A message from the Investigator

When I was asked to lead the investigation into the August 2008 Listeriosis outbreak, I recognized this was not just a professional challenge but also a great responsibility. My goal, from the time I accepted this role, was to provide Canadians with answers about how and why this outbreak occurred. While examining thousands of pages of research findings, participating in hundreds of hours of interviews, and being guided by the advice of experts, I stayed committed to this objective. I felt a strong obligation to find the facts and make recommendations that will help to protect the Canadian public from future outbreaks or optimize the response if they do arise.

No one deserves answers more than the families and friends of those who died as well as the individuals who became ill. I extend my deepest sympathy, and dedicate this report, to all those who were affected by this tragedy.

Many people shared their experiences and perspectives to better understand the events that took place, and many came forward with proposed solutions to prevent similar foodborne emergencies. Over 100 interviews and fact-findings meetings were conducted with individuals from all sectors.

I learned that, in hindsight, it is much easier to see the sequence of events that led to the outbreak and to identify steps that could or should have been taken. I heard, repeatedly, that if people had only known or recognized then what they now know, these events may have evolved differently.

Despite these insights and the best efforts of everyone concerned, the fact remains: 22 lives were lost. These individuals, mostly elderly and at risk of infections, put their faith in Canada's food safety system, expecting it to protect them. Their faith, and that of all Canadians, was shaken. For all the effort of all involved, the food safety system let them down.

This is a serious matter with potentially deadly consequences for vulnerable individuals - people with compromised immune systems, the elderly, pregnant women and their newborns. Although outbreaks of listeriosis are rare, the risks of foodborne illnesses are on the rise and will only intensify in the future for reasons explained in this report. And once the bacteria causing the disease finds its way into the food chain and onto peoples' plates, it is difficult to get under control no matter how committed and dedicated those involved in food safety may be.

As we learned from this event - the worst national listeriosis outbreak in Canadian history - it is often too late to save people at greatest risk from an unnecessary illness or untimely death once food contaminated with Listeria monocytogenes is on the market. It is vital that we take all necessary measures to avert another listeriosis outbreak.

Some point out that Canada's food safety approach receives high marks and is considered among the best in the world. A 2008 international food safety review ranked Canada fifth among 17 member countries of the Organization for Economic Co-Operation and Development (OECD), identifying it as a superior system.

It is true that, for the most part, Canadians can have confidence in Canada's food safety system. However, this investigation found problems that need to be addressed to better protect Canadians.

These problems, which apply not only to federal organizations but to industry and other governments as well, fell under four broad themes.

The first was an insufficient focus on food safety among senior management in both the public and private domains. Even though there was evidence of contamination on production lines producing ready-to-eat meats months before the outbreak, these trends were not being monitored to identify the recurring presence of the bacteria. There was a lack of understanding about intergovernmental protocols to deal with such emergencies, which created confusion about who should do what and when. Government approval processes for new food additives and techniques, with a direct bearing on food safety, were not prioritized or fast-tracked. Information did not always make its way to the senior ranks of the public service and company headquarters which exacerbated these challenges. There were also cases of inadequate decision making which was apparent, for example, in implementing a new program designed to improve food safety. In addition, some policies and directives were vague leaving them open to interpretation, thus creating opportunity for problems.

The second, related area of concern was the state of readiness. It appeared there was not enough advance planning and preparation on a number of fronts, which left people unprepared when the outbreak struck. Examples include the shortage of workers needed to handle surge capacity in times of emergency, summer vacation with substitutes who did not always understand their roles, the lack of exercises to sort out these issues in advance of an actual crisis, insufficient training for food inspectors charged with the new inspection procedures, and confusion over where lab samples should be sent.

The third observation was the lack of a sense of urgency at the outset of the outbreak. For instance, key pieces of information and even personnel were unavailable over a given weekend delaying decisions until the start of the following work week. Another key element was the differing views on when to warn the public about the potential harm from certain foods. Once the gravity of the situation was recognized, emergency operations centres were not immediately activated, if at all. As well, some who might have been prominent on the national stage were not as visible as expected.

The fourth area that left room for improvement was communications - to members of groups at increased risk for listeriosis, health professionals and the general public. Canadians generally do not understand which level of government, let alone what organization has specific jurisdictional responsibility for public health or food safety. What they do know is that they want someone to explain to them, simply and clearly, what is happening and what they should be doing to protect themselves. Subsequent polling, along with the personal anecdotes of family members and others who shared their views during this investigation, indicated that communications about the outbreak did not provide the information they needed. There was near unanimous agreement that Canadians were confused following news of the food recalls.

There is no question this was a complex undertaking and everyone involved was under great pressure to deal with the foodborne emergency while responding to public concerns. I discovered how hard people worked and recognize how dedicated all those involved were in finding the source of the illness, linking the bacteria DNA fingerprints between humans and foods, removing contaminated food products from the market, communicating and managing the event.

Encouragingly, actions are underway to correct problems that were identified immediately following the event. I urge those with a role in food safety to continue to examine their policies, programs and practices and to look for long-term solutions to the remaining challenges. For, while the measures taken to date are a good start, this investigation has concluded that many areas require ongoing improvements.

Until the system is remedied, events like those of the summer of 2008 remain a real risk. That is why I am recommending changes that span all sectors - from food processors to regulators to public health professionals and individual consumers. As this report explains, ultimately, all Canadians need to take ownership of food safety because we are collectively responsible for ensuring the security of the foods we eat.

I am calling for swift and significant action in key areas that are critical to food safety - the culture of food processing companies, the design of food processing equipment, the rules and requirements for food safety set out by the federal government as well as governments' capacity to manage national foodborne emergencies. This includes governance considerations and relationships among all levels of government involved.

Equally important, I am calling on the Government of Canada to establish food safety as one of its top priorities and to report back to Canadians on the steps it has taken to improve Canada's food inspection and food safety emergency response systems.

As much as there is a legal obligation to uphold the laws and regulations governing food safety in this country, there is a moral duty of care to consumers - especially the most vulnerable. Safeguarding Canadians must be at the centre of the consciousness and collective actions of all those involved in food safety.

It is my hope that, this time, the recommendations being offered will be acted upon. This is not the first report on food safety produced in this country that has called for fundamental change. From past food safety audits by the Auditor General of Canada to the "Farm to Fork" Haines report following the Ontario Meat Regulatory and Inspection Review a decade later, there have been repeated calls for action.

It is in the best interest of all Canadians that these recommendations be implemented. Action in these areas will not only protect Canada's food supply and the health of older Canadians and members of other vulnerable groups. It will also contribute to industry's competitiveness in a world that wants assurance that food products are safe. By being proactive, Canada can raise its global food safety ranking from superior to the best in the world. If we have good standards and regulations, good adherence to the rules and good oversight, it will be a win-win for public health and safety, national economic and employment growth, and the food industry.

It took the 2008 listeriosis outbreak to raise awareness that food safety cannot be taken for granted. We cannot wait for another foodborne emergency to occur and more lives to be lost before we act. While there will be costs in implementing some of these recommendations, the costs of inaction - whether measured by the damage to individual Canadians' lives, lost revenues and reputation for industry, or Canada's global competitiveness in an increasingly food safety conscious world - are far greater.

The lessons learned from this outbreak provide an opportunity for Canada to show leadership. I call on all sectors to step up and meet this challenge. Canadians expect no less.