The John E. Fogarty International center for Advanced Study in the Health Sciences (FIC) convened the seventy-sixth meeting of its Advisory Board on Monday, February 7, 2011 at 9:00 a.m., in the Conference Room of the Lawton Chiles International House, National Institutes of Health (NIH), Bethesda, Maryland. The closed session was held on February 7 from XXXXXXXX, as provided in Sections 552(b)(4) and 552(b)(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. The meeting was open to the public on February 8, 2011 at 9:00 a.m., until adjournment at 2:50 p.m. Dr. Roger I. Glass, Director, FIC, presided. The Board roster is appended as Attachment 1.
Director’s Update and Discussion of Current and Planned FIC Activities
Dr. Roger I. Glass, Director, FIC
Dr. Glass called the meeting to order and welcomed those present. He commented that, in addition to being Fogarty International Center Director, he was Associate Director of International Research at NIH, a position that has become increasingly important since NIH Director Dr. Francis Collins established his focus on global health. That emphasis has resulted in a significant increase in activities for the Center.
Transitions
Since the last meeting a number of new ex officio members have been appointed, including Dr. Alan Guttmacher, Director of NICHD, Susan Shurin, acting director of NHLBI and Dr. Kevin DeCock, director of the CDC Center for Global Health Centers.
Dr. Glass recognized Dr. Guttmacher, who was described in a Lancet article as a visionary leader of developmental research, and who is developing the NICHD global health strategy. He also noted that Dr. Robert Black, FIC Board member, was awarded the Prince Mahidol Award for 2011 in recognition of his zinc supplementation studies.
Transitions at Fogarty include the award of a Fulbright scholarship to Dr. Joshua Rosenthal, who will take a leave of absence to work on ecology in Argentina; and the appointment of Dr. Duane Alexander and Dr. Joel Breman as Senior Scientists Emeriti. Both recently retired after distinguished careers at NIH. Mr. Timothy Tosten has moved to CSR after serving as Fogarty Executive Officer for more than three years. Finally, Dr. Glass announced that Mr. Steve Goldstein had left the world of journalism and joined the FIC communications group, and that Dr. Karen Hofman had returned from a sabbatical in Africa working on the Disease Control Priority Project, to resume her position as director of DISSPE.
Board Meetings
Dr. Glass announced the dates of future Board meetings, noting that the date of the next meeting May had been changed:
- May 25-26, 2011
- September 12-13, 2011
- February 6-7, 2012
- May 14-15, 2012
- September 10-11, 2912
Overview of Fogarty International Center Operations and Activities
FIC EXTRAMURAL PROGRAM FUNDING. Dr. Glass commented on the exceptional rise in funding during the last two years, mainly attributed to co-funding with partners, which now accounts for about half of the Fogarty extramural program funding. Appropriated funding has risen only slightly in the last several years, except for ARRA funding which boosted funding available to Fogarty and the partners, including OGAC, HRSA, CDC and others.
FIC STRATEGIC PLAN. Recalling the effort to develop a strategic plan for Fogarty, which began shortly after he arrived as director, Dr. Glass noted that a number of concepts emerged for consideration as the plan developed. The first was summed up in the phrase “early childhood education,” and it implied identifying young students in the early stages of their education and providing an international experience that might guide their careers into international health. A second was a focus on improving international centers of excellence to enable them to provide education and research opportunities as a contribution to training future leaders. The third was an emphasis on the importance of “twinning” between U.S. and foreign institutions to nurture a bilateral approach to research and education. The fourth was for Fogarty to become a leader in building partnerships and supporting collaborations, and the fifth concept was to support increased funding for global health initiatives.
As the plan was finally developed, the following key goals were defined:
- To train the next generation of U.S. and foreign global health researchers;
- To build sustainable capacity for global health research in the developing world;
- To advance implementation science;
- To continue to support infectious disease research, but additionally increase support for research in the non-communicable diseases, and even for other areas of health research - bioengineering, health economics, health journalism, ethics and business practices that impact health care;
- To partner with other U.S. agencies to increase involvement in global health; and
- To strengthen institutional capacity through twinning programs and research collaborations.
ACTIVITIES SINCE LAST BOARD MEETING. Turning to activities since the last Board meeting, Dr. Glass mentioned the use of ARRA funds to integrate information and communications technology into Fogarty programs, including 54 grants and awards in the developing world that were targeted at long-distance learning, infrastructure, modeling, mHealth and the development of IC tools.
The first scholars and fellows alumni conference was held on September 24-26 and over 200 alumni participated. They had been involved in Fogarty programs during the last six years and were enthusiastic about talking about how those experiences had changed their lives.
Dr. Glass stated with regret that for the first time a Fogarty fellow died while actively engaged in an HIV-AIDS project in Uganda. He was killed in a vehicular accident. It underscored the importance of safety and security when Fogarty fellows are working in foreign countries. An award is being established to recognize outstanding Fogarty Scholars and to remember Sajul Parikh and to emphasize the dangers that may be associated with international travel.
Fogarty was involved with the mHealth Summit held in October. Dr. Glass described one of the applications that was presented at the Summit, a device developed by a group of students at the MIT Media Lab. The device attaches to a cell phone and allows refraction of an individual’s eye, which provides the basis for a prescription for eyeglasses. The device only costs a few dollars and the National Eye Institute has agreed to validate the device, after which a field application can be developed. A similar field test project supported by the Carlos Slim Foundation is a glucometer that can be used by a community nurse to identify diabetics who have insulin management problems. Fogarty facilitated a partnership with the Diabetes Institute and the Institute of Bioimaging and Bioengineering to pursue future development of the test device.
The James B. Herrick symposium held on November 16-17 focused on sickle cell anemia in developing countries which affects, for example, 2% of newborns in Ghana, most of whom will die before age three, compared to life expectancies of over 50 years for children with the same condition in the U.S. In another area, Thai researchers have had long-term NIH support for research on thalassemia, a serious problem in that area of the world. They are now interested in developing research partnerships in Laos, Cambodia, Myanmar and Vietnam. Fogarty can play a role in supporting that effort.
Dr. Glass described several upcoming conferences, including the David E. Barnes Global Health Lecture (February 15) at which Rajiv Shah will speak; a conversation with Lord Nigel Crisp, former head of the National Health Service, UK, on February 24; and on March 21-22, the NIH Fourth Annual Conference on Science of Dissemination and Implementation Policy and Practice.
Dr. Glass commented that as NIH Director, Dr. Collins, had developed a significant interest in global health and Fogarty has played a role in supporting that interest, particularly in facilitating international travel. Dr. Collins visited China in October, taking part in the Global Alliance for Chronic Disease and the U.S-China meeting on hypertension and stroke (stroke being the number one cause of death in China). He visited the Chinese health ministries and their national academies, and recently the first joint RFA was released in English and Chinese that will jointly fund research in several disease areas. There is also an indication that the Chinese will partially support U.S. postdoctoral fellows and scholars in their studies in China.
Finally, in December, Fogarty hosted a meeting of the Heads of Biomedical Research Organizations (HIRO) - all of the G7 countries and the Institute Pasteur, Wellcome Institute and the European Developing Counties Clinical Trials Program. A web site was conceived out of that meeting that visually plots the research investments each of the members of the HIRO have in all of the African countries. As the web site is populated with more and more data, it will be possible to click on any site and see details about specific grants that are active at that site. This availability of data should improve the potential for synergistic partnering.
NIH DIRECTOR TO VISIT AFRICA. Dr. Glass noted that Dr. Collins will be going to Africa in March to help launch the Human Heredity and Health in Africa (H3) program, which involves a number of NIH institutes. He also plans to open the Medical Education Partnership Initiative (MEPI) conference in Johannesburg. Finally, in consonance with Dr. Collins’ focus on global health, there are several activities on the agenda involving health research in Russia, beginning with a meeting in April that may lead to a forum on health research that could be a product of a partnership between Fogarty and the Foundation for the NIH. There are seven ICs that have active programs in Russia and, although there is no funding set aside for the effort, it is hoped that the first meeting of the U.S.-Russia Health Research Forum held in November will begin to stimulate funding and begin to bridge the gap that has existed between the two research communities.
CLEAN COOKSTOVE INITIATIVE. Dr. Glass discussed the State Department’s Clinton Health Initiative on clean cook stoves and indoor air pollution. Fogarty was asked to assess NIH investments in this area and it was determined that the NIH devotes about $5 million a year to research relating to indoor air pollution, but that there are few studies that provide scientific evidence as to what research questions should be pursued in that area. A forum in late spring is planned to address the issue with CDC, NIH, USAID and NSF participating.
BUILDING 16 RENOVATION. Dr. Glass mentioned that the Center for Global Health Studies will be housed in Building 16, adjacent to the Stone House, which is being renovated for that purpose and for the purpose of serving as a think tank/conference center for the consideration of global health policy as an integral part of NIH. Nalini Anand is heading that project to completion and will report on progress at the next Board meeting. Among other activities on campus, Dr. Glass mentioned the course on global health offered to NIH employees, now in its second year. It is headed by Linda Kupfer, who is working to have videoconferences with investigators in the field and perhaps a lecture series.
COMMUNICATIONS OUTREACH. Offering two quotes - “Fogarty is the best kept secret in global health,” and “We are better known in Africa than in the US,” -- Dr. Glass underscored the importance of an effective communications strategy. He stated that the new communications group will be working to change those quotes. There was a comment that the web site had improved significantly in the last year. Dr. Puderbaugh acknowledged the compliment and noted that a new web manager had been on board for about a year. She added that a completely new web site would be launched within a few months. It will be easier to navigate and will offer simpler access to data about grants.
PUBLIC-PRIVATE AND INTERAGENCY PARTNERSHIPS. Finally, Dr. Glass briefly discussed the Fogarty effort to develop public-private partnerships, which will be on the agenda for discussion at the next Board meeting. The Global Health Initiative Research Working Group, co-chaired by ex officio Board members Dr. DeCock and Ms. Levine, and supported by the NIH Director, has been looking at where NIH should invest in future research, and the Trans-NIH Working Group has been working on several issues. One subcommittee, the International Health Research Database has focused on identifying NIH investments in global health, which are not easy to parse out from the various data available from the institutes, mainly because each institute has its own method for monitoring activities. The Clinical Trials Subcommittee is addressing the issue of harmonization with European researchers, and the Communications Subcommittee is working on improving communication on global health activities and relating achievements both across ICs and the public.
Dr. Glass invited discussion.
Discussion
Dr. Black observed that implementation science was an appropriate high priority for Fogarty and wondered what the best approaches would be to move the science forward. Dr. Glass offered two examples. The first, the collaboration between Fogarty and USAID in the Helping Babies Breathe program was intended to bring both training and equipment into the field to increase infant survival under respiratory stress conditions. It was the effort of two individuals at NICHD and USAID to facilitate a partnership with a manufacturer of resuscitation devices and American Academy of Pediatrics. The second example was the CAPRISA microbiocide trial in South Africa which involved an NIAID field site, PEPFAR funding, and included a number of Fogarty grantees, including the principal investigator. Both involved unselfish cooperation by those who created the projects.
Dr. Black agreed that the projects were good examples of implementation science, but expressed concern that delivering NIH research products to a program may require follow-up to ensure that the implementation continues. Dr. Guttmacher concurred that in the case of the Helping Babies Breathe, which was really a pilot project, there would have to be a scale-up element that would be part of the implementation science effort. Dr. Hotez recommended a meeting with Dr. Michael Kremer, a Harvard economist, who is working with USAID on developing innovative projects. Part of his effort includes looking at implementation science.
Dr. Michael Johnson commented that, although the projects mentioned as examples of implementation science were good illustrations, they were idiosyncratic and a way to apply an implementation process in a systematic way to any project has not been developed. He added that USAID is considering adding an incentive to each grant to encourage grantees to develop processes to improve collaboration with USAID missions.
Dr. Vermund commented that strengthening the link between training initiatives and centers of excellence should be a part of the Fogarty grant process. He noted that such a link existed in the very productive International Maternal and Child Health Research Training program, and that it served to motivate the grantees to remain in research as a career.
Noting that the U.S. public does not appear to be enthusiastic about sending research dollars abroad, Dr. Stanton wondered if Fogarty had experienced resistance to its programs at the political level, and whether or not Fogarty could be an influence in educating the public about the importance of such research funding. Dr. Glass responded that Fogarty certainly had anecdotes about the experiences of grantees that would be useful in such an effort, experiences that would illustrate the importance of global health investments. For example, the New York Times featured an article on a study of Alzheimer’s disease in a small, unique population in Colombia that is predominantly descended from a family who arrived there in 1745. The following generations of that family expressed a specific mutation that led to early Alzheimer’s and a National Institute on Aging study is looking at biomarkers of the disease in this population. Dr. Freire commented that in the study, which could contribute to the science of Alzheimer’s, it is equally important to clarify that there is benefit to the subjects in the study, and that they are collaborators in the research as well as patients.
Dr. Hotez suggested that two messages might be needed, one for the global health community and another for the U.S. public. For the former, Fogarty’s unique focus on training would be appropriate, which is important to capacity building. Dr. Reingold noted that CDC is also involved in training and that there are opportunities there for collaboration with Fogarty.
Dr. Bremen agreed that implementation science is actually more about social science. The factors that make implementation science work include the intervention itself and access to the intervention, compliance by both the health care providers and the patients. The sticking points to successful implementation science are the latter two involving compliance. More than the research product and the practical intervention, it really has to do with logistics, management and incentives.
Dr. DeCock agreed that implementation science was a broad concept that should be defined - it can range from an application specifically tied to a research project to a more global component of social systems and health sciences research. He added that the Global Health Initiative (GHI) was also not well defined, with little clarity as to the research agenda or to the funding that would be provided for that research. The research agenda could range from specific interventions to a broad health system research approach. The infrastructure of the GHI is also very broad and perhaps in need of coordination -- PEPFAR is managed separately and has its own funding, NIH is traditionally associated with the academic community, CDC is more involved with the ministries of health and multinational organizations, and the ministries of health in the various nations tend to be conservative and, in fact, sometimes old-fashioned and separated from cutting edge science.
The Sub-Saharan African Medical School Study (SAMSS)
Dr. Fitzhugh Mullan, Murdoch Head Professor of Medicine and Health Policy George Washington School of Public Health
Dr. Mullan described the genesis of the sub-Saharan African Medical School Study, when the Gates Foundation was involved with setting up a program called Human Resources for Health (HRH), addressing issues related to workforce and education, particularly in Africa. Although it was launched with support from the Gates Foundation, because the Foundation redirected its interests away from human resources related education, the program ended and there was the opportunity to explore other areas of interest in Africa. There were a number of possibilities - medical education, including postgraduate medical education, non-physician clinician, nurse education, community health worker education. Ultimately the Foundation agreed to support a study of traditional medical education in Africa, which became the Sub-Saharan African Medical School Study (SAMSS).
The program began two years ago and it was clear at the outset that there was a dearth of knowledge about medical education in Africa. It is a huge and diverse continent in terms of political and governmental institutions, funding mechanisms, and cultures, with a medical school profile that is widely varied.
Dr. Mullan discussed the structure of SAMSS and the flow of activity that results in final recommendations. The Secretariat is composed mainly of associates at George Washington University, who form the managerial arm of SAMSS, working closely with the Advisory Committee, chaired by Dr. Francis Omaswa, Executive Director of the African Centre for Global Health and Social Transformation (ACHEST) and former Executive Director of the World Health Organization Global Health Workforce Alliance (GHWA). The Advisory Committee is mainly composed of members of the African medical and human resources communities.
Although it would have been a good approach to conduct a survey as Abraham Flexner did at the turn of the century in the U.S., there was no transportation infrastructure that would allow a visit to the majority of medical schools. Therefore, the Secretariat selected ten schools that would be visited by a site visit team that would conduct interviews and an in depth inspection of facilities. Having learned that there were an estimated 103 medical schools in Africa (it turned out that more than 168 were identified), there was a decision to attempt a survey of the schools to begin to build a knowledge base.
Dr. Mullan explained that the site visits would be conducted by members of the Advisory Committee, formed into small teams. Each team consisted of two members of the Secretariat from George Washington University and two members of the Advisory Committee. The Committee was composed of six at-large members from the health and human resources community, and one member from each of the ten medical schools that would be visited (either the dean of the school or a senior administrator).
It was clear that medical educators had a very limited awareness of medical schools outside of their own countries and, although there had been two attempts to create an organization that would bring the educators together there was no such organization, no medical journals and no effective networking between countries.
The 168 medical schools identified were geographically plotted and it revealed that the largest number of schools were in Nigeria and the Sudan. Four countries did not have a single medical school - Cape Verde, Lesotho, Swaziland and Sao Tome and Principe. Dr. Mullan mentioned one school in the Sudan, in Al Gezira, which was a community-based school established in 1997, whose graduates have retained the community-based philosophy in their practice of medicine. The school has been a positive influence for other schools.
Describing the SAMSS process, Dr. Mullan explained that the Secretariat performed a literature search, reviewed 642 abstracts, and conducted about 50 interviews with key informants, to arrive at the selection of the ten schools to visit. The schools included University of Gezira, Jimma University, Makerere University, Hubert Kairuki Medical University, University of Malawi, Catholic University (Mozambique), UFR Sciences, University of Ibadan, Walter Sisilu University and a university in Mali. There were two private schools; the rest were public.
Once selected the Advisory Committee was established and site visits scheduled. The individuals on each site visit would develop a list of about ten key findings, both positive and negative, before leaving the site. The findings from the ten sites were consolidated into a list of findings from which the final recommendations were developed. A survey was sent to all schools and 146 responded, a 72% response rate, which suggests the result could be considered valid. Under contract, the University of Pretoria administered the survey. The Secretariat felt it would have been better received if it came from an African institution. The George Washington support was in the form of analysis and statistical backup. There was a financial incentive to complete the survey. Many returned the survey with some questions unanswered. The survey served as a basis for a more in depth survey that will be sent to the MEPI schools. There will also be a financial incentive to complete the MEPI survey.
Dr. Mullan described some of the findings from the site visits and the survey. The data showed few new school start-ups until a brief spurt in the sixties. Then there was little activity until 1990 when new school openings significantly increased. For the first time private schools began to appear, now making up about a third of the new schools opened in the last 20 years. These private schools include for profit, non-profit secular and a few non-profit faith-based schools. Although about 22% of new schools are private, because the public schools are large and have been established longer, the private school student population is probably about 5% to 10% of total medical students. Public schools are supported mainly by government funding and tuition is generally lower than tuition in private schools.
Although data was generated projecting out migration of graduates, such that about a third leave the country to practice abroad (22%) or in other African countries(6%), the data is not reliable because only a few schools have any tracking system at all. Nonetheless, it is important for workforce projections that a reliable tracking system be developed. Part of the MEPI program will be to see if such a tracking program can be developed, but Dr. Mullan commented that relying on active alumni associations would probably be more effective than trying to develop governmental programs. Data is more reliable for teaching and staff loss, with about a third of those who leave moving out of the country and more than two thirds being enticed to other opportunities within the country (government service, NGOs, private practice). The remainder is mainly retirees and a small percentage who leave for miscellaneous reasons.
Dr. Mullan commented that involvement in research is a more complicated picture but that about half of the schools are able to engage only about 20% of faculty in research. In terms of partnerships with other countries, about three-quarters of the schools have agreements with institutions in Europe and the U.S., and with various international organizations. About a quarter of the schools have affiliated with other African countries and a few with countries in Asia, the Middle East, Australia and South America,
The Advisory Committee and the Secretariat developed ten recommendations from the findings:
- Grow faculty capability. No surprise to anyone involved, faculty shortages are everywhere. There are opportunities for U.S. medical educators and scientists to contribute by supporting twinning and partnering efforts, which will be an integral part of MEPI. One imaginative approach might be a U.S. “health corps.” One dean stated that a valuable contribution would be for a specialist to contribute as little as two weeks as a visiting faculty member.
- Build medical education infrastructure. Infrastructure almost everywhere needs improvement, including the student’s main complaint that dormitories are woefully inadequate. But the need extends to labs, libraries, IT and even provision of computers.
- Support MOH-MOE coordination. Medical schools are funded by ministries of education, and ministries of health are the consumers of the medical school output of physicians. There is little communication between the two and very little joint planning.
- Fund research. Funding for research is needed to improve the opportunities for faculty to participate in research.
- Promote primary care education. The U.S. model is to train specialists, but in Africa the primary care, family medicine physician is most needed, and that training process is at various stages in the various countries.
- Expand GME. Expanding graduate medical education, postdoctoral work, serves to keep graduates in country during the important early stage of a physician’s career development. A successful example is the Ghana Board of Specialties, which certifies specialists, including family practitioners, which encourages increased retention of doctors within the country.
- Align medical education with national needs. When national needs are well characterized the development of a national plan is facilitated.
- Recognize private medical school contributions. Although there are mixed feelings about whether there should be a private medical school structure in some counties, the fact is they exist and it would be appropriate to consider including them in the medical education process.
- Expand accreditation and certification. Both accreditation and certification are slowly developing in many African countries and its development should be supported.
- Revitalize an African medical school association. There is a fledgling medical school association that needs to be supported. MEPI will also be an organization of medical educators who should have an influence on education, but who may also develop a political influence.
Dr. Mullan showed photographs to describe a medical school in Mali with a first year class of probably 2,000 students sitting in a large, hot, poorly ventilated lecture hall, with those in the rear of the room struggling to hear and take notes. As a francophone school, admission is open to everyone, but of the 2,000 only about 350 will reach the second year. The dorm rooms in the Mali school, designed for four students, house up to eight. A school with a thousand or more students may have a computer lab with only 50 computers. Most students do not own laptop computers.
In contrast, Dr. Mullan described the Medical Board of Sudan that administers computer-based certification exams in a well-equipped computer lab, drawing on students from 29 medical schools. Although there is variation among those schools, one must be certified to practice medicine in the country, perhaps a sign of the future.
Discussion
Noting that funding of research was one of the ten goals, Dr. Reingold asked whether there was a capacity to do research since it seemed that in many of the institutions that capacity was very limited. Dr. Mullan agreed that, although there are some schools that have a history of NIH funding and have developed some research capability, there are many whose labs are far below standards. He added that one of the ten school visited had declared research as a priority and planned to require students to write theses as a qualification for graduation. That would perforce provide the students with a research experience. However, there may be a significant lack of qualified faculty to mentor these students.
Dr. Mullan mentioned that this issue was on the MEPI agenda, but that the primary objective of MEPI is to develop educational capabilities and the assumption that creating a research foundation will inevitably lead to improved educational capabilities is not necessarily valid.
Recalling the earlier mention of the Flexner report, Dr. Hotez commented that it was written with a gold standard in mind, specifically Johns Hopkins Medical School. He wondered if the site visits revealed any such gold standard schools in Africa. Dr. Mullan noted that the University of Cape Town was well established as a research institution on the model of a successful U.S. research university. However, he added that Africa may not need such schools now and that focusing on producing large numbers of qualified medical practitioners whose interests lie in the domestic health area is more important. Those graduates may have an interest in research, but should also be interested in service, policy and education. He added that the school at Al Gezira was a good model - a mature school of 30 years having graduates return as faculty, remain in the country as practitioners, and join the local and national health ministries.
Dr. DeCock questioned whether a single approach would apply to a continent so diverse. He added that there are examples of twinning experience that might be helpful - the longstanding association between the University of Nairobi and the University of Washington is a successful example. There was recently Gates Foundation funding for several twinning programs that were to last for ten years, but were ended when the Gates Foundation redirected its interest away from education. Finally, there were collaborations with sufficient funding that actually produced a number of products, but they lacked focus and it was difficult to evaluate the real outcome of the twinning experience. He noted that the MEPI would try to focus the participating schools so that the programs are limited, specific and the outcomes measureable.
Finally, he noted that, as important as networking is to Africa, one of the major impediments is lack of funding to support the significant travel involved. He recalled that the African medical school association had been tried in the 1960s, met twice and disappeared. Later, in the 1990s, there was a second effort supported by WHO/AFRO that also met only once or twice. Dr. DeCock suggested that it would take outside money for as much as five years to support the build and support a viable association. Perhaps then there would be enough resources for education that such an association could survive.
Dr. Stanton mentioned that the American Board of Pediatrics Foundation has supported a number of groups in Africa, South America and Europe to come together and determine what components of postgraduate training should be assembled that would lead to international certification. The process has been going on for more than a year. She asked if a similar effort would be appropriate for the undergraduate training level. Dr. DeCock responded that there is a West African College of Physicians and Surgeons that has been using a version of the British Professional and Linguistics Assessments Board criteria, which may not be working as well as intended. He cautioned against superimposing developed world standards for accreditation and certification on a countries in Africa. He offered the example of the Educational Commission for Foreign Medical Graduates that uses the United States Medical Licensing Examination for accreditation and certification. Developing a curriculum in Africa designed to help students pass that exam may not be the best approach to accreditation and certification.
Dr. Harford commented on continuing medical education, which is important to staying abreast of scientific developments in medicine, questioning whether or not such CME was going on in sub-Saharan Africa. Dr. Mullan commented that the survey did ask about licensure requirements, which turns out be quite varied, and there is no indication that there is any follow-up once a license has been granted. Again, tracking is costly and difficult and there is very little tracking information about CME.
Cook Stove Initiative
Dr. William Martin
Dr. Martin stated that, in early 2010, an international concern for the billions of people exposed to indoor air pollution around the world was spotlighted when the Global Alliance for Clean Cookstoves was established as a public-private partnership. The Alliance is managed by the UN Foundation, which has set an initial goal of providing 100 million clean cookstoves to underdeveloped countries by 2020.
The U.S. announced support for the Alliance through an announcement by Secretary of State Hillary Clinton in September 2010, at a function sponsored by the Clinton Global Initiative. Dr. Martin noted that 3 billion in the world are exposed to indoor air pollution, and nearly 2 million die annually from its effects - acute pneumonia in children under five, COPD and lung cancer mainly in adult women. NIH will lead a federal government-wide workshop on the state of the science regarding indoor air pollution. The State Department will support travel for 30 international representatives. The objective of the workshop is to identify a research agenda to support the efforts of the Global Alliance. Dr. Glass added that at least seven NIH ICs are involved.
Human Heredity and Health in Africa (H3 Africa)
Dr. Charles Rotimi, Director of the Center for Research on Genomics and Global Health, NHGRI, NIH
By way of laying a foundation for his interest and his part in the Human Heredity and Health, H3 Africa, program, Dr. Rotimi mentioned that he was born and raised in Nigeria, studied biochemistry at the University of Benin, dealt with recurring malaria that in those days was treated with chloroquine, all of which contributed to his awareness of infectious diseases in Africa. After graduate work in the U.S., he returned to Africa and has done research in several countries, including Kenya, Nigeria, Ghana, Ethiopia and Cameroon. He added that he was president of the African Society of Human Genetics, which was formed to provide a forum for researchers in Africa interested in genetics. It meets annually, this year in Cape Town. The African Society, concerned that, like various revolutions in agriculture, IT and others, the genomic revolution might pass Africa by, established what was originally called the African Genome Project.
Dr. Rotimi said that Drs. Collins and Guttmacher, then at the Genome Institute, published an article in 2003 using the metaphor of a house with the Human Genome Project as the foundation and floors dedicated to the benefits of genomics to biology, human health, and society in general. Dr. Rotimi stated that the African Society of Human Genomics was concerned than that there would be a room in that house for African scientists to work. There was also concern that as genomics advanced the development of pharmaceuticals that incentives would not exist to include the neglected diseases that are present in Africa. He pointed to a specific example, podoconiosis, caused mainly in agrarian workers who work barefooted in very fine sands that invade the skin and have a cytotoxic effect causing extreme swelling of tissue. There is evidence that there is a genetic component related to susceptibility that is part of the etiology of the disease.
In 2007, before he was associated with NIH, Dr. Collins agreed to speak at an African Society meeting in Cairo, and communication was continued after that meeting. There was also contact with the Wellcome Trust, and in 2009 the African Society convened a meeting that included a number of interest groups to discuss genetic and genomic research in Africa. Out of that a working group was established to pursue the issue. Application was made for funding to the Common Fund, which was approved, and the Common Diseases in Africa Project (the first name chosen for H3 Africa) was begun. The Common Fund provided initial planning funding, and $5 million a year for five years. The Wellcome Trust added another $12 million. To reflect the much broader vision of the project, the name was finally changed to Human Heredity and Health (H3 Africa).
Dr. Rotimi explained that two working groups were formed; one for communicable diseases and one for non-communicable diseases, and the membership of both groups was predominantly African scientists. The charge to the working groups was to identify genomic research and large biomedical studies being conducted on the continent with the purpose of developing a strategy for H3 Africa. The working groups developed a white paper on the subject which is now available on the H3 Africa web site for public comment. It will be formally adopted at the upcoming H3 Africa meeting in Cape Town.
Dr. Rotimi stated that the published vision of H3 Africa is:
To create and support a pan-continental network of laboratories that will be equipped to apply leading-edge research to the study of the complex interplay between environmental and genetic factors which determines disease susceptibility and drug responses in African populations.
Data generated from this effort will inform strategies to address health inequity and ultimately lead to health benefit in Africa.
Part of that vision is to establish a network of clinical centers, a network of research laboratories, and to build the necessary infrastructure to support the centers and labs. One way to judge the success of that effort would be to see H3 Africa investigators publishing articles in leading journals as first author. Dr. Rotimi said that particular objective came out of an inquiry he made to scientific journals at the very beginnings of H3 Africa. He asked how many African investigators had been lead authors on articles published - the answer was, probably none.
Dr. Rotimi offered a visual presentation of the conceptual framework of H3 Africa, which revealed the significant fact that African scientists don’t really talk to each other. The lines of communication go from African institutions to institutions in the U.S. and Europe, but not between countries in Africa. If scientists in Africa do not begin to interact, they will remain isolated, which stifles exchange of ideas. Hopefully, H3 Africa will change that, and change the fact that, for the most part, African scientists have become clinicians who implement, and not scientists who conduct research.
Dr. Rotimi explained that the working groups developed recommendations. At the top of the list was improved infrastructure, a daunting challenge in part because of the heterogeneity of the country. Solutions that work in South Africa for example, just do no apply to many of the smaller countries. Secondly, a database is needed that includes information on everything going on in the African research community - genomics research, identification of resources, including hardware, software, biobanks and so on. Dr. Rotimi stated that effective genomics research requires biorepositories. There are very few in Africa, and most of those are small labs with limited storage facilities. There must also be an extensive bioinformatics infrastructure, fed by multiple labs providing genotyping, phenotyping and sequencing data derived from multiple clinical centers relying on a standard protocol.
The working groups recommended a number of diseases that should be included on the research agenda, most of which do not receive significant funding like HIV/AIDS and malaria. In the communicable disease group the working groups identified tuberculosis, human African trypanosomiasis and certain cancers caused by infections. The non-communicable diseases included sickle cell disease, hypertension/stroke (a leading cause of death), type 2 diabetes, and cancer (there is a very high rate of breast cancer in women). Finally, H3 Africa should include pharmacogenomics on its research agenda.
Dr. Rotimi concluded the list of recommendations with training and education. There should be enhancement of mentoring programs and a focus on training for a purpose, and more than just acquisition of knowledge. There should be an element that looks at how and where that knowledge will be used by the individual being trained. That alone should contribute to greater retention of researchers.
Dr. Rotimi closed by noting the revolutionary importance of cell phones, which have freed the people from reliance on government landline infrastructure that may or may not be installed as promised and may or may work once installed. He suggested that technology often has unexpected benefits for the individual, in this case a political consequence.
Discussion
Dr. Freire asked about the impact of repositories - integration with other repositories, the infrastructure required, the ultimate use and users. Dr. Rotimi commented that H3 Africa has assured African scientists that they will be the owners of the data, that it will reside in African repositories, and that there will be regional repositories that may also be specialized in the kinds of samples collected. For example, there are some in existence now - Kenya has a fairly significant agricultural/livestock repository. Properly developed repositories may also encourage the sharing of data, which is often a stumbling block to a scientist’s willingness to contribute data.
Dr. Reingold asked whether H3 Africa had addressed the retention issue in its considerations and recommendations. Dr. Rotimi admitted there was no specific policy or recommendation with regard to retention, but he added that the development of centers of excellence would provide a fertile environment for young scientists, especially if there was a mechanism to support them in the long-term as well as the short-term.
Dr. DeCock expressed concern that the cell phone example belied the importance of government in the larger requirements of society - public health, disease surveillance, support of universities, and so on. He wondered if certain countries should be prioritized in terms of the H3 Africa programs. Dr. Rotimi responded that it could be fruitful to focus on certain countries in Africa that are stable and provide appropriate support for those countries. He added that it is important not to not to succumb to an exclusivity that ignores people in need who are in countries that are less stable. Finally, Dr. Rotimi expressed a philosophical view that the major threat to African health is bad government, which is really beyond the control most of the health-related programs in Africa.
Dr. Chockalingam remarked that NHLBI had begun to fund centers of excellence in developing countries, funding the centers by grants to the governments. Dr. Rotimi commented that a number of NIH ICs have similar projects in Africa, but that in a country so diverse some effort at coordinating such projects would be helpful.
Finally, Dr. Singer asked about ownership of data and how data would be made available to researchers, especially since Western scientists would become interested in the data if the repositories became very large. Dr. Rotimi agreed, adding that scientists from Africa and a number of non-African countries are involved in discussion about ownership and availability of data. One model is the U.S. system that restricts availability of data for a period of time (nine months) so that the researcher has time to produce and publish a paper. If the same system were adopted in Africa, because of delays in working through the process of producing a paper, that time period would have to be two or three times as long. One factor is the difficulty of working with a very unreliable and slow Internet.
Medical Education Partnership Initiative (MEPI)
Dr. Michael Johnson, Deputy Director, FIC, NIH
Dr. Letitia Robinson, Program Officer for sub-Saharan Africa, FIC, NIH
Dr. Olufunmilayo “Funmi” Olopade, Director, Center for Clinical Cancer Genetics and Global Health, Walter L. Palmer Distinguished Service Professor of Medicine and Associate Dean for Global Health, University of Chicago
Dr. Glass commented that Fogarty has traditionally been involved in training and research in sub-Saharan Africa, but that the Medical Education Partnership Initiative (MEPI), which has its focus on medical education, is a new area of interest, and a new direction. The MEPI partnership, put together by the NIH Director’s Office, involves Fogarty, PEPFAR, HRSA, other NIH ICs in a major new initiative that will extend over the next five years. As individuals interested in MEPI, Dr. Glass welcomed Dr. Olopade, who will soon become a member of the Board, and Dr. Jack Whitescarver, director of the Office of AIDS Research, who has been a significant supporter of Fogarty partnership in the past, including the foundational phase of MEPI.
Dr. Johnson added that Ambassador Eric Goosby, U.S. Global AIDS Coordinator and head of PEPFAR, stepped up to develop a vision for medical and nursing education in sub-Saharan Africa, including providing significant support for the MEPI. The initiative is in part a response to an Institute of Medicine recommendation that PEPFAR should extend its programs to include sustainability and to incorporate a long-term perspective, which this five-year program has.
Dr. Johnson stated that, as the new NIH Director, Dr. Collins added his tangible contribution with Common Fund support to expand the reach of the program beyond AIDS research. WHO is also establishing a parallel program to promote guidelines for transformative medical education. Dr. Johnson invited Dr. Robinson to describe the Initiative.
Dr. Robinson explained that MEPI is a partnership that includes PEPFAR, Fogarty, HRSA, and several NIH ICs. Ambassador Goosby considered MEPI supportive of the PEPFAR mandate to increase the number of health care professionals in Africa by 140,000 and, although the primary mission of MEPI is to focus on medical education, in doing so it will contribute to the PEPFAR objective as well.
MEPI will directly contribute to a number African medical education institutions to strengthen clinical and research capacity. An RFA was published in March 2010, for submission in May of that year. Over 60 applications were received and 13 institutions were selected. The majority of funding, which amounts to $130 million over five years, is provided by PEPFAR ($105 million) with additional funding from the Common Fund ($25 million) and individual contributions to certain projects by several NIH ICs.
Dr. Robinson described three types of awards under MEPI. The largest is a programmatic award that can include up to $2 million for up to five years. Eleven medical schools received this award as a result of the RFP. The linked awards are supported by funds from the NIH Common Fund and cover areas of education other than those focusing on AIDS. Six African institutions received support of up to $500,000 for up to five years, and two pilot studies were funded at $250,000 a year. Finally, a coordinating center award was granted to a U.S. institution (George Washington University School of Public Health) to provide technical assistance, manage the web-based platform that will available to all grantees, and to provide funds for coordinating monitoring and evaluation. The responsibility for the coordinating center will be transferred to an African partner by the end of the five-year period. At present the Coordinating Center has an African partner, the African Center for Global Health and Social Transformation in Uganda.
Dr. Robinson explained that, although there were only 13 grants awarded, some of the grantee institutions have developed partnerships with other institutions so that more than 30 institutions are associated with MEPI. Four universities have taken the lead in developing such partners, accounting for 17 of the total 30 regional partners (Addis Ababa, Eduardio Mondlane, Makerere and Ibadan). And some grantees have also developed links with their respective ministries of health which improves opportunities for identifying decentralized sites and community-based learning opportunities. Finally, there are more than 20 U.S. institutions collaborating with the grantees, providing technical advice and assistance in getting the programs going.
Dr. Robinson commented that when the grantees were asked about including multidisciplinary components in their programs it was clear that the programs would extend beyond just medical education. Responses showed that 80% planned to include community-based education and rural training; 70% would focus on tuberculosis and malaria in addition to HIV/AIDS; 75% indicated their programs would integrate nursing education (some included pharmacy and dentistry); 64% planned to offer public health education; and all of the grantees will include a significant internet capability and/or focus on mHealth and distance learning.
Going beyond the PEPFAR priority areas of HIV/AIDS, tuberculosis and malaria, three grantees plan to become involved in maternal and child health, one in mental health, one in cancer (specifically related to AIDS), two in cardiovascular disease, one in emergency medicine and one in surgery. Dr. Johnson interjected that the Office of Research in Women’s Health had participated in the development of MEPI, both by providing intellectual input and some funding.
Dr. Robinson noted that a requirement of each programmatic award is to set aside 5% of the total award to build research and grants administration capacity and to build research support centers, both of which are important to sustainability when and if the grant support ends in five years.
Dr. Robinson stated that the Coordinating Center would encourage MEPI grantees to create effective networks (only four have begun working on multi-institution networks). There are also opportunities for tie-ins to existing U.S.-funded programs - CDC’s Field Epidemiology and Laboratory Training Program (FELTP), DoD military training programs at African universities, HRSA’s - Nursing Education Partnership Initiative (NEPI), and USAID programs, including Capacity Plus, Human Resources Alliance for Africa (HRAA), etc. There are also NIH cross-over initiatives with objectives compatible with the MEPI program.
Discussion
Dr. Johnson invited comments. Dr. Whitescarver stated that the Office of AIDS Research (OAR) is responsible for NIH international AIDS activities, which are conducted in partnership with Fogarty. As a global effort other countries must build capacity, and MEPI is a program that is in consonance with that objective. One important aspect of MEPI is the inclusion of training in comorbidities of AIDS, often related to antiretroviral treatment - cardiovascular disease, certain malignancies and others. He noted that the emphasis on networking was very important, adding that Lancet cited a paper on an OAR study of microbicides, a bilateral international effort, that was possible because of such networking.
Dr. Whitescarver commented that the coming pressure on budgets will increase competition for new program funding, and he stated that it was very important that the MEPI program remain secure in its funding in order to move the global health research agenda forward. He added that at the Conference on Retrovirus and Opportunistic Infections this year an initiative would be announced that will seek to find a cure for AIDS. It will be supported by a number of partners - NIH, the Gates Foundation, the European Union and others. Medical training, such as that being contemplated by the MEPI, will be important to that initiative.
Dr. Olopade commented that she had attended medical school in Nigeria, a school that was associated with University College London, an early partnership in medical education that resulted in a medical system based on British medicine. There was a focus on research that ended when a military coup resulted in most of the faculty leaving the country. The medical education infrastructure deteriorated and the out migration of talent continued into the nineties. She noted that there was a time before the coup when there was stability and the medical university system was functioning that Africa contributed significantly to scientific discovery. She felt that to return to that level of contribution, a systems approach must be developed at the medical school level, and MEPI could be the beginning of that effort.
Dr. Olopade commented that, while banking and technology in Africa have begun to be more independent, medical education continues to rely on donor support. She noted that in Nigeria, because the universities are dependent on the government, governance of the university has become an issue. Because of support from the MacArthur Foundation and others, the schools have begun to develop some level of autonomy and are amenable to accepting outside counsel on how to best spend that donor support.
Asked about the role of the diaspora physicians from Nigeria, Dr. Olopade stated that she had been able to invite seven faculty members from the University of Ibadan to accept visiting positions at the University of Chicago. There are Nigerian faulty at most large universities in the U.S. who could do the same. Valuable knowledge is returned to Nigeria as a result of such temporary commitments. She added that when Prime Minister Tony Blair was head of the G-8 he sent an envoy to talk to members of the U.S. diaspora and the envoy concluded that the support Africans in the diaspora sent home to family was a major factor in preserving many parts of Africa. In addition, the MacArthur Foundation’s Nigeria Higher Education Foundation was established in the U.S. to provide support for four universities, from contributions from alumni and others in the U.S. who support the Foundation. One outcome has been that all four universities have established alumni organizations which will establish continuing support for the school among the alumni association members. Another group is the Association of Nigerian Physicians in the Americas that has established a neonatal initiative in Nigeria. Finally, Dr. Olopade commented that he class held a 30th reunion and raised $100,000 to support technology in medical education.
Finally, Dr. Olopade mentioned the development of private enterprise in Nigeria, exported from the U.S. A cardiology group from North Carolina set up a facility in Nigeria to provide cardiac surgery. As a middle class develops in a country, able to pay for medical services, the private practice model will become more prevalent.
Dr. Glass commented that by funding the African institution directly there was an opportunity for the institution to direct funds to support travel for U.S. diaspora physicians to visit the institution. That would be an extremely cost-efficient way to obtain training from well-qualified individuals.
Dr. Johnson invited general comments and questions and Dr. Freire began the discussion by asking whether MEPI had a specific component that would seek to bring health services to areas outside the high population urban centers, perhaps by working with the various ministers of health? Dr. Robinson affirmed that moving health care providers into the rural areas is a significant objective of MEPI, and there are already associations being developed with ministers of health to help identify rural areas where the program can encourage medical practice. Dr. Mullan commented that the RFP included capacity development, retention and regionally relevant research. None of the MEPI RFA proposals were sufficiently definitive about these areas of research, so there is an effort now to help the grantees produce programs more focused on these three important areas. Capacity building is relatively straightforward, although admittedly expensive. Retention is more difficult to define because it involves keeping physicians in country (when they stay they tend to settle where they were educated, where the technology is and where the money is), but it also involves creating a distribution of health care resources within the country. There are serious obstacles to inducing physicians to move into areas where there are few, sometimes no amenities. The challenge is to introduce concepts of primary care that are undergirded with motivation based on community service and even patriotism.
Dr. Olopade commented that the University of Ibadan always included community and social medicine in its curriculum, emphasizing primary, secondary and tertiary care. After the coup those academic structures crumbled. Now the Ministry of Health has built medical centers and requires a period of national service of all newly graduated physicians. Since there are few senior physicians to mentor these fledgling doctors, sending them to distant assignments may involve a risk to patients simply based on inexperience in the profession.
Dr. Johnson commented that the MEPI grants really represent an experiment to test a number of interesting models that the ministers of health in the various countries might take advantage of in terms of replicating those that are successful.
Noting that the education part of MEPI will probably cover primary, secondary and tertiary care, Dr. Black recommended that research cover a span of interest from the sophisticated basic research level through translational and implementation science, and that proposals for research should originate not only in university laboratories, but in environments at the service level even in rural areas. He asked whether MEPI had a mechanism to insure that spectrum of research.
Dr. Bridbord responded that the research agenda was a work in progress and that the Coordinating Center was in discussions with various institutions about extending the research effort into other areas, such as non-communicable diseases. Dr. Glass added that the grantee institutions will be very identifiable on the research map of Africa and they could serve to attract other programs that may be searching for direction, perhaps bringing resources together with partnerships in research with others from Europe and Asia. Dr. Johnson added that the MEPI was a novel approach that funds the African institution directly and anticipates that partnerships will be initiated by that institution, a change in the culture of grants that may take some effort to realize.
Dr. Stanton commented that the goals expressed thus far are daunting - expecting African institutions to develop collaborations with other institutions not associated with MEPI, training practitioners to go into the rural areas. She questioned whether the goals were actually achievable in a five-year period. Dr. Mullan conceded that, after initial discussions with the grantees, it is evident that a number of the projects will exceed their grasp, and with others that issue is not yet clear. One step has been to ask the grantees to plot by function each component of their proposals with a commentary on how they will accomplish each function. The project should have quantifiable outcomes so that a metric can be established to monitor progress throughout the period. That should provide a document that will allow some negotiation with regard to each project to make it more practical and more capable of completion in the given timeframe. Each program will be reviewed annually. At this stage the reception to the idea has been good, but it will take time to see if the revisions necessary to accomplish each goal will be enthusiastically accepted.
Pointing to the lack of interest in working in rural areas that may even lack plumbing, Dr. Reingold asked if MEPI included training of village health workers and, if so, was there consideration to encourage physicians to provide such training? Dr. Johnson commented that training village health care workers is not part of MEPI’s mission, which is to focus on medical education. PEPFAR has a mandate to train 140,000 health care providers of all types, and there are initiatives in CDC, USAID and other federal agencies to support that objective. Nonetheless, there may be peripheral benefits to MEPI that could contribute to PEPFAR’s goal.
Dr. DeCock commented that the U.S. is so dominant in promoting global health that MEPI should be considered as an integral part of that process, and that it should not only support the PEPFAR objectives, but should be consonant with the Global Health Initiative. Therefore, MEPI needs to keep in mind the importance of training the other health care cadres. He also expressed the opinion that, although five years is not a long period of time to realize some goals of MEPI, the federal government is usually faithful to its commitments and often will extend support when a program is clearly successful.
Dr. Vermund stated that in his PEPFAR-supported work the focus has been on non-physician training, including training nurses and pharmacy techs. He felt that MEPI was an acknowledgment that support for medical education was overdue in Africa, and that to allow the neglect of medical education to continue would result in an impoverished physician pool, which in itself would be poorly trained. Although in many areas of Africa doctors are basically irrelevant, since most health care is delivered by non-physicians, there are other areas where doctors are very relevant but are in short supply. Dr. Black agreed that, although MEPI is not concerned with non-physician training, the research arm of the program could address the delivery of services and efficient and effective utilization of physicians, which could provide ideas on how to address rural health care delivery.
Considering the fact that MEPI’s mission includes both research and training, Dr. Vermund asked whether the NIH funding, which is usually restricted to research, would be used exclusively for research? He added that if training (capacity building) is the primary goal, rather than sustainability based on scientific output (research), that would influence the future structure of MEPI. Dr. Bridbord responded that if MEPI was exclusively an NIH program it would be difficult to justify a significant medical training program. But as a partnership with other federal agencies, including PEPFAR, OGAC and HRSA, there is a shared vision that provides flexibility in structure and approach. In order to attain the goal of attracting the best to the medical schools in Africa, which is integral to the success of MEPI, those schools must have an effective training capability and a strong research capacity, and a culture that values research.
Dr. Harford commented that, for sustainability, the health care systems of the various countries cannot be maintained by continued outside financial support. He asked if MEPI had a plan to reduce reliance on outside funding. Dr. Johnson answered that it was too early to be able to visualize that process, but that PEPFAR has begun to negotiate agreements with host countries, called partnership frameworks, to begin to transfer responsibility for programs to the host country. The timeframes related to that transition have not been clarified.
Dr. Mullan reflected on the question of why MEPI was focusing on medical education (and NEPI on nursing education) when most have arrived at the conclusion that training doctors and nurses in Africa is a futile process because very few will remain to contribute to the health care system in their own countries. Part of the dilemma, and the basis of some criticism, is the fact that PEPFAR funding to address the mandate of adding 140,000 to the health care human resource pool is taking money away from treatment. Dr. Mullan’s response was that a country cannot develop a stable health care delivery system without a stable physician corps. Health policy makers, researchers, teachers and health community leaders come from that physician corps. The MEPI investment, predominantly by PEPFAR, serves the purpose of developing that stable physician population, even though those physicians may not be delivering direct care to individuals. Hands on care is mainly provided by non-physician health professionals, graduates of health profession schools. It is interesting to note that some of those schools have spontaneously become involved in the MEPI proposals.
Concerning the proportion of funding directed to research versus training, Dr. Mullan noted that it would vary with each grantee institution, but that to develop a stable physician core requires medical schools that have a research competence, which is the rationale for directing MEPI funding to research ends.
Dr. Glass closed the discussion, commenting that Human Heredity and Health in Africa and the Medical Education Partnership Initiative were bold, challenging experiments focused on changing medical education. They are linked in time to the Human Resources for Health Initiative (WHO); the challenge of Dr. Julio Frenk published in Lancet, Health professionals for a new century: transforming education to strengthen health systems in an interdependent world; and the Institute of Medicine report on AIDS that concluded that there has been investment in treatment and it is time to consider investment in sustainability. He commented that MEPI will be launched at meetings in Cape Town and Johannesburg, the first time that the representatives of the grantee institutions will meet together.
Dr. Glass concluded the meeting by recalling that, in 1915, the Rockefeller Foundation decided to provide funding for the fledgling Peking Union Medical College. The investment resulted in one of the finest medical training institutions in China. Dr. Glass commented that perhaps a decade or so in the future MEPI may have contributed to a better medical education system in Africa.
Dr. Glass expressed appreciation for the attendance and the contribution of the members of the Board and the participation of the ex officio members and adjourned the meeting.
The meeting was adjourned at 2:50 p.m.