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-sixth Meeting of the Advisory Board
Minutes of Meeting
May 9, 2017
The Advisory 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.
ROGER I. GLASS, M.D., Ph.D., Chair
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
WALTER J. KOROSHETZ, M.D., Ex Officio Member
Kristen Weymouth, Executive Secretary
Nalini Anand, FIC
Rick Berzon, NIMHD
Kevin Bialy, FIC
Gretchen Birbeck, University of Rochester
Michele Bloch, NCI
Robert Bollinger, Johns Hopkins University
Joel Breman, FIC
Ken Bridbord, FIC
Lois Cohen, NIDCR
Dexter Collins, FIC
Jim Curran, Emory University
Robert Einterz, Indiana University
Robert Eiss, FIC
Ghada El-Hajj Fuleihan, American University of Beirut (AUB)
George Herrfurth, FIC
Christine Jessup, FIC
Flora Katz, FIC
Stephen Katz, NIAMS
Peter Kilmarx, FIC
Vesna Kutlesic, NICHD
Debra Litzelman, Indiana University Center for Global Health
Marya Levintova, FIC
Keith Martin, CUGH
George Mensah, NHLBI
Kathy Michels, FIC
Amit Mistry, FIC
John Monahan, Georgetown University
Claudia Moy, NINDS
Avindra Nath, NINDS
Olugbenga G. Ogedegbe, NYU College of Global Public Health
Jackie Officer, FIC
Vivian Pinn, FIC
David Platter, Indiana University
Patricia Powell, NIAAA
Leshawndra Price, NHLBI
Bill Riley, OBSSR
Josh Rosenthal, FIC
Francine Sellers, FIC
Lana Shekim, NIDCD
Leandra Stubbs, NIMH/DAR
Myra Thomas, FIC
Cecile Viboud, FIC
Director’s Update and Discussion of Current and Planned FIC Activities
Roger Glass, Chair of the Fogarty International Center (FIC) Scientific Advisory Committee, called the meeting to order at 9:03 a.m. He spoke about the budget concerns posed by the President’s budget proposal, for FY 2018 which decreased the NIH budget by about 18% and eliminated the FIC entirely. Consequently, the FIC saw an outpouring of support from grantees, trainees, and former board members. Dr. Glass cited letters and articles from Peter Hotez, Chris Beyrer, Michele Barry, Derek Yach, Art Rheingold, Madhukar Pai, and Wasim Maziak, among many others. These testimonials recount the role FIC has played in leadership in the global health realm around the world.
Dr. Glass demonstrated some of the valuable activities FIC undertakes. He discussed a series of FIC fact sheets on Alzheimer’s disease, its relationship to The Fulbright Program, and on Ebola in Liberia. He also pointed out that 80% of the $54 million in funding that the FIC provides annually goes to U.S. institutions while 100% of it involves U.S. scientists in some way. Dr. Glass credited his communications team, led by Ann Puderbaugh, with making these fact sheets available which demonstrate FIC’s value.
In terms of biomedical research, 37% of almost 85,000 papers funded by the NIH have involved a foreign author, with China being the most frequent collaborator. Of those papers, many have focused on lower middle-income and lower-income economies. Dr. Glass noted work in developing countries is a seed for further research capacity, however there were almost no notable international publications in the 1970s, China is projected to surpass the U.S. soon in its number of publications. Congress’ recent omnibus budget agreement for FY 2017 included a $2 billion or 6.2% increase for NIH and of that amount, FIC received a 2.51% increase of $1.766 million.
The 8th Annual Consortium of Universities for Global Health (CUGH) conference took place in early April. Dr. Glass shared photos from the event featuring FIC supporters wearing green Fogarty Center wristbands to show their support. The CUGH forms part of the Center’s basis for ongoing development and support in the global health field, akin to the American Heart Association or the American Cancer Society, by convening various global health stakeholders. Part of this conference featured a panel which included Dr. Gary Gibbons, Director of the National Heart Lung and Blood Institute (NHLBI), and a Ugandan researcher and physician Dr. Nelson Sewankambo. Dr. Glass also highlighted the work of Bill Steiger in promoting FIC’s agenda and distinguishing between it and programs which provide foreign assistance.
FIC engages with the Global Alliance for Chronic Diseases (GACD) to establish international collaboration on noncommunicable disease issues. Accordingly, the next call will be on implementation science for prevention and treatment of mental health disorders. Efforts in this arena are being led by Pamela Collins at National Institute for Mental Health (NIMH) with a series of international funders already established. This call will endeavor to generate solutions for future collaboration given that there’s such a diverse group of partners.
The FIC held a meeting with the Wellcome Trust at the close of April 2017 which was attended by the data teams from various organizations working on the NIH’s global scan, which identifies current research projects as well as research gaps in countries around the world. Researchers have compiled data into an interactive online tool called the World RePORT. International partners from the U.S., Canada, and the U.K. have all contributed funding to ensure that the project remains up to date and open access.
Dr. Glass discussed the legacy of John Fogarty and highlighted some other current activities. Mary Fogarty McAndrew, the daughter of John Fogarty, recently met with congressional members to discuss continued funding for FIC. Drs. Soumya Swaminathan and Vijay Raghavan visited the NIH as a part of the Indo-U.S. Vaccine Action program. The new Rwandan Minister of Health, Dr. Diane Gashumba, also visited. Dr. Glass noted the high vaccination rates in Rwanda, especially with HPV vaccines among girls. Supported by Dr. Eliseo Perez-Stablé, Director of the National Institute on Minority and Health and Health Disparities (NIMHD), along with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH is hosting the first Rwandan visiting fellow.
Representative Tom Cole from Oklahoma affirmed his support for global health initiatives, stating support of programs such as building capacity in West Africa to fight Ebola. Dr. Barbara Sina, Deputy Director of FIC’s Division of International Training and Research (DITR), spoke further about this specific program. FIC held a meeting with regional stakeholders in February to discuss collaboration and effective use of the region’s scarce resources.
Dr. Cecile Viboud in FIC’s Division of Epidemiology and Population Studies (DIEPS), spoke about the Research and Policy for Infectious Disease Dynamics (RAPIDD) program’s workshop on management of arboviral diseases. The workshop outlined programs in two locales. The first program concerned mosquito control in the Maldives, which has been susceptible to mosquito-borne dengue fever epidemics. The Maldives pose unique problems because of the sheer number of islands as well as the heterogeneous landscape. The second seeks to curb yellow fever in Esperito Santo, Brazil while it remains confined to forests.
Dr. Rachel Sturke, Deputy Director of FIC’s Division of International Science Policy, Planning and Evaluation (DISPPE), spoke briefly about the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) Forum. The conference convened 15 teams of researchers from different countries along with several funders, including the WHO and UNICEF among others. The researchers’ main request that came out of this meeting was the need for more training to build their capacity to address these issues. In addition, the cost of these HIV interventions and navigating cultural hurdles were deemed the two biggest impediments of implementation. Dr. Glass highlighted some of the former FIC fellows who attended the AHISA Forum.
Dr. Glass shared some upcoming events. May 15th will mark the publication of the National Academy of Medicine’s Report on Global Health. That same week, a symposium will be held in honor of Dr. Ellis McKenzie who spent over 15 years at FIC where he co-founded the RAPIDD. Dr. Kilmarx will travel to Lilongwe, Malawi, for the 2017 INTEREST Workshop. In early June, there will be a networking meeting on the science of clean cooking for the Implementation Science Network (ISN). Dr. Josh Rosenthal elaborated that the organization’s mission is to establish the science behind clean cooking fuels in order to promote their uptake in developing countries, reducing indoor air pollution. The FIC Fellows and Scholars Orientation will occur on July 17-21, 2017. The African Forum on Research and Education in Health (AFRE Health) will hold its 2nd annual meeting at the beginning of August in Accra, Ghana.
A series of symposia will be held in honor of the FIC’s 50th anniversary. In June, there will be a symposium on NIH’s collaboration with Peru, which has led that country to become the second most research intensive nation in Central and South America. A number of FIC board members as well as representatives from other institutes will attend. The International AIDS Symposium will be held in July; the American Neurological Association will hold an FIC session in October; and the American Society of Tropical Medicine and Hygiene will hold its meeting in November. The next FIC Advisory Board Meeting will occur on September 11-12, 2017.
Rob Eiss, Senior Advisor to the FIC Director, spoke about the Bill & Melinda Gates Foundation Meeting, happening on June 2nd, which will focus on vaccine R&D among other research topics of mutual interest. After a long time conducting ad hoc projects with the Foundation, Dr. Francis Collins gave it a structure through the development of joint milestone projects around common global health issues. Currently there are about nine working groups which meet annually. In addition to the workgroups, the June 2nd meeting will also provide Bill Gates an opportunity to meet personally with directors of the various ICs and with senior scientists. Dr. Jim Curran suggested that, given the discovery of increased mortality rates in children vaccinated with DTP in Africa, the FIC prepare research on this topic for Mr. Gates’ visit.
As a final note, Dr. Glass listed a few other upcoming events. He also informed the group that Dr. Collins spoke to the Board the day before and assured them of his support for FIC and its mission.
Nalini Anand, DISPPE Director, gave an update for the Center for Global Health Studies (CGHS), The Stigma workshop in June will feature a two-day conference and one-day writing session, with the goal of establishing stigma studies as a field of research. CGHS has also begun a new project on the challenges of conducting research in emergency care settings in lower-middle-income countries (LMICs). Blythe Beecroft spoke about the upcoming meeting on this topic stating that previous research in this arena has occurred only at a general level or has been focused on Europe and America. Several working groups have begun working in advance of the meeting, in order to be prepared for the first meeting.
CGHS also recently announced its PEPFAR-NCD modeling awards, meant to address the need for country-level data on non-communicable disease burdens in people living with HIV. Three awards were made to researchers at the Imperial College London, Brown University, and Harvard University to model a set of specific NCDs in Sub-Saharan Africa.
The CGHS is also finishing work on its research guide to enhancing HIV/AIDS platforms to address NCDs as well in Sub-Saharan Africa. The supplement, with over 80 authors, will cover a diverse array of topics intended to establish the evidence and to create research agendas. The partners on this project extend beyond researchers to include policymakers and health officials.
Dr. Geetha Bansal, DITR Program Officer, presented a program concept which focuses on the role of stigma in HIV/AIDS prevention, treatment, and care in people living with HIV. Stigma, as a behavioral manifestation of prejudice against those living with HIV impedes treatment and, therefore, aids transmission. FIC has worked on this issue previously, holding an international conference on stigma and global health back in 2001. Subsequently, in 2002 a Request for Applications (RFA) was released on the role of stigma in the health and welfare of individuals and communities with grantees both in the U.S. and in LMICs. In 2013, a series NIH of program announcements were made on the issue of stigma, but none of those ultimately funded related to HIV. In 2014, NIH announced a set of R01s focused on developing tools for measuring HIV stigma, but only two applications were funded. Currently, there are no active RFAs or PAs to study stigma.
Dr. Bansal’s RFA proposes to stimulate new research into stigma and its impact on treatment and care. It will have an interventional aspect, looking to gain insight into methods of decreasing stigma by accurately measuring it. Additionally, the RFA will be looking for proposals that focus on the effects of stigma in adolescents, the effects of stigma on family or caregivers, and the effects of stigma on seeking care as well as decreasing transmission.
Dr. Wafaa El-Sadr commented that while there has been some substantial work already on stigma and HIV, what is missing in the field is an interventional approach. Consequently, she suggested that the grants be large enough to support the design and assessment of interventions. She also supported the idea of targeting key populations with specific interventions. Dr. Gretchen Birbeck echoed Dr. El-Sadr’s concerns, sharing her experience with the disproportion between the vast research into epilepsy compared to the limited research to stigma related to that condition and the few extant interventions. Dr. Wasserheit agreed, saying that the time for observational work is over. She added that there is an opportunity to cross-reference this work with the development of an implementation framework. Moreover, there is also an opportunity to address co-stigmatizing behaviors that amplify the effects of HIV stigmas. Dr. Bob Einterz agreed, voicing support for larger interventional studies.
While Dr. Curran acknowledged that there is a need for interventions, he pointed out that the money attached to the RFA may not enable those kinds of programs. He explained that stigma is intractable in human society. Most everyone agrees that it should be dealt with, but oftentimes the corresponding understanding of the determinants of stigma are missing. Dr. Bansal replied that Dr. Curran’s comments are an indication of the need for further stigma workshops to gain a more granular understanding of how stigma functions in different communities. Dr. Birbeck responded that, while Dr. Curran’s point is well taken, there are currently some indications of simple and effective interventions that have not yet been tested.
World Economic Forum on Africa:
Rob Eiss discussed the Coalition for African Research and Innovation, established at the previous World Economic Forum (WEF) in January 2017. The NIH has over 1,000 active programs in Africa, most of which involve training. The prospect of those trainees being able to compete for NIH resources, however, is problematic. Cognizant of this, Dr. Collins has established partnerships to sustain the African biomedical research enterprise. WEF was chosen as the nexus for this loose coalition because of how efficiently it gathers political and economic figures. Mr. Eiss emphasized the timing for this decision, pointing out that Africa’s collective GDP has tripled since 2000 and, at 2.2%, is set to have the largest population of working age adults by 2040.
A meeting of African leaders in Durban identified the following impediments. Stakeholders have not made the financial case for supporting African biomedical research nor has the evidence base for these arguments been established. Universities in Africa are considered to be strictly pedagogical and are, therefore, considered centers for innovation by neither the government nor the university population. Furthermore, African macroeconomic policy has not historically included investment in research. An academic panel there also demonstrated some of the research breakthroughs on the horizon in Africa. This panel also identified potential models that could be replicated on the continent.
Mr. Eiss enumerated the four broad objectives that came out of these meetings: 1) to reduce the vulnerability of African-led science projects through improving financing; 2) to build demand for domestic investment in R&D infrastructure; 3) to mobilize resources for African-directed research priorities; and 4) to increase private sector involvement in African-led research. He acknowledged the scope and breadth of these objectives, but indicated that Dr. Collins was invested in this project and that, at a minimum, they have begun the conversation.
SMART Vaccines Update:
Stacey Knobler, DIEPS Scientific Program Director, discussed the Institute of Medicine’s (IOM’s) Strategic Multi-Attribute Ranking Tool (SMART) Vaccines 2.0 framework. Looking to establish a new perspective on vaccine priorities for immunization and for R&D, the framework moves beyond cost-effectiveness toward a multivariable approach. This approach would draw clear connections between prioritization decisions and specific variables to aid both efficiency and transparency. The current candidate platform retains the variables that drive cost-effectiveness analyses while also incorporating other pertinent values that are used in making these decisions. These variables are assigned a value and then ranked. The sum total of this process becomes the SMART score for this decision.
Unlike other decision-making tools, the focus of SMART Vaccines 2.0 was not narrowed by a specific set of questions or developed around the needs of a specific stakeholder. In light of this, the tool is currently being piloted in partnership with the Ugandan National Immunization Technical Advisory Group (UNITAG), which was asked to prioritize immunization decisions for the nation’s next application to the Global Alliance for Vaccines and Immunizations (GAVI). The hope is that SMART Vaccines 2.0 disaggregates the steps and sources utilized in making immunization decisions in a clear and precise manner. Being able to identify what information was used for specific decisions helps build consensus and increases access for external stakeholders. Ms. Knobler shared some screenshots of the tool in action. It accounts for uncertainty in the data used to weight each attribute, allowing users to reconfigure datasets in real time. The tool records the actions taken to produce the individual SMART scores and aggregates into a report, complete with graphs and charts. It also allows users to create and attach a bibliography to that report.
Dr. Curran asked whether Ms. Knobler’s team has engaged with WHO on this subject. Ms. Knobler answered that they ran SMART Vaccines 2.0 in parallel with the WHO’s R&D Blueprint process to see how it measured up. She reported that they are in an ongoing discussion with the WHO about utilization from an R&D perspective.
Cracking the Code of Nodding Syndrome in Africa at NIH with CDC
Dr. Avindra Nath, Chief, Section of Infections of the Nervous System, and Clinical Director, National Institute of Neurological Disorders and Stroke (NINDS) presented to the group on his work with Nodding Syndrome and played a video of CNN’s coverage of the disease in Uganda. While the first reports of the disease occurred around 1990, the first cases were not documented until 2003. There has been a fair amount written about the disease since then. Dr. Nath highlighted a meta-analysis linking Onchocerca volvulus infection with epilepsy and another suggesting that seizures improve with treatment by ivermectin. Today, there has been some foray into mass treatment with ivermectin with some correlated decrease in the incidence of nodding syndrome.
Dr. Nath discussed the etiology of the disease. While it is known the O. volvulus causes river blindness, the parasite never actually enters the brain. The question then becomes how patients can develop neurological symptoms. In August 2012, Dr. Nath traveled to Kampala, Uganda to investigate nodding syndrome. There, in meetings with the CDC, it was suggested that the disease may stem from autoimmune complications due to the parasitic infection. Stakeholders in the region identified a patient family as candidates to bring to the NIH for further study and treatment. It was decided that the first avenue of investigation was to determine whether this was a genetic disorder that appeared to be an infection, which was determined not to be the case.
Extensive testing was performed on the family. In terms of anthropometrics, two of the affected siblings were slightly microcephalic, suggesting mild developmental retardation. Though they had access to anti-epileptic medication, one of the affected children had failed to take their medication on the way there. That child had three seizures, only one of which was able to be measured by EEG. Extensive spinal tap profiles, neurological testing, anthropometrics and toxicological testing revealed no large abnormalities that could explain the presence of nodding syndrome.
They performed antibody testing with a different methodology than what was commonly pursued, where they used human fetal tissue as the control. Through this analysis, it was discovered that patients with nodding syndrome had an incidence of a protein, leiomodin-1, 30,000-fold higher than the controls. Leiomodin-1 is a protein homologous with worms. This discovery was confirmed in the Ugandan family, where the two girls who were most affected had higher LMOD-1 antibodies as compared to the boy who was least affected.
They then turned to investigate what leiomodin-1 does in the brain, on which there was no literature. The protein has a distinct and large presence in the brain. They found it in specific regions of the hippocampus, but not on its most vulnerable region. An investigation into the antibodies for leiomodin-1 revealed that they are neurotoxic. There is also a structural homology between leiomodin-1 in humans and tropomodulin in Onchocerca. The papers produced on this topic led to the life cycle of the parasite to include causation of nodding syndrome.
Dr. Wasserheit asked what changed in the 1990s to account for the appearance of this disease. Dr. Nath explained that the incidence of Onchocerca had to reach a critical burden before nodding syndrome happens. Dr. El-Sadr asked why this disease has not been reported in West Africa where onchocerciasis is much more prevalent. Dr. Nath suggested that onchocerciasis is related to multiple types of epilepsy and that a meta-analysis would likely show an increased incidence of epilepsy in these populations. Dr. Birbeck asked how Dr. Nath could be sure that ivermectin was responsible for the decrease. Dr. Nath replied that because of the destruction caused by the neurotoxicity, ivermectin can only prevent new cases. The widespread application of ivermectin has correlated with a decrease in cases. Dr. Joel Breman offered up for reflection the question as to whether it is better to build large research centers that can handle these types of analyses rather than tackling problems with piecemeal funding.
Program Update: Chronic, Noncommunicable Diseases and Disorders Research Training (NCD-Lifespan)
Dr. Kathy Michels, Program Officer, Division of International Training and Research, introduced the three grantees who will be speaking, all of whom are from the NCD research training program. This program aims to strengthen research capacity in institutions within LMICs with the ultimate goal of better implementing evidence-based interventions there. Since 2001, there have been 70 awards, 42 of which are currently active. These awards have resulted in 601 long-term trainees and 1,720 publications that feature at least one trainee author. Most grants are a mix of a specific set of health issues and risk factors.
Dr. Ghada El-Hajj Fuleihan, Professor of Medicine, American University of Beirut
Dr. El-Hajj Fuleihan introduced herself, gave a brief overview of the American University of Beirut (AUB), and discussed work with the Scholars in Health Research Program, known as SHARP. The mission of SHARP is to provide training in the NCD research sphere for physicians and healthcare professionals to advance the care agenda in Lebanon and the region. The program was begun by a number of AUB faculty in conjunction with U.S. counterparts from Harvard Medical School and Harvard School of Public Health. It provides a hybrid curriculum/building training grant that serves as the region’s only summer certificate program for quantitative research methods. Dr. El-Hajj Fuleihan gave an overview of the SHARP curriculum and course structure.
With the exception of last year, the number of enrolled students increased each year of the program. The dip for Summer 2017 occurred because it was the first year that AUB accepted students who were paying for 25% of their certificate which, in the long run, will make the program sustainable. Certificate candidates have come from nearly every country in the region spanning from Morocco to Pakistan. The majority of graduates go on to become research fellows either at AUBMC or a U.S. institution, while the next largest portion go on to other healthcare roles in Lebanon. Dr. El-Hajj Fuleihan noted that even if AUB sees only 5-10% of its graduates come back from studying at U.S. institutions, it would represent a big step forward for increasing Lebanese research capacity. From 2006-2016, AUB’s receipt of this NCD training grant from FIC was the largest NIH grant that the institution received.
Dr. El-Hajj Fuleihan introduced the committee to some of the SHARP graduates who had received grants. Students have received a number of awards as well as a Knowledge is Power (KIP) grant and an MPP grant. SHARP graduates have given presentations at the American College of Radiation Oncology, the American Society of Parenteral and Enteral Nutrition (ASPEN), and a presentation at the American Public Health Association (APHA), among others. Three graduates are currently residents at Johns Hopkins, one completed a nephrology fellowship at the Mayo Clinic, and a fifth is enrolled in a program at the University of Pittsburgh Medical Center. SHARP staff have identified 214 publications from graduates, 10 of which were begun while attending the program and 51 of which were a result of skills acquired there. The majority of these publications were on NCDs. These data were confirmed by the graduates themselves.
Dr. El-Hajj Fuleihan discussed the work of former students, highlighting the work of Marlene Chakhtoura, a former student of the SHARP program who is now its assistant director for the summer certificate program. Dr. Chakhtoura has been working on vitamin D issues in Middle Eastern populations and on osteoporosis. Her work has influenced regional vitamin D guidelines and has prompted a trial studying vitamin D replacement in pregnant women. For osteoporosis, she completed a policy brief and gap analysis that compared osteoporosis work in Lebanon with that of the U.S. She gave an overview of testimonials from graduates.
Dr. Stephen Katz praised the summer certificate program, suggesting that it’s a model that should be imported to the U.S. He then asked Dr. El-Hajj Fuleihan to comment on fractures data relating to osteoporosis in Lebanon. She responded that they have analyzed data from 2001 to 2006 and are in the process of extending that analysis to 2016. Currently, they are analyzing it to see if trends against bisphosphonate as treatment for osteoporosis noticed in U.S. populations will be replicated in Lebanese ones.
Dr. Curran asked Dr. El-Hajj Fuleihan to comment on establishing CTSAs at the AUB. She replied that the administration has been working on how to navigate that issue, seeing as they function as a quasi-American institution. For example, they’re governed by American-based bylaws but certain institutions don’t recognize AUB as American. In reference to CTSAs, she stated her hope is that, now that the summer program has demonstrated sustainability, AUB can establish a research award system for SHARP graduates.
Michael Engelau asked what was missing from the SHARP program. Dr. El-Hajj Fuleihan answered that beyond large regional datasets, they were missing resources to pay people and mentorship to continue student development.
Dr. Debra Litzelman, Director of Education, Indiana University Center for Global Health
Dr. Litzelman discussed enhancing research capacity in Kenya from the Academic Model Providing Access to Healthcare (AMPATH) Training Institute. The goal of Indiana University’s D43 program was to transition its Clinical Translational Science Institute program, called the Clinical Investigator and Translational Research Education (CITE) program, to its partner in Kenya and then institutionalize it. The latter part of this effort revolved around establishing a clinical delivery system laboratory for Kenyan research projects. Curricular modules were transferred online to be delivered to Kenya in order that the curriculum occurred entirely in country. There were three cohorts over three years, involving eight students, whose projects covered a variety of common NCDs. Through FIC, some of these fellows have taken a yearlong no-cost extension to continue their research.
Of the eight fellows, the Kenyan CITE program has retained four of them to teach seminars. Another has gone on to the Department of Medicine, where he has been assisting Moi University with advancing the CITE program agenda. With his assistance, 14 of the 20 curricular modules have now been standardized in Moi University’s School of Medicine. These eight fellows have published 22 journal articles, with many more in progress.
In general, these fellows have brought task shifting methods and new knowledge about how to use community health workers to the Kenyan public health system. While community health workers are used all around the world, the CITE program has developed innovative research methods for testing the fidelity of these workers to their education in order to identify what has been effective and what has not. The program has also been focused on the lack of qualified MDs in Kenya, changing regulations to allow advanced practice clinical officers to take additional certification in NCDs. Dr. Litzelman stressed that this relationship is bilateral, utilizing the experience of their Kenyan partners. IU-AMPATH leaders informed the response to the HIV outbreak in southern Indiana as well as the ongoing effort to improve poor infant mortality rates in the state.
Bob Bollinger praised the program, saying that it really has enabled Kenyans through Moi University to translate research into real clinical outcomes. Paul Otieno Ayuo, site principal investigator for the program, spoke about the importance of educating and empowering clinical health officers who do the bulk of medical work in Kenya. He hoped that the program would continue to build capacity and that more fellows could be trained through the program. Dr. El-Sadr supported these comments, explaining that while physicians tend to leave for urban centers or foreign institutions, the health officers tend to stay.
Dr. John Monahan asked if there were other stakeholders who had benefited from the bilateral relationship with Kenya. He also asked whether there had been any exchange between community health workers in Indiana and CITE’s. Dr. Litzelman said that a table identifying all the reciprocal benefits was included in the application. As for Dr. Monahan’s second question, she replied that she thought it was a great idea and that she would take it back with her. Drs. Glass and Greg Germino asked if Drs. Bollinger and Litzelman could compile that list of examples and share it with the committee.
Dr. Bill Riley asked what the major implementation science challenges were that Dr. Litzelman’s team faced in translating their science from Indiana to Moi University in Kenya. Dr. Litzelman said that there has been an increasing cadre of mentors and experts in Kenya who have helped guide local efforts to address health problems there.
Dr. Einterz commented that because Kenyans and Indians, with whom he has had experience working with, have been providing healthcare on a community basis for generations, there is a tremendous opportunity to learn about how they do it in order to inform U.S. models of community care.
Dr. Olugbenga G. Ogedegbe, Vice Dean & Chief Medical Officer, NYU College of Global Public Health:
Dr. Ogedegbe began by providing context for his training program. His work on capacity building began with a trip to Ghana where he noticed that the research agenda there was driven by North America and Europe, which struck him as strange. A report commissioned by the World Bank revealed that between 2002 and 2014, Sub-Saharan Africa increased its research output by less than 1%. Of that output, between 0.9%-2.9% of it comes from intra-African collaborators. That means that diasporic Africans are producing the rest of it. Dr. Ogedegbe indicated that poor resourcing is the principal cause of this deficiency. On average, African countries designate seven times less for R&D as compared with developed countries.
Drawing from a report from the Council on Health Research for Development (COHRED), Dr. Ogedegbe argued that the way health programs are funded in Africa has to change. Instead of causing scientists in LMICs to compete for funding, grants should promote collaboration among experienced researchers. Oftentimes, researchers become siloed within their funding institution, returning only to the NIH or the Wellcome Trust without regard for the other institutions.
Consequently, Dr. Ogedegbe wrote the grant that eventually produced the Cardiovascular Research Training (CaRT) Institute as an FIC-funded D43 training program. CaRT is a collaborative effort between the NYU School of Medicine, Loyola University, and the University of Ghana School of Public Health. Its goal is to establish a development pipeline for matriculated graduate students and junior faculty to serve as independent investigators. Training occurs entirely in Ghana over a period of two years and requires trainees to form multidisciplinary research groups. Dr. Ogedegbe outlined the curriculum over the two years, characterizing it as intensive. While the first cohort broke down into study groups in major NCDs, the second, third and fourth cohorts broke down into developing programs that would benefit both Ghana and Nigeria. Including the current no-cost extension year, there have been 84 people trained through this program. Instead of focusing on certification, like Dr. El-Hajj Fuleihan’s program, they focused on writing publications, pairing each group with a mentor from the U.S. or Europe. They supplemented these workshops with webinars which have been so successful that they continue today, funded by NYU.
Dr. Ogedegbe highlighted two students from the sickle cell cohort. Samuel Oppong is an OB/GYN whose specialty is high-risk pregnancies in sickle cell patients. Together with Michael Debaun from Vanderbilt University, they founded the High-Risk Pregnancy Program in Sickle Cell Disease in Ghana and Nigeria. While before this Dr. Oppong was a clinician, teaching one day a month, now he publishes regularly. Najibah Galadanci, the other student, manages R01 and an R21 grants to look at sickle cell prevention methods. He finished his presentation arguing to increase capacity in these countries by empowering local leadership.
Dr.Flora Katz asked what precipitated the shift to multidisciplinary groups, since they began being focused solely on cardiovascular disease. Through his experience working on decreasing hypertension in African-American communities in the U.S. and his experience with a U01 he had received at the time to implement the WHO’s CVD plan, he realized the importance of convening a variety of stakeholders in order to solve any single problem. In Sub-Saharan Africa, health officials and community health workers deliver most of the care, so Dr. Ogedegbe wanted to instill in his students an ability to work with others.
Dr. Germino asked for examples of how the European or American agenda diverged from what was determined to be important locally. Dr. Ogedegbe’s initial charge in Ghana was to look at hypertension and diabetes. When he got to the clinic, however, it became clear that the clinic was also handling depression and other quality of life issues due to limb amputations. Another example comes from the sickle cell treatment program set up in conjunction with Vanderbilt where clinicians found that they also had to treat diabetes in their patients.
Dr. Engelau asked what the role of other, more developed nations like South Africa is in increasing the research output in Sub-Saharan Africa. He also asked about Dr. Ogedegbe’s mention that he oftentimes had to import mentors from American institutions and what that meant for sustainability going forward. As for the second question, those members of the first cohort who went on to become faculty also became peer mentors for subsequent cohorts. Any additional mentors who were brought in came by their own choice. Building out this capacity further will simply take time. With respect to South Africa, Dr. Ogedegbe’s concern is that it will become a local arena for brain drain: already there are many Nigerian physicians established there.
Dr. Bollinger asked, with these multiple academic institutions, how Dr. Ogedegbe navigated the needs of each. Ghana was easy because it was building upon an already established relationship with NYU. With Nigeria it was more difficult, which they explained by the lack of that same institutional relationship they had had in Ghana. The junior physicians and students, however, flocked to the program. Dr. Bollinger then asked what the next steps will be for the Ghanaian students. Programs building publication writing skills have proven very popular there and Dr. Ogedegbe hopes to continue to build on those successes. Beyond that, funding programs properly from the start is crucial to enabling the passion of the students there to carry them forward.
Dr. Wasserheit asked what has been included in the dissemination and implementation research portions of this training. While trainees readily understood efficacy, they often struggled with the importance of context. Consequently, they spent a lot of time with trainees distinguishing between effectiveness and efficacy as well as comparative effectiveness strategies. They were also able to use two U01s they had recently been granted as models to improve their training. He hopes that the next step after this is to get student programs funded because practice is the best teacher. They have brought in health ministers and WHO officials previously, but Dr. Ogedegbe felt that the conceptual understanding was not as practically useful.
Dr. Glass exhorted Dr. Ogedegbe to take charge of a regional program to lower blood pressure by 10 mmHg, given his experience with these training programs and his involvement with the GACD. Dr. Ogedegbe said that he will be publishing an article in NEJM soon about a task shifting method for hypertension control in patients with uncomplicated hypertension. The prevalence of hypertension in Ghana is about 30%. In response, researchers trained a variety of health workers to administer interventions to about 3,000 people who were screened with incredible results. The major problem is that until they have buy-in from a well-funded audience, hypertension will remain another regional problem. Dr. Bollinger asked if one of the things Dr. Ogedegbe was considering for this program was hypertension health insurance for the region, subsidized by the World Bank, for example. Dr. Ogedegbe said that that would be great. He had included health insurance in his proposal because national health insurance had just come out in Ghana while he was writing the grant.
Dr. Glass asked about the prevalence of stroke in the populations Dr. Ogedegbe studies. He responded that, with the high levels of hypertension, he is seeing stroke in young people now. Instead of running stroke care through hospitals as is done in the West, in Ghana care is run through stroke centers, funded in part by NINDS. One of the issues is that there is a lack of follow-up care after the initial treatment. Dr. Glass also asked what can be done to increase and maintain participation from diasporic scientists. Dr. Ogedegbe answered that, in his experience, seeing successful people who look like you and who come from similar contexts does a lot to inspire people.
Closing Remarks & Adjournment:
Dr. Glass asked the presenters, as Fogarty makes work possible in their countries and across the world, that they help FIC demonstrate the benefits and value of that research investment. Dr. Glass pointed to the scientific breakthroughs such as the one outlined earlier by Dr. Nath as an example and the use of community health workers by AMPATH to screen for hypertension as another. He thanked board members and staff for making the meeting possible. The meeting was adjourned at 3:00 p.m.