Health Committee on Nov. 21st, 2017

[Dr. Timothy G. Evans]

I think it's a good question, which is, as you say, what are the primary drivers of AMR globally? I think, first, the way in which tuberculosis is managed in low-income countries is the biggest driver, and the reason you have so much resistance is that health systems are not geared to supporting people for treatment completion. That relates to the fact that they haven't discovered the lesson learned in this country, that when you're ill, you have to pay, and in order to pay, you have to sell the farm. That's what led to the 1962 Saskatchewan medicare act, which prevented that from being the case.

We've moved to a system in Canada of prepayment, and in so many countries of the world, when people are sick, they have to find the money to pay, and finding the money to pay for four drugs for six months for TB is near impossible. But if the message is that all countries need to move toward UHC, which is what WHO is advocating, then the likelihood that people are going to buy drugs one week and not get them the next—which is the fastest way to accelerate resistance—is going to go down.

To me, Canada's leadership on this is.... Everybody globally loves the health care system in Canada. I'm proud to say I'm from Canada. People say, “Oh, you guys have got a great health care system.” But we should be advocating that other countries, other governments, make the same sorts of reforms that we did in the 1960s to ensure that people have access to care, because the correlation across countries is very clear. The more a system promotes universal access, the lower the rates of antimicrobial resistance. That's number one.

Number two is the ubiquitous use of antibiotics as growth promoters. We see that not only in Canada. We see that all over the world, and this is dangerous. This is really dangerous because we have seen in China this jump of resistant strains to very important antibiotics like colistin from animals to humans. This was documented in 2011.

If you don't look and see that there's a need to move towards antibiotic-free livestock rearing and aquaculture, then that's being blind to another huge area.

The opportunity, I think, is an immense one. The knowledge agenda here—and Gerard represents this most fundamentally in this group—is perhaps one of the most exciting science frontiers there is, but it's not limited in geography to McMaster. It's a global knowledge challenge, so I think, then, if you say we need to solve this problem collectively, there needs to be efforts by the Canadian Institutes for Health Research, the Canadian Institutes for Advanced Research, and other bodies to join up with the alliance for TB drugs and other efforts, and use Canadian resources in a way that is going to give value, not only to Canadians but to global citizens.

I think there's a huge opportunity to address the science agenda on that front, which would be a third effort to tackle this problem.

[The Chair, Liberal, Bill Casey]

We have to move along now to Ms. Sidhu.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, Chair. Thank you for a very informative session.

My question is for Dr. Evans.

Dr. Evans, in your view, how knowledgeable are individuals about AMR? Is there a need for greater public awareness of this issue in the agricultural industry? What types of steps do we need to take to increase awareness about AMR?

[Dr. Timothy G. Evans]

That is a great question. I think one of the things we're seeing—and I think our first witness mentioned this—is that there's a shift in demand toward foods that are antibiotic free. I think this is growing awareness that having foods laced with antibiotics is not necessarily a good thing. I think awareness of consumer preference on that front and educating consumers with respect to the dangers of ubiquitous use of antibiotics are extremely important.

Second, I think it's very important that consumers understand better that sometimes not getting an antimicrobial when you see the doctor for a fever is actually the best thing. It's very tough as a clinician when people come in with a fever that looks like a viral infection, which will be self-limited and is likely to go away, but the patients say they're not leaving unless they have an antibiotic. It's a very tough thing, and I think consumer education on that front will be particularly important.

The third is consumer education that, when you're prescribed a course of antibiotics, you need to take it as recommended. We see a lot of this, and I'm guilty of it myself. You start to feel better and you say you don't really need those drugs, but we know that poor treatment adherence is another driver.

Those are three areas where I think consumer awareness and mobilization of demand for change would be effective.

[Sonia Sidhu, Liberal, Brampton South, ON]

Dr. Wright, in Canada, are there particular population groups or...?

What type of research needs to be funded to address AMR both in Canada and globally?

[Prof. Gerard D. Wright]

Do you mean in terms of education?

[Sonia Sidhu, Liberal, Brampton South, ON]

No, I mean research that needs to be funded.

[Prof. Gerard D. Wright]

What kind of research? I think again we've heard a lot about it already, and it is really in the area of diagnostics, in particular. One of the things Dr. Evans just mentioned is asking if you have a viral infection or a bacterial infection. Do you really need this antibiotic? The reality is that at the pointy end of the stick, which is the family doctors seeing 30 people a day, a lot of times they can't really tell. We need innovation in that area.

[Sonia Sidhu, Liberal, Brampton South, ON]

What kind of a gap is there in AMR and AMU surveillance done in Canada? Can you describe what additional data needs to be collected at the national level?

[Prof. Gerard D. Wright]

Right now, there is a patchwork of surveillance data across the federation, as I'm sure you know, because of the jurisdictional issues we have in Canada that are particular to the country. I think there are voluntary surveillance collections where provinces and hospitals provide the federal government with information on a lot of antibiotic resistance. That really needs to get tightened up. That's something that we need to know, what bugs are out there. We just have to know this. This is critical to our health, and in a lot of cases, we just don't.

[Sonia Sidhu, Liberal, Brampton South, ON]

Dr. Evans, we have a pan-Canadian framework. You mentioned financing the health system. AMR surveillance uses a sputum sample in Uganda. What kind of diagnostic testing should be the first step in Canada if we have to do that?

[Dr. Timothy G. Evans]

I don't think I can give advice on what the system for surveillance should be. I think it's something that benefits, as I said, from scale efficiencies. Rather than having each province have special laboratory capacity for antimicrobial resistance, there's probably a division of labour and reference laboratories that would be a much more cost-efficient organization of high-cost diagnostics for drug susceptibility testing for antimicrobial resistance.

What would be important in the design of laboratory networks is to think about how you can take advantage of scale efficiencies and modern technology, which is instantaneous in the digital age, and avoid creating expensive infrastructures that will be difficult to sustain in the long run and not necessarily the best use of public resources.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you.

[The Chair, Liberal, Bill Casey]

Your time is up.

Now we'll go to Ms. Kusie.

[Stephanie Kusie, Conservative, Calgary Midnapore, AB]

Thank you very much, Mr. Chair.

Thank you to all of our guests for being here today.

Ms. Kramer, you mentioned that you felt that Canada, specifically, was well-positioned for AMR response, and I want to know a little bit more about that. Why do you think Canada, specifically, is so well-positioned for AMR response?

[Jane A. Kramer]

At the risk of flattering you too much, it's because I think, culturally, there is a special quality about Canada. As I mentioned, I think you're a leader in social responsibility. I think you have intellectual, scientific qualities. You clearly have the commitment to embrace this issue, this problem. You're spending a lot of time on this right now. You're reaching out to different resources now.

I think what's needed to address this is a public-private partnership among the academic community, the scientific community, the commercial enterprises that are involved in this, the food production community, the agricultural community, because it truly is.... This is a very complex issue. Our founder, Dr. Stuart Levy, who I'm sure Dr. Wright must know, wrote a book called The Antibiotic Paradox. This problem is a paradox. Antibiotics are a miracle, but they have caused a crisis. This is a crisis that we're talking about here, and if it's not addressed, it's going to kill us. We'll be in a post-antibiotic era.

One of the problems I'm sure you're all aware of now is that if we solve the problem in North America, we still have to deal with the rest of the world. I mentioned CARB-X earlier. CARB-X is a global initiative. It's not U.S.-centric. It's global. Organizations and companies around the world can participate if they have the right inventions.

With regard to your question, I think Canada is small enough and large enough at the same time to address this effectively. I mentioned Portugal because Portugal is tiny, but it has the equivalent to Health Canada. It has a small, nationalized health system where it's able to identify every single patient in the country, where it can solve HCV—hepatitis C—and eliminate it, effectively.

I know that you all know about its decriminalization of its drug abuse problem, and that's why it essentially doesn't have any addicts anymore. It can take on certain health problems that other countries can't because it has health registries there. Canada is much bigger than Portugal is, but Canada can take on somewhat bigger problems and be a model in a way that other countries can't because the truth is that Canada is more sophisticated than other countries are. Also, I think Canada has a bigger conscience than other countries do, and as I said, Canada is diverse. That diversity doesn't exist in a lot of countries. It's a blessing. It's wonderful. It's magnificent.

[Stephanie Kusie, Conservative, Calgary Midnapore, AB]

It's also a curse. That's a lot of pressure, Ms. Kramer.

[Some hon. members]

Oh, oh!

[Jane A. Kramer]

I know. I tried to look this up—

Are we out of time?

[The Chair, Liberal, Bill Casey]

You have 10 seconds.

[Jane A. Kramer]

I tried to look it up, to see if there was a word for people who love Canada but aren't Canadians. There isn't a word for it as far as I can tell, but that's me. That's how I feel about Canada.

[The Chair, Liberal, Bill Casey]

Thanks very much.

I'm sorry your time's up. It was a great contribution.

Mr. Ayoub.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Thank you, Mr. Chair.

I am honoured to hear your testimony. You are experts, leaders in the field, and you have worked on these issues for many years. That said, I have the impression that this is work in progress that we'll never see the end of. We must learn to cope with this phenomenon and establish a plan of attack. This is what we are trying to do together. The testimony we've heard so far has given me the impression that the work was done in a vacuum. It's very difficult in terms of communications and interrelations, whether it's here, at home or elsewhere. Indeed, I have the impression that it is a global scourge.

What are the global consequences of not addressing antibiotic resistance or not addressing it adequately?

I would say, in my own words, that there are outbreaks worldwide, possibly in the third world, where antibiotic resistance is triggered.

Canada is one of the developed countries that has strategies in this regard. But I would like to know what it costs us not to help developing countries with insufficient strategies and action plans they can't implement effectively. As you told us earlier, people don't take all of the medication they have been prescribed, or they take too much because they want to find a quick fix to their problems, which could be solved otherwise.

My question is fairly broad, but I would like Mr. Wright and Mr. Evans, in particular, to respond. If the other witnesses want to add something, I would like them to feel welcome to do so.

[Gerard D. Wright]

I'll answer in English because my French is a bit rusty.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

And we only have five minutes.