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May 7, 2019 Advisory Board Meeting Summary Minutes

The FIC Advisory Board met in the Stone House Conference Room, Building 16, National Institutes of Health, 9000 Rockville Pike, Bethesda, Maryland, at 9:00 a.m., Roger Glass, Chair, presiding.

PRESENT

ROGER I. GLASS, M.D., Ph.D., Director, Fogarty International Center; Chair
ROBERT BOLLINGER, M.D., Johns Hopkins University School of Medicine
WALDEMAR CARLO, M.D., University of Alabama at Birmingham
MYRON COHEN, M.D., University of North Carolina
JAMES CURRAN, M.D., Emory University
ROBERT EINTERZ, M.D., Indiana University School of Medicine
JACOB GAYLE, JR., Ph.D., Medtronic Foundation
GREGORY GERMINO, M.D., National Institute of Diabetes and Digestive and Kidney Diseases; ex officio
KING HOLMES, Ph.D., M.D., A.B., University of Washington; Harborview Medical Center
VIKAS KAPIL, D.O., M.P.H., Centers for Disease Control and Prevention; ex officio
JOHN MONAHAN, J.D., Georgetown University
GBENGA OGEDEGBE, M.D., M.P.H., F.A.C.P., New York University School of Medicine

ALSO PRESENT

PETER KILMARX, M.D., Deputy Director, FIC
KRISTEN WEYMOUTH, Executive Secretary
CHRISTOPHER AUSTIN, M.D., Director, National Center for Advancing Translational Sciences
GEETHA BANSAL, Ph.D., FIC
BARBARA BASS, M.D., F.A.C.S., University of California, Los Angeles
KEVIN BIALY, FIC
JOEL BREMAN, FIC
KEN BRIDBORD, M.D., FIC
ANTHONY CHARLES, M.D., M.P.H., University of North Carolina
JANE COURY, NIAID
PAUL GAIST, Ph.D., M.P.H., Office of AIDS Research, NIH
JOSHUA GRUBBS, FIC
LILY GUTNIK, M.D., University of Utah
FLORA KATZ, Ph.D., FIC
JOSEPH KOLARS, M.D., University of Michigan Medical School
TY LAWSON, NIEHS
WILLY LESCANO, Ph.D., University of California Global Health Institute
KEITH MARTIN, M.D., P.C., Executive Director, Consortium of Universities for Global Health
RAUL MEJIA, M.D., Director of Health Research, Argentine Ministry of Health
JOE MILLUM, FIC
AMIT MISTRY, FIC
JAMIE NISHI, GHTC
SUSAN PERKINS, Ph.D., National Cancer Institute
ROBIN PETROZE, M.D., M.P.H., University of Florida
VIVIAN PINN, M.D., FIC
ANNA PRUIT, FIC
SCOTT SOMERS, Ph.D., National Institute of General Medical Sciences
DAVID SPIRO, Ph.D., FIC
SARAH SCHARF, FIC
BARCLAY STEWART, M.D., University of Washington
GIRMA TEFERA, M.D., F.A.C.S., University of Wisconsin*
JUDITH WASSERHEIT, M.D., M.P.H., University of Washington
MARY WILSON, M.D., American Society of Tropical Medicine and Hygiene
CELIA WOLFMAN, FIC
SANAH ZIA, NICHD

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

Dr. Roger Glass opened the meeting at 9:01 A.M. He welcomed Dr. Raul Mejia from the Argentine Ministry of Health and Dr. Keith Martin, Director of the Consortium of Universities for Global Health (CUGH). Dr. Glass also introduced Dr. Willy Lescano, a former Fogarty Fellow from Peru. Dr. Glass discussed upcoming changes to the Board. He thanked Dr. Joe Kolars for service on the Board and asked that he attend open session meetings when his schedule permits.  Dr. King Holmes will be rotating off the Board after this meeting. New members will include Drs. Judith Wasserheit, Michelle Williams, and Steffanie Strathdee.  Dr. Glass congratulated ex-officio Board member Dr. Greg Germino on being named the 2019 Shaul Massry Distinguished Lecturer by the National Kidney Foundation.

A symposium was held at the end of February in honor of the late Dr. Adel Mahmoud who was a former Fogarty Board member.  Dr. Mahmoud had a long and distinguished career as the Chair of the Department of Medicine at Case Western Reserve University, President of Merck Vaccines, and professor of molecular biology at Princeton University.

Dr. Glass discussed recent activities related to stigma research, including the publication of an article called “Collection on Stigma Research and Global Health” in BMC Medicine. A webinar will be held on May 9th entitled “Health Stigma and Discrimination: A Global, Cross-Cutting Research Approach.”

The NIH Office of Intramural Research, with assistance from Fogarty, has established the African Postdoctoral Training Initiative. The initiative hopes to address the historical relative scarcity of Africans among the approximately 2,800 postdocs on campus from overseas. Funding came from the NIH Director’s discretionary fund, direct support from participating ICs, and from the Bill & Melinda Gates Foundation.

FIC has continued its outreach to professional organizations that began as part of its 50th anniversary activities. Dr. Kilmarx recently attended a conference of the International Alliance for Global Health Dermatology and many FIC staff, grantees, trainees and Board members attended the 10th Annual CUGH Global Health Conference. Dr. Glass highlighted some of the panels held at the conference, such as “Training the Next Generation of Global Health Researchers: The NIH-Fogarty Global Health Fellows Program,” a panel on stakeholder engagement in implementation science, and “Strengthening Mentoring in LMICs: A Call to Arms.” FIC Board member Dr. King Holmes and FIC senior scientific advisor Dr. Ken Bridbord both received the 2019 CUGH Distinguished Research Award at the conference.

Dr. Glass recently attended two bioengineering competitions: The Rice 360 Institute for Global Health Design competition led by former Board member Rebecca Richards-Kortum, and a Pediatric Academic Societies competition, which was won by a team from University of Maryland-Baltimore County. Dr. Glass also highlighted Gayatri Gatar’s company EarthEnable that is working in Rwanda to eliminate unsanitary dirt floors and provide affordable, sanitary flooring that can be washed, cleaned, and used to create a healthy home environment.

Dr. Glass noted several visitors to Fogarty in recent months, including Dr. Takeshi Kasai, WHO Regional Director for the Western Pacific; Dr. Adolfo Rubinstein, Argentine Minister of Health; and Dr. Nelson Sewankambo, professor of medicine at the Makerere University College of Health Sciences in Uganda. Fogarty held a Trauma and Injury Network meeting, noting FIC’s first grant to the University of Global Health Equity in Rwanda.  Dr. Glass also discussed the 2nd Annual International Cohorts Summit, held in Iceland in April, which focused on identifying research projects and establishing international collaborations, funding opportunities, and how to harmonize international research on cohorts, among other topics.  Organizations from 27 countries attended the summit, representing approximately 40 research cohorts.

Dr. Glass recently traveled to India to meet with new leadership in the clinical trial and public health research fields in hopes of refreshing the relationship between Fogarty and Indian institutions, which had experienced some struggles in the past few years. He met with Dr. Renu Swarap from the Ministry of Health’s Department of Biotechnology; Dr. K. Srinath Reddy, President of the Public Health Foundation of Indian; Dr. Dorairah Prabhakaran, the Director of the Centre for Chronic Disease Control; Dr. Balram Barghava, Director General of the Indian Council of Medical Research; Dr. K. Vijay Raghavan, Principal Scientific Advisor to the Prime Minister; and Dr. Gagandeep Kang, Director of the Translational Health Sciences and Technology Institute and the first Indian woman to be elected to the Royal Society.

Dr. Linda Kupfer updated the Board on FIC’s work the Center for Global Health Studies project, “Research to guide practice: Enhancing HIV/AIDS platforms to address NCDs in low-resource settings (the HIV/NCD Integration Project).”  Dr. Kupfer and colleagues recently submitted a letter to the editor of The Lancet in response to an article called “Advancing global health and strengthening the HIV response in the era of the Sustainable Development Goals: the International AIDS Society.” The letter highlighted the urgent need for evidence to support the recommendations in the report on which NCD services to integrate, at what level of the healthcare system, how to finance it, how and who should deliver the integrated care, and the effects of integration on quality of care. FIC will publish a supplement to JIAS to emphasize the importance of modeling the burden of NCDs in persons living with HIV as well as the effects of integrated care on HIV and NCD care.

Dr. Kilmarx discussed recent activities with the WorldRePORT and the 3rd U.S.-India Health Dialogue organized by the Department of Health and Human Services. Dr. David Spiro updated the Board on recent publications by Fogarty Division of International Epidemiology and Population Studies (DIEPS) staff, upcoming DIEPS disease modeling activities, and the Workshop on Digital Surveillance for Infectious Diseases co-organized by FIC and held in Addis Ababa, Ethiopia in late February.

Dr. Glass congratulated Dr. Kilmarx and the “take the stairs team” for winning the HHS Green Champion Award, Wellness category. Dr. Jeremy Farrar from the Wellcome Trust will be the 2019 NIH Barmes Lecturer. The lecture will take place June 19th at Masur Auditorium in the NIH Clinical Center.  Dr. Glass noted the dates of the next Advisory Board meeting, September 5-6, 2019, and highlighted events of note that will take place before then.

Dr. Glass introduced Dr. Raul Mejia, Secretary of Health Research at the Argentine Ministry of Health. Dr. Mejia was a Fogarty grantee working under Dr. Eliseo Perez-Stable and Dr. James Sargent on tobacco use in youth.

Review of Fogarty’s HIV Investments

Celia Wolfman, Global Health Research and Policy Analyst, Division of International Science Policy, Planning and Evaluation, FIC

Dr. Flora Katz, Director, Division of International Training and Research (DITR) introduced Ms. Celia Wolfman to present the results of the historical analysis of Fogarty’s HIV/AIDS research grants. The goal of the presentation is to provide context for Dr. Bansal’s concept proposal on HIV-associated NCDs.

Ms. Wolfman began by providing an overview of Fogarty’s HIV/AIDS award history. The first program was the AIDS International Research Training Program (AITRP), followed by the ICOHRTA-AIDS/TB Phase II (IAPH2) for international clinical operations and health services research training, and the HIV Research Training Program (HIVRT). The first two programs have closed while HIVRT is still underway. Over the three programs, beginning in 1998, Fogarty has issued 150 awards totaling $423 million. Ms. Wolfman described the various funding mechanisms for these grants and presented information on the regional distribution of the direct awards, showing that the majority went to Sub-Saharan Africa. The number of grantees from low- and middle-income countries (LMICs) has grown with each program. Ms. Wolfman’s analysis identified 2,899 unique trainees that participated in the three programs, representing 85 countries. The analysis also looked at the awards by research area. The top three areas of research were biology/basic biomedicine, comorbidity research, and epidemiology/biostatistics.

HIV Concept

Dr. Geetha Bansal, Program Officer, Division of International Training and Research, FIC

Dr. Bansal presented a program concept titled “HIV-associated Non-communicable Disease (NCD) Research at LMIC Institutions.” According to the WHO, 71% of all deaths globally are from NCDs. Eighty-five percent of these deaths occur in LMICs, where 15 million people aged 30 to 69 die prematurely. The leading cause of death is cardiovascular diseases, with 17.9 million deaths annually, followed by cancers (9.0 million), respiratory diseases (3.9 million), and diabetes (1.6 million).  Eighty percent of all premature NCD deaths are attributed to these four groups of diseases.

People living with HIV (PLWH) also have high rates of NCDs. Increasing uptake of antiretroviral therapy (ART) has led to decreased mortality rates due to HIV, but PLWH on ART are developing non-HIV-related chronic conditions of aging similar to the rest of the population. They are at higher risk for the early onset of non-communicable diseases, which often occur with more severity.

Based on a review of the literature, Dr. Bansal identified several research gaps to be addressed by this program concept, such as the etiopathogenesis of NCDs in PLWH, and immunopathologic responses that lead to morbidity, including immune reconstitution inflammatory disease and long-term physiologic and metabolic complications. Other avenues to explore include investigating causes for early onset of geriatric syndromes in the stable PLWH population on ART, developing better tools for early diagnosis of NCDs in PLWH on ART, and examining long-term options for better quality of life and integrated care of PLWH with NCDs, including mental health and neurocognitive disorders. More work is needed to understand the mechanisms responsible for increased susceptibility and higher risk of NCDs and accelerated aging process in PLWH, which can lead to better design of future interventions aimed at decreasing the effects of such comorbidities.

Dr. Bansal described past Fogarty initiatives relating to NCDs and HIV and the NIH grant portfolio over the past decade. Overall, there have been very few grants focused on HIV and associated NCDs in LMIC institutions from all the other programs across NIH. The long-term goal of the program concept is to support locally relevant and catalytic research in critical NCD areas to enhance research capacity building efforts at LMIC institutions. In addition, the program will seek to build a network of researchers both within and across LMICs to collaborate and complement unique resources and strengths to build and expand the scientific workforce. More specifically, the program aims to fill gap areas via exploratory studies to understand the etiopathogenesis of NCDs in HIV-positive people for effective diagnosis, prevention, therapeutic interventions, and clinical care. Along the way, the objective is to develop capacity for research focused on HIV-associated NCDs and form new multidisciplinary teams and partnerships. The program hopes to begin the first of two rounds of funding in FY20 using the R21 grant mechanism. The grants are for two years, but the goal is to connect grantees with other NIH ICs along the way in the hopes of continuing the research.

On the last point, Dr. Myron Cohen said the grantees will be challenged to make their research generalizable in ways that will be attractive to the chronic disease ICs. One way to bridge the gap would be to focus on types of chronic disease that affect the HIV community, such as HIV-associated multicentric Castleman disease. Dr. Germino noted that most ICs have a specific HIV fund that can be used for these types of international grants, which they may see as a way to mitigate concerns about lack of generalizability. Dr. Bansal noted this program will be funded by the Office of AIDS Research (OAR), which requires that the research be directly related to HIV/AIDS. Dr. James Curran suggested that the program try to identify unique areas of research and topics that are difficult to study domestically, such as HIV-associated cancers or even diseases that aren’t strictly NCDs. Dr. Paul Gaist, from the Office of AIDS Research, said OAR is interested in exploring cofounding or collaborative funding opportunities with the ICs to help bring together HIV and non-HIV research together in the ways described in some of the comments. Dr. Judy Wasserheit suggested encouraging comparison groups of subjects without HIV in order to improve generalizability. She also recommended bringing in young NCD investigators to have them trained on HIV-associated diseases. Dr. Einterz discussed his efforts in Kenya to establish models of integrated healthcare so that HIV can be treated like a chronic disease along with traditional chronic diseases.

Catalyzing Translational Innovation

Dr. Christopher P. Austin, Director, National Center for Advancing Translational Sciences (NCATS)

Dr. Glass introduced Dr. Austin and thanked him for presenting on the work of NCATS and potential arenas for partnerships with Fogarty. He noted Dr. Austin’s and NCATS’ role in rare diseases, the study of which demands an international lens, as well as in developing capacity for clinical trials.

Dr. Austin began by providing an overview of NCATS and translational medicine. There is a consensus in the medical research community that while fundamental science has seen unprecedented advances in recent decades, treatment development has not proceeded apace. There has been poor transition of basic or clinical observations into interventions that tangibly improve human health; development of interventions has been failure-prone, inefficient and costly; and there has been simultaneously poor adoption of demonstrably useful interventions. Translation is the process of turning observations in the laboratory, clinic, and community into interventions that improve the health of individuals and the public, from diagnostics and therapeutics to medical procedures and behavioral changes. Translational science is the field of investigation focused on understanding the scientific and operational principles underlying each step of the translational process. The translational science spectrum includes basic research, pre-clinical research, clinical research, clinical implementation, and public health aspects. The spectrum is not linear or unidirectional; each stage builds upon and informs the others. At all stages of the spectrum, NCATS develops new approaches, demonstrates their usefulness, and disseminates the findings. Patient involvement is a critical feature of all stages in translation.

NCATS’ mission is to catalyze the generation of innovative methods and technologies that will enhance the development, testing, and implementation of diagnostics and therapeutics across a wide range of human diseases and conditions. Dr. Austin described in more detail NCATS’ efforts on pre-clinical and clinical programs to accelerate translation, such as the Cures Acceleration Network, Clinical and Translational Science Awards (CTSA) program, Rare Diseases Registry Program (RaDaR) and Rare Diseases Clinical Research Network, as well as divisions devoted to pre-clinical and clinical innovation.

Dr. Austin highlighted the NCATS Trial Innovation Network (TIN), an initiative within the CTSA Program designed to be a national laboratory to study, understand, and innovate the process of conducting clinical trials. The TIN tests new processes designed to improve clinical trial operations, speed, and quality while aiming to reduce overall trial costs. The TIN tackles issues ranging from recruitment to IRBs to contracting. One of the ancillary objectives of the network is to make the field of clinical human research more appealing to young scientists. TIN has a partnership with the Recruitment Innovation Center (RIC), which provides resources such as planning and feasibility assessments, recruitment materials, EHR assessments, and participant compensation assessments. Dr. Austin noted that half of NIH trials fail due to inability to fully recruit over their lifespan, and the RIC was designed to improve this state of affairs.

Dr. Austin also highlighted NCATS’ efforts at community engagement. NCATS’ goal is to engage patients and communities in every phase of the translational process. NCATS supports research in the structures, rationales, operations, purposes, outcomes, and metrics of engagement with stakeholders at each step of the translational process to help define principles and practices that make translation maximally efficient, focused, and relevant. In addition, CTSA community engagement activities help ensure that communities and researchers have the capacity to participate as full partners; that communities are consulted for their research priorities; that all stakeholders are respected, valued, and rewarded for their time and expertise; that more effective implementation and dissemination strategies are developed; and that there is increased public support for research, and ultimately improvements in the health and well-being of communities.

Other major focus areas at NCATS that Dr. Austin highlighted are rural health, such as the Appalachian Translational Research Network, and rare diseases, including the Therapeutics for Rare and Neglected Diseases Program and the Microphysiological Systems Program, working on scientific advancements such as tissue-on-chips. Dr. Austin finally touched on the Drug Discovery, Development, and Deployment Map (4DM), which is designed to more accurately lay out the drug development process.

Dr. Glass asked Dr. Austin what potential areas he thought existed for partnerships between FIC and NCATS. Dr. Austin pointed to NCATS’ work on pre-clinical models, devices or agents without commercial applications, teaming up with the Trials Innovation Network, and many other ways, too. The TIN has yet to tackle an international clinical trial, but Dr. Austin said it is eager to do so. Dr. Wasserheit asked about implementation science and Dr. Austin said NCATS is discussing internally how to enter this field in a way similar to the TIN and is open to partnering with FIC and others in this field as well.

The Lancet–O’Neill Institute/Georgetown University Commission on Global Health and the Law

John T. Monahan, JD, Senior Scholar, O'Neill Institute for National and Global Health Law, Georgetown University

Mr. Monahan briefed the Advisory Board on the Lancet–O’Neill Institute/Georgetown University Commission on Global Health and Law, which was recently established to answer the question of how best to harness the power of the law to improve global health. The Commission is chaired by Mr. Monahan and Larry Gostin and its members are experts in the fields of global health law and medicine. The foundational message of the Commission is that law is a powerful, yet underutilized, tool for improving health. In its report, the Commission wanted to encourage the community and stakeholders to raise their voices to reform law and promote better health outcomes. The report begins with a basic primer on health and law, defining what the law is for the purposes of the report and what its functions are. It notes that the international sphere has very few hard laws (the International Health Regulations being one example), but is mostly governed by soft rules, such as non-binding standards articulated by the WHO and other organizations. The law is vital to establish standards of conduct, resolve disputes, and govern public and private institutions.

The Commission chose to utilize the lens of the legal determinants of health as a means to situate within the larger social determinants of health movement. The hope was to engage health and science audiences in looking beyond laws as rules to be applied and instead seeing law everywhere, thus enabling them to focus on ways in which law both advances and hinders health outcomes for communities and individuals. Mr. Monahan gave some examples of legal determinants of health, such as translating the vision of universal health coverage into action, strengthening governance to combat poor compliance to standards, implementing evidence-based interventions, and building legal capacity that bridges disciplines.

The Commission’s report has seven recommendations: 1. Measure compliance with Sustainable Development Goal 3.8 relating to universal health coverage; 2. Establish legal frameworks for rights-based universal health coverage; 3. Adopt stronger good governance standards for international agencies; 4. Implement legal frameworks for good governance in domestic agencies; 5. Create a global resource of evidence-based public health laws; 6. Strengthen legal capacity of public health agencies; and 7. Form an independent standing commission on global health and law.

For next steps, Mr. Monahan said the Commission is looking for input on whether a standing commission on global health and law would be feasible, working on creating a legal solutions network for universal health coverage (drafting toolkits), and looking for new partner institutions. Dr. Martin briefly touched on CUGH’s work responding to the Commission’s report, including the establishment of a Working Group on Global Health Law and related capacity-building activities. Dr. Glass noted that Fogarty currently has its first lawyer Fellow and is looking forward to following his work. Dr. Curran noted the political aspects of the law and the role of tort law in the medical field and asked whether the report addressed those issues. Mr. Monahan said it does, and he agreed with Dr. Curran’s emphasis on the political aspect.

Global Health Surgery

Dr. Glass introduced this session by noting the unique challenges faced by researchers in global surgery. Finding post-fellowship grants from NIH can be difficult for early career surgeons and Fogarty has been closely following past surgical fellows and the field of global surgery in general to see how to improve prospects for the next generation of global health surgeons.

Dr. Anthony Charles, Director of Global Surgery, UNC Institute of Global Health, Adjunct Professor of Public Health, UNC School of Medicine

Dr. Charles began by emphasizing the vital, but frequently overlooked, role that surgery must play in any effort to improve global health outcomes. Deaths from NCDs in LMICs still surpass mortality from communicable diseases such as HIV, TB, and malaria combined, yet most of the international research funding goes to the latter. Dr. Charles attributed this state of affairs to national security concerns, which are understandable, but to truly improve global health outcomes from NCDs like cancers and cardiovascular disease, more funding and support are needed in the field of surgery. Dr. Charles described the work of the UNC Malawi Surgical Initiative training surgeons in country via general surgery and orthopedic surgery residency programs, creating a research program to study HIV outcomes in surgical patients, and developing trauma, emergency, and pediatric registries. The program has made a great deal of effort to secure funding since its inception. It began by focusing on epidemiological studies before moving into randomized trials. The financial situation has improved over the years thanks to the support of UNC, philanthropic organizations, and a sponsorship from Johnson & Johnson. Dr. Charles highlighted cancer as a field that still needs much more funding in the surgical research arena, particularly breast cancer, pediatrics, and trauma surgery.

Dr. Robin Petroze, Assistant Professor of Surgery, Division of Pediatric Surgery, Assistant Chair of Global Surgery, University of Florida

Dr. Petroze focused her talk on how her experience as a Fogarty Fellow impacted her career development, the challenges of choosing a career in academic global surgery, and potential future directions. Dr. Petroze pointed out that the training of a global surgeon is a long-time course; whereas fellows with a specific disease focus can expect to complete their program and return to apply for independent funding in a 2-5-year time period, the global surgical training takes considerably longer, up to 10 years post-medical school in Dr. Petroze’s case. During her Fogarty fellowship, Dr. Petroze worked in Rwanda conducting a hospital-level survey of emergency and essential surgical capacity, developing a trauma registry at Rwanda’s university teaching hospitals, and a Surgeons Overseas prevalence of surgical conditions survey.

In addition to the time requirements, other challenges for junior faculty in the surgical field include the lack of mentorship, difficulty finding a job that values global surgery, and difficulty developing a niche that can attract funding and mentorship and is sustainable. Dr. Petroze identified pediatric global surgery as a future focus area. Two-thirds of children worldwide lack access to safe surgical care. As access to pediatric surgical expertise improves, outcomes are hampered by infectious complications both in the initial presentation as well as postoperative complications. Assessing outcomes is essential to ensuring cost-effective development and quality care delivery. Dr. Petroze is working to develop a pediatric surgical unit that offers collaborative, multidisciplinary training, eventually developing neonatal and pediatric critical care capacity, and providing infrastructure for multi-institutional outcomes research.

Dr. Barclay Stewart, Chief Resident, General Surgery, Department of Surgery, University of Washington

Dr. Stewart discussed his path to become a general surgeon working in global surgery. He was raised in the rural South in the United States and was witness to poverty, extreme social and health disparities, and health systems that were unable to return people to their way of life after illness or injury. He enrolled in medical school with a goal to gain the knowledge and skills required to address these issues, but there were no obvious local opportunities to do so as a student. He ultimately discovered the Fogarty Clinical Scholars program through an internet search and ultimately ended up in Kenya studying the impact of HIV/Helminth co-infection on the progression to AIDS. Afterwards he went on to earn his master’s degree studying neglected tropical diseases among pastoralists in South Sudan. Dr. Stewart applied for his surgical residency while in South Sudan, and was accepted by the University of Washington, which has world-renowned global health and implementation science programs. He noted that he was pointed to the University of Washington by his Fogarty Mentor, Dr. Walson. During his residency, he was selected to be a Fogarty Fellow, and worked in Ghana on establishing a roadmap and action priorities for emergency, trauma, and surgical care system development nationwide.

For Dr. Stewart, the support from the Fogarty International Center was vital to his career path. FIC provided him with multiple projects with positive and lasting impacts for target populations, a network of new surgeon collaborators from more than 15 countries, a portfolio of more than 70 peer-reviewed manuscripts that reflect our work and relationships and created in Dr. Stewart a young mentor ready to train the next generation of global surgery research trainees. Dr. Stewart will be continuing his career at the University of Washington providing trauma, burn, and general surgical care at a county hospital dedicated to the underserved and to a region with problems similar to those faced by populations worldwide. He will also have the opportunity to coordinate and grow UW’s global surgery programs.

Dr. Stewart identified three challenges that he has discovered in his career thus far. First, funding for global surgery often does not consider its multidisciplinary nature and the contributions that are needed from diverse stakeholders. Second, surgery requires practice, and training often occurs at night and on weekends. Many departments of surgery find the time restrictions defined by some grant mechanisms to be incompatible with building and supporting clinically excellent junior faculty.  Lastly, global surgery programs are generally less developed than their global health counterparts, making lofty program and research goals more challenging to achieve. Dr. Stewart suggested some actions to address these concerns: 1. Recruit all types of surgical stakeholders and support multidisciplinary research; 2. Strategically fund global surgery programs and research capacity building in addition to specific projects, such as supported by the T32 and D43 grants; 3. Re-design a series of K awards with surgeons in mind and lighten the restriction on clinical workloads to 50% full-time equivalent; and 4. Develop a plan to fund Global Surgery Centers of Excellence with United States institutions and their partners to improve the health of populations locally, regionally, and internationally by addressing issues like access, equity, quality, and system preparedness.

Dr. Lily Gutnik, Resident, General Surgery, University of Utah

Dr. Gutnik is a surgery resident at the University of Utah and is currently applying for breast surgery fellowships. Dr. Gutnik was a Fogarty Fellow in Malawi where she developed a project to train laywomen to conduct clinical breast exam screenings. Her ultimate goal is to establish a comprehensive breast center in an LMIC such as Malawi.

The burden of breast cancer in Sub-Saharan Africa is high and, unlike in high-income countries, women are ultimately diagnosed at a younger age and more advanced stage. The incidence/mortality ratio is also much higher in Sub-Saharan Africa. The five-year survival rate for women with breast cancer is 50% as compared to 89% in the U.S. There are many reasons for such disparities, including cultural and access to care barriers, but a key reason is lack of screening and early detection, especially in awareness and lack of organized mass screening that is believed to be a positive force in the downstaging of breast cancer in high income countries. These trends are evident in Malawi where less than half of women sampled in the capital, Lilongwe, had any sort of knowledge or awareness about breast cancer. In addition, there is a huge delay in diagnosis from the onset of symptoms, and almost half of mastectomies for breast cancer are for palliative reasons rather than curative.

Dr. Gutnik described the program she conducted during her Fogarty fellowship to train laywomen to conduct clinical breast exams and educate community patients on breast cancer in general. She trained four women of various ages and backgrounds. Results of the study were positive and showed that the training was feasible in this population and accepted by the community. Going forward, models need to be developed to apply this program for wider implementation, the performance needs to be assessed in rural communities, and cost-effectiveness assessments need to be conducted. Dr. Gutnik also touched on technological approaches to providing quick, effective, and financially feasible ways to provide breast exams in LMIC.

Dr. Gutnik’s Fogarty fellowship was crucial in shaping her career trajectory. It introduced her to rigorous research on the ground in LMICs and connected her with valuable mentors and professionals. Her experience in Malawi has led to her being named to the boards of three international organizations related to breast cancer in LMICs.

Discussion

Dr. Kapil asked how global health surgery deals with the fact that outcomes in LMICs are deeply connected to other factors, such as infection control, anesthesia, and rehabilitation. Dr. Charles said that is one of the reasons global surgery faces such unique challenges. The UNC Malawi Surgical Initiative attempts to address this in part by adding an anesthesiology training program in addition to surgical programs. Other fellows have worked on ICU development and critical care, but the funding to address all these related factors simply does not exist. Dr. Cohen added that pathology is another connected field that could be an area for future efforts. Dr. Petroze agreed that a health systems perspective and focus on multidisciplinary and collaborative relationships is vital in global surgery. Dr. Barbara Bass said that the surgical societies have career development awards that could be coupled with NIH awards to help infuse more cash into global surgery areas that need it. Dr. Glass suggested that academic medical schools consider adding international rotations to surgical residency to help young researchers gain experience overseas. Dr. Martin asked the panelists what they need from stakeholders to make academic careers in global surgery viable for more researchers. Dr. Petroze highlighted funding and mentorship; the latter will keep improving as scholars from the panelists’ generation get jobs and can start providing mentorship themselves. Dr. Charles said that a system that can provide surgical care can provide all care, but there is no clear path to participate in surgery at a system level; the global health field remains siloed.

Funding Opportunities for Surgeons

Dr. Susan Perkins, Acting Chief, Cancer Training Branch, Center for Cancer Training, National Cancer Institute (NCI)

Dr. Perkins discussed funding opportunities offered by the National Cancer Institute to support clinical training. Several years ago, the NCI became concerned that the number of applications from clinician-scientists had been dropping off. In response, NCI increased the salary level and research development support for the Mentored Clinical Scientist Research Career Development Award, also known as the K08 award. NCI has also worked to streamline the award process, combining the K23 grant into the K08, and eliminating the K07 in further efforts to increase interest from potential applicants. As a result of these changes, the number of awards has increased in the last few years by a factor of three while maintaining the success rates. Unfortunately, very few applications are received from surgeons. This has been attributed to the fact that the K awards require 75% minimum protected time, but analysis over other ICs with lower requirements suggests this might not be the primary reason for the lack of interest from surgeons. Other mechanisms NCI offers to support clinical scientists include the T32 institutional training grant often used for surgical oncology and the K12 Career Development Award for Clinical Oncology. Dr. Perkins said NCI believes the K12 is underutilized, and she noted that this award can be used for international research. She added that NCI is working on establishing an NCI D43 for international collaborations.

Dr. Scott Somers, Program Director, Pharmacological and Physiological Sciences Branch, National Institute of General Medical Sciences (NIGMS)

In addition to his role as Pharmacological and Physiological Sciences Branch program director, Dr. Somers oversees NIGMS’ postdoctoral training grants and career awards in Trauma and Burn Injury. NIGMS is NIH’s basic science institute and is currently the fifth largest IC by funding level. As part of its scope, NIGMS has historically taken on areas of research that don’t fit into the other ICs’ purviews, such as trauma research and anesthesiology, among others. As far as funding mechanisms of interest to Fogarty, NIGMS offers T32s, similar to the ones offered by NCI and other ICs. It also has funds dedicated to supporting research of trauma and critical illness, the first round of which was awarded to a multi-PI consortium led by Dr. Alfred Gilman at the University of Texas-Southwestern Medical Center. Dr. Somers encouraged prospective applicants to contact NIGMS directly to discuss potential avenues for research.

Discussion

Dr. Gbenga Ogedegbe noted the R38 grant at NHLBI, also known as the Stimulating Access to Research in Residency (StARR) grant, which funds residents specifically and might be of interest to surgical residents or departments, particularly as a way to help attract future surgeons to clinical research and potentially global health research. Dr. Perkins said NCI does participate in the R38 program.

Dr. Einterz concurred with the comments made by the panelists regarding the importance of addressing global health issues at the system level. Project-based research is important and worth funding but is inadequate by itself. Dr. Einterz attempts to take the systems approach through the AMPATH Consortium based in Eldoret, Kenya, and has included a surgical aspect for the very reasons noted by the panelists. Academic health sciences centers across the country have the funding and resources to establish more programs like this but the impetus from leadership at these institutions is currently lacking. There are other successful programs taking this approach, such as UNC in Malawi and UW in Kenya, but more are needed. Dr. Glass noted that similar programs are planned in Ethiopia and Uganda.

The Board discussed with the panel the need to convey to foreign governments and institutions the importance of establishing a robust surgical culture in improving health outcomes across the spectrum. Dr. Gutnik discussed her experience in Malawi where the Ministry of Health’s NCD unit was staffed by two individuals while the HIV department had over 30 staffers. This is not to say the Malawian government has skewed priorities, but rather that funding is limited and most of the funding from overseas has been earmarked for HIV/AIDS research. Continued outreach to government employees, diplomats, and external funding groups can nudge things in a more balanced direction.

Dr. Bollinger raised the possibility of partnerships with DOD, particularly on trauma-related surgery. Mr. Monahan added that foreign militaries might be interested in funding this type of research, as well. Dr. Kolars suggested looking back at past Fogarty programs as potential springboards, pointing to a renal transplant program in Ethiopia which ultimately led to great strides in the surgery field there.

Closing Comments

Dr. Glass thanked the participants for igniting a robust conversation on the future of Fogarty-funded research. Dr. Austin and the representatives from other ICs discussed a myriad of ways for potential grant applicants to connect with NIH to support global health research. Dr. Glass thanked the Board members, panelists, and visitors for their active participation and input.

Dr. Glass closed the meeting at 3:02 p.m.