The John E. Fogarty International Center for Advanced Study in the Health Sciences (FIC) convened the seventy-fourth meeting of its Advisory Board on Monday, May 10, 2010, at 2:00 p.m., in the Conference Room of the Lawton Chiles International House, National Institutes of Health (NIH), Bethesda, Maryland. The closed session was held from 2:00 p.m. to 5:15 p.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 on Tuesday, May 11, 2010, from 9:03 a.m. to 2:40 p.m. Dr. Roger I. Glass, Director, FIC, presided. The Board roster is appended as Attachment 1.
VI. Introductory Remarks
Dr. Glass welcomed two guests: Dr. Robert Spengler, Acting Associate Director for Science, Center for Global Health (CGH), Centers for Disease Control and Prevention (CDC), and Dr. Alan Guttmacher, Acting Director, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). Dr. Glass noted that Dr. Kevin DeCock will participate in Board meetings once he becomes Director, CGH. The participation of representatives from other government agencies in NIH board and council meetings is an outcome of recent discussions between the NIH and CDC directors, Dr. Francis Collins and Dr. Thomas Frieden, on potential collaborations in global health. Dr. Glass also noted that maternal and child health has been re-instated into the global health agenda, after being sidelined for a decade, and is strongly supported by Secretary of State Hillary Clinton. Dr. Duane F. Alexander serves as the FIC interface with NICHD.
Dr. Glass commented that several Board members were unable to attend the meeting because FIC had to change the date so as not to conflict with the World Health Assembly on May 17–22. He noted that three new members will attend the next Board meeting, on September 14. These are Drs. Maria Freire, Derek Yach, and Adel Mahmoud.
At the close of the meeting, Dr. Glass recognized Drs. Claudio and Antman (in absentia) whose terms on the Board expire after the meeting. He thanked them and presented a token gift to Dr. Claudio.
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 September 2009. He noted that FIC has made substantial progress in engaging the NIH institutes and centers (ICs) in the global health agenda. Global health is one of Dr. Collins’ five themes for NIH, and the ICs are incorporating global health into their performance plans. As part of his update, Dr. Glass called on several staff members to present their program activities.
FIC Update
Barmes Lecture. On December 15, 2009, FIC co-sponsored with the National Institute of Dental and Craniofacial Research (NIDCR) the annual Barmes Global Health Lecture at NIH. The speaker was Dr. Julio Frenk, dean of the Harvard School of Public Health, who spoke on “Health: Knowledge World.” Dr. Glass invited the Board to suggest speakers for the 2010 Barmes lecture.
Global Health Metrics. On February 22, Dr. Hans Rosling spoke at NIH on “The New Health Gap: Science for Emerging Economies vs. the Bottom Billion.” Dr. Glass encouraged Board members to peruse the global health metrics data available at www.gapminder.org, a nonprofit World Wide Web venture in global statistics developed by Dr. Rosling and colleagues. The website also contains information on all NIH-supported programs and grants worldwide.
NIH Working Group. The Trans-NIH Working Group in global health research, which was initiated in 2009 at the beginning of Dr. Collins’ leadership of NIH, now comprises representatives of 21 ICs. Dr. Glass co-chairs this group with Dr. Susan Shurin, the acting director of the National Heart, Lung, and Blood Institute (NHLBI). The group has established three critical subcommittees to address, respectively, international clinical research, database of NIH activities, and NIH communications on international activities.
NIH Global Health Meeting. On January 6, 2010, Dr. Collins convened an NIH Global Health Meeting attended by approximately 45 invited global health leaders. They gave presentations on and actively discussed future directions for NIH in global health. Three outcomes of this effort are the Medical Education Partnership Initiative (MEPI) in Sub-Saharan Africa (see section XI below); an NIH investment of approximately $7 million a year from the Human Genome Project to support centers of excellence on chronic diseases in Sub-Saharan Africa, in partnership with the Wellcome Trust; and discussions between the NIH and CDC directors on potential global health collaborations.
Follow-Up to G8 Summit. On February 25–26, FIC hosted a follow-up conference on the development of centers of excellence in Sub-Saharan Africa. Dr. Glass noted that Mr. Robert Eiss, Senior Public Health Advisor, FIC, led an effort 2 years ago to develop a proposal on this topic and that action was sparked by President Obama’s remarks about a global health agenda during the July 2009 G-8 Summit in L’Aquila, Italy.
Mr. Eiss elaborated on the follow-up conference, the purpose of which was to construct a roadmap of actions for the G8 to consider for strengthening the systemic and institutional capacity of African research centers to address the needs of African populations. Mr. Eiss noted that the participants focused on four possible initiatives: (i) development of an African-led network to reduce major risks to maternal, newborn, and child health (MNCH); (ii) convening of a series of consultations and workshops to increase the capacity of the African National Research Council to support local research; (iii) development of an initiative to encourage donor organizations to generate ideas about best practices and to collaborate as research agencies; and (iv) development of guidelines for best practices to foster inclusion of capacity-building measures in funding agencies’ support of research. Mr. Eiss remarked that a consistent concern is donors’ lack of ability in providing adequate support for administration and management of research in Africa.
Dr. Glass reported that a summary statement emanating from the conference has been endorsed by Dr. Collins and is being reviewed within the Administration. He said that FIC has requested funds for this effort and that other-country partners are committed to it. FIC intends to link its support for centers of excellence in research and training with Canada’s specific interest in MNCH.
In discussion, Dr. Glass suggested that the next immediate step after the upcoming G-8 Summit, on June 25 in Muskoka, Canada, is to have a fuller consultation with African governments. This would include the participation of national academies of science. Drs. Cassell and Pablo–Méndez noted the importance of research on maternal and child health, and Dr. Cassell highlighted an opportunity to coordinate intramural and extramural research on pediatric multidrug-resistant tuberculosis (TB) in China.
FIC Speakers. Dr. Glass highlighted several recent events hosted by FIC for the NIH community. Pursuant to FIC’s initiative in chronic diseases, Dr. Nicholas Wald spoke on “The Polypill and the Primary Prevention of Cardiovascular Disease.” Via videoconference, Sir Richard Peto and staff of the National Institute of Alcohol Abuse and Addiction discussed alcohol as a cause of mortality among adult men aged 15–54 in Russia and the United Kingdom. Also via videoconference, researchers at the Russian Institute of Child Health met with counterparts at NICHD to discuss stem cell research in cancer. Dr. Glass commented that videoconferencing can have a high impact on stimulating research collaborations at a low cost.
Health Sector Reform. In discussion, Dr. Glass reported that Dr. Collins convened during the previous week a consultation of IC directors and external experts (a “Big Think”) to consider the themes he defined for NIH other than global health (which was addressed in January). In relation to health sector reform, the participants focused on health systems, comparative effectiveness research (CER), and improving health outcomes while reducing health costs. Dr. Guttmacher mentioned that Dr. Collins said that NIH has been a large supporter of CER for years and now is considering new ways to approach it. Drs. Glass and Johnson noted that Dr. Collins convened a group of health economists soon after becoming NIH director; that NIH is currently hosting a big-think session on health economics; and that Dr. Collins is an active leader in pursuing the health systems strengthening principle of the Global Health Initiative (GHI).
Dr. Glass highlighted the need to align NIH’s domestic interests in health sector reform with international activities. Dr. Pablo-Méndez suggested that the needs for analysis and health economics cross countries and that FIC could define these opportunities internationally. Dr. Glass asked the Board to think about how best FIC could do this—as a sole FIC initiative, or by leveraging FIC resources in partnership with other ICs and bridging to other agencies [e.g., Centers for Medicare and Medicaid Services (CMS)]. Dr. Pablo-Méndez suggested that the answer depends on the NIH director’s “lens” for CER at NIH. He and Dr. Guttmacher said that FIC could serve as a platform for “precise thinking” on the two-way, domestic–international dynamic of health systems research. Dr. Pablo-Méndez emphasized that collaborative research in this area is urgently needed and that U.S. leadership is key, as the United States accounts for one-half of the total spending on this research.
FIC Budget
Mr. Timothy J. Tosten, Executive Officer, FIC, reported on the President’s Budget for FIC for Fiscal Year (FY) 2011. The proposed budget would total slightly more than $73 million, or approximately $3 million over the FY 2010 budget. If the budget is passed by Congress, the FIC will receive the largest percentage increase over FY 2010 of all ICs—that is, 4.3 percent, compared with 2.5–3.5 percent for most ICs. The budget would include $1 million for global health. This amount would be allocated from $18 million authorized to NIH for global health, which would be distributed among eight ICs and FIC, with the largest amounts going to the National Institute of Allergy and Infectious Diseases (NIAID) ($9 million) and the National Cancer Institute (NCI) ($2 million). The total FIC budget for FY 2011 would be distributed among extramural research and training ($53.9 million), research and development activities ($4.6 million), and research management and support ($14.4 million).
Program Developments
FIC staff members described four new award programs that FIC expects to fund in FY 2010.
Independent Scientist in Global Health Award (ISGHA). Dr. Yvonne Njage, AAAS Fellow, Division of International Training and Research (DITR), FIC, described the ISGHA—one of FIC’s newest programs—which FIC established based on the Board’s discussions at its September 2009 meeting. Supported by the K02 mechanism, it focuses on new investigators who have completed their postdoctoral or other terminal degree within the previous 7 years and who are either tenure-track scientists with or without independent NIH research awards, or non-tenure-track scientists with independent NIH research awards. Expanding on the K01 program, which focused on non-tenure-track scientists, the K02 program helps to fill a gap in the pipeline of scientists that FIC nurtures in global health research. The ISGHA offers up to $85,000 in salary support and up to $25,000 for research support each year for 3–5 years. It was announced in December 2009, and applications were due by March 1, 2010. Applications will be reviewed during the summer, and awards will be made in September 2010.
Framework Programs for Global Health Signature Innovations Initiative. Dr. Flora Katz, Program Officer, DITR, FIC, described this 1-year initiative, which FIC announced in January 2010. Using NIH funds allocated from the American Recovery and Reinvestment Act of 2009 (ARRA), FIC was able to build on the multidisciplinary educational model of FIC’s Framework program and “push it one-step further” to support actual collaboration among expert teams. Using the R24 mechanism, FIC will support the design of training programs for U.S. and foreign postdoctoral scientists to work together with others outside their field to solve complex problems, produce a deliverable, and consider implementation issues. Applicants are asked to define their meaning of innovation within the context of global health and how they would increase innovation on their campuses. The institutional award provides up to $250,000 for a single institution and up to $400,000 for institutions working in partnerships or consortia, which could include institutions in developing countries. This pilot program is a “signature” initiative for which the NIH Office of the Director is providing matching funds. With these funds and others from several ICs, FIC has $2.7 million available to support 8–10 awards. Applications were due on March 22, and the earliest anticipated award date is September 30, 2010.
Program to Enhance NIH-Supported Global Health Research Involving Human Subjects. Dr. Barbara Sina, Program Officer, DITR, FIC, described this second pilot effort, which also was made possible by ARRA resources. The purpose of the program, which is supported under the S07 mechanism, is to improve the review and monitoring of protocols for NIH-supported research at institutions in developing countries. Participating in this initiative, FIC will support 1-year grants awarded to U.S. institutional review boards (IRBs) to collaborate with an IRB in a developing country that is reviewing some of the same NIH research protocols in specified areas. Applicants are asked to submit plans for 1 year of training and collaboration in which to build a joint relationship by sharing workshops and training and developing joint resources (e.g., interchangeable databases). FIC anticipates that this initiative will generate new models for how IRBs can collaborate and accelerate research, speed review, and enhance ethical competency. Applications were due on March 22, and the earliest anticipated start date is August 31, 2010.
FIC–National Institute of Mental Health (NIMH) Collaborations. Dr. Kathy Michels, Program Officer, DITR, FIC, reported on two recent collaborations with NIMH. First, on November 16, 2009, FIC participated in the NIMH Global Mental Health Strategy Meeting, entitled “On the Pulse of Mental Health Action: Identifying Strategic Research Opportunities.” Led by Dr. Thomas Insel, director of NIMH, the participants focused on access to mental health worldwide, information gaps between researchers and practitioners, and use of evidence-based research to better help populations (e.g., those in conflict situations, AIDS orphans). Second, NIMH has signed back on to support FIC’s Brain Disorders in the Developing World: Research across the Lifespan (BRAIN) Program. Dr. Michels noted that NIMH was an early partner in the BRAIN Program and in FIC’s International Clinical, Operational, and Health Services Research Training programs. She noted that its renewed participation has resulted in an uptake of applications from the global mental health community.
Dr. Michels commented that Dr. Insel is fully committed to global mental health and, in his own recent director’s blog, made the case for NIMH to focus on this area. Dr. Glass reported that subsequent to Dr. Insel’s presentation at the Board’s September 2009 meeting, Dr. Pamela Collins joined NIMH as director of the Office for Research Disparities and Global Mental Health. Located within the office of the NIMH director, she is developing a global mental health initiative for NIMH. In addition, NIMH is participating in the Global Alliance for Chronic Disease, of which FIC is a founding partner. Dr. Glass noted that the Global Alliance now includes mental health on its agenda and will be publishing, in the fall, a strategic plan for global mental health. Mental health conditions are the second most common cause of disability-adjusted life years (DALYs), according to the Disease Control Priorities Project.
FIC Implementation Science for Global Health Meeting
Ms. Sejal Mistry, Policy Analyst, Division of International Science Policy, Planning, and Evaluation (DISPPE), FIC, and chair of the FIC Implementation Science Working Group, reported on the Implementation Science and Global Health Satellite Meeting. Hosted by the working group, the meeting was held on March 17 following the 3rd Annual NIH Conference on the Science of Dissemination and Implementation: Methods and Measurement, which the Office of Behavioral and Social Sciences Research (OBSSR) hosted on March 15–16. Ms. Mistry reported that the satellite meeting focused on international implementation science and attracted approximately 90 FIC grantees from 13 countries and across research programs who participated enthusiastically in panel sessions on research, linkages and partnerships, and training and curriculum development in implementation science. Among the major discussion points emanating from the meeting, the participants urged FIC to convene the meeting annually, raise the profile of international implementation science, and provide additional funding and support in this area. Ms. Mistry said that the working group will be addressing how to incorporate implementation science into the broader context of major global health initiatives. In discussion, Ms. Mistry said that the meeting is likely to be a yearly event and, perhaps, with OBSSR backing.
Fulbright Scholar Programs
Dr. Myat Htoo Razak, Program Officer, DITR, FIC, updated the Board on FIC’s activities with the Fulbright Scholar Program. Dr. Glass noted that biomedical science was only recently included in the program, which is administered by the Council of the International Exchange of Scholars (CIES), when Ms. Julia Royall of the National Library of Medicine applied for and received a fellowship to work in Uganda. FIC initiated its Fulbright program 2.5 years ago to extend collaborations with Fulbright into the biomedical sphere and, especially, in Sub-Saharan Africa. Dr. Razak reported that, in early May, FIC agreed with the Department of State to support clinical research training and mentoring, to be conducted by Vanderbilt University, of five predoctoral Fulbright fellows at six sites in five Sub-Saharan African countries (Botswana, Malawi, South Africa, Uganda, and Zambia). The Fulbright program at CIES will support logistics and administration.
In discussion, Dr. Razak noted that the fellows include graduate students, 1st-year medical students, and Ph.D. students. She and Dr. Glass remarked that FIC intends to expand its collaborative support to postdoctoral investigators and to embrace the broad aspects of biomedicine as well as related fields (e.g., health informatics, health economics, health systems management, bioengineering, medical anthropology). Dr. Cassell noted the potential for collaboration with business schools, and Dr. Glass commented on the opportunity to expand collaborations, particularly through public–private partnerships. Extension to Latin America also was suggested.
Recent and Upcoming U.S.-China Conferences to Stimulate Joint Research Collaboration
Ms. Tina Chung, Program Officer for East Asia and the Pacific, Division of International Relations (DIR), FIC, talked about recent and upcoming U.S.–China conferences to stimulate joint research collaboration. In November 2009, the Chinese Academy of Medical Sciences (CAMS) and NCI celebrated 30 years of collaboration by reviewing their joint accomplishments in cancer research and opportunities for future collaboration in personalized cancer medicine. FIC assisted in the planning of this workshop. Both sides agreed on several areas for continuing collaboration: establishment of a bilateral working group to pursue discussions of personalized medicine, development of scientists who can perform multidimensional analyses such as computational analysis, research on cancer genomics, and development and implementation of international standards for biobanking. In January 2010, the Chinese Academy of Sciences and four ICs, including FIC, met to identify emerging areas of cooperative research in environmental pollution (e.g., tobacco smoking) and its impact on cancer in China and the United States; NCI is preparing the meeting summary. Later in May, Secretary of Health and Human Services Kathleen Sebelius is expected to travel to China, as part of a U.S. delegation, and present a lecture at CAMS and, possibly, meet with Chinese officials to discuss biomedical and behavioral science.
Currently, CAMS and several ICs, including FIC, are planning a meeting on U.S.-China hypertension research—past successes, present achievements, and future opportunities—that will be held in Beijing on October 13–14, 2010. Ms. Chung noted that China is very interested in this meeting, as stroke is the number one cause of death in China, and that the NIH director will deliver summary remarks.
Upcoming Events
Dr. Glass reported that Dr. Bill Pape will speak at NIH on June 17. Dr. Pape has been an FIC grantee for 20 years under FIC’s AIDS International Training and Research Program (AITRP) and has been instrumental in efforts to reconstruct Haiti after its devastating earthquake in January.
Dr. Glass encouraged the Board members to attend the alumni reunion of FIC scholars and fellows on September 24–26. Approximately 200 U.S. and foreign alumni of FIC programs over the past 6 years are expected, and their research will be highlighted in a scientific symposium on the 24th to which the IC directors will be invited.
VIII. Consortium of Universities for Global Health (CUGH)
Dr. Haile Debas, Executive Director, USCF Global Health Sciences
Dr. Debas summarized the evolution of CUGH and suggestions for collaboration between FIC and CUGH. First conceived by Dr. Jerry Keusch, former director of FIC, at a 2004 Boston, Massachusetts, meeting of all U.S. and Canadian universities with global health programs, the idea of a CUGH developed over recent years such that 58 universities participated in the 1st annual meeting of CUGH, held at NIH this past September. Dr. Debas, who chairs the CUGH board of directors, noted that the meeting was very successful and included speakers from the White House and Department of State. The 2nd annual meeting is scheduled for September 21–22, 2010, in Seattle, Washington. A joint meeting with the Global Health Education Consortium (GHEC) is possible in September 2011.
Dr. Debas commented that the role of universities in global health has been displaced over the years by that of nongovernmental organizations (NGOs). He noted that, in recognition of the tremendous competitive advantage that universities can now have in global health, CUGH has adopted a vision to make the university a transforming force in global health. Its mission consists of collaboration and exchange of knowledge and experience among universities, creation of equity and reduction of health disparities globally, promotion of long-term partnerships among universities across resource-rich and resource-poor countries to develop human capital and strengthen institutions, and advocacy for universities to play a key role in global health. Reflecting this mission, CUGH has standing committees in education, enabling systems (e.g., legal, intellectual property), and advocacy.
Dr. Debas highlighted, in particular, the priority of supporting international partnerships for building human and institutional capacity as an important contribution CUGH can make to global health. He noted that the number of new global health programs in universities has increased dramatically between 1964 and 2009, with most of this growth beginning in 2004 and the most new programs (19) initiated between 2007 and 2009. During the past 3 years, student enrollment in these programs, across all levels, has doubled. Responding to this tremendous enthusiasm and need, 269 U.S. and Canadian universities have established global health activities, 188 of which have a full portfolio (education, research, clinical services), while 81 have some, but not education.
Dr. Debas reported that, as of May 1st, 21 universities are full members of CUGH and another 16 memberships are in process. To be considered for full membership, a university’s global health programs must span two or more schools within the university; relate to all three university domains—education, research, and service; and have at least one substantive, long-term relationship with a partner institution in a low- or middle-income country. Dr. Debas said that CUGH offers associate and partner memberships for universities that do not meet all these criteria and that CUGH anticipates eventually having 50 full members, which would include all major universities in the United States, Canada, and Mexico. The CUGH is incorporated in Washington, D.C., as a nonprofit organization, and is planning to open an office in D.C.
Dr. Debas elaborated on ideas suggested by the board of directors of CUGH for potential FIC–CUGH collaboration. Three potent suggestions are to collaborate on (i) research training and infrastructure development in developing countries, which would include onsite training of research administrators and mentoring and consulting services; (ii) structuring of academic “twinning” programs (i.e., long-term institutional partnerships between CUGH members and universities in developing countries); and (iii) building global health capacity in U.S. universities (e.g., through T32-type, multidisciplinary programs and North–North partnerships). With regard to the twinning programs, Dr. Debas congratulated FIC on its new Medical Education Partnership Initiative (MEPI) and noted the need for NIH to sustain and expand partnership programs with the Bill and Melinda Gates Foundation. Two additional suggestions made by the CUGH board of directors were to collaborate on the design of FIC’s Framework-II programs, as needed, and on the development of universal guidelines for ethically responsible academic partnerships.
Discussion
Dr. Pablos-Méndez applauded CUGH on its mission and commented on potential difficulties for partner institutions. For example, universities may not have or be willing to commit sufficient resources to support and sustain global health collaborations, and resources that are committed may not reach those for whom they are intended (i.e., may be intermediated). In addition, many developing countries are giving priority to primary education, rather than university research. Dr. Pablos-Méndez emphasized the need for universities to embrace implementation science and health systems analysis. Dr. Debas posited that universities are a powerful engine for advancing the U.S. interest in building research capacity overseas and that partnerships with universities in developing countries could foster the capacity needed to address local populations’ needs. Dr. Joel Breman, Senior Scientific Advisor, Division of International Epidemiology and Population Studies (DIEPS), FIC, suggested that CUGH may want to “latch” research training efforts to one or more major disease problems in global health, to focus these efforts and help control and eliminate disease problems.
Dr. Glass considered the possibility that the NIH T32 mechanism could be used for training at international sites. One complicating factor may be that institutional T32 recipients that are not already engaged in global health may not want to use their T32 slots for research training overseas. Dr. Reingold mentioned that the NIH Minority International Research Training (MIRT) program supports short-term research training overseas for under-represented minorities. Dr. Debas suggested that, given the tremendous demand among students for careers in global health, a specific mechanism is needed to support global health research and research training.
Dr. Glass thanked Dr. Debas for his presentation and said that CUGH’s priorities are complementary to and build upon FIC’s programs, particularly its Framework program which also requires participation of multiple schools within a university. Dr. Glass noted that CUGH and GHEC represent groups that could be advocates for global health programs on university campuses.
IX. New Developments in Chronic Disease Research and Training
Dr. Judith Fradkin, Director, Division of Diabetes, Endocrinology, and Metabolic Diseases, NIDDK
Dr. Susan Shurin, Acting Director, NHLBI
Drs. Fradkin and Shurin presented two NIH agendas for international research and training in chronic diseases. Dr. Fradkin described NIDDK’s research agenda for the global diabetes epidemic, and Dr. Shurin described NHLBI’s research agenda for noncommunicable chronic diseases related to the NHLBI mission.
NIDDK—Global Diabetes Epidemic
Dr. Fradkin described the large and growing global burden of diabetes. The International Diabetes Federation (IDF) estimates that diabetes affects 285 million people worldwide, 70 percent of whom are in low- and middle-income countries (predominantly India and China) where urban populations are twice as likely to have diabetes as rural populations. Approximately 6.6 percent of the world’s population has diabetes. Type 1, an autoimmune disease predominantly affecting Caucasians and people in developed countries, accounts for 5–10 percent of cases; type 2, the epidemic form that is expanding rapidly in relation to obesity, accounts for 85–90 percent; and gestational diabetes is thought to affect 7 percent or more of all pregnancies. Dr. Fradkin noted that the 4 million deaths attributed to diabetes for adults worldwide is a huge underestimate because the cause of death for approximately two-thirds of these individuals is listed as cardiovascular disease, for which diabetes increases the risk by two- to fourfold. The annual direct cost of caring for people with diabetes is approximately $376 billion, one-half of which is spent in the United States. According to the IDF, the largest increase in cases by 2030 is projected to occur in countries or regions that had a lower prevalence of diabetes in 2000 (e.g., India, Southeast Asia, South America, Sub-Saharan Africa).
Dr. Fradkin noted that accurate surveillance measures and methodologies are key to future projections. For example, in 2000, China projected that they would have, in 2030, 42 million people with diabetes, but after applying CDC methodology, found that they already had 92 million people (about 9.7 percent of the population) with diabetes in 2008. Data from the 2009 Diabetes Leadership Forum in China, which were published in the New England Journal of Medicine, show that diabetes is a major public health problem in China: approximately 60 percent of people with diabetes are undiagnosed, 55 percent of men with diabetes smoke, and 3.2 percent of young adults have diabetes while another 9 percent have pre-diabetes. These data have important implications worldwide, as they may be replicated in other developing countries and indicate that diabetes is arising increasingly at younger ages.
Dr. Fradkin highlighted prevention as one approach to the global emergence of diabetes. She noted that the U.S. Diabetes Prevention Program, conducted by NIDDK, showed that the rate of development of diabetes in a diverse population could be reduced substantially (by 58 percent with lifestyle intervention and by 31 percent with metformin medication) in all groups and over the long term (10 years). NIDDK is moving forward from this pilot study to translational research to determine how lifestyle changes could be accomplished more cost effectively and whether the approach is feasible globally. Dr. Fradkin called particular attention to obesity as a pre-diabetes condition and to end-stage renal disease, which tracks with the duration of diabetes and, with diabetes occurring earlier, is now seen among working-age adults. Referring to the Barker hypothesis on the fetal origins of adult disease, she showed data demonstrating a hugely increased rate in the development of diabetes among offspring of women who had diabetes or impaired glucose tolerance prior to pregnancy.
Dr. Fradkin noted that Dr. Glass recently facilitated her participation in a World Health Organization (WHO) group that addressed priorities for diabetes research in low- and middle-income countries. Four priorities emanating from this group are to (i) improve outcomes for people with diabetes (e.g., through low-cost diagnostic testing and therapies, detection and management of complications); (ii) achieve population-based primary prevention (e.g., through lifestyle, dietary, and physical activity interventions); (iii) promote surveillance (e.g., monitoring, standardization of protocols and definitions); and (iv) address co-morbidities (e.g., HIV, TB).
Dr. Fradkin listed several priority opportunities for NIDDK to collaborate with FIC and the broader global research effort. These include development of common surveillance approaches, dissemination of diabetes education materials already developed by NIDDK, exploration of environmental contributors to diabetes, and possibly clinical trials. She noted that NIDDK’s studies of Pima Indians in Mexico and the United States, who share common genetics but have different environmental factors, exemplify research that could be highly informative for understanding diabetes in the United States and abroad. Similar studies could be conducted among, for example, South Asian populations that have emigrated throughout the world.
In discussion, Dr. Glass mentioned several opportunities for positive research partnerships with, for example, the World Diabetes Association and various foundations interested in the genetics of diabetes and low-cost tools for testing and monitoring diabetes in the field.
NHLBI—Noncommunicable Chronic Disease
Dr. Shurin discussed how global health fits into the priorities and vision of NHLBI and specific NHLBI interests and activities in global health. She outlined four strategic priorities for these activities: (i) basic, clinical, and population research that inform each other; (ii) research priorities driven by science; (iii) the tying of observational and population-based studies to basic science on gene–environment interactions; and (iv) partnerships with colleagues throughout the world. Research priorities reflect a combination of scientific opportunities and public health needs. For NHLBI, three major opportunities in global health are: (a) chronic diseases (i.e., cardiovascular diseases, pulmonary diseases, diabetes/obesity), (b) genetic diseases (i.e., hemoglobinopathies, bleeding and clotting disorders), and (c) blood safety. The efforts in these areas reflect goals set forth in the NHLBI Strategic Plan and a vision to “provide global leadership through research and education to enhance the health of all individuals….”
Dr. Shurin noted the worldwide shift in burden of disease from acute to chronic disease. She cited WHO data which project a 10–20 percent increase in deaths worldwide from chronic disease from 2006 to 2015, while deaths from infectious disease decrease substantially. For cardiovascular diseases, the reasons for the increase include children’s survival into adulthood and broad environmental factors—for example, populations’ migration from rural to urban areas (as associated with increased prevalence of diabetes, hypertension, and coronary heart disease) and increased weight and obesity (leading to dyslipidemia, dysglycemia, high blood pressure, and diabetes). Commenting on the complexity of the Barker hypothesis, she cited research showing an association between intrauterine exposure to famine and increased risk of pre-diabetes in adulthood.
Dr. Shurin referred the Board to a feature article in Nature (vol. 450, 22 November 2007), entitled “Grand Challenges in Chronic Non-Communicable Diseases,” of which Dr. Glass and former NHLBI director, Dr. Elizabeth G. Nabel, are among the authors. She noted two major activities that grew out of this article. First, NHLBI established a partnership with United Healthcare to support a network of 11 collaborating centers in chronic disease in diverse world regions. Second, NHLBI became a partner in the Global Alliance for Chronic Diseases (GACD). Initiated in June 2009, this partnership of government funders of biomedical research is the first of its kind to address noncommunicable chronic diseases. FIC and NIMH are other alliance partners. The goals are to coordinate research on prevention and treatment globally, identify common approaches to guide policy and development of best practices, and build capacity in research, training, and healthcare delivery in low- and middle-income countries and among low-income and indigenous populations in more developed countries. Dr. Shurin said that the top three emphases currently are hypertension, tobacco use, and indoor air pollution from cook stoves.
In addition to these two major partnerships, NHLBI has a specific interest in understanding the relative contribution of genes and environmental factors, an interest that accords with the NIH Genes and Environment Initiative. NHLBI researchers also are studying the interaction of populations and genetics with economics, environment, and culture. Dr. Shurin noted that many opportunities for reducing cardiovascular and pulmonary diseases (e.g., chronic obstructive pulmonary disease, asthma) are public health in nature—cleaning up the air and water, improving nutrition, and confronting transportation needs (e.g., to improve access to care).
With respect to blood diseases, she remarked that NHLBI is investing to advance understanding of the hemoglobinopathies of thalassemia and sickle cell disease and to promote the health of individuals affected. She highlighted the importance of surveillance aspects and noted that survival rates and life expectancy of individuals with these diseases can be increased dramatically through preventive interventions (e.g., screening, antibiotics for infections, vaccine development, improved use of blood transfusion), as has been done in the United States. Toward this end, NHLBI is interested in pursuing collaborations with researchers in Sub-Saharan Africa and Southeast Asia.
In closing, Dr. Shurin said that the ultimate goal is to optimize the future for citizens across the world and that NHLBI wants to leverage its limited abilities to do so. Health issues are global, and international research partnerships would complement, and be of benefit to, many NHLBI studies involving minority and indigenous populations in the United States.
Discussion
Dr. Glass asked the Board to consider how FIC could collaborate with NHLBI on existing activities and with NIDDK on new activities in global health. Board members noted the potential for collaboration with other ICs [e.g., NICHD, National Institute of Environmental Health Sciences, CDC, and the National Science Foundation (NSF)]. Dr. Reingold urged that engineers (e.g., as funded by NSF) be involved in addressing health issues related to water and air pollution, and Dr. Glass said that some FIC collaborations include engineers. He mentioned several areas as ripe for international collaborative research—for example, infectious and respiratory diseases arising from indoor air pollution, diabetes in childhood, surveillance (e.g., of hemoglobinopathies), and interventions to prevent high-risk effects (e.g., maternal hemorrhaging) in high-risk populations. Dr. Shurin noted the importance of a country’s ownership and acceptance of public health changes.
X. Report of the CSIS Commission on Smart Global Health Policy
Dr. Stephen Morrison, Senior Vice President and Director, Global Health Policy Center
Dr. Morrison described the process for preparing the commission’s report and presented highlights from the report. As background, he noted that the Center for Strategic and International Studies (CSIS) was established 48 years ago as a bipartisan, nonprofit organization headquartered in Washington, D.C., to focus on global security and foreign policy. In 2001, CSIS entered the health arena by creating the CSIS HIV/AIDS Task Force, which is now part of the CSIS Global Health Policy Center that CSIS launched 2 years ago. The center’s first signature action was to create the Commission on Smart Global Health Policy to demonstrate that a diverse group of high-level opinion leaders and strategic thinkers could develop a strong consensus statement about U.S. interests in global health and to experiment with different forms of outreach. The 25-member commission includes experts in and outside of global health and four members of Congress.
Dr. Morrison reported that the commission, which is co-chaired by William J. Fallon and Helene D. Gayle, met in April 2009 for 2 days. It commissioned papers; created a video and an online website (http://SmartGlobalHealth.org); published short, analytical pieces (e.g., on metrics and measurement); sponsored essay and photo contests; and held events, with webcasts, at U.S. centers of excellence in global health (e.g., University of California at San Francisco, Harvard University, Boston University, Research Triangle Institute). The commission released its report, entitled “Report of the CSIS Commission on Smart Global Health Policy – A Healthier, Safer, and More Prosperous World,” in Washington, D.C., on March 18, 2010. The report is available on the above website and at http://csis.org. Dr. Morrison remarked that there were 20,000 downloads of the full report in the first 10 days after it was issued. He provided a copy to each Board member.
Dr. Morrison noted that the report argues that global health is a distinctly different phenomenon in American politics, in that it touches upon multiple foreign interests and national interests, and that its core humanitarian and health aspects are as vital as U.S. interests in security, stability, and economic growth. Global health is a strategic part of U.S. foreign policy and is a “best buy” in terms of the impact of U.S. investments. The report focuses on integration of U.S. efforts in global health, including integrating the vision of NIH with that of the GHI and overcoming the gap between global preparedness efforts and global health initiatives such as the GHI and the President’s Emergency Plan for AIDS Relief (PEPFAR). It emphasizes measurement and accountability and U.S. diplomacy with multilateral partners.
In discussion, Dr. Morrison cited five substantive priorities, or principles, for a U.S. global health strategy that the commissioners outline for 2010–2025. Three are to (i) maintain the U.S. commitment against HIV/AIDS, malaria, and TB; (ii) prioritize women and children in U.S. global health efforts; and (iii) strengthen prevention and health emergency response capabilities. The fourth (iv) principle is to ensure that the United States has the capacity to match its global health ambitions (by, for example, creating a deputy advisor at the National Security Council to formulate and oversee global health policy; a senior-level, comprehensive interagency council for global health; and a consultative group to engage Congress in structuring support for global health). The fifth (v) principle is to make smart investments in multilateral institutions (e.g., United Nations agencies, the World Bank) as integral partners in global health.
Dr. Morrison noted that the report is written to be accessible to interested readers and the American public. Going forward, the commission will continue to have “roll-out” events around the country and identify students, industry, and political leaders motivated by global health needs. Attention is shifting to a focus on specific countries, as laboratories, where issues laid out in the report can be tested operationally, with the continued involvement of many commissioners, particularly members of Congress. Dr. Morrison noted an interest in building a relationship between the center and FIC and other ICs, and he welcomed the Board’s advice and comment.
Discussion
Dr. Glass said that “smart power” and the GHI are key to FIC’s work and that FIC and NIH are actively participating in and incorporating ideas from this largest-ever U.S. Government investment in global health. He noted that a 15-year agenda is more realistic for research and education than is 5 or 10 years. He also noted that FIC relies on the support of partnerships to enhance the impact and sustainability of its programs.
Dr. Reingold asked about the tension in U.S. funding levels for different global health priorities (e.g., PEPFAR, vaccine development). Dr. Morrison noted that the report argues for a steady, sustainable trajectory in funding over 15 years to preserve the commitment to, and momentum in, global health and that U.S. initiatives in HIV/AIDS, TB, and malaria are viewed as bulwarks for carrying global health agendas forward. Commenting on concerns expressed about the GHI approach and fragmentation of resources spread across broad agendas, he called for greater efficiencies, continued vitality of existing programs, and a more unified and clear consensus on relative priorities and the place of global health in U.S. foreign assistance. He mentioned that the commission’s report argues for increasing the share of U.S. commitments to global health alliances from 15 percent to 20 percent.
Dr. Cassell emphasized that permanent, full-time U.S. attaches for science and health are needed, especially in “critical” countries. She suggested that CSIS address this issue in a follow-up study focused on the Department of State.
XI. Overview and Discussion: Medical Education Partnership Initiative (MEPI)
Dr. Michael P. Johnson, Deputy Director, FIC, NIH
Dr. Letitia B. Robinson, Program Officer for Sub-Saharan Africa, FIC, NIH
Drs. Johnson and Robinson described the context and aims of MEPI, a broadly collaborative effort to support medical education in Sub-Saharan African institutions receiving PEPFAR support. Dr. Glass noted that MEPI is an outcome of the January 2010 Global Health Meeting convened by the NIH director and that it enables FIC to lend its research training expertise in support of the GHI.
The concept of MEPI arose in discussions between FIC and Dr. Eric Goosby, U.S. Global AIDS Coordinator (GAC), and was embraced by the NIH director. Initial funders were Dr. Goosby’s office (OGAC) and the Office of the Director, NIH, (through the Common Fund), which includes the Office of AIDS Research (OAR) and Office of Research on Women’s Health. MEPI is administered by FIC and the HIV/AIDS Bureau of the Health Resources and Services Administration (HRSA) and now engages 17 ICs and other agency partners (e.g., CDC, Department of Defense, Department of State, U.S. Agency for International Development). Dr. Glass noted that MEPI will provide more than $100 million over the next 5–6 years for training in global health in Sub-Saharan Africa. The funding opportunity announcement was issued on March 15, applications were due May 12, and the earliest anticipated start date is September 30. Awards will be funded through the R24 mechanism.
Context
Dr. Johnson said that the context for MEPI rests on FIC’s emphasis on long-term training, beginning more than 20 years ago when FIC launched AITRP, which created the human capacity for subsequent HIV/AIDS programs such as PEPFAR. Now as the second phase of PEPFAR begins, Dr. Goosby has a legislative mandate to train 140,000 health workers and to strengthen medical and nursing education in Sub-Saharan Africa. Dr. Johnson outlined the development of interest in centers of health innovation and the building of research capacity in this region, as addressed in G-8 discussions, the Wellcome Trust’s African Institutions Initiative, implementation of the GHI, and the NIH Director’s Global Health Meeting.
Dr. Johnson stated that a key influence on MEPI is the recent Sub-Saharan Medical Schools Study, the first of its kind. Funded by the Bill and Melinda Gates Foundation, this study was guided by and involved medical school deans and included creation of a database of schools, a survey of medical schools, and 10 site visits. Dr. Johnson reviewed the key findings, which were recently reported at a meeting he attended in Tanzania. The data show, for example, that approximately one-half of the 150 medical schools in the region are in Nigeria and Sudan and that approximately one-half were founded within the past 20 years. Emigration of graduates and faculty is high, and most faculty have to supplement their incomes, while few are conducting grant-funded research. Resource constraints and needs (e.g., in telemedicine, teleconferencing, Internet connectivity, laboratories, libraries, salaries) are severe or inadequate for improving the quality and quantity of faculty. Yet, innovative models of education exist—for example integration of pre-medical programs, community-based recruitment and education, interdisciplinary learning, emergence of private medical schools, national and international partnerships, and use of research as a tool for faculty recruitment and retention.
Dr. Johnson said that the conclusions from the study will be published in The Lancet within the next couple of months. They pertain, for example, to the development of faculty capacity, investment in the infrastructure of medical education, funding of research and research training, establishment of national and regional quality standards and accreditation, and revitalization of the African Medical Schools Association.
Within this context, MEPI will provide grants to Sub-Saharan African medical institutions to foster recruitment and development of medical school faculty; devise innovative models for recruitment, training, and retention of students; blend research funding with clinical service training; and support bridges between AIDS and non-AIDS funding streams and PEPFAR. Dr. Johnson noted that awards will be flexible in content and that African institutions are tasked with selecting their partners, developing their research and training agendas, and specifying the content of the support they seek.
Aims
Dr. Robinson noted that MEPI will include three types of awards: a coordinating center, programmatic awards, and linked awards. One coordinating center grant will be awarded to a U.S. institution for up to $2 million per year for up to 5 years. This center will coordinate and provide technical assistance for the entire initiative, develop an African leadership network, and evaluate MEPI to identify best practices and models that could be replicated in other areas. The center will partner with an African institution or organization that could potentially assume the role of coordinating center after the 5 years.
Programmatic awards, the main type of award, will focus on the PEPFAR priority areas—HIV/AIDS, malaria, TB. The OGAC and OAR will provide up to $2 million per year for up to 5 years to African institutions. Awards will support development of new training and career development opportunities for medical students and faculty, multidisciplinary approaches to medical education and health research, and innovative education models. Linked awards will be supported by the NIH Common Fund. Institutions applying for programmatic awards must also apply simultaneously for linked awards, and they can apply for up to two linked awards for up to $500,000 a year for the project period. Linked awards are intended to increase the expertise beyond HIV/AIDS, strengthen implementation and sustainability of education and research training, and strengthen faculty contributions and student participation in research beyond HIV/AIDS. Applicants will be encouraged to partner with NIH-funded projects.
Dr. Robinson listed the 20 countries eligible to apply to MEPI, as PEPFAR recipients, and said that more than 40 letters of intent had been received from 14 African countries. Based on the letters of intent, the likely research areas are noncommunicable diseases, maternal and child health, mental health, family planning, reproductive health, TB, malaria, emergency medicine, critical care, surgical morbidity and mortality, and health informatics.
Discussion
Dr. Cassell highlighted the potential for award recipients to partner with the American Association of Medical Colleges and with professional societies to stimulate interest in basic science. Dr. Johnson anticipated that FIC could catalyze these partnerships and funding opportunities. Dr. Moore suggested that FIC encourage and, possibly, host tours to U.S. community colleges, as a unique, affordable, and successful model of education. Dr. Claudio asked about support for administering award funds, and Dr. Johnson noted that the coordinating center will function in this regard and that applicants have to demonstrate that the approach they are proposing is sustainable.
Dr. Pablos-Méndez suggested that the initiative include labor economics research to evaluate the effects of MEPI in increasing the number of local health care workers and physicians in relation to demand for services and potential “brain drain” problems. Dr. Johnson said that, while the coordinating center could perform this function, the focus of MEPI is more on improving the quality of medical education, rather than achieving unspecified numerical targets. Dr. Glass commented on the comparatively high cost of placing American physicians in developing countries. He noted that the challenge is to “be smart” with the resources and long-term opportunities at hand. Dr. Pablos-Méndez noted that MEPI funding must be additional to the local funds available. In response to other questions, Dr. Johnson said that MEPI models could include a payback requirement and that synergies with partner institutions in other countries (e.g., in Europe) are encouraged.
The meeting was adjourned at 2:40 p.m. on May 11, 2010.