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September 10, 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
Eightieth Meeting of the Advisory Board
Minutes of Meeting
September 10, 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, September 10, 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 on September 10 , 2013, prior to the open session meeting, 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 September 10, 2013 at 9:00 a.m., until adjournment at 2:00 p.m. Dr. Roger I. Glass, Director, FIC, presided. The Board roster is appended as Attachment 1.

Attendee Information

Board Members Present

Gail Cassell, Ph.D.
George C. Hill, Ph.D.
King Holmes, M.D., Ph.D.
Rebecca Richards-Kortum, Ph.D.
Michael Merson, M.D.
Bonita Stanton, M.D.
Bill Tierney, M.D.
Derek Yach, M.B.Ch.B.
Dr. Alan Guttmacher, NICHD (ex-officio)
Dr. Susan Shurin, NHLBI (ex-officio)
Tom Kenyon, CDC (ex-officio)

Board Members Absent

Michele Barry, M.D.
Barry Bloom Ph.D., D.Sc.
Adel Mahmoud, M.D., Ph.D.

Members of the Public Present

Jennifer Ellis
Wafaa El Sadr
Joeseph Kolars
Cynthia Lewis
Mary Fogarty McAndrew
Thomas McAndrew
Steve Morrison
H Sondberg

Federal Employees Present

Farah Bader, FIC
Danielle Bielenstein, FIC
Katrina Blair, FIC
Jason Bowman, Dept of State
Maggie Brewinski Isaacs, ORWH
Kevin Bialy, FIC
Kenneth Bridbord, FIC
Kasima Brown, FIC
Bruce Butram, FIC
Pat Lee Callahan, FIC
Lois Cohen, NIDCR
Dexter Collins, FIC
Jill Conley, HHMI
Robert Croyle, NCI
Ann Davis, FIC
Austin Demby, HHS/OGA
Mary Fanning, OGAC
Steve Gust, NIDA
George Herrfurth, FIC
James Herrington, FIC
Christine Jessup, FIC
Michael Johnson, FIC
Robert Kaplan, OBSSR
Flora Katz, FIC
Cathy Kristiansen, FIC
Linda Kupfer, FIC
Gabrielle Lamourette, HHS/OGA
Judy Levin, FIC
Yuan Liu, NINDS
Enid Light, NIMH
Patty Mabry, OBSSR
Paulo Miotto, OAR
Nora Volkow, NIDA
Kathy Ormanoski, NIAID
Emmanuel Peprah
Sybil Philip, NICHD
Vivian Pinn, FIC
John Prakash, NEI
Ann Puderbaugh, FIC
Myat Htoo Razak, FIC
Leslie Rowe, Dept of State
Maria Said, FIC
Luis Salicrup, NCI
Lana Shekim, NIDCD
Hillary Sigmon, CSR
Stacy Wallick, FIC
Melissa Wan, FIC
Kristen Weymouth, FIC
Liz Whittington, FIC
Laura Povlich, FIC

Closed Session

Open Session

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

Update

Dr. Glass opened the meeting and welcomed all present. He briefly reviewed the meeting agenda, noting that there would be a presentation by Ms. Nalini Anand on the Center for Global Health, an update of the Medical Education Partnership Initiative (MEPI), and a discussion about emerging research and capacity building priorities in global tobacco control. Dr. Glass announced that this year marked the 100th birthday of Congressman John Fogarty, and his daughter, Mary Fogarty McAndrew would speak to the Board later in the meeting. He expressed appreciation to her for the gift of three historic posters that will be housed in the Stone House. Finally, he congratulated Board member King Holmes on receiving the Gairdner Award, Canada’s highest science award. And he introduced four new Board members-elect – Dr. Steve Morrison (Global Health Policy Center), Dr. Joseph Kolars, (University of Michigan), Dr. Wafaa El-Sadr (Columbia University), and Dr. Ram Sasisekharan (MIT).

Dr. Glass mentioned several senior staff transitions. Dr. Maria Said has joined the Division of International Training and Research; Dr. Linda Kupfer has returned from a brief stint with OGAC; and Dr. Michael Johnson is with Fogarty part-time until next year, when he will become full-time. There was no May Board meeting, in part because of planning for the sequester.

Dr. Glass discussed a number of global health activities that have taken place since the last Board meeting. Fogarty has been working with other ICs to promote a coordinated global health agenda, and an important resource in that endeavor was the Fourth Annual Consortium of Universities for Global Health (CUGH) Conference held in Washington on March 14-16. Dr. Collins, NIH Director, delivered an address, as did the Directors of four ICs, including NIDA, NIAID, NCI and NHLBI, in addition to FIC. In the area of health diplomacy, about 20 Russian scientists came to NIH in May to participate in a workshop on pediatric diseases, and in early June Fogarty hosted a meeting on Cholera Control. Fogarty assisted the NIH OD with hosting a meeting of the Heads of International Research Organizations (HIROs) on June 10 at the Stone House. HIROs represents about 90% of the research funding in the biomedical sciences. The following day the Global Alliance for Chronic Diseases (GACD) met to examine how to develop an RFA for research on non-communicable diseases. Since there is limited funding in this area, coordination and cooperation are essential. Hypertension will be addressed first, followed by diabetes. Finally, in late June, there was a forum on new directions in global tobacco control. Tobacco was named by Bill Gates as the most important problem in global health today.

Turning to Fogarty’s Fellows and Scholars program, Dr. Glass noted that the number of participants, medical students, postdocs and Fulbright Scholars, had reached about 90, who would spend a year overseas in mentored research programs funded in part by 18 ICs. Five Fulbright scholars are supported by the Department of State in the Fulbright-Fogarty program. Dr. Glass invited board members who travel abroad to obtain the list of Fellows and Scholars and to contact them whenever possible in their travels. He added that Dr. Harold Varmus visited Fogarty Fellows associated with the Cancer Institute of the Chinese Academy of Medical Sciences on his trip to the Far East in March.

Dr. Glass briefly discussed his July trip to Africa, which included a site visit at the University of Nairobi, at which he observed the significant improvement through MEPI support in transforming the library, a room full of books on shelves, to a modern Internet-based e-learning center. The Coptic Hospital there, with AITRP funding and MEPI support, is now training medical students, including hands on treatment practice. Dr. Glass mentioned his visit to the Kenya Medical Research Institute, which hosts a number of NIH-supported fellows, and the nearby CDC laboratory housed on the same campus. His next stop was MOI University, followed by a visit in Kampala, all of which provided multiple examples of MEPI support and dedicated service by Fogarty Fellows.

In conclusion, Dr. Glass mentioned the next significant event on campus pertaining to global health, a visit by Bill Gates, who will present the Barmes lecturer on October 7. The IC directors will have time to talk to him about issues important to the Bill and Melinda Gates Foundation and global health in general. In the following months, through May of 2014, there will be numerous networking opportunities focused on informatics, mHealth, a brain disorders meeting and the next CUGH meeting.

Ms. Ann Puderbaugh provided a brief guide of the Fogarty Center website, highlighting the information available in the “About Fogarty” section, the Director’s page and the extensive funding opportunities section. Finally, Dr. Glass pointed to the link to the NIH World RePORT map that can be used to identify NIH activities all over the world. He concluded by inviting Board members and others to re-visit the Fogarty web site, which had been significantly updated, and includes a section on the latest news releases related to Fogarty and global health.

Discussion

Asked about the impact on Fogarty of the sequester, Dr. Glass commented that staff had been planning for the eventuality throughout the year and there were some cuts in long-term support, pay lines for grants and the number of grants awarded. Dr. Rosenthal added that there were some NIH-wide restrictions that resulted in cuts of about 5% to 10% and the limitations imposed on co-funders also affected the Fogarty funding decisions. Travel was significantly affected. Dr. Glass invited Ms. Nalini Anand to provide an update on the Center for Global Health Studies.

Update on the Center for Global Health Studies, Ms. Nalini Anand, Acting Director

Ms. Anand reminded the Board that the Center had been up and running for a year and a half. The Center is meant to be a trans-NIH resource; a hub for project-based scholarships in global health; a forum for international dialogs on science and collaboration; and a platform for short-term training. There are two major activity areas; a focus on implementation science and science policy, and the conduct of projects that are collaborative and result in concrete products that identify priorities in research and capacity building, and support the global health agenda. The Center tries to enlist not only support from other ICS, but from the outside partners, including other federal agencies, private foundations and private sector stakeholders. There is a proactive effort to involve scientists, implementers and policy makers from low and middle income countries to support the objective of producing useable and implementable products. Finally, there is an effort to design projects that cut across IC goals and objectives, and are multidisciplinary.

Ms. Anand commented that since the beginning the Center has tested several models – a training institute approach; a forum for consultations around a scientific theme; focused scientific programs that are followed by a writer’s retreat out of which come publishable papers; and a mechanism by which scientists and implementers are brought together to consider a focused scientific issue or theme. In the future the Center is interested in establishing a scholar- in- residence program, project-based mentoring programs, and a framework that would allow development of new tools and methodologies.

Ms. Anand reviewed the ten or so activities that have been sponsored or hosted by the Center during the last year, which have been diverse in terms of subject matter as well as participants. Many of those events, although only one or two days in duration, result in continued effort over months to develop a useful product. An example of a project was the March meeting on improving the practice of prevention of mother to child transmission (PCMCT) of HIV infection. Researchers, implementers, programmers and policy makers attended. A follow-up meeting will take place in South Africa in January. Another activity was the June meeting on new directions in tobacco control, a discussion of which is on the meeting agenda. Finally, there was a major program on HIV and non-communicable disease co-morbidities that included a symposium followed by a two-day writer’s conference and a funder’s roundtable.

In the future the Center will participate in the follow-up PCMCT meeting in January, a major brain disorders symposium with a writers retreat in February, a meeting in May on childhood obesity with a global slant, and a third PCMCT meeting in November.

Ms. Anand announced plans to establish a Center steering committee under the auspices of the Board, and invited Board members to consider participating as active steering committee members. Since there have been a number of successful projects, the Center is considering establishing a relationship with the NIH Director’s office. The product of those efforts could contribute to the evolution of the NIH global health agenda. Finally, the Center is putting in place an evaluation framework to begin to establish a data resource in terms of the contributions of the Center’s programs.

Comments by Dr. Leslie Rowe, Department of State on the newly established Office of Global Diplomacy

Dr. Rowe explained that the Office is very new, having been in existence since January and only being permanently and fully staffed since August. The primary goal of the Office is to make global health a priority in U.S. foreign policy. There are three important missions. First, to support our ambassadors and heads of mission so that they can work with their host countries to address health issues affecting the populations of those countries; second, to encourage country ownership of health agendas and programs and to strengthen the sustainability of global health programs around the world; and third, to encourage and support shared responsibility between the U.S. government and private sector investment and the bilateral and multilateral partners that we support.

Dr. Rowe recalled the PEPFAR experience, which was begun with one goal, to save lives, a goal that has been met with spectacular success. Today there are 5 million people in Sub-Saharan Africa on antiretroviral therapies (ART), compared to only 50,000 ten years ago. Another successful program was the result of research that indicated that male circumcision could reduce HIV transmission by 60%. However, Dr. Rowe commented, the funding environment is very different now and such programs need to move much more in the direction of country ownership, which involves not only paying the bill, but the country’s ability to plan, implement, manage, build capacity, monitor and evaluate its health programs. There are examples of success in that area – South Africa now finances its entire ART program; Namibia is paying for most of its health workers; and Uganda is taking responsibility for its lab research program.

Dr. Rowe noted that in April, in cooperation with the World Bank, the State Department convened a meeting of the ministers of health and finance of most developing countries to look at the issues related to country ownership. The Department is working closely with the Global Fund on the upcoming replenishment. Finally, the Department will support its diplomatic officers, especially the ambassadors, in promoting global health. The ambassadors have contact at the highest level and can get agreements signed; and the economic officers have contacts at the mid-level in ministries of health, finance, planning and development.

During discussion, Dr. Yach commented that the historical link between diplomacy and health programs is well known, but perhaps underused. He added that the PEPFAR example proves the efficacy of sustained, long-term investment in specific health care programs. He expressed concern that, in spite of the success of the tobacco control program, the federal government may not preserve that success by removing exemptions currently required by trade agreement that are being renegotiated.

Dr. Glass expressed appreciation for Dr. Rowe’s participation in the meeting.

Medical Education Partnership Initiative (MEPI) Update

Introduction, Dr. Myat Htoo Razak

Dr. Razak introduced the discussion of the MEPI program, which is in its third year, noting that the goal of the program is to strengthen clinical and research capacity in Sub-Saharan Africa by supporting transformative medical education. The primary outcome is to increase the quality and quantity of well-trained health care providers and faculty, who will remain in their home countries to provide health services and conduct regionally relevant medical research. PEPFAR provides $100 million in funding and NIH adds another $30 million for grants through 2015. There were 13 institutional awards in 12 countries, mainly in eastern Africa, from Ethiopia to South Africa. The MEPI program is managed jointly by HRSA and the Fogarty International Center.

Decentralized training is an integral part of the program since most of the population lives in rural areas, while most health care workers live in urban areas. Because of that information technology and communications (ICT) are important, so that eLearning and eLibraries are part of the curriculum at most universities. As well, faculty development is critical to providing the kind of training that is required to lift the standards of health care. Finally, MEPI has focused on research capacity building.

Dr. Joeseph Kolars

Dr. Kolars observed that the first important outcome is the expansion of networking and collaboration, not only between the African institution and its American counterpart, but collaborations that are being built among African institutions, including the ministries, and among the professional health care workers. It has taken the form of consortia among universities, and collaborations among research PIs in the form of a PI Council that has taken on a leadership role.

Second, there is a trend for ownership of the program to shift away from the early strong northern influence in awarding grants, to the increased influence of MEPI’s African colleagues. The schools and the PIs are seeking greater influence in what is transpiring in the program.

The third outcome has been the dramatic growing importance of eLearning in an environment where the technology has bypassed landlines and jumped directly to the cell phone technology. There are new models of disseminating education, testing the result, and activating the learners to obtain the education that is available.

Dr. Kolars mentioned some challenges. Sustainability is probably at the top of the list, which makes efficient use of funding more important, and demands that the grant dollar stretch further. Second, there must be a stronger focus on results, innovation in research, more publications from researchers, and generation of evidence that can demonstrate the effectiveness of the MEPI approach.

As well, the Africans must be encouraged to find their own solutions and not be influenced by the notion that the U.S. model of education is the best approach, nor by the traditional concept that measuring knowledge acquisition is a better indicator of success than measuring competence and understanding. The criterion should be what people can do with the education they receive under the MEPI program.

The MEPI Ethiopia Experience, Dr. Miliard Derbew

Dr. Derbew explained that MEPI-Ethiopia works with five U.S. investors and four Ethiopian investors. The system is both wired and wireless, offering up to 50 megabyte connectivity to the students and faculty. There is a computer lab that offers a laptop loan program so that students can use connectivity anywhere on campus. Faulty members are given personal laptops. The University installed Moodle, an online course management system, and eGranary, which contains 5 million pages of medical information. About a thousand tablets were purchased for distribution to students, and 1,300 more are on order. There are two types of tablets, brand name, which are more expensive but well tested in the market, and non-branded, which are less expensive, but as yet untested. The tablets function as small computers, have Internet connectivity, can load up to 100 textbooks, and work with the eGranary library. The MEPI tablets can also function with or without an Internet connection, which is critical when working in rural settings.

The anticipated long-term impact is to facilitate quality medical education during what will be a massive scale up. The tablets should also facilitate collaboration among medical students, and make possible more effective use of limited resources, such as faculty time. They could also solve the chronic textbook shortage.

Discussion – Dr. Glass

Dr. Glass observed that medical education curricula and content changes significantly about every five years. The use of tablets should make staying current easier for today’s MEPI students. Dr. Glass invited several MEPI partners present to comment.

Dr. Mary Fanning (OGAC) commented that there have been exceptional changes in many of the MEPI countries, although it may take more than the two remaining years to stabilize those changes. She mentioned three important issues. First, the impact of partnerships and collaborations has created a special environment in MEPI schools in which, although students are competing with each other, they still have developed a willingness to form partnerships and encourage cooperation. Second, the PIs and deans and faculty in the MEPI schools are leaders in their countries. The MEPI program has clarified opportunities as evidenced by Ethiopia’s program to train 20,000 physicians over a very short timeframe. And the program has developed access to the ministries giving the MEPI institutions an influence in policy matters. The last piece is sustainability and one aspect of that is the example of PIs who have integrated their innovations and curriculum development into their own institutions, and they believe those contributions will remain even if funding ends in 2015.

Dr. Chiliade commented that there is a challenge and an opportunity to document the success of MEPI. There is also an opportunity and perhaps an obligation to scale up the best practices and new approaches to education that have been developed.

Dr. El Sadr commented that her institution was privileged to be awarded a grant from a MEPI sister organization, the Nursing Education Partnership Initiative, NEPI. Clearly nursing skills are important to good health care. NEPI has focused on building partnerships with ministries of health, acting as the voice of the nursing profession, and helping to establish nursing councils in various countries. NEPI has also been working with certain nursing schools selected by a special council, and has efforts at capacity building, faculty development, curriculum development, and expanding student opportunities. There are good communications and relationships between MEPI and NEPI that will open up even more opportunities for collaboration.

Dr. Henry Sondheimer, representing the Association of American Medical Schools, commented that it is important to enroll all schools in Sub-Saharan Africa, which are in a phase of very rapid expansion, especially in light of the absence of francophone colleges in MEPI. Research in the past, in most schools, has been focused on communicable diseases, for obvious reasons, but the MEPI grants encourage young faculty members to consider medical education research.

Dr. Morrison posed a question for Dr. Derbew about two issues in Ethiopia. How does the program there cope with the explosive increase in newly minted physicians, which raises concerns about the quality of the education, and what is the solution to the crippling lack of Internet coverage in the country, which is estimated to be only three percent of the population. Dr. Derbew agreed that there was a significant increase in the number of medical schools operating in Ethiopia. Enrollment is currently 3,000 and the government has set a goal of 7,000. The Minister of Health is working to provide more tablets. Fortunately, the tablet does not require Internet connection; it is based on a LAN system, so when there is connectivity in the compound the tablets function. Nonetheless, Internet service in Ethiopia is beyond reach at the moment. He added that the LAN structure also limits the number of schools that can participate. Dr. Glass described a computer expert who visited Makerere and observed the very limited Internet access, but who worked around some of the issues that included problems with design – they were only using a small percentage of their capability because of poor routing design.

Emerging Research and Capacity-Building Priorities in Global Tobacco Control

Ms. Anand introduced the discussion, noting that, as mentioned earlier, a global tobacco meeting was held at mid-year at the Center for Global Health Studies. She noted that the session would include an overview of that meeting by Dr. Rachel Sturke, comments by Dr. Yach, and presentations by Ms. Cynthia Lewis (Bill and Melinda Gates Foundation) and Dr. Robert Kaplan (OBSSR) and Dr. Robert Croyle (NCI).

Dr. Rachel Sturke

The Center for Global Health Studies (CGHS) meeting in May on global tobacco control included an integrated evaluation component, suggested by Dr. Yach as a possible platform for reflecting on the ten-year history of the program. The purpose of the evaluation was to gain a better understanding of the International Tobacco and Health Research and Capacity Building Program, TOBAC.

History showed that in the late 1990s tobacco use shifted from high income to low income countries, and the latter lacked the capacity to address the issues, including health effects. After a number of consultations, in 2001, with NCI and NIDA as partners, the TOBAC program was launched as an RO1 grant program. The objective of the program was to build a network of global tobacco researchers to look at the issue in low and middle income countries (LMICs). The program simultaneously focused on research and capacity building, and more than 60% of the direct cost was required to be spent in the LMICs. From the outset TOBAC had a special relationship with the WHO Framework Conventions on Tobacco Control (FCTC).

Most of the awards are to U.S. institutions with international collaborators, but two were made to foreign institutions. Most of the studies relate to behavioral and intervention research, but some focus on policy and economics. There is a 50-page report on results to date, and over 400 publications have come out of the various components of the program. The CGHS meeting identified gaps in terms of economics and capacity building and an emerging issue was identified, the increased risk of women smoking. Dr. Sturke noted that the cornerstone of Fogarty’s programs is capacity building and, as part of that, over 3,500 individuals have been trained by long-term and short-term Fogarty grants.

Dr. Derek Yach, M.D.

Dr. Yach commented that epidemiology is the foundation of the study of tobacco use and control, and this often has to be based on an individual country’s experience because governments often do not trust data from other countries. Long-term studies are impractical and costly, but there has been some recent success in developing epidemiologic data from death certificates.

There is also a legal aspect to developing tobacco control programs. Agreements take time to negotiate, and treaties are even more challenging because there is always a transnational element to work through, issues like smuggling, counterfeiting, falsification, advertising, sponsorship and duty free issues.

When the Tobacco Atlas was begun it focused on surveillance and epidemiology. The World Bank released a report, “Curbing the Epidemic,” which had a positive effect on heads of state, ministries and development agencies in various countries. However, the World Bank did not see tobacco control as a high priority and another international agency, UNICEF, is strangely silent on the issue. A Michigan court case did expose the machinations of tobacco companies to thwart tobacco control programs, including some illegal activities such as bribery. That publicity had a chilling effect on countries that did not want to be exposed as unsympathetic to the efforts to protect public health. The CGHS meeting recommended a new look at the problem, which involves the design of tobacco products and their impact on fashion.

On the other hand, he noted the success of tobacco control in Africa where adult consumption of cigarettes, which peaked in 1980 at 80 packs per adult per year, subsequently dropped to half that amount by 2000. The imposition of excise taxes on tobacco products was an important incentive to quit. Even so, Chinese tobacco companies, that produce about 40% of all tobacco worldwide, enjoyed significant increases in common stock prices during the same period. Controlling these companies will be much more difficult than was the case for U.S. and European companies’ decades before.

There has been a decline in interest in tobacco control among journalists and in many foreign countries physicians continue to smoke in large numbers, often 60% or more in some areas. Governments focus more on policies versus campaigns that target individuals, perhaps because those governments feel that population-based approaches are a better option. Dr. Yach suggested that approaches involving behavioral economics should be considered, such as the study by Kevin Volpp that was recently published in the New England Journal of Medicine. But there is also data that indicates that all smokers are not created equal genetically, and that the higher taxes may only influence a segment of smokers, albeit that segment may be as much as half. More research and more evidence is needed, although it can be shown that an abundance of evidence does not necessarily influence the political process of policy making. The right evidence, offered repeatedly at the right time, can nonetheless impact policy.

Discussion

Dr. Volkow observed that anti-smoking campaigns consistently pursued over time have reduced smoking among teens by half, but the challenge is how to extrapolate that success into the global environment. Taking advantage of lessons learned and new technology may have a positive effect, and the social media will be an increasingly important messenger. In terms of making good use of research, the NGOs have been more effective at rapid evidence review and synthesis because they are able to function more efficiently and faster than the federal agencies. Dr. Yach agreed that social media could be an important tool, noting that a team of interns was commissioned to look at how social media might best be used. One thing they identified was the new “selfie,” a photo or video of the individual taking the picture. They reasoned that a campaign of “healthy selfies” might catch on, people taking pictures of themselves doing healthy things.

On the subject of taxes, Dr. Yach commented that most countries do not have tax rates that are high enough to impact use. Those countries need to analyze the impact on increased taxes to fully understand the value of considering them. The U.S. could also provide a study of the U.S. experience that might be useful to other countries.

Asked about the impact of eCigarettes, Dr. Kaplan stated that NIH would be funding 14 new tobacco research centers and part of their agenda will be to look at eCigarettes. He also mentioned the text messaging cessation trial that recruited 8,000 smokers in a very short time, revealing that such an approach to trials may offer incredible scale-up opportunities. In addition to information on eCigarettes, Dr. Yach suggested that brand-specific data should be collected to look at characteristics such as package design and messages that may be printed on the packs. Dr. Volkow observed that social media could be an effective way to collect knowledge about shared values among young people and to identify cultural issues.

The Bloomberg Philanthropies, Dr. Jenifer Ellis

Dr. Ellis described the Bloomberg Philanthropies ten-year tobacco control program, now in its seventh year. The focus of the $600 million program relies on six articles of the WHO Framework Convention on Tobacco Control, which have been labeled MPOWER:

  • Monitoring tobacco use and prevention programs:
  • Protecting people from risks, such as second-hand smoke;
  • Offering help to people who want to quit;
  • Warning the public about the risks of tobacco use;
  • Enforcing bans on advertising, promotion and sponsorship;
  • Raising taxes on tobacco products.

During the first seven years the program followed 15 countries representing two-thirds of the world’s smokers. For the remaining years the focus will be on five countries, representing half of the world’s smokers. Bloomberg funding is awarded to a significant number of grantee organizations through subgrant programs. The major partners that administer the subgrants are:

  • CDC Foundation - large global survey of adult smokers
  • Campaign for Tobacco-Free Kids – advocacy
  • Johns Hopkins Bloomberg School of Public Health – research
  • IUATLD - technical assistance to governments
  • WHO – support for the MPOWER program
  • World Lung Foundation – media support

There has been significant momentum to cover populations for at least one article under the FCTC MANPOWER program – currently about 2.3 billion are protected by at least one article, but nearly 4.7 billion are not covered. During the remaining four years Bloomberg will continue to focus on MPOWER. Litigation will become an increasingly useful tool, especially in the area of public policy advocacy.

Dr. Ellis commented that a number of issues must be addressed, including countering industry interference with tobacco control programs and policies; developing innovative funding mechanisms; and supporting forums such as the Fogarty Board’s session on global tobacco control.

Finally, Dr. Ellis mentioned the tendency of other funding entities to become complacent when large funders like Bloomberg and Gates are in the picture. That support is vital but not sufficient to overcome the issues related to global tobacco control. Finally, there must also be a way to develop an evidence base to evaluate effectiveness.

Bill and Melinda Gates Foundation, Cynthia Lewis

Ms. Lewis stated that the Foundation was established in 2000 and the tobacco control program was set up in 2008. The overall vision of the Foundation is to help people lift themselves out of hunger and poverty, and that has a direct impact on health. Tobacco is certainly a determinant of health outcomes. The Foundation is headed by three co-chairs – Bill and Melinda Gates, and Warren Buffet. Operational control is under a chief executive officer. There are five operating groups – global health; global development; global policy and advocacy; international policy, programs and advocacy (which houses the tobacco program); and U.S. programs.

The basic strategy for all programs is to target policy change, take advantage of social marketing, and develop an evidence base. There are four major policy areas in the tobacco program: tobacco taxes, graphic warning labels, indoor smoking bans, and advertising bans.

The Foundation operates in more than two dozen countries in Africa and Asia, and has dozens of programs funded through subgrants usually administered by principal partners such as the American Cancer Society, the Bloomberg Foundation, Emory University and WHO.

During discussion, Dr. Yach observed that the Gates Foundation is very involved in food and farming, which fits well with the fact that parity between food and tobacco prices is narrowing such that farmers may begin to consider which is more profitable.

Dr. Compton asked if the Gates foundation was involved with the issue of pregnant women and tobacco use, since the National Survey on Drug Use revealed that pregnant teenage girls have a surprisingly high rate of tobacco use. Dr. Bloch added that WHO has an interest in addressing smoking and second-hand smoke exposure in pregnant women, as well as children who are exposed to smoke in the home. Dr. Yach added that a study in South Africa revealed that tobacco was a major contributor to tuberculosis, and there are some studies that indicate that in some countries as many as 70% of tuberculosis patients smoke.

Concluding Comments

Dr. Glass closed the discussion by noting three aspects of the issue. First, tobacco as a health problem is not going to go quietly into the night and strong, consistent leadership is needed. Second, a solid evidence base must be built, and Fogarty has been consistent in its programs to include that part of the equation in its research. Third, the MEPI platform of forty schools training health professionals should produce a strong cadre of advocates.

Dr. Glass expressed appreciation to Kristen Weymouth and Rob Eiss for producing such a productive meeting, and thanked all present for attending and participating in the discussions.

Adjournment

The meeting adjourned at 2:00 p.m.

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