Thank you very much for inviting me.
I'm going to begin by saying I've read the summaries of many people's statements and I think we need to bring some perspective to the discussion. That is not to say this is not a problem, but I think there are many interventions to consider. There's no single intervention.
I think we also need to keep the scope of this problem in perspective. Comparisons have been made to the opioid crisis. I don't think those are entirely fair. We expect to have zero deaths from opioid overdoses in the ideal world. When it comes to antimicrobial resistance, we are still unfortunately going to see some deaths from it. They're not all preventable. The idea of getting to zero antibiotic use is also a utopian goal that we are not going to achieve. Antibiotics also save lives.
Let me begin by talking about the so-called epidemiologic triangle that I think a lot of people forget about.
There is an interplay between the status of the host—how healthy the host is, how old the host is, any underlying disease the host has—the agent, or the bug; and the environment.
When I speak of environment, if somebody with a tracheostomy is on a breathing machine for a prolonged period of time in an intensive care unit, and they've been on it for a month, they're going to be at much higher risk than a marathon runner who falls and cuts her arm.
Here's a superbug story for you about somebody with cystic fibrosis, a 19-year old cystic fibrosis patient I saw two weeks ago. She's been in and out of hospital, with repeated rounds of antibiotics, and she's on the verge of a lung transplant. She had an almost untreatable infection. If she ends up dying of an infection, did she die of cystic fibrosis or did she die of the infection? This is the existential question that comes up.
Pseudomonas aeruginosa is a bug I'll talk about. That bug is something of an opportunist. This is the bug that causes severe disease in someone with an underlying disease. It doesn't cause infections in otherwise healthy people. There's always this interplay between these three, and we have to remember it's not just the bug and its superiority and smartness that's winning; it's an aging population.
Dr. Morris spoke to the fact that he didn't see drug-resistant infections 20 years ago. Well, average life expectancies have increased in the past 20 years. We're transplanting more people than ever before and we're putting new heart valves and grafts into people like never before, so of course we are seeing more infections. People used to succumb to other diseases that would kill them; now, unfortunately, infections can be the end of the lives of some people. Obviously we try to keep that to a minimum, but there is something of a crisis in that some people reach the point where there are no options left in terms of antibiotics. We need more antibiotics. I'm not completely diminishing this problem, but I'm trying to bring some perspective: life expectancies continue to increase.
Let me show you an example of pneumococcal sepsis. This is an example of what happens with death before and after the advent of antibiotics. This is from Robert Austrian in 1963, when he looked at the pre- and post-penicillin era. If you look at the curves, they actually overlap for the first two days. There's no difference between having antibiotics and not having antibiotics. We often forget this. Things improve after day two and beyond. That's where antibiotics make a difference, but some people will still succumb to an illness whether or not they have antibiotics.
Let me go to the World Health Organization priority pathogens list that has been spoken of as an imminent crisis or “slow-moving tsunami”, to quote Dr. Margaret Chan.
TB is a huge problem, especially in developing countries. Again I speak to the epidemiologic triangle. There's a whole factor about the environment: people live in crowded conditions, so there's more spread; they don't have access to care; they don't get proper rounds of first-line therapy, so they have resistance generated because they're being improperly treated. That's an environment factor that's driving resistance. Is this a problem? Of course it is. There need to be new drugs for TB. A few are in the offing, but this has been an ignored disease.
Let me speak to death rates prior to TB therapy, though. Here's another example of how much of a role antibiotics play and how much they don't. The first part of these graphs looks at the U.K. TB antibiotics were developed in 1950. Death rates were already falling before we had antibiotics for TB, just due to better health and better nutrition. This is the McKeown effect. McKeown actually has a Canadian connection. He was trained at McGill. He was originally from Northern Ireland and he went to England. He wrote the textbook of social medicine. We forget sometimes that the host factor is extremely important.
Of course, TB antibiotics reduced mortality still further, but that was the blip you were seeing at the end. A lot of it was just improvement. This other curve is from Massachusetts, with the same effect.
There are critical priority pathogens, but let me talk about where we're actually seeing them.
If you look at them, you see they're all mainly among hospital patients. This is a problem in hospitals. I spoke about the intensive care unit in the cystic fibrosis example that I gave. You have cystic fibrosis. You have oncology. You have people who've had a bone marrow transplant. You have people who've had an organ transplant.
We do see some drug-resistant infections in people who have not been in hospital. As a case in point, in my practice there is someone who is from the Indian subcontinent, who has gone back and forth, and she comes back with a urinary tract infection and she's pregnant. The only options I have remaining are intravenous antibiotics.
There is a dearth of antibiotics that needs to be filled through a better drug pipeline, which I will speak to. This so-called discovery void is a problem, but the number of these cases is still relatively small. I'm not saying it's not a problem, because that number could change, and because we have foreign travel and interplay with what's happening in other countries, we need to be ready for a change.
For example, I was recently in Kuwait as part of a Royal College of Physicians and Surgeons initiative. The rates of drug resistance are much higher in Kuwait, so they have completely different lab strategies in Kuwait to deal with this emerging threat. We don't have those strategies available here, but we need to be tooled up to respond in that fashion if it does become a problem.
Let me continue. Just focusing on these critical priority pathogens—and the WHO document beautifully references what's critical, what's high priority, what's medium priority—I do want to emphasize that these are mainly hospital pathogens. That's where the theatre of war is right now with this issue. There are some community issues that come up, but these are not widespread. Sexually transmitted infections that are resistant are not widespread and common; they are limited to certain populations. TB I spoke of; it's not widespread here, but if we don't control TB well in Nunavut, we could have that problem here. Again, these are problems that are localized to certain areas.
Hospital-wide, we don't have big problems yet in Canada, but in teaching hospitals in Canada, you'll see some of this. In Canadian cities where we have people from other countries coming and going, even from southern Italy, the Middle East, Asia, or the Philippines, we are going to see more of this and we have to be ready.
I don't have the solution right away. We have this discovery void in antibiotics that the WHO is trying to address with governments. That's something for which we could be contributors, but I don't think we alone as Canadians can solve the problem of a lack of antibiotics.
How am I doing for time, Mr. Chair?