Internationally unique, the CIHR Institute of Population and Public Health (IPPH) represents a synthesis of the old and the new in public health research. The Institute's broad ambit encompasses traditional public health investigations of disease and injury prevention, health promotion and the protection of the population from hazards (including, but not limited to, infectious disease control, and environmental /occupational health research) as well as the newer field of "population health." The latter can be thought of as the inter-disciplinary study of the fundamental determinants of individual- and population-level health, especially the interaction of social and physical environments with genetic predispositions, as played out in entire societies, over the life course. The IPPH field includes, among the determinants of health it studies, public/private/voluntary sector policies and programs that have an impact on population health status.
The overarching objectives of the IPPH are intended to transcend these diverse sub-fields. They are:
To develop Canada's capacity for high-quality research in population and public health (PPH), which by its very nature tends to be inter-disciplinary, and to catalyze the development in Canada of internationally-respected research projects and findings in this field, by capitalizing on our national research strengths.
To build bridges between researchers and users of PPH research, namely policy-makers and program administrators in the public, private and voluntary sectors that affect health, so as to increase research uptake/transfer, fostering evidence-based public health policy and practice.
To demonstrate clear value added from funding strategic (as opposed to purely investigator-initiated) research in this field, in accordance with the ongoing transformation of CIHR itself.
To act as an effective partner in CIHR cross-Institute activities that span the four "pillars" of health research (basic science, clinical, health services and policy, and public/population health).
Context
The current state of PPH research in Canada is not well documented. Indeed, current bibliographic information systems available in Canada's research funding agencies (including CIHR) are only partly able to capture the very diverse community of researchers in this field. The great breadth of subject matter involved defeats the usual biomedically oriented key-word lists and search strategies for health research. It is particularly difficult to track the participation in PPH research of social and behavioural scientists (such as sociologists, psychologists, anthropologists, geographers, political scientists and economists), as well as investigators from the arts and humanities (such as philosophers and ethicists). However, available information concerning current and recent grant-recipients, from CIHR alone, suggests there are several hundred active investigators in this field in Canada, scattered across an extraordinary range of institutions, faculties and departments. Consequently, a prime initial task of the Institute will be to assist researchers with interests in particular topics to contact CIHR-IPPH and each other, and to develop joint proposals.
The historical lack of a common forum for discussing Canadian PPH research priorities follows from both the diversity of researchers described above, and the plethora of policy-makers and program administrators engaged in activities that impact the public's health. As a result, IPPH must itself act as a national "meeting ground" for bringing these groups together to decide on PPH research priorities for Canada, and on how best to develop new investigative programs to strategically address those priorities. This process has already begun, with the inaugural meeting of the IPPH Institute Advisory Board (IAB) on March 21, 2001. After considerable deliberation, the IAB selected six broad themes or priorities for Institute initiatives in the coming years. These priorities are described below, in no particular order of importance.
Priorities
Training for Innovative Research: Building Canadian Capacity
Vision: The CIHR-IPPH will facilitate, with the active participation of PPH stakeholders across Canada, the establishment of a coordinated, high-quality and comprehensive PPH training capacity across Canada - a virtual/networked Canadian National School of Population and Public Health.
It is widely acknowledged that both the quantity and quality of PPH researchers in Canada, while they are recognized as leaders in that field internationally, will require augmentation if Canada's PPH research capacity is to reach world-class status, and the field is to optimally participate in the vision of CIHR "cross-pillar" activities in the future. This Institute has a special responsibility, together with the Institute of Health Services and Policy Research, to plan for the considerable person-power that will be needed to fully collaborate with other CIHR Institutes in activities that span the four pillars: basic biomedical science, clinical research, health services and policy, and population/public health.
With respect to quality, the current training programs for PPH researchers in Canada have many strengths, but need assistance with respect to:
basic funding levels for many graduate students, which hardly constitute a living wage;
the workspace quality of now-aging university physical plants in which much graduate research education is carried on;
inter-disciplinarity, especially at the post-doctoral (and potentially doctoral) levels;
connections to policy and program users of research in the field;
unevenness in training capacity across Canada's regions: the majority of PPH researchers are trained in large, comprehensive programs in Canada's largest cities, and often continue to work there after training is completed, providing them limited contact with the health problems of the rest of the country. Smaller and much less comprehensive programs in the smaller universities, on the other hand, suffer from the severest resource constraints; their few faculty are often heavily committed to undergraduate health professional education.
Strategies and Actions: The IPPH strategies and actions described in Table 1 are intended to address the needs of the current training system. In the short term, the Institute will examine opportunities to both jump-start existing trainee numbers (through increased personnel awards), and immediately offer special training grants for innovative programs, centres and networks. In the longer run, stakeholders will want a step-by-step participative planning process, if we are to move towards a national coordinated system of training programs linked in a virtual and networked "Canadian National School of Population and Public Health." The specific needs of current programs are not well documented and may vary considerably from centre to center. Therefore, fact-finding activities will likely be necessary, to better gauge the precise gaps in each region's training capacity that must be addressed. Any substantial changes that are recommended as a result of this process will need to be implemented in close consultation with the universities, other advanced training centres, and their (largely provincial) funding sources across the country.
2. Population-Based Health Database Design and Development
Vision: The CIHR-IPPH will collaborate -- with Health Canada, the provinces, Statistics Canada, the Canadian Institute for Health Information/Canadian Population Health Initiative and other key stakeholders --in the coordinated planning and development of a national system of linked and integrated population-level health databases designed to meet the research needs of the next century, while also serving policy-makers' needs for ongoing monitoring of the health status of Canadians.
Canada already has some of the best-developed databases in the world for studying and monitoring the health of entire populations. Particularly in Manitoba, British Columbia, and Saskatchewan, these databases are increasingly capable of anonymously linking routinely collected vital statistics and administrative health/social services data, for each individual resident in the province over his/her lifetime. Additional insights are now available from sophisticated new longitudinal surveys of representative population samples, initiated by Statistics Canada and other federal agencies, as well as some provincial Ministries of Health. These surveys are, or shortly will be, collecting primary data -- biological (laboratory and physical exam) variables, individual-level risk factors and health outcomes, and local community characteristics. When these surveys are also linked (with fully informed consent of participants) to administrative data, such as hospitalization and ambulatory care outcomes, we will be much better able to assess the influence of the full range of determinants of health in our society, over the life-course.
The current challenge, however, is to develop a more coordinated approach to the development and funding of new databases, especially those to be used for research purposes. Such far-sighted planning and coordination is critical, given the typically high front-end costs of establishing such databases, and the careful scientific design needed to ensure that subsequent analyses over many years have the necessary baseline information available. In addition, new knowledge, such as that from the Human Genome Project, requires that cutting-edge science be brought to bear on the design of such databases, from a much wider range of research disciplines than in the past.
Strategies and Actions: In response to these challenges, CIHR-IPPH will embark on a series of interactive processes -- described in Table 1 -- with research and policy-maker stakeholders across the country. The purpose will be to facilitate the coordinated planning of both new database development, and existing database augmentation/ linkage and analysis. A first step in this process will be to establish a set of national priorities for population-level health database development, taking into account Canada's leading expertise in linked administrative data, and the opportunities afforded by collaboration with a wide variety of other research disciplines, both inside and beyond CIHR. Simultaneously, CIHR-IPPH, CIHR-IHSPR and the other CIHR Institutes have already begun high-level discussions with the Canadian Foundation for Innovation, the other federal funding councils, and other major funding sources for database development with research implications (including Statistics Canada, Canadian Institute for Health Information/Canadian Population Health Initiative, Health Canada, and the provinces) to develop a coordinated, comprehensive and scientifically strategic Canadian funding policy in this field.
3.Gene-Environment Interactions
Vision: The CIHR-IPPH will develop Canada's capacity to integrate population-health sciences and genetic research methods, to provide rich fundamental insights into the causation of the common multifactorial (and genetically "complex") diseases of modern society, that are jointly determined by our genetic inheritance and the sequence of social and physical environments to which we are exposed as we age.
New knowledge of the human genome, and of the very complex ways in which environmental exposures affect its variable expression over time, are beginning to revolutionize the study of disease etiology. To move forward our understanding of prevention, studies of the causes of cancer, heart disease, hypertension and stroke, diabetes, asthma, and major mental illness such as schizophrenia and mood disorders -- to name only a few examples -- now require high-quality measurements of both multiple aspects of the environment, as it changes over time, and the relevant genetic features of study subjects. Canada has distinguished scientists expert in both sorts of measurement, as well as epidemiologists, biostatisticians and social scientists familiar with novel study designs and powerful new data-analytic techniques. Working together, such broad inter-disciplinary teams can make great strides in our understanding of how such typically chronic diseases arise in some individuals and not others, at various stages of life.
Strategies and Actions: What is needed to spark this field is increased intellectual interaction between these groups of investigators, who are often situated in widely scattered university departments/faculties and off-campus research institutes. The CIHR-IPPH will work with other stakeholders to catalyze such interactions. The Institute will also seek to increase international collaboration, so as to allow the identification of the research opportunities in this new field for which Canadian research capacity is especially suited. For example, the ethically conscientious addition of genetic data collection to selected national health surveys, especially those anonymously linkable to administrative databases (described above) can greatly increase the power of longitudinal studies of chronic disease. Such study designs are especially helpful in efficiently identifying the forerunners of conditions that take many years to develop, and/or have subtle clinical manifestations in the initial stages that may not be hospitalized (e.g. angina in heart disease, chronic cough in asthma, glucose intolerance in diabetes, minor depression, etc.) Canada is therefore in a good position to capitalize on one of its historical strengths - population-based health databases - if newly identified measures of the genetic and environmental co-determinants of these ubiquitous diseases of our society can be incorporated in properly designed studies, built on the databases we have.
Making this happen, as with all new scientific paradigms, will take time. The Institute, together with our sister Institutes such as the Institute of Genetics, is committed to promoting the sort of creative scientific dialogue that is needed. The initial activities described in Table 1 are designed to launch that process.
4. Context (Home/Family; Daycare/School; Work/Recreation; Institutional versus Domiciliary Living for the Elderly and Disabled; Neighbourhood/Community) as Determinants of Health over the Life-Course
Vision: The CIHR-IPPH will create a rich and diverse network of researchers and policy-makers/program administrators across Canada to identify, in an ongoing way, the critical research questions arising from the physical and social features of these "micro-environments" that could be altered so as to improve population health status. CIHR-IPPH will then partner with other research funders to ensure that those research questions are tackled in a peer-reviewed program of innovative inter-disciplinary investigations that feeds back to the research users who can improve these environments.
There is wide agreement that the "places" where we live, learn, play and work, throughout our lives, have major influence over our health. A broad range of Canadian researchers are already engaged in high-quality investigations of the effects on health of these environments. CIHR-IPPH will facilitate increased dialogue between these researchers and the policy-makers and program administrators who are in a position to make changes in these environments, whether they be in private sector workplaces, public housing projects, or voluntary sector recreation facilities.
Strategies and Actions: Because of the broad scope of this initiative, and the plethora of researchers and research-users involved, the IPPH Institute Advisory Board (IAB) may select one or two of the "micro-environments" listed above to pilot the Institute's facilitation of enriched researcher-stakeholder dialogue. Then, over the next few years, the Institute would fund a limited number of research projects, in areas prioritized by that dialogue, through specific Requests for Applications. Over the longer term, it is hoped that other research funders, such as CIHI/CPHI, SSHRC and NSERC, may be willing to partner in the funding of trans-disciplinary investigations of the social and physical attributes of these micro-environments that impact on health.
To assist stakeholders, for the various micro-environments listed above, to engage in participatory research planning and prioritization, the CIHR and the Institute are currently issuing a generic "Needs/Gaps/Opportunities Assessment" Request for Applications (RFA) with a maximum grant value of $80,000 over eight months. These short-term planning grants are designed to enable researchers and research-users in a well-defined sub-field of population and public health -- e.g. Health and Daycare Policy; Health in Schools; Work and Health -- to identify and prioritize research and research-capacity needs, gaps and opportunities in Canada. [This funding mechanism will also be offered to stakeholders to generate national research plans for the "Interventions" priority described below. Thus it is described on the third page of Table 1, under "Cross-Priority Activities."]
5. Population-Level Interventions to Improve Health
Vision: The CIHR-IPPH will:
Recent comprehensive reviews of the effectiveness of population-level interventions to improve the public's health, such as that by the U.S. Institute of Medicine, released this year, have emphasized that the best strategies are those that tackle a health problem simultaneously on several fronts. For example, under-age smoking, a phenomenon notoriously resistant to all control efforts, has been shown to respond only to a combination of culturally appropriate educational programs, economic policies (especially taxation), and regulatory strategies (e.g. restricted access to purchase), executed in tandem. At the same time, researchers internationally have new methodological knowledge concerning how best to plan, carry out and especially evaluate such multiple public health interventions, in the usual context where many stakeholders (e.g. government at several levels, the private sector, public institutions, the voluntary sector) are involved, and must be full partners in such projects.
Canada is well-positioned to take advantage of this new knowledge. Often it is possible in this country to "get everyone in the same room" who has an interest in such interventions - a situation not mirrored in more populous and institutionally complex countries. Again, CIHR-IPPH has a unique opportunity to act as a catalyst and host for the development of the broad coalitions and partnerships required to do this kind of applied research. Efforts will be made to capitalize on "natural experiments" involving existing policies and programs, slated to change for any reason, and thereby often offering an opportunity for quasi-experimental evaluation of health impact.
Strategies and Actions: As already noted , the Institute is in the process of issuing a Needs/Gaps/Opportunities Assessments RFA, specifically targeted to both "Context Over the Life Course" and "Population-Level Interventions" (see Table 1). Based on the findings of these Assessments, support will then be made available from the Institute and partnering organizations for building Canadian capacity where needed. For example, support could be available for methodological development activities, such as workshops and courses, involving both researchers and community stakeholders, as well as pilot projects to prepare for specific intervention studies. [The latter often require seed funding, to nurture the complex process of partnership-building between researchers and other players, and adequate participatory planning to occur, before actual interventions can begin.] Special attention will be given to developing innovative joint financing structures between CIHR/ other research funders, and other bodies which fund interventions as part of their usual mandate, but have limited monies for research per se. An example of the latter is Health Canada's "Population Health Fund," which has launched a program of funding for interventions to decrease falls in the frail elderly.
6. Global Health
Vision: CIHR-IPPH will champion and facilitate, in partnership with other Canadian organizations committed to international collaboration and technical assistance, the development and utilization of our national research capacity to address the overwhelming health problems of the developing world and many middle-income countries.
There are a number of reasons why Canadians can and should do more as global citizens to investigate and solve the extraordinary health problems that now face the less advantaged world. First, our international image is built on a history of generous and competent assistance to other nations in times of acute need, such as war and famine. However, there is remarkably little research in Canada tackling the everyday health problems, both biomedical and infrastructural, faced by these populations. In many settings, particularly Eastern Europe, Africa and war-torn parts of Asia, overall health status is now worse than at any time in decades. Canadian health researchers, especially in population and public health, have knowledge and skills of great value in investigating and addressing these countries' health and health-care-delivery problems. Much of the work that needs to be done would also be "good science," in that it would increase global knowledge of evidence-based public health practice.
Less altruistically and more self-centeredly, Canada now finds increasingly that the world is literally at its doorstep. Globalization of economic structures, including food and tobacco markets; ubiquitous civil and military strife, with concomitant political instability, that cause increased mortality and morbidity by a host of pathways; widespread ecological degradation with major potential public health effects (e.g. global warming); and vastly increased international travel and immigration to and from tropical and other inherently hazardous environments - all call for increasing Canada's capacity in global health research, while at the same time helping to further develop that capacity in less developed countries.
Finally, investigation of the determinants of health at the level of entire populations requires comparative international studies. For example, recent research funded by CIHI/CPHI and carried out at Statistics Canada, in collaboration with U.S. colleagues, has shown that the influence of province/state- and city-level income inequality on local mortality is much better buffered by social, taxation and health insurance policies in Canada than in the USA. Yet some would argue that the World Trade Organization is aiming to label publicly sponsored national health care systems as contrary to free trade principles. Further investigation of such important questions requires the active collaborative study of population health phenomena internationally. Canada would benefit from greatly developing this collaborative capacity, and the Institute is prepared to take a leading role in making it happen.
Strategies and Actions: Initial discussions have begun with the International Development Research Centre, the Canadian International Development Agency, the Canadian Society for International Health and several Canadian researchers active in the global health field. The good news is that everyone is thinking the same way: a comprehensive, planned national approach, to technical assistance and collaboration in health research on strategically chosen global health problems, is urgently required. Together with these stakeholders and funders, the Institute will sponsor a series of national workshops and meetings (see Table 1) to forge a set of priorities for this field. We need to build on the considerable strengths of our national PPH research community, and facilitate the greater involvement of Canadian PPH researchers in such international work, in ways that are consistent with promoting high-quality research at home and abroad, while transferring the lessons learned to the wider global audience. That audience includes Canadians themselves, for much can be learned by comparative international work that is useful in one's own back-yard. Specific topic areas for action will require more deliberation and negotiation, but early candidates include: HIV/AIDS control programs; population health database development; the effects of air, water and soil pollution on health; the impact of socio-economic inequalities on population health status; coordinated tobacco control policies; and national research planning and prioritization itself.
Cross-Priority Activities
Listed at the end of Table 1 are cross-priority Institute activities already underway, or planned in the near future, in response to either opportunities that have arisen spontaneously, or through early collaborative initiatives with other CIHR Institutes. They include: coordinating the research of IPPH and the two-year-old Canadian Population Health Initiative at CIHI; acting as a lead Institute at CIHR for cross-Institute initiatives in Rural and Remote Health, and in Minority/Immigrant Health; collaborating with other Institutes (not as the lead) in initiatives in Environmental Toxic Effects on Children's Health, and Prion/BSE-Related Disease; and perhaps expanding an existing peer-reviewed journal to focus on Canadian research in population health, and health services and policy.
Next Steps: A Nation-Wide Stakeholder Consultation
This "Strategic Directions Outlook" is intended only as an initial planning template, for the first year of CIHR Institutes' operations. The CIHR corporate planning cycle requires each Institute to submit, to the Governing Council, a three-to-five year Strategic Plan in November 2001. In preparation for writing this plan, the IPPH Scientific Director and Assistant Director will be engaging in an extensive stakeholder consultation process, in major cities of all regions of the country, in September and October. In each setting, local co-hosts from the IPPH Institute Advisory Board and/or Governing Council will assist the Institute in contacting in advance key regional, provincial and local organizations that may have an interest in responding to this document: government at various levels, especially those branches responsible for public health services; the voluntary sector, and academic institutions where PPH research is conducted, including university departments outside of health science centres per se, where important social and behavioural science investigations into the determinants of health, for example, are based. A wide range of such organizations will be invited to attend interactive multi-stakeholder sessions, present summaries of their reactions to this document, and suggest other specific priorities for the IPPH over the coming years. This input will then be utilized in drawing up the IPPH long-range Strategic Plan in November.
