Foreign Affairs Committee on June 4th, 2015

[The Chair, Conservative, Dean Allison]

Good morning, everyone. Pursuant to Standing Order 108(2), this is our briefing on global action against malaria. We'll get started.

I want to welcome all of our guests here today. We have with us the Roll Back Malaria Partnership. Joining us is Mr. Verhoosel, who is a representative to the United Nations in New York and head of external relations. Welcome, sir. We'll be hearing from you first, after I introduce everybody.

Also representing the Roll Back Malaria Partnership is a senator from the Cameroon Senate, Senator Ngayap. Welcome. We're glad to have you here today as well.

Next to him, from the Medicines for Malaria Venture, we have Andrea Lucard, who is the executive vice-president. Welcome. We're glad to have you here today.

We have quite an international panel today, with someone from Geneva, someone from Cameroon, and someone from the United Nations in New York. We're looking forward to hearing from all of you.

Mr. Verhoosel, we're going to start with you, sir. We will give you the floor for seven minutes. We'll move through the testimony from all of our witnesses, and then we'll spend the next hour asking questions and clarifying anything the members may want clarified.

I'm going to turn it over to you, sir. We're glad to have you here. The floor is yours.

[Hervé Verhoosel, Representative to the United Nations in New York, Head of External Relations, Roll Back Malaria Partnership]

Thank you, Mr. Chair.

I will do the beginning of my presentation in French and then switch to English.

Good morning, Mr. Chair and members of the committee.

My name is Hervé Verhoosel. I represent the Roll Back Malaria partnership at the UN. Secretary General Ban Ki-moon has made the fight against malaria a priority of his second mandate. Canada’s priority in maternal, newborn and child health is perfectly aligned with this priority of the UN secretary general to fight malaria.

It is important for the UN and for the Roll Back Malaria partnership to stress the public-private partnership. I gather that, here in Canada, there is also some interest in involving the private sector in development and in health. That is what we are doing by gathering around the same table donor countries, endemic countries, research and development organizations like the Medicines for Malaria Venture, represented here by Andrea, NGOs, and those from the private sector in order to better coordinate the fight against malaria.

Worldwide we have 3.2 billion people at risk of malaria. Almost half of the world's population is at risk of developing malaria, and we have a bit less than 200 million cases of malaria every year. We have 584,000 deaths.

Also, what's amazing is that we can prevent and cure the disease. We have everything today, all the tools, basically to save 584,000 people in the world a year. Sub-Saharan Africa is affected by 90% of the burden of malaria.

Knowing that we have everything to prevent and cure the disease, what we need is political leadership both in endemic countries and in donor countries. With the new United Nations development goals that member states are developing now for the UN, we hope that malaria will keep an important place on the agenda in the future. We are a bit sorry that for the next G-7 malaria is not directly there anymore. But we hope to work with Japan and we hope to have the support of Canada for the next G-7 to put malaria back on the agenda in the future.

It was important for us, in cooperation with the APF, to ask one of your colleagues to come, because maybe I'm not the best witness for you, coming from my desk in New York. Who better than a senator coming from an endemic country, who is also a pharmacist and an economist, to speak with you about the burden every day in his country? That's why, with your permission, Mr. Chair, I would like to take less than seven minutes and maybe ask the senator to speak a tiny bit more than seven minutes.

As some of you do, I very often travel in Africa, and every time I witness the burden on the socio-economic development of the country. Professor Jeffrey Sachs, who is an economist, calculated a few years ago that Africa loses $12 billion every year just in lost productivity. The senator, I assume, will come back to that. Just because people are not at work and they are sick at home, $12 billion is lost in productivity.

Malaria is also the first cause of preventable absenteeism at school for both the children and the teachers. The senator will be able to develop that also.

There are a lot of links between malaria and development in general and, of course, maternal, newborn, and child health.

We really hope to have the support of the Parliament of Canada, the House of Commons of Canada, to keep Canada on track as a supporter of the Global Fund to Fight HIV, TB, and Malaria. Canada has contributed $2.1 billion to the Global Fund since it was launched, including $650 million for 2014 to 2016. Next year Japan will host the next Global Fund replenishment meeting.

I can tell you that today it is an organization that's working well and the money that the Global Fund puts at the disposal of countries is working and is giving results. Since 2000 we have cut in two the numbers of both deaths and cases of malaria. We've cut it in half. That's amazing. We have received half of the money we were asking for from the international community and we have delivered half of the results. We are very much on track and we hope to have the understanding of countries like Canada, and your own understanding as members of this Parliament, that the fight against malaria is a good investment and it gives value for money.

Thank you, Mr. Chair.

[The Chair, Conservative, Dean Allison]

Senator.

[The Honourable Pierre Flambeau Ngayap, Representative, Senator, Cameroon Senate, Roll Back Malaria Partnership]

Thank you, Mr. Chair.

My name is Dr. Pierre Flambeau Ngayap. I'm a senator from Cameroon. I'm very happy to be here today. Canada and Cameroon have the same history concerning language. We are a bilingual country. We speak both official languages, French and English.

Permit me to develop my topic in French, because it's the main language I use as a pharmacist, as an economist, as a teacher at university, and also in the Parliament of Cameroon.

Thank you very much.

Today is important because of the privilege that you are granting me, as a parliamentary colleague, to share with you the gravity of malaria. To do so, I will not use epidemiological terms, since it is well-known that this disease is endemic and that it is rampant in some regions, principally in Black Africa, south of the Sahara. It is most appropriate to tell you about the direct impact of malaria on the economic capacity of the African continent.

I am going to give you two or three examples to demonstrate the extent to which malaria affects our continent’s ability to develop. The continent develops often with the support of countries like your own. The cooperation between Cameroon and Canada is an old and truly excellent one. It is based on the mutual understanding that unites us.

Malaria is a disease that mainly affects two major sectors of the population in Africa: the young, including children from birth to five years of age, and adults, especially pregnant women. Those two population groups, the most vulnerable and the most severely affected by the disease, are particularly important. The young are the future of the continent while women are the mothers of humankind.

In reproductive terms, pregnant women are particularly vulnerable. When a pregnant woman is afflicted by malaria, her capacity to carry the fetus to term is reduced. The baby the mother carries is often born prematurely. Even if it is not premature, the baby’s physiological growth or developmental capacity are affected. Some forms of malaria even attack the nervous system. This is what is called neurological or cerebral malaria. If a pregnant woman does not receive proper care during her pregnancy, there can be a dual consequence: on her own health and on the health of the baby she is carrying.

Children too are particularly vulnerable in early childhood, by virtue of the very fact that they are children. But it becomes most important when they begin to go to school. The main symptoms of malaria are fever, headaches, fatigue and vomiting, all of which require students to stay at home. They cannot go to school with symptoms such as those, hence the high absenteeism rate of children with this disease.

As teachers too may be affected, you can imagine the cumulative absentee rate that it represents. At the end of the day, it means lack of productivity for both children and teachers. Children are not able to reach the level of instruction they might have reached under normal circumstances and teachers cannot complete the curricula for the children.

The third example involves adults working in a company, or, in rural areas, in a plantation. Their malaria symptoms are the same as the children's. People are incapable of moving and must stay in bed. In our countries, generally speaking, malaria is the cause of 30% to 40%, if not more, of hospitalizations and up to 50% of medical consultations, outpatient visits, we might say.

All these factors make the workers less productive, tired, or not there at all. They cannot perform to the level they would if they were in good health. All those factors have a very major impact on overall productivity, the performance of the economy and the country's GDP level. It has been seen that overall productivity drops considerably, sometimes as much as 30% or 40%, because of absenteeism or because people are unable to assume their normal social or economic responsibilities

For those reasons, I was pleased to team up with Roll Back Malaria in this mission. It is important for you to hear from one of your colleagues from the countries of the south who is telling you how important it is for you to continue making the effort you have always made to fight this disease. It must be understood that the fight against poverty includes one essential element, malaria. Malaria is both the cause and the effect of poverty. The efforts you make globally to combat poverty should greatly help to combat malaria. It is one specific way to fight poverty.

Thank you.

[The Chair, Conservative, Dean Allison]

Thank you very much, Senator.

We'll now welcome Ms. Lucard.

The floor is yours.

[Andrea Lucard, Executive Vice-President, Medicines for Malaria Venture]

Mr. Chair, honourable members of the committee, ladies and gentlemen, my name is Andrea Lucard. I'm an executive vice-president at Medicines for Malaria Venture, otherwise known as MMV, a Swiss foundation that discovers, develops, and delivers effective and affordable medicines for patients around the world, including those you've just heard about in Cameroon. MMV is a proud member of the Roll Back Malaria Partnership. We're responsible for developing the new medicines that will help make the ambitious goals of the partnership possible.

It is a pleasure for me to be here today. Thank you for giving me that honour.

The MMV offices are in Geneva, but I will spare you my Swiss French.

I will continue in English,

as you can see, with an Anglo-American accent. I'll be more comprehensible, I hope, and I won't be quite so self-conscious. Nevertheless, I have to say that I very much enjoyed your remarks, which were very eloquent. I need to get the specifics in French for my future.

I'm certain my colleagues will join me in recognizing Canada's long-standing efforts to fight malaria around the world, and particularly the government's international policy focused on maternal, newborn, and child health, commonly known as MNCH.

I'd like to make three points in my remarks this morning. First, you've heard my colleagues speak about the burden of malaria, particularly the disproportionate burden of malaria on pregnant women and children, and speak quite eloquently about the impact on communities and nations. I'd like to re-emphasize that malaria, although deadly, is also treatable provided effective and affordable medicines have been created and are available to those in need. However, as those affected by malaria are also frequently those with the fewest resources, creating effective and affordable medicines that are easily delivered is no small feat.

This is where MMV comes in. The traditional approach to drug development is business-driven, exchanging significant risk and capital investment in exchange for financial return. However, as global health pandemics have multiplied, reliance on this model alone simply does not work for neglected and poverty-related diseases that continue to plague the developing world—indeed, that continue to plague all of us.

What MMV has done to address this for malaria is to leverage best practices, scientific knowledge, and the experience of hundreds of partners to help develop new drugs. We pool and leverage funding from governments around the world, including the U.K., Switzerland, Australia, Japan, Norway, Ireland, and the United States, and get funding in kind from the governments of South Africa and Thailand. We have private sector funding from the Bill and Melinda Gates Foundation, the Wellcome Trust, and extractive companies such as Newcrest Mining in Australia and ExxonMobil Foundation in the United States.

By pooling both the funding and the expertise, we reduce the risk of drug development for all partners, and we're able to deliver drugs more quickly and at a lower cost than a traditional pharmaceutical model The model has worked. When we were formed in 1999, our goal was to deliver one new anti-malarial drug in the first 10 years of operation. This was a pediatric drug to treat those who were most at risk. By 2009 we had delivered two drugs—not one, but two—and those have been rapidly followed by three more that have met regulatory approval or WHO pre-qualification.

The first of the medicines we developed with a major pharma partner has seen 250 million doses delivered in endemic countries. The second medicine we developed with an international health company has seen 25 million courses of treatment delivered, particularly, as the senator spoke about for cerebral malaria, for those children who are in the course of severe febrile illness.

These drugs are effective, but they are far from perfect. They're at risk of succumbing to resistance, particularly in the Mekong region, which can spread elsewhere in the world. The dosing regimens are not a single dose, but are required to be given over several days. As well, they have some side effects that are manageable but not perfect. So we need to do more.

This brings me to my second point, which is common cause with Canada on maternal, newborn, and child health.

I was here in February—you can pity me, albeit I was here with my warmest boots on—to participate in a round table on malaria co-hosted by the Government of Canada, Bill Gates, and Ray Chambers, the UN special envoy for malaria. In fact, just last night I was in contact with the UN special envoy's office, and he noted that they're particularly pleased that Canada is considering creative financing mechanisms to bring private capital and to increase domestic spending for malaria and child health more broadly.

Present at the February round table were some of the many partners within the Canadian MNCH network. We have been warmly welcomed into this network and are reaching out across Canada to leverage our expertise in humanitarian work, in informatics, and in drug discovery to make our work even stronger to benefit the patients in countries like Cameroon. We're working with NGOs such as the Aga Khan Foundation, and research and development partners such as Structural Genomics Consortium, as well as government officials and parliamentarians. We're also reaching out to Canadian small and medium-sized enterprises that have expertise on data collection, which we need to measure our work.

We need to do more, and we are doing more. I'd like to leave you with a couple of actionable proposals and make three recommendations to help strengthen this work, some of which is already being undertaken by the Canadian MNCH network.

As the senator said, we particularly need to protect women who are pregnant. As he noted, women who are pregnant are at risk of losing their fetus, but they are also at substantially greater risk of serious illness and death themselves if they contract malaria during pregnancy. It's a major cause of anemia and associated post-partum hemorrhage, which is itself the leading cause of maternal mortality in Africa. To combat this we need greater research to develop the drugs that are safe for women to use for preventing malaria in the first trimester of pregnancy, and we need to have better delivery for those drugs that we know to be safe both to prevent malaria and to treat it, should the woman become ill.

The prevention of malaria in pregnancy is not only a drugs issue. It is also the use of insecticide-treated bed nets and other ways of using malaria prevention. From our side, however, we speak on the medicine.

We also need to protect children. While malaria is a treatable illness, even better than getting sick and being treated is preventing malaria in the first place. We can work to improve acceptability and uptake of certain prophylactic medicines, particularly in the Sahel region, where seasonal malaria chemoprevention is working at rates of 75% or better for only a few cents per treatment.

We hope a vaccine will come along one day that will solve this problem, but until it does, we need stopgaps and prevention. For those children who get sick in rural areas, MMV is supporting the first ever single-dose suppository for severe malaria, which has been shown to reduce by 50% the risk of mortality in children under the age of five.

Underpinning all of this is a registry to support and monitor the safety of these medicines, especially for pregnant women. We know that civil registration and vital statistics are a key priority for the Government of Canada, and I have to say, just as an aside, it's an incredibly impressive way of thinking about international development. This is one of the backbones of our own development in our own countries, to understand that civil registries on the births and deaths of people are very important.

A key priority for the Government of Canada and Canada's MNCH network, pregnancy registries also fall within routine surveillance systems approved by the World Health Assembly. It is essential to monitor the safety of both existing and new anti-malarial medicines during pregnancy. While there are some basic infrastructures in place to do this, much more needs to be done, including strengthening the registries of pregnant women exposed to anti-malarial drugs for follow-up on their pregnancy outcomes, and using that information to identify and evaluate safety signals so that we can help empower local health authorities to make policy decisions. The overall goal is to strengthen the national health systems within Africa, to improve natal care, and to reduce the numbers of deaths and disability to women, newborns, and children.

We're doing more, and we can stretch even further.

To quickly conclude, malaria remains one of the world's largest killers. It has a huge economic impact, as you've heard. Public-private partnerships, as everybody has spoken about, are a major part of the solution, and we want to work with Canada to eradicate malaria in our future.

On behalf of my colleagues and partners at MMV,

thank you again for giving me the opportunity to talk to you today.

I'll be happy to answer any questions that you may have.

[The Chair, Conservative, Dean Allison]

Thank you very much, Ms. Lucard.

I think we'll have time for two full rounds, if we stick to our times.

I'm going to start with Madame Laverdière, for seven minutes, please.

[Hélène Laverdière, NDP, Laurier—Sainte-Marie, QC]

Thank you very much, Mr. Chair.

My thanks to the witnesses for their very interesting presentations.

Before I ask my questions, I must tell you that I lived in Senegal for three years. While there, I saw the damage that malaria can do to a society at all levels. There are also economic and social repercussions, in education, as an example. The problem has broad and significant repercussions.

Mr. Verhoosel, your organization brings together about 500 partners. I personally believe that there can be no single approach when it comes to dealing with global epidemics of this kind. Can you explain a little more how the 500 partners operate and why the partnership is important?

[Hervé Verhoosel]

Thank you for the question.

The partnership is very important. If you are fighting malaria by yourself, coordination will not be possible, the result not be as good and the cost will be higher. The idea of the partnership is to bring together all the economic players, the donor states and the endemic countries around one table to see who is in a position to do what. How can we divide up the work, country by country or expert area by expert area? Donor countries alone will never achieve a complete result just as the UN and the NGOs alone will never do so. We will only be able to do so by working together.

The work with MMV is an example. This partnership has a board of directors and bodies like commissions, each with its own specialty. Much like here, we have around the same table all the members of those 500 partners you mentioned, madam. They divide up the work, they choose priorities, they develop a global action plan. A few years ago, we developed a global action plan for the first time and the new edition is now complete. It is likely to be released in the coming months.

This global plan is approved by all the partners and areas so that everyone can move forward in the same direction at the same time. The problems are different at regional level. The malaria problem in Africa is different from the one in southeast Asia. We are talking with very different partners in southeast Asia, where, in addition, there is a problem with drug resistance. Hence the importance of the research and development that MMV does. Unfortunately, we are starting to see drug resistance in southeast Asia, and that is a real problem.

Because of the work with the various partners, we really are able to get better results on the ground. At times, it helps us to fight corruption in some countries where it is a major issue. It also enables us to better target our care and our response. Sometimes, the private sector will be more successful in delivering a product to a given village in Africa. I am not sure if I can use brand names here, but I am talking about all those little black bottles of Coca-Cola. Why can you find a bottle of Coca-Cola anywhere in Africa, but you cannot find a mosquito net? Maybe a private-sector company and one of those 500 partners can help us to deliver mosquito nets, and why not in the same truck as the bottles of Coca-Cola? Coca-Cola, in fact, is starting to provide help by distributing medication, especially AIDS medication.

Each of those 500 partners has something to bring to the table. It does not have to be financial. It can have to do with their knowledge, or their presence on the ground. This is a public-private partnership that works very well and we are very happy that we have those 500 partners that MMV is a part of.

[Hélène Laverdière, NDP, Laurier—Sainte-Marie, QC]

Thank you very much.

We have also talked a lot about the importance of the health care system, and not just for malaria. For Ebola, the challenges for the health care system were quite striking.

Senator, how is the public health care system in Cameroon?

[Pierre Flambeau Ngayap]

Thank you, madam.

Mr. Chair, I believe that Cameroon is quite a typical case that can be used as an example, because it is right in the centre of the Gulf of Guinea, putting it in the geographical centre of this endemic disease. What can be done in Cameroon can easily be done in the other countries of the sub-region.

In general, we consider that malaria-related care represents between 30% and 40% of public health care costs. You can see the significance: more than one-third of the public health budget goes to fighting a single disease. That shows how significant the disease is. In those same regions, the proportion of the budget is higher than is allocated to other pathologies such as AIDS, tuberculosis or other diseases endemic to the region. That shows both the age of the disease—a lot older than the others—and its persistence and ability to spread, given that poverty is not getting any less. In fact, malaria is a poverty-based disease, showing clearly the significance of malaria in public health policies.

At the same time, if so many resources are being devoted to managing the disease, a distinction has to be made between the resources for prevention and the resources for treatment.

In 2012, 10 million mosquito nets were distributed at no cost to the people of Cameroon, with a population of 23 million. That means that, in theory, a little less than half the population received free mosquito nets.

In 2013, 12 million mosquito nets were distributed. All those nets were the result of your efforts—the efforts of the international community—because they were distributed at no cost.

In one year, the number of mosquito nets distributed has moved in a positive direction. But you see the difference between the 12 million nets distributed and the 23 million inhabitants. A little less than half the population does not yet have access to this minimal level of protection. The mosquito nets cost only $3. You see the effort needed to reduce the disease by that means.

[The Chair, Conservative, Dean Allison]

Thank you very much. That's all the time we have.

We're going to move over to Mr. Hawn, for seven minutes, please.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Thank you, Mr. Chair, and thank you all for being here.

Mr. Verhoosel, you mentioned that basically half the world's population—3.2 billion people—is at risk. What defines “at risk?” What makes a population at risk?

[Hervé Verhoosel]

That is a population in a country where mosquitoes carry the disease of malaria, which is 90% of the people in sub-Saharan Africa, but there are also many countries in Southeast Asia, the Caribbean, and South America.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

You mentioned that in Southeast Asia one of the difficulties or challenges is drug resistance.

[Hervé Verhoosel]

Yes.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Why is Southeast Asia different in that respect from Africa, for example?

[Hervé Verhoosel]

Mr. Chair, the problem of resistance is really an important problem. As in the past, Southeast Asia is often historically the region where the first problem of resistance occurs, meaning that the actual medicine called ACT, which was working very well, doesn't work as well anymore. We see some limited cases of resistance, and the WHO and other partners are working to make sure that we geographically contain that problem of resistance before we try to eliminate that problem.

The risk could be that the problem of resistance could spread to other regions—and, to be honest, that would be catastrophic. That's why many countries, the Global Vaccine and Immunization Research Forum, Bill Gates, and others invest a lot of money in that region at the moment. It's also why the research and development community is trying to work on a potential new generation of medicines for the future, and maybe MMV could develop that a bit more.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Okay, I'll go to you, Madam Lucard, and allow you to develop that a bit more.

[Andrea Lucard]

Indeed, one of the problems we are facing is multiple drug resistance. Malaria drugs are delivered in combination in order to prevent resistance from developing. What the world saw the last time it was using single-dose therapies was that resistance developed very quickly.

We develop medicines in combination and they're delivered in combination. Unfortunately, because malaria is so common, because the parasite is so virulent, we're developing resistance now to several different medicines simultaneously.

The result of this is that, as Hervé said, the global community is working very hard on containment, but we really must have an entire portfolio of medicines to back up each one of the ones currently being used in order to stay ahead of resistance.

Resistance really could be catastrophic. It's easy to come and pound the table and tell you that the sky is falling, but what has happened is that as we are fighting malaria very well, fewer and fewer people are developing natural resistance, so it becomes critically important that we genuinely have a full pipeline of medicines that will be able to support us.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Are we spending enough and paying enough attention to academia and the research and development side of it today?

[Andrea Lucard]

“Enough” is an interesting word. Are we paying a lot of attention to it? Yes, indeed.

In fact, from the point of view of MMV, we are continuing to spend a significant amount of time on the discovery of new molecules. This is coming out of academia and biotech from around the world. We have partners in more than 50 countries that are working on discovery to find new mechanisms of action. This is critical.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Are there countries that are leading in that area that we could learn from or help to promote?

[Andrea Lucard]

What's really important is that we're doing it from multiple countries.

Canada certainly is engaged in this area, and the United States, the U.K., France. We're also beginning to develop a lot more work with scientists in endemic countries, so South Africa has become quite important, Thailand, Cambodia, and other places.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Are we doing enough—again, “enough” is an open word—to help educate academia and researchers in those countries that are directly affected? Are we developing their ability to do more research and development?