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37th PARLIAMENT, 2nd SESSION

Standing Committee on Health

EVIDENCE

CONTENTS

Monday, September 29, 2003

1320

The Vice-Chair (Mr. Réal Ménard (Hochelaga—Maisonneuve, BQ))

Professor Steven Morgan (Assistant Professor, Medicine / Health Care and Epidemiology, Centre for Health Services and Policy Research, University of British Columbia)

1325

The Vice-Chair (Mr. Réal Ménard)

Dr. James M. Wright (University of British Columbia Therapeutics Initiative)

1330

The Vice-Chair (Mr. Réal Ménard)

Dr. James M. Wright

The Vice-Chair (Mr. Réal Ménard)

Professor Robert D. Sindelar (Professor and Dean, Faculty of Pharmaceutical Sciences, University of British Columbia)

1335

The Vice-Chair (Mr. Réal Ménard)

Prof. Robert D. Sindelar

The Vice-Chair (Mr. Réal Ménard)

Ms. Carol Cole (Canadian Centre for Policy Alternatives)

1340

The Vice-Chair (Mr. Réal Ménard)

Mr. Rob Merrifield (Yellowhead, Canadian Alliance)

Ms. Carol Cole

Mr. Rob Merrifield

Ms. Carol Cole

1345

Mr. Rob Merrifield

Ms. Carol Cole

Mr. Rob Merrifield

Prof. Steven Morgan

Mr. Rob Merrifield

Dr. James M. Wright

Mr. Rob Merrifield

Dr. James M. Wright

Mr. Rob Merrifield

Dr. James M. Wright

1350

Mr. Rob Merrifield

Dr. James M. Wright

The Vice-Chair (Mr. Réal Ménard)

Dr. Thomas L. Perry (University of British Columbia Therapeutics Initiative)

Mr. Rob Merrifield

Dr. Thomas L. Perry

The Vice-Chair (Mr. Réal Ménard)

Ms. Hedy Fry (Vancouver Centre, Lib.)

Prof. Steven Morgan

1355

Ms. Hedy Fry

Dr. Thomas L. Perry

Ms. Hedy Fry

The Vice-Chair (Mr. Réal Ménard)

1400

Mr. Greg Thompson (New Brunswick Southwest, PC)

Ms. Carol Cole

Mr. Greg Thompson

Ms. Carol Cole

Mr. Greg Thompson

Ms. Carol Cole

Mr. Greg Thompson

Ms. Carol Cole

Mr. Greg Thompson

1405

The Vice-Chair (Mr. Réal Ménard)

Dr. Thomas L. Perry

The Vice-Chair (Mr. Réal Ménard)

Mr. Greg Thompson

The Vice-Chair (Mr. Réal Ménard)

Dr. James M. Wright

The Vice-Chair (Mr. Réal Ménard)

Ms. Bonnie Brown (Oakville, Lib.)

Prof. Robert D. Sindelar

Ms. Bonnie Brown

Prof. Robert D. Sindelar

Ms. Bonnie Brown

Prof. Robert D. Sindelar

Ms. Bonnie Brown

1410

Prof. Robert D. Sindelar

Ms. Bonnie Brown

Prof. Robert D. Sindelar

Ms. Bonnie Brown

Prof. Robert D. Sindelar

Ms. Bonnie Brown

Prof. Robert D. Sindelar

Ms. Bonnie Brown

Prof. Robert D. Sindelar

Ms. Bonnie Brown

Prof. Robert D. Sindelar

Ms. Bonnie Brown

Prof. Robert D. Sindelar

Ms. Bonnie Brown

Prof. Robert D. Sindelar

Ms. Bonnie Brown

Prof. Robert D. Sindelar

Ms. Bonnie Brown

The Vice-Chair (Mr. Réal Ménard)

Ms. Bonnie Brown

Dr. Thomas L. Perry

1415

The Vice-Chair (Mr. Réal Ménard)

Mr. Svend Robinson (Burnaby—Douglas, NDP)

Prof. Robert D. Sindelar

Mr. Svend Robinson

Prof. Robert D. Sindelar

Mr. Svend Robinson

Prof. Robert D. Sindelar

Mr. Svend Robinson

The Vice-Chair (Mr. Réal Ménard)

Mr. Svend Robinson

Ms. Carol Cole

Mr. Svend Robinson

Ms. Carol Cole

Mr. Svend Robinson

Ms. Carol Cole

The Vice-Chair (Mr. Réal Ménard)

Prof. Steven Morgan

Mr. Svend Robinson

Prof. Steven Morgan

1420

Mr. Svend Robinson

Ms. Carol Cole

Mr. Svend Robinson

Ms. Carol Cole

Mr. Svend Robinson

Ms. Carol Cole

Mr. Svend Robinson

Ms. Carol Cole

Mr. Svend Robinson

Ms. Carol Cole

Mr. Svend Robinson

Ms. Carol Cole

Mr. Svend Robinson

Ms. Carol Cole

Mr. Svend Robinson

Ms. Carol Cole

Mr. Svend Robinson

Ms. Carol Cole

The Vice-Chair (Mr. Réal Ménard)

Ms. Carolyn Bennett (St. Paul's, Lib.)

Dr. James M. Wright

1425

The Vice-Chair (Mr. Réal Ménard)

Prof. Steven Morgan

Ms. Carolyn Bennett

Prof. Steven Morgan

The Vice-Chair (Mr. Réal Ménard)

Dr. Thomas L. Perry

The Vice-Chair (Mr. Réal Ménard)

Mr. Jeannot Castonguay (Madawaska—Restigouche, Lib.)

1430

Prof. Steven Morgan

The Vice-Chair (Mr. Réal Ménard)

Dr. Warren Bell (Pharmawatch)

1440

The Vice-Chair (Mr. Réal Ménard)

1445

Mr. Derek Desrosiers (Vice President, British Columbia Pharmacy Association)

1450

The Vice-Chair (Mr. Réal Ménard)

Mr. Derek Desrosiers

The Vice-Chair (Mr. Réal Ménard)

Mr. Rob Calnan (President, Canadian Nurses Association)

1455

The Vice-Chair (Mr. Réal Ménard)

Mr. Rob Calnan

The Vice-Chair (Mr. Réal Ménard)

Mr. Rob Merrifield

The Vice-Chair (Mr. Réal Ménard)

Dr. Warren Bell

Mr. Rob Merrifield

1500

Dr. Warren Bell

Mr. Rob Merrifield

Mr. Derek Desrosiers

Mr. Rob Merrifield

The Vice-Chair (Mr. Réal Ménard)

Mr. Rob Calnan

Mr. Rob Merrifield

Mr. Derek Desrosiers

Mr. Rob Merrifield

Mr. Derek Desrosiers

Ms. Marnie Mitchell (Chief Executive Officer, British Columbia Pharmacy Association)

1505

Mr. Rob Merrifield

Dr. Warren Bell

Mr. Derek Desrosiers

Mr. Rob Merrifield

Mr. Derek Desrosiers

Mr. Rob Merrifield

1510

Mr. Derek Desrosiers

The Vice-Chair (Mr. Réal Ménard)

Ms. Carolyn Bennett

Dr. Warren Bell

Ms. Carolyn Bennett

Mr. Rob Calnan

The Vice-Chair (Mr. Réal Ménard)

Mr. Derek Desrosiers

The Vice-Chair (Mr. Réal Ménard)

Dr. Warren Bell

Ms. Carolyn Bennett

Dr. Warren Bell

1515

The Vice-Chair (Mr. Réal Ménard)

Mr. Greg Thompson

Dr. Warren Bell

Mr. Greg Thompson

Dr. Warren Bell

Mr. Greg Thompson

1520

Dr. Warren Bell

Mr. Greg Thompson

The Vice-Chair (Mr. Réal Ménard)

Mr. Greg Thompson

Mr. Svend Robinson

Dr. Warren Bell

The Vice-Chair (Mr. Réal Ménard)

Mr. Derek Desrosiers

The Vice-Chair (Mr. Réal Ménard)

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

Mr. Derek Desrosiers

Mr. Stan Dromisky

1525

Mr. Derek Desrosiers

Mr. Stan Dromisky

Ms. Carolyn Bennett

Mr. Stan Dromisky

Dr. Warren Bell

The Vice-Chair (Mr. Réal Ménard)

Mr. Stan Dromisky

The Vice-Chair (Mr. Réal Ménard)

Mr. Svend Robinson

The Vice-Chair (Mr. Réal Ménard)

Mr. Svend Robinson

The Vice-Chair (Mr. Réal Ménard)

Mr. Svend Robinson

1530

Dr. Warren Bell

Mr. Svend Robinson

Mr. Derek Desrosiers

1535

Mr. Svend Robinson

Mr. Derek Desrosiers

The Vice-Chair (Mr. Réal Ménard)

Ms. Hedy Fry

The Vice-Chair (Mr. Réal Ménard)

Ms. Hedy Fry

The Vice-Chair (Mr. Réal Ménard)

Ms. Marnie Mitchell

1540

Ms. Hedy Fry

The Vice-Chair (Mr. Réal Ménard)

Mr. Rob Calnan

Ms. Hedy Fry

Ms. Marnie Mitchell

Ms. Hedy Fry

The Vice-Chair (Mr. Réal Ménard)

Dr. Warren Bell

The Vice-Chair (Mr. Réal Ménard)

Mr. Jeannot Castonguay

1545

The Vice-Chair (Mr. Réal Ménard)

Dr. Warren Bell

Mr. Rob Calnan

The Vice-Chair (Mr. Réal Ménard)

CANADA

Standing Committee on Health

NUMBER 050

2nd SESSION

37th PARLIAMENT

EVIDENCE

Monday, September 29, 2003

[Recorded by Electronic Apparatus]

· (1320)

[English]

The Vice-Chair (Mr. Réal Ménard (Hochelaga—Maisonneuve, BQ)): I would like to call the meeting to order.

[Translation]

Now let us hear this afternoon's witnesses. Who would like to begin?

[English]

Who wants to introduce the presentation? Who wants to be the first?

We have the list. All right, it's going to be Mr. Morgan.

Professor Steven Morgan (Assistant Professor, Medicine / Health Care and Epidemiology, Centre for Health Services and Policy Research, University of British Columbia): Thank you very much. I appreciate the opportunity to present a few remarks here.

I'm going to begin with the punch line. The reason I actually wanted to speak at the committee meeting today was just to make the case for investing more money at the federal level in infrastructure that would allow for better analysis of drug utilization patterns, appropriateness, and outcomes. The title of my presentation is “Cost Dynamics in the Pharmaceutical Sector”. I'm a health economist, not a clinician. I don't have a medical background. I approach the area as an economist. I just want to put that out as a caveat.

The first slide I've made available to the committee members depicts real per capita expenditures in Canada on a historical basis. The message from the slide, quite frankly, is that drug expenditures are out of control and, moreover, we've never had control over them. In the past 20 years drug expenditures in Canada have increased from approximately $120 per capita to approximately $500 per capita without any great sense whether this investment is delivering value for money because, frankly, we are not tracking the health outcomes achieved through the consumption of pharmaceuticals.

I have a slide here that references how much is a lot of spending. Currently we are consuming approximately $16 billion per year on pharmaceuticals. That consumption is increasing at a rate of $1.5 billion per year. If you put it in terms of prescribing by practicing physicians in Canada, it's approximately $1,000 worth of prescription drugs prescribed by clinicians per day that they practice. That's more than the average physician bills in a given day, so it's a fairly significant component of our health care system.

One of the dilemmas in the context where you have such extraordinary expenditure inflation is understanding what the sources of that expenditure inflation are. I have a slide here that references “minding our p's and q's”: are expenditures driven by increased prices, quantities, or both?

The research centre I belong to, which is the Centre for Health Services and Policy Research, has a new program established on evaluating pharmaceutical sector productivity. The purpose of this research program is to investigate the causes of drug spending trends. I'm going to save you the details of the next few slides. They reference various cost dynamics, but I'm just going to highlight the “sources of growth” slide here.

There are three predominant categories of expenditure growth in Canada: price factors, which are increases in the price of products that are already on the market; therapeutic choices, which are changes in the mix of products prescribed and the quantities prescribed per course of therapy; and then volume of therapy prescribed to Canadians.

There is a multi-coloured chart—unfortunately, our slides are in black and white—that refers to the seniors' cost dynamics here in British Columbia. This is the first output from the detailed analysis we're doing here in British Columbia on cost dynamics in the pharmaceutical sector, and the results are fairly striking.

The most notable result from our analysis is that price factors are not a major contributor to expenditure trends in Canada. That is to say that changes in the price of drugs that are already on the market do not have a considerable impact on the cost of drugs consumed by Canadians. The predominant drivers of costs in Canada are increased utilization of drugs and, perhaps most importantly, changes in the drugs used per course of therapy.

This provokes a number of questions concerning whether the increased utilization is appropriate, whether the right people are getting the right kinds of drugs, and, at the end of the day, whether we are delivering value for money in terms of health outcomes.

None of these questions can be answered currently, given the state of the science on drug utilization and outcomes, and it's not because it's not technically feasible; it's just due essentially to a lack of data infrastructure and investment in research.

As I mentioned earlier, we spend $16 billion per year on pharmaceuticals in Canada. If you were to invest one tenth of one percent of that cost on better pharmaceutical outcomes research, we would be a long way towards answering the goals as to whether or not Canadians are getting value for money in that investment.

Thank you very much. That's my presentation.

· (1325)

The Vice-Chair (Mr. Réal Ménard): Thank you very much.

Our next presentation will be Mr. Perry, coming from the University of British Columbia.

Dr. James M. Wright (University of British Columbia Therapeutics Initiative): I'll be speaking on behalf of Dr. Perry and myself.

My name is Jim Wright. I'm a clinical pharmacologist, and I'm the managing director of the Therapeutics Initiative. I have provided my powerpoint, but I didn't have it translated into French. It is over on the table. I've also distributed one example of our Therapeutics Letter, letter number 47, plus the brochure which describes the Therapeutics Initiative.

I would like to briefly define and introduce you to the Therapeutics Initiative and to suggest on behalf of our group that we are a very small part of the solution in terms of drug utilization and expenses in Canada.

We were established in 1994, and our objectives have been the same since we were established. I would say we have learned a lot in the last nearly ten years, and we couldn't possibly be as effective and have grown to the degree we have if we were just being started now. Groups like ourselves need to be funded and supported, and it takes time to establish their effectiveness.

I'm just going to briefly go over a couple of our objectives. Our first objective is to assess new and existing drug therapies by the standards of the best evidence of clinical effectiveness in the scientific literature, and we have become considerably more expert in doing this over the ten years we've been doing it.

The second objective is to use these assessments to establish cost-effective first-choice drugs and recommendations for their optimal clinical use. Then we go on to other objectives, among which is to disseminate that information to physicians and pharmacists.

I've shown the organization of our group. We have a major committee, which is the scientific information and education committee, that takes responsibility for the accuracy of our assessments and the messages we disseminate. That group meets monthly. We also distribute the Therapeutics Letter. We now are working on number 49; we have 48 published. I have provided you with number 47, which I'll be discussing briefly in terms of the solution.

Our Therapeutics Letter publications are all free on our website and are all accessed on a regular basis. At the present time they are accessed over 3,000 times per day. We have a chart that shows how that has grown over the years. In the last year we averaged more than 3,000 times per day—over a million hits in the last year.

Our website is translated into Spanish and is available to Spanish countries around the world. The letters are also on the CMA clinical practice guidelines website, and recent letters have also been published in the Canadian Family Physician.

We have an education working group that disseminates the messages. They have an annual drug therapy course, a travelling road show, tele-health conferences, and other ways of disseminating the messages.

I'd like to briefly go through a case scenario that is really related to letter number 47. It has to do with treating patients with elevated blood pressure, or hypertension. The scenario I've put forward is that we have 100,000 new patients with hypertension in a year. That's an approximate number, but realistic. There are actually over 50 drugs available that will lower blood pressure, so the physician has to choose from these more than 50 drugs. All of them, since they lower blood pressure, would be basically correct, but wouldn't all be an answer from a societal perspective or be the best drug for that particular patient.

· (1330)

We've summarized the evidence in this letter that demonstrates from the ALLHAT trial and others that thiazides are the—

The Vice-Chair (Mr. Réal Ménard): We're running out of time. Would you summarize in one minute, and not more than that, because we have a lot of witnesses.

Dr. James M. Wright: Very quickly, then, thiazides are the drug of choice, and it would cost around $4 million a year for thiazides. If we took a non-evidence-based approach and used calcium channel blockers and alpha blockers, it would cost over $80 million per year and additionally cause approximately 400 patients to be hospitalized for heart failure unnecessarily as a result. So this has implications not only in terms of cost, but also of health outcomes.

I'll just come to our solutions. We feel that more government resources are needed for groups like the Therapy Initiative and other groups across the country. We feel we can share the workload and have been actively involved in the common drug review—

The Vice-Chair (Mr. Réal Ménard): I'm sorry to interrupt, but some members would like some questions, and we have a lot of information.

We are now going to move to Monsieur Sindelar.

Professor Robert D. Sindelar (Professor and Dean, Faculty of Pharmaceutical Sciences, University of British Columbia): Good afternoon.

The text of my presentation is on the table.

I sincerely want to thank the committee for the opportunity to meet with you today. The University of British Columbia Faculty of Pharmaceutical Sciences is one of nine faculties of pharmacy in Canada and the sole pharmacy educational program in British Columbia. I returned to B.C. last year as dean after an absence of 21 years, the last 19 at a U.S. school of pharmacy.

Since returning to UBC, I have consistently articulated as my number one goal the enhancement of the health and well-being of the residents of this province, the nation, and beyond.

Within the terms of reference for your committee, there are several points I would like to touch on briefly today. This will be done in the context of several important relationships. These are tripartite relationships, as I describe them, including learning innovation and implementation, factors contributing to health care success, universities and their affiliated hospitals, the pharmaceutical industry and government, environments contributing to health care success, and the interdisciplinary health care team, such as the physician, the pharmacist, and the patient, human resources contributing to health care success.

Recently Canada has undergone a health research renaissance. With funding for the Canadian Institutes for Health Research, the Canada research chair program, Canada Foundation for Innovation, Genome Canada, they're all at their funding high in the present day.

The unprecendented allocation of funds for research, especially health research, has helped us enter a prolific period of learning and basic discovery at universities across Canada that will help create technologies for new life-saving, cost-saving, and life-enhancing medicines. Pharmaceutical companies will apply these technologies and develop even more to create the next generation of government-improved medicines. The environment for effective communication, true partnerships, and the removal of barriers for research and development investment needs to be solidly in place to assure innovation.

A health care innovation environment is a very complex and fragile entity. The decision of several large pharmaceutical companies and many biotechnology companies to invest and build major new laboratories near academic institutions in the U.S., Europe, and Asia provides one example of the growing commercial value of academic innovation, specialized talent, and an environment for exchange of ideas and learning.

Universities and their affiliated hospitals, Canada's pharmaceutical industry, and government must work together to transform Canada into one of the world's most innovative health care economies. I see this as one component of a larger picture to assure a quality, sustainable health care system for all Canadians. Clinical researchers, including physicians, pharmacists, nurses, and other health scientists, evaluate the potential of new pharmaceuticals while at the same time questioning and re-examining treatments in long use.

Implementation of the new drug innovations result after a series of expensive lengthy trials. These trials are usually funded by pharmaceutical companies and occur at a variety of sites, including university-affiliated hospitals, attracting significant new dollars for research and development. Thus, limited government funds at the university as a publicly funded institution are leveraged with pharmaceutical investment. This public-private partnership creates new learning opportunities for a variety of health science students at the undergraduate, graduate, and post-graduate levels and ensures future generations of Canadian health researchers. This partnership also adds to the economy in a value greater than the corporate monetary investment.

The highest level of evidence for efficacy for drug therapy is obtained from randomized placebo-controlled clinical trials, or RCTs. Such studies are the only way, in principle, to firmly establish the efficacy of drug therapy. However, to investigate efficacy, RCTs typically include patients from a relatively narrowly defined population, and they exclude other patients with co-morbidity, concurrent drug therapy, or other features that could increase patients' risks or complicate the results of the study, much like many of the patients we treat. As a consequence, RCTs provide evidence that drugs can work, and they allow an estimation of the magnitude of the benefit among those eligible for the trial; however, they are not always informative about how well the drug will work in routine clinical practice.

Upon implementation of drug therapy in broader patient populations, the interpretation of the results of these trials not only affects timely government approval to market, but also many times forms the basis for policy decisions about therapeutic use and inclusion in payment plans. However, to make better-informed treatment decisions, physicians, pharmacists, and nurses ideally need to have good estimates of the nature and magnitude of the benefits and risks of drug therapy in patients similar to those encountered in their practices.

· (1335)

They also need to be informed of clinical factors that may increase or decrease the likelihood of these outcomes in individual patients. To make better-informed drug policy decisions, health care policy-makers require better information regarding the outcomes of drug therapy and the populations they serve, not necessarily those enrolled in randomized clinical trials.

The Vice-Chair (Mr. Réal Ménard): You have one more minute.

Prof. Robert D. Sindelar: Okay.

An understanding of genomics, particularly pharmacogenomics, as they become more integrated into our health care system of decision-making.... The individuality of our patients may necessitate greater decision-making authority being invested in interdisciplinary health care teams. Both the Kirby committee report and the Romanow report recognized the importance of the interdisciplinary health care teams. A series of reports in the U.S. also echo that call. Such interdisciplinary education is now beginning in British Columbia under the auspices of the UBC College of Health Disciplines.

To ensure appropriate sustainable access to drug treatments, the interdisciplinary health care team, especially the team of the physician, pharmacist, and patient, along with other health care providers, must work well in a seamless environment that improves the detection of patients at risk.

In conclusion, as one of the most studied health care systems in the world, one might ask how do we assure a quality sustainable system for all Canadians? By stimulating learning, creating environment for informed dialogue among all health care stakeholders, generating new knowledge and pharmaceutical innovation, establishing the right investment climate, and helping mold the attitudes of our health care providers to be change leaders for interdisciplinary health care provisions. A great deal is riding on these issues. Our health care future, our competitive advantage, depends that we work together to successfully meet these challenges.

Thank you.

The Vice-Chair (Mr. Réal Ménard): Thank you very much.

The last speaker will be Madam Carol Cole, from the Canadian Centre for Policy Alternatives.

Ms. Carol Cole (Canadian Centre for Policy Alternatives): Thank you.

I have a nursing background and a master's degree in interdisciplinary health. I have fifteen years of health research experience. I'd like to spend four of my five minutes speaking on behalf of the Canadian Centre for Policy Alternatives, and my last minute speaking from my seven years of experience as a former employee in the research department of one of the giant multinational pharmaceutical companies.

The CCPA has recently published a study on the way Canadian newspaper articles report information on new prescription drugs. The study was also the cover story in a recent issue of the Canadian Medical Association Journal. I was a co-investigator on this study. We found that the information Canadians get on new prescription drugs from a major and trusted source of information--daily newspapers--is incomplete and may promote unrealistic expectations about the benefits of new drugs.

The first of its kind in Canada, the study examined approximately 200 stories in Canada's 24 largest daily newspapers about five major prescription drugs launched in recent years. Sixty-eight percent of the articles made no mention whatsoever of possible adverse effects, and when identified these harms were usually downplayed and mentioned toward the end of the article.

As I was one of the investigators actually reading each of the articles, I can state that I was struck by how similar the articles were to each other and how much they resembled industry press releases rather than what we expect from journalism: a balanced perspective. Here's an example. The wording that was chosen was sensational rather than informative in quantitative terms. “Wonder drug” and “breakthrough drug” are incorrect promotional terms.

We are concerned that newspaper journalism regarding prescription drugs has now become a form of marketing and lobbying to prescribers and to consumers--two of the topics that you are studying. This also relates to a third topic you are studying: the misuse, abuse, and addiction within the general population.

When the average person reads in an entrusted newspaper that a wonder drug has been developed for an illness they have, studies have shown that they tend to request it from their physicians, and their physicians tend to oblige, whether they fully agree or not. This contributes to rising drug costs and unnecessary adverse effects, raising numerous health care costs.

You can act on three specific points:

One, like all of the nations in the European Union, Canada must provide objective, approved product monographs when medication is dispensed. Currently, Canadians only learn what the manufacturer or the media wants to tell them about the safety of their drugs.

Two, like every nation in the world except the United States and New Zealand, Canada currently restricts direct-to-consumer advertising of pharmaceuticals for the sake of public health, and this law should not be changed. In fact, it should be better enforced. Not allowing drugs ads in magazines or newspapers improves public health.

Three, we found that most conflicts of interest regarding pharmaceuticals are not reported. For example, Canadians need to know that many so-called patient groups or spokespeople for diseases are actually funded by pharmaceutical companies that stand to benefit from the greater sales of their products. Making potential conflicts clear and transparent must be a prerequisite for any group consulting with this committee or any Health Canada consultation process in the future.

To this end, I would like to disclose that I am not receiving funds directly or indirectly from the pharmaceutical industry. In other words, neither the CCPA nor the institute at which I am employed at UBC receives any funding from the pharmaceutical industry. Our study was funded by the Office of Consumer Affairs of Industry Canada.

In my last minute, I'd like to speak from my seven years of experience as a former employee in the research department of one of the giant multinational pharmaceutical companies. I monitored clinical trials in B.C. for them. I repeatedly saw how data tabulation and statistics can be manipulated to produce favourable results. Therefore, I fully support independent assessment of clinical trials, such as the work done by the Therapeutics Initiative. I would also like to support the independent assessment of how the clinical trials are conducted.

I know that Health Canada is piloting a human clinical trial inspection process, but I've looked at these records for 2002 through the Access to Information Act and I believe they are nowhere near thorough enough. For example, I don't see any assessment of recruitment practices. This was an agonizing issue for me when I was a monitor. I was ordered by my superiors at the pharmaceutical company to encourage unethical recruitment strategies, which they said were successful elsewhere in Canada. Some of these so-called strategies were dangerous to patients and they falsely created favourable research results. Ultimately, I was fired for refusing to cooperate.

I desperately wanted to expose these appalling practices, but I was bound by a confidentiality agreement that I was required to sign. Therefore, I encourage Health Canada to enhance its inspection process and to enact whistle-blower protection legislation.

Thank you.

· (1340)

The Vice-Chair (Mr. Réal Ménard): Thank you very much.

We'll now move to Mr. Merrifield for the first question.

Mr. Rob Merrifield (Yellowhead, Canadian Alliance): Thank you for coming in.

I want to start where you left off. What you're saying is that the pharmaceuticals are manipulating the process. There are lots of accusations that they're manipulating physicians in how they prescribe, and there are lots of accusations that they manipulate politicians in the way they vote. And what you're saying is that they are now covering up as far as the press is concerned and influencing the way they report on certain adverse reactions. Is that what you're saying?

Ms. Carol Cole: I'm not sure they're covering up, but I think they in many ways are controlling what is said in the press. I presented some of this information to a forum on media concentration, and the journalists and the editors there were very supportive of the study and said they really thought a lot of it had to do with media concentration and the problem with reporters just not having the time to look for independent sources of information. Incidentally, we do have a journalists' guide to how to seek this information, and a big problem is, as I said, that they just don't have the time, so they get whatever is most easily accessible, which generally means press releases from the pharmaceutical companies.

Mr. Rob Merrifield: Were you a victim of not having whistle-blower legislation? Is that why you're an advocate?

Ms. Carol Cole: Absolutely. I desperately was seeking a way to stay employed. I was told that if I didn't carry out these recruitment practices, I should quit. I countered with codes of ethics from the nursing association and the medical association, to no avail. Ultimately, I told my investigators that my boss had ordered me to ask them to do these things, and fortunately my doctors all said, you've got to be kidding. So that way I was able to stay employed, until they fired me about a year later for another disagreement about ethics.

· (1345)

Mr. Rob Merrifield: I'm a little foggy. You're saying they asked you to recruit?

Ms. Carol Cole: With one study in particular, we were having trouble recruiting eligible patients, so they were encouraging me to ask my investigators to recruit patients who didn't actually have the disease.

Mr. Rob Merrifield: That's really interesting.

To look at what Steven has said with regard to seniors and the amount of prescription medication that is being used now compared to any time in history, as far back as we want to go, Steven, can you give us what you expect over the next five to ten years? We've asked this same question of the department and got a kind of blank stare. Do you have any projections, and what do you base those projections on?

Prof. Steven Morgan: I was asked, actually, by Romanow to write a report forecasting the next twenty years of health cost drivers in Canada, and it was almost laughable. If only I had that crystal ball, of course, I wouldn't need to work at the university; I'd be making a lot more money on the stock market. What I can tell you is that there are competing projections for the pharmaceutical industry. Major research firms in North America and globally anticipate that pharmaceutical spending world-wide is likely to double in the next seven years. In Canada, roughly by 2010, which is an important year for Vancouver and British Columbia, and Canada for that matter, we'll be spending about $1,000 per capita, if you believe those figures.

I suspect they are probably correct, but there are newer figures coming out of Germany and other places where there is skepticism as to whether or not the genomic revolution is really going to result in a new therapeutic revolution, in time at least for pharmaceuticals to actually ramp up spending again--for them it's ramping up sales--in the near future. The reason is that genomic technologies are extraordinarily complicated and there are very few illnesses for which there is a single gene responsible. With those that have been identified, we've been searching for as long as thirty years for cures, and they haven't come around. So some people suspect that the genomic revolution in pharmaceuticals is going to come on more like a trickle than a waterfall, so to speak.

Having said that, I think that the next ten years are boom years, simply because of the demographic change. We have a fairly wealthy, independent, and influential cohort of baby-boomers coming to the high drug use years. That in and of itself is a major driver, so you can expect drug costs and drug use to continue to go up.

Mr. Rob Merrifield: The study you're doing through the University of British Columbia, that's just a provincial study, is that right?

Dr. James M. Wright: It's funded by the Ministry of Health in British Columbia, yes.

Mr. Rob Merrifield: Is the lack of mandatory reporting of adverse reactions hindering the amount of research or studying you're doing, as far as the numbers you're getting are concerned? How cooperative are you with the federal government in getting the information? Is that a very positive relationship, or is it negative and you don't talk? How could you improve it?

Dr. James M. Wright: We strongly believe all trials should have to report all serious adverse events, and that's not happening. There is a requirement to give that information to the regulatory authorities, but it's not a requirement in published articles, and it's seldom provided in published articles. So we strongly believe that should be in the public domain and we all should have access to it, because there are ways of looking at the data that are going to be different.

Mr. Rob Merrifield: Are your data skewed because of this?

Dr. James M. Wright: We feel we're getting an exaggerated view of the benefits of drugs and not getting the proper perspective on the harms.

We haven't had a good relationship with Health Canada in getting information. We've asked on a number of occasions and got back the answer that it's proprietary and we should ask the company for the information, and we haven't had much success in getting data from the company either.

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Mr. Rob Merrifield: This astounds me. Why would Health Canada not be open and transparent and forthcoming?

Dr. James M. Wright: I can't tell you, but that's been our case. I think they feel they are in a bind because of the proprietary legislation that's presently in place.

The Vice-Chair (Mr. Réal Ménard): Would you like to add something?

Dr. Thomas L. Perry (University of British Columbia Therapeutics Initiative): My name is Tom Perry. I work part-time with the therapeutics initiative, and I'm a hospital specialist at Vancouver Hospital.

I think mandatory adverse drug reporting, in principle, would be a good idea. I've certainly increased my adverse drug reporting in the last few years. But no one should ever be under the illusion that it will capture anything more than a tiny percentage, perhaps 1%. On a hospital ward there's sort of a standing joke when I teach medical students. I challenge them every night we're admitting patients that if there are ten patients admitted to VGH, at least half of them will have a significant adverse drug reaction, either contributing to their hospitalization or during the hospital stay. I'm not kidding you about that; it's way more than what is in the medical literature. Every time we do an exercise of counting, it is about half of the patients who experience something. I'm not talking trivial things, I'm talking potentially life-threatening problems, like a serious bleed leading to hospitalization or aspiration of stomach contents into the lung in hospital and pneumonia.

Mr. Rob Merrifield: So why wouldn't it help?

Dr. Thomas L. Perry: It will help a little bit, but it won't capture what you're really trying to do.

The other point about the cooperation of Health Canada is an example of the latest drug our group has reviewed as part of the common drug review, a new antibiotic called telithromycin.

The Vice-Chair (Mr. Réal Ménard): I'm sorry to interrupt you, but it's ten minutes, and we're going to move to Mrs. Fry.

Ms. Hedy Fry (Vancouver Centre, Lib.): Thank you very much.

I wanted to direct my question to Steven Morgan. You've got a nice deck here on prescription drug cost dynamics. I think you have answered my question partly with your last answer, when you talked about the fact that we're going to be using more and more pharmaceuticals as time goes on, because of an aging population and because we have now found newer ways to treat diseases other than through invasive procedures, which used to be the only way, and also because people are living longer--they are being treated, so they have a longer life.

Have you done in your cost comparisons anything that showed what the savings were with the use of prescription drugs, which has gone up, and the decrease of invasive procedures as a result of prescription drugs? For instance, nobody runs around operating on people with ulcers any more; we have medication for that. Have you done a comparison? It would be interesting to see what the net gains and losses are. I think sometimes we tend to see a very simplistic black and white view of things, and this is complex. If we're going to have good recommendations, we need to understand the complexity of the issue.

Prof. Steven Morgan: As I mentioned, our centre just started a new program in pharmaceutical productivity measurement. Our outcome measure is serious morbidity or serious disabling morbidity and mortality among the population. Our analysis is using an exemplary database here in British Columbia, the PhamaNet data, which capture universal prescription drug use and costs, linked to what's known as the British Columbia linked health database at UBC. These databases permit us to do a longitudinal, cross-sectional analysis of British Columbians' access to drugs since 1996, which is when the data became reliable, and it will go on, quite frankly, until we've finished our research on this, which could be three to five years.

To our knowledge, this is the first study in the world to track patient-specific total health care utilization as it relates to variation in the use of pharmaceuticals. There are scholars in the United States who claim they've done this kind of work, but if you look carefully at their analysis, it's not quite as factual as they might claim. Patients in the databases used by leading American health economists can reappear many times, and a single death can be counted several times, depending on the number of drugs the patient is on.

The short answer is that no one in Canada or globally has done the kind of work you're asking about, and that's something I think we really need to be investing in. I put this forward to you as committee members. I know you represent the federal government, and the federal government's in a perfect position to leverage investment in infrastructure, which is data capture. British Columbia actually has a very good model; better models might be found, expanded into other provinces. Manitoba has a universal capture as well, and Ontario, I understand, is working towards one.

Investment from the federal government in this sort of initiative could really push forward the envelope and make it possible to actually answer these questions you're asking, and those are the most important questions. What are the facts? Let's separate fact from fiction, health outcomes from hyperbole, and really find out what's going on.

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Ms. Hedy Fry: Tom Perry, I know you've been working very much on educating physicians with regard to appropriate prescribing practices. You said you don't think mandatory reporting of adverse drug reactions is a silver bullet. It's obvious that it's not a silver bullet, but I think physicians and nurses need to be mandated to report adverse drug reactions on patients. What we do have is this sense of hyperbole, “he said, she said”--I know somebody who had a terrible time, I know somebody who died. But we don't have the data, and a clinical trial doesn't give you the answer. People out there, ordinary Canadians, have very different reactions as individuals to whatever they take. So a reaction may not have been noted in a clinical trial, it may never have occurred, but it would have occurred in somebody in a community taking it, because we have a broader cross-section of people.

Don't you think it would not only assist the pharmaceuticals themselves, keeping their feet to the fire on proper reporting of the drug, but it would help Health Canada to look at safety, and it would also help physicians in understanding prescription practices?

Dr. Thomas L. Perry: Yes, I agree with Dr. Fry. If one wants it to really work, it would require a lot of resources. It would require, for example, a trained clinical pharmacologist, in my opinion, not a physician and not just a pharmacist, but maybe two working together and/or a very highly skilled nurse searching every chart.

Even if it were mandatory, and even it were enforced with a whip or by law or a prison sentence, most would not be captured now because most of our colleagues don't even recognize what's happening. Most nurses and most pharmacists don't recognize what's happening right under their eyes.

Ms. Hedy Fry: Thank you.

The Vice-Chair (Mr. Réal Ménard): Thank you very much.

I have four more speakers: Mr. Thompson, Mrs. Brown, Mr. Robinson, and Madam Bennett.

Mr. Thompson.

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Mr. Greg Thompson (New Brunswick Southwest, PC): Thank you, Mr. Chairman.

I apologize for coming in a little late, but I did have the opportunity to read a little bit, and to read Carol Cole's brief. There are some points I wanted to comment on.

Carol, you talk about the European Union and doing things somewhat differently to how we do them in Canada in terms of product monographs, when medication is dispensed, and so on. You of course understand that the drug approval by the regulatory side in Europe is suggesting that, in terms of drug approval, we could adopt some of what they're doing in the European Union. Do you see a problem with that? What could we put in place to achieve that objective in terms of product monographs? Why are we not doing that in Canada?

Then I guess we can move to the media thing, in which I'm interested as well. Could you start off on that point?

Ms. Carol Cole: Sure.

I don't know why we're not doing it in Canada. I think that we should. I think, from my understanding of the European Union model, that it's working very well.

Some of you were mentioning earlier that you thought product monographs were being distributed to people currently, now. I'd like to reply that some pharmacies are indeed distributing monographs, but it's certainly not standardized. It's not uniform, and the wording has not been approved by an independent body.

Mr. Greg Thompson: Product monographs for the greater public, what are you actually talking about in terms of understanding? How does the average consumer, if that is available, then interpret the information on whether this will help in making an informed judgment as to whether one should be using this medication or prescription drug versus something else?

Ms. Carol Cole: That's a good point. It needs to be the type of monograph that's easily readable by lay people, using language that most people understand. Generally, I think the grade-8 level is what we write consent forms for, so it has to be quite simple language. That currently doesn't exist. As you say, alternatives to drug treatment also have to be included.

I think probably the whole point of the CCPA study was that consumers need to receive balanced information. There isn't one perfect point of view. They need to be given all of the different points of view and decide for themselves.

Mr. Greg Thompson: It might be an affliction that, as parliamentarians and as politicians, we're often accused of, which is not speaking in plain language. It's a disease that's probably catching on for whatever reason.

Of course, you're talking about the media. You're suggesting that media concentration has in fact probably led to journalists being somewhat sloppy and lazy in terms of the information they're disseminating.

You're using some of the headlines like “wonder drugs”. I read about the so-called wonder drug on the front page of Time magazine, or whatever, and immediately request the drug from my doctor. Could you get in a little bit of the media hype that surrounds some of that? Basically, you're suggesting a level of lazy journalism and uninformed journalism. Can you make that connection between the media a little clearer?

I understand the media concentration. I think that most of us in this room, regardless of politics, are concerned about it. Could you add your perspective to that, please?

Ms. Carol Cole: First of all, I shouldn't say that the media concentration issue is a conclusion of the CCPA study. It was only something that came up when I presented it to a group of journalists. I think that what the study actually showed, though, was that there wasn't a balance.

I think you're asking me what my opinion is. I would say that a lot of the problem is because newspapers need to sell newspapers. I think people are very accustomed to sensationalistic journalism, such as the tabloids. Newspapers compete with each other, and glorified headlines help sell papers.

Mr. Greg Thompson: Give me at least one or two recent examples, to see whether I agree with you or not, of a drug that has the hype and the total hysteria that surrounded the introduction of that particular drug, whether the information is accurate or not. Could you give me a couple of examples?

Ms. Carol Cole: Probably the two MDs from Therapeutics Initiative can speak better to the efficacy of these drugs. It wasn't something the CCPA studied.

I do know that for the five drugs we studied, Therapeutics Initiative also reviewed them. They didn't find any of the five to be wonder drugs.

Probably the most common example was the COX-2 inhibitors, where there was a lot of hype. You can certainly see how consumers really are very desperate for something that would help a very painful chronic disease, such as arthritis. There's a huge demand out there.

I'm very sympathetic, but I also think that misleading these same patients is worse.

Mr. Greg Thompson: Thank you.

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The Vice-Chair (Mr. Réal Ménard): Thank you.

At this point, we have Dr. Perry. After that, we're going to move to Mrs. Brown.

Dr. Thomas L. Perry: I was wracking my brain for a good example, but I think I came up with a good one. There is a new cholesterol-lowering drug. The brand name is called Ezetrol and the generic name is ezetimibe. This is a drug that is approved by Health Canada on the basis that studies showed it lowers cholesterol safely over 12 weeks.

We know nothing more about it than that. We don't know whether it would prevent heart attacks, stroke, death, or any other complication of arterial sclerosis, or whether it would cause other problems, including nutritional problems. We have no idea.

Our group, when assessing a drug like that, has to say that we don't have any idea whether this is a good or a bad thing. Yet it's launched onto the market as a wonderful new drug that could be a great boon to people who have trouble tolerating statins. They are drugs for which we know that under certain circumstances, such as the treatment of someone who has suffered a heart attack, they are beneficial.

The Vice-Chair (Mr. Réal Ménard): Thank you. Your seven minutes are up. You may have one quick question.

Mr. Greg Thompson: Thank you.

I only throw this one out for your thoughts. I'd like to see the drug approval process in Canada shortened. You do make reference to the European Union. If we followed some of their standards in the procedure of the drug approval there, would you be willing to see that happen?

I'm not sure who I'm directing this to. I'm not sure who is the best qualified to answer that.

Do you see any problems with, in other words, the speeding up of the drug approval process, provided we have some of the other safeguards that Ms. Cole had in her paper?

The Vice-Chair (Mr. Réal Ménard): Could we have the answer to your question, please? It has been eight minutes, and I have two more speakers.

Dr. James M. Wright: I can briefly say that the really critical thing about reviewing the drugs is the quality of the review and the appropriateness of the decision, not the speed of the review. If you could improve the quality, get the right decisions, and also shorten the time, I don't think anybody would have any problem with it.

The Vice-Chair (Mr. Réal Ménard): Thank you, Mr. Thompson.

Mrs. Brown.

Ms. Bonnie Brown (Oakville, Lib.): I'm looking here, and we have four people essentially from the University of British Columbia. We've had some presentations in the past and this morning that have made me fairly concerned about the investment that pharmaceutical companies are making in universities and how much control they might be gaining.

Wth the particular faculties and schools you represent, might it be possible for you to find out and send to us, maybe not today but later, how much money your faculty is getting from pharmaceutical companies in the form of chairs that they fund, public-private partnerships, projects, and clinical trials? That would have to be the school of medicine, I guess. For all the money that pours in through a variety of avenues to the University of British Columbia, would it be possible to get that?

I'll let you think about that for a minute.

I'd like to move on to Dr. Sindelar, who seems to be very enthusiastic about the investments by the pharmaceutical companies in and around health science faculties in universities, and the partnerships that result.

In your experience in the school of pharmacy, do the researchers and the students assisting them in the projects have to sign confidentiality agreements?

Prof. Robert D. Sindelar: My area is drug design and drug discovery. I've had funding for that from competitive government sources, such as the National Institutes of Health in the U.S. or the Centers for Disease Control. In all of the projects I have personally been involved with, and also some corporate research, never once have we had to sign a confidentiality agreement in the way we had established the relationship. The reason for that is because they've all been research grants truly for discovery. They haven't been directed for a particular product. They've been looking at new science.

Ms. Bonnie Brown: Within the UBC School of Pharmacy, are there other projects that are partially funded, at least, by pharmaceutical companies that maybe aren't quite so pure but are a little more down the applied line, where students have had to sign confidentiality agreements if they wish to help?

Prof. Robert D. Sindelar: I cannot tell you if there has not been or never has been a student, having been on the faculty now for a year. I don't know of examples personally.

I do know that we have funding from a number of the biotech companies in Vancouver on particular research projects. Since these deal with projects that are related to masters or PhD dissertations, in no case are those ones in which there is a secrecy agreement. That I'm sure of.

As far as funding from the pharmaceutical companies, we have no chairs that are funded by the pharmaceutical companies.

Ms. Bonnie Brown: I don't need to know those facts.

Prof. Robert D. Sindelar: Okay.

Ms. Bonnie Brown: I would appreciate it if you would try to find out the global budget of your school and how much comes from the pharmaceutical companies.

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Prof. Robert D. Sindelar: I'd be glad to.

Ms. Bonnie Brown: And perhaps get it to the clerk.

Prof. Robert D. Sindelar: I think what is important is that the type of funding we receive from the pharmaceutical companies tends to go for education programs. For instance, we have an outreach program to the community dealing with aspects of health, and particularly prevention. We've had funding from pharmaceutical companies for that. Indeed, the pharmaceutical companies that have funded that actually have no drugs in the area we've looked at.

Ms. Bonnie Brown: You're making them sound very pure, but other presenters have given us the completely, totally other view--the school of medicine, for example. My question to you was going to be on the role of the university as the seeker and defender of truth and your responsibility to your students vis-à-vis these confidentiality agreements, which might cause them to keep silent and not promulgate the truth. You're telling me that pharmacy, in your school at least, is totally clean of that--there are no students being taught to compromise the truth.

Prof. Robert D. Sindelar: Certainly there are no students taught to compromise the truth. I do not know of secrecy agreements signed by any students in that area.

Ms. Bonnie Brown: What about the faculty?

Prof. Robert D. Sindelar: I know of no faculty, for instance, involved in clinical trials who have signed secrecy agreements in the time I have been there, because they would have come through my office.

Ms. Bonnie Brown: What about in your years of experience in the States, do you know of it there?

Prof. Robert D. Sindelar: There are examples in which there is information that is new technology that is part.... And again, my area was drug discovery.

Ms. Bonnie Brown: Yes, but hopefully all research is going to be new technology of one sort or another. The problem is if it's causing adverse reactions, for example.

Prof. Robert D. Sindelar: Okay, right.

The areas I personally am involved in actually are at that early stage of discovering a new cure. In other words, I synthesized molecules that have the potential to be drugs.

Ms. Bonnie Brown: But as the dean you're not just responsible for the area you're involved in.

Prof. Robert D. Sindelar: No.

Ms. Bonnie Brown: You're responsible for every researcher in the school of pharmacy.

Prof. Robert D. Sindelar: Right.

Ms. Bonnie Brown: I'm asking you about that too, because I guess it's your responsibility to know that.

Prof. Robert D. Sindelar: Right.

Indeed, as I said, in the time I have been there I have not had one confidentiality agreement come through my office.

Ms. Bonnie Brown: Okay.

I want to get on to the adverse—

The Vice-Chair (Mr. Réal Ménard): Question, please.

Ms. Bonnie Brown: —reaction reporting. Dr. Perry doesn't seem very hopeful about getting a lot of people to report these reactions so that we can develop a database. We're a little more optimistic, thinking if we can get the technology in place to make it simple for people to do, they might be more inclined to do it than to fill out the very complicated form they have to fill out right now.

What do you think of the conflict between a doctor's duty to report adverse effects and a constraint that might be imposed by a confidentiality agreement that's part of a clinical trial? The person from the school of medicine was here this morning. He too was very enthusiastic about the contracts that they get out of pharmaceutical companies and how that helps to fund the school, and this whole thing about recruiting doctors and Canadians citizens to serve as, in my view, guinea pigs for new drugs and then the confidentiality agreements that prevent the doctors administering those drugs, having recruited their own patients, from telling some of the sad stories that result from it.

Dr. Thomas L. Perry: Dr. Wright knows a lot more about this than I do. My understanding is the law is absolutely clear. If there is a significant adverse event, the physician is required under international law to report it no matter what.

The bigger issue that has arisen in our group studies is that in many clinical trials physicians report adverse effects, which they judge to be related to the drug. They do not routinely report publicly all serious adverse events, as they have to to the regulatory authorities. Therefore, for many of the new so-called blockbuster drugs, if you look at your leisure through our newsletters on the website, you'll see that for some blockbuster drugs such as Celebrex or Vioxx our group has been concerned with the possibility that these drugs actually are more dangerous than what went before, when you add together all of these serious adverse effects. This is a controversial subject, but our letters speak for themselves on it, and they have received a good reception in a lot of academic groups around the world.

The subject of Health Canada allows me to come back to the issue of a recently licensed drug, telithromycin. It was rather rapidly licensed in Canada and is not yet licensed in the United States. It's an antibiotic that is clearly more toxic, according to the studies, than the alternative antibiotics we have. This appears to be why it has not been licensed in the U.S. Our group recently reviewed it for the common drug review for the provincial governments, and we really are at a loss to understand why Health Canada approved it, because there doesn't appear to be any compelling reason why it would be better than what we have for infections, and it appears to be clearly more toxic.

To attempt to use a post-marketing reporting system to deal with an issue like that is obviously inappropriate. Don't misunderstand me, I think anything that captures post-marketing accurately is good, but simply may not work.

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The Vice-Chair (Mr. Réal Ménard): I'm sorry, I have to interrupt you. Thank you very much. I'm so sorry, but time has expired.

Mr. Robinson.

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

I want to join in thanking the witnesses. As an alumnus of the University of British Columbia myself, it's a pleasure to see you here. I also want to particularly thank the Therapeutics Initiative representatives. I think the work that you do is incredibly important. I was very pleased to note that I believe it was the government of which Dr. Perry was a member that initiated the Therapeutics Initiative almost a decade ago. Something should be happening right across the country.

I think Ms. Brown raised some fundamentally important issues around confidentiality agreements. We all know this happens far too often. Think Nancy Oliveri, think Eli Lilly, think Prozac, and I could go down the list. It's shameful, frankly.

I'd just like some clarification, Dr. Sindelar, because I'm pleased to hear that at least on your watch this hasn't happened. If you were approached by a professor or graduate student in your faculty who wished to pursue research that was bound by a confidentiality agreement in terms of publication, because that's the issue, would you support that or not?

Prof. Robert D. Sindelar: I would not support it. We've actually had an individual in our area in pharmaceutics, in our division, who had a small biotech company come and approach them, and who wanted to have not only a confidentiality agreement, but basically control over everything that was going on. We don't put our students into those environments. We don't do clinical trials like physicians do, even though pharmacists participate in those—at least in our faculty.

Mr. Svend Robinson: Are you aware of what happens in the faculty of medicine?

Prof. Robert D. Sindelar: Again, I am not as familiar with what happens in this faculty of medicine, having been here just a year now.

Mr. Svend Robinson: It would be interesting, if you wouldn't mind, just checking on that and getting back to us in terms of whether the same standards apply in the faculty of medicine. I suspect they probably don't, but—

Prof. Robert D. Sindelar: I would strongly recommend simply approaching the dean's office in the faculty of medicine.

Mr. Svend Robinson: Yes, but you're there, and it would be helpful for us.

The Vice-Chair (Mr. Réal Ménard): To Madam Cole.

Mr. Svend Robinson: Yes, I was actually going to ask Ms. Cole a question.

Ms. Carol Cole: Can I just answer related to that?

Mr. Svend Robinson: Yes, sure.

Ms. Carol Cole: I can say, as a monitor for a pharmaceutical company, I did approach many members of the faculty of medicine at UBC, and many of them did sign on and they were required to sign a confidentiality agreement.

Mr. Svend Robinson: A confidentiality agreement. So in the medical faculty, then, that's happening.

Ms. Carol Cole: It was when I was a monitor.

The Vice-Chair (Mr. Réal Ménard): Mr. Morgan.

Prof. Steven Morgan: I just want to add to that. Not all strings attached to money are as clear as confidentiality agreements. There is this notion of what is the university's role in research. Clinical research is exemplary of an area where pharmaceutical funding, whether or not it's with confidentiality agreements, is associated with systematic differences in reporting of the results of trials.

Perhaps even worse yet, and maybe it's just because it's my field of study, is that in policy work the role of a policy researcher ought to be to better the good of society, for the public good. If you do public policy, that should be why you're in the university institutions. However, there is an incredible increase in the private sector funding of research that is done on particularly health policy, and a large majority of it is funded by the pharmaceutical industry. Not all of that research comes with explicit strings, but as a researcher you realize who's calling the tunes. It has its effects on what you will ask and what you will not ask and what you will say and what you will not say.

Mr. Svend Robinson: If you want to keep on getting funding.

Prof. Steven Morgan: If you want to continue with your career track and publish. Not all strings are as transparent as some others.

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Mr. Svend Robinson: I appreciate that.

Ms. Cole, first of all, thank you for your integrity in speaking out. Who were you working for? Which was the company?

Ms. Carol Cole: I can't tell you that until I have whistle-blower protection.

Mr. Svend Robinson: Well, as you've testified before this committee, you're protected by parliamentary privilege.

Ms. Carol Cole: I would have to consult my lawyer.

Mr. Svend Robinson: Do you not have a CV you give people that shows where you worked for a seven-year period?

Ms. Carol Cole: Yes, I do.

Mr. Svend Robinson: Can you share that CV with us, then?

Ms. Carol Cole: I'd have to consult my lawyer.

Mr. Svend Robinson: On whether or not you can share your CV?

Ms. Carol Cole: I've been very careful not to discuss this for years, and frankly, what I've said already is of concern to me.

Mr. Svend Robinson: Let me ask you this: Did you report this to Health Canada?

Ms. Carol Cole: No.

Mr. Svend Robinson: Why not?

Ms. Carol Cole: I didn't know who to turn to.

Mr. Svend Robinson: Well, now that you've shared it with the committee, are you prepared to in fact forward the relevant information to Health Canada and to members of this committee?

Ms. Carol Cole: Yes.

Mr. Svend Robinson: Thank you. We'll certainly follow up.

Ms. Carol Cole: Thank you.

The Vice-Chair (Mr. Réal Ménard): Thank you, Mr. Robinson.

The last person will be Madame Bennett.

Ms. Carolyn Bennett (St. Paul's, Lib.): Thank you, monsieur.

A lot of what we've been talking about today is in regard to physician behaviour. First, the facts. Regarding my colleague Dr. Fry's question about whether we even know how many fewer ulcer operations have taken place or fewer pacemakers put in, or fewer admissions for pelvic inflammatory disease, we don't seem to be tracking the other side of the need for drugs. Until we see the big picture, I don't think this committee can make up its mind in terms of looking at graphs that all seem to do this. Yet we know it's doing this, whether it's hypertension, that we're prescribing much more expensive things than we should, or that we're prescribing macrolides for strep throat. Somehow the doctors seem to be the ones with the signatures on the bottoms of these scrips.

So can you tell me, in physician behaviour studies--and obviously that's not the purview of Health Canada, but I think we can do lots of things federally around patient empowerment and education to patients, around producing and disseminating guidelines, even eventually through CIHI, I hope, in terms of the data capture that you're talking about--and the PharmaNet process or your therapeutics initiative, do those have any information on whether doctors in fee-for-service models are more likely to prescribe greater amounts than spending the time on reassurance as opposed to prescribing? Is there anything in terms of the milieu in which a physician prescribes that would be important?

The other question is, do you have any data on giving doctors back their own information about how many prescriptions for macrolides they give compared to diuretics, or if you tell them they're prescribing all this Valium and they thought it was really only a couple of patients?

My experience in trying to change behaviour in obstetrics was that if you showed them their episiotomy rate, they're actually quite competitive and they don't like to be out of sync with their peers and whatever. So could you hand doctors back their own information, or is there something else you would do in terms of changing physician behaviour as a national strategy?

Dr. James M. Wright: I can answer the second part, in that we have done a project through the health transition fund, called the better prescribing project. In that, we did give feedback to the participating physicians on the rate at which they were prescribing the different classes of anti-hypertensive drugs. We encouraged them to increase their prescribing of thiazides, and we were able to show that it did have a significant effect and it would be very cost-effective. So that audit and feedback does work with physicians and is something that would be worth while, but it does cost something and it does require some investment. We would have to get government to buy into that and invest in that.

In terms of whether the practice style has an effect on prescribing, that is an answerable question through PharmaNet, but as far as I know, that has never been asked or looked at.

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The Vice-Chair (Mr. Réal Ménard): Mr. Morgan, do you want to add something?

Prof. Steven Morgan: You've asked the good questions, and actually, in the Achilles heel of research and pharmaceutical policy, the first is outcomes at a population level. We just don't know; nobody does.

The second is physician behaviour. It's a bit of a quagmire for researchers and policy-makers, because it's tough to change physicians' behaviour--and I know you're a physician. The research out there does suggest that there are some interventions that work. The TI has evaluated some of their work.

On funding style and prescribing patterns, somewhat disheartening is the fact that in the U.S., if you look at an area where there is a multiplicity of different organizations or primary care structures within the U.S. market, no segment of that market has had particular success in controlling cost escalation in pharmaceuticals any more than another segment--that's for sure. The one exception might be the veteran administration in the U.S. The VA has implemented systems, particularly electronic feedback at the point of prescribing, that makes recommendations, allows physicians to override, and also gives them some of this peer oversight or comparison of benchmarking to say here's where you fit with respect to your peers. That seems to be influential.

Ms. Carolyn Bennett: Do they prescribe just electronically in the VA now?

Prof. Steven Morgan: The VA, I believe but am not sure, does almost 100% electronic prescribing. Their data platform is quite remarkable. There's a fellow in California by the name of Adams Dudley, a researcher who's done a lot of work on it. If you're interested, I could probably put you in touch.

Lastly, financial incentives work. With the U.K. fund-holding scheme, where physicians were allocated primary care funds for their hospital services, primary care, and drug budget, overnight drug prescribing changed dramatically. You could debate about the net effects, whether for the better or the worse, but there was a dramatic effect on prescribing.

The Vice-Chair (Mr. Réal Ménard): Mr. Perry, you may give a short response.

Dr. Thomas L. Perry: Thank you, Mr. Chair.

Doctors do change their prescribing behaviour when there's something really good. When streptomycin was discovered, everybody started treating TB with streptomycin.

But I'm thinking of things your committee can usefully do in the future. When was the last Canadian trial that answered a really fundamental question, a randomized control trial in Canada? I can think of British, Australian, and American ones. Has there been a Canadian publicly funded trial that addressed a big question like how we best treat diabetes to prevent heart attacks, strokes, and other complications? The British did, and it showed we don't have a very good treatment for that; most of what we're doing doesn't have any impact. We don't pay attention to that because the trial had a negative finding, so we just keep shovelling the stuff out there.

One thing the federal government could do is insist that the really big questions be publicly funded, ones like what the best treatment is for high blood pressure or what the best cholesterol-lowering treatment that actually prevents strokes, heart attacks, and premature death would be. These are multi-million-dollar trials. This isn't peanuts, this is tens of millions, maybe $100 million, for a big trial, but it could save so much money and yield such good outcomes. We're one of the only countries in the world that no longer does this--or never did.

The Vice-Chair (Mr. Réal Ménard): Thank you very much.

The last person for this round is Dr. Castonguay.

[Translation]

Mr. Jeannot Castonguay (Madawaska—Restigouche, Lib.): Thank you, Mr. Chairman. And I thank our witnesses.

Formerly, pharmaceutical companies would often meet physicians in various hospitals to hand out samples. A little later, we saw them inviting them out for lunch, dinner, or sometimes they would buy drinks. Finally, they are inviting them to a one-hour conference that takes an entire weekend in some vacation spot. I think that there are no limits for pharmaceutical companies when it comes to conveying subliminal messages.

Do you think that this really influences the behaviour of health care providers? Do you also think that we should find a way to ensure that these pharmaceutical companies, which, it seems, have a great deal of money for this kind of activity, are stopped from contributing to programs such as this one, to transmit messages other than their own? I would like to hear your comments on this point because I am slightly uncomfortable with this behaviour which seems to be evolving, over time, into something that I am extremely uncomfortable with.

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[English]

Prof. Steven Morgan: Could I just make a comment?

The economist's answer as to whether or not this is influential on prescribing is quite simple. I'm a shareholder in pharmaceutical companies because I have mutual funds in my retirement plan. If those investments in taking doctors to dinner, out on holiday vacations, or to retreats and seminars are not paying off in terms of increased shareholder returns or increased sales, then the company's wasting my money. Over the long run, firms don't make repeated mistakes. These investments they're making have a significant influence on behaviour. If they didn't, we as shareholders would revolt.

Whether it's evidence-based prescribing that's the result is highly questionable. There was quite a good recent analysis done in the Journal of the American Medical Association last year that did a sort of summary review of literature on the influence of this kind of gift-giving by the pharmaceutical industry. It came to the conclusion that it is certainly influential and it's not necessarily evidence-based.

The Vice-Chair (Mr. Réal Ménard): Thank you.

Time has expired for this round.

[Translation]

I thank everyone for coming.

[English]

I will invite the next witnesses to join us, and we will have a short break.

Thank you very much.

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The Vice-Chair (Mr. Réal Ménard): Welcome, each of you. We have three other groups, and we're going to start with Warren Bell, from PharmaWatch.

Dr. Warren Bell (Pharmawatch): Thank you very much, monsieur le président.

I know this committee has a vast area to cover, but unfortunately I'm going to broaden the scope of the inquiry somewhat, so bear with me.

So far the talk about drug costs and the health effects of the pharmaceutical sector in general has focused on comparing one drug to another drug or to yet another drug, on generic versus patented drugs, and on over-the-counter versus prescription drugs. I think we're really talking about Tweedledum being compared to Tweedledee, and it's very hard to make significant inroads on drug costs when you do that.

We live in a society that's actually acculturated to drug industry perspectives. There has been talk, for example, about lazy journalists. Well, lazy journalists get crafted promotional material from drug companies on a regular basis. One of my colleagues, Alan Cassels, a researcher at the University of Victoria and with the B.C. government, went to a meeting of public relations experts working for the drug industry. He was told by the keynote speaker that they were proud to say that every release about the new breakthroughs, the extra therapeutic benefits being achieved, was in fact crafted by their public relations sector; they were very proud of that fact.

The industry has captured non-governmental organizations through funding programs, controls the media in many respects in terms of the material that's fed to them about drug industry behaviour, and has captured my profession. I'm a physician. By the way, I'm a practising physician, a primary care physician. I work in a small town in the centre of British Columbia. I work with patients day in and day out, including in emergency rooms and in hospital-based care.

What I'm hearing many speakers say is that drugs equal health, and nothing could be further from the truth. People I see in my practice who are healthy are people who have not resorted to drugs. In fact, most of the healthy people take the fewest number of drugs, and in fact in many respects their health derives from the fact that they have taken responsibility for their own behaviour. Drugs do not equal health, and the healthiest societies in the world are not those that practise extensive drug use.

Furthermore, I mentioned earlier we're comparing Tweedledum to Tweedledee. The comparators for our health care system and our drug use system are skewed. All the countries that are used by the Patented Medicine Prices Review Board are countries that have very large drug-producing industries, pharmaceutical industries. We're not comparing, for example, drug prices in our countries to those in third world countries, such as Bangladesh, in Asia, Africa, and Central and South America. We're doing a very narrow comparison, and as a result we look at prices in countries where drugs are already embedded in the health care system.

I think the essence of this whole process that's leading to high drug costs is the patent or intellectual property rights system. If you ask anybody from the drug industry, they will tell you, we are searching for patentable remedies, and I think everyone who works in this area knows that.

In my paper I've listed 14 remedial interventions, all of which are aimed at curtailing the power patents confer upon companies that seek them. I've mentioned something about corporations and I've also talked at the end, in the last two recommendations, about one of the really important outcomes of this skewed, insane patent process. It is that all other remedies of all sorts are eliminated from the table, either through dying on the vine through lack of funding or through the aspersions cast upon them by very wealthy corporate spokespeople, who have the capacity to say there have been no studies done on, for example, vitamins or homeopathic remedies.

Ironically, if you look at the broad peer-reviewed literature, there are tons of studies on alternative remedies, but they get neglected and ignored. When I see someone in the emergency room and, instead of an expensive antibiotic for a swelling and redness and pain in their hand, I offer them vitamin C and Epsom salt compresses, I know I'm doing it without evidence-based support. I can't say the antibiotic and the Epsom salt compresses went nose to nose in a study, because no one will ever do that study. And that applies to thousands and thousands of potential interventions.

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So, in brief, the system is skewed around intellectual property rights. It's managed to find products. Costs are escalating. The intrusiveness of the drug industry is increasing, and the kinds of recommendations I've put forward are the kinds that I believe can curtail this runaway process.

Thank you.

The Vice-Chair (Mr. Réal Ménard): Thank you very much.

The next speakers are from the British Columbia Pharmacy Association, Derek Desrosiers and Marnie Mitchell.

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Mr. Derek Desrosiers (Vice President, British Columbia Pharmacy Association): Thank you.

Good afternoon. I'm the vice-president of the board of directors of the British Columbia Pharmacy Association. With me today is Marnie Mitchell, our chief executive officer.

By way of background, the B.C. Pharmacy Association is a voluntary association incorporated under the Society Act. We represent over 500 pharmacies in British Columbia and 1,850 pharmacists, including those employed in both community and hospital pharmacies, the pharmaceutical industry, and academia.

I would like to thank the Standing Committee on Health for the opportunity to present the views of B.C. pharmacists today around prescription drugs in Canada.

Pharmacists in B.C. recognize the enormous challenges facing the country in terms of prescription drugs, particularly as the population ages and the demand for medication increases. It's our hope that our presentation today will make a positive contribution to the committee's study on prescription drugs in Canada.

For our presentation we have focused on two of the issues we felt could make the greatest contribution to the committee's study. They are, number one, the monitoring of adverse effects and prescribing practices, and number two, the misuse, abuse, and addiction within the general population.

Before we begin focusing on those two areas, it's important to understand the role of the pharmacist and to understand the contribution of pharmacists with regard to these two areas. It's important for you to understand the basic education of pharmacists and our role.

No other health professional has a comparable degree of specialty training in drug therapy as does a pharmacist. The key purpose for the profession of pharmacy is now widely recognized as ensuring responsible provision of drug therapy for the purposes of achieving improved patient health outcomes.

In the past when the pharmacist's primary role was to prepare mixtures of medications, services were compensated purely on the basis of a dispensing fee.

Today, in recognition of providing valuable services over and above the dispensing of medications, new payment models are needed to compensate pharmacists for their counselling services. Pharmacists counsel on a number of health care issues such as asthma, diabetes, and anticoagulation services.

When it comes to monitoring the adverse effects of medications and prescribing practices, pharmacists have an important role to play in monitoring the effects of prescription medications and in making recommendations for revised therapeutic approaches when appropriate. However, it is important to point out to the health committee that issues around prescription drugs in Canada should not be looked at in isolation from the overall health care system, particularly when it comes to cost.

For example, adverse drug reactions or inappropriate prescribing can result in increased visits to family physicians and specialists, as well as increased emergency room visits and hospital stays. In other words, adverse drug events impact on the entire health care system.

As stated in the final report of the Romanow commission, as part of the primary health care team, pharmacists work with patients to ensure they are using medications appropriately and to provide information to both physicians and patients about the effectiveness and appropriateness of certain drugs for certain conditions.

For these reasons, the Romanow commission supported an expanded role for pharmacists that would allow pharmacists to consult with physicians and patients, to monitor patients' drugs and use of drugs, and to provide better information and communication on prescribing drugs.

In British Columbia pharmacists are particularly well-positioned to take on an expanded role in the health aspects of prescription medications because pharmacies use an integrated computer system called PharmaNet. PharmaNet provides valuable information for the pharmacist, including profiles of all drugs dispensed, reported drug allergies and clinical conditions, and drug interaction evaluation. In combination with the knowledge and expertise of the pharmacist, PharmaNet puts the B.C. pharmacist in an excellent position to monitor and prevent adverse effects of medications.

What's needed to encourage optimal use of the pharmacist in monitoring adverse effects of prescription practices is a new model that provides more support for pharmacists in this area.

When it comes to the misuse of medications, pharmacists are very aware of the problems, particularly among seniors. Studies have estimated that up to 50% of all medications used by seniors are used inappropriately, and the resultant drug-related problems in seniors can contribute to additional physician visits, emergency room visits, hospitalizations, institutional care, or perhaps even death.

According to the Canadian Pharmacists Association, the estimated costs of misuse and overuse of prescription medications could range from $2 billion to $9 billion a year.

Despite the serious problems of the misuse of medication, the role of the community pharmacist in Canada has largely been overlooked. Even though pharmacists routinely intervene in the drug prescribing/dispensing process to prevent harm from coming to their patients, they are proactive in reducing medication problems and conflicting prescription errors.

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In a landmark study, the Fredericton pharmacy initiative, pharmacists worked with asthma and gastrointestinal patients by providing education and improving compliance with medications. These extra pharmacists' services resulted in a significant decrease in the frequency of physician visits because of better symptom control through improved medication use.

To improve compliance with medications, the B.C. Pharmacy Association believes there is a need to develop and fund pharmacy programs similar to that in the Fredericton pharmacy initiative to secure these benefits on an ongoing basis. Expanding the role of pharmacists to provide greater education and patient counselling can reduce the misuse of medications, improve the health outcomes of patients, and help lower overall health costs.

The Vice-Chair (Mr. Réal Ménard): You have taken six minutes. May I suggest you--

Mr. Derek Desrosiers: I have 30 seconds left.

A new compensation regime is needed to encourage and provide incentives for pharmacists to consult with physicians and patients, to monitor patients' use of drugs, and to provide better information and communication on prescriptions. So with a greater role of pharmacists in both preventing adverse events and ensuring optimal therapy, the health care system will benefit from lower costs and patients will benefit from improved outcomes.

Thank you.

The Vice-Chair (Mr. Réal Ménard): Does Ms. Mitchell have a statement? No? Thank you.

Now we're going to Mr. Calnan, Canadian Nurses Association.

Mr. Rob Calnan (President, Canadian Nurses Association): Merci, monsieur, and welcome to everybody.

As I look around the table, I see many of you whom I have visited in your offices in Ottawa, and I have this opportunity to welcome you to my part of Canada. When I visit you again, perhaps on a cold February morning in Ottawa, I'll remind you of what wonderful weather it is here--and this is what it's like 365 days a year.

We have offered our whole brief to you, so I'll be addressing just the Coles notes version here today.

I represent 230,000 registered nurses who work in Canada in very many different settings, whether it be in hospitals, homes, schools, or in our workplaces.

This study on prescription drug use is an important issue for Canadian nurses because nurses do work in multidisciplinary teams that diagnose and treat patients. We provide medications, write prescriptions, and educate patients and their families. We're also concerned about the unintentional misuse of pharmaceutical products due to low literacy rates, and we're concerned about the lack of system-wide coordination of pharmaceutical prescribing.

As mentioned earlier today, in 2002 it's estimated that Canada will spend in excess of $15 billion on prescription drugs. This is almost double what was spent in 1995, and it's 344% greater than what was spent in 1985. It's the second-largest component in the health care section.

Both Commissioner Romanow and Senator Kirby have recognized these as issues that need to be dealt with. This is a huge expenditure in our system. Canadian pharmacists have said that we know how much we spend, but what we don't know is how much we are wasting.

Dr. Steve Morgan was just here, and he stated that recent studies are questioning the efficacy and the safety of some of the newer, more frequently prescribed drugs that are not significantly more effective than our older or less expensive drugs in terms of improving survival rates, user quality of life, and patient safety.

The CNA would like to see increased government investment in regulation and approval processes to address both the public confidence and risk management issues. In Canada 82% of drug approval processes are funded by pharmaceutical companies, and the perception and the reality is that the current system presents a conflict of interest. We do believe that drug approval process should fall to government.

On Canada's drug patent laws, there needs to be a balance between protection of the intellectual property and the pharmaceuticals and the real need to provide Canadians with improved access to non-patented prescription drugs. We need to learn from the experience in Africa regarding the anti-retrovirals as an example of what can happen if the legislation around pharmaceuticals is dictated by patent legislation.

CNA supports a concerted review of Canada's drug patent laws and we support the development of a national pharmacare strategy. We believe that nobody should have to forego, because of cost, prescription drugs that are essential for their health. We know that 12% of Canadians have no insurance, mainly the working poor; another 100,000 have annual drug expenses exceeding $5,000.

I have a young fellow who is in hospital right now. He is one of those working poor, a 23-year-old seasonal worker. He has an infected finger that requires plastic surgery and six weeks of antibiotic therapy. If he is discharged home from hospital, his treatment will not be covered. He will have to stay in hospital to have his procedures and his costs covered.

CMA believes that the cost of prescription drugs for people receiving community-based, acute-care treatment should also be covered by these plans.

On the unintentional use of pharmaceuticals, 36% of Canadian workers have marginal reading and writing abilities; 80% of people aged 65 have literacy skills that fall below the level of everyday reading demands. The literacy skills of new Canadians who do not have as their first language French or English may not be adequate to understand written instructions. So we would ask that plain language, larger print type, and national, consistent images be used on all prescription labels, and that the information for the patient should be emphasized with side effects and warnings in bold-face type and bullets.

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Now the lack of coordination. I work in an emergency department, just like my colleague. I'm in charge of four emergency departments on southern Vancouver Island in Salt Spring. Daily there are people who come into the emergency department with bags of various prescriptions, not knowing what they're for--I see you're going to cut me off.

The Vice-Chair (Mr. Réal Ménard): I don't want to rush you--I know how popular the nurses are across Canada--but it's my duty to say there is one minute remaining.

Mr. Rob Calnan: That's right.

I would just say that as more and more people go to drop-in clinics and there is a fragmentation in their care, more and more people come and we rely on either their knowledge of why they're getting the drug or their family's knowledge of why they're there. We believe the federal government could take the lead in the necessary infrastructure to facilitate better the communication and coordination among professionals and consumers relating to pharmaceutical prescribing.

Merci, monsieur.

The Vice-Chair (Mr. Réal Ménard): You are very reasonable. Thank you very much.

Now, Monsieur Merrifield has the floor for 10 minutes.

Mr. Rob Merrifield: Thank you very much for coming in.

Actually, Mr. Bell, I'd like to start with you, because from my perspective, you're a breath of fresh air in the sense that you have put the patient first. You're the first person who we've talked to in quite some time not talking about pharmaceuticals, not talking about big companies, not talking about big business, but talking about the patient, and there is this other perspective that maybe we're not going to find every answer to every problem in a pill. Thank you for that perspective. I think it needs to be said, and you said it very cleverly and very well, and I want to thank you for that.

When you start looking at some of the figures that actually Derek had shared with regard to seniors and misuse, I believe, if I heard it right, you said 50% of the meds by seniors were misused--50%. Those are phenomenal numbers when you couple that on top of understanding that they're the largest consumer of the meds to start with.

That's the one side. So they're consuming and they're misusing. What are the effects of that, and what is spilling out? What are we seeing? Maybe the physician would be a better person...and maybe the nurses even can tell us what they're seeing.

The Vice-Chair (Mr. Réal Ménard): Comments, Mr. Bell.

Dr. Warren Bell: Adverse reactions to drugs statistically are very high, and the frequency of adverse reactions increases with the number of prescriptions. In addition, you've noticed that for the so-called basket--which I think is a cutesy kind of term for drugs--the cost of the basket has gone up because there are newer drugs being used to substitute for older drugs that are better known. The likelihood of unknown and unforeseen adverse reactions is increasing because of this trend.

The recent study showing that an ancient drug--a diuretic for blood pressure control--was very effective and more effective than many of the recently introduced drugs is a classic example. It's not a perfect substance; it has a number of side effects, but we know exactly what they are after 40 years of it being on the market. With drugs that have come out for two or three years, we don't know. In the last five years, 20% of drugs that have been introduced have been either recalled or are severely curtailed in terms of their use because of unforeseen adverse effects.

Mr. Rob Merrifield: This is absolutely amazing. I think some of you were in the room when Thomas Perry, I believe, said that 50% of patients who go into hospitals have adverse reactions, most of them not reported.

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Dr. Warren Bell: I'd make one point. Tom told me of his champion. There were forty-seven different medications this person had brought in a bag. It took him something like three-quarters of an hour to film him taking each medication out of his bag.

Mr. Rob Merrifield: That is absolutely amazing to me. I'd heard that we're getting multiple use, patients are on five different medications, up to a dozen, and you're telling me 47. So we see we have absolutely a massive problem. How do we get into that pickle? Who would be prescribing? Which physician would be prescribing 47? And how many physicians would it be? Maybe that's going to point to some of the solutions, but give me your perspective on that.

Mr. Derek Desrosiers: There are a couple of points. That isn't the norm certainly, but it happens more frequently than it ought to for sure. There's no doubt that part of the problem is the fact that a patient who might be on 47 medications--or 30 or 20--is oftentimes seeing a large multitude of caregivers, many physicians, including GPs and multiple specialists, none of whom, clearly, are communicating well with one another.

In British Columbia, fortunately the PharmaNet system does provide the pharmacist with an effective tool to help bridge that communication gap and provide information from one health caregiver to another. So we do have the ability to curtail that in British Columbia, perhaps better than most other provinces, at least through the pharmacies.

Mr. Rob Merrifield: That--

The Vice-Chair (Mr. Réal Ménard): I think Mr. Calnan wanted to add to that.

Mr. Rob Calnan: I think the other part of it is that we did do a limited study of patients presenting in our emergency department who were 65 years and older, and 78% of them have at least six or more prescriptions filled poly-pharmacy; 78% are presenting in the emergency department. You asked, what is the fallout of that? Whether it be because they have a GP and multiple specialists or because they're going to clinics where they're seeing multiple physicians, we haven't got a way of clustering and bringing together all the medications there are. The danger is we're relying on the patients themselves or their family members to know why they're on the drug and how long they've been on it. Oftentimes people will tell us, “I take two of the blue ones, and the yellow one, or a green one, and I think this is my blood pressure pill and this might be for my water.” And we are relying on people to do that.

We have a PharmaNet system here, and I think it is a good start. That's why we would say one of the things the federal government can do is make an investment in the infrastructure to develop those kinds of things that can get a handle on poly-pharmacy.

Mr. Rob Merrifield: I'll tell you something. What bothers me, and what I've heard in the last two or three weeks since we've been looking at this study, is that we know very clearly that the government is doing absolutely nothing as far as knowing what kind of a problem we even have out there when it comes to addiction to prescription medications. You're starting to tell us numbers that are absolutely alarming, if they're anywhere close to being accurate. If you cut those by 50%, it's a disaster.

So we have a very serious problem that has not been really addressed or looked at. Hopefully this study will point to moving it towards looking at some of those solutions.

When you get to your PharmaNet program, what percentage of your physicians are hooked into that? We heard that there are very few from one of the physicians this morning.

Mr. Derek Desrosiers: That in fact is true. It has been made available to physicians for some time now, but the number of physicians is very small, quite likely more due to the fact that they aren't willing to put out the dollars it might require to raise the level of technology in their own offices to be able to make that connection than for any other reason, not because they don't believe in the true benefits the system can provide to them.

Mr. Rob Merrifield: Pharmacists are engaged in the process, but physicians are not, is that right?

Mr. Derek Desrosiers: Every single pharmacist and every single prescription dispensed in this province must go through that system. There's no other way for it to happen.

Ms. Marnie Mitchell (Chief Executive Officer, British Columbia Pharmacy Association): I want to reiterate Derek's point that there is low physician use of the PharmaNet system. It has been made available. It started on a pilot basis and a certain number of physicians stayed with it. There are some technological problems for them, so it hasn't become a particularly effective tool in the physicians' hands. In the pharmacists' hands, they are all on it and extremely familiar with it.

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Mr. Rob Merrifield: What would it take to fix that? Just funding or technology?

Dr. Warren Bell: Physicians can call their local community pharmacist and find out the profile of anybody in the system, but they don't have the technology to access it electronically.

I think physicians just don't bother to do it, to be honest.

Mr. Derek Desrosiers: That quite often is the case. We could make better use of the technology, however, if we did have all physicians connected to it and the physicians used it appropriately, because it would result in them having better information at the actual time of the prescription being written for the patient, and therefore potentially more appropriate prescriptions being written, as well as the fact that we could get into using the technology for other purposes such as electronic prescribing.

Mr. Rob Merrifield: One of the other things I was interested in, in what you said, Derek, with regard to what you're asking for is that one of your recommendations is that you fund the pharma-community much more to do more of the surveillance of adverse reaction.

What kind of funding would it take, and why would it take more funding when you're already into this?

Mr. Derek Desrosiers: It's really a question of getting us out of the silo-type of mentality that drugs and funding for drugs is separate from all other types of health care funding. We seem to have had that mentality both at a federal and a provincial level forever. We need to get out of that and recognize it and make a disconnect between that link of pharmacists with drugs.

Pharmacists provide a lot of other services, and if we funded those services from elsewhere within the health care budget, not necessarily, for example, at a provincial level, from the pharamacare budget, but perhaps rather from MSP, where some physician funding comes from, because we're providing a similar type of service in regard to pharmaceutical care, then we're really talking of a reallocation of resources, not necessarily new resources, because in the end we're talking about pharmacists providing services that are going to prevent patients from potentially showing up in the emergency department from long hospital stays.

The disability costs to employers in this country are absolutely enormous.

Mr. Rob Merrifield: What would it look like? Are you suggesting that when an individual presents himself and you see he's on 47 drugs, you have somebody funded to be able to look after consultation about that? Is that what you're looking at? What are you really contemplating?

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Mr. Derek Desrosiers: You could have in fact a number, multiple types, of funding models, but essentially it would be that the pharmacists would be providing a level of what we call pharmaceutical care that would essentially monitor the patient's medication and use of medication to ensure that it was being used appropriately to maximize their outcomes and prevent adverse drug reactions and to correct those that have already taken place.

The Vice-Chair (Mr. Réal Ménard): We'll go now to Ms. Bennett.

Ms. Carolyn Bennett: Thanks very much.

One of the things that has been proposed from the CIHR is centres of clinical excellence as the next step. From what Dr. Perry had suggested the proprietary interest is still what's funding lots of the research, so best practices, or optimal treatment, in terms of chronic diseases doesn't tend to happen in a holistic way.

If you were sitting on this committee, is this something you would support, that CIHR have the ability to fund centres of clinical excellence that would do a multidisciplinary approach, so that whether it's the nurse giving advice and taking time with patients, or whether it's the ginger root or acupuncture, or whatever, we should be able to find ways of finding out what actually is the best treatment for certain conditions?

Dr. Warren Bell: I think as long as people, or groups or entities, whose financial survival depends on product development are funding programs of education--for example, the clinical competency program at UBC is funded by the drug industry, which is amazing because it trains doctors at the beginning of their careers--I think the ability to have a true, broad, and holistic focus is sharply limited.

We're talking about a cultural shift here, and our culture has been skewed towards seeing pharmaceutical products as engendering health when really they are for crisis intervention.

I think, for example, if pharmacists were introduced into the medical curriculum early on, as well as a variety of different kinds of practitioners and approaches--if the nursing profession was made part of the medical profession's sphere of experience early on in training--yes, these kinds of things would happen.

I think the unfortunate cultural bias of our profession has been that we're top banana and we don't really need to listen to other people because we have the answers. We're starting to realize that's not the case, and we're becoming holistic in our thinking. But in terms of broad care, I think unless we introduce alternatives we will have 47 drugs, if all doctors think the only thing you can do is give drugs to patients.

Ms. Carolyn Bennett: In terms of being trained together, I think that's something a lot of us felt should happen; that is, why don't we take pharmacology classes with the pharmacy students? Why don't we take counselling classes with the social work students? If we actually ran a health science faculty in a multidisciplinary way, we then could be surprised if people don't know how to work on teams when they come out.

I wonder if you think that would be a recommendation. I remember sitting on a subcommittee on drugs in the early 1990s that had something to do with what the Ontario government was doing, and we sat on the subcommittee in the role of the pharmacist. Everything we did got blocked by the medical association, whether it was that the pharmacist should be allowed to do things like send in the patient's fax form of their blood pressure over the month, or renew a prescription if it's within the criteria, as they do in hospitals, or do throat swabs, or all kinds of things.

Do you think this expanded role of pharmacists would actually be helpful, and are these things that you would see as part of the drill, where if people get into the doctor's office they're more likely to get drugs?

Mr. Rob Calnan: If we looked at maximizing the knowledge, skills, and abilities of all health care providers, which is really what Commissioner Romanow was saying, I think that will really optimize health care availability to all Canadians. That I think would be a step in the right direction.

The other thing is that centres of clinical excellence have really moved agendas forward, and I think if they're multidisciplinary that could really be beneficial.

The third thing I think is the whole idea of a patient safety institute. We know that many of the problems we're talking about today are drug problems or drug-related problems, or poly-pharmacy. I think this initiative of looking at a patient safety institute can really further our understanding of many of those difficulties, so I think you're on the right track.

[Translation]

The Vice-Chair (Mr. Réal Ménard): Mr. Desrosiers.

[English]

Mr. Derek Desrosiers: I completely concur with what Dr. Bell has said on this issue, and Mr. Calnan as well. The multidisciplinary approach is one that we fully endorse in pharmacy, and it's an opportunity. Just as with physicians, if we can get away from reimbursement for pharmacists being solely on the basis of the provision of a product, then we're going to start to move to pharmacists providing other alternate types of care, because there is a segment of the population whose first contact with the health care system is when they enter the pharmacy. There are a number of people who will come to a pharmacy before they'll go to the doctor. And it may be that the pharmacist provides a recommendation to see a health care provider of another sort--it may be a physician, it may be somebody else--or provides perhaps an over-the-counter herbal or homeopathic remedy, or even some kind of home remedy. But right now there's no incentive for pharmacists to move in that direction because they don't get paid unless they give somebody a drug.

The Vice-Chair (Mr. Réal Ménard): A final statement, Mr. Bell, and then we're going to Mr. Thompson.

Dr. Warren Bell: I would include, Carolyn, one other key component in these kinds of holistic, multidisciplinary approaches, and that is patients or patient representatives, or citizens, if you like--I don't mean patient in the sense that somebody is already ill--who don't have a professional or corporate, a regulatory, perspective but do care deeply about how the system works. The College of Physicians and Surgeons in B.C. has some wonderful physician representatives on its board--

Ms. Carolyn Bennett: Citizen representatives.

Dr. Warren Bell: Yes, citizen representatives, and they keep the docs on their toes--one of them is a medical anthropologist.

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The Vice-Chair (Mr. Réal Ménard): Thank you very much.

We're going now to Mr. Thompson.

Mr. Greg Thompson: Thank you, Mr. Chairman.

I'm quite taken, Mr. Bell, by your story on Gravol. Yes, there's no medication like it. I want to let you know, though, on the floor of the House of Commons, where nausea is often experienced, depending of course on the speaker at the time, in all my years in Ottawa I've never used Gravol. Maybe I'm an exception to the rule. Maybe I should try it, that's true. After today, I probably will.

Some hon. members: Oh, oh!

Mr. Greg Thompson: That being said, I want to go through this cultural dependency question, if you will. I do know we have physicians at the table and so on.

Where the problem is, I guess, to someone who's outside looking in, is that it almost intrudes into every aspect of health care, because physicians are basically trained to the understanding that there's a pill out there, a cure there somewhere, but not concentrating on good health, on vitamins and supplements and all the rest of it. My oncologist is probably one of the best in the world, a Canadian oncologist, but he knows virtually nothing about nutrition. And it surprises me. I say “How could a person so intelligent and so well-trained not examine that little area?”

I guess what this leads me to say is possibly prescriptions for placebos might be the best prescriptions written in many cases. Would you comment on that?

Dr. Warren Bell: The only difficulty with a placebo is that you're putting a barrier of understanding between yourself and your patient. You're assuming the patient is incapable of understanding the fact that he or she doesn't have a condition requiring a drug. I found it much more helpful to broaden my therapeutic horizons.

I started out being trained at McGill as a conventional medical doctor. After critiquing the pharmaceutical industry for a number of years, I got tired of that. I thought there must be something else to do, and I discovered that once I opened my mind, remarkably, patients came to me often with superb and peer-reviewed medical literature documentation for therapeutic interventions that I had never considered, because I believed the conventional cultural attitude within my profession that there's nothing out there besides drugs, surgery, and maybe radiation if you're in dire straits.

As it turns out, there is a plethora of alternatives that can be used. The primary one is looking after yourself. Plato talked about the six non-natural things that you wouldn't...different from wine, women and song; things like exercise, temperance in your eating habits, and sensible behaviour of that nature. So these are not new ideas.

If the culture, not only the culture within my profession but the culture broadly, is so imbued with all-pervasive pharmaceutical thinking--and Health Canada often thinks like the drug industry as well--keeps on going that way, we'll never get a handle on costs and we'll have people with bags full of medications coming into emergency rooms.

Mr. Greg Thompson: Thank you.

On page 3 or 4, whatever, of your report, in the section titled “Patents”, I.... Not that any of us really disagrees philosophically one way or the other, I guess, and I'm not saying I do or I don't, but where does the balance come in? Obviously, the patent drug protection allows the intellectual and financial protection for investing in drugs and so on. Maybe I'm passing judgment on the formula you're suggesting for fixing that, but it looks very simplistic in the sense of how it might....

It's not a reflection on the author, but I know you're basically struggling to come up with a solution to this problem. Obviously, you know full well the advantages that come with the investment and research and the tons of dollars it takes. But where do we cut this thing off and say you have made a reasonable return on your dollar? I guess the genie is sort out of the bottle, or is it in the bottle? Where do we go from here?

Dr. Warren Bell: There are two specific suggestions. One is the restoration of compulsory licensing after a short period of time. In Canada it used to be four years. Then you had to allow someone else--

Mr. Greg Thompson: Let me break in there. Of course, we were out of the world order, if you will. In other words, we were not getting that type of investment in Canada in the pharmaceutical industries. They just refused to make that kind of investment because they didn't get that intellectual protection. So can we basically throw that away?

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Dr. Warren Bell: Actually, they didn't invest in Canada because they were extremely annoyed at the Canadian government for setting a very bad example to the rest of the world. Canada was punished by the industry because it felt that Canada was setting an example that other countries in the third world would pick up on. In fact, many did. They established national formularies. Bangladesh, for example, had the United States government after it because they established a national formulary and resisted patent imposition on the country.

The industry was very happy when, first, under the FDA and then the NAFTA negotiations, patent protection was extended, not because they were losing money but because they feared the example would be picked up by too many other jurisdictions. There is not a shred of evidence, I said here, that profitability was impaired during that period of time.

Joel Lexchin, who is a well-known critic of the industry in Ontario, has written extensively about this, and he communicated to me before I came here, because I wrote this “not a shred of evidence” statement, and he said...then we had an argument. Peter Mansfield, who is in Australia, a healthy skepticism writer, said the core of this was that in fact, yes, they were upset, but they did not--

Mr. Greg Thompson: Just a short question. I don't want to take this subject--

The Vice-Chair (Mr. Réal Ménard): Last one.

Mr. Greg Thompson: I think I'm the only one at the table here who actually stood up and voted for that piece of legislation in 1991 or 1992.

Mr. Svend Robinson: I voted against it.

Mr. Greg Thompson: Svend did vote against it, much to his...whatever. I won't get into that.

I guess the reason I'm saying that is, why the change in philosophy by the current government? Every Liberal member of Parliament at the time voted against it. Now Mr. Martin embraces it, John Manley embraces it, and so does the present Prime Minister. Why that change of heart? In other words, is it working? Why would they have that philosophical change if they were so opposed to it then and today they embrace it?

Mr. Svend Robinson: Well, Mr. Thompson, shall we take a bit more of my time to pursue the question?

Dr. Warren Bell: I think they've changed because the cultural climate has changed, and the political realities are that if you approve that, you'll maybe get more votes. In terms of whether it's right or whether it's working for the benefit of Canadian health, I have serious doubts about that.

The Vice-Chair (Mr. Réal Ménard): A short comment.

Mr. Derek Desrosiers: The only thing I would add is that potentially one part of the justification for it is that we do have a very healthy generic drug industry in this country. We have probably one of the most healthy generic drug industries in the world, so it isn't a stretch for patent-producing drug companies to point to the health of the generic industry and say it's doing very well, thank you very much. They don't want to make any changes to the way they're regulated because clearly they're not suffering either.

The Vice-Chair (Mr. Réal Ménard): Thank you very much. I'm sure some colleagues will raise other questions on this topic.

Now it's Mr. Dromisky.

Mr. Stan Dromisky (Thunder Bay—Atikokan, Lib.): Thank you very much. Your presentation was most refreshing. In light of all the other presentations we've had before the committee in the past weeks, there's hope.

I will get to the point. The federal government has put out all kinds of wonderful brochures and pamphlets and all kinds of documents with all kinds of rhetoric, and when any person who's capable of reading tries to understand those concepts, they think they're in heaven. The rhetoric contains such wonderful, wonderful statements about our health care system, but when you start examining and questioning them, you find out there's nothing really there.

There are so many gaps, so many holes in that whole system. You believed...you were brainwashed into believing they were there, and the same thing is applicable to the medical system. The same thing applies to the pharmacists. I can't find anything negative about the nurses. They work their asses off, that's true.

You talk about PharmaNet. We had a witness here earlier who said it's practically non-existent. There are very few who are involved in the Net and very few have the computer or the system or the program. You're giving me the impression, with the statement you've made, that it's comprehensive, it's all-inclusive, and it covers everybody, but I don't think that's what you really meant.

Mr. Derek Desrosiers: It is what I really meant, actually. The statement you heard earlier, from whoever said it, was that there are very few physicians involved. Every single pharmacist and every single pharmacy and every single prescription that goes through a community pharmacy in this province, whether it's for you or for somebody visiting from Germany or for a resident here, goes through that system.

Mr. Stan Dromisky: So it's the doctors who are not plugged in.

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Mr. Derek Desrosiers: Correct.

Mr. Stan Dromisky: Oh, okay. Very good.

Now, let's look at the doctors. In light of all the comments that have been made by so many witnesses and so forth--the overprescribing of drugs, and I've been told things like every doctor has a stable of maybe 8, 9, 10, 11, 12 drugs, and I'm generalizing, I know. They say, “Oh, this doesn't work any more, Mrs. Brown? Try this one. Oh, the blue one doesn't work any more? Try the green one.” They keep going through this kind of process. I want to know why.

Ms. Carolyn Bennett: There are good doctors too.

Mr. Stan Dromisky: I know that. I'm just generalizing. Yes, those are bad doctors. Those are bad doctors, okay?

I think we have to find out why these kinds of things are happening. We know they happen. We don't need a committee to find out they're happening. But why are they happening?

In Ontario the other day a doctor said to me “I'm on half time.” I said “Well, how many patients do you see in a day?” He said “Up to 40.” Wow! But what does that mean? That's an encouragement, possibly, to give them drugs as fast as possible, and not counselling or spending time to examine and to discuss and to have explanations and so forth. I don't know.

Could I have a reaction to what I've just said? I think we have a very serious problem and we're not really looking at why. We're talking about how, but we can't come up with an answer to how if we don't know why.

Dr. Warren Bell: Video studies of doctors in their offices seeing patients have shown that when patients don't receive a prescription, in general they're more comfortable with the visit. The handing out of the prescription is often the signal that the visit is over, so physicians do indeed use it, pulling out a prescription pad as a gesture to indicate the time is up.

I think when you're dealing with a profession like mine, which unwittingly or otherwise has stumbled into a very intimate interrelationship with the pharmaceutical industry, to the point where the establishment of medicine tends to decry involvement with other kinds of practices and with other professions, you are dealing with a sort of cultural problem that needs to be addressed, first through medical school, but it also needs to be addressed maybe in a more public way. One of the recommendations I made here was for a royal commission examining publicly the relationship between the pharmaceutical industry and the medical profession.

It is true that when you tell in public what doctors are doing in private, doctors react very sharply. A study done comparing Saskatchewan's and Manitoba's hysterectomy rates showed that one province's rate was double that of the other. They put it in the newspaper. Bingo! Within a couple of months the rate in the high province dropped down to the rate in the low province. Physicians are very susceptible to adverse publicity. The trouble is maybe there isn't enough of it, or it's not focused enough. It has to be detailed and precise. So I think that would be one very important step to take.

The Vice-Chair (Mr. Réal Ménard): Do you have a last question, Mr. Dromisky?

Mr. Stan Dromisky: No.

The Vice-Chair (Mr. Réal Ménard): Thank you very much.

We'll move to Mr. Robinson.

Mr. Svend Robinson: Thank you very much.

This has been a fascinating panel, actually, because we have people who are really on the front lines here--pharmacists, physicians, nurses--and we'll be able to benefit from your experience. Certainly it has been a real eye-opener for me.

I wasn't exactly sure whether my colleague, Mr. Ménard, would agree with Dr. Bell's prescription of wine, women and song. I think we're with you on the wine and the song, but on the--

[Translation]

The Vice-Chair (Mr. Réal Ménard): Listen, Mr. Robinson, I will take up this challenge, if you agree.

[English]

Mr. Svend Robinson: It's two out of three. That's not bad.

The Vice-Chair (Mr. Réal Ménard): You forgot the Viagra.

Mr. Svend Robinson: I'm not sure if Bonnie, Hedy, and Carolyn would necessarily agree with that formulation either.

Moving right along, you've talked about incentives to pharmacists to get more actively involved in some of these issues around follow-up and so on. One of the suggestions I've seen is to give them the same opportunity for tax deductibility as others who do get that. I believe the Canadian Pharmaceutical Association made the suggestion. That's certainly something we would want to look at seriously as a committee.

I have a couple of questions. Dr. Bell, the patent issue is one I certainly feel very strongly about. As my colleague, Mr. Thompson, mentioned, we fought tooth and nail against an end to compulsory licensing. I was actually there long before 1991 and 1992, when we first saw the erosion of access to affordable drugs. Canada used to have some of the most affordable drugs in the world, as you know, and that's gone.

I came across a fascinating study from 1963 by a body called the Restrictive Trade Practices Commission. It actually recommended that we get rid of patent protection, and to the extent that we had to support research, that it be publicly supported.

Now, 40 years later, an article was published recently in one of the prestigious journals making exactly the same point--I think it was the New England Journal of Medicine. I'll circulate it to my colleagues. They made the point from a financial perspective as well. They said taxpayers would save literally billions and billions of dollars if, instead of sort of accepting this siren call from the big pharmaceutical companies.... Basically it's bribery, you know. Unless we give them 20 years, they're going to pull out their research facilities and go somewhere else. I know in Quebec we hear that a lot. The Bloc is struggling with that, so far unsuccessfully.

The reality is--I'd be interested to hear from you, Dr. Bell--that maybe it's time we looked at a bit more radical solution here. Do we really need to provide this industry with 47.1% return on investment, which is what it was in a study that was recently established? Maybe we have to look at some serious options, in terms of public support for research, that will not just be based on the bottom line but will actually--and this is a revolutionary thought--be based on how we find cures for diseases. How do we promote wellness?

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Dr. Warren Bell: Milton Friedman, the guru of market economics, who won a Nobel Prize for his work in this area--a free-market promoter par excellence--hated patents. He said they were collusive agreements and allowed profit taking that would otherwise never take place. That's the first point I'd like to make. As a general rule, patents not only give enormous profits to small numbers of corporations, but they also de-emphasize every non-patentable approach whatsoever.

In fact, if you go down the list of so-called alternative remedies, they're all things that can't be patented. That's all they are. You can't patent chiropractic, massage therapy, or vitamins. Any molecule that is produced in the natural world is off the stage, as far as patent-seeking entities are concerned. So basically you've got a skewed system from the get-go, with the existence of patent laws.

That said, notice I haven't said in my recommendations to abandon the patent system. I have made some specific recommendations to get away from this overweening gigantic profitability factor that I think is there.

A study done at the University of Arizona some years ago showed that whereas companies claimed it took them something like eight years to get their money back, it actually took them four years. So they had at least eight years of pure profitability. Then, of course, they have patent duration of 15 to 17 to 20 years, depending on jurisdiction, so they are making money hand over fist. Patents can be owned by corporations, not by people. The inventor often has to sell his patent rights these days to a large corporation, because he or she cannot afford the development costs.

I've recommended to have an independent panel that judges when the costs have been recouped. Give the company or individual an extra margin of 25% to 35%, whatever, and then leave it at that. You've got your return. You're out of the business. Also funnel money that's derived from patent revenue into some of the remedies that do not have access to those kinds of gigantic treasure boxes.

Mr. Svend Robinson: You make that point in your brief.

I have just one other brief question, if I may, to representatives of the B.C. Pharmacy Association. One of the concerns that I know has been raised in a number of jurisdictions in Canada is the extent to which pharmacists are subjected to the marketing excesses of the big pharmaceutical industry, as well as physicians. We've certainly heard about physicians. We heard earlier today about the cruises, the conferences, and everything else.

To what extent are you as pharmacists also subjected...or perhaps from your perspective you wouldn't necessarily be subjected. But to what extent do you receive offers of generous conferences, or other financial incentives, to promote particular products?

Mr. Derek Desrosiers: It's by no means as rampant in the profession of pharmacy as it is in the medical profession, for sure, but it is there. It's usually conferences. It's quite often, I would have to say, the generic industry, or certainly they're doing it as much as the brand name drug industry, for sure. Quite frankly, though, it's usually without the attachment of much in the way of strings, mostly because I don't think those companies truly believe pharmacy has enough influence to affect the prescribing of their products, or certainly not the type of influence that the medical profession has.

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Mr. Svend Robinson: If you had more influence, then, you might be more subject to that.

Mr. Derek Desrosiers: Probably, yes.

The Vice-Chair (Mr. Réal Ménard): It's eight minutes. Thank you very much. Good questions.

Ms. Fry.

Ms. Hedy Fry: Thank you, Chair.

I'm sorry, but I have to comment here. I think there are a couple of things we need to put on the table. Any drug, by nature, will have a side effect. Because a drug is something you take to counteract something else, it's going to have a chemical reaction in your body, a physiological reaction in your body. So what we're talking about here is how we keep tabs on the effects of drugs that cause mortality and morbidity, how we flag that, how we report that, how we know about that.

We must be mindful of history and remember all the small children who used to die from simple things like scarlet fever. The advent of antibiotics has really helped us a great deal. At the same time, I don't want us to say, “Drugs bad, everything else good”, and to think that the laying on of hands and everything is what we must turn to. There is a use for pharmaceutical therapies within any kind of treatment. How we use it appropriately is the question we want to answer. What are the parameters we put around it to ensure that it is being used in a manner that is the best, the most cost-effective, that gives the best outcomes for the patient?

That's my first question, and I'd like to hear what you have to say with regard to that. What are the checks and balances we need to put in place for that?

Now, Rob talked about access to drugs by low-income persons, the kinds of persons who do not have any kind of prescription insurance, the working poor. This issue is of great concern to me. I remember these people would come into the office when I was practising medicine. If they had two kids that they had to give medicine to, they couldn't afford to go out and buy that medication. They weren't on welfare but they didn't have the money to buy that kind of stuff.

How do you help those people have access? That's the question I would like to ask. In other words, how does bringing down the cost of drugs give that availability to low-income families to be able to have appropriate drugs when they need them?

Perhaps, Rob, you can give me some ideas on how you see that happening.

I just want to say one more thing about PharmaNet.

The Vice-Chair (Mr. Réal Ménard): Please keep it short.

Ms. Hedy Fry: The chair and I were both on a special committee on the non-medical use of drugs, and we were quite impressed with the British Columbia presentation with regard to not only PharmaNet but also triplicate prescriptions, etc. We had recommended in our report of December 2002 that this become a national practice and that colleges of pharmacists, colleges of physicians, and government work together to make this so, in order that we can link them.

You know, poly-doctoring and poly-pharmacy really are things that one needs to keep tabs on with that kind of system, in terms of how that information becomes accessible. We know that is a good thing, and we made the recommendation to bring it forward, but I'd like to hear from Rob, perhaps, or whoever chooses to answer on my first question.

The Vice-Chair (Mr. Réal Ménard): We can start with Ms. Mitchell.

Ms. Marnie Mitchell: Thank you.

I want to comment on the question about the working poor and the ability to purchase pharmaceuticals. In this province there was a change in the provincial drug plan this year. It was a change that actually had been advocated and supported by our association, which was to go to an ability-to-pay system for the provincial drug plan that started to eliminate the distinction based on age, which had been the way the drug plan had been set up before, where it was very generous for seniors but not very generous for low-income families. That change did come in, and it's meant for the lowest-income parts of the population. They actually are getting quite a bit more support from their provincial drug plan than they used to.

So that's one approach that's been taken here, and as I say, it's one that we supported.

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Ms. Hedy Fry: Thank you.

The Vice-Chair (Mr. Réal Ménard): Monsieur Calnan.

Mr. Rob Calnan: Dr. Fry, I remember following your career as a physician dealing with some of those patients who couldn't have access to different drugs and those sort of things, and I've always admired you for that.

One of the things we know is that 12% of Canadians currently do not have insurance for prescription drug expenses. They may work in small companies or in jobs that don't have medical coverage, those sorts of things. So we know a lot of people, through their workplaces and other means, can have access to drug coverage. We also know there are 100,000 Canadians who have drug expenses over $5,000 a year, and seniors are the most affected by this. Many of them told Senator Kirby in his hearings that they were worried about their life savings being lost trying to maintain the cost of their drugs. The Canadian Nurses Association believes that if we are to have a national pharmacare strategy--and this was promised in the first ministers health accord in February of this year--it should extend the terms of that commitment, not just to the catastrophic drugs, but to those drugs.

Ms. Hedy Fry: Thank you, Rob. I wanted you to say that for the record, because I needed it.

With the formularies we have at the moment, as you well know, generic drugs are the drugs that are being paid for. We know that not as a general rule, but occasionally, there are patients who do not do very well on the generics and actually need a brand name. What happens to those patients, and what can you suggest we do for those patients, so that they can have access and that the government formulary doesn't override either a physician's or a pharmacist's recommendation for the patient?

Ms. Marnie Mitchell: Here there actually is an exception process. If the physician is going to make the case that their patient needs the patent product, they can do that and the plan will pay for it.

Ms. Hedy Fry: I understand, though, that if the physician, knowing this, has written the brand name drug, there is an automatic substitution, even if the physician says no substitution on the prescription. How does that work? I know that happens. I have been reading a series of articles in the Vancouver Sun about people who have not been able to have access, because it was automatic. As long as it was a formulary patent, there was automatic switching to a generic, even if the physician said no.

[Translation]

The Vice-Chair (Mr. Réal Ménard): Mr. Bell.

[English]

Dr. Warren Bell: The difficulty in this area is that some of what is being said is more general than I would be comfortable with. I am old enough to remember the QUAD program in Ontario, which was a program of monitoring drug labels, date, and potency. It showed that there was an equal number of problems on the brand name and the generic side. I'm not convinced that generic drugs are always inferior and, by contrast, that brand name drugs are always superior in respect of basic pharmaceutical characteristics. I think we need to have a spot monitoring program--zip in and buy a couple of bottles, take it off to the lab, and check it. It's a shame that we don't have it. We certainly need it for natural health products.

[Translation]

The Vice-Chair (Mr. Réal Ménard): Mr. Castonguay, you have the final words.

Mr. Jeannot Castonguay: Thank you, Mr. Chairman, and I thank our guests.

We spoke a great deal about drugs and about over- prescription and the fact that health care providers often work in isolation, or in silos. In this regard, we said that it is important to have more communication and information sharing, and that this could help to reduce the internal costs of the system.

First, do you think that the electronic file, or the so-called smart card, would improve information sharing? In this way, patients could bring their cards or files to the drugstore or to the physician. It could contain much information; however, confidentiality will have to be ensured.

And then, what role would the federal government play here? We know—as we are constantly reminded—that health care delivery is a provincial matter. Now, if we want to reach our goals, how can we improve relations between the federal and the provincial levels?

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[English]

The Vice-Chair (Mr. Réal Ménard): Mr. Bell.

Dr. Warren Bell: My sense is that there are many technologies available now to improve communications. I think we need the will to do it and action taken to make it happen. I don't think the obstacles are primarily a lack of technology; I think it's a lack of perception that the communication needs to take place. I've commented earlier about the sometimes obstructionist behaviour of my profession in working out better relations, for example, with pharmacists and the nursing profession. We're not the only problem, but there's a cultural bias towards thinking of ourselves as top banana. When that's surrendered, these technologies will start to be used. They're available. PharmaNet is beautiful. It's a wonderful way of finding out everything you need to know about a patient's drug profile, but you have to use it, you have to believe, and that means education, starting in medical school, at the very beginning of one's career.

Mr. Rob Calnan: One of the things I think the federal government can look at is that collaboration, communication, and coordination in health care are very fragmented across this country and in every province. I believe the federal government can take a lead in the electronic health record, and I think that will go a long way in moving forward on the disparities and the discrepancies between provinces and jurisdictions.

The Vice-Chair (Mr. Réal Ménard): Thank you for coming.

Now I'll adjourn the committee.