Debates of Nov. 1st, 2005

Cross-Border Drug Sales

[Ujjal Dosanjh, Liberal, Vancouver South, BC]

Madam Chair, I am somewhat confused as to the position of the opposition benches. We have the opposition critic saying that we should not be moving at this point and that we should be sending this issue to the committee and the committee should be spending time talking about it. On the other hand, we have the member who just asked the question asking why are we not moving quickly.

I believe the opposition members need to sort out what their position is. I guess the kind of confusion that has reigned in the ranks of the opposition on this issue still reigns unchanged.

I want to tell hon. members that we are consulting very quickly. We want to make sure that the legislation on bulk exports is introduced by the end of November.

[Steven Fletcher, Conservative, Charleswood—St. James, MB]

Madam Chair, it was interesting to hear the federal health minister speak tonight because it was indeed, as my colleague mentioned, the Conservatives who moved forward on banning bulk exports. My colleague from Yellowhead brought forward a motion in the health committee that passed and was brought to the House. Therefore it actually was the Conservatives who moved on bulk exports.

Bulk exports should not be confused with the legal export of one on one retail prescriptions. The importance is critical because, obviously, we need to protect Canada's drug supply, which is why, if it can be demonstrated that price, supply or the safety of Canadian drugs are compromised, the Conservative Party will support taking action. In fact, the online pharmacy industry is aware of this and that is why it also supports a ban on bulk exports. Nobody is pushing for bulk exports and, in fact, it would be impossible to do.

Having said that, we see a health minister creating a crisis where there is no crisis. In fact, the industry has declined in the last 12 months. The minister needs to understand that this industry was created and developed under the Liberals but it is the Liberals who are trying to do it.

I will also note that the political minister from Manitoba has agreed with the position that there is a compromised solution to be found, and that is to ban bulk exports while protecting Canadian prices, supply and safety.

I also find it interesting that the minister fails to recognize that the health committee is chaired by a Liberal member and if this were such a priority for the government, there would have been unanimous consent, I am sure, at the health committee to bring forward a study to review this issue. However the minister and the government decided not to and left it up to the Conservative Party to actually take action and ban bulk exports through a concurrence motion, which the Liberals voted for. They supported the Conservative initiative to ban bulk exports, which is not to be confused with one on one retail.

The minister has claimed that the U.S. Congress could act at any time to allow the import of pharmaceuticals. The fact is that those bills are not imminent. There is surely time to review the impact that may occur by the minister's actions.

The other interesting point is that the minister has made some claims that somehow it would be unethical to prescribe medication when the doctor is not present. In fact, this practice happens throughout Canada. Our first nation communities and other remote communities often have nurse practitioners prescribe drugs for their patients. That very fact alone undermines the minister's comment that there must be a direct patient-doctor relationship because today that does not occur in many cases. It is my understanding, from what was presented to me as recently as last week by nurse practitioners, that they do have the ability in many provinces to prescribe pharmaceuticals independent of a practising doctor.

The fact that the political minister of Manitoba had stated that there should be a compromise and the fact that the minister is not open to compromise is very disturbing. The fact that the minister is not willing to allow the health committee to do its work as per the concurrence motion is very disturbing.

The minister and the consultation process at Health Canada has been criticized quite broadly due to the lack of time and ability of presenters to fully present their cases on either side of the issue. Even Health Canada has said that supply has not been affected by the online pharmacy industry and that there has been no evidence to support that claim.

The fact that the Conservatives were the ones who brought in the PMPRB demonstrates a commitment on behalf of the Conservatives to ensure that Canadians have affordable, high quality medications and that quantities are sustainable.

The interesting aspect to this debate is the price difference between some drugs in Canada and some drugs in the United States. However there is even a greater difference between drugs in other countries and the United States. The fact is that the industry, by and large, is moving offshore. I fear there will be unintended consequences.

The federal government may not have the jurisdiction to interfere with provincial regulatory bodies when it comes to issues of doctor-patient relations and I think the federal government needs to be very careful before it treads on areas of provincial jurisdiction.

The federal government should also be very careful in not allowing proper consultation by Canadians. I think the federal government is showing a great deal of disrespect toward the health committee. A motion was passed in the health committee last year to study this issue. The minister does correctly point out that the health committee has started but not completed that study.

I would also like to point out that the chair of that committee is a Liberal member. If this were such a high priority for the government, the government could have easily brought forward an agenda that would have accommodated a timely and steadfast study of the implications of online pharmacies, but it chose not to.

The government is playing to Canada's rhetoric rather than actually dealing with the issue.

[Don Boudria, Liberal, Glengarry—Prescott—Russell, ON]

Madam Chair, I almost cannot believe what I am hearing this evening. It is a total negation of the facts as they have happened.

The hon. member on the one hand said that he is against the bulk shipments, but then he spent the rest of his speech defending the Internet pharmacies as somehow being virtuous in this country. For more than a year the hon. member will know that I was the only member of this House who raised the issue of Internet pharmacies and their threat to the Canadian health care system. I thank the minister who is sitting nearby for his attention to this issue. This has been a very difficult issue for the minister to manage. He has done an absolutely outstanding job thus far and I am sure he will continue to do important work in this area.

The hon. member knows, as I do, that groups representing the disabled across Canada, groups representing the elderly, the Canadian Medical Association, pharmacists in his own province have denounced the Internet pharmacies and the member, in the face of one of his own colleagues who spoke a little earlier, defends that whole industry.

In the case of Tamiflu, it is absolutely unbelievable. Let me share this article with the House:

Online, demand by individuals is skyrocketing. “It's crazy,” says Mark Catroppa, a vice president with CanadaMedicineShop.com in Vancouver, British Columbia.

Guess what they do for a living. The company has about 175,000 U.S. customers. That is 175,000 doses of medicine destined for Canadians going across the border to the United States, a product that we know we will need and do not have enough of. How can the hon. member defend that? How can he say that this is legitimate, that this is right, that this is virtuous somehow, when everything that all of us really know is that it is wrong and it is threatening the future of health care probably more than any other issue in this country?

[Steven Fletcher, Conservative, Charleswood—St. James, MB]

Madam Chair, what is threatening the future of health care in this country is the Liberal inaction in dealing with issues like wait times and the Liberal inaction in dealing with the human resource crisis. It is that government that caused the health care crisis in the first place when it cut $25 billion from the health care system and cut medical graduate positions 10 years ago. That is the crisis. The crisis is the government when it comes to health care.

To answer the member's questions directly, the fact is that supply, price and safety of the drugs have not been affected. The fact is that the government's political minister for Manitoba, Mr. Alcock--

[The Assistant Deputy Chair]

Order. The member will please refrain from referring to any member who is sitting in the House by name.

[Steven Fletcher, Conservative, Charleswood—St. James, MB]

Madam Chair, I do not see that person present--

[Don Boudria, Liberal, Glengarry—Prescott—Russell, ON]

That is also out of order.

[Steven Fletcher, Conservative, Charleswood—St. James, MB]

--but I could be wrong.

To get back to the main issue, I would like to read something from a Health Canada document:

Internet pharmacies practising CBDS [cross-border drug sales] have emerged over the past several years. The advent of the Internet has expanded the volume of exported drug products from Canada, currently representing a significant percentage of the total Canadian drug market - approximately 8% of total prescription drug sales. While anecdotal reports have identified increased difficulty and delay with obtaining certain drugs, there is no evidence to date to suggest that CBDS have caused a pan-Canadian shortage of prescription drugs.

That is from Health Canada from last week.

The member is suggesting that is not the case. Is he saying that health Canada is wrong? If so, I would be very interested.

The document makes a distinction between retail drug sales, which is from individual purchases, versus wholesale or bulk importation of Canadian drugs. It is the bulk that the Conservative Party is calling for a ban on. In fact, it is the Conservative Party that has led the initiative. On Tamiflu I think the member has raised a valid point. That is why the online pharmacies have voluntarily decided not to export that particular product. The industry is showing responsibility in that regard.

Given what we know from Health Canada, I think we need to wait for the health committee to do its study.

[Jean Crowder, NDP, Nanaimo—Cowichan, BC]

Madam Chair, in May 2004 Health Canada released three backgrounders with information on prescription drugs and Internet pharmacies regarding regulation, supply and cross-border sales.

On the supply side, and this is Health Canada's own information, it says that Health Canada actively investigates any drug shortage claims that are brought to its attention and where there is cause for concern, appropriate action is taken. The way I read this is that Health Canada is on it. It is paying close attention to any potential drug shortages.

The second piece is on cross-border sales. Health Canada says that neither Canada's international trade obligations nor our domestic laws prohibit these exports. Again, Health Canada's information is currently saying that Internet pharmacies and exports are okay.

In talking about price it says that the PMPRB regulates the first price at which the drug product is sold by the manufacturer, regardless of the purchaser, whether it be the wholesaler, pharmacy, hospital, or other.

The member has spoken about the difference between individual Internet sales versus bulk sales. They are completely separate.

It seems to me Health Canada's release is saying that individual sales are okay and that there are regulations to protect Canadians. I wonder if the member would comment on that specifically.

[Steven Fletcher, Conservative, Charleswood—St. James, MB]

Madam Chair, I have to say that my colleague seems to be very well-researched on this issue and has raised a number of excellent questions. I wish the Minister of Health would be so informed.

The distinction between bulk and retail is very important. The member has raised the issue of the legality of this industry, the fact that it is a legal industry and it has occurred under the government's watch. Implicit in the member's comments was the hypocrisy of the government on this issue. On one side, it says that it is unethical. If we use the government's logic, this unethical practice has occurred under the Liberal watch for the last 10 years. Therefore, have the Liberals been condoning unethical practices for the last 10 years? The hypocrisy is really quite something.

Again according to a Winnipeg Free Press article in February, the President of the Treasury Board, the Manitoba political minister, actually supports what I have been saying all along.

It is too bad the Liberals contradict each other on this issue. I would like to talk about it more later.

[Nicole Demers, Bloc, Laval, QC]

Madam Chair, as a Bloc Québécois member, I am going to have to put another fly in the ointment: the on-line sale of drugs in Canada is not exclusively under federal jurisdiction.

On the contrary. While the federal government has the power to legislate on e-business, Quebec and the provinces have jurisdiction over legislation governing medical practices and the supervision of professions.

As hon. members are certainly aware, when it comes to child care, parental leave and a number of other areas, Quebec has a big head start. This is also the case with our measures to control drug sales, and we have taken steps to prevent on-line drugs sales to Americans. There was a good reason for these measures. It is very important, because the most vulnerable members of society are involved, such as the elderly, who generally suffer from chronic conditions, and these are the ones most likely to make use of Internet pharmacies. They have no way of knowing that the medication prescribed to them is appropriate when combined with something they might be prescribed later on.

I did a quick survey to see what we were talking about. In March or April, the Standing Committee on Health met with pharmacists filling prescriptions online who spoke highly of their profession and their products. They said that, according to their estimates, they get about three million orders per year. This means that, every year, three million people get their prescriptions filled online by Internet pharmacies. So, for fun, I did the math.

According to a study on this subject, Canadian medical practitioners signing prescriptions, such as physicians in Manitoba or British Columbia where Internet pharmacies are currently operating, get $10 per prescription they co-sign. These physicians are licensed to work in Quebec, the provinces and across Canada. So they are part of the health care system.

So, for fun, I calculated what co-signing, signing and verifying 3 million prescriptions work out to. At only five minutes per prescription, that works out to 15 million minutes. If we divide that figure by 20 minutes, which is the approximate time it takes a physician to examine each patient, how many more patients could practitioners see? The answer is an additional 83,333 patients per year. That is a lot of patients at a time when waiting lists are a serious issue.

We complain about the waiting lists and the fact that we cannot meet much of the demand. Yet, we allow physicians to sign prescriptions for people they have never seen or met and about whose true physical condition they have no idea. Is this what we want? I cannot understand this. In this day and age of globalization, clearly, some things need to be considered with regard to the Internet.

Yet if we need to be extra cautious about anything, it is health care and prescriptions. Only physicians are qualified to make a diagnosis. They still need to see the patient to do that. Otherwise, how can they make a proper diagnosis?

Once in my life I went to see a doctor. I was taken aback to find the doctor was a woman. I went into her office and described my symptoms. She did not examine me. She decided that I had something and she was way off the mark. I left her office insulted and angry that she had considered me a number and had paid no attention to my fears.

If we accept the principle of Internet pharmacies we accept fewer services to the public and agree to lowering the quality of interaction among doctors, pharmacies and patients.

This cannot be allowed to happen. Most people with chronic disease are old, defenceless, alone and isolated and with no one to depend on. So they trust their doctor or pharmacist. How can they count on them when they are Americans on the other side of the border and have never seen them?

I do not want to be mean to our fellow citizens on the other side of the border, but we know that, in the United States, the slightest thing leads to court proceedings if rights are deemed infringed. I do not think the Canadian health care system can afford such proceedings simply because care was not taken and the system was implemented without the appropriate precautions. It is too dangerous.

In the Standing Committee on Health, we were told that some people sent their prescription to Canada, regardless of where the Internet site is located—Manitoba, I think—and the Internet pharmacy gets it countersigned by a physician. Then, if the drug is not sold in this country, they send the prescription to another country over which we have no control as far as drug manufacturing, packaging and quality are concerned. That country sends the person's drugs to him or her. So the party responsible throughout is the Internet distributor. This is alarming to me as a woman, and as someone whose mother might one day have access to such services.

I do not think that we want to subscribe to a system with so many loopholes, one that is so lax and does not care about the people it serves. They are the ones who should always be the focus of our concerns. Increasingly, we are realizing that it is not the individual that counts, but profits. As a woman and as an MP, this angers me a great deal. As legislators, we need to focus primarily on the needs of our fellow citizens, of those whom we serve and represent. Those citizens are not across the U.S. border, they are Quebeckers and Canadians who need services and need our attention.

I hope the minister will take the necessary decisions on this matter and will use extreme caution before making any decisions.

[Robert Thibault, Liberal, Parliamentary Secretary to the Minister of Health]

Madam Chair, I want to thank the hon. member for her comments. As members of Parliament, we sometimes face dilemmas. On one hand there are economic interests, but on the other hand the interests of safety for individuals, our health care services and our drugs come first.

I understand full well that the economic issue may pose a problem for the hon. member from Manitoba. We do not want to challenge that. We understand that job creation is important to a community, as is safety. Nonetheless, we must have certain rules and a minimum of measures in the first place to ensure the safety of individuals.

Consultations are now under way with respect to the strategy developed by the minister. These will continue and we will introduce a bill for consideration in committee. This bill targets three aspects on which I would like the hon. member to comment.

First is the matter of a drugs and pharmaceuticals network in Canada. There might not be any problems in this area now, but there could be some in the future. We have to know where these drugs are and whether they represent any risks. If there is a surplus in one region of the country, then perhaps the excess drugs could be transferred to other regions. As far as the quantity of available drugs is concerned, if we get to a critical point where safety is an issue, we could take the necessary measure of restricting cross-border sales.

The second aspect is the matter of safety measures with regard to the health of Canadians. We have to be able to prevent the cross-border transfer of drugs in an emergency if the situation became critical to the health of Canadians.

The third aspect is to ensure a certain level of ethics, which would be imposed on all Canadians, including our professionals in every province and territory of Canada. A doctor could give a prescription for drugs to a sick person only after a consultation. We have to make sure of that. These conditions will be imposed on anyone wanting to work in Canada as a doctor or professional, in order to protect the patients and for the safety of the system.

Would it be ethical to have less stringent rules for the sake of doing business with other consumers, clients or patients, just because they do not live within our borders?

I would like the hon. member to comment on these points.

[Nicole Demers, Bloc, Laval, QC]

Madam Chair, I want to thank my colleague. As members of the Standing Committee on Health, we do not always see eye to eye, but we greatly enjoy working together.

As I said earlier, at the start of my remarks, the federal government is responsible for legislating Internet sales and transactions. However, it is not the federal government's responsibility to determine how pharmacists or medical practitioners will address the various problems that may arise in conjunction with Internet drug sales.

In Quebec, in accordance with the Pharmacy Act, a pharmacist may only sell drugs to patients whose prescriptions have been written by an individual authorized under Quebec legislation or legislation from a Canadian province that would authorize that individual to prescribe medication if they practised in Quebec. I do not think that we can draw any comparisons with the United States.

Also, the physicians' code of ethics stipulates that, in order to issue a prescription to a patient, a Quebec physician must have examined that patient, formulated a diagnosis and a treatment plan, in addition to providing information to that patient and obtaining his or her consent. I do not think that this is applicable to customers living in the United States, unless they live in a state bordering the jurisdiction in which the Internet pharmacy is located. If so, such individuals could cross the border to obtain the various services they need. Otherwise, I do not believe that this is sufficient.

Based on what the Parliamentary Secretary to the Minister of Health said, I think that the minister wants to adopt a very conservative approach to Internet pharmacies and I congratulate him on this. I want to reiterate what I said earlier, and I hope that his approach to breast implants will be equally cautious.

[Dave Batters, Conservative, Palliser, SK]

Madam Chair, I appreciate the comments from the member for Laval. I appreciate the work she does on the health committee. I hear the passion in her voice when she talks about ensuring the drug supply for Quebeckers and for Canadians.

Certainly, I am very concerned about the issue for my constituents in Palliser, Moose Jaw, Regina, Rollo, Pense, Caronport, et cetera. This is an issue of importance to all Canadians, to ensure the supply of our drugs.

I would like to hear the thoughts of the member for Laval on the progress to date that the government has made to ban bulk exports in this country. That is, indeed, where the threat truly lies.

The threat of bulk exports, to quote a study on May 5, 2004 led by Dr. Marvin Shepherd, director for the centre for pharmacoeconomic studies, College of Pharmacy at the University of Texas, was submitted to the house committee on energy and commerce and the senate permanent select committee on investigations. It outlined his analysis on the implications for drug importations from Canada to the U.S.

Dr. Shepherd said that, based on the number of prescriptions filled, if the proposed legislation in the U.S. were to pass and bulk exports were allowed, the Canadian annual prescription drug supply meant for this country would last only 38 days.

That is a real threat, whether we are talking about heart medication, senior citizens who need medication for Alzheimer's disease or cancer therapies. It is essential that we safeguard the supply for the Canadian public, people in Saskatchewan and Quebec, and people throughout Canada.

I would like to hear the member's comments on the progress that she thinks the government has made and whether or not it has been adequate to protect Canadians from bulk exports. We should not wait until there is a shortage, until our citizens are begging for pharmaceuticals. We should take measures now to ensure that the supply is there.

I would like to hear the member's comments on whether or not the government could be more proactive instead of reactive, and what it has done to date on the bulk export issue.

[Nicole Demers, Bloc, Laval, QC]

Madam Chair, I think my colleague for his question. I have listened to him most carefully. I have relatives in that part of the country, so it is important for me to be sure that my Canadian family members are as well treated as my Quebec ones.

I believe that my colleague is right to be concerned. Moreover, some in the U.S. and Canadian media have suggested that the drug companies might limit the supply of drugs to Canadians if Canada did not stop pharmacies from selling to U.S. citizens. This is particularly significant because there are only a few grounds on which imports and exports can be restricted, among them protection of public health.

Under article XI of GATT, export restrictions are allowed to avoid shortages. In the event of a shortage, the federal government could stop drug exports, bulk shipments or others, so that Canada would have sufficient stocks to ensure public safety.

Moreover, in all of its actions, the federal government should consult Quebec and the provinces, since they have jurisdiction over health. They must stop trying to always encroach on areas under others' jurisdiction. Let them keep to their own side of the fence.

I have been greatly disturbed lately by the fact that the situation in Kashechewan has been going on for over 10 years. This was a real opportunity for the government to take action to help people, but it has not done so in 10 years. Let it stop encroaching on other people's yards. Let it stay inside its own property line and use its own tools to build what it is supposed to be building.

Being a woman of passion, I can easily get carried away, but I just want to tell my colleague in closing that he is justified in being concerned and that I too am concerned. I hope that, for once, the minister will take the proper steps to consult the others before making a decision.

[Jean Crowder, NDP, Nanaimo—Cowichan, BC]

Madam Chair, I welcome the opportunity to take part in this very important debate.

We believe that access to a safe and reliable drug supply by Canadians is extremely important. However, we do not believe that Internet pharmacies with proper precautions threaten our drug supply. To be very clear, when I am talking about Internet pharmacies, I am not talking about bulk drug exports. I am talking about the individual relationship between consumers in the United States and Internet pharmacies.

Canadian Internet pharmacies currently supply between three million and six million Americans with chronic health problems who do not have medical insurance and are not eligible for medicaid. We are talking about a vulnerable population. Let us talk a bit more about these numbers.

People on medicaid cannot have their drugs covered if bought outside the U.S. and people on medical insurance do not need the hassle of buying drugs online. We are talking about a very small percentage of the market. It is about .5% of the U.S. pharmaceutical market.

These pharmacies cannot provide drugs needed on an acute basis such as antibiotics for an infection, nor can they provide the types of medication that require special storage like refrigeration.

Canadians are very concerned that this business will affect our own drug supply or affect the price regime that is currently set up in Canada, and these are valid concerns for Canadians.

Pharmaceutical companies must abide by the decisions of the Patented Medicine Prices Review Board, which governs the original sale price and any annual increase in new pharmaceuticals. If they were to give up that restriction, they would also give up the patent protection laws.

I want to refer specifically to some testimony that was given before the Standing Committee on Health by Donald Macarthur. He said that in Europe there is a legal and vital parallel trade in medicines. It is well regulated and provides significant direct and indirect savings to health care systems. There are incentives and sanctions to encourage pharmacists to participate in this parallel trade.

He talked a bit about the shortages that have occurred at times in Europe. He also talked about the fact that in 1998 Glaxo Wellcome, which is now GlaxoSmithKline, refused to supply wholesalers that did not sign up for its new general sales conditions. The government's competition authority had to step in with interim measures. This is an example of a manufactured shortage.

Macarthur went on to say that the reasons for drug shortages can be multiple and complex, including higher regulatory user fees, stricter good manufacturing principles, enforcement by regulatory authorities, plant rationalization as a consequence of company mergers, and just in time delivery practices leading to less availability of bigger stock in the distribution chain.

There are a number of factors that contribute to drug shortages when they occur. As I stated earlier, the government has assured us that it has oversight into drug shortages.

Most of the pressure to prevent cross-border sales in Canada has come from the big pharmaceutical companies that have lobbied hard for increased drug prices. They have also threatened to not introduce new breakthrough drugs or withdraw or slow research and development investment, and they have.

Although it is a requirement of Canada's generous drug patent laws that pharmaceutical companies maintain a base research and development percentage of 10%, that percentage has been declining and we are not holding those pharmaceutical companies to account for that decline.

Many of us in the House have heard of incredible drug price increases, for example, the price of the drug used to treat Hodgkin's Lymphoma called procarbazine. This is a drug that has been on the Canadian market for over 20 years. The manufacturer and distributor have recently increased the price from $48.40 for 100 capsules to $5,660 for 100 capsules. The distributor, Nucro-Technics, claims that the price increase from the manufacturer was justified because of U.S. cross-border shopping. This is smoke and mirrors. This cancer drug is used exclusively in hospitals. It is not provided through Internet pharmacies. Big Pharma is using cross-border sales as an excuse to increase the cost of drugs not currently covered by the PMPRB.

The NDP is not advocating closing Internet pharmacies to acquiesce to Big Pharma's demands. We need the Liberal government to start enforcing the patent laws.

They are some of the most generous patent laws in the world and big pharma cannot have it both ways. It cannot have all the protections from generic competition long past the time that other countries would have opened the market. It cannot refuse to abide by an agreement and reduce its commitment to research and development, and then complain when a small portion of Canadian drug sales go to a small segment of the U.S. population.

In an article by Michael Geist on February 7 of this year in the Toronto Star he said:

First, the refusal to supply drugs is already being challenged in both Canada and the U.S. with several pending antitrust lawsuits as well as complaints before the Canadian Competition Bureau. Second, the Canadian government could respond to the pharmaceutical companies by issuing compulsory licenses that would allow their generic pharmaceutical competitors to manufacture the same product in Canada provided the brand-name companies are given reasonable compensation. While such an approach would spark an outcry from the industry, no industry should be permitted to hold a country hostage with threats that undermine public health.

I think that comes to the crux of this matter.

However, the NDP does have one clear problem with Internet pharmacies. They do cause a shortage in the number of pharmacists who are available in Canada. This whole issue speaks to the lack of a pan-Canadian strategy to deal with human resources in the health care field. We have shortages of pharmacists, doctors, nurse practitioners, physiotherapists, and technicians for MRIs. There is a wide range of shortages in health care practitioners.

The practitioners themselves have been asking for years for a pan-Canadian strategy. They want the federal government to step up and take some leadership. It is a role that the federal government could play in terms of coordinating a pan-Canadian strategy. We need that kind of strategy to help us talk about the kinds of training needs that are going to emerge over the next 10 to 15 years, and the number of health care professionals that we are going to need in a variety of fields as we have an aging population.

When we are talking about Internet pharmacies and pharmacists, it is just one small part of the overall picture when we are talking about human resources.

When we are talking about this, we need to also make sure that students can actually afford to go to school. Students who go into a variety of health care professions come out with monumental debt loads. We need a very proactive program to ensure that access is there for students who wish to pursue a health care profession.

We agree that an important protection is the ban on bulk export drugs. It is absolutely essential that we have this ban on bulk export drugs. We are not interested in becoming a supplier to municipal governments or state governments for drugs. This is what one of the bulk exports could be used for.

An unscientific poll in the Globe and Mail and other news outlets clearly shows that a majority of Canadians thought cross-border sales should be allowed. That was an unscientific poll, but there was a measure out there that Canadians thought that Internet pharmacy sales were perfectly okay.

After seeing the signs of devastation in New Orleans after hurricane Katrina, I think even more Canadians will say that individual cross-border sales should be allowed. It would be nice to know that we were helping our American friends that truly need our help when they need it and not the owners of the big pharma companies.

As for the new rules that the Liberal government promoted back in July, we still have not seen any action. There is no legislation yet to ban cross-border sales. We have not seen the new drug supply network up and running yet.

This is not a new issue. This has been around for months. There was actually a meeting of deputy ministers of health around risk assessment of international pharmacies back in June 2004 and still we wait for action.

The NDP believes Internet pharmacies with proper controls, which are absolutely critical, do not threaten access to a safe, reliable supply of drugs by Canadians. There is action needed and we would like to see the Liberal government act on its pronouncements that it made earlier this year.

[Robert Thibault, Liberal, Parliamentary Secretary to the Minister of Health]

Madam Chair, I have had questions for all of the other speakers, just as I have for the critic for the NDP, and specifically one question that is the same.

Understanding that there are economic interests and that people encourage entrepreneurship, that we encourage people to develop jobs, whether it is Internet pharmacies or others, can it be done while maintaining the security of our drug supply and the security of patients, whether they are Canadians or international? I do not think that the member would want a lesser standard being imposed on people outside our country than we would impose on our own people. If we can do that, then would those jobs and industry be permitted?

We certainly want to encourage the manufacture of drugs for export in Canada, but we also want to protect drugs for Canadians and protect the security of our people. I would ask the member to speak specifically of the three elements of the strategy. Does she agree with those elements? Does she agree that a bill based on the three elements of that strategy would be worthy of consideration by the House and, by extension, by the health committee?

I would remind her that one of the elements is the creation of a drug safety network or drug supply network, so that we understand what is the state of our supply in Canada and so that if problems were to arise--and the member correctly addressed this earlier when she said there are currently no identified problems that we can think of--and we were concerned, the system would feed the information to us. Another element is that we restrict the exportation of drugs at any time when medically necessary or necessary for the protection of human health in Canada. Third, for all transactions in all provinces, we would require that for a prescription to be given and a drug to be sold to an individual that person must have a relationship with the physician. As I understand it, all provincial jurisdictions now ask for this.

Does the hon. member agree with those three elements? I would ask her to comment.

[Jean Crowder, NDP, Nanaimo—Cowichan, BC]

Madam Chair, I agree with the parliamentary secretary that the entrepreneurial aspect is a very important point, because we do encourage entrepreneurial activity in Canada. Again I will quote Health Canada's own website, which stated that by November 2004 it was estimated that of the over 7,000 pharmacies in Canada, approximately 270 operated either strictly via the Internet or through a combination. It is a very important piece of job creation in Canada and is more important in some provinces than others.

It would be irresponsible for us not to consider regulations and the protection of consumers. It is critical that those elements are included. My understanding is that there is a protocol already set up to address that, with two points to it. First, in the case of Internet pharmacies, the online purchases by consumers in the United States generally begin with a prescription from the doctor in the United States who has assessed them and the consumers then find a Canadian pharmacy and complete a form establishing their medical history. The online pharmacy then arranges for a doctor with a Canadian licence to review the prescription and co-sign it.

My understanding is that a number of Internet pharmacies were actually investigated and audited to make sure that people were in compliance with regulations that were set out. In general, it was found that most of the pharmacies were in compliance. Those that were not were written up and efforts were made to bring them into compliance.

In addition, the National Association of Boards of Pharmacy, which is a professional association that represents state boards of pharmacies in 50 states and a number of countries, also has been assisting members in developing, implementing and enforcing uniform standards. It has developed a certification for Internet pharmacies.

There is a substantial amount of work that is being done around making sure that the patient, the most vulnerable person, will not be at risk from this kind of practice, while at the same time ensuring that individuals have access to a safe supply of drugs.

When we are talking about numbers in Canada, I would absolutely agree with the hon. parliamentary secretary when he says that it is essential to have some sort of oversight to ensure that Canadians continue to have access to the drugs they depend upon. It is important to have some mechanism to protect Canadians, to oversee this and to ensure that Canadians come first when drugs are being supplied.

[Steven Fletcher, Conservative, Charleswood—St. James, MB]

Madam Chair, I agree with the member on the issue of medical graduates. There is no question about it. This government has allowed the situation for medical graduates to become a crisis situation.

I think the member and I would both agree that education is the best investment society can make in an individual and the best investment an individual can make in themselves. Certainly an education in the medical profession is a great way to spend one's life and contribute to Canadian society.

I do have one question for the member. Would she agree that the Liberal Party has failed abysmally on this issue and also that it is the party that is responsible for the medical graduate shortage? That is one question.

I wonder if the member would also agree that there are situations when a patient is unable to see the doctor. I know that after my accident there were times, due to other factors like getting proper attending care and so on, that I was not even able to get out of the bed but I needed prescriptions. I did not see the doctor but I was able to get the prescriptions. There may be issues such as that of a nurse visiting a patient living in a care home. The patient is obviously ill, the nurse phones the physician and the physician may or may not talk to the patient.

I wonder if the government has considered those types of scenarios. I wonder if there are situations in remote communities where nurse practitioners often have authority for prescriptions. I wonder if the member is concerned about unintended consequences on the third plank that the government is proposing: that there must be face to face consultation. In many cases, it just not practical.

Could the member comment on those points?

[Jean Crowder, NDP, Nanaimo—Cowichan, BC]

Madam Chair, the member for Charleswood--St. James--Assiniboia has given me a lot to comment on, so let me try to go through it because I am sure my time is running out.

On the human resource strategy, we have known for a number of years that we have been facing serious shortages in a number of health care occupations, yet the pan-Canadian strategy that has been asked for and continues to be asked for by a coalition of health care practitioners still is not there and we are now in a serious shortage. Many people in Canada cannot get family physicians. We have a serious problem.

To roll into that, we have physicians living in Canada who have foreign credentials and cannot get their foreign credentials recognized in Canada. There is a broad range of issues around a human resource strategy and I would encourage the Liberals to take action now on this because we will be talking about this in four more years' time if this keeps up.

On the issue of face to face consultation, it is very interesting that we say it is acceptable for some people in remote communities in Canada to rely on telehealth. We already do it. We already have people in Canada who have nurse practitioners, and as the member rightly pointed out, in the north. We already have these practices in place in Canada. If they are good enough for Canadians, surely we can look at the very professional practices that we already have in place to manage these kinds of situations and deal with them in the Internet pharmacy context.

I think the last thing is the unintended consequences. I think we have covered that in terms of talking about the fact that we already have practices in place where people do not see physicians face to face. The member rightly pointed out his own experience in terms of how we already have people who have to manage without that face to face consultation.

[Marlene Jennings, Liberal, Notre-Dame-de-Grâce—Lachine, QC]

Madam Chair, it is a pleasure and an honour for me to take part in the debate this evening, because I believe that this matter is extremely important to all Canadians.

I would like to begin by talking a little bit about the context of this debate on cross-border Internet drugs. Over a year ago, when he was in Boston, the Minister of Health stated that “Canada cannot be the drugstore for the United States”. He also stated that Canada could not “meet the prescription drug needs of approximately 280 million Americans without putting our own Canadian supply at risk”.

The government's June 29 announcement to conduct consultations signalled an important commitment to putting Canadians first when it comes to making available the necessary supply of prescription drugs. Canadians should be concerned about this, because allowing bulk exports is a model that is simply unsustainable here in Canada.

For example, Canada's research based pharmaceutical companies are mandated to supply Canadian patients with the necessary supply of products to meet their needs, and not, quite frankly, to oversupply the Canadian market so that a few what I would call profit-hungry players can engage in arbitrage and ship to the United States or to any other jurisdiction products that are price controlled in Canada and meant for Canadians.

Simply stated, Canadian medicines are for Canadian patients first. I believe that this must be the foundation of the discussion in the House this evening.

There is a concern surrounding this practice among members of Canada's health care community. For example, the Canadian Medical Association, the Canadian Pharmacists Association and the Federation of Medical Regulatory Authorities of Canada, to name but a few, are part of the health care community that has expressed serious concerns about the growth of the Internet drug pharmacies in Canada, pharmacies that are shipping drugs outside of Canada, drugs that are made for the Canadian market and price controlled for the Canadian market, drugs made and price controlled for Canadians.

Let us look at just one other jurisdiction, that of the U.S. Let us look at the environment there and what impact it could have on Canada. While there are varying estimates of the volume of prescription drugs that has been diverted over the last several years, the Minister of Health himself estimated the volume of these cross-border sales of prescription drugs at approximately $1.5 billion per year. Earlier estimates were much lower. This demonstrates that the shipments continue to grow.

It is also noteworthy that, while these sales are occurring, the practice in the United States is illegal. However, there continues to be a growing political pressure at the state level and the municipal level in the United States to do two things.

The first is to expand programs that allow Americans to buy Canadian, even though under federal law in the United States the practice remains illegal. The second is to pass resolutions or laws that call on Washington to legalize these imports.

The population of American state jurisdictions with “buy Canada” programs in place already exceeds that of Canada. This makes the threat of large scale importation into the United States or exportation out of Canada a reality.

Legislation in the United States to legalize imports from Canada has been introduced. The passage of just one of these laws would be expected to dramatically increase the flow of drugs to the south of our border.

Let me give members an example. At last count, some 25 states, representing 145 million Americans, are at some stage of implementing a drug import program. Ten American states already have legislation for a drug import program in place. That puts our drug supply for Canadians at serious risk.

Furthermore, the possibility of U.S. legalization of bulk imports poses an unacceptable risk to our continuing supply of safe, affordable prescription drugs for Canadians. In my view, a proactive, responsive stance on the part of the Canadian government is a matter of responsible, good governance.

I would like to come back to the environment in the United States. A study was conducted by Dr. Marv Shepherd, who is the director of the Center for Pharmacoeconomic Studies at the University of Texas. He will be participating in a newsmaker breakfast this week at the Press Club in Ottawa on this very subject. His study found that if all United States residents were to buy their drugs from Canada, the Canadian supply would dry up in approximately 38 days.

The Canadian pharmaceutical industry develops, manufactures and distributes medicines predicated on meeting the needs of Canadian patients and the Canadian market. Forecasting is done to take into account the size of the population to be served and the prevalence of the disease or condition to be treated. Given that one country importing supply from another country reduces the inventory available for that country to meet its own forecasted domestic patient needs, aside from cross-border trade of prescription drugs being detrimental from a public policy perspective, it is virtually impossible to do.

Let us take the Tamiflu example. Just last week, when Roche Canada took the unprecedented step of suspending sales of Tamiflu to the Canadian market, there were reports that Internet pharmacies in Canada were busy filling foreign prescriptions at a significant profit. One B.C. pharmacy alone was reportedly filling 400 orders a day for the United States. That is a significant number, when according to the Canadian Pharmacists Association only 4,000 Canadians received the drug in September. Another Internet pharmacy in Montreal, where I live, issued news releases promoting to U.S. customers its Tamiflu stocks.

The Canadian Pharmacists Association reacted to the Tamiflu incident by saying that the government should have acted to protect the country's supply of drugs. Again, when supply gets siphoned off to the United States then it is Canadians who come up short. The situation of Tamiflu is a perfect example of the types of scenarios Canadian patients will face if our government continues to allow drugs to be diverted to the United States.

What is the Canadian opinion on this issue? A public opinion poll commissioned by the Ontario Pharmacists' Association found that some 83% of those surveyed agreed or somewhat agreed that the federal government should take immediate action prior to the implementation of U.S. importation laws in order to protect Canada's drug supply. The same survey found that 76% said that it was unacceptable or somewhat unacceptable for Congress to plan for mass importations of Canadian medicines without consulting the Canadian government.

What are the policy options? The Minister of Health has put forth some important public policy solutions to address the issue of cross-border trade, and in my view, this is noteworthy progress. However, we have to keep in mind that while the government considers its options, the United States continues its movement toward permitting the bulk importation of Canadian products. Once allowed, wholesalers looking to profit from larger, more lucrative markets to the south will act rapidly to divert the product.

While I herald the decision of the Canadian government and our Minister of Health, with the three-prong process of measures that he has put into place, I believe that we have to act even more firmly. I believe that our government should make all exports of pharmaceuticals subject to a permit requirement by adding them to a list of products prohibited for export.

I also believe that wholesalers should not be granted permits to export in bulk a product that was produced for the Canadian market, based on the forecast of the needs of Canadian patients and was meant for Canadian patients. I believe that would prevent wholesalers from exploiting the arbitrage opportunities created by our price control system.

I also believe that legitimate exports of pharmaceuticals by innovative and generic pharmaceutical manufacturers and exports by and to Canadians living abroad would continue as permitted.

I support innovation in Canada. I support job creation in Canada, but I do not support job creation that is based on putting the health of Canadian patients in danger.

[Steven Fletcher, Conservative, Charleswood—St. James, MB]

Madam Chair, I would like to clarify a few points the member made, dealing with imports from the United States.

A few bills were introduced in the House of Representatives in 2001. Each of these bills have failed to become legislation. The most recent bill, the pharmaceutical market access act, 2005, has garnered some attention, both north and south of the border. There was a recent proposed amendment to the bill in the fiscal year 2005, an agricultural appropriations bill. Although anything is possible, it is unlikely that the amendment or the bill will become law.

President Bush stated on September 20 that he would veto any agricultural appropriations bill that would permit the reimportation of prescription drugs into the United States. As a proactive measure, the international pharmacy trade associations in Canada has publicly supported a ban on public sale of prescription drugs from Canada.

The Conservative Party introduced a motion to the same effect, which passed through the health committee and the House. It was the Conservatives who raised the issue of bulk exports and that it should not be allowed. On that we are agreed.

Does the member recognize the harm, the unintended consequences that could be caused if physicians and patients are forced to have face to face meetings? There are numerous situations where it is not practical due to the geography in Canada, due to patient immobility and due to regular refills. Could the member could comment on unintended consequences?

[Marlene Jennings, Liberal, Notre-Dame-de-Grâce—Lachine, QC]

Mr. Chair, I thank the member his information concerning legislation in Congress, whether at the House of Representatives or at the Senate. However, when I was talking about the issue of drug importation into the United States, I said that the practice was illegal at the federal level.

The federal government in the United States has not as yet made the practice legal. However, at the state level, states have already passed legislation allowing for bulk importation and for patients, residents of their states, to import prescription drugs produced in another country for another market into their country.

I would like to provide a bit of information. Let us look at the state importation status. Past importation legislation was thankfully vetoed by the governor of California. However, it was not vetoed in Texas, Nevada, Washington, Maryland, Vermont, Virginia and Rhode Island. All those states have passed importation legislation to make it legal for their residents to import prescription drugs made for another market into the United States even though it has not been approved by federal legislation.

Utah, Indiana, Arizona, South Dakota, North Dakota, Iowa, Arkansas, Louisiana, Mississippi, Alabama, South Carolina, North Carolina and New York State have adopted web enabled mail order personal importation. When the member talks about it being illegal in the United States, yes, it is an illegal practice. However, the states already have moved to allow their residents to order and bring into the United States, through the Internet, primarily Canadian prescription drugs that were made and manufactured for Canadian patients.

[Dave Batters, Conservative, Palliser, SK]

Mr. Chair, I hear the member's passion for this issue and I agree with her on many points tonight. The point that we probably disagree on, and I would like to hear her comments on this, is when she talks about the importance of banning bulk exports and the threat that poses to Canadians. She referred to Dr. Shepherd's study that indicated that our drug supply in Canada would be depleted in 38 days if this legislation were to pass. It is a real concern for Canadians.

The Minister of Health spoke last November 10 at Harvard. He commented that Canada would not be the pharmacy for the United States. The bulk export issue is not something that has arisen overnight. Perhaps it has been discussed at length recently with the pending threat of avian flu and the Tamiflu drug question.

I hear the members passion. However, given the importance of this issue, why has it taken so long for the government to do anything about this? It has not introduced any new regulations. It has yet to introduce any new legislation. Patience is a virtue, but this is getting to be a bit ridiculous.

On the one hand she talks about how critical this issue is to Canadians, and I agree with her, but why has the government done absolutely nothing to protect Canadians in Saskatchewan and Montrealers in her province of Quebec? Why has the Minister of Health not done anything to safeguard Canadians to this point? It has been over a year. I would like to hear the member's thoughts, hopefully with the same passion.

[Marlene Jennings, Liberal, Notre-Dame-de-Grâce—Lachine, QC]

Mr. Chair, I will certainly respond to that with the same passion.

Canada is a complex country and we have many different jurisdictions. One of the things about good governance is that we ensure that whatever legislation is developed does represent and respect the jurisdiction and our Constitution. The other thing is to attempt to have solid information, solid facts in which to move and consult. This government has taken the time to consult the stakeholders.

Who are the stakeholders? The primary stakeholders are the Canadian people themselves and they have been consulted. The health care providers, whether it be the pharmacists, the doctors, the nurses or the technicians, they also have to be consulted. However we also must consult with the provinces. The previous member said that an unintended consequence could be that physicians would not be able to prescribe medicine unless they met face to face with their patient.

Under provincial jurisdiction, it is the province that determines the medical acts. Therefore, before our government moves on legislation, we must be sure we have it right, that we are not trampling on provincial jurisdiction and that we have the health care community and Canadians on board. The government is acting. I am proud of this government and I expect the Minister of Health will listen to this debate and to my call, which echoes the call of many others, for banning bulk exports of Canadian prescription drugs.