Health Committee on June 11th, 2021

[Prof. Jillian Kohler]

Yes, it does. I'll keep it short here, because I know we're pressed for time.

I'll go back to my days working with the World Bank. I was in a program with a representative from a large pharmaceutical company. I asked him, “How do you determine prices?” He put his hands in the air and said, “Wherever the wind blows.”

There is a lot of variability in terms of how prices are negotiated, who does it, when, how and why. Again, I'm not saying that greater transparency is going to be the solution, but it's probably the beginning of getting to a better solution, in terms of more equity of access and more transparency in pricing.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you, Dr. Kohler.

[The Chair, Liberal, Ron McKinnon]

Thank you, Mr. Davies.

That wraps up round one. We have a few minutes left. I'm going to propose to the committee that we do a snapper round. We have time for maybe one minute per party. With that in mind, I'll go to Mr. Maguire.

Mr. Maguire, please go ahead for one minute.

[Larry Maguire, Conservative, Brandon—Souris, MB]

Thank you, Mr. Chair. I think we probably have a couple of minutes.

I just want to say in regard to my NDP colleague's comment just now, he is absolutely correct. We paid double what the Americans paid and three and four times what some of the European countries paid, even for some of the Pfizer vaccines we got early, and even throughout the period of time here.

To your comment, what kind of a premium did we have to pay on those and why? How will the rest of the world be looking at paying for these? I think it's roughly 80% that are not even vaccinated yet and do not have vaccines yet. What's Canada's role in that?

[Prof. Jillian Kohler]

To answer the question where I feel I can, again, this goes back to bigger questions like, why are we offering intellectual property? Why are we allowing for pricing to be so secretive?

The best thing we can do is expand access through the waiving of intellectual property rights, by allowing for technology transfer where it's needed, more manufacturing and more access for the global population. I will repeat again that when the global population has equity of access to COVID vaccines, we all win. It's not an “us versus them”. We all win if we are all getting equity in terms of access.

[Larry Maguire, Conservative, Brandon—Souris, MB]

That's actually—

[The Chair, Liberal, Ron McKinnon]

Thank you, Mr. Maguire.

We'll go now to Ms. Sidhu.

Ms. Sidhu, please go ahead for one minute.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, Mr. Chair.

Before my time starts, I have a point of clarification. We need to clarify that there's never been a contract between CanSino and the Government of Canada. I believe it was suggested earlier that there was one. This is not correct.

My question is for the witnesses from Dan's Legacy.

As many young people are going back to school, or will be going back in the fall, we know that all levels of government are looking at how to support our return to normal. Where do you think the federal government can be most effective in supporting youth as we reopen, particularly youth in similar circumstances to those your organization supports?

[Tom Littlewood]

As I mentioned, thousands of young people have gotten CERB fraudulently. There were websites that showed them how to do it and what to say. These kids are not self-regulated, so they responded to this in droves. If we keep that repayment program that's in place now, we're going to see...I think it was 48 million that went to high school students. That doesn't count the kids that are not in school or anything. We really need to look at that as a potential way to solve a problem, rather than creating a barrier.

This is going to affect thousands of young people, and we're not going to get the money back anyway. We could encourage them to engage in things that will help them, like going back to school, working, recovery, etc.

[The Chair, Liberal, Ron McKinnon]

Thank you, Ms. Sidhu.

Mr. Thériault, go ahead for one minute.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you, Mr. Chair.

I'd like to speak to Mr. Labrie.

We have to find solutions. I know you'll be making another statement shortly, but first I want to discuss a proposal that Research Canada is also attached to.

Rather than postpone the reform, as was previously done on two occasions, the proposal is instead to implement it in stages. First of all, there appears to be a consensus that the reference basket of countries with substantial economies should be redefined. Then all it would take would be for all the players to sit down at the same table and discuss solutions related to pharmaco-economic factors.

Would that be a desirable solution? Would it be a promising point that we could agree on to begin the discussion and come up with win-win solutions?

[Yanick Labrie]

Yes, absolutely.

I mentioned in my remarks that this reform wouldn't likely generate long-term benefits for Canadians. On the contrary, there's considerable risk for access to new drugs. Access could be delayed or R&D investment undermined. You know the rest. I won't repeat it all because I've already said it.

One thing is certain, and that's that the various industry stakeholders could sit down around the same table and show that drugs aren't just pills. They're backed by an ecosystem, a body of knowledge and research, both basic and applied. It's very important that all those people, including patient groups, have a voice in that discussion.

You definitely have to be transparent and honest with Canadians. It's not true that this reform doesn't offer benefits; it entails not negligible costs. That's what you have to present to people in order to reach informed decisions.

[The Chair, Liberal, Ron McKinnon]

Thank you, Mr. Thériault.

We will go now to Mr. Davies.

Go ahead for one minute, please.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

Mr. Littlewood, you touched on the impact on indigenous youth in particular. I think I can fairly safely assume that there's probably no group in Canada that has suffered more trauma than indigenous youth, on a variety of factors.

I've read a lot of Dr. Gabor Maté and his theory that one of the foundations of addiction substance use is rooted [Technical difficulty—Editor]. I'm just wondering if you have an opinion on criminalization of drugs, whether or not that serves to reduce or exacerbate the trauma. Would you support a move to decriminalize drugs and move to a health-based approach to dealing with substance use and addiction?

[Tom Littlewood]

I would, absolutely. Even though there have been some changes whereby small amounts are legal or are not criminalized, the police still intercept it and take it away from clients. A lot of my clients who are indigenous basically wait for the next beating. It is not a good situation for them, and the more stigma there is around drugs, the less we're going to see progress and reform.

Reform has to happen. Even if it's made legal, it's still a lethal dose, so whether it's legal or not, it's not going to be a good thing. There needs to be a safe drug supply as well. They're not going to stop using them because we want them to stop. They need to get through a therapeutic process. Yes, I think it would be good, not only to legalize drugs but also to make sure there is a safe supply.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

[The Chair, Liberal, Ron McKinnon]

Thank you, Mr. Davies.

Thank you to all the witnesses for sharing your time with us today and helping us with our study. Thank you to the committee for all your great questions.

With that, we will suspend and bring in the next panel.

Thank you all.

[The Chair, Liberal, Ron McKinnon]

We are now resumed. Welcome back, 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. We have as an individual, Mr. Yanick Labrie, health economist.

As an individual, we have Dr. Joel Lexchin, medical doctor. From Jacobs Engineering we have Mr. Ansar Ahmed, vice-president.

With that, I will invite the witnesses to give statements.

I will point out to witnesses and everyone that when your time is nearly up I will display a yellow card, and when it is actually up I will display a red card. When you see the red card, you don't have to stop instantly but do try to wrap up in good order.

Thank you all.

With that, I will invite Mr. Labrie to make a statement. Go ahead, please, sir, for five minutes.

[Yanick Labrie]

Thank you, Mr. Chair.

I would like to thank 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.

Earlier this afternoon, I showed that spending on prescription drugs was not out of control in Canada, despite frequent statements to the contrary. In fact, spending on prescription medicines represents a steadily declining share of Canada's economy and health budget.

I also noted that there is a risk that the tightening of price controls that the PMPRB is considering may force down the number of new drugs launched in Canada or delay their launch, in addition to discouraging pharmaceutical R&D investment.

Now I intend to address the issue of drug prices and value.

In the past two years, the public debate on the regulatory changes the PMPRB is contemplating has largely focused on the launch price of new medicines.

According to one idea that is making the rounds, Canadians pay more for their drugs than citizens of other countries. For example, the most recent annual report published by the PMPRB contains a comparative analysis showing that the average price of all patented drugs in Canada in 2017 was 19% higher than the average of the OECD countries. However, that excludes manufacturer discounts. The PMPRB's data on medicines for treating rare diseases show that current prices in Canada in 2019 were 3% higher than median prices in all OECD countries.

However, you must take care in comparing prices of Canadian pharmaceutical products with those in effect in countries with much lower standards of living, such as Greece, Chile and Turkey, to name only a few. An international comparison of drug prices is a complex undertaking, since many factors must be considered, including differences in products consumed in each country, respective market shares of generic and innovative drugs, distribution costs and retail sales, exchange rate fluctuations and purchasing power of the various currencies.

In addition, information on real prices is limited in most countries. Where available, it paints a misleading picture that fails to reflect the actual prices of medicines as a result of confidential discounts that pharmaceutical companies offer payers. Those discounts or rebates are generally required by public drug insurance plans in Canada under agreements respecting registration on provincial drug plan forms. For example, the Quebec government has received a total rebate of more than $1 billion from innovative drug manufacturers over the past four years.

The situation regarding drug prices also cannot be analyzed in isolation without considering the value attached thereto.

In recent decades, major advances have been made in the treatment of many health problems through the use of innovative medicines. Those new-generation drugs have revolutionized the world and medicine by responding more effectively to patient needs than previous drugs.

In the case of rare diseases, the PMPRB itself has established that 35% of new drugs launched in Canada in 2019 resulted in modest or major improvements and that 27% represented major discoveries relative to existing therapies. The rising influx of these innovative molecules both intensifies competition and affords patients new and better therapeutic options.

For example, researchers at McGill University recently considered the long-term impact of biological treatments for Quebec patients suffering from ulcerative colitis. They showed that the risks of having to undergo a colorectal procedure considerably declined after biological drugs arrived on the market. In the year when those drugs were first used, the mortality rate among Quebec patients requiring colectomies declined by more than half from the previous year. The reduction in the number of surgical procedures and hospital stays thus helped reduce the burden of medical expenses associated with ulcerative colitis in Quebec by 25%.

Similar benefits are observed in cancer cases, which impose a substantial financial burden on patients and society as a whole. Many innovative drugs developed in recent years have completely revolutionized the treatment of cancers and improved patients' quality of life and life expectancy. Drug therapies now more accurately target the genes and proteins responsible for cancerous cell growth, thus vastly improving patients' chances of survival, while reducing the secondary effect generally associated with chemotherapy. By helping to reduce the number of hospital stays and thus work absenteeism and to minimize productivity losses, these innovative drugs thus generate major cost savings to society.

In conclusion, the situation regarding drug costs should not be analyzed in isolation from consideration of related benefits.

Once again, I would like to inform the members of the Standing Committee on Health of the negative impact on the people of Canada that could result from the stricter price controls being envisaged by the PMPRB. This kind of reform would not only reduce the number of new medicines launched in Canada, or slow their launch down, but also discourage research and development investment, which is nevertheless indispensable for the development and availability of new medicines for Canadians in the future.

Thank you for your attention.

[The Chair, Liberal, Ron McKinnon]

Thank you, Mr. Labrie.

We go now to Dr. Joel Lexchin.

Go ahead, Doctor, for five minutes, please.

[Dr. Joel Lexchin, Medical Doctor, As an Individual]

Thank you for the opportunity to appear before the committee.

I work as an emergency physician in downtown Toronto. Between 2001 and 2016, I taught health policy at York University. Over the past 40 years, I've been involved in researching and writing about pharmaceutical policy issues.

I want to address the question about proposed reforms to the Canadian regulatory system, although I will also touch on some points that Mr. Labrie made.

When the pandemic started, Health Canada brought in an interim order to allow for a more rapid introduction of products to treat and prevent COVID-19. More recently, it's produced a discussion document about what it terms “agile regulations”, which are supposed to decrease regulatory burden and get new drugs onto the market in Canada faster.

The first point to make is contrary to Mr. Labrie's. Independent research has shown that only about 10% of new drugs that are introduced into Canada—or, in fact, in other markets—offer any substantial therapeutic gain over what already exists. This applies to drugs that are approved in general. It applies to drugs that are approved through Health Canada's priority review process. It applies to drugs that are approved with limited data through the notice of compliance with conditions process.

Even if you look at what are called first-in-class drugs—drugs that are unlike anything else on the market—the proportion of those that are innovative is only about one in six. When you look at drugs for orphan diseases, about one in five of these are substantial therapeutic improvements. This is not based on my assessment. This is based on independent assessments by organizations that have nothing to do with the pharmaceutical industry.

When we think about changing the regulatory system, we also need to think about the safety of drugs that are on the market. The push for agile regulation makes mention of safety, but it seems to put safety second to reducing regulatory burden, which is a mistake. It ignores what we know about the safety of drugs that come on the market based on how long they are reviewed by organizations like Health Canada.

If a drug goes through a standard review process, eventually about one in five of those drugs will acquire a serious safety warning. If it goes through a priority review process, which is shorter—instead of the standard 300 days, it's 180 days—one-third of those drugs will acquire a serious safety warning, up from one in five. If you look at drugs that go through a notice of compliance with conditions process, about one in four of those drugs will acquire a serious safety warning.

There are consequences to changing the regulatory system in terms of safety. Currently, in any five-year period, if you look at the drugs that are withdrawn from the Canadian market, about one out of every 20 will eventually be pulled from the market for safety reasons. If we go ahead with changes in the regulatory system, that percentage may increase.

In conclusion, it's reasonable to change how we get drugs on the market in response to a pandemic. As a doctor in the emergency department, I recognize that. If you're talking about making long-term permanent changes, then you have to look at whether that results in better, more effective drugs reaching the market and in the increased or decreased safety of the products that come onto the market.

Until Health Canada can come up with good data to show that we'll get more therapeutically efficient drugs and more safety, we should not be going ahead.

Thank you.

[The Chair, Liberal, Ron McKinnon]

Thank you, Doctor.

We'll go now to Jacobs Engineering. I need to apologize to Mr. Ahmed. I think I skipped over his name when making introductions. If that's the case, I certainly apologize.

From Jacobs Engineering, we have Mr. Ansar Ahmed, vice-president.

Mr. Ahmed, please go ahead, for five minutes.

[Ansar Ahmed, Vice-President, Jacobs Engineering]

Thank you, Chairman McKinnon, and thank you, Vice-Chairs Rempel Garner and Thériault, for the opportunity to speak to the committee today.

I'm pleased to be here today representing Jacobs Engineering. First of all, on behalf of all of us at Jacobs, I'd like to extend our deepest condolences to the families of the nearly 26,000 Canadians who have lost their lives during this pandemic.

As engineers and architects, we approach problems from a very simple perspective of an unbiased lens. We examine the causes, and we identify what needs to be done differently in order to achieve more favourable outcomes in the future.

I'd like to focus my remarks today on the impact of COVID-19 in our long-term care homes.

In January, Jacobs hosted an industry round table to examine how the built environment—the actual interior and physical space—may have contributed to the disproportionate impact of COVID-19 within our long-term care homes. The round table report outlined a series of nine recommendations, and I'd like to speak to two of them today.

Many jurisdictions have design standards for long-term care homes that have not been updated for years, and in some cases decades. In homes designed to those outdated standards, residents were confined, for the most part, to their rooms. They had little, if any, physical or social interaction with others, simply because the facility was not designed, or improved over the years, to meet the challenges of containing the spread of COVID-19.

It was acknowledged in the round table that the built environment is as important an element of health care as any other medical or clinical intervention. There needs to be a legislated framework that mandates regular updates to design standards, so the built environment within our long-term care homes keeps pace with the latest clinical research on caring for those with physical or cognitive impairments.

A second recommendation involved evidence-based decision-making and value-based procurements. Following the January round table, Jacobs and the Ontario Association of Architects, in consultation with the Ontario Ministry of Long-Term Care, have funded a research study by the University of Toronto’s Centre for Design + Health Innovation to conduct performance assessments of long-term care homes. This is the type of experiential data that governments need to have access to in order to ensure they are making the right investments in the right areas at the right time.

The findings of such work must become the basis for value-based procurement. In a sector as sensitive as long-term care, seeking out the lowest-cost and technically compliant bids should not be the benchmark we are striving to achieve. Rather, it should be about value creation in design, construction, maintenance and operations to help secure the best outcome for our most vulnerable citizens.

The COVID-19 pandemic has challenged governments at all levels to respond with urgency to its devastating outcomes, including the loss of over 15,000 lives in long-term care homes. In examining the root causes of these losses, it's important to recognize the pre-existence of structural and systemic vulnerabilities that heightened the risk of such outcomes occurring in our long-term care homes.

To make the most of proposed investments in long-term care, it's vital that governments first identify and, through updated standards and guidelines, resolve those structural and systemic vulnerabilities. Without this first critical step, we miss an important opportunity to ensure the best results for the investment of public funds.

If I had three recommendations to make, they would be that governments at all levels need to come together: first, to establish grant-based funding programs to vigorously re-engage Canada in public health research and development; second, to activate and mobilize Canada’s manufacturing sector to produce vast supplies of PPE and other mission-critical supplies and equipment; and lastly, to mandate regular updates to design and operating standards governing long-term care homes, to ensure these remain resilient places of care for our most vulnerable citizens.

In closing, I'd like to make one last observation with respect to mental health. This pandemic has raised awareness of the importance of mental health. As we emerge from this pandemic, it's my sincere hope we do not lose the momentum that has been created, and that the attention drawn to mental health does not fade away. All levels of government have a role to play in ensuring that hospitals across the country have access to stable and long-term funding for mental health programs, and that local non-profit organizations, delivering invaluable intervention programs, similarly have access to predictable and long-term government funding and support.

Thank you very much for your time and attention today.

[The Chair, Liberal, Ron McKinnon]

Thank you.

We will start our rounds of questions now, with Mr. d'Entremont.

Mr. d'Entremont, go ahead, please, for six minutes.

[Chris d'Entremont, Conservative, West Nova, NS]

Thank you very much, Mr. Chair.

To our witnesses today, welcome to the health committee.

Welcome for the second time, Mr. Labrie.

My first question is for Mr. Ahmed.

When it comes to long-term care, it continues to interest me to see how different provinces look at long-term care standards. There was a tremendous move in Nova Scotia a number of years ago to come up with a standard that makes sense. It's not necessarily included in the building codes, but it was knowing their square footage per patient and making sure there isn't an opportunity for different pathogens to go from one patient to another.

Have you looked across Canada to see who is doing this and what other provinces may not be doing it?