Summary of Discussion
Science Advisory Board Meeting
November 26-27, 2002Help on accessing alternative formats, such as PDF, MP3 and WAV files, can be obtained in the alternate format help section 
Table of Contents
Day 1
Day 2
Members: Judith Hall, Karen Grant, Irv Rootman, Ardene Robinson Vollman, Linda Lusby, Stuart MacLeod, Keith Bailey, Patricia Clements, Kathryn O'Hara, Michel Bergeron
Ex Officio Members : Munir Sheikh, Kevin Keough, Diane Gorman, Alan Bernstein, Dann Michols
Others: Lisa Camelon, Lesley Drummond, Roger Neufeld, Laurie Maus
Secretariat: Tammy Davies, Glennis Lewis, Valerie Marshall, Constance Brook
Day 1, Tuesday, November 26, 2002
Opening Remarks
(Chair - Dr. Judith Hall)
The Chair welcomed members to the meeting, especially welcoming three new members: Keith Bailey, Patricia Clement and Kathryn O'Hara. The fourth new member, David Roy, was unable to attend the meeting.
An orientation binder for new members has been produced by the Secretariat. All members will receive copies of these binders.
The Chair praised the recent Health Research Forum, organized by the Office of the Chief Scientist, describing it as a wonderful meeting of scientists highlighting the outstanding research done within Health Canada.
Health Canada: A Report
(Mr. Munir Sheikh, Associate Deputy Minister)
The Associate Deputy Minister focussed his comments on the immediate issues facing Health Canada: the release of the Romanow Report, progress on commitments from the Speech from the Throne and the recent Innovation Summit.
The Associate Deputy Minister paid tribute to the members of the Science Advisory Board, describing their dedication, professionalism and steadfast attention to issues.
On the Romanow Report, the Associate Deputy Minister said Health Canada expected Mr. Romanow to reaffirm the value of a public medicare system and to call for strong federal leadership.
Early in December, the Federal/Provincial/Territorial (F/P/T) Deputy Ministerial and Health Ministers will meet and discuss initial responses to the Romanow Report, as well as the Kirby Report and commitments made in the Speech from the Throne. This meeting will contribute to a First Ministers' meeting early in 2003 which will develop a comprehensive plan for health care.
The government, he said, is committed to a universally accessible and publicly funded system of health care. The challenge will be to pursue positive change, guided by the views and values of Canadians. Government response to the Romanow Report would most likely include short, medium and long-term measures in the areas of primary health care, home care and health care system innovation.
While response to the Romanow Report will be important, Health Canada is also responding to commitments made in the Speech from the Throne, including a national strategy for healthy living, investments in therapeutic products access, measures to improve the health status of Aboriginal people and consultation on the renewal of health protection legislation.
In the area of healthy living, the policy framework targets common risk factors for multiple diseases and the determinants of health. The Department will engage partners across the systems that affect health and draw upon and strengthen community capacity, public health infrastructure and primary care.
The first-ever national summit on healthy living strategies is planned for March 2003.
The Speech from the Throne promised to speed up the regulatory process for drug approvals to ensure that Canadians have faster access to safe drugs. It is also expected to create a better climate for research in pharmaceuticals.
Four elements, timeliness, transparency, innovation, and sustainability, will guide Health Canada as it strives to improve therapeutic approvals.
Health Canada is already working on increasing transparency by providing clearer information on therapeutic access issues and decisions through various media. A Public Advisory Committee has also been established. The goal is to have the review process better known and understood by all Canadians.
By working internationally through consultations with the United States and the European Union, Canada can incorporate best international practices and work towards sharing international evidence. Having access to a greater body of scientific knowledge will result in faster reviews of new therapeutic products, based on the best international evidence.
In the area of Aboriginal people's health, the Associate Deputy Minister described a long-term vision to support the development of an integrated health system in which First Nations and Inuit peoples will have the same availability and access to effective and efficient services as other Canadians. The vision shifts the focus from treatment and crisis response to investing in promotion and prevention.
A recent Innovation Summit brought together 450 stakeholders from academic, non-governmental, and public sectors with the objective to establish a set of national priorities to which all parties could commit. Innovation in the health sector, through renewal of the health system, science and research, disease prevention and health promotion, will lead to healthier lives.
The Associate described recent meetings wherein Health Canada's science community engaged in a series of open discussions with him and the Chief Scientist. The discussions covered a wide range of issues, which could be categorized in four broad areas: what kind of science do we do and how; how well do we do it; what is the science and policy link, and how can we better manage our administrative obligations.
Mr. Sheikh said he had come away from these discussions with a better appreciation of the challenges faced by our scientists and researchers. The Associate Deputy Minister indicated that discussions with Health Canada scientists will continue.
Discussion included the following points:
- Social scientists working at Health Canada lack a sense of belonging to a social science community within Health Canada because they work in so many different areas. Members of the Science Advisory board (SAB) from social science backgrounds are concerned that social science input may not be considered to the extent it could be.
- There appears to be a lag between research and uptake in findings of policy and practice. This applies to research across many disciplines, including human science research.
- Health Canada should be the model for integration of scientific efforts of all kinds.
- The Post-Doctoral Fellowship program needs to encourage interest among human science researchers and among managers in all branches at Health Canada to identify ways in which human science post doctoral fellows might add value to the work that is being done by Health Canada's biophysical and medical scientists.
Update - Office of the Chief Scientist
(Dr. Kevin Keough, Chief Scientist)
The Chief Scientist reported to the Board that the Health Research Forum had been very successful, especially in terms of providing a link for scientists and researchers. There were 500 participants for the two-day forum, which included 200 posters and presentations.
There will be a formal evaluation of the forum, but initial responses were very positive.
The Post-Doctoral Fellowship (PDF) program had 130 candidates submit applications. Of those, 33 have been matched with potential supervisors. The response from social scientists within Health Canada has been disappointing. The OCS will work with the social science community to encourage greater participation.
The Research Ethics Board (REB) is up and running and has a busy schedule. The Chief Scientist expects the Board will meet once a month. The Manager of the Secretariat has been meeting with Health Canada researchers in the regions to explain REB requirements.
A competition for funding strategic new initiatives and new equipment attracted 83 letters of intent. After a screening process and external peer review, 31 of the original submissions were funded, including six of nine social science proposals.
Meetings in New Zealand and Australia by the Chief Scientist provided insight into challenges faced by these two Commonwealth countries. Many of the challenges are similar to those faced by Canadians and institutions such as the Canadian Institutes of Health Research (CIHR). One noticeable difference was the emphasis placed on mental health in those two countries compared to Canada.
The OCS is sponsoring, with the Canadian Food Inspection Agency (CFIA), a workshop on the science of risk assessment. The workshop, set for Dec. 2-3, has attracted 200 people.
Discussion included the following points:
- Accrediting ethics boards should be done by an arms-length body so there isn't real or perceived conflict of interest.
- There will be a follow-up on the science of risk assessment workshop by the Chief Scientist.
Approval of September Meeting Record
(Dr. Judith Hall, Chair)
The meeting record was approved with minor changes.
Activities of the Science Advisory Board: Report to the Minister of Health, 2001-2002
(Dr. Judith Hall, Chair)
This report is meant to summarize the kinds of issues the Science Advisory Board has dealt with over the 2000-2001 time frame.
During discussion, the Board indicated that it may wish to discuss international health at some future date.
Action Item : The report was approved with minor changes and should be translated , transmitted to the Minister, and posted to the web.
Health and Environment Agenda
(Mr. Dann Michols, Assistant Deputy Minister (ADM), Healthy Environments and Consumer Safety Branch (HECS); and, Mr. Ray Edwards, Director General, Policy and Planning, HECS)
Dann Michols outlined the purpose of the overview of health and environment, which was to highlight the science underlying activities related to the physical environment.
The ADM told the Board that there is not enough specific research funding allocations in this area and that funding this research as a priority is an ongoing challenge.
Ray Edwards, the Director-General of Science and Policy of HECS, outlined Health Canada's role in this area, as regulator, leader/partner, information provider/advisor and service provider.
Research challenges include inadequate baseline science and knowledge, capacity to meet international commitments, ability to deliver F/P/T commitments; and, capacity to conduct mandated research.
Discussion included the following points:
- In terms of where health and environment priorities fit into Health Canada's overall health care reform priorities, health and the environment, has strong linkages with the Healthy Living Strategy; also with workplace health and Speech from the Throne (SFT) commitments: contaminated sites, water quality, and air quality.
- HECS remains committed to searching for partnerships to accomplish its work.
- Funding for the Toxic Substances Research Initiative (TSRI), which was a three-year substantive research project, is now finished. This $40 million initiative fostered policy relevant research partnerships between federal and university researchers.
- The department is building a Health Canada health and environment research agenda. The Branch will be exploring opportunities with CIHR or Federal Innovation Networks of Excellence (FINE) for possible sources of funding for health and environment research.
- One of the challenges for setting standards is that some areas are not under federal responsibility, for example, water, which is a provincial or municipal responsibility.
Climate Change
(Ms. Sue Milburn-Hopwood, Director, Health Impacts Bureau, HECS)
In terms of the Kyoto Protocol, ratification is focusing on mitigation, which is reducing emissions of greenhouse gases. Health issues have not been featured in Kyoto discussions.
The 1980s and 1990s have been the warmest decades on record and the 20 th century the warmest in the past 1,000 years.
Health impacts of climate change, related to pollution, ozone depletion and extreme weather events include cold and heat-related illnesses, respiratory and cardiovascular stress, enteric diseases and contaminants, mental health and allergies.
Vulnerable populations, such as the elderly, children, low-income individuals, immuno-compromised individuals and aboriginal populations, will feel effects of health impacts more than others.
Discussion included the following points:
- The real issue which affects health is pollution. It is important to challenge decision-makers concerning this health issue.
- Communication is key in this issue.
- In the current debate on climate change and the Kyoto protocol, the issues being discussed seem to be economic, not health-related.
- Alternative technologies for reducing green-house gas emissions should be evaluated for their health risks as they may have their own set of health risks.
Air Quality Research
(Dr. David Stieb, Medical Epidemiologist, Air Health Effects Division, Environmental Contaminants Bureau, Healthy Environments and Consumer Safety Branch)
Generally speaking, the area of health and pollution effects has not been an attractive area for non-governmental researchers funded by granting agencies. Health Canada scientists have endeavoured to fill this gap and to make a direct link with policy development within Health Canada.
The prospective research agenda is targeted at areas where there are regulatory gaps, including toxicological research on mechanisms and mixtures/synergisms, clinical (human exposure) studies, exposure assessment studies, special/susceptible populations studies, population health studies, economic benefits studies; and, risk communications.
Researchers know more about short-term than long-term effects of air pollution. Short term effects of air pollution are being found at levels previously thought to be safe.
Discussion included the following points:
- Research should be done on the kinds of choices Canadians are making; for example, public attitudes to pollution, the significance of consumer product choices, and the availability and marketing of alternatives.
- Air pollution affects us today. Data indicate that children and the elderly are particularly susceptible.
- In addition to partnerships with CIHR, opportunities exist to partner with the Natural Sciences and Engineering Research Council (NSERC) and the Social Sciences and Humanities Research Council (SSHRC).
Children's Health and the Environment
(Ms. Sue Millburn-Hopwood, Director, Health Impacts Bureau, HECS)
Young children are more vulnerable to environmental threats than adults because of unique pathways of exposure in utero and beyond, as well as biochemical and physiological factors. There is also increasing evidence that health in childhood is a key determinant of adult health.
Some of the potential health impacts of environment exposures in childhood are asthma, neurobehavioral and developmental effects, endocrine disruption, and cancers.
The Board was told that the issues as related to children growing in scope and complexity.
Discussion included the following points:
- There are opportunities for Health Canada to partner with the CIHR Institute of Human Development, Child and Youth Health .
- There is a link between infectious disease and environment.
- Strategic investments in health research involving children and youth are important. There should be a connection with the National Children's Agenda .
- There is a false assumption that everyone is exposed to the same levels of pollutants and that we all react in the same fashion.
Current Challenges in Drinking Water Quality
(Ms. Patricia Lemay, Director, Water Quality and Health Bureau, HECS)
Walkerton raised the profile of drinking water quality for Health Canada and the rest of the country, but the fact is that safe water is important at all times.
Health Canada's responsibilities for water are as a regulator of water used by First Nations and Inuit peoples, National Parks, National Defence, transportation common carriers, and, water used in food production; as a leader and partner on quality standards guidelines; as an information provider and advisor; and, as a service provider.
Provinces and territories have the major responsibility for the provision of safe drinking water, although some responsibility is delegated to municipal governments.
Health Canada develops the Guidelines for Canadian Drinking Water Quality and works with its counterparts in provinces and territories.
This remains a complicated area of research because water systems in Canada are not homogeneous. Differing geography, climate, water usage and water sources require differing water systems.
Discussion included the following points:
- Health Canada has jurisdiction for water quality for First Nations and Inuit communities, and federal lands such as Department of National Defence bases and national parks.
- Health Canada is the scientific lead in the development of the Guidelines for Canadian Drinking Water Quality and provides the secretariat for the federal/provincial/territorial Committee on Drinking Water.
- The Source-to-Tap approach, which is a multi-barrier/multi-layer approach to drinking water management, provides a holistic approach to drinking water quality. This approach is endorsed by Health Canada and Environment Canada, which have responsibilities related to drinking and source water respectively.
- New technologies need to be explored to allow quicker testing time and better treatment protocols.
- There is no national regulatory system for water.
Environmental Risks of Pharmaceuticals and Personal Care Products
(Dr. Elizabeth Innes, Health Products and Foods Branch, Dr. Mark Servos, Environment Canada)
The presence of pharmaceuticals and personal care products in the environment is a complex, emerging, international issue. Recent studies in Europe and the United States have documented the presence of a wide variety of substances contained in pharmaceuticals and personal care products in the environment.
While the issue is not well researched, there is mounting evidence that some of these substances have the potential to induce adverse health effects in non-target species and possibly humans, even when exposure is at .
Scientific understanding about this issue is currently limited and additional research is critical for the development of regulations, risk assessment and risk management approaches that will protect Canadians and the Canadian environment.
Discussion included the following points:
- Many pharmaceuticals and metabolites are water-soluble.
- Research is needed to assess the level of risk associated with pharmaceutical and personal care product residue in water.
- Some of the pharmaceuticals and their metabolites that end up in municipal water systems may be treated in sewage treatment plants, but no one yet knows which substances are amenable to treatment or how they can be treated. This is a complex issue.
- There are likely to be subtle differences in how individuals respond to these residual substances.
- There may be relatively small changes to sewage treatment, or even to toilet design, that will be effective in dealing with some pharmaceuticals that up until now have found their way into the water supply .
- Communication will be an integral part of any change in this area. A risk communication strategy is needed.
Day 2 - Wednesday, November 27, 2002
Members Present: Judith Hall, Karen Grant, Irv Rootman, Ardene Robinson Vollman, Richard Lessard, Patrica Clements, Keith Bailey, Kathryn O'Hara, Linda Lusby, Stuart MacLeod
Members Absent: Michel Bergeron, Paul Paquin, Carol Herbert, Lillian Dyck, Rodney Ouellette, Elizabeth Jacobson, David Roy.
Ex Officio Members Present:, Kevin Keough, Scott Broughton, Munir Sheikh (closing session only)
Secretariat: Tammy Davies, Glennis Lewis (morning only), Valerie Marshall, Constance Brook
Others: Janice Hopkins, Constantin Tikhonov, Leslie Drummond, Lisa Camelon
Issues Surrounding Adverse Reaction Reporting: A Follow-Up to the Atkinson Inquest
( Dr. Christopher Turner, Acting Director General, Marketed Health Products Directorate)
The November 4 - 13, 2002 inquest into the death of 6 year old Ashley Marie Atkinson in New Brunswick raised questions about: off-label drug use with children (It is generally accepted that between 70% and 80% of drugs used in children in Canada and the US are off-label; about adverse drug reaction reporting in Canada, about the nature of related risk communication with stakeholders; and, about Health Canada's role and responsibilities in dealing with these concerns.
Health Canada has neither authority over off-label use of regulated pharmaceuticals nor a monitoring system for off-label use .
It seems likely that only a small portion of adverse drug reactions are reported to Health Canada. Physicians have a professional responsibility to report adverse drug reactions but Health Canada does not have a system for monitoring or evaluating whether or how the information it communicates about adverse drug reactions is used by health care institutions or health care professionals. Nor is Health Canada in a position to force compliance with reporting requirements since the provinces and territories are responsible for regulating Health Care professionals. Privacy considerations further complicate efforts to improve the collection of adverse reaction information. For example, it is not clear whether Health Canada has the authority to collect personal information for regulatory purposes.
The Department is developing improved risk communication strategies to help ensure that information about adverse drug reactions gets the attention of health care professionals, many of whom are already beset by information overload and competing priorities. Accessibility of adverse drug reaction and off-label drug use information is also important to consumers, a growing number of whom want to make health care decisions for themselves; for example about using pharmaceuticals off-label.
The Department is also seeking ways to foster a culture of reporting adverse drug reactions and is reviewing the categories of people who can submit these reports.
Discussion included the following points:
- To encourage a culture of reporting, Health Canada must engage in social marketing aimed at all parties responsible for the safe use of drugs, including physicians, patients, hospitals, and the College of Physicians and Surgeons. Key messages might be that 1) all drugs have risks, and, 2) the responsibility for becoming informed is a shared responsibility. The importance of having a social marketing policy was noted.
- HPFB could perhaps seek a post-doctoral fellow to do something very specific on social marketing.
- Risk communication strategies should guard against placing undue emphasis on web/internet use; we cannot assume that because something is on the web it is being accessed. At the same time, the growing use of palm pilots, especially by physicians, presents an important risk communication opportunity.
- Given the key communication role they play with and between doctors, patients, and the families of patients, nurses could play a greater role in adverse drug reaction reporting and risk communication. In fact, perhaps all health care professionals should be directly involved in adverse drug reaction reporting. Quality health care involves everyone in the chain.
- Regarding the seriousness of the problem of widespread use of off-label drugs with children, and the fact that the most prominent inquests in Canada recently have involved children, the Board noted that pediatricians might welcome an examination by Health Canada of the mechanisms for bringing off-label use of drugs in children "on-label".
- It is important to clarify the implications of the Privacy Act in adverse drug reaction reporting and risk communication. The work of the National Steering Committee on Patient Safety (Royal College of Physicians and Surgeons of Canada; Report released September 2002) was noted as relevant to future work undertaken by Health Canada on the issue of adverse event reporting and risk communication.
Major Discussion Summary:
Social sciences research is needed in order to find more effective ways to have complete adverse reaction reporting.
In any studies of adverse drug reaction reporting and/or associated risk communication strategies, Privacy concerns must be addressed. Clear delineation of the roles played by the full spectrum of health care professionals is also needed. In addition, the study of sub-populations, especially children and the elderly, to further define and clarify the element of risk in adverse drug reaction reporting is needed .
The Non-Human Primate Colony: An International Resource for Health Research
(Dr. Paul Mayers, Acting Associate Director General, Food Directorate, HPFB; Dr. Frank Plummer, Scientific Director, Canadian Science Centre for Human and Animal Health [Winnipeg]; and, Dr. Michael Coulthart, Chief, National Laboratory for Prion Diseases, Canadian Science Centre for Human and Animal Health [Winnipeg])
The Health Canada non-human primate colony was established in the context of the Department's polio vaccine testing program . When that program ended in 1996, the Department sought and implemented advice from the Royal Society of Canada about the future of the colony. The question of the future of the colony is relevant once more in view of current and emerging research priorities.
Major Discussion Summary:
The Board discussed reasons to resume the breeding of Health Canada's non-human primate colony as a resource for health-related research in accordance with the recommendation of the Royal Society.
Ensuring appropriate care of animals maintained within Health Canada and those it makes available to external researchers is very important.
Hormone Replacement Therapy
(Dr. Robert Peterson, Director General, Therapeutic Products Directorate, HPFB; and, Mr. Philip Waddington, Director General, Natural Health Products Directorate, HPFB)
Dr. Peterson updated the Board on the results of the US National Institute of Health (NIH) Women's Health Initiative (WHI) study of Hormone Replacement Therapy (HRT). The combined (estrogen and progestin) HRT study, intended to continue until 2005, was ended in July 2002 it when it was concluded there were more risks than benefits for the group using HRT in terms of coronary heart diseases, strokes, blood clots and invasive breast cancer.
In Canada, HRT is only approved for the alleviation of menopausal symptoms. Some products are indicated as well for prevention of osteoporosis. The conclusions of the US study regarding coronary heart disease are already well documented and explained in the current labelling materials approved by Health Canada for these products. None of these products has been approved for the prevention of heart attack or stroke or any other cardiovascular disorder.
Health Canada strongly recommends that the use of HRT should be based on the particular needs and specific health condition of each patient after careful medical evaluation. Health Canada will convey these messages in the "It's Your Health" document to be posted on Health Canada's website.
Discussion included the following points:
- If the recommendation is for short-term use of HRT, what definition is used for "short-term"? The study shows what the risks are for five-year use, but no one knows yet what risks, if any, there are for long-t erm use.
- In terms of Natural Health Products (NHP), there is nothing on the market that would replace HRT. The highest percentage of Natural Health Product users are women and those who use NHP are typically proactive in their health care choices and place priority on the ability to make informed choices about their health care options.
- Much of the information surrounding NHP relates to cultural and/or historical use , and relies heavily on word of mouth communication and testimonials.
- There are often strong psychological and cultural factors motivating the use of traditional medicines.
- The most important consideration is dosage. How much is safe and what effects is the dosage having? Likewise, claims for effectiveness of these products should be supportable.
- It is premature to ask how to communicate this kind of information, since there is relatively little scientific information related to NHP.
- There is an issue of "off-label" use of HRT for long periods of time in the absence of evidence that long-term use is beneficial in reducing the risk of cardiovascular disease.
- There may be issues related to the need to modify physicians' prescribing behaviours related to HRT.
Major Discussion Summary:
There are multiple concerns related to the use of hormone replacement therapy in women.
Canadians want science-based, evidence-based studies of the natural health products that women are using for the management of symptoms of menopause. [Addition by one person.] More research, from both social science and health science perspectives is needed.
Economic Burden of Illness in Canada, 1998
(Mr. Scott Broughton, Assistant Deputy Minister, Population and Public Health Branch (PPHB); and, Dr. Sylvain Paradis, Director, Policy Research Division, PPHB)
This is the third edition of this report developed by Health Canada. The primary goal is to contribute to an understanding of the cost of illness in Canada. The report was designed to create a tool for health-policy development and to provide evidence for decision-making.
In the last five years, the top five most costly diseases in Canada are, in rank: cardio-vascular diseases, musculoskeletal diseases, cancer, injuries and respiratory diseases. The direct costs represent the total amount invested in treatment, care and rehabilitation. The indirect cost refers to the value of lost production due to illness, injury, disability or premature death.
Discussion included the following points:
- In future work, the data base may be expanded to include health regions and additional disease subcategories.
- It is imperative that health researchers be made aware of this tool.
- The link between environment and health needs to be made. This group might consider making a link with the environmental community.
- The four-year lag time for updating the database remains a problem.
- This report looks at the cost of one year of care. There are some diseases which require long-term care.
Major Discussion Summary:
These EBIC reports and the EBIC On-Line Web application are useful and they are the basis of policy development. The continued collection of data is important .
While these periodic EBIC reports are an impressive achievement, the report and associated on-line information would be even more useful if they could be updated more frequently. Stable funding would have to be found to make this possible. Including international comparisons in the EBIC analysis would enhance its usefulness.
The existence of the EBIC on-line tool may not be widely known and should be promoted, especially to the government policy community.
Healthy Living Strategy
(Mr. Scott Broughton, Assistant Deputy Minister, Population and Public Health Branch)
The ADM updated the Board on this issue. He noted that a previous suggestion from the Board about acknowledging the effect that settings have on health was being considered, but that as far as determinants of health were concerned, the branch was still working with those which had been identified earlier.
Key stakeholders will be invited to Canadian Strategic Roundtables to be held in February 2003 as a first step to developing partnerships and defining the key elements and common themes of the Strategy. Roundtable participants will also be asked to identify short-term initiatives of the Strategy and to prioritize the medium and long-term objectives.
A Healthy Living Symposium will be convened in spring 2003.
Discussion included the following points:
- Healthy Living is an area in which both the federal government and the provinces and territories are interested. The provinces have well-developed Healthy Living agendas of their own.
- Health Canada is trying to ensure that other federal departments and other sectors are involved in the Healthy Living file.
- While it is promising that governments are interested in this file, it will be up to individuals to accept the Healthy Living challenge. Social science can play an important role here by studying how people deal with the results of lifestyle-related research; that is how they deal with perceived risk.
- The time frame to measure anti-smoking efforts was about 30 years. How will Health Canada measure whether the Healthy Living Strategy has worked?
Major Discussion Summary:
It is good to see progress in this important, evolving initiative. The Healthy Living initiative will need sustained, collaborative effort to achieve good results in the long term.
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