This is an edited version of a speech about the challenges facing medical research given by outgoing National Health and Medicine Research Council (NHMRC) CEO Warwick Anderson at the National Press Club on Wednesday:
It’s been a great privilege to have been the head of NHMRC for going on a decade. That’s four governments, six health ministers, a funding increase from A$437 million in 2006 to A$859 million today and tens of thousands of applications for funding. And when I finished in March, I was […] the longest-serving head of a major public medical research funder internationally!
We get more benefits than you might know from medical research – and we should get even more, and faster. A theme that you will hear is that we need always to be vigilant against vested interests.
All polls show that Australians overwhelmingly support government funding of medical research. I believe that people support medical research because it brings hope, hope for new treatments and cures for the diseases that they and their families suffer from.
Having successful innovative industries that rely on brains, knowledge and research is essential for our nation’s future. Think of this – the US government estimates that, though the Human Genome Project cost it $3.8 billion over 15 years, it has delivered $178 for each one of these research dollars to the US economy. So, by any measure, supporting medical research is an investment with an excellent return!
But so much more can be done to increase the value of medical research.
We could make savings to the public and private purse if we could make better use of research.
Of course, the challenge goes well beyond individual pieces of research. To derive evidence-based conclusions from the world of health and medical research is a huge challenge. There are thousands of new findings coming out of the worldwide medical research effort daily.
How is an administrator or a practitioner able to keep up, make sense and adjust her or his practice as the evidence accumulates?
Turning the research into guidelines for policymakers and practitioners is currently done in an ad hoc, piecemeal fashion. Of the more than 1,000 clinical guidelines in Australia, only a minority have been developed with rigour and are demonstrably free of vested interests. This is an area that really calls for new approaches.
We need 21st-century ways of reliably “reading” this vast amount of literature and providing it in reliable digestible forms. We can’t afford to leave this work to commercial interests only.
Another way to more quickly and effectively gain patient benefit from research is to better connect the leaders in administering the health system and leaders in medical research, towards common aims. Health care is a very large industry, costing us in total around A$140 billion a year through Commonwealth and state government spending and out-of-pocket expenses.
Like any industry, health needs research and development to progress. In most industries, research and development are integral parts of the industry itself. But in health, here and most everywhere, we do something different; we separate research from the delivery of health care.
We fund health research mainly through the higher education system. We fund health care though a wide range of policies and mechanisms, but there is not a clear stream of support for research.
Fixing the workforce
Now I would like to turn to research itself, how I think it will need to change, and how self-interest could derail the changes needed.
First, let’s stop wasting half of the best talent in the country. Women are 60% of applicants for NHMRC’s Early Career Fellowship. But for the top, most senior fellowship, less than 20% of applicants are women. Why are women leaving research?
NHMRC recently surveyed all institutions funded by it to analysis their policies on retaining and promoting women in medical research. The results of the survey were disappointing – only two of around 70 institutions sent us policies that were comprehensive and practical.
Looking around at research leaders, less than 10% of medical research institute directors are women. Only one is dean of medicine at the Group of Eight universities.
So, I recently amended NHMRC’s policy to require institutions to have proper polices for the retention and promotion of women in medical research and to have these in place by the end of this year.
Next, I want to issue a challenge to the leaders in the medical research sector itself. I have spoken many times about my concern that the Australian medical research sector is too fragmented, with too many too small institutes.
Cracking the hard questions in health now requires teams, access to a range of equipment, facilities, disciplines and know how. Modern scientific equipment is expensive and it makes no sense to duplicate or under-utilise expensive equipment.
The current trend too is strongly towards international cooperation in order to tackle to big health issues. That’s why I made sure NHMRC joined a range of top-shelf international research consortia and collaborations, such as the International Cancer Genome Consortium and the Global Alliance for Chronic Disease research.
We are just 3% of the world’s effort. We must band together better to compete with the much bigger international players – whether they are established ones like Harvard and its teaching hospitals, or the massive new Crick Institute of the three big leading London universities or, more and more, with China, South Korea and even tiny Singapore.
Australia has more than 50 independent medical research institutes. Yet almost two-thirds of medical research is conducted at just seven universities and a further 17% at the sixth-largest medical research institutes. The remaining 20% or so is spread around more than three dozen other independent medical research institutes and more than 30 universities.
No doubt it is satisfying to be king of a small castle, but is it best serving Australia’s medical research effort?
Sticking to peer review
I am guessing that for many outside science, peer review is a little mysterious. But really, it’s pretty simple – it’s about getting the best possible experts judging the science of other scientists, and doing it fairly and without bias.
I see three challenges to peer review right now. The first comes from the political world. For example, in the US, the National Science Council’s peer review is under attack.
The second attack comes from within, from a small section of the medical research itself. This group belongs to what I have called the “father knows best” school of research funding.
Using the argument that applying for grants and peer reviewing wastes time, the “father knows best” school urges that NHMRC stop all this peer reviewing and just give them the money because they are wiser than everyone else. In short, it’s a wish to return to the old days when NHMRC gave institute directors a large amount of funding and then left them to decide how it should be spend internally.
It’s a hankering for the past.
Most researchers support peer review and participate very willingly. Of course, they don’t always agree with the outcomes, especially if their own grant is not funded.
The third challenge to peer review comes from vested interests who want to bypass bodies like the NHMRC and ARC altogether and go direct to governments for funding. In recent years we have seen election promises to direct funding to prostate cancer, Type 1 diabetes, tropical health research and for many new laboratory buildings.
I’m not saying that diabetes, prostate cancer and new labs are not worthwhile, but without peer review of the merits relative to other calls on funding, the taxpayer cannot be sure that they got the best value for money.
It will be especially important to be vigilant as the Medical Research Future Fund is rolled out. Decisions must be made through peer review and it was reassuring to hear the prime minister say that “the vast majority of disbursements from the fund will be in the hands of the National Health and Medical Research Council”. But vested interests are already circling like sharks.
My next point relates to early career researchers. Let’s do train lots of PhDs, but train them too for many careers, not just full-time research. A full-time, lifelong career in research can only ever be available to a proportion of the hundreds of biomedical and life science PhDs we produce each year.
Right now we face a difficult situation. We have an overabundance of bright, emerging biomedical researchers wishing to have a career in full-time research, many more than the number of full-time fellowships that are available. We need to find ways in which this group of highly talented, highly trained people can benefit Australia in other ways too.
It’s understandable why so many great young Australians want a career in medical research. It is deeply satisfying to work on a project that is challenging mentally and to feel that your work has the potential to benefit humankind. But as the chief scientist has pointed out, we could do with many more research-trained people in the private sector where we compare unfavourably with our advanced country competitors.
We also need more researchers working in government and the public service, in NGOs and the community sector, and in teaching.
We need research institutions to better help emerging researchers with a wider range of possible careers. We need them too to provide more security of employment for those who do want to shoot for a full-time research career. Making postdocs totally dependent on gaining a NHMRC Fellowship is a poor employment model and very unfair.
Choosing evidence over magic
Finally, we need to move away from magic.
I have talked a lot about using science and the outcomes of research more rigorously in health care. So it’s distressing when unscrupulous people exploit the sick for their own personal gain, selling products that have no hope at all of helping the patient.
It’s one thing when people sell magic therapies to the worried well. That’s mostly just a waste of money, even perhaps a little placebo effect without harm.
But it’s an entirely different matter when people who are ill, with a treatable illness, are pushed therapies that don’t work and are often implausible, by practitioners who either believe in magic or perhaps are just dishonest.
Ill health has attracted charlatans since time immemorial, snake-oil merchants wanting to take your money by proposing false hope. False because its doesn’t offer hope if it’s ineffective.
Maybe this sort of behaviour was understandable before science began to come up with real, effective treatments and cure. But this is no longer justified. Science and medical research have the means to test everything for its effectiveness above a placebo effect.
As others have said, it makes no logical sense to classify things as either conventional medicines or complementary and alternative medicines. There are just medicines that work (shown by rigorous scientific peer-reviewed research) and those that don’t work (also shown by rigorous scientific peer-reviewed research!).
So it’s astounding that 19th-century quackery lingers into the 21st century. Did I say lingers? Better to says “roars into the 21st century”.
I can see no excuse for practitioners (or anyone else) urging people who are ill with diseases that are entirely treatable and even curable by what its critics call conventional medicine, to substitute this treatment with an ineffective product. This is especially so when the practitioner personally benefits, say by selling a line of herbal extracts or miracle foods, or an app, or a cookbook.
We tend to metaphorically shrug our shoulders when we hear about these cases. But we shouldn’t. We should take the same serious approval approaches to so-called alternative medicines as we take to those produced by the pharmaceutical industry. There is too big a gap between what happens in the health system and what should happen if we could better implement the findings from research.
Finally, always be wary of vested interests. We all have them – pharmaceutical industry, the “wellness” industry, lobby groups of all kinds, professional associations and certainly researchers too.
Health is big – a big business. Restraining the growth in costs and providing better treatments and cures needs a healthy national medical research effort.