Speech from the President: Unlocking the value of Health Research

An address to the Economic Club of Canada, Ottawa
(Check against delivery)

I am grateful to the Economic Club for inviting me to speak here today and I am particularly thankful to all of you for having taken the time out of your busy schedules to come and hear about health research and its contribution to a healthier, more productive society.

As you will no doubt agree, this is not a subject that receives sustained and meaningful discussion either in the media or on the lecture circuit. Yet, I do believe that it deserves more than a customary interest, if only because it represents a $6 billion investment every year, in Canada alone.

And, I will add, an excellent investment it is. Though we do not have a large amount of reliable data about the rate of return on this investment, the information we do have indicates that it is somewhere between 20 and 67 per cent annually.

In some areas of health research, the returns can be even more impressive. A recent study that my organization, the Canadian Institutes of Health Research (CIHR) co-sponsored with the Canada Foundation for Innovation showed that our joint investments in new medical imaging technologies to diagnose strokes have provided a return of more than 200% on an annual basis!

But, more importantly, health research is essential for providing people with quality health care and improving their health. Health research is key to ensuring a healthy and wealthy society.

Paradoxically, despite the lack of public mobilization around health research, the public intuitively grasps its importance and keeps on supporting it. In a recent survey of the public by Research Canada, 90% of the respondents said that they consider health research either important or very important. In fact, 65% even said that they would be willing to pay $1 per week out of their own pockets to support new health-research projects!

Health research not only extends life, it improves the quality of life.

For instance, it is thanks to health research that the incidence of heart disease and associated deaths and illnesses has decreased considerably.

It is thanks to new surgical techniques such as coronary bypasses, and new medications such as statins and thrombolytics, which help prevent blood vessels from becoming obstructed or help clear them when they are already obstructed.

Health research has also allowed us to achieve considerable progress in our fight against cancer, even if we are still short of having won the war.

Consider breast cancer. Today, research provides us with diagnosis and treatment options that look at factors such as the genetic profile of a tumour or the status of its hormonal receptors, so that we can offer treatments that are far better targeted than in the past.

We don't talk enough about these successes. Did you know that Canada ranks among the world's top countries in health research, as measured by our scientific impact in several key areas, including clinical research, neuroscience, and pain research?

Did you know that young researchers from all over the world come to Canada to get their training or establish their laboratories?

In a knowledge-based economy, this influx of high-qualified, motivated professionals represents significant economic value for Canada.

This picture emerges quite clearly in a report from the Council of Canadian Academies, which also shows that Canada is internationally recognized to punch above its weight in the production of scientific knowledge in the health field.

Yet another recent report, this one from the Science, Technology and Innovation Council of Canada, shows our performance lagging in several vital areas, namely in its capacity to "effectively move knowledge developed in higher education institutions to companies that have the ability to absorb it and translate it into commercially viable products and/or solutions to health, environmental and social problems."

Indeed, the most recent data show that in all research areas combined (not health research alone), the number of licences acquired in Canada is stagnating, while the number of spin-off created is actually in decline.

If anything, the picture is even less rosy when it comes to our performance in health care.

According to a study by the Commonwealth Fund, Canada ranks second to last among all OECD countries for a set of indicators that include the quality, effectiveness, and accessibility of care. If it weren't for the United States, we would rank dead last.

Is it acceptable that in a country that invented evidence-based practice, fewer than 50% of all health-care interventions are truly evidence-based?

Is it acceptable that 25 to 30% of all these interventions are, if not dangerous, at best unnecessary? True, these figures come from U.S. data, but they are not thought to be very different here in Canada.

Have you ever thought about what all these unnecessary interventions cost?

So how can we ensure that Canada's strong performance in knowledge creation translates into greater economic and societal benefits?

How can we ensure that as a society, we take better advantage of our talent and creativity to enhance economic growth and prosperity and address the societal challenges that confront us in the 21st Century?

Or, to paraphrase the British philosopher and statesman Francis Bacon, how do we ensure that science discovery is driven not only by "the quest for intellectual enlightenment, but also for the relief of man's estate"?

First of all, we need to recognize that research is a competitive game, and that there is no point in engaging in this expensive activity unless we are committed to playing in the major leagues. Some people may call this elitist, and so be it. Such elitism is necessary because mediocre research can only lead to mediocre impacts.

A core driver of research excellence involves individuals. To reach for success, we must attract and retain the best researchers, the ones who are the most gifted and inventive. That's why the federal government has established a set of programs to attract, encourage, and support research talent, such as the Canada Research Chairs and Canada Excellence Research Chairs, the Vanier graduate scholarships, and the Banting postdoctoral fellowships. Research is done by researchers. They and they alone can guarantee its quality.

But it is not enough to attract the best research minds. We must also provide the conditions for them to flourish. As the Governor General reminded us recently, minds are like parachutes: they work best when open. For this reason, we must offer our researchers intellectually stimulating environments where they can hone their minds in the daily give and take with their peers.

We have to trust our researchers and let them follow their instincts. They are usually the ones who know best which avenues of exploration are the most promising and potentially the most productive.

Furthermore, it is essential to allow for serendipity as one never knows which investigations will lead to the discoveries that will ultimately have the greatest impact.

Consider, for example, the discovery by 2006 Nobel Prize Laureates Craig Mellow and Andrew Fire that some cells can use a particular type of RNA to stop certain genes from being turned on. This process, known as RNA interference, or gene silencing, is now the focus of a number of highly promising drug development efforts. And yet, its discovery started, of all things, with a study of hereditary transmission of colours in petunias!

Examples such as this are why CIHR spends more than half of its $1 billion annual budget on purely investigator-driven research: best minds - best ideas.

I would add that a large part of this investigator-driven research is what we commonly refer to as basic research, even though I am a little weary of this simplistic dichotomy between basic and applied research. What we are really talking about here is a continuum with boundaries that are often fluid and types of research that are performed by the same investigators.

Checking the facts

Now, you may have read in the press that Canada's research funding agencies are spending less and less money on blue-sky, investigator-driven research. Let's check the facts.

In 2000, the first year of its existence, CIHR invested $150 million in investigator-driven research. In the most recent fiscal year, this figure had climbed to $472 million, and although its growth has been slowed by economic conditions in recent years, the budgetary envelope for this type of open research has never fallen and we have committed to increasing it by a further $10 million a year over the next five years.

So does this mean that all of health research should be left to the researchers' initiative and that none of it should be targeted? Does it imply that pointed research investments are, as some would have it, doomed to failure?

Let me put the question to you a bit differently: would it have been socially and economically responsible to remain deaf and blind to the threat of the SARS or H1N1 pandemics?

Not to react to the threatened shortage of medical radioisotopes when the Chalk River reactor broke down?

Not to respond to the disturbing spread of hospital-acquired infections, in particular C. difficile?

In all of these crises, CIHR issued in record time targeted requests for proposals, with the following results:

• the SARS virus was cloned;
• adjuvants were added to the H1N1 vaccine to make it more effective; and
• new methods were discovered for producing medical imaging isotopes using simple cyclotrons.

I am convinced that it is through similarly targeted investments that we can best tackle the challenge of translating research findings into social and economic benefits and, in particular, increasing the impact of research on health and on quality of care.

Changes are imperative

This being said, while money may be a key issue, it is not the only one. Certain changes in the way that we conduct research, and utilize research results, are imperative.

1. First of all, we must break down the silos between disciplines. Everyone agrees that interdisciplinarity is one of the keys to innovation. This is a concept that Wilder Penfield understood well when he founded the Montreal Neurological Institute and brought together a wide range of highly specialized scientists from disciplines as diverse as physiology, pathology, chemistry, and psychology.

   Penfield correctly predicted that letting these scientists compare their ideas and work together synergistically would enable them to work creatively. And that is how the research field now known as neuroscience was born. Looking forward, we can only begin to imagine the impact of new fields being created by interactions between traditional biomedical scientists and the likes of economists, mathematicians, physicists or engineers.

2. Second, we must break down the silos between professions—between clinicians and researchers, social scientists and biological scientists, doctors and nurses, to give but a few examples.

   Here again, coming back to the Montreal Neurological Institute – you will forgive my indulgence: I worked at the Neuro for almost 25 years! – Penfield understood that research could not be left to doctors alone; they had to collaborate closely with scientists.

   Dr. Brenda Milner, still active in her nineties, provides a wonderful example of how this type of collaboration can benefit both research and the clinic. By working closely with neurosurgeons, she not only learned from their errors – I am thinking here of her study of the famous patient HM, which shed new light on how memories are formed and stored, – but she also provided guidelines for future brain surgery by identifying the memory centres that should be spared at all costs.

3. Third, we need to break down the silos between public and private sectors, between government organizations such as CIHR and the health industry, from biotech and pharmaceutical sectors, to medical devices and IT providers.

   The recent State of the Nation report by the Science, Technology and Innovation Council highlighted a long-term decline in R&D spending by Canadian business. In 2000, private sector R&D spending in Canada was 1.05 per cent of GDP. Now we are down to just 0.81 per cent, below the OECD average and nowhere close to the top five economies. Countries such as South Korea, Finland and Japan are above the threshold of 2.0 percent.

   I feel strongly that closer collaboration between public and private sectors in areas of converging interests would go a long way in helping us address this worrisome shortfall in R&D investments.

4. Lastly, we need to break down the silos between jurisdictions and players in the healthcare sector –silos between universities and teaching hospitals; between researchers and research users; and, most importantly, between federal and provincial governments.

   How can we ever expect health research to have an impact on health care if the provincial and territorial authorities, who have constitutional responsibility for providing care, do not embrace the perspective and hard evidence that research can provide?

The provinces and territories, which are currently facing nearly uncontrollable growth in their health care costs (which average 40 to 45% of their budgets), too often see research as a major cost driver.

Now, in all fairness, this perception is not totally unfounded. Health research can indeed lead to the development of diagnostic and therapeutic tools that are quite costly.

But, health research can also result in significant cost savings. For example, it is thanks to research that patients with gastroduodenal ulcers are now almost never hospitalized, because research has shown that these ulcers are caused by a bacterium, Helicobacter pylori. Patients can thus be treated at far lower cost with antibiotics.

It is also because of research that uterine fibroids can now be treated in the doctor's office for a fraction of the cost of older surgical approaches and that the vaccine for human papilloma virus may soon make surgery for cervical cancer a thing of the past – or at least that is my hope.

If breaking down these various silos is necessary, it is not sufficient to translate the benefits of research in better health outcomes and more efficient care.

It needs, in addition, that we better support research that directly addresses the issues faced by patients, caregivers and policy makers. Research on disease prevention and pre-emption; research on the effectiveness and cost effectiveness of current diagnostic and therapeutic approaches; research aimed at improving the quality and accessibility of care.

Because, make no mistake: the quality of the care that we provide is directly linked to our ability to conduct quality research, which in turn is linked to our ability to assimilate research findings made by others.

The statistics are undeniable: morbidity and mortality rates are significantly lower in hospitals where leading-edge research takes place – 15% lower, according to the latest studies.

So how can we change our current model, to do a better job of evaluating not only new technologies, new treatments, and new models of practice, but also the ones that we are already using, so that we can, at the very least, stop using those that do harm? Is such a thing possible?

The story of Dr. Shoo Lee, a pediatrician, researcher, and health economist at the University of Toronto, begins to provide some answers.

Disturbed that health indicators in neo-natal intensive care units had not improved in over 10 years, Dr. Lee first made an inventory of what had been published on the subject over the past several years. He then compiled a list of effective interventions, applied them systematically, and evaluated their effects using a controlled research protocol in cluster randomized trial at 12 Canadian NICUs.

The results were nothing less than spectacular: a significant drop in mortality rates, a 32% decrease in rates of hospital-acquired infections, and a 15% decrease in the frequency of chronic lung disease. Not to mention over $7 million in savings from the reduction in hospital days!

Dr. Lee then shared this protocol with other neo-natal intensive care units across the country and, once again, evaluated the results of its implementation in a controlled manner. To his great surprise, no significant improvements were observed in any of the indicators that he had used originally. It was only when he and his team personally trained and engaged staff in other neonatal units across Canada in these new practices that the same results started to be seen Canada-wide.

During the past 3 years, they have seen a 40% decrease in retinopathy of prematurity (severe eye disease causing blindness), 30% decrease in hospital acquired infections, 30% decrease in necrotizing enterocolitis (potentially fatal intestinal infection), and 20% increase in survival with no complications across Canada.

As Dr. Lee told me, "Obtaining evidence is only the beginning. The real challenge is to ensure that your research findings are actually applied and that the changes in practice are actually implemented." This is not an objective that you can achieve flying by the seat of your pants. In fact, it has given rise to a whole new research field, called intervention or implementation research.

Here's another, different example of the impact of health research on current health-care practices. There are currently two medications available to treat macular degeneration. One, Lucentis, costs $1575 per course. The other, Avastin, costs only $7! According to a study published in the Journal of Ophtalmology in 2012, the effectiveness of the two treatments is identical. Needless to say, these findings have not been endorsed unanimously and will have to be confirmed. But a lot is at stake here: we're talking about potential savings of over $100 million per year!

It is to support this kind of evaluative research and, more broadly, to improve our capacity to conduct quality clinical research, that CIHR has evolved from a pure focus on building research strengths and addressing gaps in specific areas of research, towards mobilizing this capacity for impact and transformation.

Strategy for Patient-Oriented Research (SPOR)

In collaboration with a broad coalition of federal, provincial and territorial partners, the pharmaceutical sector, patient organizations, health-care authorities, academic health centres and philanthropic foundations, CIHR has launched an ambitious initiative called the Strategy for Patient Oriented Research, or, SPOR, just slightly more than one year ago.

The purpose of SPOR, which has been strongly endorsed by the Minister of Health, the Honourable Leona Aglukkaq, is to make sure that research and research evidence is rapidly and efficiently delivered to patients. To make sure that each patient receives the right clinical intervention at the right time.

The objective of this strategy is both simple and complex.

It is simple in that it places patients and decision makers at the heart of the research agenda. It is based on close collaboration among researchers, clinicians, patients, and decision makers.

But, it is also complex, because it involves a new way of designing and conducting research.

First of all, it requires new types of researchers: not only intervention and implementation researchers, as I have just mentioned, but also epidemiologists, biostatisticians, health economists, and more.

Next, and most importantly, it requires a whole new culture, one where:

• all preventive, diagnostic, and therapeutic methods, whether new or already in use, are evaluated systematically; and,
• most importantly, where the results of this evaluation are taken into account and translated into changes in practice.

This is not something that CIHR can accomplish all on its own. Everyone must put their shoulder to the wheel. The provincial governments have already provided enthusiastic support for this strategy, with financial investments to back it up. Between now and the end of 2014, every province and territory will have a patient-oriented research support unit, funded by federal and provincial investments on a 50/50 cost-sharing basis.

The charitable sector has also answered the call. The Graham Boeckh Foundation has agreed to provide half of the funding for a network that will conduct patient-oriented research on mental health. The total funding will be $25 million over five years, with CIHR providing the other half.

Finally, industry—the pharmaceutical industry in particular—has also committed to invest with us. It sees this patient-oriented research strategy as an opportunity to enhance Canada's competitiveness in clinical research and its ability to attract international clinical trials, which has declined disturbingly in recent years.

With SPOR, we are building on a valuable and longstanding collaboration with the pharmaceutical sector through the Rx&D Foundation and are effectively challenging the orthodoxy that academic research and private sector concerns cannot and must never intersect. In fact, through SPOR, we hope to engage new so-called "non-traditional" partners who understand the contributions of health research to the bottom line.

As I conclude my remarks, I would say that I see a very positive outlook for health research in Canada.

Health research continues to open new horizons whose existence we didn't even suspect until quite recently. And that is largely because health research has been transformed from a primarily biomedical undertaking to an activity at the interface of disciplines as diverse as engineering, computer science, mathematics, economics, sociology, and, of course, biology.

Furthermore, I am optimistic in sensing, among the new generation of researchers, a significant and growing awareness of the social role that they must play. I also sense, in politicians and policymakers, recognition that they cannot run a $200 billion per year operation—because that is what health care costs us annually—while spending only a few billion dollars per year on R&D.

All of this optimism will be necessary to help carry us through the enormous challenges that are upon us. I'm referring, among other things, to the high costs of caring for, and managing the increasing incidence of chronic diseases such as diabetes, or the emergence of antibiotic-resistant bacteria that threatens to undo all that we accomplished in the fight against infectious diseases in the 20th century.

I am thinking of the aging of the population and the accompanying increase in the incidence of neurodegenerative diseases. The Alzheimer Society estimates that a generation from now, there will be more than 1 million Canadians with dementia, if nothing is done to reverse this alarming trend. We are talking about costs on the order of $153 billion per year by 2038, which is not that far away.

And those are just a few examples.

Given these challenges, it is imperative to make research central both to our health agenda and to our economic agenda because the links between these two areas are clear.

And as a society, we need to recognize the extraordinary contribution that health research has made to our lives, and we need to celebrate the efforts, the talent, and the extraordinary impact of the people who do this work. We must also ensure that health research is brought to its greatest point of impact: where the patient can fully benefit from such excellence.

It is a social imperative to do all that we can to fully unlock the value of health research.

Thank you.