Health Committee on March 23rd, 2022

[The Chair, Liberal, Sean Casey]

I call the meeting to order.

Welcome to meeting number 12 of the House of Commons Standing Committee on Health. Today we meet for two hours to hear from witnesses on our study of the emergency situation facing Canadians in light of the COVID-19 pandemic.

Before I introduce today's witnesses, I have a few regular reminders for hybrid meetings.

Today's meeting is taking place in a hybrid format, pursuant to the House order of November 25, 2021. Members are attending in the room and we have one attending remotely—Mr. Davies, I believe—using the Zoom application. We will, of course, keep a consolidated speaking list and try to pay attention when you indicate that you want to be on it, Mr. Davies.

Of course, you are aware that screenshots should not be taken during the meeting. The proceedings will be made available via the House of Commons website. In accordance with our routine motion, I'm informing the committee that all witnesses have completed the required connection tests in advance of the meeting.

With us here today, we have, as an individual, Dr. Shirin Kalyan, adjunct professor of medicine at the University of British Columbia.

We also have Ms. France-Isabelle Langlois, executive director, and Ms. Colette Lelièvre, responsible for campaigns, both from Amnistie Internationale Canada francophone.

From the Canadian Mental Health Association, we have Margaret Eaton, the national chief executive officer. From the Canadian Psychological Association, we have Dr. Karen Cohen, chief executive officer. From the National Advisory Committee on Immunization, we have Dr. Bryna Warshawsky, medical adviser. From the Ontario Association of Radiologists, we have Dr. David Jacobs, president and diagnostic radiologist.

Thank you to all the witnesses for taking the time to appear today. We have a very esteemed and plentiful panel, and we certainly look forward to the discussion.

We are going to begin with opening remarks from each witness in the order they appear in the notice of meeting, so that makes you first, Dr. Kalyan. You have the floor for five minutes.

Welcome to the committee. Please go ahead.

[Dr. Shirin Kalyan, Adjunct Professor of Medicine, University of British Columbia, As an Individual]

Thank you, honourable chair and committee members, for the opportunity to speak today.

The thoughts I'm presenting are my own, as an immunologist, and not necessarily those of my affiliated organizations. I submitted notes that contained further data and references for the issues I'll be addressing today—

[Luc Thériault, Bloc, Montcalm, QC]

Mr. Chair, on a point of order.

The volume is far too loud for me to hear any of the interpretation. The volume should be turned down in the meeting room.

[The Chair, Liberal, Sean Casey]

We're going to fix this problem.

Dr. Kalyan, if you could start again from the top, we'll restart the clock and hopefully the volume is a little more regulated.

[Dr. Shirin Kalyan]

Did you want me to speak louder?

[The Chair, Liberal, Sean Casey]

We have you coming through the speakers, but you're being simultaneously translated, and both need to work.

Try again, and if there is a problem, I'll interrupt again.

[Dr. Shirin Kalyan]

Okay. Take two.

I thank everyone for the opportunity to speak today. The thoughts I'm presenting are my own, as an immunologist, and are not necessarily those of my affiliated organizations.

I have submitted notes that contain further data and references for the issues that I'll be addressing today. They involve Canada's vaccine mandates and the manner in which they have been implemented, which includes the lack of recognition of infection-acquired immunity and the suboptimal data collection and availability required to evaluate the efficacy and consequences of the public health policies and mandates to guide evidence-based decision-making.

Any time a medical intervention is mandated, it needs to meet a fairly high bar for its justification. We should have a solid understanding of both the safety and the efficacy of the intervention. Its purpose needs to be clearly stated. We need to ensure that we have in place ongoing surveillance to evaluate how well it is working to achieve its stated purpose.

With that base, a vaccine mandate may be justifiable if there is clear evidence that the vaccines we're using reliably prevent disease and its transmission; we have a clear grasp of their safety profile, which should be acceptable for prophylactic use for the disease in question; the mandate is not overly broad or unreasonable; and those subjected to the vaccine mandate can provide informed consent, which requires their understanding their own personal long- and short-term potential risk from vaccination in view of their own personal risk of severe disease from infection.

It is clear, especially with omicron, that the vaccines we have cannot really be relied upon to prevent either transmission or infection. As an example, the first omicron case in Israel came from a triple-vaccinated doctor returning from a conference, who passed it on to another triple-vaccinated physician. The omicron spread into many countries has been through fully vaccinated, often boosted, individuals. This really questions the validity of the current vaccine mandates for travel within and outside of Canada. Data from Ontario and other jurisdictions from around the world show that vaccine efficacy drops below zero after the end of the second month in those who are fully vaccinated. Boosters appear to show a similar rapid timeline for waning.

With this evidence, we should have moved quickly to lift heavy-handed measures and explain the evolving evidence. This is necessary for public trust. It is also good for public health to have a well-informed populace. Having a false sense of security has obvious negative consequences.

When it became evident during the delta wave that the mRNA vaccines had poor durability in their ability to prevent infection and transmission, the messaging justifying mandates shifted to the prevention of hospitalization and serious disease. If that was the new purpose, then Canadians with infection-acquired immunity should have had their superior immune protection recognized from the outset. The data have been unequivocally clear that those who have had COVID-19 and recovered are better protected—as would be expected—from infection, serious disease and death compared with those who are fully vaccinated. They would also be less likely to transmit infection if they get reinfected, as a greater mucosal immunity limits viral replication better, unlike those who are fully vaccinated and who experience a first breakthrough infection and can have viral loads very similar to immune-naive individuals.

Recent data from the U.S. CDC confirms that vaccinating those who have infection-acquired immunity really provides them no real additional benefit. Thus, these already immune individuals are primarily being exposed to unnecessary risks, as rare as they may be. They're also more likely to experience adverse effects following vaccination.

This lack of risk stratification for the blanket vaccine mandates has also been poorly considered for emerging vaccine-associated serious adverse effects. When the signal for vaccine-linked myocarditis appeared, it was repeatedly conveyed that the risk was far less than after COVID-19 infection. Data show that, actually, for males under 40, the risk of myocarditis is in fact greater after vaccination than following infection. The error in the statements previously made with respect to this risk was never publicly corrected, which means that these individuals haven't been given the opportunity to provide proper informed consent. We are requiring those who are probably among the least likely to experience serious disease to be subjected to a medical intervention for which they bear the greatest potential risk of a non-trivial nature.

As we move into the endemic phase of COVID-19 with omicron, I hope we take the opportunity to investigate how we could improve our strategy, especially around blanket mandates, for future pandemics, because they do have consequences.

I'll close now with a statement made recently by the head of vaccine strategy of the European Medicines Agency, the EMA, who had spoken directly to the lack of data and sustainability of continuing down the path of multiple boosters as a rational approach to the pandemic at this time. The EMA is aware that such an approach may actually do more immunological harm than good, and it is their position that further data is needed for the omicron variant, particularly with respect to the utility of the current vaccines and whether different types of vaccines are needed now.

Given the evidence, and its lack, I feel this is the most reasonable and responsible approach.

Thank you again for the opportunity to speak to these issues.

[The Chair, Liberal, Sean Casey]

Thank you very much, Dr. Kalyan.

We now turn to the representative of Amnistie Internationale Canada francophone.

Ms. Langlois, you have the floor for five minutes.

[France-Isabelle Langlois, Executive Director, Amnistie internationale Canada francophone]

Thank you, Mr. Chair.

Good afternoon, ladies and gentlemen. Thank you for inviting us to appear before the committee.

The health and lives of Canadians, in the context of a pandemic, depend on the health of all humanity.

Amnesty International, as a global human rights organization, has been involved since the earliest moments of the pandemic to call for unwavering international solidarity from all countries, including Canada.

Under international human rights law, states have an obligation to provide the financial and technical support necessary to implement the right to health, particularly in the case of the international spread of a disease.

We therefore call on Canada to strongly support the proposal for a temporary waiver of intellectual property protections for health-related technologies related to COVID‑19 put forward by South Africa and India in October 2020 at the World Trade Organization, or WTO.

However, we are deeply concerned about a draft text that has been leaked to the media, which proposed a compromise for this waiver between the European Union, the United States, India and South Africa, and which appeared to be under consideration last weekend.

As currently drafted, this text will never ensure the supply and transfer of technology that is necessary for equal access to COVID‑19 care resources and the protection of the right to life and health. We therefore urge Canada not to endorse this text.

The original waiver sought by India and South Africa from the WTO Agreement on Trade-Related Aspects of Intellectual Property Rights, the TRIPS Agreement, is intended to democratize the production of medicines needed to combat COVID‑19 until global herd immunity is achieved.

The World Health Assembly has recognized the role of “extensive immunization against COVID‑19 as a global public good for health in preventing, containing and stopping transmission in order to bring the pandemic to an end [...].”

However, pharmaceutical companies around the world are continuing business as usual, thus limiting production and supply capacity.

We will have to live with COVID‑19 for years to come. Everyone must have access not only to vaccines, but also to treatments. We need to democratize production, especially now that new treatments are becoming available.

By supporting the lifting of intellectual property protection for vaccines and other products to fight COVID‑19, Canada will put the lives of people around the world, and of Canadians, ahead of the profits of a few pharmaceutical giants and their shareholders.

The only way to end the pandemic is to end it globally. The only way to end it globally is to put people before profits.

International human rights standards to which Canada adheres and international trade regulations make it clear that intellectual property protection must never come at the expense of public health.

The COVID‑19 pandemic crisis is also a human rights crisis. It cannot be overcome without a genuine commitment to one of the United Nations, or UN, Sustainable Development Goals, namely “reducing inequalities and leaving no one behind”. Based on the premise that no one will be safe until everyone is safe, Canada has an opportunity today to make a decision that can help achieve this goal.

Amnesty reiterates its express request to the Canadian government to support the original waiver request in its entirety and to show exemplary leadership in international solidarity.

Thank you for your attention.

[The Chair, Liberal, Sean Casey]

Thank you, Ms. Langlois.

Next is the Canadian Mental Health Association's national chief executive officer, Margaret Eaton.

Ms. Eaton, you have the floor for the next five minutes.

[Margaret Eaton, National Chief Executive Officer, Canadian Mental Health Association]

Thank you so much.

Hello. I'm Margaret Eaton and I'm the national CEO of the CMHA. The CMHA is the most extensive community mental health network in Canada, founded in 1918. We have 330 community locations in 10 provinces and the Yukon territory. We reach over 1.3 million people each year and we employ 7,000 Canadians.

CMHAs are independently governed charities that deliver free mental health supports to anyone who needs them, from counselling and psychotherapy, substance use treatment and youth programs, to housing and employment services. CMHAs keep people out of hospitals by intervening early to promote mental health and prevent mental illness.

Our recent research shows that most Canadians worry that COVID will never go away: 64% of Canadians are worried about new variants and 57% are worried about COVID-19 circulating in the population for years to come. The chronic stress of dealing with the pandemic is taking its toll. It makes basic decisions harder, it saps our energy and it leaves people tired and burned out.

As you know, we've all been in the same storm for the past two years, but we haven't all been in the same boat. Forty per cent of Canadians say their mental health has declined since the onset of the pandemic, and this spikes in vulnerable groups, such as those who are unemployed due to COVID-19, those who had a pre-existing mental health condition, people who identify as LGBTQ2+, young people, people with a disability and people who are indigenous. Vulnerable people have experienced much worse mental health over the last two years.

These significant inequities have made it impossible to ignore the long-standing service gaps and systemic barriers in our mental health system. Our research shows that almost one in five Canadians felt they needed help with their mental health during the pandemic, but they didn't receive it because they didn't know how or where to get it, there was no help available or they couldn't afford to pay for it.

Millions of Canadians rely on free mental health and addiction services and supports provided by the not-for-profit sector, but these organizations are strained to the breaking point. Community and mental health care workers receive lower wages, have higher work demands, experience compassion fatigue and are more likely to experience burnout than other health care workers.

Despite these difficult conditions, they have creatively and compassionately met people's needs. When there was no housing available and food banks were closed, CMHAs purchased tents and had food boxes delivered. Some CMHAs called their entire wait-lists to see how people were doing and offer whatever supports they could. Some launched new crisis lines and chat services to give isolated people a friendly conversation and a wellness check-in.

However, this emergency mode isn't sustainable, either for our staff or for our clients, who need stable, long-term help.

Two years in, we've moved from crisis to chronic. Even if the immediate impacts of COVID-19 are subsiding, the mental health effects persist and will likely continue for years to come. The community mental health and addiction sector cannot meet these growing needs with the current patchwork funding and disjointed service delivery model. It's time to overhaul our mental health system.

CMHA calls on the federal government to do these four things: one, establish long-term and stable federal funding for key programs, services and supports delivered by the community mental health sector; two, invest in mental health promotion and mental illness prevention programs and strategies; three, publicly fund community-based counselling and psychotherapy; four, invest in housing, income supports and food security.

We must integrate community mental health services into the health care system, and we must ensure that provinces and territories are held accountable for how federal funds for mental health are spent.

We have a critical window of opportunity to transform Canada's mental health system. Let's not miss it.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you very much, Ms. Eaton.

Next is Dr. Karen Cohen, chief executive officer of the Canadian Psychological Association.

You have the floor.

[Dr. Karen R. Cohen, Chief Executive Officer, Canadian Psychological Association]

Thank you very much for the invitation to appear before you today.

The psychological factors implicated in the COVID-19 global pandemic are several.

First, successful management of health and illness depends on how people think, feel and behave as individuals and in groups. Wearing masks, keeping physically distant and getting vaccinated all involve making decisions and changing behaviour. Psychological science is critical to the success of public policies intended to bring about these changes.

Dr. Kim Lavoie, a Canada research chair in behavioural medicine, has shown that to increase vaccine uptake, different approaches are needed, depending on why someone has resisted vaccination. Dialogue and education may work for people who are afraid of or who lack trust in vaccines, whereas mobile vaccine clinics work with people who haven't gotten vaccinated because they can't leave work or get to a clinic. How health providers talk to their patients who resist vaccination will impact whether they change their minds. Policies affecting people will be more effective if they take into account how people think, feel and behave.

Second, while too many Canadians have contracted the COVID-19 virus, every Canadian has lived its psychological, social, and economic impacts. Recent surveys of the psychological impacts have shown that nearly half of Ontarians said that their mental health has worsened since the pandemic began, which is up from 36% when the pandemic started. More Canadians continue to report high levels of anxiety and depression now than when the pandemic began. More Ontarians are accessing mental health support now than at any other time during the pandemic, but 43% have said it is difficult to get help.

While self-reported mental health problems and reaching out for professional help may have increased, timely access to psychological services has not. Having asked about barriers to accessing psychological services, a 2021 CPA-Nanos survey showed that more people cite financial factors than stigma. Unless the psychologist is salaried in a public institution like a hospital, their services are not covered by medicare.

As public institutions face budget pressures, there are negative impacts on the number of salaried positions and on conditions of work. Increasingly, psychologists work in the private sector, where their services are inaccessible to those who cannot afford them. Even when psychological services are covered by private health insurance plans, the median amount of coverage is $1,000 annually, which is less than a third of what it costs for the average person to have a successful treatment outcome.

The CPA, in collaboration with provincial and territorial psychological associations, has just issued a paper entitled “New Federal Investments in Mental Health: Accelerating the Integration of Psychological Services in Primary Care”. We outline ways in which some provinces have addressed this service gap and how the federal mental health transfers can further reduce this gap.

Finally, even as Canada addresses the funding barriers Canadians face in accessing psychological services, there are other barriers that need attention. For effective mental health human resource planning, we need to collect better data. While we have some data about the demographic and practice characteristics of health providers whose services are delivered under medicare, we know very little about health providers like psychologists, whose services are delivered in the private sector. A large class of students training to become psychologists is 10, compared to the hundreds of students in medical or nursing classes. To better meet the diverse mental health needs of Canadians, we need to train more psychologists.

The pandemic has shown us that much health care can be delivered virtually. The regulation of Canada's health providers is done provincially and territorially. Entry-to-practice requirements vary from one jurisdiction to another, and a health provider cannot necessarily provide services outside of their province of registration. While the agreement on internal trade and the Canadian Free Trade Agreement mandated health regulators to ensure mobility, these federal directives did not give regulators the authority to set common licensing requirements. When it comes to health care, the pandemic has underscored the limitations of systems that are provincially and territorially based rather than nationally based.

In summary, global health crises have mental health impacts, and the successful management of any global health crisis depends on psychological factors. To address these, we must develop pandemic policies that are informed by psychological science, redress funding barriers to accessing psychological care, and attend to the training and regulation of Canada's health human resources.

Canada has no health without its mental health.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Cohen.

Next, on behalf of the National Advisory Committee on Immunization, is Dr. Bryna Warshawsky, medical adviser.

Dr. Warshawsky, the floor is yours.

[Dr. Bryna Warshawsky, Medical Advisor, National Advisory Committee on Immunization]

Thank you very much, Mr. Chair.

I have no opening remarks, but I'm happy to take questions at the appropriate time.

Thank you.

[The Chair, Liberal, Sean Casey]

Well, that gives us an extra five minutes for questions. Thank you.

Representing the Ontario Association of Radiologists, we have Dr. David Jacobs, president and diagnostic radiologist.

Dr. Jacobs, you have the floor.

[Dr. David Jacobs, President and Diagnostic Radiologist, Ontario Association of Radiologists]

Fantastic. Thank you so much.

I was just admiring the previous speaker's opening remarks. I think that's brilliant, and I'll do that next time.

What I'm going to do is just give you a very brief look into health care through the eyes of my specialty, which is diagnostic radiology, and how it has impacted patients and health care in general.

Diagnostic imaging and interventional radiology is a subspecialty in medicine. We interpret images—CT, MRI, mammography—and we also perform procedures like breast biopsies, basically biopsing any solid tumour from head to toe, angiography and other interventions.

Our services were highly used during the pandemic. Prior to the pandemic, we had wait-lists that far outstripped what was end-dated by government. What we found during the pandemic, despite a large drop in utilization of hospital services outside of COVID-19, was that the wait-lists skyrocketed. There were a number of reasons for that. Again, I want you to think of this. It wasn't just with diagnostic imaging, but with medicine as a whole. Wait-lists for all interventions and all specialist appointments skyrocketed during the pandemic.

Really what it came down to was access—access to imaging, access to health care. When we went into pandemic mode, we forgot many of the lessons we had learned with the first pandemic, with the first outbreak of SARS. Now, this has been a much more dramatic pandemic than the initial SARS, but what we didn't do was a very good job of compartmentalizing risk and need. What we ended up doing was basically shutting the system down. We assigned the same level of risk to all procedures and to all interventions.

Right now we have over one million Canadians on wait-lists for CT and MRI. Over the course of the pandemic, our wait-lists ballooned for MRI from what was unreasonable but acceptable—three months or so for an MRI examination—to over nine months for some centres.

Delayed diagnosis had a major impact, so as we saw waves of COVID going through the population, one of the unfortunate things we saw was malignancies coming in that were very much delayed. From what we had seen early in the pandemic or just prior to it, when we did the follow-up studies, because of lack of intervention and delay in the ability to get the imaging that was necessary, what we saw was that cancers that started off as resectable, as treatable, became unresectable or palliative in nature in terms of what we could offer the patient. That is unacceptable.

The causes are multifactorial. Some of the causes that we could change are not shutting down low-risk procedures like medical imaging, CT scans and MRIs. We basically turned a key, turned everything off, and shut down the system. We can't do that again. It had a major impact on screening services such as mammography. We had 300,000 women who were not screened. That will, unfortunately, result in an increase in the number of breast cancer-related mortalities in the years to come. Approximately 6.5% of all screened women will have a finding on their study that will require a further workup, so I'll let you do the math on that.

The other issues uncovered were human resources issues. As we came out of waves, money was sent to increase the number of studies that we could do to play catch-up, but what we found was that we simply didn't have the human resources to catch up on those studies. Mostly it had little to do with radiologists and physicians. It had more to do with support staff. Clearly we are not training enough technologists for radiology, nurses for the floors, the ORs and the ICUs. We really need to think about how we manage human resources and what kind of slack we have in the system.

The other issue I want to talk about is stalled health initiatives. In this two-year period, as in any two-year period, we would see movement forward and progress on how we care for patients, not just in terms of technology but in terms of the organization and how we structure a patient's trip through the health care system as there are more innovations.

One thing that stands out, from a diagnostic imaging point of view, is that over the course of the pandemic we had some studies that came through that showed breast screening should actually be done for women ages 40 to 50, which currently we don't do because of a previous flawed Canadian study. We had been trying to implement that, but over the two years we weren't able to. That's one example of many where we were so focused, laser-beam focused, on COVID-19 that a lot of other important health initiatives fell by the wayside.

I'm happy to discuss any of these, but really, I think the fundamental point is that when we face another wave, when we face another pandemic, what we have to remember is that there is more to medicine than simply the pandemic. The pandemic was incredibly important, and in many ways very well taken care of, but we neglected other areas of health care. We can't do that again.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Jacobs.

That concludes the opening statements. We're now going to move to rounds of questions, beginning with the Conservatives.

Mr. Lake, you have six minutes.

[Mike Lake, Conservative, Edmonton—Wetaskiwin, AB]

Thank you, Mr. Chair.

This is a really interesting panel. I'm making notes here. It's interesting to listen to Dr. Cohen talk about how we increase uptake and the different approaches to increase uptake of vaccines. After having listened to Dr. Kalyan, it sounds like she's suggesting that maybe getting the vaccine right now isn't a great idea for omicron. I may have that wrong. Both have significantly stronger credentials in health care than I do. I think it creates a good opportunity.

We have NACI here, represented by Dr. Warshawsky, who didn't make opening comments. I'm going to go to her first because I'm interested to hear what she thinks about what Dr. Kalyan had to say.

[Dr. Bryna Warshawsky]

The national advisory committee has made recommendations with regard to booster doses. It has strongly recommended that booster doses be offered for people 50 years of age and over and certain other high-risk groups, and has a discretionary recommendation for those 18 to 49 years of age, as well as for high-risk adolescents 12 to 17 years of age.

NACI is currently also looking at its booster dose recommendations for additional booster doses and also whether to strengthen its booster dose recommendations. NACI is constantly looking at the evidence and the epidemiology to make its booster dose recommendations.

Thank you.

[Mike Lake, Conservative, Edmonton—Wetaskiwin, AB]

Does NACI have a position on whether vaccines should continue to be mandated at a federal level for the folks they're mandated for right now, for two shots?

[Dr. Bryna Warshawsky]

NACI doesn't make recommendations with regard to mandates. That's provincial, territorial and federal jurisdiction. NACI provides recommendations with regard to what vaccines should be used and how they should be used for Canadians, but mandates are not within its scope.

[Mike Lake, Conservative, Edmonton—Wetaskiwin, AB]

Dr. Jacobs, I'll go to you and just ask you if you have any opinion to offer. I know that, in following you on social media, you're very pro-vaccine. Are there any thoughts on Dr. Kalyan's position as it relates to omicron? It's a good opportunity to have a back-and-forth.

Then if Dr. Kalyan wants to weigh in, I'd be glad for her to have the opportunity to do so.

[Dr. David Jacobs]

I think Dr. Kalyan has made some very good points. We have to look at that, but I also have to look at it from a pragmatic point of view in terms of what I see in the hospital.

To Dr. Kalyan's point in terms of mandates, yes, omicron was highly contagious and, no, the vaccine didn't do much in terms of preventing the spread of COVID. If it did, it was minimal. Omicron spread very rapidly. For delta and other previous strains, there was a more robust prevention of transmission, but for omicron there wasn't, and that takes away some of the need for a vaccine mandate, except—and this is a big exception—that what we saw in the hospital were patients who were immunosuppressed, elderly—so de facto immunosuppressed—and patients who did not receive a full vaccine regime. They were the ones who were getting very severe COVID pneumonias. I saw a lot of people come in with COVID in the omicron wave, but it was predominantly the ones who were unvaccinated, immunosuppressed or the frail elderly who were getting desperately ill from it.

From a larger population point of view, I can't make those arguments—that's more the world of NACI—but from an individual recommendation, for those three groups it would have been much better for them to have been vaccinated and boosted than not.

[Mike Lake, Conservative, Edmonton—Wetaskiwin, AB]

Dr. Kalyan, do you want to weigh in on this too?