September 16, 2014 Advisory Board Meeting Summary Minutes

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 16, 2014

The John E. Fogarty International center for Advanced Study in the Health Sciences (FIC) convened the eightieth meeting of its Advisory Board on Tuesday, September 16, 2014 at 9:00 a.m., in Building 31, Conference Room 10, National Institutes of Health (NIH), Bethesda, Maryland. The closed session was held on September 16, 2014, 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 16, 2014 at 8:30 a.m., until adjournment at 2:30 p.m. Dr. Roger I. Glass, Director, FIC, presided.

Attendee Information​

Board Members Present
Roger I. Glass, M.D., Ph.D. (Chair)
Michelle Barry, M.D.
Wafaa El-Sadr, M.D., M.P.H.
George C. Hill, Ph.D.
King Holmes, Ph.D., M.D.
Joseph Kolars, M.D.
Michael Merson, M.D.
Stephen Morrison Ph.D.
Ted Trimble, M.D., NCI (ex-officio)
Greg Germino, NIDDK (ex-officio)
Walter Kotoshetz, M.D., NINDS (ex-officio)

Board Members Absent
Gail Cassell, Ph.D., D.Sc. (Hon)
Derek Yach, M.B.Ch.B. (Hon)
Bill Tierney, M.D.

Members of the Public Present
Douglas Heimburger, Vanderbilt Institute for Global Health
Sally Mouakkad, RCUK (British Embassy)
Carla Saenz, PAHO

Federal Agency Representatives Present
Nalini Anand, FIC
Farah Bader, FIC
Craig Bayes, FIC
Deshire Belis, NHLBI
Rick Berzon, NIMHD
Danielle Bielenstein, FIC
Rachel Bishop, NEI
Katrina Blair, FIC
Joel Bremen, FIC
Kenneth Bridbord, FIC
Bruce Butrum, FIC
Tina Chung, FIC
Janine Clayton, ORWH
Dexter Collins, FIC
Ann Davis, FIC
Michael Engelgru, NHLBI
Mili Ferreira, FIC
Dan Gerendasy, NLM
Christine Grady, CC
Zjeffrey Gray, FIC
Paul Gresham, NICHD
Tom Gross, NCI
Gray Handley, NIAID
George Herrfurth, FIC
James Herrington, FIC
Maggie Isaacs, ORWH
Flora Katz, FIC
Linda Kupfer, FIC
Vesna Kutleyic,NICHD
Judy Levin, FIC
Marya Levintova, FIC
Yuan Liu, NINDS
Thomas Mampilly, FIC
Jeanne McDermot, FIC
Kathleen Michels, FIC
Mark Miller, FIC
Joseph Millum, CC/FIC
Jin Park, OS/OGA
Vivian Pinn, FIC
Laura Povlich, FIC
Ann Puderbaugh, FIC
Myat Htoo Razak, FIC
Maria Said, FIC
Carolyn Sampselle, NINR
Lana Shekim, NIDCD
Hillary Sigmon, FIC
Barbara Sina, FIC
Marcia Smith, FIC
Rachel Sturk, FIC
Natalie Tomitch, OAR
Stacy Wallick, FIC
Melissa Wan, FIC
Liz Whittington, FIC
Kristen Weymouth, FIC
Mitch Wolfe, HHS
Celia Wolfman, FIC

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Director's Update and Discussion of Current and Planned FIC Activities

Dr. Roger Glass

Dr. Glass called the meeting to order and welcomed three new ex-officio Board members, Dr. Greg Germino, NIDDK, Dr. Walter Koroshetz, NINDS, and Dr. Ted Trimble, NCI. He added that Dr. Mitchell Wolfe, the new Deputy Assistant Secretary, OGA, HHS, might be attending later in the day.

Concerning activities since the last Board meeting, Dr. Glass noted that Dr. Collins had visited Brazil for the first time, participating in the largest scientific meeting there, conducted entirely in English. He also signed agreements with the Brazilian Ministry of Health and Ministry of Science and Technology to co-fund programs in AIDS, cancer and infectious diseases. He affirmed new partnerships with FAPESP and FAPERJ, significant research organizations in Sao Paulo and Rio de Janeiro respectively. One interesting project funded by FAPESP concerns anti-fungal research involving Brazilian ants that create an antifungal compound to protect their own environment. Finally, Dr. Collins met with 21 NIH alumni who are working in Brazil.

Dr. Glass noted that the Global Health Fellows and Scholars orientation took place in mid-July. In the last year the program has sponsored 91 individuals (40 U.S. postdocs, 30 LMIC postdocs, 19 predoctoral students and two foreign med students) working on a wide range of issues. Dr. Collins demonstrated his support by visiting the group during the orientation, and there was support from a number of the institutes that support the program.

Dr. Glass mentioned that he and Dr. Collins attended the Heads of International Biomedical Research Organizations (HIRO) meeting, and the Global Alliance for Chronic Diseases (GACD) Board meeting, both in Shanghai. The GACD's current joint call for applications is focused on diabetes, and the next call (2015-2016) will be on environmental lung disease.

In July, NIH and the Bill and Melinda Gates Foundation held a consultative workshop on global health R&D, which was a byproduct of the Barmes Lecture last year. The focus was on several healthcare areas – maternal and newborn health, HIV, malaria/TB and neglected diseases, plus capacity building.

In August, the White House hosted the U.S.-Africa Leaders Summit bringing leaders of several African nations to Washington DC to discuss the ties between the United States and one of the world's most dynamic and fastest-growing regions with the focus on trade and investment in Africa. There was not a strong emphasis on health care at the summit and Dr. Glass explained that to compensate for that lack, a DHHS "side event" was conducted on August 2 and 7 bringing together for the first time at NIH the presidents of Kenya, the Republic of Congo, Tanzania, Malawi and the vice president of Zambia, who represented the president who could not attend because of illness.

Next on the agenda was a visit to the MEPI annual meeting in Mozambique, which marked the fourth year of a five-year program. The MEPI program was covered in an issue of Academic Medicine, which included contributions from 225 authors in 32 articles. Fogarty staff developed a concept announcement intended to support the next steps in the MEPI program. That announcement is now on the Fogarty web site. An important focus area is West Africa, which needs more physicians and health care workers.

Dr. Glass stated that on July 24 he took advantage of a visit by Rwanda's Health Minister, Dr. Agnes Binagwaho, to invite her to attend the meeting of the NIH IC Directors, after which she provided a briefing of healthcare activities in Rwanda. He also commented on the work of Partners in Health who is working in Rwanda, mainly supported by private funds.

Dr. Glass commented that the Global Alliance for Clean Cookstoves has the goal of distributing a hundred million clean cookstoves, although there is still no solid research to validate the efficacy of the stoves, and there have been claims that biofuels would be less desirable than LPG and electric in lowering levels of indoor air pollution.

Dr. Glass noted that the ten-year anniversary of Global Health Sciences Program at the University of California, San Francisco (UCSF) was celebrated by a $20 million gift from philanthropist Chuck Feeney to build a new hub for Global Health Sciences at the UCSF Mission Bay campus. Fogarty is also involved with the second Get Health summit in Ireland which is looking at bridging the health care workforce gap in developing countries through partnerships with innovators in global health education and information technology. There will be a focus on the mobile health agenda.

Dr. Glass invited Nalini Anand to provide an update on the Center for Global Health Studies (CGHS). Ms. Anand noted that there was a February symposium on brain disorders, followed by a writers retreat; in April the African Journals Partnership Project looked at broader dissemination of information through the development of a dissemination tool kit. In July, the Center looked at adapting existing cognitive assessment instruments to culturally diverse environments in low and middle income countries. In August the JAIDS HIV/NCD co-morbidity series was published, and a steering committee, co-chaired by FIC Board members Wafaa El-Sadr and Bill Tierney, was established to look at enhancing HIV/AIDS platforms to include NCDs. The cookstoves implementation science network will meet in September, and in October a symposium on prevention of childhood obesity in Latin America will involve several ICs, CDC, OGA and PAHO. Finally, in January the Prevention of Mother-to-Child Transmission Network will meet. Ms. Anand clarified that the programs described are not interventional, and each of the projects result in a deliverable, usually a publication.

Dr. Glass reviewed future Board meetings in 2015, which will take place on February 9-10, May 11-12 and September 14-15. Ending his update, he introduced Dr. Douglas Heimburger from Vanderbilt University for a discussion on the impact of Fogarty's Global Health Fellows and Scholars Program. Dr. Glass noted that Vanderbilt was one of the first institutions to be associated with the program.

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The Value Added: Impact of the Fogarty International Clinical Research Scholars and Fellows Program

Douglas C. Heimburger, M.D., M.S., Vanderbilt Institute for Global Health

Dr. Heimburger commented that the Scholars and Fellows Program, originally called Fogarty-Ellison, began in 2004, offering postdocs from the U.S. ad LMIC countries an opportunity to take a year to conduct mentored clinical research. There were eight cohorts through 2012, and during the last four years, when the program was called the Fogarty International Clinical Research Scholars and Fellows program, each year it supported about 90 scholars and fellows studying abroad. There were 540 individuals involved, divided about equally between U.S. and LMIC students. Applicants increased steadily through 2008, then leveled off at about 150 applicants per year. By 2011 grant applications significantly increased, and almost all of the increase was attributable to noncommunicable disease research proposals. Dr. Heimburger commented that the scholars and fellows have been prolific in publishing articles, with 1,361 unique publications (534 as first author and 125 more as collaborative authors), and a substantial number of journals in which these articles are published are rated as high-impact journals.

Dr. Heimburger described a survey of a sample of scholars and fellows that had a 94% response rate. The survey revealed that, in that sample, 117 grant applications resulted in 79 awards, with a total value of $26 million. The survey also showed that 80% of fellows and 47% of the scholars returned to their original sites. Asked about the importance of their training experience, there was an indication that interest in global health research was increased, and there was an improved incentive to compete for grants.

In conclusion, Dr. Heimburger stated that the program has clearly contributed significantly to building the global health research work force (with the addition of 536 alumni); and that the program has exerted a major influence n the professional career trajectories of its participants.

Dr. Glass invited discussion from the Board, keeping in mind that there have been about 150 medical students who have graduated, and others who have moved on, and it is important to consider the value of the program to those individuals. Dr. Kolars suggested that some outcomes of the program might be the basis of speaking points for audiences such as the Congress. He also commented that the alumni of the program could be asked to expand on what they are doing in their careers, with the experience gained from the program, and whether it has increased the time they spend on global health and whether or not they feel their research has had an impact on global health. Finally, Dr. Kolars suggested that it would be useful to know when, after their training, they began to publish.

Dr. Merson asked if there was information on whether the fellows went into academia, and Dr. Heimburger indicated that the comprehensive survey showed that the majority are remaining involved in global health and in research. Although it was not easy from the survey to pinpoint where they were in their post-program activities, being in the research environment was the most prevalent response. In the "sliding scale survey reponses" it asked for the fellow's historical and current focus on research, which indicates that across all of the fellows it seems that about 70% of the fellows' time has been devoted to research. The same is true of the global health involvement. Other data from the survey showed that their experience in global heath significantly influenced future health positions. The fellows responses confirm that the program had a major influence on future career decisions.

Dr. Holmes noted that economics suggests that long-term payoffs are less influential than short-term payoffs (e.g., the immediate effect of circumcision in teens and adults versus a program to circumcise infants at birth). He wondered if the value of the training program for the younger scholars might be less impactful in terms of decisions related to focusing on the scholars versus the postdocs. Secondly, he asked about the emphasis on AIDS research and journal publications, and whether that had an effect on funding. Dr. Heimburger suggested that it was a question for Dr. Glass.

Dr. Barry noted that Fogarty has developed an extensive human capital resource. She asked if Fogarty would be able to continue to engage and support that resource. Dr. Heimburger agreed that there was now a significant community of alumni that are coming into their own in terms of global research leadership. Fogarty could help track that resource and maintain contact, although it might require increased funding support. Documenting capacity building would be an important contribution.

Dr. Razak, the program officer, commented that the systematic updating of the alumni is critical to future success, and the Board could provide counsel on how best to do that. Secondly, he noted that the number of publications on NCDs was increasing and keeping track of that new resource is not in the remit of Fogarty – Fogarty's charge is to support research. The discussion concluded that this would be another area where the Board's advice would be valuable.

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Fogarty Investment in Bioethics: Future Directions

Dr. Barbara Sina, Division of International Training and Research, FIC
Dr. Joseph Millum, Division of International Science Policy, Planning and Evaluation, FIC
Dr. Christine Grady, Department of Bioethics, Clinical Center

Dr. Glass introduced the session on bioethics noting that Fogarty had established the bioethics program ten years ago and it is currently being led by Barbara Sina. There is a current review going on. Dr. Sina explained that in 2000, when the first efforts were made to develop a bioethics review process, the availability of bioethics review was woefully lacking. Although a number of committees were created in the years prior to 2000, most were not functional and only one, South Africa was in operation continuously since its inception in 1990. Most LMICs in Africa created continuously-operating committees by 2004.

The first global forum, convened by the previous Fogarty Director and supported by the then NIH Director Dr. Harold Varmus, resolved to develop more training programs in spite of the fact that there was no clear career path in bioethics. At the outset the program established a goal to develop a curriculum targeted at professionals with master's degrees, with appropriate social and cultural components, and to create practical opportunities to apply the knowledge gained through the curriculum. The program also developed practitioners, health professionals and academics who could have an immediate impact in their institutions. Almost 600 individuals were trained in a wide variety of countries, although about half the funding went to African nations. In evaluating the results, an assessment revealed that before training only 23% of the trainees were involved in bioethics activities for more than half of their work time; after completing training about 53% were involved, and 95% were involved in some aspect of bioethics in their institutions.

Dr. SIna mentioned one very successful program, led by Clement Adebamowo at the University of Ibadan, that re-formed the National Health Ethics Committee, drafted legislation on bioethics that was passed by the legislature, established and trained 25 Nigerian bioethics committees (in almost every state), and helped develop the Ethical, Legal and Social Implications (ELSI) agenda in collaboration with the National Human Genome Research Institute at NIH. Finally, he helped design the ethical response to the Ebola outbreak in West Africa.

Dr. Millum described a meeting at the Center for Global Health Studies that brought together a number of grantees and bioethics experts to discuss the state of the art in five regional areas – Africa, Asia, Middle East, Latin America and Eastern Europe. It produced five papers covering those regions. The meeting examined cross-cutting themes in several broad areas including pedagogy (mentoring, distance learning and curriculum), cultural aspects (considering vulnerabilities that arise in approaching ethics in different cultures, and examining perspectives in South Asia and East Asia since issues differ in those two areas), and impact (assessing training materials and publications aimed at different populations, analyzing policies and programs in different political environments, and considering trainee development).

Looking more globally, Dr. Millum mentioned that research in LMICs has been increasing, and there are more players in the field – the Wellcome Trust, the European Union, and increased interest by NIH through the ELSI program and with new NIAID funding. Also, more countries are codifying human subjects protection systems and establishing formal regulations. There are still gaps including insufficient expertise in the LMICs about bioethics review; the dialogue about bioethics is dominated by high income countries and there is a tendency to focus support on English-speaking countries; there is a lack of institutional commitment and financial support; and ethics is not integrated into the whole of research.

Dr. Millum explained that in order to address the needs of ethics review in the future, the gaps already mentioned, the goals that are identified to fill those gaps, and the actions designed to achieve the goals, should be approached in a collaborative way, and not by Fogarty alone. The goals include insuring that there is one expert bioethicist in every LMIC bioethics committee, and a sustainable in-country capacity to maintain a bioethics research program at institutions within each country. Fogarty can contribute by continuing to support master's level training as well as doctoral programs, by identifying funding sources for bioethics training and review, and by enabling the integration of bioethics and bioethics review across the entire research spectrum.

Dr. Millum posed three questions for discussion: what are the most significant gaps in bioethics review and research in LMICs; what novel mechanisms could be proposed to support and sustain bioethics review and research; and how can Fogarty help? He invited Dr. Christine Grady and Dr. Saenz to begin the discussion. Dr. Grady agreed that there are too few bioethics experts in LMICs, and no partnerships to support the pursuit of the goals. She believed that Fogarty's experience and success in developing collaborations would be critical to putting those partnerships together. The kinds of issues related to this are not unique to Fogarty's experience, but capitalizing on Fogarty's reputation would make the job a lot easier.

Dr. Saenz agreed, adding that the progress made in the LMICs in bioethics review and training can in large part be credited to Fogarty support. She also agreed that training at the master's and doctoral levels is important, but it is also important to include in that focus individuals who are perhaps just researchers, practicing physicians or who are members of IRBs, to make sure that a familiarity and understanding of bioethics review is widely understood. She also commented that including ministers of health and other government agencies is important.

Dr. Merson conceded that Duke has faced challenges in dealing with bioethics review. He asked if the goals articulated earlier were to develop a cadre of bioethics scholars, with advanced degrees in bioethics, or to insure that there are individuals with a competency in bioethics review, for example, on IRBs. Dr. Kolars added that his institution has been trying to mainstream bioethical thought into projects. For example, global health research fellows must be able to identify bioethical issues in their work.

Dr. Barry commented that the research review boards in LMICs are very slow mainly because they don't have the capacity to process all of the projects. Third, there is a significant migration of research overseas, mainly by pharma, and the ethics issue in that area should be addressed. And fourth, research in the field is often subject to change that puts a strain on ethics review, especially by IRBs who are operating at a distance. Finally, Ebola research is a special challenge.

Dr. Holmes offered several comments. Leading journals have required contributors to identify where trials have been conducted and the bottom line has been that only a nominal 3% increase was seen in trials being conducted in Africa, and a 10% increase in trials in the U.S, Europe, and Latin America, but a 450% increase in trials conducted in Asia, perhaps because that is where the market or the products resides. Concerning the shift to Asia, the Western IRB brings in individuals from Asia for experience in IRBs, but most of them resist involvement in Africa. Third, one Fogarty fellow who returned to Kenya became the research director of the Kenya Medical Research Institute, and the IRB there was so dysfunctional that she independently got a master's in bioethics to run that IRB's bioethics review. Next, Dr. Holmes noted there is a difference between research ethics and bioethics research. Doing research on bioethics has its own approach. Finally, there has been a lack of coordinated reviews when multi-country studies are involved.

Dr. Koroshetz noted that the local IRB is the key player in successful ethics review, and it would be constructive if there was a mechanism to connect the local IRB's in LMICs to bioethicists in the U.S. in a consultative way. He added that an organization called the Alliance for Clinical Research Excellance and Saftey (ACRES), whose mission includes improving the ethical level and integrity of clinical research, might be a helpful partner. Dr. Monahan commented that, although the tax-like contribution suggested by Dr. Glass would be a helpful approach to funding support, that approach would have to be carefully tailored to the culture of the individual country. He added that small contributions from a broad range of sources would probably be more successful.

Dr. Morrison commented that the Ebola crisis offers a leadership opportunity for Fogarty, but also significant challenges in terms of bioethical issues related to providing low-tech options in that environment. Finally, Dr. Holmes suggested recruiting individuals for IRB service who have had global health training. He added that there is also the issue of defining research versus program evaluation or needs assessment.

Dr. Glass noted that at NIH there is a continuing education program to keep leadership updated on ethics review, including required online refresher sessions, and the mechanics of that process may be appropriate to the global bioethics training efforts.

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Research to Guide Practice: Enhancing HIV/AIDS Platforms to Address NCDs in Low Resource Settings

Dr. Linda Kupfer, Center for Global Health Studies, FIC
Dr. Wafaa El-Sadr, Columbia Mailman School of Public Health, Board Member

Dr. Kupfer explained that the project relies on research to support practice in the field, and focuses on the HIV/AIDS platforms to address NCDs in low resource settings. The goal is to convene researchers, implementers, policy makers and government representatives to articulate practical approaches to take advantage of the AIDS experience to address the NCD burden. Dr. Kupfer showed that the burden of noncommunicable disease increases with age. She compared the HIV/AIDS burden of a very few percent of total disease burden with the 40% noncommunicable disease burden, and the disproportionate funding that put about 30% of total funding into HIV/AIDS and less than half that into noncommunicable diseases.

Dr. Kupfer described the project support, which was $1.5 million from PEPFAR and a matching amount from Fogarty, for a two-year project started in September 2014, with an inaugural face-to-face meeting. The structure of the project is headed by a Secretariat, guided by a steering committee co-chaired by members of the FIC Advisory Board, Drs. Wafaa El-Sadr and Bill Tierney, and an interagency technical working group that will develop the project's agenda. These three groups will contribute individuals to be members of three proposed track operating groups – health systems, clinical and disease issues, and awareness and information dissemination. Frameworks have been designed for each of the three track operating groups. Dr. Kupfer invited the Board to consider recommendations, including additional stakeholders who might have been overlooked, suggestions for topics to focus on and for products that might be delivered.

Dr. El-Sadr invited discussion by the Board. Dr. Barry suggested looking at linked awards to NCDs, since much of the awards were funded by PEPFAR and the PIs on those awards might be appropriate partners. Dr. Kupfer clarified that the initial patient base for the NCDs would be the AIDS cohorts developed through the PEPFAR HIV/AIDS program. After that other populations would be considered. Dr. El-Sadr commented that the focus would first be on the HIV/AIDS infected populations to garner lessons learned and develop strategies for the NCD population. Dr. Holmes asked if the program would be limited to the co-morbidities of HIV/AIDS. Dr. El-Sadr explained that funding would be from PEPFAR, and the population would be composed of individuals with HIV/AIDS who are aging and beginning to experience NCDs such as hypertensions, heart disease and so on. The co-morbidities would be part of that health profile.

Dr. Glass expressed appreciation to Dr. El-Sadr and Dr. Kupfer for the presentation and recessed the Board for lunch.

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Evolving Landscapes in Academic Global Health Research and Research Training

Dr. Flora Katz, Division of International Training and Research, FIC
Dr. Mike Merson, Duke University
Dr. King Holmes, University of Washington
Dr. Joe Kolars, University of Michigan Medical School

Dr. Glass invited Dr. Katz to introduce the session discussion. She posed three questions for consideration:

  • How has the landscape for global health research and research training changed in the last five years?
  • What are the greatest needs going forward?
  • Are FIC programs structured to accommodate these changes?

NIH received a large number of unsolicited grant applications, and in areas where NIH sees a need invitations for proposals are published. Of the total NIH-funded grants, about 80% fall into the unsolicited category, and about 10% to 30% are targeted.

Fogarty's broad interests are mainly in global infectious diseases, HIV training and NCDs. There are also focused programs and gaps that must be addressed, such as the bioethics discussed earlier, and others like TRAUMA, GEOHealth, and research in various areas (e.g., tobacco and mHealth). It was also noted that within Fogarty funding is equally divided between targeted and unsolicited grants.

The question of whether Fogarty has stayed "ahead of the curve" is answered in three areas. Fogarty established a formal implementation science program ten years ago, at about the same time the noncommunicable and chronic disease program was set up. In zoonotic diseases, Fogarty initiated a program in ecology and evolution of infectious diseases in 2000, became involved in One Health and RAPIDD, and recently started an innovation program in Mongolia where animals are an integral part of the human environment. Dr. Katz mentioned the importance of including programs related to venture capital, which at Fogarty include mHealth, Framework Innovations, eCapacity and GEOHealth. She invited Dr. Merson to make the first comments.

Dr. Mike Merson

Dr. Merson stated that his charge was to discuss, from the university perspective, how the landscape in global health has changed. He cited a number of significant changes, including the fact that student interest in global health careers has grown dramatically in the last few years; more universities are setting up graduate and undergraduate courses and programs in global health; there is more faculty involvement (but not enough) in public health and medicine; and in an area that needs more consideration there is diversity in terms of location, resources and funding. Universities are also beginning to establish overseas presences in terms of a physical presence and built infrastructure, but many universities choose already "clogged" sites, like Makarere or University of Cape Town. Finally, there is an expansion of university-based global health programs not directly affiliated with the U.S. universities, such as the recent ten-university consortium in China, and networks among universities in other countries.

Dr. Merson commented on the changes in the research agenda over the past five to ten years, which has seen an increased focus on the NCDs, in health care delivery (health systems, implementation science) and innovation, both in services and technology. He suggested another important research need in zoonotics - animal-human health interaction. He cited a statistic that bats, vectors for a number of serious diseases, compose one-sixth of the world's mammals. With regard to globalization of faculty, Dr. Merson noted that there has been a significant increase in investigators conducting research in the LMICs, which creates a different tension between research in the north and the south, in ownership of data and authorship. There will be new challenges in how to balance careers of investigators in the north and in the south. Finally, Dr. Merson asserted that universities are becoming better at providing the infrastructure to work abroad in IT, legal and financial support, and dealing with ethical and compliance issues.

Lastly, Dr. Merson commented that funding across the board has improved, from philanthropists and foundations, from middle income countries (like China, India, Brazil), and from increased interest by NIH institutes and other government agencies.

Dr. King Holmes

Dr. Holmes observed that funding for global health has steadily increased for the past 25 years, despite the recent drop in NIH funding of about 30%. A large number of universities have become involved in global health, mainly in education programs and training foreign nationals (e.g., exchange programs). The focus has also shifted from infectious diseases, a specialty that does not earn professionals nearly as high an income as NCD specialists, and then involves significant research for which funding is decreasing.

Dr. Holmes presented the model of the Center for AIDS Research (CFAR), which ten years ago began adding more institute support to the point where today there are nine institutes involved plus the Fogarty International Center. The structure of the CFARs begins with a steering committee which oversees the process, the multiple institutes that provide funding to extramural research projects, which in turn provide support to CFARs.

Dr. Holmes described five consortia, each including four universities, that support the Global Health Program for Fellows and Scholars, and an RFA designed to enhance research in an area including NCDs. However, there was a limiting condition for 2014-2015 that funds be awarded to trainees in AIDS-related research.

Dr. Joseph Kolars

Dr. Kolars noted that his institution was innovative about the art and science of collaborations and the development of partnership platforms. Often an individual or small group or department, rather than a specified program, drives the success of a collaboration and identifying such partners is key to ultimate success. He cited the example of an early University of Michigan project in Ghana that generated a number of collaborations, including an emergency medical program with MEPI, and another in China with the Peking University Health Science Center. In the latter case the partner was identified first and the details of the program were developed later. China was so impressed there was an offer of $17 million in matching funds, which Michigan was able to fund. There were other projects in India, Brazil and Ethiopia.

Dr. Kolars explained that the first step is to design the charter of collaboration, a framework for working together, before addressing the details of an RFA or program. Dr. Kolars noted that funders have appreciated this innovative approach. There is also a reticence to build into the partnership framework any commitment to bricks and mortar. Dr. Kolars felt that this approach was complementary to the Fogarty mission statement that includes "building partnerships between health research institutions in the U.S. and abroad."

Discussion

During discussion Dr. Merson mentioned Duke Medical School's collaboration in Singapore that was completed at the invitation of the Chinese government, supports a medical school that has become a significant factor in global health education, and includes master's programs in environmental health, health systems, and in chronic disease research. Dr. El-Sadr reported on Columbia University's eight global health centers around the world that have become hubs of research and training. She noted that they were co-funded by NIH and some foundation money. Dr. Kolars added that there is a prestige factor when NIH co-funding is part of the package.

Dr. El-Sadr commented that, although students are enthusiastic about participating in global health training, it is not clear that the experience instills a lasting interest in global health careers, especially involving undergraduates. Dr. Holmes noted that his institution tracks nearly a thousand graduate degree alumni, and in that advanced degree population there is a high percentage of employment in global health. The undergraduate programs are too new to provide reliable statistics.

Mr. Monahan commented that at Georgetown University there is significant interest in global health, including a focused global health master's program. He added that a substantial number of science and technology students strongly identify with global health interests. He felt that undergrads may be less interested in global health, per se, than with global citizenship. Dr. Merson agreed, noting that about a third of medical students have an overseas component in their education (at Duke it is two-thirds). But there is a need to overcome the traditional tourism effect of study abroad and redirect the student's interest into a more serious consideration of global health as a possible career choice. There was also a study of residents who completed rotations abroad, but only ten percent or so felt that the experience would directly impact their global health careers.

Dr. Glass said that there should be consideration of broadening the scope of the effort to include others not as well represented, such as engineers, lawyers and business people. Dr. Merson commented that the FIC Framework One program was an effective approach and a program like that might be constructive. Dr. Holmes commented that the need might include an effort to get universities who are engaged in the global citizenship approach to focus more on global health. Dr. El Sadr added that support for training and education abroad is not robust, especially in mentoring, and NIH mechanisms don't appreciate that. There is a need for more support for mentor training.

Dr. Holmes stated that one CFAR he reviewed has been awarding grants of $30,000 to $50,000 to fellows in LMICs, but they are not able to obtain follow-on funding or employment, which is a significant problem.

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Adjournment

Closing Comments, Dr. Glass

Dr. Glass expressed appreciation to the Board members and guests for their participation and insightful and valuable dialogue. He confirmed that there would be more evaluation of the comments related to the various overseas experiences of the fellows and scholars. The bioethics program review was informative and there were some clear ideas about partnerships, and the difference in training scholars and practitioners. As important as the huge platform created by PEPFAR to care for HIV/AIDS patients has been, the collateral advantages that the platform offers to looking at other health problems, such as noncommunicable diseases, may be equally important. The last panel confirmed the expansion of the global health agenda on university campuses.

Dr. Glass thanked everyone for their attendance and contributions, and adjourned the meeting.

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