HEAL Committee Meeting

STANDING COMMITTEE ON HEALTH

COMITÉ PERMANENT DE LA SANTÉ

EVIDENCE

[Recorded by Electronic Apparatus]

Wednesday, October 17, 2001

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[English]

The Chair (Ms. Bonnie Brown (Oakville, Lib.)): Good afternoon, ladies and gentlemen. I'd like to welcome you to this meeting of the health committee. And on your behalf, I welcome in a very special way our illustrious international guest, Dr. Gro Harlem Brundtland.

Dr. Brundtland is a medical doctor and a master of public health. In addition to all her service in the health care system of her country, for more than twenty years she was in public office, ten of them as prime minister.

Dr. Brundtland stepped down as Prime Minister of Norway in October 1996 and put in a bid to become director general of the World Health Organization. She was successful, and her many skills as a doctor, politician, activist, and manager have come together to the benefit of that organization. In January 1998 she was nominated to that position, and in May 1998 the assembly elected her to her post.

Some of us had the privilege of seeing Dr. Brundtland in action when we attended the last assembly of that organization, last May or June. It is a great delight to welcome her to Canada.

Dr. Brundtland, welcome. I invite you to address us.

Dr. Gro Harlem Brundtland (Director General, World Health Organization): Thank you very much indeed. I am glad to be here. In fact, this is my last meeting in these two days in Canada, meeting with parliamentarians. I really enjoy that opportunity. It is an honour indeed to visit the country and the Standing Committee on Health.

Since 1998, when I became director general, I have seen first-hand the very important role that Canada plays in health and equity. Yesterday I met with a number of Canadian cabinet ministers, government officials, and representatives from non-governmental organizations. Over and over again, we spoke of the need to invest in global public health, recognizing that putting resources into health is an investment in our common future, sustainable development, and poverty eradication, in times of recession and uncertainty.

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The work of WHO's commission on macro-economics and health again confirms the strong link between ill health and poverty, particularly among the 2.5 billion people who live on less than $2 a day. I established this independent commission, headed by Harvard professor Jeffrey Sachs, because I knew from my experience as a former prime minister the importance of demonstrating the economic link between investing in health and development. We know that good health is a prerequisite for earning, learning, and taking advantage of opportunities to emerge from poverty, and that is the objective of the work we do.

Yesterday I had very constructive discussions with the highest levels of Canadian policy-makers and decision-makers about the growing political commitment to action for health equity, particularly in the areas of infectious diseases, non-communicable diseases, and illnesses of pregnancy and childhood. We also discussed other health-related issues that are important to Canadians, including disease surveillance, food safety and security, and bioethics.

Canada has shown its dedication to the efficient use of funds to achieve results in the health field. Canada's multilateral focus has led to the rollback of the diseases of poverty, including HIV-AIDS, tuberculosis, and malaria, and to better nutrition and child health. We have also seen Canada's active role in the United Nations General Assembly special session on HIV-AIDS, Canada's initial vital support for the global TB drug facility, and your generous $150 million Canadian pledge to the new global AIDS and health fund.

Secretary General Kofi Annan launched the fund when I was with him in Abuja, Nigeria, this past April. A transitional working group is currently establishing the fund in Brussels. The objective of this fund is to get vital and proven interventions, particularly in the area of HIV-AIDS, TB, and malaria, to those people who so desperately need them. It will no longer be business as usual.

The fund has already received pledges of $1.4 billion U.S., before even being established, and this is only the start. With the commitment and support of G-7 countries, including Canada, private donors and others, we hope this fund will be a source of new investment in health care and poverty eradication, to the tune of $7 billion to $9 billion per year.

We also see in Canada and around the world unprecedented joint action between government, civil society, NGOs, researchers, the private sector, and the international community, widely speaking. This joint action has allowed us to establish the best strategies for tackling HIV-AIDS, to seek public involvement in the implementation of these strategies, and to scale up action to implement these strategies, with special attention to the monitoring of progress.

One exceptional example of productive and life-saving public-private collaboration is the Global Alliance for Vaccines and Immunization, GAVI. Canada's commitment to GAVI and to improving the health and well-being of children through immunization is noteworthy. The Canadian International Development Agency was the first development agency present at the early meeting that led to the launch of this new alliance back in 1999. This commitment is ongoing, and Minister Maria Minna made a very generous pledge to the vaccine fund during the GAVI board meeting taking place here in Ottawa today.

Through such interactions as this, we have seen breakthroughs in research, for instance, in the areas of life-saving medicines, increased access, and slashing of prices for many essential drugs, including those that combat TB and prevent mother-to-child transmission of HIV. Canada has also played a key role in WHO's tobacco-free initiative and in the ongoing work on the framework convention for tobacco control. With your work to reduce tobacco consumption and strictly regulate use and advertising, your country serves as a role model to the entire world.

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Canada plays a key role in the global surveillance and response network, a network of 72 organizations that together monitor and respond to disease and illness outbreaks. This network already in existence—and we're happy that this is so—allows us to identify and respond rapidly to infectious disease outbreaks such as the recent outbreak of yellow fever in Côte d'Ivoire, as well as to deliberate attacks such as we are now experiencing with anthrax.

Finally—or nearly—another priority for WHO is mental health. This month we issued the World Health Report 2001, on mental health. Our aim is the breakdown of stigma and discrimination associated with mental and brain disorders, disorders that account for almost one-third of the global burden of disease.

I very much look forward also to next year's G-8 summit. Your prime minister is dedicated to focusing the work of this summit on the health issues of one of the poorest parts of the world, Africa.

Canada and the WHO have pledged to work together to address these vital health equity issues. That is one more example of Canada's recognition that investment in health is investment in development.

Thank you very much.

The Chair: Thank you, Dr. Brundtland.

I know Dr. Brundtland is happy to answer questions, so we'll begin with Mr. Merrifield.

Mr. Rob Merrifield (Yellowhead, Canadian Alliance): Thank you very much for coming, and I certainly appreciate your taking the time to share with us this afternoon.

I was actually privileged to be in Geneva and was struck at how small the world has become, particularly when you deal with problems such as HIV, which afflicts, I believe, every nation in the world. I sit back to discern some of the problems that countries such as some in Africa are going through with this affliction in its worst ways. Can you give us your wisdom with regard to tackling it even at home? We see it as a somewhat distant problem, and yet it will probably affect each and every one of us in a dramatic way in North America. Can you tell us your expertise on what you see happening with HIV in North America?

Dr. Gro Harlem Brundtland: If we take North America and Europe, and New Zealand and Australia—frankly, the OECD countries—we were able at a relatively early stage to start containing and dealing with the epidemic, by that means never getting to the kinds of incidence and prevalence levels that we see in so many countries today.

It started, as you know, mostly in the homosexual communities. As one started to deal with the issue, it had a stigma, which was also linked with that. In our countries in the OECD region it started to spread into the heterosexual general population. Of course this is what is now happening in Africa, in Asia, in eastern Europe—in all of the places where there is a staggering increase—because the capacity and the background with which to deal with a public health threat like this has not been there, the way it has been in Canada, the U.S., or Europe.

That is the tragedy, because it is therefore taking a big toll in human and economic terms in countries that are already poor and are losing the young parts of even their educated populations: teachers, nurses, doctors.

Frankly, in our part of the world, even before the new drugs came, which now even better contain the situation, there was a reasonable degree of ability to tackle and prevent the spread of the disease.

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Mr. Rob Merrifield: Okay, thanks. If I put that in a nutshell, you're suggesting that because of the education we have, there's much less impact in North America looking five, ten, fifteen, or twenty years into the future.

Dr. Gro Harlem Brundtland: It's because of the education, the ability to deal with a societal issue in a systemic way, and because we have institutions, public health authorities, and systems in place that make it possible. But of course the education level is essential.

Mr. Rob Merrifield: May I have one more quick—

The Chair: I should warn you that Dr. Brundtland herself has to leave at four o'clock. She is going to leave behind Dr. David Nabarro, also from the World Health Organization, to continue answering questions, but I wonder if we could just have a few more people ask questions of Dr. Brundtland.

I'll go to Dr. Lunney.

Mr. James Lunney (Nanaimo—Alberni, Canadian Alliance): Thank you, Madam Chair.

Just on the AIDS question—and then I'd like to go another way with a comment—we hear staggering figures about 25 million people infected in Africa. Is that a figure that's realistic to you, Dr. Brundtland?

Dr. Gro Harlem Brundtland: Yes, it's that kind of dimension.

Mr. James Lunney: Yes, exactly.

I'd like to go another way. You mentioned the tobacco-free initiative of the WHO. In our country there's a lot of debate right now where we're talking about tobacco concerns. But there's also debate on another concern, with the decriminalization and legalization debate going on regarding marijuana. I notice the irony wasn't lost on some doctors, and I wonder if you'd comment on this.

At the same time that we're combatting tobacco and trying to reduce the risk of smoking, it seems there's a bit of encouragement for people who are smoking marijuana. The long-term effects of smoking marijuana, of course, have not been studied—certainly not in this country. I'm not sure they have been elsewhere. It seems to me it's not likely that the long-term effects of smoking marijuana will be less than those of smoking tobacco in terms of adverse consequences to health. I wondered if you had any expertise or comments to share with us in that realm.

Dr. Gro Harlem Brundtland: Let make make two comments. In my former life as the Prime Minister of Norway and a politician in Norway, we had absolutely no doubt in our minds, in the Norwegian Parliament or government, that we were not going to be in any way liberal with regard to marijuana. As I come to the World Health Organization, this is the dominating scientific basis, as it is also with other addictive substances. Belonging to the category of narcotics, it is on the list that we don't advise for use. It is clear in our work on this that it belongs there.

However, there are countries that are member states of the World Health Organization that have a different opinion, because they look upon marijuana as less dangerous than some other alternatives, such as heroin and other drugs that we know are worse, if you try to list the danger level. There is a debate where a minority of member states is asking those questions and making policies that are different. Switzerland is one example, the Netherlands another. That is what I can say.

Mr. James Lunney: Thank you.

The Chair: Thank you, Dr. Lunney.

Ms. Sgro.

Ms. Judy Sgro (York West, Lib.): Thank you very much, Dr. Brundtland, for being here with us.

I'll try to be very quick with my questions. On the AIDS issue, are we getting our drugs now fast enough and at a lower cost? There's been a big issue about lowering the cost of the AIDS drugs especially. If we don't deal with the 25 million in Africa and help them, we're in an enormous problem.

The second question is this. I'm pleased to see that the WHO is making mental health another important issue. We're trying to put it on a higher level here in our own committee and in our own country. Where do you see it going in your role at the WHO in mental health?

Dr. Gro Harlem Brundtland: Let me start on the mental health question. I feel that it really was necessary to increase awareness globally about mental health. For some reason, the conditions linked with mental illness and brain disorders had not been given an equal attention to physical illness for decades. In the last century this was certainly the case. Even in the most advanced countries, I think this is still the case.

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There is still some stigma linked with mental illness. Gradually, as more modern treatment became available and it was more treatable earlier and with much better results than ever before, it even happened in our countries, in the OECD area, that it was still in the dark. The patients and their families were not given a parallel opportunity to people with physical illness.

That was in our part of the world. When you look at the developing countries, obviously the situation is much worse. There is the need to raise awareness and see, at the community level, primary health care action picking up people at an early stage, so they can get simple treatment before they become long-term chronically disadvantaged people with disabilities for life, sometimes. There is a big unmet need, and there are many interventions that are not being used.

On the question of HIV drugs, we have to be aware that although, in a combination of United Nations activities—WHO on AIDS, the Secretary General—and public opinion pressure, the prices have gone down to less than 10% of what they were 10 or 15 months ago, we still have a situation where that level is far beyond reach for the poorest countries. In fact, although there have been improvements in the price level, without the new health fund and without a complete scaling up of action to reach patients in poor countries, there is no way to bridge the gap. What is available is not accessible to so many patients, because of the high price level.

We have a challenge. This is one reason why the new health fund will also have to deal with bridging that gap, pushing the prices down further with generic competition and other methods that can help us on that. It will also help fund some of the remaining gap, because otherwise these drugs will remain out of reach for the poorest countries.

The Chair: Thank you.

Ms. Wasylycia-Leis.

Ms. Judy Wasylycia-Leis (Winnipeg North Centre, NDP): Thank you, Madam Chairperson.

I'm very honoured, Dr. Brundtland, to have you here. You probably know you're a role model for many women in politics around the world, and certainly here in Canada. We're very glad you're here.

I have two questions. One pertains, of course, to bioterrorism and the World Health Organization's statement that came out on September 24, I believe, talking about the need for a coordinated strategy worldwide to deal with chemical and biological warfare.

First, where are we at in the process of trying to achieve such coordination, and what advice would you have for Canada, which has acknowledged that we're at the very beginning stages of an anti-bioterrorist strategy?

My second issue has to do with the matter you raised on tobacco control. We've been struggling here in this country, our Minister of Health has been working hard on this issue, but obviously we need to look at it globally.

In terms of the framework of the convention on tobacco control, what can Canada do, in terms of advancing this kind of global treaty, and what advice would you give us as a health committee on being helpful in that regard?

Dr. Gro Harlem Brundtland: Canada has been a role model, through its domestic policies and by being an advocate for that kind of active policy. But it has also been helpful, as we have been preparing the international negotiations, by supporting through secondment and funding some of the tobacco work.

Now we are in the middle of negotiations, and it is important that we continue supporting and working with the countries that are not as lucky as we are in the richer countries. We are able to defend ourselves against marketing. We are trying to close off our populations from this marketing of a deadly product, but the poor countries around the world are getting the effects. That's why we really need this solidarity, and to get the negotiations concluded in a positive way.

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We all have to help the developing countries and tobacco producers find ways of dealing with this, so we can get concrete and good solutions. Canada's role will be important in the coming one and a half or two years, as it becomes difficult to find ways to have reasonable consensus among nations. You can imagine there are strong opposition forces, and the industry itself is working hard to avoid a good framework convention.

On the other question you mentioned, I talked about our surveillance and response network, which has been set up over the years, also with Canada's support. On September 24 we delivered an updated version of a manual from 1970, which dealt with the health aspects of biological and chemical weapons. Luckily, that updated version was under preparation. It was due for publication in November, so we took hold of the manuscript that was going to be published in November and put it on the web, after the attacks of September 11, because of the fear that, as atrocious things like this can happen, some of our other fears could also materialize.

We put it on the web so health officials in governments could get access to it, get the general advice they need to increase preparedness, look at contingency planning, and see whether we in the different countries are prepared to tackle any such threat. I think many countries had not been doing what was really necessary, and we didn't want to lose any time.

I think government ministers in many countries have started to look at the issue, update their own public health communities, and look at how best to deal with it, in case we have such a situation. Then, of course, one week or one and a half weeks ago the anthrax cases started occurring in the U.S. I was happy that we had at least done that to increase the general preparedness, by thinking about what to do in such a situation.

I will be going to New York for what is called the ACC, which is the committee for coordination of UN agency heads, with the Secretary General. Many of the issues, including Afghanistan, anthrax, and so on, will be on the agenda for that meeting, which is why I have to leave now.

David Nabarro is the executive director of my office and will be able to respond on my behalf, if you have further questions.

Thank you very much, indeed.

The Chair: Thank you very much for including us on your busy schedule.

Dr. Gro Harlem Brundtland: Thank you very much.

The Chair: We wish you well on your flight to New York and your meeting there.

With that, I would invite Dr. Nabarro to come to the table. I know we have one more questioner at least, and we may have more.

The next questioner is Dr. Dromisky.

Mr. Stan Dromisky (Thunder Bay—Atikokan, Lib.): Thank you very much, Madam Chair.

In my riding, I've often told my constituents that Canada is not doing as much as I think it should in helping the more unfortunate people throughout the world. But every time I speak publicly regarding our contributions, people always make statements of this nature. Many countries are receiving funds from the United States, the European Union countries and Canada, but a high percentage of the dollars don't go for buying medicine and all the other necessary services that are required. A lot of it ends up in private bank accounts in Switzerland and in the back pockets of corrupt officials and bureaucrats throughout the entire system—not just government agents, but people who are working in the system, in the villages and towns and so forth.

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It's very difficult for me to defend my position when those kinds of statements are being made, in light of so much information that is being shared throughout the world about the corruption that is quite prevalent in quite a few of these countries we're sending money to.

I would like a response from you, Doctor, regarding what WHO or any other agency within the United Nations is doing.

Dr. David Nabarro (Executive Director, World Health Organization): Thank you very much indeed.

I think I will just go straight in and answer as follows. I've been a director of what was called human development in the British government overseas development administration, like your Canadian CIDA, for 10 years before I joined WHO, and before that I spent 15 years working for Save the Children Fund. I have virtually never encountered corruption in relation to development assistance, whether through official bilateral assistance, non-governmental organizations, or the United Nations system.

I see, on the other hand, the extraordinary efficiency with which very limited resources are used. I've been working in health systems that try to provide basic care for people with an average of around $5 to $10 U.S. per person per year spent on health care. That is a hundred times less than what is spent in the U.K. And despite that and despite the very large range of problems that are faced, I see people providing heroic health care, often on no or very low salaries. For example, in Nepal, where I worked as a district medical officer for three years, nurses would earn about enough money to feed their families for 15 days in each month. The rest of the time, they had to either grow food or have second jobs.

I think the World Health Organization is a remarkably efficient deliverer of development assistance. One of my jobs is to be in charge of studying how we spend our money. I'm also in charge of all checks for fraud or any other kind of misdemeanour. I calculate that currently, our administrative costs as a percentage of our total transfer of resources run at about 13%, which is a very low overhead when you consider what we're trying to deliver. In international health care, we are much more rigorous about identifying the most effective treatments for the conditions that are being diagnosed, because we have no luxury, no limit, no space to use high-cost medicines or ineffective therapies. We probably, in WHO, put much more emphasis on the following of standard protocols for prevention and treatment of illness than most OECD nations.

I don't know how to stop people referring to development assistance as money-wasting or corruption. Canada's development assistance is some of the best-managed I've ever seen, and I would be very happy to furnish you with chapter and verse on that, because I think Canada's CIDA does Canadian citizens proud.

Mr. Stan Dromisky: It's good to hear that. Thank you very much.

The Chair: Thank you.

[Translation]

Ms. Thibeault.

Ms. Yolande Thibeault (Saint-Lambert, Lib.): Thank you, Madam Chair.

[English]

The Chair: Just wait a minute.

Ms. Yolande Thibeault: I think we can all speak in English. All right?

[Translation]

An hon. Member: If you wish.

[English]

Ms. Yolande Thibeault: Doctor, I must say I'm very impressed by your commitment to humanitarian causes.

I have one concern that comes to me from somebody in my riding who is very much involved with....

[Translation]

In french, it is Pharmaciens Sans Frontières. Have you heard of it?

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[English]

As a matter of fact, I have the Canadian president of that organization in my riding, a person I know personally, and he tells me that in many instances when they get to a country...for instance, when they were in Bosnia, and Kosovo after that, they got to inspect some medication that had been sent for humanitarian reasons from all over the world, and in many instances either the drugs were not properly labelled and identified or the due date was expired. I wonder if you have any comments on that particular aspect.

Dr. David Nabarro: It's a terrible problem. What happens is when there's a disaster, people imagine that anything they give will be valued. They don't realize that when you have a terrible situation, resources on the ground are scarce, so receiving lots of donations of inappropriate, often unwanted, or old medicines is just unhelpful.

We've issued guidelines now from the World Health Organization on donations of medicines. They apply to donations from companies of nearly-date-expired medicines or inappropriate medicines. They apply to donations from charities or individuals. In all cases we say it's a great idea to give, but give cash or something that can be quickly converted into cash, so the people on the ground who know what to do can do it.

In essence, when you have a disaster you probably need between 50 and 100 different medicines, common medicines, and it's best to buy those from standard suppliers and get them labelled in language that is appropriate for the community. For example, if you have a disaster in Kosovo or Bosnia, have the medicines labelled in the local language with proper materials that show the local staff how to use them.

Pharmaciens Sans Frontières has been a very effective non-governmental organization, like Médecins Sans Frontières, in drawing public attention to these issues. I commend them to all of you as a great organization.

The Chair: Thank you.

I think we'll go back to Mr. Merrifield, and then to Ms. Wasylycia-Leis.

Mr. Rob Merrifield: I'd like to follow up on my earlier question with regard to HIV in Africa. I think we all understand and the world understands how we need to be compassionate and try to deliver cost-effective drugs so that pain will be reduced. That's just our natural bent to be compassionate that way. But I'm a little concerned when so many dollars are going directly to drugs and not to education—and maybe they are; maybe you can help me with this. For me, I see a long-term solution of the problem as much more than curing an illness that is continually inflicted. Wouldn't we be wiser to put considerably more money into education? How do you balance that? Can you explain to me what you're doing?

Dr. David Nabarro: Thank you very much indeed.

First of all, I want to be very precise. There may be 25 million people with HIV infection in Africa, but probably fewer than 100,000 of those are receiving the treatment they need. That's not just anti-retroviral medicines. They also can't get antibiotics for what we call opportunistic infections.

If we were to be in rural Uganda and have HIV, unless we were lucky and lived close to a mission hospital, we wouldn't be getting much care at all.

What we've been promoting, and we're promoting it more strongly now that we have better evidence on its effectiveness, is good prevention: the use of condoms during sex if partners are changing; education that delays the onset of sexual relations for young people and encourages reduced partner change; and efforts to empower women so they're not in a situation where they're forced to be subject to sexual activity against their will. At the same time, we want to be sure health services can provide safe blood and can inject people safely.

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It does work. In Uganda, we have seen HIV incidence rates fall dramatically. That's as a result of a large number of community-based organizations—probably between 500 and 600 organizations in that small country—for the last seven or eight years all following the same basic strategy of community-based education and prevention. They've also provided care for other sexually transmitted infections, and that reduces HIV spread.

We've seen the same good results in Senegal. We've seen pretty good results in much of Kenya, though not all, and excellent results in Thailand. We're beginning to see good results in Cambodia. All these countries are adopting the same approach: prevention first, concentrating on the strategies that we know work, getting everybody doing it, not just the government health services, and measuring the results.

Really, the introduction of care for people who have HIV is just at its very earliest stage, and we would need to be doing that in a way that is properly balanced with the continuation of prevention.

Mr. Rob Merrifield: Thank you.

The Chair: Ms. Wasylycia-Leis.

Ms. Judy Wasylycia-Leis: Thank you.

I'd like to pursue this issue, because it seems to me that we're really not going to be able to deal adequately with the necessary medications to people with HIV and AIDS worldwide, given the numbers you've cited, unless we can actually break this monopoly of brand-name drug companies over the price and access to those drugs.

Maybe this isn't the time to get too political, and maybe you don't want to answer it, but I want to raise that and at least ask you what role Canada should be playing, or what role the WHO is playing with respect to international strategies to deal with pharmaceutical companies and access issues, and what advice you would have for Canada on that front.

The other issue—if I can go back to tobacco for a moment—is that I appreciated Dr. Brundtland's response on the whole issue of the need for the advance of this convention internationally on tobacco control, but we didn't get a chance to discuss the harmful impact of international agreements on dealing with smoking worldwide and the whole pressure for advertising, sale, and marketing of tobacco products globally. Again, I'm not sure if you want to get into that, but I'd love to hear your comments on that whole area as well.

Dr. David Nabarro: Thank you very much indeed.

These are actually very complex issues and ones that take up probably about 15% to 20% of my time and my staff's time. But they could take up a lot of our time, and the chair might wish to shorten the response.

The Chair: The chair doesn't need to save you, Dr. Nabarro; I think we'd all be interested in your views.

Dr. David Nabarro: Thank you. I'm more worried about your time.

Let's start at the top on your question about care for people who have HIV. If you or I have HIV and it's advanced, we need to take, on a continuous basis, a cocktail of medicines, probably two or three times a day—three different kinds of medicine at a minimum. That's a lot of drugs. They're not very nice. They make you feel rotten, and you need to have medical support, nutritional support, and laboratory back-up at a pretty sophisticated level.

Some of the mission hospitals in developing countries can provide that care. Some of the university hospitals in capital cities, like Kenyatta National Hospital in Nairobi, or Mulago Hospital in Uganda, do it very well. But it's a complicated care rationale for HIV at the moment, and I don't think it's going to get easier. So the primary limitation, in our judgment, for people who have HIV in many developing countries is that they need to have a good health system. Once they have the health system, they need to have the medicines.

You're absolutely right: two or three years ago the costs of medicines per year were completely out of the question: $10,000, $15,000, or $20,000 per patient-year. They were unreasonable. During the last year, as a result of a mix of factors, some of which were described by Dr. Brundtland, the costs of medicines have dropped to one tenth of what they were, and they'll go down further. But it's not the cost of medicine that is the current barrier to access.

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I'll give you an example. One of the most awful things happening in poor countries with HIV at the moment is that a pregnant woman who has HIV has between a 13% and 20% chance of passing that HIV on to her child, either during delivery or during breast-feeding. You can prevent that by administering intermittent doses of an anti-retroviral called nevirapine during the third trimester of pregnancy. We spent a bit of time checking out whether that was safe for the mother as well as for the child, but last year we issued a recommendation that nevirapine should be widely used.

The manufacturer of patented nevirapine is Boehringer Ingelheim, and they've offered to provide all of that drug that is needed to stop mother-to-child transmission for as long as required, but at least five years in the first instance. They can't move the drug. People aren't taking it up because of the complexity of making sure we have good diagnostic testing for HIV in antenatal clinics and making sure that the doctors know how to administer it.

I accept that there are circumstances where the prices are still holding up too high, and particularly private health care providers or missions are not able to access them. Where that is the case, under the safeguards in the current TRIPS or trade-related intellectual products agreements that exist, it is possible for a country to compulsorily license the production of a drug or to import it from a generic manufacturer in another country through parallel importing. In addition, if there is no patent protection in a country, it can import the stuff anyway without compulsory licensing and without any difficulty, through the World Trade Organization or other processes.

At the moment, it is our judgment that the safeguards in the TRIPS agreement and the options available to many countries are adequate, so that if they did want to access anti-retroviral drugs, they could do so. We also believe that if the markets could be improved by increasing the capacity of health systems to provide care, we would see a further reduction in the prices.

That position is not taken by some campaigning organizations and by some governments, including the governments of Brazil, South Africa, and India. There will no doubt be quite a big debate on this issue of TRIPS, medicines, and treatment for people who have HIV, in and around the WTO ministerial meeting in November in Doha.

Canada has a position in the run-up to that meeting—we think the Doha trade meeting is still going to take place, but perhaps it won't—but its position has shifted. I think it's best that I don't try to characterize that position, because I think it is shifting.

It's clearly going to be important from the WHO perspective that ministers of trade do state clearly in whatever comes out of the Doha meeting that public health considerations should be given priority when issues around medicines are being discussed and debated, but at the same time, the rights of the individual manufacturers to intellectual property should be safeguarded, if possible. We do think the latter is important, because we are concerned that, otherwise, drug discovery will be reduced.

That's a long answer, but there are very many facets to this question, and I would be very happy to provide briefing material around these questions for the committee.

The Chair: I think that would be very helpful.

I knew you didn't need my help. You handled that one beautifully. But I think there was a second issue, was there not?

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Dr. David Nabarro: I know. It's a very simple one, that one. Why do we need a framework convention on tobacco control with legally binding protocols? The answer is because we want to stop any kinds of other international processes facilitating the transport or trade in tobacco, or more importantly, the transport or promotion of tobacco smoking, particularly to children, or the creation of markets, for example, among young women in the way that is now so shamefully done.

This legal instrument is vital. Canada, fortunately, is a fabulous backer of this process that is under way, and it's going to be important to make sure that friends in neighbouring countries perhaps take a similar position to the Canadian position.

The Chair: Thank you, Ms. Wasylycia-Leis.

I have no other names on my list, so I will now, on behalf of the committee, thank you, Dr. Nabarro, for filling in for Dr. Brundtland and doing so well. I wish you a happy stay in Canada until you leave.

Dr. David Nabarro: Thank you very much.

The Chair: Thank you very much.

Dr. David Nabarro: Just make sure your constituents understand the value of Canadian development assistance.

The Chair: Thank you very much.

Ladies and gentlemen of the committee, there is a piece of correspondence that's being handed around now. I apologize to the members of the committee. I know I told you yesterday that health department officials would be here. I knew we had invited them, but instead of their presence today we have this letter from the minister, who, as you will see in the third paragraph, would like to appear before us, I believe with his officials, next week.

It looks as if our meeting today is actually finished. As this letter pretty well covers Ms. Judy Wasylycia-Leis's request in her letter and her notice of motion given yesterday, which would have had us voting first thing tomorrow morning, I'm going to ask her if this will be satisfactory to her and if she'd like to withdraw her motion.

Ms. Judy Wasylycia-Leis: Madam Chairperson, I'll seek some clarification first.

My first question is on what basis we would not want to pursue discussions both with the officials, as you had suggested would be a good idea yesterday, as well as with the minister. I think there was a real interest on the part of some committee members that we put aside enough time to actually have an overview of the issues pertaining to bio-terrorism, the current threats and some of the initiatives being considered by the government.

I think it would be helpful, given the developments of the day, that we hear from officials today if they're still here just to begin clarification of the whole area, and as well to have the minister appear before us as soon as possible. I'm not sure I would want to dispose of my motion at this point until we have some clarification and some understanding of how and when these briefings and these discussions will take place.

The Chair: It's my understanding, first of all, that the minister wishes to come with officials so that they are also available for your questions when he comes. He says next week at a time of your convenience. And in order not to disrupt our schedule and those witnesses scheduled to appear on assisted human reproduction, I had on Monday asked the clerk to see if he could find a room for us next Monday, or this coming Monday, that might accommodate this session.

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At that time it was tentative, because I thought the health department officials would be here today, and then I wanted to know whether you wanted to hear more than you heard today. We're hearing nothing today. The minister has offered to come next week. With your approval, I would invite him to come on Monday, because we already have confirmed attendance of witnesses on Tuesday, Wednesday, and Thursday of next week.

What time was that room booked for him, Mr. Clerk?

The Clerk of the Committee: For 11 a.m.

The Chair: Monday at 11 a.m.

I could, upon leaving here, contact the minister's office and invite him to come at 11 o'clock on Monday if that is convenient to people. That would give us at least two hours. And if you needed more, probably we could go until maybe 1:45, prior to question period.

Are you here Monday?

Mr. Rob Merrifield: I am.

The Chair: Dr. Lunney?

Mr. James Lunney: No.

The Chair: Dr. Lunney is not.

Ms. Wasylycia-Leis?

Ms. Judy Wasylycia-Leis: I have another commitment, but, obviously, if this is our only time, I'm going to change my plans.

My concern today is that we are losing some time. We could be talking to officials to begin with and still hear from the minister next week.

I'm also concerned that, by all news reports, the minister is making his announcement tomorrow in Winnipeg about his complete plans pertaining to emergency preparedness and this government's response to the threat of bio-terrorism. I think it would be useful for this committee to have at least an opportunity to hear generally the nature of the concerns, to give some feedback, and to play a useful role in the process, not to simply be there to receive the reports that he's already made to the media.

We've dealt with this in Parliament time and time again over the last couple of weeks. Everything in terms of this government's strategy and policies around responding to the attacks of September 11 has been made first in the media, then brought to Parliament. Could we not have a chance to hear some of the plans, even in camera, today? Then we can have an understanding about where this government is headed so we can be in a better position to both offer constructive criticism and to respond appropriately.

The Chair: I'm a little confused. It seemed to me that your motion was one of concern that the government have plans, and I'm surprised that you're concerned the minister is making a major announcement tomorrow, you're telling me. It would seem to me that should be helpful to address your concerns. I can't provide anybody to brief us today.

Ms. Judy Wasylycia-Leis: Then that's it?

The Chair: There is no chance to do it today, but we do have this offer from the minister to come at our convenience next week. We can't do anything today. There's nobody here to brief us.

What was your other question? You were expressing your wish that the committee have at the plans before they are public, and I don't think that's going to happen. I think that's wishful thinking.

Ms. Judy Wasylycia-Leis: My concern was twofold. To refer to my letter that I sent to you last Friday, it was both to get a briefing from the minister and officials—

The Chair: And that will happen.

Ms. Judy Wasylycia-Leis: —about the concerns that are emerging, about the threats in the field of bio-terrorism, and about plans for addressing those concerns as well as to allow for input and support and help from parliamentarians, who have a very deep interest and concern in this area and believe we have a useful role to play in supporting and helping government through these difficult times.

The Chair: Mrs. Chamberlain.

Mrs. Brenda Chamberlain (Guelph—Wellington, Lib.): I think it is a really good thing that you brought this up, Judy, really good, because I'm very interested in it too. But from my standpoint, I'm a lot happier Allan would come, as opposed to not be here, and I don't have any problem with the longer session.

The one thing I would ask the chair, though, is some leniency, because James can't come, and I have a problem with Monday morning, not knowing that this was going to be on the agenda. Judy has already mentioned that she would have to try to renegotiate. Could we not consider Tuesday? You usually have a much better turnout, too, on your panel.

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This is a really interesting topic and an important one. We should try to accommodate many members. When the minister is willing to come, I think it's a big bonus.

Madam Chairman, would it be possible to go on Tuesday, from 3:30 to 7:30 or something like that?

The Chair: May I ask who has committee at 3:30 on Tuesday?

Jim is not available until Wednesday. I think Hélène also has a committee at 3:30. Do you have a committee at 3:30?

Ms. Judy Sgro: No.

The Chair: That's the problem.

I'm grateful when everyone comes on Tuesday, Wednesday, and Thursday to this committee. I know Hélène can't come on Wednesday afternoons, but people have done well so far. Mrs. Beaumier is not free Wednesday afternoons either at this point.

In order to accommodate the workplan to get this report done by Christmas, we had to add Wednesday afternoons. Even prior to that, it was my understanding that a second meeting on Tuesdays and Thursdays was impossible because of people's commitments to other committees. Some of them are doing clause-by-clause right now.

It was my suggestion to meet on Monday. I'm quite flexible if people want to meet on Tuesday evening at seven or 6:30, after voting or whatever, or on Wednesday evening. I prefer not to meet on Thursday evening if we can help it. We could possibly meet in the evening on Monday, Tuesday, or Wednesday, if people would like to do that, rather than meeting at 11 on Monday morning.

Would that be helpful, Mrs. Chamberlain?

Mrs. Brenda Chamberlain: I think it would be helpful. I think it's a bonus to have Allan come. I think it's a big plus.

The Chair: When would you be coming next week? Would you be flying on Monday afternoon?

Mrs. Brenda Chamberlain: Yes.

The Chair: How about you, Mrs. Wasylycia-Leis?

Ms. Judy Wasylycia-Leis: Yes. It would be fine on Monday afternoon.

The Chair: How about Monday evening at seven?

Ms. Judy Wasylycia-Leis: Sure.

The Chair: Would that accommodate almost everyone? James won't be in town at all until Wednesday.

Mr. Rob Merrifield: Monday evening would be better.

The Chair: Would Monday evening be better?

With your permission, seeing a consensus, could I, on your behalf, ask the clerk to try to find us a room for Monday evening at seven? The clerk will alert us to the meeting.

Mrs. Wasylycia-Leis, do you still want us to vote on your motion tomorrow morning, or would you like to withdraw it?

Ms. Judy Wasylycia-Leis: No. I'll withdraw it. I know I still have the ability and the right to introduce new motions as the situation requires.

The Chair: Absolutely.

Ms. Judy Wasylycia-Leis: I'll withdraw it and proceed accordingly.

The Chair: Thank you very much for your cooperation.

Ladies and gentlemen, you probably have your notice in your office for tomorrow's meeting. Another one will be coming prior to the end of the week as to Monday night.

Thank you very much for your cooperation. Everyone gets to go home a little early.

This meeting is now adjourned.