Few federal employees have been more demoralized in recent years than those at Health Canada. Stuck a few kilometres from Parliament Hill in Tunney's Pasture, Ottawa's bureaucratic theme park, the department has been groping for a role in the face of controversies, cutbacks and criticism.
The bad news never seemed to end. The department's reputation for scientific rigour was damaged by the tainted-blood tragedy in the 1980s and by subsequent criticism of its conduct by Justice Horace Krever. Federal cutbacks since the early 1990s - the Health Protection Branch budget has been slashed from $63 million in 1993/94 to $22 million this year - eroded Health Canada's ability to fulfil its health-protection functions. The RCMP has launched 3 investigations into the behaviour of Health Canada officials. And the legitimacy of Ottawa's health care responsibilities has come under attack from the provinces, which deliver health care to most Canadians and have had to pay an increasingly large share of the health bills as the feds beat a fiscal retreat. Add to this angst a string of ineffective ministers and deputy ministers, and it is easy to see why the department - which has 6000 employees and an annual budget of $1.9 billion - had become a slough of despond by the mid-1990s.
"We've been spread too thin," explains Alan Nymark, Health Canada's associate deputy minister. "We have not gone for excellence, and we have often confused the important and the unimportant. There has been no vision, no coherent sense of purpose. That's going to change."
But how? Turning around a huge public-sector organization with several thousand employees cannot be achieved solely by uttering words like "change" and "vision" - management by cliche - or by publishing a string of booklets with titles like Shared Responsibilities, Shared Vision.
Labour relations are sour, particularly in the Health Protection Branch, where scientists have accused their bosses of being too heavily influenced by the drug industry. This year's controversy surrounding Monsanto's bovine growth hormone is only the latest sign of internal friction. And the fact that Health Canada employees had not received a pay increase in 7 years didn't help either.
However, a year ago a new sheriff arrived at Tunney's Pasture. Deputy Minister David Dodge, a tall, pipe-smoking economist, is one of the most powerful members of the Ottawa mandarinate, with both the authority and the intellectual muscle to rethink the department's mission. A former deputy minister of finance, he served both Conservative and Liberal governments, and was Paul Martin's bureaucratic backup at Finance when Martin slew Ottawa's deficit dragon. Now he is performing a similar function for Allan Rock at Health Canada by coming to grips with difficult problems and giving people a sense of the future.
In Dodge's view, a major difficulty is that the department has lost contact with many of its constituents. "Our real problem is that we've got to find some way to have the professional community play an important role in the reshaping of where we go in health," he says. He has therefore focused on rebuilding the department's "science platform." This means recruiting Canada's most highly skilled scientists to work with the department. It also means strengthening the scientific basis for decisions and integrating the department's scientists with their colleagues in university laboratories. "Science is now the main line of business here," explains Nymark. "We want to open the department up to both professionals and the public."
The first sign of the new thinking came with Rock's announcement of a blue chip Science Advisory Board, headed by astronaut Roberta Bondar. Rock says the 16-member board, which includes Dr. Wilbert Keon, founder and head of the University of Ottawa Heart Institute, and Laval endocrinologist Fernand Labrie, will provide the department "with a significant capacity for the consideration of important issues related to science and health in this country." All major scientific decisions emanating from the department will be reviewed by this committee, providing a new form of internal peer review. It is currently conducting an internal review of the drug-approval process.
The next sign of the department's renewed heft came in the February budget, with the announcement of $550 million for the Canadian Institute of Health Research, the successor to the Medical Research Council. The CIHR represents a new way of funding research, a system in which "virtual" institutes will be formed around research topics such as women's health or cancer, and will link biomedical and clinical researchers with epidemiologists and service-delivery experts. Close links with the CIHR will allow the department to keep tabs on current research that is too expensive to be done in-house.
The third phase of the department-wide shake-up came with a string of recent appointments. Dr. Bob Peterson, former chair of pediatrics at the University of Ottawa and past director of the Children's Hospital Research Institute, was appointed associate director-general of the key Therapeutic Products Program. His mandate is to review and upgrade the scientific and medical capacities of that division, which regulates all drugs and medical devices.
Dr. Bob McMurtry, the dean of medicine and dentistry at the University of Western Ontario, was appointed to the newly created post of G.D.W. Cameron visiting fellow at Health Canada. In this "senior" post, he will advise the minister, deputy minister and department on emerging health issues from a health expert's perspective.
Within days of McMurtry's appointment, 2 more announcements were made. Dr. Judith Shamian, the vice-president of nursing at Toronto's Mount Sinai Hospital and an associate professor at the University of Toronto, was appointed to yet another new position, executive director of nursing policy at Health Canada. And then Dr. Marc Le Maguer, executive director of the University of Guelph's Agri-Food Research Program, joined Health Canada as director-general of the Health Protection Branch's Food Directorate.
And at the moment, the hunt is well under way for a chief scientist, a move suggested by Bondar and her Science Advisory Board. It said the person filling this new post should be an "activist, innovator and agent of change."
"Two years ago," says Nymark, "the department would not have thought of hiring these kind of people and they wouldn't have thought of coming here. But in our quest for excellence, we sought out high-quality personnel so that we would all feel proud of the science we do and the role we play in the regulatory process."
He says the appointments have had a significant impact on departmental morale. "Science has been elevated. It used to be left at the bench, and our scientists felt ignored. But the message is getting out: we are out to build the best science department there is. We have a 10-year game plan." The various items in the 1999 budget that boosted Health Canada's programs were "just a down payment," says Nymark. He is confident that the department will recoup its losses from the cutback years and get new resources for its new direction. "I'm confident that by the year 2002, the budget of the Health Protection Branch will have doubled."
Elevating science within the department is only one side of the coin. A more difficult challenge is to restore public confidence in the federal government's capacity to protect our health. At present, Canadians expect Health Canada, through its regulatory system, to provide guarantees of safety for every drug or product on the market. They expect to be protected from fraud and health hazards. Are public expectations too high? "Everything has risk," says Nymark. "Our job is to set risk tolerance levels." The department is shifting from a regulatory model to a "risk-management" model. According to Dodge, "the regulatory approach is an old-fashioned way to deal with risk . . . . We have to operate in the face of uncertainty. The [current] process is now geared to not making decisions."
Science cannot always give categorical answers, and sometimes, as in the case of measles vaccinations, for example, the good of the many may entail risk for a few. "Risk management" is about maximizing benefits and minimizing risks. The difficult decisions facing departmental scientists will only increase as the first wave of biotechnology products becomes available.
Health Canada critics argue that this shift in approach is the result of severe downsizing and loss of expertise, rather than a necessary modernization. There is a widespread fear that drug manufacturers, who pay 70% of drug-review costs, have far too much influence in the drug-approval process, and that concern for their corporate health is put before concern for public safety.
Michael McBane, national coordinator of the Canadian Health Coalition, says that whenever he hears "the man running the federal health department refer to health-protection regulations as an old-fashioned way to deal with risk, I get scared . . . . Safety becomes just another trade-off." Nymark sighs when he hears comments like that. "There's no doubt that risk management is very polarizing. The public want zero risk. We have a big education job to do."
One way to restore public credibility, the department's senior officials say, is to allow public anxieties to be aired. Last May Dodge announced the creation of a new office for public consultation and involvement, a sort of open-door ombudsman within the Health Protection Branch to whom Canadians can express their concerns about products that are being considered for approval. "Transparency is absolutely key," Dodge told a Senate committee. "The public can't [trust us] if there is a sense everything is hidden under the rug."
Today, the new sheriff at Tunney's Pasture hopes that good visibility and good science will get a demoralized department back on its feet.
Charlotte Gray is a contributing editor at CMAJ.