STANDING COMMITTEE ON ADMINISTRATION OF JUSTICE
ASSOCIATION OF LOCAL OFFICIAL HEALTH AGENCIES
ONTARIO PROFESSIONAL FIRE FIGHTERS ASSOCIATION
METRO TORONTO CIVIC EMPLOYEES UNION, LOCAL 43
ADVOCACY RESOURCE CENTRE FOR THE HANDICAPPED
CONTENTS
Monday 1 November 1993
Health Protection and Promotion Amendment Act, 1993, Bill 89, Mr Tilson / Loi de 1993 modifiant la loi sur la protection et la promotion de la santé, projet de loi 89, M. Tilson
East York Health Unit
Dr Sheela Basrur, medical officer of health
Marie Klaassen, communicable disease nurse
Association of Local Official Health Agencies
Dr Colin D'Cunha, chairman, medical officers of health section
Dr Doug Kittle, past chairman, medical officers of health section
Ontario Professional Fire Fighters Association
Peter McGough, district vice-president and chairman, occupational health and safety committee
Metro Toronto Civic Employees Union, Local 43
Phillip Micallef, health and safety representative
Advocacy Resource Centre for the Handicapped
Gerry Heddema, legal counsel and AIDS-HIV mentor
STANDING COMMITTEE ON ADMINISTRATION OF JUSTICE
*Chair / Président: Marchese, Rosario (Fort York ND)
*Vice-Chair / Vice-Président: Harrington, Margaret H. (Niagara Falls ND)
*Akande, Zanana L. (St Andrew-St Patrick ND)
Chiarelli, Robert (Ottawa West/-Ouest L)
*Curling, Alvin (Scarborough North/-Nord L)
*Duignan, Noel (Halton North/-Nord ND)
Harnick, Charles (Willowdale PC)
*Malkowski, Gary (York East/-Est ND)
Mills, Gordon (Durham East/-Est ND)
*Murphy, Tim (St George-St David L)
*Tilson, David (Dufferin-Peel PC)
*Winninger, David (London South/-Sud ND)
*In attendance / présents
Substitutions present/ Membres remplaçants présents:
O'Connor, Larry (Durham-York ND) for Mr Mills
Clerk / Greffière: Bryce, Donna
Staff / Personnel: Swift, Susan, research officer, Legislative Research Service
STANDING COMMITTEE ON ADMINISTRATION OF JUSTICE
MONDAY 1 NOVEMBER 1993
The committee met at 1536 in room 228.
HEALTH PROTECTION AND PROMOTION AMENDMENT ACT, 1993 / LOI DE 1993 MODIFIANT LA LOI SUR LA PROTECTION ET LA PROMOTION DE LA SANTÉ
Consideration of Bill 89, An Act to amend the Health Protection and Promotion Act / Projet de loi 89, Loi modifiant la Loi sur la protection et la promotion de la santé.
The Chair (Mr Rosario Marchese): I'd like to call the meeting to order. We are resuming hearings on Bill 89, An Act to amend the Health Protection and Promotion Act.
EAST YORK HEALTH UNIT
The Chair: We have today the East York Health Unit, Dr Sheela Basrur, Ms Marie Klaassen, Ms Linda Shortt and Dr Bryna Warshawsky. You're all welcome to come to the front. The other two, the people I mentioned?
Dr Sheela Basrur: I believe they'll just sit in the audience, playing it safe.
The Chair: That's fine. Very well.
Mr David Tilson (Dufferin-Peel): Before we proceed, I understand that legislative research was preparing a summary of recommendations. I just want to confirm that. I think the committee would find that most useful.
The Chair: I understand that request was being made and we'll follow through on that.
Mr Tilson: So that's coming in due course?
Ms Susan Swift: Yes. Mr McNaught is the researcher who's assigned to this committee. He's had to be in another committee this afternoon so I'm sitting in for him, but I will relay the message from the committee.
Mr Tilson: Thank you. It would just be useful for clause-by-clause discussions.
The Chair: Okay. Sorry. Is it Sheela Basrur?
Dr Basrur: Yes, it's Dr Sheela Basrur. I'm the medical officer of health for the East York Health Unit, in the borough of East York in Metro Toronto. This is Marie Klaassen, who is a communicable disease nurse with the East York Health Unit.
The Chair: You have half an hour for your presentation. Leave as much time as you possibly can for the different members to ask you questions.
Dr Basrur: Okay. Thank you very much to the Chair and members of the committee. We are here today to speak on Bill 89, An Act to amend the Health Protection and Promotion Act.
A synopsis of the health unit's position is that, first of all, the presence of the bill attests to the very real concerns of emergency service workers. Mr Tilson's bill I think reflects the fact that their needs, although we believed they had been met under the current system, were not being sufficiently met according to their perceived needs.
We believe, however, that the bill does not actually address those needs in a manner that will be satisfactory for them and in fact that it creates other problems for public health, for the community at large and ultimately even for emergency service workers if their needs are not being met by the bill.
In other words, we believe that the bill as it is currently written is unnecessary and that alternative measures are needed to safeguard the rights and responsibilities of emergency service workers, to maintain the principles of good public health practice and to safeguard the interests of the public at large.
We have a number of concerns about the bill. I'll preface those by describing what we understand the current problem to be, as it's perceived by emergency service workers. We understand that they have concerns about being exposed to communicable diseases in their line of work and, firstly, they feel the need for assurance about the real risks of disease that they may be exposed to and, secondly, the risks of disease that they may be exposing their family members to.
I also believe that they feel the need for clearer lines of communication between their host agencies and with health authorities, medical officers of health, their family doctors, occupational physicians etc, who can serve as a reliable source of information, advice and support.
Those are very legitimate reasons for their concern. However, it is worth noting that there are many in public health who feel that those concerns, while real for the service workers, are not justified by scientific data, as we presently have it, and that any real risks that do exist are covered by current legislation. Nevertheless, we do believe it is our responsibility, as public health, to work with emergency service workers and to participate in solving their problems with them.
The bill is a tangible example of the political support that has been given to these concerns, but the bill does not deliver the solutions it promises. We feel that there are better ways to address these needs.
I'll outline our problems with the bill, I'll outline some recommendations and then provide responses to any questions the committee may have. I will also submit a written statement to the committee by the end of the week, with the hope of incorporating responses to the committee's questions within that statement.
First of all, it's important to note that the bill attempts to address some needs that already are met with current legislation.
For some infectious diseases where exposure is obvious, such as meningococcic meningitis, in which a sick individual may be transported to a hospital, contact tracing for any exposed individuals, including emergency service workers, would be covered under current legislation. It ought to be happening now, and while there may be anecdotal reports where it has not happened in a timely fashion, that's not because of an absence of legislative requirement. The requirement is there, and public health makes every attempt to follow it where it possibly can.
I think what is not covered by current legislation is contact tracing for chronic diseases that may be of a blood-borne nature; in other words, where a person's getting sick, transporting to the hospital and diagnosis of the disease are not closely linked in time, which makes it difficult for people to recognize all of the opportunities for exposure of unsuspecting service workers to a contagious disease. We believe that Bill 89 does not effectively address that problem either.
We feel that it reassures emergency service workers about their real risk of disease and gives them a false hope, if nothing else. I've heard a number of times that firefighters and ambulance workers etc would just like to know the disease status of the patient they're transporting so that they can feel risk-free or disease-free and so they can reassure their wives and their children that they will also be free of risk.
In fact, we cannot give any kind of assurance that there is no risk in a certain situation. There's no guarantee possible. I think it's an old adage that doctors never say never and scientists never say never. This is another instance here where we can never guarantee that a significant exposure to someone has not occurred, or we can never guarantee that someone is disease-free or infection-free. The absence of notified information to us does not call that person healthy; it just means we have no information. That's why I say that the bill may provide, if anything, a false sense of assurance to emergency service workers who are told that we'd have no information on the disease status of the patient they transported.
The other thing to note is that the advice we will give out will be identical whether or not we know the disease status of the patient. If the person is diseased, if they are not diseased or if we don't know, the advice we give will be the same.
What I would like to do is turn it over to Ms Klaassen, our communicable disease nurse, to describe for you the types of scenarios that we commonly encounter to illustrate that point.
Ms Marie Klaassen: As Dr Basrur has said, I'm the one who takes the phone calls and gives advice to people over the phone about HIV and other communicable infections, as well as dealing with the people with the disease themselves.
The advice that we give people over the phone -- generally the calls are from the general public who have concerns about the school yard or a needle in the park or something like that -- the advice we give to them about exposures is exactly the same advice that we give to a dental care worker who has been poked with a needle in the course of her work with someone who is a known HIV carrier.
Because of the nature of the disease, we have to give the same advice, partly because of the window period of three to six months when the serum conversion in the blood hasn't happened, so they don't know whether they're positive or not themselves. We would speak to them about transmission, about how it happens, what behaviours pass on the infection and assess their actual risk. Often the advice stops at that point. Getting the facts straight and talking about the issues will often relieve people's fears and questions that they had.
We talk about the actual virus transmission, how that happens, what needs to be present for a virus to move from one person to another: There has to be an exit from the body it's in; there has to be enough of the virus; certain body fluids carry more virus than other body fluids -- we talk about what body fluid was in question; the virus has to exist in an environment that is conducive to its survival; it has to be kept warm and not exposed to cleansers or air or any of those things, and it has to have a viable route of entry into the bloodstream of the other person.
We go over all that basic factual stuff, and then we get into testing. The advice is the same again: If people want to be tested, if they feel they're at risk, we'll tell them how to get tested, where to get tested, what their options are, what the implications and ramifications of testing are.
Again, we talk to them about the facts of their risk. The riskiest occupational exposure, by all accounts, is a deep needle-stick injury. The bore of the needle is containing blood in a warm, enclosed environment and is deeply stuck into another person's bloodstream. There have only been 30 cases ever of conversion from that, and only one in Canada. So that works out to about one in 300 cases. If someone is stuck with the blood of someone who's definitely HIV-positive, one out of 300 times they'll seroconvert. It's not a very high rate.
So I'm talking to people about those facts; it can make a difference. If they do want to get tested, we'll talk to them about their options, when testing should happen. They should get a baseline test to ensure they weren't HIV-positive before this incident. If they're HIV-positive now, then that wouldn't be from the exposure that we're talking about, because it takes that time for the body to seroconvert. So we would talk to them about getting a baseline test, one at three months, one at six months and one in a year. At three months, 99% of people who are going to seroconvert will be seroconverted. Generally, it's that three-month time period that we're talking about.
I'll talk to them about precautions they should be taking in the present if they are worried about seroconverting, in terms of their partners, what precautions to take with their spouse, other activities, that kind of thing. I will review prevention with them, assess their understanding and use of Universal Precautions and what they should change or improve on, or go over what they know about it.
A lot of the exposures, once you investigate them, could have been prevented by proper use of Universal Precautions. A lot of times, that's the education that needs to be done. If it's a hep B issue, we'll suggest immunoglobulin and a hepatitis B vaccination.
If a person has been exposed to somebody who we know is HIV-positive, we'll give them the advice that they should do A, B and C, which we just talked about, in terms of getting the testing, taking care of the precautions, practising universal prevention, that kind of thing. If the person who the exposure is with is unknown and refuses testing, we'll offer the same advice, because we have no other option. We can't provide them with false reassurances.
If the person is unknown and consents to testing and is tested, we will still offer them the same advice, because that person could be in the window period before seroconversion. We can't offer 100% assurances that that person isn't in the process of seroconverting and having their blood become HIV-positive. We don't know what their risk activities have been in the previous three months.
After three months, the person who had the exposure can be tested with a 99% degree of accuracy that their test will reflect their HIV status, and there's no need to go back and test the other person.
Generally, the phone calls that we get are more fear-based than fact-based. People aren't exactly sure of the modes of transmission. Just through a discussion of what actually happens, how a virus is transmitted, those basic biological things, then their fear is much reduced and they're much happier. As I said, in the majority of cases, anecdotally through my work, where exposure has happened it's been a case of failure of Universal Precautions.
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Dr Basrur: I think Marie has illustrated to you why we feel the bill is not sound in terms of its principle, because the principle underlying the bill is to provide information on the disease status of the patient, where in fact the disease status of the patient has no bearing at all on the kind of advice that is given and ought to be followed by the emergency service worker. It begs the question of what possible good will come of the bill when it's not aimed at anything that would be different, with the bill or without.
That raises the question of what problems the bill might provide if it is fully implemented. I can think of many problems that might surface, bearing in mind again that the benefit from the bill is likely to be negligible.
I might turn now to the individual sections of the bill. I'll refer to them as 27.1, 27.2 etc.
Subsection 27.1(1) provides for the definition of an "emergency care provider." I would note that this definition is extremely broad, in that it covers any person who takes someone to hospital or who treats or assists a person who later goes or is taken to hospital. It's extremely broad. The application far exceeds the work-related circumstances that prompted the bill and, to be frank, it's a little like slicing a tomato with a chainsaw.
Subsection 27.1(2) deals with the written request to the medical officer of health regarding exposure. This is where a person may make a written request to the MOH. It gives extremely broad notification rights to the general public. Again, we're not talking merely about ambulance workers, firefighters etc; we're talking about anybody who is involved with a person who somehow gets to a hospital. They have the right to require the MOH to divulge the disease status of that person.
We feel that the notification rights to the general public are not balanced with any demonstrable risk that might occur through work or through any other means. It could cover, for example, a taxi driver who drives up to Toronto East General Hospital, which is one of the hospitals in our jurisdiction, drops a person off at emerg, feels that he might be infected and somehow finds a way of requiring the MOH to tell him whether that person was diseased, whether or not it was a significant exposure.
I would also point out that this process would be open to abuse or to frivolous requests from people who are curious or malicious in some way.
I would note particularly that their actual involvement with the person is unsubstantiated. When you have an ambulance worker or a firefighter, clearly their professionalism and their reputation depend on giving a truthful report of their exposure. If you have someone who is a disgruntled family member or a neighbour or a stranger off the street, they can easily come forward and say, "I gave CPR to this person and I think they're infected," when in fact they've not really had an exposure, and there's no way of proving that they haven't. In the meantime, the MOH is compelled, under this law, to divulge that information, and we think that's a very dangerous thing for the government to do.
We would finally say that the law is a blunt instrument in that it's not exposure-based. Transporting or assisting people is usually a no-risk situation. It does imply that the MOH can make determinations of what is a meaningful exposure but gives no guidance to the MOH nor certainty to the workers as to how that would be done.
I turn to subsection 27.1(4), where the MOH gives written advice about the exposure and the name of the disease or agent, if applicable. I would note again that the medical officer of health would be compelled to release sensitive personal information without the consent of the patient, which is an unusual step to take if we don't have compelling reasons of personal health and safety, and I believe in this case you might not.
You would be releasing information to persons who are unknown to public health, unknown to the hospital, potentially even unknown to the patient. These people would be impossible to control in the sense that you would have nothing but their self-reported name and address and telephone number as to locating their whereabouts if the information was misused in some way. In any event, these people would be under no obligation to safeguard the information they receive. They're not bound by a professional code of ethics. There's not a job they fulfil where protection of personal privacy is a responsibility under that.
It's a very open-ended system and it's really open to all kinds of abuse that I think would be beyond the intent of this legislation but which are very real possibilities for us. In other words, there's a total contradiction in this bill of the principles on which medical nursing and public health practice is based and the principles also that are contained currently within the Health Disciplines Act, the Health Protection and Promotion Act, freedom of information etc.
One of the major risks we foresee with this is that it could drive the disease underground. I think many of you would be aware of the government's push for anonymous testing, largely because people were afraid to come forward for testing that was based on nominal reporting, or reporting to authorities like myself of name, address, phone number etc. Anonymous testing was a way of getting around that fear, because they wanted people to come forward for testing because they wanted people to get counselling, wanted them to get early intervention etc and other support services they might need.
I would suggest that if a person thought they were infected with HIV and knew that if they were transported to a hospital someone could find out what their disease status was, they might not want to go and get tested. They might not even want to get to the hospital if it was an unusual circumstance.
We think it's going to be detrimental not just to public health and to emergency service workers; we think it might be detrimental to the community at large. We feel that a greater number of people infected increases everyone's risks. We ought to be supporting the system that currently is in place, rectifying any weaknesses that currently exist and making the system stronger, not making it weaker in unintended ways.
Section 27.1(5) provides for the MOH to give written advice if they're unable to make a determination. Again, I would emphasize that this is the most likely scenario, since knowledge of their disease status depends on a person first of all being tested at all, that the test was correct and that they had disclosed the results that it was a nominal test. There was a duty of the hospital administrator to record info on all emergency providers.
This is anybody who walks into a hospital with someone in tow. It covers anyone who was involved in any way with the person, regardless of how long ago their involvement was, because you'll note that there is no reference to involvement with the last two weeks or immediately transported the person to hospital. It's not a time-sensitive clause. It makes an administrative nightmare for hospitals and ultimately it's unworkable or very expensive if they do try to put it into practice.
The Chair: Dr Basrur, if you were to complete your comments now, there would be time for each member to ask you one question. Otherwise, there won't be time for that either.
Dr Basrur: Okay, perhaps I've said enough and anything I've not said can be in the written statement.
The Chair: One question per caucus.
Mr Gary Malkowski (York East): Thank you very much to the East York Health Unit. A very impressive and very comprehensive presentation; lots of information in there and very valid points that you raise where you talk about emergency care and provision to people and the misinformation that is currently out there; that this might just go a long way to providing further miscommunication on how a communicable disease is spread when in fact we have legislation now which is effective which deals with this. I appreciate your valid points.
My understanding of some of your comments is that you don't recommend Bill 89 be passed. What kind of alternative or suggestions would you say to alleviate some of the fears? Do you have any recommendations or any kinds of ideas we could then offer to emergency service providers in terms of taking care of people with HIV or others?
Dr Basrur: Absolutely. We believe their concerns need to be addressed and not swept away. The bill itself does not properly address those concerns. We also are aware that the public health branch, in consultation with the emergency service workers, has developed a set of proposed mandatory guidelines as a supplement to the set that currently exists. We believe those are a viable alternative to Bill 89. We believe those guidelines need to be further worked upon. We would view them as a work in progress, if you like, and a very good start; perhaps not the final version.
We note specifically that they have involved emergency service workers and that they have already given their support to the guidelines. We would lend our support to those on the understanding that they would continue to be worked upon with the involvement of all key stakeholders.
I would note finally that the guidelines do address a need, and that is the provision of a clear and consistent framework for communication, education and the outline of expectations among public health and emergency service workers. That, to date, has been missing in the sense of clear and consistent across the province.
Mr Malkowski: Thank you very much; a very productive answer.
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Mr Alvin Curling (Scarborough North): Thank you for your presentation. It's a pity we didn't have more time to ask a lot more questions. As you express yourself, you say it is unnecessary to have this bill because it may be counterproductive.
Let me ask you from another point of view, if emergency workers are saying that they are concerned, and Mr Tilson put forward the bill because there are concerns within that community or those workers, would you say it's because of lack of training? Because these are the people who are much nearer to the situation than even the general public; that is, firefighters or nurses or whoever is involved, ambulance drivers or so, in this respect. Would you say that therefore why this has come about is that there is a lack of proper training and information within the training process?
Dr Basrur: I would say that the fact that this bill was put forward and supported in the way it has been reflects the fact that there is a current need and that much of that need can be addressed through further education and training.
In East York, for example, we did do in-service training with both the police and the East York firefighters in 1988. We have many areas to cover in public health, so we've not gone back since then. I think it would be incumbent upon both us and the firefighters in East York to work together to continue to keep that training current and up to date because of turnover, because of changes in practice and knowledge etc. So training will be a very important component in addressing these concerns, because as Marie pointed out, many of the questions that come forward are fear-based rather than fact-based.
The Chair: Thank you.
Mr Curling: I thought I had a supplementary.
The Chair: Combine it in one question. Mr Tilson.
Mr Tilson: I will tell you that the bill, as you obviously know, was introduced by myself. It was introduced not in a reactive fashion; it was introduced in a proactive fashion. In other words, stats are being put forward as to the minimum chances of this and the minimum chances of that, and notwithstanding the fact that there have been at least 27 states in the United States, as well as the United States Congress, that have enacted legislation requiring the notification of emergency response personnel, so this is not a novel idea.
I'll be the first to admit that this bill may need some work with respect to definitions. I'm a layperson. I don't know anything. I don't have the resources of the Ministry of Health. But speaking in general principles, assuming that improvements could be made to the bill in definitions or whatever, I will say it was intended to include the good Samaritan, the off-duty police officer, the person who isn't going to show up on a medical report or a report, who just helps, who is there. It is intended to include those people. It is intended to be as broad as that.
My question to you has to do with the guidelines, which you have indicated are in the draft stage. I must say it's taken two years to get to this stage, because this whole issue arose at least two years ago. Would you have any difficulty, if you support the principle of mandatory guidelines, of the mandatory guidelines developed by the Ministry of Health, that portions of those guidelines be incorporated into legislation?
Dr Basrur: To be honest with you, no, and I say that because legislation is much more restrictive in terms of our capacity not to interpret but to modify in light of experience. When we have mandatory guidelines that are issued by the branch we have opportunity to participate in the drafting of them. There is a mandatory program advisory committee that oversees implementation and recommends changes to program standards.
It's a much more consultative, collaborative and flexible process by which those can be developed. Here we're working with the constraints of a bill that is already in place, and in order for it to not -- I don't know the proper process -- die on the order paper and so on, I wouldn't foresee a proper process that would really make this bill meet everyone's expectations in the time frame that you've got and keep it that way. I think with the guidelines you can do that.
Mr Malkowski: On a point of privilege, Mr Chair: I would like to emphasize to the member for Dufferin-Peel that I think this is an excellent presentation, maybe a good learning experience for you this afternoon. I wish to congratulate Dr Basrur for her excellent presentation.
The Chair: Thank you very much for the comment. Dr Basrur and Marie Klaasen, thanks very much for your presentation and your participation in these hearings.
ASSOCIATION OF LOCAL OFFICIAL HEALTH AGENCIES
The Chair: We'll invite the Association of Local Official Health Agencies, Dr Colin D'Cunha and Dr Doug Kittle. Just as a reminder, you have half an hour. It is useful to allow for as much time as possible for the members to ask questions.
Dr Colin D'Cunha: We'll give the committee all the time because I plan to speak fast for five minutes and have you focus on what's in front of you.
My name's Colin D'Cunha. I'm acting medical officer of health for Mr Curling's area, Scarborough, and also chairman of the medical officers of health section of ALOHA. Dr Kittle is the medical officer of health for part of Mr Tilson's area and he's a past chairman of the section.
By way of background for a minute, I will speak to the organization, get into the details of the presentation and then entertain questions from the committee till the time runs out.
ALOHA is the umbrella organization representing 42 health units. It has two sections and a number of affiliate organizations. The two sections are the board of health trustee section and the medical officer of health section, and amid the affiliates most disciplines working in a health unit are represented from the management standpoint. That then is the organization, and when the two of us speak, we are addressing concerns and perspectives from the membership at large; namely, all 42 health units as distinct from individual medical officers of health, whom I gather are scheduled to present on a one-to-one basis depending on who has indicated that interest.
When we look at the whole area of what Bill 89 is getting into, it's essentially touching on areas of emergency workers' right to know. From our perspective, there are essentially two predominant routes of exposure by which communicable diseases may, and I stress the word "may", be spread. I'll address comments in terms of risks of exposure when I talk about each one.
The two basically are the respiratory route and the blood-borne route. The faecal-enteric route is not normally seen in an emergency worker care-giving situation.
When we look at the respiratory route of exposure, the risk is low, virtually minimal, and there are only two diseases for which there may be some concern, and I stress the adjective "some" before "concern": meningococcal disease, of which one has seen lots of activity around, particularly partially in Mr Tilson's riding, and tuberculosis. I stress again that in tuberculosis the risk is very low for having transported an infectious patient from point A to point B. It's far more in situations of close contact, sharing the air space for prolonged periods of time.
The other route of exposure is blood-borne in an emergency care-giving situation, and the two diseases predominantly of concern are hepatitis B, for which there is a vaccine available -- there is a current National Advisory Committee on Immunization for Canadians recommendation that all Canadians are candidates for immunization -- and HIV or AIDS, as it's commonly known.
If all people, consistent with the NACIC recommendation, are immunized against hepatitis B, I propose that hepatitis B is, relatively speaking, a non-issue. It's something that I gather this government is looking at for implementation some time in the near future, if I can quote the minister's letter to me in my capacity as chairman of the medical officers of health, a letter that I received last week, which then brings me specifically to the situation around HIV-AIDS.
In broad terms, one has to balance the need of the worker's right to know versus the individual's privacy versus the risk of transmission, and in the Canadian context there is virtually no risk for transmission in these situations. The only Canadian occupational case of HIV transmission occurred in a laboratory health care worker.
When you look at the protection of the individual's right to privacy, I am sure that you will want to hear from the office of the privacy commissioner, because when I look at what that particular individual had to say when commenting on HIV-AIDS and the need for privacy, the privacy commissioner had lots of concerns on maintaining confidentiality in that area.
When I bring it explicitly down to an individual who is infected with HIV who gets transported, where a worker may believe that he or she may have been exposed and contacts an MOH, what one is asking an MOH to do is to violate that confidentiality if the MOH in fact knows.
Given the route of anonymous testing that is proposed, and more or less in place in subcentres around the province, our concern is that there may be a false sense of security conveyed to the individual worker because that particular case has not been reported. The other situation is that there is a window period when somebody is infected, capable of transmitting the disease and not testing positive where in fact false assurance may be provided to this individual should the bill become law.
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Finally, it is our position that the Health Protection and Promotion Act, as it is presently worded, adequately protects the general public and emergency workers.
The one observation I'd like to make before I close and then entertain questions from the committee is that this is essentially an occupational health issue. This is a want expressed by the emergency care workers. It has to be properly assessed. If members of the House are keen on addressing this want and it manifests itself from perception on to need, as properly assessed, one is probably wise to consider putting resources into occupational health in the form of worker training etc.
For the record, I think I should say that the Scarborough health department has offered training to the fire department, having already done training with the police department for the last two years in a row, and we're still waiting to get on the agenda to talk about transmission of communicable diseases. So from my local perspective, as an anecdote, I just share that with the committee for the committee to take into account.
With that, we'll now open up to questions from the committee.
Mr Curling: Thank you very much, Dr D'Cunha and Dr Kittle, for coming in and making this presentation because your presentation is almost similar to the previous presenter's. I then ask the question again, though, because your last statement surprised me. I want to go back to training for the emergency workers.
I would have thought, as a matter of fact, for the previous presenter and yourself, that it would be a compulsory part of the training program that this be done where emergency workers were working with these communicable diseases, that they be trained in the matter of knowing what the reality is, more than all this perception that goes out. If they feel like that, can you imagine, as I said, the general public feeling this way?
Just coming in on your last part, why would those areas that you ask to put your part of the training program in resist that contribution? Is there some explanation for that?
Dr D'Cunha: I don't have any insight, other than to once again stress to committee that for the last two years, on the record, I have been known in Scarborough to consistently say, "I am willing and my staff are willing at any time to come in and speak on transmission of communicable diseases with my local fire department." The fact is that till today I've not been taken up on that offer and I can only go with the fact. I can speculate on a whole variety of reasons.
Part of the training program that emergency workers such as firefighters, ambulance attendants and police do does cover elements of infection control. However, down the road there is a critical need for refresher training. There is a critical need to address ongoing new developments as they occur in health and medicine, no question.
I think part of the problem also is that two of these three services are at the local level. If the provincial government consistently continues to download and require more and more training without making dollars flow with that, you have a problem. As you are well aware, in Metropolitan Toronto the local health departments are only funded to the extent of 40% by the province and 60% by the local property taxpayer. In the rest of the province, 25% is paid for by the local taxpayer. When you look, this is an additional financial burden that's going to be passed on.
Mr Curling: You're saying that because of lack of funds --
Dr D'Cunha: I can't speak for the other departments, but I can speak definitely in broad terms. If this is going to involve significant work for public health departments, I think going along with that is a commitment on the part of the House to put more money there.
Mr Curling: It continues to be frightening, as you say, that because of lack of funds -- let me go back to that -- the kind of training that should be compulsory is not being done. Therefore, the fear that is perceived in the minds of the emergency workers is reflected in the community. If the police officer, firefighter or ambulance attendant is fearful about this, can you imagine us in the general public?
My feeling then is that there is a lack. Again, we always say we're not being partisan in this matter, but it's a matter of serious concern that a lack of funds would have caused this fear to generate Mr Tilson bringing forth a bill. Because the fear is real out there, whether or not people being infected is real. It doesn't seem so; that's what you doctors are saying. But the fear is real, and sometimes it's worse to deal with that fear. Furthermore, I'm saying that it's still a lack of funds, and the government is not acting upon this. It should be law, it should be compulsory that these people are trained in this manner.
Dr Doug Kittle: If I may respond to Mr Curling, I wish it was as simple as lack of funds, but I'm afraid it isn't. It's a situation of in-servicing and updating and refresher, and our departments are available to emergency worker services within our areas to do just that. We can be proactive, but we still require an invitation.
Mr Tilson: As the originator of the bill, I can tell you that I have received an untold number of letters of support from all types of care givers who are very concerned about this issue. I'm just flipping through some of them trying to make notes: the Metropolitan Toronto Civic Employees Union, police from all across this province, firefighters from all across this province, nurses' organizations, ambulance people, undertakers, hydro workers.
In spite of the scoffing of my friend Mr Malkowski over here, I can simply tell you that the care workers in this province are very concerned about this issue and, quite frankly, are insulted by people coming and saying that they don't know what they're talking about. They have grave concerns.
The bill does go beyond the care worker. It's intended to go beyond the care worker. It's intended to go towards -- the previous delegation referred to taxi drivers, to the good Samaritan. It's intended to cover everyone who comes in touch or could come in touch with a communicable disease. People are entitled to know, because of the effect it could have on their friends, co-workers, members of their family and any other person who could be at risk. So early detection of potential communicable diseases may reduce the risk of transmission.
Now, you mentioned that some of these diseases may be remote, and I'm not going to challenge your knowledge. I will say it's my understanding, however, that the hepatitis B virus, for example, is remarkably resilient and can survive seven days outside the body. I'm not going to get into a medical debate, because you'd win. I'm simply saying that care givers across this province are concerned and so are members of the public.
Dr D'Cunha: My only observation on hepatitis B -- and don't take my remarks out of context. I said if this province follows the national recommendation on universal immunization for all Canadians, and you can have the Hansard recorder read back my record, it's a non-issue because after you're immunized the order of developing active immunity is to the extent of 95% to 97%. It's in that context that it's a non-issue.
If the recommendation is not followed through, very separately you should know that public health departments, certainly in the case of the emergency care workers, have made recommendations predominantly for hepatitis B immunization among those occupational groups that you mentioned. I'd just like to clarify that so that my remarks in the context of hep B are not taken out of context. You can check back with the Hansard record.
Mr Tilson: I'm not going to challenge you on that, sir. The fact of the matter is I understand there's in the neighbourhood of 60 diseases that have been designated communicable. The four major ones have been listed: tuberculosis, meningitis, hepatitis and HIV. Some of them may be more contagious than others; some of them may last longer.
All I'm saying to you is that whether it's the police officer or the good Samaritan or the taxi driver, those people are entitled to know, as are members of their families, whether or not they have come into communication with someone who has a communicable disease.
The bill does not ask for the identification of those individuals. I would be prepared to concede that the bill needs work with respect to amendments and I would look forward to suggestions from people such as you as to potential amendments. But I can only tell you that concern is out there. If the people who are responsible for health in this province are simply saying that there's no problem, I can tell you that every care giver in this province disagrees with you.
Dr Kittle: Yes, and I agree with you too, Mr Tilson. I would not belittle the concern that the emergency care workers may have, but I think we're losing the greater picture here, and that is that there is current legislation before us that we presently act under, the Health Protection and Promotion Act, to which this is a proposed amendment. That in and of itself is excellent legislation which provides us as medical officers of health the opportunity to do consistent and effective contact tracing when we are apprised of someone who has been reported as having one of those 60 reportable diseases, and we follow through with that.
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To the best of my knowledge, there is no problem with the current legislation. There hasn't been a fault. There hasn't been someone who has slipped through who has acquired a communicable disease as a result of a faulty follow-through of the current legislation. If there was, I would be the first to say, "It's broken; let's fix it." I don't see and I'm not convinced that it's broken, but on top of that, I also agree that there is a perception out there of a lot more risk than in reality there actually is.
So we have a job to do. We have a job to work proactively with our emergency care worker departments in our jurisdictions to see that they are appropriately assessed as to what constitutes a viable exposure, what constitutes a viable transmission and what they can do proactively, such as immunization in the case of hepatitis B, to protect themselves before an event should occur.
Mr Tilson: The difficulty, as I understand the current legislation, is that it is discretionary.
Dr Kittle: In what way, sir?
Mr Tilson: My understanding is that it's discretionary as to what the medical officer of health --
Dr Kittle: Could you explain "discretionary" there, please? I'm a bit confused.
Mr Tilson: Well, I don't have this legislation in front of me, but my recollection of it is that it is discretionary as to whether or not that information can be made available. My question is really, do we have to wait for something to happen? If we know it could happen, isn't that the real issue, not that the chance is or is not remote but the fact that it could happen? I mean, there's nothing really wrong with medical administrators keeping records.
Just allow me briefly, Mr Chair. How the bill works, as you know, is that hospital administrators would be expected to maintain records as to who provided emergency care to any particular person. The emergency care provider, be it a professional or a good Samaritan, can make a written requirement -- I'm oversimplifying what is intended. Finally, the medical officer of health would respond in writing confirming whether that person was so exposed and, if so, to what disease. What's wrong with that?
Dr Kittle: The problem is that we're working from the supposition that a disease might be present, back to confirming that, rather than identifying that a disease is present and contacting the people who have had appropriate contact with that disease, which is the proactive, current approach which the Health Protection and Promotion Act mandates us to do.
If we take a scenario here -- and this bothers me most. Let's say emergency worker X delivers John Doe to the emergency department. Then, for some reason only known to emergency worker X, he's suspicious that John Doe might have a communicable disease, so he puts this thing into process. Then it comes to my attention.
It would have come to my attention, however, if there was a communicable disease that I knew about in the first place. I would have been contacting emergency worker X if John Doe was known to have a communicable disease, because that's part of what we do under the Health Protection and Promotion Act. Okay? But the other way around means that I have to ascertain whether John Doe is or is not infectious. If I have no indication that he is infectious -- he may well be carrying the HIV virus, he may well be carrying the hepatitis B virus, but nobody has checked his blood for that because he hasn't presented with that type of illness that would lead the physicians to ask for that type of test -- what am I going to say to emergency worker X? I don't know. I'm sorry. Basically, I cannot force the individual, John Doe, to have a hepatitis B screen, I cannot force him to have an HIV screen, so what possible information can I give to this emergency worker which he wouldn't have before? If I did slip that information through to him, he knows the man's name is John Doe and I have told him basically that the guy's got HIV. I have therefore gone against all of the privacy commissioner's demands on me for slipping information. I don't know how else it can be done.
Mr Larry O'Connor (Durham-York): We've heard from a lot of people to date. We have another full day of hearings tomorrow. It seems the preference is for the guidelines as a viable option to this. I guess my colleague here has a bill before us that has been brought forward because of concerns raised by emergency health care people, firefighters, whatever. A number of people have approached him.
Would you have concerns about putting anything like this into legislation that may not have the flexibility for changes? The guidelines may offer a little bit more flexibility to offer even greater protection to the people he's concerned about. My concern is that you put something in there, that part is adhered to and you don't actually offer flexibility that will protect the workers he's trying to protect.
Dr D'Cunha: If the choice is between the bill and the guidelines, very clearly the guidelines look more attractive, on the clear understanding that the guidelines need a lot more work to make them practically workable in the context of other legislation, and on the clear understanding that what's fuelling this is a predominantly occupational health issue, and on the understanding that some resources have to come along with that.
Mr O'Connor: The information-gathering through the hospitals seems to be a real concern, that they're going to have to have enormous staff just to deal with the administration of the potential possibilities of any of 60 reportable diseases to date. Do you feel it would also have an impact on yourselves?
Dr D'Cunha: Either way, there's going to be an impact on us. The question is, do we pull someone else in to take the same financial hit as us or not? And clearly, in these times of fiscal restraint, if you are going to require work, far better to have only one agency do the work rather than have four. But you've got to clearly understand that you are asking the public health sector to pick up something extra. With that have to come resources. If there's any way I can summarize it, that's the way I'd summarize it.
Mr O'Connor: You have that responsibility today, though, for the --
Dr D'Cunha: We already have that, but any additional, because theoretically, what the designated officer in the guidelines that you have before you in draft form is doing is an occupational health function. If you are going to legislate something, legislate a better occupational health requirement on the part of all the emergency care givers. That, of course, won't address Mr Tilson's good Samaritan acts.
The Chair: Thank you, Dr D'Cunha and Dr Kittle, for coming today and giving us your presentation.
Dr Kittle: Thank you very much.
ONTARIO PROFESSIONAL FIRE FIGHTERS ASSOCIATION
The Chair: I'd like to call upon the Ontario Professional Fire Fighters Association, Mr Peter McGough. Mr McGough, you have half an hour for your presentation. You might take 10 or 15 minutes to talk about your concerns and leave time for the members to ask you questions.
Mr Peter McGough: Obviously I won't read through the entire brief. I'll leave some of the appendices for you to look at at your leisure. But to try to sound somewhat eloquent, I'll read from some of it. I can begin any time?
The Chair: Any time.
Mr McGough: My name's Peter McGough and I'm a district vice-president of the Ontario Professional Fire Fighters Association as well as chairman of the occupational health and safety committee. I'm a full-time firefighter holding the rank of captain with the Kitchener fire department, where I've been employed for the past 20 years. I'm an active firefighter and this issue that we're talking about is something my crew and myself deal with on a daily basis.
The Ontario Professional Fire Fighters Association represents approximately 4,500 full-time firefighters from 53 fire departments across the province of Ontario. Those departments are listed on pages 2 and 3 of the brief.
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The members of the Ontario Professional Fire Fighters Association would like to take this opportunity to thank the members of the standing committee on administration of justice for allowing us to appear before your committee to voice our support in principle for Bill 89, An Act to amend the Health Protection and Promotion Act.
Since the mid-1980s, the OPFFA has been mandated through convention action, as well as the individual concerns of our members, to pursue the appropriate legislation and/or regulations that would allow our firefighters to be made aware of information related to exposure to both hazardous and toxic substances as well as contagious or communicable diseases.
After years of countless presentations and a myriad of correspondence to all levels of government, we were delighted to be informed of Mr Tilson's initiatives with respect to the issue of right-to-know in the area of communicable disease notification through his private member's Bill 89.
From the outset, a major focus of our efforts has been the proper notification of firefighters when they have been exposed to a patient who is known to have or can be reasonably suspected of having a life-threatening or disabling disease. Speaking specifically to this issue, we have advocated the desire of firefighters for appropriate, confidential disclosure of life-threatening or disabling respiratory and/or blood-borne diseases.
Firefighters from across the province are exposed on a daily basis to reportable life-threatening or disabling diseases. Not only is society changing, but the traditional role of the firefighter is also changing. In many communities, firefighters, police officers and ambulance workers all respond to medical emergencies in a tiered-response system which sends all three services to any life-threatening medical emergency. For most fire departments involved in this system, emergency medical calls now account for one third to one half of all the responses.
With the increased call volume comes the increased threat of exposure. This increased exposure, coupled with the increasing number of carriers in the aforementioned category of diseases, has placed firefighters in a most unenviable position. On many occasions, the only indication that a firefighter might have regarding exposure to a communicable disease is an anonymous telephone call from the local hospital emergency ward or a brown manilla envelope that shows up at the fire station. This scenario as often as not provides inaccurate information as well as accurate. There is presently no way for us to inquire and find out for certain if such information is correct. We believe that Bill 89, with certain amendments, is the first step in obtaining that information.
There is a recent case in Ontario where the fire department responded to a medical call which subsequently turned out to be the beginning of a fatal outbreak of meningitis. The firefighters involved found out about their exposure after reading about the fatality in the local newspaper and realized they had worked on that individual. In other instances, entire pumper crews have been removed from service after a medical call, quarantined and decontaminated, all as a result of erroneous information.
Unlike the controlled atmosphere of a hospital setting, where the necessary precautions can be taken to preclude the spread of disease, in most cases firefighters are unable to protect themselves adequately due to the nature of the tasks and the locations and conditions in which they must be carried out. Whether it's the firefighter rescuing a victim from a fire, extricating a patient in an automobile accident, performing CPR on a vital-signs-absent patient or assisting in other emergency functions that they perform, the potential for contact is enormous.
We as firefighters believe in Universal Precautions to prevent or lessen the chance of contact with the body fluids of our patients. They must be practised without hesitation or thought no matter what the circumstances. However, Universal Precautions can be and are compromised because of the settings that we work in. There's no way around it.
When a firefighter is exposed or believes he has been exposed due to the compromise or failure of Universal Precautions, it is not just the firefighter who has a concern; it is also the firefighter's family that is potentially at risk. Unthinkable tragedy could occur if a firefighter were to expose his family and loved ones to a life-threatening or disabling disease. The only way to prevent this from happening is the prompt notification of that firefighter if it is apparent that one of the patients he had worked on had any of the aforementioned and the worker experienced a compromise or failure of Universal Precautions.
It has been stated by opponents of this bill and the mandatory guidelines that any system of notification would ultimately lead to a decline in the use of Universal Precautions. We view this premise as absurd and compare it to a normal fire response by any fire department. Firefighters always wear their full protective clothing ensemble to all fire alarms even though they may turn out to be false. We always prepare ourselves for the worst and work backwards from there.
We have a deep concern for respecting and protecting the rights and privacy of the patients with whom we come into contact. We certainly do not want to infringe on the rights of these individuals and we do not want to know who they are, but only to be informed if the medical community becomes aware that they have a specific, reportable life-threatening or disabling respiratory and/or blood-borne disease. This will allow the firefighter to take the necessary precautions or start required treatment.
Along with what we believe is our right to know in situations like these goes a responsibility to educate ourselves to be sensitive to a patient's need for anonymity, particularly dealing with freedom of information and protection of privacy aspects.
We believe that to ensure the complete confidentiality of any information obtained under the authority of this bill or any other initiative the bill should be amended to specifically ensure by statute that the firefighter, as well as any other emergency response worker, maintains the strict confidentiality of any information obtained.
At present it appears we are faced with a double standard. The firefighter, other emergency response workers, co-workers and family are not afforded the same rights as their patients. We realize --
We had that siren piped in just for the effect.
Mr O'Connor: Well done.
Mr McGough: Thank you. That was the hardest part to do in this whole effort.
We realize the sensitive nature of this matter as well as certain barriers relative to confidentiality. However, we strongly believe that the health of a firefighter and that of his family must be taken into consideration.
We believe that the spirit of Bill 89 is intended to provide such protection to the firefighter, police officer and ambulance attendant as well as the private citizen who stops to render assistance in an emergency.
As you are aware, at the present time the Ontario Professional Fire Fighters Association, as well as other emergency response professionals and organizations who sit as members on the public safety services liaison committee, have been working with Dr Richard Schabas, chief medical officer of health for the province of Ontario, and members of his staff, to develop what has come to be known as the Mandatory Guidelines for the Notification of Emergency Workers, which will be enforced under section 5 of the Health Protection and Promotion Act.
The Ontario Professional Fire Fighters Association supports the efforts that have been put into this process and sincerely thanks Dr Schabas for the remarkable job he has done in preparing these guidelines.
We believe the provisions as outlined in the guidelines will address most of the concerns put forward by the Ministry of Health and those concerned with potential breaches of confidentiality. However, a major concern of the guidelines as they now stand is the permanence of such an effort and whether the guidelines as we have proposed will ever see the light of day.
Representatives of the public safety services liaison committee who worked on the subcommittee that developed the guidelines, myself included, attended the Ministry of Health/medical officers of health fall meeting on October 27, 1993, where the mandatory guidelines were discussed in front of a gathering of medical officers of health from across the province. Their comments on the guidelines, from those who spoke, ranged from "totally not needed" to "a complete waste of time."
Given such comments by the people who are to implement such a system, my confidence regarding the final outcome and disposition of the guidelines is not very high since that meeting.
As a result of the aforementioned, we would propose that the mandatory guidelines for notification of emergency workers, instead of being attached under section 5 of the Health Protection and Promotion Act as originally proposed by the Ministry of Health, be added as an amendment to Bill 89, An Act to amend the Health Protection and Promotion Act.
This would allow for the addition, among other things, of the designated officer as outlined in the guidelines, which we believe is the critical component for screening the unnecessary inquiries and the catalyst for making the system work.
At the present time, this protection in one form or another is afforded to firefighters and other emergency response workers in the United States; I won't go through all those individual states. The question we'd like to ask is, why can we not provide our professionals with the same level of protection as our American counterparts?
We'd ask you to consider the remarks of the Honourable David Christopherson, Solicitor General for the province of Ontario, in a letter dated July 13, 1993, and addressed to our association, and Mr Mike Farnan, the NDP member for Cambridge, who spoke in favour of Bill 89 during second reading on December 3, 1992.
Mr Christopherson wrote:
"I recognize the concerns of firefighters and support the principle of Bill 89, provided that notification is limited to specific reportable communicable diseases and does not compromise individual rights to privacy."
Mr Farnan said in the Legislature:
"We are all potentially dependent on emergency care givers, be they firemen, ambulance drivers, prison guards or even just bystanders with some Red Cross training. We want to believe that they would take action to save our lives should the need arise.
"Emergency care givers are people who are willing to take extraordinary risks to save lives and protect individuals. It hardly seems unreasonable that we should give them the information that will help protect themselves and their loved ones, especially when we can do so in a way that protects the privacy of the person needing care."
When you or your families need us, we're there. During those times of need and urgency you trust us to do the right thing to help, protect and, if need be, save the lives of you and your families. Please give us the same consideration and trust us with this information. We will not abuse it.
We respectfully request the standing committee on administration of justice to support Bill 89 in principle and to recommend the appropriate amendments to make the legislation workable within the parameters as detailed in our submission.
I'd like to thank you today for allowing us to make this presentation before your committee.
The Chair: Thank you. Mr Tilson, five minutes.
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Mr Tilson: Thank you, sir. I appreciate your coming today. Most of the delegations that have been to see us so far have been health officials, medical officers of health. I can tell you that to date I am being killed on this bill with respect to those people. Even Mr Malkowski, who is normally very supportive of everything I say, is very cynical with respect to the care giver.
They're saying such things as: "The transmission of communicable diseases is remote. There's no real problem. Everything's okay. There's too much bureaucracy. It's going to be too expensive." In fact, they simply say -- not you personally -- in a polite sort of fashion, that you, the care giver, really don't know what you're talking about, that it's not a serious problem.
They start asking for specific examples of where there are problems, and their comment is there are none or very few, if any. Their comment is: "At the very least, all we need are mandatory guidelines. We don't need any legislation." Can you comment on that?
Mr McGough: We were involved with the mandatory guidelines process from last May when we were approached by the Ministry of Health. The criteria or the format that we were looking for to provide our people with some type of information when we respond to these calls seemed, by and large, to be addressed by the guidelines, but our view has always been that if it's not ensconced in the legislation, if it's not a regulation that's enforceable, it won't get done. There will be some very progressive fire departments that will move ahead and make sure that all their people are taken care of but, by and large, it just won't get done.
I was very supportive and I still do support the concept behind the mandatory guidelines and the things that are in there we were looking for with respect to the designated officer, that sort of thing, but when we went to the Ministry of Health's meeting last week, the impression I got from those public health professionals who got up and spoke to us was that your comments are exactly what they said to us, that we don't need it, it's a waste of time, things along that line.
Obviously, we don't believe that. We are very cognizant of the fact that when you look at the United States, for an example, if there are any, there are very few reported cases where an emergency service worker has developed, let's say, HIV or AIDS as a result of the performance of their duties. There are cases where they have developed hepatitis B, things like that.
If I can just deviate for one second, I think one thing a lot of people think is that we're in this to find out if we've been exposed to AIDS. Personally, and from the information that we transmit back to our people, AIDS or HIV is down the list of the things that we're concerned about. I'm more concerned about hepatitis B than I am about HIV.
I think another thing people think -- when we're out looking for this information, we're not looking to have every person that we come in contact with, with a valid exposure, tested to see if they've got something. We're only interested in finding out the information that the medical practitioner who treats the individual may come across during that treatment, if it's of some concern. We're not out there looking for a carte blanche to test every party we come across.
The Chair: One last question.
Mr Tilson: We've had two groups of medical officers of health come to the committee this afternoon. One or both of them, at least one of them, has said that the mandatory guidelines need more work. Is there something else that we're not hearing?
I must confess that this topic, as I understand it, has been on the back burner at least, the far-distant back burner, for a number of years. How much work do you perceive in your working with the Ministry of Health that the Ministry of Health needs to develop the final mandatory guidelines?
Mr McGough: There's no doubt in my mind that the mandatory guidelines came about as a result of your bill. We've been after this for a great number of years. As was mentioned last Friday by the other firefighter representative, it's been many years that we've been working on this, and if it wasn't for the fact of your bill coming forward, there's no doubt in my mind that we would not have the mandatory guidelines.
That having been said, we thought the mandatory guidelines were a good start, like I say, until last Wednesday. There were a lot of comments made with respect to going back to the drawing table, to working on the mandatory guidelines.
I have to say I have a lot of respect and confidence in what Dr Schabas did in a very short period of time. The man is a tremendous go-getter. However, he made some comments here last week when he made his presentation that surprised me, and they were not my understanding of one of the premises of the mandatory guidelines.
He mentioned that if you had a firefighter who had a concern about a valid exposure, he would contact his designated officer within his department, who would determine if that was valid. If it was, that designated officer would approach the local medical officer of health, who would then in turn, within the 48 hours, get back to the designated officer.
I was under the understanding that if that medical officer of health was able to determine that the individual had a specific communicable or respiratory disease that fell under the guidelines, he would report that back to the designated officer, and that if he didn't know, what he would report back would be some generic, "This is what you should do." If they weren't able to find out, they'd report back the generic information: "If it's this, this or this, you should take these precautions. Don't do this, don't do that. See your family doctor."
Dr Schabas, to my understanding, said that would be the way they would report back on every instance. Whether they knew or not, they would not tell you specifically whether that individual had something, but they'd give you the generic safeguards. That's not my understanding of the way it was supposed to go. So obviously there is a lot of work to be done, if that's his understanding, because it's not mine.
Mr O'Connor: I appreciate your coming today. I guess you've been present in the room while we've had our hearings today?
Mr McGough: Yes, I was here on Thursday, or the last day you were meeting.
Mr O'Connor: Last week. Yes, Tuesday.
Mr McGough: Whatever.
Mr O'Connor: I appreciate that. You've done a lot of work, making sure you get the sound effects lined up and everything else.
Mr McGough: You can't believe how much trouble that was.
Mr O'Connor: Oh, that went over quite well.
One thing that did disturb me when we heard the presentation today from the medical officer from ALOHA was that they had suggested to the Scarborough fire department, I believe it was, that they were willing to go and make a presentation to them to equip their employees there with some knowledge if they were placed in a situation where they were going to be exposed to communicable diseases. They've been trying to go to this department for two years now.
Given that this is very serious -- and I appreciate that; I've congratulated my colleague there enough for that, I think -- why would that fire department not want to get the information that's being offered? It's not a high-cost item to provide that.
Some of the other items we've talked about -- we've talked about the high cost of a huge inventory of every person who comes in contact with the hospital, almost, in emergency wards, and trying to catalogue all that information, which would be a huge undertaking. But to provide those emergency care workers with some training that is going to potentially save them infection and infection of their family, which of course is why we're debating this, why would they not respond to that?
Mr McGough: I can't answer the question for Scarborough. They're not in our association. They're in Mr Kostiuk's association.
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However, the only thing I might say, using my own department as an example, is maybe they have already had the training that these people offered them. That's the only thing that comes to mind. I know in our department and in most larger Metropolitan departments, especially if they're involved with tiered response, which Scarborough is, various Universal Precautions, all that sort of stuff, that's not new. I hate to use the term "old hat," but that's part of the operating procedure. Maybe they have the information. I honestly can't answer that question specifically because I don't know.
Mr O'Connor: The Ontario professional association that you belong to, does your association or have your association members, maybe at a convention, had a resolution debated that we go back to our communities and request that all the medical officers of health come forward and offer a program of educating our employees so they can be as up to date on this very important health and safety matter?
Mr McGough: We have not had a resolution specifically speaking to what you've talked about. We had a resolution speaking to the issue of why we're here today. But I know that our association, and I know Mr Kostiuk's association as well, has sent out a tremendous amount of information on Universal Precautions. We've sent out a letter that Dr Carlson sent to the chief medical officer of health last year.
Mr Kostiuk and myself are both on the public safety services liaison committee. We sent that information out. I'm on a section 21 fire service advisory committee of the Ministry of Labour, as is Mr Kostiuk, and I think under guideline 6 you'll see what we have distributed from that committee, which is made up of fire chiefs, the firefighters, the volunteers, AMO, the fire marshal's office and the Ministry of Labour. That piece of paper is in every fire department in the province of Ontario, full-time or volunteer. In that regard, the information may not be coming by convention resolution; it's just coming as a normal course of action under occupational health and safety. The information is out there on what they should be doing to safeguard themselves.
Also, the information is out there with respect to trying to dispel some of the hysteria that goes along with certain communicable diseases that is inaccurate but has taken on a life of its own. That information is out there; there's no question it's out there. I know I've sent it, Mr Kostiuk's sent it and it's been sent through the government agencies we're involved with.
Mr O'Connor: Just to follow up with that, because this is a serious issue. I appreciate the people who have come before us and we've heard a number of different concerns. The privacy commissioner had concerns about the privacy element of it. The chief medical officer of health for the province -- you can check back in the Hansards and you can see how he realizes this is an important issue and needs to be dealt with. I wonder if there isn't a way that the professional firefighters' association shouldn't try to approach their local medical officers of health. If the guidelines aren't going to work and you fear that they may not, has there been a process then where you have gone to your local medical officers of health to try to establish a local protocol or something?
Mr McGough: My fear with the guidelines is that they may not work because of the local medical officers of health. My fear was developed last Wednesday at the meeting, given the comments from those people.
There was a letter that came out last June from Dr Carlson reminding the local medical officers of health with regard to certain contacts -- I was going to bring it and I didn't -- reminding them to get hold of emergency service workers and that sort of thing. That has been distributed to everybody in our association. Every full-time firefighters' association in the province has that letter because that came out as a result of an issue from the public safety services liaison committee. However, a number of our people have met with the local medical officers of health and the reaction is mixed, to say the least. Some hadn't seen the letter, some said they might be able to help through a back-door method and some said there was nothing they could do, given the present constraints they work under.
Believe me, we've tried every angle you can possibly imagine. We've tried the guys going back individually in their own municipality, through their family doctors. The only thing we haven't tried is wining and dining the emergency room staff. We have tried everything.
Mr O'Connor: My concern isn't the disclosure of some private information, and I don't feel that's yours either, but providing the employees you represent with the proper health and safety requirements and the knowhow so that some of the myths we've talked about here can be dispelled and the correct information --
Mr McGough: There are always going to be some things that haunt us in this regard. I think people have an image -- I don't know what their image is -- of what we're going to do if we get this information. The issue with Toronto a number of years ago where they posted that list comes back to haunt us at every step. That's the only time I've ever heard of something like that happening.
There was also a remark made on Friday, and I think it was by the privacy commissioner. He had a concern that maybe we would treat a patient differently if we knew they had a specific reportable communicable disease. I don't know how to assure you that wouldn't happen. I'm almost to the point that, as professionals, as someone who has been doing this for 20 years, I found offensive the fact that somebody would think that we would treat somebody else differently, given our training and what we're there for. The only thing I can say to you is that if we were to have this information we only want to know to protect our people and our families. We're not going to spread it around.
Obviously, with every system there's a breakdown somewhere. Every now and then you read in the newspaper where a physician has inappropriately disposed of his confidential medical records and they end up on the street or in the garbage. There are provisions in statutes to prevent that from happening; unfortunately it does.
But I know that by and large the people that we represent are going to treat the information with the highest level of respect that it deserves. I tried to get that across in our brief, that we honestly believe that anybody who has such a condition or such a disease that's mentioned in Bill 89 -- that we respect their privacy. We don't want to know who they are. There are some valid points about working your way back through the system and you can finally figure out who that is. I'm sure that's going to happen at some point, but that's not what our people are going to do.
Mr Tim Murphy (St George-St David): Thank you very much for your presentation and all the work you've put into it. That's very helpful.
I want to ask some specific questions on some of what you have in here. You talk on page 7 about Universal Precautions and how, despite Universal Precautions, there can be breakdowns. I'm just wondering in what circumstances you see Universal Precautions being insufficient.
Mr McGough: I guess the one that comes to mind right off the top would be an automobile accident, where you have an injured patient whom you have to extricate. There's no way around it. Even when you're wearing the leather gloves and the turn-out gear, there's so much jagged, sharp metal that everybody comes away with some type of wound in that instance.
I'll give you another example. This happened to me with my crew during the summer. We got a tiered-response call at about the time the bars close. We get a lot of those. There's this fellow who's been involved in a fight in a tavern and he's intoxicated and putting up quite a fight. We arrive first. He's covered in blood from head to toe and we have our latex gloves on and we're wearing our turn-out gear even though it was warm.
We get into what turns out to be a bit of an altercation with this fellow before the police arrive. We get him subdued and quieted down; put him on the stretcher. Then he goes off again. We have to tie him off to the stretcher. His arms and his legs are bound. So the ambulance takes off and they go up to the hospital. We're covered in blood, all of us, because of the altercation; it wasn't a normal treatment. When you're fighting with somebody -- maybe "fighting" is a strong word -- but when you're trying to subdue somebody the gloves are the first things that get torn, your sleeves get pulled up, you have short-sleeved shirts on, you have a number of different contacts.
So the ambulance takes off. The fellow breaks loose in the ambulance, starts a fight. We happen to come across the ambulance. We sent three of our guys up to the hospital to subdue the guy. We get up to the hospital and he's telling everybody at the hospital that he's HIV- positive. So that's a concern.
A lot of times where there are situations that I mentioned, a rescue or even a fire, where you've pulled somebody out who is burned, by virtue of the other tasks that go along with actually rescuing somebody -- picking them up and pulling them out, whether you have to use ropes, no matter what -- Universal Precautions are not designed for our line of work in a lot of cases. I'm speaking specifically of latex gloves and --
Mr Murphy: I'd like to deal a bit with the confidentiality issue and I know your response. In a sense I'm asking you the question to get the answer on the record because I asked your companion organization representatives the same question because in the riding I represent there were circumstances where this came up and that was, a firehall had, and I think they've since learned their lesson, a list of people with certain communicable diseases posted, and that raised, obviously, privacy concerns and confidentiality concerns and I guess concern in some people's minds that there would be a hesitancy to respond to a call from the names on that list. I just would like you to put your view and response to that concern on the record.
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Mr McGough: I can see no hesitancy. I'm using my own case as an example. In tiered response, you do end up responding to some familiar addresses, and after a while you get to know some of these people and you get to know what their ailment is. As was mentioned by Mr Cassidy here from the Toronto fire department last week, you know what you're dealing with in some of these cases, and it does not change your response at all.
I mentioned the Toronto situation where they put the list up earlier on. I'll use HIV because it always comes up as the big topic when you're talking about something like this. At the beginning of that, let's say in the early 1980s when it was becoming very prevalent and people were starting to know about it or talk about it, there was a lot of hysteria out there. In the fire department, there was a tremendous amount of hysteria. You couldn't even walk by somebody with AIDS without fear of developing the disease. That was ignorance; that's all it was. People didn't know. In fact, the medical community, from our point of view, didn't know that much either. It wasn't being transmitted to us.
But as time has gone on and we've developed Universal Precautions, we're more informed about that issue, those types of things haven't happened. That Toronto incident was very unfortunate. I can remember reading about it in the paper at the time it happened, thinking something to the effect of, essentially, "How could you be so stupid?" But as I mentioned before, using the medical records as an example, I can't see it happening, but there's always going to be something somewhere.
Mr Murphy: Do I have --
The Chair: We're running late.
Mr McGough: I never thought it would go half an hour, ever.
The Chair: Oh, indeed. I want to thank you for the presentation you made to us today and for taking the time to meet with us.
Mr McGough: You're welcome. Actually, I am supposed to be on days today, but this is my social contract day. I didn't have to go to work.
The Chair: We appreciate it. Thank you.
METRO TORONTO CIVIC EMPLOYEES UNION, LOCAL 43
The Chair: We invite the Metro Toronto Civic Employees Union, Local 43 to come forward. Is it Mr Phillip Micallef?
Mr Phillip Micallef: Phillip Micallef.
The Chair: Welcome to this committee. You have half an hour also for your presentation. Please leave as much time as you can for questions.
Mr Micallef: Well, I'm afraid I'm not quite as prepared as I thought I should be. However, I'm not going to be ad libbing this; I'm going to be reading most of it, I'm afraid. I hope it's not too repetitious. So here we go.
As ambulance personnel, we have a special relationship between the nurses, the doctors at the hospital of definitive care and our patient. We are very often the first to contact the patient. We are the extended reach of the treating doctor in the area hospital. We are the first to assess the patient's condition, to stabilize, to determine emergency care, priority, transport to a definitive care facility.
In order to treat the patient to the fullest level of our training, we accumulate a lot of personal information, and that's a necessity. This very personal information can only be disclosed to the appropriate individual in the hospital for the consistent purpose of definitive care. Policy directives from the Metro department of ambulance services interpret these various acts carved in stone. We could literally lose our jobs if we do otherwise.
The ambulance service is not an outside institution, not a banking industry or an insurance enterprise; banking, insurance and other commercial institutions do not share the same foundations with medical care institutions. Our society requires the ambulance service to stand on the same foundations that our medical institutions stand on. Although administratively the footings associated respectively with the hospitals and the ambulance service are of a different shade, the foundations are the same.
Not too many people stand between the patient and the doctor: the EMA and the nurse. The distinction between the latter two from the patient's point of view is negligible: the lights and siren or the needle. The EMA stabilizes, immobilizes, essentially initiates the treatment, establishes base vitals and monitors the patient, and the nurse continues the same. The direct link is inalienable.
For the purposes of disclosure of possible adverse exposure to communicable disease, we are treated like the average citizen or like an outside institution. The inconsistency is indifference. Ambulance personnel are an integral, essential part of the patient's treatment process and should at the very least get the same immediacy and urgency regarding the disclosure of exposure to infectious disease as the hospital staff.
I have no doubt that the doctor who forms the opinion of an infectious patient and orders or advises Universal Precautions and indeed orders placards to identify an isolation category or orders body substance precautions, along with the nurses involved on the floor, will put their exposure to this patient in perspective and indeed modify their own approach and behaviour around this patient and, if necessary, around their peers, with other patients and family. Why not put the EMA exposure to this patient in perspective as well at the same time?
A lot of ambulance personnel and indeed a lot of firefighters and often the police complain that we are not being notified of exposure to infectious patients by the hospitals, much less the doctors or the Ministry of Health. However, the way the act is written, there are exemptions that will allow a universal policy directive to be derived and an agreement entered into administratively, institutionally between the hospitals, through the OHA, and the Metropolitan Toronto department of ambulances, indeed provincially, in conjunction and directed by the Ministry of Health.
In fact this interpretation has already been established by the Ministry of Health, the precedent being meningitis and the requirement that that will be disclosed within 24 hours. Of course, when you pursue, when you want the documents relating to this meningitis disclosure, the theory is that apparently the infection control nurse at each hospital is required to notify the Ministry of Health.
What is unwritten, however, is that this infection control nurse apparently has not so much taken it upon herself -- she has been disclosing this information to the department as well, directly, more or less at the same time, within minutes of having to disclose it to the Ministry of Health. The problem is, you cannot have any paper trail to establish this.
The success of Bill 89 is indeed remarkable, Mr Tilson. History does not offer a high success rate for private members' bills. However, important as Bill 89 is, it does not showcase or champion the importance of the immediacy and urgency of disclosure to the emergency care giver of the exposure to infectious disease. The health and safety of the emergency care giver, his family, his peers and other patients still remain unprotected and exposed to danger.
Bill 89 serves three important fundamental functions from my profession's point of view, that is, ambulance personnel and, by extension, fire, police and the good Samaritan.
First, Bill 89 reinforces the legal status of the ambulance call report. This is very important, especially when it comes to the exaggerated claims regarding the increased amount of recordkeeping and the cost that has been argued by other presenters.
In fact, I would go so far as to suggest that the ambulance call report would be all that the hospital requires in terms of recordkeeping, because we include a lot of information, not only as professionals but in terms of personal information regarding name, address, contacts, the good Samaritan. We are supposed to indicate whether the police have been on the scene, and these people can all be traced.
Frankly, to whatever extent Bill 89 is amended, this could be part of it as well; that is to say, whatever amendments there may be, you can even limit the increased recordkeeping to the ACR that we have to fill out after every patient.
The second fundamental factor is that it puts the Ministry of Health on notice that a just balance does not contradict the Freedom of Information and Protection of Privacy Act. Although I have to admit that I called the policy advisers at the commission and two of them told me that, yes, it is workable. I submitted a policy directive, which I called a universal, to each and every member of this committee back in May, and what I describe here is workable to these two ladies at the commission.
However, when I required it to be in writing from Mr Wright, it's not quite what I hoped for. It did not reflect what these two people have told me. Although I looked at the act myself, the interpretation is really narrow, frankly, the way Mr Wright has chosen to interpret it.
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What this calls for as the doctor essentially recognizes a reportable disease or in fact diagnoses it is that he should be required to contact us directly through our dispatch or whatever, and he will put in perspective our exposure to the disease. Essentially, I suppose he could as well delegate this information to the head nurse on the floor, rather than having to go through the loop of having to notify the Ministry of Health and in turn the Ministry of Health having to contact us and then having to do it all in writing.
However, Bill 89, along with the amendments we seek to Bill 89 under the title of a universal policy directive to identify forcefully with the Ministry of Health, has failed, and so Bill 89 and the amendments we seek to the bill should become law under the Health Protection and Promotion Act.
Bill 89 has a very broad scope. It establishes the concern of the public; it speaks for the public. Frankly, I'm not so sure that we as professionals should disassociate ourselves from the public. Somebody has to speak for the good Samaritan who renders help.
Bill 89 offers a broader scope beyond the emergency service and away from the employer-employee type relationship right to some form of disclosure regarding the interests of fairness and justice. At least a more equivocal balance could be sought in the not-too-distant future, we hope. Bill 89 is much more than a foot in the door. The public can see and the public can look at the unfairness and the lack of accountability on the part of the doctors and the hospital as allowed under the health act.
Mr Tilson must be encouraged and sustained as a champion of Bill 89 and therefore the citizens of Ontario. He has designed a pair of shoes that we all can wear: the missing link, the unfairness and the inequity and the injustice knocking on the individual citizen's door; whereas if we simply accept what Dr Schabas has allowed, as presented in the mandatory guidelines, our fears and hopes are going to be bureaucratized. Let's keep it in the house, so to speak.
The consequence is that, from the public point of view, this issue under disclosure will be internal bickering that is far removed from the public, and therefore the status quo will remain; presumably that's what Dr Schabas wants to achieve. I have no doubt in my mind that Dr Schabas treats what the public safety services liaison committee is apparently willing to resign to as a cliché in the right direction to stop the momentum Bill 89 may pick up and its concern for the good Samaritan.
My participation in this public safety services liaison committee has been very peripheral. This of course is chaired, as you know, by Dr Schabas. I would describe my role in the process of this committee as sort of a complicity to undermine common sense. From Dr Schabas's vantage point, the concessions he offered constitute no more than the repackaging of the eraser to the extent that disclosure has to be made through the Ministry of Health. Efficiency, consistency of application, immediacy and urgency can only be a promise.
Now, if the public safety services liaison committee members can present the guidelines to their respective constituents with unchallenged acceptance, I submit to you that the Ministry of Health, our employers, lobby groups, would-be educators, the media et al have failed miserably with regard to AIDS and hepatitis.
I find it sad and appalling to think, as the guidelines pronounce loudly, that whole categories of our emergency services cannot add open cuts plus other people's blood to spell danger, that they will need a designated officer to put this exposure in perspective as to whether they need seek medical intervention.
If the use of Universal Precautions fails me and I discover my patient's blood on my open wound, I'd go to a doctor, the one to whom I would take the patient, immediately and not wait for interpretation from the designated officer, because, after all, as the guidelines reveal, the process will not tell me any more or less than the doctor would.
My doctor will not confirm the disease or officially associate the disease with our mutual patient, but he will prescribe a treatment to follow and changes in behaviour to whatever degree is required, particularly when these guidelines do in fact become mandatory guidelines.
Why do we have to go through this lengthy process? It's the patient, the doctor, the process at the hospital to gather the information to reveal to the Ministry of Health and the Ministry of Health having to process this information to reveal it to me.
First of all, with the four diseases mentioned in the guidelines, I will be able to put two and two together. We're not animals; we can think. We're trained professionals. It may be a surprise to Dr Schabas, but we can think. When we're prescribed a treatment protocol and change in behaviour towards our wives or children, peers and patients, we realize what the disease is and to whom we've been exposed.
We, as ambulance attendants, have the professional and legal obligation to act and render treatment according to our training and the obligation to give evidence in the eventual court appearance. Towards these ends, we keep records of all the patients we treat and transport. This record will contain a lot of personal information, as just basically required by the Ministry of Health.
You can be sure that if we suspect something as serious as meningitis, active TB, hepatitis or AIDS, we will record this information not only in our own personal notebook, which we are obligated to keep for legal purposes but, as the Ministry of Health requires, in the ambulance call report, which we fill out for every patient with the same information. Misuse of this personal information will cost us our jobs.
The average experience of an ambulance attendant in the department is about 12 years. So you can collectively say that in the department we have 12,000 years of experience collecting this information, and none of us ever recall anybody complaining that we have in fact disclosed information where we shouldn't have.
What are the guidelines offering us to replace Bill 89 and the rights that it offers for the public to know of their exposure? With regard to meningitis and tuberculosis, these are reportable diseases already under section 27 of the health act. So the guidelines are not offering anything beyond the status quo in this regard.
The problem is that the process goes round and round and round. The emergency worker will have gone home to potentially expose his family, reported to work the next day, again to potentially expose further his peers and perhaps more patients who, by the way, when we approach them, have a lowered immune system already, before he's told of his exposure.
May I remind all that medical books on infectious diseases are printed to number 800 pages or more, and that has been the norm. But in his wisdom, Dr Schabas chose only the four. As for the viral haemorrhagic fevers, Dr Schabas wondered out loud why he chose them. In fact, at the October 27, 1993 medical officers of health meeting, he was somewhat ridiculed for the inclusion of these diseases.
Now the blood-borne diseases, in this category mainly hepatitis B and AIDS: When emergency care givers, nurses or doctors get a patient's blood on their open wounds or prick themselves with needles, if uncertain as to whether the patient is infected or not, they routinely take the hepatitis B series of vaccine, including the single-dose hepatitis B immunoglobulin. This is just a routine thing.
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So, under the guidelines, if I initiate notification by request, and I am told not to have sex with my wife or to wear a condom and I'm given this vaccine series, well, you know where I'm heading obviously. We're getting into ruling out whether it's AIDS or hepatitis or whatever. So why the charade that could endanger my life, specifically, or my family and other patients?
The Chair: Mr Micallef, we are running out of time. We do have time for a question from each caucus, if you would like, or you can complete your remarks and then we can end it that way.
Mr Micallef: I suppose these guidelines are a way of circumventing common sense, from my point of view. I will take your advisement and stop here. I will answer any questions you have. I hope I did not bore you.
Mr O'Connor: You didn't have the sound effects that your colleague from the firefighters had. He had a siren go by as he was presenting. Unfortunately, it's not always possible to have the sound effects. I appreciate that.
Mr Micallef: Well, my claim is that I was not prepared and it would not have crossed my mind.
Mr O'Connor: My concern, of course, is the confidentiality. No one's downplaying the health and safety element that you're bringing forward to us. I appreciate that. The confidentiality I think is an issue that we all have to be concerned with. The reason I raise this is because, did I not hear you in your presentation say something about an emergency nurse providing information that should be going to the medical officer of health and then, through in appropriate fashion --
Mr Micallef: It is a convoluted process.
Mr O'Connor: -- to somebody from your field? I wouldn't see that as being an appropriate process, and that's not the process that's suggested through the guidelines.
Mr Micallef: No, that's only to alert us that we have been exposed. Nobody's going to be telling us anything specifically about the patient's name or to associate the name with the disease. Nobody's going to tell us that.
Mr O'Connor: This is where my concern is, that inappropriate information can be passed through a process that doesn't offer the full explanation and may cause needless stress on a family. There's somebody going home saying that you could have been exposed to this, and in fact might have been, without actually having all of the information.
Mr Micallef: That's a red herring as far as I'm concerned. I want to know if the doctor suspects potential infection of that patient, diagnoses that patient with an infection, a communicable disease that's going to be detrimental to my health, disable me, have me alter my life towards my wife, my children or whatever. I want to be told before I go home. If that's what the doctor is suspecting, to the point where he will order isolation for that patient or precautions for the other nurses to deal with him, then I want to know. I want to have that same privilege. That's it.
Mr Murphy: Is it the call report you call it? I'm sorry I'm not familiar with that. There was a report that you say you fill out.
Mr Micallef: Oh, the ambulance form that we have to fill out? Yes, that's right.
Mr Murphy: Who gets access to that?
Mr Micallef: Well, we have to pass that, as what the act refers to as a consistent purpose, to the emergency nurse for the doctor. It's there for the doctor to read. We communicate to the nurse, in brief, what we put in the form. The doctor, if there's anything further that the nurse has not explained to him, is supposed to be looking at that call report. That's a legal document. It identifies the patient, who was at the scene, who was treated, what his symptoms are.
We know quite a bit. So for anybody to claim that we do not already have enough personal information and that because of the stigma in and around AIDS for some reason we are to be prevented from being told by a doctor that we have been exposed -- as an ambulance attendant, I am not worried about body fluids. What I'm really worried about are situations where there are airborne diseases I'm not familiar with. As I say, the library has a textbook on infectious diseases of about 800 pages. We're supposed to be told of only two airborne diseases. What about the enteric diseases?
Blood-borne, fine: If the Universal Precautions fail me, I will be able to assess for myself, as an ambulance attendant, is my hand cut, is there blood on the cut hand? Then I will start to worry, but until then I can take the precautions. I recognize the signs and symptoms of active AIDS, if you want the vernacular. I recognize those. It's easy to tell. As for TB, it's the same thing, and maybe to recognize jaundice. Body fluids are not the problem. The personal information that is already there is quite an amount as well.
Mr Murphy: Then your concern is really the extent of the notification related to airborne diseases and not blood-borne at all.
Mr Micallef: I can deal with it myself, blood-borne. It's really telling, I would think. It seems to me the whole aspect of these guidelines is to deal with AIDS. It seems Dr Schabas is really catering to the AIDS problem, to the blood-borne diseases. To me it's apparent, anyway.
My problem is that if I'm exposed to body fluids, I can deal with it. It's not a big deal. It's really telling on our society, on how we have failed to deal with these circumstances. If you've got blood on a wound, you worry about it, you go to your doctor. I would think he's not performing his duty if he will not endeavour to prescribe a protocol and perhaps a change of habits or behaviour towards your family.
Mr Tilson: I appreciate your comments. As a layman whose knowledge of health is minimal, this exercise has been most interesting to me, particularly when we look at the police officer, the firefighter, the ambulance worker, the nurse, other people in service with respect to health and who are knowledgeable people, who are well trained and have to become more trained as life becomes more complicated, as diseases become more complicated. We rely on those people, in many cases, for our lives.
What I have found simply amazing in this whole process, and this is the question I asked Mr McGough in the previous delegation, is that we're having individuals from the Ministry of Health and different medical officers of health come to this committee and say to all of these care givers, all of whom have indicated, in spirit, support of the bill -- some have questions with respect to certain aspects of it, but all of them have indicated their support of the spirit of the bill -- that, "You don't know what you're talking about," not you, but the care givers don't know what they're talking about, that transmission of diseases is remote, that there's no real problem, that there are no real specific examples where this has happened, or at least there aren't very many of them and that we're really making a mountain out of a molehill. Could you comment?
Mr Micallef: These learned professionals, when you actually try to corner them, will speak in terms of education, probabilities, statistics. Yes, if you pursue them further, "Oh, yes, we make mistakes." However, when it comes to probabilities or educating, "We will interpret for you the Bible," so to speak, and with whatever religious fervour they would actually endeavour to protect your interest is unclear. What I tell them is, "What you're really telling me is sort of putting a glass wall between the street reality and myself as a new victim."
How do you reinforce these things? You reinforce them. The aggregates that are required are very simple: You inform me and do not just leave it up to the doctor as to what I should be worried about. I lost my train of thought.
Mr Tilson: You've been fine.
The Chair: Mr Micallef, I want to thank you for your feisty participation in these hearings today. Thank you for taking the time.
Mr Micallef: I'm afraid that's all I perhaps had to offer. Thank you.
The Chair: We have someone else we have scheduled, but that person is not here, is that correct? Either we could recess for five minutes or we could adjourn for the day. Do people have suggestions?
Mr O'Connor: Can we wait five minutes?
The Chair: Should we wait five minutes? Okay.
Mr Tilson: I think we should at least give five minutes.
The Chair: Okay, so this committee will recess for five minutes.
The committee recessed from 1729 to 1734.
ADVOCACY RESOURCE CENTRE FOR THE HANDICAPPED
The Chair: I'm calling the meeting to order. I'd like to welcome Mr Gerry Heddema. Welcome to this committee. We have approximately 25 minutes left for this part of it. Leave as much time as you can for members to ask you questions, 10 or 15 minutes if you can.
Mr Gerry Heddema: I haven't prepared a written presentation for today, simply because there wasn't a lot of notice to pull something together as I would have liked. But I've got an oral presentation and I've also circulated a document which I'd like to refer to at one point in my presentation. We'll have copies made, I understand, at some point, and members of the committee will have a copy of that as well.
My name is Gerry Heddema. I am a lawyer at the Advocacy Resource Centre for the Handicapped. My title at ARCH is AIDS-HIV mentor. My project is funded by the Ministry of the Attorney General to develop legal services for people living with HIV and AIDS in the province of Ontario.
I've reviewed two documents that were sent to me. One is the document that I believe the standing committee is looking at in the form of a private member's bill, and a second document has been circulated by a group of concerned emergency care workers. I have about four main comments to make on both documents.
Generally, I'm a bit perplexed when I review both documents. From the perspective of someone who works in legal issues affecting people who are HIV-positive, I do not understand why HIV is present on this bill. To explain why I'm puzzled in this way, I'd like to take you through perhaps four parts of what I would put forward as my analysis, the first heading of discussion being sort of a discussion of apples and oranges, which I feel the conditions listed in this bill are best portrayed as.
If you note in section 1 of the Health Protection and Promotion Act the definition of "virulent diseases," the conditions which are listed in the private member's bill exist under that definition and side by side with HIV and AIDS, while HIV itself is not classified as a virulent disease. I think what first needs to be understood from my perspective is that HIV is not in the same category as the other conditions which have been listed: tuberculosis, hepatitis B and a variety of haemorrhagic fevers.
First, these other diseases, the diseases other than HIV, may be preventable after a person has been exposed to them, so there is medical science available to perhaps prevent a person becoming infected with a particular condition after he or she has been exposed to that condition. To date, HIV infection is not preventable, so a person who would have been exposed to HIV in a way that would transmit the infection to that person, for the present, does not have technology available to prevent HIV actually becoming an infection.
Secondly, it's in the nature of the classification schemes that you can see that HIV does not subject itself to the same analysis of transmission as some of these other conditions. I'll come to discuss it a bit more when I talk about the incidence of HIV transmission and the ways people receive HIV.
Essentially, what you need for HIV transmission is a bodily fluid with significant concentration of the HIV, which the medical literature tells us right now is blood, semen and vaginal fluids, introduced directly through the skin. Generally speaking, you don't have the situation for HIV transmission present in the average workplace, in the health care provider workplace and in very rare occasions where injuries such as needle sticks and where an actual open wound is present in the skin of the health care provider. This being the case, it would appear that the best way to deal with a situation like this would be to provide Universal Precautions, as is suggested in the draft bill. But I would suggest that this is all that would be required.
I think the bill is generally contributing to the climate of misinformation about HIV and AIDS that exists presently in the popular media and is promulgated in corners where AIDS education has not had the benefit of taking root. The role of the Health Protection and Promotion Act is one of the roles statutorily defined as to protect the public health.
My question to the committee is, whose health is being protected here and what are the concerns? If we have a situation where a person has been exposed to a possible HIV transmission risk, then what public good is fostered by then following the person who may have been infected, advising them of the status of the person from whom they may have been exposed, other than perhaps to warn potential future partners, who would then engage in high-risk activity for HIV transmission with the person, who may or may not be infected at this point? I think it is much better dealt with by providing HIV and AIDS education around the true risks of transmission and the ways to prevent it, and to make this available to health care workers.
If a health care worker feels they have been exposed to a real risk of HIV transmission -- I again posit that those risks, while they do exist, are narrowly defined and easily understood and easily prevented if Universal Precautions are used appropriately -- in those few situations where someone finds themself exposed to HIV, such as a needle stick, we have statistics that demonstrate the risk of HIV transmission from a person who has received a needle stick where that needle was inside someone known to be HIV positive is 0.3 of 1%.
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What that means by seroconversion and some of those other words is that if you have a needle stick from somebody where that needle was inside someone who was HIV positive, it's 0.3 of 1% risk of HIV transmission. These statistics are very, very small. You have a better chance of being hit by the TTC crossing the street, I would posit, than seroconverting in a setting such as that. The risks are real; they exist. But understanding the size of the risk is what I think is quite important.
When the legislation lumps HIV together with these other conditions, I think it creates the impression that it's something that's easily transmitted, which is not supported in the medical literature, and that this is something that requires more than Universal Precautions to prevent its transmission, and I would argue that's incorrect as well.
The other thing to point out: If you understand the epidemiology of HIV, there is what's called a window period. I believe that this legislation would be misinforming and perhaps creating the type of situation it's trying to avoid. There's approximately a 14- to 16-week window period from the point at which a person has been exposed to HIV to the point at which they might develop the antibodies which are used to indicate that the virus is present. The tests that we perform right now don't test for the virus; they test for the antibodies. That takes up to 14 to 16 weeks. Most people might have that present in their bodies up to nine weeks, 10 weeks, some people earlier, but for the most part at the end of 16 weeks you have a pretty good indication of whether a person was infected by HIV.
Under this type of scheme that's proposed, if a person has been exposed to a possible risk of HIV transmission and they ask the person who may have been the actual, potential carrier, "Are you HIV-positive?" if they don't know and there's no test and they say they're not, is that the information that's going to be communicated, in which case would the health care worker go home and continue to engage in high-risk activities with their partner?
If the person who is the possible carrier of HIV tests negative, what does that test result mean? It means that they're really negative, or maybe they're carrying HIV and they simply haven't seroconverted yet, in which case I believe that the rationale behind this type of legislation is undermined, and it's undermined simply by the nature of how HIV infection works. I think this type of an approach, as it's been tried in many other situations -- when I say other situations, I'm talking about the ideas here having been used in other arguments before to try to put forward the need for mandatory testing and it has failed. Those arguments have not won any support in any jurisdiction in this country.
I think it's useful to note as well that we do not at present have a system similar to the one which is being proposed. Some information out of the federal committee, the Report of the Standing Committee on Health and Welfare, Social Affairs, Seniors and the Status of Women on a similar private member's bill: My indications are that they've stopped this process, or they referred similar discussions to a committee which explored this discussion in great detail.
I think you're already aware of this report, but I would also recommend this to you. They went into great detail. I think that if this committee is serious about pursuing this bill, and in particular including HIV in the discourse, a lot more research and work has to go into this. I think you need the benefit of more studies and more information, because I think some of the assumptions in this bill are simply wrong.
I would recommend to you the document that's been passed around, the CMA Position Paper: HIV Infection in the Workplace. There are a couple of cogent points I'd like to bring to your attention on page 3.
The document talks about how: "It has been theorized, for example, that police work or firefighting may place a worker in possible contact with body fluids of HIV-positive people. In such examples, the risk of transmission is extremely small and no cases have been recorded. However, as a general measure to minimize the risk of HIV and other infections, workers should take reasonable precautions when handling (eg, cleaning up) any human blood." It talks about what those examples might be.
On page 4, it talks about the health care work setting:
"Risk of HIV transmission: The nature of the health care setting carries with it a greater risk of occupational exposure to HIV than is found in the general workplace. It is possible for a health care worker to be directly exposed to the blood or body fluid of an HIV-positive patient through a work-related accident such as a needle stick. Nevertheless, the occupational risk of HIV infection in health care workers, though not zero, is very low."
I want to make that point as clearly as I can. There is a risk. There is a risk here, but the risk is very, very low. That risk is minimized when the proper education is put into place to explain to workers what the real risks are, what the methods of transmission are and how to prevent them.
This document from the CMA, which is certainly not one of the most radical organizations I've encountered in the last little while, supports a lot of the things I've been saying. There is some discussion later on in the document where they talk about a situation where a health care worker might have had a needle stick and been exposed to the blood of a person who's HIV-positive. They proposed a system of voluntarily going up and asking the patient, "Are you positive?"
I'd just like to caution you, when you get to that part of the document, that wasn't the focus of their discussion. That wasn't the area where they went into a lot of detail. I think they got it wrong, because they didn't spend a lot of time looking at it. I don't think it's appropriate to be approaching people and asking about their HIV status any more than it is to be releasing information about their HIV status.
The discrimination that occurs for people who are HIV-positive is very real. I get at least five to six calls a day by people who are saying: "My family has disowned me. I'm losing my apartment. I've lost my job." I've had four people call me today who no longer have jobs because someone found out they were HIV-positive. I have concerns about the confidentiality if this document goes forward, but I don't feel there's really a lot of time to discuss that, because what I really want to put forward to you is that I think HIV does not belong in this document. It's not the kind of concern that these other diseases represent.
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The Chair: There's time for one question from each caucus.
Mr Murphy: Thank you very much, Mr Heddema, for your presentation. It's interesting to hear what you said, because the presenter just before you talked about his concern was not blood-borne risk at all but airborne transfer. He said you could see when there was blood and you could go from that situation. It was in a sense the lack of knowledge that arose out of airborne transmission that created the greater uncertainty.
I'm just trying, if I can, and it's probably because I'm a bit slower than others, to encapsulate your position, and I'll try to do it quickly. Anything like this in the draft bill presents a tradeoff between obviously the degree to which you impose on the confidentiality of the information regarding the medical condition of certain patients versus easing the minds of the health care providers.
What you're saying is that in an HIV situation, even at the worst case, the possibility of transmission is extremely low, and that in any event the fact of being told that the situation presented a potential for risk exposure, even being told that there may or may not be a person who had HIV -- in other words, being told yes gives you some information, but the fact of being told no doesn't necessarily tell you anything. So you've got a low benefit and a high cost, I guess, is ultimately what you're saying.
Mr Heddema: Exactly.
Mr Murphy: Sorry. That was a long preamble for a short answer, but I appreciate it.
Mr Tilson: I don't think anyone is doubting the issue that meningitis, tuberculosis, hepatitis B are easier to transmit. I don't think anyone's denying that. The care giver, however, the care provider or the taxi driver or passerby or good Samaritan wants the right to make the decision as to whether or not he or she can take precautions.
Everyone agrees that the risks with respect to HIV are, to use your words, real but remote, but having said that, the very fact that they're real, why wouldn't you want to give the care givers, the providers in this province who are saving lives on an hourly basis across this province, every second for all I know, why wouldn't you want the right for the care giver to protect his or her family from the remote possibility, to use your words, of contracting -- and your main issue is -- HIV? Why wouldn't you want to give them that right?
Mr Heddema: I think it hasn't been proven that the risk exists to the degree that that person is entitled to that information, such that they're entitled to have the right of this person to the protection of this very important information, to have that confidentiality.
Mr Tilson: The problem is, sir, it exists. That's the problem.
Mr Heddema: I know, but as I said before, we all take risks on a daily basis. If you sit down and you measure what the risk is, I say that the risk is real simply because we have the statistic that says 0.3 of 1% of situations where a needle stick occurs -- that's an important statistic, I think, because that's one of the situations where you can see where the HIV gets past the skin, which is considered to be the first level of defence in public health analysis, and the HIV is actually possibly in the person's body, where that type of situation happens.
Statistically it's very rare in the provision of the types of services for health care providers, 0.3%, and I can just say I don't think we create health care policy on exceptions to rules. I think we develop health care policy on situations where we have the statistics that demonstrate that it's required, not people's fear and anxiety. I think you use education to deal with the anxiety.
Mr Noel Duignan (Halton North): Two very brief questions: It's my belief that if this legislation was to be workable, it would require mandatory testing. Would you support that? If the legislation was passed and proved unworkable, given the length of time to change legislation, how would you propose it be dealt with? Would the guidelines be easier to more effectively implement and work with?
Mr Heddema: To be quite honest, I find that's a really complicated question. I would like to reiterate that in terms of the amount of notice and the amount of work that's gone into the presentation, I focused on a couple of issues that I felt were evident on the face of the bill.
What your question demonstrates to me is that this is an infinitely complicated set of societal values and legal issues, and if you're prepared to go ahead with this, I think it needs a lot more time for the community to consult and to go through all of these different possible scenarios. The mandatory testing is certainly not one that I've thought of, and I think all of this needs more exploration if you're going to pursue this.
Mr Duignan: I think your answer is very worthwhile. In fact, it points out some of the complications of this bill.
Mr Heddema: Yes, it's very complicated.
The Chair: Thank you for taking the time, Mr Heddema, to give your presentation to us today. This committee is adjourned until tomorrow at 3:30.
The committee adjourned at 1756.