The humble visionary
Pamela Cowan, Regina Leader-Post
Dr. Brian Graham, the current president and CEO of the Lung Association of Saskatchewan, with a spirometer. He will be retiring at the end of the year. Graham has been the association's CEO since 1985, and is the third CEO in the association's 105-year history. Don Healy / Regina Leader-Post
When Brian Graham was a University of Saskatchewan engineering student, he scoffed at the suggestion he might stray from his career path.
"I still remember one of my engineering professors telling us, 'If you look around at the fellows in your group — one on the left, one on the right — in five years, only one of you is going to be doing engineering. The rest of you are going to be doing management and those kinds of jobs.'
"I thought, 'No, I'm going to be an engineer!' " says the CEO of the Lung Association of Saskatchewan.
Retiring at the end of the year, Graham spoke about his career, which has taken many twists and turns in his passionate quest to improve lung health for residents in Saskatchewan, Canada and the world. And, along the way, he has achieved many firsts that have earned him national and international acclaim.
Lungs trump the heart
While working on his PhD in biomedical engineering, Graham focused on the cardiac system and was measuring electrocardiograms to get data for his thesis. One day, he took his equipment to what's now the Royal University Hospital in Saskatoon, where a new pulmonary function lab was being set up.
"They were excited that there was an engineer there who knew something about equipment, so I helped set up the lab," he says.
From an engineering perspective, he found lungs far more interesting than the heart.
"There are so many more things that go on in the lung and there were so many more engineering and mechanical aspects of the lung that were of interest to me," Graham says. "As a result of that interaction, I was asked to join the pulmonary division and finish setting up the pulmonary function lab."
He computerized the lab in 1976 — a time when there was limited access to computers. It was the start of many career firsts.
At the same time, he was researching lungs.
"Something that was very serendipitous was that Dr. David Cotton joined about three months later," Graham says. "He was really my mentor in terms of research. He had just completed a research fellowship in San Francisco and had ordered a wonderful piece of equipment called a mass spectrometer, which allowed gases to be measured, based on their mass. That is something an engineer can really get excited about!"
Rewarding work
Graham's excitement builds when he describes gas exchange, which measures how efficiently the lungs get oxygen into the bloodstream.
He and Cotton started a research project to figure out how to improve measuring gas exchange in the lung. In the process, they developed new methodology.
"There's a test that's done in routine pulmonary function labs called the diffusing capacity of the lung for carbon monoxide," Graham says. "Carbon monoxide is a poisonous gas, but if you use it in very small trace concentrations, it's a really good tracer gas in the lungs to see what's happening."
To assist their work, they got a cutting-edge computer — the third of its kind in the world to come off the assembly line.
"It was one of the first computers that had the central processing unit, which is now on a chip — it was all on one circuit board," Graham says. "People came from across campus to have a look at it."
The computer was hooked up to rapid gas analyzers, which provided greater analysis of what happens during a breath — a first.
"We were able to look at the whole process of gas exchange over the entire breath," Graham says. "That's what made the difference for us. We were able to show how we could improve that measurement a lot, plus get a lot more information about the lung in that process."
Now he's helping to develop new world standards for measuring diffusing capacity — a joint project with the American Thoracic Society and the European Respiratory Society.
"Those groups really do set the standards for how everything should be done around the world," Graham says.
When it was time to update the standards, the Americans nominated a co-chair, the Europeans picked a co-chair. The Americans selected Graham.
"We work with a global group of a dozen or so experts from around the world to come up with new guidelines," Graham says. "They're going to be published later this year and I will be presenting the world standards at the European Respiratory Society World Congress in London in September — that's an area where I feel that I've made a contribution."
Down on the farm and deep in the mine
Another innovation Graham led was improving the instrumentation and computerization to measure lung disease in farmers, potash miners and grain handlers. That was his first introduction to the Saskatchewan Anti-Tuberculosis League, which later became the Lung Association of Saskatchewan.
"In 1976, Labour Canada said all grain handlers needed to have a chest X-ray and a lung function test," he explains.
Outside the Prairies, grain handlers were concentrated in terminals in big cities, where it wasn't a problem to test their lung capacity. But in Saskatchewan, "every little cross in the road had a grain elevator," Graham says. "The big question was, 'How could we do that?' "
An agreement was made to use the Anti-Tuberculosis League's X-ray vans and Graham developed a mobile computerized system to measure the lung function of elevator agents around Saskatchewan.
Next came a major study of potash dust on miners' lungs.
"Potash is soluble and dissolves in the body and doesn't become a problem," Graham says. "The biggest problems we found were associated with smoking because there were very high smoking rates and, secondly, there was diesel exhaust — that was a real problem in mines because it produces a very fine carbon dust that gets deep into the lung and is hard to get out."
Although mines are well ventilated, miners use small diesel vehicles to navigate kilometres of underground road.
"The work that we did there is still the main reference work in this whole area," Graham says.
Tackling tuberculosis
When he became executive director of the Saskatchewan Anti-Tuberculosis League, the agency was responsible for the diagnosis, care and treatment of tuberculosis patients in the province.
"We had to purchase and dispense all of the TB drugs, we had to maintain a registry of everybody with tuberculosis and we had to do all of the surveillance work for tuberculosis," Graham says.
He introduced the directly observed therapy short course (DOTS) for tuberculosis, which is now the world standard.
Drugs introduced in the late 1940s effectively treated TB, but many patients didn't understand it can take six months to cure tuberculosis. So, after taking multiple drugs for three or four weeks, they started feeling better and typically quit taking medication.
"If you stop taking the pills before you completely cure that case of tuberculosis, then the TB that grows back can be resistant to those medications and it becomes much harder to treat and more expensive," Graham explains. "The World Health Organization started recommending that you don't just need to give people the pills, but watch them take the pills. That's the only way you know that they've taken them so that's where the directly observed therapy comes in."
Saskatchewan became the first jurisdiction to introduce DOTS.
That experience led Graham, by now CEO of the Lung Association of Saskatchewan and professor in the Department of Medicine at the University of Saskatchewan, to Ecuador in 1999.
Ecuador had the worst tuberculosis program in the Americas, so it asked the Canadian Lung Association for help. Graham became the project leader because he was the only provincial CEO with TB experience.
"Canada is blessed with some really good TB docs," Graham says.
With those doctors on board, a strong team was put together. Over seven years, they worked in Ecuador to develop a program to control TB.
The first step was training locals on managing the disease and using DOTS.
"One of the things we found was lacking was TB instruction in the medical schools and nursing colleges," Graham says. "We developed a five-day tuberculosis program to teach nurses about DOTS and a three-day program for physicians. Those programs that we developed are, to this day, still being used in Ecuador."
Following medical school, doctors in Ecuador must serve two years in rural areas. Now, they are prepared to go to TB problem areas.
Graham gave selflessly to lead the program — he learned Spanish and took holidays to travel to Ecuador three or four times a year. Back in Canada, he kept in constant contact with the program.
He and his wife travel to Costa Rica, but "she won't let me go back to Ecuador because she knows that I would get involved in a project right away," Graham says with a laugh.
A global spirometry expert
Nowadays, you can buy spirometers off the shelf and computer programs are available to assess how well the lungs work by measuring how much air you inhale and exhale and how quickly you exhale.
"At the time we were doing research, you pretty much had to build your own instrumentation," Graham says. "And you had to write your own programs, so that's what I did."
In 1992, he was asked to develop spirometry world standards.
"Since then, we've also looked at training people to conduct spirometry, so we developed a course for that," Graham says.
He's been a member of the American Thoracic Society Pulmonary Standards committee and, since 2011, chairs the Canadian Thoracic Society Clinical Assembly on Pulmonary Function Standards.
"We also wrote a paper for the standards on how spirometry should be conducted in the primary care setting — for family physicians and so on."
Over the years, balancing his staggering work load and family commitments has been tricky.
"I've been really blessed with a supportive wife," Graham says. "She was a stay-at-home mom and that made a huge difference in all of these areas."
Up at the crack of dawn, he jogs before work.
"I don't drive a car," Graham says. "I walk to work. I bike to work … If you're going to talk the talk, you have to walk the walk. One of the things we stress in the Lung Association is if you're going to be educating people about good lung health, you should be a leader by example."
He started jogging at 35 and got serious about it when he was 40. At 45, he was running marathons; he has completed five, and several half-marathons.
Dryly, he says his marathon days are over, but jogging is "high-quality alone time to work out problems and process things."
When he accepted the job to head the Lung Association in 1985, the university lent him to the association on a part-time, short-term basis.
"It was to help them through because I'd done so much work with the Anti-Tuberculosis League — a lot of it on a volunteer basis," Graham says. "I wrote the fundraising program for them, I computerized their registry, so I knew a lot about the organization.
"When my predecessor passed away suddenly, then I was approached to take the position. I was more than happy to help them out, but my job morphed from working in research and teaching at the university to being able to really work in a community environment."
His links to the research and medical communities have allowed the Lung Association to develop programs, such as RESPTREC, in which health-care professionals are trained how to educate patients.
"If you look at how to manage lung disease, the very first thing that comes up is patient education," Graham says. "But if you look at the medical schools and the nursing schools, there's very little on how to educate patients. We developed that program — mainly in Saskatchewan because we had some good educators."
Across Canada, there was demand for the developed program.
"We still administer it and run it out of Saskatchewan, but now 70 per cent of the people who are certified respiratory educators are graduates of our program," Graham says. "We've trained 40 faculty across the country that teach our programs."
A major pharmaceutical company looking for the best program to train their American reps about Chronic Obstructive Pulmonary Disease (COPD) sent 100 people to be trained by the Lung Association of Saskatchewan.
Retiring, but still working
On retirement, Graham plans to spend more time with his wife, three children and four grandchildren. Many jobs await the handyman — including a two-year "honey-do" list his wife has prepared, a bathroom renovation for his daughter and future research projects.
Since 2014, he has been professor emeritus in the Department of Medicine at the U of S.
"I'm working on research projects now and some of those will continue," he says. "There's other bits of research I've been wanting to do for quite some time and I just haven't been able to devote the time to it.
He plans to continue his involvement in some international committees to set new standards and work in those areas.
Graham's contribution to the Lung Association of Saskatchewan has been motivated by his unfailing passion to improve the health and quality of life of people suffering from lung disease, says Jan Neumann, the association's vice-president of professional education.
"He is highly respected as a leader in lung health by all who have worked with him," Neumann says. "His knowledge of lung health and his contributions to research has led to the development and support of many initiatives, including a number of 'firsts' in not only our province, but nationally and internationally. Under his leadership, the Lung Association has grown and excelled in many areas of education, research and advocacy."
When asked to describe Graham, Pat Smith's first response: "He's the smartest person I know!"
"He is such a hard-working person and world-renowned in his field," says Smith, board chair for the Lung Association of Saskatchewan. "He's shown total dedication to the Lung Association — it is going to be hard to replace him."
Dr. Darcy Marciniuk, associate vice-president of research (acting) and professor of medicine at the University of Saskatchewan, credits Graham and the Lung Association for recruiting him to the province in 1990 and assisting his research career.
"As an individual, he's earned the respect and trust of our colleagues in our research world," Marciniuk says.
As CEO of the Lung Association, Graham has cast a national light, and beyond, in terms of his leadership, he adds.
Marciniuk describes Graham as a humble visionary.
"Sometimes, the people who dream just dream, but Brian can realize those dreams … He's very goal-oriented and really cares less about whether he gets the credit or the Lung Association gets the credit — he just wants to see meaningful results," Marciniuk says.
10: Chapters in books
50: Papers in refereed journals
120: Conference presentations
21: Research grants — total value $1,025,000
pcowan@postmedia.com
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