HEAL Committee Meeting

37th PARLIAMENT, 2nd SESSION

Standing Committee on Health

EVIDENCE

CONTENTS

Thursday, October 2, 2003

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1315

The Chair (Ms. Bonnie Brown (Oakville, Lib.))

Honourable Dave Chomiak (Minister of Health, Manitoba Health)

The Chair

Hon. Dave Chomiak

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1320

·

1325

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1330

The Chair

Mr. Rob Merrifield (Yellowhead, Canadian Alliance)

Hon. Dave Chomiak

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1335

Mr. Rob Merrifield

Hon. Dave Chomiak

Mr. Rob Merrifield

Hon. Dave Chomiak

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1340

Mr. Rob Merrifield

Hon. Dave Chomiak

Mr. Rob Merrifield

Hon. Dave Chomiak

Mr. Rob Merrifield

Hon. Dave Chomiak

Mr. Rob Merrifield

Hon. Dave Chomiak

Mr. Rob Merrifield

Hon. Dave Chomiak

The Chair

Mr. Greg Thompson (New Brunswick Southwest, PC)

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1345

The Chair

Mr. Greg Thompson

Hon. Dave Chomiak

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1350

The Chair

Mr. Stan Dromisky (Thunder Bay—Atikokan, Lib.)

Hon. Dave Chomiak

Mr. Stan Dromisky

Hon. Dave Chomiak

Mr. Stan Dromisky

Hon. Dave Chomiak

Mr. Stan Dromisky

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1355

Hon. Dave Chomiak

Mr. Stan Dromisky

The Chair

Mr. Svend Robinson (Burnaby—Douglas, NDP)

Hon. Dave Chomiak

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1400

Mr. Svend Robinson

Hon. Dave Chomiak

Mr. Svend Robinson

Hon. Dave Chomiak

Mr. Svend Robinson

Hon. Dave Chomiak

Mr. Svend Robinson

Hon. Dave Chomiak

Mr. Svend Robinson

Hon. Dave Chomiak

Mr. Svend Robinson

Hon. Dave Chomiak

Mr. Svend Robinson

Hon. Dave Chomiak

Mr. Svend Robinson

Mr. Milton Sussman

Mr. Svend Robinson

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1405

Hon. Dave Chomiak

The Chair

Mr. Greg Thompson

The Chair

Mr. Rob Merrifield

Hon. Dave Chomiak

Mr. Rob Merrifield

Hon. Dave Chomiak

Mr. Rob Merrifield

Hon. Dave Chomiak

The Chair

Mr. Greg Thompson

Hon. Dave Chomiak

Mr. Greg Thompson

Hon. Dave Chomiak

Mr. Greg Thompson

The Chair

Mr. Stan Dromisky

Hon. Dave Chomiak

Mr. Stan Dromisky

Hon. Dave Chomiak

Mr. Stan Dromisky

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1410

Hon. Dave Chomiak

Mr. Stan Dromisky

The Chair

Mr. Svend Robinson

Hon. Dave Chomiak

Mr. Svend Robinson

The Chair

Hon. Dave Chomiak

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1415

The Chair

Hon. Dave Chomiak

The Chair

Hon. Dave Chomiak

Mr. Jack Rosentreter (Executive Director, Pharmaceutical Drug Programs, Manitoba Health)

The Chair

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1430

The Chair

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1435

Grand Chief Andrew Kirkness (Indian Council of First Nations of Manitoba)

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1440

The Chair

Ms. Madeline Boscoe (Women's Health Clinic)

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1445

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1450

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1455

The Chair

Mr. Rob Merrifield

Ms. Madeline Boscoe

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1500

Mr. Rob Merrifield

Ms. Madeline Boscoe

Mr. Rob Merrifield

Grand Chief Andrew Kirkness

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1505

Mr. Rob Merrifield

Grand Chief Andrew Kirkness

The Chair

Mr. Greg Thompson

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1510

Mr. Greg Thompson

Mr. Greg Thompson

The Chair

Mr. Greg Thompson

Grand Chief Andrew Kirkness

Mr. Greg Thompson

The Chair

Mr. Stan Dromisky

Grand Chief Andrew Kirkness

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1515

Mr. Stan Dromisky

Grand Chief Andrew Kirkness

Mr. Stan Dromisky

Grand Chief Andrew Kirkness

Mr. Stan Dromisky

Grand Chief Andrew Kirkness

Mr. Stan Dromisky

Grand Chief Andrew Kirkness

Mr. Stan Dromisky

Grand Chief Andrew Kirkness

Mr. Stan Dromisky

Grand Chief Andrew Kirkness

Mr. Stan Dromisky

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1520

Grand Chief Andrew Kirkness

Mr. Stan Dromisky

Grand Chief Andrew Kirkness

Vice-Chief Glenn McIvor (Indian Council of First Nations of Manitoba)

Mr. Stan Dromisky

Vice-Chief Glenn McIvor

The Chair

Grand Chief Andrew Kirkness

The Chair

Grand Chief Andrew Kirkness

The Chair

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1525

Grand Chief Andrew Kirkness

The Chair

Ms. Madeline Boscoe

The Chair

Ms. Madeline Boscoe

The Chair

Vice-Chief Glenn McIvor

The Chair

Mr. Greg Thompson

The Chair

Kay Schwartzman (As Individual)

Ms. Madeline Boscoe

Mr. Greg Thompson

Ms. Kay Schwartzman

Mr. Greg Thompson

The Chair

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1530

The Chair

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CANADA

Standing Committee on Health

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NUMBER 056

l

2nd SESSION

l

37th PARLIAMENT

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EVIDENCE

Thursday, October 2, 2003

[Recorded by Electronic Apparatus]

·  (1315)  

[English]

    The Chair (Ms. Bonnie Brown (Oakville, Lib.)): Order. Good afternoon, ladies and gentlemen. It's my pleasure to welcome you to the Winnipeg hearings of the Standing Committee on Health on the subject of prescription drugs.

    We're very happy to have with us in this first hour, from Manitoba Health, Minister Dave Chomiak and Deputy Minister Milton Sussman; Marcia Thomson from health programs; Jack Rosentreter, executive director of the pharmaceutical drug programs; and Ulrich Wendt, the federal-provincial adviser.

    I would imagine we're going to hear from the minister first.

    Minister, the floor is yours.

    Honourable Dave Chomiak (Minister of Health, Manitoba Health): Thank you very much, and thank you for the pleasure and the honour of being here, Madame la présidente.

    I have a presentation I will make. I believe copies have been handed out, or will shortly be handed out, to members of the committee.

    The Chair: The clerk is saying he doesn't have them.

    Hon. Dave Chomiak: Having been on the other side of the microphone on numerous occasions, I appreciate the fact that we should get it to you.

    I'd like to begin by congratulating the Standing Committee on Health for focusing on this issue. This presentation will deal with several of the questions that your committee has raised, and in particular will focus on the issue of drug costs and drug prices as cost drivers of the system; mechanisms and opportunities for reviewing and controlling prices and costs; the marketing to and lobbying of prescribers and dispensers; and direct-to-consumer advertising.

    I should indicate that most of these topics that I'll be presenting have been the subject of federal-provincial conferences that I've been involved with over the past four years and that I think have been worked on by various federal and provincial agencies.

    We'll focus on these questions because, from the perspective of Manitoba Health, they are key areas where the federal government can plan an important role in helping to keep the health care system sustainable. Our system is highly valued and envied throughout the world. As you know, medicare is only one component of the system. In Manitoba, our system includes such components as a comprehensive home care program, a comprehensive long-term care program, a strengthened public health system, and five separate pharmaceutical programs. Provincial drug programs include hospital-based services, a palliative care drug access program, drugs provided through personal care homes, and drugs provided through the Manitoba Department of Family Services and Housing for low-income Manitobans, and a pharmacare program.

    Provincial drug programs represent a relatively small portion of total health care costs, which in Manitoba are now around $3 billion. In 2001-02, provincial drug programs represented only 6.7% of total health care spending, but drugs are a far more important component of our sustainable health care system than this ratio implies. There are two reasons for this--rising drug costs and rising drug prices. Pharmaceuticals are the fastest-growing component of the health care system in most provinces and territories.

    I'm sure members of the committee are familiar with some of the statistics. For instance, between 1998-99 and 2001-02, provincial drug program expenditures outside of hospitals increased by over 80%.

    Provincial drug programs are also subject to the effects of a complex interrelationship between the industry, health research, service providers, and consumers. The interaction among these factors is leading to positive outcomes in the form of research results, new effective treatments, and new ways of keeping people healthy or reducing their dependence on the rest of the health care system. It may also lead to negative outcomes in the form of artificial industry-driven demand, rising costs and prices, inappropriate and redundant treatments, and pressures on the sustainability of the overall system.

    One important innovation to provincial drug programs has been the introduction of the palliative care drug access program, which was implemented in December of 2002. This program provides deductible free coverage for patients who are assessed to be palliative. It's anticipated that the demand will rise for this access program as palliative care patients and families become more familiar with it. The biggest cost drivers, however, will continue to be the approval of new and more costly drugs and the rise in demand.

    Like most provinces, Manitoba has experienced a varying degree of success with attempts to control both costs and prices. For example, before a drug is listed in Manitoba's drug formulary, it is subject to rigorous cost-benefit analysis. The national common drug review process, which will be implemented shortly by the provinces, territories, and the federal government, has the same philosophy. Wherever possible and appropriate, generic drugs are substituted for higher-priced patented drugs in Manitoba. We continue to explore a common tendering process for bulk purchasing. These initiatives help to mitigate the rise in costs, but many factors remain outside of the province's control.

·  (1320)  

    The federal government also has an important role to play in mitigating costs and prices. There are some key areas that the federal government could explore or revisit. The first is patent issues. When Bill C-91 was passed in 1993, it extended the period of time during which new drugs are protected from competition from lower-priced generic substitutes. We appreciate that this standing committee does not focus on industry-related issues, so we will confine ourselves to the impact on the health system of some of the key provisions of this act.

    One of the things the Patent Act did was to eliminate the practice of compulsory licensing. Compulsory licences permitted a generic firm to apply for a licence to manufacture and sell a patented drug subject to a fixed royalty fee. The act also extended patent protection for brand names to at least 20 years. It also provided technical means for patent holders to block or hinder rapid entry into the market of generic products, even after the patents expired. Without getting into the technical details, the result has been, from our perspective, a much slower ability for lower-priced generics to come onto the market.

    The federal government could revisit the Patent Act to make it easier for generic companies without affecting our international trade obligations. For example, a greater onus could be placed on the patent holder to demonstrate that a new generic indeed infringes on patent rights. It could also be made more difficult for a patent holder to make minor changes or produce near identical products in order to extend the patent beyond the 20-year life plan. This practice is sometimes known as evergreening.

    Secondly, we could streamline approvals for generic drugs. Health Canada has the regulatory responsibility for pharmaceuticals. This also includes the reviewing and approval of generic drugs. We are aware that Health Canada is considering mechanisms for streamlining the process of approving generic drugs. This initiative should be accelerated in order to bring generics on the market more quickly and to allow provinces to list generics more quickly.

    Thirdly, on non-patented single-source products, there are a number of important pharmaceutical products that are not patented but for which there is a single manufacturer. In 1998-99, Canadian prices for top-selling, non-patented, single-source pharmaceutical products averaged 28% above median foreign prices, that is in those countries used by the Patented Medicine Prices Review Board to review prices of patented drugs.

    The average prices of these non-patented single-source drugs were highest in the U.S., followed by Canada, Germany, Switzerland, Sweden, the U.K., France, and Italy. Price levels in Italy and France were 53% and 44% lower than Canadian prices respectively. The federal government could expand the role of the Patented Medicine Prices Review Board. Since 1987, when the board was established, the price increases of patented drugs have stabilized and now are more comparable to prices in Europe.

    We are aware that a good deal of work has been done to examine the feasibility of extending Canada's price review mechanisms to non-patented drugs, especially single-source. We are not aware of any reasonable barriers. We therefore urge the federal government to expand the role of the Patented Medicine Prices Review Board in this area as soon as possible.

    Fourth, on reviewing and tracking prices and costs, we are aware that work is continuing on a national prescription drug utilization information system. This system will provide a critical analysis of price, utilization, and cost trends so that Canada's health system has more comprehensive and accurate information on how prescription drugs are being used. It will help us also to better understand the sources of the cost increases.

    This work is being conducted in collaboration with the Canadian Institute for Health Information and the Patented Medicine Prices Review Board. We urge that this work be continued and in fact accelerated. From the point of view of Manitoba Health, we would be willing to share the data produced by our drug programs information network to facilitate this initiative.

    The inherent logic behind pharmaceuticals is that they are needed to treat illnesses and keep people well. They are different from other consumer products because the decision about their use ought to be made on medical grounds rather than on a basis of consumer choice; that's aside from recreational drugs. That is why regulation is appropriate and why marketing and advertising practices need to be carefully examined.

    In the pharmaceutical industry, the emphasis on marketing has been increasing. The proportion of total sales revenues allocated to marketing has been rising continually. A 1997 article in Scrip Magazine estimated that pharmaceutical companies spend approximately 35% of sales revenues on marketing. I'm advised that's about twice what they spend on research and development. Moreover, even some of the research and development could be called “marketing by other means”.

·  (1325)  

    We will come back to direct-to-consumer advertising in a moment. Our focus here is the promotional and marketing activities of the industry that are self-regulated by a code of marketing practices. As we understand it, in 1997 a semi-autonomous organization called the Pharmaceutical Advertising Advisory Board was established as an alternative to direct government regulation of promotion. This board is responsible for pre-clearing published advertising. The board consists of representation from the pharmaceutical industry, the advertising industry, the Canadian Medical Association, the Canadian Pharmaceutical Association, and the Consumers' Association of Canada. It was set up in a pluralistic model, but the majority of the members are representatives from particular industries.

    A review done in 1990 showed that a significant proportion of advertisements do not comply with guidelines established by the board. I'm advised that in 1991 nearly half of the advertisements included no risk information, although it is a clear requirement of the board. However, this structure does provide some positive features for our system. There is probably less misinformation than in some other regulatory systems. Manitoba would like to see these positive features enhanced. Health Canada, through the enforcement of the Food and Drugs Act, could do a more aggressive job of monitoring the function of this board.

    Clinical drug trials and the Health Canada special access program are also sometimes used as a means of enhancing consumer demand. And I make that statement quite clearly understanding that it has implications in both directions. Clinical drug trials are intended to ascertain the efficacy and effectiveness of new drugs prior to licensing. The Health Canada special access program provides unapproved drugs on an emergency basis to treat patients with a serious or life-threatening illness when conventional therapies have not been successful. The practice sometimes employed of using clinical trials and the special access program as a means of building consumer demand for the drug needs to be regulated.

    The federal government could play a stronger role in ensuring ethical practices in the use of the special access program and clinical drug trials, including the requirement to disclose all of the risks of the drug study, and by making transparent any potential conflict of interest between the researchers and the sponsors. Stronger federal regulation would have been helpful, as an example, in 2001 when patients using the drug Remicade under the special access program were asked by the Canadian Advisory Reimbursement Exchange, on behalf of a drug company, to write to the provincial governments to request that Remicade be placed on the provincial drug formulary.

    Direct-to-consumer advertising is not permitted in Canada. Nevertheless, there are issues around advertising to the public that should be noted. A study published in the British Medical Journal in 2002 showed that doctors were more likely to prescribe a drug that a patient has seen advertised even when the doctor was uncertain about its appropriateness for the patient.

    There are three essential ways in which the pharmaceutical industry manages to directly influence Canadian consumers through advertising. The first is due to proximity of the United States, which is only one of two industrialized countries that allow this type of advertising. There is a significant spillover effect from the U.S. advertising in magazines and on U.S. television penetrating the Canadian market. The argument is often raised that nothing can be done about U.S. television advertising, but the parallel example of tobacco and alcohol advertising shows that Canada can effectively block unwanted advertising signals from the Canadian market, except in narrow instances of illegal satellite signals. We urge the Government of Canada to more aggressively block direct-to-consumer advertising by upholding and enforcing existing Canadian law.

    Pharmaceutical companies are permitted limited advertising provided that it is confined to the drug's name, price, and quantity. Marketers are finding ways around these constraints, as the example of Viagra advertising so eloquently illustrates. Frequently they will use sophisticated advertising to entice consumers to visit websites where further product information is provided, including a sales pitch.

    Other forms of prescription drug promotion are becoming increasingly common. These fall outside of Canada's regulatory codes. Sponsorship of patient advocacy groups, public meetings, public relations activities, video news releases, and upbeat releases to the media all contribute to increased product sales regardless of actual medical need. There is room for federal regulatory enhancements to prevent or at least mitigate some of these activities.

·  (1330)  

    In conclusion, we'd like to emphasize that the purpose of our presentation is not industry- or drug-bashing. The pharmaceutical industry is an extremely important and integral part of keeping Canadians healthy and treating disease. We are cognizant of the very important economic role and research contribution that the industry makes. Our goal is to enhance the relationship between industry and our health system. Stronger federal regulation in advertising practices, faster approval of generic drugs, and the other mechanisms for containing costs and the other recommendations we have made in this presentation are all intended to sustain our health system and the role pharmaceuticals play in it. We think that everyone, especially the Canadian consumer, can win by this approach.

    Thank you very much. I'm prepared to answer questions.

    The Chair: Thank you, Minister.

    We'll begin the questioning with Mr. Merrifield.

    Mr. Rob Merrifield (Yellowhead, Canadian Alliance): Thank you, Mr. Minister, for coming in and sharing your ideas with the committee.

    We've really had an interesting time this week getting a bit of a handle on this whole area of drug pricing in terms of the amount of addiction we have within our seniors population as well as the problem we have within our own hospitals. We've had testimony that up to 50% of individuals who are hospitalized have a bad reaction to medication within the hospital settings. A lot of doctors and nurses are not trained or are not knowledgeable enough or don't have the time; I'm not here to judge motives or capabilities. So it becomes a pretty serious problem when you really look at it, and yet very little study has been done on it.

    My question to you is this. Really, 50% of your presentation to us was on the pricing of drugs. We had testimony this morning from individuals from the pharmacy group who had some serious concerns about the rising cost of drugs in Canada, particularly in this province, with regard to brand name pharmaceuticals because of the Internet sales. That is within your jurisdiction and within your mandate, and I'd like your response on how you can come and say we should be changing patent law, and looking after all the proposals you have here, and yet on the other side it is directly in your mandate to deal with the Internet pharmacy group, which is right now impacting drug prices in Canada, potentially in a very significant way.

    Hon. Dave Chomiak: Thank you. I'll answer both of the questions you raised.

    The first question is on drug utilization within the province and the issue of overuse, perhaps inappropriate use, etc. We have an information system, an electronic system of information for all prescriptions in the province, that tracks that. It's an automatic system that red-flags. It's not perfect, and there obviously are more areas to be brought in, but we have a system that tracks drug utilization through prescriptions, and cross-references, etc., which allows pharmacists to understand dispensing and when drugs might have inappropriate interaction.

    Second, we also have programs with the College of Physicians and Surgeons, which is our regulatory body, that track particular drugs with particular systems they have in place--that is, essentially for narcotics-based drugs and other drugs--in terms of overuse or inappropriate use. So that deals with one of the issues.

    I'm also quite cognizant of two other issues in that area. First, we are working on processes with our College of Physicians and Surgeons and our medical association to do a better job of drug utilization within our borders by physicians and others for a more appropriate use of drugs. I also raise the issue of antibiotics use. That's the first part of the question.

    The second part of the question deals with the Internet pharmacies, per se. The fact is that we have been able, in this country, to maintain, relative to the United States, a lower cost for our drugs, which has had the effect of creating an industry that provides cross-border utilization of drugs. I'm not cognizant of direct drug price increases as a result of that in Manitoba, per se. I am aware that the industry has considerable impact on the Manitoba economy. I'm also aware that the FDA has expressed some concerns. I'm also aware that there is a bill in Congress to in fact permit it. So I think there is a divergence of opinion.

    What I do know is that for decades U.S. consumers have been coming up to Manitoba to purchase drugs and continue to do so, and in fact are now doing it on the Internet. Whether or not that industry will continue in the future and survive in the future is a question that's still up in the air.

    In terms of Manitoba's response, we've put together a very aggressive mediation process with the industry, with the Pharmaceutical Association and others, to try to reconcile something that is relatively new and that, I suggest, will only expand in the future and is just not confined to pharmaceuticals; the cross-border utilization of medical services is something that is going to grow. In Manitoba now we are involved in a process in conjunction with France to do surgery via telecommunications from international locations. So it's an issue we're going to have to face.

·  (1335)  

    Mr. Rob Merrifield: Yes, we certainly are. The point is really that we can't determine, and shouldn't, what the United States is doing; it's not our jurisdiction. From a federal perspective, of course, we may want to enter into some dialogue with regard to the problem.

    What is our mandate? It's making sure that Canadians receive and have the ability to receive pharmaceuticals at the lowest price possible. As we move forward into this next number of years, as pharmaceuticals come even more in demand, what we heard this morning is that they're compromised in two areas--first, availability, and also the price because of Internet sales. Internet sales have gone from $400 million to $1.2 billion in one year. That's tremendous growth. Not only that, you're lacking the ability to have enough pharmacists to be able to dispense in the province.

    My point is that if you don't realize that this is a serious problem, that's a problem. I'm sort of bringing it to your awareness and hopefully looking for a response to see how you plan to deal with it.

    Hon. Dave Chomiak: I don't think the lack and the shortage of pharmacists in fact occurred directly as a result of the Internet pharmacy. We were short in this country of pharmacists for perhaps the last decade.

    Mr. Rob Merrifield: So it's not impacting ...?

    Hon. Dave Chomiak: It's an impact, but I think it would be inappropriate to suggest that the shortage of pharmacists is attributed solely to Internet pharmacies. The fact is that U.S. companies were offering major signing bonuses to Canadian-trained pharmacists before the Internet became an up and growing business. So we may or may not have faced that same difficulty whether or not Internet pharmacies were online.

    I do recognize that it has put pressure--and we face that in the public sector--where we have to purchase the services, through contract or otherwise, or on staff of pharmacists, such that we've had to increase dramatically the price that we pay for pharmacists in our public system. I recognize that this has been a pressure, and we continue to grapple with that. We're not aware of...and we've monitored very closely and are in touch with pharmacists and associations and individual pharmacies across the province to ensure that supply is not affected.

    The long term is not just a Manitoba issue. It's a Canadian issue. Manitoba is not the only province that is engaging in this particular enterprise. I think it's something that has to be addressed, but I also suggest that there is a difference of opinion with respect to the U.S. and how they're going to apply their regulations in law in relation to this.

·  (1340)  

    Mr. Rob Merrifield: So you'd dispute the numbers we heard this morning about it causing a 20% reduction in pharmacists, and availability of pharmacists, in your province?

    Hon. Dave Chomiak: I don't see how you could apply a particular shortage because of this. The fact is that I was Minister of Health before the Internet pharmacies became a major issue in Manitoba, and I was grappling with pharmaceutical shortages prior to that.

    Mr. Rob Merrifield: So you had the shortages prior to, plus you had the shortage of pharmacists prior to. That's your comment.

    Hon. Dave Chomiak: There's a national and international shortage of pharmacists.

    Mr. Rob Merrifield: And health care workers from beginning to end. That's not news to anyone.

    Well, that's interesting. Let's get back to the price of the pharmaceuticals, then. If you think it's not affecting the shortage of either the drug or the pharmacists, then how about the pricing? The testimony this morning is that the pricing of brand name pharmaceuticals is moving up this last year in relation to the degree or amount of Internet sales. On whether there's a direct correlation there or not, I suppose we need more witnesses. The testimony this morning certainly indicated that was the case.

    Can you comment on the pricing side of it? That would be pricing not only for Manitobans but for all Canadians.

    Hon. Dave Chomiak: The price has been increasing dramatically over the past decade, I suggest. I didn't hear this morning's discussion, but we are not aware of any particular shortages that are driving up the prices here.

    Mr. Rob Merrifield: And you're not having any more availability problems now than you were before?

    Hon. Dave Chomiak: They've been monitored very closely, and while anecdotal incidents have been reported, we've followed up and found those not to be substantiated.

    Mr. Rob Merrifield: It's interesting; when you sit in our chairs and have witnesses come forward and tell you one state of facts, and then others come refuting those, somebody is either not understanding the issue or not being straight up with us. I guess we'll have to determine who that is.

    Hon. Dave Chomiak: Let me just add that I think part of the issue one has to understand is that the, in quotes, “shortages” of drugs has been a factor and a fact of life for certain drugs and in certain areas for some time because of inventory and related matters. The fact that Internet pharmacies are present in Manitoba has been pointed to as the reason for any shortage or continuing shortage or difficulties. We have been tracking this on a regular basis. We have written to pharmaceutical companies, we've been very aggressive, and we've indicated to all of our suppliers that Manitoba consumers are supplied first. We have made that very clear, and that is very clearly where we're going on this. So the issue of, in quotes, “shortages” has been present before. I think the committee should understand that.

    Second, the issue of pharmacist shortages has been present for some time and has been exacerbated, I suggest, by the fact that more pharmacists are providing Internet pharmacies. But I just want the members to recognize that we faced the same issue in perhaps the mid- to late nineties, when the mom-and-pop drugstore was moving to the large big-box stores. We were in somewhat of the same dilemma at that time in terms of pharmacists etc.

    So there are factors at play in the free market that have impacted on this for some time and will continue to impact on it.

    The Chair: Thank you very much. Thank you, Mr. Merrifield.

    Mr. Thompson.

    Mr. Greg Thompson (New Brunswick Southwest, PC): Thank you, Madam Chairman, and thank you, Mr. Minister, for coming in with your staff.

    I want to pick up on that same issue of Internet pharmacies or mail order pharmacies. We did hear testimony this morning from various groups, one of them being the Coalition for Manitoba Pharmacy. In addition to that we heard from the Manitoba Pharmaceutical Association.

    To put it very plainly, they don't seem to be very impressed with your aggressive move to stop this Internet pharmacy. They're saying, as been mentioned by my colleague, that in fact it's growing exponentially. And it's not anecdotal information, I might suggest, but very factual. For you as minister to suggest that it's anecdotal.... I think you'll have to go back to your officials, because it's more than anecdotal. They're saying that it's bringing about shortages they see themselves, because they're in the drugstore every single day doing their work. So it's far from being anecdotal, I would suggest.

    In addition to that, they're saying that you're basically skirting PMPRB voluntary participation--in other words, voluntary from the sense that some of the innovative drug companies eventually will choose not to sell some of their products in Canada. So it's going to have not only an effect in terms of pharmacists being pushed out of either a family practice or some of the bigger drugstores....

    I mean, we've had evidence here today that some of those stores have actually shut down. They've actually seen these people move into the Internet pharmacy. Again, this is not anecdotal. It's very factual. And it's something that has to be addressed, I think openly and by the government, that it goes way beyond anecdotal. An exponential increase in this type of behaviour is only going to make the problem worse, not better.

    In addition to that, as you would well know as a health minister, doctors are co-signing or countersigning on these prescriptions where they never in fact have seen the patients.

    I'll leave it at that, but we had testimony this morning again from the.... I just want to make sure that I have the correct name here for you.

    Madam Chair, I'm looking for the name of the person who represented the Manitoba Pharmaceutical Association this morning.

·  (1345)  

    The Chair: Ronald Guse.

    Mr. Greg Thompson: Yes, the registrar, Ronald Guse.

    Mr. Guse was suggesting that the Pharmaceutical Association, which has certain guidelines, acts in much the same way as the Canadian College of Physicians and Surgeons. Their mandate is to protect the public...basically no teeth. In fact, I guess they're suggesting that you've taken some of those teeth away from the Pharmaceutical Association in terms of their ability to police the industry, if you will.

    Minister, I'll leave it at that, and I look forward to your response.

    Hon. Dave Chomiak: Well, thank you. I think it is unfortunate that the fact that the average ingredient costs of the brand pharmaceuticals have gone up in Manitoba--by our tracking, $35 per prescription in 1996-97; $37 in 1997-98; $40 in 1998-99; $44 in 1999-2000; $48 in 2000-01; and $48 per prescription in 2001-02--is related to Internet pharmacies. The point I made in my presentation is that prices are a function of a number of factors. On the information you provided this morning, in fact we have tracked every representation that's been made to us, that I call anecdotal, that has been provided to us on pharmaceutical shortages, and in every instance that's been provided to us we have found that there hasn't been a difficulty.

    So regardless of how one characterizes it, the point I want to make is that if one wants to discuss the issue of Internet pharmacies and focus totally on Internet pharmacies as the reason for the cost drivers, I think that's wrong. I think that's inaccurate. I think that focusing totally on that issue misses the larger mandate of this committee of dealing with an issue that's been a problem for over a decade.

    With all due respect, there has been representation. There's been representation on both sides of this issue to myself as Minister of Health. My number one job in this province is to protect the patients, and we've taken every step we can to do that.

·  (1350)  

    The Chair: Thank you, Mr. Thompson.

    Mr. Dromisky.

    Mr. Stan Dromisky (Thunder Bay—Atikokan, Lib.): Thank you.

    Thank you very much for appearing before the committee this afternoon. We truly appreciate it. It's interesting the various presentations we've had across the country and before the committee in Ottawa. Somehow we have to make sense out of the whole picture.

    We have a shortage of pharmacists, as you've indicated, and we've had them for a long time. I'm talking about the shortage not just in Manitoba. There have been some thoughts bandied about regarding a model very similar to nurses, the nursing practitioners. We see some value in something of that nature with the people who are most knowledgeable and have a tremendous amount of expertise in the area of prescribed drugs.

    Communities are isolated. We have very few of these professional people scattered throughout northwestern Ontario and the northern parts of all the provinces in isolated communities, and we have do something. The first question I have is related to this area.

    Is the Government of Manitoba encouraging the school of pharmacy to increase the number of places to increase the supply of pharmacists in this province? Is there any thought given in that direction?

    Hon. Dave Chomiak: In fact we are in discussions with them on that. We've increased the supply in every single health professional school, doctors, therapists, nurses--every single health profession--and we're in discussion with the Pharmaceutical Association with respect to actually increasing their number of students as well. We're also engaged in discussions with the Manitoba Pharmaceutical Association, who appeared this morning, about expanding the role of technicians. In this jurisdiction, we've also allowed midwives and other health care professionals to prescribe drugs.

    Mr. Stan Dromisky: Is there any thought given to enriching the program--I note the five-year program now in Manitoba to become a pharmacist--introducing programs from the medical school, harmonized with the program in the pharmacy school so that the pharmacists will be able to prescribe drugs under certain conditions?

    Hon. Dave Chomiak: That's a really interesting question. I am familiar with one health minister in the country who has indicated to me, why wouldn't we have pharmacists prescribing per se for routine matters right at the pharmacy? That idea has been bandied about. At this point, I don't think we're considering.... I think it's an interesting idea, and a useful idea, and it is one component that I think we're examining. The actual integration between medical and pharmacy hasn't taken place in this province.

    Mr. Stan Dromisky: I'm intrigued by the kinds of programs you have in this province in terms of the sharing of information between and among the various people who are involved in the health care-giving system.

    I may have misinterpreted something by one of the presenters this morning. You have a special act governing the responsibilities and the mandate and job specifications and so forth regarding the pharmacists in this province. Is there anything in that act that curtails their sharing of information within the province or beyond the boundaries of this province, with other health care givers across the country?

    Hon. Dave Chomiak: I'm advised that we're in fact attempting to obtain that kind of authority through our legislative office right now, and we are in discussions regarding that.

    Mr. Stan Dromisky: That's good. I ask that question because, you know, the people in this country are very migrant, like nomads travelling all over the place. There are a lot of people from Thunder Bay, from my community, who live in Winnipeg right now, and in Brandon, and who move back and forth. I think these political and geographical boundaries we have need to be erased in order for us to have a more effective health care delivery system in this country.

    Thank you.

·  (1355)  

    Hon. Dave Chomiak: I should just add that our legislation was drafted prior to some of these issues becoming current, and I do suggest to the committee that we are facing a major technological revolution. In Manitoba we're thinking of how we're going to deal with cross-border issues increasingly across the health care spectrum and the health care field, because it's clearly.... We are probably not prepared for it at this point.

    Mr. Stan Dromisky: Thank you very much.

    The Chair: Thank you, Mr. Dromisky.

    Mr. Robinson.

    Mr. Svend Robinson (Burnaby—Douglas, NDP): Thank you very much, Madam Chair.

    To Minister Chomiak and your officials, we certainly appreciate your taking the time to appear before the committee this afternoon.

    If I may say, I very much value many of the recommendations you've made to the committee in a number of areas, whether it's direct-to-consumer advertising or the issues of patents.

    I also value your leadership in an area that I personally feel very strongly about, and that's palliative care. I was delighted to see that you moved ahead with the palliative care drug access program. I think you probably know that the first jurisdiction in Canada who pioneered that program of making palliative care drugs available was in fact a New Democrat government in British Columbia. Unfortunately, that government is temporarily not in office, but this too will change--a visionary government, Madam Chair.

    I did want to come back to the issue of Internet pharmacies. You said, Mr. Minister, that your number one job is to protect patients, and I respect that. I am very concerned that the Internet pharmacy industry, while it may provide jobs--and I recognize that it provides jobs--raises many very serious health questions. I have a couple of questions that I want to put to you on this.

    We heard evidence, and I thought it was quite compelling evidence, this morning from witnesses with respect to, for example, the concern around the fundamental health issue. My colleagues have raised issues about prices. I'm not focusing on prices here, I'm talking about health. The fact is that this is an industry in which too often drugs are prescribed without a direct link between the physician and the patient. You know that. That is a problem, a health problem.

    As well, certainly hearing the evidence this morning, I don't think there's much doubt that there are some serious issues around the movement of pharmacists into the Internet pharmacy industry from the general pharmacy industry. You say it's anecdotal evidence, and I appreciate that, but quite frankly it's pretty serious anecdotal evidence around some shortages of drugs.

    We heard from the coalition this morning about Temodal, Purinethol, and some other drugs, and about pharmacists who have had to search for a long time to find drugs that previously were available. Now, whether that's directly a result of Internet pharmacies, I'm not sure. It may very well be.

    My question to you is this. If your number one job is to protect patients and ensure quality health care, why has the government not taken a much tougher stand on this Internet pharmacy industry? In particular, why is it that Manitoba continues to allow prescriptions to be filled if they're signed by doctors outside Manitoba, unlike a number of other jurisdictions in Canada?

    Hon. Dave Chomiak: Thank you for your opening words and for the questions.

    In terms of your preamble and the two drugs you mentioned, I wasn't aware that those had come to the committee. We will do follow-up on those two. The previous three drugs raised by that group, we had done follow-up on. So we'll do follow-up on that with respect to the two drugs you mentioned in your preamble.

    We undertook in Manitoba to put in place a mediation process where we brought in probably the most renowned mediator in Manitoba to try to reconcile some of these issues in order to provide for patient safety, to see if industry can still function within proper guidelines, and to protect the interests of the Pharmaceutical Association. We had agreement between all the parties, and the agreement brought together by the mediator was put to the general membership of the Manitoba Pharmaceutical Association. It was defeated something like 320 to 270. So it was relatively close in terms of the licensing body membership.

    We're continuing discussions with the industry to try to--and we will, if necessary--amend our regulations and amend our act in order to ensure that the system is protected.

    The issue at this point...that we monitor on a regular basis. There now are essentially two associations in Manitoba that represent pharmacists, the traditional Manitoba Pharmaceutical Association and the Manitoba Internet pharmacists. We are advised by them that issues of patient safety have been adequately protected.

    It is true that our College of Physicians and Surgeons has directed its membership to not co-sign, to not sign prescriptions without direct contact between the physician and the patient. We do have the ability for the industry to function within guidelines that they feel are acceptable.

    At this point, we are still continuing to try to reconcile these views and achieve a legislative regime that will continue to protect the patient and will still allow for appropriate cross-border use of pharmacists.

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    Mr. Svend Robinson: How do you deal with the issues, though? Your doctors have said, look, we will not be a part of signing off on prescriptions, co-signing prescriptions, which are ordered over the Internet. Your doctors have said this is a health problem. You're the health minister, and yet your province still allows doctors from other jurisdictions to sign off. You can change that by changing the law. Why won't you?

    Hon. Dave Chomiak: At this point, we're attempting to reach an accommodation that would protect both those interests. I also have our College of Physicians and Surgeons saying that we should maintain small hospitals in rural Manitoba on a call rotation of 2:1 doctors, and we're continuing to do that.

    Mr. Svend Robinson: But we're talking about pharmaceuticals. Are you satisfied that a doctor in Saskatchewan or Ontario should be able to sign off on a prescription that's ordered over the Internet?

    Hon. Dave Chomiak: If our mediation process succeeds, we will eliminate the co-signing issue and we will have the College of Physicians and Surgeons brought on side. And that continues to be our goal.

    Mr. Svend Robinson: Sorry, just so that I understand--

    Hon. Dave Chomiak: If we were able to achieve our mediation, we would have the agreeance and the acquiescence of our College of Physicians and Surgeons. We'll continue to work on that.

    Mr. Svend Robinson: But do you need the agreement of the College of Physicians and Surgeons to change Manitoba law to say that doctors from outside Manitoba shouldn't be able to co-sign? You don't need that. You don't need their--

    Hon. Dave Chomiak: No, I don't need that.

    Mr. Svend Robinson: So why can't you move ahead on that, then?

    Hon. Dave Chomiak: Because we're still attempting to reach accommodation to allow our pharmacists to participate and for Internet pharmacies to continue.

    Mr. Svend Robinson: And how will that happen?

    Again, maybe I'm missing something here, but I assume you accept that it's wrong that patients should be able to order drugs over the Internet without those prescriptions being authorized by a physician with whom they have met.

    Hon. Dave Chomiak: In some ways, it'll be not dissimilar to the question that was raised by one of your colleagues insofar as the pharmacist would have the relationship with the patient to allow the drugs to be prescribed in a safe fashion.

    Mr. Svend Robinson: So the patient would in fact have to have a personal relationship with the physician in order to order those drugs over the Internet?

    Hon. Dave Chomiak: With a physician, but not necessarily in Manitoba.

    Mr. Svend Robinson: Where could that physician be, then?

    Mr. Milton Sussman: The relationship would be with their own physician. Our pharmacist would--

    Mr. Svend Robinson: So you're saying that an American physician, then, could sign a prescription and they could order the drugs from Manitoba, over the Internet, if an American physician okayed it?

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    Hon. Dave Chomiak: That is one of the options.

    The Chair: Thanks.

    Do you have another question?

    Mr. Greg Thompson: If we have the time, I do have another question.

    The Chair: I'll have to give Mr. Merrifield the first chance, or we could maybe do one quick question with quick answers.

    Mr. Rob Merrifield: I just wanted to pick up on what my colleague was saying with regard to Manitoba's Pharmaceutical Act. That's the one I think he was talking about that just needs to be changed. I still am not quite clear on whether we got a commitment that you are going to change it or not.

    Hon. Dave Chomiak: We are changing the act. We're in a mediation process in order to have all parties agree to the act, and we're in the process of discussion with all of the groups, including the college, to ensure that hopefully we can change the act with the agreement of all parties concerned.

    Mr. Rob Merrifield: Is the intent to change the act so that it would not allow prescribing anywhere outside of Manitoba for people within Manitoba? Is that how you're planning to change the act?

    Hon. Dave Chomiak: No.

    Mr. Rob Merrifield: So what are you trying to do? What are you changing the act to?

    Hon. Dave Chomiak: One of the options being considered is that we would have patient, pharmacist, and doctor, and there would be a relationship between patient, pharmacist, and doctor that would allow for pharmacists to dispense the drug with the consent of the doctor, not necessarily a Manitoban doctor.

    The Chair: Mr. Thompson, a quick one.

    Mr. Greg Thompson: On the idea of the pharmacist dispensing the drug, you're still not addressing that issue of anonymity, where patients are being signed off without the close supervision or scrutiny that would normally occur. What you're suggesting now, Mr. Minister, is the pharmacists are going to have the ability to sign off, so the person who sells the drug is now the person who's going to write the prescription.

    Do you feel that--

    Hon. Dave Chomiak: No. An American doctor who sees the patient could write a prescription that could be filled by a Manitoba pharmacist, just as a Manitoba physician can write a prescription that can be filled by a Manitoba pharmacist.

    Mr. Greg Thompson: What stops that from happening today, simply that there is no provincial legislation that allows that to occur?

    Hon. Dave Chomiak: At present the regulations permit a pharmacist in Manitoba to fill a prescription by a doctor who is licensed in Canada.

    Mr. Greg Thompson: But that's the co-signing aspect of it.

    The Chair: Mr. Thompson, I think you're finished.

    Mr. Dromisky.

    Mr. Stan Dromisky: I have just a simple question. I'd like to know what your government's position is regarding a national data bank pertaining to drugs and a drug review process. I know you're involved in some of that right now, but I'm talking about a process and a data bank that could be shared between and among all the people who are involved in that critical stage of providing effective care service to a certain individual.

    Hon. Dave Chomiak: Just 100% support, unequivocal. Anything we could do to assist that process, we've been active, and would be active in.

    Mr. Stan Dromisky: I hear that kind of talk in Ottawa, too, but I'm not too sure what it really means. I know in Ottawa a lot of information flows into the Canada heath department, but it stays there, or it's buried, and nobody seems to have much use for it, or it is not being put to use.

    I don't know what the answer really is, but all I know is that it's a dead end.

    Hon. Dave Chomiak: Part of the difficulty...and there's no question, I think, about the black hole of information. We find that as well.

    The second point is our own DPIN system. We can, and if we could legitimately make it available, we would in terms of cross-patterns.

    I think the third thing is that we have found that the personal information legislation has hindered some of these issues, and we have found that with out research ability. In Manitoba we have the largest database of health information perhaps in the world, and we've managed to work a way around it by specific legislative amendments. I think we're going to have to look at that in terms of drugs and other related issues, because I think that's probably one of the main factors.

    Mr. Stan Dromisky: I have one little question related to that, and that pertains to your colleagues across the country who have the very same position as you do in the cabinet. Has there been, at any time in the past year or two or three, discussions pertaining to the sharing of information on a data bank of that nature?

¸  (1410)  

    Hon. Dave Chomiak: The implications are very broad, because the larger issues are issues of application, who has access to the information, is that information saleable, etc. It becomes very complicated.

    The use of the database and having particular criteria applied to it has been successfully utilized for research and other clinical purposes, but I don't think we've effectively done that in terms of drug information, if that's where you're going, and I think we are encouraging of that.

    Mr. Stan Dromisky: Thank you very much.

    The Chair: Mr. Robinson, a quick point.

    Mr. Svend Robinson: On the American doctor thing, I just want to say that I would proceed with extreme caution on this one. I think the potential for abuse is very grave if you go down that road, but obviously that's something you'll be looking at seriously.

    I did mention earlier the evidence we heard this morning from a group of pharmacists, the Coalition for Manitoba Pharmacy, who did raise the concerns about a couple of the drugs, which you said you'd look into, and I very much appreciate that. I understand they have been seeking a meeting with you. I know it's tough to schedule meetings, but I would just encourage you, if it's at all possible, particularly in following up on this issue, to meet with the folks from this coalition who met with our committee. It would be very helpful. They did raise some important concerns, and I would hope they'd be able to raise those same concerns with you as minister in the near future.

    Hon. Dave Chomiak: Thank you.

    I was under the impression that they presented to our caucus, which I attended last week, but...or at least some of the members of the group were there as well. So if I haven't met with them recently, I've met with groups, or parts of them, last week, and I will continue to meet with them. And my deputy minister met with them as recently as a week ago.

    Mr. Svend Robinson: Thank you.

    The Chair: If my colleagues can tolerate it, I have a couple of questions too.

    We're not unaware of the pressures in government between health ministries and industry ministries. There are many people who served on the health committee who would like to repeal Bill C-91, and we know it has something to do with the increases in prices and all these points you made so well in your presentation. Therefore, I have to assume that this new mail-order or Internet drug industry in your own province is probably adding something to your gross domestic product that is considered favourably by your colleagues in cabinet. And I understand that. But the piece of the puzzle that bothers me is the potential shortage of certain drugs.

    I'm wondering whether, from the bully pulpit that the health minister has, you've made any enquiries of the major pharmaceutical companies to increase the amount of product that they normally and traditionally would have allocated to Manitoba. In other words, if this new industry increases your economy, creates a whole bunch of new jobs, brings money into the province, and does not drive up the price--it might get to the point where it would be kind of a wash--the main thing I think we want to be sure of is that Manitobans, and therefore Canadians, are not denied access to certain drugs because a truckload of them has just flowed over the border to some patients in the United States.

    So it would seem to me the manufacturers, who want to make money, need to be told that they need to increase Manitoba's allocation to cover the increase in business that is coming from here.

    Hon. Dave Chomiak: Thank you. I think your comments are well founded.

    We are in contact regularly with the industry. I know I've written directly to several of them, and we are in daily if not weekly contact with them concerning supply and any perceived or potential shortages. The issue of the industry providing additional supplies in order to permit an export industry I think would be delicate to discuss with the industry. I don't think we'd be averse to doing that, but I think we probably wouldn't succeed very effectively. But we have gotten assurances, and we have made it very clear, that Manitobans have first access to all supplies, and every follow-up we've made in this regard has suggested that.

    I won't go on about this too much, but it does raise broader issues. I am not unaware, and we are not unaware, of the long-term developments and complications in this matter concerning price and future prices, concerning various factors that might occur in the United States and various pressures that can be brought, given a political turn of events. So we're cognizant of that, and we're very carefully trying to encourage an industry without hampering or affecting at all the health of Manitobans. If there were any occasions where we were aware of the safety of any Manitoban being compromised, then we would not fail to act.

¸  (1415)  

    The Chair: I'm wondering if in your own system, whereby pharmacists can report to you on drug utilization, whether you might add some space on that for them to report when they can't get access to a drug. Then the information would not be anecdotal. It could be recorded, and it would give you a clearer picture as to whether or not there are these shortages.

    Hon. Dave Chomiak: On every occasion, both the coalition and other organizations and pharmacists are aware of the fact that we monitor this. It is monitored on a regular basis, and we do have it....

    You're suggesting that we have in place a flagging system, perhaps, that--

    The Chair: Each time a pharmacist cannot get hold of a drug that he or she needs, they could alert you so that you could collect the data to find out whether it's just the odd day or whether it's an ever-increasing phenomenon, which is what was implied to us this morning.

    Hon. Dave Chomiak: I'll ask Mr. Rosentreter to respond.

    Mr. Jack Rosentreter (Executive Director, Pharmaceutical Drug Programs, Manitoba Health): We met with the Coalition for Manitoba Pharmacy a number of weeks ago, and we actually gave them that direct invitation, that whenever they had any particular problems with shortages, they can contact my office. I have four pharmacists who would immediately look into it and find out if there's a particular problem.

    In the past while in the newspaper, there were three shortages reported by the Coalition for Manitoba Pharmacy. We investigated them. Two of them basically were global shortages, not only in Manitoba but also in North America. In the third one, basically there was stock available in Manitoba, so we did not understand where that came from.

    The Chair: I see.

    On behalf of the committee, I think I can say that in this particular period of the evolution of the pharmaceutical industry in Manitoba, none of us would like to have your job, Minister. It looks like you're stickhandling your way through an evolutionary process, and it doesn't seem as though it's probably much fun.

    We're doubly grateful to you for taking time out of your day and bringing your staff along to share your ideas with us. I'm going to take very seriously your brief, which I think was very thorough and helpful to us. Thank you very much.

    To members of the committee, we were supposed to go from 2:15 to 3:45, but we've had some cancellations. I'm going to suggest that we take a break until 2:30 and go until 3:30, at which time our hearing will end.

    We're adjourned for a few minutes.

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¸  (1430)  

    The Chair: Order. Welcome to this session of the Standing Committee on Health and its study of prescription drugs.

    It's my pleasure to welcome representatives from the Indian Council of First Nations of Manitoba and from the Women's Health Clinic. I will caution you that we have just an hour to both hear from you and get some questions in.

    From the Indian Council of First Nations, we have Grand Chief Andrew Kirkness, Vice-Chief Glenn McIvor, and the secretary-treasurer, Tom Kirkness. I would assume the Grand Chief is going to begin.

    You have the floor, sir.

¸  (1435)  

    Grand Chief Andrew Kirkness (Indian Council of First Nations of Manitoba): Thank you.

    First of all, I'd like to greet the committee. I'm happy that I'm able to get five minutes in. According to what we were told, we have five minutes, and we'll try to do that.

    I'll start with just a brief description of Indian Council of First Nations' history and involvement with Health Canada, including the diabetes initiative. Our organization is 19 years old. We represent off-reserve and non-status Indians in Manitoba, and being that, we're pretty hard on.... When you talk about any issue, and you talk about drugs, I guess the issue of access to prescription drugs by Manitoba off-reserve and non-status Indians...and a lot of people wonder what “non-status” Indians means. We've included an attachment here that explains how these people became non-status.

    The access to drugs usually is not too bad in communities where you have doctors and a drugstore, but many of the small communities don't have that. It is difficult. As far as the non-status Indians, they can't get drugs like the people who are treaty can get drugs, through medical services, the Department of Indian Affairs. Non-status Indians do not have status under DIAND programming to prescription drugs.

    Now, from our point of view, all Indians have treaty rights, including health, under section 35 of the Constitution Act. That's also attached here. These treaty rights are the basis of the aboriginal envelope of the primary health care transition fund. I believe that's in the third attachment.

    Basically, we are here to make some recommendations for this committee to look at: to ensure that prescription drugs to Manitoba non-status Indians are always provided under the aboriginal component to the fund; to involve off-reserve and non-status Indians and their organizations in partnerships to ensure access to prescription drug programming by Manitoba off-reserve and non-status Indians; and to ensure that those participating in the aboriginal envelope of the transition fund develop methods by which aboriginal people in Manitoba have access to high-cost prescription drugs for growing incidence in aboriginal communities of diabetes and HIV/AIDS. Such access should include prescription drugs for emerging cures to diabetes and AIDS.

    Now, it is difficult, I guess, in some of these communities, as I said, to get drugs. You can't just go into a drugstore when there are none in a lot of the small communities that we represent along the bay line. So it is awkward.

¸  (1440)  

    First of all, drugs are costly. For non-status Indians, they won't give them any drugs under DIAND, because they're not treaty. The non-status Indian doesn't have a treaty card, which is what you use to get drugs. There are some drugs that we cannot get near that they don't...that we have to pay for, certain drugs.

    As I said, it is fairly easy in a bigger community. I don't know what it would be like in Winnipeg, as I haven't had much experience here, but in the community I live in, The Pas in Manitoba, we have a place to go and see a doctor, and then we have a couple of drugstores. One's on a reserve there, so it's fairly good. But for the non-status Indian in the smaller communities, it's almost impossible to pay for the drugs. When the community is actually 90% unemployed, how do you do that? You can't buy drugs if you don't have a job. It's almost impossible.

    That's the basic reason for our appearing here, and I guess maybe I'll leave it at that. If there are any questions the committee wants to ask, we'll try to answer them the best we know how.

    Thanks.

    The Chair: Thank you very much.

    Our second witness is from the Women's Health Clinic, Ms. Madeline Boscoe.

    Ms. Boscoe, we remember your presentations to our hearings on reproductive technology and we look forward to what you have to say today.

    Ms. Madeline Boscoe (Women's Health Clinic): Thank you very much. I take it that tomorrow might be our lucky day on Bill C-13; I hear the gossip circulating. I'm assuming that you're all going to be back in Ottawa for it.

    I want to thank you very much for creating an opportunity for me to come today, and I also want to take a minute to introduce to you my daughter, Katie Schwartzman. This is sort of our version of “Take Your Daughter to Work Day”, because she doesn't get to see very often what it is I do. You may have questions to ask her later--but not about my mothering, I'm hoping.

    Before I get into my brief per se, I did want to take the liberty of commenting a little bit from my perspective on the Internet pharmacy piece, and perhaps provide you with a bit of information that you may not be aware of. This is primarily driven by the consumer health movement in the United States seeking lower prices. Our price review board is better at regulating prices than is their open competition program, and we should, as Canadians, take great pride in that, because there are huge numbers of people in the United States who are not covered and who are dying because they cannot afford prescriptions. I think we need to kind of put that into the mix.

    The other piece is that I think we should be outraged that the pharmaceutical industry would threaten Canadians by withdrawing services in this country because they don't like our practices. This is the same industry that screams about competition, and removing barriers, and decreasing protectionism in every other jurisdiction, and I can't help but think that if we had someone who had been in the Soweto meetings around access to HIV treatment, from this very same industry, that they would give us a very different kind of perspective on Internet pharmacy regulation.

    I can say that, as a former member of the minister's advisory committee on the health information highway, I feel quite confident that we can develop accreditation and cross-border processes that will meet standards for health care to reinforce what we already have in place.

    So I wanted to let you know that you may not get an opportunity to hear from a slightly different perspective, but there are those of us who are quite outraged at this incursion into our sovereignty by the very industry that sits at trade tables and says “free enterprise”. The fact that we've been able to deliver a cheaper product to their public says to me that they should lower their prices down south. I mean, it seems obvious that's what they should do. This is not an industry that is starving to death in any way, shape, or form.

    With that little comment, I'm going to talk to you about women's health and why we're here before you yet again.

    The Women's Health Clinic has been around as a community health centre for women for over 20 years. Our commitment has always been to both improve the health quality of care for individual women and address public policy issues that are relevant to women. Our big project right now is actually reducing poverty for women, so in fact I should be talking to the economics committee of the House rather than health protection. However, drugs and devices have been a big, big problem, partially because of the lack of good regulatory teeth in drug approval processes at the federal level.

    I'm going to just read off a few of them for infamy's sake. Diethylstilbestrol is a drug that was given to women to prevent miscarriages. It never prevented miscarriages but caused all sorts of horrible sequelae in the offspring. There's also the Dalkon Shield, Depo-Provera, breast implants, reproductive technologies, and the overmedicalization of our health.

    Currently we've been dealing with things like the impact of direct-to-consumer advertising for Diane 35, which is technically a second-line treatment for acute acne. This is a very tough drug. The marketing is that it's a contraceptive with this neat side effect of clearing up your complexion, which has been very problematic in the health and safety area.

    As well, we've been pleading with the department for years and years to take a proactive response to RU-486 and on non-prescription status for emergency contraception.

¸  (1445)  

    We think that, as we go forward, it is really critical that we develop a framework for managing pharmaceuticals in Canada. Right now it seems to us that there is a dialectic: Is this about helping an industry develop and thrive or is this about health and health care? Because you can't have it both ways. You have to come to ground one way or the other.

    We also think it's really important that we have something that talks about our values and beliefs about drugs and what their role is in health care. Too frequently we are able—even for free—to prescribe things like antidepressants or sleeping medication when those of us in the health field know that in fact if we were able to offer people free massages, free access to exercise, for example with child care, those folks would do just as well with those interventions. We never offer them because we do not think about it as a whole package; not just as providers but as society as a whole, we like to run to treatments when we don't necessarily need them all the time.

    It is also important to remind Health Canada that its role is to advance and protect the health of Canadians and that the development and provision of drugs is a contribution to economic growth. It is not their mandate. Frankly, neither is it their mandate to protect the interests of the media--which I'm adding now, given the expressed enthusiasm by newspaper editors for direct-to-consumer advertising in our country. I agree that our media need support, and our grassroots media need support, but I do not think it should be on the back of health.

    We need to really enshrine much more strongly a gender-based analysis in all aspects of drug management. Despite Health Canada's statements on requiring gender equity in drug research of any kind, that is not occurring in any substantive way. Within the CIHR I've even put inquiries in there, and they're going to get back to me.

    We strongly support implementation of the recommendations from the Romanow report and the National Forum on Health regarding establishing a national pharmacare program with a cooperative buying program. We need to get past the territorial aspect and develop some consistency and expectations for Canadians.

    In terms of a national formulary, I must emphasize that we all need non-prescription drugs on it, such as condoms and emergency contraception. It's really important. The term “catastrophic” means very different things to very different people, and in the practice we have, lack of condoms is a catastrophic event.

    We need a much more robust and transparent consultative process in both the approval and review of drugs as they go onto the formulary. Recently, for example, infertility treatments were removed from some provincial formularies without any consultation or debate, affecting those Canadians who are dealing with this condition who can't afford them elsewhere.

    You need to remember that there is a gender bias in participation of Canadians in extended medical benefits. People who are part time do not get access to those benefits, and the far majority of those workers are women.

    We do support, in a very guarded way, improved timely access to drugs, but we need to unpack this a little bit. There's a very big difference between a new drug, when you have an old drug that isn't working for you, and you're dying, and a new drug that's going to be used for healthy populations to prevent something, hopefully. We need to be able to be way more sophisticated in our analysis and our thinking about what this means.

    We also need to tie this into a way more robust post-marketing and adverse reporting process than we have, and we need to fund that. I'm sure you will hear from other researchers in the community about how frustrated they are with the way in which the pharmaceutical industry has been using its budget, that there is no comparison, that there is very little post-market work. That is by far where we need those investments, and because we do not, as Canadians, have power over where those dollars are, we get very frustrated very quickly.

    In fact, I think we have lots of evidence to say that we do need to repeal the patent protection act for this industry. I think they've had lots of chances and they've had lots of criticisms, and they don't seem to be able to respond.

    We also need to think about a decision-making process for how we approve and bring new drugs onto market. There is an assumption among the Canadian public that once we approve a drug, they're going to have access to it, that if we think it's good enough to be marketed, it should be good enough to go onto our formulary and become part of our parcel of care, which means that we think about it not as something that needs to be sold but as something that we need, that adds value. And that's quite a different process.

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    Norway, for example, has used the system for over 15 years, basically saying there's a need clause in their drug approval process. That way the staff is not overwhelmed with “same as”, or drugs that are being changed slightly to protect their patent, through patent protection. They ask, “What is it we need?” before they will approve it.

    This leads me, briefly, to a couple of other points. You asked about international harmonization. I have provided you with a summary of a very detailed paper about this. There are right now ad hoc meetings, which Canada participates in, primarily set up by the industry, called the International Conference on Harmonization of Technical Requirements. This is primarily an industry-sponsored group, with the participation of Europe, the United States, and Japan, with the view of trying to blend approval processes for drugs.

    On one level, this sounds like a very useful process. However, this is not a process that's open to public scrutiny and it's not done under the auspices of the WHO or other international organizations that represent the interests of governments. So we think it would be very useful for this committee to actually explore this in some depth.

    We are concerned because of our similar issues. One is that there is no gendered analysis or requirement in these processes right now, and it looks like Canada is starting to adapt these recommendations in Canada without any public scrutiny or debate or discussion.

    I'll leave it to you. I've left you with a small booklet that goes into this in some detail. We actually have one of those big-sucker documents if you ever want to read 200 pages on international harmonization of drug approval--on the way home to Ottawa or something like that.

    My last point is really about consumer health information and direct-to-consumer advertising. We are in the business of trying to provide credible health information to the public, and we think it's of critical importance. Our brief to the Romanow commission stressed that it's very frustrating to believe that you want to empower Canadians when you do not give them access to good, intelligent information about it. Canadians are overwhelmed right now by the promotion materials of the United States.

    I have circulated a little graph coming out of the Canadian Medical Association Journal this month on the cost of promotional advertising in the United States. It's close to $21 billion, so you can do the math here. And yet, I would argue, advertising is not information now any more than it was five years ago; it's just getting worse. We need to develop a coherent strategy on providing consumer health information on drugs and devices to the public in the context of managing the disease, because it's not just about drugs.

    I'd like to observe that in fact, from my perspective, DTCA looks like information in the same way that sand looks like water to a thirsty man. This is not a panacea to our problem, and it's a real one. We've never invested in it, and we need to.

    My last comment is around a compensation fund. This is a new idea, I suspect. As someone who has worked with people who have been hurt by drugs and devices, who have tried to use the criminal courts and class action suits to cover compensation for their injuries, whether those were fraudulently experienced or not--that is, the company knew there was something terribly wrong and did nothing about it, or it's a legitimate error coming from putting something on the market perhaps a little prematurely--Canadians are being put out-of-pocket in many ways as a result of exposure to these things. I think we have a right and a duty to think of a mechanism to address this, because these things are happening and will continue to happen.

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    Finally, speaking as an organizer at Women's Health Clinic, the amount of energy I have to put into spending time helping the Canadian public understand some of these issues is enormous. There are very few of us out there, talking to the public about these issues. For example, the reason that there may have not been consumers up here talking about Internet pharmacies and why that's helpful for them is that there's a lack of infrastructure in the voluntary sector to address these issues.

    I'll leave it at that. Thank you very much.

    The Chair: Thank you very much, Ms. Boscoe.

    We'll move to the second portion of our meeting, and Mr. Merrifield will begin the questioning.

    Mr. Rob Merrifield: Thank you for coming in. I wasn't going to comment on it, but you waded into it, so I have to.

    Forgive me if we're not all as excited about Bill C-13 as you seem to be. This is a piece of legislation that we worked very, very hard on for two years, and the piece of legislation that's before the House does not reflect the view of this committee when it came to the actual recommendations that we felt we put forward in a very non-partisan way. Nonetheless, it's proceeding, and hopefully we can use some sanity as we move ahead with that piece of legislation, or hopefully make a new one that's better.

    So that's one thing, and the other thing you waded into is the Internet issue. You're saying that it's there to help those in the United States who cannot afford the more expensive drugs in the United States...and your passionate plea for that. I wonder how you square that with the fact that right now we have a challenge in our wheat, with the countervail or duty on our wheat. The claim is that it's subsidized through the Canadian Wheat Board. We have the softwood lumber with the 27% countervail in tariffs. We have the threats of steel and other products going into the market, to the United States, that they are saying we are subsidizing.

    Now, why would you not think that they look at our drugs, through our patent law and price review board, as a direct subsidy in the sense of artificially lowering the price of those pharmaceuticals? Do you not think that challenge would raise the price of our drugs rather than force lower ones south of the border?

    Ms. Madeline Boscoe: I believe--and I'm going to say “believe” because I'm not an expert in this--the way our drug price review board works is that it makes an assessment of what it actually costs to produce the drug and develop it. It's not necessarily related to the generics. It's actually the cost of the same drug--literally the same drug--in Canada and the United States by the same manufacturer, the same stuff, the same materials. The name on the label might be the same...but it comes from the same source. It's just that we have a review board that limits what they can--

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    Mr. Rob Merrifield: And they'll say that you're doing it on a dollar valued less 30%, so in essence your buying power and the competition between the two countries is there, and then you're flooding that into another market. Our challenge is that it's going to compromise cheaper product for Canadians. Under the patent law that you just said we should throw out and review...but that's the one that has given us the cheaper brand name products. The generics, you say, we should maybe put under the price review board, but generics are not part of patent law, and they're much higher than in the United States.

    It's a very difficult thing. It's not as simple as, “Just throw it out.” It's a very complex issue.

    Ms. Madeline Boscoe: No, I think Mr. Romanow--and I agree--called for a review of the Patent Act, which I think is about to take place. The issue for the industry was a 20-year patent on the assumption that this amount of money would be invested into research in Canada. The kind of research we're getting into in Canada right now, I would argue, is not quite robust enough. It's very much on the clinical trial. There's very little on actually comparative studies or post-marketing surveillance.

    For example, in a review where one would look at that, it might be useful to put those issues on the table and address that.

    Mr. Rob Merrifield: Sure, I understand where you're going on the research dollars: Are they going to actual research or to studies? I think that's what you're saying. Fair enough, if you want to look at that in our patent law, but to just throw patent law out and say it should be repealed, without recognizing that this is the reason we have the cheap products and actually give us the dilemma of the Internet problem and so on.... So it's not really a dilemma but actually an advantage we have here in Canada because of patent law.

    At any rate, that's a little bit off the subject you came to talk to us about, but I just wanted to make those comments to you.

    I want to go back to non-status Indians, and I would just make these comments. I'm not sure that what you're asking for is really in our jurisdiction at all with regard to whether you should have a card or not. And that's really what you're coming here saying, that you can't afford these drugs because you don't have a treaty card. Really, we're looking at the health and safety and actually more on the addiction to prescription medication side. I know that the native population is victimized very much so because of that problem. Whether you get drugs under the card or not, it's still a significant problem for you, but I don't think it's in the purview of this committee to really deal with whether you should be part of the drug plan, say, of the government as a treaty Indian.

    Maybe I'm missing the mark here, in which case perhaps you could help me with that.

    Grand Chief Andrew Kirkness: The status Indian gets drugs free of charge. The non-status Indian doesn't get any. All I'm saying is that we're making a recommendation that they be able to be treated the same. After all, they're all Indians. The only difference is that one guy has a card and he's treaty, and the other guy doesn't have it for some reason or another. I gave you the attachment outlining the reasons for their being in that situation. There are 18 points.

    I mean, I was given this, but I can think of a lot more people who have lost their status. All I'm saying is that we make certain recommendations that these people be treated the same.

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    Mr. Rob Merrifield: Yes, but you have to understand that it will be the same thing with the entire population. They're going to be coming saying, “Why aren't we treated the same?” We get that all the time. But I just don't think it's something we can deal with.

    Nonetheless, I'll read your recommendations and read your information to find out exactly why you're in that situation and follow through from there.

    Those are my comments.

    Grand Chief Andrew Kirkness: If you want to know why we're saying this, we have a different... Non-Indians are different from Indians. If you look at the Constitution Act, it states in there that we have a special status with the Crown. I mean, it's right there in the rights listed of the aboriginal peoples of Canada.

    That's all we're saying, that we'd like to see some kind of a recommendation or have something said on that. Now, maybe the battle is over here. You see, a lot of these people are trying to get their status; they're Indians, but they can't seem to get the proper information to make that connection. In terms of their ancestry there may be, for some reason, no documents. For instance, they'll ask, “My father was a full Indian, so why can't I get that same status?” That's where the problem is, in a sense, and all we're saying is, okay, make these recommendations.

    I mean, the committee, from my understanding, is going around asking, “What are some of the problems?”, and I presume that's what you're here for. I don't think you're here just for the fun of it. We're just making that recommendation. If you choose to say something on it when you make your report, that would be up to you.

    The Chair: Thank you, Mr. Kirkness, and thank you, Mr. Merrifield.

    Next we'll have Mr. Thompson.

    Mr. Greg Thompson: Thank you very much, Madam Chair.

    I'm just sorting through all this paper here, trying to figure out all these names. I think I'm overloaded today with paper.

    Ms. Boscoe, I was interested in your reference to Americans buying drugs over the Internet. Just for clarification, the cost of drugs in Canada as compared to the United States has nothing to do with the price.... The Patented Medicines Prices Review Board has nothing to do with the cost of manufacturing drugs. Basically, we have established a model where the average price in seven industrialized countries, most of them in Europe, drives our price, and then it's limited to inflation factors in terms of future increases in the price. It has nothing to do with the cost of the production of that medication either in Canada or the United States.

    What I would suggest is that some of the people that you represent, your constituency, if you will, of women, particularly disadvantaged women, and I presume rural women are included in your mandate, are not being well served by that. They're not being well served by that because we heard testimony today that we have a shortage of skilled pharmacists that are dedicating themselves to the American market.

    I understand the empathy, and I understand your concern, because I have relatives in the United States and I know they're held hostage by their system of regulated or unregulated drug prices. I agree totally with you. Unfortunately, Canada has only one-tenth of the population of the United States, and we have 300 million people scrambling for cheaper drugs. Unfortunately, some of our citizens are suffering because of that, not only in terms of shortages of pharmacists but also doctors writing prescriptions in absentia, if you will, which is wrong, completely wrong. There's some evidence that it's in fact starting to drive up the price of drugs in Canada. But we're losing that critical element, and that is the pharmacists who provide very factual and detailed information to people that you and I both represent. So I want to make that point.

    I know that you were sort of freelancing beyond your paper for a little bit when you introduced that. We really appreciate your coming and the work you do with your people, but I just wanted to put that on the record, as it might be helpful to you and all of us.

    It's particularly nice to see your young daughter with you, because it's a real treat to have people younger than we are at the table. They're the future, and it's such a learning experience. When I was a young person, I was fascinated by politics and how government works. I always dreamed of going to Parliament, and I had to wait until I was in my thirties or forties before I arrived.

    A voice: It sounds like a nightmare.

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    Mr. Greg Thompson: It does, yes.

    So it's nice to see you bringing your young daughter out here.

    I'm often reminded of John Diefenbaker, who said when he went into the House of Commons he was always kind of scratching his head, amazed at how he got there. After about 30 days of watching all the other characters, he was trying to figure out how they got there.

    Voices: Oh, oh!

    Mr. Greg Thompson: That's just a bit of humour.

    On the information in your testimony, I'm impressed by the work you've done. I'm going to take it home for future reading.

    Now, I don't want to pass up the opportunity, Madam Chair, to talk to our Métis group here today and understand their concern--

    The Chair: They're not Métis.

Right.

    Mr. Greg Thompson: Right. Why did I say “Métis”? Am I looking at the wrong paper...? I am. Excuse me for that.

    Mr. Kirkness, I was taken by your presentation in terms of the affordability of drugs and the difficulty that imposes on your community. Again, anything that we could do to help I'm sure we will, so if there's one message we could take back to the Minister of Indian Affairs, what would it be?

    Grand Chief Andrew Kirkness: Well, I guess you could tell him to recognize Indians as Indians.

    A few years ago I was a non-status Indian, but now I'm a status Indian. I presume you've all heard about Bill C-31, when in the court case it came out that a lot of the women who lost status because they married non-Indians lost their treaty. On the other side, when a white woman married an Indian, she became treaty. I mean, it was really crazy, it was absolutely crazy. Now that they put that in order, we have a lot of these Indians caught out there. They can't get their treaty number.

    Mr. Greg Thompson: What do you think we have to do to find a way or solution around that? You mention the number of your people who don't have income, the 90% not working, and the hardships that would bring in terms of their medical health. We know that the diabetes issue is just one example of that, but it's a huge problem.

    Madam Chair, I'll turn it over to you so that Mr. Dromisky will have his chance.

    Again, if there's any information you can provide to us additionally to what you have, we'll do whatever we can. I'm not on the aboriginal affairs committee, so anything you provide to me would be very helpful.

    Thank you.

    The Chair: Thank you, Mr. Thompson.

    Mr. Dromisky.

    Mr. Stan Dromisky: Thank you very much, Madam Chairperson.

    I'd like to talk about the non-status natives who are in Winnipeg, for instance. There are thousands of native people living in Winnipeg at the present time. Is a very large percentage of them non-status, or do they still have their status?

    Grand Chief Andrew Kirkness: I believe approximately 10,000 Indians in Manitoba, or close to that, got their treaty status back. I don't know how many still.... You know, you fill out a form and you send it down to the reinstatement unit. They keep asking for more information: “We can't make the connection.”

    But there are lots of them. And don't get mixed up here; Métis are Métis, and Indians are Indians, period, whether they're status or non-status. These are Indians. Now, don't ask me how you'd describe a Métis, because I don't know anything about it.

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    Mr. Stan Dromisky: There are many reserves in Manitoba, just as there are in northwestern Ontario and other parts of Canada. When a native person leaves a reserve and comes to live in Winnipeg, do they become non-status?

    Grand Chief Andrew Kirkness: No, they're off-reserve Indian. You see, that's the other catch.

    Mr. Stan Dromisky: So they're off-reserve. Now, we know that for every person registered in a band of, say, 1,000, each one gets an allocation of so much money that comes into the chief and council to spend it on whatever they have to spend it on. When someone leaves that reserve and there's no longer 1,000 people there, does the money follow the people who leave, or is the money decreased?

    Grand Chief Andrew Kirkness: No, the money stays there. I'm a member of a band, and I've not been there for a number of years. Whatever money goes in there, I guess it stays there. I don't get any benefit out of it because I'm off-reserve. On this off-reserve thing, we're kind of caught between a rock and a hard place.

    What happens is that, even for funding, you go to the government, say to the provincial government, which says that you're the responsibility of the federal Department of Indian Affairs. So you go to them for funding or something and they say, yes, but you're an off-reserve Indian.

    So where the hell do you go? It's difficult. Right now we're working on diabetes--

    Mr. Stan Dromisky: For those natives who left the reserve and are in Winnipeg, and the money is going to the reserve, wouldn't the chief and council be responsible for covering the cost of those people who are living in Winnipeg as far as their drugs are concerned?

    Grand Chief Andrew Kirkness: Yes.

    Mr. Stan Dromisky: So they have no problem, then? They should be able to get their drugs?

    Grand Chief Andrew Kirkness: Not too much trouble there, no--except the non-status, those are the ones.

    Mr. Stan Dromisky: Okay. I have that clear in my mind. I see the problem.

    Now, is it the problem of non-status Indians here in Manitoba because certain treaties have not yet been sort of recognized or ratified, or they're going through negotiations pertaining to certain treaties?

    Grand Chief Andrew Kirkness: No, not necessarily. The thing is, for a long time what was happening was that people who were off-reserve.... I remember that my dad...that's how I was out. He lived in the community away from the reserve and they were telling him that to get the benefits, he had to stay over there. In other words, he was fenced in. He lived in a community about 25 miles out. What happened was that he didn't speak English, and he didn't understand. In those days they used to have Indian agents. He got a form and it enfranchised him. Anybody in that family under 21 was automatically enfranchised. That's what happened to me and one of my brothers.

    As you say, there are many ways in which Indians lost their status.

    Mr. Stan Dromisky: I know there were natives from Manitoba who went to war, and when they joined up, they couldn't join up until they signed the paper and got rid of their status category. They could not be status Indians--

    Grand Chief Andrew Kirkness: What would you say was the reason for that?

    Mr. Stan Dromisky: Oh, I don't want to go into that, because you know why.

    So these people have come back and they have not been able to reclaim their status as--

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    Grand Chief Andrew Kirkness: Well, they should be able to under Bill C-31.

    Mr. Stan Dromisky: I know, but I'm talking about all those years that have gone by where they went to fight, and many of them died, and they gave up their status because they wanted to do the right thing for their own people and for the rest of the country and whatever. So there you have a situation where these people were penalized for many, many years. Even Bill C-31 is not helping some of them.

    Grand Chief Andrew Kirkness: No, it's still discriminatory.

    Vice-Chief Glenn McIvor (Indian Council of First Nations of Manitoba): Subsections 6(1) and (2) of the Indian Act are discriminatory. For example, if I were to marry a non-status woman, a white woman, for example, being an Indian male I can pass my status under subsection 6(1). But if I were a status under subsection 6(2), marrying a white woman, then I wouldn't be able to pass my status to my children. Among Indians, that's where the cut-off is.

    So we would like to see as Indian people, off-reserve or regardless, if you're an Indian you should be recognized as an Indian and not anything else, like in subsection 6(1) or (2). Categorizing your people is not a good thing to do in Canada.

    Mr. Stan Dromisky: Yes, we heard that in Edmonton, that an Indian is an Indian is an Indian. That's absolutely clear.

    Vice-Chief Glenn McIvor: For example, in my family I have a granddaughter who can't be Indian, but I'm a treaty Indian. My kids had the subsection 6(2) status because my wife wasn't eligible for status. That discrimination shouldn't be there. An Indian should be an Indian.

    In terms of drug costs, the other thing I wanted to bring up was that we've had a meeting in the past...and other organizations in Winnipeg had meetings in Manitoba regarding discontinuation of the delivery of drugs to U.S. For example, if you lived in Wabowden we'd have to ship drugs from here to you. We're trying to discontinue that. The primary sickness among first nations people is diabetes, and the cost of that is $1,000 to $2,000 per month. If you start paying for your own costs when you don't have a job, it's pretty hard when you have to pay a $300 drug bill when it comes in, to try to receive the drugs.

    I guess that's the main concern we have about drugs, the cost to deliver them to the reserve. They tried that up north and we said, no, we're recognized under section 35 of the Constitution and we want these services delivered to us. As I said, diabetes is the primary sickness among first nations.

    We did have a program with MOAUIPP, from Ottawa, a diabetes initiative. We had a contract with them under Ottawa and the Indian Council of First Nations of Manitoba, for 2003-04. We're having problems with them. We're trying to get funding, trying to continue the project, trying to go to the communities. Maybe we can eliminate some of the costs if we can educate them ahead of time on exercising, trying to work against diabetes, but it's hard when you don't have funds to do that.

    That's where the costs of shipment of diabetes...because people are not educated about this stuff. They're not being given information ahead of time to try to work against it. The younger generation especially should have that information. They should be able to look after themselves without having to go through all the complications of what diabetes can be, as well. So it's pretty hectic.

    The Chair: Thank you, Mr. McIvor, and thank you, Mr. Dromisky.

    I have a question. If a non-status Indian is unemployed--and as you said, in your community about 90% are--it means they don't have a card to give them access to the pharmaceuticals they may need. But if they're non-status, do they not have access to social assistance, and if they're accepted as recipients of social assistance, does that not give them access to free prescription drugs?

    Grand Chief Andrew Kirkness: It should be covered, I guess, if they're on welfare--

    The Chair: Yes, that's what I mean.

    Grand Chief Andrew Kirkness: --but this welfare system is an off and on thing. It's difficult; some people work part time, because those are the only jobs they have, such as fishing.

    The Chair: Oh, they're seasonal workers or they're part-time workers. So they're not totally unemployed.

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    Grand Chief Andrew Kirkness: Sometimes they work for only three months. They get cut off the minute they start to make a few dollars. Nevertheless, they have a great deal of problems with drugs regardless of....

    The Chair: So essentially it's a matter of poverty--working sometimes, not working other times, and then getting a little bit of part-time work. You're not totally unemployed, therefore you can't get social assistance, but you don't have a card.

    Okay. So it's something like Ms. Boscoe's clientele. We're talking about lack of access to pharmaceuticals, to prescription drugs, due to economic conditions, and it would be the same thing with your clientele.

    I have just one comment to Madeline Boscoe. I'm really glad you came today, because I work single-handedly trying to enlighten Mr. Merrifield about feminist theory.

    Ms. Madeline Boscoe: It's working.

    The Chair: His homework is going to be to memorize all of the words in your pamphlets over the weekend. And we're going to try to keep him out of Ottawa on Friday when Bill C-13 is up.

    Ms. Madeline Boscoe: I did want to say that is absolutely true around this issue of unemployment insurance and welfare and working in the employed sector. When we did our research on our women, income, and poverty project--again, it's quite a huge document--one of the things we found when we did focus groups with women, and it would be the same for working men, is that in the movement from welfare, where they did have some minimal coverage, although not maybe as robust as it should be, to working, the gap between minimum wage and the benefits that those entry level jobs had and welfare meant that in fact it was better for them to stay on welfare because they lost income.

    That, to me, is another issue around getting a handle on a pharmacare program where we don't have some of the crazy shenanigans that end up going down.

    The Chair: Mr. McIvor wishes to say something else.

    Vice-Chief Glenn McIvor: I guess the other hard part of it is that if, for example, you come down with a sickness, or if you're off the job for a couple of months and you don't have any options, when you do get your paycheque all of it goes to medication. You don't have anything to go to cost of living, food, stuff like that. That makes it hard, especially if you have a bad period. I listen to the radio a lot of times, and you hear about people going through cancer treatment for six months, and they don't have any money to buy medication. A lot of people, because they lack that financial help, just go on and they pass away. There should be no need for that.

    I was in a situation like that one time, but I'm not going to go through that here. It's bad when people can't help themselves.

    The Chair: Mr. Thompson, do you have another comment?

    Mr. Greg Thompson: I had a short question for our youngest witness. If we could put the youngest witness' name into the record, Madam Chair, it would be helpful.

    The Chair: Can you give us your name?

    Kay Schwartzman (As Individual): Katie Schwartzman. My full name is Katherine.

    Ms. Madeline Boscoe: Katie was hoping you were going to ask us a question about emergency contraception.

    Mr. Greg Thompson: Okay.

    I have a question for the youngest witness, Madam Chair, and I think this might sum up the entire sense of the meeting, the feeling of all the meetings we've had. It will be an answer that most politicians don't give, a yes or no answer--or hopefully it'll be yes or no.

    Do you think the price of drugs in Canada should be lower to help all sick people? Yes or no.

    Ms. Kay Schwartzman: Yes, actually, because they want to keep the population up so we can keep our country running. And if they want to help people get better, why have the price of prescription drugs so high, or any other drug for that matter?

    Mr. Greg Thompson: Thank you.

    That's a pretty darn good answer, I'd have to say, Madam Chair. I think that sums up a whole week's work, don't you?

    The Chair: On behalf of the members of Parliament, I want to thank you very much for coming down from The Pas and for coming in from your very big responsibilities at the Women's Health Centre, presenting your ideas to us and putting them on the public record, which they now are. We will be reviewing what you've said as we move forward and try to develop the framework and the meat around the framework of a report. Thank you very much for your time and your effort.

    Before we adjourn, ladies and gentlemen, I would like to thank the interpreters who have followed us in our western tour, and our technicians, and our researcher and our clerk. I think we should give them a little hand.

    Some hon. members: Hear! Hear!

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    The Chair: With that, I will adjourn these hearings and look forward to seeing you all in Ottawa.

    The meeting is adjourned.