On November 22, 2022, as part of the Ontario Chamber of Commerce’s Ontario Economic Summit, The Hub’s executive director Rudyard Griffiths moderated a “Munk-style” debate involving Globe and Mail columnist Andrew Coyne, C.D. Howe Institute CEO Bill Robson, former Ontario Cabinet minister Sandra Pupatello, and The Hub’s own editor-at-large Sean Speer. The debate’s resolution read: Be It Resolved: Ontario Needs Reshoring as Part of Its Growth Agenda. Pupatello and Speer argued in favour of the motion. Coyne and Robson against it. The Hub is honoured to publish the debaters’ opening statements.

I’m delighted to be here to tell you there are three good reasons why reshoring needs to be part of Ontario’s growth strategy. Number one, we’re in it all by ourselves here people, so we’ve got to rely on ourselves. Number two, we know what the risks are now with the experiences that we’ve gone through recently, and it behooves us to do something about it. And number three, regionalization is already happening around the world, and we can’t miss that boat. 

So, number one: we’re in it alone. Do you remember where you were when the U.S. administration swooped in to take our 3M PPE supply? When the president at the time threatened a Patriot Act against the company if he didn’t relinquish the shipment? I know the mayor [John Tory] knew because the media raced to him at that time to say, “Are we okay? Are we going to be okay here?” But it was a seminal moment for us. I know where I was: standing in my living room, gobsmacked, thinking “Are you kidding me? I thought we had laws here, trade laws.” Not when the going gets tough, though. We’re on our own. We need to truly realize that and prepare accordingly. 

Reason number two: we know the risks. We knew that these experiences were not just limited to businesses, but government too. So, for example, for government, we know we’ve got to worry about health issues, health businesses, and health access. We know we’ve got to worry about security, defence, cybersecurity, and all of the scamming that happened during the pandemic. And then there’s that big issue: energy. Do we have the capacity? Or can we create the capacity if that should happen again and our borders close? Can we take care of at least those basic necessities that the general public would expect of government? And for business, if there is any one item that is going to risk your whole enterprise, all of a sudden you need to look at it again. 

Case in point: in April of 2011 or so Toyota had massive shutdowns around the world. Why? The tsunami in Japan. And at that time they realized they had never expected something like that could happen—not just were they dealing with thousands of people who lost their lives during this tremendous tragedy, but they were shutting down plants around the world because they had not accounted for what could happen. So they got their heads around this and came up with a list of 500 essential products, and they said, “This isn’t going to happen again.” So they worked with their supply chain, and in some instances were prepared to pay more so that they could backstop their inventory. 

Fast forward ten years later in a pandemic, when every other car company that was trying to manufacture cars couldn’t because of a chip shortage, guess who was still producing cars and delivering them to the dealership floor? Toyota. Now, that didn’t last the whole pandemic, but it lasted a long time because they were prepared. 

So, imagine if we asked everyone who’s here tonight what are the top ten prescription drugs that Canada needs. We could probably figure that out, just with those of us we have here in-house. We could also figure out what would we need for energy generation and transmission and the utility grids across our land.

Finally, I want to say, regionalization is already happening, and it’s happening on continents. Those big international firms that have plants all over and are reliant on huge supply chains, they’re asking their suppliers, “Who’s your supplier?” What is the implication there? They’re saying, “We want you close by. We’re not going through what we just went through again.”

What does this mean for us here in Ontario? It means that there is a North American phenomenon happening. This presents huge, huge opportunities for Ontario businesses. My friends, we can deliver. Thank you. 

As we get older, the fear of marked cognitive decline for many is greater even than the fear of dying. At a recent friends dinner many of us recounted our experiences with a parent who suffered cognitive decline. My wife and I share similar experiences as both of our mothers suffered disabling strokes in their 80s and 90s and both of our fathers had progressive and severe cognitive declines that were very painful to witness. 

How can we better understand what dementia is and can we prevent it or slow its progression? 

Dementia isn’t a specific disease but rather a term used to describe the development of a group of symptoms with impaired ability to think, remember, and problem-solve to make everyday decisions. It is caused by damage to the brain’s nerve cells and their surrounding connections and can have multiple causes.

Alzheimer’s disease

The most common form of dementia is Alzheimer’s Disease named after Dr. Alois Alzheimer, a German psychiatrist who in 1906 described the abnormal brain findings in a 50-year-old woman with presenile dementia; that is, dementia occurring at a much earlier age than expected. In 2020 it was estimated that this progressive degenerative condition of unknown cause affected 5.8 million Americans over age 65 and 55 million people globally. It is expected to rise significantly as more people will live longer over the next few decades. 

As Alzheimer’s dementia develops, the brain typically shows progressive clumps of a beta-amyloid protein and fibrous tangles made up of a Tau protein. These tangles interfere with the communication points (synapses) between cells and can lead to cell death and loss of brain volume. 

While the progression of cognitive decline is usually relatively slow, Lewy body dementia, characterized by the deposition of other proteins, is a form that progresses more rapidly and has an overlap with Parkinson’s disease. 

Vascular dementia

The second most common form is vascular dementia, which usually refers to people who have had a loss of brain function due to a stroke. Mixed dementia refers to people with Alzheimer’s who may progress faster if they have abnormal brain blood flow due to atherosclerosis, which is the hardening of the arteries to the brain. 

Other forms of dementia may include brain cell damage due to repetitive brain trauma, nutritional deficiency, immune disorders, or hydrocephalus, which is a build-up of pressure causing tissue shrinkage inside the brain. 

What causes Alzheimer’s?

It is hypothesized that accumulation of the beta-amyloid protein in the brain may arise from various triggers and then leads to the development of tangles of Tau protein that affect communication between brain cells causing loss of function. While genetics plays a role in certain family clusters of early-onset dementia, its role in Alzheimer’s isn’t as clear.

It appears that multiple genetic abnormalities that affect inflammation, protein build-up, and ageing may each contribute. Advances in gene sequencing and the creation of large genetic databases of Alzheimer’s patients are providing insights into calculating the risk of developing the disease as well as helping to formulate targeted strategies to treat it before major irreversible damage occurs.  

How is Alzheimer’s diagnosed?

The diagnosis is typically made by demonstrating decreased performance in cognitive testing that evaluates memory and the ability to perform routine tasks. MRI scans may detect atrophy or shrinkage of the brain which may be non-specific and not just due to cognitive decline. PET scans can determine whether there is decreased metabolic function in different regions of the brain, and a specialized PET scan using targeted tracers can measure the build-up of abnormal amyloid or Tau deposits in the brain. A challenge is that not all people with amyloid protein on scanning have evidence of cognitive decline. While such scans can detect abnormal protein deposition they don’t always predict disease severity. 

Preventing dementia

Modifiable risk factors for dementia patients are easier to define for vascular dementia. Stroke risks can be reduced by eating a healthy diet, regular exercise, avoidance of excessive alcohol intake, control of diabetes and hypertension, lowering cholesterol, and avoidance of smoking. 

There are conflicting studies on the benefits of a healthy Mediterranean-type diet in reducing the risk of Alzheimer’s disease. While such a diet is healthy in many ways in reducing the risks of atherosclerosis, food-based studies are difficult to do given the lack of vigorous control groups and high-quality data on compliance as well as the inability to control for confounding variables. Eating a healthier diet is clearly good for you but at best only has a small role to play in maintaining brain health beyond stroke prevention.  

Blood tests

Newer blood tests may provide insight into the risk of developing Alzheimer’s. Measurement of a protein, p-Tau217, in the blood may help identify those at risk of Alzheimer’s and track progression; however, their value is not yet fully defined. This newer blood test measuring Tau protein may soon be marketed as a direct-to-consumer option. It is more accurate than what is offered by the 23 and Me personal genome test which evaluates a different and less specific genetic protein abnormality. There are risks and benefits to having this potential knowledge about the lifetime risk of dementia when treatment options are limited and rates of gene expression and progression are unclear. 

Conventional drug treatment

Conventional drugs targeting the treatment of Alzheimer’s have limited benefits, significant side effects, and work best in the early stages of the disease, despite the many TV commercials anecdotally touting their use. Because there are decreased levels of a brain chemical messenger, acetylcholine, drugs that are cholinesterase inhibitors such as Aricept, Razadyne, and Exelon are commonly prescribed. They work best in early disease and can cause nausea, vomiting, diarrhea, and cardiac arrhythmias. Their benefits are limited. 

A second class of drugs such as memantine regulates the activity of glutamate, a brain messenger chemical, and may be useful in moderate Alzheimer’s if the significant side effects can be tolerated. 

Exciting new drugs

Traditional drugs don’t deal with the underlying causes of dementia. Newer approaches look to try and remove amyloid and Tau proteins that have accumulated in the brain on the assumption that they are the cause of the disease. 

The FDA in a controversial decision recently approved the use of Aducanumab (Aduhelm), the first new drug approved in 18 years for people with mild Alzheimer’s. It is a drug that is a human antibody administered intravenously that sticks to the amyloid protein, followed by your body triggering an immune reaction to remove it. The controversy and decision by some insurers to not pay for it relate to cost/benefit and side effects.

The drug is not benign and can cause brain swelling and micro bleeding. It is highly expensive, costing tens of thousands of dollars a year, thus limiting potential use. More worrisome is that the improvement in cognition wasn’t nearly as great as the removal of abnormal proteins. More studies are underway to see if earlier use before permanent damage may be more beneficial. Levanamab is a similar drug undergoing extensive testing. 

Dementia remains a highly challenging disorder that has tremendous societal and personal costs to patients, families, and caregivers. While newer tests have improved diagnostic accuracy, they remain somewhat imperfect predictors of preclinical disease and progression. After many frustrating years of little progress in treatment options, a combination of genetics, advanced imaging, and new therapeutic targets finally show some light at the end of the tunnel. New applications are being studied that help to clarify the optimal timing of drug initiation and effectiveness in different ethnic populations. 

In the meantime building a cognitive reserve that softens the decline and keeping healthy and fit to enjoy life as best we can, remains crucial. We need to remember that those affected need our care, love, and emotional support despite the painful challenges. Rather than living in fear of decline, we need to live the life we have to its fullest.