 I think we're ready to get going. Thank you all so much for being here, both online and in the room. I'm Sheila Wildman, and I'm the Associate Director of the Health Law Institute. And it's my pleasure to welcome you to the last in this year's Health Law and Policy Seminar Series. We're meeting in hybrid form today, both online and in-person in MiG-Magi, the ancient and unceded territory of the MiG-Magi. We pay respect to the indigenous knowledges held by the MiG-Magi people and the wisdom of their elders past and present. We also acknowledge the histories, contributions and legacies of African Nova Scotians who have been in this territory for over 400 years. This year, we convened the seminar series around the theme health and social justice, making the connections. It sounds really simple, but perhaps it's simpler in theory than in practice. Today's lecture brings our series to a fitting conclusion and opens the way for a whole new set of conversations. I have the great honor of introducing Dr. Nav Persaud. Persaud, thank you. Dr. Persaud holds a Canada Research Chair in Health Justice, is a staff physician in the Department of Family and Community Medicine at St. Michael's Hospital in Unity Health, Toronto, and is also an associate professor in the Department of Family and Community Medicine at the University of Toronto. Dr. Persaud's research focuses on health equity or fairness, especially as it relates to medicine access. In just one expression of that, he's involved in comparing national essential medicines lists in collaboration with the World Health Organization. Dr. Persaud's lecture is entitled, As You See, Access to Essential Medicines, More Than Just a Human Right. Please join me in welcoming Dr. Persaud. Thanks very much for that really kind and generous introduction. It's really great to be here with all of you and appreciate the invitation. Just a standard disclosure slide. Don't have any funding from the pharmaceutical industry and it might be clear why, as the talk goes on. Although I have received some interesting offers, actually, that we can chat about if you're interested. Grateful for support from my research from a number of public sources and from the University of Toronto at St. Michael's Hospital in Toronto. And I'm really pleased to be able to present some of the work my colleagues and I have done on a clinical trial some international comparisons of essential medicines access. And then finally, talking about human rights here in Canada as it pertains to medication access. Canada is the only high income country in the world where healthcare services are publicly funded but access to medications generally are not. And instead, access to medicines tends to rely on employment or on social assistance. People on welfare or disability often receive publicly funded access to medicines but there would be many people who don't and nationally representative surveys indicate that millions of people don't have any type of insurance and cannot afford medications. Those would include lifesaving medications like insulin for people with type one diabetes was discovered more than a hundred years ago and their rights for insulin were sold for a dollar each to the co-discoverers in the interest of having access to insulin for everyone who needed it. And yet there are people today, my patients who can't afford insulin. And this issue of cost-related non-adherence not being able to take medications as instructed specifically because of the cost does not apply equally. It's a highly gendered and racialized issue because it's tied to employment. Several studies looking at cost-related non-adherence have found that indigenous people and other racialized people are more likely to report cost-related non-adherence compared with white people. So that's not being able to afford medications because of the cost. And so I'm about to present some of the results of a clinical trial that my colleagues and I from across Canada conducted addressing this issue. There are a number of sites involved. Most of the patients were from family medicine sites and primary care sites associated with St. Michael's Hospital. And there were three other sites, three rural sites in Ontario close to Manitoulin Island. So we randomized 786 people who reported that they couldn't afford medications. And these would include people who work in jobs where they didn't have private insurance. So there were some artists in the study. There were people who worked in factories. There were taxi drivers. And these people wouldn't have access to private insurance. And they often would have a low or uncertain income and therefore not be able to afford medicines. And anyone who reported cost-related non-adherence in the last 12 months was eligible to participate. And then half the participants roughly were randomly allocated to receive free access to a carefully selected set of medicines. And the other half continued with their usual poor access to medicines. And there were around 140 medicines that people could have access to. And these were based on the World Health Organization's model list of essential medicines. In general, people got their medications from our remote pharmacists. We set up a pharmacy specifically for the purposes of the study. The pharmacists had access to the electronic medical record and receive medication orders online and then communicate with the patient over the phone usually and then mail or courier the medications to the patient depending on the need. For a small number of medications like antibiotics, they were available in the clinic and dispense to patients at the point of care so that they could go home with the medication and not have to wait for delivery but the vast majority of medications were delivered. And what we found was that there was an improvement in the primary outcome of this study which was adherence to medicines that were appropriately prescribed. We also registered some improvements in certain surrogate health outcomes like control of diabetes as measured through the hemoglobin A1C and control of the systolic blood pressure. There was no change that we registered in terms of the LDL or low density like the protein measure of cholesterol. The biggest improvement that we noticed though was in the ability to make ends meet or afford basic necessities like rent and food without incurring debt. So there was an absolute increase of almost 60%. So it was around 20% of people in the usual access group. Reported the ability to make ends meet but around 80% of those who got free access to medicines reported the ability to make ends meet or afford basic necessities. And this finding was remarkable partly because in typical circumstances providing free access to these medicines would only decrease costs by around $30 or $50 per month. But even that relatively modest savings could be the difference between being able to pay the rent or not. We also tracked using health administrative data, total healthcare costs. And we found that the annual total healthcare costs were around $1,000 lower and those who got free access to medicines and the largest cost was related to hospitalization. So there were some patients in the control arm the usual access arm of the trial who were for example being repeatedly admitted to the hospital because they did not have access to insulin and they would be admitted to the hospital including sometimes to the ICU, provided with insulin given a box of insulin to go home with. And then when that box ran out they would come back to the hospital and it may be just back to the intensive care unit. There were some additional benefits that we found through some qualitative work participants both in the free access group and the usual access group. One interesting and somewhat unexpected benefit was an improvement in the relationship between patients and their provider and better adherence actually to attending appointments and having blood work done. For example, we heard from some patients with diabetes that when they weren't taking the medications they didn't see a point in going to the lab and checking their blood work because they knew it was just gonna show that their blood sugar level was high because they weren't taking the treatment but when they were taking the treatment there was a purpose to doing the blood work and that helped to improve the relationship and also increase the likelihood that they would attend appointments with their primary care provider also with some other consultants. Some short films were made about the experiences of people in the study and one example was an individual on Manitoulin Island who talked about how he was better able to work on the land and to produce food when he had access to his puffers and how he had to take frequent breaks without the use of his puffer and sometimes not be able to work at all if his lung condition was acting up. When we presented the study as a proposal to some of the sites there was a lot of questions about only providing access to a short list of medicines and not 2,000 medicines that might be on a public formula available to people on social assistance but by the end of the study both patients and clinicians found the short list of medicine modeled after the World Health Organization's list to be acceptable with some exceptions. So typically essential medicines lists only contain a few agents from each class and within the classes of antidepressants and diabetes treatments some clinicians suggested that there might be more options available but other than that I think there was a consensus that the list met the needs and I'll just maybe provide some of my own commentary on a short list of medicines that provide 2 examples that actually led me towards this concept of an essential medicines list. One was when I was a student I attended a series of lectures it was mandatory as part of medical school at the University of Toronto and then I later found out in part through when I was a resident I reviewed the lecture notes of a then medical student and found a number of inaccuracies in the information that was being provided to medical students and then subsequently found out that the lecture series was supported by Purdue Pharma that now is recognized to have contributed to the opioid crisis by mismarketing long-acting opioids like Oxycontin and falsely claiming that they had a lower abuse potential than other opioid products and I had raised some concerns with colleagues about the lectures and actually took quite a while for things to change and for some time this false messaging, these marketing messages kept getting out to medical students. I mean now it's like not so controversial I hope to say these things there's even like you could even open up Disney Plus and see Batman as like a doctor prescribing opioids and running into trouble so these things hopefully are like a little bit more mainstream now but at the time it occurred to me that there were a lot of openings in the way that medications were selected and a lot of opportunities for marketing messages to end up shaping prescribing in ways that could be avoided if there was a more centralized independent process for selecting medicines. You know another example that led me towards the essential medicines concept was diaplectin, doxilamine, pyridoxins a commonly used medication to treat nausea and vomiting during pregnancy, commonly referred to as morning sickness and in the United States it's sold under the brand name of diaklegis and some of you might have heard about Kim Kardashian advertising this medication and running into some problems with the American regulators about some of the advertisements through her social media for this medicine but the way I came onto it was a patient of mine questioned whether or not she should take this medicine and I reassured her that it was the first line treatment it was commonly prescribed and after she left my clinic I then felt that maybe I had overstated the case so I went back to the guidelines and I saw the first thing that got me interested was instead of citing clinical trials the clinical practice guideline document that recommended this medication as the first line treatment actually cited the product monograph from the company that produces this and this is like a document that the company submits to Health Canada not something that usually clinicians would be relying upon and over many years was able to get information about this medication including some of the original clinical trial reports indicated that the medication is not effective that the benefits that you see in terms of the reduction in nausea and vomiting or pregnancy symptoms over two weeks are almost identical even as they're reported to those seen with the placebo and on this scale here the pregnancy unique quantification emesis scale or puke scale is acutely known three means no symptoms so it's a bit like the Glasgow Coma Scale for those of you familiar with it so there's almost no symptoms in any group and this is also not even taking into consideration the way they handled dropouts or those lost to follow up in the study if you take those into consideration there's really no difference at all and yet this medication continues to be really commonly prescribed and it's another example of a medication that likely wouldn't be prescribed at all if there was a better fidelity to a carefully selected set of medicines and this might be a controversial view and one that we're interested to discuss afterwards especially in the setting but I grew up in a neighborhood that was I think under-resourced and over-policed and at the same time I grew up watching Law and Order and really liking it and enjoyed seeing the good guys, police, and prosecutors track down the bad guys and in most cases put them behind bars all within 60 minutes minus commercial rights and but there was a disconnect I think between what I was seeing happening in my neighborhood and this idealized version I was seeing on TV the reason I mention it is because I think earlier in my career thinking about medications, prescribing, and access earlier I believed that the good guys would appear and save the day, the way that it happened on TV and through examples like the opioid crisis this issue with that collect-in which has like much less of a health implication than the opioid crisis you know I just came to believe that the good guys were not ever going to show up when it came to promoting access to effective medicines and ensuring that people aren't harmed so you know the police, the regulators like Health Canada, provincial governments that select medications to be publicly funded they just weren't going to appear in the way that the police and the prosecutors appeared on law and order one of the other aspects of the intervention that was somewhat novel was our pharmacy model where there was a remote pharmacist who had access to the electronic health record and this also was actually supported both by patients and the providers who enjoyed having a pharmacist with that access to this list makes suggestions about changes and actually it was very controversial before we did the study the research ethics board at the University of Toronto at St. Mike's Hospital they asked us to speak to patients before doing the study to see what their views would be about allowing a pharmacist to have access to their electronic health records and the response we got from almost every patient was exactly the same it was you mean my pharmacist doesn't have access to my electronic health record already like why doesn't my pharmacist have access to my electronic health record if they are prescribing medications they should know about my health history and about other medications I am on and so this is I think another part of the intervention that's generated some interest we estimated what would be the total cost implications across Canada if a medication list like the one we used in the study was publicly funded for everyone and in order to make these calculations we assume that we would see curtail prices similar to prices in other countries like in New Zealand where these medications are publicly funded in Canada as I mentioned we rely on private insurance and on public insurance for people on social assistance and people over age 65 many jurisdictions private insurance companies generally take a percentage of each claim so they actually prefer higher curtail drug prices and therefore we have higher drug prices in Canada than in other countries including smaller countries like New Zealand and Iceland and the estimate was around three billion dollars overall in price reductions in cost reduction sorry and that would involve though obviously we're moving over to the public books an extra approximately one billion dollars but private spending including out-of-pocket spending and on private insurance would be reduced by around four billion dollars and yet like several years later Canada continues to be one of the highest per capita spenders on pharmaceuticals much higher than like a host of countries that have less purchasing power we once had this dream that we would do a study show that publicly funding access to these medicines improved health reduced costs and that those medicines would therefore be publicly funded across Canada in fact what happened is we got a number of questions from decision makers in Canada and maybe there were some delays for other reasons but one of the questions we got back was what medicines are considered essential elsewhere and so we went to the World Health Organization and asked them like so which are the medicines that are most commonly available in other countries and they said that's a good question we should answer it so together we created this database of national essential medicines list that in some countries determine which medicines are publicly funded for people in other countries they're more advisory about which medications should be prescribed and used but we obtained lists for 137 countries that listed a total of around 2000 unique medicines and I think if we had known how much time and effort this would take like translating all the lists into English and like converting all of the non-standard medication names into standard ones we may not have done it and basically there's a big team of people who helped to do it my role was very small mostly involves like showing up to talks like this and taking credit for it even though there's a large number of people who worked really hard to do it and so there were lots of good news stories like many of the medications you'd expect like insulin are listed by almost every country with a national essential medicines list as we would hope and expect and in some general categories like the common treatments for cardiovascular disease like beta blockers ACE inhibitors etc common treatments for diabetes like metformin insulin they're listed by the vast majority of countries some like nicotine replacement therapy for tobacco dependence less commonly listed it's what we found through just a like simple overview of all of these lists we also compared national lists to the World Health Organization's model list so the WHO first made a model list of essential medicines in 1977 and they've been updating the list every two years since then and they also provide guidance to countries about how they should update their lists so if we take the WHO list as a standard you can see that there actually are some countries that stay very close to the WHO list they have fewer than a hundred differences but other countries where you know there'd be more than 500 differences and in most of those countries it's that they have additional medications that the WHO does not list and the model the essential medicines concept or idea is that a short list of medicines can meet the priority health needs of the population we found some examples of countries that were very similar in terms of their health needs like one example would be Slovakia and Slovenia so countries right next to each other similar histories, similar populations, similar healthcare systems and I know like I don't know if there's anyone from Slovakia or Slovenia here but I'm sure I'm skipping over some important differences between Slovakia and Slovenia so feel free to interject here and I know also like there are these examples because there's so many similarities between Slovakia and Slovenia Slovakia will win a hockey game and then they play the national anthem for Slovenia and it's a huge issue so I'm not hopefully making that same mistake but there are like more than 400 differences in the essential medicines list for Slovakia and Slovenia and my main point in mentioning that is to say that it's those differences likely don't reflect differences in the needs of the populations of Slovakia and Slovenia the needs are the same and actually even if you look across the whole world the actual number of treatable conditions conditions that can be treated with a specific medicine that truly vary by region it's very small actually there are not a thousand such conditions there's not 500 there's likely not even 100 such conditions so it's not differences in the needs like the main conditions the main killers are the same across the globe right the main killers are cardiovascular disease cancer and common infectious diseases and those treatments for those conditions are needed all over the world so the differences usually are reflecting differences in the processes for selecting medicines and not the health needs one example in terms of using the standard of the WHO is they've created this stratification system for antibiotics so some antibiotics should be available everywhere those are called the access antibiotics some should be held in reserve to prevent anti-microbial resistance and for some other reasons and we actually found that there were some countries that disproportionately listed the reserve antibiotics and actually didn't list some of the access antibiotics that should be available basically everywhere and we are there's some ongoing work providing some feedback to countries on that we've also done some comparisons between the nationalists and sort of ignoring the standard of the WHO's modelist and I think one of the most interesting findings is that the vast majority of medicines the 2000 medicines that are listed by at least one country are actually listed by a small number of countries less than 10 percent of countries and so if you accept what I said about most of the health conditions the important health conditions being common across the globe this would actually be quite a surprising finding and it means that the selection of these medicines is likely not principally in tune to health needs unfortunately we found that almost a hundred medicines that were withdrawn for good reason in at least one country were in fact prioritized for access by their inclusion in an essential medicines list and one example of those medicines is sysopride which is what's sold in Canada as propulsive for various gastrointestinal symptoms and it was found to cause cardiovascularness sudden deaths and this is a book by Terence Young whose daughter Vanessa died after taking sysopride and he led a campaign about trying to ensure that information about adverse effects of medications were shared globally and you know in that vein we are also trying to provide feedback to countries about removing medicines that have been withdrawn elsewhere phenotorol is another example that's interesting also causes cardiovascular death it is a puffer that's used for the treatment of asthma compared with salbutamol which would be the common medication used here which is sold under the brand name Ventolin it has the same effects in terms of opening up the airway and salbutamol is actually less expensive but phenotorol is actually prioritized for access in some countries despite its higher price and higher risk of sudden death and then one of the issues that we have encountered in providing some feedback to countries is that they don't necessarily always appreciate being compared to the WHO standard or to all other countries so we've now been working on some regional projects where we compare countries within a region or use some other characteristic to identify peers of country like their income level or health care spending and compare them within that subcategory and then provide them with feedback on how they're listed for it is like which medicines they list that other countries don't list and which medicines are listed by other countries but not listed by them so there are lots of things that you can do with this database that's available at essentialmeds.org and for the students and trainees in the audience I get you know using this database is a fairly efficient way to complete research studies so if you're interested you can have a look we actually maybe this is ill advised but we recently agreed to update our database and we've identified more lists so hopefully by the summer we'll have a more recent database of essential medicines lists in the last part of the talk and I'll be wrapping up soon I want to talk about human rights so I think like if people in Canada hear about people in another country in a low-income country who don't have access to basic necessities like clean water food or medicines like insulin or vaccines it's a reason for concern and there are Canadian based nonprofits that and charitable organizations that try to accumulate funds to provide basics that people need people living in other countries similarly when refugees arrive in Canada there are a number of non-governmental and community agencies that work to support refugees and ensure that they have a winter jacket food furniture for a new apartment and that their kids have toys and I think all of that is really wonderful but I mean if you take human rights seriously then we do need to I think pay some more attention to what are the obligations of governments in these situations and specifically I'm thinking about the obligations of the Canadian government to provide access to life-saving treatments to everyone in Canada and I mean this this image actually I just inserted into the slide to access the 20-year marker so I'd say anniversary but it doesn't seem right for the invasion of Iraq and according to what I know about this photograph from those associated press nobody knows exactly like who this detainee is or what ended up happening to him but it looks to me like he is potentially saying goodbye to his child before he's taken away and we know that some people who are taken away in this manner never returned and I guess I decided to include here although it's not directly related to medication access just when we're thinking about how human rights can be applied selectively when my understanding of human of the purpose of thinking about human rights is that they would apply to everyone everywhere and in Canada because Canada is a signatory to the international covenant on economic, social and cultural rights the access to the highest attainable physical and mental health or the right to health is recognized here and part of that part of recognizing the right to health is recognizing a core obligation to access to essential medicines including the life-saving treatments like insulin and you know there are cases where a person has needed emergency access to healthcare services and there's been a question and this would be a person who doesn't have a health card and there are processes in place to ensure that those individuals get access including in emergency circumstances and there have been cases where that hasn't happened and they've been challenged but I think there's maybe sometimes less attention to what happens when someone exits a hospital and goes home and dies of a heart attack or a stroke because they don't have access to preventive treatment and I mean we can talk about a little bit more the difference between how we think about people who are admitted to a hospital and what happens when someone goes home towards the end I think there are lots of things we could say about COVID vaccines and this would be a good place to have some discussions about them one thing I'll say here before we shortly open up for the discussion is that it seems obvious during the COVID pandemic that everyone should have access to COVID vaccines and I'm not sure how things rolled out in Nova Scotia but I know in Ontario a lot of the usual restrictions on access to healthcare were lifted and you didn't have to actually provide a valid health card in order to get a COVID vaccine refugees people who arrive in Canada without status migrant workers you know the so-called temporary foreign workers were all granted access to COVID vaccines and if the reason that people were provided access to vaccines is because that would protect everyone then I think we have to really ask ourselves like where our priorities are if it's only when there's an infectious disease that could impact the health of affluent people or people with a valid health card that we then want to ensure that everyone has access to a medicine and we probably need to rethink our priorities I just in wrapping up in after providing these talks in the past I've been told you should say a little bit about yourselves hopefully you won't find this too boring even though it's going to be short but I'll say so I grew up in in Toronto in like what some people would describe as like the bad part of Toronto and it was then very lucky to have the opportunity to study at the University of Toronto and then in England for a few years came back completed my medical training there and some of the work that we've done has gotten some like interesting attention that I never would have anticipated was invited a couple of years ago I guess now to testify before a subcommittee of the United States Senate related to medication pricing and there were interesting price differences between Canada and the United States it's got the opportunity to speak to Senator Bernie Sanders for a little while actually and I could tell you he's exactly the way he seems on TV so I mean if it's an act then he's like he's very good at it that seems quite genuine in his views in his demeanor and have been really fortunate to be able to to work through this partnership with the World Health Organization and to present in Geneva a few times about our comparisons of national essential medicines list and a few of us just before this talk we're talking about how some of the work we're doing on medication access connects with some other work that I do related to racism within medicine I'm trying to highlight some of the achievements of Dr. Alexander Thomas Augusta and all of this is really to say that I have this extremely privileged position now and that I feel very fortunate to have it and I recognize that it is relatively uncommon so we did a study of who gets involved in clinical practice guidelines and this is in guidelines national guidelines in the United Kingdom the United States and in Canada and you can see like most of the panel members are white men and very few racialized women are included in these panels so I feel that I am in a position where I should be using my role as best as I can so recently you know we made a series of recommendations about ways to try and promote health equity during the pandemic recovery period because there was maybe some more interest in promoting health equity during the pandemic but the last thing that I want to think about is because one of the recommendations from that was publicly funding medicines for everyone so ensuring that no one goes without essential medicines in Canada prior to the pandemic back in 2017 together with a medical student and a legal scholar Professor Lemons at the University of Toronto we wrote an article about a mechanism for potentially precipitating a policy change and right now there's a difference between access to publicly funded medicines when you're admitted to hospital versus not so when you're admitted to hospital you get access to an inpatient pharmacy that's all publicly funded it's part of the inpatient services that are generally publicly insured with just a few exceptions and so our proposal would be to administratively admit our patients to the hospital without them ever setting foot in the hospital so that they could access publicly funded medicines through the inpatient pharmacy which is publicly funded as part of the hospital's general budget and that same mechanism actually based on our review seems to apply across Canada and the idea would be to first immediately provide access to people who can't afford them and also to precipitate a change so either governments would allow us to continue doing this in which case we could expand the program and ensure that everyone has access or could precipitate a government to try and end the program and then explain why they would want to stop people from having access to publicly funded medicines that are life-saving and that their healthcare providers believe that they need so I leave you with this partly like as an example of some of the work we've done at the intersection between health and law but also maybe if you know someone who might be interested in helping us to do this because we would ideally like to implement it in multiple places at the same time I would be interested to connect on that point and on anything else that you might like to so I'm really glad that I had the opportunity to deliver this lecture and I'm really looking forward to the discussion thank you about 25 minutes or so 30 minutes per question and I'll let you know there are also people online and so I will be watching the Q&A box online so folks who are online if you do have questions please insert them in the Q&A box and I will keep my eye on that but I'd like to first ask if anybody in the room has a question Lauren I see you too hi I thank you for your talk it's a pleasure to be here and I'm interested in talking about the topic I had sort of two questions so one's just kind of the beginning but I was wondering if you find there's any factors in bearing it in a sense that I think with regards to like treating common conditions by women for example menstrual medications can be considered essential whereas you know obviously like I don't like for insurance office but a lot of the time I've heard of it which is a many, many reasons largely and then yeah like that's the way of treating so I was just wondering if that small thing well I'm not really into medication but does it kind of go up a lot of that one? Yeah I mean I think medication access and selection is highly gendered and I think I'll just I'll talk about a few examples one is just medication access which has made my main interest and because it's determined by by employment you know there are many jobs typically held by women that don't come with private insurance whereas other jobs like typically male dominated like more likely to have private insurance and therefore more likely to be able to access medicines I think as you were saying I think drug development can often target men and that was probably the case with treatments for erectile dysfunction yeah in terms of essential medicines lists I think in most cases the medicines would be available at treating most common conditions experienced by women I think there are some different standards you know my own view and I think a lot of people would probably disagree with this but I think one of the reasons that I collect in is so commonly prescribed and was so commonly prescribed based on these like all studies from the 1970s or even like some from the 1950s is because it's only used by women and only for like a relatively short period of time when they're pregnant and I don't think if it was a medication that was commonly prescribed to men that it would have been used based on that scant evidence there's a lower standard applied when a medication is mostly used by women or exclusively used by women could I just I'm so sorry I'm going to double right up with you here because I had a comment online that it was difficult to hear the questions enough so when a question is asked if you could sort of restate it that would be great and I just wanted to also say so everyone can hear who's online if you have a question please use the Q&A box and we will keep our eye on that I did see Matt Herter and Elaine Gibson sorry so Matt go ahead thanks so I was really struck by the point about and health needs being quite common across some of these jurisdictions and in some ways I love that it shows that to the extent there's lots of variations for other reasons that might have serious value let's try but I'm struggling with it at the same time and that's because and I worry it's just a little bit of a gentle challenge about the value of essential medicines and what they're trying to do to wrestle with this and the extent you think it is a challenge and that is the ways in which for structural reasons so if someone's about three things that I mean quite attuned to the risks and benefits one treatments actually very quite you know quite a bit so we have this workshop in the fall where we were talking to the regulators about whether they should be thinking about equity it's part of their job and they're putting the products on card and they were looking at a product one of the people that participating brought up this product that Elaine's known so Janice if you don't remember what Elle's mentioned but it was a I think a vaccine or medicine that had a serious safety issue that was very rare but awful that happened withdrawn and she her point was basically like the people who needed that most because if they didn't get it in other words the safety risk is real taken off the market because it's on the market in the US and they're coming worried about liability and so on but the risk benefit calculus in an impoverished part of Africa where people are dying from symptoms of diarrhea or motor virus was quite different you know and so the struggles have drawn and yet from at least some of those perspectives it's still been very useful in that context and so like how do you how do you deal with the fact that essential medicines was sort of essentialized the problem don't necessarily be about the local circumstances you know the health needs are broadly similar instead you know clean water and other ways access to health care systems so dealing with diarrhea like they might be they're so varied can you speak to that attention at all or sure yeah definitely not dismiss it so yeah great comment it was about like the extent to which is true that that health needs are really common across the world in the one example Professor Herter provided was around a rotavirus vaccine I believe that was withdrawn by the manufacturer it sounds like mostly related to concerns around liability in the united states but then that might have consequences for lower income countries that maybe no longer able to access it and even if there are the same risks probably the benefit of the medication is greater in settings where red virus is more common and the complications are more common yeah I mean I think the concept of the world health organizations modelist of essential medicines is that the WHO provides a model list which is not held out as a list that any country should use but then that model should be adapted to local circumstances and it actually does not necessarily need to reflect withdrawals or or even approvals in other countries and I mean I gave some examples of how that plays out in a bad way like when the medication that is removed for a legitimate reason continues to be used in other countries but I wouldn't necessarily see it as a as a as a limitation of the essential medicines list movement because it's clear that like rotavirus vaccines should be available and in this case the question is like about which specific product to use likely and maybe in the case of rotavirus like what schedule should be used and whether it should be given to older children or not and those are things that subsequent decisions that should be made after a rotavirus vaccine is included in the national essential medicines list that's not really none thanks so much I could have listened to you all day long you have a wonderful style but also the study is so detailed and interesting my question is where we scan in terms of the liberals had promised a universal fire and care program for Canada my sense is that it's gotten logged down in part based on private funding student private insurance and how that would all work in but I've just come here just to comment on the present state the concept in Canada the universal fire and care program great thank you so first there was a I'll just record for everyone that there was a positive comment about my style because that has never happened I'm sure it's never going to happen again so I just want like if anyone's taking notes here just make sure that's recorded about the main question well I mean like less importantly there was also a question about about like where we stand in farm and care in Canada right now and like specifically with the the current government liberal government that has you know announced several times that they're in favor of farm and care of including medicines in in our publicly funded healthcare system so there was a parliamentary report that released prior to the pandemic that was titled farm and care now and then subsequent to that there was a national advisory council that was put together and led by Dr. Eric Hoskins and you know both of those reports ended up recommending including medicines in our publicly funded system but we know that that hasn't actually happened and I think there are some reasons to be concerned about whether or not that will happen one is related to proposed changes at the patent medicines patent and medicines prices review board where years ago there was an announcement that the price ceilings were going to be reduced in order to reduce the maximum prices of patent medicines consultations and then you know policy was developed and then it actually has not come into force it seems like you know may never happen in the way that it was originally intended and I think the reason is because of lobbying from the pharmaceutical industry and the private insurance industry and you know coming back now to farm and care private insurance is publicly subsidized so there is this view that by publicly subsidizing private insurance that only some people have access to you'll increase the number of employers who provide it to employees and somehow make things more equitable even though we know that you know the current system leaves millions of people without insurance so yeah I think the bottom line is like officially the government the federal government has made public statements that are positive about farm and care but then I think they get like lobbied hard by private insurance industry and by the pharmaceutical industry and I don't think it's a secret also that there is a revolving door between you know political parties and these industries like the private insurance industry and the pharmaceutical industry so although at least 80% maybe 90% of people in Canada support farm and care including medicines in our publicly funded system and there are all these reports saying it will save billions of dollars it isn't happening right now well first of all I just want to say thank you so much for your presentation as a former member of the portfolio community in Toronto I really appreciate probably being able to bring a lot of intersections together in the reserve of new data and like collaboration so my question is like a little bit less academic than everyone else's essentially in numbers to kind of galvanize on this global class even though that was great by COVID-19 we touched on I think it's really important for us kind of bring this to sports on essential maxims to support non-infectious medical concerns such as NCEs of focus and I was wondering what implementation and like partnerships at community-based governments like being globally in translating this research and implementing it to equip community-based organizations and civil society advocates at the individual level and regionally with this data so they can kind of like push forward regional task forces around essential maxims but I think currently we're live on like the 2016 insect commission and I think we're updated in the data we're live great so the comment and question was about non-communicable diseases and how to ensure that like changes made at the level of the WHO let's say get implemented properly throughout the world yeah so I think it's it's a really great point that connects with a number of things and I think you know like essential medicines less and promoting access to essential medicines is one part of ensuring that people actually get access to appropriate care you know for some of the main NCDs non-communicable diseases we're thinking about like treatments for high blood pressure or hypertension there's also obviously depend on people being diagnosed with hypertension having that blood pressure appropriately measured and then having some sort of like convenient and reasonable supply of the medicines and someone to prescribe them and I mean that you know in terms of the implementation there are some countries we've identified where they actually hold back treatments for cardiovascular disease like even treatments for primary hypertension as tertiary level medicines so these would be available in practice only in big hospitals so then in practice only in a large city so the idea then would be that people would have to travel from a small town or village to a big city in order to be diagnosed with hypertension and then at a on a regular basis to have their blood pressure checked and then to get access to their treatments so you could and I think maybe this is to your point about implementation you could fairly easily say at the level of the national essential medicines list that yes they check the box they they provide treatments for hypertension but actually most people in that country would not be receiving appropriate treatment so there's a part that you could change in the national essential medicines list like downloading it to like the primary care sites and hopefully that would come with like the additional resources needed to ensure that people really do have a primary care provider and that this is an expected part of primary care I have a question and again I'm going to encourage people online to come up with questions too because I know there's some very informed people online actually in our virtual room but my question relates to the politics of formularies I guess and it's something outside my area of study and that I just am very curious about and feel like I don't know enough about so I appreciate what I understand to be your response so far to some of the questions which is I think that the kind of co-model list would be potentially a fairly high level so people can make choices you know the drop-down best choices that stack what specifically the medications would be rock circles would be that would be on a specific list but then to go back to my question about the politics of formulary making what I'm thinking about are very sort of localized examples of distinctions in formulations and some of which I'm aware of and some of which I hear tell of but I haven't actually seen the formulary that gets referred to so first I would think kind of province by province we can talk about Canada even as you know one country unit that we might look at to have some consistency in terms of essential publicly funded ideally medicine but then province by province there are differences right as to how the different provinces go and so this is my first question sort of goes to federalism and this matter you know sometimes we talk about provinces as laboratories for you know policy experimentation and going different directions in this case it seems you will more concrete choices around farm up coverage and then within a given province my only experience being here in Nova Scotia you'll get sites like you know the hospital site certain choices made there as to like hospital covered things then you've got the pharmacare program so folks who are on social assistance and are accessing some medications but there's choices there's restrictions there's right there may be differences as between one and the other and the last example to my mind is prisons and and provincial jails where as people move in between community where for instance they're on social assistance so they do have a list of you know apparently publicly funded medicines they're different in the jail and I have not actually seen the formulary it's a recent report that we did asked for public transparency as to what the formulary is but what we do know is that the type of medication the you know form of administration all kinds of things shift as between in the community and there and so I know that there are committees but it's not even clear to me who are on the committees and what kind of criteria they use when they make these choices so I guess that comes back to your project which is I think it's just amazing wonderful work and pushing toward a sort of normative outcome but it's back to this well it's simple in theory but then in practice in part it's the politics of it that I'm curious about yeah great yeah so the comment question was about the politics of formularies and other lists of medicines and some of the complications caused when lists vary between like there's a federal can be federalists provincialists institutionalists at hospitals or is important mention made of correctional facilities so there there's actually a for federal facilities there is actually a formulary that I was actually looking at recently but I think the the most recently posted one is I think from 2017 or 2018 maybe there's a more recent version that you're looking for looking at which I'd be interested in I was thinking of provincial what I mentioned not being able to access one yet oh I see okay yeah so and I'll say you know one of the challenges with our database is sometimes when we're contacting countries and asking for their national list they'll say we have a nationalist or we don't have a nationalist but in addition we have we have these provincial or territorial lists and we have these institutional lists and like from the perspective of trying to create a data in international database we say whoa whoa like we don't we can't input like 30 lists for one country but I think one of the benefits of the national essential medicines list is that you can avoid some of that mess and I think like I know this is not going to be a popular thing to say but healthcare providers like their autonomy and I know like even in my setting you know like I work at a downtown hospital and then people who work at hospitals that are not in downtown Toronto say you know medicine is totally different here you know like you guys from downtown Toronto shouldn't be telling us which medicines we should be prescribing here because you don't understand the way things work in this community and then you know I have actually had these conversations where I say like okay but like which medicines do you use to treat diabetes here like actually like this neighborhood I grew up in like diabetes is not different here and you don't actually have a different medicine here so there are I would say and again this will not be popular to say in Canada but there really are no differences across Canada in terms of which medicines are needed between provinces there aren't I mean the only real exception to that would be for conditions where you really need quaternary care like in the specialist centre then maybe and in some cases you do have to travel between provinces to access them but even in those cases people living in each province still need access to those medicines even if they need to access a prescriber in one province so there really are no differences the way it can work here in Canada is similar to the way it works in other places there'd be a single national essential medicines list and the federal government would say to the provinces if you publicly fund at least this list of medicines you'll get access to these federal funds that will cover 50 or 60 percent of the medication cost and that's what we deem as medically necessary in the same way that you know we're going to publicly fund medically necessary healthcare services these are the medically necessary medicines and you could say to provinces if you want to publicly fund other medications or provide other medications go for it and you know then the provinces would say the same thing to the hospitals say these are the medicines we're going to publicly fund if you want to provide other medicines take it out of your budget that's up to you so in that model you can allow for people to have their autonomy if they really believe that diabetes is treated differently in this part of Toronto versus that part of Toronto then fine they can they can do that but it's not necessarily going to be tied to our funding situation when they kind of thought of beginning it's kind of like too quickly that during a lot of communities it's not like that would be sort of like some sort of wrap that had to be as sort of a result of the the strength the more even the expected of them and one being that we're able to like financially stabilize themselves better and like be less in debt when they had access to their medicines that I I personally think that like when I want a patient review that I come for and that it's great for and that I call the property and I have that if a doctor is like I think my stress is obviously reduced and I have less stress so that means I have a lot more to the general like to deal with the rest of my life and I think that that sort of social understanding of the health care model that we currently have is really really important and I think the findings are extremely important I wish they were everywhere because I think there is like a really ending that's what the standing tied to like how narrow the health care and pharmacare seems to need to take in by the overall even when to people like within the law school and if you know like they have an idea if you first you know you have you have a chronic health condition you get a medication you solve the condition that's not how it works but it's so much different than that and I this really speaks to that so I first wanted to thank you I guess like a question I find is how exactly would they like would they like the like the quality of survey or like how did the product come up with how did it evolve after again like how did you discover that yeah yeah so great comments and questions about some of the like non-medical implications of improving medication access and about how we did our qualitative work so in a nutshell it's both survey results so we had some like standard surveys that we sent in questions that we asked people and then we recorded their comments and then we also additionally did qualitative we did interviews with individual patients and some focus groups with clinicians trying to understand the experiences of people and then you know in addition to that there were the short films that we made and then we used this concept mapping technique which is a technique for analyzing qualitative data where basically you code different experiences and then you actually usually meet together as a group and this we did with our community guidance panel and you try and group these different experiences in different ways and then eventually you can come up with this sort of quantitative map of how closely things clustered together and draw a diagram like this well if there is not a last burning question we'll go on it's time to sadly bring to a conclusion today's seminar and the seminar series for this year so before I take the opportunity to thank Dr. Kershaw for this wonderful presentation that you've given us so much to think about I just want to thank a couple of other people starting with Dr. Matt Herter the director of the Health Law Institute so thanks for another year of leadership and guidance and community building I also want to thank Ashley Johnson who is our administrative assistant and does so much behind the scene work to make these seminars possible I want to thank everybody who has come out to the seminar series certainly in person as we build back from COVID as well as online it's wonderful to have the participants come from all around the world to view the seminar and participate with us in thinking more about health law and policy again the series this year it's called health and social justice making the connections and those are connections that we'll continue to make I think all of us from our different disciplines and different locations in and outside the university we really hope as a seminar series to be open to a variety of perspectives social locations and to build community and collaboration and rich discussions about the challenges that we face when it comes to achieving equitable access to health social determinants of the health obviously at the four in many of these seminars that we convened this year but medications pharmaceuticals being an absolutely essential as you say piece of that and I was so glad that you could conclude the seminar by reminding us of the deep inequities in access to pharmaceuticals and essential medications the way that you have described so folks please come back next year when we reconvene our seminar series in September but for now please join me again in warmly thanking Dr. Purcell for his work