Grand challenges Canada: inappropriate emphasis and missed opportunities in global health research?

Larson, Charles P. ; Haddad, Slim ; Birn, Anne-Emanuelle 等

In its 2008 budget, the Government of Canada committed $225 million over five years to the Development Innovations Fund (DIF), "... to support the best minds in the world in a collaborative search for solutions to global health challenges." (1) The Fund is intended to address and reduce the enormous global disparities in health indicators that persist in spite of remarkable gains in recent decades. These disparities led, in part, to international agreement on the Millennium Development Goals (MDGs); the DIF, in particular, is intended to focus on reducing extreme poverty and hunger (MDG 1), increasing child and maternal survival (MDGs 4 and 5), and combating HIV/AIDS, malaria, tuberculosis and other diseases (MDG 6). In May 2010, Grand Challenges Canada (GCC) was launched with the mandate to identify global challenges in health that could be supported through the Fund. The GCC offers a potentially excellent mechanism for taking Canada's participation in global health challenges "to a higher level".

The GCC will unfold in five stages, two of which have been announced. The first Grand Challenge, announced in May 2010, addresses point-of-source diagnostics. (2) The second, announced in September 2010, is the "Canadian Rising Stars in Global Health" program. Both announcements signal important new developments in Canadian global health research. They also raise new questions about the emphasis the GCC is placing on technological discovery or "catalytic" research. Missing so far are opportunities that the Fund could offer in order to support innovative research addressing i) health systems strengthening, ii) more effective delivery of existing interventions, some of which are attractive because they are "low-technology", and iii) policies and programs that address broader social determinants of health. The Canadian Grand Challenges announced to date risk pushing to the sidelines good translational and implementation science and early career-stage scientists addressing important social, environmental and political conditions that affect disease prevalence, progress and treatment; and the many unresolved challenges faced in bringing to scale proven interventions within resource-constrained health systems.

We think that the GCC's research portfolio should be consistent with the four pillars of the Canadian Institutes of Health Research: biomedical, clinical science, health systems and services, and social, cultural and environmental factors that affect the health of populations. There is nothing inherent about why a grand challenge would preclude this, apart from how one might arbitrarily choose to define it; the GCC outlines this possibility in its argument for an 'Integrated Innovation' approach to addressing global health problems. (3) Integrated innovation is seen as a confluence of three spheres of activity: scientific/technological (which makes the discovery), business (which commercializes it), and social (which allows it to go to scale). Social innovation includes reference to health systems and the determinants of health, and to uptake, ownership and sustained implementation of health promotion and support innovations by civil society, all levels of governance and, particularly, at the community level. However, our reading of the announcements is that these are described more as contextual factors of importance to implementation of the basic discovery than as meritorious scientific grand challenges in themselves. Our concern is with the apparent prioritization of biotechnical innovation research and the subordination of the social, environmental, economic and political context in which human health is either protected or eroded.

The Global Health Research Initiative (GHRI--a consortium comprised of CIDA, CIHR, PHAC, Health Canada and IDRC) has supported balanced funding across all four of the CIHR pillars; but its funding is now mostly spent and its renewal is still in doubt. In the absence of GHRI funding and the GCC emphasis primarily on biotechnological solutions, opportunities to support the full spectrum of Canadian global health researchers could become significantly narrowed. What is needed besides further discovery of technologies is research into operational and policy areas where more immediate impact in improving lives can be achieved and where Canadian taxpayer money can be best applied to most effectively leverage the scaling up of proven and highly cost-effective interventions, whether technological, socio-political, or, ideally, an integration of the two.

Returning to the MDGs, of the 8 million deaths per year in children under five years of age, (4) perhaps between 1 and 2 million could potentially be influenced favourably by new discoveries in vaccines, drugs or innovative technologies. Excellent examples include oral rehydration therapies, antibiotics, new vaccines and antiretroviral medications. However, none of these discoveries will result in significant numbers of lives saved without a much improved, evidence-based understanding of how they can be developed, delivered and sustained in resource-constrained settings in order to reach those in greatest need; or what policies (national and international) might reduce such resource constraints. For the remaining 6 million early childhood deaths per year, affordable, applicable interventions currently exist. For example, global scaleup of promotion and support of optimal infant feeding practices alone could prevent one in five (19%) of these deaths, (5) and immunization, mainstreaming micronutrient supplementation, fortification and other community-based nutrition interventions already offer powerful solutions to the challenge of global health and malnutrition. (6,7) These and other such solutions have in many cases been known and available for several decades or, in the case of sanitation, for over a century.

Among the lessons learned by the global health research and implementation community is that bringing such solutions to scale has been and continues to be significantly hindered by inadequate funding of research in support of strengthened health systems, better policies, changing health behaviours, health services and bolstered human resources for health. Moreover, the long-term sustainability of these efforts depends on the local and transnational political and economic conditions that drive social policymaking. Much the same case can be made for maternal mortality, which accounts for nearly 350,000 largely preventable maternal deaths per year; 99% of these are in low- and mid-developed countries. (8) The vast majority of these deaths occur during delivery or shortly thereafter and can be directly attributed to poverty, gender inequity and lack of access to affordable and effective emergency obstetric care. This huge burden will not be reduced through new technological discoveries alone.

We wholeheartedly support integrated approaches to innovation, but with recognition and funding strategically applied to research addressing discovery, development and delivery. What, constructively, can be done to redress this imbalance between discovery-and delivery-focused research? We offer the following recommendations:

1. GCC specifically, and global health research generally, should align with the four CIHR research pillars;

2. Global health research and career path funding of early career stage Canadian scientists should offer balanced opportunities covering the domains of biotechnology, clinical, social, political, population and public health sciences;

3. 'Discovery' research is needed on "best practices" models of integrated political, social and clinical means of reducing inequities in health. In this regard, there is a great deal we can learn and apply in Canada from work done in low- and mid-developed countries;

4. Emphasis in such research should include partnerships with low- and middle-income country scientists. By this we mean that developing-country partners must be truly equal partners, initiating ideas as well as shaping the research agenda and questions in collaboration with Canadian scientists.

REFERENCES

(1.) Grand Challenges Canada. Available at: http://www.grandchallenges.ca/whowe-are/ (Accessed March 23, 2011).

(2.) Grand Challenges in Global Health. Available at: http://www.grandchallenges.org/ diagnostics/Pages/GCCanada_POCDiagnostics_RFP.aspx (Accessed March 23, 2011).

(3.) Grand Challenges Canada/Grand Defis Canada. Integrated Innovation. August 2010.

(4.) Rajaratnam JK, Marcus JR, Flaxman AD, Wang H, Levin-Rector A, Dwyer L, et al. Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970-2010: A systematic analysis of progress towards Millennium Development Goal 4. Lancet 2010;375(9730):1988-2008.

(5.) Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. How many child deaths can we prevent this year? Lancet 2003;362(9377):65-71.

(6.) Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, et al. What works? Interventions for maternal and child undernutrition and survival. Lancet 2008;371(9610):417-40.

(7.) Copenhagen Consensus Center, 2008. Available at: http://www.copenhagenconsensus.com/Projects/Copenhagen%20Consensus%202008/Out- come.aspx (Accessed March 23, 2011).

(8.) Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980-2008: A systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010;375(9726):1609-23.

Received: November 8, 2010

Accepted: January 27, 2011

Author Affiliations

Charles P. Larson, MD, [1] Slim Haddad, MD, PhD, [2] Anne-Emanuelle Birn, ScD, [3] Donald C. Cole, MD, MSc, [4] Ronald Labonte, PhD, [5] Janet Hatcher Roberts, MSc, [6] Ted Schrecker, MA, [7] Daniel Sellen, PhD, [8] David Zakus, PhD [9]

[1] Clinical Professor, Department of Pediatrics, University of British Columbia and Director, Centre for International Child Health, BC Children's Hospital, Vancouver, BC

[2] Directeur, Departement de medecine sociale et preventive, Universite de Montreal, Montreal, QC

[3] Professor and Canada Research Chair in International Health, University of Toronto, Toronto, ON

[4] Director of the Collaborative Program in Global Health and Associate Professor, Dalla Lana School of Public Health, University of Toronto, Toronto, ON

[5] Canada Research Chair, Globalization/Health Equity and Professor, Faculty of Medicine, University of Ottawa, Ottawa, ON

[6] Executive Director, Canadian Society for International Health, Ottawa, ON

[7] Scientist/Associate Professor, Department of Epidemiology and Community Medicine and Institute of Population Health, University of Ottawa, Ottawa, ON

[8] Professor of Anthropology, Nutritional Sciences and Public Health and Canada Research Chair in Human Ecology & Public Nutrition, University of Toronto, Toronto, ON

[9] Director, Canadian International Immunization Initiative, Phase 3, Canadian Public Health Association, Ottawa, ON

Correspondence: Dr. Charles P. Larson, BC Children's Hospital, Centre for International Child Health, Room K4-104, 4480 Oak Street, Vancouver, BC V6H 3V4, E-mail: clarson@cw.bc.ca

Conflict of Interest: None to declare.