Health Committee on May 20th, 2020

[The Chair, Liberal, Ron McKinnon]

I now call this meeting to order.

I'd like to welcome everyone to meeting number 22 of the House of Commons Standing Committee on Health. Pursuant to the orders of reference of April 11 and April 20, 2020, the committee is meeting for the purpose of receiving evidence concerning matters related to the government's response to the COVID-19 pandemic.

In order to facilitate the work of our interpreters and ensure an orderly meeting, I would like to outline a few rules to follow.

First, interpretation in this video conference will work very much like in a regular committee meeting. You have the choice at the bottom of your screen of floor, English or French. Please speak slowly and clearly and hold your microphone in front of your mouth.

If you will be speaking in both official languages, please ensure that the interpretation is listed as the language you will speak in before you start. For example, if you're going to speak in English, please switch to the English feed and then speak. This allows for better sound quality for interpretation.

Before speaking, please wait until I recognize you by name. For witnesses, the questioner will basically identify who they would like to respond to the questions. When you're ready to speak, click on the microphone icon to activate your mike. Should members need to request the floor outside of their designated time for questions, they should activate their mike and state that they have a point of order.

As a reminder, all comments by members and witnesses should be addressed through the chair. Should any technical challenges arise, please advise the chair or the clerk immediately and the technical team will work to resolve them. It may be necessary to suspend the meeting in such cases in order to sort things out.

Before we get started, could everyone check on the upper right-hand corner of their screen if they're using a personal computer. In the top right-hand corner there's a choice between speaker view and gallery view. Gallery view will ensure that all video participants can see each other.

I'd now like to welcome our witnesses. Each witness will have 10 minutes for an opening statement, followed by the usual rounds of questions from members. First, as an individual, we have Dr. Amir Attaran, professor, faculty of law, University of Ottawa. As an individual, we have Dr. David Fisman, professor of epidemiology, University of Toronto; and as an individual, Dr. Richard Schabas, former chief medical officer of health for Ontario. From BlueDot we have Dr. Kamran Khan, chief executive officer and founder; and from Dynacare we have Vito Ciciretto, president and chief executive officer.

Welcome everyone. Thank you for joining us today.

We will begin with Dr. Attaran. Welcome back. You have 10 minutes. Please go ahead.

[Professor Amir Attaran, Professor, Faculty of Law, University of Ottawa, As an Individual]

Thank you.

Good afternoon, ladies and gentlemen. Thank you for having me back at the health committee. I hope you've been well.

[Tony Van Bynen, Liberal, Newmarket—Aurora, ON]

Mr. Chair, I'm sorry. The interpretation is overriding the English language.

[The Chair, Liberal, Ron McKinnon]

Dr. Attaran, are you on the appropriate translation channel? You should be on the channel for the language you're speaking.

[Prof. Amir Attaran]

I'm sorry, I forgot that. Let's start over.

[The Chair, Liberal, Ron McKinnon]

Thank you.

[Prof. Amir Attaran]

Good afternoon, ladies and gentlemen.

Thank you for having me back at the health committee. I hope you've been well and that your families have been keeping safe.

When we last met, Canada was in a full lockdown, and I strove to explain how we might get out of it. I offered a road map for exiting the lockdown gradually. That road map remains valid. First, a nationwide lockdown to bring disease transmission to virtually nil, and simultaneously a massive push to increase testing and contact tracing by a factor of ten or more, followed by a sequence of gradual reopenings and infection wavelets that are well calibrated by disease forecasts and monitored by testing to minimize deaths. No competent expert disagrees with this basic strategy.

I said that following this road map would be long and difficult, and I reassured you that there is light at the end of the tunnel. Sadly, some weeks on, today I am here to tell you that the light seems dimmer than I imagined, not for scientific reasons, but for political reasons, which you can fix.

As you know, countries like Australia, Denmark, New Zealand and Norway are executing successful reopenings. Meanwhile, Canada is flying somewhat blind because provincial and federal governments have still not solved their massive failure to co-operate in sharing and analyzing epidemiological data. Without data and analysis, many experts think reopening is arriving too early in some places like Toronto, which will kill people needlessly, and arriving too late in others, like Kingston or the Maritimes, after crippling the economy and ballooning the deficit. This isn't good.

My goal today is to offer a frank reality check, franker than Dr. Tam and Dr. Nemer delivered. I was saddened and frustrated that yesterday many of you asked excellent questions, but got evasive and, at times, mealy-mouthed answers. Please feel free to ask me those same questions. If I can help, I promise I will.

First, let's start with some data and the big question. Is Canada really bending the curve? The answer is sort of.

Many Canadians think we have done well because we are better than the United States, a country that has no public health care, vocal COVID-19 deniers and a president who recommends injecting bleach. The Americans are obviously not the right comparison for us. It's better to compare Canada with other wealthy countries, especially confederations, because they have federal-provincial complications like our own.

Please turn to the line graph I've provided to the committee. It's one of two graphs that were provided.

This graph shows confirmed COVID-19 cases, adjusted for population, starting on the day that a country exceeded the threshold of one case per million population. Canada was the last country to face COVID-19. That's luck, and it gave us extra time to prepare and the benefit of learning from others who went before us. With those advantages we achieved a lower infection peak. However, we come to the question of bending the curve down, we're doing poorly. Instead of the successful nosedive the graph shows for France, Germany, Spain or Switzerland, which they achieved despite a faster and higher peak than ours, our curve looks more like an undulating plateau that gradually drops off like a bunny ski hill. By May 18, our daily confirmed cases were tied with those on April 4. Between those dates are weeks of squandered time, lives and money, the latter being around $12 billion a week to the macro economy.

I find the comparison with Australia the most interesting. It proves that Canada could have done better. It is a large confederation of states, much like our own provinces, and it crossed the threshold of one case per million just one day before we did. In other words, we started off tied, but instead of dithering, Australia smacked down its curve hard and fast. Its results are almost as impressive as South Korea’s, which many reckon to be the world’s most successful country. Now Australia is opening thoroughly, and we are not, so the costs of this failure are just massive. The next time you hear the Prime Minister and Dr. Tam say that Canada is bending the curve, be skeptical. Be much more skeptical than you have been.

Let’s now talk about testing. You heard from nearly everyone that Canada is doing a poor job and that without more and faster testing it is impossible to reopen without unnecessarily risking and losing Canadian lives. The scientific goal is not simply testing the sick, but over-testing the vulnerable and anyone else who might have come been contact with the sick so as to isolate them for 14 days and nip outbreaks in the bud, yet Canada’s testing remains awful, especially in Ontario and Quebec.

The bar graph I furnished to the committee shows over-testing as the ratio of total COVID-19 tests per positive test. The higher that ratio, the better the chance of spotting infections and avoiding outbreaks. If one chooses not to worry about the price of testing—and one shouldn’t, because testing costs peanuts compared to hospitalizations or lockdowns—then it is far better to test too much than too little.

On this measure of testing, Canada lags behind not just top performers like Australia and South Korea, but also behind Ethiopia, Rwanda, Kenya, Cuba and Ghana. We are such testing tightwads that low-income countries in Africa surpass us. Africans also outclass Canada on contact tracing. Addis Ababa’s extensive testing and contact tracing puts Montreal and Toronto to shame.

For Canada to be beaten by the world’s poorest countries has got to puncture the myth of competence and success. It cannot be that Canada lacks Africa's scientists, laboratories, equipment or chemicals, any of that. No. The reason we have failed is the cupidity and stupidity of certain governments, and this is where I put my constitutional lawyer hat on to talk about federalism. American lawyers have a great saying. They say that the Constitution is not a suicide pact, but I’m afraid, ladies and gentlemen, that during a killer pandemic our usually accepted federal-provincial relations can turn into a suicide pact.

I believe that our most fundamental failing right now is that pandemic responses are handicapped by a mythological, schismatic view of federalism. Thus, when provinces withhold epidemiological data or do a poor job of testing, collectively we grumble, we shrug and we mutter that health is provincial, but this is wrong. Speaking as a constitutional lawyer, health is actually a shared federal/provincial jurisdiction. The Supreme Court is dead clear about that. It says, “Health is a jurisdiction shared by both the provinces and the federal government.” That’s our Supreme Court, and it’s perfectly accurate.

I think it is good for the federal government to let provinces run their show, and that’s normally how it should work, but I'll suggest that a pandemic is not normal. There comes a point when the federal government must step in, the point where provincial actions are killing Canadians. If our country cannot show that once-in-a-century flexibility, then, yes, we are turning the Canadian Constitution into a suicide pact.

I know that what I've just said will be outrageously controversial. I’m sorry, but as a person who loves this country, I cannot let obvious mistakes pass and kill my neighbours.

Let me close with three recommendations.

First, Parliament must pressure cabinet into taking legal steps to force provinces to share epidemiological data. These are the data that scientists like Dr. Fisman and Dr. Khan absolutely need to keep me, you and your loved ones alive as this lockdown lifts. Parliament gave cabinet the power to demand data in section 15 of the Public Health Agency of Canada Act, but the Prime Minister has not used that power. It’s frankly pathetic.

Second, demand that the Public Health Agency of Canada set minimum standards for things like testing. We cannot remain stuck behind Africa. Come on. It was only last week that the Prime Minister proposed a national testing strategy. That is much too late. We need it now.

[The Chair, Liberal, Ron McKinnon]

Dr. Attaran, you're at 11 minutes. Could you wrap up, please?

[Prof. Amir Attaran]

Sure.

Third, sign an accord with the provinces on co-operating throughout this pandemic. In Australia, the prime minister and the premiers signed a COVID accord on March 13, and the Vikings have killed this thing. Those Australian Vikings have put it down.

It’s unbelievable that two months later, Canadian governments still have no COVID accord.

I'll close there. I hope you take these suggestions in the spirit they are intended, not to gore anyone’s sacred cow, but to save the lives of the Canadians we love.

Thank you for hearing me.

[The Chair, Liberal, Ron McKinnon]

Thank you, Dr. Attaran.

We go now to Dr. Fisman.

Dr. Fisman, please go ahead. You have 10 minutes.

[Dr. David Fisman, Professor of Epidemiology, University of Toronto, As an Individual]

Honourable committee members, thank you for the privilege of appearing before you.

The last several months have offered us as a country extraordinary challenges. As an epidemiologist, internist and parent, these challenges have subsumed every part of my work life and my personal life. I haven't hugged my kids since mid-March. I have watched patients admitted to hospital with mild breathing difficulties and have seen these same patients wheeled into the intensive care unit 72 hours later. My colleagues have cared for married couples, and have had to tell the surviving spouse of the death of their partner while on clinical rounds. I've had the gratifying experience of watching our modelling work influence policy. I've also experienced the annoyance of watching epidemiological data abused, misused and distorted in support of various political, economic and social agendas.

The challenges I have faced pale next to those faced by many Canadians, those who have lost their jobs or lost their loved ones, often without the chance to hold hands or say goodbye. They pale next to the challenges faced by those who have worked at essential jobs under pressure from employers but without access to adequate personal protective equipment. We've watched extraordinary leadership from senior public health officials across the country. Here I'd like to single out the clear, compassionate messaging from Drs. Henry, Hinshaw and Tam for special praise.

We have also struggled with more limited leadership in other provinces. Here I would note in particular the failure of provincial public health officials in Ontario to act swiftly and courageously to stop the spread of COVID-19 in long-term care facilities, the failure to clearly articulate that COVID-19 was spreading in our communities in early March, and the failure to keep up with the best epidemiological evidence on important issues like transmission of disease by individuals with few or no symptoms.

So yes, we have seen many challenges, some of which we have met and some of which we have not. My group prepares forecasts for several federal and provincial colleagues each morning. We have documented a reproduction number for the epidemic in Canada of below one since around May 9, 2020. That's a hopeful sign. The reproduction number of an epidemic, the number of new cases created by an old case, is an index of epidemic growth and decline. A sustained reproduction number of below one suggests that this first wave of the COVID-19 pandemic is approaching an end in Canada.

I have been concerned by how this encouraging turn of events has been interpreted by some to mean that this wave is ending in spite of, rather than because of, the patient and selfless actions of many Canadians who've experienced hardship, isolation and deprivation in order to distance themselves from workplaces, friends and family. In Canada we have seen health care systems stretched and challenged, but we have not witnessed the tragic overflow of intensive care units as has occurred in Wuhan, Lombardy, New York and Madrid.

Make no mistake, our failure to experience these tragedies does not mean that models were wrong. Cities around the world that failed to react to approaching epidemics as promptly as Canadian cities did have experienced astounding surges in mortality—a 300% increase in deaths in New York, 75% in Stockholm, 460% in Bergamo, and a 100% increase in mortality in London. We reacted to approaching disaster in time to avert the worst of this first wave, but in our two largest cities, Montreal and Toronto, we still have several hundred individuals in intensive care units.

Now we face what I'll refer to as the “paradox of prevention”. By preventing widespread infection in the country, we've maintained susceptibility in the population, which leaves us vulnerable to future epidemic waves. This is the defining paradox of public health. Our fundamental deliverable is the non-occurrence of events. Those of us who work in the field are accustomed to having our outputs taken for granted. To note one familiar example, vaccination programs are criticized because their very success means we don't experience outbreaks. Perhaps a silver lining to this episode, moving forward, will be a greater appreciation of what public health provides us in normal times.

To go back to our successful avoidance of even greater tragedy in Canada in March and April, having achieved this important success, we need to move forward with economic revitalization. I think the presentation of our choice as economic revitalization versus prevention of disease transmission is a Hobson's choice or false dichotomy. We can't ignore our economy, but we won't have robust revitalization without strong surveillance systems and health protection measures. A frightened and grieving population will not drive a strong economy. In the United States, data assembled by JPMorgan Chase show clearly that declines in spending are strongly linked to levels of disease activity.

The bedrock on which revitalization rests will be public health surveillance and laboratory testing. We can't see this epidemic without testing, and we can't fight an epidemic that we cannot see.

The virus is a slippery foe, and it's a study in contradictions. I call it Schrödinger's coronavirus. It's dangerous and it's lethal, but it causes mild illness and even infection without symptoms. It kills over 7% of the Canadians with recognized infection, but it gives most children a free pass.

Asymptomatic and presymptomatic infections are a Trojan horse that gives entry to congregate settings like long-term care and retirement homes, health care facilities, prisons and food processing plants. Once it's spreading in these institutions, it can take a terrible toll, as we have seen in long-term care facilities.

We can look around the world for successful responses to this epidemic and emulate best practices, but we can also emulate best practices here in our own country. Colleagues in Newfoundland have controlled COVID-19 rapidly; they tell us to hunt the virus and be proactive. Colleagues in British Columbia teach us how important clear strategy and communication are in this fight. Alberta can show us how to scale up testing, and our northern territories can show us how to protect isolated remote communities. Saskatchewan has shown us how to deal swiftly with growing outbreaks to prevent geographic spread of infection.

But I do believe that our most potent weapon in the fight is testing. Work by my colleague, Dr. Ashleigh Tuite, shows that without aggressive testing, control measures like contact tracing are likely to be fruitless, as we will only perform contact tracing on tested cases. If we fail to test at scale, we will miss too many additional cases for contact tracing to change the dynamics of the epidemic. It will simply be a waste of resources. If we test at scale, we can keep the epidemic in our sight and move toward economic revitalization while keeping Canadians safe.

Testing will be our eyes and ears as we move forward to open our economy, but the laboratory is a tool that needs to be used differently in different settings. We need to establish regular testing regimens for those who work in congregate settings with vulnerable individuals, especially in long-term care and in hospitals. Testing in a stable and consistent way allows us to estimate the reproduction number of the epidemic and know when we're headed back into exponential growth. We want to find all the cases we can. That's how we prevent sparks from turning into forest fires.

Hospitalizations and deaths are easy to see, but they're lagging indicators. Instituting control policies once those are surging means that we've already missed the boat. We can use non-traditional surveillance tools, too, like web-based syndromic surveillance, and even surveillance of sewage for coronavirus levels, as is already being done in other countries. Situational awareness will keep us safe as our economy comes back to life.

We can also demand more of our country. This epidemic shows us that having laboratories with 21st century diagnostic technology, but public health information systems that depend on fax machines from 1995, will hold us back. We can demand more transparency from our leaders. As action by the public is central to disease control, it's important that the public be kept in the loop and made to feel like they're on the team. Indeed, they are the team.

We need clear, transparent benchmarks across the country on testing, on turnaround times for case reporting and contact tracing and for the reproduction numbers that will be used to determine when we need to strengthen distancing and when we can loosen it. We will have more setbacks; the countries with the strongest response programs in the world have all suffered them. We will too. I'd ask you not to throw your hands up and let the virus win.

Don't let uncertainty distract you from the mission. Uncertainty is to be expected for a disease that's been in humans for 24 weeks. Don't let smug professors bully you about the absence of randomized controlled trial evidence for control of a disease that has only existed for half a year. We can acknowledge uncertainty and be humble about this disease, but always put the lives and livelihoods of Canadians at the forefront when we make our decisions.

Thank you for the opportunity to answer your questions today.

[The Chair, Liberal, Ron McKinnon]

Thank you, Dr. Fisman.

We go now to Dr. Schabas.

Please go ahead. You have 10 minutes.

[Dr. Richard Schabas, Former Chief Medical Officer of Health for Ontario, As an Individual]

Mr. Chair and members of the committee, it's a privilege to speak with you today.

I'm a retired physician. I practised medicine for 40 years in two specialties: public health and internal medicine. I worked in local public health for 15 years. I was Ontario's chief medical officer of health for 10 years. I was directly involved in the 2003 SARS outbreak as the chief of staff of York Central Hospital. I have published academic and popular articles on relevant subjects, such as SARS, quarantine and bird flu.

Canadians on the whole enjoy a wonderful standard of health, resting on the foundation of the social determinants of health: education, employment and our social fabric. Anything that threatens these foundations threatens our public health.

Canada is now faced with both a tragedy and a crisis. The tragedy is caused by COVID, a respiratory virus. It has the potential to cause the deaths of tens of thousands of Canadians, overwhelmingly old and infirm.

The crisis is caused by our attempts to control that virus. The crisis has the potential to cause severe and lasting damage to the fabric of our country's economy, education, social and cultural institutions, and mental health that will have repercussions for our public health for decades.

The tragedy is a natural disaster that saddens me and saddens us all. The crisis is a self-inflicted wound that frankly terrifies me. It offends social justice, because the burden of the crisis falls disproportionately on children, young families and blue-collar workers. The more we focus exclusively on COVID, the greater the danger to our public health.

The best analogy to the COVID outbreak is the H2N2 Asian flu pandemic that swept around the world in the fall of 1957. Asian flu caused more disease and a much higher death rate, especially in younger people, than COVID. Asian flu killed between one million and two million people in a matter of a few months in a world population one-third the size of today's. That's the equivalent of three million to six million deaths today, many more than from COVID. Asian flu was a tragedy, but it wasn't a crisis, because 60 years ago people responded differently. Some modest control measures were taken, but they were very temporary. The world moved on.

Perspective isn't very popular with COVID, but I think it's important. We get spooked by COVID deaths because every day we see the numbers for COVID, but not for anything else. Death is a common phenomenon in our world. Almost 300,000 Canadians will die this year, like every year, from cancer, heart disease, stroke, motor vehicle crashes, suicide and a myriad of other causes. Since mid-March, for every Canadian outside long-term care who has died of COVID, 50 Canadians have died of something else.

We have frightened people. Predictably, the media has led the way. But public health has also frightened people, I think, to promote better compliance with social distancing. This was wrong for two reasons: first, it's cynical; and second, it now will make it that much harder to step down.

My wife and I live in Toronto. When we walk our dog, we see two kinds of people— those like us who have done the math and aren't really frightened by COVID, and those who think walking the streets is dangerous. But there's a third group, the people in our building whom we haven't seen for two months who are too terrified to even go outside. Getting them to re-enter the world will be a tremendous challenge.

The only reliable defence against a respiratory virus is immunity. You can get immunity from being infected or you can get it from a vaccine. A safe and effective vaccine would be wonderful, but it would be foolish to build public policy around expectations of a vaccine any time soon. Any strategy that doesn't take us towards immunity ultimately leads us nowhere. So long as the disease is circulating elsewhere, it's coming back here too. Provincial or national elimination is a false promise.

Population immunity leading to herd immunity is a natural phenomenon not an intervention, not an experiment. Herd immunity is what has controlled every other respiratory virus. We will get there sooner or later with COVID. The policy challenge is to mitigate the worst effects of the disease while protecting the real determinants of our health: education, employment and our social fabric.

We have better information about COVID than we did two months ago. We know that COVID is very serious, certainly much more serious than I, for one, expected. However, it's also not the apocalypse that some of the models had predicted, not even remotely close. The comparison should be with 1957, not 1918.

We know that our health care system can cope. A combination of expanded capacity, better treatment strategies, and triage mean that the apparent capacity crisis in Italy has not been repeated here or really anywhere else. We know that the great majority of people in Canada are at very little personal risk of death from COVID. For virtually everyone under the age of 60 and for people without serious comorbidities to a much older age, the risk of death from COVID infection is not materially different from the risk of dying from influenza. We are two populations: the frail elderly for whom COVID is a deadly disease and the great majority for whom it is not.

Canada's experience in the last two months has been problematic. We seem to have been reasonably effective at reducing infection in the community, but we have not been effective in protecting the institutionalized, frail elderly because of a massive failure of infection control in some facilities. As a consequence, we have had many deaths, but we have relatively little population immunity.

The COVID outbreak in the northern hemisphere has been on the wane since late March—for almost two months. The policy tide worldwide is now towards reopening. Canada will be swept along.

My real concern is that the virus will return, probably in September, and that our attempts to control it with widespread testing and contact tracing will probably fail. I've worked long enough in public health to understand the limitations of contact tracing as a disease control strategy, particularly for a disease like COVID.

However, when this strategy fails, will we panic and lockdown again, this time indefinitely, or will we respond in a more measured and rational way? We have some time to prepare. If plan A is based on testing and contact tracing, we need a plan B. What should we do now?

First, we need to identify those things that are fundamentally non-negotiable. Education, which requires the reopening of schools, and employment, which requires that many people return physically to work, should be top of the list, along with access to medical and dental care.

Second, we need to be clear that we are pursuing the policy of mitigation not elimination. With mitigation, we can tolerate an increase in cases when we open up now, and again when the disease resurges in the fall. We will regard community spread as inevitable and as a step towards population immunity.

Third, we need to do serious policy work to identify those aspects of social distancing that are effective, acceptable and sustainable. Canada's latest fad is for non-medical masks, based on the thinnest of evidence. Let's think carefully before we change ourselves into a society that hides its face in public.

Fourth, we must develop better strategies to protect the vulnerable, particularly better infection control in long-term care institutions. This alone will go a long way towards reducing mortality.

Fifth, we need to change our messaging to the public to better reflect their real risk of serious illness and death so that people will be willing to come out of isolation and resume normal life.

Sixth, we need to look for ways to develop public health policy nationally. We need a national, not a federal, public health agency that engages the provinces with the federal government as equal partners.

Thank you.

[The Chair, Liberal, Ron McKinnon]

Thank you, Dr. Schabas.

We'll go now to Dr. Khan from BlueDot. You have 10 minutes.

[Dr. Kamran Khan, Professor of Medicine and Public Health, University of Toronto, Chief Executive Officer and Founder, BlueDot]

Good afternoon, ladies and gentlemen, and thank you for inviting me to be a part of this important discussion today.

First let me introduce myself and tell you a bit about my background and its relevance to today's meeting. My name is Kamran Khan, and I'm a physician trained in internal medicine, infectious diseases, and preventive medicine and public health. I practise medicine and am an epidemiologist who has been studying outbreaks and emerging infectious diseases at St. Michael's Hospital in Toronto for the past 17 years. I'm a professor of medicine and public health at the University of Toronto and am the founder and CEO of a digital health company called BlueDot.

What has motivated me to dedicate my professional life as a clinician, an academic and an entrepreneur to the field of emerging infectious diseases? Twenty years ago, I began my training in infectious diseases and public health in New York when West Nile virus arrived in the city and began its westward march across the continent. Two years later, shortly after the terrorist attacks of September 11, 2001, anthrax was weaponized and dispersed through the U.S. postal system, reminding us that deadly outbreaks can arise from deliberate acts. After returning to my home in Toronto two years later, a coronavirus known as SARS spread from mainland China to dozens of cities and countries around the world, including Toronto, where it triggered a deadly outbreak that lasted four very long months. While the world had never seen an outbreak quite like SARS before, it was clear that this wouldn't be the last time.

The world is changing in ways that are driving the emergence and spread of dangerous diseases, but it's also changing in other ways that can play to our advantage. The rise of big data, the advent of artificial intelligence and emerging digital technologies offer us the raw materials needed to literally spread knowledge around the world faster than any outbreak. This was the inspiration for BlueDot's founding six and a half years ago, to build a digital global early warning system for infectious diseases that can transform how the world prepares for and responds to tomorrow's inevitable infectious disease threats, whether they arise from Mother Nature, accidents or deliberate acts.

The early warning system we have developed at BlueDot serves three key objectives: first, to detect infectious disease threats as early as possible to buy ourselves valuable time; second, to assess their potential for global spread and impact so that we can channel our finite resources to the right place at the right moment; third, to empower a wider array of decision-makers, from government to health care to the private sector, with timely insights so that together we can mobilize highly effective, efficient and coordinated responses.

To detect threats at their earliest stages, our early warning system processes vast amounts of online data in 65 languages, searching for early signals of outbreaks involving over 150 different diseases and syndromes, 24 hours a day, 365 days a year. The surveillance engine does not rely solely on official news of outbreaks reported by government agencies, but also analyzes unofficial information generated through digital media, health blogs and other online sources.

This engine picked up an article in Chinese on the morning of December 31, 2019, reporting on an outbreak of pneumonia of an unknown cause in Wuhan, China. This event certainly captured my attention, given the number of parallels to the emergence of SARS in 2003. Within a few seconds of detecting the outbreak in Wuhan, our system analyzed the flight schedules and anonymous itineraries of hundreds of thousands of travellers departing Wuhan on commercial flights for destinations around the world. Given our early concerns about this outbreak, my team submitted results of this analysis for publication in an open access, peer-reviewed scientific journal on January 8, 2020, in order to make this data freely available for anyone to access. This analysis accurately identified many of the cities outside of mainland China that were among the first to confirm cases of COVID-19.

As cases of COVID-19 arrived in North America, our team began generating insights to support public health efforts to mitigate domestic transmission of this virus within our communities. These analyses made use of anonymous location data generated from mobile apps to understand the movements of populations—critical insights for public health officials to optimize and strategically make use of their finite human resources across the country and over time.

It's worth noting that BlueDot only makes use of third party data that is anonymized, adheres to all legal and regulatory requirements, and is aggregated up to the level of populations. These location data have been used for years in sectors from urban planning to transportation to retail, among others. Here, we're making use of them for the sole purpose of safeguarding communities and protecting lives during the midst of a pandemic.

At BlueDot, our diverse team, comprising physicians, veterinarians, epidemiologists, geographers, ecologists, data scientists and engineers, has been diligently working for the past six and a half years leveraging data, advanced analytics and emerging digital technologies to develop innovative solutions that are capable of generating insights to mitigate risks from infectious disease threats in our rapidly changing world. But insights are only meaningful if they are translated into action, and that translation can only happen through partnerships.

In this regard, BlueDot has a long-standing partnership with Global Affairs Canada, going back to 2014, in which we have been building and implementing digital systems to manage infectious disease risks across the Association of Southeast Asian Nations. In 2019 we began a partnership with the Public Health Agency of Canada, channelling our efforts to mitigate domestic risks from global infectious diseases. Now, as the COVID-19 pandemic evolves into new phases, we continue to work together to mitigate its impacts across the country.

I’d like to conclude by saying that Mother Nature is sending us a message. A confluence of forces in our rapidly changing world—population growth, urbanization, the industrialization of agriculture, the disruption of wildlife ecosystems, climate change and increases in global population mobility—is accelerating the emergence and global spread of infectious diseases with unprecedented consequences. As global citizens, this is a reality we have to confront, or we risk finding ourselves in the same precarious position we are in today a few years down the road.

We have also learned that outbreaks move incredibly fast in our hyper-connected world. If we want to remain a step ahead, we are going to have to move even faster. Thankfully, we have what is needed to generate powerful insights: access to diverse and novel data, and human intelligence coupled with artificial intelligence to derive meaning from these complex data.

We need to translate insights into actions that reach across the whole of society. Governments empowered with timely insights will be better able to protect their citizens and economies from dangerous global infectious diseases. Hospitals and health care providers will be better able to protect themselves and the rest of us from these very same diseases. Businesses will be better able to protect the lives and livelihoods of their employees and customers. Creating an ecosystem to manage these risks together is not only possible, but, in my opinion, necessary.

A final thought to leave with you is that our most valuable resource is time, and it is a non-renewable resource. When we get through COVID-19—and we will—the question for all of us will be whether we will use every day of peacetime to prepare for the next inevitable threat with the same sense of urgency with which we are responding to COVID-19 today.

Thank you for the opportunity to share my thoughts with this committee.

[The Chair, Liberal, Ron McKinnon]

Thank you, Dr. Khan.

We go now to Mr. Ciciretto, president and chief executive officer of Dynacare.

Go ahead, please. You have 10 minutes.

[Vito Ciciretto, President and Chief Executive Officer, Dynacare]

Good afternoon. Thank you, Mr. Chair and members of the House of Commons Standing Committee on Health, for your invitation to this very important meeting. I hope that each of you and your families are healthy and well. It is a privilege to be with you today on behalf of Dynacare to discuss the Canadian response to the COVID-19 pandemic.

At Dynacare, we believe that life is precious. Our mission is to support the health of Canadians with commitment and care. That is why we do what we do. Our 2,900 Dynacare employees deliver the highest level of clinical and scientific testing to provide the necessary information that supports the diagnosis, treatment and well-being of Canadians. Each and every day we provide testing and medical laboratory services to over 32,000 Canadians across the country, amounting to over 11 million tests annually. We operate 200 convenient and accessible specimen collection centres in Ontario, Manitoba and Quebec. We operate seven state-of-the-art laboratories in four Canadian provinces. We report over 500 critical results requiring immediate action by physicians.

Our goal is to inspire confidence in Canadians when it comes to managing their health and well-being. To achieve this, we have elevated the patient experience at our specimen collection centres. We continuously innovate by introducing new and improved test methodologies such as genetic testing; liquid-based cytology; non-invasive prenatal testing; and the piloting of Pixel, a self-collection test methodology utilized in remote rural communities. We have introduced patient-friendly diagnostic testing reports and digital apps that help Canadians better manage their health journeys.

This unprecedented pandemic has highlighted that the work we do at Dynacare matters now more than ever. We are very proud to play a critically important role in supporting the provincial public health authorities of Ontario, Manitoba and Quebec in their efforts to control this pandemic. Since March 25, our talented scientific and laboratory professionals at Dynacare have conducted over 40,000 COVID-19 molecular tests across these provinces, including COVID-19 testing for members of vulnerable and priority populations, such as those in emergency shelter systems, residents of long-term care facilities, EMS first responders and health care workers.

Even throughout this pandemic, Dynacare has continued to operate its laboratories and accept patients at our collection sites for urgent non-COVID-19 testing. In addition to the provision of COVID-19 testing, our community laboratory infrastructure has helped to alleviate pressure on provincial public health systems and hospitals. In particular, our medical couriers have quickly and safely transported COVID-19 test specimens from screening and assessment centres to Dynacare, public health and hospital laboratories. On behalf of the provincial public health labs, we have delivered negative COVID-19 test results to over 25,000 patients. We have supported vulnerable populations by establishing designated Dynacare specimen collection sites for immunocompromised patients and for COVID-19 positive patients. We have engaged in non-COVID-19 sample collection at long-term care facilities.

Our employees have rallied behind Dynacare's response to this pandemic and, as such, we celebrate the many acts of compassion through our Dynacare health care heroes social media campaigns. Our people are the ones who have truly stepped up.

The COVID-19 testing system has generally been working well with strong collaboration among public health agencies, community laboratories and hospitals. But, as with any unprecedented and rapidly evolving environment, there are challenges and opportunities for improvement.

The technical nature of the nasopharyngeal collection process, along with the required swabs that are employed in the collection of a COVID-19 sample, have been rate-limiters in terms of testing and have increased the demand for PPE. At over 200 collections centres, Dynacare has over 850 phlebotomists who are not authorized to collect samples using the current collection devices.

By employing alternative specimen collection procedures used in other countries, our team can support provincial screening. To this end, Dynacare is embarking on a study with Sunnybrook Occupational Health to validate alternative sample collection methods using saliva and front-of-nose collected specimens. The results of this study are expected within a few weeks.

Second, shortages of testing reagents and collection kits were common early in this pandemic. Due to increased vendor production and the proactive response of our supply chain team, we appear to have sufficient supply for our current volume of testing. However, in order to support expanded testing needs, our intention is to increase testing capacity, both through new collection techniques and through supply chain preparedness. Global demand has made it very difficult to secure additional testing capacity and reagent supply on a timely basis. Vendor allocation practices drive more test capacity and reagent to jurisdictions that have been more severely impacted by the COVID-19 virus than Canada has.

It's important to everyone at Dynacare that at the end of every laboratory test we perform there is a person—a mom, a dad, a daughter, a friend. It is not uncommon for our dedicated teams of employees to go above and beyond the call of duty by helping to secure a replacement test requisition for a patient, by leading a drive-by convoy to acknowledge the efforts of front-line health care workers at hospitals, or by making extended efforts to contact a patient with a critical result.

We treasure the value that our dedicated employees bring to the health care system, and we go to great lengths to take care of them. Notwithstanding the significant drop in non-COVID-19 test volumes during this pandemic, we have not thus far implemented furloughs, layoffs or reductions in base pay, due to our long-term philosophy and government wage programs. We are very proud of this and believe that it positions us well for the future. As doctors' offices and clinics reopen, as elective surgeries start again, as insurers and employers resume regular activities, Dynacare will be in a position to meet the laboratory testing needs of our patients and clients and support our health systems across Canada.

Unquestionably, our workplace will be defined by a new normal, with new social distancing and PPE protocols that will protect our patients and our people. As the number of patients requiring service continues to increase, these new protocols will demand the need to adapt, and we will.

Across Canada, some provinces are slowly beginning to open back up in ways that we would not characterize as business as usual. In the absence of a vaccine and lack of scientific consensus on the potential for immunity to the COVID-19 virus, some employers are expressing concern that their workplaces could be prone to COVID-19 outbreaks. Employers across a number of sectors, including food and beverage production, natural resources, manufacturing and many more have expressed an interest in the provision of COVID-19 testing at their own cost. Dynacare's priority will always be supporting health systems in responding to the emergency presented by COVID-19. As the economy opens up, we see a need to work with industry to avoid workplace outbreaks as a means to limiting the community spread of COVID-19.

Key to restarting the Canadian economy is high-quality antibody testing, which can determine whether an individual has been exposed to the COVID-19 virus. Public health authorities, in conjunction with medical and scientific experts, are working to determine how COVID-19 antibody testing could be applied.

This past week, two COVID-19 antibody tests were approved by Health Canada. Dynacare is currently working with two additional vendors who will be seeking Health Canada approval for an antibody test. A community laboratory like Dynacare is very well positioned to support large-scale provincial COVID-19 antibody testing surveillance programs through its extensive specimen collection network of 200 centres, our well-equipped laboratory facilities and our extensive logistics network. We do this every day—efficiently, effectively and with compassion.

In public health emergencies, those in poor health or with underlying chronic conditions are often the most vulnerable.

For many, the COVID-19 pandemic has emphasized the importance of keeping Canadians healthy and decreasing the prevalence of chronic conditions such as cardiovascular disease, lung disease, metabolic syndrome and diabetes.

At Dynacare, we believe that life is precious, and we look forward to continuing to improve the health of Canadians by providing ongoing support to provincial health care systems and through health and well-being programs at Canadian workplaces both through the COVID-19 pandemic and beyond.

Thank you again for the opportunity to address this committee.

Take care and be well.

[The Chair, Liberal, Ron McKinnon]

Thank you, Mr. Ciciretto.

We'll start our rounds of questioning now. We will do three rounds. We will start the first round with Ms. Jansen.

Ms. Jansen, please go ahead. You have six minutes.

[Tamara Jansen, Conservative, Cloverdale—Langley City, BC]

Thank you to everybody for all your presentations. That was very wholesome. It was great.

I'd like to start with Professor Attaran. I found your written submission very interesting, and I had to chuckle when you pointed out the fact that some hospitals are still faxing in their data. My first foray into state-of-the-art technology on the farm was when we bought a fax machine back in 1992, 28 years ago.

However, in order to stay in business, we obviously had to invest in better and better data collecting technology. I have to say that I was completely shocked to find out from previous witness testimony at this committee that our health care system doesn't have a real-time data collection system in place, especially considering the different recommendations that have been made following previous pandemics.

We have had several witnesses come to this committee and beg us to find a way to move forward with a pan-Canadian data collection system that works in real time. A system like this could help us on so many different levels, not just during a pandemic, but it seems there is this fear that sharing information in this way will compromise the autonomy of provincial and local health authorities.

In your opinion, is there not a way to ensure that each provincial and regional jurisdiction can continue to make decisions that make sense for them while still sharing their data and helping the country with a more informed pandemic response?

[Prof. Amir Attaran]

What a great question, thank you.

On the question of sharing epidemiological data, it's like this: If you had a number of people who had pieces of a map of a minefield, would you tolerate them not sharing that data? I think you'd probably want to have a map of the entire minefield, not just your little patch of it, if you were setting out on a journey.

The current situation is as foolish as that. Each province has a certain amount of data about the outbreak within its borders, and it can either contribute that piece to modelling exercises or not, and depending on whether it does so or not, we have a better or worse view of the epidemic.

The answer to your question lies in a legal part as well as an administrative part. Legally it's very simple. Cabinet just needs to use section 15 of the Public Health Agency of Canada Act and issue an order in council that data must be provided, period.

Parliament gave it that power. It simply leaves me speechless that the current cabinet hasn't used it. That is something I hope you follow up.

[Tamara Jansen, Conservative, Cloverdale—Langley City, BC]

Okay, I have a really short amount of time, sorry.

[Prof. Amir Attaran]

I'm sorry.

[Tamara Jansen, Conservative, Cloverdale—Langley City, BC]

Okay, I appreciate that.

You mentioned in your submission the dysfunction that we have in sharing data, and, again, being from a business background.... I worked in the retail sector for many years, and our spring season was always very short. We had an eight-week period across multiple provinces, so that meant timely data was absolutely critical to make these decisions on where to send what product and when. We were able to take into consideration those regional differences to ensure the right assets were sent to the right place at just the right time, and we know the technology is available for a pan-Canadian data system.

Yesterday Dr. Tam mentioned that PHAC has no choice, and now you are mentioning they actually do under section 15, so it strikes me that, if Statistics Canada is able to aggregate information about Canadians without violating privacy rights, surely the health care system can do the same.

[Prof. Amir Attaran]

Statistics Canada can do the same, too. They could build the system inside of about a couple of weeks, I'm told, but they need the mandate from cabinet. That is what's missing. There you go.

[Tamara Jansen, Conservative, Cloverdale—Langley City, BC]

Okay.