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-fifth Meeting of the Advisory Board
Minutes of Meeting
February 7, 2017
The Board met in the Stone House, Building 16, NIH Campus, 9000 Rockville Pike, Rockville, Maryland, at 9:00 a.m., Roger I. Glass, Chair, presiding.
BOARD MEMBERS PRESENT
ROGER I. GLASS, M.D., Ph.D., Chair
JANINE CLAYTON, M.D., Member (Attending by proxy)
WAFAA M. EL-SADR, M.D., M.P.H., Member
GREGORY GERMINO, M.D., Ex Officio Member
KING HOLMES, Ph.D., M.D., A.B., Member (via teleconference)
WALTER J. KOROSHETZ, M.D., Ex Officio Member
MICHAEL MERSON, M.D., Member Emeritus (via teleconference)
J. STEPHEN MORRISON, Ph.D., Member
Kristen Weymouth, Executive Secretary
Nalini Anand, FIC
Gretchen Birbeck, University of Rochester
Michele Bloch, NCI
Robert Bollinger, Johns Hopkins University
Ken Bridbord, FIC
Dexter Collins, FIC
Pamela Collins, NIMH
Jim Curran, Emory University
Robert Einterz, Indiana University
Robert Eiss, FIC
Laura Foradori, Peace Corps
Maria Freire, FNIH
Flora Katz, FIC
Vanessa Kerry, SEED Global Health
Peter Kilmarx, FIC
Marya Levintova, FIC
Keith Martin, CUGH
Kathy Michels, FIC
John Monahan, Georgetown University
Vivian Pinn, FIC
Patricia Powell, NIAAA
Carrie Hessler-Radelet, Project Concern International
Josh Rosenthal, FIC
Francine Sellers, FIC
Jordon Tappero, CDC
Cecile Viboud, FIC
Director's update and discussion of current and planned FIC activities
Dr. Glass opened the meeting by welcoming new board members Gretchen Birbeck, Robert Bollinger, Robert Einterz, and John Monahan. He also congratulated Peter Kilmarx on being named a Rear Admiral. Dr. Glass welcomed Flora Katz as the director of the Division of International Training and Research and David Spiro as the director of the Division of International Epidemiology and Population Studies. New program staff include: Jong-on Hahm (Program Officer, DITR, Fellows and Scholars, MEPI), Geetha Bansal (Program Officer, DITR, HIV portfolio), and Amit Mistry (Scientific Program Manager [contractor], DISPPE Bioengineer).
Georgetown University awarded Dr. Glass with its 2016 Cura Personalis Award upon the university launching its very own global health initiative.
The Global Alliance for Chronic Disease (GACD) launched the Lung Diseases Program in 2016; it includes 13 international research projects in 30 countries representing $55 million of international funding. Part of this initiative was exploring whether the transition to LPG fuel will improve health outcomes in LMICs. There is a current call for implementation science for prevention and treatment of mental and/or substance disorders in LMICs. One new MEPI (Medical Education Partnership Initiative) linked awards published in December was by Dr. Chibanda on the Effect of a Primary Care-Based Psychological Intervention on Symptoms of Common Mental Disorders in Zimbabwe.
In October, the Global Health Research Working Group and the FIC hosted a symposium honoring the leadership of Francis Collins. One of the activities of the working group is World RePORT which is a website that lists all of the research done by NIH and a half-dozen of the major funding institutes.
The Barmes Lecture was on November 16, and featured Paul Farmer. Dr. Farmer gave an amazing talk about health equity. On December 6, FIC hosted a fireside chat with Peace Corps Director, Carrie Hessler-Radelet.
MEPI has been one of FIC's main projects in recent years. There has been concern over whether or not it would continue to be funded. The program supported 13 grantees in African medical schools to engage in training and research in global health. The 13 original grantees reached out to 40 other schools. This group formed its own organization called African Forum for Research and Health Education in Health (AFRE Health). FIC has been working with PEPFAR to extend support for MEPI-related activities.
Robert Eiss gave an update on Africa. FIC collaborated with AESA (Accelerating Excellence in Science in Africa), the Wellcome Trust, and the Bill & Melinda Gates Foundation to host a meeting at the World Economic Forum. Foreign direct investment in Africa has increased tenfold over the past decade. By 2034, Africa is expected to have the largest working-age population in the world. But African research is starting from a low baseline. The collective GDP of Africa is $2.7 trillion. The money for research and development exists in Africa, it's just a question of political will. The Coalition for African Research and Innovation (CARI) is an alliance of African science leaders and international funders with the goal of advancing a generation of scientists to lead Africa's transformation. Predictors of success will be to identify critical path investments to build and sustain capacities, build research demand among African governments, and create public and private activities, despite limited short-term return. Next steps will include Delphi exercises among scientific and political leaders and developing business plans.
The 8th Annual CUGH Conference will focus on Healthy People, Healthy Ecosystems. The core program will highlight six major tracks: 1) Governance and political decision-making; 2) Health systems and human resources; 3) Planetary health; 4) Infectious diseases old and new; 5) NCDs and social determinants of health; and 6) Women's health is global health.
David Spiro gave an update on the activities of the Division of International Epidemiology and Population Studies (DIEPS). DIEPS' international and multinational network was established in 2000. It seeks to foster research and training in computational biology, links between academia, NGOs, bi-lateral/multilateral agencies and the U.S. Government, informed use of models to guide policy/decision-making. There has been a high return on investment for DIEPS with four FTEs and nine on-site contractors. Nimble, independent projects leverage group expertise and name recognition to create excellent scientific output. In the near term, DIEPS hopes to 1) Identify new partners and funding streams for flagship programs, 2) Consolidate recent activities and partners, 3) Expand or initiate new research activities.
President Trump presented an opportunity for great optimism in his inaugural speech when he said, “We stand at the birth of a new millennium, ready to unlock the mysteries of space, to free the earth from the miseries of disease, and to harness the energies, industries and technologies of tomorrow.” President Trump's stirring words on innovation and technology should give hope to all those passionately concerned about global health.
Upcoming meetings include: Promotion for Rear Admiral Kilmarx (February 10), Trauma Network Meeting (March 28), CUGH (April 6-9), NCD Network Meeting (May 10-12), Fellows and scholars (July 17-21).
John-Arne Rottingen, Director of CEPI (Congressional European Parliamentary Initiative), gave a brief overview of CEPI. CEPI emerged out of the Ebola outbreak. CEPI plans to identify key priority pathogens for which they will develop test vaccines (MERS, Lassa, and Nipah). CEPI has a broad-based coalition of partners and anticipates having the ability to achieve a lot in a year.
Steve Morrison gave a political update on global health. He said that everyone should be patient and not race to categorical judgements. There seems to be a focus on innovation in the Trump administration and there has been some continuity in the administration with several officials for capacity building and health security.
Arthur Kellerman of the Uniformed Services University of the Health Sciences said that the university has established a center for global health engagement. The Department of Defense can bring value to global health. The university is working to form strong partnerships with multiple institutes at NIH.
Jordan Tappero from CDC said that CDC has been thinking about how their field epidemiology training program could begin to work with FIC and NIH. One of the pillars of the global health security agenda is improving the public health work force. CDC believes that there will be support for mitigating health threats through emergency response. CDC hopes that with Ambassador Birx staying on, that means a strong continued support for PEPFAR. CDC is hopeful that the replacement for the Affordable Care Act will continue to have a strong prevention portfolio.
Next Steps for MEPI-2: Partnership Initiative for Health Professional Research (PIHPR) and the African Association for Health Professional Research (AAHPR)
Flora Katz introduced the session and gave an overview of the MEPI ecosystem. The MEPI programmatic awards were supported by PEPFAR and administered by FIC and HRSA. The NIH came forward with linked awards which were designed to build research capacity. There was a coordinating center that was administered by HRSA. The Principle Investigators (PIs) of these awards formed themselves into a PI council that provided leadership across the network. There was also a parallel initiative for nursing, NEPI, also administered by HRSA. There were thirteen first generation awards in twelve countries in Africa. These awards were $100 million over five years and the money was supplied mostly by PEPFAR but NIH/OAR also contributed. The NIH linked awards were a $30 million investment. NIH can capitalize on the $30 million ($15 million from the Common Fund) it has already invested and continues to leverage the $100 million PEPFAR investment by building the research pathway and institutional infrastructure. African principal investigators credit MEPI for stimulating a movement within their institutions toward a new research culture and culture of collaboration. From NIH awards alone, there have been 511 mentored research projects and over 250 peer-reviewed publications.
The activities of the networks included: facilitating communication, logistics symposia, development of evaluation metrics, and providing technical assistance. The PI council, which has existed since 2011, meets twice a year, provides leadership to the network, proposes working groups, and provides leadership for the annual symposia. AFRE Health was launched out of the network.
The second-generation awards included the MEPI Junior Faculty Award. This award helped to create a pathway to research careers and sought to strengthen institutional research structures. There were eleven awards funded through the Common Fund with additional funding from 10 ICs for a total of $36.6 million over five years.
Dr. Katz presented two concepts for MEPI going forward. Concept one was the Partnership Initiative for Health Professional Education and Research (PIHPER). This would be an evolution of the MEPI programmatic awards and would support health education institutions in PEPFAR priority countries with the highest HIV burden and most limited resources in Africa. Concept two was the African Association for Health Professions Education and Research (AAHPER). Its purpose would be to enhance the leadership structure of the PI council, build on the initial successes of MEPI, and include additional institutions that did not participate in MEPI.
MEPI is integrating an educational component into the second generation because the strongest medical schools tend to be research schools. More integration is the goal. Having research opportunities helps clinician retention. More money should go to strengthen institutions rather than having endless meetings. Individual institutions need support. In order to build strong associations, getting the commitment of the African institutions is critical.
MEPI and NEPI need years of investments to be successful and having the voices of nurses included is critical. The ministries of health need to be involved with MEPI to inform the research and education agendas. The issue of retention needs to be more fully fleshed out. The word “retention” is very broad. MEPI should also put in something that motivates early inter-professional action and collaboration. The institutions need to have more flexibility to meet their own needs. In some countries, perhaps the evaluation process has not worked that well.
Increasing the number of mental health professionals in Africa has been very successful. There are opportunities to partner with Africa CDC. There is always going to be a tension between the research and education needs.
The biggest gap is the junior faculty leadership. MEPI is now addressing this gap. Educational initiatives could introduce community-based online learning. The African institutions have moved to a more hands-on type of instruction rather than lecture/notes system. FIC should continue to support this type of case/experiential learning.
Global health at the Peace Corps and SEED Global Health
Dr. Kilmarx said that there are currently 7,000 Peace Corps volunteers in 63 countries, 45% of these volunteers are in African countries and 24% of them are in the field of health. One example of a successful Peace Corps health initiative was a partnership with the Senegal Ministry of Health that involved a mass implementation of a visual inspection of the cervix with an acetic acid screening program. Services were extended to over 10,000 women. This effort also led to a prevalence study of cervical dysplasia being completed. In the future, NIH and Peace Corps could facilitate linkages between universities in the US and in LMICs to conduct implementation research and build implementation research capacity. Peace Corps volunteers already work with local leaders, have trust within local communities, and have an ongoing, well-integrated presence. Getting Peace Corps volunteers more engaged with NIH programs can provide them with an appreciation for evidence-based policies and programs and would encourage them to pursue careers in global health research.
Dr. Vanessa Kerry, CEO, SEED Global Health
Dr. Kerry gave a presentation on SEED's partnership with the Peace Corps and the initiatives they have developed through the Global Health Service Partnership (GHSP). In 2006 the World Health Report discovered that the more healthcare workers a country has, the higher the rate of survival among the population. 24% of the global burden of disease is in Sub-Saharan Africa but only 3% of the world's health care workforce and only 1% of the world's health expenditure. Brain drain drives this healthcare worker disparity. The vast majority of training institutions in Africa are missing up to 50% of their faculty. There needs to be more clinical research papers from areas carrying more of the disease burden, so, more “indigenous” research would be good because those are the folks closer to the day-to-day reality of disease. There is also a specialty gap in dealing with communicable disease and future conversations need to be centered around how global health initiatives will meet the training challenges around dealing with this shortage.
GHSP came about around the time when PEPFAR was asking about how to enhance care delivery. In the GHSP model, healthcare workers serve as clinical faculty for at least one year. Partnerships are fostered with host country institutions and existing clinical training systems. The volunteers must have teaching experience, the doctors that volunteer must have completed their training and nurses must hold a BSN plus an additional degree. In 2016-17 there were 34 GHSP training sites at 22 institutions in five countries. GHSP is preparing people in the country sites to teach and train. So far there have been 155 GHSP faculty with 128,328 service hours. There have been 454 courses taught and a total of 8,321 total trainees. Evaluation processes include generating actionable insights, building useful feedback loops, and learning from what works.
One place that has particularly dire needs is Liberia. Since the medical schools have been reopened, no one has passed the entrance exams. Within six to ten years, GHSP hopes to have a robust, self-sustaining system in place in Liberia where the graduates of training programs become the faculty and mentors. Dr. Kerry had several stories about successful training regimes in African countries. Evidence-based training has been remarkably successful in the institutions where GHSP has sent faculty. Training faculty is only one component, working to make sure that health institutions have reliable broadband and electricity is another.
Progress is possible. Rwanda has had some of the sharpest declines in mortality in history. From 2000 to 2008 new HIV infections fell by 35%, AIDS-related deaths fell by 28% with some 8 million lives saved. The Ebola vaccine was rapidly developed and is highly effective.
Laura Foradori, GHSP Program Manager
Ms. Foradori gave a brief overview of Peace Corps' health programs. What draws people to Peace Corps is the fact that it is a service opportunity for motivated change makers to immerse themselves in a community abroad working side-by-side with local leaders to tackle the most pressing challenges of the current generation. Different volunteers are trained in different sector competencies, like HIV prevention, maternal care, community health, promoting healthy living, etc. Ms. Foradori shared several Peace Corps Health success stories around malaria surveillance, water sanitation, and hygiene. Peace Corps is a fully integrated partner with PEPFAR. Building trust with local communities is a critical part of getting them to adopt/seek-out health interventions.
Dr. Bollinger said that the most important challenge for research is to ask the right questions. Having people who know the community defining the research is important. Care needs to be delivered at the community level and those lessons need to be leveraged. Care service models always need to be relevant. Peace Corps volunteers are in a unique position to disseminate research to communities in helpful ways.
Dr. Einterz thought that what needs to be done is “leading with care.” Everyone needs to join together and be accountable to the healthcare of the population. Building institutional partnerships with host institutions will build sustainable relationships. Dr. Kerry said that she welcomes every academic institution to talk to SEED, because institutional partnerships are something her organization wants to foster.
Dr. Hessler-Radelet said connections should be made with the Peace Corps volunteers who are teaching secondary school math and science.
Dr. Balbus said that there is a whole world at the nexus of healthcare and energy to be explored. Generators in hospitals are not necessarily the solution to the problem.
Dr. Pamela Collins added that mental health initiatives should be part of the discussion as well.
Fogarty at 50: Overview of Anniversary Activities
Dr. Glass gave an overview of the FIC's 50th anniversary activities. Broadly, the FIC wants to be visible at medical society symposia, in-country symposia, and engage in other meetings and non-symposia activities. The overall goal for medical society conferences is to engage trainees and faculty in the value of global health research in order to build support for programs and partnerships. There will be a strong push for global health awareness at the American College of Cardiology meeting in March and the American Heart Association meeting in November. There will be sessions on opportunities for research in global cardiology, launching careers in global cardiology, and new opportunities for careers in global health cardiology research.
The goals for in-country symposia include growing collaborations, increasing local research funding with partnership agreements for NIH-funded grantees in-country, and seeking local private and philanthropic partners. There will be a Peru-US Symposium in 2017 on the ascendance of biomedical and behavioral research in Peru. NIH has been heavily engaged in Peru for 30 years. The objective of the FIC section of the symposium will be to consider the impact of training programs in Peru and consider next steps. There will be keynotes by Drs. Patty Garcia and King Holmes and multiple panel discussions. There will also be site visits to NAMRU-6 and AB PRISMA.
Some other activities for the year include proclaiming the value of global health research to the American public through the following: Consortium of Universities for Global Health (CUGH), CSIS meetings, Georgetown University meetings, New York Academy of Sciences, American Thoracic Society/Lung Disease, International AIDS Society Conference, and the Fogarty @50 Scientific Symposium which will be on May 1, 2018. The overarching goal is to emphasize the value of global health research for scientific discovery, research leadership, health diplomacy and economic development.
Dr. Balbus said that FIC should come up with a set of core messages that are consistent across all the anniversary year activities. Having three key themes would be helpful. Environmental health could be integrated into these themes.
Dr. Curran suggested putting together a history project detailing the evolution of FIC over the years. Ms. Puderbaugh (FIC's communications director) said that FIC is putting together a brief history book and that FIC has a strategic communications plan. There will also be more detailed histories for publication in scientific journals. Dr. Morrison suggested looking at USAID's anniversary history materials as an example. A short motion graphic that can be shown at events could be very useful. Trying to clearly articulate the future of FIC will be an important part of any history presentation. Dr. Glass said that he would like to see the FIC mission greatly expand. What has been done for HIV/AIDS could also be done for the global epidemics around obesity, kidney diseases, mental health, and lung diseases. Highlighting the work on HIV/AIDS will be central to showcasing FIC's successful impact. Focusing on capacity building and investing in people long-term will be part of the FIC vision going forward.
Dr. Bollinger said there might be some people that FIC hasn't spoken to, like folks in the technology and innovation space. Also, one of the big themes of the anniversary year should be to emphasize the payoff of global health research. The private sector and potential funders also need to be involved.
Dr. El-Sadr suggested getting testimonies from the ministers of health from the countries where FIC has operated. There are many health leaders in the countries where FIC has operated that were former FIC trainees.
Dr. Martin pointed out that the public needs to be able to clearly understand what FIC does and what FIC grantees do. Short video clips can help the public to understand the mission and vision of FIC. This is a unique opportunity to reach the public. Dr. Bollinger said that young people are already thinking globally - the number one undergraduate degree at Johns Hopkins is public health.
Dr. Hessler-Radelet said that FIC should be doing events on Capitol Hill, in congressional districts, and at governors’ meetings. Exploring media and social media possibilities can also expand the message. Giving FIC fellows a crash course in how to use social media would be fantastic.
Dr. Curran suggested that this is really a history of global health at NIH and that the FIC anniversary is being used to tell that story. There is a broader context of NIH involvement that should not be left out.
Dr. Merson suggested getting a group together to talk about where FIC is going to be in 15-20 years. Dr. Glass thought that this was a good idea and could energize FIC. FIC should also host a symposium on lessons for the US from the global health experience and the dividends that funding global health initiatives have paid back to the US over the years.
The meeting adjourned at 2:55 p.m.