Speech from the President: Health Research: How is Canada Doing?

Delivered to the Montreal Council on Foreign Relations
Montreal, Quebec
June 5, 2013

I am very pleased to be here with you today to talk about health research.

As you will no doubt agree, this is not a subject that gets talked about a whole lot in the media, or on the lecture circuit.

Yet health research represents a $6 billion investment every year, in Canada alone.

It is an activity that matters to Canadians. 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 to support new health research projects!

The public understands that it is thanks to research that we live longer and, more than ever, healthier lives.

It is thanks to research that the incidence of cardiovascular disease, and especially its associated deaths and illnesses, has decreased considerably.

This research has led, for example, to new surgical techniques such as coronary bypasses, and new medications such as statins and thrombolytics, which can help prevent blood vessels from becoming obstructed or help clear them when they are already obstructed.

It is also thanks to health research that we have achieved considerable progress in our fight against cancer, though we know that we have not yet won.

But remember that 50 years ago, the only way to detect breast cancer was by physical examination, and the only recommended treatment was mastectomy.

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 far better targeted treatments 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 and establish their laboratories?

This picture emerges quite clearly in a recent report from the Council of Canadian Academies, which also shows that Canada enjoys an enviable international reputation in these fields.

Unfortunately, the picture is far less rosy when it comes to health care indicators.

According to a study by the Commonwealth Fund, Canada ranks second from the bottom 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 Canada, the 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 these interventions are unnecessary, if not dangerous? True, these figures come from U.S. data, but they are thought to be very similar here. Have you ever thought about what all these unnecessary interventions cost?

And when it comes to commercializing research results, Canada's performance is not much more impressive either.

A recent report by the Science, Technology and Innovation Council shows 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 firms created is actually in decline.

I'm sure you'll agree with me that academic researchers cannot simply sit back in their ivory towers and accept this state of affairs. If they want to play their rightful role in society, they must change the way they do things and the way they target their investments.

But how can they play this role more effectively? How can they increase the impact of their research?

First of all, by continuing to make excellence work to their advantage. Research is a competitive world, and there is no point in playing unless you play in the big leagues. Some people may call this elitist, but it is true, and such elitism is necessary, because mediocre research can only lead to mediocre results.

Excellence in research begins with individuals. In fact, the key to success is simple: attract and retain the best researchers, the ones who are the most gifted and inventive. That's why the federal government has established programs such as the Canada Research Chairs, the Vanier graduate scholarships, and the Banting postdoctoral fellowships to attract, encourage and support research talent. 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 in which they can flourish. A mind is like a parachute: it works best when it is 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. The researchers themselves are often the ones who know best which avenues of exploration are the most promising and potentially the most productive. But even the researchers often cannot tell which investigations will lead to the discoveries that ultimately have the greatest impact. Consider, for example, the research done by Mello and Fire. They started 25 years ago by studying the hereditary transmission of colours in petunias and ended up describing RNA interference, a fundamental process that allows cells to inhibit the expression of certain genes.

Or consider that the development of the vaccine for human papilloma virus – a vaccine that has now saved millions of lives – began with Harald zur Hausen's observation that this virus was prevalent in cancers of the cervix.

These and other examples illustrate why CIHR spends more than half of its $1 billion annual budget on investigator-driven research: better research minds mean better research projects.

A large part of this investigator-driven research is basic research. Let me take a minute here to correct a few misconceptions.

Contrary to what you may have read in the newspapers, it is not true that Canada's research funding agencies are spending less and less money on basic research.

In 2000, the first year of CIHR's existence, it invested $150 million in basic research. In the most recent fiscal year, this figure had climbed to nearly $411 million, and although this growth has necessarily been slowed by economic conditions in recent years, the amount that we invest in basic research has never fallen and will continue to increase.

And that's not even counting the investments from other sources, such as the Canada Foundation for Innovation, which has just been awarded $100 million to invest in each of the next five years, or Genome Canada, which has been assured annual funding of $60 million.

It's pretty simple: without basic research first, there can be no applications and hence no commercialization later on. It is basic research that fills the innovation pipeline.

But does this mean that we should turn up our noses at applied research? First of all, I think we should be leery of this simplistic dichotomy between basic research and applied research. What we are really talking about is a continuum with boundaries that are often fluid. In fact, it is often the same researchers who do the basic research and then develop the applications growing out of it.

The question is whether some portion of research funding should be directed or whether, as some would have it, any research that is not investigator-driven is doomed to failure.

Let me put the question to you a bit differently: would it have been socially responsible to remain deaf and blind to the threat of the SARS and H1N1 pandemics? To not react to the threatened shortage of medical radioisotopes when the Chalk River reactor broke down? Or to not respond to the disturbing spread of hospital-acquired infections, in particular C. difficile?

CIHR issued targeted requests for proposals for research on all of these problems in record time, 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 translate research findings into social and economic benefits and, in particular, increase the impact of research on health and on quality of care.

That said, while money may be the key issue, it is not everything. Changes in the way that we conduct research 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 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.

2. Next, we have to break down the silos between professions – between clinicians and researchers, social scientists and biological scientists, doctors and nurses ...I could go on ...

Here again, if you'll allow me another reference to the Neurological Institute, Penfield understood that research could not be left to clinicians alone; they had to collaborate closely with scientists.

Dr. Brenda Milner provided a wonderful example of this kind of collaboration. Her work with the famous patient HM shed new light on how memories are formed and stored, and practically gave birth to the new field of neuropsychology.

3. Lastly we need to break down the silos between jurisdictions – the public and private sector, universities and hospitals, patients and policy makers, and, most important, federal and provincial governments.

Ah, the taboo subject! How can we ever expect health research to have an impact on health care if the provincial and territorial authorities, who are responsible for this care, do not embrace the research agenda?

It is true that the provinces and territories are currently facing nearly uncontrollable growth in their health care costs (which average 40 to 45% of their budgets) and that they see research as generating further costs. This perception is not totally false. Health research often leads to new technologies and new diagnostic and therapeutic tools that are quite costly.

But it is also thanks to research that patients with gastroduodenal ulcers are practically never hospitalized anymore, because we now know that these ulcers are caused by a bacterium, Helicobacter pylori, and that they can 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.

But that said, it is clear that we do not conduct enough research to truly validate the cost-effectiveness and the comparative effectiveness of the diagnoses and treatments that we currently provide.

Nor do we do enough to ensure that research is better integrated with care and has a greater impact at the point of intervention – not only to achieve greater cost-effectiveness, but most of all, to improve the quality of care and to standardize this quality in all parts of the country.

Make no mistake: the quality of the care that we provide is inextricably linked to our ability to conduct quality research, which in turn is linked to our ability to assimilate research findings made elsewhere.

Moreover, 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.

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

Let me tell you a story about Dr. Shoo Lee, a pediatrician, researcher and health economist at the University of Toronto. Worried that health indicators in neonatal intensive care units had not improved in over 10 years, Dr. Lee first made an inventory of everything that had been published on the subject over the past several years. He then compiled a list of the interventions that were effective, applied them systematically, and evaluated their effects using a controlled research protocol in his unit at SickKids.

The results were nothing less than spectacular: a significant drop in the mortality rate, a 20% decrease in rates of hospital-acquired infections, a 20% decrease in retinopathy of prematurity, and a 15% decrease in the frequency of necrotizing enterocolitis, a fatal illness. Not to mention over $7 million in savings from the reduction in hospital days!

Dr. Lee then shared his protocol with the neo-natal intensive care units across the country and, once again, evaluated the results in a controlled manner. To his great surprise, no significant improvements were observed in any of the indicators that he had used at SickKids. Only when he and his team trained the practitioners in these new practices personally did the same results start to be seen Canada-wide.

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 – intervention and implementation research – that is not all that far removed from behavioural psychology.

Here's another example of the impact of health research on current health care practices. There are two medications available to treat macular degeneration. One, Lucentis, costs $1575 per month. The other, Avastin, costs only $7! According to a study published in the Journal of Ophthalmology in 2012, the effectiveness of the two treatments is identical. A lot is at stake: 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 develop our ability to conduct quality clinical research, that CIHR, in partnership with provincial governments, the charitable sector and industry, launched Canada's Strategy for Patient-Oriented Research just over a year ago.

The objective of this strategy is both simple and complex.

It is simple in that is 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.

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

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.

More 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 especially,
• the results of this evaluation are taken into account and translated into changes in practice.

This is not something that CIHR can accomplish 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 equally by the federal and provincial governments.

The charitable sector has also answered the call. The Graham Boeckh Foundation in Montreal 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 had a worrying decline in recent years.

So I see the outlook as very bright.

First of all, health research continues to open up new horizons that we didn't know existed 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.

Consider, for example, nanomedicine, which will soon let us target the effects of medications, or microfluidics, which will let us make precise microbiological diagnoses in record time.

Or the brain/machine interface that will soon let amputees use their thoughts to control the movements of their prostheses.

Or stem cells and regenerative medicine, which will soon let us treat diseases ranging from septic shock to retinal degeneration.

Another reason that I am so optimistic is the new generation of researchers, in whom I sense an important, growing awareness of the social role that they must play.

I also sense, in politicians and policy makers, a 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.

The challenges that await us are enormous. How can we not be concerned about the aging of the population and the accompanying increase in the incidence of chronic diseases, including neurodegenerative diseases? Two other daunting challenges are the terrible burden of mental illness, which even now remains largely beyond our ability to diagnose and treat, and the emergence of antibiotic-resistant bacteria, which threaten to undo all that we accomplished in the fight against infectious diseases in the 20th century. And those are just a few examples.

Given these circumstances, it is imperative to make research central to our health agenda. But researchers must also do their part:

• they must keep the public informed about what they are doing, without creating unrealistic expectations by, for example, promising miracles from genetic discoveries whose actual applications are in some cases still 30 years down the road; and
• they must also take the necessary steps to ensure that their discoveries are in fact translated into social and economic benefits.

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. Canada can be proud of its successes in this field, but we cannot rest on our laurels, because the competition remains intense, and the challenges, tremendous.

Thank you for listening.