A letter from ‘O Canada’

Maybe it's the ‘Trump Effect’ but the once peaceful, tranquil and innocuous ‘O Canada’ is making headlines across the world on a daily basis. On the political front, we have been outwitted and outmanoeuvred by Mexico (according to some political pundits) and have been shut out of the revised North American Free Trade Agreement (NAFTA). This has our Foreign Minister (D.D.S.’s school class mate) Chrystia Freeland scrambling to strike a deal to save NAFTA and prevent it from becoming MUFTA (Mexico-US Free Trade Agreement), which just sounds horribly wrong (Update: On October 1, 2018, the United States, Mexico and Canada have tentatively agreed to an updated NAFTA). Internally, our Prime Minister promised to build a pipeline that would carry bitumen from Alberta to the coast of British Columbia where it will be sold to the highest bidder (i.e. China) to the delight of Albertans but to the chagrin of British Columbians. After years of battles between environmentalists, indigenous groups and pro-business advocates, the courts have sent this back to the drawing board. No such impediments have been encountered by the government in its attempts to make the population less confrontational by introducing the ‘Cannabis Act’, legalizing recreational marijuana use. Potential health concerns cannot compete with revenues from a new ‘sin’ tax. This will make Canada the second country in the world after Uruguay to legalize the use of marijuana for medical and recreational purposes. The legislation is also called the ‘great Canadian Ganja Experiment’, because no one really knows the full societal impact of making ‘weed’ available at a local convenience store. It is hard to believe that the health benefits of marijuana cigarettes would outweigh the potential harm given that the only major difference between tobacco and marijuana cigarettes is the active compound tetrahydro-cannabinol (THC) (as opposed to nicotine in tobacco).1 The epidemiological studies to date have generated mixed results, mostly because of methodological limitations including small sample sizes, short follow-up time, measurement error, confounding by tobacco smoke and assessment of relatively rare adverse outcomes (such as lung cancer and chronic obstructive pulmonary disease, COPD) in young people, who are unlikely to develop these conditions for many years even with heavy exposures. Canada is a relatively small country with about 30 million people (representing approximately 0.5% of the world's population). Yet, it publishes 6% of the world's respiratory research papers each year.2 The most notable areas of excellence are (i) COPD, (ii) sleep apnoea, (iii) cystic fibrosis and (iv) occupational lung diseases where Canadian researchers produce 50–100% more papers than the ‘average’ rate for other OECD (Organization for Economic Cooperation and Development) countries.2 In COPD, for example, Canada has published 20 of the 100 most influential papers over the past 50 years.3 Notably, the most cited original paper in COPD over this time period was published by Hogg et al.,4 which has been cited 1246 times since its original publication in 2004. Some other bright spots in the Canadian Respiratory Research landscape include: (i) CanCOLD (Canadian Chronic Obstructive Lung Disease) and (ii) Allergen. CanCOLD is a population-based cohort of Canadians aged 40 years and older that was established to evaluate the natural history of COPD (from a population perspective). Despite modest funding (a common story in Canada), it has generated new knowledge that has advanced our understanding of COPD including the importance of ‘exacerbation-like’ events in smokers without airflow limitation5 and health status of patients and total airway count on computed tomography (CT) scans in predicting forced expiratory volume in 1 s (FEV1) decline.6 Allergen is part of the Canadian Network Centres of Excellence (NCE) programme and has been funded over the past 14 years to improve the care and outcomes of patients with atopy, allergy and asthma. Allergen launched the Clinical Investigative Centres (CIC) across Canada, which have been hugely successful in evaluating early Phase 2 therapeutic compounds in asthma and the CHILD (Canadian Healthy Infant Longitudinal Development) Cohort, which is studying the clinical and molecular determinants of asthma from birth to adulthood. However, some dark clouds are on the horizon for the respiratory research community in Canada. The share of total funding for respiratory research from the Canadian Institutes of Health Research (CIHR), the major funder for research in Canada, has fallen from 4.5% in the mid-2000s to 2.4% in 2014.7 The number of CIHR-funded postdoctoral fellowships in respiratory sciences has decreased by over 50% over this period of time.7 To address these worrisome trends, Institute of Circulatory and Respiratory Health (ICRH, a branch of CIHR), along with the Canadian Lung Association and many pharmaceutical companies, created the Canadian Respiratory Research Network (CRRN). CRRN was mandated to create a pan-Canadian network of investigators and research platforms to enable innovative, collaborative, respiratory research that will impact patient care, policy and enable high-quality training and career development of a new generation of respiratory researchers. CRRN has been a model of success and has breathed in new life for the Canadian respiratory research community. Since its inception in 2013, CRRN investigators have published more than 200 papers, trained hundreds of graduate students and postdoctoral fellows and created multi-institutional/multidisciplinary collaborations that have led to millions of dollars in new research funding and many ‘world's firsts…’ (e.g. world's first FEV1 decline calculator, world's first micro-simulation modelling of COPD, world's first large-scale demonstration of diagnostic instability of COPD and asthma, etc.).8, 9 The funding for CRRN, regrettably, will end in 2018 owing to strategic decisions by CIHR. Thus, the future of this important network remains uncertain. Despite these challenges, Canada is still one of the leading countries in the world for respiratory research (not to mention one of the most beautiful in the world; figure 1). Canadians are resilient, innovative and resourceful. There is a new generation of respiratory researchers on the horizon (e.g. Leung, Ryerson, Sadatsafavi, Obeidat, Bhutani, Gershon, Smith, etc.), who will carry on the legacy of great Canadian respiratory researchers (e.g. Hogg, Macklem, Slutsky, Pare, O'Byrne, Cockroft and Boulet to name a few). Canada remains ‘strong and free’ and will bring in the next great revolution in respiratory research. D.D.S. has received research funding from AstraZeneca (AZ), Boehringer Ingelheim (BI) and Merck; received honoraria for sitting on advisory boards of AZ, BI, Regeneron, Sanofi-Aventis and Novartis; and for speaking engagements from AZ, BI and Novartis. R.R.S. has received honoraria for advisory boards of CSL Behring, Merck and Sanofi-Aventis, and is a data safety monitoring board member for Boston Scientific and Green Cross Corporation.

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