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
Eighty-first Meeting of the Advisory Board
Minutes of Meeting
February 10, 2015
The Cloisters, Building 60 Conference Room
National Institute of Health, Bethesda, MD
The John E. Fogarty International Center for Advanced Study in the Health Sciences (FIC) convened the eighty-first meeting of its Advisory Board on Tuesday, September 16, 2014 at 9:00 a.m., in Building 60, Conference Room, National Institutes of Health (NIH), Bethesda, Maryland. The closed session was held on February 10, 2015, 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 February 10, 2015 at 8:30 a.m., until adjournment at 3:00 p.m. Dr. Roger I. Glass, Director, FIC, presided. The Board roster is appended as Attachment 1.
Attendee Information
Board Members Present
Roger I. Glass, M.D., Ph.D. (Chair)
Michelle Barry, M.D.
Janine Clayton, M.D. (ex-officio)
Wafaa El-Sadr, M.D., M.P.H.
Greg Germino, M.D. (ex-officio)
George C. Hill, Ph.D.
King Holmes, M.D., Ph.D.
Vikas Kapil, M.D. (ex-officio)
Joseph Kolars, M.D.
Walter Koroshetz, M.D. (ex-officio)
Michael Merson, M.D.
Stephen Morrison Ph.D.
Bill Tierney, M.D.
Ted Trimble, M.D. (ex-officio)
Board Members Absent
Rebecca Richards-Kortum, Ph.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 Barger, 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
Pat Lee Callahan, FIC
Tina Chung, FIC
Lois Cohen, FIC
Dexter Collins, FIC
Jill Conley, HHMI
E.A. Davis, FIC
Anna Ellis, FIC
Michael Engelgau, NHLBI
Mili Ferreira, FIC
Tom Gross, NCI
Gray Handley, NIAID
George Herrfurth, FIC
Maggie Isaacs, ORWH
Christine Jessup, FIC
Robert Kaplan, AHRQ
Flora Katz, FIC
Linda Kupfer, FIC
Vesna Kutlesic, NICHD
Marya Levintova, FIC
Yuan Liu, NINDS
Thomas Mampilly, FIC
Jeanne McDermot, FIC
Kathleen Michels, FIC
Mark Miller, FIC
Joseph Millum, CC/FIC
Jerusha Merugen, FIC
Vivian Pinn, FIC
Laura Povlich, FIC
Ann Puderbaugh, FIC
Myat Htoo Razak, FIC
Lana Shekim, NIDCD
Hillary Sigmon, FIC
Barbara Sina, FIC
Maria Smith, FIC
Rachel Sturk, FIC
Natalie Tomitch, OAR
Stacy Wallick, FIC
Melissa Wan, FIC
Kristen Weymouth, FIC
Mitch Wolfe, HHS
Celia Wolfman, FIC
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Closed Session
Open Session
Director's Update: Current and Planned FIC Activities
Dr. Glass called the meeting to order and welcomed all present. He noted the passing of Dr. Richard Krause on January 6 at the age of 90. He had a long and distinguished career at NIH, first as Director of NIAID followed, by a brief retirement when he served as Dean of Medicine at Emory University, then returning to NIH as a Senior Scientific Advisor to Fogarty from 1989 until his death.
Dr. Glass also announced that Dr. Don Lindberg, long-time director of the National Library of Medicine, would retire in March. He serves as an ex officio member of the Fogarty Advisory Board. He also mentioned the retirement from the Board of Dr. Gail Cassell and Dr. Derek Yach. They both provided valuable experience not only in science but from their backgrounds in business. Dr. Glass welcomed, as ex-officio members, Dr. Janine Clayton, from the Office of Research on Women’s Health, and Dr. Vikas Kapil, from CDC’s Center for Global Health. He noted the important role Dr. Bill Tierney was playing as the FIC representative on the BD2K Multi-Council, which is involved in dealing with big data sets. Finally, he mentioned the “Toast and Roast” celebration at the University of Washington (UW) for Dr. King Holmes, marking his tenure as Founding Chair of the UW Department of Global Health and his retirement from that position to take on the responsibilities as UW Director of Research and Faculty Development in the Department of Global Health.
Dr. Glass recognized Ann Puderbaugh’s role in ramping up the Global Health Matters newsletter and the FIC website, which has grown dramatically in terms of visitor hits, now numbering in the tens of thousands each month. She explained that the activities of each Institute and Center involved in global health are covered on the website and in the newsletter. Laura Povlich, who has been covering Fogarty’s mobile health programs, supported the second GETHealth Summit in Ireland in November. Dr. Glass mentioned that he had participated in the World Health Summit in Berlin, and an important message from that meeting was to encourage European governments to consider investing in MEPI programs in Africa. The Germans are setting up a parallel program.
Since there was interest in Fogarty’s role in the West African Ebola outbreak, Dr. Glass referred to an article in Global Health Matters in which he stated that a modest investment in health infrastructure and health care provider training could produce excellent results in interrupting the spread of Ebola, and the Fogarty-supported MEPI programs in Africa have accepted the challenge to respond to new outbreaks. Cecile Viboud published the first article on modeling case containment based on a Nigerian infection, and other FIC staff have added 16 more papers in the past six months.
In the area of environmental pollution, Dr. Glass pointed to the meeting of the Global Alliance for Clean Cookstoves (GACC) in late 2014, which convened almost a thousand stakeholders. The GACC Director, Radha Mittiah, has set a goal of 100 million families using clean cookstoves by 2020. Dr. Kirk Smith, who is on the agenda to discuss clean cookstoves, published an editorial advocating development of LPG, natural gas and electricity to displace the use of fuels that pollute. Dr. Glass noted that eight NIH institutes have weighed in on clean cookstoves programs.
Another area of interest mentioned by Dr. Glass was the Global Alliance for Chronic Diseases (GACD), which began a program two years ago to reduce hypertension, and a second call is going out this year to address diabetes and perhaps develop a global agenda for research. The upcoming call is on lung disease caused by a variety of pollutants including air pollution, smoking, and household pollution from indoor cookstoves. Finally, the GACD is discussing two potential future calls, one focused on mental health and the other on scaled-up hypertension, perhaps through policy and regulations.
Another area of interest described by Dr. Glass is Fogarty’s focus on building overseas partnerships, which began a few years earlier with agreements with the BRICS (Brazil, Russia, India, China and South Africa) countries. This year NIH Director Dr. Francis Collins visited Brazil to negotiate a partnership that covers topics of mutual interest. Within this agreement, NIH funds at the 50% level, any institute can participate with no prior financial commitment, and NIH will provide the peer review. One of the more active Brazilian partners is the Sao Paulo Research Foundation (FAPESP).
Dr. Glass stated that Australia became interested in the Brain Initiative and worked out a partnership, committing $40 million to collaborative research with NIH. Dr. Glass mentioned his recent trip to Taiwan, where the Minister of Science and Technology indicated an interest in partnering with NIH and financially supporting Taiwanese researchers. There are 250 members of the National Academy of Taiwan who live in the U.S. and who would be excellent research partners.
Dr. Glass briefly discussed the possibilities that have arisen as a result of President Obama’s policies with regard to Cuba. For the first time in 50 years, U.S. scientists can discuss science with Cuban scientists, and there is the possibility that U.S. scientists may be able to attend scientific conferences in Cuba. A small step has been the licensing of monoclonal antibodies against cancer that have been licensed from Cuba. These are all very early steps, but the Departments of State and Treasury are working to increase access. Dr. Morrison mentioned another breakthrough happened when Cuba sent almost 300 doctors and nurses to West Africa to staff a treatment center in Nairobi that was built by USAID.
Dr. Glass commented on activities in India, which had been damped down by government policies related to clinical research and clinical trials, in part because of concerns about risk and liability related to those trials. Finally, after two years, on January 14-16, Dr. Collins was able to lead a delegation to India to discuss the future with Indian health officials. That visit was followed in late January by a visit from President Obama with the Indian prime minister. NIH offered some ideas for partnering including cancer research, vaccines, antimicrobial resistance, climate change, and air pollution. Another critical issue for India is the very high mortality from rotavirus, about a quarter of all death worldwide. This partnership is contributing to the development of a dollar-a-dose vaccine, which would have an enormous impact on reducing those deaths.
The MEPI Principal Investigators Council met in January when new funding was announced. There have been 17 grant applications received from 11 countries, and the Board can expect to review the applications at the May meeting. The grants are supported by eight ICs. The last meeting on the current grant will be in July in Zimbabwe. OGAC is reviewing a request to extend the PEPFAR portion of the grant.
In other activities, Dr. Glass commented that Secretary Burwell, who was associated with the Gates Foundation before becoming Secretary of DHHS, visited on January 29, and assured Dr. Collins that global health will be a very high priority. Gerry Keusch, former director of Fogarty, will host the 6th annual Consortium of Colleges and Universities for Global Health (CUGH) in Boston on March 26-28. The Consortium is a strong advocate for global health. On the agenda is a session with the Fogarty Fellows and Scholars.
In conclusion, Dr. Glass briefly mentioned several other activities, including the revival of the Global Forum on Bioethics in Research, which was established in 2003, but became relatively inactive by 2008 because of lack of funding. It will be re-launched under the aegis of HIRO in 2015, with funding from Gates and the Wellcome Trust. Finally, at a meeting on April 29-30 entitled Landscaping Global Health Research Investments, NIH and the Wellcome Trust will offer an agenda including addressing data needs, enhancing WorldRePORT, and looking at communications
Update on the Center for Global Health Studies, Nalini Anand
Ms. Anand presented a timeline of activities at the Center, beginning with the October 2014 meeting on Prevention of Childhood Obesity in Latin America. A supplement to the American Journal of Clinical Nutrition will be one product of that meeting. Then the Prevention of Mother-to-Child Transmission meeting was held in South Africa in January 2014. That PMTCT meeting brought researchers, program implementers and policy makers together to discuss interventions. The stakeholders needed to establish the interventions. In March, thinking that the PMTCT model might be appropriate to the brain initiative, the Center will sponsor a meeting entitled Global Brain Disorders Research: Thinking Forward to Implementation. In April the Center will host the Research Funding Mapping process (with Wellcome Trust and members of HIRO). Also in April will be the launch of the Clean Cooking Implementation Science Network. In May the final PMTCT Alliance meeting is planned, and in June the Nature Supplement: Brain Disorders in LMICs will be released. Also in June the Center will host the annual meeting on disseminating African science, an African journal partnership project, which Linda Kupfer will lead. A dissemination toolkit is being produced for journals interested in expanding their readership beyond the traditional subscribers and into the policy maker and health worker communities. Finally, Board members Bill Tierney and Waffa El-Sadr will host the second annual meeting on a Research Guide to Practice – Enhancing HIV/AIDS Platforms to Address NCDs.
Dr. Glass expressed appreciation for Ms. Anand’s report, noting that the Board would review the activities of the Center for Global Health Studies in greater depth at the May Board meeting. He concluded his report by thanking Kristen Weymouth for her yeoman’s service in keeping the Board running, noting that the next Board meeting would be May 11th and 12th.
Concept Clearance, Dr. Flora Katz
Dr. Katz announced that this concept clearance was included in the agenda because of the importance of facing NCDs in LMICs. Fogarty has worked on the issue for 14 years, conducting five training programs and awarding 91 training grants, which have supported almost a thousand trainees in 45 countries. The last broad NCD program, NCD Lifespan, has just completed its last competition and has been paused so that an evaluation of the program and the changing funding landscape of NIH can be assessed. Committing to that program would establish an eight-year obligation. Therefore, Dr. Katz explained, this alternative concept is presented for Board consideration.
The purpose of the proposal is to increase capacity for NCD research in LMICs, to provide opportunities for former trainees, and to support locally-relevant exploratory research. The latter speaks to the reality that relevant research is not always the same in the various countries. This proposal would encourage relevant NCD and injury research; focus on implementation science; promote cross-cutting studies, and provide a research nexus for non-communicable and infectious diseases. The R21 grant mechanism, a two-year award, was selected, excluding research programs that would be duplicative. The grant life allows an interim evaluation in two years.
Dr. Glass thanked Dr. Katz for the clear description of the proposal and invited Board members to direct questions and comments to Dr. Katz.
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Impact and Direction of the Fogarty International Trauma and Injury Research Training Program
Dr. Myat Htoo Razak, Program Director, Division of International Training and Research, FIC
Dr. Razak provided a brief background of the Trauma and Injury Research Training Program, noting that over 5 million die each year from injuries, almost twice the number of those who die from AIDS, TB and malaria. Millions more are injured (WHO 2014 data). The leading cause is traffic accidents, killing 1.2 million and injuring up to 50 million. Traffic fatalities account for 24% of all deaths, followed by suicide (16%) and falls (14%). Falls alone cause more deaths that all war/crime related deaths.
Looking at NIH-funded research, Dr. Razak compared funding for health-related research and injury-related research – the latter is at the bottom of the funding scale. He noted that Fogarty started a program in 2004 focused on injury-related mortality and morbidity in LMICs, to provide research training on diagnosis, prevention and treatment related to injuries. The goals of the program included developing research training programs, strengthened capacity, and the development of a cadre of research experts to address the situation. At the beginning Fogarty was able to fund 12 grants of about $160,000 each in 12 countries. In the most recent round only six similar grants could be funded because of budget constraints. The grants were focused on a broad number of interests – pediatrics, violence against women, war and crime, road traffic injuries and others. The grantees did achieve some notable successes – training thousands of health care workers, publishing over a hundred journal articles, and participating in a wide variety of research networks.
Dr. Razak stated that the discussion should focus on priorities for the next five years; how to engage global leaders in the area of injuries; and identifying institutions that might lead the effort.
Dr. Gail Wyatt, Director of the Center for Culture, Trauma and Mental Health Disparities’ at UCLA.
Dr. Wyatt outlined a series of research projects that attest to the importance of continued research of violence against women and children.
- One-third of women globally have experienced intimate partner violence and/or non-partner sexual violence, and almost a third of all women have been in relationships that included physical or sexual violence.
- Thirty-eight percent of murders of women are committed by an intimate partner.
- Two-thirds of women living in South Africa report sexual assault by strangers.
- Women who have histories of sexual abuse often report severe depression and PTSD.
Dr. Wyatt noted the themes of several studies related to violence against women.
- Relationship between intimate partner violence during pregnancy and stillbirth (Pakistan)
- Injuries sustained in a hospital setting in Ghana.
- Levels of xenophobic violence, resilience and HIV/AIDS-related stigma on mental health of Mozambican immigrants.
- Effects of trauma on South African women in abusive HIV sero-discordant relationships.
Noting the establishment of the first Childhood Injury Registry in Romania in 2009, Dr. Wyatt mentioned child-related issues.
- Reports on war-related injury to children in Croatia, Serbia and Bosnia-Herzegovina
- Topics on the agenda at the Annual Emergency Care Conference in Pakistan – resuscitation of children, poisoning of children, and child-friendly emergency care.
- A survey in Ghana related to injury prevention specifically for children.
- A study of the epidemiology of acute poisoning in children admitted to Ain Shams University Poison Control Center (Cairo) from 2009 to 2013.
- A study of child pedestrian injuries in Romania, looking at risk factors.
Dr. Wyatt concluded that the Fogarty Injury and Trauma Research Training Program has been critical in establishing injury research capacity with regard to women and children. She urged continued support.
Dr. Jon Mark Hirshon, University of Maryland School of Medicine
Dr. Hirshon reiterated the costs of vehicular mortality and morbidity, about 1.3 million dead, and millions more injured with a financial burden of over $500 billion annually. He pointed out that the risks are greater in LMICs because vehicles are older and less safe, emergency medical care is less available than in the more developed countries, and post-trauma rehabilitation is often not available. He noted that, in the U.S., traffic deaths have declined in part because of significantly improved safety systems on cars, not available in the older cars that are more common in the LMICs. He suggested that this disparity should be a fertile area for research. Solutions as simple as speed bumps could be the subject of research, as could developing effective surveillance of injury numbers and characteristics.
With regard to alcohol-related mortality and morbidity, the level of alcohol consumption is a key factor. In some countries, such as in the Middle East, alcohol consumption is reduced by policy and by moral and religious beliefs, and the level of death and injury is consequently reduced. Finally, Dr. Hirshon commented on the need for research in the area of brain injury in terms of identifying the problem, the importance of collecting epidemiological data, developing effective treatment and assessing the long-term effects of early age traumatic brain injury.
Dr. Junaid Razzak, Johns Hopkins University and Aga Khan University (Pakistan)
Dr. Razzak stated that he would provide a broad perspective of how investments in Pakistan have achieved a higher level of training. Over 4,500 individuals have participated in training; there have been five major national conferences on injury trauma emergency care; and 30 workshops were held at the basic and advanced level of care. More broadly, in Eastern Europe 50 scientists have been trained, 850 in the Middle East, 250 in Ghana, and 36 in Guatemala.
Looking at long-term training, requiring a year that includes formal coursework and a thesis, the numbers are smaller but the results are perhaps as effective. Pakistan has enrolled 27, graduated ten, many of whom have become faculty in the Department of Emergency Medicine at Aga Khan University. In Eastern Europe, five postdocs are working in emergency medicine, in the Eastern Mediterranean area there are 35 who have completed long-term research training and 12 from Guatemala and 11 from South Africa have completed similar programs.
Institutional infrastructure and capacity is important to provide places to participate in training. The Aga Khan University has responded by establishing the first department of emergency medicine in South Asia, collaborating by supporting the WHO Collaborating Center on Emergency Medicine and Trauma, offering Pakistan’s first residency program in emergency medicine, and setting up a Center of Excellence on Emergency and Trauma Care. Finally the University added emergency injury training to its masters of health policy and management program.
Finally, Dr. Razzak described several research/policy developments, including:
- Road traffic injury surveillance program that has data from five centers on over 30,000 accident injury patients;
- Establishment of the Pakistan National Emergency Department Surveillance System, with seven centers in six cities, covering over 250,000 registrants the largest emergency visit database in the LMICs;
- A trauma system profiling for EMRO (Eastern Mediterranean) region;
- Research output has been gratifying, with 25 published papers from grant projects, and over 100 publications by program-supported personnel.
In closing, Dr. Razzak pointed to successes – in creating a core group of researchers, a robust administrative structure to support them, and a greater understanding among policy makers of the importance of trauma and emergency care. There are also challenges, including the current fact that few researchers can compete for independent grants; a high level of training and mentoring is needed; additional funding support will be needed to sustain the early successes, as well as to support linkages between institutions.
Discussion
Dr. Razak invited comment from those on the teleconference. Dr. Mock commented that there are different outcomes related to trauma care in part depending on the socioeconomic status of the patient and the location of the treatment. LMICs have a higher mortality in part because of lack of resources, training and continuity. Dr. Mock suggested that up to two million lives could be saved if the quality of care in the LMICs could be improved to match that in the richer countries. That is to say, if what is already known in some areas could be applied to all areas, especially in the rural areas and in small hospitals. Money is spent on equipment that then may not have a proper level of maintenance. There is a need for equipment that is more durable, easier to operate, and less costly to maintain.
Dr. Peek-Asa commented that the Fogarty Trauma Program has been effective over the last eight years because it encompasses a wide range of prevention activity, from primary through tertiary prevention. The support of the United Nations, World Health Organization and the World Bank has increased awareness in many countries of the importance of injury prevention, especially among children, where the mortality rate is higher than acceptable and early life trauma often has long-term health effects.
Dr. Brown presented statistics about NIH spending on health issues – the money spent compared with the burden of disease – and the bottom line was that spending on HIV/AIDS and cancer is significantly out of proportion with the burden of disease, and the spending on injuries/trauma is the reverse. That is in spite of the fact that injuries are the leading cause of death in Americans below the age of 45. In terms of dollars, of the total spending for cancer, heart disease, HIV/AIDS, and trauma, the last category received only 4.5% of the total funding. In fact, in 2013 the NIH reported that 140 projects on trauma were supported with $55 million. The breakdown for that funding: traumatic brain injury, $24 million; spinal cord injuries, $13.5 million; and new and ongoing research, $17 million. Dr. Brown noted that funding for actual emergency trauma (ER admissions, ambulance transport) was only $2 million. He found only four research grants targeting this narrow focus.
Turning to the plight of children, Dr. Brown noted that the World Bank had projected that in Sub-Saharan Africa, by 2050, road accidents will be the predominant killer of children, far more than HIV/AIDS, tuberculosis and malaria combined – and Africa is the least motorized country in the world. It has the highest road accident rate in the world, 24 deaths per 100,000 population, which is twice the rate of the U.S. Road accidents kill more young men there than HIV/AIDS.
In Pakistan, road accidents are increasing and a Fogarty-supported researcher published a paper that calculated the cost effectiveness of relatively low-cost interventions – better traffic law enforcement, speed bumps in areas having a high rate of lethal accidents, and the positive effect of training volunteer and lay first responders. The World Bank published a similar assessment of the effect of stronger bicycle and motorcycle helmet laws, enforcement of seatbelt laws, and the use of speed cameras and breath testers. Dr. Brown reiterated that most of these measures are not costly and have been proven effective in reducing traffic fatalities.
Dr. Glass expressed appreciation for the comments and presentations, and invited Dr. Patrick Kelley, from the Institute of Medicine (IOM), to comment about their recent study of traffic accidents and injuries.
Dr. Kelley recommended considering a much more multi-sectoral and multidisciplinary approach to the traffic accident/fatality problem. Involving not only health, partners would include behavioral science, engineering and law enforcement. He noted that within the National Academies structure, the Transportation Research Board holds the largest transportation meeting in the U.S., drawing more than 10,000 attendees. Dr. Kelley also noted that Fogarty has been a founding member of the Academies’ Forum on Public-Private Partnerships for Global Health and Safety, which includes a number of public sector stakeholders. He mentioned two major corporations, Anheuser Busch and the United Parcel Service Foundation, that were also founding members. He made the point that the IOM might be able to facilitate collaborations, adding that there may be funding in the private sector and among foundations that could leverage the federal investment.
Dr. Glass invited Dr. Vik Kapil, CDC, to comment. Dr. Kapil stated that he was part of CDC’s Center for Global Health, which has offices in 50 countries, providing a very broad opportunity for developing collaborations. The road injury part of the Center actually focuses mainly on U.S. traffic issues and injury prevention, although a number of international partnerships have been developed. An important resource at CDC is its experience and expertise in surveillance and data development. Dr. Kapil mentioned several areas of interest at the Center, including helmet safety, reducing the burden of traumatic brain injury, and occupational road traffic injuries. Finally, he noted his interest in injuries related to violence against children and domestic partners, adding that violence against children can have long-term negative effects on behavior, use of alcohol and sexual violence.
Dr. Glass invited board members to discuss activities ongoing in their institutions. Dr. Kolars commented that, being located in Michigan, his university had benefitted from significant funding support from the automotive industry, emphasizing the comment by Dr. Kelley that there were opportunities for support in the private sector and with foundations. Concerning activities overseas, he mentioned an advocacy for a systems approach and systems strengthening, although that is sometimes a challenge at the individual project level.
Dr. Barry noted the first steps in India to bolster 911 training and paramedic training for emergency medicine. She suggested that Fogarty might consider focusing on the LMICs during the next five years, focusing on advocacy and proactively enlisting the support and participation in projects of policy makers.
Dr. Holmes noted the positive development from Dr. Mock’s institution in the establishment of an undergraduate course in injury and violence prevention. He also mentioned the appropriate shift of emphasis in the bio engineering and bio design fields away from high technology, high cost developments to more practical and less expensive solutions. As an example he pointed to reusable plastic braces for broken legs that can be applied with straps.
After spending twenty years in emergency medicine, much of that in ERs, Dr. Tierney observed that there is a need to balance the expenditure of funds for training and research, so that those who come out of training have some funds to work with in their research endeavors. He noted that the dramatic decrease in road traffic deaths in the U.S. since 1980 was more the consequence of policy than technology and medical care. The steady pressure to enforce seat belt policy and laws had a significant impact on reducing traffic fatalities. He recommended considering fellowships for health policy studies. Dr. Tierney also recalled that when he first became associated with Fogarty, he met an Exxon Mobil executive who explained that the company’s interest in reducing LMICs was directly related to the company’s high employment of thousands of LMIC residents, who were far more productive when they avoided debilitating injuries. He suggested that similar companies would make good candidates for partnerships and collaborations.
Dr. Hill endorsed the earlier comments about the importance of policies, such as seat belt laws. He also felt that developing good epidemiological data is critical to tracking improvements in trauma reduction and providing grist for research. He suggested that the MEPI model should be promoted, that of developing networks among institutions to develop multidisciplinary research programs.
Dr. Glass commented that one observation from the Ghana MEPI PI meeting last year was that half of the hospital admission in Ghana come in through the emergency departments, and those admissions include not only trauma cases, but some general medicine cases, such as HIV screening. He invited representatives on the NIH ICs to contribute.
Dr. Janine Clayton, Office of Research on Women’s Health, commented that violence against women and intimate partner violence is connected to other health outcomes including those affecting mental health and the well-being of children. She added that developing data on violence and epidemiological data on the effects of violence is an important priority.
Dr. Walter Koroshetz, NINDS, commented that his Institute often collaborates with NICHD in the area of traumatic brain injury (TBI) research. In partnership with the European Union, there is a program to collect data from tens of thousands of individuals with TBI. With regard to research in LMICs, Dr. Koroshetz noted that the model in the U.S., which is driven by legislative mandate that includes moving the brain-injured to facilities that can best care for them, may not be appropriate for less developed nations where transportation systems and infrastructure are not well developed. However, there has been research in South America and Europe. He felt that there was a need for specialized centers that can care for patients who have general and neurological trauma.
Dr. Guttmacher, NICHD, stated that his Institute is interested in brain trauma, especially as it relates to family violence. In terms of pediatric trauma, he noted that NICHD has recently reorganized its extramural program to include a Branch on pediatric trauma and critical illness. With that Branch came a funding opportunity to support a consortium for research. It offers the possibility of creating a community of researchers working together on these issues. It requires a systems approach with multidisciplinary participation among interested Institutes and Centers.
Dr. Mock recalled the figures discussed earlier showing that trauma is at the bottom of the funding. However he commended Fogarty for being a dominant funder in the area of research into injury reduction globally. He recommended, if NIH has another funding cycle that includes trauma/injury research, that a MEPI-type opportunity for LMICs to participate be included.
Dr. Ralph Kingston, NIAAA, stated that his institute was very concerned about the fact that alcohol abuse is responsible for a third of trauma-related deaths in the U.S. He added that alcohol-related traffic deaths have been reduced by half since the early eighties in part because federal agencies have amassed a database on the causes of traffic deaths that provides a rich resource for research. That data has also been used to good effect by advocacy groups, such as Mothers Against Drunk Driving, that have lobbied for over 2,000 laws passed by federal, state and local governments. The NIAAA maintains an alcohol policy information system that tracks 30 national policies. The WHO developed a global traffic safety strategic plan and a plan to reduce alcohol misuse. WHO issues regular status reports, including data from several surveillance systems and epidemiological data sources.
Dr. Glass closed the discussion, inviting board members to provide bullet points taken from the discussion:
- Research should be linked to policy.
- Research should focus on interventions.
- Broad networks of partners in research and training should be encouraged.
- There should be an emphasis on developing prevention and treatment systems.
- The future agenda should include defining new goals for trauma prevention.
- Some modest, focused investments have delivered some very significant results.
- Obstacles to solving the problems discussed should be identified.
Dr. Razak expressed appreciation to those who participated in the session.
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Reducing Household Air Pollution to Improve Respiratory Health
Dr. Joshua Rosenthal, Fogarty International Center
Dr. Glass introduced the second session that, like the first on trauma and injury research, is included in the Fogarty NCD portfolio. Dr. Rosenthal led the discussion, which would address research capacity building. In the last several years the negative health impact of household air pollution has become a high priority in the environmental health field, in part because of more accurate disease burden assessments. It is the causal factor in about 4 million premature deaths from diseases such as acute lower respiratory infection (ALRI), chronic obstructive pulmonary disease (COPD), lung cancer, stroke, and injury deaths caused by burns and smoke inhalation. Dr. Rosenthal added that 3 million people in LMICs rely on cooking with solid fuels, often in poorly ventilated environments.
There is a substantial effort to reduce these outcomes, mainly led by the Global Alliance for Clean Cookstoves, which promotes the use of advanced biomass stoves that result in more complete combustion of fuels, and the use of cleaner fuels. Dr. Rosenthal observed that research should develop evidence that these advances actually result in improved health outcomes. Several NIH ICs collaborated with the Alliance in 2011 to sponsor a meeting on the NIH campus to develop a set of research priorities. They have been refined since then to include research questions related to effective interventions, identification of health factors that can be positively improved by research, and how Fogarty can support research globally.
Dr. Rosenthal emphasized the importance of developing metrics to measure health effects and build an epidemiological database to support future research, a particular challenge when longer term outcomes are studied in the limited timeframes of many grants. One of the biggest questions is how clean do stoves and fuels have to be to make an impact? The RESPIRE study in Guatemala showed that a substantial 50% decrease in solid fuel waste produced only a modest effect on lowering respiratory infections. Perhaps the improvement has to be in the 80% or higher range. Alternate energy sources – liquid propane gas, electricity, biogas and solar – could make a significant impact. There are also cultural challenges that emerge when the technology is available, but the populations who have access to that technology continue to use traditional cooking process. It results in a patchwork and inconsistent effect on air quality.
Finally, Dr. Rosenthal mentioned several important aspects of the development of improved cookstoves and cleaner fuels, including developing a market for the products, creation of distribution networks to enhance access to fuels, and wider uptake of the technology as it is made available.
Dr. Radha Muttiah and Dr. Sumi Mehta, Global Alliance for Clean Cookstoves
Dr. Muttiah explained that the Global Alliance was launched in 2010 with a single goal, to count 100 million households that had adopted clean, efficient cookstoves by 2020. The Alliance enlisted support of institutions involved in research, health, and the environment, as well as businesses and manufacturers. The Alliance also solicited support from policy makers and funding from investors. There was a focus on household air pollution and the injuries related to cookstove accidents. From the outset there was an understanding that standards would be needed to insure quality in the manufacture of cookstoves and the development of clean fuels.
Dr. Mehta commented that one aspect of early research was to leverage existing research, such as collaborating with NIH random controlled trials to include a clean fuel research arm in the protocol design. For the first three years the focus was on child health and survival, especially the latter when it was determined that 96% of burn-related deaths were in the LMICs. This was particularly urgent when it was clear that research in the burn accident area was lacking. There was little data on the root causes of burn injury and death.
During discussion Dr. Muttiah stated that, with regard to the hundred million household goal, the current count is about 25 million. He added that a flat start was anticipated and there is confidence that the rate of uptake will increase and the goal will be reached by 2020. A factor is the availability of clean fuels for most of the population. The distribution network is also key, especially getting supplies to the rural areas.
Dr. Kirk Smith, UC Berkeley
Dr. Smith commended the capacity-building of Fogarty funding, which he described as modest but consistent over time and flexible to the needs of the research grantees. It is the approach that is needed in the case of developing efficient cookstoves. As a health scientists, Dr. Smith stated that he had known that developing some technologies, like new vaccines, requires large up-front investment and a sustained effort after the vaccine is proven to bring the price down so that a greater number can benefit. The development of cleaner cookstoves has been different. It has been a long evolution that has not yet arrived at success, especially considering the comments made earlier in the meeting about how clean cookstoves really need to be to impact health. Just building a very clean cookstove has little impact unless it is nearly universally accepted in a particular population. If that does not happen, it is a big problem that requires a big solution. He cited the example of China’s $215 million grant to facilitate a complete replacement of traditional cookstoves for induction stoves in Ecuador.
Dr. Smith noted that the solution to the poor health outcomes of home air pollution caused by inefficient cookstoves is well known in over 60% of the world – the use of gas and electricity by whole communities. The world certainly understands the cause and effect of household air pollution, and it is important to understand that solutions at the household level will not work for two reasons. First, communities must experience a herd effect -- using a clean cookstove in a few homes will not overcome the negative effect of most of the neighborhood relying on open fires to cook. Second, developing the circumstances in which the herd effect is effective requires political and social action/pressure.
Finally, Dr. Smith reiterated the importance of capacity building, noting Fogarty’s role in the past. He noted that Dr. Balakrishnan’s household pollution research program, probably the best in the world, was encouraged and supported by Fogarty.
Dr. Kalpana Balakrishnan, Sri Ramachandra University, India
Dr. Balakrishnan focused on the India-specific issues as they relate to the discussion of household air pollution. Recalling the mention of a goal of increasing clean cookstove/clean fuel use to 100 million households, if they were all in India that would leave 700 million households still using traditional cookstoves lacking the clean air improvements. That number is too large for a prescriptive, one-size-fits-all approach. After two extensive assessments it is clear that, in India, household pollution is a leading contributor to the disease burden.
Dr. Balakrishnan noted that the focus on the negative effects of solid fuels dates back more than 40 years, and the resolution of the problem involves rural development, improved energy efficiency, and poverty reduction. The efforts to ameliorate the problem have been mainly outside the health sector. In fact, she felt the health sector was just beginning to recognize the health problems associated with traditional cookstoves. The technology improvements have not included health considerations. Dr. Balakrishnan stated that a critical mass of people generating health-related evidence, interpreting and communicating that evidence to policy makers, must occur before improvements in air quality will become a reality.
Dr. Balakrishnan observed that a critical lesson learned has been that success in the lab is no assurance that the success can be replicated in the field. Lab models are often not compatible with households in the real world. A second obstacle is that communities may want to leapfrog to LPG and electricity before implementation is a realistic goal. There is a significant issue of access and broad-based public acceptance that must be achieved to make that work.
Noting that there has been some progress, Dr. Balakrishnan described the Ministry of Health’s action in establishing an inter-ministry steering group to address household air pollution. The group will develop an action plan to encourage collaboration between institutions like NIH and similar institutions in India to support programs and projects that would promote the transition to LPG and electricity. Second, the Ministry of New and Renewable Energy will support multiple projects to develop biomass cookstoves for use in larger institutions, like schools, restaurants and hotels. Finally, there must be an effort to reduce the current significant shortage of trained individuals to help in implementation of the programs.
Discussion
Dr. Glass expressed appreciation for three excellent presentations and invited comments.
- Dr. Tierney noted that often there is a massive distribution system for fuels like charcoal, but almost no infrastructure for distributing LPG – clearly an issue that merits attention.
- Dr. Balbus stated that NIEHS has extensively supported cookstove research. NIEHS is currently supporting 32 grants in 17 countries. The Institute has also collaborated with other NIH ICs, WHO and PAHO on cookstove research. The Institute is involved with the development of exposure monitoring technology, including a project in the NIEHS toxicology program to look at polycyclic compounds in cookstove emissions.
- Dr. Fanning commented that NCI has research related to indoor air pollution exposure in perinatal and child cohorts. A significant challenge is having data that will take time to analyze, when policy decisions can’t be delayed until the analysis is complete.
- Dr. Guttmacher stated that NICHD has been involved in air pollution issues for several years because it has a negative impact on pregnancy, newborns and early childhood health. There is also concern about trans-generational effects and epigenetic modifications that are associated with household pollution exposure.
- Dr. Kapil mentioned CDC’s work in Kenya that pointed to the question, how clean is clean enough? The effort there is now focused on cleaner fuels. He added that there is also interest in improving accident-related burns surveillance. Collection of fuels is usually done by women and children, which also exposes them to risks of injury.
- Dr. Glass noted that behavioral research would be important to understanding acceptance. Developing an expertise in marketing would affect the success of that acceptance. It would also be important to understand that acceptance does not necessarily mean the new user will employ a clean cookstove properly. Using traditional fuels in a clean cookstove is self-defeating.
Closing Comments, Dr. Glass
Dr. Glass thanked all who contributed to the success of the meeting. He noted three important aspects to the meeting. First, that both of the discussions – on trauma and on household air pollution – are part of the noncommunicable disease strategic plan. Second, he was particularly pleased that Dr. Balakrishnan was present in person to talk about her program. It was gratifying to be able to talk about a successful grant in the presence of the individual who made it happen. Finally, since partnerships is an important part of the Fogarty strategic plan, he noted that the day’s discussion included references to several partnerships between Fogarty and other ICs, and with CDC, USAID, DoD, the Global Alliance, and others.
Dr. Glass especially thanked Kristen Weymouth for the successful planning and execution of the meeting, and Myat Htoo Razak and Josh Rosenthal for bringing the two panels together. He noted that the next Board meeting would be on May 11-12.
Adjournment
The meeting was adjourned at 3:00 p.m.
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