Mr. Chair and honourable members, I am honoured to have the privilege and opportunity to present to you on antimicrobial resistance.
I come to you as chair of the antimicrobial stewardship and resistance committee of the Association of Medical Microbiology and Infectious Disease Canada. We represent the medical specialists in Canada with expertise in antimicrobial resistance: how it develops, how to prevent it, and how to manage it.
I am also a practising academic infectious diseases physician, running the country's oldest and largest antimicrobial stewardship program at Sinai Health System and University Health Network in Toronto.
I want you to know that I became an infectious diseases physician so that I could cure people. Antibiotics are used to cure, miraculously. This book, titled The Clinical Application of Antibiotics: Penicillin, is from 1952. As you can see, it is 700 pages long, and it describes the miracle of penicillin. If we were to revise it today, it would be about 100 pages long, as most of penicillin's utility in medicine has been lost because of resistance. In fact, most doctors today don't even know how to prescribe penicillin.
Antibiotics, to infectious diseases physicians, are like scalpels to surgeons. The only difference is that infectious diseases physicians don't really get the glory; the antibiotics do. That heuristic of reliably curing people with antibiotics ended for me relatively early in my career, about 14 years ago, when I was taking care of a young man—a husband and a father—in Hamilton, Ontario, where I was working at the time. He had a brain infection due to a drug-resistant bacterium. It became resistant because it was repeatedly exposed to the antibiotics he was receiving. I had to use what at the time was relatively experimental therapy. He died, either despite me or because of me.
That event, which was the critical event of what I had seen emerging over the years prior, due to overuse of antimicrobials, has shaped what I do today, and it leads me to what I want to cover with you in the next few minutes.
First, what is antimicrobial resistance? Antimicrobial resistance, or AMR, is basic Darwinian selection. Bacteria in the environment—in humans, animals, birds, or aquaculture—are exposed to antibiotics, and as many of the drug-susceptible bacteria die off, bacteria that have randomly developed a mutation rendering them resistant to the antimicrobials thrive. There are only two things required for antimicrobial resistance to develop: bacteria and antimicrobial use. When the drug-resistant genes in bacteria take hold in a community or a population, the ability to reverse the growth of drug resistance ends up being rather uncertain.
Why should the House Standing Committee on Health and the Canadian public care about AMR? Canadians pride themselves on their health care. They have come to expect safe pregnancy and delivery, including C-sections; neonatal care; management of common infections such as pneumonia and urinary tract infections; routine surgeries such as appendectomy, cardiac surgery, and joint replacement; cancer care; and even organ and stem cell transplantation. These are all threatened by antimicrobial resistance.
For some of these conditions, it is actually a present-day threat, rather than a future one. Up to half of the pathogens causing infections in cancer and surgery are already resistant to first-line antibiotics in the U.S. I would like to quote Canadian data, but we don't really have reliable ones. It is likely comparable.
Whereas untreatable infections were unheard of when I first started practising medicine, physicians like me are already routinely seeing patients for whom we are using novel therapy to treat routine infections. Many antibiotics are rendered so obsolete by drug resistance that manufacturers have stopped producing them and clinicians have stopped learning about them.
When I started practising medicine, the only common AMR acronym in our lexicon was MRSA, methicillin-resistant Staph aureus. Today, that list also includes KPC, ESBL, NDM-1, VRE, and CDI, and the list goes on.
These all cost the health care system billions of dollars. This is juxtaposed with the over $1 billion we spend on prescription antibiotics in Canada, about half of the use of which is unnecessary. More important, it is an overall threat to national security. It threatens Canadians in a manner greater than violence and accidents combined.
AMR doesn't have headlines. When a woman needing a lung transplant recently ran out of effective antibiotic options to keep her alive, the story in the media was on the heroic removal of the infected lungs and keeping her alive, rather than the fact that she had a tipping point of completely drug-resistant infection.
AMR has no walks, runs, bike rides, golf tournaments, or galas. It has no ribbon, and the pharmaceutical industry has either distanced itself from antimicrobial development or fought to prioritize drug innovation over antimicrobial stewardship, or the wise use of antimicrobials.
What is needed to tackle AMR? Almost a year ago today, on June 16 and 17, I co-chaired the national action round table on antimicrobial stewardship, co-hosted by HealthCareCAN and NCCID. That event included 50 thought leaders and stakeholders from across all sectors, some of whom you will hear from today. We came up with a menu of what needs to get done.
For starters, convene and fund a national network to coordinate stewardship, herein known as AMS Canada; nominate executive leads on AMS at the federal, provincial, and territorial levels for strategic planning and implementation; enhance accreditation for AMS; support and scale up core operations in hospital-based AMS; enhance awareness of AMR and AMS among prescribers and public; establish an AMS or antimicrobial stewardship research and development fund; develop and support core datasets in AMU or antimicrobial utilization surveillance; incent community prescribers, using audit and feedback mechanisms; develop national guidelines for antimicrobial prescribing and mechanisms to promote adoption; and finally, develop a network of centres of excellence in knowledge mobilization for AMS.
As I mentioned, that was one year ago, almost to the day, and what has happened? Its the same thing that happened with the 2004 report, “National Action Plan to Address Antibiotic Resistance”, and the 2009 report following pan-Canadian consultation by the since-defunded Canadian Committee for Antibiotic Resistance.
In 13 years, we have had three national reports on antimicrobial resistance, and the collective response from the federal government remains a tacit one. In fact, the Public Health Agency has all but eliminated any anticipated funding towards antimicrobial stewardship and surveillance for the upcoming year. “Suspended” is the term we have been given. This pales in comparison to the United States, which spends over $1 billion annually to combat antimicrobial resistance, with an effort that includes the Departments of Defense, Justice, and Homeland Security, amongst other departments. The United Kingdom has equally provided strong leadership and effort, with their chief medical officer of health, Dame Sally Davies, perhaps the strongest world advocate on the subject.
In Canada, antimicrobial stewardship and resistance research funding is less than $10 million per annum. More has been announced recently, but this compares with CIHR funding of $273 million for cancer or oncology, which has another $95 million from the Ontario cancer institute, $91 million from the Fonds de recherche du Québec—Santé, and numerous other research sources.
I could go on, but suffice it to say that, in Canada, antimicrobial resistance is not being sufficiently addressed. This is reinforced by our own Auditor General who two years ago concluded that the Public Health Agency of Canada and Health Canada “have not fulfilled key responsibilities to mitigate the public health risks posed by the emergence and spread of antimicrobial resistance in Canada.”
The Auditor General also stated that the Public Health Agency of Canada:
||has not determined how it will address the weaknesses it has identified in its collection, analysis, and dissemination of surveillance information on antimicrobial resistance and antimicrobial use. The Agency has taken some steps to promote prudent antimicrobial use in humans, such as developing and disseminating guidelines for health professionals, but has identified the need for more guidelines.
Honourable committee members and Mr. Chair, on behalf of AMMI Canada, I stand here to tell you that Canada has been lucky to avoid an antimicrobial resistance catastrophe. I am not a boy crying wolf. There were warning signs around opiates for decades and they only became front of mind when the deaths escalated, researchers started identifying the public health crisis, and civil society took notice. Governments have had to play catch-up ever since.
Today, I represent the voices of Canada's experts on infectious diseases and antimicrobial resistance telling you that the current situation and the crisis that we will be facing will be like it is with opioids, only worse. The victims will span all ages. Our health care system will be paralyzed. The costs of ignoring AMR today will be paid many times over in lives lost. When the post-mortem will be done, as it was for the Naylor report following SARS, the country will look to missed opportunities and ignored warning signs. You have an opportunity to heed those warning signs.
Thank you for your attention.
Good morning, Mr. Chair, and members of the committee. My name is Karey Shuhendler. I'm a registered nurse and policy adviser with the Canadian Nurses Association, the national professional voice for over 139,000 registered nurses and nurse practitioners in Canada.
I'm pleased to be here with Yoshiko Nakamachi, who is with us today as CNA's antimicrobial resistance nursing expert. She will be able to answer questions that may be more technical in nature. Yoshi currently serves as the antimicrobial stewardship program lead and program manager at the Sinai Health System and University Health Network antimicrobial stewardship program in Toronto. She has also worked with community hospitals to develop antimicrobial stewardship programs, is involved in a multicentre antimicrobial stewardship initiative in primary care, and is a member of provincial, national, and FPT antimicrobial stewardship committees.
At the outset, I'd like to thank the committee for studying this important issue and for giving CNA the opportunity to speak on behalf of registered nurses and nurse practitioners. We have a professional responsibility to advocate for federal action on antimicrobial stewardship, henceforth referred to as AMR, as it is a major threat to the health of people in Canada and is projected to worsen over time if appropriate actions are not taken. As you may know, antimicrobial resistance occurs when an organism, like a bacteria or virus, stops an antimicrobial medication from working against it. This means standard treatments no longer work, and infections can persist and spread to others. AMR leads to increased human illness, suffering, and death; increased costs and length of treatment; and increased side effects from the use of multiple and increasingly powerful medications.
Prior to outlining our two key recommendations and taking your questions, we want to paint a picture of the impact of AMR internationally, as well as providing some national context.
The director general of the WHO has referred to AMR as a “slow moving disaster”, one of the most serious threats to human health and safety. The WHO has also warned that AMR is putting the gains of the millennium development goals at risk and endangering the achievement of sustainable development goals. AMR is an issue that requires action by all areas and disciplines in health.
In its 2017 position statement on AMR, the International Council of Nurses notes:
||Nurses and other healthcare workers have a vital role to play in preserving the power of antimicrobial medicines. Nurses play a central role in patient care and interdisciplinary communication and, as such, are in a key position to contribute to reducing AMR and critical for the function of antimicrobial stewardship programmes (ASP).
The statement goes on to point out that nurses contribute to assessment and diagnoses of infections, administer and may prescribe antimicrobials, monitor outcomes and report side effects, provide vaccinations, and educate patients, families, and communities.
At the national level, CNA acknowledges the planning efforts of the federal government to respond to the threat of AMR through the development of the 2014 document “Antimicrobial Resistance and Use in Canada: A Federal Framework for Action”, the 2015 document, “Federal Action Plan on Antimicrobial Resistance and Use in Canada: Building on the Federal Framework for Action”, and the 2017 draft document, “Tackling Antimicrobial Resistance and Antimicrobial Use: A Pan-Canadian Framework for Action”.
CNA has also been doing its part to combat AMR by contributing to national work on infection prevention and on stewardship. Do Bugs Need Drugs?, a community-based antimicrobial stewardship program in B.C. and Alberta, defines “stewardship” as:
|| ...the practice of minimizing the emergence of antimicrobial resistance by using antibiotics only when necessary and, if needed, by selecting the appropriate antibiotic at the right dose, frequency and duration to optimize outcomes while minimizing adverse effects. The principles of antimicrobial stewardship apply wherever antimicrobial agents are used including hospitals, long term care facilities, community medicine, agriculture and veterinary use, and in the home and community.
CNA's efforts in this area include membership and participation on the antimicrobial stewardship or AMS Canada steering committee, and engaging in the Canadian Roundtable on AMS to develop a Canadian multidisciplinary, multi-sectoral action plan on antimicrobial stewardship.
We are also active participants in the federal-provincial-territorial AMR stewardship task team to develop a pan-Canadian framework and action plan. In addition, through partnering with Choosing Wisely Canada, a national program to engage clinicians and patients in conversations to reduce overuse, CNA has developed a broad list of nursing recommendations to reduce the use of tests, treatments, and interventions that may lack benefit or cause harm. Several of these recommendations advance the AMS agenda, including recommendations to reduce inappropriate or unnecessary use of antimicrobials.
CNA is planning to release a speciality Choosing Wisely nursing list, in partnership with Infection Prevention and Control Canada. This list includes recommendations to reduce the use of interventions that can lead to infection, as well as reducing inappropriate laboratory testing, which can lead to unnecessary use of antimicrobials. It also includes stewardship recommendations focused on reducing inappropriate antimicrobial use.
Despite work done by CNA and other partner organizations across the county, additional effort and investment is required by the federal government to further address antimicrobial use and resistance. Of particular note is the need to emphasize an interprofessional approach to stewardship that includes nurses, in collaboration with physicians, pharmacists, patients, and caregivers, as a cost-effective preventative approach to AMR.
We have two key recommendations to address the issue of AMR in Canada with a focus on stewardship. We encourage the committee to include these recommendations in your final report on this important study.
Our first recommendation encourages the federal government to support the 10 action items on antimicrobial stewardship put forward in HealthCareCAN and the National Collaborating Centre for Infectious Diseases document entitled “Putting the Pieces Together: A National Action Plan on Antimicrobial Stewardship”. The 10 items are outlined in CNA's brief, but also nicely summarized by Dr. Morris.
Our second recommendation urges that the federal government commit to providing significant funding over the next five years to support scaling up of antimicrobial stewardship programs across acute care and community-based settings in the provinces and territories, conditional on an accountability framework, and that the federal government support the role of nurses in antimicrobial use, resistance, and stewardship.
Why is funding needed? Historically, education and reform around antimicrobial use and stewardship has been targeted to physicians and pharmacists but not to regulated nurses, who make up the largest group of health care professionals in Canada.
According to the Canadian Institute for Health Information's report entitled “Regulated Nurses, 2016” and released just last week, there are more than 400,000 regulated nurses in Canada. This number represents over 100,000 licensed practical nurses, approximately 6,000 registered psychiatric nurses, and nearly 300,000 registered nurses, including 5,000 nurse practitioners. Nurses are present in every health setting. They are well positioned to contribute to antimicrobial stewardship, for the preservation of health and the improvement of health outcomes for all people in Canada.
I would like to close with the reminder that antimicrobial resistance is a national and international issue with local implications. Every person in Canada, including those who live in the ridings that each of you represent, is not immune from the evolving threat of AMR. That is why immediate action by the federal government is required.
CNA encourages the Standing Committee on Health to urge the federal government to adopt all 10 expert-developed recommendations in “Putting the Pieces Together: A National Action Plan on Antimicrobial Stewardship” as a key component of addressing antimicrobial use and resistance in Canada.
Furthermore, the federal government can take additional concrete action by investing in established AMS programs with proven results to reduce inappropriate antimicrobial use, and by investing in the education of nurses to leverage their potential as antimicrobial stewardship leaders across all health settings in Canada.
Good morning, everyone, and thank you for the opportunity to be here today.
My name is Shelita Dattani, and I am the director of practice development and knowledge translation at the Canadian Pharmacists Association, which is the national voice of Canada's 42,000 pharmacists. I am also a practising hospital and community pharmacist and have significant experience leading and participating in antimicrobial stewardship initiatives in the hospital setting.
Since the discovery of penicillin by Sir Alexander Fleming in 1945, as my colleague described, antibiotics have made an enormous contribution to the treatment of infectious disease, and they have made so many other treatments and procedures, such as surgeries and transplants, possible for us.
It is worth echoing my colleagues here today that AMR has been described as a “slow moving disaster”. As others have said, it is a very serious threat to health and public safety. If left unchallenged, it could lead to 10 million deaths a year by 2050, and with few new antibiotics in current drug development, it's frightening. It's everyone's problem, and everyone must be part of the solution.
I want to talk to you today about antimicrobial stewardship and the role of the pharmacist.
As others have said, stewardship is a team sport, and our collective goal in antimicrobial stewardship is ensuring that patients get the right antibiotics when they need them, and only when they need them. As the medication experts, pharmacists are fundamental to antimicrobial stewardship. Hospital pharmacists throughout this country have demonstrated leadership in antimicrobial stewardship activities and programs for several years now. Just as I spent much of my time in hospital practice ensuring that patients were receiving the right antibiotics, and only if they needed them, I work with my primary care colleagues now to do the same when I practise at the neighbourhood pharmacy. Pharmacists can act as stewards throughout the continuum of care, as other professions can. We work in hospital settings, long-term care settings, primary care teams, public health, and the area that I will predominantly focus on today, which is community pharmacy.
Hospitals and long-term care environments have either established or evolving stewardship programs, but over 80% of antibiotics are prescribed in the community, where few formal antimicrobial stewardship programs currently exist. One large study published last year in the Journal of the American Medical Association demonstrated that 30% of antibiotic use in non-hospitalized patients is unnecessary.
Antibiotic prescribing in the community is driven by the tendencies of individual prescribers and consumer demand. Community pharmacists have the skills and knowledge to make a real difference. Pharmacists like me, in communities across this country, have established relationships with their patients and their prescriber colleagues. Pharmacists can effect real change in community-based antibiotic prescribing.
There are five key areas in which pharmacists are demonstrating leadership as antimicrobial stewards in the community. These include public education, immunization, prescribing for minor ailments, counselling patients, and optimizing prescribing by other health care providers.
Many Canadians are unaware of the impact and the risks of inappropriate antibiotic use compared with the benefits. Pharmacies are the hubs of their local communities, and pharmacists can play a big role in health promotion and transforming patients into stewards. As others have mentioned, educational campaigns in Canada, such as the community-based education program Do Bugs Need Drugs? and the Choosing Wisely campaign, include antibiotic-related information. Pharmacists have participated in the development of these campaigns. They are developing their own lists for these campaigns, and they are relaying the messages to their patients each and every day in the hubs of their communities.
For several years, Canadians have been able to go to their community pharmacy to get their flu shots. One of the best opportunities I have to talk to my patients about infection prevention, symptomatic management of viral infections, or their hesitancy in getting vaccinated in the first place is during flu shot season. I tell my patients that vaccinations don't just prevent primary infections, but they can also prevent secondary infections from antibiotic-resistant bacteria, for example, pneumonias that can follow flu infections. I use these opportunities around flu season to talk about the importance of all vaccinations.
Beyond this, pharmacists are also taking on more active, targeted, and patient-specific interventions that you may not be aware of, which include assessment, treatment, and follow-up of their patients. Because pharmacists see their patients on average 14 times a year—sometimes at nine o'clock on a Thursday night, or maybe at 4 p.m. on a Sunday—they are very well placed to provide direct care to patients.
In one province in this country, pharmacists can independently prescribe broadly, and in a few others, can prescribe more specifically for minor ailments like uncomplicated urinary tract infections or strep throat. Pharmacists are guideline-oriented practitioners, and they are very invested, as I mentioned, in campaigns like Choosing Wisely's “More is not always better”. As drug experts, prescribers, and antimicrobial stewards, we pharmacists are very conscious of responsible prescribing—and more importantly, not prescribing if not needed.
In certain provinces, pharmacists can substitute one antibiotic for another. For example, if you come into your pharmacy and you have allergies to the antibiotic prescribed, or if the initial antibiotic prescribed does not resolve your infection, I can substitute a more appropriate antibiotic. I have a relationship with you; I can do that.
These expanded scopes mean that pharmacists have a very direct opportunity to lead in antimicrobial stewardship. There is currently research under way in the province of New Brunswick to capture outcomes in patients assessed and treated by their pharmacists for uncomplicated urinary tract infections.
Pharmacists can also help support their physician colleagues who use delayed prescribing, which is a debatable practice. If a patient gets a prescription from their doctor and is instructed to start antibiotics if symptoms do not improve after a specified time, I can reinforce symptom management with my patient to ensure that we don't jump to antibiotics too quickly. I can counsel my patient on when to follow up with her prescriber. If my patient ends up needing antibiotics, I will talk to her in detail about benefits but also the other things she may not be thinking about, such as the adverse effects and other unintended consequences that have been described here today.
Rapid strep tests are also now offered in some pharmacies. Pharmacists can administer these tests and intervene immediately, either through prescribing or recommending antibiotics or over-the-counter treatments for viral illnesses, as appropriate. Expanding these services would further relieve pressure on the health care system if patients were able to avoid emergency departments or urgent care clinics. A U.K. demonstration study showed that 49% of patients would have sought care from their family doctor if strep tests were not accessible and available in community pharmacies, which are the health care hubs of their communities.
Pharmacists, as evidence-based practitioners, play a huge role in educating prescribers to support them in optimal prescribing for their patients. Pharmacists educate prescribers informally on a regular basis, and they have formal roles where they lead in individual educational outreach.
Pharmacists also have established roles in integrated primary care teams, and they collaborate every day with their colleagues to ensure optimal prescribing of antibiotics through direct and individual feedback on prescribing. This practice has met with much success in the hospital environment.
CPhA participates in the interdisciplinary AMS Canada steering committee and the Canadian Roundtable on AMS. We have demonstrated leadership in increasing the awareness and importance of antimicrobial stewardship for all pharmacists in Canada. We are engaged in continuing to shape the significant role of pharmacists as part of the team in the fight against AMR.
Pharmacists are doing a lot, but we want to do more and we could be doing more to help as primary care providers. We need to have the authority to act to make an more impactful difference. Our skills, scope, and access have enabled us to improve outcomes in chronic disease, and evidence is now building in other areas.
We also need enabling tools to be even more effective antimicrobial stewards. It doesn't make sense to me that a 32-year-old woman in New Brunswick can be treated by a pharmacist for a simple urinary tract infection, but a similar patient in Ontario can't and might have to wait longer to access treatment.
We recommend action in four specific areas. First, and most critically, we recommend that all jurisdictions, including the federal government as a provider of health services, promote harmonization of pharmacists' expanded scope of practice and associated remuneration for these services across the country. This should include prescribing for minor ailments, as well as therapeutic substitution of antibiotics.
Second, the implementation of a fully integrated drug information system and electronic health record in every province and territory would ensure that pharmacists have access to the information they need, such as patients' medication profiles and culture and sensitivity reports, to help us care for patients and work more effectively with our colleagues to ensure safe and effective antibiotic use.
Third, the Canadian Pharmacists Association, through our work with the AMS steering committee, supports the development of national prescribing guidelines. We also commit to leading the development of knowledge mobilization tools and mentorship networks for pharmacists, to ensure they are armed with the most current knowledge and skills to act as antimicrobial stewards in the interests of public safety.
Finally, we recommend that all antibiotic prescriptions include the indication for the medication—why the medication was prescribed to that patient—on the prescription. This information would help us promote optimal and safe antibiotic use, ensuring that the patient receives the correct drug, the correct dose, and the correct duration of therapy for that particular indication.
Every interaction I have with a patient or a prescriber is an opportunity to get my patient the right antibiotic, if needed, and an opportunity for all pharmacists to embrace their role as antimicrobial stewards. We need to continue to work together to solve this problem.
Pharmacists are committed to being a major part of the solution in this shared responsibility of stewardship, and we ask for the committee's support in advancing the role of the pharmacist as antimicrobial steward, as described today.
Thank you very much.
Thank you, Mr. Chair, and thank you to the committee for examining this very important topic. I'm here on behalf of the Royal College of Physicians and Surgeons of Canada, as a Royal College specialist in public health and preventative medicine. The Royal College does not currently have an official position on antimicrobial resistance but fully supports ongoing efforts to address AMR and has asked me to provide my perspective as a specialist physician in public health.
I won't reiterate all that you've already heard on the background with respect to how important a topic this is both in Canada and around the world. I'm going to focus on two specific aspects. One is that, historically, AMR has been underaddressed relative to its potential impacts. Two, going forward, it will be important to continue to support and strengthen the national processes that have been created to ensure AMR is effectively addressed across the country.
Advancing the AMR agenda can be difficult, because even though it is an extremely important and impactful public population health issue, it is one that is slow moving and doesn't tend to grab headlines. You've already heard a couple of witnesses talk about the idea that it's slow moving and referred to often as a slow-moving tsunami. It's easily pushed to the corner of the desk to make way for the urgent health issues of the day.
If AMR can be positioned, going forward, as the critically important issue that it is, and if the national and regional structures that are working on this can continue to be supported and strengthened, we will be able to fully utilize all the knowledge and resources that exist in a way that supports this work across all of Canada.
The recent inclusion by Accreditation Canada of a required organizational practice on antimicrobial stewardship is an excellent example of how embedding AMR into the health care system structures can help advance the agenda. In the regional health authority where I work, we have recently partnered with the National Collaborating Centre for Infectious Diseases to develop a pilot project that looks at, among other aspects, supporting health care provider practice and education for the public. This work is being done to meet the new Accreditation Canada ROP, or required organizational practices, in part, and our hope is to continue to grow this work in all aspects of antimicrobial stewardship.
Canada has, and has had in the past, many examples of local pockets of excellent work on antimicrobial resistance, the Do Bugs Need Drugs? program in B.C. and Alberta being one example. What has primarily been lacking is a robust structure that can coordinate, disseminate, and support these leading practices across all health care organizations and professionals in Canada. The creation over the past few years of the 2014 federal framework and the current FPT steering process, combined with the efforts of organizations like HealthCareCAN and the NCCID, have positioned Canada well to take the necessary next steps.
The key going forward will be to ensure these processes are supported and monitored in order to ensure that antimicrobial stewardship is receiving the attention and work it warrants across the country.
Again, I would like to thank the committee for examining this topic, and for inviting the Royal College of Physicians and Surgeons to take part.
I'm not sure I'd be too good at predicting 50 years from now. I'm not sure it's even necessary to go 50 years ahead.
Several countries right now don't have availability of certain antibiotics due to production problems. Australia recently had a problem with piperacillin–tazobactam, which is an important broad-spectrum antibiotic.
Having a drug unavailable because of production is, in many ways, similar to not being able to use it because of drug resistance. What ends up happening is that you reach for other drugs, you result in harm, and you get side effects. If you can't use any antibiotics, which is what will almost certainly happen if we do nothing, the complication rates.... For example, I have an artificial hip. The risk of me getting that infected at the time of surgery was somewhere around 1%. Thankfully I got antibiotics at the time of surgery so the risk went from 5% down to 1%.
If we can't use antibiotics for a simple surgery like that, then one in 20 people who are getting hips, rather than one in 100 people who are getting hips, are going to get infections. For Caesarean sections, it's the same thing. The risks are even higher. It's the same with abdominal surgeries. The list goes on.
For transplantation medicine, for solid organ transplantation, the backbone of that is antimicrobials. It requires a very broad team to be involved, but the backbone involves antimicrobials. Supportive care for cancer chemotherapy absolutely requires antimicrobials. If you have leukemia and you're receiving chemotherapy, you are almost certainly going to require broad-spectrum antimicrobials for weeks.
No cancer chemotherapy, no transplantation, no high-risk surgeries, and that's not 50 years from now; that's 15 to 20 years from now at best.
Thank you very much, Mr. Chair.
I'll tell you that the more I read about this, I get worried. It seems that humankind may have, what, only 70 or 80 years where these drugs are effective? They have been game-changers.
I want to thank all of you, because it is a huge issue and it's not getting the attention it needs. It's an issue not only here on the ground in Canada, but internationally. It affects everything from livestock to feedstocks. I'm going to try to ask you some uncomfortable questions. I hope you don't mind, but you're the experts and you're here.
Doug mentioned a really good point with our last round of witnesses, which is that sometimes in the practice of medicine or health care on the ground, people get into their prescribing habits and things along those lines.
Dr. Morris, I think you brought up the opioid crisis. Here at the federal level last year we brought up the topic. We got experts in and all that stuff, and what has happened in Canada? This past year, there were more prescriptions instead of fewer. You're here. This is a federal committee, and what we want to hear from you is what the federal government should do. Should the federal government be using more of a heavy stick here? I think it was David Cameron who called “on the governments of the richest countries” of the world “to mandate now that by 2020, all antibiotic prescriptions will need to be informed by up-to-date surveillance information and a rapid diagnostic test wherever one exists.”
You mentioned the dentists, who aren't here to defend their prescribing practice, but we have three organizations here that are hugely important and have a role to play. What would you tell these guys sitting next to you about what they should be doing? Also, what should the government be doing? How far should they be going with the carrot-and-the-stick type of thing?
I have circulated a motion. I'm going to make a couple of changes to it as we go forward, but I will quickly explain this.
This is a complex bill. It represents a fairly substantive change in the norms of how we view marijuana and the use of marijuana in Canada. I think it's really important. I've been talking to a number of committee members, and there is significant interest in hearing from many witnesses and hearing testimony from different sides of different issues. If we handle it as we would normally handle our committee business, we could be hearing witnesses for months.
It is important that we review the bill, that we give it full and open consideration, and that we hear from witnesses but also that in a timely fashion we return it to the House so it can go through the rest of the processes that need to be done.
The motion is looking at a way that will allow the committee in a very focused way to hear from a number of witnesses and to work quite diligently at this review to make sure we have a substantive number of witnesses who come forward and that we organize ourselves to hear the witnesses in a way that makes sense so that we can hear countering views around some of the more controversial issues. It's also a way for us to give full consideration and to hear from a number of witnesses to start.
Nothing in this motion is intended to say there will be no more witnesses. Nothing is intended to restrict the witnesses. We can still continue after this, but the motion proposes that we have one week of dedicated time, as a committee, on this topic to hear witnesses, that we would meet for four days, and that we would organize our work so that we can get at least 72 witnesses in that week around different topics. I'll review the topics in a second.
As I said, once that week is done, if we then determine that other witnesses are needed, or if that leads us to other areas that we should consider, then nothing limits us having more witnesses and nothing in here limits the time we have yet, because we do have to do a clause-by-clause review of the bill, and we'll need time to hear from the witnesses, to synthesize what we've heard, and then to do the clause-by-clause review and to give thought to that.
Nothing in this bill is restricting that. This is really just about setting up a time for the committee to have a focused four-day period to hear from a number of witnesses around some themes as a way to kick-start our work on this very important, very significant bill for Canadians. As I said, it doesn't limit further witnesses and it doesn't put time restrictions on the clause-by-clause study.
In addition to that, I am proposing that we come back a week early and that we meet before the House sits and that we work for the week of Monday, September 11 to Thursday, September 14, which is the four days before the House sits. Again, it gives us a focused effort. We're not being interrupted by votes in the House and other routines that often interfere with witness testimony. We can have four very focused, very good days getting through witnesses on some of the important topics that we know we have before us.
It's also at a time, because the House is not sitting, when we may actually have additional media time and additional public interest in this, because the normal things that happen in Parliament aren't happening in that week. I know it's going to put a burden on members to come back from their constituencies and the work they're doing with constituents for that four-day period, but I do believe it will give us a really good start on hearing and understanding all perspectives around Bill .
I am proposing:
||That this Committee meet from Monday, September 11, 2017, to Thursday, September 14, 2017, inclusively for the purpose of the consideration of Bill C-45—
I'll cut out some of the verbiage. You have it in front of you. I'm changing it to “and, that each party send their lists of prioritized”—rather than “proposed”. The clerk has suggested that it's easier for them if you prioritize the lists—
||—witnesses for the purposes of this study...and that the Chair be empowered to coordinate the witnesses, to a maximum of 72 witnesses, the resources, and scheduling necessary to complete this task in accordance with the following guidelines:
I'm proposing that we take those four days and break them into two four-hour blocks per day, with nine witnesses per four-hour block, and that we do two rounds of our normal questioning as well. It would be nine witnesses, and for questions it would be two rounds of seven minutes; five minutes; and then three minutes.
I propose that we organize the blocks into a number of categories. The first would be federal, provincial, and territorial responsibilities, which would include retail presentations. Revenue questions would be included in there.
The second category would be justice and public safety. We would hear from the police, RCMP, and others. If there were questions around the impact on organized crime, that would be a natural place to include witnesses around that topic.
Then we would look at other jurisdictions' experiences. Others have gone down this road, and what were the lessons learned? If there were international considerations, this would be a point in time to also build in international issues around compliance with other jurisdictions.
The next category would be the household cultivation of plants, which is a very common question that I've heard from others. It would also give us a chance to hear from landlords and tenants, and if there are rental issues on that topic.
Another category would be the age for legal possession and the impact on young Canadians. There's also prevention, treatment, low-risk use versus high-risk use, and health risks.
We would also look at workplace safety. There is a corresponding piece of legislation to this one, which is dealing with motor vehicles and heavy equipment. Otherwise, what's the impact on workplaces? Do we have appropriate detection? It would be a place to build in how we can detect and understand if somebody in the workplace is under the influence.
Then there's the impact on indigenous communities. That would be the eighth topic we would deal with.
The witnesses would be proportional to our committee. It would be five from the Liberals, three from the Conservatives, and one from the NDP. Generally on these topics we have a high degree of overlap anyway in our witnesses, but I think that would be the normal method the clerk would use to assign witnesses.
I'm changing number three. It currently says that witnesses should be directed to prepare oral remarks of five minutes. I think we can do 10 minutes. We normally do 10 minutes with four witnesses. We usually have about 20 minutes free in a two-hour block, so if we go to nine witnesses in a four-hour block, it's tight. We'll have about a 10-minute window in each four-hour block. The reason I was thinking of five minutes was really for us, just so that we have breaks. The four hours is not that intensive, and we make sure to ask for written submissions to augment the five minutes, but given that our committee practice has been 10 minutes, then we probably should stay at that 10-minute mark.
The second change I had in here is that witnesses be invited to submit their written statements prior to August 18, which would give time for the translation.
Is that correct?
Okay, sorry. It was my misunderstanding. In number three we will go back to 10 minutes, but we don't need to change the timing of the written statements on that one.
Number four really isn't about this week. I'm trying to get this week organized for us, because the House should be rising shortly and I want to make sure we have a good, robust week of study of the bill. Four is really about setting deadlines for others. Normally the committee sets a cut-off for when we receive submissions. I think we can deal with that when we come back and have a cut-off set. I'll leave it in for now and we can have discussions. In paragraph four, the chair would set a deadline of August 18 for written submissions regarding Bill .
Paragraph five proposes that the Minister of Health, the Minister of Justice, and the Minister of Public Safety be invited to appear before the committee on Thursday, September 14. It would give us, at the end of that week, a chance to hear from the ministers involved in this, if they're available. It also proposes that they be given 10 minutes for remarks.
Again, I'm not trying to restrict other witnesses and I'm not trying to force us to clause-by-clause. I'm just trying to set up a very robust week of intensive work for us so that we can hear from a number of witnesses on some of the key topic areas that have been controversial in our debates in the House so that we can get a good start to our review of this bill.
And us, and of course everybody, parliamentarians and the people we represent.
I don't think it's an exaggeration to say that billions of dollars are at stake, not only on the medicinal front but also as we move towards Canadians accessing in a legal way the sale of recreational or adult-use marijuana.
I'm pleased to see that this motion is written in a way that leaves it open-ended whether or not we have more meetings. I was concerned that if we limited this testimony to four straight days of public input, effectively in the summer before Parliament sits again, it could convey to the general public that this committee and this Parliament are looking to restrict public input.
I would point out that this part of the legislative process, this committee phase, is the only phase when members of the public and stakeholders have the opportunity to come before Parliament and express their comments on the proposed legislation.
I know that there was some consultation during the McLellan task force, and the government had a website, but that was prior to any legislative framework being designed, and that is what we have before us.
I know there are going to be a lot of people from a lot of different perspectives who will want to have their input into this legislation. Frankly, I think we will benefit from that input, so I'm very glad. I want to put on the record now that I'm almost certain that from of those four days, as always happens with every study we undertake, we'll learn a lot. Issues will arise that we haven't anticipated, although I think that John has done a good job in setting out some of the major areas. I don't think it's quite there yet, as I'll say in a moment, but it's largely there.
Certainly, there will be other issues raised by the testimony that will prompt further questions from us, and so the opportunity to have further days of testimony, later in September, is important. I will say right now that I think it will be necessary.
There are a couple of more things.
In terms of the structure of this, I don't think the subject matter is complete. I agree with Rachael on this. I had indicated originally when I saw this list that packaging and marketing were not included here, and packaging is a part of this bill. There's a very strong cleavage between those who want to see—in fact, I think the bill does speak of it—a plain-packaging regimen, as opposed to those who would like it marketed more like alcohol, where there's branding and lifestyle advertizing, particularly for the recreational aspect. That's going to be a very important part of this bill, and I think every one of us has had meetings with people who want to get in on the commercial sale and are intensely interested in how they'll be able to market this product. That should definitely be added as a subject.
Another critical subject that's missing is edibles. I don't know if the bill deals with this. I think it's a very important part of safety to determine whether these drugs will be available in gummy bear form or brownies, or any other aspect of that. I think that this committee—
—should really be looking at edibles as a subject. I think we should look at whether or not it should be covered.
Finally, medicinal marijuana is not indicated in this list, which, I think, is a subject.
I have to say there are a couple of things in here that I'm not sure warrant complete separation as subjects. For instance, workplace safety I'm not sure is a subject on its own. I think that will be touched on by adding these other subjects. I'm a little confused as to why indigenous communities would be segregated out on cannabis. I'm not sure that there's any particular aspect of this bill that has a unique application to indigenous communities.
I have a final couple of housekeeping matters.
I would rather not have one witness allocated per subject. Rather, let's just divide up the witnesses by our percentage and let each party determine where they would like to call their preponderance of witnesses. There might be a subject here for which I'm perfectly comfortable with the government's witnesses and on which I don't feel I have a witness who could add anything, but there may be another subject for which I would like to have two instead of one. I would propose that friendly amendment.
John, you mentioned something about there being at least 72 witnesses. This motion talks about the chairman scheduling a maximum of 72 witnesses. I understand that you're referring to just these four days, but I want to be clear that we're talking about 72 witnesses for these four days.
Finally, within those 72 witnesses, the last item proposes that the three ministers appear before this committee. If they have 10 minutes each, that's going to take up a significant part. I would even propose that, perhaps, we sit on the Friday, as well, and have the fifth day. Maybe that could be limited just to the ministers, as an example.
One of the difficulties I had when I thought this would be only the four straight days was that it would not give us any time, really, to digest the evidence, or if you hear something, to research and inquire among other people to get different perspectives. That's another reason I'm really going to be pressing the committee hard to have a day or several days of testimony after this, so that after these four intense days or five intense days, we have a chance to reflect on what we have heard and maybe even hone some further testimony. We've seen that in the pharmacare study, Mr. Chair. As there is testimony, it's an organic process, and we decide to call yet other witnesses to go down paths that maybe we didn't anticipate at the beginning.
Finally, on paragraph 1(i), I'm not sure federal-provincial responsibilities warrant a topic on their own. We're a federal committee, and we are going to be looking at the federal issues on this, I think.
I guess what I'm saying is, with regard to those paragraphs (i) to (viii), although I think it's a very good first proposal, I'm already seeing that some of them should be dropped and others should be added. Either we can do that now or maybe we can leave this a little bit flexible in some way. I don't know how the committee wants to have it or how my colleagues feel about that. Otherwise, I would propose that we drop paragraphs (i), (vii), and (viii), and replace them with packaging, edibles, and medicinal marijuana. I don't want to limit any particular category. If members feel there should be other areas, then I think we should add them.
Those are my preliminary comments at this point.
Thank you very much, Mr. Chair.
First, I want to say that it's interesting to get the opportunity to study this bill. Also, I appreciate the opportunity to discuss this motion, because I know that in the provinces and territories there are a lot of questions, and the timeline of July1 is being seen as an extremely tight timeline. I'll disagree with Don a bit about the provinces and territories. I believe they have a lot of questions, and I think it's incumbent on this committee to actually allow them to ask those questions and get prompt answers, because the timeline to make such a substantial change that's happening here is really going to be tight for them.
I have a couple of recommendations that will perhaps move this forward a little more quickly.
I agree with about the “maximum of 72 witnesses”.
I appreciate 's talking about these topics, but I don't think those topics actually have to be in the motion. I think they could be hashed out in a planning meeting.
brought up some really good points about edibles and things along those lines. I know that it may not be intended to be restrictive—you may not have intended it—but I think it does come across that way. As we discuss it, if there are stakeholders who want to come in and talk about a few different things....
I'd also like to point my colleagues towards the really good job the analysts have done with the legislative summary, the pre-release unedited portion of it. I think they've done a great job, and of course they're non-partisan. It is available upon request for public use, so this could get out and people could take a look at it.
They did a good job of talking about topical organization. They talked about the prohibitions, the obligations offences, criminal activities, other prohibitions, promotion, and what said, which was about packaging and labelling, displays, selling and distributing, obligations, and a miscellaneous category, which was, did they have ticketable offences...? We've heard the debates in the House. Even though this is the federal legislation, there are some options for provinces and territories and how this is understood in terms of licences, permits, general authorizations, ministerial orders, a cannabis tracking system, and inspections, which is huge, as we're finding out with the medical marijuana, and which maybe we are not doing as well as we can. What are the options for this for the general public? As well, they talk about the disposition of seized things, administrative monetary penalties, transitional provisions in the related Controlled Drugs and Substances Act and the Criminal Code, and coming into force. Coming into force is going to be huge here.
I think the analysts have done a really good job.
From my standpoint, to move the motion forward, I like your amended your motion that now includes the word “prioritized” lists. I would even take out “a maximum of 72 witnesses”. Depending on if we're doing those two-hour blocks, we might be able to leave it up to the analysts and clerk as they start booking. We might be able to be flexible there. Also, I would take out what I see could be interpreted as overly prescriptive, which is point 1 of your motion.
I would also suggest that in point 5, where you say “the Minister of Health, the Minister of Justice, and the Minister of Public Safety be invited to appear before the Committee” on the Thursday, I would like to see them here on the Monday, as the first witnesses. It's their bill. I would like to see what tone they want to have reflected in it. It may help us when questioning some of the witnesses going forward. At the end of the day, these are the guys. It's their bill. They wrote it. Things are going to be put forth to us that are really important for interpretation, so it would give us a bit of an idea on our line of questioning.
I'd also ask.... I was curious to note that, as said, it does stop on September 14. I was just wondering, is there is something happening on the 15th that we might not be able to...?
Voices: Oh, oh!
Mr. Colin Carrie: There have been all kinds of leaks about what may or may not happen. I'm glad you're not saying that this is it, because as we learn a little more as a committee, I think we're definitely going to need to study it.
In that light as well, on point 4 that “the Chair set the deadline for written submissions”, I think we can just take that out. At the end of the day, witnesses may hear what other witnesses say, and if this goes on a little longer, I wouldn't want to see them not being able to submit something in a timely manner, something that we couldn't take into account.
With those changes, I think we could almost, from my standpoint, move the motion and get it passed today.
Let's soften this down. I do want to stay with the idea of themes. I've been a bit disappointed at times with having presentations on longer topics, as they seem to be a bit meandering. You hear one presentation from one person, and then three weeks later you hear a counterpoint to it. I would like to get consolidation around the themes if possible.
So if we're saying “that the Chair be empowered to coordinate the witnesses”—we're adding an extra day, so it's now September 15, and we're adding another 18 witnesses—and we could say “scheduling necessary generally in compliance with the following guidelines” rather than “in accordance”.
“Witnesses are to be organized to speak to the following...”, and I'm going to suggest we do two- or four-hour blocks. If it's easier for you to break the topic down into two-hour blocks, then it would be four people, and if it's the four-hour block, we can get nine in.
We have a fairly substantive list now. We've added municipalities. We've added labelling and packaging. We've added edibles, and we've added medical marijuana usage. If you want to have a stand-alone one on international considerations, we could have a stand-alone for that as well, because we can do these in two-hour or four-hour blocks.
I would suggest, “That witnesses for each topic generally be proportional to committee membership”. I know you always do a very good job of balancing the witnesses according to who has presented them. Perhaps you could continue to follow those general guidelines, but as Mr. Davies said, he might have two or three around one topic, but then none on others, so let's be respectful of where one of the committee members has an interest in a topic. I think that's it.
For “That the Minister of Health...be invited to appear before the Committee...”, let's just say “in the following week”, so that we can hear from the ministers after that intensive week. It mandates it, and it gets it going, but it does organize it in a structured way.
I'd be happy to move the motion with those amendments.