February 26, 2013 Advisory Board Meeting Summary Minutes


Meeting Information

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-ninth Meeting of the Advisory Board
Minutes of Meeting
February 26, 2013

The John E. Fogarty International Center for Advanced Study in the Health Sciences (FIC) convened the seventy-ninth meeting of its Advisory Board on Tuesday, February 26, 2013 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 immediately prior to the open session, 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. The meeting was open to the public at 11:00 a.m., until adjournment at 3:00 p.m. Dr. Roger I. Glass, Director, FIC, presided.

Attendee Information

Board Members Present

Dr. Roger Glass, Chair
Dr. Gail H. Cassell
Dr. Rebecca Richards-Kortum
Dr. Bonita Stanton
Dr. King Holmes, University of Washington
Dr. Michael Merson, Duke University
Dr. William Tierney, Indiana University
Dr. Donald Lindberg (ex officio)
Dr. Susan Shurin (ex officio)

Board Members Absent

Dr. Barry Bloom
Dr. Derek Yach
Dr. Kevin DeCock (ex officio)
Dr. Alan Guttmacher, NICHD/NIH (ex officio)

Members of the Public Present

Dr. Armin Fidler, World Bank
Dr. Kristie Foley, Davidson College
Dr. Laura Guay, EGPAF
Dr. George Hill, Vanderbilt University
Dr. Allison Rose-Wood, OGA Americas

Federal Employees Present

Nalini Anand, FIC
Rick Berzon, NIMH
Danielle Bielenstein, FIC
Katrina Blair, FIC
Kenneth Bridbord, FIC
Kasima Brown, FIC
Charlotte Catz
Pat Callahan, FIC
Stacy Chambers, NINDS
Tina Chung, FIC
Liz Cleveland, FIC
Lois Cohen, NIDCR
Dexter Collins, FIC
Jane Coury
Robert Eiss, FIC
Charles Edmonds, NIGMS
Arash Etimade
Ladan Fakory, State
Laura Faux-Gable, State
Dan Geendasy, NLM
William Grace
Jeffrey Gray, FIC
Gray Hadnley, NIAID
Rebecca Henry, CSR
Michael Johnson, FIC
Samila Kahn
Flora Katz, FIC
Lydia Kline, FIC
Vesna Kulesik, NICHD
Marya Levintova, FIC
Judy Levin, FIC
Maya Levine
Wenchi Liang
Enid Light, NIMH
Kayvon Madjarrad
Jeanne McDermott, FIC
James Meegan
Kathleen Michels, FIC
Elise Morocco, FIC
Vivian Pinn
Sybil Philip, NICHD
LeShawndra Price, NIMH
Myat Htoo Razak, FIC
Joshua Rosenthal
Julia Royall, NLM
Luis Salicrup
Lana Shekim
Hillary Sigmon, FIC
Marcia Smith, FIC
Lisa Stevens
Alisha Sutton, FIC
Kristen Weymouth, FIC
Chase Willett

Closed Session

Open Session

Director's Update and Discussion of Current and Planned FIC Activities
Dr. Roger Glass

Welcoming Remarks

Dr. Glass welcomed staff and guests to the 79th meeting of the FIC Advisory Board. He recognized the outstanding contributions of Surgeon General C. Everett Koop, who recently passed away, for his efforts to enlighten the American public about the hazards of smoking and his support for global health. He also commended Board member Michael Merson, who was named a Kentucky Colonel for his contributions to global health and the science of HIV/AIDS. He added that Dr. Merson was in good company – Dr. Albert Sabin, also a Fogarty Scholar, had received the same honor fifty years earlier.

Fogarty has supported the mHealth Summit since its beginning, and this year Dr. Francis Collins and Dr. Kathleen Sibelius spoke during the December 3-5, 2012 meeting. In January, Dr. Chris Murray, University of Washington, spoke about the Global Burden of Disease Study 2010, published in Lancet, which quantified for the first time global noncommunicable disease (NCD) impacts, risk factors and morbidities. Dr. Glass commented that Sir Mark Walport, just retired from the Wellcome Trust, delivered the Barmes Lecture in late January. And Dr. Julie Makani, a Wellcome Trust grantee, spoke at NIH about sickle cell disease in Africa, where there is an extremely high mortality among children below the age of nine. She compared that to the U.S., where life expectancy of people with sickle cell disease now exceeds 50 years.

Dr. Glass commented that the MEPI program, which supports 13 grantees in 12 African countries, is now holding regular virtual seminars, linking the grantees through teleconference. There are, however, scattered connectivity problems in Africa that can challenge the virtual communication environment. Dr. Glass said he participated in a MEPI site visit in Kumasi, Ghana in January. One MEPI grantee who attended carried her iPad, that had been loaded by her medical students with programs and applications that most med school students would appreciate – including PubMed Mobile. Dr. Glass mentioned that there was consideration of an award to the MEPI grantee who comes up with the most creative idea for long-distance learning and communications technology.

There was a joint Indo-US Workshop on Innovative Approaches and Technologies for Diabetes Prevention and Management, supported in part by the Diabetes Institute in a first collaboration with the Indian Council of Medical Research. There will be more diabetics in India in the next two decades than anywhere else in the world. A second meeting in the same timeframe was held in New Delhi, the Indo-US Joint Working Group looking at HIV and sexually transmitted diseases. India and the U.S. are matching funds to support that group. Finally, there has been an ongoing 25-year rotavirus vaccine field trial, recently successfully concluded, under the Indo-US Vaccine Action Program.

Lastly, Dr. Glass mentioned a meeting with Ed Fantegrossi, the head of the Internet Education Equal Access Foundation, which has the goal of supporting Internet access in African educational institutions. He then invited Ms. Nalini Anand to talk about the Center for Global Health Studies first year of operation.

The Center for Global Health Studies, Ms. Nalini Anand

Ms. Anand explained that the vision for the Center is to provide a platform for addressing global health challenges and to develop solutions through a “think tank” process. The first year, just ending, provided an opportunity to try various models that included small meetings to develop agendas, writing sessions to create useful papers, and training programs. Participants in the early projects were a core group of NIH ICs and a few government agencies interested in global health. The Center looks forward to expanding participation to include groups in the private sector, such as foundations and perhaps some corporate entities.

The second principle was to create in each project concrete deliverables that would be available beyond the end of the event itself. The Center intends to focus on crosscutting issues, and not on disease-specific areas, and most projects will deal with implementation science or with identification of research priorities of importance to Fogarty. Finally, there should be an element in most projects that supports the Fogarty strategic plan.

Ms. Anand listed some of the major activities of the Center’s first year:

  • February - GETHealth consultations to develop an agenda for the recent GETHealth Summit, which was not a Center project but included active Fogarty participation
  • October - Cookstove Training Institute, a four-day program at which over half of the trainees came from low and middle income countries (LMICs)

Ms. Anand described future Center-related projects:

2013

  • March – PMCT Network Launch, a two-year project that involves two meetings a year to convene scientists, implementers and policy makers to address global PMCT issues
  • April – African Journal Partnership Project meeting to review ten years of activity in the partnership and to look forward to future activities
  • April – HIV/NCD Co-morbidities in LMICs Symposium at the Center, looking broadly at the state of the science, followed by a two-day writing retreat
  • May – New Directions in Global Tobacco Control. A collaboration with NCI, NIDA and the Office of Behavioral and Social Sciences Research, to evaluate the Fogarty tobacco control program (TOBAC) over the past ten years
  • September – Urbanization, Gender and Health Consultation, a joint project with the NIH Office of Disease Prevention to consider future agendas in that area
  • October – the Mentorship Training Institute, looking at mentorship models and career development mainly in the Middle East and North Africa
  • February 2014 – a writers workshop on future global research priorities on brain disorders

Finally, Ms. Anand mentioned several ideas that are under consideration, including developing a pilot scholar-in-residence program, focusing more on themes that allow continuity over time, and working on a business plan for the Center to support sustainability.

During discussion, Ms. Anand was asked about the focus on themes, she responded that the Center would avoid being labeled as a center for a specific disease or condition, and that the theme approach would allow some focus on a general area, while leaving enough space to create programs for more specific interests. Asked about the Urbanization, Gender and Health Consultation, Ms. Sturke commented that planning was in the early stages, but the vision is to hold a stakeholder workshop out of which might come a preliminary research agenda focused on the intersection of urbanization, gender and health.

Closing Remarks – Dr. Glass

Dr. Glass noted that the Fourth Annual Consortium of Universities for Global Health (CUGH) conference would convene in Washington in mid-March, having now grown to over a thousand registered to attend. Its theme this year will be innovation, implementation and impact in global health.

He observed that March 23rd is the 100th birthday of Congressman John E. Fogarty, in whose honor the Fogarty International Center was established after his death in 1967.

In May, Fogarty International Center will participate in a joint US-Russian Forum, which will consider issues related to rare diseases in pediatric research. He noted that Board member Dr. Gail Cassell was a leader in developing the relationship with the Russians that made the forum possible.

Finally, Dr. Glass noted that Dr. Collins had been made chair of the Heads of International Research Organization (HIRO), a small group of important research funders in global health. Fogarty is supporting HIRO by developing a web site interactive map on which users may locate research projects and collaborators in Africa, and obtain details of those projects.

Bridging the Gap between Science, Program and Policy: New Directions for Fogarty’s Implementation Science Agenda

Dr. Sturke recalled that when the strategic plan was developed five years earlier, filling the gaps in implementation science research and capacity was the second goal on the list. Fogarty has worked on that goal since the beginning, cooperating with other ICs, including implementation requirements in RFAs, and funding several RO3 grants that focused on implementation. That focus will continue during the next five years. She said that at this time there are several activities in the early stages, including the PMTCT project previously mentioned that includes a significant plan to launch a network of researchers, end users and policy makers to support promotion of implementation research and science.

Dr. Michael Johnson observed that the two major contributors to the HIV/AIDS system of care have created a model that should serve to provide a framework for managing use data, operations research and implementation science in other areas, such as NCDs. However, implementation science has not been well-funded, nor is there consensus on how to proceed.

Dr. Johnson commented that, since PMTCT is on the agenda, the Board might be interested in knowing that Ambassador Eric Goosby at the Department of State and Michelle Sidibe at UNAIDS are leading a political commitment to support the elimination of PMTCT. Almost a billion dollars is involved in that goal, including $100 million from the Global Fund. A motivation is the fact that transmission rates in some countries are as high as 20%, which is almost the same as in areas where there is no intervention. Dr. Johnson posed the question of what NIH’s role should be in these areas and others, such as tuberculosis and other NCDs?

Dr. King Holmes, University of Washington

Dr. Holmes posed four questions for the Board’s consideration:

  • What is implementation science in the context of global health?
  • What can existing programs contribute to implementation science?
  • What implementation science can Fogarty pursue in partnership with other ICs?
  • What implementation science can Fogarty pursue with other non-NIH partners (PEPFAR, USAID, World Bank, CDC, etc.)?

Dr. Holmes described the implementation science continuum which, in the CTSA rubric, has four phases:

  • T0 – identifying a challenge and developing funding sources
  • T1 – discovery, defining the new technology
  • T2 – assessing efficacy and developing a framework for the intervention end product
  • T3 – the actual implementation science – needs assessment, prioritization, establishing of policies, developing guidelines, and implementation including defining workforce, infrastructure needs, health system applications and training.

The Fogarty role? Dr. Homes suggested that the wording in the announcement for the Lifespan program might well be the core role for Fogarty: The proposed institutional research training program is expected to sustainably strengthen the research capacity of the LMIC institutions, and to train in-country experts to conduct research on chronic, non-communicable diseases and disorders across the lifespan, with the ultimate goal of implementing evidence-based interventions relevant to their countries.

Dr. Holmes commented on “program science,” which he described as bringing researchers and implementers together early on, to increase cooperation in reaching a common goal and to reduce conflicts that may occur when the two groups, with different objectives (the research product versus getting that product into use), try to reach a common goal. He observed that the NCATS has 61 CTSAs worth nearly a half billion dollars, that are mainly focused on the T0 and T1 phases of the implementation science continuum describe above. He suggested that this could be an opportunity to identify new science that is not too complex and has the capacity for product development and commercialization, and apply the T3 and T4 phases. He noted that NCATS cannot fund foreign researchers or institutions, but Fogarty can, and a partnership between the two could be very productive.

With regard to NIH/Non-NIH partnerships, Dr. Holmes pointed to the linked awards program, citing the example of a MEPI linked mental health award with the University of Washington, which is the only medical school for four states (Alaska, Wyoming, Montana and Idaho) and very rural in its scope, and apply the Washington model at the University of Nairobi. That model involves psychiatrists at the University of Washington working with health practitioners in the more remote areas who are not qualified psychiatrists.

Finally, Dr. Holmes briefly described a Washington PhD program in global health metrics (to measure progress in global health solutions) and implementation science (looking at a scientific approach to arrive at those solutions). Candidates take a number of courses in common plus electives in each track.

In closing, Dr. Holmes recommended a recent book by Ruth Levine, Case Studies in Global Health, for examples of successful implementation science.

Dr. Kristie Foley, Davidson College

Dr. Foley discussed a long-standing tobacco control program, the TOBAC Initiative, which focused on a central European region and Hungary in particular, where tobacco use was very high, around 35% of the adult population and a significant percentage of mid-teens (about 28%). There was little research available at that time, but in 1997 there was some early legislation that limited advertising of cigarettes and a clean air law was passed. In 2003, Hungary signed the Framework Convention on Tobacco Control, evidence that the country was in a limited way interested in the tobacco use problem.

Dr. Foley noted that she received a Fulbright grant in 2006 for a six-month study program in Hungary, and at the same time the TOBAC RFA was published. Deciding to apply for the grant, a group of ten in varied fields was assembled, and a research plan was developed – first, to advance science in the subject, and second, to create a cadre of scientists who would develop grist for tobacco control policies and programs in Hungary, and who would help implement programs that would be developed under the grant. Ultimately eleven projects were created to look at a variety of issues, including the ethnic Roma population, pregnant women, teen tobacco use, health systems studies, and legal and economic research.

There was also a capacity-building element, including training programs, mentoring and development of partnerships between U.S. and Hungarian scientists, formal training on how to effect translation of science into use, and encouraging publication of research outcomes. A definition of success was established early on, metrics for scientific output (publications), practice output (integration of results into educational curricula, clinical practice, continuing educations programs, and counseling centers), and policy output (legislation). Accomplishments in the last area included tobacco bans in certain public areas, nine excise tax increases during the initiative, and a comprehensive clean air law in 2012.

Dr. Laura Guay, Elizabeth Glaser Pediatric AIDS Foundation

Dr. Guay explained that preventing mother-to-child transmission of HIV does not require new science. PMTCT has been successful in the U.S, but far less successful worldwide. It is mainly about getting the message to women, often in remote areas, supporting adherence, and follow-up in areas that do not have established means to gather health information. Therefore, implementation science is the key to advancing PMTCT. One example of success in implementation is the Thailand ZDV studies (1996-1998). Only two years after the completion of the study, country-wide program coverage was accomplished, in part because of strong ties between researchers and policy makers that were developed during the study. The researchers began consulting with the potential implementers during the study.

Dr. Guay noted that, in Africa in 1999, sites that were able to implement programs were sites that had access to established research structures, where there was testing and counseling capability in place. But there were many places that did not offer that basic structure. To overcome some of this impediment, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) developed a program with three pillars – research, implementation and advocacy to influence policy change. An example of how that works is the collaboration with Georgetown Washington University established in 2007. It provides a vehicle for synergism between the academic environment and the EGPAF sites in 13 countries carrying out programs of research linked with implementation.

Dr. Guay described an award to look at rapid syphilis testing linked to PMTCT services in Uganda and Zambia. Collaborators included CDC for technical support and the London School of Hygiene and Tropical Medicine for data collection and analysis. The local programs provided the research base, with expertise from the collaborators and support from their ministries. In Uganda and Zambia, rapid syphilis diagnosis became a policy and standard. Although the usual scientific papers came out of the study, there were also shorter, focused policy briefs for busy policy makers who seldom read scholarly articles and papers.

In conclusion, Dr. Guay noted that there is a need to build capacity in the area of policy makers and program implementers; to help program researchers compete with academic researchers; and to build strong partnerships for implementation science research.

J. Stephen Morrison, Center for Strategic and International Studies, Center for Global Health Policy

Dr. Morrison commented on the significant change in attitude at the government level concerning global health, pointing to Secretary Clinton’s science-based AIDS-free generation speech in late 2011 and President Obama’s speech on World AIDS Day in 2012. There has also been a measured increase in global health-related travel by members of Congress and congressional staff. He expressed the thought that there should be a focus on how to advance global health science, and how to manage funding for that purpose. He also suggested that the field of endeavor should be narrowed to a few issues that offer the most opportunity for success, and some of those issues may need to me promoted in order to bring them into public awareness.

Dr. Morrison mentioned a report created by his organization that he had submitted to the Board, a review of U.S. global health policy during the past few years, and recommendations for the future. The authors of the report looked at HIV/AIDS, malaria, women’s health, polio, and the big multilaterals. He noted that there is evidence of broad public support for U.S. engagement in global health, and that global health has become an important part of American diplomacy.

Many participated in building the report – Hill staff, individuals in the Executive Branch, independent consultants, and scientists involved in applied research. The first step was to define the context of each chapter, identify problems to address, and create an intelligible description of the findings and recommendations.

The leadership in the government needs understandable information on global health. It was important to answer two fundamental questions – what are the policy choices and how would the policies be implemented. Dr. Morrison suggested that the upcoming meeting of the Consortium of Universities for Global Health would be a good forum to discuss some of these issues.

Discussion

During discussion, Dr. Tierney invited consideration of the difference between practice research and implementation. The former is a discussion of how things are done or could be done. Implementation science looks at cost-effective ways of delivering a research product. He felt there was a dearth of basic implementation science training. Dr. Shurin commented that, although there is reasonable knowledge of how to advance the field of noncommunicable diseases, the details of implementation are very much context-driven. They differ from region to region, environment to environment. The metrics must be meaningful to the local context. Mr. Handley observed that, as a researcher becomes a researcher-implementer, the implementation of the program often influences the direction of the research.

Mr. Handley noted that there has been an effort to develop a more cohesive NIH perception of implementation science, and program announcements have recently been re-issued, but there are very few globally-oriented applications. He added that NIH is in its third iteration of a training institute for dissemination of implementation research, which is mainly U.S.-focused, although there is some effort to involve the international community.

Dr. Holmes commented that Fogarty should consider whether or not to brand itself with a formal new program in implementation science. Dr. Cassell suggested that if that were accepted, it would provide an umbrella under which many other Fogarty programs could reside.

Concluding Comments

Dr. Glass offered a few observations in closing. First, there will be a retreat before the next Board meeting at which the topics discussed at the Board meeting would be included on the agenda. Second, implementation has to do with access to people, and it should be remembered that there are more cell phones than availability of running water in many LMICs – an entry point for mobile health as a part of implementation. Third, leadership in health diplomacy requires scientific information effectively packaged, and simplification of implementation targets could be powerful. Finally, in visits to Africa, it is clear that ambassadors are beginning to develop portfolios that include global health and, while they see the CDC programs and the military regularly, their contacts with the academic community are less solid. Those three groups of stakeholders should be encouraged to engage.

Dr. Glass expressed appreciation for the participation of those in attendance and closed the meeting.

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