How far does your position at Dalhousie inform your decision making, and what advantages are afforded to CAHS from your post at the University?

Being part of a university, especially as the Dean of the Faculty of Medicine, is a privilege. It also allows me by virtue of office to interact with government, usually provincially, and to be attuned to healthcare issues in general. Moreover, as Dean of a Faculty I gain a greater understanding and appreciation for the other professional sectors that comprise CAHS – namely nursing, pharmacy, rehabilitation medicine and dentistry, and veterinary medicine, to name a few.

One major objective of CAHS is to provide assessments of and advice on key issues relevant to the health of Canadians. Why was it deemed necessary to set up an assessment body in 2004, and who calls for these assessments?

The answer to this is deceptively simple – because prior to this there did not exist in Canada an organisation such as ours that could do the kinds of assessments that we feel are necessary. Most of the assessments have arisen from issues that our fellows see as important. We usually hold a symposium on one of these issues at our annual meeting and then decide whether or not to do an assessment. Currently, we are carrying out work at the request of one of the departments in our federal government. We have also partnered with the Royal Society of Canada in an assessment that was requested by a private foundation.

How are assessments funded and what impact, if any, has the current economic climate had on CAHS?

It is certainly more difficult to raise funds for such assessments in the current economic climate.

The CAHS-initiated assessments are funded by money raised through presentations to groups who would naturally have an interest in the outcome. For example, for the assessment ‘Making an impact: A preferred framework and indicators to measure returns on investment in health research’, we approached agencies who fund research.

Our recent contract with one of the federal government departments for an assessment is a reflection of the quality of our work, and this type of sponsorship will allow us to continue our work better than if we had to rely solely on raising funds ourselves.

Two projects currently underway, in collaboration with the Royal Society of Canada (RSC) and other bodies, are an assessment of Early Childhood Development, and Dietary Reference Intakes of vitamin D and calcium.

What is the procedure for selecting projects?

Expert assessments are prepared on the initiative of CAHS, or in response to specific requests from governments or other parties. Such assessments are designed to be balanced, thorough, independent and based on a deep knowledge of all of the published research that is pertinent to the question(s) posed. They frequently point to areas where knowledge is lacking and deserving of further work.

The Standing Committee on Assessments (SCA) reports to the CAHS Board. It comprises 10-12 members appointed on the advice of the SCA Chair and chosen to collectively provide broad expertise in the areas of science and policy that are within the remit of CAHS. The SCA may consult broadly with CAHS fellows and external parties as needed, and its role is to work closely with the Board to develop potential topics for assessments; determine their scope and type; recommend the exact questions to be addressed by the assessment panel; identify potential panel chairs for Board approval; work with the appointed chair to select appropriate panel members; liaise with the chair/panel during their work; arrange for independent external review; and conduct an internal review of the panel’s draft report, advising the Board as to whether it should be approved by CAHS.

How are urgent health issues identified and prioritised? What, in your view, is a major health concern for Canadians at the present time?

Urgent health issues (for assessment) are identified in a variety of ways: through environmental scans (including monitoring the assessments that are done by the Institute of Medicine in the US); through discussion at the Board; and through suggestions from our fellows.

The major health concerns of Canadians are probably the rising cost of healthcare, which now accounts for almost half the entire budget of several provinces, and the increased and unacceptable wait times for some elective procedures.

Scientists who are recognised nationally and internationally for their contributions to health science can become a Fellow at the Academy following a nominating and peer review procedure. What is the purpose of these fellowships? In what way do Fellows serve CAHS?

Membership in the Academy is seen as an honour, and worthy recognition that one has achieved a certain status in the field. As academics in Canada we feel we have benefited enormously from society, and being a fellow of CAHS is one of the ways that we can give back. Fellows give freely of their time and expertise to conduct assessments.

In a recent assessment of Canada’s strategic role in global health it was deemed that Canada could make more of a concerted effort to analyse strategic investments or policy choices. What are your hopes for the outcome of this assessment? What steps does Canada need to take to align itself with the US and the UK in this regard?

The assessment has reached some key insights with respect to Canada’s role in global health. It has identified five areas of opportunity:

• Indigenous and circumpolar health research

• Population and public health

• Community orientated private healthcare

• Smart partnerships in education and research

• Global health innovation

There is also a strong theme of mutual learning between the global and the local, and a clear call for an approach to global health that includes multiple sectors such as academia, civil society, government and the private sector. Our hope is that future initiatives in global health, both in Canada and elsewhere, might be informed by these and other aspects of the report.

In the same report, the potential for scientists to take a leadership role in addressing the health challenges of the Canadian aboriginal population was highlighted. What particular health issues does this population face and how would addressing these challenges be testament to Canada’s legitimacy in global health?

One of the novel aspects of our report was the inclusion of a focus on aboriginal and circumpolar health. Both in Canada and globally, aboriginal populations face a range of challenges, including a high prevalence of some non-communicable diseases such as diabetes, and difficulties in service delivery due to remote and hard to reach communities. Our report recognises that Canada has made significant investments in research on aboriginal and circumpolar health issues which are beginning to bear fruit (although we still have a long way to go in implementation) and that this is an area where Canada can and should show leadership globally.

Could you offer an example of instances where CAHS fellows collaborate internationally?

This is an evolving area for us. We have not been able to participate in these efforts to the extent that we would like, due to a very slim operating budget. Certainly our members participate in such collaborations as part of their professional activities at their home universities.

Finally, what have been the highlights of your tenure so far and what are your hopes for the future?

My greatest hope for the future is sustainable funding so that we can perform two to three assessments per year.

The release of the assessment on global health has certainly been a highlight, as has been the opportunity to serve on the board of the Council of Canadian Academies.

Another highlight has been the interest in CAHS amongst academics in health-related fields across Canada. Our membership, despite a very rigorous selection process, continues to grow.

www.cahs-acss.ca

To begin, what brought you to this position, and to what extent do your own research interests inform your role?

For more than 20 years, I have been working as a cardiovascular disease scientist, educator and physician at the Texas Heart Institute (THI) in Houston, in several different leadership capacities. My own research is focused on vulnerable atherosclerotic plaques, non-invasive imaging procedures of the heart and blood vessels and, recently, stem cells. When I originally came to the Institute, Dr Cooley, then President, wanted me to be the Medical Director of Cardiovascular Research. When he decided to resign in 2008, he asked me to succeed him in that position.

Can you offer a short summary of the organisation’s mandate?

THI has been dedicated to education and research discovery since it was founded in 1962. Our commitment is to new discovery that ultimately prevents cardiovascular disease in all of its forms, and in the interim, to relieving and improving the hearts of patients with cardiovascular disease.

Since 1962, we have been involved in training cardiologists, heart surgeons, imaging specialists in cardiovascular medicine and cardiac electrophysiology, and pathologists, and we have educated hundreds of cardiovascular specialists during this period.

It has been 50 years since the Institute was first established. What have been its greatest moments, and what challenges has it had to overcome?

Simply, it is an exhilarating challenge ensuring that THI conducts cutting-edge research and educational programmes in cardiovascular medicine, and is dedicated to applying these to the care and prevention of cardiovascular disease in humans. Each of our research discoveries and their applications to humans has been a great moment.

Also, THI is a non-profit organisation in the truest sense. Unlike most institutions that have a source of operating revenue, the Institute has primarily been supported by research grants and philanthropy and this has represented a challenge annually over the past 50 years.

Accounting for over a quarter of all deaths in the US each year, cardiovascular disease is a major health concern; however mortality from coronary heart disease (CHD) has substantially decreased in recent decades. What might account for this trend?

I believe that the decrease in mortality from CHD in the US is a result of research discoveries that have provided insights into mechanisms responsible for thrombosis in injured coronary and cerebral arteries, and led to improved treatment. For example, advancing the understanding of ‘bad’ low-density lipoprotein (LDL) cholesterol in patients to values well below 100 mg/dl has been a very important contribution. The development of statins to lower LDL has also been crucial. The use of aspirin, medications to control blood pressure, avoidance of smoking and use of recreational drugs, control of blood sugar in patients who are diabetic, emphasis on diet and exercise, and improved imaging techniques for blood vessels and the cardiovascular system, generally, have played a role in protecting patients and decreasing mortality risk.

However, the greatest risk factor for cardiovascular disease is a genetic one, and we must identify the genes that contribute to this risk; ultimately silencing the most dangerous ones using microRNA methodology.

THI is recognised nationally and internationally for important contributions in the battle against cardiovascular disease. Could you outline some of the successes?

The Institute has established itself as an international leader in the area of mechanical circulatory support research, ie. implanting more left ventricular assist devices (LVADs) and conducting more heart transplants than any other institution in the US. We are also making great strides in the area of myocardial regeneration, ie. the use of patients’ own stem cells (autologous) and also allogeneic cells to repair damaged heart tissue.

We have conducted numerous clinical studies in patients with cardiovascular disease using a variety of stem cell types, including mesenchymal stem cells taken from the bone marrow or adipose tissue. Through the pioneering work of Dr Doris Taylor, we are now able to deplete human hearts of their cellular structure and then restore that same heart to normal function by the infusion of stem cells. With continued success, these efforts could fill a great unmet need and pave the way to a new area of transplant medicine.

More women than men die of heart disease. Why is this so, and how is THI addressing this issue?

There are presently 43 million women living with heart and vascular disease in the US. In comparison, there are 8 million women living with cancer. If you are female, you are more likely to die of heart and vascular disease than all cancers combined; and five times more likely to die of heart and vascular disease than breast cancer. Women’s symptoms are also often different from those found in men. For instance, some women with heart attacks may experience pain in their ear or may simply not ‘feel well’. Moreover, their responses to various procedures, including bypass surgery, are often different than in men.

Recognising this, we have created the Centre for Women’s Heart and Vascular Health – one of the first in the US. This new Centre allows us to educate women about their heart disease risks. We are also working to develop new approaches for effectively identifying and treating cardiovascular diseases in women.

An ageing population, increasing levels of obesity, lack of physical activity and rising numbers of Americans living with diabetes, are all contributing factors to cardiovascular disease. To what extent do lifestyle factors limit the impact of research?

Part of THI’s mission is to educate men, women and children about the risks for developing cardiovascular disease. We are creating educational programmes that may be used throughout Texas to inform children and adults about risks associated with obesity, lack of physical education and diabetes. We are also recruiting young people who have been very successful in their athletic endeavours to be representatives and role models to children, women and men all over the US in this war against cardiovascular disease.

Cardiovascular disease costs the US $449 billion each year in healthcare services, medications and lost productivity. What measures could be taken to reduce this outlay in the long term?

Prevention would be the single most effective means of reducing healthcare costs. Prevention should be the main concern initiated at very young ages and continuing throughout adulthood. There are a variety of other measures, including healthcare clinics that educate, treat simple abnormalities, and direct patients that need more complicated cardiovascular care to advanced facilities.

www.texasheartinstitute.org

How did you originally become interested in diabetes research?

During my undergraduate and early graduate studies I had the opportunity to work with two eminent nutritional biochemists: the late Dr Kenneth Carroll and Dr Murray Huff. We worked on the effects that the plant-derived molecules known as flavonoids have on cholesterol and fat metabolism. I was drawn to this project because of the potential that adding small plant-derived molecules to our diets could improve metabolism and perhaps prevent cardiovascular disease.

As I progressed in my career, so did the worldwide epidemic of obesity and type 2 diabetes. During my postdoctoral training I chose to study the effects of excess fat and glucose on the cells of the heart and blood vessels, with the hope that I could contribute to finding treatments for cardiovascular complications that are the leading cause of death in obese individuals and those with type 2 diabetes.

What successes in your past research are you most proud of?

Singling out individual research successes as points of pride is challenging. I have been fortunate that at each stage of my career, projects I initiated (or at least have been involved in) have been carried forward by others, and continue to evolve. I now see this happen on a daily basis as the students in my lab progress through their programmes. I am most proud of this continuity. It makes me feel that, in the long term, our cumulative work will have an impact on our understanding of obesity and type 2 diabetes, and perhaps influence healthcare approaches for people with these diseases.

Can you describe your current CDA-funded research project?

Blood vessel (vascular) complications are very common in patients with obesity and type 2 diabetes, and can contribute to high blood pressure, reduced blood flow to the legs and feet, and heart disease. Damage to endothelial cells, which line all blood vessels, is caused by high blood glucose and lipids. Once these cells are injured, their ability to repair further damage is limited. With the help of the CDA, I am investigating whether increasing the level of NAD+, an important molecule involved in endothelial cell survival, will improve the ability of blood vessels to repair the damage that occurs during obesity and type 2 diabetes. This research could help in the development of new drug therapies that would increase NAD+, improve endothelial cell survival and reduce vascular complications in obese people with type 2 diabetes.

What are your hopes for the future of diabetes research?

Many current medications to lower blood glucose and lipids were not developed with the obese individual in mind. For type 2 diabetes, my hope is that we as a research community can develop complementary drug and lifestyle modification-based treatment regimens to effectively manage the devastating cardiovascular consequences of this disease in the context of obesity.

www.diabetes.ca

How did you originally become interested in diabetes research?

I have had a relatively circuitous research career and have worked in both academic and industrial laboratories. Through the years my scientific interests have shifted, from very basic biochemistry to more applied biomedical research that is directly relevant to human disease. Our laboratory is currently investigating the molecular mechanisms that link diabetes to an increased risk of heart attacks and strokes. This is an interesting and important problem because incidence of diabetes is increasing dramatically, and 70 per cent of individuals with diabetes die of heart attack or stroke.

What successes in your past research are you most proud of?

We have made considerable progress in understanding why people with diabetes are predisposed to cardiovascular disease. Our research has led to the identification of new targets for drugs that may reduce the risk of heart attack and stroke. These findings could change the way we treat patients with diabetes.

During the course of this research, many graduate and undergraduate students have been trained in my laboratory. I have been very privileged to work with these very intelligent, enthusiastic young people who are the next generation of diabetes researchers and healthcare professionals. I am proud to have contributed to their education and their future successes.

Can you describe your current CDA-funded research project?

People with diabetes have a higher risk of heart attack and stroke because of a disease of the large blood vessels (macrovascular disease) called atherosclerosis. People with diabetes can also suffer from vision problems, kidney disease, and other circulatory problems that are a result of a disease of the very small blood vessels (microvascular disease). Traditionally, microvascular and macrovascular disorders are treated as separate problems. Our CDA-funded research project is investigating the possibility that diabetes causes atherosclerosis by injuring the small blood vessels that supply the walls of the large blood vessels; in other words, that macrovascular disease (atherosclerosis) is a microvascular complication.

What are your hopes for the future of diabetes research?

We have learned a lot – from the discovery of insulin in 1922 to the development of many new and effective drugs to control diabetes and treat complications. But we have a long way to go: incidence of diabetes continues to increase and the majority of individuals with diabetes still die from cardiovascular disease. There is a lot that we still do not understand. However, I am confident that, together with other diabetes researchers, we can increase our knowledge and develop new and better treatments and preventative measures that will have a positive impact on the healthcare and quality of life of the millions of people with the condition.

www.diabetes.ca  

How did you become interested in diabetes research?

As a paediatric endocrinologist, I take care of children with type 1 diabetes on a daily basis. Early in my career I decided that I could not passively wait for something to happen. It was at about this time that the new molecular genetics methodologies became available and I decided that this is where I wished to devote my career: discovering the genetic causes of the disease would, someday, allow us to get to its root.

A great influence in this decision was Dr Eleanor Colle, my mentor in diabetes research who kept challenging me with questions that demanded answers. I remember her as an unassuming old lady sitting at the corner of the seminar room with her eternal knitting who, at the end of the talk, would surprise those who did not know her by addressing the speaker with the most insightful and penetrating questions. Her work on the early genetic mapping of the lymphopenia phenotype in the biobreeding rat model of diabetes was, perhaps, what first awakened my interest in genetics research.

What successes in your past research are you most proud of?

Although it is the genome-wide association studies that have attracted the most attention, the work that I cherish most is the discovery of insulin expression in the thymus, and its modulation by the insulin gene polymorphism. Type 1 diabetes happens when the T-cells of the immune system fail to recognise the pancreatic islets as ‘self’, and destroy them. T-cells learn to recognise self in the thymus, so the thymus needs to make a tiny bit of insulin for this purpose. A polymorphic allele (ie. a different version) of the insulin gene that makes less insulin in the thymus puts those who carry it at a two-fold higher risk of type 1 diabetes. This finding led other researchers to discover that the thymus makes hundreds of proteins that, until then, were thought to only be expressed in one organ (like insulin in the pancreas).

Can you describe your current CDA-funded research project?

The most effective prevention/cure of type 1 diabetes would be to eliminate the few T-cells that recognise insulin as a foreign substance and attack the cells that produce it. Many attempts to do this in a nonspecific manner have resulted in immunosuppression that limits the extent and duration of the treatment that can be given. The antibody-like molecule with which T-cells recognise their target is extremely variable; each of the billions of T-cells in the body has a different T-cell receptor (TCR), and only a handful of these will fit the insulin molecule. Such enormous complexity was impossible to address with conventional methods but next-generation sequencing (NGS) is now offering a window that I am exploring. Knowledge of the types of TCRs that attack insulin can be used to identify biomarkers and, in the long run, will help us to target therapeutics.

What are your hopes for the future of diabetes research?

The new powerful methodologies of genetic analysis give us hope that we will, someday, discover not only what causes type 1 diabetes, but also different cellular and molecular disturbances in different individuals, which may lead to an individualised selection of treatment that fits the patient – the ideal of personalised medicine.

www.diabetes.ca

Could you provide an overview of the state of diabetes in Canada, as well as any recent shifts or developments in research?

Diabetes rates in Canada have almost doubled over the past decade and are continuing to rise. A number of factors contribute to the growing number of Canadians being diagnosed with diabetes each year: behaviour patterns such as high rates of physical inactivity and excessive ‘screen time’, dietary patterns that promote obesity, and immigration from countries where rates of diabetes are high. At the same time, more effective treatment of diabetes and its complications mean that people with the condition are living longer, which also contributes to an increase in the prevalence.

Recent advances in our understanding of the causes of diabetes at a cellular level have supported the development of new treatments for type 2 diabetes. Altering activity patterns to reduce the risk of type 2 diabetes in individuals at high risk has been a focus of research across the spectrum from fundamental physiologic processes through enhancing clinical interventions to the design of neighbourhoods to support healthy living. Similarly, in type 1 diabetes, the underlying immune causes of the condition continue to be unravelled and exciting new approaches to replacing the functions of the pancreas move us closer to a cure.

What is the main thrust of the Canadian Diabetes Association’s (CDA’s) work?

Our mission is to lead the fight against diabetes by helping people live healthy lives while we work to find a cure. We deliver on our mission by:

• providing people with diabetes and healthcare professionals with education and services

• advocating on behalf of people with diabetes

• supporting research

• translating research into practical applications

What types of studies are you currently facilitating?

Each year, the CDA supports excellence in research by funding the most innovative scientific minds in Canada. Since 1975 and the establishment of the Charles H Best Research Fund – named after insulin co-discoverer and Association co-founder Charles Best – the Association has awarded more than $110 million in research grants to scientists and clinicians in their quest for new developments in the prevention, treatment and management of diabetes. There are currently five types of research grants and awards supported by CDA: Operating Grants, Scholar Awards, Clinician Scientist Awards, Postdoctoral Fellowship Awards, and Doctoral Student Research Awards. These grants and awards offer support to research projects in the areas of obesity, complications, genetics, pathophysiology, prevention and management, and the search for new treatments.

Although the research we fund is diverse in its scope, covering a broad range of specialties, the key aspects of every study and researcher remain the same – to improve the quality of life of people living with diabetes and/or to find a cure.

Can you offer some examples of where the CDA is translating research into practical applications?

Published every five years, the Association’s Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada represent the best and most current evidence-based clinical practice data for healthcare professionals. On a global stage, the Guidelines support CDA’s status as a leader in diabetes prevention and management, and help physicians guide their patients in the screening, prevention, diagnosis, care, management, and education for Canadians living with prediabetes, type 1, type 2 and gestational diabetes.

What progress in the search for new treatments has the CDA seen in recent years?

Researchers funded by the CDA are making great strides in the search for new treatments. In the past, Association-funded researchers were instrumental in the discoveries that led to the development of two new classes of oral medications to treat type 2 diabetes: GLP-1 analogues (like exenatide and liraglutide) and DPP-4 inhibitors (like sitagliptin).

www.diabetes.ca

What is the Young Professional Chronic Disease Network (YP-CDN)?

Imagine you are a student or a young professional (under age 40) in Hyderabad, India and you have an idea, a fundamental idea that could re-imagine how your government, the private sector in your country or how NGOs could address the drivers of a sick society: to challenge the permissive, conflicted and perhaps unclear agendas that fuel the ‘causes of the causes’ of such a sick society.

Now, if you wanted to take a stand, where would you go? Who would you talk to? How would you network with other young, like-minded individuals around the globe? And, critically, how would you get your idea in front of the real decision makers, the folks that actually have the power to change the status quo? This is where our organisation comes in. We give individuals that platform, focusing on building a fresh movement on non-communicable diseases (NCDs).

We are the first young professional global NCD network in the world. We were invited to the UN General Assembly to deliver remarks and organised the first-ever rally on NCDs at the UN HQ. We have crowd-sourced a Youth Manifesto on NCDs from members around the world to advance our generation’s (Generation Y’s) vision on addressing a sick society and made our voice heard via a TEDMED lecture in 2012.

Why is it important to focus on NCDs?

A silent epidemic, NCDs affect millions. Today, heart disease is the leading global killer, with nearly 80 per cent of cardiovascular deaths occurring in poor countries. Four risk factors (tobacco use, poor diets, inadequate physical activity and harmful use of alcohol) account for four diseases – heart disease, Type 2 diabetes, lung disease and cancers – that now kill six out of every 10 people worldwide. Mental illness is comorbid with many NCDs, further frustrating health progress (there can be no true physical health without mental health).

There is emerging consensus that NCDs are a development issue that disproportionately affects the poor but receives less than 1 per cent of total global health funding. There are important new questions as to whether NCD indicators should be integrated into the Millennium Development Goals – and if so, what are the highest priority interventions and objectives? Figuring out the best-buys and political economy of this development is a unique opportunity for the group and we have the rare invitation to participate rather than sit on the side-lines.

Now, in the context of a globalised world, children as young as eight years old have fatty streaks in their arteries due to poor diets. We realise that we have a stake in this – that we, as the next generation, are growing up in a society and environment full of risk and that we can, should and must speak out to help reverse the tide. After all, what choice do we have?

By engaging in the discourse now, and seeding appropriate relationships with each other, we are preparing ourselves for the long haul.

What brought about the establishment of the Network?

There is a mistaken belief that NCDs do not capture the interest of the millennial generation – that the diseases are self-inflicted and the fault of the victim. We challenge this view, engineering a global social movement on NCDs using student and trainee networks, particularly in academic institutions in resource-poor settings (eg. Rwanda, Liberia, Tanzania, South Africa and India). We started with 12 people in two countries to champion the idea that NCDs were the social justice issue of our generation – and have expanded to over 1,500 members in 100 countries. We hope to bring as much energy to the table as we have showed for HIV/AIDS; the latest data (Global Burden of Disease 2010) show that NCD risks are increasing while infections/under-nutrition are on the decline.

What do you consider to be some of the foremost socioeconomic issues and concerns where NCDs and their treatment are concerned?

The elephant in the room seems to be trade. Two colleagues, Sanjay Basu and David Stuckler, came up with the term ‘manufactured epidemic’ and that is precisely what the NCD epidemic is. The risks are manmade and, in a sense, we are standing by, watching this happen. The compression of morbidity that Professor James Fries highlighted is being replaced by an expansion of morbidity where populations are living longer with diseases that develop earlier.

We are headed in the wrong direction. Beneath trade are the causes of the causes – the policies, structures and inequalities – that lock-in ill health. Addressing inequality needs to centre on freedom from oppression (in this case the ability to live a healthy life). These issues are complex and start to nudge up against the politics of the nanny state where individual liberties are pitted against public and collective security and health. What our generation is saying is enough – we are sick, chubby and poor – it is time to reimagine what is possible, at the policy and community level if we are to continue health gains this century.

How urgent is the need to develop effective policies and best practice for the secondary prevention of global NCDs? Can you detail how YP-CDN is tackling this?

The secondary prevention and access to treatment agenda is critical. There are two looming issues.

First, how do we enable access to ‘cost-effective’ tools like off-patent, generic medicines such as diuretics or hypertension medications to individuals in low-resource settings? Inspired thinking on procurement and new business models are important here, including curating examples and best practices from around the world and sharing them. The polypill, the first fixed dose combination for primary and secondary prevention of cardiovascular disease, is an example of one innovation. Public sector units as seen in India, particularly for vaccines, is another example of government helping protect against poor production/supply issues by guaranteeing medicines. We have worked on petitioning the World Health Organization’s (WHO’s) Essential Medicines List, with a group called Universities Allied for Essential Medicines, to add new NCD drugs. In India, the national essential medicines list has been updated with NCD medicines in 2011 and now any medicine on this list will be available for free in the public sector.

The second issue is to move past cost-effectiveness to effectiveness, and ask how we make medicines that are taken for granted in high-resource settings available in low-resource settings. It comes as a surprise to some that diabetes or cancer exists in the poorest parts of the globe – and yet there is no reliable access to effective medications. This, particularly in the case of cancer, is due to the high cost of therapies, a lack of global demand forecasting, and the absence of a strong call for equitable treatment. Here, we have also petitioned the WHO Essential Medicines List to add medicines such as the blockbuster therapeutic trastuzumab (Herceptin) for breast cancer. I have worked in a personal capacity to petition WHO to include imatinib (Gleevec) for chronic myelogenous leukaemia on the EML, as well.

How does YP-CDN facilitate meetings among its members, both regionally and internationally? Can you discuss the focus and outcomes of any recent events?

The Network is open to the public, and members are typically below the age of 40 and range from any discipline and any geographic area. On the third Thursday (3T) of each month, members host regional gatherings around the world.

A 3T meeting provides an opportunity for students and young professionals in cities and towns throughout the world to share stories, discuss common interests and identify mutual opportunities for collaboration in both local and global contexts. New people join every month, and you never know who might show up at a meeting. Past meetings included local students, people from the private sector, urban planners, architects, economists, professors and even local politicians. Outputs include networking; engaging in discussions; making new friends and meeting colleagues; writing articles for journals, newsletters, blogs or opinion pieces; engaging in local action projects; and pairing with another 3T group elsewhere in the world. There are now 25 such 3T groups led by local action leaders internationally.

By connecting the experiences and ideas of local communities with the wider global network, we achieve a powerful local-to-global model for action that will harness the ideas, energy and passion of students and young professionals to transform the way we develop effective NCD solutions.

In what ways does YP-CDN seek to harness ties among the research community, industry, NGOs and policy makers?

Our manifesto lays out a charter of our recommendations as well as our core commitments to action that gives members our identity in a snapshot. We have profiles and a vibrant community discussion group that airs different perspectives on contemporary debates. For instance, one recent discussion with members of the Network was on the Pan American Health Organization’s (PAHO’s) alleged receipt of funding from the food/beverage company Nestlé. And another was on the politics behind the Bloomberg soda size policies in New York. These generate lively, thoughtful critiques and we provide a ‘safe space’ in each others’ homes or over the web. This is a place where people can blend their personal narratives with their professional/technical expertise.

From a member’s perspective, what might you suggest are the benefits of belonging to the Network?

Our member survey results suggest the top interests are health systems/health policy; implementation science; and education/training/capacity building. From a representative sample, the average age was 31.6, and MD and PhD degrees were the most common qualifications. Members cite participating in the global conversation (to identify political and social opportunities for leadership), professional networking, connecting with like-minded individuals for collaborations, learning more about NCD training opportunities and access to peer mentorships as benefits.

What is your vision for the Network moving forward?

We have achieved success when the voice of any member anywhere in the world reaches local and global policy leaders – as well as potential peer collaborators. We are hoping to mature our Network and increase the quality of the relationships through more in-person meetings. We hope to put more policy directives and narrative voice projects into motion to create and curate approaches that could be used at the national level, where the NCD struggle will be waged.

www.ncdaction.org

To begin, can you explain the mission of the Max Planck Institute for Molecular Cell Biology and Genetics (MPI-CBG) in Dresden?

The question of how cells form tissues has been, and still remains, a problem. Researchers at MPI-CBG are tackling this issue from different angles, and we take a multidisciplinary approach to address this. We work on both cell and developmental biology, trying to understand how the collective property of cells contributes to the behaviour of the tissue in much the same way as attempting to understand how birds flock, for example. You might know how individual birds fly but that doesn’t necessarily explain how birds perform flocking behaviour. This originates from an interaction between birds, and the same goes for cells; we might understand how an individual cell works but that doesn’t tell us how the cells communicate with one another to form tissue.

Molecular cell biologists provide insights into the basic processes of cellular life and organisation. Developmental biologists and geneticists place these functions into the context of tissue development in different model organisms such as zebrafish, drosophila, Caenorhabditis elegans or mice. MPI-CBG has also invested extensively in services and facilities to allow research scientists shared access to sophisticated and expensive technologies.

Could you highlight the investigations underway to determine how cells form tissues?

We are considering the question of how to make an embryo from a single cell. For example, we will try to follow the division and movement of each cell using computer science and imaging. We are developing microscopy to see how cells work. It is very difficult to track individual cells, so computer science is necessary. We also have to develop the theory to understand them.

What are the benefits of understanding how cellular control systems work? How will this help diagnosis and treatment?

In the end, understanding pathology requires knowledge of the cell as part of a cohesive group of cells. What we have to understand over the next 20 years is how the basic mechanisms of a cell are altered in disease; without this we will not be able to do anything. I have a strong feeling that in the next 20-30 years we will make enormous strides in this area.

Could you reflect on some of the most exciting aspects of MPI-CBG’s research and discuss your advancements in recent years?

When we initiated the Institute, developmental biology focused mainly on transcription. However, we decided we wanted to work on the problem of how cells are involved in this process rather than a transcription pattern. This seems obvious today but when we were pioneering this it was an unknown problem, and so we were leading the field.

Looking ahead, we are all excited that the Institute is employing computational biology and extracting information from images. As I said before, if you have a flock of birds, you might want to extract the flight times, patterns and movements of all the birds, and from that try and understand how a flock develops. This is similar to what we are attempting to do with cells.

The Nobel Prize in Physiology or Medicine 2012 was jointly awarded to Sir John B Gurdon and Dr Shinya Yamanaka for the discovery that mature cells can be reprogrammed to become pluripotent. Has this recognition had an impact on the work conducted at MPI-CBG?

This was a huge step forward and something the Institute was very excited about. Yet we have to temper our enthusiasm for this success. Although we are not able to put mature cells back into organisms straightaway, we are able to work on humans, taking cells from patients and creating stem cells to study what is wrong with them. This is further advancing our research.

Molecular cell biologists, developmental biologists and geneticists work together at MPI-CBG. What research environment does this foster?

This creates a vibrant working environment and an exciting atmosphere. Bringing together people from different parts of the world and from a wide variety of backgrounds engenders an environment where everyone is pushing boundaries. People from the various fields learn from each other, as well as how different individuals conduct research. I think cross-disciplinary research doesn’t happen enough. At Max Planck, the secret is hiring great people and creating an environment that allows them to thrive. We put everyone in the same building and encourage them to attend the same seminars, which naturally leads to fruitful research and good working relationships.

As I mentioned before, when we first set up the Institute, biomedical research was only just beginning. Max Planck made a huge impact by placing MPI-CBG in Dresden. It only costs a relatively small amount of money – €15 million a year – to run but we have had a massive effect on the local economy, having created at least 2,000 jobs. We don’t just want to generate individual professorships but rather to create teams of people that want to make a difference.

Having invested extensively in services and facilities, MPI-CBG allows scientists shared access to sophisticated and expensive technologies. Could you outline some of these technologies?

We try to ensure that all core technologies necessary for research are available at the Institute, such as microscopy facilities and spectronomy, DNA sequencing, microarray analysis and transgenic core facilities for making transgenic mice. Everything is centralised so that all our staff have access to this equipment.

As one of 80 institutes of the Max Planck Society, what level of interaction and collaboration do you enjoy with the sister organisations?

We collaborate when there is a need, which means we often look to expertise in the Max Planck Society when we have research that necessitates collaboration.

The Scientist voted MPI-CBG as the best place in the world to work in academia and undertake a postdoc. What contributing factors make MPI-CBG a great place to work? How important is it for researchers to have attractive and inspirational surroundings?

The Institute is like a family. It is a place where everyone is looked after so that each employee feels involved and at home. We nurture our employees as much as possible, offering childcare services, family-friendly policies and social events.

The directors are also interested in this aspect of the Institute. My father gave me a great bit of advice when I became a director; he said places only work when the director takes an interest in the details, and so this is what we attempt to do.

The Institute is in a nice area of a beautiful city where people can live cheaply, so our employees do not have to worry about expensive rents or long commutes. For that reason, they can focus on research and enjoying their job.

Regarding your personal research, your team is interested in spatial control of the microtubule cytoskeleton, and how this applies to the events necessary for mitosis and cell division. What success have you had to date?

It is hard to quantify success! We have published lots of ground-breaking papers and I personally have published about 180 over the course of my career. Some of these are taken up and others are not. My first paper – my PhD – is still cited today some 25 years later, while others that were initially cited are no longer cited a few years on.

Finally, with the uptake of science in schools falling, are you confident that there will be enough researchers in the future?

I think there are a number of talented researchers coming through the ranks. It is more about quality than quantity, and I am not convinced that an increase in quantity is actually beneficial. When I attended university in England only 10 per cent of people went to university. Those who really wanted to be a scientist were the ones who succeeded.

www.mpi-cbg.de

Can you remind us of HCI’s history and mission?

HCI was established thanks to the generosity of Jon and Karen Huntsman, who provided both major founding gifts, as well as continued support. The Huntsman’s philanthropy enabled the University of Utah to capitalise on its rich history of contributions to human genetic research to focus more closely on the cancer problem. As a result, HCI very swiftly developed into a world-class cancer research enterprise. I was excited and honoured to be part of this process and am proud of the strong scientific research environment we have created. I have served as CEO and Director of HCI since 2006.

The overarching goal of HCI is to alleviate the suffering of cancer patients through compassionate clinical care and the most advanced interventions available. To do this, we take a three-pronged approach: research to better understand how cancer begins and behaves; application of research discoveries to the development of clinical treatments; and education and outreach to the public to enable them to better understand and cope with disease in themselves and their loved ones.

Aside from state-of-the-art medical care, HCI’s ethos is underpinned by a belief in the importance of emotional support and wellness. What has experience shown about the value of this holistic approach?

There is no question that emotional support and an emphasis on wellness helps our patients. Studies have shown that managing stress positively affects treatment outcomes. For this reason, we incorporated space within the design of our new cancer specialty hospital expansion (dedicated 2011) to support patients and their family members with physical therapy and fitness activities, nutrition advice, and complementary treatments such as acupuncture. We have also created a late effects clinic to manage side-effects in cancer survivors years after treatment.

In an era where the global population is ageing fast, how might your strategic priorities be shifting? Will you be necessarily moving towards a ‘care’ rather than ‘cure’ paradigm?

It is our role as a National Cancer Institute (NCI) designated Cancer Centre to generate new research findings and apply them to relieve suffering. The research we do is directed towards both care and cure, as well as prevention. Our goal would be to control both the growth of cancer cells and the impact of the disease on patients’ quality of life.

It is true that because of increased health standards around the country and the world, life expectancy is increasing, and as a result we can anticipate that the number of cancer patients will also rise. With the exception of childhood cancers, which are typically the result of genetic changes that happen in the development of the embryo, cancer is a disease associated with age. This is because, in addition to whatever inherited susceptibility an individual possesses, one acquires genetic changes based on environmental exposures or random chance throughout one’s lifetime. The accumulation of these changes is associated with cancer development. Therefore, unless we can discover effective strategies to prevent cancer, we can expect to see a larger number of cancers develop as the population ages. Towards this end, HCI focuses on genetics and the definition of susceptibility genes, as well as on education about lifestyle changes that can reduce risk for developing cancer. HCI’s researchers make progress on many fronts, not only in the development of drugs to combat cancer cell growth, but also techniques to communicate genetic testing information and strategies for coping with a cancer diagnosis; all apply to our goal to relieve suffering. So, care and cure, as well as prevention, are all part of our mission.

To what extent are individuals empowered to take a proactive approach to their health in times of wellness? How can institutions such as HCI help in developing educational strategies to quantify the impact of lifestyle on the pathology of disease?

HCI has been at the forefront of this movement by devoting considerable resources to develop the Huntsman Cancer Learning Centre (CLC). The CLC encourages and empowers patients and the public to become active participants in their healthcare by increasing their knowledge and understanding of cancer topics relevant to their personal health needs. The CLC reaches tens of thousands of people annually in Salt Lake City and at similar HCI centres throughout the entire state of Utah with information regarding well-established recommendations for cancer screenings that promote early detection and better outcomes.

In addition, it is clear that certain lifestyle choices can dramatically increase risk for developing cancer, the most obvious being use of tobacco and exposure to the Sun. Part of HCI’s mission is to convey information to the public about healthy lifestyle choices and help to give them pathways to adopt those healthy lifestyle choices. In April 2012, HCI held our 13th Annual Skin Cancer Screening for the public. Free ‘total body’ skin exams and education were provided for 433 people. 34 possible skin cancers were detected and 27 per cent of these individuals were referred to a dermatologist for care. Through public screening events such as these, HCI seeks to save lives, as well as raise awareness of steps we can all take to promote our health.

HCI hosts a plethora of oncology events and conferences throughout the year. What is achieved by bringing together a range of speakers in such a forum; are you for example seeking to influence policy at local, regional or national levels?

HCI is the official cancer centre of Utah, an NCI-designated Cancer Centre, and a part of the University of Utah – we consider it our privilege and responsibility to serve as a research resource to our partners around the world who work together with us to eradicate this disease. In large part due to our impact in cancer genetics, HCI is widely viewed as a thought-leader in this field. Speakers regularly visit HCI to describe their latest results to our community; similarly, scientists from HCI travel the world to share their research. Sharing of knowledge is key to discovery in science. Different researchers approach the same problem from multiple angles and it is only when their insights are shared, that the impact of their gathered understanding becomes clear. Intellectual interaction seeds future advances, which are the desired outcome.

With respect to policy, our cancer institute takes the importance of publicising insights derived from research very seriously when they can benefit the public and translate appropriate research findings into changes in public health policy. HCI works with the community and in partnership with policy makers to enact laws based on scientific research. For example, it is unequivocally known that exposure to ultraviolet radiation increases susceptibility for a variety of different types of skin cancer. This past year, HCI was successful in helping to enact legislation in Utah to protect minors from harmful UV radiation by outlawing the use of tanning beds for persons under the age of 18 without parental consent. Our role here is to advocate for public health by striving to advance the dissemination of the most current scientific knowledge to benefit the people.

What legacy would you like to leave at the end of your tenure at HCI?

Scientists and physicians now recognise that cancer is a very complex disease and there are many different types of cancer. Tackling any one of these cancers to impact patients in the clinical setting requires expertise in many, many different areas and specialties. One thing that I would like to leave, as a lasting legacy at HCI, is the strongest possible assembled core of faculty in the disparate disciplines that are necessary to make progress on the cancer problem. My goal is to build a team – with the best investigators in laboratory, clinical and population research – that can change clinical practice for the better and ensure the impact of the Institute going forward.

Putting the right people in place will ensure that the creative approaches and insightful investigations necessary to further probe this complex problem will occur. That would be a lasting legacy toward the future of relieving cancer suffering.

www.huntsmancancer.org

Could you begin by describing how the Robotic Surgery, Research and Training Centre came into existence?

In 2001, Boston Children’s Hospital (BCH) was the first children’s hospital to obtain a robotic surgical system. The leadership felt that this technology held significant benefits for patients. Since its role in the paediatric population had not been investigated, they felt it essential for our hospital to be the leader in defining the role of robotic surgery in children. Consequently, not only did BCH purchase a unit for clinical use, but an additional unit for research. In 2005, I was put in charge of the robotic programme here at BCH. We recognised that not only was clinical practice and research needed in robotic surgery, but training was also required to ensure safe and efficient use of the robotic system. These three components were essential and interdependent.

Consequently, I formalised the establishment of the Robotic Surgery, Research and Training Centre, recruiting surgeons, anaesthetists, radiologists, nurses and other healthcare professionals – as well as researchers. Problems identified during clinical practice could be rapidly investigated in the animal laboratory; the benefits and costs of robotic surgery could be explored in a systematic manner with the help of statisticians and clinical researchers.

As Director, what is expected of you and how do you fulfil this role?

I oversee the activities in the clinical, research and training area. In particular, I monitor cost and utilisation in clinical practice, and identify best practice and novel applications. In research, I help to identify key questions for database analysis or animal model experimentation, and design new technology to improve robotic surgery. I also supervise training, ensuring standards are consistent, and delineate training methodology to maximise the training process.

Is this robotic equipment difficult to operate and what training opportunities does the Centre offer?

As the name implies, the use of robotic equipment is quite intuitive. However, the complexity comes when trying to understand the mechanics of the system and how to troubleshoot. Consequently, we are not only teaching surgeons how to perform specific robotic surgical manoeuvres, but how to handle emergency situations and ensure efficient docking and positioning of the robotic system.

To what degree is the Centre involved in the design of this equipment?

Ultimately, we are not engineers but end users. Consequently, we have a hand in the conception and testing of equipment. For example, several nephrology colleagues and I are working with a bioengineering company to develop a novel method of dialysis. We meet with the engineers to go over biological principles and specifications needed for such a device, and then the engineers develop models for us to bench test.

The Centre promotes provider and patient learning through its wide range of research projects. Could you outline some examples of these projects and what they aim to achieve?

One of our projects evaluates the learning curve associated with robotic-assisted surgery compared to standard laparoscopic surgery. We identify the factors associated with robotic learning and document the frustration linked with performing laparoscopic surgery. We hope that this information will help surgeons and trainees to learn robotic surgery more efficiently and rapidly.

Another project evaluates the costs associated with robotic surgery compared to open and standard laparoscopic surgery. Our findings help to identify factors associated with the cost of robotic surgery and to develop strategies to minimise this cost. In collaboration with our anaesthesia colleagues, we are working to define pain management protocols to make robotic surgery even less painful and allow for even more rapid recovery, and potentially no hospitalisation following surgery. Moreover, we are working with engineers to develop a next-generation robotic system that will be less costly and more independent, and have more advanced features.

The most expensive way to deliver care is in a hospital – but discharging patients too soon can lead to complications and rehospitalisations. One of your pilot projects has been to call the family at home and conduct the check-up remotely. How does this work and what is this robot able to provide?

As an extension of our robotic work, we are performing research in evaluating the use of robots in the home for post-operative care. We recognise that it is less costly to transition the patient’s recovery from hospital to home. However, this may lead to increased complications and decrease the standard of care. We postulate that remote monitoring could help to put the healthcare provider into the patient’s home environment, so he/she can be monitored, cared for and, more importantly, educated about their disease process. We utilise the robot not only to take care of patients but to engage them and their families in understanding and participating in his/her healthcare. The robots help to reinforce good health practices and provide educational materials, which demystify the diseases and make them more understandable.

What opportunities does seeing the patient in his/her natural environment afford the doctor?

The caregiver could better see how the patient is managing with his/her daily activities. Rather than just asking, they can evaluate the recovery process based on the patient’s individual circumstances, eg. can he/she climb the stairs to the bedroom, or are they recovering on the couch because they cannot get to the bedroom? More importantly, the robot system provides the patient with a sense of security – they know that there is someone to watch over them.

How is patient satisfaction assessed?

In our research, we evaluate patients’ quality of life and satisfaction with surveys. These assessments are as important as surgical outcomes and complications rates (readmission or unscheduled emergency room/office visits). In addition, we regularly survey the patients on their perception of the technology and its usability.

Regarding the development of new fields, what areas are you currently looking into?

We are very interested in evaluating additional applications of robotic surgery, including foetal surgery. Robotic surgery can significantly decrease the surgical risk for both the mother and foetus. We are still working in animal models to ensure safety and efficiency.

We are also evaluating novel methods of visualisation of the human body without the use of radiation or ultrasound. We have published several studies in fluorescence imaging as an alternative to using radiation in medical imaging.

www.pedsrobotics.com