
c. Funding must be sequestered specifically for new initiatives related to public health. Additional money could also be acquired through funding from the Canadian Foundation for Innovation, which received an additional $500 million in 2002–2003 (announced in the 2003 federal budget) to enhance the Foundation’s support of public health infrastructure.
APPENDIX 3: CHRONOLOGY OF THE CMA’S RESPONSE TO SARS
* First known case of atypical pneumonia (SARS) occurs in Guangdong province, China
* World Health Organization (WHO) receives reports from the Chinese Ministry of Health about SARS; 305 persons affected and 5 deaths
* Canadian index case arrives in Hong Kong for a family visit
* Canadian index case is a guest at the Metropole hotel in Kowloon
* A medical doctor from Guangdong checks into Metropole hotel in Kowloon. The physician, who became ill a week before staying at the hotel, is considered to be the original source of the infection
* This leads subsequently to outbreaks in Vietnam, Hong Kong, Singapore and Canada after guests leave the hotel and return home
* Canadian index case returns home to Toronto
* Canadian index patient dies in Toronto, 9 days after the onset of her illness
* WHO issues global alert about SARS
* National and international media reports begin appearing about SARS
* The Canadian index patient’s son, Canada’s second SARS victim, dies 15 days after the onset of his illness
* First reports from Toronto about deaths from SARS
* Health Canada receives notice of SARS patients in Ontario and British Columbia; begins regular updates on SARS on its website
* Health Canada initiates its pan-Canadian communication infrastructure, based on its pandemic influenza contingency plans
* CMA calls Health Canada to offer assistance and request “real time information.” CMA immediately placed on list of participants in daily pan-Canadian teleconferences.
* CMA adds a SARS page to its website home page (cma.ca) with CMA Shortcuts to expert information and daily updates
* CMA alerts all its divisions and affiliates to the Health Canada and CMA SARS web pages
* eCMAJ includes SARS updates on its website
* CMA divisions add a link to SARS information for health professionals to their websites
* Health Canada requests CMA’s assistance to inform physicians of the public health management guidelines for SARS
* CMA sends an email to 33,000 members (copied to divisions and affiliated societies) to alert them to Health Canada’s SARS public health management documents and SARS web page
* CMA CEO initiates cross-directorate task force and deploys dedicated staff resources. Some other CMA programs deferred/delayed. Task force begins daily staff SARS Working Group meetings
* CMA communicates with the Ontario Medical Association on a daily basis
* CMA holds teleconference with divisional communication directors re: SARS
* CMA contacts the British Medical Association to establish whether we can secure a supply of masks from European sources
* CMA organizes a teleconference among national health care organizations to discuss SARS developments
* CMA posts electronic grand rounds on SARS for clinicians on cma.ca;
* CMA sends email and fax communication to physicians to raise awareness of SARS e-grand rounds on cma.ca
* Working with the Mental Health Support Network of Canada, CMA prepares and posts on cma.ca, fact sheets for health professionals and the public on coping with the stress caused by SARS
* CMA hosts second teleconference among national health care organizations to discuss SARS developments
* Electronic grand rounds on SARS updated and promoted through cma.ca
* CMA sends email to membership requesting volunteers for the CMA Volunteer Emergency SARS Relief Network
* CMA consults with the American Medical Association regarding the possibility of US physicians volunteering for the relief network
* CMA CEO sends letter to deputy minister of health about the urgent need to create a national ministerial SARS task force
April 30-May 1
* CMA participates in Health Canada-sponsored international SARS conference in Toronto
* Health Canada announces the National Advisory Group on SARS and Public Health, headed by Dr. David Naylor
* Opinion editorial by Dr. Dana Hanson, CMA president, on SARS and public health surge capacity published in The Ottawa Citizen;
* CMA organizes a meeting of national health care organizations to discuss lessons learned from SARS
* CMA receives an invitation to submit a brief to the National Advisory Group on SARS and Public Health
* CMA sends e-mail to targeted segment of its membership (community medicine, public health, infectious disease and medical microbiology) requesting volunteers for the CMA Volunteer Emergency SARS Relief Network
* CMA president outlines the CMA’s Public Health Action Plan during a speech at the Canadian Club in Toronto
* CMA submission to the National Advisory Committee on SARS and public health
APPENDIX 4: CMA’S PROPOSED HEALTH EMERGENCY ALERT SYSTEM
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Health alert may be declared in:
* Any area under federal jurisdiction
* Any community or province/territory with a risk of transmission to other provinces/territories or countries
* Any community or province/territory with insufficient resources to manage the public health emergency within the capacity of the local public health authorities
Definition of the area of concern
Voluntary quarantine for individuals or property
Chief public health officer takes the lead in coordinating the response
Regulation or prohibition of travel
Reviewing and updating health emergency procedures
Determination of local capacity to lead and respond
Coordinating necessary response efforts with national disaster relief agencies, armed forces or law enforcement agencies at the federal–provinical–territorial level
Medium to significant limitations of civil rights and freedoms
Assessing future resource requirements
Deployment of a national response team
Medium to significant limitations of civil rights and freedoms
Evacuation of persons and the removal of personal property
Providing the public with necessary information.
Discretionary deployment of the national response team or on request of local authorities
Quarantine of individuals and/or property with enforcement by law
Implementing interventions, as appropriate, and emergency response actions
Regulation of the distribution and availability of essential goods, services and resources
Assessing further refinement of actions
Restricting access to the area of concern
Requisition, use or disposition of property
Required consent of governor in council
Lead response team
1. Garrett, L. Betrayal of trust: the collapse of global public health. New York: Hyperion; 2000.
2. Health Canada. National consultations, summary report: renewal of the federal health protection legislation. Ottawa: Health Canada; 1999.
3. Federal, Provincial and Territorial Advisory Committee on Population Health. Survey of public health capacity in Canada: highlights. Ottawa: The Committee; 2001.
4. Canadian Institutes for Health Information. National health expenditure trends: 1975–2002. Ottawa: CIHI; 2002.
5. Lévesque M. The economic impact of SARS. TD Economics Topic Paper. TD Bank Financial Group; 6 May 2003. Available: http://www.td.com/economics/topic/ml0503_sars.html (viewed: 20 June 2003).
1 Many countries (e.g., United States, United Kingdom, Norway and the Netherlands) have developed critical masses of public health expertise at the national level. The Centers for Disease Control and Prevention in the United States, which has a critical mass, great depth of scientific expertise and the tools and fiscal resources to fund public health programs at both state and local levels through demonstration projects, is a sterling example of the effectiveness of such a central agency.
2 A review by the Canadian Institute for Health Information recognizes the problem with current expenditure tracking systems and has recommended separating public health from government administrative costs and prepayment administration in future health system cost estimates.
3 On 6 May, the TD Bank released a paper<5> suggesting that the cost of SARS to the Canadian economy may be between $1.5 and $2.1 billion.
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
That the government create a one-time Health Care and Innovation Fund to resume health care services, bolster public health capacity and expand primary care teams, allowing Canadians wide-ranging access to health care.
That the government recognize and support the continued adoption of virtual care and address the inequitable access to digital health services by creating a Digi-Health Knowledge Bank and by expediting broadband access to all Canadians.
That the government act on our collective learned lessons regarding our approach to seniors care and create a national demographic top-up to the Canada Health Transfer and establish a Seniors Care Benefit.
That the government recognize the unique risks and financial burden experienced by physicians and front line health care workers by implementing the Frontline Gratitude Tax Deduction, by extending eligibility of the Memorial Grant and by addressing remaining administrative barriers to physician practices accessing critical federal economic relief programs.
Five months ago COVID-19 hit our shores. We were unprepared and unprotected. We were fallible and vulnerable. But, we responded swiftly.
The federal government initiated Canadians into a new routine rooted in public health guidance.
It struggled to outfit the front line workers. It anchored quick measures to ensure some financial stability.
Canadians tuned in to daily updates on the health crisis and the battle against its wrath.
Together, we flattened the curve… For now.
We have experienced the impact of the first wave of the pandemic. The initial wake has left Canadians, and those who care for them, feeling the insecurities in our health care system.
While the economy is opening in varied phases – an exhaustive list including patios, stores, office spaces, and schools – the health care system that struggled to care for those most impacted by the pandemic remains feeble, susceptible not only to the insurgence of the virus, but ill-prepared to equally defend the daily health needs of our citizens.
The window to maintain momentum and to accelerate solutions to existing systemic ailments that have challenged us for years is short. We cannot allow it to pass. The urgency is written on the faces of tomorrow’s patients.
Before the onset of the pandemic, the government announced intentions to ensure all Canadians would be able to access a primary care family doctor. We knew then that the health care system was failing.
The pandemic has highlighted the criticality of these recommendations brought forward by the Canadian Medical Association. They bolster our collective efforts to ensure that Canadians get timely access to the care and services they need. Too many patients are succumbing to the gaps in our abilities to care for them. Patients have signaled their thirst for a model of virtual care. The magnitude of our failure to meet the needs of our aging population is now blindingly obvious. Many of the front line health care workers, the very individuals who put themselves and their families at risk to care for the nation, are being stretched to the breaking point to compensate for a crumbling system.
The health of the country’s economy cannot exist without the health of Canadians.
Long wait times have strangled our nation’s health care system for too long. It was chronic before COVID-19. Now, for far too many, it has turned tragic.
At the beginning of the pandemic, a significant proportion of health care services came to a halt. As health services are resuming, health care systems are left to grapple with a significant spike in wait times. Facilities will need to adopt new guidance to adhere to physical distancing, increasing staff levels, and planning and executing infrastructure changes. Canada’s already financially atrophied health systems will face significant funding challenges at a time when provincial/territorial governments are concerned with resuscitating economies.
The CMA is strongly supportive of new federal funding to ensure Canada’s health systems are resourced to meet the care needs of Canadians as the pandemic and life continues. We need to invigorate our health care system’s fitness to ensure that all Canadians are confident that it can and will serve them.
Creating a new Health Care and Innovation Fund would focus on resuming the health care system, addressing the backlog, and bringing primary care, the backbone of our health care system, back to centre stage.
The CMA will provide the budget costing in follow-up as an addendum to this submission.
RECOMMENDATION 1 Creating a one-time Health Care and Innovation Fund
It took a global pandemic to accelerate a digital economy and spark a digital health revolution in Canada. In our efforts to seek medical advice while in isolation, Canadians prompted a punctuated shift in how we can access care, regardless of our location or socio-economic situation. We redefined the need for virtual care.
During the pandemic, nearly half of Canadians have used virtual care. An incredible 91% were satisfied with their experience. The CMA has learned that 43% of Canadians would prefer that their first point of medical contact be virtual.
The CMA welcomes the $240 million federal investment in virtual care and encourages the government to ensure it is linked to a model that ensures equitable access.
A gaping deficit remains in using virtual care. Recently the CMA, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada established a Virtual Care Task Force to identify digital opportunities to improve health care delivery, including what regulatory changes are required across provincial/territorial boundaries. To take full advantage of digital health capabilities, it will be essential for the entire population, to have a functional level of digital health literacy and access to the internet.
The continued adoption of virtual care is reliant on our ability to educate patients on how to access it. It will be further contingent on consistent and equitable access to broadband internet service.
Create a Digi-Health Knowledge Bank
Virtual care can’t just happen. It requires knowledge on how to access and effectively deliver it, from patients and health care providers respectively. It is crucial to understand and promote digital health literacy across Canada. What the federal government has done for financial literacy, with the appointment of the Financial Literacy Leader within the Financial Consumer Agency of Canada, can serve as a template for digital health literacy.
We recommend that the federal government establish a Digi-Health Knowledge Bank to develop indicators and measure the digital health of Canadians, create tools patients and health care providers can use to enhance digital health literacy, continually monitor the changing digital divide that exists among some population segments.
Pan-Canadian broadband expansion
It is critical to bridge the broadband divide by ensuring all those in Canada have equitable access to affordable, reliable and sustainable internet connectivity. Those in rural, remote, Northern and Indigenous communities are presently seriously disadvantaged in this way. With the rise in virtual care, a lack of access to broadband exacerbates inequalities in access to care. This issue needs to be expedited before we can have pride in any other achievement.
RECOMMENDATION 2 Embedding virtual care in our nation’s health care system
Some groups have been disproportionately affected by the COVID-19 crisis. Woefully inadequate care of seniors and residents of long-term care homes has left a shameful and intensely painful mark on our record. Our health care system has failed to meet the needs of our aging population for too long.
The following two recommendations, combined with a focus on improving access to health care services, will make a critical difference for Canadian seniors.
A demographic top-up to the Canada Health Transfer
The Canada Health Transfer (CHT) is the single largest federal transfer to the provinces and territories. It is critical in supporting provincial and territorial health programs in Canada. As an equal per-capita-based transfer, it does not currently address the imbalance in population segments like seniors.
The CMA, hand-in-hand with the Organizations for Health Action (HEAL), recommends that a demographic top-up be transferred to provinces and territories based on the projected increase in health care spending associated with an aging population, with the federal contribution set to the current share of the CHT as a percentage of provincial-territorial health spending. A top-up has been calculated at 1.7 billion for 2021. Additional funding would be worth a total of $21.1 billion to the provinces and territories over the next decade.
Seniors care benefit
Rising out-of-pocket expenses associated with seniors care could extend from 9 billion to 23 billion by 2035. A Seniors Care Benefits program would directly support seniors and those who care for them. Like the Child Care Benefit program, it would offset the high out-of-pocket health costs that burden caregivers and patients.
RECOMMENDATION 3 Ensuring that better care is secured for our seniors
The federal government has made great strides to mitigate the health and economic impacts of COVID-19. Amidst the task of providing stability, there has been a grand oversight: measures to support our front line health care workers and their financial burden have fallen short.
The CMA recommends the following measures:
1. Despite the significant contribution of physicians’ offices to Canada’s GDP, many physician practices have not been eligible for critical economic programs. The CMA welcomes the remedies implemented by Bill C-20 and recommends the federal government address remaining administrative barriers to physicians accessing federal economic relief program.
2. We recommend that the government implement the Frontline Gratitude Tax Deduction, an income tax deduction for frontline health care workers put at risk during the COVID-19 pandemic. In person patient care providers would be eligible to deduct a predetermined amount against income earned during the pandemic. The Canadian Armed Forces already employs this model for its members serving in hazardous missions.
3. It is a devastating reality that front line health care workers have died as a result of COVID-19. Extending eligibility for the Memorial Grant to families of front line health care workers who mourn the loss of a family member because of COVID-19, as a direct result of responding to the pandemic or as a result of an occupational illness or psychological impairment related to their work will relieve any unnecessary additional hardship experienced. The same grant should extend to cases in which their work contributes to the death of a family member.
RECOMMENDATION 4 Cementing financial stabilization measures for our front line health care workers
Those impacted by COVID-19 deserve our care. The health of our nation’s economy is contingent on the health standards for its people. We must assert the right to decent quality of life for those who are most vulnerable: those whose incomes have been dramatically impacted by the pandemic, those living in poverty, those living in marginalized communities, and those doubly plagued by experiencing racism and the pandemic. We are not speaking solely for physicians. This is about equitable care for every Canadian impacted by the pandemic.
Public awareness and support have never been stronger. We are not facing the end of the pandemic; we are confronting an ebb in our journey. Hope and optimism will remain elusive until we can be confident in our health care system.
Thank you very much for inviting the Canadian Medical Association back to this committee as you continue your study on healthy living.
A few weeks ago my colleague Dr. Doig was here to talk about the health consequences of poor nutrition and lack of physical activity and the policies CMA has advocated to promote healthy living.
Today I would like to expand upon nutrition labelling and health claims on foods, and on the labelling of foods regulated as natural health products.
Nutrition facts tables can be an important source of information, but many Canadians have difficulty interpreting them. A 2009 Health Canada review of research on nutrition labelling indicated that:
* those with little nutrition knowledge have difficulty using the tables and are unable to relate the information they contain to their own dietary needs; and that
* the concept of percentage of daily value is often misunderstood.
There has been an increase in the use of health claims on the front of packaging expressed as slogans or logos such as "healthy choice," as well as in disease reduction and nutrient content claims.
Studies have shown that foods carrying health-related claims are seen by consumers as healthier choices. But the myriad of different claims can be confusing and may, in fact, draw attention away from the less healthy characteristics of a food, or oversimplify complex nutritional messages.
We believe a standard consistent "at a glance" approach to front-of-package food labelling could reduce confusion and help consumers make informed dietary choices.
The "traffic light" front-of-pack labelling currently in voluntary use in the UK is an example. The front-of-pack labels on composite processed foods use green, amber and red to indicate low, medium or high levels of the nutrients most strongly associated with diet-related health risks: fat, saturated fat, sugars and salt. Also included is calorie count per serving and percentage daily amount information.
Research in the UK has shown that consumers generally understand these labels. Shoppers are most likely to use them when buying a product for the first time; to compare different products; when shopping for children; when trying to control intake of certain ingredients such as fat or salt, for health reasons; or when trying to lose weight.
Not surprisingly, research in the UK and Canada also shows that those most likely to read nutrition labels are those who are already interested in healthy eating.
For this reason, labelling policy must be embedded in a broader nutrition policy that uses multiple instruments to foster education and interest in healthy eating, and helps ensure that Canadians have healthy food choices by, for example, regulating amounts of salt in processed food.
In addition, physicians have become quite concerned about a recent tendency toward regulating 'fortified foods 'as Natural Health Products.
The Food and Drugs Act effectively prevents products classified as foods from being marketed as having medicinal benefits unless there is compelling scientific evidence that the claims are true and the products are safe. The same strong legislation does not apply to Natural Health Products (NHPs), which are regulated under a different act.
This is a concern because a trend is emerging whereby manufacturers of products normally sold as foods fortify their products with approved natural health products such as vitamins or minerals. Examples of these are energy drinks and vitamin-enhanced juice, power bars, gums and candy.
The manufacturer can then request federal approval to market the product as a 'health product in food format.' If approved, food labelling requirements no longer apply and health claims that would not be allowed under the Food and Drugs Act can be made.
Without proper nutrition labelling, it is difficult, if not impossible, for consumers to make informed food choices. This can be particularly troubling for those with special diets or health concerns. Further, those misled by dubious health claims might be consuming empty calories or high amounts of fat or sodium, with no corresponding benefit. The result is that the health of Canadians may be compromised.
The CMA has called on Health Canada to require compelling evidence of health benefits before changing a product's regulatory status from food to natural health product, and nutrition labelling for all foods regulated as a natural health product.
Faced with an array of products and health claims, and a barrage of advertising extolling their benefits, Canadians can find it challenging to make healthier food choices.
To find our way through to the right choice, we need good nutritional information, and the ability to access and understand this information.
Governments and health care providers share a responsibility to help Canadians make choices that will help them achieve and maintain good health. Canada's doctors are partners in healthy living and are ready to work with governments and others toward a healthy population.
I welcome your questions.
The CMA believes that comprehensive long-term efforts that incorporate both deterrent legislation and public awareness and education constitute the most effective policy in attempting to reduce the number of lives lost and injuries suffered in crashes involving impaired drivers. The CMA supports a multidimensional approach to the issue.
The CMA therefore recommends the following:
* developing awareness campaigns and education programs, particularly at the high school level where the pattern of alcohol misuse is often established;
* retaining the curative treatment provision found in Section 255(5) of the Criminal Code;
* providing comprehensive treatment suited to the needs of the individual person. Those repeatedly convicted of impaired driving should be considered for mandatory assessment;
* seizing or impounding the driver’s vehicle for the length of the license suspension if an individual is charged with impaired driving while his or her licence is suspended because of a previous impaired driving conviction;
* lowering the legal BAC limit to 50 mg%; and
* creating probationary licence systems for new drivers that would make it an offence to drive a motor vehicle during this probationary period with any measurable alcohol in the body.
The Canadian Medical Association is the national voice of Canadian physicians. Our mission is to provide leadership for physicians and to promote the highest standard of health and health care for Canadians. The CMA is a voluntary professional organization representing the majority of Canada's physicians and comprising 12 provincial and territorial divisions and 43 affiliated medical organizations. On behalf of its 45,000 members and the Canadian public, CMA performs a wide variety of functions, including advocating health promotion and disease and accident prevention policies and strategies. It is in this capacity that we present our position on proposed amendments to the Criminal Code sections on impaired driving.
The CMA welcomes this opportunity to comment on the issue of drinking and driving and the safety of our public roadways. The injuries and deaths resulting from impaired driving present a major public health concern. Physicians see the consequences of impaired driving in their practices. In 1996, 3,420 persons were killed in motor vehicle crashes. Alcohol was involved in 39.7% of those fatalitiesi.
In CMA policy documents and publications like the Physicians’ Guide to Driver Examination, the CMA has advocated for measures to reduce injury and death resulting from drinking and driving. The CMA has previously endorsed legislation aimed at reducing the incidence of drinking and driving, including the use of the breathalyser test, more severe penalties for those convicted and the taking of a mandatory blood sample if the individual is unable to provide a breath sampleii. Several of CMA’s provincial and territorial divisions have also issued policy statements on impaired driving (Appendix 1).
II. Multidimensional Approach
From 1987 to 96, there was a general decline in the percentage of fatally injured drivers who had been drinkingiii. In 1996, of tested drivers fatally injured in motor vehicle crashes, 41.6% had been drinking (with a Blood Alcohol Content (BAC) over 1 mg%>) while 34.9% were legally impaired (BAC >80 mg%)iv. CMA believes that to reduce the number of fatalities and injuries even further, a comprehensive, multidimensional approach encompassing the expertise, resources and experience of health professionals and all levels of government is required. This approach encompasses: (1) public education, (2) medical assessment and treatment interventions and (3) legislation.
1. Public Education
Drinking and driving must be viewed as socially unacceptable behaviour and until this change in attitude occurs, the judicial system cannot be completely effective in controlling the drinking and driving patterns of individuals. Education and information programs which increase society’s awareness of the consequences of using alcohol in combination with driving are integral parts of any attempt to reduce injuries and fatalities.
The CMA supports and recommends the development of awareness campaigns and education programs, particularly at the high school level where the pattern of alcohol misuse is often established.
2. Medical Assessment and Treatment Interventions
CMA shares the belief of specialists in the field of addiction medicine that punishment in the form of incarceration will not solve the problem of impaired drivingv. Rather, in addition to public education campaigns and criminal law sanctions, government must create and fund appropriate assessment and treatment interventions.
Impaired drivers may be occasional users of alcohol. They may also suffer from the disease of Substance Dependence. In the case of alcohol, this disease is commonly known as alcoholism. There are several assessment tools and screening tests to diagnose chronic alcoholismvi.
The term “Hard Core” drinking driver has also been coined to describe impaired drivers who repeatedly drive after drinking, often with a high BAC of 150 mg% or more. They are also resistant to change despite previous actions, treatment or education effortsvii. Although roadside surveys have revealed a general decrease in the overall level of drinking-driving in Canada, drivers with very high levels of BAC (over 150 mg%) seemed immune to this trendviii. “Hard Core” drinking drivers are most likely suffering from substance dependence or alcoholism, a condition requiring significant treatment interventionix.
Physicians, in their educational capacity, can assist in establishing programs in the community aimed at the recognition of the early signs of alcohol abuse or dependency. These programs should recognize the chronic, relapsing nature of alcohol addiction as a disease. There is also good evidence that physician interactions like the Alcohol Risk Assessment and Intervention program developed by the College of Family Physicians of Canada can have a positive impact on the behaviours of moderate drinkersx.
Another tool to aid physicians in the assessment of patients who drive impaired is the CMA publication, The Physicians’ Guide to Driver Examination. The Physicians’ Guide to Driver Examination is a collection of guidelines and expert opinions designed to help physicians assess their patients’ medical fitness to drive. The Physicians’ Guide discusses the impact of a variety of medical conditions on driving, including alcohol use, abuse and dependency. The Physicians’ Guide underlines the fact that alcohol-induced impairment is the single greatest contributor to fatal motor vehicle accidents in Canadaxi. The Physicians Guide to Driver Examination takes a strong stance on the status of drivers with chronic alcohol problems. It recommends that a chronic alcohol abuser should not be allowed to drive any type of motor vehicle until the patient has been assessed and received treatment. The Physicians' Guide to Driver Examination is currently under revision with an anticipated distribution date in the fall of 1999 for the sixth edition.
(a) Discharge for Curative Treatment
The Standing Committee on Justice and Human Rights has asked whether it is appropriate under Section 255(5) of the Criminal Code to allow the courts to discharge an impaired driver who is in need of “curative treatment” by placing that person on probation with a condition that he or she attends such treatment.
Section 255(5) of the Criminal Code reads:
Notwithstanding subsection 736(1), a court may, instead of convicting a person of an offence committed under section 253, after hearing medical or other evidence, if it considers that the person is in need of curative treatment in relation to his consumption of alcohol or drugs and that it would not be contrary to the public interest, by order direct that the person be discharged under section 730 on the conditions prescribed in a probation order, including a condition respecting the person’s attendance for curative treatment in relation to his consumption of alcohol or drugs.
The CMA believes that Section 255(5) should remain within the Criminal Code. Section 255(5) is an important recognition within the punitive framework of the Criminal Code of the necessary medical and rehabilitative elements at stake in the issue of impaired driving. CMA believes that there are sufficient safeguards within the wording of Section 255(5) to conclude that it does not invite misuse. There are several hurdles to meet in Section 255(5) before the court may award curative treatment. First, the court hears “medical or other evidence”.
In essence, the granting of the curative treatment order is not merely dependent on the pleas of the impaired driver. Second, the court must be satisfied that the discharge is not contrary to the public interest. In determining what is in the public interest, the courts look to the accused’s motivation and good faith, whether he or she was already subject to a driving prohibition, the risk of recidivism, previous convictions for impaired driving, prior curative discharges and the circumstances of the offence, including consideration of whether the accused was involved in an accident which caused death, bodily harm or significant property damagexii. Finally, it is highly unlikely that the “curative treatment” at issue in Section 255(5) would be involuntary or enforced against the wishes of the accused because his or her motivation or good will in pursuing treatment as an alternative to conviction is a key factor in the court’s decisionxiii.
The CMA recommends retaining the curative treatment provision found in Section 255(5) of the Criminal Code.
(b) Assessment and Rehabilitation
Rehabilitation can occur through education and treatment programs designed for impaired drivers. The CMA believes it is important to provide comprehensive treatment suited to the needs of the individual person. The CMA recognizes that as an exception to the general rule that medical interventions should be voluntary, individuals repeatedly convicted of the offence of impaired driving should be considered for mandatory assessment. This mandatory assessment, followed by medical recommendations for appropriate treatment, would not only benefit those with a chronic alcohol problem but could also help to reduce the incidence of drunk driving incidents attributable to repeat offenders. Physicians have the training, knowledge and expertise to assist in developing alcohol assessment, treatment and rehabilitation programs. Currently, nine jurisdictions have some form of mandatory assessment and rehabilitation programsxiv.
The CMA recommends providing comprehensive treatment suited to the needs of the individual person. Those repeatedly convicted of impaired driving should be considered for mandatory assessment.
On the issue of whether the current penalties provide sufficient deterrence, the CMA is in general agreement with the impoundment measures currently found in eight provincial and territorial jurisdictionsxv. CMA would encourage jurisdictions that do not have these impoundment programs to consider enacting them.
Since 1989, the CMA has recommended that if an individual is charged with impaired driving while his or her licence is suspended because of a previous impaired driving conviction, the suspended driver’s vehicle should be seized or impounded for the length of the license suspension.
(b) Blood Alcohol Content (BAC)
In response to the question of whether the legal BAC limit should be lowered from 80 mg%, since 1988 the CMA has supported 50 mg% as the general legal limit. Studies suggest that a BAC limit of 50 mg% could translate into a 6% to 18% reduction in total motor vehicle fatalities or 185 to 555 fewer fatalities per year in Canadaxvi. A lower limit would recognize the significant detrimental effects on driving-related skills that occur below the current legal BACxvii. Finally, the CMA notes that many jurisdictions have 50 mg% as the limit for impairmentxviii.
The CMA recommends lowering the legal BAC limit to 50 mg%.
The CMA has also supported the 1987 recommendation of the former Standing Committee of National Health and Welfare on Alcohol and Drug Abuse in Canada that the provinces establish a probationary or graduated licence system for new drivers that would make it an offence to drive a motor vehicle during this probationary period with any measurable alcohol in the body. Several studies have remarked on the significant reduction in casualty collisions when there is a 0 BAC limit for novice drivers xix. The CMA notes that several provinces have instituted such a graduated licensing systemxx.
The CMA supports probationary licence systems for new drivers that would make it an offence to drive a motor vehicle during this probationary period with any measurable alcohol in the body.
(c) Police Powers
On the issue of police powers to demand breath, blood or saliva samples for alcohol and/or blood testing, the CMA reiterates its earlier support for mandatory blood alcohol testing as outlined in the Criminal Code. At the request of CMA, physicians and other health care workers who take blood samples under this law are specifically protected from criminal and/or civil litigation, but it is not an offense for these health care workers to refuse to take a blood samplexxi.
The CMA believes that comprehensive long-term efforts that incorporate both deterrent legislation and public awareness and education campaigns constitute the most effective policy in attempting to reduce the number of lives lost and injuries suffered in crashes involving impaired drivers. It is prefererable to use countermeasures that prevent the occurrence of motor vehicle crashes involving impaired drivers rather than those that deal with the offender after the fact.
The multifaceted nature of the issue of impaired driving requires multidimensional countermeasures as part of a comprehensive policy involving all levels of government, private organizations, communities and individuals. The CMA urges all Canadians to support such efforts to reduce the prevalence of drinking and driving.
IV. Appendix 1
A List of Some Policy Statements and Resolutions on Impaired Driving from CMA Provincial and Territorial Divisions:
* Alberta Medical Association, 1983:
That the AMA recommend to the Government of Alberta that it take whatever steps are necessary to ensure that there are adequate penalties for impaired driving and that such penalties are well enforced.
* New Brunswick Medical Society:
February, 1988.“Statement on Driving Impairment”
October, 1992. “NBMS Position Statement on Alcohol”
* Northwest Territories Medical Association:
Endorsed June, 1998. “Strategy to Reduce Impaired Driving in the Northwest Territories: Interagency Working Group on Impaired Driving. June, 1996.”
* Ontario Medical Association:
November, 1994. “An OMA Position Paper on Drinking and Driving”.
i.Traffic Injury Research Foundation (TIRF) (1998).Strategy to Reduce Impaired Driving 2001: STRID 2001 Monitoring Report: Progress in 1996 and 1997. Ottawa: Traffic Injury Research Foundation at 25, 28.
ii.Canadian Medical Association (1989). Substance Abuse and Driving: A CMA Review. Ottawa: Canadian Medical Association at 3.
3. Mayhew, D.R., S.W. Brown and H.M. Simpson. (1998) Alcohol Use Among Drivers and Pedestrians Fatally Injured in Motor Vehicle Accidents: Canada, 1996. Ottawa: Traffic Injury Research Foundation at 19.
iv.Ibid at 13-14.
v. Hajela, Raju CD, MD, MPH, CCFP, CASAM, FASAM, President of the Canadian Society of Addiction Medicine. Letter to CMA dated January 13, 1999.
vi.American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, DSM-IV. Washington, D.C.: American Psychiatric Press.
vii. Beirness, D.J., H.M. Simpson, and D.R. Mayhew (1998). Programs and policies for reducing alcohol-related motor vehicle deaths and injuries. Contemporary Drug Problems 25/Fall 1998. See also the Century Council (1998) National Hardcore Drunk Driver Project. http://www.dwidata.org.
viii. Beirness, D.J., Mayhew, D.R., Simpson, H.M. and Stewart, D.E. (1995) Roadside surveys in Canada: 1974-1993. In Kloeden, C.N. and McLean, A.J. (eds). Alcohol, Drugs and Traffic Safety-T’95.Adelaide, Australia:NHMRC Road Accident Research Unit, University of Adelaide, pp. 179-184 as cited in Mann, Robert E., Scott Macdonald, Gina Stoduto, Abdul Shaikh and Susan Bondy (1998) Assessing the Potential Impact of Lowering the Blood Alcohol Limit to 50 MG % in Canada. Ottawa: Transport Canada, TP 13321 E at 14-15.
ix. Hajela, note 5 at 2.
x. Brison, Robert J., MD (1997). The Accidental Patient. Canadian Medical Association Journal, 157 (12) 1661-1662.
xi. Canadian Medical Association (1991).Physicians' Guide to Driver Examination. Ottawa: Canadian Medical Association at 51.
xii. R v. Storr (1995), 14 M.V.R. (3d) 34 (Alta. C.A.).
xiv.Traffic Injury Research Foundation (TIRF), note 1 at 12.
xvi. Mann et al., note 8 at 54.
xvii. Moskowitz, H. and Robinson, C.D. (1988). Effects of Low Doses of Alcohol on Driving Skills: A Review of the Evidence. Washington, DC: National Highway Traffic Safety Administration, DOT-HS-800-599 as cited in Mann, et al., note 8 at page 12-13.
xviii.Mann et al., note 8 at 24.
xix.Hingson, R., Heeren, T. and Winter, M. (1994) Lower legal blood alcohol limits for young drivers. Public Health Reports, 109, 738-744 as cited in Mann et al., note 8 at 36.
xx.Mann et al., note 8 at 29.
xxi.Canadian Medical Association, note 2 at 3.
On behalf of its more than 54,000 members, the Canadian Medical Association (CMA) is pleased to provide the House of Commons Standing Committee on Health with recommendations in regard to protecting the national blood supply from the West Nile Virus (WNV). As physicians, we understand both the perceived and actual risks associated with blood-borne diseases and the impact on individuals, families and communities.
WNV has emerged in North America, presenting a threat to public, animal and equine health. The most serious human manifestation of WNV infection is fatal encephalitis (inflammation of the brain). WNV is spread by the bite of an infected mosquito and can infect people, many types of birds, horses and some other animals. Most people who become infected with WNV will have either no symptoms or only mild ones. However, on rare occasions, WNV infection can result in severe and sometimes fatal illnesses. Certain people, including seniors, the young and those with weak immune systems, are at greater risk for serious health effects.
In 2002, West Nile Virus was documented in five provinces (Manitoba, Nova Scotia, Ontario, Quebec and Saskatchewan). Further to this, the United States Centre for Disease Control and Prevention reported the first documented cases of person-to-person West Nile Virus transmission through organ transplantation, blood and blood product transfusion and possibly breastfeeding. It is imperative that the risk associated with the transmission of West Nile Virus through blood transfusions be minimized.
We understand that the Canadian Blood Services (CBS) is working towards a validated laboratory test which may be available by the next mosquito season and that in the absence of this test there are a number of contingency plans. It appears that the CBS and Hema Quebec are maintaining vigilance and maximizing efforts towards controlling contamination through blood. This is commendable. We believe that these efforts are one component of what is required to maintain the health and safety of Canadians from the spread of known and emerging diseases. A second component is to ensure that communication about WNV to the public is accurate, timely and consistent. Effective risk communication is imperative not only to promote a safe blood supply, but also to manage risk perception associated with a positive test for WNV.
A comprehensive approach is required to protect the public from emerging health problems such as the WNV. A strong public health infrastructure is necessary to ensure that governments are able to protect and promote health and to prevent illness. This involves prevention, early detection, containment, communication and information dissemination.
STRENGTHENING PUBLIC HEALTH
Through its public health infrastructure, society protects and promotes health and works to prevent illness, injury and disability. In today’s world these public health functions require an increasingly specialized and well-trained workforce; sophisticated surveillance, monitoring and information systems; and adequate and continuously available laboratory support. Its ultimate effectiveness, however, depends upon the ability of the system to communicate crucial information and health advice to the right professionals in real time, when they need it.
The devastating impact of the failure to effectively communicate essential information is evident in examples as diverse, yet dramatic, as the tragedy of Walkerton and the untimely death of Vanessa Young. In both cases the information health professionals needed to make optimum decisions was not accessible in a reliable and timely manner.
Reports indicate that across this country public health workers are stretched to the limit to perform routine work. The public health infrastructure is put to the test further whenever there is a disaster, large or small, in Canada and, not withstanding best efforts, it does not always pass. The public health system is also challenged by the potential for a disconnect in communications between differing jurisdictions that may be found when, for example, First Nations communities under federal jurisdiction overlap areas of provincial/territorial jurisdiction. In the aftermath of 9/11 and the anthrax scare in the United States, Canadians must be assured of a rapid, knowledgeable, expert response to emergency public health challenges.
Commissioner Roy Romanow suggests in the recent report of the Royal Commission on the Future of Health Care that “a portion of the proposed new Primary Health Care Transfer should be targeted to expanding efforts by provinces and territories to prevent illnesses and injuries, promote good health, and integrate those activities with primary health care.”
The Fifth Report of the Senate Committee on Science, Technology and Social Affairs, chaired by Senator Kirby, notes that “The major problem with public health programs is that funding is low, and usually unstable or inconsistent. As a result, the public health infrastructure in Canada is under considerable stress and has deteriorated substantially in recent years.”
The Senate Committee recommended that the federal government, “ensure strong leadership and provide additional funding of $200 million to sustain, better coordinate and integrate the public health infrastructure in Canada as well as relevant health promotion efforts.”
During the First Ministers’ meeting in September 2000, the First Ministers committed to strengthening their investments and commitments to public health, including the development of strategies and policies that recognize the determinants of health, enhance disease prevention and improve public health. They made several commitments towards achieving the goal, including:
* Promoting those public services, programs and policies that extend beyond care and treatment and which make a critical contribution to the health and wellness of Canadians;
* Addressing key priorities for health care renewal and supporting innovations to meet the current and emerging needs of Canadians;
* Reporting regularly to Canadians on health status, health outcomes, and the performance of publicly funded health services, and the actions taken to improve these services.
In 1999, the Auditor General found Health Canada unprepared to fulfill its responsibilities in public health; communication between multiple agencies was poor and weaknesses in the key surveillance system impeded the effective monitoring of communicable and noncommunicable diseases and injuries. In 1997, Justice Horace Krever reported that the “public health departments in many parts of Canada do not have sufficient resources to carry out their duties.”
The capacity of the public health care sector to deliver disease prevention and health promotion programs in Canada is currently inadequate, and its ability to respond varies from coast to coast. This is due to a lack of trained professionals and a lack of operational funds. Enhanced commitments are needed from governments at all levels to ensure that adequate human resources and infrastructure are in place to respond to public health issues when they arise. This includes the expansion of the public health training programs to enhance the resources in this field. The ability of the public health system to respond to these issues has a direct impact on the wellbeing of the people of Canada in a manner as important as the ability of the acute care system to respond to medical emergencies.
Therefore the CMA recommends that:
The federal government invest in human resources and infrastructure needed to develop an adequate and effective public health system capable of responding to emerging public health issues.
The public health system is complex and multifactorial. It is therefore imperative that different departments and sectors coordinate and communicate effectively to coordinate efforts and avoid duplication. The development of an adequate surveillance system and consideration of mandatory reporting of WNV infections in humans is one component of this requirement. In addition to collecting these data, a more extensive communication and dissemination plan should be developed to enhance the impact of skilled professionals, programs and policies. Responsible messaging should be developed in a timely manner, for the public and for individuals who are detected to have (or previously had) a WNV infection. Such messaging must carefully balance public awareness of risk against threats to the CBS/Hema Quebec donor pool and the creation of anxiety in people who need to use blood or blood products.
It is essential that the federal government take a leadership role to ensure that the communication tools and information technology necessary to enable a more rapid and informed response to situations such as identification of emerging diseases in the blood supply, natural disasters, disease outbreaks, newly discovered adverse drug reactions, and man-made disasters or bio-terrorism are accessible in real time in all regions of the country.
In its pre budget submission, the CMA called on the government to strengthen the public health system to ensure that governments are able to protect and promote health and to prevent illness. This involves the detection of emerging health problems, like West Nile Virus transmission, as well as containment, communication and information dissemination.
Therefore the CMA recommends that:
The federal government provide a one-time infusion of $30 million for the creation of a R.R.E.A.L (Rapid, Reliable, Effective, Accessible and Linked) Health Communication and Coordination Initiative which would strengthen Canada’s public health infrastructure and enhance coordination and communication amongst all levels of government, public health officials, health educators, community service providers, physicians and organizations such as the Canadian Blood Service/Hema Quebec, Canadian Public Health Association and the Canadian Medical Association.
This document presents the position of the Canadian Medical Association (CMA)on the discussion papers “Proposed New Labelling Requirements for Tobacco Products” and “Options for Tobacco Promotion Regulations”, which were released by Health Canada on January 18, 1999. The document assesses the proposals outlined in the two papers and places them in the context of CMA’s comprehensive policy on tobacco control.
The CMA is the national voice of Canadian physicians. Our mission is to provide leadership for physicians and to promote the highest standard of health and health care for Canadians. On behalf of its 45,000 members and the Canadian public, CMA performs a wide variety of functions, including advocating health promotion and disease and injury prevention policies and strategies. It is in this capacity that we present this brief, the most recent of many statements on tobacco which CMA has made since it issued its first public warning on tobacco’s hazards in 1954.
We have spoken out strongly and consistently for more than forty years because physicians have first-hand experience of the havoc that tobacco plays with the lives of Canadians. Tobacco kills 45,000 people a year in this country1 - more than traffic accidents, murders, suicides, drug abuse and AIDS combined. Because many people with tobacco-related diseases do not die of them, this number greatly underestimates the actual burden of suffering caused by tobacco in Canada.
This burden of disease comes with a high price tag. Health Canada estimates that tobacco costs the Canadian health care system $3.5 billion a year in direct health care expenses. This does not include the cost of the disability, lost productivity and human pain and suffering caused by tobacco, which has been estimated at between $8 and 11 billion annually.2
It is for these reasons that the CMA has consistently recommended tough legislative and regulatory measures to control tobacco use. Since the Supreme Court of Canada struck down portions of the Tobacco Products Control Act in 1995, we have advocated strong replacement legislation. We supported Bill C-71, the Tobacco Act, and welcomed its enactment in 1997; since then we have repeatedly expressed our opposition to suggested amendments that would weaken the Act.
CMA now commends Health Canada on its proposal to augment the Tobacco Act with regulations to mandate strong health warnings on packages of tobacco products, and on initiating discussion on regulations to control tobacco advertising and promotion. The following discusses in detail Health Canada’s specific suggestions.
II. “Option for Tobacco Promotion Regulations”
Before discussing specific options it should be said that the CMA advocates the prohibition of all forms of tobacco promotion in Canada. This includes advertisements in broadcast and print media, the sale of accessories and tobacco products displaying brand names, logos or colours, and advertising at point of sale. Accordingly we view the options described in the paper as compromises rather than ideal solutions, and our recommendations should be considered from this viewpoint.
a) Tobacco Products, (Sections 3.1 (a) to 3.1 (f))
The CMA recommends a total ban on advertising and promotion of tobacco products at point of sale. The eye-catching “power walls” of cigarettes that one sees in corner stores could be considered a form of advertising. CMA therefore recommends the most restrictive option proposed in the paper, i.e. that tobacco products not be displayed above counter-tops. There should be no exemption from this restriction for any store.
b) Accessories and Nontobacco Products (Section 3.1 (g) to 3.1 (k))
CMA’s recommended ban on tobacco advertising extends to a ban on the sale of accessories and nontobacco products carrying tobacco brand elements. We are aware that the Tobacco Act permits the use of tobacco brand elements on nontobacco products; however, we recommend that regulations restrict their use to the greatest extent possible.
c) Service (Section 3.1 (l))
We assume that this provision is intended to control in-store advertising for events sponsored by tobacco companies. CMA has publicly opposed all advertising related to such events. We note that this advertising will be removed from stores altogether by 2003, under the provisions of Bill C-42.
d) Availability Signs (Sections 3.1(m) - 3.1(p))
The CMA questions the need for availability signs; however, if they are permitted, Health Canada’s regulations must ensure that they not be used as advertising. For example, the number of signs that a location can display should be limited; the text on signs should be in plain black and white font; and the content should be restricted as described in Section 3.1(p).
e) Advertising (Section 3.2)
Again, CMA reminds Health Canada that it opposes tobacco advertising in all forms and would prefer a total ban to the options proposed in this section. However, since the Tobacco Act permits a limited amount of advertising, we recommend that Health Canada act on its stated intent to restrict this advertising’s attractiveness to young people and its potential to reach them. Accordingly we recommend the following:
* that all advertisements for tobacco products, accessories or nontobacco products displaying tobacco product brand elements carry prominent health warning messages as proposed;
* that advertisements be “text-only” without illustrations or decorative fonts;
* that if it is impossible to keep brand elements off advertisements, they occupy as small a space as possible;
* that advertisements be print-only and restricted to adult-circulation publications, as mandated in the Tobacco Act;
* that the size of advertising signs be restricted; and
* that the above recommendations also apply to advertising signs in places where young persons are not permitted. The Tobacco Act allows advertising in such places with the proviso that it not be “lifestyle” related. However, the concept of "lifestyle" advertising is vague and open to broad interpretation; as such, it is difficult to police and could be easily ignored or circumvented. Therefore CMA believes that a comprehensive ban on advertising is preferable to a partial one.
f) Tobacco Product Packaging (Section 3.3)
Packaging is an important part of the marketing of any product, and tobacco is no exception. Cigarette packages should not serve as an advertising tool and inducement to purchase. Plain packaging would reduce the attractiveness of cigarette boxes to consumers; accordingly CMA recommends that tobacco products be sold in plain packages.
We are pleased to see standardized plain packaging presented as an option in this section, and we recommend that this option be adopted.
III. “Proposed New Labelling Requirements for Tobacco Products”
As Health Canada’s own research indicates, package labelling is a health education tool that can reach a large number of people for minimal cost; we believe that health warning labels have contributed to raising public awareness of the dangers of smoking and the toxic content of tobacco.
Accordingly, CMA supports in principle the proposals in this paper. In addition to our support for plain packaging, CMA recommends that packages of tobacco products:
* Contain health warnings prominently displayed;
* Display messages that are as simple and direct as possible; this applies not only to health warnings but to all proposed messages, e.g. those reminding of the ban on sales to minors;
* Use messages that are supported by scientific data and focus on the health effects of tobacco rather than social norms or emotional appeals. In particular, CMA recommends eliminating the message, “Smoking is a weakness, not a strength.” We believe that this message unfairly blames the victim for an activity that is in fact an addiction, not a weakness;
* Display a list of toxic ingredients and additives; and
* Provide information on treatment for tobacco addiction, for example, information on nicotine replacement, advice to smokers to consult their physicians if they are ready to stop smoking, and information about available cessation programs.
Packages might also include inserts containing additional information on product content and health risks. This information should also be based on scientific evidence focusing on the medical consequences of tobacco use. However, the use of inserts should be carefully evaluated in light of its possible impact on the environment.
The labelling requirements proposed in this paper are consistent with the spirit of CMA’s policy. We commend Health Canada for taking these steps, and for mandating health warnings not only on cigarettes but on all tobacco products.
IV. The Larger Context
It is important to emphasize that CMA does not consider the proposed regulations, or any other single initiative, a “miracle cure” for Canada’s tobacco problem. Just as there are a variety of reasons why children take up the smoking habit, so it will take a variety of initiatives, working in combination, to effectively fight tobacco. We urge the government of Canada to augment its proposed regulations on labelling and promotion by:
* Providing support for smoking cessation services for those who are addicted to tobacco. CMA has been involved with three of its provincial divisions in the “Mobilizing Physicians for Clinical Tobacco Intervention (MP-CTI)” project, whose purpose is to help physicians counsel their patients on how to stop smoking. Evidence shows that even brief counseling by a health professional increases the quit rate, particularly when combined with the “patch” or other nicotine replacement therapies.3 MP-CTI has provided physicians and other health professionals with motivation to make smoking cessation counseling a part of their routine and with tools to enhance their counseling practices. The CMA believes that the government should support MP-CTI and other programs that encourage evidence-based practices in health care.
* Continuing to increase consumer and manufacturer tobacco taxes, raising them as high as is compatible with discouraging smuggling. In our 1998 pre-budget brief to the Standing Committee on Finance we recommended that the government gradually increase tobacco taxes, and we supported the tobacco tax increase implemented in February 1998.4
* Providing funding to ensure that Canada maintains strong, sustained and effective programs to discourage children from smoking. In 1997 the Liberal Party promised to commit $100 million over five years for tobacco control programs, including $50 million for public education5. We would like to see this amount committed as a minimum, and preferably increased.
The CMA also continues to support the concept of a levy on tobacco products to fund programs to discourage tobacco use, and we urge the government to take action soon in this regard.
Tobacco is the number one cause of preventable disease and death in Canada. The CMA urges the Government of Canada to deal with it as strongly as the burden it imposes on this country warrants.
1. Ellison LF, Mao Y, Gibbons L Projected smoking-attributable mortality in Canada, 1991 2000. Chron Dis Can 1995; 16: 84 - 89.
2. Health Canada. Economic Costs due to Smoking (Information Sheet). Health Canada, November 1996.
3. Agency for Health Care Policy and Research. Smoking Cessation (Clinical Practice Guideline Number 18). U.S. Department of Health and Human Services, 1996.
4. Canadian Medical Association. Canadians’ Access to Quality Health Care: a System in Crisis. Brief submitted to the House of Commons Standing Committee on Finance, August 1998.
5. Liberal party. Securing our Future. Liberal Party of Canada, 1997.
Re: Standing Committee on Health’s study on violence faced by healthcare workers
Dear Mr. Casey:
I am writing on behalf of the Canadian Medical Association (CMA) to submit recommendations for
consideration by the Standing Committee on Health (the Committee) as part of the study on violence
faced by healthcare workers.
The CMA is deeply concerned with the state of workplace safety in all health care settings, including
hospitals, long-term care, and home care settings. As in all experiences of violence, it is
unacceptable for healthcare workers to be victims of violence in the provision of care to patients.
While there is limited data nationally to understand the incidence of violence against healthcare
workers, anecdotal evidence suggests that these experiences are increasing in frequency and severity.
A 2010 survey of members of the College of Family Physicians of Canada shockingly found that, in
the previous month, nearly one-third of respondents had been exposed to some form of aggressive
behaviour from a patient (90%) or patient’s family (70%). The study concluded that “Canadian family
physicians in active practice are subjected to regular abuse from their patients or family members of
These concerns were brought to the CMA’s General Council in 2015, where our members passed a
resolution calling for:
“the federal government to amend the Criminal Code by making it a specific criminal offence to
assault health care providers performing their duties.”
The CMA is prioritizing initiatives that support physician health and wellness. Increasingly, there is a
recognition of the role of the workplace, primarily health care settings, and safe working conditions as
having an important influence of physician health and wellness.
1 Miedema BB, Hamilton R, Tatemichi S et al. Monthly incidence rates of abusive encounters for Canadian family physicians by patients and their families. Int J Family
Med. 2010; 2010: 387202. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3275928/pdf/IJFM2010-387202.pdf (accessed 2019 May 9).
Mr. Bill Casey
Addressing violence against providers in healthcare settings will require action from both federal and
provincial/territorial governments. In light of the above, the CMA respectfully submits the following
recommendations for consideration by the Committee in its study on violence against healthcare
1) The CMA recommends that the Committee on Health support the call to amend the Criminal
Code of Canada to introduce a new criminal offence for assault against a healthcare
provider performing their duty.
2) The CMA recommends that the Committee on Health support establishing monitoring of
violence against healthcare workers, that is consistent across jurisdictions, and have an active
role in responding appropriately to trends.
3) The CMA recommends that the Committee on Health support federal leadership in a pan-
Canadian approach to support workplace safety in healthcare settings, including
collaborating with the provinces and territories to improve violence prevention.
Finally, the CMA welcomes and supports the petition recently tabled in the House of Commons by
Dr. Doug Eyolfson, calling for the Minister of Health “to develop a pan-Canadian prevention strategy
to address growing incidents of violence against health care workers.”
In closing, the CMA is encouraged that the Committee is undertaking this study. I look forward to the
Committee’s report on this topic and the opportunity to collaborate on federal and
provincial/territorial action in this matter.
F. Gigi Osler, BScMed, MD, FRCSC
c.c.: Marilyn Gladu, M.P., Vice Chair, Standing Committee on Health
Don Davies, M.P., Vice Chair Standing Committee on Health
Thank you Mr. Chair.
I am Dr. Jeff Blackmer, the Vice-President of Medical Professionalism for the Canadian Medical Association.
On behalf of the CMA, let me first commend the committee for initiating an emergency study on this public health crisis in Canada.
As the national organization representing over 83,000 Canadian physicians, the CMA has an instrumental role in collaborating with other health stakeholders, governments and patient organizations in addressing the opioid crisis in Canada.
On behalf of Canada’s doctors, the CMA is deeply concerned with the escalating public health crisis related to problematic opioid and fentanyl use.
Physicians are on the front lines in many respects.
Doctors are responsible for supporting patients with the management of acute and chronic pain. Policy makers must recognize that prescription opioids are an essential tool in the alleviation of pain and suffering, particularly in palliative and cancer care.
The CMA has long been concerned with the harms associated with opioid use. In fact, we appeared before this committee as part of its 2013 study on the government’s role in addressing prescription drug abuse.
At that time, we made a number of recommendations on the government’s role – some of which I will reiterate today.
Since then, the CMA has taken numerous actions to contribute to Canada’s response to the opioid crisis.
These actions have included advancing the physician perspective in all active government consultations.
In addition to the 2013 study by the health committee, we have also participated in the 2014 ministerial roundtable and recent regulatory consultations led by Health Canada — specifically, on tamper resistant technology for drugs and delisting of naloxone for the prevention of overdose deaths in the community.
Our other actions have included:
· Undertaking physician polling to better understand physician experiences with prescribing opioids;
· Developing and disseminating new policy on addressing the harms associated with opioids;
· Supporting the development of continuing medical education resources and tools for physicians;
· Supporting the national prescription drug drop off days; and,
· Hosting a physician education session as part of our annual meeting in 2015.
Further, I’m pleased to report that the CMA has recently joined the Executive Council of the First Do No Harm strategy, coordinated by the Canadian Centre on Substance Abuse.
In addition, we have joined 7 leading stakeholders as part of a consortium formed this year to collaborate on addressing the issue from a medical standpoint.
I will now turn to the CMA’s recommendations for the committee’s consideration. These are grouped in four major theme areas.
1) Harm Reduction
The first of them is harm reduction.
Addiction should be recognized and treated as a serious, chronic and relapsing medical condition for which there are effective treatments.
Despite the fact that there is broad recognition that we are in a public health crisis, the focus of the federal National Anti-Drug Strategy is heavily skewed towards a criminal justice approach rather than a public health approach.
In its current form, this strategy does not significantly address the determinants of drug use, treat addictions, or reduce the harms associated with drug use.
The CMA strongly recommends that the federal government review the National Anti-Drug Strategy to reinstate harm reduction as a core pillar.
Supervised consumption sites are an important part of a harm reduction program that must be considered in an overall strategy to address harms from opioids. The availability of supervised consumption sites is still highly limited in Canada.
The CMA maintains its concerns that the new criteria established by the Respect for Communities Act are overly burdensome and deter the establishment of new sites.
As such, the CMA continues to recommend that the act be repealed or at the least, significantly amended.
2) Expanding Pain Management and Addiction Treatment
The second theme area I will raise is the need to expand treatment options and services.
Treatment options and services for both addiction as well as pain management are woefully under-resourced in Canada.
This includes substitution treatments such as buprenorphine-naloxone as well as services that help patients taper off opioids or counsel them with cognitive behavioural therapy.
Availability and access of these critical resources varies by jurisdiction and region. The federal government should prioritize the expansion of these services.
The CMA recommends that the federal government deliver additional funding on an emergency basis to significantly expand the availability and access to addiction treatment and pain management services.
3) Investing in Prescriber and Patient Education
The third theme I will raise for the committee’s consideration is the need for greater investment in both prescriber as well as patient education resources.
For prescribers, this includes continuing education modules as well as training curricula. We need to ensure the availability of unbiased and evidenced-based educational programs in opioid prescribing, pain management and in the management of addictions.
Further, support for the development of educational tools and resources based on the new clinical guidelines to be released in early 2017 will have an important role.
Finally, patient and public education on the harms associated with opioid usage is critical.
As such, the CMA recommends that the federal government deliver new funding to support the availability and provision of education and training resources for prescribers, patients and the public.
4) Establishing a Real-time Prescription Monitoring Program
Finally, to support optimal prescribing, it is critical that prescribers be provided with access to a real-time prescription monitoring program.
Such a program would allow physicians to review a patient’s prescription history from multiple health services prior to prescribing. Real-time prescription monitoring is currently only available in two jurisdictions in Canada.
Before closing, I must emphasize that the negative impacts associated with prescription opioids represent a complex issue that will require a multi-faceted, multi-stakeholder response.
A key challenge for public policy makers and prescribers is to mitigate the harms associated with prescription opioid use, without negatively affecting patient access to the appropriate treatment for their clinical conditions.
To quote a past CMA president: “the unfortunate reality is that there is no silver bullet solution and no one group or government can address this issue alone”.
The CMA is committed to being part of the solution.