The John E. Fogarty International Center for Advanced Study in the Health Sciences (FIC) convened the seventy-third meeting of its Advisory Board on Thursday, September 17, 2009, at 10:45 a.m., in the Conference Room of the Lawton Chiles International House, National Institutes of Health (NIH), Bethesda, Maryland. The closed session was held from 8:00 a.m. to 10:30 a.m., as provided in Sections 552b(c) (4) and 552b(c) (6), Title 5, U.S. Code, and Section 10 (d) of Public Law 92-463, for the review, discussion, and evaluation of grant applications and related information.1 The meeting was open to the public from 10:45 a.m. to 3:10 p.m. Dr. Roger I. Glass, Director, FIC, presided. The Board roster is appended as Attachment 1.
VI. Introductory Remarks
Dr. Glass welcomed everyone to the open session. He introduced new staff members. Joining the Division of International Training and Research (DITR) are Dr. Myat Htoo Razak, Project Officer; Ms. Farah Bader, Public Health Analyst; and Dr. Yvonne Njage, AAAS Fellow. Two additions to the Division of International Relations (DIR) are Dr. Rob Lyerla, Program Officer for Europe and the European Union, and Dr. Letitia Robinson, Program Officer for sub-Saharan Africa. New to the Division of Epidemiology and Population Sciences (DIEPS) are Dr. Ottar Bjornstad, Ms. Stacey Knobler, and Ms. Zeba Rasmussen. In the Division of International Science Policy, Planning, and Evaluation (DISPPE), Ms. Britt Ehrhardt is on rotation as a 2011 Presidential Management Fellow.
Later during the meeting, Dr. Glass thanked Dr. Kleinman for extending his service to the Board for this meeting. He noted his significant contributions to the Board and his strong advocacy for global health. He presented a plaque to Dr. Kleinman in appreciation.
VII. Director’s Update and Discussion of Current and Planned FIC Activities
Dr. Roger I. Glass, Director, FIC
Dr. Glass presented an update on FIC activities since the previous Board meeting, in May 2009, and noted events for October to January 2010. He thanked members who participated in recent activities and encouraged the Board to be actively involved in the events ahead.
Global Health—A Priority for the Administration
Dr. Glass said that “the stars are aligning for global health as never before.” The President is committed to science and global health. He and the Secretary of State have mentioned global health as a priority in each of 13 countries to which they have traveled so far, and the Administration has invested $63 billion in a Global Health Initiative. At the NIH, the new Director, Dr. Frances Collins, has made global health one of his five areas of special opportunity, and he spoke at the FIC-hosted Consortium of Universities of Global Health (see below). There is a new trans-NIH Global Health Working Group (see below), and more institutes and centers (ICs) are developing strategic plans for global health.
Global Health Initiative. Dr. Glass said that Secretary Hillary Clinton has stated that the President’s Global Health Initiative is a critical component of U.S. foreign policy and smart power. He noted that although approximately 75 percent of U.S. global health funds are disseminated through foreign operations and the U.S. Department of State (DOS), the U.S. Department of Health and Human Services (HHS), including representatives from NIH and FIC, are actively engaged in the process to disperse initiative funds. The priorities for funding include the President’s Emergency Plan for AIDS Research (PEPFAR), malaria, family planning, maternal and child health, and neglected tropical diseases. Emphasis in being given to transforming programs by improving integration between PEPFAR and other initiatives, recognizing the essential role of women and mothers, and focusing on diseases that have high disability-adjusted life years (DALYs), can be cured easily or cheaply, and affect children. Other features include independent evaluations, investments that are driven by data and focused on outcomes, and partnerships within the U.S. Government and with the private sector.
NIH Areas of Special Opportunity. Dr. Glass noted that expansion of research into diseases affecting the developing world is the fourth (iv) of five themes that Dr. Collins has set forth for NIH and one in which he has highlighted FIC activities. The other themes are: (i) fostering of high-throughput technologies in genomics and nanotechnology; (ii) development of diagnostics, preventive strategies, and therapeutic tools through public–private partnerships (in which FIC also plays a role); (iii) reining in of costs of health care with comparative-effectiveness research and personalized medicine; and (v) increasing the budgets and investments in training and peer review to achieve predictable funding trajectories. Dr. Glass mentioned that Dr. Collins had spent time early in his medical career in Nigeria where he became interested in the genetic aspects of diabetes.
FIC Leadership and Action
Dr. Glass highlighted the following activities.
Mental Health in the Arctic. On June 1–3, 2009, FIC joined with other ICs to support a meeting on Behavioral and Mental Health in the Circumpolar Arctic, held in Anchorage, Alaska. The aim was to develop a research agenda that could lead to broader interest and action on the high rates of suicide and mental disease among Alaskan Native American populations. Dr. James Herrington, Director, DIR, is the FIC contact.
Orientation for Scholars and Fellows. On July 5–8, FIC hosted an orientation for 96 Fogarty International Clinical Research Scholars and Fellows, one-half of whom were from developing countries and one-half from the United States. The fellows include four cardiologists who will work in developing countries on projects linked with the National Heart, Lung, and Blood Institute (NHLBI) Centers of Excellence which are set to combat chronic diseases in developing countries. Board member Dr. Kleinman participated as a speaker at the orientation.
The “Kitchen Cabinet.” On July 10, FIC held its Second Annual Fogarty Consultation with Global Health Leaders. As Board members, Drs. Hotez and Stanton hosted the “kitchen cabinet” of 13 leaders who advised FIC on research areas to promote. Dr. Hotez elaborated on the meeting, noting that it was very productive. An important conclusion drawn from the presentation and discussions was that the Administration, particularly the Office of Science and Technology Policy and the Office of the Global AIDS Coordinator, is very interested in FIC perspectives on innovative programs in HIV/AIDS health metrics, training related to health systems, and capacity building in science and technology in Africa. The leaders suggested a potential role for FIC as the “go-to” organization for the Consortium of Universities in Global Health and the possibility of embedding FIC representatives in agencies to strengthen linkages. Other considerations included linking with the Bill & Melinda Gates Foundation on research training; building U.S. capacity in chronic diseases and global health, particularly cardiovascular diseases; and using NIH mechanisms of support (e.g., K and T32 awards) to develop faculty and expertise in global health (e.g., in health systems informatics).
Trans-NIH Global Health Working Group. In September, the NIH formed the Trans-NIH Global Health Working Group, which will be co-chaired by Dr. Glass and another IC director. The working group is the outcome of an August 26 retreat that involved 21 IC representatives, including 11 IC directors and deputy directors. Dr. Glass said that Dr. Collins suggested at the retreat that the participants consider an NIH Roadmap initiative—hence, the working group. The retreat followed on a series of FIC-led activities that included a white paper on global health, a May 21 meeting of IC representatives who presented best practices in global health, and a report of recommendations from this meeting to the IC Directors in June. Dr. Barbara Alving, who represented the Board at the retreat, elaborated. She noted that the group’s current action item is to agree on a governance document. A share site has been set up, and two working groups have been established. The metrics working group, co-chaired by Dr. Sally Rockey, Director, Office of Extramural Research, Office of the Director, NIH, and Dr. James Herrington, Director, DIR, FIC, will work on making the IC databases interoperable to better track NIH global health activities. The clinical trials working group, co-chaired by Dr. Susan B. Shurin, Deputy Director, NHLBI, and Dr. Hugh Auchincloss, Deputy Director, National Institute of Allergy and Infectious Diseases (NIAID), will determine best practices for clinical trials in developing countries.
Consortium of Universities of Global Health. On September 14–15, FIC and the Foundation for the National Institutes of Health (FNIH) co-hosted the first formal meeting of the Consortium of Universities of Global Health. Led by Dr. Haile T. Debas, University of California, San Francisco, the meeting brought together five presidents from universities that have FIC Framework program grants (The Johns Hopkins University, Duke University, Emory University, Boston University, and the University of Washington). The attendees included more than 250 individuals from 53 universities with global health programs in training and research. Dr. Collins opened the meeting, laying out his mission for global health. Board members Drs. Black, Hotez, Kleinman, Pablos-Méndez and Vermund participated. Dr. Black remarked that the meeting was a substantive start that included high-level speakers, establishment of working groups, and discussion of a possible annual scientific meeting. He noted that the consortium will be a tremendous collaboration and asset for connecting FIC and universities.
Other FIC Collaborations. Dr. Glass said that FIC is approaching other collaborative partners, as recommended by the Board, to leverage FIC investments. For activities in Africa, FIC is speaking with the Wellcome Trust, Doris Duke Charitable Foundation, Earth Institute’s Millennium Villages, and The Rockefeller Foundation. In addition, FIC has received funding to help implement the Disease Control Priority Project (DCPP) by fostering networks to introduce best practices in developing countries. For example, FIC collaborated in August in a network meeting in South Africa that included the country’s Deputy Minister of Health.
Dr. Glass noted that FIC is guiding a planning process for a G8 initiative in sub-Saharan Africa to support centers of excellence in training and research in global health. FIC developed this idea with former NIH Director, Dr. Elias Zerhouni, and has been working on it for the past year and a half. President Obama introduced the idea at the recent G8 summit in Italy, and it was accepted. Mr. Robert Eiss, Senior Public Health Advisor, is the FIC contact.
Upcoming Events. On October 29–30, FIC will participate with five other ICs in an FNIH public–private partnership meeting, the Mobile Health Summit, in Washington, D.C. The participants will address how to use mobile technologies as a platform for health research and health care delivery. Dr. Glass noted that the partnership between FIC and FNIH continues to expand with opportunities.
On October 28–30, the NIH Office of AIDS Research is hosting an HIV prevention workshop in Moscow. Dr. Glass noted that NIH and FIC are reviewing their U.S.–Russia activities following President Obama’s visit to Russia and his stated commitment to expand global health research with Russia. Several ICs are already invested or interested in collaborations focused on, for example, alcoholism, declining life expectancy, and clinical trials in Russia. Board member Dr. Cassell described a developing collaboration initiated in January 2009 when Eli Lilly and Company hosted a group of Russian scientists on a visit to NIH and the National Academies of Sciences (NAS). She noted that NAS and the Russian Academy of Medical Sciences and Russian Academy of Sciences are discussing topics of mutual interest. In particular, the Institute of Medicine and the Russian Academy of Medical Sciences have signed an agreement to co-host a meeting on multidrug-resistant tuberculosis in Moscow in spring 2010. Dr. Glass mentioned that, in August, FIC had collaborated with the National Research Council to host a meeting on nanoscience and prostate cancer that was attended by Russian scientists.
On November 9–10, in Beijing, the National Cancer Institute (NCI) will host, with FIC support, a 30th anniversary symposium entitled Enabling a Future of Personalized Cancer Medicine. Dr. Glass said that FIC hopes to use this forum to link Chinese NIH alumni with their former U.S. mentors and NCI scientists to pursue collaborative research, including clinical trials.
On November 16–20, the Global Forum for Health Research will be held in Havana, Cuba. The topic is “Innovating for the Health of All.” Dr. Glass said that FIC has been invited to attend and has submitted paperwork to request travel authorizations for him and Dr. Collins. He encouraged others outside of government to attend and mentioned that Dr. Lois K. Cohen, who recently retired from NIH, will be attending. Dr. Cassell, who visited research institutions in Cuba with other NAS scientists in 2005, urged those who could attend to do so.
On December 15, FIC and the National Institute of Dental and Craniofacial Research (NIDCR) will co-sponsor the annual Barmes Global Health Lecture at NIH. The lecturer will be Dr. Julio Frenk, Dean, Harvard School of Public Health.
In closing, Dr. Glass thanked FIC leadership staff for their outstanding efforts.
Review of DIEPS
Dr. Glass introduced a report on FIC’s external review of DIEPS. He requested this review in December 2008 and convened a panel of four experts chaired by Board member Dr. Reingold. All Board members received the final report of the expert panel review (dated May 21, 2009).
Background on DIEPS. Dr. Mark Miller, Associate Director for Science, and Director, DIEPS, gave a brief overview of DIEPS. He noted that FIC established DIEPS in 2001 to address the translation and adaptation of research and the application of new tools in epidemiological research. The division, envisioned as an intramural type of research group, has concentrated its efforts on systems science, specifically an interdisciplinary approach to population science, and longitudinal issues and challenging policy questions. The four research areas focused on are rapidly transmissible viral agents (e.g., influenza); integration of malaria, nutrition, and enteric diseases; vaccines; and policies (e.g., the DCPP). Dr. Miller noted that DIEPS has the respect of other HHS components and agencies and that the staff has been able to leverage its $1 million budget to approximately $9 million in matching funds from other sources, much of this through the FNIH. He highlighted three challenges facing the division: the reliance on short-term funding, the near reaching of a critical mass, and a decision on whether to be a catalytic group or a research unit.
Panel Recommendations. Dr. Reingold summarized the conclusions and recommendations of the expert panel. He noted that the panel was asked to address three topics: the scientific and other impacts of DIEPS; the contributions of DIEPS to the mission, goals, and needs of FIC; and recommendations for the future. The panel met twice, had numerous telephone consultations, reviewed documents, and met with staff. The panel unanimously and strongly concluded the following: the scientific quality and productivity of DIEPS have been outstanding and should be a source of pride for FIC, the work conducted is clearly within the scope of FIC’s mission and should be continued, and the division should be better supported administratively to facilitate the science. Dr. Reingold noted that FIC already has made substantial progress in addressing the last issue since completion of the report.
In terms of the future, the panel strongly recommended that DIEPS deserves further support and that FIC should address at this time the possibility of formally establishing DIEPS as an intramural program within FIC. Dr. Linda Kupfer, Acting Director, DISPPE, said that FIC has addressed the latter possibility with Dr. Glass and Dr. Michael M. Gottesman, Deputy Director for Intramural Research, NIH, and is preparing a 2-page strategic vision of the future of DIEPS for discussion with Dr. Collins.
Dr. Glass thanked the panel for conducting a very important review. Dr. Hotez noted that DIEPS has had an extraordinary record of productivity, and he urged FIC to assure large-scale NIH support to maintain the program.
VIII. Progress, Challenges, and New Directions within the FIC Framework Programs
Dr. Patricia J. Garcia, Universidad Peruana Cayetano Heredia
Dr. Paula Palmer, Claremont Graduate University
Dr. Anderson Johnson, Claremont Graduate University
Dr. Glass introduced presentations on two Framework programs supported by FIC. The aim of FIC’s Framework initiative is to energize the global health agenda by supporting university-wide collaborations to develop global health programs, curricula, and activities across different schools. Dr. Flora Katz, Program Officer, DITR, said that FIC has issued 35 Framework grants, all of which have different models. A few programs involve a coalition of universities and institutions internationally, and three grants are direct foreign awards. Dr. Glass invited the Board’s discussion on the impact and future directions of this initiative.
Universidad Peruana Cayetano Heredia (UPCH)
Dr. Patricia J. Garcia, Principal Investigator, and Professor, School of Public Health and Administration, UPCH, described the Framework-supported global health demonstration program in Peru. The Framework grant, awarded in 2005, builds on UPCH’s long tradition of research collaborations with U.S. institutions (The Johns Hopkins University, University of Washington, and University of Alabama, U.S. Naval Medical Research Center Detachment) and other FIC awards. A privately funded organization founded in the 1960s, UPCH has become a research hub as it is the largest research institution in Peru, with eight schools and approximately 6,000 students. Dr. Garcia noted that Peru receives the second largest amount of NIH funding ($6 million) in Latin America, after Brazil and similar to Mexico, and that UPCH has seen a significant increase in competitive research funding since 2000.
The Framework program at UPCH combines research, training, and dissemination. Collaborative links are established between the university’s schools; with UPCH’s U.S. partners; and with the international Global Health Network and Infectious Diseases Research Network. Dr. Garcia highlighted five specific accomplishments: (i) development of undergraduate and postgraduate curricula in global health; (ii) support of innovative research projects conducted by students and faculty at UPCH and other institutions; (iii) expansion of collaborations through faculty exchanges and visiting professors; (iv) publication of more than 10 peer-reviewed articles in local journals; and (v) development of other resources, including a global health Website (www.globalhealthperu.org), a video conferencing facility, and a distance-learning module. She noted that, most importantly, the Framework program “…has allowed the university community to understand and share the vision of global health, recognizing that health problems transcend boundaries and need multidisciplinary and cooperative solutions….” The Framework program has had an impact on trainees and young researchers and is building sustainable research capacity through collaborations among UPCH scientists who are alumni of other FIC programs and students involved in the Framework program.
Lessons Learned. Dr. Garcia emphasized that creating awareness in global health and building capacity take time. Institutional bureaucracies need to be, and can be, overcome. At UPCH, developing a critical mass is still ongoing and more coordination is needed to achieve efficiency within the program. The interaction among students between schools and with other national and international students and faculty is catalytic, and more opportunities for South–South collaborations are needed.
New Challenges. Dr. Garcia listed the following new challenges for the UPCH Framework program: (i) include professionals from “neglected” disciplines (e.g., lawyers, physicists, mathematicians, engineers, communicators, economists); (ii) address the global agenda of chronic diseases, cancer, violence, mental health, and environmental health; (iii) link more with other global health programs (e.g., operations research, informatics); (iv) foster regional training centers for excellence in the South; and (v) improve and organize Framework partnerships, and strengthen institutions to enhance North–South and South–South collaborations on leadership and management issues.
Claremont Graduate University
Dr. Paula Palmer, Associate Professor and Director, Global Health Programs, and Dr. Anderson Johnson, Professor and Dean, School of Community and Global Health, Claremont Graduate University, California, described the Claremont–University of Southern California (USC) Pacific Rim Global Health Network. They are the principal investigators of an innovative Framework program located at Claremont and linked to this network.
Dr. Palmer noted that the global health effort is focused on chronic disease. Beginning in 1977 at USC with NCI funding, the researchers conducted a small study to assess issues and risk factors associated with tobacco use in China. The study subsequently was expanded to become the China Seven Cities Study conducted in collaboration with China’s Centers for Disease Control. Working at both national and local levels, the investigators helped to develop a public health surveillance system, initially for tobacco use and then for obesity and diabetes, that was applied for 4 years in a population cohort of 59,000.
Dr. Palmer said that the availability of the FIC’s Framework program gave the investigators, who were recruited to move to Claremont (a university without a medical school), an opportunity to engage other partners in Asia and to leverage NCI’s original investment. She noted that chronic, non-communicable diseases account for 60–70 percent of disease morbidity and mortality in the Pacific Rim. With the Framework grant, the investigators are studying all non-modifiable risk factors (e.g., age, gender); individual risk factors (i.e., tobacco use, diet, alcohol use, physical activity, and mental health); and rapidly changing socioeconomic, cultural, and economic conditions. They are working in Bangladesh, China, Sri Lanka, Thailand, and India. Dr. Palmer noted that a number of other Asian countries, as well as Guatemala, have asked to become members of the Framework and have provided some funding to maintain contact and attend meetings.
Challenges and Solutions—A Virtual Global Health Classroom. Dr. Palmer noted that a major challenge is the growing number of students in both the United States and elsewhere who desire a foreign research experience in global health. She said that the Framework program at Claremont is pursuing technological solutions to meet this challenge by specifically creating a virtual global health classroom for dynamic distance education. This “cyber campus” is available to Framework members of the Pacific Rim and includes synchronous and asynchronous learning modes; online curricula; live Web conferencing for teaching; forums, wikis, chat rooms, and blogs; catalogued presentations; and technical advice and tutorials. The aim is to provide excellent training in global health in countries with different capacities.As one example, students in different countries are conducting an assessment of tobacco use among young women by using cell phones and sharing real-time data online.This case-study approach is centered on the student and learner, and students learn to work in teams and to become problem solvers.Dr. Palmer noted that this model has attracted the interest of Cisco Systems, Inc., which may donate or provide low-cost technology to support the effort in a number of countries.
Expansion to a Regional Network. Dr. Johnson elaborated on the development of the Claremont program and the expansion of a regional Asia–Pacific network.He noted that the Claremont Colleges, a group of seven independent liberal arts colleges that includes Claremont Graduate University, has made a long-term commitment to develop a School of Community and Global Health that would bring the colleges together around an important social issue.He and Dr. Palmer were recruited to lead this effort. Joining the effort is the City of Hope Medical Center.
Dr. Johnson noted that the Claremont Framework program is taking advantage of two forums to expand its Pacific Rim Global Health Network.These are (i) the Asia Pacific Rim Academic Consortium on Public Health, consisting of a group of universities throughout the region, for which Claremont serves as the regional center for the Americas, and (ii) the new Public Health Forum of the Asian–Pacific Rim Universities (APRU) World Institute, which consists of the largest research universities throughout the Pacific Rim, including the western United States.Dr. Johnson noted that the intent of the World Institute is to foster collaborations in two areas: the environment and public health.Similar to the U.S. Consortium of Universities in Global Health, 12 countries are participating in the development of collaborations in research and training.
Dr. Glass commented that these two novel and different Framework programs are satisfying the Framework requirements by promoting attention to global health on university campuses, multidisciplinary interaction among schools, and North–South and South–South training. They are energizing the field and taking advantage of unique linkages.
The Board noted that gains are being made beyond FIC’s relatively modest investment in Framework grants. Members addressed the next iteration of Framework programs (“Framework 2”) and considered the possibility of regional centers of excellence, small grants, and evaluation of the overall program.
Regional Centers of Excellence. Dr. Vermund mentioned that UPCH is well poised to serve as an efficient South–South center of excellence in research training. Dr. Garcia responded, saying that research institutions in developing countries have learned to be very efficient and creative in using limited research and training dollars. She also mentioned that she has been able to leverage her NIH support to influence Peru’s health agenda.
Dr. Garcia suggested that a relatively small investment could catalyze a regional center of excellence in Latin America and probably in Asia. A South–South center of excellence in Latin America could foster, in the South, a sharing of experiences in collaborating with the North; linkages with large research institutions in Brazil and Mexico; and research training for scientists from the South and the North. Dr. Garcia advocated that Framework 2 incentivize the development of regional consortia as well as centers of excellence and offer higher amounts of funding for longer durations (beyond 3 years). She noted that a regional center (e.g., an Andean Center of Excellence) could address issues shared by countries throughout the region and be multidisciplinary, recruiting other specialties into global health (e.g., engineering, mathematics).
Small Grants. Dr. Cassell suggested that Framework 2 could include a small grants program to promote collaborations, sustainability, and, possibly, matching funds from governments. Dr. Garcia noted that UPCH has been able to use administrative funds to award small research grants to students. Dr. Vermund cautioned against requiring potential grantees to secure matching funds and suggested, instead, that shared investments by countries be prenegotiated. Dr. Alving noted that part of the funds for a program could be used to administer small grants awarded locally and that support of consortia could attract other funds, for example, from businesses. She suggested that an international component could be added to the NIH Small Business Innovation Research (SBIR) program.
Evaluation. Dr. Glass asked for comments on how to evaluate the impact of the Framework program on global health. Dr. Palmer noted that the Claremont program uses 10 criteria, both quantitative and qualitative, to evaluate impact. She emphasized that evaluation of outcomes is not feasible until after 10 years of continuous funding. Dr. Garcia stated that evaluation also is a component of the UPCH Framework program. Some of the criteria discussed were the leveraging of collaboratively developed grants, internal and external recognition, new faculty appointments, number and types of students/trainees participating, productive collaborations with other researchers and institutions, outreach (e.g., newspaper articles), and publication in local and international journals, including the open-access Public Library of Science.
IX. Global Aspects of Mental Health
Dr. Thomas Insel, National Institute of Mental Health (NIMH), NIH
Dr. Arthur Kleinman, Harvard University and Harvard Medical School
Dr. Glass introduced this session by noting that, according to the DCPP, mental illness is the second most common cause of DALYs worldwide. He asked the Board to consider areas of investment for FIC in global mental health and the role of mental health in FIC activities.
Global Mental Health: NIMH Perspective
Dr. Thomas Insel, Director, NIMH, said that global mental health has been on his agenda for NIMH since he became director near the end of 2002. In 2004, he created the Office of Global Mental Health and, with the encouragement of FIC and the appointment of Dr. Pamela Collins to direct this office, NIMH is pushing the agenda aggressively. He noted that NIMH focuses on about a dozen types of mental illness.
Dr. Insel summarized data on mental illness in industrialized countries and in low- to middle-income countries. The World Health Organization (WHO) Health Report 2002 shows that, in the USA, Canada, and Western Europe, mental illness, combined with related self-inflicted injuries and alcohol and drug use, accounts for more than 50 percent of DALYs for non-communicable diseases in individuals ages 15–44. A relatively few disorders (depression, alcohol use, road-traffic accidents) top the list. The high morbidity reflects a 6 percent prevalence of serious disorders and the fact that mental illnesses are chronic and disabling, begin early (50 percent of cases by age 14; 75 percent by age 24), and are the chronic disorders of young people. Dr. Insel emphasized that mental illness is associated with high mortality as well. In the United States, approximately 90 percent of the 30,000 suicides each year are related to mental illness, a rate that is almost twice that of homicides, AIDS, or most cancers. The greatest sources of mortality are from medical causes in that individuals diagnosed with a major mental illness (e.g., psychosis, schizophrenia, bipolar, severe depression) have an increased likelihood of dying from cardiovascular and/or pulmonary disease, as well as suicide, and they die on average by age 56. Although these individuals account for perhaps 7–10 percent of the population, they smoke about 44 percent of cigarettes consumed in the United States and have a very high rate of alcoholism and other drug abuse.
Dr. Insel noted that mental illness in low- to middle-income countries has received relatively little attention because of the focus on infectious diseases. Yet, WHO predicts that, by 2020—10 years from now—depression will top the list of all DALYs globally in all age groups. The issues are slightly different than in industrialized countries because of the projected high prevalence and limitations in treatment. Among the issues are the limited numbers of trained mental health personnel per capita; restricted formularies, lack of newer drugs, and few psychosocial treatments; more stigmatized and separated mental health care; and a dearth of information on evidence-based care in low-resource settings.
Dr. Insel said that NIMH has an active portfolio in global mental health research and is identifying opportunities to pursue. In Fiscal Year (FY) 2008, NIMH directly supported 192 grants for research in foreign, mostly high-income countries. Of these, 33 grants were awarded to foreign institutions, many in Canada and the United Kingdom. NIMH is addressing three areas of opportunity: (i) partnerships (with FIC and WHO; specific projects), (ii) specific research topics (e.g., genomic studies, population cohorts/isolates, HIV/refugee issues, implementation/policy science), and (iii) training (to create a cohort of global mental health experts). Dr. Insel emphasized the critical need to create new training programs to “grow the field,” and he envisaged scaling up an NIMH–FIC partnership in this area.
Global Mental Health: Where It’s Been, Where It’s Headed, and What NIH Might Contribute
Dr. Arthur Kleinman, Board member, and Esther and Sidney Rabb Professor, Department of Anthropology, Harvard University, and Professor of Medical Anthropology in Social Medicine and Professor of Psychiatry, Harvard Medical School, provided a historical perspective on global mental health research. He said that this research has a long tradition and, 40 years ago, had a robust cohort of outstanding researchers with good support from various foundations and NIH. The field evolved from clinical cases, in the 19th century, to epidemiological studies and examinatioan of cultural issues, in the 20th century. He noted, in particular, an international pilot study of schizophrenia conducted by a Taiwanese psychiatrist, T. Y. Lin. In the late 20th century, the DCPP brought to fore the significance of global mental health and the gap between its importance and investments in it. Dr. Kleinman noted that researchers now have available to them meta-studies of existing data, including effective treatment of depression in primary care, and numerous surveys conducted by WHO and others. He called special attention to the more recent development of implementation studies, particularly those by Vikram Patel in Goa.
Global mental health research today is headed toward collaborations, research centers, and North–South research training programs. Dr. Kleinman mentioned that he is particularly interested in the development of population laboratories to build epidemiological and ethnographic databases on which to base mental health services and clinical interventions (e.g., suicide-reduction programs). This research would be collaborative and interdisciplinary; span basic and applied science; include surveillance, intervention, and evaluation; and inform local policymakers. He suggested that sample sizes of approximately 100,000 individuals could be piggybacked onto existing population studies to generate baseline data for interventions. Particularly important are community and sociocultural research studies of the clustering of mental health problems with poverty, stigma, substance abuse, infectious disease, political violence, and social displacement
Dr. Kleinman tied the future of global mental health research to the following three areas: (i) demonstration projects, with rigorous external evaluation and funding to support generalization of programs if outcomes are positive; (ii) creation of a network of global mental health policy research centers in industrialized and developing countries; and (iii) networking of centers, researchers, and trainees. He emphasized that NIH, and particularly FIC and NIMH in partnership, has a key role to play in (i) initiating training programs for researchers from the United States and resource-constrained societies (including the pairing of U.S. and foreign researchers), and (ii) providing and assuring research support to enable researchers to build and sustain careers in global mental health. Also crucial are the development of research centers, or hubs, that link North and South and the funding of implementation research. Special research opportunities include autism, suicide, mental health of migrants, substance abuse, and outliers and high-risk populations. Dr. Kleinman concluded by saying that the development of training programs and research support is what matters most, not the specific disease focus.
Dr. Glass mentioned that FIC has developed good models (e.g., the AIDS International Training and Research Program) for building capacity in research and research training. The Board commented on the global workforce, the need for public education, and the causes of mental illness. At Dr. Glass’s request, the members suggested action items for FIC.
Global Workforce. Dr. Vermund remarked on the difficulty of transporting a conventional Western model of medical doctors and teams in psychiatry and neurology to developing countries where trained psychiatrists are few and mental health care is provided by primary care physicians addressing a gamut of mental and neurological diseases. Dr. Insel noted an irony insofar as neuroscience split from psychiatry after 1950 in the United States and the NIMH is now trying, over the next 10–15 years, to “remarry” the two disciplines into one—clinical neuroscience. This approach reflects new understanding of the brain and the need to recombine neurology and behavioral psychiatry, much as now occurs in practice in developing countries. Dr. Kleinman agreed and suggested a community service approach that would engage a broader base of researchers, including social scientists trained in mental health.
Public Education. A participant remarked on the morbidity and mortality data presented and called for a vigorous education campaign to inform the public about the global need for mental health care, much as was done to raise awareness of the importance of treating HIV/AIDS in poor countries. Dr. Kleinman referred the Board to his perspective recently published in The Lancet, entitled “Global Mental Health: A Failure of Humanity” (vol. 374, issue 9690, pp. 603–04, August 22). Dr. Insel stated that mental health is a civil and human rights issue, and agreeing with Dr. Kleinman, urged that the word stigma not appear in public communications.
Causes of Mental Illness. Dr. Hotez cited evidence that malaria and worms are two factors in the different incidence of mental retardation in industrialized and developing countries (3–5 cases vs. 5–22 cases, respectively, per 1,000 population). He noted that these conditions are both preventable and may be a leading cause of mental illness worldwide. They also may compromise cognitive development, educational attainment, and wage-earning abilities, and, yet, the mechanisms are unknown. Dr. Hotez noted that the United States is funding research and interventions for malaria and worms, but is losing an opportunity to monitor and evaluate the outcomes for mental health. Dr. Insel said that this topic is very interesting and would be a great question for NIH and FIC to frame and begin to explore.
Dr. Cassell mentioned fetal alcohol spectrum disorders, which Dr. Insel agreed posed a very high risk for a number of conditions, including mental retardation, attention-deficit hyperactivity disorders, cognitive problems, and behavioral disorders in children. He noted that heredity plays a large role in the major mental illnesses such as schizophrenia, of which the prevalence, onset, and phenotype are relatively consistent worldwide except for some large regional variations (e.g., Afro-Caribbean) that suggest the possibility of environmental causes as well.
Action Items for FIC. Dr. Vermund noted that having a research agenda for global mental health is enormously compelling, and he enthusiastically supported initiatives in this area. Dr. Kleinman suggested two areas: (i) implementation research on treatment of depression and anxiety disorders using a health services model in primary care (a demonstration project), and (ii) research on the treatment of psychoses using differential intervention models. Dr. Insel emphasized the need to create, through training, a new workforce and to obtain “buy-in” from key payers of treatment (e.g., Centers for Medicaid & Medicare Services). Dr. Vermund suggested creation of a partnership of all ICs that are supporting research in mental health and illness.
In closing, Dr. Glass said that he and Dr. Insel are convinced of the need to move forward in global mental health research. Dr. Insel urged FIC to become involved in the NIH Blueprint for Neuroscience Research, which provides a structure for action across ICs. Dr. Kathy Michels, Program Officer, DITR, is the FIC contact.
X. Administration Perspectives in Global Health
Dr. Jennifer Klein, DOS
Dr. Robert A. Black, The Johns Hopkins University Bloomberg School of Public Health
Global Health Initiative: Status and Focus
Dr. Jennifer Klein, Office of Global Women’s Issues, DOS, reported on the status and focus of the President’s Global Health Initiative. Announced by President Obama in May, this $63 billion initiative is part of a U.S. Government strategy to promote better health in long-term sustainable ways. The charge is to maintain a strong commitment combating HIV/AIDS, tuberculosis, and malaria; reduce mortality of mothers and children under age 5; avert unintended pregnancies; and eliminate some neglected tropical diseases. The DOS and USAID were asked to guide the effort and to bring in other government agencies as partners.
Dr. Klein noted that DOS and the U.S. Agency for International Development (USAID) envisage a two-part process that builds on successes in global health already and to think anew about ways to improve programs (e.g., through coordination and cost effectiveness). They have established a set of guiding principles. First and foremost, it was decided that women should be at the center of care, for the health of women, families, and communities. In addition, there should be better integration and coordination within and among U.S. health programs, development programs, and internationally; support for the specific needs and plans of countries, to promote country ownership; improvements in sustainability and strengthening of health systems; and improved metrics, evaluation, and research, to assure accountability for results.
Dr. Klein said that budget details are currently being worked out with the Office of Management and Budget and will become part of the President’s Budget in February. DOS and USAID have already engaged many partners from other agencies and have formed a steering committee for the initiative as well as several working groups (e.g., on integration and coordination, health systems strengthening, maternal and child health, family planning and nutrition). Dr. Glass serves on the steering committee, and Dr. F. Gray Handley, Associate Director for International Research Affairs, NIAID, co-chairs the working group on metrics, evaluation, and research.
Dr. Klein noted that the initiative includes a significant new investment in maternal and child health, to improve maternal morbidity and mortality rates in line with the Millennium Development Goals, and to assure a coordinated continuum of care for girls and women throughout the life cycle. She highlighted two roles for FIC and NIH in this and other areas: (i) bring innovations into practice as quickly as possible in the short term, and (ii) monitor and evaluate programs over the long term. Specific research challenges include finding ways to assure that effective interventions reach people in need; capturing efficiencies; and measuring integration, implementation of the continuum of care, and strengthening of health systems.
Implementation Research and Impact Evaluation
Dr. Robert A. Black, Board member, and Edgar Berman Professor in International Health, The Johns Hopkins University Bloomberg School of Public Health, expressed enthusiasm for the integration of a global health initiative. He noted that Johns Hopkins is involved in an evaluation of the health impact of major initiatives in global health, including maternal and child health. He cited an overriding need for implementation research to facilitate cost-efficient and cost-effective delivery of already-known effective interventions. He also noted the importance of focusing on the evaluation of health impacts, over sufficient time, to assure that indicators are true measures related to mortality and morbidity. Dr. Black encouraged FIC to take a leadership role in building capacity in implementation, evaluation, and health metrics research.
In response to a question from Dr. Cassell, Dr. Klein agreed that best practices in maternal and child health need to be identified and applied in the United States, particularly in inner cities, as well as in other countries and that evidence of best practices needs to be shared in both directions. Dr. Vermund commented on the complex of issues affecting maternal mortality in developing countries and the need for a major public education effort and evidence-based practices. Dr. Hotez noted that some “quick fixes” may be possible. For example, up to one-third of pregnant women in sub-Saharan Africa are infected with hookworm and malaria, which can be treated preventively at a very low cost to significantly reduce maternal morbidity and mortality.
Dr. Glass expressed his delight in partnering with DOS and USAID on the Global Health Initiative and to be able to infuse a research perspective from the NIH and academic community. Dr. Klein noted that while the budget process is short, the planning process will be long and will involve the seeking of input from, and ongoing partnerships with, the academic community.
The meeting was adjourned at 3:10 p.m. on September 17, 2009.