STANDING COMMITTEE ON ADMINISTRATION OF JUSTICE
ONTARIO PUBLIC HEALTH ASSOCIATION
ADELA M.
RODRIGUEZ
RICHARD ISAAC
REGION OF NIAGARA HEALTH SERVICES DEPARTMENT
CONTENTS
Tuesday 2 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
Ontario Public Health Association
Nancy Day, president
Allie Lehmann, member, policy and resolutions committee
Joan Anderson, member, policy and resolutions committee
Adela M. Rodriguez; Richard Isaac
Ontario Hospital Association
Peter Harris, chair-elect
Susan Smythe, OHA hospital consultant
AIDS Action Now
Glen Brown, representative
Brent Southin, representative
Region of Niagara Health Services Department
Dr Megan Ward, medical officer of health
STANDING COMMITTEE ON ADMINISTRATION OF JUSTICE
*Chair / Président: Marchese, Rosario (Fort York ND)
*Acting Chair / Président suppléant: Winninger, David (London South/-Sud 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)
*In attendance / présents
Substitutions present/ Membres remplaçants présents:
O'Connor, Larry (Durham-York ND) for Ms Harrington
MacKinnon, Ellen (Lambton ND) for Ms Akande
Also taking part / Autres participants et participantes:
Schabas, Dr Richard, chief medical officer of health, Ontario
Clerk / Greffière: Bryce, Donna
Staff / Personnel: McNaught, Andrew, research officer, Legislative Research Service
STANDING COMMITTEE ON ADMINISTRATION OF JUSTICE
TUESDAY 2 NOVEMBER 1993
The committee met at 1541 in room 228.
HEALTH PROTECTION AND PROMOTION AMENDMENT ACT, 1993 / LOI DE 1992 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 / Loi modifiant la Loi sur la protection et la promotion de la santé.
ONTARIO PUBLIC HEALTH ASSOCIATION
The Chair (Mr Rosario Marchese): I call the meeting to order and invite the Ontario Public Health Association to come forward. I'd like to welcome you to this committee and say you have half an hour for your presentation. At times it tends to go much longer than you think in terms of your own remarks, so if you could leave 10 or 15 minutes, we'd appreciate that, to give members time for questions to you. Would you like to introduce yourselves to us and then you can begin.
Ms Nancy Day: I am Nancy Day, the president of the Ontario Public Health Association.
Ms Allie Lehmann: My name is Allie Lehmann. I'm here representing the Ontario Public Health Association and I'm also an AIDS educator with the city of Toronto health department.
Ms Joan Anderson: Joan Anderson. I'm a member of the policy and resolutions committee of OPHA, and I'm bringing, together with Allie, our experience in front-line education with agencies, including firefighters and police.
Ms Day: On behalf of the Ontario Public Health Association, I would like to thank you for the opportunity to address the standing committee on this very important issue and bill.
To give you a sense of the Ontario Public Health Association and why we might be interested in this, the Ontario Public Health Association's mission is to strengthen the impact of people who are active in the community and public health throughout Ontario.
OPHA represents the collective advocacy interests of approximately 3,000 individuals in public and community health.
Today, OPHA is not here to represent any one of the four specific groups that are influenced by this proposed legislation: the medical officers of health, hospitals, emergency service workers or the individuals whom they serve. OPHA is here to speak to the broad public interest and the implications for health policy in Ontario that this proposed legislation addresses.
OPHA's purpose in addressing this committee today is to raise the issues that we believe underlie the purpose of this proposed legislation. OPHA believes that the fundamental issue that is behind the proposed legislation is an occupational health and safety issue, the protection of workers and the individuals they serve.
OPHA believes that the first and primary objective is to prevent exposure. Emergency service workers work in many varied and often unpredictable situations where they don't know what's going on or what might be facing them. Therefore, the priority must be given to efforts to reduce exposure.
Ms Lehmann: Given the stress and potentially life-threatening results of infections, Universal Precautions are an absolute must. Just as for health care workers in institutional settings, anything less is very dangerous for the worker, so our basic premise is that awareness of risks and preventive strategies are the best tools in ensuring the safety of workers and members of the public. But there are a number of points we need to make in terms of principles and components when we look at the education and training needs of emergency service workers.
First of all, any education and training must be mandatory, ongoing, with the requisite number of refreshers. In order for the education to be effective, it needs to be in keeping with adult learning principles. It needs to be experiential. It must be relevant.
You need to recognize the many barriers that exist to education. Certainly, many emergency service workers are under the strain of shift work, and that creates a very, very big barrier to education. There are emotional and attitudinal issues that interfere with anyone's acquisition of information. Certainly, in my experience working with people in Toronto, emergency service workers like firefighters and police who have worked through the emotional issues around infection are not overly concerned about exposures. That doesn't mean they take risks, however.
The other point is that we need to have a system that's devised for communicable disease exposure that would be implemented, monitored and evaluated by the representative group involved, and then it has to be revised in an ongoing way. It needs to be a living kind of reporting system for it to work. Any kind of education obviously has to be evaluated from both an attitudinal and a behavioral perspective, and we would like to develop a workplace culture of prevention and support.
Components in this education really must stress infection control principles. People need to understand what the actual threat is as well as what the perceived threat is, and what the difference is. People need to have a very firm handle on basic principles and practices of infection control. People need to know what the actual risks are. As well, people need to have and experience a process of problem-solving around what the risk of exposure is. For example, there are exercises we've used with firefighters in the city of Toronto where people could actually explain a scenario, identify what kind of risk they would be under, list protective measures, as well as problem-solve for the future so that future exposures would be limited.
There needs to be a debriefing and reporting system that would allow for a systematic system of analysing exposures. We can, through debriefing exposures, prevent future incidents of exposures. We can learn from our mistakes. We need to be able to take the time, regardless of the kind of work strain we're under, to review the steps to responding prior to and then while responding so that we can learn, but I want to emphasize that generally, the actual incidents of exposure are not that many.
As well, there are a couple of other points that need to be included in an educational system for it to be effective. Those are the legal obligations of the emergency service workers as well as the monitoring of the health needs of the employee who may have had an exposure.
Ms Anderson: Finally, an important aspect of training is to help the emergency service worker understand that protection equals prevention of exposure and does not equal knowing the diagnosis after the fact, after the exposure. Protection means understanding what true exposure is and how to prevent it.
The emphasis on knowing provides false security for the worker. This is especially important for blood-borne diseases such as hepatitis B and HIV, where a diagnosis may not be made or may not be known. It is further complicated for HIV, where no curative treatment is known.
Developing systems to track down diagnoses in these instances is of no help to the worker and provides no benefit to the public. The individual loses their right to privacy and confidentiality without a tangible benefit to the worker.
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The conclusions the OPHA brings to you today for Bill 89 are that any legislation or guideline addressing this issue must address the needs of the emergency service worker and the broader public. OPHA recommends the withdrawal of the proposed legislation. The legislation does not meet the needs of either emergency service workers or the public. The legislation is based solely on after the fact -- after exposure and potential infection has happened. It implicitly relies on treatment that may in fact not be available rather than on true protection, which is prevention.
Therefore, the proposed legislation provides a false security to the emergency service worker. Further, for the public, the proposed legislation undermines our system of confidentiality and privacy and erodes human rights.
OPHA has been informed that you've been presented with draft guidelines from the Ministry of Health. Our one comment on the guidelines is that although the legislation needs to be withdrawn, your political action has sparked this process to develop guidelines.
OPHA does support a stakeholder process which will build collaborative relationships. Through this kind of process, the guidelines that would be developed will lead to consistent comprehensive policies, procedures and training that will in fact benefit emergency service workers and the public.
The Chair: Thank you. Mr Murphy, five minutes per caucus.
Mr Tim Murphy (St George-St David): Thank you very much for your presentation. One of the issues we've been trying to get at around the mandatory guidelines -- have you had a chance to review them before coming here?
Ms Anderson: We've reviewed them. At this point, OPHA hasn't responded officially to the Ministry of Health.
Mr Murphy: My sense is that there is, within broad parameters, a developing degree of satisfaction within emergency health care services to the mandatory guidelines. I guess what has come out of that are two unresolved issues. One of them is a concern that they continue to be enforced.
We had Peter McGough in from one of the two firefighters' organizations yesterday who said he was at a meeting of the medical officers of health last week and came away with a sense that there wasn't going to be a lot of support for this from the medical officers of health. So there is that political question: How do you make sure that the train keeps going in this direction?
The other thing we've been trying to grapple with is the good Samaritan issue: the person who is not an emergency health care worker, who doesn't have the occupational health and safety issue but comes upon a scene and assists, may not have Universal Precautions, any of those other things which I think we all agree are the appropriate first step. I'm wondering if you could comment both on the issue of how we continue to maintain the push on mandatory guidelines for emergency health care workers and what you see being a resolution for the good Samaritan situation.
Ms Anderson: I'd like to address the good Samaritan situation first. Certainly, good Samaritans can seek the advice and support of public health units and medical officers of health, people within health units who are knowledgeable about communicable disease, and receive advice in terms of the kind of exposure they had and what needs to happen, the advice depending on what kind of exposure.
I think without legislation there is some support available to good Samaritans, but the way the legislation is written -- I think you've heard this from other deputations -- the breadth and vagueness of it really leaves it so wide open that we can't guarantee privacy and confidentiality within it.
Ms Day: I think the whole keeping the train on the track around the guidelines comes from not necessarily tossing out a guideline or adopting it as it currently stands. There has been work done on it, but as we've indicated, there are a number of different groups that have very much a vested interest in this process. The variety of emergency service workers themselves, as well as other experts, some within the Ministry of Health, people who are working in the field, all have expertise, and it's bringing together these individuals into a collaborative process to sit down and say, "What truly are the issues here?"
As OPHA has indicated earlier in this presentation, it's not closing the barn door after the horse has fled; it's beforehand. It is the prevention and starting to consider and doing education among those groups about where truly is the problem in the issue, moving the solution upstream to prevent the whole possibility. That gets into training and setting up policies, procedures and training that are consistently applied across this province for all emergency service workers.
That is not a one-shot deal. Guidelines can be developed and set. There have been attempts in the past, successful and otherwise, to develop these. The public health branch has made a stride forward in proposing guidelines, and now it's moving it to the next step of ensuring that this kind of process gets in place; to bring together the people who know how to do this kind of training, the people who know about how to put solid public policy that's workable into the hands of the people who need it, and have them sit down and work through this. It's an important issue. We need to have the right solution, not just a solution.
The Acting Chair (Mr David Winninger): Thank you, Mr Murphy. Mr Tilson.
Ms Anderson: Could I just add to that, though?
Interjection: I liked the old Chair better.
Mr Murphy: Me too.
The Acting Chair: Your time was up, Mr Murphy.
Ms Anderson: Further to that, though, the kind of process we're talking about will build much greater consensus than you've heard so far, because we're really in the middle of a process; we're not at the end yet. Ultimately, we will have a mandatory guideline. Mandatory guidelines are just that. Public health units are accountable to provide those programs.
Mr David Tilson (Dufferin-Peel): I have a question for either the people before us today or legislative research, and that has to do with the issue of confidentiality, which has popped up continually since this bill was introduced; the fear of lack of confidentiality. Of course, the bill is not asking that the individual's name or any description would be released, because that's not the law. The hospitals can't do that now, nor can care givers.
My question has to do with whether you're talking this bill or whether you're talking mandatory guidelines. It's been indicated at these hearings that mandatory guidelines could be extended to cover the good Samaritan or the passerby. I believe the care giver has a legal responsibility with respect to not divulging the confidentiality of persons with a communicable disease, by finding it through deduction or inadvertence or otherwise in this process. I don't know what that law is, but I believe that exists. If not a moral law, it may even be a legal law, and that's part of my first question.
I know good Samaritans or the passersby do not have any legal responsibility. If that is the case, then there would have to be a law, would there not? If the mandatory guidelines were extended to the good Samaritan, there would have to be a law passed or an amendment to a piece of legislation, perhaps the privacy legislation, that precludes the good Samaritan who may inadvertently or through deduction find out the identity of this person. My question is to either, perhaps both.
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Ms Day: Around the issue of the good Samaritan, although it's an important one, it is probably beyond our immediate response and our purview to be able to speak about the legal implications.
Mr Tilson: That's why I have been pushing this bill, because the mandatory guidelines to date do not go to the good Samaritan. My bill, and I'm the one who introduced it, does. My bill includes everyone, from the passerby in the street to the off-duty firefighter to the off-duty police officer to someone who isn't part of the process, because I think we have to cover them. Why would you just cover one segment of society and not others? There are other trained individuals -- St John Ambulance people, who are trained -- who may be providing a volunteer service who happen upon a scene of an accident. Surely we're going to provide the same sort of protection to those people as we would to the care giver.
Ms Anderson: As I mentioned earlier, what you could do is call upon the guidelines to stipulate what the role of public health is with regard to good Samaritans so it's clarified and clear so that the public has an understanding of what they might look to public health for in terms of support.
Mr Tilson: I can tell you that to date the mandatory guidelines do not include a good Samaritan individual. I'm assuming that the ministry officials will honour their undertaking to put those individuals into the guidelines.
My question, therefore, goes to the issue of confidentiality, because that is a concern of the bill and it would be a concern of the guidelines. Does anyone know the answer to that question? If not, how do I get an answer to that question?
The Acting Chair: I wonder if Dr Schabas wants to respond to that question.
Mr Tilson: I have no problem with that, but perhaps legislative research could undertake to --
Mr Andrew McNaught: I can't answer that right now, but I'll look into that if you want.
The Acting Chair: Come forward for a moment, Dr Schabas.
Dr Richard Schabas: Mr Tilson is quite correct. There is legislation which mandates confidentiality. First of all, there's the Health Disciplines Act, which requires that all information which is part of the professional confidential information acquired by doctors or other health professionals is mandated as confidential unless there are specific legal requirements that it be divulged. There are two or three such pieces of legislation, and the Health Protection and Promotion Act is one where physicians and people who operate medical laboratories are required to report to medical officers of health what would otherwise be confidential information about a person who has a reportable or communicable disease.
Public health then uses that information to do what is necessary to control the spread of that disease, which may involve ensuring the person is counselled, that he or she receives treatment, and in some diseases it means they then go and identify partners; for instance, with sexually transmitted diseases. But even in that context there are provisions under the Health Protection and Promotion Act -- I believe it's section 39 -- that specifically require that the confidentiality of the individual be protected. That's specifically what is wrong with Bill 89, because Bill 89 requires the release of the name of the disease the patient is infected with. That is a requirement that is fraught with hazard in terms of compromising confidentiality.
The difference with the guidelines is that, as we would do with identifying someone who, for instance, is a contact of a sexually transmitted disease, we don't come and tell them that they have such-and-such a disease; we come and tell them what they must do to protect themselves, to determine if they have an infection. We advise them on a course of action. That's particularly important in this context, because the emergency worker by and large will know the identity of the patient in terms of whom they're worried about exposure.
It's critically important that we not come and say, "That person had HIV infection" or "That person had hepatitis B infection." What is more important is that we advise them on what they should do, including maybe blood tests for HIV, maybe to be aware of certain symptomatic illnesses. It will be more generic advice rather than the specific information that a patient has a disease.
The Acting Chair: Mr Tilson, I can give you one more minute and then we'll have to move on because we have other speakers waiting.
Mr Tilson: I appreciate that. My question was not about the fault of the mandatory guidelines or the question of the fault of the bill. My question has to do with whether or not individuals, whether they be care givers or good Samaritans, inadvertently or through power of deduction, discover the identity of someone who has a communicable disease. I'm led to believe that the care giver can't divulge it, but there is no law that precludes the good Samaritan if he or she discovers it. My question is, am I correct in those assumptions?
Dr Schabas: You are quite correct. If someone doesn't acquire that information as part of a professional service as covered by the Health Disciplines Act or the Health Protection and Promotion Act, then there are no legal bounds on confidentiality. If someone tells you over the back fence that you next-door neighbour has a communicable disease, that's not confidential information in the eyes of the law.
Mr Larry O'Connor (Durham-York): The concern I have is of course the confidentiality, and maybe we go on a little bit further. Yesterday in one of the presentations, somebody referred to the fact that quite often emergency room staff will notify the medical officer of health, the health unit and also then make a call to the ambulance service. What really bothered me was that here we are talking about confidentiality and we've already got a system that isn't respecting this confidentiality. When we talk about the ongoing education process you just mentioned, it needs to take place now. There are some people out there who obviously don't realize the importance of confidentiality.
Ms Anderson: Absolutely. It's of great concern to us, this kind of reliance on diagnosis, this reliance on knowing, because that knowledge is of so little benefit to begin with, but also there's so much that we don't know. For both health workers and emergency service workers, the prevention issue is where they get protection. There's this false reliance on after the fact, which is extremely dangerous to their lives.
Mr O'Connor: Clearly, we haven't been involved in the guidelines process, and the people involved will go through it quite diligently. They are looking at a designated person within a workplace who would be somebody they can turn to. What's your response in terms of that being the process? It's one that will get discussion, but I just wonder if you'd like to comment on it.
Ms Anderson: Basically, at this point we can't comment on those kinds of specific procedures because we've literally only received them over the last week. In terms of OPHA's feeling about the guidelines, it is to be able to support a process that involves stakeholders. We really see them as in process themselves. These guidelines are not complete as they are, and are going to need to involve other stakeholders so that there's buy-in from all the people who are involved in emergency service worker care and those interactions.
This particular procedure, this particular person, is not of critical importance to OPHA today. It's the process that's important, that involves the stakeholders, and we have every belief that the collaborative process will bring the buy-in, will being the consensus that's necessary that will establish those kinds of working relationships that need to be there consistently throughout the province.
Ms Day: In addition, the guidelines would then start to include the whole preventive side of it and the training and not leave it only after the fact but bring them in before the fact.
Mr O'Connor: One of my colleagues mentioned that yesterday Mr McGough from one of the firefighters' associations had concerns about a meeting that took place last week. There's a firefighters' lobby actually taking place here at Queen's Park today, so I had an opportunity to talk to some firefighters and raise this issue because we heard a concern yesterday.
I was talking to the person who actually had made a presentation to us last week and asked for his read on it, and he felt reassured. There may be a little bit of apprehension, but the process itself is evolving if the stakeholders who need to be involved in the process are being involved. Though we heard some concerns yesterday, I got a bit of reassurance from the lobby that's taking place today that some of those concerns are being addressed.
The Acting Chair: Thank you, Mr O'Connor, and thank you, Ms Anderson, Ms Day and Ms Lehmann, for your thought-provoking presentation.
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ADELA M. RODRIGUEZ
RICHARD ISAAC
The Chair: Is Adela Rodriguez here?
Ms Adela M. Rodriguez: Yes.
The Chair: We welcome you both to the committee. You've seen how the process works. Basically you will give a brief presentation, hopefully no longer than 15 minutes so we can leave five minutes per caucus. We know who you are, but we don't know who your colleague is.
Ms Rodriguez: This is Dr Richard Isaac. He's a coroner. While I was preparing the written submissions that are going out to all of you, I used him as a consult, along with a large number of health care lawyers. My practice is mostly in health law, which is my motivation for coming today.
The Chair: Yes, please.
I'd like to say that initially an appointment had been made for a Canadian Bar Association-Ontario submission. When I first started working on this, that was the intent. The CBAO understandably and for good reason has a very stringent process of approval. It may be that at some point some of the comments that I'm going to make today will become part of a CBAO submission, but at this point I should make it clear I'm here solely on an individual basis, as is Dr Isaac.
Mr Tilson: We believe you.
Ms Rodriguez: Thanks. We're not in court.
First of all, I'd like to thank Mr Tilson for instigating this whole process through Bill 89. Although ultimately my recommendation is that this bill not go to third reading, I do not want in any way to sound like I minimize the stress and strain that an individual would go through. I know it's happened to me, the stress and strain that you go through, wondering if you've been exposed. So I just want to say that at the outset.
Because my written submissions are so short, I'm just going to basically go through them. I don't mind if anyone wants to interrupt. Dr Isaac is then going to augment what I have to say and also is going to be available for all of your questions, some of which he's more qualified to answer than I am.
The Chair: Will you be going through the whole thing?
Ms Rodriguez: Yes. It's only six pages, so it's quite --
The Chair: Remember, you only have a half an hour and that will leave very little time for your presentation and his by way of questions to both of you after that.
Ms Rodriguez: Yes. I'm going to try and just highlight it and not read it out.
The purpose of my visit's obvious. By way of introduction, I want to acknowledge that Bill 89 was introduced in reflection of the purpose of the act, which is to promote and protect the public's health. However, despite its good intentions, in my submission, it raises three troubling issues that must be brought before you today. These I'll outline and relate to you: the scheme of written requests and contact tracing proposed by Bill 89 -- and if I use any terms that maybe are more familiar to me than any of yourselves, please interrupt me -- secondly, how confidentiality is affected by this scheme, and thirdly, the reports to be kept and the reporting to be done by a hospital under Bill 89. Individually and together, I feel that these issues demonstrate that there is a potential harm and impracticality by bringing Bill 89 into law.
Because it's my impression that the impetus for Bill 89 is AIDS, I'm going to concentrate my submissions on that, and if you have any questions otherwise, feel free to ask.
In this regard, the bill aspires to provide an emergency care provider, whom I'll refer to as a "provider," with the HIV status of a person to whom he or she has provided care, whom I'll refer to as the "recipient," in order that the provider can be hopefully afforded some peace of mind or, alternatively, be given the incentive to be tested and practise safe behaviour. However, the scheme itself is unreliable, in my submission, and, as a result, dangerous.
It cannot serve to protect those it aspires to protect for two reasons: the first reason being, if an MOH, a medical officer of health, has information that a recipient has tested negative for HIV, that does not mean the provider was not exposed to HIV in the course of providing the emergency care. The test for HIV does not detect the virus, as you know, but rather the antibodies produced by the body in order to combat the virus. This is significant because the antibodies can take anywhere from a few weeks to six months to actually be produced and detectable by the test. Therefore, a recipient may test antibody negative but he or she may have been actually virus positive at the time the emergency care was provided.
Secondly, if the medical officer of health has no HIV information, this again does not necessarily mean that the provider was not exposed to HIV in the course of providing emergency care. It may be that the recipient was never tested, is HIV-negative, resides within the jurisdiction of a health unit other than the one in which the hospital is located, or tested HIV-positive but the test result was not reported to the medical officer of health because the person was tested anonymously or non-nominally.
Therefore, I would submit that the only way a provider is going to know whether or not he or she is infected is to undergo HIV testing. To forgo testing in reliance on this scheme can result in a lack of opportunity for the provider to obtain early treatment or counselling, especially regarding the risk of exposure and the avoidance of behaviour which could result in transmission. Of equal concern, which I've already heard brought up too, is that this scheme seems to promote reactive measures rather than proactive, precautionary ones that can be taken in advance, like Universal Precautions in the case of emergency care providers.
On the second issue of confidentiality, I would submit that subsection 39(1) of the act, which is the confidentiality section of the act which was mentioned by the doctor who spoke before I began, and similarly subsection 27.3(1) of Bill 89 purport to protect the recipient's identity. However, subsection 27.1(3) of Bill 89 stands in stark contrast, because even if the provider doesn't know or disclose the recipient's name, the provider has to give sufficient identifying information so that confirmation of exposure by the MOH is possible.
Therefore, upon reporting the likelihood of exposure as a result of contact with the recipient, the MOH is revealing the HIV status of the recipient and thus breaches confidentiality. This obviously, and I'm sure you've heard this over the week, can be an incredible intrusion on somebody who is HIV-positive, whether it's a matter just of discrimination, loss of employment, housing or disastrous consequences with relationships.
I also submit that confidentiality is not protected by the act, by the Health Protection and Promotion Act, just for civil rights purposes but also in the interest of public health.
At this point, I'm almost done. How much time do I have?
The Chair: Well, you've spoken for about six or seven minutes.
Ms Rodriguez: Okay. Let me just finish it up then. Am I speaking too quickly?
The Chair: No, you're doing fine.
Ms Rodriguez: Okay, thanks. It's one of my downsides of public speaking.
With respect to the act protecting confidentiality in the interest of the public, I would raise Ontario regulation 749/91, which was amended by 233/92, which both amended the reports regulations under the act by introducing anonymous HIV testing. This anonymous HIV testing responds to the fact that people are deterred from testing if they fear their HIV status could be revealed. Of course, this avoidance of the public health system places the public health at greater risk because people who do not know they're infected and do not get pre- and post-test counselling are less likely to be careful about transmission than those who do.
The extent to which the MOH presently protects confidentiality under the act, as stipulated by section 39, really depends upon that MOH's interpretation of section 39. Dr Isaac will elaborate on this, I'm sure. To some, it implies presently that you can contact-trace; some say you can contact-trace and answer direct requests; some say no, neither; and some say both.
I submit that Bill 89 actually further confounds this, because if responding to written requests and contact-tracing are permitted by the act already, then Bill 89 isn't really necessary or at least should clarify that once and for all. But by setting out a special scheme for emergency care providers, it suggests that responding to written requests and contact-tracing are not presently permitted by the act. If that's the case, then I'd have to query why emergency care providers are the ones who are getting special treatment. I think we can easily see how all health care providers would have an interest; the public in fact might have an interest.
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Finally, I just want to make a comment on section 27.2 of Bill 89, the one that deals with the hospital records. Pursuant to subsection 27(1) of the act itself, the hospitals are required presently to report patients who have or may have a reportable disease or are or may be infected with an agent of a communicable disease. As a practical matter, I understand that compliance with this reporting is low. You'd probably have better information as to numbers, but I understand it's quite low. So this practical reality, compounded with the limited ability of hospitals to ascertain who may have provided emergency care, because this bill is not just directed to paramedics -- I mean, being a health law lawyer, I know there's a lot of incidents where people are just dropped off at the hospital, people don't stop or that sort of thing. So the practical reality, compounded with the low reporting reality, renders that section of the bill, 27.2, virtually useless and therefore I would submit is an unjustifiable administrative burden to impose at this time on our already overburdened hospitals.
I've already told you what my recommendation is, based on the submissions I've made, that it not go to third reading. It's not to say that's the end of the story. I think it will become probably clear in your questioning -- I hope I can be clear -- that my view is that in terms of the least intrusive means, because of course, speaking from a lawyer's perspective, this legislation has to survive charter analysis, the least intrusive means to deal with all these issues, weigh them, is that obviously education is crucial, especially in this particular subject of emergency care providing Universal Precautions, plus education on safe behaviour, as those precautionary measures be proactive ones.
Also, the idea that if this is actually a special group, whether regular testing should be something that's encouraged. I'm not trying to suggest that's an imposition that's justifiable, but there are other alternatives and guidelines. I have received a copy of the guidelines that were provided from the Ministry of Health. I've read them. I can't say I'm familiar enough with how guidelines work in practice to give my personal opinion at this time as to whether, "Oh, yeah, those are great, let's do that instead," but what I did like about it and the whole idea of it is that given the state of knowledge of this disease and its transmission and all that sort of stuff, given that there are so many interests to be weighed, it seemed that by setting up different tiers of who you talk to and all that sort of stuff and getting information from it, there is an attempt to weigh, balance, so let's just look into this and really see whether there was a chance of exposure so if we can avoid naming the disease and therefore naming the person, that sort of thing. So I see more room and flexibility in dealing with the realities that we're confronted with through a guideline perspective. Again, I say that in light of the fact that I'm not insensitive to the stress and strains that health care providers and many other people are going through when fearing risk of exposure for probably very good reasons.
I'll leave it up to Dr Isaac.
Dr Richard Isaac: A few comments, ladies and gentlemen. First of all, the exclusion. Although I happen to be a physician, a lawyer, coroner, a member of the HIV primary care group, even a member of the CBAO and a few other places, don't blame any of those for what I'm going to say; just blame me personally.
I'm going to suggest to you six or seven things quickly. First of all and most important: This bill is, while well-intentioned, superfluous and shouldn't be supported. I think it's superfluous for one reason in particular. You know about contact-tracing -- standard, garden-variety contact-tracing that the MOH does. There's no reason that process can't work in reverse. If the MOH hears of a contact, say, for a sexually transmitted disease, then goes to the person who is perhaps the recipient of that contact and says, "We can't tell you who may have given it to you or what they gave, but this is our advice as to what to do," that's done now. It's not directly supported in the Health Protection and Promotion Act, but it's being done.
If I see myself as the possible recipient of a contact or of a risk event -- I like that terminology -- why can't I go to the MOH and say: "Look, I've had this circumstance. Tell me, do you want to come and trace back to me and advise me to do something?" That, I think, can work perhaps informally, the way the standard contact-tracing is done now, and it would require something -- I don't like the oxymoron "mandatory guidelines," but some sort of guidelines like that. One of the problems I've seen in Ontario is that there are many MOHs and many of them interpret things differently, so guidelines, maybe not mandatory, may be helpful. So my first point is that this is not particularly necessary.
Secondly, I think it can be better handled with education and knowledge of what risk events are. The previous presentation, which I only heard half of, probably addressed that, so I won't go on.
The bill is vague, perhaps explicitly designed to be so. What's an exposure? The MOH will supposedly decide that. But an emergency worker is someone who takes the person to the hospital. The ambulance, the family friends or so on may take to the hospital, but what about the person who doesn't take to the hospital, say, the fire people? In tiered response, fire comes first, the ambulance may come second and the police come third. At least, that's the way it happens in Metro. But only the people who take the patient to a hospital are covered by this definition. That's not good, and I don't think that's what was intended in the legislation. I think it's sort of vague.
There sure is a chance for breach of confidentiality in this, because medical confidentiality, that cloak, descends at the emergency room door. But most of the emergency workers will know or will be able to find out who lived at that house, who they took. They do a report. Most often that report has a name, the name of the soon-to-be patient on it. So I think there are real problems with confidentiality in this schema.
The next thing I want to say is cost. This schema imposes, especially on the hospitals, a lot of paperwork identifying who the "emergency care workers" are. Right now they usually list one person and maybe an ambulance number or so, but they don't list all of these, and you're imposing on an already strained hospital system a lot more paperwork, most of which will be unnecessary. I ask you to consider the burden of this legislation as well as the cost.
This would, I think, give a false sense of security. Unfortunately, you can't give a full sense of security, but knowledge, counselling which may be done by the individual groups -- the ambulance group, the fire group, the police group -- or the person's family physician should be prepared to give adequate education to give at least some sense of, if not security, at least knowledge.
Finally, I'd suggest to you that we have a well-developed and I hope reasonably balanced schema for reporting in Ontario. It seems to work fairly well generally. It's a climate which should be fostered to enhance this climate, based on knowledge and scientific experience, knowledge of what risk events are, goodwill, absence of discrimination -- maybe I should put that in a positive sense but let me just say absence of discrimination -- and a chance for communication.
If all those are fostered, and particularly fostered at the very basic level with an individual patient, why would that patient not want to self-reveal? If there has been a true risk event and the patient sees someone else who may be at emotional risk in a situation that the patient probably went through before, if they have one of these many diseases, why would the patient not choose to self-reveal and deal with it on that level first? If that doesn't work, I think the MOH system is in place to augment it.
Those, very briefly, are my comments.
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The Chair: Thank you. I would just remind the members we don't have much time, so if you have one question, try to make it as short as possible.
Mr Tilson: Thank you for your presentation. There's no question the bill needs improvement as to the mandatory guidelines. The problem we have is that on the one hand, we have the need for confidentiality, the protection of the person who may or may not have a disease. On the other hand, we're asking care givers to put their lives, their health on the line to assist people.
Ambulance records, records that are kept that end up in the offices of the medical officer of health will not have everyone's name. They may not have all the names of the police department who was involved. They may not have all the names of the firefighters who involved, or other care givers. They certainly will not have, or are unlikely to have, the person who's dropped off, to use your words, I'm sorry; I've lost your name.
Ms Rodriguez: Adela.
Mr Tilson: They will not have the name of the individual who may have just dropped somebody off at the hospital, or to use the words that have been used in this committee, the good Samaritan. That's the problem. You say the system is fine now. The care giver says it's not fine now, that we're asking these people, these very qualified people to stick their health and their lives on the line, and they're asking for more protection. You're not giving them much comfort with your presentation, quite frankly.
Ms Rodriguez: I guess it's my submission that neither does the bill. That's the problem, and I think that's a struggling problem, and that's why I suggested that if you give it a shot with guidelines, those are flexible and you can move with them and provide assistance. One of the health law lawyers, who actually in his day-to-day practice has to give advice to health care providers who are in the situation you're describing, was suggesting that at least even through guidelines, by setting processes where if there is a discrepancy between what we should do, we know we're going to reveal confidentiality -- I hate to increase bureaucracy, but some sort of board or group that could help weigh these things. You talk about cost, but really, that's the question too.
Do we have the answer in this bill? I don't think so, and I empathize with how they feel. It's horrible. Of course, there's the public perception as well that despite the good they do -- and I've been in the emergency room; I know how much blood there is; it's unbelievable -- who still perceive because of the information they get, whether it's Newsweek or journals, that despite that, because of Universal Precautions etc, which should also be used by fire persons and police officers and that sort of thing, they're not a high-risk group.
Is there another way we can alleviate their stress and their strain and their concern, if the risk isn't there?
Mr Tilson: No, the risk is there.
Ms Rodriguez: Yes, sorry, that's true.
Mr Tilson: We wouldn't be here if the risk wasn't there.
Ms Rodriguez: I know, but I'm just saying in terms of the public perception. There's a fear element. I guess that's what I'm trying to address. Can we alleviate their fear somehow by education, by that sort of thing, better than we can with this bill which, as I've explained, isn't necessarily addressing the problem, addressing the question they have?
Dr Isaac: Could I comment on that?
The Chair: Please.
Dr Isaac: Once a risk event occurs in fact I, as a coroner or an MOH, could from the paperwork track back and identify the ambulance drivers and attendants, the police, the fire department. We can do that. But the risk event has to occur first. That's very simple. The condom breaks, the blood gets splashed into a mucosa or there's a needle stick or there's a birth, and those are the only three risk events for HIV infection. You can weight them differently for other infections.
Once that happens, I think the schema is in place for either, as I say, the coroner if there happens to be a death involved or the MOH to track back --
Mr Tilson: The care givers say you can't find everyone.
Dr Isaac: The care giver will know or should know by public education or professional education that they've had a risk event and then follow up from that.
Mr Tilson: How will they know that?
Dr Isaac: Because one of those three things that I described happened --
The Chair: Excuse me, we're running out of time.
Dr Isaac: -- and only one of those three things. If there's no risk event, there's nothing to worry about, as such. The rest is paranoia.
The Chair: Thank you. There is an urgency, of course, or desire for people to engage in dialogue, but we're running out of time and it'll be difficult if we don't move on.
Mr O'Connor: A concern I have about the process: If we were to continue along the line that we've got a problem here, to address this problem, be it the bill, the guidelines, do we then have to go even further, to suggest that not only is the concern for the health care attendants who could come in contact but even the patients who could come into contact? To truly provide for the concerns people have, will we not have to go through a mandatory testing of all health care providers?
I think we're heading down a path of trying to make ourselves feel more secure when really what we need is an education process. To address all the concerns, we're going to have to go through mandatory testing for all communicable diseases of everybody involved in health care, or attendants or taxi drivers.
Dr Isaac: I don't speak for the CBAO. I was on the special committee that did a first report and we're doing a second report on an aspect of it now. We address mandatory testing. The consensus, I think in North America as well, is that mandatory testing is counterproductive. Even if you had mandatory testing, it won't give you the level of certainty. Those who are paranoid will never be certain and it won't deal with the window of negativity when we're talking about HIV infection.
Unfortunately, a lot of this tends to revolve around HIV, but one should say that there are other diseases that kill people too, and things like hepatitis B can be handled by vaccination. A lot of these can be handled, at least most of the time -- there are exceptions -- by Universal Precautions or by safe sex. These things can be dealt with and that's education; that's not mandatory testing.
Mr O'Connor: We've seen the hysteria --
The Chair: Mr O'Connor, we're running out of time.
Mr O'Connor: -- that could cause problems without going through a proper education process.
Mr Alvin Curling (Scarborough North): Thank you for your presentation. Doctor Isaac, or Barrister Isaac, or all the titles you carry, you mentioned education. I agree with you in that legislation may not be the answer. We are legislators and we try to resolve every problem through legislation. Sometimes we try our best to make proper legislation and we get resistance in that order.
It is very interesting, as you said, that education may be one of the key things -- you didn't say the word "key" -- to resolve that. The concern I raise is not among the lay people, basically. There are people who are care givers and that doesn't try to bring that out; there is a concern and that's why somehow we've got to bring some legislation. I don't know if legislation is the answer in order to address that issue.
I want to go back to education itself. There was a case, as you know, I think in Windsor, where there were some rumours that this individual was, I think, murdered, and they said he was an HIV-positive individual, which was not so. The coroner, I gather, over there, actually refused to conduct the case, or the process that was involved in that. Here is somebody who should have been educated, who should know, and then refused.
If those individuals are saying, "Listen, we need some sort of guidelines and some legislation in order to handle this kind of stuff," and if they are backing off, how would you respond to that then? Mr Tilson tries to bring forth legislation to deal with that; as he said, it's not perfect. Do you think education to the coroner would have been helpful? I thought he would be educated.
Dr Isaac: Far be it for me to comment on one of my colleagues in a situation that I have not heard about.
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Mr Curling: Not your colleague. I'm just trying to say there are people who are professionals who understand that kind of disease who are also still refusing somehow to give that kind of service. We thought they would be educated in that field.
Dr Isaac: For some of my own professionals -- I include at least two, and maybe some of you share some of those professions -- voluntary blindness sometimes is frustrating. But it is a professional standard, at least in medicine, that you should know about these things. Sure, the standard is not always honoured, but we're continually striving to achieve that.
I could address how I, as a coroner, would deal with the case where there is a risk event. I think that would be a good argument for doing an HIV test to see if there was a real risk event, but coupled with the knowledge that with the window of negativity it's not going to provide the certainty. The individuals who see themselves as having had a risk event will have to go through counselling, have to go through their own testing and have to weight that window of negativity for themselves to get their own test.
Still, education is good. My last comment is, if you have to do something, do something good with your own process, which is the legislative process.
The Chair: Thank you very much, Ms Rodriguez and Dr Isaac. Thank you for taking the time to come and give your presentation to this committee today.
ONTARIO HOSPITAL ASSOCIATION
The Chair: The Ontario Hospital Association: Mr Peter Harris, Ms Carolyn Shushelski and Ms Susan Smythe. Welcome. As you have noted, we do run out of time very quickly, and if you want the feedback of the members you'll have to leave time for that. Otherwise, we'll just get your presentation, which is fine as well if that's what you want. Please begin any time you're ready.
Mr Peter Harris: My name is Peter Harris and I am the chair-elect of the Ontario Hospital Association. I am joined today by Carolyn Shushelski, OHA legal counsel, and Susan Smythe, OHA hospital consultant. We are pleased to be provided with this opportunity to address the committee with some comments on Bill 89, An Act to amend the Health Protection and Promotion Act.
Communicable diseases or reportable diseases do exist in our society. We acknowledge that health care providers, whether employed by hospitals, community care agencies or emergency medical services, and the general public acting in a good Samaritan capacity can in fact become infected with a communicable disease or reportable disease if a significant exposure to contaminated blood or body fluids takes place.
In addition to significant exposure, many other factors must be taken into consideration; for example, effective method of transmission, that is, a sharp-object injury versus direct blood contact on intact skin, and whether there is a sufficient amount of infecting agent present in the blood or the body fluid.
We recognize that the issue surrounding communicable diseases and reportable diseases may at times be one of societal rights versus individual rights. The challenge is how to deal with them (a) in the workplace and (b) in the community, as responsible citizens functioning as good Samaritans.
International research has shown that police and firefighters, by the nature of their work, may come in close contact with the blood or body secretions of members of the public. The results of the research conclude that there is no evidence of police or firefighters having been at increased risk of hepatitis B infection. This research was conducted by comparing the incidence of infection in these groups with that of the general population.
In hospitals, we often deal with patients who have been involved in trauma; for example, accident victims as well as patients who may be suffering from reportable diseases or communicable diseases. Let me briefly outline for you the current procedures that hospitals observe with respect to the potential exposure of our employees to infectious diseases.
Universal Precautions: The procedure-driven isolation system is an infection-control concept based on the premise that all patients are potentially infectious. The procedure to be performed, rather than the patient's diagnosis, determines the precautions to be taken. Since it is not an easy task to determine which patients have which infectious diseases, this isolation system recommends that health care workers take precautions with the blood and the body fluid of all patients. In addition, all blood and body fluid laboratory samples are considered infectious and treated accordingly. The procedure-driven isolation system is designed to protect both the patients and the employees from infection. One of these isolation systems is Universal Precautions, or universal blood and body fluid precautions.
Universal Precautions, or UP, was developed by the Centers for Disease Control, or the CDC, in Atlanta, and the Laboratory Centre for Disease Control, or the LCDC, in Ottawa. The system is designed primarily to prevent the spread of blood-borne disease. Universal Precautions involve applying the former isolation category of blood/body fluid precautions to all patients but maintaining the rest of the diagnosis-driven isolation system. In other words, Universal Precautions are superimposed on the existing isolation system; they do not replace it. Patients with recognized communicable diseases or reportable diseases, for example, tuberculosis or salmonella infection, are isolated as they were previously, with the addition of blood and body fluid precautions. The CDC and the LCDC recommend that Universal Precautions be used in the case of all patients, especially including those in emergency care settings in which the risk of blood exposure is increased and the infection status of the patient is usually unknown. The Universal Precautions system could be adapted to other organizations whose workers, like health care workers, may physically interact with individuals, any of whom could have an infectious disease. The following are some examples of elements of the Universal Precautions system.
First, gloves: Waterproof gloves, vinyl or latex, should be worn when it is likely that hands will contact body substances, mucous membranes or non-intact skin. Gloves must be changed or discarded after contact with each patient. Gloves do not negate the need for handwashing.
A second example is face protection. A mask and goggles or glasses or a face shield should be worn for procedures in which body substances may be splashed on the mucous membranes of the eyes, nose or mouth.
A third is the obvious: handwashing. Hands should be washed immediately whenever there is a likelihood that they may have been soiled with body substances, as well as when obvious soilage with body substances occurs.
Finally, CPR: Although saliva has not been implicated in the transmission of any serious disease, including HIV, hepatitis B or herpes, to minimize the need for emergency mouth-to-mouth resuscitation, mouthpieces, resuscitation bags or other ventilation devices should be available for use in areas in which the need for resuscitation is predictable.
In 1991, the Ministry of Health's Task Force on Universal Precautions recommended that Universal Precautions "be adopted and used in all health care settings and with all procedures where there is a risk of exposure to blood and/or body fluids."
The communicable disease surveillance protocols: Under regulation 965 of the Public Hospitals Act, hospitals are responsible for establishing and providing for the operation of a health surveillance program, including a communicable disease surveillance program for their employees. OHA, together with the Ontario Medical Association, developed and published protocols for a consistent standard of follow-up and treatment, post-exposure, to communicable diseases. These protocols are approved by the Ministry of Health. The practicality and the necessity of this effective directive has been transferred to many health care settings and would be applicable to many emergency service outlets. In fact, the Metropolitan Toronto Ambulance Authority has already incorporated these protocols in its occupational health and safety guidelines. Other organizations may also find these protocols of value and of interest.
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In health and safety in the workplace, hospitals have a duty to patients and to staff to maintain a safe environment to the extent reasonably possible. In addition, the hospital as an employer has duties under the Occupational Health and Safety Act related to health and safety in the workplace. The act requires, among other things, the employer to:
"25(2)(a) provide information, instruction and supervision to a worker to protect the health or safety of the worker;"
"25(2)(h) take every precaution reasonable in the circumstances for the protection of the worker."
The risk of exposure to infection exists in the hospital environment, without question. Hospitals take reasonable steps to minimize the risk of exposure to infection by instituting policies and procedures based on the most current clinical information. Hospitals review and update these policies and procedures as well as ensuring that they are being carried out properly in the hospital.
We would recommend that any organization or association whose members could potentially come in contact with blood or body fluids in the course of their employment activities institute universal precautions and take whatever steps are necessary to meet their obligations under section 25 of the Occupational Health and Safety Act.
In the management of accidental exposure of health care workers, we recognize that there are situations where, despite the best efforts of existing policies and procedures, exposure to blood or body fluids takes place. We would ask that the following protocol for the management of accidental exposure of a health care worker to the blood of a patient be considered. I would like to note that the protocol was endorsed by the Centers for Disease Control in Atlanta and the Department of Health of Canada. Generally, the protocol states:
If a health care worker has a parenteral -- for example, needle stick or cut -- or mucous membrane -- for example, a splash to the eye or mouth -- exposure to blood or other body fluids or has a cutaneous exposure involving large amounts of blood or prolonged contact with blood, especially when the exposed skin is chapped, abraded or afflicted with dermatitis, the source patient should be informed of the incident and tested for serologic evidence of HIV infection after consent is obtained.
If the source patient has AIDS, tests positive for the HIV antibody or refuses the test, the health care worker should be counselled regarding the risk of infection and evaluated clinically and serologically for evidence of HIV infection as soon as possible after the exposure. The health care worker, in turn, should be advised to report and seek medical evaluation for any acute febrile illness that occurs within 12 weeks after the exposure.
A health care worker who sustains an exposure to a patient with AIDS or a patient with clinical manifestations of HIV infection or serological evidence of HIV infection should be enrolled in the national surveillance program coordinated by the federal centre for AIDS. The protocol requires that participants receive HIV serology tests within 30 days of the occupational exposure. Testing is carried out at six-week intervals for the six-month period after enrolment, then at nine and 12 months, at which time post-exposure follow-up is terminated. Confidentiality is assured by using a coding system for record management which does not require any personal identifiers. In other words, there's an anonymity factor in that mechanism.
Individuals who are exposed to blood from an unknown source or from a patient who refuses to be tested cannot be enrolled in the national surveillance program. However, the Centers for Disease Control suggests that workers should be monitored in a manner similar to that described above, or in an individualized manner appropriate to the situation. This may be done by the employee's family physician or the facility's occupational health service.
The Centers for Disease Control and the Laboratory Centre for Disease Control also recommend that if a patient has a parenteral or mucous membrane exposure to blood or other body fluids of a health care worker, the patient should be informed of the incident and the same procedure outlined for the management of exposure should be followed for both the source health care worker and the exposed patient. We would recommend that any organization or association whose members could potentially come in contact with blood or body fluids in the course of their employment activities institute a similar type of protocol.
OHA recognizes that a good Samaritan, in the course of rendering first aid to a victim of an accident, may come in contact with the person's blood and/or body fluids. We recommend that if this exposure takes place, regardless of the health status of the victim being assisted, the good Samaritan go to his or her family physician to receive counselling with respect to the need for testing or further medical assistance. We believe that an intensive public education campaign could communicate the issue to the public.
We have presented this to you as we understand that the motivation for bringing the bill responds to the concerns of emergency care workers, firefighters, police officers or ambulance drivers, that in their opinion significant procedures are currently not in place to protect them from exposure to reportable diseases or communicable diseases. However, we do not view Bill 89 as being necessary in this context. That's not to say we do not believe that improvements in education for health and safety cannot be made. We are simply concerned that the bill will not achieve its intended aims either efficiently or effectively. By following the existing example of the hospital sector, many of the concerns being expressed by these groups will be met to the extent that can be reasonably expected. Specific concerns related to the provisions of the bill itself are attached as appendix A to this submission.
This concludes my formal presentation. We would be pleased to entertain any questions you may have.
The Chair: One question per caucus.
Mr O'Connor: Then I won't ask him how long he's going to be president-elect. I've seen you a couple of times, so I won't ask that.
You suggest that in the example of the good Samaritan, they should approach their family physician. I don't know whether they could go to the public health unit directly or not. It's been suggested that this is the process that should be undertaken inasmuch as they would be the ones in the community who would be involved in any sort of communicable disease. Would that not be the direction they should go?
Mr Peter Harris: Susan, do you have a preferred choice of action?
Ms Susan Smythe: I think it's recognized that the family physician is the primary point of access for any individual citizen. If the public health system were required to support that action, then it would have to be a plan made in terms of the public health access for individual attention.
It's these types of issues that I think need to be thought upon, given more consideration in terms of how we actually implement actions that are to be taken with various parties. We've done it with the health care sector, specifically in the hospital sector. What we're suggesting is that it can be done outside of more legislation. Therefore, give us collectively the opportunity to work out these questions you would have for access for the public.
Mr Peter Harris: Just as a follow-up point to the original, all going according to the divine process, on November 8 I will shed the chair-elect handle and become chair.
Mr Curling: Thank you for your presentation. With only one question, I think the bottom part of 7 really summarizes or focuses on exactly the concern. As you said, there are concerns, and you said there is a lack of significant procedures. You state that although you don't believe Bill 89 is necessary in this context, you further state your concern that something must be done.
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My question then is, as this bill may not see royal assent and become law, would that be a sad situation in the sense that it would have not addressed that procedures are lacking, that legislation or procedures should be in place? You think it's important that the government, or we as legislators, address that concern immediately, that people are expressing these very, very serious concerns.
Mr Peter Harris: My first reaction would be that the mechanism to address the problem could be more effectively implemented through education as opposed to a piece of legislation that creates a number of problems in terms of the practicality of recording this information with all of the variability: We've heard of the person dropped off and no one knows who dropped them off and so on and so on, which produces a non sequitur in the system.
The route of having people understand the potential for risk: There's been a notable success, I believe, in advertising and calling the public's attention to the potential for exposure and risk and the utilization of condom protection. In the same fashion, or slipstreaming with that, we feel the public could be educated to the potential risks of exposure to body fluids or that type of thing in the good Samaritan role. It seems to be working well on the one side and we feel it would be equally applicable on the other.
Mr Tilson: Thank you very much for coming today. I also would like to thank Ms Smythe for coming to my office and explaining your organization's position even further. I understand the issue of the philosophy of education and trying to educate all of us. There are many fears out there, no matter what disease you're talking about. I will say, though, speaking to the care givers who have spurred this bill, with its many faults and many flaws -- you talk about universal blood and body fluids precaution; there's no question, and they all sound fine and necessary, and we must continue to educate all of us, I suppose. But the taxi driver or the good Samaritan, in terms of the person who's dropped off at the hospital, which is the new example given today, won't have the foggiest idea what is being talked about.
Further to that, the off-duty ambulance driver or the off-duty firefighter may not have their gloves or mouthpieces or whichever precautionary methods you're talking about with them. Or the person who knows first aid -- and there may be a whole slew of people in this room who know first aid -- simply won't have that available, so what do they do?
Ms Smythe: Mr Tilson and I debated this quite at length yesterday. As I indicated before, I think we really need to separate the group of individuals who are highly trained professionals in the application of medical and nursing care from the good Samaritan and really look at the risk events, as the previous presenter said, in terms of what their actual risk is associated with contact and, ultimately, transmission of infection from one person to another, and put it into proper context and deal with exactly what they do need to know.
We've given you a model of what health care professionals need to know in terms of Universal Precautions. In lay language, in lay terms or precautions, applicable to the type of events related to the activities or the first aid that is applied by a good Samaritan, there would be an appropriate set of guidelines or precautions to be taught, just exactly as Mr Harris has identified in terms of protection in personal risk situations.
The public tends to see their responsibility necessarily a minimal responsibility in terms of response to their using precautions. They tend to want us, as health care providers, to give them all the answers and to wholly protect them, and I think that's unreasonable for every one of us. As either a lay person, a good Samaritan, or as a health care professional, we must recognize that we need to take personal responsibility in learning how infection is transmitted and how we can prevent it from being transmitted according to the tasks or the acts we do.
I'm not suggesting that anybody in an off-duty situation or a good Samaritan not apply first aid or health care to an individual, but certainly identify that most of the contact they're going to have with them does not put them at risk. We've identified specific events which do put them at some risk, but that's not all contact with everybody.
Mr Tilson: Can I continue, or are you paused?
The Chair: No pause; just running out of time. We thank you very much for the presentation you've made and for taking the time to make your submission to these hearings.
AIDS ACTION NOW
The Chair: I'd like to invite AIDS Action Now, Mr Glen Brown and Mr Brent Southin. Welcome to these hearings. You have approximately half an hour for the presentation. I notice that we're leaving less time for members to ask questions, so if you can do that, we'd appreciate it.
Mr Glen Brown: My name is Glen Brown, and to my right is Brent Southin. Just by way of introduction, AIDS Action Now is a Toronto-based activist group. We have been around for a little over five years. Our mandate is to fight for improved treatment, care and support for people living with HIV. I should also note that we receive no government or pharmaceutical company funding and we are entirely volunteer.
Normally, at this point in the proceeding, I would say how pleased we are to be here. We're not pleased to be here. As one of a number of community-based groups that's spending increasing time fighting to protect lives and fighting over scarce resources, we're frankly irritated to be having to spend so much time responding to badly-thought-out bills that only respond to hysteria -- in fact, fuel it.
We recognize that the context for this is that there are emergency service workers who have fears. The fact that those fears exist and some of them are not grounded in reality reflects badly on the education and support services we've offered them. The fact that you have produced this bill in response reflects badly on the political process.
The alleged purpose of Bill 89 is to enable rescuers or emergency care workers to be informed if they've been exposed to danger of contacting a communicable disease. It's based on false assumptions to begin with. It conflates a dangerous situation with a dangerous person. It suggests that simply by being in contact with someone who has a communicable disease you are at risk, and it ignores a wealth of research that actually documents what the risk may be of various communicable diseases.
This bill not only doesn't address those misconceptions, it in fact fuels them. First off, it's unworkable. Even if those assumptions were not false, the bill is unworkable.
I'm going to address HIV, because that's the area in which we have some level of expertise in this community we represent. The vast majority of people living with HIV and AIDS are not reported to any authority, with good reason, and I'll return to that in a minute. The vast majority are not reported, and in fact there is a process going on right now, although there has been considerable debate on the results of the process, to codify the non-reporting aspect of the Health Protection and Promotion Act for HIV. There will be fewer and fewer people living with HIV reported. I will return in a minute to why there are good reasons for that, but that is the background.
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So in fact you will have very few of the possible patients who might be in this situation being on any record whatsoever. It's an entirely hit-and-miss procedure. Even if someone has been tested for HIV antibodies, there's a period of months in which he may be infected and yet not be registering antibodies, so in fact any assurance that this person is HIV-negative is a false security.
The bill would also create an administrative nightmare. It would impose significant additional administrative burdens on hospitals and medical officers of health at a time when these resources are already severely stretched. Hospitals would need to organize whole new extensive categories of records of those who provided emergency care. They'd need to be able to correlate them to lists of those identified as having various communicable diseases, and we can foresee all kinds of very worrisome scenarios: hospital clerks routinely scanning the lists of patients; computer programs that flag people with particular conditions for special scrutiny etc.
There would also be corresponding extra work for medical officers of health. They would have to keep a whole new set of records of cases passed on to them of those who have been determined to have a communicable disease. They would have to make questionable and inevitably arbitrary judgement on whether or not a particular situation exposed an emergency worker to danger on the basis of limited and no doubt sketchy information.
Therefore, this bill would do nothing in fact to address the fears about transmission of communicable diseases to emergency service workers and, worse, it could in fact put their lives in danger by giving them a false sense of security and fuelling the misconceptions that already clearly exist about the levels of risk of transmission.
I note that in the introduction to the bill, Mr Tilson said it is difficult for some service workers to practise Universal Precautions, and the logic thereby of this bill is in fact you should create an opportunity where that's less necessary. I think that's very dangerous. Certainly if people are in a position of not being able to practise Universal Precautions, a bill like this won't do them any good whatsoever. They may or may not find out some very sketchy information months after they've already been exposed to risk.
We can learn a lesson, I think, from the gay community about the notion of how to protect yourself. In the gay community we have learned that you can protect yourself, not by worrying about the status of your partner but by worrying about your own behaviour and being consistent with it.
We're worried that this bill would endanger confidentiality. Whatever assurances there might be in the bill, once people have been identified as HIV-positive in this process, there's a very real danger of their identity being known. It would create two new lists of people identified as HIV-positive, both in the hospitals and with the medical officers of health. The danger of confidentiality being breached is increasing dramatically.
The emergency workers would certainly know the identity of those they had treated. You can look at the scenarios by which one would file a report saying: "This happened to me. Can you let me know whether or not something was putting me at risk?" Then it would be narrow enough that they would certainly know the identities. There's no protection in the bill whatsoever to ensure that confidentiality would then be protected. I'll remind you that it wasn't that long ago that we saw a list of HIV-positive people posted in a public hall, in a Toronto firefighters' hall, and it was seen by both reporters and people from the general public who were there dropping off donations to the food bank.
The bill is also dangerously intrusive. The context for it is a pervasive hysteria and misinformation around AIDS and the significant discrimination and stigmatization that people identified are still undergoing. I think it's somewhat disgraceful that the bill ignores these issues.
It says that it wouldn't authorize or allow forced testing of people. But there have been far too many instances already of tests or procedures being done without fully informed consent in Ontario hospitals, and that's particularly true of people who may already be marginalized: youth, IV drug users, people of colour. I think this bill would contribute to a climate in which coercion and pressure to get tested are more likely.
Finally, this bill sends out the wrong messages about health care. It fuels the misconceptions which initially started the fears. It will strengthen AIDS hysteria and misrepresentation. That misinformation and hysteria have had a profound impact on our community and on the lives of people living with HIV and AIDS. We've known, for instance, for years that people have avoided getting tested if they have any fear that their names will be turned over to the authorities. There was a report not long ago done in the city of Toronto of gay men, and of those who had not yet had an HIV test, 77% responded that their prime reason for failing to get an HIV test was because they were worried about ending up on a government list.
That reality of people living with HIV is what's fuelled a number of policy changes, one of which has been access to anonymous testing, the other of which has been a change in the reporting mechanism. Although we're currently in a debate about how the regulation will be changed to allow non-reporting, we got there because doctors simply refused to report and they refused to report for good reason. They saw that the reporting mechanism did a greater danger to public health than it provided any protection. The danger was, because of the fear people had of ending up on a government list, of being subject to surveillance, subject to interference from the authorities, subject to discrimination, people were simply avoiding the public health system all together. They were avoiding getting tested. They were also avoiding being honest with their doctors. If you see a situation where a physician is obligated to report you to the authorities based on certain criteria, you simply don't tell them. Now in this context, where you see a possibility that your name will be turned over to the authorities so that they can trace back the emergency service worker, you have a similar disincentive for being honest; you have a similar disincentive for letting anybody know that in fact you're HIV-positive.
I should note that I was having a conversation just a few hours ago today with one of the chief primary care physicians in Toronto servicing HIV-positive people, Dr Philip Berger, and he assured me that he would continue to refuse to report under the conditions of this bill.
Much more fundamentally for us is the waste of scarce health care resources that this bill would entail. I'm not sure whether or not Mr Tilson, who moved the bill, or any of the rest of the committee has done any estimates on the additional health care personnel and the cost needed to administer the proposed changes, but I will remind you that we're in an era where our fight to save the lives of people living with HIV is very linked to available resources. We've been fighting for many months now, for instance, for a catastrophic drug policy, a policy that would extend coverage on the drug benefit plan to people with high drug costs because of their HIV status. That policy is overdue and it's urgently overdue and it would save lives and the reason why we haven't seen action on it is because of fiscal restraint. In the face of that, to see this kind of bill that would simply squander money is outrageous.
We note also that there is the development of mandatory program guidelines being initiated by the ministry. We've just seen them very recently. We haven't had a chance to do much of a thorough evaluation of them. I can say that we're rather alarmed that they're this far along in the stage without some kind of community consultation but we do think that this whole episode is an illustration of the need for better education and support for emergency service workers, both about the real risks of transmission and the real protections that they can put in place. We would welcome the development of guidelines that would help encourage those educational and support services.
As an example, I want to point to the federal government where there was a parallel process that took place. There was a private member's bill that was proposed kind of along similar lines and fortunately it was withdrawn. But at the same time, the issue was referred to the standing committee on health, welfare, social affairs, seniors and the status of women and that committee invited key practitioners, experts. They examined the research on the exposure, preventive practices, risk of exposure, legislation in other areas. They did a lot of homework and they did it in consultation with community-based groups and service providers. They made a number of recommendations which are now publicly available and we think that there's some good homework there that might be useful in fact to deal with the fears that have been expressed during this process.
So in summary, I would urge this committee to drop this bill immediately before any additional resources are spent on battling it and instead to help initiate a consultative process to address the real concerns of emergency service workers and the protection of people living with HIV.
The Chair: Thank you. Mr Murphy, three minutes per caucus.
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Mr Murphy: Thank you very much. I'm sorry we don't have longer than three minutes. We had Gerry Heddema in here yesterday, whose position was pretty consistent with yours, and I know you haven't had a long time to look at the mandatory guidelines, and that's unfortunate, but one of the things in here which it proposes is a system where an emergency care worker can go to what they call a designated officer, who basically is a first-level check, a sort of "Don't worry about it," or "Well, I'll go and talk to the medical officer of health."
The medical officer of health then can advise the designated officer whether or not some further steps may or may not be required and then that is communicated back. I guess the theory is that is both a confidentiality protection and a sort of real-world test to at the first level say: "There's no reason to fear. There's no hysteria." Does that concept, on the face of it, give you a problem?
Mr Glen Brown: I would, off the top of my head, have some concerns about the nature of the designated officer and how they're trained and appointed and what their confidentiality rules were, but it strikes me that the concept that what people in that situation need is access to good counselling is a good one. I mean, that's far more the issue than any attempt to track down the patient who was involved, because that's not going to do you any good anyway. What you do need is good counselling in that situation, and that's certainly the concept that we would support.
But I would also say that if the education process is more thorough before that point, (a) you would have less risk of exposure in the beginning and (b) you would have a more thorough knowledge of your exposure risk before you got to that point.
Mr Brent Southin: Just to add to that, I think that could also lead to health care workers wanting to use this designate before they gave care to a person living with HIV, and I find that really scary. I think if they're that fearful of contracting HIV, if they have someone they think is a gay man or someone they think may be at risk, an IV drug user, they will refuse to give service until they have this proof that it's okay to give service.
Mr Murphy: It's actually interesting. There's a gentleman sitting behind you there who came before us yesterday who's an ambulance worker who said actually his concern was not blood-borne diseases at all, because he could tell; it's sort of obvious visually. It was the airborne diseases that in fact gave him the greatest concern.
I agree with you about education and training being the key, because I think what this responds to is really in a sense a concern that derives more from a lack of knowledge about these issues. The concept behind a designated officer, I think, is that person in a workplace who is given the education and training to be able to be that first-line, "Don't worry about it" kind of thing.
Do you have a sense of resources that can or should be dedicated to that kind of person in the workplace? Can community organizations be -- I mean, you've got plenty on your table already. What are the kinds of organizations you can see can assist in that education and training, and how can that be worked out, in your view?
Mr Glen Brown: I think I would more insist that the setting up of those guidelines and processes have a community-based component to it. I'm not sure about the ongoing training. I know that, for instance, there are public health nurses who are very skilled at providing those kinds of assurances and reassurances, and there may well be a very productive role for public health in this bill.
Mr Tilson: You and other delegations have come to this committee and have informed us that the likelihood of the transmission of HIV through the provision of emergency care is remote. However, we're looking at other diseases, because unlike the HIV virus, the hepatitis B virus, for example, is remarkably resilient -- and I'm sure you know; you sound very informed with diseases -- and can survive seven days outside the body.
In cases where intravenous support is begun, for example, in the ambulance, the risk of transmission of hepatitis is substantial, and other diseases such as meningitis or tuberculosis are also much easier to transmit.
So I understand your thoughts with respect to HIV, and there are four that have been identified. I think there are something like 60 communicable diseases, not all of which are life-threatening, so we're looking at the whole gamut of diseases.
I get back to the opening remarks you made. Just for clarification, are you telling us that with respect to assistance that's being provided by the health care provider or the good Samaritan, the passerby, there are no risks?
Mr Glen Brown: No, I'm certainly not suggesting there are no risks in that kind of scenario. I presume there are always calculable risks. The federal committee that looked at this very issue of blood-borne pathogens also concluded that of course there were risks in such cases but that they did not warrant this kind of measure. They did a lot of homework to back that up. Certainly the risk of HIV transmission in most circumstances like that is so minimal as to be incalculable, certainly so minimal as to not warrant any kind of intrusion like this. There has been a number of studies, particularly in the United States, which have documented that. I'm not aware of the research that's been done on the transmission to emergency service workers of hepatitis B in these cases, but I know the federal committee did look at all of that homework and reached a similar conclusion that we're recommending.
Mr Tilson: The care provider simply is taking the position that due to the very fact that there is a risk, there is a need to take precautions. In many cases, you need to know what you're dealing with to take the precautions, because there are so many different types. I know your entire presentation has zeroed in on HIV, but there are all kinds of other communicable diseases that the care provider fears.
Mr Southin: That's true. However, these communicable diseases have been around for a very long time and health care workers have been using precautions and been able for the most part to prevent themselves from getting these communicable diseases. I think why this bill is being brought up now is only because of AIDS and the fear and the hysteria that's been created around that.
Mr Tilson: That's not true.
Mr Southin: Why has this not been an issue for many years? I'm not an expert on all the communicable diseases, but I think there are definite guidelines that are used. When I worked at home care, they had specific guidelines around hepatitis, specific guidelines that the good Samaritan -- obviously, you can't question that. Obviously, if you're going to stop and help someone and they have hepatitis, there's no way of knowing. That's the chance people take if they're going to be good Samaritans, that they can get hepatitis.
Mr Tilson: Surely not.
Mr Southin: You can't say: "Here is a person who's dying on the side of the street. I'm going to wait and find out."
Mr Tilson: Exactly.
Mr Southin: Obviously, you can't. If you want to help someone, you have to help them. If there's a risk later, then I don't believe this bill will do anything to improve that. What are these people going to do? Can any human being who's ever helped someone on the side of the street -- I haven't read your bill.
Mr Tilson: I think what is being hoped --
The Chair: Mr Tilson, we're running out of time.
Mr Tilson: Thank you, Mr Chair. Thank you very much.
Mr Gary Malkowski (York East): Your presentation was very comprehensive and very powerful and well-thought-out, very cogent. I was involved with the deaf outreach project at the AIDS Committee of Toronto in my past, prior to my elected life, so I have many friends and I've experienced and I see the discrimination that happens to people with HIV or people with AIDS. It's a real problem in society, specifically for emergency care providers.
I understand some of the misinformation and some of the fears. All of us in society at one point shared those until more information was made available, but education is the answer. I agree with you. This bill looks pretty oppressive. To me, it's just one more form of oppression against people with HIV. I have no argument with that.
What I'd like to do is ask you a question about the mandatory guidelines for, let's say, health care providers or firefighters or ambulance attendants or rescue wagons, those kinds of things. Do you think it's not important for the consumer group to have a role in developing guidelines with the professionals as a part of the education, so that you could sit down together and talk directly to each other to alleviate concerns and some of the hysteria?
Mr Glen Brown: Yes, I think that's quite critical. For one thing, I think you can find the expertise in this area, both in the social aspect but also in the medical aspect. Real transmission routes can be found in the consumer-based movements. They can be found at the AIDS Committee of Toronto or they can be found in AIDS Action Now. We're the people who have to a large extent been on the front lines of this epidemic for a decade, and we know how to work with it. I'm quite convinced that if any of these guidelines are going to be effective, the involvement of community-based organizations is quite key.
Mr Malkowski: Thank you very much. You've convinced me. I don't support this bill at all. To me, it's just one more bit of oppression. Thank you very much for educating members, especially the member for Dufferin-Peel.
Mr Tilson: I won't even bother responding to that.
The Chair: Mr Brown, Mr Southin, thank you very much for coming today and taking the time to give your presentation.
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REGION OF NIAGARA HEALTH SERVICES DEPARTMENT
The Chair: I'd like to invite the Region of Niagara Health Services Department, Dr Megan Ward. Welcome. You've been here for quite a while; you know exactly what you need to do.
Dr Megan Ward: Yes. It's been very interesting. Thank you for inviting me.
I'm the medical officer of health for Niagara region. Niagara region includes 12 municipalities. We have regional ambulance and police services, and then each firefighting force is located in a municipality.
I have personally dealt with many questions from emergency service workers about their potential exposure to communicable diseases of all sorts over my years in public health, so this is something that is familiar to me. There are a few points I would like to emphasize about how we handle questions from emergency service workers to give you an understanding of what a medical officer of health will do in these circumstances.
The first point I'd like to make is that the concern from an emergency service worker about exposure to a communicable disease is real. It is a genuine concern. They have a genuine concern about personal infection, particularly in the experience I've had with HIV infection. They have a very special concern about potentially infecting family members and, in the case of HIV, their spouse or sexual partner and other family members, particularly their children. This causes an emergency service worker who thinks he may have had exposure to a communicable disease a great deal of distress. This is extremely distressing.
About a month ago, for example, we had a worker call who believed they had had an exposure, and the spouse of that person would not eat at the table with them, let alone lie beside them in bed. This was extremely distressing to the worker, to the spouse and to the whole family.
The concern is genuine and it's real, and in every case we treat it as genuine and real and an important question to be resolved and to assist the person to resolve. That's the first point.
The second point I'd like to emphasize is that ambulance workers, firefighters and police officers are often people who, by their very nature, are helpers. They are the folks who stop at the side of the road when they're off duty and get right in there and help the situation. Many of them go way beyond the call of duty, as it were; in fact they're off duty. Their nature is to help. They tend to be quite courageous individuals, prepared to really put themselves personally on the line and, as a result, will often step into the brink without a lot of extra concern about their own personal safety because there's a situation that's an emergency and they feel they need to assist. That puts them, in a way, at extra risk.
We had a call two weeks ago from four firefighters who'd been driving along the QEW and had come upon an accident. They were off duty, actually on their way to the United States. It was a serious accident and there was quite a lot of blood spilled. They just jumped out, did their thing, provided the first-line response until additional care came, and afterwards thought, "Well, what about the gloves, what about Universal Precautions and so on?" We needed to go through with them what their risk might have actually been in this case.
As a group, these people are often first responders, both on and off duty, and don't have the tools available to them for Universal Precautions and so on. This is also a real and important aspect of the protection of this group.
It is my belief, and I wrote to this committee many months ago, that the Health Protection and Promotion Act as it now stands does support the medical officer of health in addressing these very real concerns for this group. We certainly take it as our responsibility to deal with each situation as it arises and use, as our authority for doing that, the Health Protection and Promotion Act. I continue to believe that. We do have under that act a special requirement with respect to communicable disease control and taking all measures that are required to control communicable, reportable diseases within our jurisdiction.
I'd like to give you an example of how we manage these reports as they come in. If, say, a firefighter or an ambulance attendant or a police officer calls us -- we do get called several times a year -- about a situation where they're concerned they might be exposed, at that point we talk with them in a very detailed way about the nature of the exposure they've had and the concern they have.
You're right, it might be for any number of diseases, so the kind of history we'll take from the individual will be according to the kind of exposure they believe they've had. It's very important to be quite precise in this matter as communicable diseases are spread in different ways and you can only spread them in certain ways. There isn't any sort of general transmission, as it were, so a detailed history is very important to take.
If we believe they have had significant exposure, then we will go on to outline for them the course they may wish to consider taking. A lot of this is to put control, as it were, back into the individual's hands, and we will support them in taking whatever protective measures they require.
If, for example, upon assessment, we felt they had had a significant blood exposure, a needle-stick injury, a major mixing of blood through significant wounds on both sides, that kind of very significant exposure, then we would be working through with them the course they should take with respect to the blood-borne infections, particularly hepatitis B and HIV. We will outline for them the options they have. If they wish us to discuss with their doctor their plan or have their doctor call us, then we will offer to do that. If it's helpful to them for us to talk with their spouse or other family members or partners, we will do that. So it really outlines a course for them to take.
I've found in my experience that usually after talking with us, emergency service workers have a pretty clear idea of what they'd like to do. It's pretty rare that there's a significant blood exposure, for example, and very rare for meningococcal disease and tuberculosis, but in the event that there is something significant, then we do follow along with them in detail and we seem to get a pretty good response from them about the kind of support we can offer. But I think it's not really possible to do this in a general way; that is, it is very situation-specific.
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Mostly what this group will say to us or to me is, "I just want to know if this person had X." But in fact what they really want to know is that the person didn't have X, because then they don't have to worry. The problem is that as a medical officer of health, I'm not genuinely able to say that the person didn't have X, particularly in the case of HIV and hepatitis B. It's easier with tuberculosis and meningococcal disease. The reason I'm not, as was explained to you actually by the previous speakers, is that a person can be infected but test negative for a window of time. So if it's a significant exposure, I must always treat it as if the person could have X, say HIV, and provide advice along those lines.
It doesn't really help the person to know if person A has HIV or whatever it is because it doesn't really alter the management that we would recommend to that person; that is, if there's a significant exposure there, we're going to recommend a particular protocol for follow-up. When we handle it that way, it allows us to not walk down this avenue about whether or not we know a person has HIV or some other thing. It allows us to just proceed according to whether there's a genuine risk, and that protects confidentiality.
I think the provision in the Health Protection and Promotion Act that we must protect the confidentiality of somebody reported to us with a reportable disease is very important and historically has been important to us because it has allowed us to develop procedures to deal with exposures that do not force us to release the name of somebody. So we have got quite detailed procedures for protecting confidentiality, and I think that's really important.
The other sort of technical issue, aside from the one that we can't really say person A doesn't have HIV or something -- we're not going to be able to do that for HIV or hepatitis B -- is that the Ministry of Health has made a policy decision to allow non-nominal reporting and anonymous testing in the province. The reasons for that are to encourage testing and early treatment of people who have been infected and so on. As a result, medical officers, of course, don't have detailed named databases. So even if we took another route and decided we would look up the name of the person in every case to see if they were on our database, in all likelihood they won't be there for HIV.
In Niagara, for example, the closest anonymous testing site is in Hamilton. We know that we have lots of residents who go to Hamilton and even to Toronto to avail themselves of anonymous testing, so we don't really have that information available to us anyway. Even if we did, though, I think we have a way to handle each of these significant exposures that doesn't involve referring back to a specific individual whom the emergency service worker may have been in contact with.
I do think that as a result of the bill that's been developed and the concern that's been expressed by emergency service workers to the Legislature, it's clear that we need to have more conversation about this: medical officers, the HIV-infected community, emergency service workers and so on.
It is true, in my experience, that I have not had an emergency service worker call me up and say, "I've had no information about HIV or hepatitis B." They have, and they will be quite open that they've had it, but it doesn't help them on a particular situation; namely, their own, when they have to look their spouse in the face and be sure that they're not going to transmit an important infection to that person. So translating general information to a specific individual, a personal situation appears to be difficult, and I think advice that can be provided by the medical officer of health and other people in the community is needed in order to help a person with their own individual situation, should it arise.
It would be helpful to have more conversation and dialogue. I don't think Bill 89 will really help solve these issues for us. The Health Protection and Promotion Act, as it is, gives us the authority to speak with each person, as they need to speak with us. I don't really think we need anything more than that in terms of legislative support, but it's clear, because this is a continuing concern for our emergency service workers and they're important to us, that we do need to have some more conversation.
If, as a result of that, we need to have guidelines from the public health branch of the Ministry of Health, that's fine. I certainly wouldn't object to them, and indeed they might be quite helpful.
I'm not sure that we need them, per se, to fit into the 22 mandatory program guidelines we have -- that's a technical issue -- but we can have guidelines in any number of ways, and if that's what turns out to be most helpful then I think we should go ahead with that.
Those are my thoughts and I'd certainly welcome any questions you might have.
Mr Tilson: Thank you very much for your presentation. From my perspective, it's certainly been one of the most reasoned presentations we've had, and I was particularly interested in your comments with respect to counselling. Notwithstanding Mr Malkowski's comments -- of course, he knows everything and is an expert on everything -- I think all of us have learned a lot through these proceedings. It is a complicated subject.
Mr Malkowski: Thank you very much. I appreciate your comments.
Mr Tilson: My observation is that in listening to the medical officers of health and the care providers, it is a complicated issue.
For members' consideration, I would recommend that this committee stand down the subject of the clause-by-clause discussion of this bill to enable Dr Schabas, the chief medical officer of health for Ontario, to develop the mandatory guidelines. We've seen the draft guidelines. He's indicated he would consider expanding that to the good Samaritan. I know he's got problems with that, but he's at least indicated he would consider that. If that information were made available within a reasonable period of time, perhaps the committee could look at that at a later date. That's my suggestion to members of the committee.
The Chair: Mr Tilson, I would like to deal with that, and we can in a few moments. First of all, I'd like to get --
Mr Tilson: I said that now because I may run out of time.
The Chair: It was my intention to deal with it, so if you have a question of --
Mr Tilson: No, that's fine. I thank you for your presentation.
The Chair: Very well. We will deal with that in a few moments, but I'd like to get the other members to ask questions of Dr Ward.
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Mr O'Connor: I appreciate your presentation. Earlier on, we had somebody refer to my colleague over there as the "instigator," and I think "facilitator" might be a better way to say that we've had a good conversation and discussion around this.
Your statements around the concern being real, I think, are exactly from where people have approached my colleague. I think the public health units are underutilized. I would like to see a 1-800-NURSE process being used, for example, where people -- it could be the good Samaritan, it could be the taxi driver -- who have a real public health concern approach the medical officer of health or the local health unit about a concern they've got and ask those questions so they can get the information they need. I think the whole problem we've got is a lack of dialogue, a lack of information. It's not that the information isn't there for availability; it's the conduit or whatever.
We heard from the Ontario Hospital Association, and the question I asked them in the brief time I had was that they have referred to the suggestion that somebody should approach the family physician with a concern they may have about exposure. My concern was that maybe that isn't the best way and maybe we should be utilizing the resources that we have available to us and using our public health unit, for an example. I just wonder if you could comment on that for me, please.
Dr Ward: I think family physicians are enormously helpful to individuals who have individual concerns. I get a lot of calls from family physicians to consult about a particular exposure, and we work in collaboration on these matters. It is important, because the actual care provided to an individual will likely be through their family doctor. That they have a family doctor is in fact one of the things we check, that there is someone to provide that. For example, if they were to need immunoglobulin because of a hepatitis B exposure, we'd make sure there would be someone they would be able to go to to actually get that.
They're enormously important. We provide consultation to our family physicians. We can be first responders to a question or we can be consultants to a family doctor. It doesn't much matter, in a way, to us. I do get a tremendous number of questions, though, from family physicians, so I think that link is happening. I expect it's one of those things that if we do our job well, could get even better and hopefully it will get better. They are important as well.
Mr O'Connor: Not to undermine the role that they play, it's just that we need to speak about the education process that health units do provide. Whether it's this type of forum where we initially have a discussion, it's to talk about these, bring these issues up to the forefront so that people are comfortable even talking about it, because people aren't necessarily always comfortable in talking about different risks.
The Chair: Mr O'Connor, can you comment on the suggestion Mr Tilson raised?
Mr O'Connor: I agree with the suggestion made by Mr Tilson to perhaps to stand this down and allow the public consultation that no doubt will take place as a follow-up to all the discussions we've had, and we could deal with it at some point in the future if need be.
The Chair: Thank you. Mr Murphy.
Mr Murphy: First off, let me participate in the joyous opportunity to make this unanimous -- it's a rare treat and I'm just glad to be part of it -- that we stand this down to allow the opportunity for the mandatory guidelines to be developed and implemented and come back to us. I think that's a sensible way to go. We've obviously heard, I think, from this presenter a very reasoned and reasonable presentation that has a logic to it, and we need to see.
I do have one question, if I may, while I have the time, and that is, we've heard a lot about the real issue being education and training. Universal Precautions is part of it, but ultimately it's an education and training issue. I'm wondering if you could comment for me on the resources that you or people in a similar situation to you in your regions have to provide that education and training to emergency care providers.
Dr Ward: We see it as part of our mandate. We do it regularly with our, I guess, 14 different services, as it were, in our region. Our resources are shrinking. I'm cutting nearly half a million out of my budget to meet expenditure control, and that is real; there's no question about that.
This is also a priority. These are important infections and communicable disease control is very important to the work of health departments, so --
Mr Murphy: Do you have a sense yet of what you're not going to be able to do in order to do this?
Dr Ward: It cuts across the board, you know, and it's a board of health decision about what not to do. We don't, for example, come anywhere close any more to inspecting institutions that prepare food with the schedule we're supposed to inspect them. We have cut back on those. We don't hope any longer to cover, in the way we're supposed to cover, our 80,000 school children with the sorts of services that they're supposed to receive. We don't have those resources any more. We have pretty severely cut back the services we've been providing to young families and parents and children of toddler age. These are real issues for us.
The Chair: Thank you, Dr Ward, for your presentation and your participation in these hearings today.
Dr Ward: You're welcome.
The Chair: Given that there is unanimous support to defer this matter to an undetermined date in the future, we'll leave it that way without having to have a motion and vote on it.
I would report to you that hopefully we will be dealing with Bill 79 on November 15. That as yet is not con firmed, but it is our hope that that's what we'll be dealing with on November 15.
Mr David Winninger (London South): We also have Mr Murphy's bill too, Mr Chair.
The Chair: I understand that. As soon as that is confirmed, I will let the members know. If that is not the issue that we would be dealing with, then Mr Winninger's suggestion is probably a likely one that might come up. That is all I need to report on that matter.
Mr Murphy: Mr Chair, if I can, I'm very happy to have my bill considered. Of course, I'd also be happier if we saw the government omnibus bill on that same issue come forward.
The Chair: We appreciate your comments, Mr Murphy.
Mr Murphy: We're all waiting for that.
The Chair: This committee is adjourned.
The committee adjourned at 1757.