Department of Health and Human Services
Public Health Service | National Institutes of Health
John E. Fogarty International Center for Advanced Study in the Health Sciences
Seventy-seventh Meeting of the Advisory Board
Minutes of Meeting
May 15, 2012
The John E. Fogarty International center for Advanced Study in the Health Sciences (FIC) convened the seventy-seventh meeting of its Advisory Board on Tuesday, May 15, 2012 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 May 14 from 8:30 to 9:00, 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 May 15, 2012 at 9:15 a.m., until adjournment at 3:00 p.m. Dr. Roger I. Glass, Director, FIC, presided. The Board roster is appended as Attachment 1.
Board Members Present
Dr. Roger Glass, Chair
Dr. Robert A. Black
Dr. Barry Bloom
Dr. Gail H. Cassell
Dr. Peter Hotez (via telephone)
Dr. Arthur Reingold
Dr. Bonita Stanton
Dr. Derek Yach
Dr. Kevin DeCock (ex officio)
Dr. Alan Guttmacher, NICHD/NIH (ex officio)
Dr. Donald Lindberg (ex officio)
Board Members Absent
Dr. Maria Friere
Dr. Roscoe Moore
Dr. Susan Shurin (ex officio)
Members of the Public Present
Dr. Michelle Barry, Stanford University
Dr. Robert Bollinger, Johns Hopkins University
Dr. George Hill, Vanderbilt University
Dr. King Holmes, University of Washington
Dr. Alain Labrique, Johns Hopkins University
Dr. William Tierney, Indiana University
Dr. Funmi Olopade, University of Chicago
Federal Employees Present
Nalini Anand, FIC
Rick Berzon, NIMH
Danielle Bielenstein, FIC
Katrina Blair, FIC
Kenneth Bridbord, FIC
Kasima Brown, FIC
Bruce Butram, FIC
Lois Cohen, NIDCR
E. Ann Davis, FIC
Robert Eiss, FIC
James Herrington, FIC
Flora Katz, FIC
Lydia Kline, FIC
Cathy Kristiansen, FIC
Deborah Langer, ODP
Maya Levintova, FIC
Edith Light, NIMH
Susan Maier, ORWH
Jeanne McDermott, FIC
Paulo Miotti, OAR
Elise Morocco, FIC
Myat Htoo Razak, FIC
Sally Rockey, OER
Julia Royall, NLM
Rachel Sturk, FIC
Makeda Wiliams, FIC
Mr. Sean Jeffrey, FIC/NIH
Director's Update and Discussion of Current and Planned FIC Activities
Dr. Roger Glass
Dr. Glass welcomed Board members, federal staff and guests present, and briefly reviewed the agenda. He highlighted the recent achievements of three leaders in global health - Dr. Jim Yong Kim, former FIC Board member, who was recently appointed president of the World Bank; Dr. Salim Abdool Karim, a Fogarty grantee in the AITRP program, who has been appointed interim leader of the South African Medical Research Council; and Dr. Bill Foege, recent winner of the Presidential Medal of Freedom.
Activities since the last Board meeting included participation at the Global Forum for Health Research in South Africa, at which Rob Eiss organized a panel on the MEPI program. NIH Director Dr. Francis Collins and FIC jointly established the NIH Global Health Research Working Group, which includes representatives from the ICs who meet about every three months to keep abreast of all of the international activities at NIH. Dr. Glass stated that he and Dr. Susan Shurin, an ex officio FIC Board member, jointly chair the working group. One challenge being addressed is the need to map NIH participation in international research, some of which is not under the official aegis of NIH. Dr. Collins authorized a million dollars to create a database of funding to include an NIH component.
Dr. Shurin and Dr. Hugh Auchincloss, Jr., Principal Deputy Director of NIAID, are chairing a harmonization group to look at inconsistencies in rules related to indemnification, ethics and clearance that vary from country to country and often impede cooperative arrangements with U.S. researchers. Finally, there is a communications activity led by John Burklow (NIH OD), Ann Puderbaugh (FIC) and Gray Handley (NIAID) to support an NIH web site that will include all of the NIH global health programs.
Following up on a presentation at the last Board meeting about the BRICs countries, Dr. Glass noted that there are a dozen active partnerships in India dealing with a number of health issues - child health, eye disease, cancer, brain disorders, vaccines and more. In China, Dr. Collins negotiated a joint agreement with the Chinese National Science Foundation to co-fund grants. Five ICs have provided about $5 million for that program. Brazil has significantly increased its funding for science and Fogarty facilitated an agreement to allow the Brazilian National Council of Research to provide financial support for Brazilian postdocs who are working on campus. In the fall NIH will work with Brazil to expand that limited agreement so that the two countries can jointly fund research projects.
Dr. Glass noted that the Program for Fellows and Scholars, approved by the Board at the last meeting, now has five consortia, including 20 universities, funded in the amount of $20.3 million over five years to support one-year T32 type grants for postdocs to work in lower and middle income countries, to hopefully develop partnerships there that will support future applications for K and R awards. Fogarty has enlisted the support of 17 ICs that have either contributed to the funding or promised support if an appropriate candidate/research project arises.
The Fulbright-Fogarty fellowship program received 77 postdoc applicants, 19 of whom were recommended for further consideration. All were vetted by the embassies in country, but only seven were accepted, which was something of a disappointment. Dr. Hyatt Mtoo Razak explained that in some of the cases funding limitations at the State Department was responsible for the reduced acceptance rate.
Turning to activities at Fogarty, Dr. Glass announced that pre-launch pilot programs had occurred at the Center for Global Health Studies, which is housed at Building 16A, next door to the Stone House. Ms. Nalini Anand, Center Acting Director, explained that one of the first activities coincided with the Grand Challenges in Global Mental Health Conference. In cooperation with NIMH, a two-day writers’ retreat that looked at publications which could be considered by decision makers in low and middle income countries who might be interested in integrating mental health care into existing service delivery platforms. Secondly, Ms. Anand noted that Dr. Bob Bollinger would develop a future conference to look at ICT and global health education. Dr. Bollinger held a number of stakeholder discussions at the Center as part of the planning process for the conference.
Finally, Dr. Glass commented that a consultation on ending preventable childhood deaths was hosted at the Center, at which current and former Board members participated - Dr. Guttmacher, Dr. Ariel Pablos-Mendez and Dr. Bob Black. Dr. Guttmacher added that one consensus at that meeting was that the goals should be evidence-based, challenging, even a bit of a stretch, but achievable. Dr. Glass noted that there was agreement that under age five mortality should be less than 20 per thousand by 2035, and the group discussed possible interventions and models that might support reaching that goal.
Dr. Glass announced that he would be going to Burma (Myanmar) as part of a State Department effort to propose an initiative to the new government of Myanmar to improve international relations, especially with an eye to Myanmar working with USAID. Then Dr. Glass indicated he will attend the World Health Assembly at the end of the month, where he will meet with ministers of health from countries involved with the Medical Education Partnership Initiative (MEPI) program. The agenda will also include mental health, eye disease, and non-communicable diseases (NCD).
Dr. Glass commented that in July, in conjunction with the 19th International AIDS Conference, the 25th Anniversary AIDS/TB Program Meeting will be held at NIH. In August the MEPI program will hold its second annual meeting in Addis Ababa, Ethiopia. It should draw more than 200 participants representing the 12 MEPI countries (with 13 institutional grants), and 36 affiliated medical schools. Julia Royall, formerly at NLM, has set up a web site that identifies the key MEPI PIs and provides a vehicle for communications among the various institutions. It is hoped that the African Medical School Association, which has been relatively inactive, might access the site to reinvigorate biomedical education in Sub-Saharan Africa.
Dr. Glass stated that in the fall there will be a cookstoves meeting that will include a discussion of the relative dearth of data available to evaluate various proposals to promote clean air through improved cookstoves. He commented that a significant amount of research was needed, not only in the hard sciences, but the soft sciences in terms of the behavioral and economic aspects of encouraging use of clean cookstoves. As part of the program, cookstoves will be set up outside the Center for Global Health Studies (Building 16A) to demonstrate their use.
Special Council/Board Review of Applications for Investigators
with Grants Totaling $1.5 Million.
Dr. Glass invited Mr. Bruce Butrum to discuss the new grants policy. Mr. Butrum explained that NIH has proposed a special council review (SCR) before any award can be made to an investigator who has current grants that total $1.5 million or more. The review will look at unique research opportunities inherent in the application, and whether the proposal supports the NIH mission. The review will also assess whether the project is highly promising and distinct from other currently funded projects.
FIC Strategic Planning: Priorities for the Next Five Years
Nalini Anand, Director, Division of International Science Policy
Dr. Glass recalled that, when he first became FIC director, he tasked staff to develop a five-year strategic plan, which was subsequently approved by the Board. That plan had five major goals.
- First, to mobilize the scientific community to address the shifting burden of disease and disability;
- Second, to bridge the training gap in implementation research;
- Third, to develop human capital to meet global health challenges;
- Fourth, to foster a sustainable research environment in low- and middle-income countries; and
- Fifth, to build strategic alliances and partnerships in global health research and training.
Dr. Glass stated that he had asked Ms. Anand, head of the FIC Policy Division, to work with Ms. Rachel Sturke and staff to review and revise those objectives.
Ms. Anand explained that the strategic plan revision process was in progress, and that staff was building on the present goals, working to better focus the objectives and to ensure that the strategic plan was complementary to the NIH mission in the global health arena. She invited Ms. Sturke to discuss the process that began with consultations with the Board members, FIC staff and NIH ICs involved in global health. Ms. Sturke added that there were also external discussions, including attending the Global Forum for Health Research to talk to outside stakeholders, and conversations with ESSENCE (Enhancing Support for Strengthening the Effectiveness of National Capacity Efforts), which is sponsored by WHO. Finally, public comment was recently solicited through the FIC web page.
Ms. Sturke commented that an outside contractor had been hired to develop a “landscape analysis,” which will focus on very specific themes mainly related to the current five strategic objectives. The analysis should be delivered by early summer. Noting that Fogarty’s current objectives include addressing the shifting burden of disease and disability, implementation research, human capital, a sustainable research environment, and alliances and partnerships, Ms. Sturke invited several Board members to offer comments and suggestions.
Dr. Cassell commented that Fogarty should balance its limited financial resources with the most strategic uses of those resources. The landscape analysis should include a look at the more wealthy players in international health, including foundations both here in the U.S. and abroad, and the BRIC countries that are becoming more involved in financing health programs. She noted that Fogarty has always been good at developing human capital, but that it might be appropriate to evaluate the training mechanisms being used to ensure that they provide optimal opportunities.
Dr. Cassell cited an example of innovative financing that evolved at the Burroughs Wellcome Fund, which created a grant that would support a researcher in an initial institution, but could be retained by the researcher if he or she moved to another institution - a portable award. Applied to the middle and low income countries, a researcher might receive funding support for study abroad but be able to retain some of the funding for initial support upon returning home.
Finally, she suggested consideration of a meeting at the Center for Global Health Studies on training future leaders in global health, enlisting the participation of senior scientists who have dedicated some of their careers to career development.
Dr. Yach observed that Fogarty has focused on human and institutional capacity and the development of networks and relationships that derive from that focus. With that has come an expertise on the trends in human capital and institutional capacity in many countries, an expertise that should be considered in developing a strategic plan. He suggested one challenge that could be addressed, the difficulty of filling the gap of mid-level scientists in countries that experience a brain drain and are left with entry level postdocs and aging scientists nearing retirement.
Dr. DeCock commented that Fogarty’s greatest impact could be its role as a convening facilitator and in the area of capacity building. He saw a potential role in the whole area of medical education where Fogarty may be the center of gravity focusing on that education. Finally, he suggested that there should be a new look at the definition of global health, which now might be focused on the low-income countries, about 35 as defined by the World Bank. He submitted that global health really involves every country in the world. He suggested reconsideration of where Fogarty’s emphasis geographically and socioeconomically should be.
Dr. Lindberg suggested that there might not be a distinction between training and education, adding that education is a more elevated goal that might be the most important activity at Fogarty.
Ms. Sturke invited comment on the second strategic objective, activities related to chronic disease research and research training. Fogarty is involved with research programs in brain disorders, Geohealth, tobacco, and NCD-Lifespan. There is also support of a number of partnership activities - the NCI Center for Global Health; NIMH focus on implementation science, collaborative hubs and integration of mental health into chronic disease platforms; the NHLBI Collaborating Centers of Excellence; and NICHD’s focus on developmental origins of disease. As part of the strategic planning process, Ms. Sturke commented that it is important to have a complete picture of what other institutes are doing and determine where Fogarty fits within that NIH context.
Dr. Black agreed that emphasis on birth cohort studies and early origins of disease is appropriate, but that one aspect of these studies should be nutrition, both in terms of under-nutrition and causes of rapid weight gain and obesity in childhood. Research into the role of nutrition in non-communicable diseases should be included in considering research agendas.
Dr. Tierney expressed the opinion that the health care model in the U.S. is inappropriate to the developing countries because it is facility-based and demands significant resources to maintain. There is also a lack of continuity of care in that more and more reliance is being placed on urgent care facilities where there is very little follow up.
Dr. Merson recommended focusing on areas where Fogarty has experienced the most cooperation from the ICs, because that increases the leverage needed for success. Dr. Glass responded that since the majority of funding from Fogarty is for training, not direct research, Fogarty might consider becoming a training resource such that those groups who are financially more aggressive in research programs can rely on Fogarty to supply well-trained researchers to staff them. He added that in his travels he has seen the research impact of Fogarty-trained scientists. On the topic of Fogarty as a convener, Dr. Glass commented that the recent pilot projects at the FIC Center for Global Health Studies suggest another niche role for Fogarty, which could promote consensus on some issues, and generate ideas for projects and grants.
Dr. Cassell noted that ICT would be an excellent vehicle for addressing chronic disease research and training, as well as implementation science, health care delivery systems and so on - all fairly expensive in the traditional setting. ICT can produce results at much lower costs. She added that very few institutes provide training in health economics, law and policy, a possible niche for Fogarty.
Ms. Sturke suggested thinking about bridging the training gap in implementation science, a goal that is not easily defined in terms of projects, but may be more an integrative issue, such as injecting implementation science into the NIH Dissemination and Implementation Science Annual Conference, and adding implementation science to RFA language. She invited comments from Dr. King Holmes and Dr. Bonita Stanton.
Dr. Holmes commented that in the last three years NIH has made about $200 million available for implementation science, three-quarters of which went to AIDS-related programs. There has been a kind of evolution from operations research, to implementation science to program science. The distinction is that implementation science is taking new science from the lab and effecting implementation at the user level. Program science is a kind of interaction by which needs within a program are identified and new approaches to responding to the needs are tried.
There are about 60 CTSAs (Clinical and Translational Science Awards) awarded in four categories. The first two pertain to bench-to-bedside products; the latter two pertain to community health systems and services. In global health, the focus has been on the first two, individual care and clinic level services, and not on community health systems. In the context of Fogarty, the implementation is different from health care in the U.S., and it is important that those who implement in developing countries are very familiar with the needs and resources of those countries.
Dr. Holmes cited an example of a failed implementation of rapid syphilis testing in a clinic in Peru. The investigator found that women had to travel to the clinic, wait for up to four hours for the test, and had to return to the clinic as many as five more times to finally get the results. If the results were positive, she had to return several more times with her partner for treatment. It was a health system in need of implementation science.
Dr. Stanton described her experience in Bangladesh in the eighties when oral rehydration salts therapy (ORS) was used to prevent/cure diarrhea. There was almost no research or information about designing a behavioral intervention, which only appeared in the literature when the AIDS epidemic demanded it. Her point was that implementation science today is in about the same place as behavioral interventions were in the eighties - the definition was not clear, the research questions had not been formulated, and no one knew how to set the new science up. Dr. Stanton suggested that a niche for Fogarty would be to push the concept toward being a science, whether it is called implementation research or program research.
Ms. Sturke introduced the third strategic plan area, capacity building. Dr. Reingold commented that independent researchers require three things - infrastructure for research, money to support the research, and training in how to develop the capacity for the research. He suggested that an NIH independent researcher cannot be fully trained in a year, but must have long-term mentoring. The challenge is to encourage senior researchers and faculty to devote more time and a longer period of time to mentoring. He added that it is also important that researchers have access to mentoring outside of the academic environment, with agencies like CDC.
Dr. Barry suggested that Fogarty may have been remiss in not mining the extensive alumni corps that has been produced over the years. Connecting them through social media could significantly enhance the availability of mentors. She suggested a number of other opportunities: partnering with Brazil’s Science Without Borders program; accessing the huge number of university students associated with the Consortium of Universities for Global Health; and working with the Foundation for Advancement of International Medical Education (FAIRE).
Dr. Merson discussed the last strategic goal area, a sustainable research environment in lower and middle income countries. He suggested that it was really capacity building, which has been a mainstay of Fogarty’s program for years. One of the most important aspects of building sustainability is staying with the program. It can take decades to build sustainability. Secondly, Dr. Merson commented on the importance of developing and maintaining core capabilities - data management and analysis, grant writing, knowledge synthesis and others not related to specific diseases. Focusing on areas of competence will cross over into a number of diseases. Finally, Dr. Merson recommended networks and hubs as a way of sharing information and new knowledge. He pointed to the NIMH Collaborative Hubs for International Research on Mental Health, and to the effective sharing of science among the MEPI sites.
Closing the discussion, Ms. Sturke expressed appreciation for the contributions of the Board members and guests.
Harnessing Information and Communications Technologies to Enhance Global Health Research, Flora Katz, Program Officer, Division of International Training and Research, FIC
Dr. Katz stated that information and communication technology was a core resource for global health research and training - communicating with colleagues, adding education and training, accessing information, and taking advantage of rich informational databases that are available. Fogarty established one focused training grant for global health informatics in 1997, and now there are eight five-year awards. She noted that informatics may be described in a number of ways - medical, imaging, clinical, biomedical and others. As mentioned before, establishing an informatics program requires persistence, taking up to 20 years to fully convert an institution to a commitment to informatics.
Dr. Katz mentioned two current programs, one an Andean project that includes Peru, Ecuador and Colombia, which is now associated with the Latin American Informatics Association; and another in Sub-Saharan Africa which is building a master’s program in informatics in five countries there. All of the programs incorporate distance learning, including one framework program in the mental health of trauma. That program addresses major catastrophes, such as tsunamis and incidents of genocide. Finally, there has been some funding in the ICT area for distance learning, modeling mHealth, using ICT tools and very focused ICT training.
Broadband penetration is limited in some areas, available to only 3.2% of the population in some areas. However, cell phone subscriptions are increasing rapidly, which provides an alternative.
Dr. Katz announced that three guest speakers would discuss informatics (Bill Tierney), eLearning (Bob Bollinger) and mHealth (Alain Labrique).
Bill Tierney, President/CEO, Regenstrief Institute
Dr. Tierney stated that he viewed health care as a service business - to offer advice, prescribe medication and devices, perform surgery and offer physical therapy. In fact there is an informational foundation to all of those services that requires gathering and transmitting information, and the quality of care offered to patients depends on effective management of information. But he commented that it is not all about information and getting electronic medical records in place, but about being able to organize, analyze and store medical information.
In 1990, Indiana University established a partnership with a medical school in Kenya and for the first eight years it was an exchange program, faculty, students and residents going back and forth between the two schools. In 1998, a Fogarty grant was received to develop an electronic health records system, which resulted in a simple, computer-based medical record system in rural western Kenya. Also in 1998, Indiana University launched the Academic Model for the Prevention and Treatment of HIV and AIDS, AMPATH. It was ambitious, with far more computer power, a catchment area of 2 million and a population of several hundred thousand HIV patients. By 2009 it was expanded to handle not only the original HIV/AIDS records, but primary care and chronic disease management, and the patient base expanded to 450,000.
Although the electronic record component of AMPATH expanded significantly, the data is collected through the use of paper forms filled out by patients at the clinics. The forms have proliferated from an original four - adult and pediatric, initial and return visit -- to cover a myriad of areas of clinical interests including reproductive health forms, high and low risk patient forms, adherence forms, post-exposure prophylaxis forms, outreach forms, support group forms, more than a dozen nutrition forms, and more. All of the data on the forms is entered into the system, although many of the forms require only a few minutes to complete. One of the form-based programs is the home-based counseling and testing program, which undertook a program to visit every home in the catchment area and test for HIV and TB, later expanded to include blood sugar and blood pressure. The measurement tool is an Android phone.
The people who run the program are Kenyans who have been trained through a collaboration between the U.S. investigators and the Kenyans, supported by Fogarty funding. The MPATH OpenMRS system, which is an open-source system, has been established in nearly every country in North and South America, Europe, Africa and the Far East. Most of the medical care is provided not by physicians, but by trained clinicians and nurses (90%) and the system tracks so well that only about 1.5% of patients are lost to follow-up each month, and there is an 85% adherence to antiretroviral therapy. Drugs are provided by USAID and other costs amount to about $100 per patient per year. Dr. Tierney observed that without the initial Fogarty support, this success story could not have happened. It created the infrastructure that made the system possible.
Bob Bollinger, Johns Hopkins School of Medicine, Department of International Health at the Bloomberg School of Public Health, and Johns Hopkins School of Nursing
Dr. Bollinger stated that the impetus for establishing the Center for Global Health Education at Johns Hopkins actually came from an earlier experience in India, funded by an NIH grant, to rely on ICT to support education and build research capacity there. That effort provided support for clinical training, was a resource for U.S. investigators there, and was an adjunct to reporting and managing adverse events. He recalled that he began the Fogarty project in Pune, India in 1992, when the most significant component of distance learning in his proposals was to build a reliable e-mail structure and maintain a fax machine.
Describing the state of the art today, Dr. Bollinger explained a regular course in global health that combines students at Johns Hopkins and at Makerere in Africa via a videoconference system, allowing the students in both places to exchange ideas. That same system supports several meetings a week on various subjects and for various reasons - reviewing adverse events, working on proposals and grants, and so on.
Dr. Bollinger described an early project for CDC to set up a distance learning infrastructure in Uganda for PEPFAR partners. Fortuitously the cell phone towers already installed in Uganda had an unused 4G capability that allowed development of mobile technologies to enable transmission of high definition photos, video and data. With a burgeoning of fiber optics infrastructure in many parts of Africa, it was clear that the fiber optics could be connected to the existing cell phone system.
Johns Hopkins set up a web site several years ago that, with almost no marketing, has grown to the point where there are 4 million hits annually from 80 countries. The web offers online courses that have trained over 8,000 registered providers. Dr. Bollinger described a recent six-week course on confronting gender-based violence that enrolled 41 students from 12 African countries. The course was interactive and the students were required collaboratively to create a final product, a proposal. With Fogarty support, two courses were created, an ethics course that has been completed by over 400 individuals, and a biostatistics course that was taken by over 1,700.
Dr. Bollinger discussed a platform based on wireless technology, called EMOCHA - electronic, mobile, open-source, comprehensive health application. The system collects actual clinical patient data, supports interactive training and consultations, and offers phone capability for text and message alerts and reminders. Data in the system is analyzed to develop educational resources and to identify gaps in education and training.
Regarding gaps that can be addressed through distance learning technologies, Dr. Bollinger commented that a significant challenge is training people in the use, management and maintenance of ICT systems, and distance education skills. There must also be bricks and mortar to house the ICT facilities, and there is a team in place in Uganda that provides an institutional IT needs assessment. That team completed a needs assessment for the five MEPI sites in Uganda, including Makerere University. As an example of the findings, Dr. Bollinger stated that the main complaint by users was lack of bandwidth. The team discovered that there were about 50 servers being used by various collaborators that were very poorly networked. Most were working at a meager 5% of capacity. Secondly, the team revealed that 80% of the bandwidth use was devoted to downloading music videos. Makerere needed better management of the ICT system, but did not have the people trained to do it.
Dr. Bollinger concluded, commenting that distance learning has arrived as evidenced by the MIT - Harvard University collaboration to release most of their courses as open courseware, available free anywhere in the world where the web can be accessed. He suggested that Fogarty might have a catalytic role in supporting distance learning, which is already being used by Fogarty collaborators.
Alain Labrique, Johns Hopkins School of Medicine, Department of International Health at the Bloomberg School of Public Health, and Johns Hopkins School of Nursing
Dr. Labrique presented an example of the advanced technology being used in Bangladesh to maintain patient health care records - a two dimensional barcode, about the size of a postage stamp, that stores a significant amount of data and can be scanned and read by any properly programmed Smartphone. He also showed a map of Facebook usage that reveals an increasing number of users in Sub-Saharan African and Southeast Asia. Finally, he offered the statistic that 83% of WHO member countries maintain some form of mHealth or eHealth system. Those systems can be quite different and most include, to a greater or lesser extent, education opportunities, diagnostic support, disease-tracking capabilities, supply chain management, remote monitoring, data collection and connectivity to health care providers, many of whom work in remote locations.
The technology allows patients to participate in the management of their health care needs, to maintain treatment regimens and adhere to prescribed medications. One important aspect of mHealth is the ability to monitor vital signs using cell phone technology. In global health another important opportunity is human performance enhancement technology, focusing on the patient’s use of technology to monitor his or her own health, the community health care worker’s ability to manage a client base, and the provider’s ability to provide a timelier, higher standard of care. As an example, Dr. Labrique described a program in Bangladesh that provides pregnant women with cell phones that they use to notify their providers of the onset of labor. That has significantly increased the number of deliveries that are attended by a health care provider.
Dr. Labrique agreed with an earlier comment that having the technology infrastructure is important, but just as important is having the human resource that is trained and able to manage and maintain the system. He commented that, in countries that may have only a few dollars per capita to national health care infrastructure, there are hard decisions on how to spend that money. There is also the reality that gross statistics may be misleading. In Bangladesh there has been a recent increase in cell phone ownership from 20% to 45% of the population, but when stratified by socioeconomic status large gaps exist in phone ownership.
USAID has established a Mobile Alliance for Maternal Action (MAMA), with support from a number of private foundations. MAMA monitors a woman’s pregnancy and sends voice and text messages as reminders to take certain health-related actions.
Dr. Labrique listed several training needs that might be considered by Fogarty in developing a long-term strategy: health informatics; improved user-focused design; technology assessment; cost-benefit evaluation; and evaluation of evidence to improve decision making. He commented that although there are new developments in mHealth occurring continually, mHealth does not work in a vacuum and it should be integrated into the broader national health care system. In order to do that well there should be efficacy research to identify what works and what does not work, and to measure the impact of various approaches to the integration process. Some of the considerations in moving integration forward are the following mHealth possibilities:
- Behavior change and adherence
- Supporting electronic medical records
- Enhancing emergency response systems
- Connecting mHealth with mFinance
- Promoting health-related use of social media
- Making the research process more efficient and more productive
Dr. Katz thanked the three speakers and invited discussion and comments from the Board and guests. Dr. Yach observed that the next few years would see a transformation of the technology, but he suggested that there should be consideration of the sustainability aspect - how will money be made in the new environment and who will provide funding? He stated that one of the most exciting opportunities is the potential to promote adherence by patients with lifelong chronic conditions, the ability to continuously monitor, and to remind the individual about adherence, all with cell phone technology. He commented that per transaction costs are minimal, so it should be technologically easy to provide services across populations. He added that the cell phone companies and service providers should be involved in the discussions. Dr. Cassell commented that, along with adherence comes supply-chain management, the ability to forecast needs and manage the distribution of supplies.
Dr. Barry commented that there are very few studies that look at impact and that could be one project that Fogarty could take on. Dr. DeCock mentioned two challenges. Regardless of effective regional systems, like MAPATH, there is a lack of effective patient management systems. The 7 million patients on antiretroviral therapy is a messy example. Second, there is the problem of technology exceeding the health care community’s ability to effectively use the technology, such as DNA fingerprinting in tuberculosis treatment, an effective procedure that has never caught on.
Dr. Adam Slote, from the USAID Bureau for Global Health, commented that his office is drafting a new eHealth strategic framework, part of which will be to begin to focus on more specific objectives. For example, issues of interoperability are becoming more important, especially with similar pilot programs in different countries that cannot talk to each other. There are also bottlenecks in disseminating information, such as informing mothers that ORS can prevent diarrhea and save lives. mHealth can help overcome some of those problems. Finally, Dr. Slote mentioned the concept of a South-to-South peer-assisted network that might help fill gaps in IT capability from one country to another. He added that the private sector might be a resource in developing the network.
Dr. Merson suggested that Fogarty should consider the question, what research would be appropriate for Fogarty to take on that would not be accomplished by any other group? Dr. Tierney described the way OpenMRS was developed in Tanzania and Uganda, which was to identify IT expertise in the institutions and then show that expertise how to integrate health into their existing IT systems. In effect, Johns Hopkins created a consulting company for those institutions that continues in operation today. In Nigeria, four such companies exist. He suggested that Fogarty might be able to develop a university-based model that could then spin off similar private sector companies.
Finally, Dr. Holmes commented that, although expensive lab equipment and related infrastructure is not readily available to low and middle income countries, access to informatics is much more available, which in turn makes some areas of research more accessible. On another note, he added that looking at opportunities to enhance research training through the use of social media might be a good exercise. Students may learn more efficiently through that medium.
Dr. Glass expressed appreciation for the rich discussion. He welcomed Dr. Sally Rockey to make the final presentation on the agenda, a discussion of the NIH RePORT tool.
World RePORT Presentation
Sally Rockey, Deputy Director of Extramural Research, NIH
Dr. Rockey began by mentioning her participation in the recent meeting of the newly organized Global Research Council, a consortium of science leaders from 50 nations, who convened the first meeting of the Council to develop a Statement of Principles on Merit Review. Dr. Rockey said that she discussed the Heads of International Research Organizations (HIRO), which was organized in 1998, and as Dr. Collins representative, emphasized to the Council the importance of the life sciences in the global research enterprise.
Turning to the NIH resource, RePORT, Dr. Rockey explained that NIH considers it very important to provide complete information on all research grants and awards. To that end a web site was developed, www.rePORT.nih.gov, that is available to the public and contains detailed information on extramural and intramural activities. There is an inquiry form to enable a very specific search (project title or number, principal investigator, funding information, educational institution, company associated with project, and so on). There is information available on the individual projects, and the individuals associated with the projects (including some profiles provided by the investigators), and patents associated with research projects.
The site includes a wide range of agglomerated data, presented in both tabular and chart formats. For example, funding can be viewed by institute, agency, state, and congressional district, to name a few.
Dr. Rockey explained that a substantial amount of funding that may go to international projects is distributed as sub-awards of contracts under a protocol. Although the total funding information can be found on the web site, the system cannot at this time identify those sub-awards and contracts, so it is not possible to obtain data specifically related to international activities. However, during the next year there will be a program to identify that funding and specifically include it in the database.
During discussion, Dr. Yach observed that the database should allow an investigator to identify research being done in the same country or region on the same subject area. Dr. Rockey agreed, but added that making such a search mandatory or to require that the researcher certify that his or her work is not or has not been duplicated would be impractical.
Dr. Glass expressed appreciation for all of the contributions to a very successful meeting. He adjourned the meeting at 2:40 p.m.