Health Committee on May 28th, 2021

[The Chair, Liberal, Ron McKinnon]

I call this meeting to order.

Welcome, everyone, to meeting number 39 of the House of Commons Standing Committee on Health.

The committee is meeting today to study the emergency situation facing Canadians in light of the COVID-19 pandemic. Today we are specifically examining Canada's national emergency response landscape.

I'd like to start by welcoming the witnesses. Appearing as an individual, we have Dr. James Maskalyk, associate professor of emergency medicine, University of Toronto, and Toronto-Addis Ababa academic collaboration in emergency medicine. Also appearing as individuals, we have Dr. Andrew Morris, professor and physician, and Mr. Patrick Taillon, professor, faculty of law, Université Laval.

From Switch Health, we have Dilian Stoyanov, chief executive officer; Jordan Paquet, vice-president, public affairs; and Olga Jilani, chief financial officer.

I will now invite the witnesses to present short statements of six minutes. We will start with Dr. Maskalyk. Please go ahead.

[Dr. James Maskalyk, Associate Professor of Emergency Medicine, University of Toronto and Toronto-Addis Ababa Academic Collaboration in Emergency Medicine, As an Individual]

Thank you so much. It's such a pleasure to be here.

I'm an emergency physician and trauma specialist here in Toronto and with Médicins Sans Frontières. I've worked in epidemics before the COVID-19 pandemic and I intend to afterwards.

First, I'd like to say that the response overall by Canada and Canadians has been remarkable and exceeded my and so many peoples' expectations. I just wanted to extend my thanks as a citizen and a clinician for feeling so well supported...having mitigated the worst of this for all of us.

Normally, I speak about issues of global equity, particularly knowledge translation through critical care and emergency medicine to the global south. Today I want to speak about issues that are particularly relevant to the Canadian context in the emergency landscape that the COVID-19 pandemic has made so clear. I will focus my testimony today on how we might continue these lessons from the pandemic to create a stronger, more robust and safer health system for Canadians. In particular, I will focus the discussion today on the topic of national licensure for doctors, nurses and other health care professionals in our country.

As you likely know, provincial licensure is what health care professionals require to gain the ability to treat patients. It's only in the confines of their province. Should you want to move to another province, either in times of disaster, pandemic or otherwise, you require an emergency order to do so. That process is cumbersome, ineffective, risky and really unsafe.

I believe we are the last remaining Commonwealth country—I wasn't able to go through the whole list, but we were the last—that doesn't have national licensure. It prevents more equitable distribution of health care resources, particularly as we move into greater virtual care opportunities. What's happening now is that I can't treat a patient in Iqaluit without a special reciprocal licence between our provinces. I think that needs to change.

As you can see, the nature of this pandemic, like all disaster, is one of asymmetry. This means that it doesn't just happen demographically; it happens geographically. You're seeing Manitoba going through a crisis right now that Ontario's just coming through to the other side of. You're seeing patients being transited from Manitoba to Ontario. That's dangerous. It's risky for the individual because if you're a sick person, it's much more risky to send you to Ontario than send a healthy nurse, doctor or RT to Manitoba. I think that through national licensure, we can start to equilibrate some of these resources.

While mathematical modelling can help predict something with the COVID-19 pandemic, it certainly can't predict an earthquake on the west coast or how high the Red River will rise. Giving physicians, nurses and other health care professionals the ability to move freely throughout the country would be an easy way to start redistributing these resources in times of emergency, and also overall.

I think, as you'll see in the coming months, we're about to face a crisis of a different kind. We're about to face a crisis of burnout. Pretty much every doctor I know, as they look to the future of their whole careers perhaps wearing the mask and shield, is thinking about doing something else. This is real.

I bring up this issue of national licensure because it's close to my heart. It initially came up when working in Inuit, Métis and first nation communities as a way to distribute health care resources there. Now I see it as a way to respond to a need in our health care community, which is the freedom of mobility to allow doctors and nurses to do what they love to do best, which is treat patients no matter where they are.

It's safer for Canadians, it's better for doctors and 91% of physicians want it. More than half of them say that it would increase the likelihood of their working in remote communities.

If we don't take this step, virtual care is going to move into a private sphere and we're going to miss an opportunity to keep it affordable for the average Canadian. With President Biden moving to insure up to 40 million Americans, there's no reason to stop a doctor in Alberta from now treating Americans using virtual care. We have to get ahead of that, in my opinion, and a national licence is the way to do that.

Reciprocity for this licence and allowing greater training is one thing that would encourage it as well, particularly as these people are committed to working in remote and indigenous communities or with those populations that have been made vulnerable by systemic inequity.

I would suggest that the federal government consider immediately establishing a reciprocal arrangement, or encouraging a reciprocal arrangement, between provinces that allows freedom of mobility of health care professionals during the COVID-19 pandemic. Then it should look to develop a plan to extend this reciprocal licensing arrangement between provinces, territories, indigenous and federal governments, allowing these health care professionals licensed in one to work in other provinces and territories.

The requirements are all the same. The training is the same. The fact is there is this expanse in the hurdles to jump over. It is kind of redundant. It makes the system vulnerable, because if someone has malfeasance in their past, it's less easy to track because they can go to another provincial college. They are siloed organizations.

Luckily, as Canadians, we haven't endured the big crimes that we've seen in the U.K. and Australia that allowed doctors to operate truly unqualified and hurt people. We're just waiting for that. Maybe that will never happen, but having a national autonomy and licensor is one way to do it.

In conclusion, there are two ways I think it can be done. One would be to start to focus on health care as administered through federal bodies, like indigenous, Métis and first nations communities. That is something that could allow them certain types of autonomy with registration, regulating who comes in and certain types of accountability.

The second and more robust way to do it would be to have the provinces, which have mandated to the college the licensing authority, mandate that authority to a national body. It wouldn't change the machinery of the provinces necessarily, but it would allow national licensure to be possible. I think ultimately it would be a good step not only to buoy the spirits of the health care workers who have been working very hard during this time, but also to encourage harmonization of health care in the country, improve accessibility to care and universality of care.

That is what I think is possible. It is what I imagine would be a positive step for the health care of Canadians.

[The Chair, Liberal, Ron McKinnon]

Thank you, Doctor.

I would just note that I have these cards. The yellow one I will display when there is roughly a minute left in your time, unless I become totally enthralled in the testimony. The red one is when your time roughly is up. If you see the red card, you don't have to stop instantly, but try to wrap up.

We will go now to Dr. Morris.

Doctor, please go ahead for six minutes.

[Dr. Andrew Morris, Professor and Physician, As an Individual]

Thanks so much. I have never paid attention when given any yellow card before, so I don't know why I should start now.

Mr. Chair and honourable committee members, thanks for allowing me to address you. Before I start, I want to acknowledge that I'm currently speaking on what I believe to be the unceded ancestral territory of the Haudenosaunee, where my family home currently rests.

I'm a professor of medicine and infectious diseases at the University of Toronto, and I'm also a consultant in infectious diseases at Sinai Health and University Health Network. Prior to this pandemic, most of my academic work was focused on antimicrobial resistance, that is, drug resistant infections.

I currently co-chair, with Dr. Gerry Wright, a project to conceive of a national network to tackle antimicrobial resistance, or AMR, and support the anticipated—and I'll say, massively overdue—pan-Canadian AMR action plan.

This is my fourth such appearance before your Standing Committee on Health related to infectious diseases over the past four years, and I'm really quite honoured to be able to have this privilege of presenting to you again.

I want to cover two things: pandemic strategy and antimicrobial resistance.

Pandemics require strategy. Strategy should be based on the best available information and should be adaptive to new information. The pace of new information that we have received has been rather incredible and unprecedented. In my first and second HESA appearances, I highlighted for this committee the potential cost involved in preparing properly for an antimicrobial resistance pandemic. I think I quoted $100 million price tag at the time. Just imagine now only spending $100 million in exchange for properly preparing for a costly pandemic. My guess is, by the way, that this government still won't commit $100 million for an antimicrobial resistance pandemic.

If we consider Canada's performance to date regarding this pandemic, and with deference to my colleague who just spoke, I think my personal and, I would say, reasonable assessment is that it was not good, but it could have been worse. We've lost over 25,000 Canadians directly to COVID-19. The fact that we will see well over 10,000 COVID-19 deaths since January 1 will remain one of the most catastrophic and tragic failures of our nation.

However, the cost to Canadians in terms of quality of life, sickness and death from other illnesses, including mental illness, will be orders of magnitude greater than this for years to come, and it didn't have to be this way.

If you compare our response in outcomes with the U.S., most of Europe and, say, Brazil, we've done quite well. When I was a kid, when I came home with a grade that was below my parents' expectations, I always mentioned the classmates who did worse. I never made a comparison when I received an A, however.

Canada's first responsibility moving forward will have to be an honest assessment of our performance, and, indeed, the Auditor General is doing some of this work, but we need a more fulsome assessment of our performance. I would suggest that the time to start such a commission, perhaps titled “Why did Canada not get an A in COVID-19?”, is now.

The U.K. and Brazil are both holding similar such commissions. Apart from the obviously gripping theatre both have provided, they've offered insight into the flawed mindset of two governments that dramatically failed their electorate. The question that should be on the minds of all of you and indeed all Canadians is: Why have you failed to seek a maximum suppression strategy?

In November, I used the term “COVID-zero” publicly, but “Zero COVID”, “Canadian Shield Strategy” and “No More Waves” have all been monikers to a strategy I've affixed my name to. It's been abundantly clear that exponential growth has meant that living with COVID-19 was never an acceptable strategy, even though it was attempted. This would be true for any future pandemics.

Moving forward, Canadian governments should have a stated policy that says, “We will work to maximally contain and suppress any new infectious diseases throughout until the nature of that threat is fully understood.” This would have meant clear and consistent pan-Canadian communication, closing our borders sooner, reducing interprovincial and regional travel, making no assumptions on the nature of its transmission, protecting the most vulnerable members of our society with a focus on obtaining the data to demonstrate this protection, rapidly and transparently sharing this data, starting up clinical trials similar to what was done in the U.K., relying on the best available scientific evidence and stating, most importantly, that the primary goal of government and public health with infectious disease threats is not to protect the health care systems or the economies from the threat, but to protect the health of Canadians.

On May 28, 2021, we can start learning from this. Our government can make a commitment to maximum suppression of COVID-19. This does not mean locking down our society for the entire summer, but doing everything possible to continue to drive our cases down so that we'll be able to start the school year in full force, with an economy that can start working in full force.

Before I address AMR, I want to make one last point. It's very possible that in an upcoming school year we will be faced with an outbreak of a non-COVID infectious disease. It could be influenza or maybe another virus. In that situation, it would be important that we do not dismiss it. I have found myself at times dismissing other infectious diseases. Do we need a flu-zero approach? I doubt it. However, the famous and proudly Canadian overburdening of hospitals in winter is unquestionably due to respiratory viruses. We can and should do much to reimagine respiratory viruses.

That brings me, lastly, to antimicrobial resistance. I've spent most of my career tackling AMR. It has not gone away, and it won’t go away. Moving forward, the AMR pandemic, which is a much slower moving one than COVID, will continue to require close and careful attention. It is not going to come and go like the COVID-19 virus. It will endure and grow in nature.

This very committee has a responsibility to Canadians. It has failed in the past to address and push government on properly addressing this. We need to address AMR in Canada and globally in the same manner that we've been addressing COVID-19. Thank you.

[The Chair, Liberal, Ron McKinnon]

Thank you, Doctor.

Professor Taillon, you have the floor for six minutes.

[Patrick Taillon, Professor, Faculty of Law, Université Laval, As an Individual]

Thank you, Mr. Chair.

My name is Patrick Taillon, and I am a professor in the faculty of law at the Université Laval.

I will summarize my main remarks briefly based on a very simple idea: one of the best decisions the federal government made in managing this unprecedented crisis was definitely its decision not to invoke the federal Emergencies Act, for the following reasons.

First, we can now see, particularly from a rights and freedoms perspective, that there was no need to invoke the act. We can also see how far the judiciary adapted its interpretation of rights and freedoms to our circumstances at the time. The government's decision not to use the act thus enabled it to maintain control and to let the judges do their work, while at the same time adapting that work.

Second, it is clear that, under our federalist regime, governments did not lack authority. The federal and provincial governments had all the necessary authorities in their toolbox to address the crisis. All they had to do was invent solutions that they could not yet know of at the time.

In short, we must not fall into the trap of thinking that each level of government inevitably did good and bad things and that uniform and centralized solutions would suddenly have solved all problems. On the contrary, the logic of subsidiarity, cooperation and autonomy that federalism presupposes runs somewhat contrary to this idea of uniformity. Federalism made a minimum level of experimentation possible during the crisis. No one had a magic solution, and federalism, under which the member states of a federation enjoy autonomy, enabled each state to exercise a degree of innovation.

British Columbia did some things right. Each province handled mask-wearing in its own way. The Atlantic bubble was an original idea suited to that part of the federation. As a member state of the federation, Quebec, where I come from, did good and bad things in its own way. Its curfew and the reopening of its schools in the spring of 2020 made it possible to gather data and to test a solution that was subsequently imitated by others. Quebec did the same when it decided to administer second doses of vaccine sooner than previously planned.

This degree of autonomy, experimentation and innovation in the spirit of cooperation was absolutely necessary in managing the crisis. With a combination of diversified measures, the two levels of government were able to imitate each other and adjust their game plans. Federalism, which fosters the autonomy of every member state in the federation, especially enabled each to play the role of countervailing power, which is essential in times of crisis.

At the lowest points, when nothing was working and the courts were virtually closed, newspapers were on the brink, incomes were clearly declining and parliamentary assemblies were closed, how else could we have exercised that countervailing power in Canada? What countervailing power could have protected citizens? The tensions and disputes that continued between the federal and provincial governments nevertheless bolstered citizens' trust in our institutions, to the extent that the sight of two leaders and two governments confronting and monitoring each other afforded a form of control, surveillance and countervailing power that were particularly necessary during those difficult times.

Obviously, the federal government could have done better. Its performance was partly shaped by circumstances. We can debate at length the state of necessary equipment reserves. We can say that borders should have been managed more quickly and efficiently. However, at some point, we have to accept that what was done is done. We must especially take note of mistakes that must not be repeated. On that point, the serious impact of underfunding for health definitely suggests that we could have intervened more effectively in that field and that we will have to do better in future.

It is therefore important to establish stable health funding. To do so, the federal government should either make a lasting commitment, over years, so that the provinces can rely on its participation, or else disengage and allow the provinces to use the necessary fiscal room. Whatever it does, we cannot play at yoyos or Russian roulette with health funding. It cannot be subject to circumstantial fluctuations. It must be stable.

Lastly—and this will be my final comment—as for what was done well but could have been done even better, I would say that cooperative federalism, that necessary cooperation between levels of government, could have gone further. Considering the powers it has, the federal government could have made adaptation measures available to the provinces. Consider travellers, for example. When it had to make decisions on how to manage the borders, the federal government could have played the cooperative federalism card to a greater degree. In the "Atlantic bubble", for example, borders and flights could have been shut down at the request of the provinces concerned, whereas other provinces could have established mandatory quarantines, a measure that moreover was ultimately adopted.

Uniformity is not the most suitable solution. It is an instinctive reaction that is contrary to the spirit of federalism and should be avoided. Management of the crisis required cooperation between the federal government and the provinces. It also called for respect for the autonomy of each government instead of the instinctive impulse to claim that one level of government is, by definition, better than another and thus shielded from the necessary interplay of trial and error, good and bad ideas and the competition between levels of government. That competition enabled us to secure countervailing powers, innovate and imitate each other. In that respect, I want to emphasize the importance of the autonomy of the federal government and federated entities in managing such a crisis.

Thank you.

[The Chair, Liberal, Ron McKinnon]

Thank you, Professor Taillon.

We'll now go to Switch Health for six minutes.

[Jordan Paquet, Vice-President, Public Affairs, Switch Health]

Thanks, Mr. Chair. We're going to split our time very quickly, but we'll be under six minutes.

Thank you, and good afternoon, honourable members. Thank you so much for inviting us today to talk about Switch Health's innovative at-home testing solution that was developed in response to Canada's fight against COVID.

I am Jordan Paquet, the VP of public affairs, and I am pleased to be joined today by Dilian Stoyanov, our CEO, and Olga Jilani, our CFO.

We want to thank the members of this committee for the important work you are doing on this study.

This past year and a half has been very difficult for Canadians, especially frontline workers. We are pleased to be here to tell you a bit more about our company, our services, and to answer any questions you may have.

[Dilian Stoyanov, Chief Executive Officer, Switch Health]

In essence, we are a homegrown Canadian success story that met a daunting task during the pandemic, bringing critical health care services to an increasingly virtual world. Meeting this need for increased domestic testing capacity required a company that was forward thinking, flexible and patient-focused.

In a matter of months, we were able to hire hundreds of experienced health care professionals, meet the needs of Canadians and collaborate with Canada's leading laboratories. This is a service Canada needed. Canada needed a novel solution to collect specimens at home with the oversight of a telehealth employee through our proprietary privacy compliant telehealth and results reporting software.

Despite the logistical challenges and early hiccups, we're proud to say that our at-home collection kits met demand and, most importantly, minimized exposure to the virus.

It is about a 10-minute process, and the results are usually returned to patients within 24 hours of reaching one of our partner labs. Courier times may vary by location. With our partner, Purolator, and other third party logistics providers, we can reach 100% of Canada. Additionally, we are proud to work with Uber to ship kits in Toronto, Vancouver and Montreal.

Our instructional manual is available in 15 languages, including three indigenous languages.

In February 2021, Canada introduced new border measures to help prevent further introduction and transmission of COVID-19, including new variants. It needed help with PHAC-directed testing of international travellers, and we applied.

PHAC required an operation with supervised testing and self-collection, kit transportation, electronic results reporting, and laboratory partnerships supported by the latest technological operations. Prior to the federal program, Switch Health was providing testing services via our clinics and mobile units with other levels of government, public health units, major companies, individuals and families.

[Olga Jilani, Chief Financial Officer, Switch Health]

We scaled up efforts at an extremely rapid pace, with close to 1,200 telehealth staff now servicing travellers. Within this federal program alone, we have administered over 600,000 tests for travellers entering Canada. We have identified over 6,400 positive cases of COVID-19, including over 2,200 second-test positives and 1,500 variants of concern. Because most of these individuals were at home when they took their test, the risk of community spread was greatly reduced.

Of course, we have experienced some growing pains, with the volume of demand for testing rising exponentially and sometimes causing delays in service. We have been working diligently to improve our operations and processes and the speed with which we deliver results, by adding more telehealth and customer service staff. For example, since introducing appointment times for telehealth sessions, the average wait time has been reduced to 10 to 15 minutes. Currently, over 99% of travellers, including those in rural and remote regions, receive their results on or before their 14th day of quarantine.

We are still adding new resources so we can better serve travellers in both official languages.

Although we've been hired to provide additional testing services for temporary foreign workers in Ontario only, we've been asked to intervene temporarily to assist in providing additional testing services for temporary foreign workers from Quebec.

Recognizing the importance of Canada's food security, we are honoured to provide assistance until a permanent solution is found. We are pleased to continue serving travellers from Quebec by supplying our Day-8 test kits.

Before I conclude, I want to take a moment to address last night's report on Global News. We're proud to employ over 1,100 nursing professionals. We also employ a small number of trained telehealth generalists, who are permitted to oversee this type of testing process. Any suggestion that Switch Health has ever instructed employees to identify themselves as a nurse when they are not is categorically false. We acknowledge the hard work of all medical professionals during this pandemic and have never instructed any of our staff to mislead the public.

Developing an innovative and accessible testing solution in Canada’s fight against COVID-19 is helping transform how health care is delivered. And with the pandemic having a disproportionate effect on women, we're proud that we're not only offering a flexible work experience for the majority of our employees, who are women, but also that we're a company with women in positions of origin and leadership.

Earlier this week, we were proud to announce our new chief medical officer, Dr. Gregory Taylor, who served our country as Canada's chief public health officer. We are proud to be at the forefront of protecting the health and safety of Canadians in one of the most challenging times in global history. We very much appreciate your support in doing so. Thank you, again, for this opportunity.

Thank you, everyone.

[The Chair, Liberal, Ron McKinnon]

Thank you to Switch Health, all of you. Thanks to all of the witnesses for your statements. We will start our round of questions now with Ms. Rempel Garner.

Please go ahead, Ms. Rempel Garner, for six minutes, please.

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

Thank you, Chair.

Mr. Stoyanov, as it relates to services provided to the Government of Canada for at-home COVID-19 testing of international travellers, has Switch Health ever been legally obligated to ensure that samples collected via the online portal were collected under the supervision of a nurse?

[Dilian Stoyanov]

Thank you for the question. Can you just clarify the last part of the question, please?

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

Has Switch Health ever been legally obligated to ensure that samples collected via the online portal were collected under the supervision of a nurse?

[Dilian Stoyanov]

All specimens collected under the supervision of a telehealth professional, a nurse or a telehealth generalist, are done in compliance with laws in the respective provinces.

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

Were you ever contractually obligated to have the supervision observed by a nurse?

[Dilian Stoyanov]

I believe my colleague Olga Jilani will have more details about the contract, if I may, please.

[Olga Jilani]

The contract calls for any individual who is overseeing specimen collection over telehealth to comply with the regulations of the province in which they reside. As you can imagine, over—

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

Thank you. Has that ever changed?

[Olga Jilani]

Over the scope of the pandemic, in fact, at the time of the pandemic the scope of service—

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

Thank you. I don't have time. Have you ever been contractually obligated to have the samples collected overseen by a nurse, and has that ever changed?

[Olga Jilani]

The contract calls for a telehealth appointment to be overseen by a medical professional.

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

By a “medical professional”. What percentage of samples collected by Switch Health to date were collected by the online portal under the supervision of somebody other than a medical professional?

[Olga Jilani]

We employ 1,172 registered nurses and registered practical nurses and 17 medical generalists. For reference, those medical generalists are respiratory therapists—

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

Thank you. That's not what I asked.

Have any samples been collected while not under the supervision of a medical professional?