The John E. Fogarty International Center for Advanced Study in the Health Sciences (FIC) convened the seventy-fifth meeting of its Advisory Board on Tuesday, September 14, 2010, at 8:30 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 8:30 a.m. to 9:30 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 9:30 a.m. to adjournment at 2:45 p.m. Dr. Roger I. Glass, Director, FIC, presided. The Board roster is appended as Attachment 1.
VI. Introductory Remarks
Dr. Glass welcomed the following guests: Dr. Kevin De Cock, Director, Center for Global Health, Centers for Disease Control and Prevention (CDC); Dr. Al Bartlett, U.S. Agency for International Development Senior Advisor for Child Survival, Bureau for Global Health, U.S. Agency for International Development (USAID); Dr. Elaine K. Gallin, Senior Advisor, Office of the President, Doris Duke Charitable Foundation; Dr. Jill Conley, Director, International Programs, Howard Hughes Medical Institute; and Dr. Harrison C. Spencer, President and CEO, Association of Schools of Public Health. He asked FIC staff to introduce themselves.Dr. Glass welcomed three new Board members: Dr. Maria C. Freire, Dr. Derek Yach, and Dr. Adel Mahmoud (who was unable to attend the meeting).
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 in the past 4 months since the Board’s meeting in May 2010. He focused on FIC efforts to build productive partnerships internally within NIH and externally with other organizations and donors to address major global health issues.
Private Sector Partnerships. On June 17, Dr. Jean Pape, founding director of GHESKIO and one of FIC’s first grantees in the AIDS International Training and Research Program (AITRP), spoke at NIH on the rebuilding of research and training programs in Haiti in the aftermath of the recent earthquake disaster. On June 22–24, FIC sought new partnerships in maternal and newborn health while participating in the Pacific Health Summit, held in London, England, and sponsored by the Wellcome Trust, Bill & Melinda Gates Foundation, and other organizations. On June 22, NIH and the Wellcome Trust announced a partnership to support population-based genome studies in Africa.
NIH Collaborations. On June 30–July 2, FIC participated in the Diabetes Summit for Latin America, along with the National Institute of Diabetes, Digestive, and Kidney Diseases (NIDDK). The summit, held in Salvador de Bahia, Brazil, was organized by the World Diabetes Foundation. Dr. Glass mentioned that FIC will be working with NIDDK on a Mexico-U.S. border project to use mHealth technologies to link management, care, and treatment of diabetes across communities. In collaboration with the Office of the Director, NIH, and six institutes and centers (ICs), FIC recently awarded $7 million to combat chronic diseases in developing countries, through the new Chronic, Non-Communicable Diseases and Disorders Across the Lifespan: Fogarty International Research Training Award (NCD-LIFESPAN) program.
FIC Scholars and Fellows. Dr. Glass highlighted an orientation meeting for FIC scholars and fellows, held at NIH on July 18–20. The approximately 100 participants included some 35 predoctoral medical students and public health researchers, who are embarking on a year of mentored clinical research at a foreign training site, and 25 postdoctoral fellows and junior faculty from various specialties, who are conducting a year of research in low- and middle-income countries. Board members Dr. Sten Vermund and Dr. Peter Hotez attended as well. He noted that, with stimulus funds from the American Recovery and Reinvestment Act (ARRA), FIC will hold, on September 23–25, the first-ever symposium for alumni of the Fogarty International Clinical Research Scholars and Fellows (FICRS-F) program. Several hundred participants are expected. Dr. Francis Collins, Director, NIH, will address the group, and two alumni will speak at the IC Directors’ meeting on September 22. Dr. Glass noted that FIC scholars and fellows have come from a broad range of specialties and that the program has engaged seven NIH components. He invited Board members to participate in the weekend symposium. Dr. Vermund noted that ARRA funds are making this possible and that FIC will need to broker other funding to sponsor future symposia for alumni.
Fulbright–Fogarty Fellowships. Dr. Glass reported that, as an extension of the FIC scholars and fellows program, FIC is partnering with the Fulbright Program to launch a program of Fulbright–Fogarty Fellowships in Public Health to Sub-Saharan Africa, which will support an initial five U.S. predoctoral fellows in Fiscal Year (FY) 2011. The FIC will support orientation and placement, and the Fulbright Program will provide stipends to support scholars’ studies.
Universities and Schools of Public Health. On September 19–21, the second annual meeting of the Consortium of Universities for Global Health (CUGH) will be held at the University of Washington, Seattle. The CUGH has 42 university members and others are applying for membership. Dr. Glass noted that CUGH is supported in part by the FIC Framework Programs for Global Health (FRAME) grants to universities (currently 35) to foster cooperation on a global health agenda. The first CUGH meeting was held last September at NIH and drew approximately 150 attendees; the second meeting, which is expected to draw more than 600 attendees, will focus on “Transforming Global Health: The Interdisciplinary Power of Universities.”
On October 24-26, in New York City, FIC will have an opportunity to play a role in extending the constituency for global health when it participates in the first meeting of schools of public health to address the changing landscape of global public health. Columbia University and the Mailman School of Public Health are the hosts of this meeting, and it is attracting many interested donors and participants.
Building Research Capacity - Some Results. Dr. Glass highlighted FIC grantees’ co-authorship of four recently published research articles. He noted that 6 of the 12 co-authors of the “Effectiveness and Safety of Tenofovir Gel, an Antiretroviral Microbicide, for the Prevention of HIV Infection in Women” are FIC fellows and that this valuable landmark study is a result of FIC’s long-term investments in building research capacity. Dr. Glass noted that the spill-over effects of this investment are significant, as researchers collaborate with other entities on related research in neighboring countries and build South–South collaborations. Three additional articles further demonstrate FIC’s role in building research capacity in high-impact disease and geographic areas. They report on a comparison of antiretroviral (ART) treatments for adults in Haiti infected with HIV, antiretroviral regimens for pregnant and breast-feeding women in Botswana, and an increased incidence of human monkeypox in the Democratic Republic of Congo after cessation of vaccination campaigns for smallpox. Dr. Glass emphasized that the ability to train researchers in these settings is critical to building next-generation researchers in the field.
Medical Education. The FIC and Health Resources and Services Administration (HRSA) will soon announce the first awards under the Medical Education Partnership Initiative (MEPI), a partnership between the U.S. Department of Health and Human Services and the President’s Emergency Plan for AIDS Relief (PEPFAR) which is administered by FIC and HRSA. Dr. Glass noted that the aim is to develop centers of excellence in research and training to build research capacity in Sub-Saharan Africa. The awards will be the culmination of a process that began with the FIC–HRSA partnership meeting in November 2009 and included an expedited review by the FIC Advisory Board in early September. Dr. Michael Johnson, Deputy Director, FIC, said that FIC anticipates funding 11 programmatic awards, several linked awards, and one coordinating center.
Other Bilateral and International Partnerships. Dr. Glass highlighted two bilateral efforts, with Russia and China, in which FIC is responding to the Administration’s interest in building bridges to other countries through public–private partnerships. The FIC is participating in activities of the U.S.–Russia Bilateral Commission to stimulate private support for research collaborations in Russia, building on six ICs’ past bilateral efforts. Dr. Glass remarked that Board member Dr. Gail Cassell and Dr. Scott Campbell, Executive Director and CEO, Foundation for the National Institutes of Health (FNIH), have been instrumental in starting a public–private partnership to obtain funding. On September 23, the Russian Deputy Minister of Health will visit FIC and, on October 5, FIC will host a Russian delegation on non-communicable diseases. Other activities (e.g., videoconferences, clinical training course) are planned.
In response to interest expressed by the National Institute of Neurological Disorders and Stroke (NINDS), FIC is planning a meeting, in conjunction with NINDS and the National Heart, Lung, and Blood Institute (NHLBI), to address U.S.–China Hypertension Research: Past Success, Present Achievements, and Future Opportunities. The meeting will be held in Beijing, China, on October 13–14. Dr. Collins will attend and, subsequently, give the keynote address at annual scientific and board meetings of the Global Alliance for Chronic Disease, in Beijing, on October 15–17. Dr. Glass noted that Dr. Collins will have opportunity to speak with leaders of the medical research councils of the eight countries involved in the alliance and to meet with major donors to encourage partnership co-funding of NIH research on chronic diseases and parity of funding for projects involving Chinese investigators.
On October 28–29, FIC and NHLBI will host a meeting of the NHLBI Centers of Excellence Steering Committee, in Crystal City, Virginia. The NHLBI is providing $50 million to support 11 centers of excellence in developing countries in all world regions. Dr. Glass commented that many of the centers and countries overlap with those in which FIC and NIH have long supported research on infectious diseases and which are now, with NHLBI support, becoming centers for research on chronic diseases.
On November 1–2, FIC and National Institute of Allergy and Infectious Diseases (NIAID) will co-host a scientific conference on artemisin-resistant malaria, in Bethesda, Maryland. Dr. Glass noted the opportunity to engage with the Food and Drug Administration (FDA) in this area, and he referred the Board to Dr. Joel Bremen, Senior Scientific Advisor, Division of International Epidemiology and Population Studies, FIC, for further information on the meeting.
Partnership with FNIH. On November 8–10, FIC and FNIH once again partner to convene the mHealth Summit, in Washington, D.C. Attendance has grown from several hundred participants last year to an expected 3,000 this year. The summit will include keynote speakers from the administration, academia, and the private sector, as well as partnership and research meetings on the use of mobile global health technologies for diagnosing and treating diseases.
NIH and U.S. Global Health Initiatives. Dr. Glass said that FIC and the Office of the Director, NIH, are defining a more direct relationship for FIC in building a global health agenda for NIH. The FIC is linking directly with Dr. Collins, as for the China meetings (see above); supporting Dr. Collins in his role as chair of the Research Subcommittee of the Global Health Initiative (GHI); and engaging with ICs to address trans-NIH issues in global health. For October, FIC is planning another meeting of the G-8 steering committee on centers of excellence for research and training in maternal, neonatal, and child health, as follow up to the G-8 Summit in Muskoka, Canada. As set forth in Muskoka, the focus is on “training of medical personnel and on establishing stronger health innovation networks in Africa and other regions.” On December 2, NIH will host a meeting of the Heads of International Research Organizations (HIRO). On December 14, FIC and the National Institute of Dental and Craniofacial Research (NIDCR) will co-host the annual Barmes Lecture, which will be given this year by Dr. Rajiv Shah, Administrator, U.S. Agency for International Development (USAID).
Dr. Glass reported that U.S. Secretary of State Hillary Rodham Clinton will announce the formation of the Global Alliance for Clean Cookstoves on September 21 at the annual meeting of the Clinton Global Initiative, in New York City. This public–private partnership is led by the United Nations Foundation. In spring 2011, in partnership with the Department of State and other ICs, FIC will host a meeting to examine the role of cookstoves in disease, the state of art in cookstoves, and the potential for interventions. The burden of disease resulting from indoor use of cookstoves is huge, amounting to an estimated 2 million deaths a year, most among women and children Dr. Glass said that six ICs are supporting research on issues related to use of cookstoves (e.g., pollution, cancer, asthma, child health), which amounts to an annual NIH investment of approximately $5 million, and that NIH is interested in accessing private sector monies to expand research and interventions in this area through a public–private partnership. In conclusion, Dr. Glass noted that partnerships are key to FIC and NIH as their budgets for global health are likely to be stable in the near term. The FIC is working to engage as many partners as possible and to build partnerships with different ICs, foundations and other private sector organizations, other U.S. Government agencies, international organizations, and academia. Dr. Glass commended and thanked FIC staff for their action in moving the FIC agenda forward, and he invited Board members to participate in the upcoming meetings, which include several networking meetings for FIC grantees in October and November.
VIII. Update on FIC Activities Related to Public–Private Partnerships
Ms. Nalini Anand, Advisor, Public–Private Partnerships and Legislative Affairs, Division of International Science Policy, Planning, and Evaluation, FIC
Ms. Anand updated the Board on past and current FIC activities relating to public–private partnerships and previewed potential strategies for the future. She said that FIC intends to engage a subcommittee of the Board to help address substantive issues pertaining to future partnerships and that the subcommittee’s suggestions would be brought to the full Board at its meeting in February 2011.
Past Activities. Ms. Anand mentioned that FIC partnered with FNIH on several activities associated with FIC’s 40th anniversary. In addition, FNIH sponsored a speakers’ series on global health at NIH and a symposium on science diplomacy, held at George Washington University Law Center in Washington, D.C. With FIC, FNIH convened two meetings on global health and public–private partnerships, which focused on building research capacity and on implementation science and which brought together broad and diverse representation from the private sector. The FNIH and FIC sponsored the 2009 mHealth Summit and collaborated on strategic consultations concerning the future FIC Center for Global Health Studies. As mentioned by Dr. Glass, FIC participated in the Diabetes Summit for Latin America, working closely with the World Diabetes Foundation and NIDDK to formulate an agenda for the meeting.
Current Activities. Ms. Anand mentioned two activities already noted by Dr. Glass (see section VII above). The first is the framework for collaboration between the United States and Russia, established via a letter of intent signed by the NIH, U.S. National Academies of Science, and Russian Academy of Medical Sciences and involving the NIH Clinical Center, NIH Visiting Fellows Program, and FNIH. The second is FIC and FNIH sponsorship of the 2010 mHealth Summit. In addition, FIC is partnering with FNIH to manage the Global Network for the Study of Malnutrition and Enteric Diseases, a 5-year, multi-site research project funded by the Bill & Melinda Gates Foundation with a $30 million grant to FNIH.
Future Strategies. Ms. Anand said that FIC is at a crossroads in thinking about the best ways to stimulate public–private partnerships in global health. She posed several potential models for the Board’s consideration with FIC. These include (i) soliciting private funding and in-kind contributions to increase the resources available for existing FIC research and training programs, (ii) developing new initiatives with shared ownership, (iii) convening stakeholders to catalyze investments in priority areas, and (iv) leveraging resources through complementary investments by FIC, NIH, and partner organizations. Specific scientific areas of focus could be implementation science, information and communication technology, chronic disease, and research management and leadership training. Collaborations could take the form of short-term training institutes and workshops, policy fellowships, and integration of research into service-delivery programs.
As next steps, Ms. Anand said that FIC will continue to work with FNIH on current projects and to identify potential new areas of collaboration. Working with a subcommittee of the Board, FIC intends to identify priority areas for partnership, explore the most promising models for partnership, develop an overall framework for FIC’s partnership strategy, and develop concepts for particular projects.
Dr. Glass noted that public–private partnerships are a fertile ground for extending FIC’s work and that support from FNIH has been essential and critical to FIC’s obtaining additional funding and support. The Board addressed various topics, as summarized below.
In-Kind Contributions from Industry. Dr. Yach said that FIC’s intent to pursue such partnerships is exciting, and he emphasized that private sector dollars may not be as important as in-kind insights and contributions, such as specific skills or intellectual know-how. Dr. Pablos-Méndez agreed, saying that the research community has come a long way in accepting the private sector’s constructive role in contributing research and development (R&D) and products for public health and global health. He noted that a framework is needed to exploit industry’s motivation to contribute to the social good and that there is much opportunity for dialogue on possibilities beyond its contribution of R&D, products, and financing. Dr. Glass mentioned that CDC’s 3-month fellowship program for U.S. government personnel in developing countries could be extended to industry personnel who offer experience in, for example, information technology and marketing.
Transparency and Disclosure. Dr. Yach emphasized the need to revisit and upgrade the thinking on conflict of interest and perception of conflict of interest—to assure transparency and full disclosure in FIC and NIH programs over the long term. Dr. Reingold agreed, noting that this critical issue applies as well to FNIH funds.
Determinants of Success. Dr. Yach suggested that identifying the determinants of success of more-established public–private partnerships (e.g., the GAVI Alliance) may be useful. That is, are there lessons to be learned from these partnerships that could apply, for example, to partnerships in chronic disease? Dr. Freire noted the changing economic realities of today in which many more countries [e.g., Brazil, Russia, India, and China (the BRIC countries)] are “players” in global health. She emphasized that, to stimulate interest in partnerships and to underpin an agenda of increased support, real data are needed on expenditures in global health by countries (e.g., for R&D, basic science, training). She said that FIC is uniquely positioned to establish a baseline and the metrics for understanding current and future investments in global health—that is, who is funding what (e.g., research, training, content areas) and where (countries)? Ms. Anand contrasted the ability to measure the success of traditional private sector participation in global health (e.g., providing bednets, antiretroviral drugs) with that of building research capacity. She noted that the latter takes far more time (10–15 years), is more difficult to measure, and currently relies on a metric—number of publications—that is less than compelling for the private sector.
Dr. Vermund said that building off other examples of successful partnerships will be important. He suggested also looking at successful NIH experiences such as Cooperative Research and Development Agreements (CRADAs), a widely praised model of public–private partnerships involving industry. Dr. Glass mentioned the opportunity to involve private sector donors in international partnerships to co-fund research and training in countries such as China, in which many scientists and science leaders have received training at NIH or other U.S. institutions. Dr. De Cock highlighted productive research on tuberculosis, sexually transmitted diseases, and HIV conducted in South African gold mines. He noted that industry was motivated to participate in this research because it was of benefit to the workforce, and he suggested that, to be successful, partnerships need to link directly to populations and consumers. NIH/FIC Role. Dr. Black noted a delicate balance between NIH and FIC funding of others to do work versus FIC and NIH doing the work itself—for example, holding workshops, doing training. He questioned to what extent certain activities should be contracted out to universities and other organizations that traditionally have fulfilled these roles.
IX. CDC Global Health Plans and Priorities
Dr. Kevin M. De Cock, Director, Center for Global Health, CDC
Dr. De Cock described the organization and priorities of CDC’s Center for Global Health (CGH) and the interests of CDC in global health. He also commented on the synergy gained by deciding on collective action and on future directions for CGH.
CGH - Who We Are. Dr. De Cock noted that Dr. Thomas R. Frieden, director of CDC, has defined increasing global health impact as one of five priorities and that this is the first time a CDC director has explicitly said that global health is a core mandate for CDC. In synch with this priority, CDC created the new CGH which has four operating divisions to address, respectively, global HIV/AIDS, parasitic diseases and malaria, global disease detection and emergency response, and public health systems and workforce development. Dr. De Cock noted that CDC supports many other international activities outside of CGH.
Showing the Gapminder World Chart of 2006, Dr. De Cock commented on the close “ecologic” association between income and health across low-, middle-, and high-income countries. He noted that positive outliers, such as Cuba and Vietnam, pose interesting questions for development, public health, and research. He also noted that the United States is, by far, the largest contributor to global health funding, contributing, for example, 58 percent of HIV/AIDS monies globally. He suggested that, given this status, a key question is how to achieve the best impact of U.S. development, public health, and research efforts—each of which has a different role and focus in global health.
Global Health at CDC. Dr. De Cock mentioned three levels of CDC’s interest and effort in global health. First, CDC aims to increase capacity in global health; that is, the ability of countries to have effective surveillance, epidemiology, laboratories, etc. Activities include health systems strengthening, which, for CDC, relates to health information systems and surveillance, research for policy and program implementation, workforce development (particularly in epidemiology and public health), and laboratory capacity. Second, CDC aims to increase global health security; that is, the ability of countries to detect, confront, and contain health threats. The CDC partners with other U.S. agencies, ministries of health, and multilateral organizations to coordinate and strengthen the public health response to disease outbreaks and emergencies and supports implementation of international health regulations. Third, CDC aims to increase global health impact, to gain safer, longer, and healthier lives in more countries through, for example, collaborative efforts in malaria, immunization, and tuberculosis.
Dr. De Cock commented that CDC has become the world’s “reference laboratory,” a global public good and anchor for the world’s public health system. In this role, CDC can “shine a spotlight” on public health problems that otherwise would be unrecognized and undetected. Two recent examples are an epidemic of a complex seizure disorder, termed nodding disease, among children in northern Uganda and an extremely severe outbreak of lead poisoning in Zamfara state, Nigeria, which was related to artisanal gold mining and resulted in the death of up to 25 percent of children. Currently, CDC has deployed personnel and support to Pakistan in response to the major flooding there.
Synergy through Collective Action. Dr. De Cock displayed a world map depicting the extent and nature of CDC’s “global footprint.” He cited the example of the CDC Global AIDS Program, which extends to 41 countries, with staff deployed in almost 50 countries and seconded to international agencies as well. He highlighted the importance of CDC’s partnership with other U.S. Government agencies, including USAID and NIH, and the interaction of CGH with these partners, civil society, and bilateral and multilateral organizations. He noted that Dr. Frieden is encouraging CDC to define “winnable battles”; that is, things that CDC can do in the short term that show measurable impact.
CGH—Future Directions. Dr. De Cock elaborated on the GHI as an underpinning for CDC efforts to increase global health impact. He suggested that although special attention is being given to eight countries initially, the GHI can be viewed as an umbrella for U.S. Government-supported activities worldwide that have a health impact—which now involve more than 80 countries. He noted the GHI’s seven principles and the importance of GHI’s targets, or specific measurable outcomes, which track with Millennium Development Goals (MDGs). He lauded the broadening of the U.S. global health agenda from the disease-specific focus of the President’s Malaria Initiative (PMI) and PEPFAR to a focus on health systems strengthening, child survival, and maternal health, thus making the agenda more multilateral and aligned with the MDGs.
Dr. De Cock noted that, under the rubric of GHI, CCG will be working on the PMI, PEPFAR, child survival, and maternal health. In addition, CGH will continue its work on global disease detection and focus on three “winnable battles”—scaling up immunization (including polio eradication), eliminating lymphatic filariasis, and scaling up efforts in non-communicable diseases (particularly atherogenic cardiovascular disease and hypertension, respiratory diseases, some cancers, diabetes, and injuries, especially road-traffic injuries). As part of CDC, CGH will focus on surveillance, data gathering, and research to inform decision-making and policy changes.
Dr. Glass and the Board complimented Dr. De Cock on his presentation. Dr. Glass commented that FIC seeks to work with CDC on common agendas in global health. He noted that the two organizations work through ministries and universities, often in the same countries, and share interests in and opportunities for training, biomedical and behavioral research, and public health, epidemiology, and metrics. In discussion, the Board members suggested the following areas and examples for partnership between FIC and CGH.
Implementation Science. Dr. Stanton highlighted the science of implementation as one area of potentially great overlap between FIC and CGH. Dr. De Cock noted that it is critically important and that CDC has a credible track record in implementation science (i.e., operational and applied research, public health evaluations), but has yet to exploit potential partnerships and synergy. He noted the tremendous opportunity and need for partnerships among CDC, NIH, and academia—for example, on how best to use ARTs for prevention, treatment, and care of HIV/AIDS. Dr. Stanton noted that this example is an excellent one and suggests a niche for FIC in implementation efforts. Dr. De Cock commented that CDC offers sizeable country-based assets and personnel placed in countries and agencies for the long term.
Dr. Glass noted that implementation science is critically needed to assess the timing and success of different HIV/AIDS interventions (e.g., microbicides, tenofovir, circumcision, ARTs). Dr. Vermund emphasized the need for another small, replication trial to confirm the effectiveness of a specific microbicide product, and Dr. De Cock argued for pursuing this research in broader context. Dr. Glass suggested that FIC and CDC could host small meetings to reach agreement on best interventions and approaches to implement and then promote the findings through the GHI to gain broad commitment from the U.S. agencies involved.
Dr. Hotez called for better integration of major GHI efforts, noting that tuberculosis, malaria, and HIV/AIDS often occur together, not in isolation. He suggested that CDC and FIC could play a critical role in exploring links among these widespread diseases geographically and providing guidance on implementation of appropriate interventions.
Dr. Yach said that the truly neglected diseases are non-communicable diseases and that attention should be focused on interventions that could begin immediately. In particular, simple assessments of risk factors for chronic disease could readily be included in current, well-financed infectious disease programs. Two obvious targets are smoking (building on CDC’s global youth tobacco survey) and blood pressure (e.g., in relation to tuberculosis). He noted that, for non-communicable diseases, having the data is often the most powerful intervention for stimulating action.
U.S. Funding of Global Health. Dr. Spencer suggested that CDC and FIC could take a leadership role in analyzing the funding streams for global health activities horizontally across agencies.
Sustainability through Training and Financing. Dr. Glass highlighted the need to ensure that GHI targets not only are met, but also are sustainable. To achieve sustainability, targets must include in-country training of local personnel (e.g., in surveillance and intervention), an effort that FIC and CDC could work on together. Dr. Bartlett agreed that this function and role are important. Dr. De Cock encouraged far more discussion of the concept of sustainability, saying that technical sustainability can be achieved by FIC and CDC, but long-term global financing is needed to sustain global health. Innovative financing methods need to be explored and could include use of very small levies on global transactions (e.g., currency exchanges, cell-phone calls), which would generate, with little notice individually, large amounts of money.
Explaining the Determinants of Health. Referring to the Gapminder bubblegram, Dr. Bartlett commented on the need to understand critical determinants for helping countries to move up vertically in (i.e., improve their) public health. He asked whether FIC should have a role in this aspect of implementation—explaining the variability in health at different levels of economic development. Dr. De Cock said that economic development is an essential contributor among the determinants and, historically, has done more for health than have many other individual actions. Dr. Glass noted two other important contributors—education of women and gender parity. Dr. De Cock remarked that the GHI must achieve a synergistic and collaborative understanding of the roles of economic development and public health as contributors to populations’ health status. Dr. Yach said that interventions to overcome the “resource curse” or improve women’s education, two critical determinants, are not within the mandate of CDC or NIH, but the two agencies could present data to stimulate public discourse on the issue.
Research on Strengthening Health Systems. Dr. Pablo-Méndez noted the need for knowledge and evidence on health systems and ways to make these systems more tractable to assure sustainability of health gains over time. He encouraged NIH to address the need for this research within the GHI. Dr. De Cock agreed, drawing an analogy between social determinants of health influencing individuals’ health in a country and social determinants of global health influencing global responses of health systems.
X. Progress and Priorities in Maternal, Newborn, and Child Health
Dr. Christopher Murray, Institute Director, Institute for Health Metrics and Evaluation (IHME), University of Washington, Seattle
Dr. Alan E. Guttmacher, Director, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), NIH
Dr. Murray addressed the global agenda for maternal and child health, a key quantifiable endpoint in the MDGs for 2015 and a priority of the GHI. Dr. Guttmacher presented an overview of NICHD’s global health activities and its process for developing a scientific vision to guide the institute over the next decade.
Progress in Child and Maternal Mortality
Dr. Murray described progress on MDG 4 (child mortality) and MDG 5 (maternal mortality). He presented data detailed in the report entitled Building Momentum, Global Progress toward Reducing Maternal and Child Mortality (IHME, 2010), and he referred the Board to IHME’s systematic analysis of maternal mortality for 181 countries that was published in The Lancet in May 2010 (vol. 375, no. 9726). He noted that measuring child and maternal mortality requires synthesizing data from many sources and dealing with large data gaps.
Child Mortality. Dr. Murray said that estimation of levels and trends in child mortality has improved as a result of new surveys released in 2007, new and more accurate methods for analyzing summary birth histories and synthesizing data, and better modeling strategies and data for assessing neonatal, post-neonatal, and childhood mortality. He noted that, unlike for other health outcomes, the database on child mortality is so rich (amounting to more than 16,000 measurements at different ages across countries) that levels and trends can now be interpreted meaningfully.
Dr. Murray summarized the data, which show substantial progress in reducing child mortality globally, along with marked variations among countries and regions. From 1970 to 2010, the number of deaths of under-5 children globally declined 50 percent. The trend in neonatal mortality rates over the same period is similar, but remains substantially higher than for post-neonatal or childhood mortality and varies dramatically by region. Annual rates of decline for under-5 children from 1990 to 2010 show a huge variation among countries, ranging from less than 1 percent to more than 5 percent, with some as high as 8 percent. Dr. Murray noted that these data indicate that child mortality rates can decline rapidly and that the pace of decline does not correlate with a country’s starting level. From 1990 to 2010, the rates of decline for neonatal, post-neonatal, childhood, and under-5 mortality varied markedly by region.
Comparison of rates of declines for under-5 children in the 1990s and 2000s suggests accelerated progress, to an approximately 4 percent decline annually, in certain regions—Central Asia, Eastern Europe, and East Asia. Dr. Murray noted that among the potential “distal” drivers of this increased rate of decline, increased schooling of women of reproductive age appears to account for approximately 50 percent of the change in child deaths (or about 2 million children) during this period. A decrease of about 450,000 child deaths is attributable to increased family income, while an increase of approximately 350,000 child deaths is attributable to HIV/AIDS.
In response to Board members’ questions about women’s schooling, Dr. Murray said that data on the effects of educational attainment will be published shortly in The Lancet (see vol. 376, no. 9745, September 18, 2010). He noted that many low-income countries that have invested in primary school education are realizing a flattening of child death rates in 6 years—a finding that suggests the need to consider substantial, expanded investments in secondary school education as a health intervention. He also noted that the effects of educational attainment of women (e.g., reduced fertility rates) on other health outcomes have yet to be explored.
Maternal Mortality. Dr. Murray said that, as with child mortality data, there are now substantial opportunities to obtain better measurements of maternal mortality owing to methodological advances—improved methods for analyzing sibling histories, processing of data on cause of death, and assessment of completeness of vital registration systems. Even so, the density of data is far less than that for child mortality, and the data have to be scrutinized and synthesized to generate a time series on maternal mortality.
Dr. Murray summarized data on trends in maternal deaths globally, which show a slower decline than trends in child deaths and, similar to child mortality, substantial variation among countries and regions. From 1980 to 2010, maternal deaths declined from more than 500,000 to the mid-300,000s, a decline that would have been even greater (to about 280,000) without the HIV/AIDS epidemic. Comparison of maternal mortality rates across countries and regions shows an enormous range, from less than 15 to more than 1,500 per 100,000 births, with consistent progress in the Middle East and Latin America. Annualized rates of decline for maternal mortality from 1990 to 2008 show consistent, spectacular progress in the Middle East and less dramatic, but sustained, progress in China and India, with rates much lower in India than those published previously by the World Health Organization (WHO).
Dr. Murray noted that the results, though unexpected, are not surprising. He suggested several “drivers” for the reduction in maternal deaths to approximately 342,000 globally in 2008. These include a drop in total fertility rate globally, from 3.70 in 1980 to 2.56 in 2008; rising income per capita, particularly in Asia and Latin America; increased maternal education (e.g., average years of schooling for women aged 25–44 in Sub-Saharan Africa rose from 1.5 years in 1980 to 4.4 years in 2008); and a steady, slow rise in skilled birth-attendance coverage.
Measurement of Health Indicators. Dr. Murray commented on the roles of academia and science in improving the measurement of health indicators. He noted that, over the past 30 years, academia has played an increasing role in analyzing key health indicators. The shift from states and multinational organizations collecting statistics to scientists in academic institutions performing causal analyses and producing descriptive measurements has been accelerated by the development of innovative methods fueled by low-cost computational power.
Four important factors for improving health measurements in the future are: development of innovative tools and instruments (e.g., survey methods); building of capacity to collect, process, and archive data; setting norms and standards for health indicators; and analysis of data. Dr. Murray noted the roles of academia, donors, governments, and multilateral organizations in these areas. For example, each and all contributors will have different roles in capacity building; WHO has a clear role in setting norms and standards; and academia will play lead roles in developing innovative instruments and analyzing data.
Dr. Murray responded to several questions concerning the data he presented. He noted that IHME is concluding a systematic analysis of contraception, which indicates, for example, that prevalence of contraception is a driver (similar to fertility rates) for maternal mortality rates. He agreed that public health interventions are likely to have a large effect on mortality rates, but noted that these effects may be difficult to ascertain. He called for more and improved data collection on maternal mortality, because the density of data for establishing causal relationships is sparse, and for improved measurement to capture current data (i.e., past 2–3 years) on child mortality.
Dr. Guttmacher stated that NICHD is the focal point at NIH for research on maternal and child health. The institute both supports a plurality of research in this area and catalyzes research conducted by other ICs and other organizations. The NICHD also supports research on reproductive health and human development and is the IC responsible for research on rehabilitation medicine. Dr. Guttmacher remarked that NICHD has worked closely and productively with FIC over the years and hopes to build on this cooperation.
Global Health Activities. Dr. Guttmacher presented four areas of activity, highlighting selected examples of NICHD efforts. He noted that FIC staff are intimately involved in many of these efforts.
The first, broad area of activity is international partnerships and research networks—through which NICHD engages with many partners, including other ICs and U.S. agencies, governments, professional associations, pharmaceutical businesses, multinational organizations, and non-governmental organizations. A major effort in this area is the NICHD Global Network for Women’s and Children’s Health Research. This global network involves U.S. clinical research mentors and teams at seven sites in Africa, Asia, and South, and Central America. The aim is to reduce maternal and child mortality and morbidity by developing evidence-based, cost-effective, sustainable interventions. Dr. Guttmacher noted that the global network has had many successes, which include demonstrating the effectiveness of oral misoprosotol in preventing postpartum hemorrhage, in India, and reducing the rate of stillbirths by 30 percent through basic training of birth attendants. Building on the latter trial, entitled “First Breath,” NICHD is collaborating with other organizations to develop new training materials and equipment for neonatal resuscitation and will participate in the WHO roll out, “Helping Babies Breathe.” Currently, the global network is conducting a trial of a package of emergency obstetric and neonatal care interventions in communities. Other ongoing projects of the global network include collection of registry data on maternal and neonatal deaths, a trial of antenatal steroids to reduce mortality among preterm/low-birthweight infants, a trial of the use of dried meat vs. fortified cereal to improve growth and neurodevelopment outcomes in poor communities in Asia and Africa, and mental health research and administration training in Pakistan and Afghanistan.
Other examples include a public–private partnership entitled Biomarkers of Nutrition for Development (BOND) through which NICHD supports a targeted research agenda to discover, develop, and use new biomarkers of nutrient exposure, status, and effect. This effort includes creation of an interactive information technology resource to support evidence-based decisions by users. In the Prenatal Alcohol and SIDS and Stillbirth (PASS) Network, NICHD and the National Institute of Alcohol Abuse and Alcoholism (NIAAA) support a prospective study of 12,000 pregnant women and their infants to investigate the impact of alcohol consumption in populations with a high prevalence of prenatal alcohol exposure. Dr. Guttmacher noted that, with Indian scientists specifically, NICHD supports collaborative research on contraception and reproduction and on maternal child health and human development. In addition, NICHD is participating in the Global Alliance for Clean Cookstoves, within which the global network will support a study in India of the health impact of indoor air pollution on pregnant women and children. In two other global partnerships—the Paediatric Medicines Regulators Network and the Global Research in Pediatrics Network—NICHD is a founding partner.
The second area of activity is HIV/AIDS. Dr. Guttmacher highlighted NICHD funding of a joint trial with NIAID of 8,000 mother/infant pairs in several PEPFAR countries to compare ART prevention approaches for mother-to-child transmission and to determine how to optimize the health and survival of infants exposed to HIV and the health of mothers after cessation of breastfeeding. The NICHD also supports studies to determine the optimal ART for infants who become infected despite their mothers’ receiving ART prophylaxis.
The third area of activity is building global capacity. The NICHD funds, for example, seven partnerships between U.S. research institutions and institutions in Botswana, China, Indonesia, Kenya, Uganda, and Vietnam to provide research infrastructure support, train junior in-country researchers, and support culturally relevant HIV-related research. Along with FIC and NIAID, NICHD supports the International Extramural Associates Research Development Award (IEARDA) program, to build capacity and infrastructure for research administration. India and seven countries in Sub-Saharan Africa currently benefit from this program. Dr. Guttmacher noted that this program is being merged with a domestic version to become a new Biomedical/Biobehavioral Research Administration and Development Award (BRADA) program, with first awards to be funded in FY 2012.
The fourth area of activity is the NICHD intramural program. Like at other ICs, NICHD intramural laboratories support a variety of training programs for foreign scientists; intramural protocols for clinical trials draw foreign patients from across the continents; and intramural investigators conduct vaccine research to combat various pathogens, many of which are endemic in developing countries.
NICHD’s Scientific Vision: The Next Decade. Dr. Guttmacher reviewed the process NICHD will undergo over the next year to develop a scientific vision that sets an ambitious and realistic agenda for addressing the most promising scientific opportunities across the institute’s mission for the next decade. He emphasized that the process will be conducted in collaboration with the NICHD external research community and partners, all of which will have ample opportunity to participate through workshops and Web-based media. The aim is to be inclusive and to engage as many diverse groups as possible. Beginning in October 2010 and continuing through March 2011, NICHD will convene a series of nine theme-based workshops to gather broad input. Dr. Guttmacher said that global health, along with training and mentoring, are two of many cross-cutting elements that will be addressed across the workshops. He presented the list of workshops and organizing committee members, and he invited the Board members to participate in the meetings and to identify others who might be interested as well.
Dr. Guttmacher noted that white papers will be developed from each workshop and will be made available for public comment on the NICHD Web site (www.nichd.nih.gov/vision). Then, in April 2011, NICHD will synthesize the white papers into a draft scientific vision and, in May, NICHD will convene a large, multidisciplinary science meeting to shape the vision further. In June, the NICHD Council will refine the vision statement, which staff will then finalize in July and August. The target date for publication in a major journal is December 2011. The NICHD will disseminate the vision through presentations and other events during the winter months and will incorporate it into the celebration of NICHD’s 50th birthday in 2012–2013.
Dr. Glass asked the Board to suggest areas in which interactions and partnerships between FIC and NICHD would have the greatest impact. The Board suggested the following.
Vaccine Development. Dr. Hotez commented on the impact of NICHD research on vaccines and noted that the institute continues to play a critical role in vaccine development intramurally and extramurally. Dr. Guttmacher agreed, saying that much of NICHD’s impact in the United States and globally has been through vaccine development and that NICHD continues to support this research.
Determinants of Health. Dr. Hotez suggested that an important niche area for FIC would be to tease apart the driving factors for reductions in child mortality (as mentioned by Dr. Murray above). Dr. Guttmacher commented that this research is hugely important and would yield the evidence needed to take action.
HIV/AIDS – Implementation Science. Dr. Vermund remarked that HIV/AIDS remains a highly conspicuous problem in countries such as Mozambique and Zambia and, although efficacy issues associated with therapy are largely resolved, the remaining looming issue is how to manage coverage to recruit more women into antenatal service, break down community stigma, and improve health systems. He noted that this type of outcomes research or implementation science has not been a focal point for NICHD. Dr. Guttmacher said that NICHD is interested in implementation science and, like other ICs, needs to play a large role in this area. Dr. Vermund commented that the NICHD “First Breath” initiative and package of emergency obstetric and neonatal services are examples of implementation science. Dr. Stanton commended NICHD on taking an aggressive role in designing and co-funding the recent NIH initiative in implementation science on HIV/AIDS, and she suggested that NICHD could work with FIC to identify established scientists from developing countries who could to serve on NIH review committees.
Large-Scale, Multi-Country Trials. Dr. Black suggested collaborations between FIC and other donors (foundations, the private sector) to support large, multi-country trials, such as the Global Alliance for Clean Cookstoves, to assess the effectiveness of various interventions. He noted the need for leadership and management of such efforts. Dr. Guttmacher said that, increasingly, NIH is looking for these kinds of collaborations and that each partner brings different strengths “to the table.” Referring to the cookstove initiative as an example, Dr. Bartlett commented that there is clear and substantial evidence of the health risks of indoor pollution from cookstoves, but that strong evidence is needed before moving forward with a specific intervention. In this regard, he commended NIH involvement in the GHI because it adds a research focus to the GHI. Dr. Bill Martin, Associate Director for Prevention, NICHD, said that technology to reduce emissions from cookstoves is now available and that the question is how to bring this technology to scale. Dr. Glass noted that a public–private partnership could develop and supply cookstoves with reduced emissions, and Dr. Martin said that formation of these partnerships is an aim of the United Nations Foundation in leading the Global Alliance.
Childhood Antecedents of Adult Disease. Dr. Bartlett raised the possibility of establishing a network of high-quality laboratories across the world that could use innovative technologies, such as microfluidic diagnostics, to identify population-based childhood determinants of health outcomes (e.g., adult disease). Dr. Guttmacher surmised that the microfluidic diagnostics could be a useful research tool, along with a number of others (e.g., genome or exome sequencing, biomarkers of early disease), to study childhood antecedents of adult disease. He suggested that, within 10 years, many new tools will be understood better and scaling up their use for this research will be economically feasible.
Bioethics and Ethics in International Research. A participant commented that FIC and NICHD have worked together on international bioethics and that this collaboration deserves closer attention insofar as NICHD addresses the most vulnerable populations (i.e., children and mothers) and FIC is the obvious NIH international partner. Dr. Glass mentioned that the Trans-NIH Global Health Research Working Group will address the bioethics of international research in its discussions of clinical trials. He suggested that approximately 40 percent of the NIH investment in bioethics research comes through FIC, and he encouraged NICHD engagement in this area. The NICHD is one of five ICs collaborating in the FIC’s International Research Ethics Education and Curriculum Development Award (Bioethics) program.
MDG Follow-up. Dr. Glass asked for specific advice on how better to achieve the MDG goals for maternal and child health, in preparation for the United Nations’ summit on MDGs, to be held September 20–22 in New York. Dr. Murray suggested that FIC could encourage comparative case-study research combining qualitative and quantitative methods, for example, to better understand discrepancies in the progress on maternal and child health among countries. Dr. Guttmacher cited the need for more research in collaboration with non-governmental organizations to develop evidence on key factors effecting reductions in maternal and child mortality rates. Dr. De Cock said that discussion is needed of a vision, informed by research and science, for work after the MDG target date is reached in 2015. Dr. Glass thanked everyone for participating in the meeting. He welcomed suggestions from the Board and others on topics to be addressed at the next Board meeting. Dr. Glass encouraged Board members to participate in upcoming FIC activities and to contribute to agenda items.
CDC Role in Maternal and Child Health. Dr. De Cock commented that CDC does not have an agenda for maternal and child health per se, but is cognizant of the need for one. Possible areas of interest and interactions include prevention of mother-to-child transmission of HIV/AIDS, vaccine development, pneumonia, diarrhea, and neonatal mortality.
The meeting was adjourned at 2:45 p.m. on September 14, 2010.
1. Members absent themselves from the meeting when the Board discusses applications from their own institutions or when a conflict of interest might occur. The procedure applies only to individual applications discussed, not to en bloc actions.