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 GLASS, M.D., Ph.D., Director, Fogarty International Center, Chair
GRETCHEN BIRBECK, M.D., M.P.H., University of Rochester Medical Center
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
GREGORY GERMINO, M.D., National Institutes of Diabetes and Digestive and Kidney Diseases (ex-officio)
KING HOLMES, Ph.D., M.D., A.B., University of Washington; Harborview Medical Center
VIKA KAPIL, D.O., M.P.H., Centers for Disease Control and Prevention (ex-officio)
WALTER KOROSHETZ, M.D., Director, National Institute of Neurological Disorders and Stroke (NINDS) National Institutes of Health (ex-officio)
JOHN MONAHAN, J.D., Georgetown University
MARY WILSON, M.D., University of California, San Francisco School of Medicine
ALSO PRESENT
PETER KILMARX, M.D., Deputy Director, FIC
KRISTEN WEYMOUTH, Executive Secretary
STEFFANIE STRATHDEE, Ph.D., University of California, San Diego
JUDITH WASSERHEIT, M.D., M.P.H., University of Washington
MICHELLE WILLIAMS, S.M., Sc.D., Harvard University
MARK DYBUL, M.D., Faculty Co-Director, Center for Global Health Practice and Impact and Professor in the Department of Medicine at Georgetown University Medical Center
DEUS BAZIRA, DrPH, M.P.H., MBA, Co-Director, Center for Global Health Practice and Impact, Georgetown University Medical Center
JOSEPH KOLARS, M.D., University of Michigan Medical School
AMIT MISTRY, Ph.D., FIC
DAVID SPIRO, Ph.D., FIC
RACHEL STURKE, Ph.D., FIC
SUSAN VORKOPER, M.P.H., FIC
BARBARA SINA, Ph.D., Deputy Director, Division of International Training and Research, FIC
KATHLEEN MICHELS, Ph.D., Program Officer, Division of International Training and Research, FIC
WILLIAM STEIGER, Ph.D., Chief of Staff at the U.S. Agency for International Development
LANA SHEKIM, Ph.D., National Institute on Deafness and Other Communication Disorders
STACEY CHAMBERS, M.S., Program Analyst, National Institute of Neurological Disorders and Stroke
PAUL GAIST, NIH Office of AIDS Research
BLYTHE BEECROFT, M.S. Global Health Research & Policy Analyst, Fogarty International Center
JUNAID RAZZAK, M.B.B.S., Ph.D., Professor, Department of Emergency Medicine, Director, Center for Global Emergency Medicine, Johns Hopkins School of Medicine
MOHAMED EL-SHINAWI, Professor of General Surgery-Ain Shams University, Advisory to the Minister of Higher Education and Scientific Research, Egypt (Remote)
UZMA KHAN, Senior Instructor, Aga Khan University, Pakistan (Remote)
JON MARK HIRSHON, M.D., M.P.H., Ph.D., Professor, Department of Emergency Medicine and Department of Epidemiology and Public Health, University of Maryland School of Medicine
STEVE HARGARTEN, M.D., M.P.H., Professor, Department of Emergency Medicine, Associate Dean for Global Health, and Director of the Comprehensive Injury Center, Medical College of Wisconsin
JEREMY BROWN, M.D., Director, Office of Emergency Care Research, National Institute of Neurological Disorders and Stroke
GEORGE MENSAH, M.D., Division Director, National Heart, Lung, and Blood Institute
ALISON CERNICH, Ph.D., Deputy Director, National Institute of Child Health Development
BRUCE TROMBERG, Ph.D., Director, National Institute of Biomedical Imaging and Bioengineering
Director’s Update and Discussion of Current and Planned FIC Activities
Dr. Roger Glass opened the meeting at 9:03 A.M. He welcomed Drs. Judy Wasserheit, Michelle Williams, and Steffanie Strathdee as new members to the Advisory Board. He thanked Dr. King Holmes for his years of service on the Board. Dr. Lana Shekim gave an update from the National Institute of Deafness and Other Communicable Disorders (NIDCD). She mentioned that NIDCD has a new Director, Dr. Debara Tucci. Ms. Stacey Chambers gave an update from the National Institute of Neurological Disorders and Stroke (NINDS). She mentioned that NINDS welcomes Dr. Richard Benson to their staff who was a previous Associate Medical Director at Washington Hospital Center.
Dr. Glass attended the 30th anniversary of the Human Frontier Science Program on May 10, 2019 with the help of Ann Puderbaugh. The 2018 Nobel Prize in Physiology or Medicine prize winner, Tasuku Honjo, spent two years as a Fogarty Fellow.
Dr. Peter Kilmarx attended the INTEREST workshop also known as the African CROI which was held in Accra, Ghana, May 14-17, 2019. The workshop is designed for training and capacity building. He mentioned that Fogarty traditionally has a strong team of alumni that attends this workshop. The 2020 workshop will be held in Windhoek.
The Fogarty International Center recently published in their Global Health Matters newsletter a recent announcement by Dr. Francis Collins that he will consider speaking invitations based on inclusiveness. Drs. Roger Glass and Peter Kilmarx have also made this pledge.
Dr. Roger Glass attended the 72nd World Health Assembly. He mentioned a Fogarty grantee, Dixon Chibanda, from Zimbabwe, a country where there are fewer than 15 psychiatrists, developed a method to deal with mental illness known as the Friendship Bench. This is an intervention to reduce the mental health treatment gap by using a cognitive behavioral therapy-based approach at a primary care level. They trained lay healthcare workers to provide problem solving therapy sessions in what became a widely published clinical study. This has led to a program in New York City in order to take care of depression. Dr. Glass then went on to attend the World RePORT Network Meeting in Brussels. World RePORT is an open-access, interactive mapping database highlighting biomedical research investments & partnerships from some of the world’s largest funders (worldreport.nih.gov). He mentioned that Dr. Bruce Tromberg, Director of the National Institute of Biomedical Imaging and Bioengineering (NIBIB), met with Jeremie Zoueu from Ivory Coast where they had a discussion on biophotonics.
Dr. Glass congratulated Dr. Ken Bridbord for receiving the 2019 Leadership Award from the HPTN Annual Meeting & Awards. Dr. Glass mentioned the HIROs Group, Heads of International Research Organizations, had their annual meeting on the NIH campus. The Fogarty International Center and the National Institute of Dental and Craniofacial Research (NICDR) took this opportunity to host the annual David E. Barmes Global Health Lecture which was given by Dr. Jeremy Farrar, Director of the Wellcome Trust. Fogarty also hosted the Indian Counsel of Medical Research (ICMR) during their visit to rekindle old ties that were on hold due to abrupt changes at the ICMR and changes with the clinical trials regulations. Dr. Glass met with the Chinese delegation as NIH attempts to continue and reignite activities with China. He mentioned that it is the 40th anniversary of activity starting between China and the NIH through openings in the National Cancer Institute.
Dr. Glass mentioned that traditionally NIH has seen very few post docs on campus that are from Africa. In order to address this, NIH intramural labs in partnership with the Bill & Melinda Gates Foundation and the African Academy of Sciences, established the African Postdoctoral Training Initiative (APTI). The annual FIC Fellows and Scholars Orientation was in July and they welcomed 116 fellows and scholars and 9 Fogarty Fulbright Scholars. There are 14 NIH Institutes that partner in this program. The orientation starts with a two-day course on epidemiologic methods, statistical methods, and research design. This year the program saw its first two neurosurgeons. Also in July, Fogarty had an HIV Research Training at the Clayton-Dedonder Mentorship Fellows Program Meeting.
Dr. Glass visited the UNC Project-Malawi and shortly after getting off the plane found himself in a symposium with a dozen speakers talking about how Fogarty programs and their training have been crucial to their career development. Satish Gopal, a FIC Fellow in 2012-13, helped start up the UNC Center for Cancer Excellence in Lilongwe, Malawi. The First National Cancer Hospital will be put near the UNC Project Annex center where oncology, pathology, surgery, and radiation therapy can be studied. Dr. Rebecca Richards-Kortum, who left the Fogarty Board about two years ago, was the Board’s first engineer member. She was awarded the MacArthur Foundation Award to develop her initiative of leading an international team of physicians, engineers and business and entrepreneurial experts known as NEST (Newborn Essential Solutions and Technology Activity). NEST is developing and implementing an integrated package of life-saving neonatal technologies aimed at preventing 75 percent of newborn deaths in Africa. Malawi Polytechnic is the hub Dr. Richards-Kortum uses for developing new devices.
Dr. Glass attended the 3rd Annual AFREhealth Symposium, in Lagos, Nigeria. AFREhealth is an Africa-led effort to improve health education and research in Africa.
Dr. Amit Mistry updated the board on the Health Research in Humanitarian Crises project. The co-chairs are Iman Nuwayhid from the American University of Beirut and Brandon Kohrt from George Washington University, with Dr. John Monahan serving as the Board liaison. The project will be publishing an article in BMJ Global Health in fall 2019. They have also put together a collection of case studies to be pushed in Conflict and Health and BMC Public Health in spring 2020. Finally, the group is partnering with several research partners to institute a Global Forum on Humanitarian Health Research.
Dr. Rachel Sturke updated the Board on the Adolescent HIV Prevention and Treatment Implementation Science Alliance. Dr. Judy Wasserheit is the Board liaison for this project. The project recently held a competition for small funding awards to catalyze long-term sustainable regional or country specific collaborations. They were able to provide seven small grants with four being regional efforts and the remainder being country specific projects. Two additional awards were made; one for the adolescent voice and the other for creating a research toolkit that can be placed online.
Susan Vorkoper updated the Board on the Childhood Obesity Prevention Across Borders: The Promise of U.S.-Latin American Research Collaboration. U.S. scientists and Latin American researchers are attempting to study childhood obesity prevention in U.S. Latino populations. By collaborating with groups across NIH, they expect to cut across all types of disciplines. This is a buildup of a previous project presented in 2017 that will identify key research gaps and find opportunities for moving forward.
Dr. David Spiro presented on FIC’s Division of International Epidemiology and Population Studies’ recent publications. From the computational volume group there have been 12 publications so far in 2019. In the Clean Cooking Implementation Science Network, the type of collaboration being focused on is clean stacking. Seven new projects have been launched to evaluate clean stacking combinations and to model their scale-up efforts. In another project, FIC is partnering with Pakistan to provide virtual training on YouTube called Biosafety on Demand. There is an upcoming workshop on RSV Genomic Diversity and Development of a Global RSV Intervention on September 25 and 26.
Dr. Barbara Sina discussed the renewal of FIC’s Global Infectious Disease Research Training Program. Some basic principles of the program are to create a critical mass of researchers, conduct independent infectious disease research, and to do all of the research training through U.S./LMIC collaboration. Many reviewers of the program mentioned that they like the Heads of Training Program as graduates of that program can go on to teach others how to successfully receive grants. NIAID is a current co-funder of this program.
Dr. Kathleen Michels discussed the program concept for the reissue of the Global Brain and Nervous System Disorders Research across the Lifespan (Global BRAIN). The program supports collaborative research and capacity building projects relevant to LMICs on brain and nervous system disorders throughout life. This program collaborates across 11 Institutes, centers and offices across NIH. In 2017, the global burden of disease estimates expanded the list of neurological disorders making it the leading cause group of disability, and the second-leading cause group of mortality worldwide. The bulk of research grants have been in and from Sub-Saharan Africa. From 2012 to 2019 there were 907 publications. One of the goals is to build up the number of applications coming directly from LMIC scientists. Another goal is to encourage more regional networking, collaborations for D43 institutional research training, and applications in gap areas.
Global Health at Georgetown University
Dr. Glass introduced Dr. Mark Dybul and Dr. Deus Bazira, Co-Directors of the Center for Global Health Practice and Impact at Georgetown University Medical Center. Dr. Glass mentioned Dr. Dybul’s role in advancing the PEPFAR program.
Dr. Dybul talked about how Dr. Bazira, who came from Uganda, used to work with Bob Redfield and ran all of PEPFAR’s clinical programs. It is predicted there will be significant declines in global health financing from the U.S. government over the next 5 to 10 years. The World Bank projects that there will only be a handful of low-income categorized countries by the years 2020 and 2025. There are signs of governments around the world increasing expenditures on HIV and health related programs. There is a global shift toward building up health insurance standards, but the resources that can be devoted to that effort vary widely by country. There is also a global shift towards building a country’s institutional capacity. Countries are looking for training opportunities in management, information systems, logistics, supply chain, et cetera. The U.S. has done a good job building up the hospital systems but still needs to work on delivering innovation at the community level.
Dr. Bazira talked about how even though Dr. Dybul works from a global view he and his team mostly come from the field and they face many of the same challenges. One of these challenges is that Dr. Bazira has seen a cycle where they will go in and develop a team and its systems, but when they do a follow up visit a year or two later there is already a brand-new team in place, requiring them to start training the new one. He mentioned there is a trend where global health financing is reducing but the disease burden is not going up. Money is going into vertical programs with less going into systems or capacity development. They are looking into initiatives that can capitalize on local innovation and interface them with global best practices. There are current institutional collaborations going on, among them the south-south collaboration. There has been a lot of building of infrastructure around labs, but the institutions are still struggling to maintain the lab infrastructure and keep it in place.
The global health field is increasingly looking into collaborative multi-disciplinary research teams. Global health problems cannot be solved only through medical information. People have not figured out how to work together across different disciplines. Getting business schools to engage global health would be a helpful key factor. Lopsided partnerships make research agendas fail. The way a relationship is structured can have an outcome on the research agenda, and one problem is that many countries do not have a regulatory framework in place regarding research. Governments increasingly have placed a reduction in emphasis in international NGOs (INGOs) and have increased their focus on building up partnerships with academic institutions and capacity building, among other areas. INGOs provide services within their own networks which is generally something countries do not want. With funding decreasing, countries will be making more decisions that will involve investing in institution building and relationships with U.S. agencies.
Dr. Robert Einterz asked what the Center for Global Health Practice and Impact and NIH can be doing to help solve the lopsided partnership problem. He also inquired about medical electronic records and their role in supporting the creation of a system for comprehensive health care delivery. Dr. Einterz asked what the Center for Global Health Practice and Impact is doing in the field of community-based solutions relating to integrated healthcare delivery systems. The financing method of universal health care coverage will also involve requiring health insurance for the low-income population, and Dr. Einterz also wanted to know what the Center for Global Health Practice and Impact are doing to solve that.
Dr. Dybul noted that almost every country is starting to implement health insurance and one of the biggest problems countries are attempting to solve is trying to figure out how to have progressive insurance premiums. Countries struggle with collecting taxes and figuring out how to allocate the funds. Dr. Dybul suggested creating a tracker that would show heads of states key indicators in building up and improving a health care system in a country. It is important not to just build vertical level programs but also to incorporate horizontal languages so that they can learn from each other. Structuring an insurance system which requires a lot of regulation, policy, and law is crucial to increasing healthcare.
Dr. Bazira mentioned that as a clinical pharmacist he was required to manage a supply chain, yet his education did not teach him these skills. He talked about working with schools of business, public health, and medicine to help build innovation and management initiatives for their graduates who decide to pursue careers in health management.
Global Health at U.S. Agency for International Development
Dr. Peter Kilmarx introduced Dr. William Steiger, Chief of Staff at the U.S. Agency for International Development (USAID). He mentioned that in 2017 Matt Barnhart, the lead on research at the Global Health Bureau at USAID, did a survey of USAID and NIH staff and discovered 26 active collaborations underway across a wide range of subjects. Last year a memorandum of understanding between USAID and NIH was signed to collaborate on various projects.
Dr. Steiger mentioned that USAID currently has 30 ways to legally engage in a financial arrangement with another institution. There is even one called “other transaction authority,” yet almost 80% of the time USAID uses a very traditional contract instrument and cooperative agreement instrument. Congress appropriates about $18 to $19 billion in foreign assistance every year out of which about 40% is allocated for the global health field. 75 institutions were responsible for 60% of spending, with 80 institutions responsible for 80% of spending. A few years ago, the USAID Global Health Bureau moved to Crystal City, which had unfortunate consequences, but they are relocating to the Ronald Reagan Building next month.
Dr. Steiger said that he hopes NIH and USAID can learn from and inform each other even when they cannot collaborate. USAID has been known to spend money on grants to try to scale-up promising technologies that will have an impact in the field. They are also involved in funding operational research, also known as implementation science, along with surveys and tools. USAID will look into World RePORT and becoming involved in that process. USAID will be entering into collaboration with NIH staff to take part in USAID grant and contract review panels.
Dr. Steiger was asked about the future of opportunities for U.S. funded global health research. Dr. Steiger mentioned that global health budgets can no longer be counted on to rise every year, yet it still remains as 40% of USAID’s spending. Even in a year where the budget remains the same Congress will authorize more funding for specific programs like ones combatting TB. Dr. Steiger mentioned that USAID will have to learn to use their allocated dollars more efficiently and that they will be relying on local partners more often in the future. USAID is increasingly moving away from paying for service delivery and instead trying to provide a catalytic role helping national governments and the private sector to take over the maintenance and finance of services previously provided.
Dr. Wasserheit inquired about what universities and the Fogarty International Center could do to help in-country ownership of USAID programs. Dr. Steiger mentioned that parts of USAID are already working on this; most notably USAID’s Feed the Future Program. USAID has traditionally viewed universities as the “backend monitoring and evaluation arms of consortia.” Dr. Steiger mentioned that that is too late in the process and that USAID is trying to gain input from universities in the design and even implementation phases of a program. Dr. Cohen mentioned that the culture of USAID has some serious problems. Dr. Steiger brought up that USAID is grappling with certain cultural problems. The largest problems include rotation cycles where an officer who started with a program is never there when the program finishes and the way in which USAID manages its award.
Advancing Emergency Care Research in LMICs
Ms. Nalini Anand introduced the session on research and emergency care settings in low- and middle-income countries (LMICs). The purpose for this session was to present the findings and research priorities that emerged from this project and discuss the state of the field of emergency care. Two former trainees from the trauma and injury research program, Drs. Mohamed El-Shinawi and Uzma Khan, discussed their training experiences and challenges.
Dr. Junaid Razzak began the presentation on research and emergency care settings. He mentioned that time is a determinant of health. In 2015 there were over 28 million global deaths due to emergency medical diseases. Ischemic Heart disease, stroke, pneumonia, COPD and diarrheal diseases are the five most frequent causes of death, and almost all of these present primarily at the end stage as an emergency. Bystander care and transport/EMS are often not considered part of the healthcare system which is a huge loss for important data. Just a few months ago at the last World Health Assembly there was a resolution on emergency care systems for universal health coverage.
Ms. Blythe Beecroft talked about some outcomes from the CGHS led collaborative for enhancing emergency care research in LMICs (CLEER). The planning committee determined the scope of the project and focused it on research that improved immediate and long-term outcomes for patients and populations with acute life threatening or potentially disabling conditions. The three factors in their definition of emergency care were: time, with a focus on the first 6 to 24 hours; location, both outside and inside the health system; and type of disease. The participants in the CLEER collaborative were divided into four specific groups: surveillance and data systems; health systems research; clinical and resuscitation research; and emergency care research ethics. In July 2017 the groups convened at NIH with over 40 participants, including emergency medicine clinicians, bioethicists, and pediatricians. The first day of the workshop consisted of group discussions and break out groups, while the second day was devoted to a writer’s workshop focused on producing CLEER-related publications. They have continued to collaborate remotely to produce a supplement in BMJ Global Health focused on advancing emergency care research in low- and middle-income countries; this supplement was published in July 2019.
Dr. Mohamed El-Shinawi talked about his time in the trauma and research injury program and said that Egypt started some serious intervention research in 2005 that is supposed to continue until 2021. In 2006 Dr. El-Shinawi had an opportunity to work with scientists from the United States, and in May 2007 he received a grant from the Fogarty International Center for research specializing in injury and trauma. When Dr. El-Shinawi came back to Egypt he formed a program that has over 25 courses and trained over 1,200 physicians. He has built up a group that currently has over 27 projects from different universities in Egypt and Sudan.
Dr. Uzma Khan spoke about her experience in the trauma and research injury program and talked about training in the context of research. She leads the emergency medicine curriculum at her institution and more recently she has been establishing linkages between institutions within Pakistan as well as internationally. Dr. Khan was one of the first participants in the program and she has continued to support a number of current fellows. She has worked on the research methods within emergency medicine and established one of the largest healthcare surveillance and registry systems in the world.
Dr. Jon Mark Hirshon talked about the importance of developing appropriate trauma registries, especially transferring the work developed countries have done to developing countries. It is important to build up an ethical format which is a challenge when doing emergency care research within the United States due to laws like HIPAA. It is often easier to develop innovative systems that are cost effective in other countries due to the infrastructure that is already in place.
Dr. Steve Hargarten introduced several case studies including injury systems or trauma care systems; this is a logical starting point that addresses diseases that affect young, vulnerable, and the disadvantaged populations. In 1966 a National Research Council of the Academies paper paved the way for pre-hospital systems and routine medical systems, and in 1971 the first emergency medicine residency was established in the United States that moved away from siloed care towards patient-centered care. Strengthening emergency care is essential and involves improving EMS with communication systems, coordination, et cetera. A recent NASEM publication also calls for a national trauma care system.
Dr. Jeremy Brown talked about the importance of being able to treat patients with trauma appropriately and said that this will require developing new systems, conducting further research, and creating better practices. Trauma is the leading cause of death of Americans under the age of 44 and yet the amount of money spent on trauma research is low compared to the burden of the disease. He contrasted this to HIV research which receives about 17% more research dollars despite the lower burden of the disease in the United States. There are over 120 million discharges from emergency departments each year in the United States. Dr. Brown said that he receives many questions on how to discharge patients more efficiently and that he would like to study how to accomplish this. The Fogarty International Center has a program initiative around trauma care, but they are not in a position to expand this work to the rest of the NIH institutes.
Discussion
Dr. Alison Cernich shared some reflections with the group. She mentioned that efforts to prevent or lessen the number of disabling conditions have been a key priority for the past two years. Her Center is focusing on a program to address pediatric trauma and its resulting disabilities that create challenges for families and communities.
Dr. Walter Koroshetz said that the global health topic could bring many institutes together and said that organizations in the United States should not be making decisions about care in Sub-Saharan Africa when the outcomes of those decisions could have huge consequences for those countries. He also talked about working on the pre-hospital setting so that the patient is protected especially in a timely fashion.
Dr. George Mensah mentioned that with many of the projects that his group works on related to prevention, the effects can be very large and also immediate. The ability to get local governments on board is very helpful for sustainability. In the area of maternal mortality due to sickle cell disease, interventions in the acute emergency care setting, if implemented and scaled out, can save many lives.
Dr. Glass asked Dr. Joe Kolars to speak about the Uganda Program. Dr. Kolars mentioned that University of Michigan has been working on emergency medicine out of Kumasi. The effort has involved some MEPI work and has been successful in training emergency department physicians who have then stayed in-country. They have also developed a trauma registry.
Closing Comments:
Dr. Glass spoke about the presentation that he and Dr. Bruce Tromberg gave at the Council of Councils, which was put together with support from Josh Gordon and Patti Brennan. Over a six-month period, they have brought together many people from 12 institutes to talk about data management and data health science, and after this presentation, five additional institutes joined the new initiative. This initiative is known as DS-I and it addresses some of the most compelling problems in global health with a focus on Africa, which has recently seen the underwater sea cable installed and this has helped to connect institutions and other groups together. Four initiatives are proposed: setting up and funding six hubs focused on key problems; establishing data science training programs; forming a group to address ethical, legal, and social implications of DS-I research; and establishing a coordinating center. There will be a symposium that will take place year 1 and year 6 of the initiative. There will also be two symposia: one that starts in year one, and the second in year six after everything is complete. The DS-I initiative received unanimous approval at the Council of Councils.
Dr. Bruce Tromberg gave a presentation on what one of these hubs may look like. He mentioned that the building block of the organization is the research hub. This hub has to have partners from multiple entities like universities, government, private sector, research centers, among others. Each hub should be focusing on a critical problem. He talked about a specific project that uses light as a tool to look at interactions between light and materials. They have the ability to quantify the extent of light scattering and look at it at many different wavelengths, and they are able to do this from the submicron level all the way to hundreds of kilometers, often with LiDAR technology. These processes can be used to find solutions for different types of global health problems. In addition, there would be four Ethical, Social, and Legal Implications (ELSI) centers, with the coordinating center holding a key role within the initiative.
There being no further business, Dr. Glass adjourned the meeting at 3:02 p.m.