Health Committee on Nov. 21st, 2017

[Willo Brock]

I'm absolutely no expert by any stretch of the imagination on high-income countries dealing with TB, but domestically one of the things that is very obvious from what I have read is that there is an issue on equity with the northern communities, and then there is an issue of identifying those people living with TB potentially, or diagnosing those. Enhanced testing for latent TB and enhanced testing for active TB, and TB services in northern communities would be, I think, widely recognized as needed in those types of remote, underserved communities.

As one of my colleagues mentioned, Canada has a role to play globally in investing in the innovation, the R and D that is needed to get new products. We can't rely on the pharmaceutical industry. People with HIV generally are poor. This is true in Canada as it is around the world, so globally pooled investments to avoid duplication of investment in new drugs and new diagnostics is required.

Canada has played a large role in funding TB programs, TB implementation and control programs, around the world. It has always shied away from significant investments in research and product development. I would hope to call on the Canadian government to consider an investment in that area.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

[The Chair, Liberal, Bill Casey]

I just want to clarify. What percentage, did you say, of people have TB who carry the...?

[Willo Brock]

Sorry, I didn't get the first part of your question.

[The Chair, Liberal, Bill Casey]

What percentage of people...? You said a certain percentage of people have TB.

[Willo Brock]

Globally, it's believed that about one-third of the population on the planet has a latent form of TB. That's obviously significantly lower in high-income countries, because if TB is controlled in a place like Canada, there will be many generations that have now grown up without TB in their environment. Their chances of being latently infected are much less, but if you're looking at places like Africa or Asia, a good one-third of the population is at risk of developing TB because they already have the bug in their body in a latent form.

[The Chair, Liberal, Bill Casey]

Thanks very much.

Mr. McKinnon, you have seven minutes.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

Thank you, Chair.

I have been following this study for a number of weeks now and we've learned a lot about antimicrobials. I've learned that antimicrobial resistance has been around as long as antimicrobials have existed, or that we've known about them. We're talking about decades here. There are all kinds of organizations out there doing research, organizations doing education. I guess I'm trying to figure out where we fit into this equation. As a committee of the Parliament of Canada, we will be making recommendations to Parliament that we hope will inform health policy down the road.

Where is the best place for us? Dr. Wright, what is your first best ask for a policy recommendation from us?

[Prof. Gerard D. Wright]

I think the AMR framework that has been adopted by Health Canada is an outstanding road map to solve this problem. What has to happen is more than just a nice, shiny paper on a website. It has to actually come with action plans, in particular with resources that will actually collect the investigators working in this area from across sectors. That includes as well the fledgling private sector that is trying to help develop, for example, new drugs or new diagnostics, or technologies to help deal with this.

One of the areas that Canada has not done very well compared with other countries is helping especially small countries bridge the valley of death. The valley of death is “What do you do once you discover something and how do you actually develop it?” Drug development is very lengthy and incredibly expensive and challenging to deal with.

Other countries have developed...as I noted before, the IMI in Europe, and the CARB-X in the United States. They are, in particular, tackling this problem head-on because we used to get them from the pharma industry. The pharma industry is not going to do this for us anymore. Unless they can find a way to make as much money as a new blood pressure medicine out of an antibiotic, we're not going to see a significant amount of investment in that area. We have to help develop an ecosystem that will facilitate this.

I think the framework is an outstanding document to help do that, but what we need is innovation in all of those areas: innovation in stewardship, innovation in surveillance, and innovation in discovery.

[The Chair, Liberal, Bill Casey]

I think Mr. Brock would also like to make a comment.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

By all means....

[Willo Brock]

One thing that triggered me, hearing you, is that in TB we've done this. We have done this for 15 years. One thing you could do is ensure that Parliament is aware of the long time it needs to develop those drugs and develop those new diagnostics. Those processes, because of the way in which pharmaceutical development works, take 10 to 15 years. That's true in pharmaceutical companies. It's our experience in a product development partnership as a non-profit. I think one of the important items is not being surprised that this is taking so long but basically planning for the length of investment that is required to deal with this issue.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

Would you say that extending the IP on antibiotics in particular would be a significant contribution to solving this problem?

[Willo Brock]

That's an interesting discussion. My colleague from the U.S. will probably go into this. The problem with the extension of IP is that you're going to pay a lot more for this antibiotic when it's being reimbursed through your Canadian health care system. It is an incentive for sure to allow pharmaceutical companies to be more interested in that market. At the same time, if you don't rely on a private health care system, I'm not sure any analysis has been done on whether in the long run that is a good return on investment.

I think things like prizes and the grant system to help pay for the research and in return request good stewardship and lower prices for the end products that are paid for by the taxpayer are things that need to be considered.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

Thank you.

Dr. Evans, you mentioned that a $0.2-trillion investment globally could pay off with a net present value of $10 trillion in benefits. How would we mobilize that kind of money? What sort of organization would do that? How would it be managed and controlled?

[Dr. Timothy G. Evans]

That's a global assessment of looking at what are deemed to be good value for money investments to stem or address the problem of antimicrobial resistance. You need to put that in perspective. Number one, about $8 trillion to $9 trillion per year is spent on health globally. This study was covering a period through to 2050. When you look at the total amount spent on just health alone over that period of time, that's a very, very large number. This is a fraction of the total cost in health.

The investment set of interventions relates to specific things in the health care sector related to good surveillance, more judicious procurement of good-quality medicines, the training of clinicians in prescription practices, and things like that. In terms of the package of interventions that were costed up, most health care systems are doing those interventions to one degree or another. The problem is that we're not doing them universally at scale, so the coverage is very patchy. You may have a centre of excellence in Hamilton, Ontario, that's doing everything right in the McMaster health care system, whereas you may find that over in Stoney Creek or Burlington there's no compliance or consistency with those measures.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

Is there any international organization, perhaps, that is situated to coordinate such an effort?

[Dr. Timothy G. Evans]

I think there are a number. I think the UN resolution to improve action on antimicrobial resistance, which was taken in September 2016, is an excellent start. It brings together the World Health Organization, very importantly, but also the food and agricultural organization, something called OIE, which deals with veterinary health problems. There are a set of institutions that I think are recommending good plans for scaling up approaches to addressing the issue.

I think the point is that those are extremely good value for money. From your perspective as a member of Parliament, what's good value for money in your development assistance? I think the question “To what extent is Canadian development assistance being used to stem the problem of antimicrobial resistance?” is one that would be very good to ask.

I say that in part because there are over 120 diasporas that make up Canada, and as we've seen in other parts of the world, people, relatives are travelling back and forth. The issue of antimicrobial resistance is a global one. The Canadian borders are not in any way impermeable to any of the bugs that travel with planes.

I think that you should be looking at how that development assistance budget is being used, recognizing that some of those investments are tiny fractions of what it would cost to try to address the issue as if it only needed to be addressed in Canada.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

Thank you.

My time is up.

[The Chair, Liberal, Bill Casey]

Now we go to our five-minute round, starting with Mr. Van Kesteren.

[Dave Van Kesteren, Conservative, Chatham-Kent—Leamington, ON]

Thank you. That's fine.

I wasn't expecting to be next on the list, but I'm ready.

Thank you all for attending. I listened with interest.

Mr. Wright, you mentioned the “valley of death”. Of course, you are referring to angel financing. For those who are wondering what he was talking about, that is the period that you're in when you are developing drugs and you have nobody to finance you. We used to refer to those who financed those individuals as the three Fs; they were the family, friends, and fools. I don't know if you knew that.

This is the dilemma that's experienced in the drug industry. Of course, big pharma companies are the ones that produce our drugs. Generics are then able—once the patent runs out—to copy that drug, in essence. They can break it down.

We keep talking about the urgency to develop new drugs, but how much of that is really the problem that we experience today? There just isn't the market for big pharma to produce these drugs. Some of these drugs cost billions of dollars. The payback just isn't there if we readily spread these drugs about.

I think that happened in Africa with AIDS. There was a real push for the drugs to help eradicate that situation in Africa. Many of the big pharma companies just backed off and said, “Listen, if we're not going to get paid for this stuff, we're certainly not going to develop it.” How much is that?

I want to go to you, Mr. Brock, because I think you mentioned, or at least someone on the video mentioned, that we need to step up as a nation. As a small country, we're relatively prosperous. We're one of the G7, but nevertheless, we're not the Unites States of America. We're not even China or some of the others that have produced these drugs.

Maybe you could just comment on that. Tell us what other countries are doing, too.

Are you, sir, from the Netherlands?

[Willo Brock]

Yes, you've deduced that correctly from my accent. Indeed I am.

[Dave Van Kesteren, Conservative, Chatham-Kent—Leamington, ON]

I've hung around enough Dutch people to pick it up I guess.

[Willo Brock]

With a name like yours, you must have the same heritage.

In reverse order, of the countries that are currently investing in TB and drug research and are prominent, one is the U.K. One of the things they have done that is interesting is to create a rule that 3% of the development budget across the board will be invested in innovation and R and D. Every program, whether it's in health, agriculture, or anything like that, does spend 3% of the total development budget. If you're looking at the numbers, given the amount of money that even a small country like Canada spends on development co-operation, that would be a significant amount of funding.

Other countries that are active in this case, next to the U.K., are Ireland, the Netherlands, Germany, Australia, and the U.S. We are very heavily reliant on foundations, especially the Gates foundation, which is a really big actor in this field.

The good news there is that in TB we have a valley of death that starts literally from the lead identification and goes all the way down to the patients. We are used to dealing with valleys of death. We have shown that in a public-private partnership, with sufficient government support, next to private initiative, you can create a new value chain that allows you to do the innovation that we've traditionally relied on fully from pharma.

I don't think there's a case to make for pharma being in or out. The connection is how we can organize ourselves globally in such a way that you can add the capacity for the academic community—the sorts of innovations that happened at McMaster that were mentioned—with pharmaceutical knowledge that can be in either a non-profit or a for-profit environment, with biotech and medium and small enterprises, and then bring together donors like Global Affairs Canada.

In terms of the money we're talking about in a disease like TB, as I mentioned, the OECD came out with the estimate that another $500 million a year would be needed to come up with four new antibiotics. If you take that in the context of the G20, that's $25 million a year. That's not a whole lot of money, even for a small country, to be honest, to set aside for investment in AMR innovation and research. Even that sort of money could go a long way already.

[Dave Van Kesteren, Conservative, Chatham-Kent—Leamington, ON]

Thank you.

We know that much of the infection is spread through sexual transmission, but what about the consumption of animals and passing on the germ that way? We talked about that at length too. Also, for instance, what about the lack of clean water? What would be the percentage? I guess what I want to know is where most of the infection is coming from. Is it from infections from the operating rooms? Is it from the way we treat our animals?

Would someone want to jump in on that? Mr. Evans?