Health Committee on June 11th, 2021

[The Chair, Liberal, Ron McKinnon]

I call this meeting to order.

Welcome, everyone, to meeting number 43 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.

I'd like to welcome the witnesses.

Appearing as an individual is Dr. Jillian Kohler, professor, Leslie Dan Faculty of Pharmacy, University of Toronto. Also appearing as an individual is Mr. Yanick Labrie, health economist.

Mr. Labrie will be joining us for both panels. He will be talking, actually, about the PMPRB, I understand.

We have, from Dan's Legacy Foundation, Ms. Barbara Coates, executive director; and Mr. Tom Littlewood, psychologist and program director.

I'd like now to invite the witnesses to make their brief statements.

Before we do that, I will note that I have cards—magic cards. I will display the yellow one when there's roughly a minute left in your time, and when your time is up, I'll display the red card. When you see the red card, you don't have to stop instantly, but do try to wrap up.

That being said, we will start now with Dr. Kohler.

Dr. Kohler, please go ahead. You have five minutes.

[Professor Jillian Kohler, Professor, Leslie Dan Faculty of Pharmacy, University of Toronto, As an Individual]

Thank you so much.

Honourable members, thank you for the opportunity to speak today.

I am going to focus on how a lack of transparency and accountability in the supply of COVID vaccines has impacted Canadians. The COVID-19 pandemic has amplified the vital importance of the role of governments to ensure access of their populations to safe and effective vaccines.

The deployment of COVID-19 vaccines illuminates the importance of transparency. The large sums of public funding involved in the research and development process, every country’s urgent need for the vaccines, and the need to enhance public confidence in them are reasons we need transparency. What is more, public funding has contributed to the development of the COVID-19 vaccines, earning the global public a right to have much more transparency around their procurement.

COVID-19 vaccines are a global public good. Everyone everywhere can benefit from them.

When information regarding the deployment and supply of these vaccines is not publicly available, there is an information vacuum. That creates fertile ground for public distrust in vaccines and may contribute to vaccine hesitancy, as well as allowing for misinformation to flourish.

Opacity in clinical trial reporting of adverse effects can contribute to vaccine hesitancy as well. According to a recent Gallup world poll, such hesitancy translates into about 32% of people worldwide who are unwilling to get a vaccine. This will put a critical dent in our efforts to end this pandemic.

Uncertainty and misinformation can only be tackled by the sharing of evidence often and clearly. The more this is done, the more likely we are to generate public trust and bolster our vaccine deployment efforts.

In “For Whose Benefit?”, a recent study my research team contributed to with colleagues from Transparency International UK, we found that Canada has done relatively well in making its clinical studies report available. Still, Canada has also participated in the alarming trend of governments censoring key details of their orders from drug companies, or not releasing them at all. This creates, and rightly so, a perception of asymmetric power between pharmaceutical officials and public officials.

Procurement in the best of times is a government function that is at the highest risk of corruption. During emergencies, these risks are amplified due to the need for speed and flexibility in the process. We need to move fast. That is why transparent and accountable public emergency procurement processes are vital during a pandemic.

Accountability helps to ensure that relevant institutions answer to those who will be affected by decisions or actions taken by them. It can also reduce the risk of abuses, assure compliance with standards and procedures, and improve performance and organizational learning. Institutions need to explain and justify their results to internal and external monitors or stakeholders and, when performance falls short, we need to let that be known.

We have witnessed a deficit of transparency and accountability on the part of the Canadian government, particularly in terms of its negotiations and purchasing agreements with pharmaceutical companies. Greater transparency will allow the public to know what prices were paid. This will allow for more informed decisions and can, over time, lead to greater purchasing power to negotiate prices with suppliers. Transparent pricing data can illuminate patterns and any outliers, such as overpayments, kickbacks, etc.

Procurement systems without accountability and transparency mechanisms create real risk in terms of credibility and trust in the process.

We know that this pandemic will only end when we are all safe. This means we, as Canadians, need to be concerned not only about our own vaccine supply but also about those of other countries, not only for health reasons but for humanitarian ones, as well.

We're dealing with the pharmaceutical industry, which is often secret in order to protect its commercial interests. This has never been acceptable. As the saying goes, in times of crisis, there is opportunity. The global pandemic is an opportunity for the Government of Canada to insist on transparency from the pharmaceutical industry and, in doing so, heighten its accountability to the Canadian people. It needs to be forthcoming with how much it's paying, what it's negotiating and why, in order to boost public trust and confidence in our supply of COVID-19 vaccines.

Early on, prior to Health Canada’s authorization of any COVID vaccine, the federal government overbought doses for the Canadian population. In our study we found that we have, as Canadians, 11 agreements in place, which translates to about 16.23 doses per person. By comparison, the United States has eight total agreements and about 10.2 doses per person.

In Canada, despite this abundance, we failed to meet clear timelines in terms of when the deliveries from manufacturers would happen. As a result, supplies were erratic and uncertain in the first quarter of 2021, and this meant frustration and fear amongst Canadians.

Even though our government made agreements with manufacturers that far exceed our population needs, we also dipped into COVAX, which is the multilateral initiative for helping to ensure equity of access to COVID vaccines globally. Canada's standing as a global health leader is now in question, as it turned to COVAX when the majority of low-income countries globally are still struggling to have enough vaccine supply to vaccinate even their health workers.

In closing, what I will say is that it's essential to integrate better transparency and accountability measures in our agreement with the pharmaceutical industry if we hope to gain public trust. Canada has the opportunity right now to champion pricing transparency, become a global leader for clinical trial transparency, and also release full information about its vaccine negotiations with suppliers.

Thank you for your time.

[The Chair, Liberal, Ron McKinnon]

Thank you, Doctor.

Mr. Labrie, go ahead for five minutes.

[Yanick Labrie, Health Economist, As an Individual]

Thank you, Mr. Chair.

Good afternoon, everyone.

First of all, I would like to thank the members of the Standing Committee on Health for the opportunity to testify today as an individual on the regulatory changes contemplated by the Patent Medicine Prices Review Board, the PMPRB.

My name is Yanick Labrie, and I am a health economist. I have taught economics at various colleges and universities in Quebec. In the past 15 years, I have conducted more than 30 studies on pharmaceutical policy issues for various research centres. My presentation today is based in large part on research that I have conducted and published in recent years.

In March 2020, the PMPRB's executive director stated that the tightening of price controls under consideration would not have a negative impact on R&D investment or drug launches in Canada. It was a surprising statement, to say the least, and one that contradicted both economic theory and the empirical literature on the subject.

First of all, we know from economic theory and experience that pharmaceutical companies rank potential investment projects in descending order of each one's expected rate of return. Obviously, in the context of tightening price controls, with increasing uncertainty surrounding R&D projects and declining anticipated profits, one should clearly expect a drop in pharmaceutical R&D investment in Canada if the PMPRB decided to implement its regulatory reform. The entire life sciences ecosystem across the country, particularly in Quebec and Ontario, would be affected.

Furthermore, there can be no doubt that pharmaceutical companies will tend to prioritize launching their drugs in countries where anticipated profits will potentially be highest. Since stricter price controls decrease companies' anticipated profits, there will be less incentive to prioritize new drug launches in the Canadian market, which is relatively small in the global context.

These are not merely theoretical predictions. Last year, I conducted an exhaustive review of the scientific literature on the links between price regulation, pharmaceutical R&D investment and access to medicines. That peer-reviewed study was published in the June 2020 issue of Canadian Health Policy. Only 4 of the 49 academic studies surveyed established a significant link between price controls and delays in new medication launches, and only one found no evidence that price controls reduce pharmaceutical R&D spending. All the other 44 studies showed that price control policies discourage R&D investment and reduce or delay drug launches in countries that impose them. Small markets for pharmaceutical companies, such as Canada, are particularly at risk of seeing delays in the marketing of new medicines.

You also have to understand that delayed drug launches generate societal costs because they prevent many patients from enjoying the drugs' health benefits sooner. These delays increase the risks of complications and premature death and have negative effects on patients' quality of life. They also increase the economic burden that patients are very often forced to bear while waiting for a more effective drug.

From 2009 to 2018, it took an average of 690 days, nearly 2 years, for provincial governments to agree to cover new medicines approved for marketing in Canada. Unfortunately, the tightening of price regulation contemplated by the PMPRB could vastly undermine pharmaceutical innovation and force patients to go without drugs they need or to wait even longer for access thereto.

The regulatory changes proposed by the PMPRB are based on the idea that the rising influx of costly drugs in recent years would compromise the capacity of insurance plans to bear the increased costs associated with them. However, the data that the Canadian Institute for Health Information has published on changes in total spending on prescription drugs in the past 10 years show that this is not all the case.

In fact, despite the rising influx of more expensive drugs into Canada, we have seen slower growth in total pharmaceutical spending in the past few years, including distribution and pharmacy services. Adjusted for inflation, real per capita spending on medicines has experienced zero growth in Canada since 2010.

Spending in all other main health expenditure categories has risen faster than spending on prescription drugs in the past 10 years. In 2019, prescription medicine spending represented 13% of total health expenditure in Canada, a figure that had declined since 2010. Spending on prescription drugs across the country also fell as a percentage of GDP from 1.7% in 2010 to 1.5% in 2019.

This pharmaceutical expenditure actually tends to be overestimated as it does not reflect confidential discounts secured by federal, provincial and private drug insurance plans.

In conclusion, I do not recommend that the members of the Standing Committee on Health support the regulatory changes contemplated by the PMPRB. Contrary to what one frequently hears, spending on drugs and pharmaceutical services is not out of control in Canada. Spending on prescription medicines has represented a steadily declining segment of Canada's economy and health budget since 2010.

The tightening of price regulation that the PMPRB is considering could well have negative consequences for the Canadian public. It will not only delay the launch of new drugs in Canada and reduce their number but will also discourage R&D investment, which is essential to guaranteeing the development and availability of new medicines for Canadians in future.

Thank you for your attention.

[The Chair, Liberal, Ron McKinnon]

Thank you, Mr. Labrie.

We go now to Dan's Legacy, starting off with Ms. Coates.

Ms. Coates, please go ahead.

[Barbara Coates, Executive Director, Dan’s Legacy Foundation]

Thank you, Mr. McKinnon.

Hello, everyone. I'm Barbara Coates. I'm the executive director of the Dan's Legacy Foundation. I'm joining you today with my colleague, Tom Littlewood. We thank you for this invitation to speak to the committee.

I'm Zooming in with you from Delta, British Columbia, which is on the traditional and unceded territory of the Tsawwassen and Musqueam first nations. Mr. Littlewood is joining us from Coquitlam, which is in Mr. McKinnon's riding and is, of course, the traditional and unceded territory of the Kwikwetlem First Nation.

My colleague, Mr. Littlewood, is a psychologist with over 45 years' experience in working with youth at risk in the community, and we're here today to offer both our testimony on how the coronavirus pandemic has affected the opioid crisis here in Metro Vancouver and our recommendations for harm prevention solutions.

I'd like to turn it over to Mr. Littlewood now.

Thank you.

[Tom Littlewood, Psychologist and Program Director, Dan’s Legacy Foundation]

Thanks, Barb.

Regarding COVID-19 and its effect on mental health, overdoses, self-harm and psychosis incidents have increased 50% with our youth clients. We serve about 300 clients a year currently, and that is about to double. Hospitalizations, because of this, cost $1,500 to $2,500 a day and up.

Anxiety and depression are widespread. These mental health issues paralyze young people, causing many to retreat and hide in their single-room occupancy, SRO suites, or basement suites.

The opioid crisis has worsened during the COVID-19 pandemic. We predict that the situation will only get worse, as there are thousands of young people in line to become the next wave of addiction to hit our streets.

Every year about 1,000 youth age out of care in British Columbia, and a further 1,000 hit the streets, running away from dysfunctional homes. Over 60% of these youths aging out of foster care will descend into entrenched addiction to numb their psychological pain.

However, there is a critical period between the ages of 15 and 25, when these young people usually ask for help. If trauma-informed therapy is provided to them for free and without a waiting list, up to 75% of these youth will respond and achieve success in school, work, recovery, housing and job-skills training. They can be diverted from the path towards homelessness, entrenched addiction, overdose and suicide and on towards lives they will enjoy living.

The initial effects of past trauma, which include physical abuse, mental abuse, sexual abuse, poverty and intergenerational trauma experienced by our indigenous clients, are normally expressed, to begin with, as anxiety, depression, eating and sleeping disorders, and self-medicating behaviour.

Our therapeutic intervention of four months of trauma-informed counselling costs approximately $2,500. Once the youth descends into entrenched addiction, it costs the community millions of dollars when police services, first responders, hospitals, corrections system, etc., are factored in. This does not even begin to take into account what the addict has to steal, or the sex acts they have to perform in order to get the money to buy the drugs they need.

Harm prevention, specifically trauma-informed therapy, can divert a youth's path away from addiction and homelessness, which not only saves valuable lives but saves millions of dollars in costs to the community.

Trauma-informed recovery is a new idea, and it's still controversial. Rather than the 12-step abstinence recovery programs, which are not best practices with youth, especially regarding opioid addiction, trauma-informed recovery involves a doctor, a therapist and a client agreeing to a contract whereby the physician prescribes an opioid replacement for the client while the client is undergoing trauma counselling.

When working with a therapist, typically over a period of four months, the client first learns self-regulation techniques. This is followed by the counselling trauma work, to help youth gain insight into their past trauma.

Once the trauma work is complete, the client has no need to self-medicate for the psychological pain, and this is when the physician steps in to provide something like an opioid replacement of Suboxone to help them come down without the drug sickness.

This approach is new and controversial, but it is becoming the best-practice model for young people with opioid addiction. Using prescribed stimulants as a replacement for street drugs like crack or meth is also being explored.

The side effect of the opioid crisis and the overdose crisis is the growing number of permanent brain damage situations caused when someone is brought back using Narcan or Naloxone. Some youth brag about how many times they have recovered using Naloxone; however, as therapists we can see the gradual deterioration of cognitive function after multiple applications of Naloxone over multiple overdoses.

A practical harm prevention idea that you can take from this is a CERB forgiveness program for young people who engage in recovery, education, work or training for a year. The money is gone; it's not going to be recovered. These kids don't have this, but it will create an insurmountable obstacle for these young people and cause thousands to give up and go underground to the street, speeding up the path to addiction and homelessness. I have had a youth end their life by suicide when faced with $1,000 in transit fines, which come due when they are about to get their first driver's licence. Imagine the chaos we're going to find when thousands are asked to repay the thousands of dollars they received from CERB fraudulently.

In summary, our goal is to get ahead of the curve of both COVID-19 and the opioid crisis by employing harm-prevention strategies of trauma-informed therapy, training and recovery.

Thank you.

[The Chair, Liberal, Ron McKinnon]

Thank you all.

We will now start our questions with Ms. Rempel Garner.

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

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

Thank you, Chair.

My questions will be for Dr. Kohler.

Dr. Kohler, our committee has had a great degree of difficulty obtaining details around the contracts that were signed by the federal government with vaccine manufacturers. One small example would be that I don't think Canada has received a single dose of vaccine from AstraZeneca, in spite of our bilateral contracts.

Based on your research, is there any reason why we as parliamentarians shouldn't be getting access to that?

[Prof. Jillian Kohler]

The short answer is that there should be absolutely no reason why you can't get access to that. What I was advocating for—and I had to shorten my presentation—was that the public as well as our representatives in Parliament should know.

What was interesting was that in our research we were looking globally, but we found it was very hard to get access to these contracts. Again, don't cite me—I can give you the proper numbers—but I think we looked at about 182. We could get good information for only—

[The Chair, Liberal, Ron McKinnon]

Dr. Kohler, could you lift your mike, please?

[Prof. Jillian Kohler]

I apologize. I'm using my own microphone. Does that work better?

Even with the contracts we found, there were a lot of redactions. Even if they are publicly available, oftentimes the information is limited. I'm speaking generally now.

My point is that I think this is a political decision. This is about the government not standing up to its suppliers and saying, “We need to have transparent contracts in place.”

The other point I want to raise here is that Canada, as we all know, has done prepurchases with suppliers that far exceed those of pretty much any other nation in the world.

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

Can I just get in on that?

Do you think that happened because they came late to the table? Once upon a time I used to work in something like that space, and that's really the only reason I can surmise.

[Prof. Jillian Kohler]

Again, I defer to you on that.

I would say, though, that it in fact gives Canada a lot of power to negotiate. When we purchase so many doses, we can say, “We're going to be a big purchaser, and this is what we want: We want transparency.”

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

I'm sorry to cut you off, but I have a very short period of time.

I've read some of your work, and I know you do a lot of work on anti-corruption and accountability. Do you have any comments on what potentially went wrong between CanSino and the federal government on that vaccine contract?

[Prof. Jillian Kohler]

It's a big question. I would argue that we're talking here about bigger issues. We're talking about foreign affairs. We're talking about geopolitics here, so I don't think we can look at that as simply a contract between the Canadian government and one supplier. I think we're looking at the global political context, in that light.

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

The other thing the committee is looking at right now, in the context of both PMPRB reform and access to vaccines, is the concept of the government's role and what the government has done in terms of supporting research and pharmaceutical research, particularly in the private sector in Canada, and then what the trade-off should be.

In bullet-point format, in 30 seconds or less, what are the types of subsidies that government would give to pharma right now, including intellectual property protection frameworks?

[Prof. Jillian Kohler]

I'm going to speak to what I know, which is intellectual property. I'm not an economist; I'm a political scientist.

I'm going to actually say we don't need to be giving IP protection. In fact, I think if anything, we need to be rethinking the IP model. That is one of the major issues we have in terms of access to COVID-19 vaccines. We've seen that, historically, the United States is actually saying we should be waiving intellectual property rights.

I would say we need to be negotiating differently with the industry. These are different times and bigger crises, and the same old doesn't work. That doesn't quite directly answer your question, but I'm hoping—

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

No, no; it's good. I think we have to talk about intellectual property rights in a broader context here.

In that context, I know that therapeutics for infectious diseases and vaccine development are normally on the low end of the priority list for pharma development. What are the incentives, and what are the reasons for that? Is it our IP protection model or what?

[Prof. Jillian Kohler]

It's about where the market is, quite frankly. The industry will be the first to say that it will invest where there are markets and where profits are greatest.

I know I'm sounding extreme here, but I've been working in this area for 25 years as a policy person and as an academic, so I've worked on many sides of this issue. The reality is that we can't rely on the industry to fill all our needs. There needs to be a rethinking in terms of the role of government—

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

I have just a last question. I'm sorry. I'd love for you to table any recommendations that you have with our committee.

It's on a different subject, but it's related. The COVID Alert exposure app has only been downloaded a few million times. One expert called this ludicrously low, but a lot of government resources have been attached to it.

You talk about value for money. Do you think additional resources for this app at this time are a good idea? This is another thing that is before our committee in terms of supplementary estimates.

[Prof. Jillian Kohler]

Absolutely not. In the development world, we look at value for money and the biggest bang for the buck. If there's not a bang for the buck and it's not working, then shift resources elsewhere. Maybe it's more about public health education and information strategies, etc.

In terms of recommendations, we should be waiving intellectual property rights, one hundred per cent. That is my strongest and probably most passionate recommendation.

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

Thank you.

[The Chair, Liberal, Ron McKinnon]

Thank you, Ms. Rempel Garner.

We go now to Dr. Powlowski.

Dr. Powlowski, go ahead, please, for six minutes.

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

My question is for Dr. Kohler as well. Let me begin by saying that I absolutely agree with waiving the intellectual property rights on vaccines so developing countries can get greater access to them.

I wanted to comment or question you about your article in The Globe and Mail in February, entitled “Developing countries won't forget Canada's 'me-first' approach to vaccines” , in which you talk about a “my-nation-first” approach to vaccines.

An article just came out in the Globe, I think, suggesting that we're committing 100 million doses to developing countries. I think you realize we are one of the biggest contributors to COVAX.

I think the question is going to be when we start sending those doses of vaccine. Let me ask you this. I'm a member of Parliament for Thunder Bay—Rainy River. I have an obligation to my constituents. I have spent seven years working in developing countries for $1,000 a month, when I obviously could have made way more money here. My kids got malaria; I got malaria and our kids got dengue, but I absolutely believe that global equality in health care ought to be one of our society's greatest goals.

Having said that, if we're advocating starting to give vaccine doses now, when Canadians haven't been fully vaccinated.... For example, my parents, who are in their 80s, have only gotten one dose. If we get the delta variant, apparently one dose decreases incidences of symptomatic disease by only 33%. It's not that good.

What can you say to us as MPs? How should we balance those two important considerations and the fact that people in my riding would probably say that they agree with giving these vaccines, but let's protect our own population first?