Federal Framework on Lyme Disease Act

An Act respecting a Federal Framework on Lyme Disease

This bill was last introduced in the 41st Parliament, 2nd Session, which ended in August 2015.

This bill was previously introduced in the 41st Parliament, 1st Session.

Sponsor

Elizabeth May  Green

Introduced as a private member’s bill.

Status

This bill has received Royal Assent and is now law.

Summary

This is from the published bill. The Library of Parliament often publishes better independent summaries.

This enactment requires the Minister of Health to convene a conference with the provincial and territorial ministers responsible for health and with representatives of the medical community and patients’ groups for the purpose of developing a comprehensive federal framework to address the challenges of the recognition and timely diagnosis and treatment of Lyme disease.

Elsewhere

All sorts of information on this bill is available at LEGISinfo, provided by the Library of Parliament. You can also read the full text of the bill.

June 8th, 2017 / 12:15 p.m.
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Conservative

Colin Carrie Conservative Oshawa, ON

Okay. Maybe we can get back to you on that.

My next question is for Dr. Hawkins.

First of all, I just want to say that when we are looking at the original Bill C-442 around the table here, I am very proud to have worked.... To get a private member's bill passed by a government is a great feat, actually, but I think the original intent was to have a framework come out that was going to make Canada's the most up to date one around the world.

From the evidence I've been hearing in the last couple of days, as far as guidelines, diagnostics, and treatments are concerned, it seems that our latest framework is failing in that regard. The bill did call for treatment. Dr. Njoo said we should be focusing primarily on diagnostics and treatments. I do realize there are jurisdictional issues there, but I'm worried that we didn't quite get it right.

Dr. Hawkins, the framework highlights the current challenges associated with Lyme disease testing; however, it doesn't actually offer any recommendations for replacing or repealing the current methods being used. I know you commented earlier today, but could you give us some specific guidelines? What changes do you think should be made, and what are the consequences of continuing to use these old methods?

June 8th, 2017 / 11:30 a.m.
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Dr. Elizabeth Zubek Family Physician, Shepherd's Hill Medical Clinic, As an Individual

Good morning. I'm Dr. Elizabeth Zubek, and I am a clinical instructor with the University of British Columbia Faculty of Medicine, department of family practice. I've also worked, from 2013-14, as a UBC consultant on the treatment of Lyme disease, with the university's complex chronic disease program, which was created to be a central provincial referral site for patients with Lyme disease. I now work in private practice, with the treatment of tick-borne infections occupying about 20% of my time.

I'm honoured to be chosen to speak at the House of Commons Standing Committee on Health regarding an action plan, the federal framework on Lyme disease. You, as our federal MPs, listened to the suffering of Canadians with chronic Lyme disease. You responded to the thousands of people in your constituencies who presented evidence that Lyme disease is not being properly diagnosed and treated in Canada. You had the courage to vote unanimously to create an action plan to correct these issues. Now it's time to take this information, designate the funding, and create a solution for all Canadians.

I urge you to remember the why, the impetus behind Bill C-442: Canadians becoming disabled from a treatable disease. This should inform our decisions.

Three pillars are addressed by the framework: surveillance, education and awareness, and guidelines and best practices. I would like to address each of those three pillars in succession. I'll address these from the perspective of a family physician and from the perspective of one of the few Canadian physicians specializing in the treatment of chronic tick-borne illnesses.

On surveillance, although surveillance is already being funded by the Government of Canada for Borrelia burgdorferi, we know that data obtained becomes obsolete quickly due to climate change and due to migratory birds, as they travel, spreading ticks into new areas. There is no region in Canada that can be considered safe from Lyme disease. As a family doctor, I assess the patient in front of me. If that person was bitten by a tick and develops an unusual rash, or neurological or arthritic symptoms, it doesn't matter to me whether the rate of infection in ticks in my area is 5% or 20%, I treat the person in front of me, and I need appropriate testing for tick-borne disease in that scenario.

We know there are multiple species of Borrelia, at least 10 of which cause human disease, and multiple strains among each species. There are then other Borrelia species that cause a relapse and fevers. We know that ticks carry multiple other bacteria, viruses, and parasites. I think it's more important to allocate our resources to test the sick human for the presence of disease rather than count how many ticks in a field contain the Borrelia bacteria. Surveillance has its role, and new Lyme cases are reported, but this already has some funding. Sick people need diagnosis and treatment, not more regional statistics.

Education and awareness is the second pillar. This is very important to prevent new cases of Lyme disease and to recognize symptoms of chronic infection. I believe the entire process of this framework has robustly increased education and awareness in Canadians. There's been so much press about Bill C-442, the all-party support, the controversies involved, and the media has effectively done more than any print campaign the government could have devised. As such, my recommendation would be that the dollars attached to this area of education and awareness be designated towards physician education.

I work in a region of B.C. that's considered endemic for Lyme disease, yet I frequently hear physicians saying, “Lyme disease isn't found in B.C.”, or physicians suggesting a Lyme test immediately after a tick bite, when the test couldn't possibly be positive yet. I teach final year medical students who have not learned about acute and chronic manifestations of Lyme disease. It is to physicians that educational efforts must be directed.

The third pillar is guidelines and best practices for diagnosis and management. On best practices for diagnosis, this framework recognizes that testing with better sensitivity is needed. We cannot accept the current two-tier tests, which as Ralph said, only have a 40% chance of picking up disease, and that's only if you're lucky enough to have your disease caused by one particular strain, B31, of one particular species, sensu stricto, of Borrelia.

Better tests exist now. I recommend that funding go toward evaluating the ELISpot test in our Canadian population. The ELISpot is a lymphocyte transformation test. This type of testing is accepted in Canada as the gold standard for assessing active versus latent or dormant tuberculosis, which is another spirochete disease.

The ELISpot can diagnose 84% of Borrelia infections, is positive earlier in the course of disease, and will go down to zero when treatment is completed. This has added benefit in areas of high endemicity, where a person can be reinfected after the treatment was completed. ELISpot testing currently costs between $200 and $400. Patients, as Ralph said, are now paying for it out of pocket. But it is being used by most of the treating doctors I know in Canada. Better testing for Canadians must be a top priority.

Finally, there are best practices for management. The framework recognizes there are two different approaches to management. One guideline is supported by the Infectious Diseases Society of America, IDSA, and the other is supported by the International Lyme and Associated Diseases Society, ILADS.

In evaluating the trustworthiness of any set of guidelines, specific criteria must be met, as outlined by the respected Institute of Medicine. Guidelines must include regular review and monitoring as new research becomes available. A multidisciplinary panel of experts and representatives from key affected groups, patients, update the guidelines.

Only one set of guidelines meets these criteria, the ILADS guidelines of 2014. These are on the U.S. National Guideline Clearinghouse website and used internationally. Strangely, we in Canada have not publicized these very current and evidence-based guidelines for doctors to use in Canada. We still post the old IDSA guidelines, published over a decade ago, in 2006, never revised, and which were discarded from the U.S. National Guideline Clearinghouse well over a year ago.

This is a critical point to address. There has been an explosion of research on Borrelia this past decade. We have discovered that Borrelia has three different shapes or morphologies and it switches easily between them. The three forms include a corkscrew shaped spirochete with a cell wall, an intracellular form, and a round body that is a more dormant form. It takes a different type of antibiotic to treat each one of these three forms. As a result, the most effective protocols use three different antibiotics all together or in a pulsing pattern.

I looked on the PHAC website just last night for any treatment advice for late Lyme disease, and in its “for physicians” section, it linked me only to a 2006 article of treatment protocols. Those old protocols use only one antibiotic by itself for only two to four weeks, even when the brain is affected. We need PHAC to acknowledge the updated 2014 ILADS guidelines and formally post this most up-to-date information for physicians on their website so that doctors can manage their patients appropriately.

In summary, priorities for funding must align with the priorities of people affected by Lyme disease and their experts. The top two priorities would be diagnosis and management related. For diagnosis, we must evaluate the use of a more sensitive yet still specific diagnostic test such as the ELISpot, and make it available to Canadians immediately as a part of that evaluation. For management, Canadian clinical practice guidelines must consider the most up-to-date research and meet Institute of Medicine standards.

We must do broad education for physicians in all specialties and in general practice. We also need to train up a cohort of physicians with special expertise in the treatment of people with chronic manifestations of Lyme disease. Physician expert engagement must include the College of Family Physicians of Canada, which has a mandate to provide holistic patient-centred care. Family doctors are the ones on the front lines, from diagnosing initial infection to caring for complex systemic diseases.

Finally, it is very important that patients be an integral part of the research direction and research network.

Thank you for your attention today.

June 6th, 2017 / 12:40 p.m.
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Liberal

The Chair Liberal Bill Casey

I want to thank the witnesses very much for coming. We have the most interesting meetings at this committee. You talked earlier of the voice of victims not being heard, but your voices were heard today. You've been broadcast all through this on the Internet, and you will be on CPAC, as well, and reruns, so you're voices are starting to be heard. That's part of our process in the committee.

I think when I met with you earlier, I told you that things take a long time here, but they do happen. I believe that process is under way, thanks to Bill C-442.

I want to say thank you very much to Dr. Lloyd. I notice you broke your pen about three times during the meeting. I'm going to make sure you get a new pen from the Parliament of Canada. I'd like you to just quicky tell us what your work is in this area, in Lyme disease and ticks. I just know you've worked on it for some time, but I don't know what your work has been; and have you had any funding from the government?

June 6th, 2017 / 11:25 a.m.
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Jennifer Kravis Lyme Disease Advocate and Patient, As an Individual

Hello. My name is Jennifer Kravis. I live in Oakville, Ontario. Thank you for having me here today.

I used to be a lawyer and a bank executive, but 11 years ago, at age 36, I was suddenly debilitated and bedridden by a mystery disease that took me hundreds of thousands of dollars and five years to determine was Lyme disease.

I had to go to the U.S. and pay even more money. I spent two years getting continuous antibiotic treatment, including a PICC line, which gave me my quality of life back, and my family's as well.

I still cannot work, but I advocate for Lyme disease now. There are five people in my family with Lyme, and my dog has it as well, but my dog was treated promptly with compassion and care, and he got five months of antibiotics, and he made a full recovery. My niece got early treatment with a bull's eye rash after seeing four doctors . The rest of us—me, my mother, and my two daughters—are permanently affected. As a mother, I live with the guilt and horror of discovering I probably infected my two kids. They both have chronic Lyme and multiple co-infections. One has encephalitis causing neuropsychiatric issues and arthritis in the spine, and she's 14 years old.

In the last week I've spent many hours thinking about what I could possibly say to you in 10 minutes to convey to you the suffering, the despair, the abuse, the financial ruin that is sweeping this country.

I can talk about my full story. I was financially secure, a Bay Street professional. I had money, connections, and access to the very best health care, but it did not protect me and my family, and it will not protect you.

I could talk about the 40,000 Canadians who signed our petition or who wrote thousands of Lyme letters for Minister Philpott, letters that bring us to tears on a regular basis. But on Thursday you will be told that petition comments are really about ticks, and stories are anecdotes not evidence.

I could talk about the independent, professional benchmark survey we did in Canada to ask how many people were affected by Lyme disease. The survey asked, have you or someone you know in Canada been diagnosed with Lyme disease? The answer is between 2.8 million and five million people.

Public health numbers are a joke because people are denied testing and not counted. People get false negative results, and they are not counted. People get positive results. They are told they are false, and they are not counted. People get positive tests from international labs, and they are not counted. Finally, those who, by some miracle know about Lyme, convince their doctor to order tests, pass the first tier, pass the second tier, prove they were in an endemic area, get to the doctor in time, get a bull's eye rash, and have the doctor visually inspect the bull's eye rash. Even the majority of those cases are not counted, just as Sue Faber talked about.

I thought about asking questions. Why has public health ignored 35 published, peer-reviewed tick studies compiled over the past 27 years by an Ontario researcher named John Scott? Why has public health not warned first nations that they are living in hyperendemic areas like Kenora, Ontario, where John Scott estimates ticks have been established for 50 years? Why have our doctors never heard of co-infections?

My 13-year-old daughter has Rocky Mountain spotted fever. This is a disease that could be fatal in up to 75% of untreated cases. I had to fight for this test, and when it came back positive, my GP fired us.

This leaves my going back to my original question, which is, what could I possibly say to you to convince you something tragic, shocking, and disturbing is happening in plain sight?

I decided I would speak about the truth, the real truth, the truth that nobody wants to talk about or believe. The truth is the bill was great, but the final framework is useless. It is inaccurate. It's going to cause harm to Canadians. The process was mangled by some powerful, unethical, and self-serving interests.

The truth is we have a massive global pandemic, one that is not easily prevented by pulling your socks up and staying in the middle of the paths. The truth is people are so desperate to get life-saving antibiotics they beg their vets, and they beg their doctors to try to get six weeks of antibiotics in a desperate attempt to avoid lifelong disability. The truth is there's a secret network of Canadian doctors who risk their licences to treat their patients. The truth is Lyme patients are horribly abused by doctors, but if they file a complaint to the college, they are harassed and blacklisted. The truth is millions of Canadians, including first nations and children, are walking around with the wrong diagnosis. The truth is U.S. doctors are getting paid by us to learn about this disease, instead of our own doctors gaining this knowledge and expertise. The truth is we have thousands of parents who live in agony and despair, hiding in their homes with sick, disabled children who scream and cry, have seizures, and are in horrific pain. The truth is people with bull's eye rashes in every province every day are being turned away and denied treatment, sent home to wind up disabled in excruciating, unrelenting pain.

Some doctors say, “I'm sorry, I can't help you; I will get in trouble and I have to protect my family over yours.” Some doctors say, “I'm not allowed to help you, but if you go to the U.S. and get treatment, you will get better.”

Many doctors say, “I guarantee you don't have Lyme disease” and, in fact, they are correct, because the system at every stage guarantees it's virtually impossible to get a Lyme diagnosis. When the Canadian test is negative, it is called gold standard; when the test is positive, it is called false; and when the test is from out of the country, it is called garbage, except if it's negative.

The truth is that surveillance is a sham and a waste of money, because ticks are dropped everywhere by migrating birds; and surveillance is not progress. It is a tool used to deny the disease. The truth is that some people don't get their Lyme test back from the national lab for months, and too many people are told their test results are lost.

The newest weapon in the Lyme war is anti-microbial resistance, which denies very sick Lyme people life-saving treatment or the dangerous side effects of antibiotics. The truth is that people with arthritis, syphilis, Crohn's disease, tuberculosis, relapsing fever, rheumatic heart fever, rosacea, MS, and acne are given months and years of antibiotics without hesitation; and cancer patients are given the choice of drugs with side effects so dangerous they can kill them.

Let's review the so-called facts of Lyme disease that we are told by public health and infectious disease specialists: one, our testing is fine; two, ticks must be attached for 24 to 48 hours to transmit the disease; three, only black-legged ticks carry Lyme; four, your risk of contracting Lyme is very low, so don't worry, and virtually zero outside of endemic areas; five, you can't have Lyme if you don't get a bull's-eye rash; six, two or three weeks of one antibiotic is all you need to be fully cured; seven, if you have any new, lingering symptoms, you have a new disease, which is called post-Lyme-treatment disease syndrome, which looks and feels exactly the same as the infectious disease you just had three weeks earlier; eight, we are told there is no scientific evidence of persistent infection or that long-term antibiotics help, and we are told there's no scientific evidence of congenital transmission.

We are told, “We don't know what all these people have, but it's not Lyme” and we're told that people fixating on Lyme could miss the chance to get a real diagnosis.

Finally, we are told other countries' tests, all of them, are invalidated, from for-profit labs, not FDA approved, purchased positives, garbage, or run by profiteers and quacks. But the truth is every single one of those sentences is untrue.

The truth is that doctors, patients, and the public are being misled, and we need you to do what no one has been able to do—despite fighting for decades—not advocates, not Bill C-442, not celebrities, not politicians, not journalists, and not even an international organization of medical doctors and scientists.

We need you to ask yourselves if it makes sense that tens of thousands of Canadians have a shared delusion about their own health and welfare, their body, and their symptoms? Does it make sense that tens of thousands of kids who've never met are suffering from a shared psychiatric disease that causes them to fake symptoms? Does it makes sense that previously rational, healthy adults are conspiring to obtain antibiotics, which if abused, give you a stomach ache and a sunburn. Does it make sense that desperately sick people bankrupt themselves for treatments that provide no relief to them?

We need you to ask the questions that always reveal the truth. Who benefits or profits from the denial and suppression of these diseases? Who benefits from patients missing the early cure with a cheap generic antibiotic, and wind up labelled with fibromyalgia or an incurable neurodegenerative disease like MS, ALS, or Alzheimer's. It's not patients, it's not taxpayers, it's not families or kids, it's not businesses, it's not our health care budget, it's not family doctors or clinicians, and it's not our economy.

The truth is that it is too late for me and my family, because there is no amount of money, drugs, connections, or treatments that will restore our health. We are here for you. We are here for all those Canadians who are so sick and in pain and feel abandoned and are on the verge of suicide. We are here for all those Canadians who will be unknowingly struck down in the parks and in their backyards. We are here because we cannot bear to hear one more story of a child with a bull's eye rash being sent away to end up disabled.

The truth is that Canadians desperately need you to stand up and do the right thing. We need your help. Please help.

Thank you.

June 6th, 2017 / 11 a.m.
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Green

Elizabeth May Green Saanich—Gulf Islands, BC

Thank you, Mr. Chairman, and thank you to all members of the committee. I will not trespass long on your time, because we have with us people I want you to hear.

I wanted to set a bit of context. Some of you were in that Parliament—Don, certainly—in June 2012 when I first tabled Bill C-442 for first reading. We have had tremendous non-partisan, all-party support from the beginning. The bill was supported in the House of Commons unanimously and went to the Senate, where it was also supported unanimously.

The bill's nuts and bolts required a conference to be held, bringing in medical experts, federal-provincial government health departments, and people from what we now think of as the Lyme disease community, people such as some of the witnesses before us today, Sue and Jennifer.

I wanted to give you a sense that the conference was an extraordinary success. Our public health officer at the time, Greg Taylor, was very strong in saying that we needed to do more. We've been failing our patients. We've been failing people with Lyme disease across Canada.

I wanted to say briefly that now that the framework has been published, the committee's work for two days this week is very important. I know you'll hear evidence about how serious Lyme disease is, how fast it's spreading, and frankly, the hell on earth it has been for patients with Lyme disease. One of my constituents went to 18 different specialists before finally thinking, “Okay, maybe we'll try going to the States,” and then finally got some help.

The bottom line here, I believe, is that any Canadian experiencing Lyme disease should be able to get treatment in Canada, and we're not there yet. The Minister of Health herself doesn't have a magic wand, nor does she have the jurisdiction to make it so, but the framework gives us some tools. I wanted to point us in that direction, as the positive work going forward.

In the framework document, in appendix 1 is the federal action plan. I wanted to turn your attention to point 2 on education and awareness and point 3 on guidelines. Both of these sections point us in the direction of finding ways to educate medical professionals.

Medical professionals are a very educated bunch. I have the deepest respect for the doctors of this community. In fact, the Canadian Medical Association endorsed Bill C-442. Their letter endorsing it made the point that Lyme disease is an extremely difficult disease to diagnose. The advice, which I agree with in this framework, is that the diagnosis is primarily a clinical diagnosis. In other words, lab tests are quite unreliable, no matter where they are taken. False positives and false negatives are problems.

What we need, when someone presents with a weird range of symptoms, is for every medical doctor in Canada, every family doc, to think to themselves, “I wonder if it's Lyme disease.” If you respond quickly and with early treatment, if it is Lyme disease, this person will be restored to full health, but if you delay, thinking that maybe it's something else, you can actually end up having the disease become much more serious and last much longer.

Here are the two pieces I'm referring to. Under “Education and awareness,” it reads:

Develop a national tick and Lyme disease education and awareness campaign

—this is the federal commitment—

in collaboration with partners, that addresses...Recognition of Lyme disease symptoms [to assist] front-line professionals [to] perform early diagnosis and treatment

Then, under “Guidelines and best practices,” in point 3, it says:

Work with international public health partners

—because, by the way, Lyme disease is spreading very quickly in Europe—

to share best practices and disseminate domestically

These are areas where we don't yet have a clear sense of how we're going to do it. The commitment is there. It's clear that we can't polarize this issue with good guys and bad guys. That's not appropriate. Everybody here is a good guy. Everybody is trying to figure out what to do, to use the right tools, and to start ensuring that every Canadian who experiences Lyme disease is helped.

There are many people who have had it for a very long time, and those particular patients are a represented group where the research money will be very helpful. We have $4 million for research. That money, I hope, will go towards finding a vaccine but also towards finding ways to help people who have what's either described as post-treatment Lyme disease syndrome or chronic Lyme disease. I don't want to get involved in that ideological divide. I just know there are a lot of people in wheelchairs who need help.

I've taken longer than I actually told you I would, Mr. Chair. You said I could have five minutes. I said I wouldn't need that, but at 4 minutes and 43 seconds I will stop, and I thank you for your attention.

June 6th, 2017 / 11 a.m.
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Liberal

The Chair Liberal Bill Casey

As we have quorum, I'd like to welcome everybody to meeting number 59 of the Standing Committee on Health.

Today we're going to study the federal framework on Lyme disease. We have three witnesses here with us in the meeting room, and we have by video conference a visitor from Sackville, New Brunswick.

On behalf of the Canadian Lyme Disease Foundation, we have Janet Sperling, board member. Then we have, as individuals, Sue Faber, Lyme disease advocate and patient; Jennifer Kravis, Lyme disease advocate and patient; and Dr. Vett Lloyd, professor at Mount Allison University, by video conference.

Welcome all. We're glad to have you here.

I'm going to seek unanimous consent to allow Elizabeth May to just make a few opening remarks because I believe we can say we're here because of her original Bill C-442, which resulted in this framework being established.

Do I have unanimous consent to allow Ms. May to make a statement?

Member for Sturgeon River—ParklandOral Questions

May 16th, 2017 / 3:35 p.m.
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Green

Elizabeth May Green Saanich—Gulf Islands, BC

Mr. Speaker, I rise today to pay tribute to my colleague and friend.

I met the member for Sturgeon River—Parkland 11 years ago.

I was not in politics yet. I was executive director of the Sierra Club Canada when I first sat down at a table opposite the current interim leader of the Conservative Party. She was then-minister of environment. It is a tribute to her personal characteristics of fairness, kindness and just plain likable that I could not help liking her as we discussed the Kyoto protocol.

I have searched my memory banks and I cannot remember a single time in the last 11 years when I have not thought well of her as a person, even if we disagreed. We share many things, including a love of dogs and hiking in the wilderness, and we also shared much when she was minister of health. I want to pause for that period and thank her once again.

She played a key role in ensuring the quick passage of Bill C-442 on Lyme disease. We are now working together on the national framework that will be implemented under that bill.

However, it took the minister of health deciding that a private member's bill from an opposition party leader would be okay to support. To have it pass unanimously in the House of Commons and the Senate is not about all the independent decision-making of all the MPs. Honestly, if the minister of health had not supported that bill, it would have died right there. I want to thank her once again for supporting remedies for the people across this country suffering from Lyme disease.

I also want to pay personal tribute to the fact that under her leadership and in the government of Stephen Harper, the strongest legislation ever, taking big pharma to task, Vanessa's Law, was passed. That is solid and it is a tribute I want to pay publicly.

Last, as another woman in politics, leading a teeny-weeny party over here in the corner, everything she has ever done as interim leader of the official opposition has demonstrated that women can do everything just as well as a man.

I saw her earlier today, standing at the podium in the foyer. I do not know how she stands in those shoes. I do not understand how anyone can walk in those shoes. They are phenomenal high heels. They are very gorgeous. It reminded me so much of what was often said of Ginger Rogers and Fred Astaire, that she danced just as well as he did but backwards and in high heels.

Hats off to the leader of the official opposition. We will miss you.

May 11th, 2017 / 12:20 p.m.
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Conservative

Len Webber Conservative Calgary Confederation, AB

I do, Mr. Chair.

I would like to present the following motion, which was submitted in advance, of course, as per the committee requirements. The motion reads as follows:

That the final framework on Lyme disease not be tabled until the Standing Committee on Health has had the opportunity to review the draft work which should aim to (a) establish proper guidelines regarding the prevention, identification, treatment and management of Lyme disease and the sharing of best practices throughout Canada, and (b) ensure the creation and distribution of standardized educational materials related to Lyme disease for use by any public health care provider within Canada designed to increase national awareness about the disease and enhance its prevention, identification, treatment and management.

I table this motion because a year ago, almost to the day, there was a clear sense of hope in the Lyme disease community. A federally funded Lyme disease conference was held right here in Ottawa in May of 2016. There was a sense that finally experts in the field of Lyme disease would be engaged in the drafting of the federal framework outlined in Bill C-442, MP Elizabeth May's bill.

The Federal Framework on Lyme Disease Act was passed on June 11, 2016. The MPs and senators who passed this bill into law passed it with the understanding that it was to be consultative. But that sense of hope has faded. This federal framework on Lyme disease is being written behind closed doors. It is to be released later this month.

A draft framework was released in February of this year, and the reaction to it was fierce. Dr. Melanie Wills, director of the Canadian Lyme Science Alliance and a professor of molecular and cellular biology at the University of Guelph, said the following:

As a researcher in the field of Lyme disease biology, I am dismayed by the lack of scientific rigor, collaboration, and leadership demonstrated in this document. The Framework does not provide a balanced or holistic portrayal of the biomedical literature, nor does it capture the experiences and needs of Canadians who are suffering from Lyme disease. The CLSA strongly advocates a thorough, inclusive, critical, and transparent evaluation of all available meritorious scientific evidence, as well as meaningful integration of input from diverse stakeholders. We can, and must, do better.

Dr. Liz Zubek, a family physician who specializes in the treatment of Lyme disease, said the following:

This draft Framework tells me to follow outdated guidelines that haven’t been revised in over 10 years. There has been an explosion of research in the past decade and newer guidelines exist that include patient input. This draft Framework also suggests that, as a doctor, I should be satisfied with our inadequate Canadian tests for now, and that maybe in the future we will find improvements. This is, frankly, ridiculous.

I urge the Minister of Health to reject the Draft Framework and insist on a real Canadian action plan for Lyme disease. This needs to be created in partnership with people affected by Lyme and those researchers and doctors who are actively attempting to treat them.

Finally, these are the words of Rossana Magnotta, a director of the Canadian Lyme Disease Foundation:

We call on the Minister of Health to intervene and insist on patient experts being involved in the writing of the framework, even if that means delaying the report to parliament. This is the correct and ethical thing to do.

Mr. Chair and colleagues, 38,000 Canadians have signed a petition clearly denouncing Canada's draft action plan on Lyme disease. The draft proposal ignores science and many major concerns that were raised at the conference. Major concerns include poor diagnosis, treatment plans that fail, human-to-human transmission, and blood bank contamination—yes, blood bank contamination.

You can see that there are some serious concerns by both professionals and patients within the Lyme disease community that this framework may lack some key items. I would like to give the Lyme disease community reassurance that they are included in the drafting of this framework. I am aware, colleagues, that this committee has no more days or time available in the near future to undertake any more studies. I'm aware of that, and I'm also aware that Health Canada intends to release this framework on Lyme disease at the end of the month.

Therefore, this motion I put forward proposes that, through the clerk, of course, we receive a copy of the framework in advance of the final copy being generated so that we can add our constructive input. I'm suggesting that we can review it independently, on our own time, as our meeting schedule is already full.

In the end, it will be we MPs who will have to answer to this framework, and it sure would help if any questions we have could be resolved ahead of the drafting of the framework. I think our input would be most valuable if it is contributed before the document is finalized, because once this framework is written, it's basically written in stone. It would be difficult to change.

Ideally, I would imagine that we could have a draft framework document for about a week to provide our input before it goes to final print, and if this proves to be a successful approach, it may help this committee in future issues.

I conclude with this question: do we all agree that having our input would be a valuable contribution to the process of developing an action plan framework on Lyme disease?

Thank you, Mr. Chair.

June 12th, 2014 / 10:20 a.m.
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Conservative

The Chair Conservative Ben Lobb

Welcome back. We're back in session.

We'll start going through the clause by clause portion of Bill C-17. We have the departmental officials at the table, at the ready, if there are any questions. So feel free to ask questions or for clarification.

In addition to that, similar to what we did for Bill C-442, the Lyme disease bill, we'll take our time and make sure everybody knows exactly what clause and what amendment we're talking about, so everybody feels good about what they're voting on.

There's lunch at the back and recognizing the fact that everybody wants to pay attention to the clauses and the amendments and to which way to vote, we can suspend at some point, when the committee feels like it, for five to 10 minutes, just to have a quick lunch so that everybody can stay focused on the clauses and the amendments, if that's okay with everybody.

We have two legislative clerks here to help us along the way if we have any technical questions. Karin is also still here as our analyst.

If everybody's ready to go, we'll get at it.

Similar to the case with the Lyme disease bill, the title and the preamble will wait until the end, and we'll get right at it.

(On clause 2)

We have amendment CPC-1. On that, I'll say that if this amendment is adopted, so will be amendment CPC-2 since they are consequential. Would somebody like to talk about the amendment?

Ms. Adams.

Federal Framework on Lyme Disease ActPrivate Members' Business

June 11th, 2014 / 7 p.m.
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Green

Elizabeth May Green Saanich—Gulf Islands, BC

Mr. Speaker, I am deeply indebted to all members on all sides of the House. I will not need my five minutes, as I do not plan on making a long statement.

I want to close at this third reading of Bill C-442 by turning our attention to the people who are suffering with Lyme disease. I want to thank Jim Wilson and the Canadian Lyme Disease Foundation, Brenda Sterling in Nova Scotia, who first made me aware of the disease through her own suffering, and my dear friends and the family of Fraser Smith. I particularly want to thank Nicole Bottles for her amazing advocacy, struggling herself against the debilitating effects of the disease.

I want to thank members on all sides of the House. We have done something good today for people who need our help.

Federal Framework on Lyme Disease ActPrivate Members' Business

June 11th, 2014 / 7 p.m.
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NDP

Don Davies NDP Vancouver Kingsway, BC

Mr. Speaker, Canadians need a national strategy on Lyme disease to ensure that testing and treatment options in Canada are improved.

The New Democratic Party of Canada supports Bill C-442 and congratulates the member for Saanich—Gulf Islands on her initiative.

This legislation lays out a concise plan for educating Canadians about disease risks and most important, provides a better quality of life for Lyme disease sufferers.

Lyme disease is caused by contact with the bacterium spread by tick bites. Ticks are small parasites that feed on the blood of animals and humans, and they pass on Lyme disease when they feed on mice, squirrels, birds, or other animals that carry the bacterium, and then bite humans. Ticks are more common during the warmer months from spring through to late autumn. Canadians who live in areas with mild winter temperatures and minimal snowfall have an increased risk of coming into contact with ticks.

Climate change is one of the factors causing more regions to be at risk, with warmer weather increasing tick distribution across many parts of Canada.

Bill C-442 is especially important to British Columbian coastal communities, as Lyme disease is currently more of a concern on Canada's west coast due to its mild temperatures.

Lyme disease symptoms can include a circular rash around the bite, fatigue, fever, headache, weakness, abnormal heartbeat, muscle and joint pain, and central and peripheral nervous system disorders. Symptoms get progressively worse if the disease is left untreated, which it is for many Canadians. Chronic Lyme can develop if the disease is left untreated and can have lasting effects for months or years afterwards, and according to Health Canada, can result in recurring arthritis and neurological problems.

In 2008, NDP MP Judy Wasylycia-Leis urged the health minister to implement a national strategy to diagnose, treat, and create better surveillance of Lyme disease. I am proud of the member for Vancouver East, our official opposition health critic, who has continued to call for a national Lyme disease strategy since that time and seconded Bill C-442 when it was introduced by the member for Saanich—Gulf Islands.

This strategy is long overdue. Canadians deserve to get adequate testing and treatment for this disease. The federal government is responsible for improving the surveillance of Lyme disease as well as establishing best practices so that the provinces can understand the disease and adopt evidence-based measures that improve outcomes.

The bottom line is that receiving early and appropriate treatment would improve the quality of life for thousands of Canadians and their families. Early treatment of Lyme disease reduces the severity and duration of illness. More accurate testing and earlier treatment of Lyme disease would reduce the health care costs associated with a lengthy illness and more severe side effects, particularly for women who suffer long-lasting side effects when their Lyme disease goes untreated.

The New Democrats have been working with Canadians in support of a national strategy on Lyme disease for years now. Now is the time for the federal government to adopt such a strategy to protect the health and safety of Canadians in the face of this rapidly spreading disease.

I urge all members to support the bill.

Federal Framework on Lyme Disease ActPrivate Members' Business

June 11th, 2014 / 6:50 p.m.
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NDP

Dany Morin NDP Chicoutimi—Le Fjord, QC

Mr. Speaker, it is a pleasure to speak to this bill this evening. As I also have the great privilege of sitting on the Standing Committee on Health, I was able to hear the witnesses and experts discuss the bill when it was referred to the committee and to learn about the improvements that we could make to strengthen it. I also saw that the government had a certain agenda.

At the Standing Committee on Health, we essentially sat down together around the table and agreed that this bill should go forward. Obviously, it cannot necessarily be perfect for everyone, although the NDP will support it. There is a consensus in the Parliament of Canada in 2014 that this bill on Lyme disease is to be taken more seriously.

As many NDP colleagues have mentioned, the tick that carries Lyme disease has been moving northward for many years as a result of global warming. Now we must find ways to protect the people living in southern Canada, and increasingly those further north as well, from this tick, which can have a disastrous impact on people’s lives.

Before discussing the more technical aspect of the subject, I feel that the people who are listening to us at home may not know what Lyme disease is. We talk about a tick, an insect. They may not understand.

My speech this evening will focus essentially on what Lyme disease is and what the tick is. Then I will talk about ways to prevent the disease. I will also talk about my region, Saguenay—Lac-Saint-Jean.

I got lucky last week. An excellent journalist from my hometown, Patricia Rainville, published a very good article on Lyme disease in the local newspaper, Le Quotidien. It will be a pleasure for me to read certain interesting excerpts from it.

The disease was discovered in 1977 in the U.S. town of Lyme, Connecticut, where several children were suffering from arthritis. The disease then gradually spread northward. Cases have been recorded in Quebec since 2011, but numbers have skyrocketed since 2013.

Therefore, we can see that the problem will only get worse for the people of Quebec and of Canada. That is why this is the ideal opportunity for the Parliament of Canada to move forward with a bill on the subject.

Once the tick attaches itself to the skin, it can stay there for approximately 72 hours if it is not detected. Seventy-two hours is the length of time it needs to feed, and during that period it can transmit the bacterium that causes Lyme disease.

A person bitten by a tick carrying the bacterium that causes Lyme disease will develop in the first few weeks a red rash more than 5 cm in diameter around the site of the bite. At that point, the disease can easily be treated with antibiotics. If nothing is done in the following weeks, however, the individual may suffer paralysis, swelling of the limbs, heart palpitations, headaches and even meningitis.

Clearly, the tick that carries Lyme disease can have a serious impact on human health. This is why people ideally should try to avoid being bitten by this tick, which could transmit the disease. To prevent infection, it is recommended that people apply mosquito repellent and wear long clothing and closed footwear before entering high-risk areas. Taking a shower and examining one’s body in the two or three hours following exposure is another excellent suggestion.

This is important, particularly since the tick is more likely to be found in wooded areas. Hunters are obviously at risk when they spend long hours in the woods, which is why many hunters have caught Lyme disease.

Ticks infected with Lyme disease have not yet settled in the Saguenay—Lac-Saint-Jean region, which is a good thing for us. Only one case was reported in the hospitals back home last year, but the disease had not been contracted in my region, thank God. There were no cases of Lyme disease in Quebec five years ago, but the blacklegged tick has come a long way since then.

Today, there are a number of cases of infection in Montérégie. Entomologist Robert Loiselle, whom I greatly admire and know personally, is urging the public to be on the lookout:

I have been talking about this for 15 years. The blacklegged tick was well established in the northern United States, but for the past few years we have been seeing more and more of them in southern Quebec, in Montérégie for example. Tourists who come to enjoy nature have to be extra careful and check themselves after a hike or a walk.

At the Agence régionale de la santé et des services sociaux, spokesperson Éric Émond confirmed that a case of Lyme disease had been reported at a hospital in Lac-Saint-Jean last summer, but the bacteria was not contracted here. This year, as I said, no cases have been reported. Obviously, we never know what will happen if we are not careful.

The Quebec ministry of health and social services is asking the public to be careful. Dr. Danielle Auger, director of public health said:

For the past few years in Quebec, we have observed an increase in the number of ticks carrying the bacteria responsible for Lyme disease. The disease can be contracted from a tick bite during activities in wooded areas, including in higher risk areas in southern Quebec, such as the northern eastern townships, southwestern Mauricie-et-Centre-du-Québec and especially Montérégie, where the majority of cases contracted in Quebec have been reported to date.

According to entomologist Robert Loiselle, it is highly likely that the blacklegged tick could end up in my region:

I recently caught a tick, but upon analysis, it was not carrying Lyme disease. Nevertheless, ticks follow the deer populations. It is therefore not outside the realm of possibility that ticks will show up one day.

I do not want to sound overly dramatic, but even my region, in northeastern Quebec, is not safe from Lyme disease. This is a growing problem, but it is also a national problem. Earlier my colleagues from British Columbia and Nova Scotia discussed the situation in their part of the country. People and health authorities are on alert and are turning to the federal government, as are patients and their families, in the hope that it will do something.

That is truly unfortunate because the Conservative government has put nothing forward for years. The NDP has been proactive in this matter since 2008. NDP member Judy Wasylycia-Leis strongly recommended in 2008 that the minister of health implement a national strategy for the diagnosis, treatment and better monitoring of Lyme disease. Yes, the NDP has been talking about it and making it a priority since 2008. The Conservative government, on the other hand, has been dragging its feet for years. That is why I am grateful that my colleague has introduced this bill. At last we can move forward in 2014.

The official opposition health critic has always recommended that such a strategy be adopted, and she supported Bill C-442 when it was introduced. That is an indication of the NDP's good faith.

The requested strategy should have been adopted long ago. Canadians deserve proper tests and care. The onus is on the federal government to improve monitoring of Lyme disease and to establish best practices so that the provinces can understand the disease and adopt more effective evidence-based measures.

Over the years, the Conservatives have taken no initiatives on important health issues such as the coordination of services provided for chronic and complex health problems and funding for innovative screening and treatment measures. The matter before us is one in which the federal government should show leadership in health care and strive to better protect Canadians.

Many patients in Canada report problems with screening and treatment for Lyme disease. The various blood tests conducted to detect the disease often yield inaccurate results. Patients who have Lyme disease may not be diagnosed with it or may be incorrectly diagnosed with multiple sclerosis or chronic fatigue syndrome. Consequently they do not receive necessary care and, as a result, their symptoms worsen. It is important that we move forward to help these patients.

Federal Framework on Lyme Disease ActPrivate Members' Business

June 11th, 2014 / 6:40 p.m.
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NDP

Hélène LeBlanc NDP LaSalle—Émard, QC

Mr. Speaker, I am pleased to be speaking after my colleagues, particularly our health and environment critics. Every speech teaches us a little bit more about Lyme disease. I am pleased to also say a few words about Bill C-442, An Act respecting a Federal Framework on Lyme Disease.

I must say that this bill is of interest to me, as are so many other bills. We have heard some stories, and last February I received a letter from a constituent about this bill:

I am one of your constituents and on behalf of the thousands of Canadians suffering from Lyme disease, I am asking you to support Bill C-442 respecting a national strategy on Lyme disease. Debate on the bill begins on March 4.

Later on in the letter, she wrote:

We need to support Bill C-442 so that we can develop a national strategy to fight this serious disease.

The person who wrote me asked me to meet with her, which is what I did. The meeting was truly amazing for me. I was there with the mother of someone with Lyme disease.

She told me about the ordeal that she and her child, now an adult, had to go through before getting a diagnosis. Finally, after several years, it was discovered that this person was afflicted with this terrible disease. The child experienced a number of symptoms, got several diagnoses, and underwent numerous tests before being accurately diagnosed. Despite numerous doctors’ appointments and hospital tests, they were faced with more questions than answers. Over this time, the disease took its toll, and became chronic. This person will have to live with the chronic symptoms of Lyme disease.

Finally, thanks to a test in the United States—not in Canada—a clear diagnosis was obtained. In spite of the trials and tribulations, and an established diagnosis, the parents told me that it was actually a relief for the person with the disease to know what the diagnosis was. Indeed, once the disease becomes chronic, many of the symptoms of Lyme disease closely resemble chronic fatigue syndrome.

What happens when a person has symptoms but no clear diagnosis? Often, those afflicted get depressed because they do not know what has caused the symptoms. Their family and friends are left wondering what to do. They do not know how to help people with the fuzzy diagnosis of chronic fatigue syndrome. When a diagnosis was established in this case, the family was able to support the person with Lyme disease and at that point they could come together to develop a plan of action as to how to cope with the disease.

The parent in question also praised the Canadian Lyme Disease Foundation, commonly known as CanLyme. The Foundation carries out very important work to raise awareness about the symptoms, diagnoses and ways to prevent Lyme disease. CanLyme is also a not-for-profit organization, and its website contains a great deal of information dispelling a number of myths and misconceptions around the disease.

I would like to commend the foundation on its extraordinary work. I would also like to salute the courage of this parent who came to meet with me to talk about their story and the plight of their loved one with Lyme disease, who had to go through quite an ordeal before getting a diagnosis.

The bill calls on the government to develop a national strategy to combat Lyme disease. I think that the government has to understand not only the need to put a strategy in place, but also the need for resources and financial backing. Parks Canada needs tools to advise people visiting our national parks on how to recognize the infamous insect that infects people with Lyme disease and the steps they should take if they are bitten, to ensure that the illness does not become chronic.

If it can be done for poison ivy, I do not understand why it cannot be done for Lyme disease. Moreover, a national strategy would help us work together with the provinces to develop tools to prevent this disease.

It is important to understand what is happening. Why is this disease spreading? It was previously a little known disease because it did not occur in Canada, where many insects die in our frigid winters and therefore do not cause a problem. However, climate change and global warming are having an effect on us as a Nordic country.

I am an agronomist by training. I got my training not so long ago. In class, we were told that Canada needed to adapt to changes in agriculture and prevent diseases that will emerge as insects head a little further north. The government must tackle these problems head on.

That is why the An Act respecting a Federal Framework on Lyme Disease is a step in the right direction, and that is why I support it. I also support it on behalf of a parent who came to meet me in my office to tell me about Lyme disease and make me more aware of it.

Federal Framework on Lyme Disease ActPrivate Members' Business

June 11th, 2014 / 6:20 p.m.
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NDP

Libby Davies NDP Vancouver East, BC

Mr. Speaker, I am pleased to rise in the House today to speak in support of third reading of Bill C-442 for a national framework for Lyme disease.

Today is a special day. It is not every private member's bill that gets to third reading. The fact that this bill has means that it has stood the test. It has gone through the challenges of going through second reading, going to committee, through amendments, and here it is back in the House. We are anticipating and hopeful that the bill will be approved today in the House of Commons and then go to the Senate.

I would like to speak briefly to the bill, but I would first like to congratulate the member for Saanich—Gulf Islands for the hard work that she has put into this bill, into building alliances and talking to people in different parties. It is a good example of the goodwill and the solidarity that can develop around an issue when people recognize that something needs to be done. I only wish it would happen more often in the House. There are so many issues that need our attention, collectively, with a spirit of fair play and goodwill. Maybe this bill will be a good model for that, but I wish it would happen a little more often.

When this bill came to the health committee, I was pleased to be there. We went through it and heard witnesses. Hearing the witnesses was incredibly compelling. We heard from Jim Wilson of the Canadian Lyme Disease Foundation. People shared personal experiences about this disease, which is not easy to do in a formalized parliamentary hearing as a witness with all of the official trappings that go along with that.

Chris Powell and her daughter Nicole were quite remarkable. Nicole, who is from British Columbia, was quite remarkable in sharing her experience of having Lyme disease and the suffering she was going through. It is not only physical suffering, which she still endures, but also the emotional anguish of not being able to get a proper diagnosis.

One of the critical elements of the bill is that it would bring together the different elements we need in terms of not only prevention and better public awareness, but a medical community that is in a much more heightened state of awareness with respect to Lyme disease, as well as better clinical diagnostic tools and testing.

We heard horrifying stories from people who had gone to extraordinary lengths to find out why they were so sick and why they could not get help. We know there are two tests available in Canada, but they pertain only to basically one strain of the tick that produces Lyme disease. There is so much that needs to be known.

We heard stories about the amount of money people had spent to go to the United States, for example, where other testing has been available, to finally get a correct diagnosis. Then they would come back to Canada and have somebody contradict that diagnosis. It a nightmare for these people to live through, not just enduring and living with the disease, but coping with systemic barriers and obstacles to proper diagnosis and get the treatment they need. We heard all of that at committee. It was compelling and it made us all acutely understand that we needed a national framework.

I want to spend a moment on that. As the health critic, I meet with many organizations across the country, in Ottawa, in my riding and elsewhere. There are so many issues and people are literally begging the federal government to show leadership to develop a national strategy, whether for dementia or Alzheimer's. This is just another example of that. It is a reflection of our complex system.

We know that health care is a provincial delivery system. There is no question about that. However, there is a necessity for federal leadership. Under the Canada Health Act, we have a duty and responsibility to ensure that all people in our country, whether rich or poor or whether they live in the north, south, east, west or the centre, in small communities or large urban centres, have accessibility to our health care system. We know the inequities are getting greater, and not just between provinces but also within provinces.

There is an overarching issue that the bill also reflects, which is that we need to see the federal government be at the table. We need to see the federal government take leadership on these issues. Many groups are calling for a national strategy. People know the reality of this kind of scattered approach. It is like a patchwork across the country and that just is not good enough.

The bill speaks about a federal framework and would bring together the players. As the member for Saanich—Gulf Islands has outlined, a key element of the bill is to convene a conference and include people who have Lyme disease and advocates so they are at the table as well. It is really about trying to bring the players together to develop that national framework.

We also heard at committee very interesting testimony from representatives of the Public Health Agency of Canada. They told us that Lyme disease had been a reportable disease only since 2009. We are only beginning to get a sense of the numbers out there. Of course many cases are not reported. Either people do not know they have the disease or if they suspect it, they do not get a proper diagnosis.

I agree with the member that we will face an explosion of cases, particularly with climate change and a warming environment. In southern Canada and places like B.C., where we really have not seen that many cases of Lyme disease, this will be on the increase.

I was very interested to hear that the Public Health Agency of Canada was conducting a fairly major public awareness campaign. In fact, the people from the agency assured us that Lyme disease should be a household word by the end of summer. People would know what it was, what they needed to be aware of and what they should do. I hope they are right because we do not want to see anybody suffer through this.

The issue of testing is very important. We heard loud and clear that there was an inadequate testing procedure in Canada. We need to have much better availability of testing with a greater depth of testing for different kinds of bacteria and strains.

Then finally on research, the Canadian Institutes of Health Research told us that some very good research was going on in Canada. I believe one of the researchers was in Calgary and another was maybe in Ontario. We need to fund that research. We need to know about the different strains so people can receive the appropriate diagnostic analysis and treatment.

The New Democrats have been very happy to support this bill all the way through. We are critically aware of this issue. It is something we speak about with our constituents. I am sure many of us have had visits from our constituents who have been affected by Lyme disease.

At the end of the day, we owe gratitude and thanks to the Lyme disease Foundation of Canada, which has done incredible work on this and has never given up. It is not easy. We have resources here. We can bring forward a private member's bill, which I do not want to diminish as it has a very important part. However, what is really wonderful is the fact that the people in the community, those who themselves are suffering, pushed this boulder uphill. They did not give up and they compelled us as legislators to take on this issue and support it.

Finally thanks go to those advocates. We need to remain vigilant and monitor what goes on to ensure this framework becomes a strategy that will help people.

Federal Framework on Lyme Disease ActPrivate Members' Business

June 11th, 2014 / 6:15 p.m.
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Green

Elizabeth May Green Saanich—Gulf Islands, BC

Mr. Speaker, I am glad that the hon. member for Vancouver East took a moment or two to put the question so that I could pull myself together. I am quite overwhelmed and very grateful.

I appreciate that there were changes made at committee. I do not believe that they take anything away from the thrust of the bill, but as with any piece of legislation, we will have to remain vigilant.

I know that the current Minister of Health is very committed to this, but the bill will require initiatives from the Minister of Health to hold a conference. That conference will gather expertise from the health and medical community and the Lyme disease patient community and, of course, engage at some level the federal, provincial, and territorial ministers for health.

One amendment changed that process from a six-month mandatory window from the point of passage to twelve months in order to incorporate and provide flexibility for the fact that Bill C-442 would mandate ministerial consultations at a very significant level.

We just have to commit that there is goodwill here. There is an intention to make a difference for people. We have all learned a great deal from the Lyme disease patient community. There are people whose lives have been cut short. They cannot do the job they used to do.

One of the most heartbreaking cases in my own riding is that of a young man who wrote to me and who I saw on Boxing Day. He had not been well enough to come down the corridor on Christmas morning to watch his girls open up their Christmas presents.

The sense of urgency is with us. In the spirit of goodwill, we will monitor this bill and keep pushing in a friendly fashion. We will not let the bill just sit on a shelf. I believe that is the motivation of the Minister of Health, as it is for my hon. colleague, the official opposition health critic.