Health Committee on May 28th, 2021

[Jordan Paquet]

Yes.

[Michelle Rempel, Conservative, Calgary Nose Hill, AB]

Why is there no record of any official or associated company from Switch Health in the lobbying registry?

[Jordan Paquet]

That is because we wouldn't have been lobbying prior to the awarding of the contract.

[Michelle Rempel, Conservative, Calgary Nose Hill, AB]

You are confirming that the answer to my first question was “no”.

[Jordan Paquet]

That's correct. No lobbying took place.

[Michelle Rempel, Conservative, Calgary Nose Hill, AB]

Nobody has ever contacted a public office holder for any purpose that might be construed as lobbying. Are you sure you want to answer “yes” on the record for that?

[Jordan Paquet]

In the process of getting to award the contract for this particular instance, we followed the process completely—

[Michelle Rempel, Conservative, Calgary Nose Hill, AB]

I asked whether you proactively contacted any public office holder for any purpose.

[Jordan Paquet]

Is that with respect to awarding the contract or throughout the process?

[Michelle Rempel, Conservative, Calgary Nose Hill, AB]

No, it's throughout the process. Have you contacted any public office holder?

[Jordan Paquet]

Yes, throughout the process, we would have been in contact with people at the ADM and DM levels as well.

[Michelle Rempel, Conservative, Calgary Nose Hill, AB]

Were those contacts registered in compliance with the federal Lobbying Act?

[Jordan Paquet]

These were sessions on information—operational procedures and sharing of information, for the most part—so everything would have been above board with regard to the Lobbying Act. None of our employees would spend more than 20% of their time lobbying in any form.

[The Chair, Liberal, Ron McKinnon]

Thank you, Ms. Rempel Garner.

We'll go now to Dr. Powlowski for six minutes.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

I think you're going to find my questioning much slower and more labourious.

Dr. Morris, let me start off by complimenting you for speaking out on issues of public health. I know a lot of health care workers have been afraid to do so, and for good reason.

I was still on staff at the local hospital until January. My hospital, for example, specifically told doctors not to speak to the press or politicians like myself. There certainly have been health care people disciplined or threatened with discipline, especially when they speak up on public health measures and against government policy.

Therefore, I certainly commend you for it. I disagree with these kinds of tactics from the hospitals. I think you'll agree that an ounce of prevention is worth a pound of cure. Certainly when somebody has gotten to the stage that they're on a ventilator, there's not a whole heck of a lot you can do for them medically. It makes more sense to prevent their getting on ventilators, which means good public health.

For a good doctor, it's not just a good decision to speak out; I would suggest that doctors have a duty to speak out. You might want to comment on that.

However, before I get there, I have a second question. You probably saw this coming, because we've talked about it before. It's about the use of monoclonal antibodies. It gets to the same thing: keeping people off ventilators. As I suggested last time, I think there's a growing amount of robust evidence that use of monoclonal antibodies in high-risk people, when used early on, can reduce by somewhere between 60% to 80% the number of people who go on to hospitalization.

Now, I know when we previously spoke, you felt that there wasn't enough evidence for that. You wrote the guidelines. You sit on the science table. I would like to point out that, since then, the NIH guidelines panel, in interpreting the evidence, gave a class IIa recommendation for the use of monoclonal antibodies.

I talked about some of the evidence before. With Chen et al. in the New England Journal of Medicine, there were certainly good results; and BLAZE-1, Gottlieb et al., in JAMA, is another study with very positive results. I brought these examples up in the last meeting.

Since then, real-world experience from Kumar et al., from the clinical infectious disease group from Chicago, found the number needed to treat was eight, treating eight high-risk people with monoclonal bamlanivimab before they got really sick. If you treated eight, it would prevent one person being hospitalized.

Bariola et al., a Pittsburgh group, in Open Forum Infectious Diseases, found that treatment, again with bamlanivimab, resulted in a 60% lower risk of hospitalization or mortality.

Now, to pre-empt you, I know that the FDA revoked approval in the U.S. for bamlanivimab alone, but that was based on in vitro studies showing that it didn't look like it would be effective against the California or New York variants, which we don't have much of here. The estimates have been in Ontario that 90% to 92% of the variants we have here, including the wild type, are covered by that treatment.

Even if you don't like bamlanivimab, there are the other newer monoclonal antibodies. The Celltrion phase II and phase III clinical trial showed a 64% reduction in progression to disease. On the bamlanivimab and etesevimab, there have been further studies with that in chronic care homes; the BLAZE-1 phase 3 trial; and REGEN-COV by Regeneron, which showed that patients who got infused treatment within 10 days of developing symptoms had a 70% reduced risk of hospitalization or death. More recently, in the COMET-ICE study, with GlaxoSmithKline, the independent data monitoring committee recommended stopping the trial early because results were showing an 85% reduction in hospitalization or death, so it would be unethical to continue.

Given all that, do you continue to maintain that there is not enough evidence for the use of monoclonal antibodies, and will the science table re-examine this in the treatment guidelines?

Thank you.

[The Chair, Liberal, Ron McKinnon]

I'm sorry, Doctor, but for whom was that question?

[Dr. Andrew Morris]

Sorry, it's was for me. Thanks for the question. I was on mute.

I think I'll address the first question later on, if we have time, but to the second question about monoclonal antibodies, I'll say a few things in response.

I sit on and chair Ontario's scientific advisory table. Even though much of the country looks to our table for advice, it's Ontario's scientific advisory table. We mainly provide advice on therapies that are currently available to Canadians. The only monoclonal antibody that is available to Canadians at present is bamlanivimab. As you pointed out, there are problems with bamlanivimab monotherapy, and they continue. They're not just theoretical. They were demonstrated in the trials, especially in BLAZE-1, where there was an emergence of antibody-resistant variants while on therapy. Because of that, I would strongly suggest that we not use bamlanivimab.

I see that my time is up, Mr. Chair. I don't know if you want me to finish the rest of the question.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

I know the previous speaker got a little extra time.

Would you consider combination therapy? If you had funding to set up infusion sites, would you consider using them if they're approved by Health Canada?

[Dr. Andrew Morris]

Yes, I think I would absolutely consider it. I think there is emerging evidence that it is of some benefit. There are some challenges with it, especially the practicalities, but definitely, as time has gone on, if you can get patients onto combination monoclonal antibodies early enough, there may be some benefit. Whether the trade-off between the cost and logistical challenges proves adequate for the benefit is something that needs to be decided.

[The Chair, Liberal, Ron McKinnon]

Thank you, Dr. Powlowski and Dr. Morris.

Mr. Thériault, go ahead for six minutes, please.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you very much, Mr. Chair.

First of all, I'd like to thank all the witnesses for their testimony. We are looking for seeking solutions and will have to make recommendations once we have completed our study. So I thank them for being here today.

I will turn to you first, Professor Taillon. Your presentation was very clear and touched on a number of complex issues in a very short period of time, and you summarized them simply and clearly. Thank you for that.

Some people have told us that the crisis would have been managed more efficiently if we had invoked the Emergencies Act or centralized our operations. Others felt that, on the contrary, decentralized management of operations was the only solution to managing what we didn't know. I understand that you fall into the latter camp.

If the government had persisted in using such an act or centralized management, we might have had to manage both an urgent health crisis—we were told from the first wave that we were lagging two weeks behind the spreading virus—and a political crisis.

What do you think?

[Patrick Taillon]

With regard to a political crisis, I imagine you're alluding to the fact that the government is in the minority position in Parliament.

At any event, I don't think that provincial MLAs naturally have better or worse solutions than federal MPs. That's really not the case. It's just a question of subsidiarity. This crisis clearly called for management that was as close to the ground as possible. Even in the provinces, it would have been better at times to have management that was closer to the ground and provided primarily by physicians, healthcare staff, local governments and, obviously, the provinces.

On the whole, I would point out that federal authorities weren't powerless when they discovered that there was a financial need and that a measure like the Canada emergency response benefit, the CERB, would be useful. With their enormous spending power, they could have carried out their policy. They didn't need the Emergencies Act or the exorbitant regime under which we suspended normal federalism, rights and freedoms and so on in a quest for exceptional means. The means at the federal government's disposal were already equal to the task of carrying out that policy. I don't think we would have produced vaccines any sooner if we had used the Emergencies Act.

[Luc Thériault, Bloc, Montcalm, QC]

Nor do I believe that the federal government ever possessed all the expertise needed to manage the crisis without calling upon the expertise acquired over many decades by caregivers in the field.

There would probably have been resistance to the exercise of this act, which would have caused delays and a situation that could have been avoided; hence my comments on the crisis.

There were some gaffes in the government's management, for example with the country's supplies, just as the Global Public Health Intelligence Network was not really effective. We saw the reports about that.

Nevertheless, we'll be able to criticize all of that in due course.

How then to explain the government's stance on not immediately wanting to provide funding to the health systems or to transfer the money needed to rapidly restore the decentralized management and coordination required by the health systems?

Cancer specialists and cardiologists have come here and told us that the redirection of patients would have repercussions, and that patients who do not have COVID-19 will suffer the consequences for 10 years and that the mortality rate will rise by 10%.

Not to mention the dramatically higher health costs! Let's say that a colonoscopy costs $1,000. Without an early diagnosis, a patient will begin to draw upon the health system and the cost of dealing with advanced cancer will be extremely high.

In view of all this, why was it decided to run everything unilaterally? On the one hand, the health transfers were deferred—that was the first mistake, from both the medical and economics standpoints—and on the other, standards and conditions were imposed. There are two sides to the way this pandemic was managed.

[Patrick Taillon]

I'll be brief, so as not to exceed the allotted time. Health is first and foremost a provincial jurisdiction, but there are exceptions, and certain aspects are clearly defined areas of federal jurisdiction.

However, there is the question of funding. When you have spending authority, it's as if the intent of the Fathers of Confederation no longer applied, because spending is not legislating. You are right to point out that through spending authority, the federal government plays a major role in health, whereas its legislative authority in health is somewhat, or even very, limited.

After this crisis is over, health will go into a new phase, in which it will have to deal with new types of problems, specifically for those who had their care postponed. In order to deal with these delays, additional costs will have to be paid and there will be many hours of overtime. These extra costs will create enormous financial pressure on the provinces in the short, medium and long term. The exercise of federal spending authority on health in a way that is not sufficiently stable, predictable and substantial, will definitely cause enormous problems.

It is therefore absolutely essential that this funding be stable, consistent and substantial; otherwise fiscal space will have to be created to allow the provinces to finance these areas on their own, because at the end of the line, the ability of citizens to pay taxes is limited. That will be the major issue in the years ahead.

Now that we are more knowledgeable about the virus, we need to take care of the other patients, and that will be very expensive.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you.