I call this meeting to order.
I'd like to welcome everyone to meeting number 26 of the House of Commons Standing Committee on Health. Pursuant to the order of reference of May 26, 2020, the committee is resuming its briefing on the Canadian response to the COVID-19 pandemic.
To ensure an orderly meeting, I would like to outline a few rules to follow.
Interpretation in this video conference will work very much like in a regular committee meeting. You have the choice, at the bottom of your screen, of either floor, English or French. As you are speaking, if you plan to alternate from one language to another, you will need to also switch the interpretation channel so it aligns with the language you are speaking. You also may want to allow for a short pause when switching languages. Before speaking, please wait until I recognize you by name or, during questions, by the member asking the question.
When you are ready to speak, you can click on the microphone icon to activate your mike. As a reminder, all comments by members and witnesses should be addressed through the chair. When you're not speaking, your mike should be on mute.
I would like now to welcome our first panel of witnesses.
Appearing as an individual, we have Dr. Joanne Liu, physician and former international president of Doctors Without Borders. With the Canadian Association of Radiologists, we have Dr. Michael Barry, president, and Dr. Gilles Soulez, vice-president. From Southlake Regional Health Centre, we have Arden Krystal, president and chief executive officer.
We will start now with the statements from our witnesses.
Dr. Liu, please go ahead. You have 10 minutes.
Thank you very much, Mr. Chair.
Good afternoon, standing committee members.
My intervention will be limited to my area of expertise, which is, basically, tackling regional epidemic-pandemic responses at the micro and macro levels as a humanitarian aid worker and then through my training as a master in education and health management. We're nearly going to hit the 100-day mark of the pandemic, and very sadly, in Quebec, we have reached 5,000 deaths of patients with COVID-19.
I want to remind everyone that we still don't have a vaccine, that we still don't have a specific treatment, and that we still don't know much about the immunity that we have once we have the infection. Therefore, our best friend and best way of tackling it is mitigating measures for the response, so my speech will be about preventing the preventable.
We have a duty to absolutely learn the lessons to be learned after these 100 days. I think that we have to understand, as well, that there's a cost for response, but that despite the cost, because of the pattern of recurrences of pandemics over the last 15 years—SARS in 2003, swine flu in 2009, MERS in 2012, Ebola in 2014 and 2015, Zika in 2015, and now COVID—whatever we're doing right now is a rehearsal for next time around, and it's an investment. We've learned a lot, and we've managed throughout the pandemic to manage a shortage of inventory. Some variables have been impacted and I think I will not go there because my first statement a few months ago highlighted that. The procurements, the patient beneficiaries, the personnel and the hospital were some of them.
The lesson that we learned over the last few months is about the brutality of the disease and the loneliness of patients dying alone. We learned about the different vulnerable communities: elders, people in prison and homeless people. We learned about how to isolate people in their communities. We learned the hard way how to personalize IPC, infection prevention control, in a meaningful way. We learned as well, hopefully, that we have to protect, mentally and physically, all our staff and front-line workers. We learned that we should manage the mobility of people. We learned that outbreaks happen in hospitals, even university hospitals, more than we want. We learned that communication needs the correct message, otherwise people will get confused. We learned that public health needs the basics to be implemented: tests, contact tracing, isolation and treatment. We learned that internal surge capacity was stretched and that access to care has been an issue for non-COVID patients.
What is the role at the governmental level, at the federal level, now that we have finally passed the peak and flattened the curve to a certain extent? We have breathing space, and we can probably switch from a mode of being reactive to something that is much more anticipatory. What I'm looking for and what I'm begging for are—knowing that the federal level is the only place where we have an overview of the whole country—some sort of norms and guidance for the best practices to be implemented.
I have five points that I'm going to share with you.
The first point is the second peak versus rebounds. There are a lot of people who talk with assertiveness about the possibility of a second peak. The reality is that we don't know what the seasonal behaviour is, if there's going to be a dormant phase for the coronavirus, so we don't know if it's going to become strong in the fall. We need to prepare ourselves for the worst-case scenario. Keeping that in mind, I think we should develop a specific strategy on vaccination for influenza, knowing that influenza is going to be back, because we don't want to overload our hospitals in the fall. We need to do everything to prevent the second wave, if ever it happens.
Meanwhile, my biggest fear is repeated rebounds, repeated micro outbreaks away from the epicentre. That's what we've seen with many other outbreaks, with Ebola, with cholera, and then with yellow fever. I know it's different, but nevertheless, I think there is repeat pattern. While we ease the lockdown and we increase mobility of Canadians, especially during the summer vacation period, we might be facing micro outbreaks in different places in rural areas.
Why is it a concern? It is a concern because in many places in rural areas, they haven't been exposed and they haven't had many cases, meaning they don't have much immunity. That's one thing. The other thing is that hospitals in rural areas are often staffed by what we call “depanneur doctors”. From 20% to 80% of the ER shifts are basically covered by locum doctors. How do we frame the visits of those doctors? We probably won't quarantine them for 14 days. Are we going to make sure that they don't become vectors of COVID-19? Are we going to test them, test them before they go, or test them while they're there? That's one thing.
The other thing about rural areas is that I would strongly advise implementing rapid response teams or SWAT teams, as I like to call them, to go in and stabilize when there's a micro outbreak, and make sure that we optimize IPC and we support the response.
My other concern is about interprovincial mobility and what it can bring in terms of having micro outbreaks. The Campbellton case in New Brunswick is a good example of how someone can move from an epicentre to a province to places where there was low transmission, and there we go, we have an outbreak. I would say that at the federal level there must be guidance about how we are going to control interprovincial mobility.
At the international level, my biggest concern is about, yes, the border. I think we have an agreement that it will be closed until June 21, if I'm not mistaken, but how are we going to follow through knowing that, at the federal level, we control the border, but actually the follow through of people is probably going to be at the provincial level by public health? Are we going to follow up on the visitors? Are we going to hand over the information on visitors? Are we going to ask them to self-monitor? Are we going to trace them? Are we going to request that they isolate?
That was my first point on the second wave of micro outbreaks.
My second point is about personnel burnout.
What I've seen in many other outbreaks is that when we pass the first wave, we are facing burnout of personnel, front-line workers. Are we ready to fill the gap when this happens? What is the buffer in terms of staff? Are we going to have a surge capacity knowing that there is also going to be pullout of military from the places where they've been deployed?
I think that in the mid term and long term, we need to start thinking about a civilian reservist workforce that would be trained and could jump in and be functional. For example, the Red Cross has developed some of those models, but we need to think about that and it should probably be at the federal level.
The third point is that we need absolute guidance on best practices for testing and contact tracing in long-term care facilities. The reason for testing is that we have people who have mobility, and we know there are some people who are asymptomatic or people who are presymptomatic, meaning they don't have symptoms but they will develop the disease in one to seven days. These people can be vectors of the disease. We need to have an overarching strategy about testing. We need swabs and serology and we need to make the system happen, and guidance on that would be quite welcome.
On contact tracing, we need to find out if we are going to have the ability and the capacity to do that if we have a second wave. We know in some provinces it's been a real challenge. What is our surge capacity in that respect?
Last, in terms of guidance, I think we need to be clear on long-term care facilities in making sure that we test the people in long-term care facilities, that we protect them and that we staff them properly. We also need to learn from some of the experiences that have been successful.
The fourth point is about access to care for non-COVID patients. In many other places we still have a health care system that is running at low regime. We need to come up with a priority list for our sector to scale up, because non-COVID-19 patients cannot be the collateral damage of the response to COVID-19. I think that guidance would be helpful.
My last point is about the international level. We've realized how much we are interconnected and interdependent, in a complex way, across the world. We know that making all of us safer depends on making each of us safer. To say it another way, making all of us healthier depends on making each of us healthier. We cannot tackle COVID-19 in isolation from the rest of the world.
Canada has been investing in R and D for a vaccine. There has been a massive investment locally in Canada of $150 million in R and D for a vaccine. We're not sure yet what the scale-up capacity would be for manufacturing it, if it were successful, and we don't know how affordable and accessible it would be. More recently there's been a pledge of more than $600 million for Gavi in the global polio response. I think if we are planning to invest that much in R and D for a vaccine, we absolutely need to get a seat at the table to influence the outcome—the outcome of the public good from the vaccine that comes from the R and D. It's important, because Canada needs to influence how we'll distribute whatever discovery happens. If we don't have a seat at the table, it would probably be really hard to influence the process.
Meanwhile, I really urge that we develop a strategy on how we would vaccinate Canadians if we were to have a vaccine available by the end of 2020 or early 2021. We should do that now, when we have a bit of a lull time. We need to find out who we're going to vaccinate as a priority, such as front-line workers or vulnerable subsets of the population. We shouldn't improvise that at the last minute. We need to think that through.
To summarize, I think it is really, really important that we do everything to do the mitigating measures. We still don't have a treatment. We still don't have a vaccine. We don't know about the immunity. We have to prevent the preventable. It's about preventing people from getting infected, and about preventing people from getting sick, but it's about lives.
Thank you very much.
Mr. Chair, I thank you and the committee for having us today. Gilles and I will be sharing the presentation. I'll tell you a little bit about who we are.
The Canadian Association of Radiologists represents about 2,800 radiologists from coast to coast who are dedicated to medical imaging excellence around the country. Today we're going to talk somewhat about the lessons learned through the COVID-19 crisis, where we were going in, where we are coming out, the lessons learned, and our recommendations/asks, at the end. I may have met some of you before, through some of our days on the Hill, within the last few years. Some of this information we're sharing on lessons learned comes from the Conference Board of Canada's report, reported a year or so ago, that many of you have received through our national organization.
For those of you who are unfamiliar with radiology, we're the physicians who are trained for about 15 years post-secondary and who diagnose and perform CAT scans, MRIs and ultrasounds. We do interventional procedures, more recently stroke events, treatment for acute stroke presentation, cancer treatment of ablating tumours, and a number of complex procedures that occur in hospitals, community and radiology alike. We also do other things: broken bones in emergency rooms, lower back pain with an MRI, and things like that. Many of you have probably used a radiologist or had interaction with a radiologist.
That's who we are. Gilles will now talk a little bit about our experience so far, and I will come back at the end.
Gilles, it's yours from here.
Okay, sorry about that.
As you know, measures related to COVID-19 postponed diagnostic imaging for hundreds of thousands of Canadians, resulting in a 50% reduction in medical imaging services across the country. On top of that, non-urgent cancer screening was suspended. This has created a real sense of urgency, causing an overwhelming backlog in diagnostic imaging services.
As you know, before the crisis we already had extensive wait-lists across the country, compared to other countries. Prior to the pandemic, patients were waiting an average of 50 to 82 days for a CT scan, and up to 89 days for an MRI, magnetic resonance imaging. Those wait times are 20 to 52 days longer than recommended. This wait-list for essential services is now putting the health of Canadians in dire straits for much longer. This is especially concerning for cancer patients who are awaiting life-saving treatment that is dependent on medical imaging.
The throughput in a radiology department, with the COVID crisis, is currently estimated to be at 70% of pre-COVID activities, mainly because of the disinfection and social distancing protocols. This reality will stay with us for a long period of time due to the eventuality of a second wave of the virus.
As an example, from Quebec City, a 20-year-old male patient presented with abdominal pain. His physician filled a hospital requisition for a CT scan at the CHUL in Quebec City. Because of the backlog of the waiting list, he finally had his CT scan after two months. The pain was debilitating. A large, 20 centimetre retroperitoneal lymphoma was found. Consequently, acute therapy was initiated with significant delay, thus hampering his prognosis.
At Quebec City, the MRI wait-list is very worrisome. There are currently 12,000 patients on the wait-list for an MRI at the CHUL. As discussed before, the throughput is currently estimated at 70% compared to pre-COVID. They are working on eliminating less relevant examinations on the wait-list. Even if they can eliminate 20% of those requisitions, the wait-list will still rise to 17,000 patients in one year, just to give you an example.
In Alberta, they calculated that with the suspension of breast screening by mammography during the last two months, they've already missed 250 cases of cancer that should be treated now.
We understand that postponing non-urgent medical imaging services was necessary during the height of the pandemic. Now that the first wave has passed and the spread of the virus has been contained, we stand to resume diagnostic imaging at its fullest capacity, but in a safe way.
The health and safety of Canadians is our number one priority. We also respect the emotional well-being of patients and staff. The resumption of diagnostic imaging needs to happen in a planned, efficient and safe manner so as not to overwhelm the health care system and our health care workers.
Our task force group on the resumption of radiology services recently provided guidelines to help radiology departments to resume medical imaging safely. It is a national emergency, given the already exhaustive wait times for these procedures, and incorporating the further delay that the pandemic has created, which caused patients to wait even longer.
Prior to the pandemic it was estimated that in 2017 the economy lost $3.5 billion in GDP due to people being unable to work while waiting for medical imaging procedures. This will be substantially increased due to the COVID-19 crisis. For example, a 25% drop in patients being seen will result in an additional $1 billion of lost GDP, so close to $5 billion.
Mike, our ask.
Thank you, Gilles, for going through some of those examples.
As the committee can see, with the delays in some of this imaging, people are still frightened to come back to the emergency room or the hospital to get their tests done. It's a really unnerving thing for people to come into the hospitals now. Almost everybody is wearing a mask.
We have two firm asks we are going to put to the committee. One you're familiar with. We asked it about a year or two ago, but a larger light has been shone on it. That is the $1.5-billion investment in medical imaging over three years to bring us up to speed with our G7 partners. We're about ninth in the world for advanced imaging with CT, MRI and some of the other high-tech procedures. We're well behind other jurisdictions. COVID-19 has exacerbated that. The $1.5-billion investment won't fix the whole wait-list, but it will be a strong start to get us in the right direction.
On the lessons learned, we found that our infrastructure is quite dated nationally. There are not enough wait rooms, consultation rooms or spacing in the hospital. There are even things as simple as engineering, like our air ventilation is from the 1970s without windows. With COVID-19 and future pandemics, that's a real concern, so CAR asks the committee to consider a large task force to look at not only new equipment with the influx of patients, but also waiting room spacing, additional cleaning and mechanisms to keep people safe during the pandemic.
As for lessons learned, in conclusion, our health care system was not ready to deal with the demand. In the large urban centres, in particular, Toronto, Montreal and, to a lesser extent, Vancouver and Calgary, we didn't have the medical equipment or the staff to handle extended wait times or deal with the acute onslaught of very sick patients. We also learned that our spacing was not strong and that our PPE was not strong. We had a lot of deficits, but we've learned, and we'll learn from that going forward.
We're asking the federal government, through your committee, to support the resumption of imaging by making an investment through the federal transfers to look at new medical imaging equipment and infrastructure, hire additional radiologists, medical radiation technologists and stenographers in particular to improve our quality of care for our patients.
That's our presentation. I believe there will be questions later.
Thanks again very much to the Chair and the committee for hearing us today.
I'll give you a bit of an introduction to Southlake and our role in Ontario, and then I want to talk about our experience with COVID-19.
We have over 525 beds. This is one of the largest hospitals in Ontario. We're located in Newmarket, which is 30 minutes north of Toronto. We provide community hospital services to a large catchment in York and southern Simcoe, as well as regional tertiary programs such as cancer care and cardiac care. We have the third-largest cardiac program in Ontario.
We've had quite an experience with COVID-19. We have seen quite an impact in our GTA hospitals. That impact has taught us many lessons. I'd like to talk a bit about those lessons and also about what some of the bright sides of this have been.
Just to give you an example of where we've been, we initiated an incident management team and an emergency operations centre in late January. This was earlier than most, and that was very helpful to us, because we started to anticipate the kinds of things that we would have to get up and running.
We had a daily emergency operation centre meeting. We staffed that for many hours a day, and we had many managers, administrators, physician leaders and others working many hours. We held daily town halls with staff and sent out a lot of information to our staff. There's no question that transparency in communication at both the local level and the provincial level, and also at a federal level, has made a big difference through this pandemic response.
One of the things we did is that we were very transparent in posting our volumes, what kinds of personal protective equipment inventory we had and our projections. We developed a logistic regression model to project demand for intensive care unit beds and also modelled the local epidemiological reproduction rate in our catchment areas to support our response.
We had our first patient in the ICU on March 16, which was five days after the pandemic was declared by the WHO. As of today, we've had 88 patients with COVID-19 admitted to our ICU and our wards, and we unfortunately have had 22 deaths.
Starting in mid-March, we developed a drive-through assessment centre. We've tested literally thousands of patients, both at that centre and as outreach to our long-term care and retirement homes in congregate settings within our catchment. We most recently have become one of the first two hospitals in Ontario that were ordered by the Ministry of Long-Term Care, under a mandatory management order, to take over the management of a long-term care home in outbreak.
With that as the background, I want to talk about a few things that were our biggest challenges and where we believe the federal government can have some role.
The first one is in procurement supply chains and PPE. There is no question that one of the most stressful aspects of COVID-19 and our response has been PPE availability. It's clear that our current just-in-time procurement and delivery approach in Ontario—and I know that it is pretty common throughout the provinces, as I've also spent a lot of my career in B.C.—needs to be fundamentally reviewed.
The pandemic stockpiles that were present federally and in some provinces, including Ontario, and that were in place for SARS were allowed to expire. That not only resulted in a lot of expensive stock not being able to be used, but it also created a scenario where we were critically short when we should have been prepared. One of the recommendations we have around this is that the federal government and the provinces work together to rotate pandemic stock with the regular supply chain to prevent expiry, so that we will be ready the next time something like this happens.
Those shortages not only created sleepless nights but also created a lot of challenges around the time and effort to manage, count, order and go back and forth with central supply chains and numerous vendors directly to reconcile and model our PPE supply. This was a massive, massive amount of labour and time, and the churn of changes in terms of strategy and approach to PPE left significant levels of stress in morale. We have to study what we've done with that and make some changes for the future.
Long-term care is the other area where I have some advice and counsel. We have known for many years that the long-term care model we have in Ontario, but also across other jurisdictions in other provinces, has significant flaws. Those were clearly illuminated during COVID-19.
A lack of sufficient oversight, inspection and integration with the rest of the system have created substantial issues for many homes. Many of these homes are very outdated, very old and very crowded. It is almost impossible to prevent outbreaks in these situations.
There is lack of training for staff, a lack of staff in some cases and a lack of management capacity in many cases. One of the things that would be of help is to have national standards for long-term care, very similar to what we have in other hospital jurisdictions.
We also need some very fast capital investments. Many of these homes simply cannot operate the way they need to operate during an outbreak because of their size and the problems they have with infection control.
I want to talk about hospital capacity. There's no doubt that hospitals across Canada, and it doesn't matter which province you're in, have been operating at over 100% capacity even well before COVID-19. Further to the comments by my radiologist colleagues, one of the challenges with working over capacity is the only way you can recoup capacity to deal with a pandemic like this is to cancel elective procedures.
Our hospital went down to 30% of our normal volume. We've modelled that for hip and knee replacements alone it could take us seven years to recoup the number of surgeries we would need to do if we don't work evenings, weekends and everything else. Of course, the problem with that is human resources. As one of my other colleagues mentioned, they are pretty burned out. To try to get them to work those extra hours, even if we were funded for it, would be very difficult. Once again, we need to rethink our hospital sector.
I'll mention bright spots very quickly. Virtual care has been a really bright spot. After years of painfully slow uptake in Ontario and other provinces, this pandemic triggered widespread adoption of virtual care. We realize now we don't need to go back to exactly the way we were doing things. We will be able to convert a substantial number of visits, particularly ambulatory visits, to virtual care.
We've also noticed the good collaboration we have had between the hospital sector and some of the other sectors has helped us, but that is not widespread. There needs to be a move toward better integration across all provinces and certainly within all sectors. That amount of integration, something we had here in Ontario through Ontario Health Teams, was very helpful.
Last, I want to extend a very big thank you to our communities. Throughout this pandemic, our staff and physicians have been continually bolstered by an unprecedented outpouring of support from the communities we serve. For people who are very tired and overwhelmed, and in some cases experiencing some level of PTSD, that amount of support was incredibly helpful, and we were incredibly grateful for it.
I will leave it at that and wait for questions.
We now resume the meeting. Welcome back.
For the benefit of our panellists on our second panel, we are continuing meeting number 26 of the House of Commons Standing Committee on Health. We are operating pursuant to the order of reference of May 26, 2020. The committee is resuming its briefing on the Canadian response to the COVID-19 pandemic.
I'd like to make a few comments for the benefit of our new witnesses.
As you are speaking, if you plan to alternate from one language to the other, you will need to also switch the interpretation channel so that it aligns with the language you are speaking. You may want to allow for a short pause when switching languages. Before speaking, please wait until I recognize you by name or, during questions, by the member asking questions. When you are ready to speak, you can click on the microphone icon to activate your mike. I remind you that all comments should be addressed through the chair.
Interpretation in this video conference will work very much like in a regular committee meeting. You have the choice, at the bottom of your screen, of floor, English or French. When you're not speaking, your mike should be on mute.
I would like to now welcome you individually.
From the Canadian Dental Association, we have Dr. Jim Armstrong, president, and Dr. Aaron Burry, associate director, professional affairs. From Doctors Without Borders, we have Dr. Jason Nickerson, humanitarian affairs adviser. From the Ottawa Hospital, we have Dr. Dave Neilipovitz, head of the critical care department.
Each group will have 10 minutes to make a statement. We will start with the Canadian Dental Association.
Dr. Armstrong or Dr. Burry, please go ahead for 10 minutes, please.
Thank you very much, Mr. Chair, and good afternoon to the members of committee. It’s my pleasure to present to you today on behalf of the Canadian Dental Association.
I have been serving as president of the CDA since April, but previously I served on the board for the past six years and have volunteered in dental associations across the country for three decades. I am also the managing doctor of a dental co-operative with 10 practices and 150 team members throughout Vancouver. As well, I'm an adjunct professor for the Sauder School of Business at the University of British Columbia. I'm an M.B.A. dentist.
I am pleased to be joined today by Dr. Aaron Burry, who is CDA’s associate director of professional affairs. Dr. Burry is a public health dentist with more than 30 years' experience in navigating issues with both practice and public policy. He's also an M.B.A. dentist. In addition to the work that he has done to lead the CDA’s work in understanding and addressing the challenges of COVID-19 for our profession, Dr. Burry has been serving emergency patients in a public health clinic throughout the past few months and can share with you that unique perspective.
We come today with three essential recommendations to share: first, that greater consideration be given to dentistry as vital front-line health care workers when considering access to PPE; second, that the federal government create a specific oral health envelope of $3 billion as part of the Canada health transfer; and, third, that basic oral health standards be part of any future review of the state of health in long-term care facilities.
I’ll come back to each of these recommendations throughout my remarks, but first I’d like to walk you through the challenges that dentistry has faced as a result of the pandemic, as well as those that are emerging.
In March, by public health orders, dental clinics across Canada ceased providing oral health treatments, with the exception of very restricted emergency care, which was designed to keep patients away from the emergency operations of hospitals. Now, dental clinics are cautiously beginning a staged return to practice in accordance with the guidance set out by their provincial dental regulators, public health authorities and workplace safety regulators.
This guidance has varied from one province to the next and has resulted in great confusion among dentists and patients. Also, within provinces, unfortunately, between those regulators, there sometimes is conflict in regard to regulations that require different protocols or procedures to be used when providing the same type of treatment. This also leads to significant confusion and angst for dentists as they attempt to establish the new normal.
What dentists are finding as they return to practice is a physically demanding and mentally exhausting experience. Dental offices are essentially mini outpatient hospitals and, like any hospital offering outpatient care, we follow strict infection control procedures and practices. That's not new. However, the new guidance and regulations stemming from COVID-19 have made performing outpatient procedures more difficult, physically draining and time-consuming.
Dentists must do considerable additional preparation before seeing each patient, and our early experience in getting back to work suggests that they treat 50% to 67% fewer patients per day. Communication with those patients is also much more difficult. It’s not simply a single aspect of the new approach that is problematic, but rather a cascading effect of changes to how every aspect of care has changed. From the pre-work before coming to the office, to the parking lot, which has now become our reception area—
—to the clinical areas where far greater separation between patients must be maintained.
Also, ensuring that the expanded range of PPE is properly worn, removed and decontaminated has significantly changed the way we work. The workflow of the office has changed to where there is absolutely no flow at all.
Some of this may resolve over time, but these challenges are putting a strain on dental practices and our ability to provide care. Of course, these challenges presuppose that one has access to the PPE to perform the necessary procedures.
From the onset of the current crisis, dentistry identified the impending shortages of PPE as a critical issue for us. We reached out through the Public Health Agency of Canada and the office of the chief dental officer of Canada to reflect that a critical shortage would hamper the ability of dental offices to provide emergency care.
We recognize the multi-dimensional challenges that led to the shortages of PPE. The current and unprecedented demands for these materials have been exacerbated by the problems in supply chains, especially in China.
In fact, early in the pandemic, when all hospitals were critically short of PPE, many dentists across the country stripped their offices of their own supplies to donate to the front-line causes in their communities, but with dental offices reopening, it's important that we emphasize that dentists are front-line providers as well. While we had initially hoped that access to PPE through our traditional sources would improve as supply chains reopened or new supply chains emerged, that has not yet happened. Some materials, such as latex gloves, have become much more difficult to acquire.
Individual dental offices are also attempting to acquire the same kinds of PPE as large government entities, most notably N95 respirators, which are essential and, in many cases, mandatory for dental care today. These government organizations, including the Government of Canada, can leverage their might to acquire mass quantities or impose guidelines on suppliers that have them prioritizing supply delivery to those entities actively on the front lines of the COVID-19 fight.
The result is a supply of PPE that remains very scarce, if not impossible to access, and at rising prices due to demand. For dentists in Canada right now, to serve our patients appropriately, we currently need one million pieces of PPE per day. This need will increase to up to four million pieces if we can reach full capacity again.
As governments and health care providers work together to find long-term solutions to sourcing and maintaining a consistent and dependable supply of PPE in Canada, dentistry needs to be at the table.
This echoes the concerns that we have stated for several years about the state of public funding for oral health care services in Canada. Most Canadians are able to access care through employer-sponsored benefit plans. Unfortunately, our public programs have been chronically underfunded across the country. Just 6% of our dental care is provided to Canadians through public programs; however, growth in the usage of publicly funded oral health care programs is particularly acute among low-income seniors, children and individuals with physical and developmental challenges. The new normal will mean even greater challenges in providing care for these individuals, if care can be provided at all.
Over the past decade, the erosion of provincial-territorial funding of these programs has created a circumstance where the needs of these vulnerable groups are no longer being adequately met. With the profound economic challenges from COVID-19 to come, many Canadians will lose access to their employer-sponsored benefits. This will place an even greater strain on these public programs.
The federal government has a clear role to play in helping to ensure that these provincial and territorial programs can appropriately address the challenges to come. Specifically, we recommend that the federal government create a specific oral health envelope of $3 billion as part of the Canada health transfer. At a time when there will be many demands on public health care dollars in Canada, we simply can’t afford to allow these programs to wait at the back of the line and hope that funds will flow through.
Finally, as we consider the challenges ahead, we clearly recognize the crisis within long-term care facilities across the country.
Several years ago, CDA asked the Department of Veterans Affairs to include basic standards of oral health care for veterans in long-term care facilities. It was our hope that these standards could have been instituted, benefiting not only the veterans in the facilities but all of those who resided in the facilities. Unfortunately, we were informed that Veterans Affairs did not have contracts with these facilities, but only contribution agreements. That left it to the provinces to ensure that appropriate care was provided.
Our suggested standards are not onerous, but are, at the very least, the minimum we believe should be provided to any senior in care. They are an oral health assessment on intake, a daily oral health plan, a yearly visit with a dentist, and a location within the facility where dentistry can be performed.
We recognize that there will be large and far-reaching discussions on how to best care for seniors in these facilities. These oral health care standards might seem minor in the current context of COVID-19, but these small steps can help to contribute to the development of a culture of care, oversight and responsibility that will be critical to setting things right for Canada's seniors.
On behalf of Dr. Burry and I, thank you very much for your attention. We'd be happy to take any questions.
Thank you, Mr. Chair, and thank you to the members of the committee for the opportunity to speak with you about the COVID-19 pandemic and the actions that Canada can take to ensure that people everywhere are able to access the medical care they need.
By way of introduction, I am the humanitarian affairs adviser for Doctors Without Borders, or Médecins Sans Frontières, MSF, based here in Ottawa. I'm also a respiratory therapist with clinical and public health experience across Canada and internationally. I have a Ph.D. in population health and have worked as a clinical scientist in Canadian hospitals and universities.
MSF is an international medical humanitarian organization that provides impartial medical assistance to people in more than 70 countries. We deliver essential health services in some of the world's most complex environments to people affected by conflict, epidemics, natural disasters, and other emergencies.
Today we are facing an unprecedented crisis, created both directly and indirectly by the COVID-19 pandemic, which has reached all of the countries where MSF works. In these places, the pandemic amplifies and deepens existing inequalities. MSF sees this on the front line every day. We are witnessing COVID-19 cases that are occurring alongside existing emergencies and creating a dangerous set of public health risks.
In the refugee camps of Cox's Bazar, Bangladesh, nearly one million Rohingya refugees live in overcrowded, unsanitary conditions that are perfect for spreading COVID-19.
In Haiti, a country where I have worked many times, our teams have opened a COVID-19 treatment centre that, within days, became full and had to double its bed capacity. We've had several patients who have died on arrival, and many more who have arrived critically ill. There are only two laboratories in the country capable of conducting COVID-19 testing, and the health system is ill-prepared for what may come.
Amidst all of this, we are all coming to grips with an uncomfortable reality, which is that our only way out of this pandemic is likely through a vaccine that does not yet exist and that needs to be globally accessible quickly to virtually every person on the planet.
Two months ago I wrote an article that warned that, given the way the global medical research and development system operates today, we face a real risk that, despite the public—that is, taxpayers—investing in the science to develop COVID-19 vaccines and medicines, these may become unaffordable, inaccessible, private-held commodities rather than globally accessible public goods. Public investment in COVID-19 science is essential, but we need to rethink our policy approaches to maximize the benefits of this investment.
Today, the pipeline of COVID-19 vaccine candidates is robust, with more than 100 candidates in pre-clinical development and 10 in human trials on eight different vaccine platforms. Many vaccine candidates are benefiting from billions of dollars of public and philanthropic funding, including more than $850 million of Canadian funding for COVID-19 diagnostics, treatments and vaccine R and D.
But the global research and development system is not designed to prioritize affordable access, especially outside of wealthy countries. Access to life-saving medicines is inequitable. This is not a problem that's unique to COVID-19, rather it is a failure of the global medical innovation system to prioritize diseases with the greatest public health threat. COVID-19 is only the latest example, and it has made it clear that we need to rethink the way we do drug and vaccine developments to prioritize patients and public health over profits.
Today, here's how the system often works. Pre-clinical discovery and work, which is what much of Canada's domestic funding is currently supporting, is done by university researchers or other publicly funded institutions. This committee has heard from some of them who are working on COVID-19. From there, promising drugs and vaccine candidates, often at a very early stage, are sold or licensed to the private sector for subsequent development, in most cases with no strings attached, no requirements that the final products be made affordable or priced fairly, and no requirements to develop them quickly or to share the data and technologies with anyone who needs them. They become private market commodities and we lose control over them, save for perhaps some small royalty payments.
Two years ago I sat before this committee during its study on federally funded health research and described how, as a result of this system, MSF teams have struggled every day for nearly 50 years to access medicines, vaccines and diagnostic tests for our patients. When they exist, they are too often inaccessible, either because of their exorbitant prices, which bear no relationship to the costs of developing or producing them, or because companies simply choose to not register them in the countries where we work because our patients do not represent a lucrative enough market.
For decades we have witnessed millions of people denied treatment for diseases such as HIV, tuberculosis and hepatitis C as a result of unaffordable patented medicines. The system cannot continue as it is, either for COVID-19 or for any other health condition.
The committee's 2018 report made nine important recommendations that should be guiding the Canadian innovation response to the COVID-19 pandemic. To my knowledge, unfortunately none of the committee's recommendations that could have helped ensure fair global access to health technologies being developed with Canadian public funding have been adopted yet.
The report included a recommendation that Canada implement common sense safeguards to ensure that licensing agreements would include specific requirements to ensure affordable global access. These provisions have already been voluntarily implemented by some Canadian universities. In their most basic sense, they would require recipients of public funds to have enforceable safeguards in place to ensure that any medicines, vaccines or other health technologies developed with Canadian public funding would be made available at fair prices in every country where they are needed, including in Canada. Essentially, it's a requirement that an investment of public funding will deliver publicly accessible and affordable health technologies—in other words, a fair return on investment for the Canadian and global public.
I'm sure we can all agree that it would be unacceptable if a vaccine to prevent COVID-19 or a medicine to treat it was developed with Canadian public funding and yet not made available or accessible to billions of people living in low- and middle-income countries, or to Canadians, for that matter. Without the right policies in place to share these technologies and the rights to them, access to them is at risk.
Now is the time to put patients' lives ahead of private profits. Here's what Canada needs to do.
First, recognize that the pandemic is global and that if we allow the race to develop and access COVID-19 vaccines, treatments and diagnostic tests to descend into nationalism, or for access to be determined by who can pay the highest price, we all lose. Not only would allowing wealthy countries to have access to essential medicines while poorer countries were going without be unconscionable, but it would also be ineffective. Until all countries and all people have access to new COVID-19 vaccines or medicines, we cannot end this pandemic.
Second, operationalize the 's commitments to ensure that vaccines and other public health tools are produced at a scale and a cost that is accessible to all countries. Despite the current rhetoric we have seen globally around making COVID-19 vaccines and therapeutics “global public goods” or “the people's vaccine”, public funders, including in Canada, have so far failed to impose enforceable public interest conditions on recipients of public funds.
Ensuring a public return on public investment should be a guiding principle behind all Canadian funding for the development of new medicines, particularly during a pandemic. Canada should also demand transparency in all stages of the R and D that it funds, including the registration and public reporting and sharing of clinical trial data, R and D costs, manufacturing costs and product prices. If the public is investing to develop these life-saving technologies, we should be able to keep control and transparency over what we have paid to help generate.
Third, endorse open science and reject monopolies on COVID-19 technologies by sharing the technologies, data and knowledge with a global platform. Researchers have worked collaboratively and openly to share an immense amount of data, knowledge and materials to understand this virus and its weaknesses. This has consequently shortened the time frame from years to mere months to develop candidate vaccines and medicines. This openness has been an exception to the rule, and given the way the global research and development system works outside of a pandemic, there's a real risk that this innovation process will instead become closed and proprietary.
Unless significant safeguards are put into place to mandate access, affordability, transparency and knowledge sharing, we will be allowing our discoveries to be privatized and sold back to us and to people around the world at prices we don't control, because, as a rule, we don't even try to negotiate these rights. To put it in industry terms, not doing these things is simply a bad business decision. No privately run company in the world would sell a technology it invested in and knows it will need access to in the future without negotiating fair and reasonable access rights for itself, and neither should we.
We are not alone in calling for these actions. An ongoing petition on the MSF website calling for Canada to impose these common sense safeguards on the health technologies we are paying to develop has garnered more than 28,000 signatures in just over three weeks. Canadians want action to ensure that people around the world are able to access the vaccines and medicines we are investing in developing.
We need you to take responsibility for what is coming next. We are increasingly worried about countries like Bangladesh, Haiti and others, where the cumulative impact of COVID-19 on top of existing crises is producing critical humanitarian needs.
Canada needs to continue its global solidarity and support for international humanitarian assistance, but Canada also can and should demand a better deal that ensures global patient access and affordability in exchange for the use of COVID-19 technologies that are developed with Canadian public funds.
This pandemic is teaching Canadians many things. One of them ought to be that we need to rethink the way that we do drug and vaccine development so that we put patients over profits.
Thank you very much for having me today. I want to emphasize that if members of the committee have any additional questions or want clarification, they're welcome to contact me directly. Thank you.
Good afternoon. Thank you, Mr. Chair and members of the committee.
I am Dr. David Neilipovitz. I am an intensive care unit physician who has cared for COVID-19 patients in our intensive care unit during this pandemic. I have seen patients make miraculous recoveries from this virus. I have also cared for patients who died from this disease, including a tragic story of a husband and wife who had been married for over 50 years who both succumbed to this virus.
I'm also the lead for critical care for Ontario east. As well, I've been the head of critical care for The Ottawa Hospital for almost 10 years. As such, I was part of the groups responsible for organizing how intensive care units prepared for caring for patients during this pandemic. As such, I hope to bring the perspective of both ICU health care professionals and critical care administrators who have been challenged by this pandemic.
The COVID-19 pandemic certainly brought out the best in many health care professionals. It also brought to light some weaknesses and failings of our Canadian health care system. An obvious failing was how our long-term care facilities operate, which I suspect will be a major focus of this committee.
However, I would like to highlight another weakness, which is that of the capacity of intensive care units, particularly in how they operate and how patients enter them. Had Canada experienced a response to COVID-19 in a manner similar to New York City or Italy, the focus, I believe, of the reviews would likely have been on intensive care units and their shortcomings.
An early concern with COVID-19, as many will recall, was whether we would have enough mechanical ventilators for critical care patients. That, however, is only one important aspect of ICU care. If I don't have the space, monitors or, most importantly, the staff to care for patients, more ventilators are essentially useless.
My team at our hospital was able to increase our level 3 ICU capacity—level 3 being the highest possible level of critical care—from our existing 57 beds to over 200 beds, an increase of well over 300%. We were not alone, as many sites across Canada were able to increase their capacity by more than doubling their existing level 3 ICUs. This, however, would not have been enough if we were New York City or Italy, so how could we improve the situation and do better?
There are three strategies that I'd like this committee to consider.
First and foremost, there are no national standards or expectations for intensive care units in Canada. How ICUs are structured, how they operate, how they are staffed and even how they are equipped have no national standards or real expectations. Some ICUs that claim to be a level 3 ICU only had enough ventilators for 20% of their beds, for example. That, quite frankly, is unacceptable. Many sites lacked formally trained ICU doctors and critical care nurses, in spite of funding being available to train nurses, and more importantly, there are trained doctors who are out of work. This cannot continue. I would hope that our federal government will address this forthwith.
Second, if we had telemedicine capacity for critical care, we could certainly improve the ability of all hospitals to provide a higher level of care to all patients in Canada. I think we all know that Canada is a vast country, so the ability to provide care in all locations is challenging at best. If, however, we had a real telemedicine capacity, larger facilities like my own could help more remote locations, be they in the north or in other various isolated areas, provide better care to their ICU patients and their citizens, our Canadians, who most certainly deserve such a high level of care.
A high level of care could have been provided in these communities, and transfers of their sick patients improved or even avoided. As I'm sure you'll appreciate, sometimes, unfortunately, there's nothing that we can do for certain patients. Avoiding a transfer, however, would allow these patients to be able to pass away in their own communities, surrounded by their families and their loved ones, which is something greatly preferable to passing away alone in a facility that is remote from their home. A comprehensive solution from our federal government to improve telemedicine capacity in Canada would be crucial to improving this situation.
I have a third and final issue that would assist the capacity of intensive care units in Canada as well as improve the care provided in intensive care units.
All Canadians have a right to health care. For this there is no dispute, in my mind. The difficult and contentious issue, however, is what care do they have a right to insist upon? ICUs in New York City and Italy had to ration critical care. That is horrible and not right. However, some families insisting that their ICUs revive their loved ones and subject them to therapies, including machines and medications, when there's no reasonable chance of recovery, is equally not correct. It is not appropriate. It also greatly limits the ability of health professionals to care for other patients and puts an undue strain on our critical care resources.
Only a change initiated by our federal government can address this issue. I would respectfully ask our government and this committee to please address this issue; even though it is unsavoury, it is sorely needed.
Thank you again for giving me this opportunity to express the three ways in which the federal government could improve and increase critical care capacity in Canada: improving ICU care by creating national standards, improving telemedicine capacity for critical care, and addressing the difficult issue of what care is or is not appropriate.
I would be happy to answer or address any of these questions or other concerns. I can also be reached directly.
Certainly a number of alternative models of research and development are under way around the world. There are organizations active in Canada. I'm probably going to keep coming back to the previous study because there were some very good comments that were made by the Structural Genomics Consortium. They're an open-science outfit that is doing drug development in a different way.
MSF is one of the founders of an organization called the Drugs for Neglected Diseases initiative, which is effectively a not-for-profit pharmaceutical research and development organization that has developed, I believe, seven different either new formulations of existing medicines—for example, pediatric HIV or anti-malarial combination therapies—or entirely new medicines, one example being a drug called fexinidazole, which is a treatment for human African trypanosomiasis, or sleeping sickness.
It's an organization that's guided by a core set of principles. They work with researchers, the pharmaceutical industry and the private sector, but I think the key thing behind the work they do, and indeed the work that the Canadian government should be doing at a federal level to create standards, is that the work is guided by a set of principles. Those are effectively that there's a need to ensure that the final products, whether drugs or vaccines, are affordable and accessible in an equitable manner to patients who need them, and there's a desire to develop medical tools that will be treated effectively as global public goods.
You do that by negotiating fair access provisions, with enforceable clauses and licensing agreements and contracts and so on that stipulate what is expected of any recipients downstream of the intellectual property—the data, the know-how, the substance of what's at the core of either drugs or vaccines—and that clearly stipulate how they're going to be priced, how they're going to be registered in endemic countries, how you're going to work with manufacturers to ensure global production and equitable allocation and so on.
There are actually many examples of how licences and different drugs and vaccines and so on can be developed in a different way. There are examples from the Medicines Patent Pool, from our organization, and from, as I say, DNDi, and I think the intent is not to replace the good work that's being done already in Canada but to recognize that we do live in a world where medicines are becoming increasingly unaffordable and expensive, including common sense safeguards. If we, the public, are paying to develop or discover something, we know the strings attached to it need to be fair-pricing clauses and an assurance that it's going to be made available to all patients everywhere who need access to it.
Thank you for both questions. I'm going to start with the second one first because it's easier.
I can't tell you how it's going to look because it's evolving daily. We had 3,000 new papers published last week on COVID. There are too many things: how long does this last, when will we get a vaccine, how long are we going to have change our processes.
I want to go back to Dr. Neilipovitz's comment about telemedicine. We're starting to use teledentistry. I think that has great potential for being able to make care more equitable.
We at the Canadian Dental Association certainly want to make care more equitable, and we also want to drive costs out, and we want to increase quality.
Coming to your first question, the $3 billion, Canada underfunds compared to many countries, the public health aspects and the public support. As one of your colleagues, the honourable Don Davies, has pointed out, somewhere between 30% and 35% of Canadians lack funding or have inadequate funding. What we're really concerned about is the number of Canadians who are going to lose it because the recession that follows this pandemic may be very deep and long.
If there was a tranche of financing that was specific to oral health care, that would help, because what happens in dentistry right now is often our funding comes through social services, not actually through health. We're the last dollar in, and we're the first dollar that gets clawed back. We have really good private facilities, but we also have really good hospital dental facilities that are just underfunded. If we could get that funding.... I think all of us have said that we would be open to any suggestions. We'd be open to looking at all ways in which to target this, but the issue is equitable access for all Canadians.
As for patients who present with it, there are several different types of presentations. What is one person's experience isn't necessarily the experience of everyone.
The patients I see unfortunately are the sickest of the sick. When they come in, many of them are struggling to breathe. There's also the fear and anxiety just with the syndrome itself, and all the hype that's been around it. Certainly, the caring that the nurses have demonstrated has been fantastic.
The one aspect that patients are experiencing that unfortunately makes them unique compared to any other disease and disorder is there are no friends or family that are around them. I think that is a tragedy of this situation that we'll be talking about for years from now. We have done our best, at least in the Ottawa Hospital, to provide means, such as videos, to permit them to see the people they really want to see. Someone touching them and holding them who's not their family is certainly better than no one, but I don't think it's the same.
In answer to how they experience...they feel short of breath. Some of them are struggling to breathe, and others, surprisingly enough, aren't struggling, albeit that the oxygen levels in their blood that we measure are quite low.
As for the recovery, certainly I know my rehab colleagues are doing their best to accommodate this. There certainly are a lot of unknowns that have been alluded to, such as whether or not people are actually infectious. They are doing their best to rehab these individuals. Some of them are staying on ventilators for almost a month, so you can imagine how much muscle...and the changes they have experienced.