September 21, 2005

Vancouver, British Columbia

Let me begin by saying how honoured I am to be asked to give the keynote address at this historic, inaugural meeting of the Canadian Academies of Health Sciences.

I need to begin, of course, by acknowledging the tremendous work that Paul Armstrong and his colleagues have done over the past two years in turning CAHS from a vision into a reality. Paul has truly worked tirelessly on Canada's behalf to bring us where we are today.

The creation of the CAHS couldn't be more timely. It will be one of the themes of this address that the revolution in the health sciences is creating a new imperative for governments and societies everywhere to rethink and re-engineer existing health institutions and ways of thinking. Now, more than ever, governments need impartial and forward-looking advice on pressing and emerging health issues. Now, more than ever, the public is looking to the academy, not just as an advisor but as a partner, working together to think through the health challenges that face our country and our globe.

There's a revolution taking place in the health sciences and it's forcing a different view of human health and health care in the 21st century.

The scientific revolutions of the 17th and 18th centuries created the Industrial Revolution of the 19th century while discoveries in physics and chemistry in the 19th and 20th century created the electronic age. Similarly, the spectacular advances in the health sciences that began in the latter half of the 20th century will undoubtedly shape and transform health care and human societies in the 21st century. The 20th century will be remembered, at least in part, for the colossal advances in deciphering the molecular basis of life. Deriving the sequence of the human genome, and the accompanying increase in experimental power in deciphering the function of these sequences and the protein networks they encode in living organisms, did more than just advance our understanding of the human body. It was a step change. In one swoop, it transformed biology and medicine from a descriptive science, quite separate from the rest of the sciences, to an information science, right in the middle of the revolution that has occurred in the handling, analysing and transmitting of information globally.

The health sciences have been globalized and digitized. Just as Wall Street can transmit their daily trading information to India for overnight accounting, biological information can now be shared in real time around the world. A clinical trial in Vancouver examining disease prognosis and gene expression patterns by micro-array analysis can be analysed just as easily and quickly in Beijing as in Vancouver.

This revolution in genomics and its sister sciences is not the only scientific and technological revolution going on in the health sciences. Clinical and population epidemiology have had remarkable successes in teasing out the risk factors of disease. One of the first major successes of the last century was the demonstration by Hill and Doll of the relationship between lung cancer and cigarette smoking. Population studies like the Framingham Study in the U.S. and most recently the Interheart Study by Salim Yusuf at McMaster, with his colleagues from around the world, have identified dietary factors, exercise, obesity, excessive drinking, etc., as risk factors for heart disease, diabetes and stroke. We no longer think of these chronic diseases as the inevitable consequences of aging - they are all due to specific attributable risk factors and they are not inevitable.

In this century, epidemiology and population health is about to undergo a second transformation, as it broadens its scope beyond the external factors that affect health to an integrated science that incorporates and analyzes the interplay between the intrinsic genetic factors that affect disease risk with the socioeconomic, environmental and behavioural determinants of health.

The fusion of engineering with nanotechnology, stem cell biology and the genomic sciences, is creating a dramatically new science of bioengineering with entirely new approaches to the early detection of disease, drug delivery and organ repair. That is why CIHR's Institute of Neurosciences, Mental Health and Addiction, led by Dr. Rémi Quirion, is leading a multi-partnered initiative in Regenerative Medicine and Nanomedicine.

As a consequence of this revolution, medicine is moving rapidly from a reactive to a proactive mode. The identification of population risk factors for disease, and the identification of individuals who are genetically predisposed to disease, will shift the emphasis to prevention. Disease and patient homogeneity will give way to disease heterogeneity as we uncover the different underlying pathways that can give rise to the same clinical symptoms. In turn, this will lead to a more targeted or personalized medicine and increased efficiency of clinical trials. Drugs that seem to have only marginal benefit may actually be very effective on defined subsets of patients.

As if the collision of these science and technology tectonic plates were not enough, the spread of literacy and education, tied to the development of the internet, is also transforming health and health care in the 21st century. An educated public, with immediate access to the very latest in medical and scientific advances, will not say as my mother used to: "Whatever you say, doctor. You know best. What do I know?" Rather, they will ask, "Why aren't you offering herceptin like they are at Sloan-Kettering?"

As Bill Castell, President and CEO of GE Health Care and long time friend of UBC has put it, "the critical interplay of these three technologies - biology, bytes and broadband - will be a fundamental driver of change in the 21st century". The interactions amongst these three technologies, coupled with the full engagement of the consumers of health care - patients, the public, providers and policy makers - is creating a new imperative for health care and view of human health in the 21st century.

These technologies will also - indeed are already - changing the process of innovation itself. Innovation is becoming democratized - both the fruits of innovation but perhaps more profoundly, the process of innovation. Innovation is no longer the sole purview of the Harvards, McGills and UBCs of this world. True innovation is now owned by everyone.

Societies that don't have to re-engineer existing institutions may, in fact, be better prepared for the profound changes taking place than societies like Canada where there are strong, structural and vested interests in maintaining the status quo.

In the last part of my talk, I'd like to turn my remarks to the title of this talk: Can the health sciences truly deliver on its promise to improve human health? To address that question, I'd like to go back to the origins of CIHR.

CIHR's conception dates back to the groundbreaking 1973 report titled, A New Perspective on the Health of Canadians, by Marc Lalonde, then Minister of Health and Welfare. Based on pioneering work by Bob Evans, Fraser Mustard, and others, the Lalonde Report challenged traditional views about health and proposed that the health of a population was not simply attributed to modern medicine or the health system. Rather, the determinants of health also included socio-economic, behavioural, environmental and lifestyle factors.

The discussions that accompanied the Lalonde Report included an aborted attempt to create an integrative approach to research by bringing together the biomedical, clinical and social sciences, and humanities under a single agency. The Medical Research Council (MRC) funded largely biomedical research while health services and population health research was funded by the National Health Research and Development Program (NHRDP).

During the 1990s, a number of health policy, financial, and scientific drivers all converged, leading to the creation of CIHR. These drivers are by no means unique to Canada and therefore our experience may be useful to other countries.

First and foremost, the changing healthcare needs and cost pressures within Canada's publicly funded health system were all leading to a crisis in confidence and cash. These changing needs include a striking shift in disease burden from acute to chronic disease, with an inevitable and significant increase in costs.

The shift in disease burden confirmed what was highlighted in the Lalonde Report: a better understanding of socioeconomic and behavioural risk factors is essential if we are to lower the incidence of obesity, smoking, and excessive drinking that are the proximate causes of prevalent diseases in Western countries (and soon India) - diabetes, hypertension, cardiovascular disease, and mental illness.

This perspective also led to the view amongst Canada's policymakers that while fundamental biological research was important, the fastest societal gains were to be found through research looking into health system innovation and improvements in the productivity and performance of our health care delivery system.

Second, Canada's demographics are changing rapidly. The aging of the baby boomer generation, the low birthrate of the past 30 years, and the increased flow of immigrants to Canada is resulting in an aging and ethnically more diverse society. This transformation, as noted by the Prime Minister in a speech he gave to senior civil servants, is placing increasing demands on health and other public services. Aging baby boomers expect immediate service, creating a political demand for immediate access to care. The central importance of this changing demographic is why CIHR's Institute of Aging has launched a cohort study, the Canadian Longitudinal Study on Aging, to tease out the determinants of healthy aging.

Third, cost pressures on the health system have been driven by more sophisticated and expensive technologies (informatics and medical imaging), and the very significant rise in the costs of new drugs.

Fourth, the 1990s also were the beginning of a profound revolution in health research, a revolution that led to the sequencing of the human and other genomes, detailed molecular understanding of the molecular pathways that control cell division, development and organogenesis, and the molecular basis of diseases like cancer and heart disease.

This scientific revolution has been driven by new technologies - DNA sequencing, mass spec, combinatorial chemistry, homologous recombination in embryonic stem cells - that have transformed research.

This excitement in biomedical research led to significant increases in the budget of the U.S. NIH. In contrast, because of growing federal deficits in Canada, the MRC's budget shrank by over 10% during the 1990s. Because of this growing funding gap between Canada and the U.S., many scientists were leaving Canada or not returning to Canada after their training.

Despite this convergence of powerful scientific and political forces, the birth of CIHR in 2000 was not an easy one. Despite the inspired and passionate leadership of Dr. Henry Friesen, the MRC's President in the 1990s, the academic community was suspicious, both of each other and of the government's commitment to multi-year investments in a new agency with a broader mandate, and federal decision makers had to be convinced that this wasn't simply a clever strategy to secure more funds for biomedical research ("MRC on steroids").

My appointment in 2000 as CIHR's inaugural President served to highlight these concerns - the biomedical community was relieved (I am a molecular geneticist), the health services community felt abandoned (NHRDP was rolled into CIHR), and everybody else held their breath.

CIHR's new mandate, passed by Parliament, states that CIHR's role is to fund biomedical, clinical, health services, and population health research, and to translate that research into improved health, a stronger health system, and new products and services.

This legislative mandate almost exactly presages recommendations made by our sister Academy, the U.S. Institute of Medicine in its Report on Academic Health Centres 3 years later which states that "society needs the results of work done across the entire research continuum. Basic research will continue to be important.however, clinical, health services and prevention research, will also be necessary to improve health and to translate the findings of basic research into clinical and community settings...."

Over the past 5 years, CIHR and its 13 new virtual health institutes have moved quickly to broaden the mandate (helped by an overall budget doubling): funding for health services and population health has risen from very low levels by over 10-fold while biomedical and clinical research funding has doubled. In addition, new programs have been launched to foster multidisciplinary and researcher-community collaborations.

What are the challenges that lie ahead? The diverse social, scientific, demographic, political and economic issues outlined above - public expectations, the changing nature of disease, the transformation in Canada's demographics, the accelerating revolution in science, the high costs of new technologies and new drugs, the growing disparities in health outcomes between rich and poor countries, the rise of India and China, not just as major economic powers, but as serious players in international science - remain challenges and opportunities for Canada's publicly funded health system and for CIHR. In addition, our challenge, both as a funding body and as a research community, is to ensure that society has confidence in both the motivations behind and the conclusions from our research, and the ethical framework within which it is carried out.

There are concerns that other social programs, particularly education, are under-funded because of a "distorted" priority on health care. Policy makers have challenged the health system to develop more cost effective, innovative and evidence-based ways of delivering care. Increasingly, Canada is moving towards an integrated and system-based approach to health service delivery. The health research community must also respond to similar challenges. The rising costs of research, the rising public expectations of research, and multidisciplinary approach to research, with an emphasis on knowledge translation, does not align well with academic rewards and evaluation structures, or with the prevalent scientific ethos.

CIHR is discussing these issues within the research community, particularly amongst academic leaders, young faculty and trainees. We recognize the need to work with Canadian universities and hospitals to develop new structures and values that allow the three core missions of these institutions - research and scholarship, education and public service and patient care to flourish in this new era of health research. We also plan to allocate new resources to collaborative and international research. And, CIHR recognizes that the research community must open its doors to society and provide a place at the table where research priorities are debated and decided.

Indeed, the creation of the Canadian academies, including CAHS, explicitly recognizes that science must inform the development of public policy. And, public policy and the pubic interest will increasingly inform and guide the broad, and in some cases, specific directions of research carried out with public funds.

The emergence of multi-disciplinary and multi-institutional teams is also a significant challenge to individual and institutional autonomy. While the creativity and innovation that comes from individuals remain the foundation of research, the development of large multi-disciplinary teams has become increasingly integral to capture the diversity of science now essential to health research. Strong institutions are also essential to the research enterprise. They are the soil that nurtures the seeds of individual scientists. And the drive and creativity of individual scientists remains the engine essential to power successful research and knowledge transfer teams.

Finally, there is also tension within the research community between those that argue that excellence remain the sole criterion for funding and those that feel that there no longer is a dichotomy between excellence and relevance, that the most exciting and important scientific questions of the 21st century are precisely those that are the most relevant to human health and disease.

The linear paradigm of discovery, first articulated by Vannevar Bush after World War II - discovery to innovation to application - has been a useful paradigm for the past fifty years. But, as expressed so well by Donald Sobell in his book "Pasteur's Quadrant: Basic Science and Technological Innovation", the reality today is that the cultural and institutionalized separation between different parts of the research and innovation universe no longer describes what is really happening. The reality is that there is now an intimate, symbiotic and non-linear relationship between scientific understanding and its application into practice, products, and policy.

Initiatives like the Human Genome Project and the Grand Challenges in Global Health, initiated by the Gates Foundation, have gone a long way in blurring this post-WW-II distinction between basic and applied research. Developing effective vaccines against HIV and the next human influenza virus are both urgent public priorities, as well as exciting scientific goals.

I believe that the health research community must respond confidently, boldly, and across disciplines and embrace these exciting opportunities. The scientific opportunities are too exciting, the global stakes are too high, and the pace is too rapid for the Canadian health research community not to soar above internal challenges. Together, we must articulate a vision so compelling, so large, so exciting, so important, and so essential to Canada's future, that it becomes inevitable.

In closing, these exciting challenges truly involve all of us here today. They are not just a challenge for the clinician, the population health researcher, the health systems researcher, or the geneticist. They are a challenge for the entire academy. How to form creative partnerships to tackle pressing global health problems, how to harness science for the public good, and how to engage society, not as vessels to be filled, but as full and equal partners.

There are encouraging signs amongst young researchers. CIHR's Institute of Genetics holds an annual retreat for new investigators across the health research spectrum - from fly genetics to ethics to genetic epidemiology. These young investigators instinctively understand CIHR's vision - an integrative and inclusive approach that includes applying research for the betterment of humankind. Not surprisingly, young people see the future because, of course, they will create it.

If we succeed in sustaining and growing this exciting revolution in health research, if we succeed in striking creative global partnerships that will shape and harness this new science to improve health and health care, and if we succeed in diminishing the disparities between those that have access to this new science and those that do not, then we will pass on a better world to our children.

Thank you again for the honour of being your inaugural keynote speaker.