Health Committee on Oct. 18th, 2018

[The Chair, Liberal, Bill Casey]

Thank you for the good questions and good answers.

Now we go to Mr. Lobb.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Thank you very much. I'm glad for your candour because in my opinion—maybe I'm wrong—universities are very much takers when it comes to public dollars, but when there is an opportunity to license something or sell something, all of a sudden they become a private business.

I've always had a bit of an issue with universities taking federal money, provincial money, and then, when an idea becomes profitable, it becomes their idea, and all of a sudden they want the money. I agree with your concept. I just don't know how you're going to make the change.

While you were talking about it, I was thinking about different drug companies. In a way, they kind of do that global licensing anyway lots of times. I think—and I could be corrected—that if a pharmaceutical company is selling a drug in North America and then decides it doesn't want to sell it in Europe, it sells the European rights to a different drug company anyway.

I see that there is a lot of value in what you're saying, and it's not just in pharmaceuticals; it's in lots of technology companies as well.

If you go back 10 years, certainly on average, the funding line is trending upwards for the money that CIHR has to invest, so if you look at the last decade, it's pretty close to $10 billion. In the midst of all of that, there's also been tremendous money invested—probably hundreds of millions of dollars—in university campuses and college campuses, on labs and other upgrades. Is there a number annually that will achieve all that we're trying to do here, or is there enough money now, but it's just not being allocated appropriately?

Does anyone have any thoughts?

[Dr. Rachel Kiddell-Monroe]

I would love to have a number for you right here. I don't have that number. I think that could definitely be something for a further study, to find out what that number should be.

To go back to your earlier point about the concern about all of this funding going in and then the results of that funding not coming out for public benefit, I think what we're proposing is exactly where this mechanism would be important, because I think that when CIHR is deciding to fund a university or some research, if they have this global access licence included in that funding.... Actually, the NIH in the U.S. has been playing with this, and it has some of these clauses included in some of the funding that it gives.

If you do that, it ensures that the university has to make the product of that research available. They can still license it to a pharmaceutical company. There's no problem. It just won't be an exclusive licence, so if that research leads to a medicine that could have benefits for people that the company is not able to provide those medicines to, then the university has the ability to license that out to another company or institution.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Doesn't the federal government already do that with some vaccinations and immunizations that would seem to be on a pandemic level?

[Dr. Rachel Kiddell-Monroe]

Well, yes, but then we often do compulsory licensing as a government, to make sure that it's....

In the time of the anthrax scare—I can't remember the year now—ciprofloxacin was actually produced under a compulsory licence, but the Ebola vaccine, for instance, sat on a shelf in a university for 10 years, even while the Ebola crisis was raging. That's the other issue: that things will sit in a place and not go to market.

[Ben Lobb, Conservative, Huron—Bruce, ON]

I agree with that too. In the past I talked to a few...I wouldn't want to call them “venture capitalists”. That's some of their frustration as well. I'm not slighting a researcher or a scientist, but they get very comfortable sitting in the laboratory and coming up with this, this and this. Instead of taking it from the lab and marketing it, they are just so content to sit there. There has to be a mechanism down the road, not to force them, but to compel them to get out of the lab and do some public good with it.

I also want to talk about something else, and again it's with no disrespect.

Dr. Nickerson, you were talking about collaboration and the need to get the universities together and the NGOs together and this together and that. The federal government can do that. I guess they can do it, but when I look at all these organizations, I see that a lot of them have government relations people, strategic people. Do they need the government to get everybody together, or can they get themselves together? What do you think?

[Dr. Jason Nickerson]

I think we need the framework. That's what doesn't really exist, this partnership model to develop products. I think we have good push funding. CIHR and other funding agencies as well are granting agencies. You apply, and it's a competitive process. They evaluate the merits of your application and they push funding out to you. That works for initial discovery, but when you get into the subsequent stages of actual product development and as you move things out of a lab, you need that collaborative framework in order to do the phase I, II and III clinical trials.

[Ben Lobb, Conservative, Huron—Bruce, ON]

I'm thinking back to 2009. You may remember this. When FedDev was first announced, they did a $20-million announcement on the Juvenile Diabetes Research Foundation and they partnered with McMaster and Western and different organizations to really put a massive investment. Is that more of what we should be looking at? Again, I was thinking about ALS. They partnered with Brain Canada to do a massive multi-year, multi-million-dollar investment to really try to push the dial. Is that more of what we should be looking at?

[Dr. Jason Nickerson]

I don't know the specifics of these funding proposals, but on this basic concept of bringing all of these actors together to work to solve a common problem, yes, but with the caveat that we need to think through the framework from start to finish, all of the steps that need to be in place, from the point of discovery through to the subsequent clinical trials to the marketing and access and affordability provisions. We can think of these things and build them into that product development pathway, and I think it's entirely possible for public funders to capture all of these things.

We have good clinical trial lists in Canadian public institutions. We have health charities and patient groups that are willing to work with collaborative models, but we need to create the framework that allows that collaboration to happen, not just at these punctuated intervals, but through a long-term perspective. Drug development is a long-term endeavour. If we don't have funding mechanisms and pathways that have thought through this and are there to provide that funding and that process and collaboration in a sustainable way, then we end up with a very fragmented system.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Do I have any time left? Did you say “Your five minutes are up”?

[The Chair, Liberal, Bill Casey]

Oh, sorry. Your time is up. You're going in a good direction.

Ms. Moore, you have seven minutes.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

Thank you very much.

My questions are for Dr. Nickerson and Ms. Kiddell-Monroe.

Three years ago, I went to South Africa, and I visited a hospital where they were treating people with multidrug-resistant and extremely drug-resistant tuberculosis. Right now, in Canada, are we prepared to deal with an outbreak of multidrug-resistant or extremely drug-resistant tuberculosis?

[Rachel Kiddell-Monroe]

No actually. The treatment for multidrug-resistant tuberculosis is very new. Currently, thousands upon thousands of people around the world do not have access to the existing drug, bedaquiline, which is very expensive and isn't available. I work up north, in Nunavut, with indigenous populations. When I see how we are treating tuberculosis cases there, it's clear how inadequate it is. We could be doing much better.

In that sense, I would say Canada has a crucial role to play on the international stage: pushing for affordable access to adequate drugs. Canada should take that initiative in this era of globalization, with people travelling all over the planet and crossing borders. I completely agree that we need to be able to deal with these epidemics. In India, for instance, countless people have multidrug-resistant tuberculosis. It breaks your heart to see that.

I believe it is our role, as a country, to make sure drugs are available worldwide and to find a way to make that happen. Doing that requires another model. The DNDi organization is working on antibiotics right now. Access to antibiotics is a global problem. Antibiotics are used to treat tuberculosis, so we really have to find a way to ensure people have access to them.

[Dr. Jason Nickerson]

To add to that, we have a major problem with tuberculosis drug development. We are quite simply running out of viable options, and this is a global problem. The Canadian tuberculosis standards reflect global treatment options that are available to everyone, and the options are quite limited. This is a disease for which there is a growing resistance to the drugs that we have available.

In the last 40-plus years, two drugs have entered the market for a disease for which there are 10 million new cases and close to two million deaths per year—two drugs since 1971. Neither is registered in Canada.

In fact, registration of bedaquiline, which Rachel talked about, is also a global problem. We issued an open letter on September 17 of this year calling for broader registration of bedaquiline, because it is not registered in 18 high-burden countries around the world despite the fact that the development of the drug was a collaborative effort that involved health charities, pharmaceutical companies, public funds and so on.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

If I understand correctly, Canada has invested public money in drug development, in partnership with charities. A drug that could be useful was developed, but Canada has not ensured that it is available or that it is registered here, in Canada. It's a drug that could be used to treat patients here, if necessary. In other words, we are contributing to research, but we can't use the results. Is that correct?

[Dr. Jason Nickerson]

I don't believe that Canada contributed to bedaquiline. There were public funds, but I don't believe they were Canadian, to my knowledge. Canada certainly contributes to the development of other treatments, such as early-stage research and so on.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

Therefore, Canada can fund charities, which then contribute to clinical data and so forth. Canada doesn't contribute directly; rather, it supports the organizations involved. Nevertheless, Canada does commit funding to the effort.

I would also like to talk about the habits of travellers. A lot of people travel. Although they tend to take airfare and hotel costs into account, they completely overlook preventive drugs against diseases like malaria. Many don't buy health insurance. Some travellers could be described as a bit careless. For example, they might start to take the drug Malarone but then decide to stop taking it because they don't like it.

How are travellers contributing to growing drug resistance?

[Rachel Kiddell-Monroe]

I have to admit I'm not an expert in that area, so I wouldn't venture to answer that directly.

However, I would say that, globally, resistance to antibiotics is a real problem because new antibiotics aren't being developed. I think that's the biggest and most significant global challenge right now. In my view, that's the reason why politicians around the world started to recognize that something had to change. Something has to be done about the fact that we don't have any new antibiotics, which we consider to be basic drugs, and the fact that people have become drug-resistant.

I can't answer your question directly, but I think that it can contribute to the situation, although it's not the number one problem. The issue is much broader than that.

[The Chair, Liberal, Bill Casey]

Thank you. Time's up.

We have to go to Dr. Eyolfson.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you, Mr. Chair.

Thanks to all of you for coming. I practised emergency medicine for 20 years, and I saw the associated problems when people did not have access to their medications. They would become my patients.

Ms. Kyle, you've been taking insulin for quite a while. I'm wondering if you know this: How long has it been since there has been any substantial reduction in the price of insulin?

[Louise Kyle]

Um...never? It's just been increasing exponentially. There have been consistent increases in the price of insulin since about 2013.

I'm not sure if folks are familiar with the history of insulin, but it's not really one drug: it's a family of different drugs. We started with pork insulin and then human insulin, and now we're into this analogue insulin period of time. The prices of these drugs are increasing in lockstep. Three big pharmaceutical companies control 90% of the insulin market, and there hasn't been a decrease in those prices at all. They control the market and are increasing the prices year over year, exponentially.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Essentially, yes, a drug that's a century old is just getting more and more expensive.

[Louise Kyle]

Exactly. Yes.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Okay.

It will take too long to ask for individual responses, so I'll just ask everyone to raise a hand if they respond “yes” to this: Is the cost of medication a barrier to access for patients?

I would say there was a unanimous raising of hands.

The reason I ask is that, as you know, we did a two-year study on national pharmacare. Many of us, including me, advocate for a universal system. I was at a meeting last week that was supposed to be a casual meet-and-greet with the new incoming head of our local chamber of commerce. I was more or less ambushed with some literature from a policy resolution meeting of the Canadian Chamber of Commerce. Among these resolutions was one on pharmacare, painting national universal pharmacare as something that was somehow going to have a number of negative effects on small business. It would take over an hour for me to describe the logic of this publication, so I won't go into that.

One of the things the publication they handed me said was that if we, in a national system, put the emphasis on cost rather than access, it would inhibit the development of new drugs and endanger the lives of Canadians.

Could we go down the line to get a response to that statement?

[Dr. Rachel Kiddell-Monroe]

There are some people who are extremely skilful at changing around discourses and narratives to serve their ends. That is how I would say it in very short terms. What we've seen and experienced over my now 20 years of working on the access to medicines issue is a shifting landscape in the pharmaceutical industry in terms of how to respond to the growing understanding that morally and ethically we are on the wrong path in terms of ensuring that people around the world are able to access the treatments they need.

I also want to recognize that pharmaceutical companies have made big steps in the right direction. They have. We have to acknowledge that. Also, we have to acknowledge that the role pharmaceutical companies can play is a very important role. We have to acknowledge that as well, but we are still unable to break down this barrier that pharmaceutical companies are there to make profits.

That's what a company does. They have stakeholders or shareholders. What we're talking about is a humanitarian goal of making sure that people are able to access the drugs they need. These two goals are in conflict with each other. We shouldn't expect a pharmaceutical company to be a humanitarian organization, just like I wouldn't like my organization to be a for-profit organization.

What we're talking about is, how do we find a way through? This question now—we shouldn't be talking about and starting to get obsessed about cost instead of access—is actually just another conflation of the same argument. Instead, we've seen that access has become the terme du jour. It's much more of a politically correct term these days.

Let's stop talking about the money. Let's talk about how we make this accessible to people. The problem is that a lot of that becomes window-dressing, because deep down it's never going to be accessible. Bedaquiline is a brilliant example.

We have this new treatment for hepatitis C, sofosbuvir, a name that I can never pronounce. These things are.... We can talk about access programs that pharmaceutical companies have, but this is not a systemic response to a crisis. What we're talking about here is how to get something that's systemic, that's really incorporated inside our system, to make sure these drugs are accessible.

I'm sorry to say that I think that's just another contortion of the narrative to serve the ends of profit.