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
Minutes of the Advisory Board
Table of Contents
- Call to Order and Introductory Remarks
- Dates of Future Board Meetings
- Review of Confidentiality and Conflict of Interest
- Review of Applications and Consideration of FY 2009 Program Plans
- Introduction and Opening Remarks
- Grand Challenges in Non-Communicable Diseases in Low- and Middle-Income Countries: Results of a Delphic Analysis
- Innovative Applications in Information Technology for Global Health
- Fogarty Strategic Plan: Implementation Strategies
The John E. Fogarty International Center for Advanced Study in the Health Sciences (Fogarty) convened the sixty-eighth meeting of its Advisory Board on Tuesday, February 5, 2008, at 10:30 a.m. in the conference room of the Lawton Chiles International House, National Institutes of Health (NIH), Bethesda, Maryland. The closed session was held from 8:30 a.m. to 10:00 a.m. as provided in Sections 552b(c) (4) and 552b(c) (6), Title 5, U.S. Code, and Section 10 (d) of Public Law 92-463, for the review, discussion, and evaluation of grant applications and related information. The meeting was open to the public from 10:30 a.m. to 3:15 p.m. The Board roster follows the minutes of the meeting.
Board Members Present:
Karen H. Antman, M.D.
Elizabeth Barrett-Connor, M.D.
Robert Black, M.D.
Luz Claudio, Ph.D.
Douglas C. Heimburger, M.D.
Peter Hotez, Ph.D.
Arthur Kleinman, M.D.
Arthur Reingold, M.D.
Ting-Kai Li, M.D. (ex-officio)
Board Members Absent:
Patricia M. Danzon, Ph.D.
Jim Yong Kim, M.D., Ph.D.
William A. Vega, Ph.D.
Sten H. Vermund, M.D., Ph.D.
Members of the Public Present:
Jose Belizan, Buenos Aires, Argentina
Linda Cottler, Washington Univ. St. Louis
Minh Dang, Vanderbilt University
Beverly Gilligan, Children's Hospital, Boston
Dr. Abdulla S. Daar, Univ. of Toronto, Canada
Ariel Pablos Mendez, Rockefeller Foundation
Kerim Munir, Children's Hospital, Boston
Erol Nese, Ankara University, Ankara, Turkey
Marina Piazza, MSU-Cayetano Heredic, Peru
Cong Tran, Vanderbilt University
Nam Tran, Vanderbilt University
Ergene Tuncay, Hacettepe University, Ankara, Turkey
Bahr Weiss, Vanderbilt University
Federal Employees Present:
Ms. Daniele Bielenstein, Fogarty/NIH
Dr. Danuta Krotoski, NICHD/NIH
Dr. Stefano Bertuzzi, OD/NIH
Dr. Linda Kupfer, Fogarty/NIH
Dr. Ken Bridbord, Fogarty/NIH
Dr. Donald Lindberg, NLM/NIH
Dr. Joel Breman, Fogarty/NIH
Ms. Sonja Madera, Fogarty/NIH
Mr. Philip Budashewitz, NCI/NIH
Mr. Thomas Mampilly, Fogarty/NIH
Mr. Bruce Butrum, Fogarty/NIH
Dr. Jeanne McDermott, Fogarty/NIH
Ms. Tina Chung, Fogarty/NIH
Ms. Peggy Murray, NIAAA/NIH
Ms. Elizabeth Cleveland, Fogarty/NIH
Dr. Kathy Michels, Fogarty/NIH
Dr. Wilma Peterman Cross, NIAMS/NIH
Ms. Sherri Park, NICHD/NIH
Dr. Lois Cohen, NIDCR/NIH Consultant
Dr. Aron Primack, Fogarty/NIH
Dr. Jean Flagg-Newton, Fogarty/NIH
Ms. Alisa Schaefer, Fogarty/NIH
Dr. Dan Gerendasy, CSR/NIH
Mr. Steve Smith, NIAID/NIH
Dr. James Herrington, Fogarty/NIH
Dr. James Stansbury, OBSSR
Dr. Karen Hofman, Fogarty/NIH
Mr. Tim Tosten, Fogarty/NIH
Mr. Sean Jeffrey, Fogarty/NIH
Ms. Joan Wilentz, Fogarty/NIH Consultant
Dr. Flora Katz, Fogarty/NIH
Ms. Linda Wright, NICHD/NIH
Dr. Elena Kousvelari, NIDCR/NIH
I. CALL TO ORDER AND INTRODUCTORY REMARKS
Dr. Roger Glass, Director, Fogarty, called the meeting to order at 8:30 a.m. and welcomed Board members.
II. DATES OF FUTURE BOARD MEETINGS
Tuesday, May 20, 2008
Tuesday, September 9, 2008
Tuesday, February 10, 2009
Tuesday, May 19, 2009
Tuesday, September 8, 2009
III. REVIEW OF REQUIREMENTS FOR CONFIDENTIALITY AND CONFLICT OF INTEREST PROCEDURES
Mr. Robert Eiss reviewed the rules and regulations, which were maintained.
IV. FULL BOARD REVIEW OF APPLICATIONS AND CONSIDERATION OF FY 2009 PROGRAM PLANS
Dr. Glass chaired the Closed Session during which the Research Awards Working Group reported its activities. The Advisory Board reviewed a total of 69 applications. The applications were in the following programs:
- 17 scored applications for the FIRCA Program out of a total of 17, for $558,802 in direct costs.
- 13 scored applications for the AITRP Program out of a total of 13, for $6,400,803 in direct costs.
- 39 scored applications for the Brain Program out of a total of 39, for $5,757,913 in direct costs.
The Board concurred with the initial review group recommendations for 69 of 69 applications.
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V. INTRODUCTION AND OPENING REMARKS
Dr. Glass welcomed the group and introduced three policy issues for discussion in the course of the day. The first concerned an agenda for chronic diseases. Fogarty's past investments have largely focused on infectious diseases, appropriately enough, he said, since "global health" throughout much of the 20th century meant infectious diseases. Moreover, half of Fogarty's Board members come from the infectious disease community. But patterns of disease are changing and a chronic disease initiative is something Fogarty needs to address, since most NIH Institutes are engaged in non-communicable disease research. Fogarty has supported programs in chronic diseases and he alluded to a network meeting scheduled over the following two days of grantees in Fogarty's International Clinical, Operational, and Health Services Research and Training Award program. He welcomed ICOHRTA members in the audience and invited Board members to engage with them during the breaks. In addition, he remarked that copies of an article in Nature on the global health agenda, Grand Challenges for Chronic Non-Communicable Diseases, were available, and that the lead author, Abdallah Daar, would address the group later.
The second item for discussion was Information Technology (IT) for global health. Ariel Pablos Mendez would speak on an IT agenda underway at the Rockefeller Foundation and Donald Lindberg, Director of the National Library of Medicine, also in attendance, could address this issue.
The third issue for which Dr. Glass sought advice focused on implementation strategies for Fogarty's new Strategic Plan, to be discussed after lunch.
With that as preamble, Dr. Glass began an overview of Fogarty activities with an enthusiastic endorsement of the Gapminder Web site, which uses software developed by Hans Rossling, who was a guest lecturer at Fogarty last fall. Dr. Glass showed a Gapminder graph that maps life expectancy against per capita income for selected countries to illustrate that users could point to any country on the graph to derive a second graph showing that country's 30-year trends in life expectancy vs. per capita income. He compared Bangladesh and South Africa, noting that in 1975 Bangladesh had a shorter life expectancy than South Africa and a much lower per capita income. But by 2004 Bangladesh had substantially surpassed South Africa in life expectancy, despite having a per capita income only about an eighth as large.
Such data analyses illustrate the effects of the AIDS epidemic in South Africa, he said. Life expectancy there was once 63--like Bangladesh's--but now has plummeted thanks to HIV, TB and the like. In contrast, there has been a slow prolongation of life in Bangladesh. Dr. Glass remarked that this comparison illustrates where Fogarty is going with its chronic disease agenda: In Africa, infectious disease will remain a key player in Fogarty's new Strategic Plan, but elsewhere, in Asia and Latin America, chronic diseases will take on new importance.
Next he highlighted personnel changes at Fogarty. Michael Johnson has joined Fogarty as Deputy Director and Robert Eiss has returned to Fogarty after a two years' absence as Senior Public Health Advisor. Ann Puderbaugh and Jeff Gray are new additions to the Center's communications office. Ken Bridbord was honored with the NIH AIDS Day Award for his pioneering development of the AIDS International Training and Research Program (AITRP). Jean Flagg-Newton, who served as Executive Secretary of the Board, has moved to the Child Health and Human Development Institute; Henry Frances has moved to the Food and Drug Administration.
Dr. Glass noted that 2008 marks the 40th anniversary of Fogarty and that Ann Puderbaugh had designed the new logo to reflect the connectivity of Fogarty with its many partners. She chose the color green to symbolize healing and the rebirth of Fogarty's Strategic Plan.
Expanding on the theme of life expectancy, Dr. Glass showed several slides to illustrate how aging has changed the global health research portfolio, noting that even the poorest countries have longer average life spans because of technological innovations. Life expectancy in China has gone from 39 years in 1960 to 73 years today--which means that problems like smoking, alcohol, and drug abuse, and chronic disease such as cardiovascular disease and stroke, are problems that must be addressed.
To illustrate these changing patterns of disease Dr. Glass showed slides of tables compiled by the authors of the Disease Control Priorities Project, a publication in which Fogarty played a key role. One slide indicates that by 2020 the top three contributors to the global burden of disease as measured by Disability-Adjusted Life Years (DALYS) would be ischemic heart disease, depression, and road traffic accidents. Another DCCP table summarized the "10 Best Buys for Health," many of which relate to non-communicable disease. Other slides included one that compared patterns of disease by world regions, illustrating the overwhelming burden of infectious diseases in sub-Saharan Africa and several which illustrated that much can be learned about genetic diseases or particular cancers by conducting research at sites around the world where the condition in question is noteworthy for being highly prevalent or particularly severe, etc.
Dr. Glass turned to the problem of smoking next, mentioning that he started his career as a student of the British epidemiologist Richard Dahl. He noted that in the U.K. the decline in smoking has led to a decline in lung cancer, whereas in France--25 miles away the English Channel--smoking continues and lung cancer rates are up.
Still other contributors to the global burden of disease are environmental disasters. Dr. Glass concluded this part of his opening remarks with a slide illustrating past and current environmental hazards to health worldwide, and the need to include an environmental focus in future global health research planning.
He next highlighted a number of Fogarty programs to illustrate Fogarty's philosophy of collaborative research and capacity building in developing countries. He noted that AITRP grantees had emerged as leaders in AIDS research; that in 2006 young American Ellison scholars had trained abroad in 16 developing world medical centers; and that Fogarty has established its Framework program as a way of enriching the curricula and uniting existing schools at a university under the common theme of global health. He mentioned that Fogarty had hosted a number of distinguished visitors in 2007, including Barmes lecture, WHO Director Margaret Chen; Chris Murray of the International Health Metrics Institute; Steve Morrison from the Center for Strategic Information; and the aforementioned Hans Rossling.
Recent staff publications include a malaria supplement to the journal Tropical Medicine and Hygiene and an article in Science on implementation science and the potential for incorporating implementation research into some of the newer funding programs for AIDS and malaria. Staff also convened a meeting at NIH of science editors whose journals had published thematic issues on global health. To raise awareness of Fogarty on Capitol Hill, staff organized an event with Families USA, with plans for future Hill events to come.
Dr. Glass accompanied NIH Director Elias Zerhouni and NIBIB Director Roderic Pettigrew to India to establish the first international agreement for NIBIB in bioengineering. He cited this as an example of Fogarty efforts to energize the NIH community to adopt a global health research agenda and expand partnerships. In this context, he mentioned that NHLBI had become a new partner with Fogarty along with a private group, Ovations, in establishing chronic disease centers in the developing world. Partnerships outside NIH now include Oxford Health Alliance and the Doris Duke Foundation among other national and international agencies.
Dr. Glass ended his overview with a calendar of events to celebrate Fogarty's 40th anniversary. A series of lectures, workshops, symposia, and network meetings have been scheduled throughout 2008, which will also include an NLM exhibit on global health, an anniversary dinner, and contributions by a number of Fogarty scholars in residence. It is hoped that an Institute of Medicine Report: Sequel to America's Vital Interest in Global Health, will be published within the year.
There being no questions from the Board, Dr. Glass proceeded to introduce Dr. Abdallah S. Daar of the University of Toronto.
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VI. GRAND CHALLENGES IN NON-COMMUNICABLE DISEASES IN LOW- AND MIDDLE-INCOME COUNTRIES: RESULTS OF A DELPHIC ANALYSIS
Dr. Abdallah S. Daar
Dr. Daar worked with a group of 155 global experts representing diverse stakeholders in a three-round Delphic process to determine consensus on the grand challenges in global health. He was pleased to report that 30 percent of the Delphi panel were women and that the work had generated considerable media interest. The panel identified six goals:
Goal A Raise Public Awareness
Goal B Enhance Economic, Legal and Environmental Policies
Goal C Modify Risk factors
Goal D Engage Business and Community
Goal E Mitigate Health Impacts of Poverty and Urbanization
Goal F Reorientate Health Systems
The panel concluded that chronic non-communicable diseases (CNCD) constitute the major burden of illness and disability in almost all countries, but that global recognition and response has not kept up. The major drawback is implementation, he said. There is enough information to begin intervening on a massive scale, or at least studying interventions on a massive scale, such as the use of the poly pill. His solution is to convert the challenge into a research question and conduct research on how implementation should be done--what are the factors for success; what are the good practices; what should be avoided--to guide future large-scale efforts or to pursue other interventions. He commended the Fogarty article on implementation research in Science as a great starting point.
Dr. Glass opened discussion by asking former PAHO Director George Alleyne, one of the editors of the DCCP volume, to comment. Dr. Alleyne said there was considerable momentum building thanks to Dr. Daar's work, including interest at the IOM in exploring the global magnitude of mental health problems and proposals at the World Health Assembly to develop strategies relating to chronic disease. That said, he felt that the reason the problems have not garnered the attention they deserve is that there needs to be action in the socio-political area. In order to effect changes in the environment, a reduction in risk factors, and so on, you must go above the level of health ministers to convince the political decision makers to take action. He believes this is a researchable question, one that requires looking at political systems and determining the pressure points that need to be pushed to effect change.
He outlined other areas to be pursued to address non-communicable diseases, including dispelling the belief that aging itself is the cause of the problems. He stressed the importance of research on secondary prevention and the need to improve training of health workers whose school curricula is "10 to 15 years behind" in addressing chronic disease issues. Comparative research, exactly the kind Fogarty can do, will also be important, such as studying hypertension or obesity as manifested in West Africa, the Caribbean, or America. Lastly, he recommended studies of the economic costs of non-communicable diseases, where the data is far from robust.
Dr. Glass commented that Fogarty has made some efforts in the area of economics as well as the political arena, but thought these areas might be more productively pursued in partnerships outside NIH. He then asked Board members from the infectious disease community for comments.
Dr. Hotez agreed that the new emphasis on chronic disease was the right thing to do, but he was concerned that this might be perceived as a move toward studying diseases of the middle or wealthier classes and away from the needs of the 2.7 billion people who live on less than $2 a day. Dr. Reingold added that studying the economic implications or exploring how to reach political decision makers went far beyond the expertise available in schools of public health, and would require incorporating a broader swath of academia. Dr. Alleyne in turn commented that a move to address chronic diseases should never come down to "my disease" vs. "your disease" and supported the idea of incorporating other disciplines into the health sciences.
Dr. Glass addressed the issue of chronic diseases affecting the middle class by saying that he had gotten questions on Fogarty's strategic plan from fellow NIH Directors concerning the meaning of global health: Was it restricted to developing countries only? Clearly chronic diseases were global in nature and scientific breakthroughs could occur anywhere. Dr. Glass agreed, but argued that a global health agenda was not needed to work in England or France, whereas Africa and parts of Asia and Latin America really do need the stimulus of Fogarty-style programs. Dr. Hotez concurred, but felt that a new emphasis on chronic disease on the part of Fogarty might diminish overall support of neglected infectious diseases at NIH.
Dr. Kleinman sympathized with Dr. Hotez, underscoring the point that support of chronic and infectious diseases cannot be framed as a zero-sum game, but should be seen as complementary, with each learning from the other. He was surprised that Dr. Daar's grand challenges did not include highly prevalent mental health problems like depression or drug abuse. As someone who had come out of the infectious disease community into psychiatry, he felt that what infectious diseases had done in the global health arena provided an excellent model for what mental health should be doing. To begin with, infectious disease research had built a very strong evidence base to influence policy. But he added that in the case of AIDS, even before the scientific base was strong, there was a moral argument that led to a powerful movement that spurred the science. He would like to see Fogarty adopt a strong intellectual agenda for addressing the meaning of global health--the whole domain--neglected and non-neglected infectious diseases as well as non-communicable chronic diseases. Further, he saw a need for an intellectual exchange between the mental health community and the infectious disease community to dispel any notion that there is no evidence base for depression, schizophrenia, or substance abuse.
The role and effectiveness of advocacy groups in pressing research priorities--as demonstrated by the early AIDS activists--was also brought up, as well as what Fogarty might do to advocate participation of other NIH institutes in selected areas. In response to Dr. Kleinman, Dr. Daar explained that mental health problems were not included in the Delphi study insofar as the etiologies, risk factors, types of interventions and effects of stigma set them apart from the non-communicable diseases the panel studied, where there are common risk factors and some interventions that can be common. Mental health problems merit a Delphi panel all their own, he said. In answer to a question from Dr. Barrett-Connor about Fogarty's Brain Disorders program, the Fogarty program officer said there had been a few grants in selected areas like schizophrenia but not a broad reflection of the field.
Dr. Barrett-Connor further remarked that training in epidemiology was a good basis for studies of any disease, communicable or non-communicable. But she thought that the terms themselves, including acute vs. chronic as well as communicable vs. non-communicable, create silos. Lung cancer and obesity could well be defined as communicable she said, insofar as cultures communicate the desirability of smoking, drinking Coca-Cola, and eating Big Macs.
Dr. Glass mentioned a Fogarty meeting of global health leaders scheduled for June. The agenda is open and could address some of the issues raised by the Board along with the political and economic points made by Dr. Alleyne. In drawing the discussion to a close, Dr. Glass said that the message he heard from the Board was that it was worthwhile for Fogarty to move into the area of non-communicable disease, but never as a zero-sum game to the detriment of support of infectious diseases. It might take time to implement, but there were opportunities to work with other Institutes to move forward. He then introduced Ariel Pablos Mendez, Manager Director of the Rockefeller Foundation, to discuss information technology (IT) for global health, an area included in the Foundation's new strategic plan.
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VII. INNOVATIVE APPLICATIONS IN INFORMATION TECHNOLOGY FOR GLOBAL HEALTH
Dr. Ariel Pablos-Mendez
Dr. Pablos-Mendez said that the Rockefeller Foundation had undergone a transition two years ago and would be moving into the area of technology for health systems. The Foundation will continue doing capacity research, looking at new competencies in areas such as non-communicable diseases. They will also be studying how to harness the private sector. He noted that in the developing world 60 to 80 percent of health services is privately financed. This is huge--and hugely neglected. "We do not have enough understanding of this important sector or how to harness it in terms of health insurance, supply chains, and the regulatory framework."
He went to focus on "e-health," a term describing the "use of information and communication technologies to improve health in a given population." The Foundation believes that e-health can improve equity, efficiency, and quality of health care. This becomes especially relevant as societies move from treating acute infectious disease to chronic care, where information management is essential. He noted that in parallel with economic and demographic changes, information technologies are rapidly progressing and spreading. In Africa, mobile phone subscribers are growing at a rate of 48 percent a year; in South Africa the subscriber rate is already 80 percent. Former skeptics now see IT as a way to transform health systems.
Dr. Pablos-Mendez noted a danger, however, in the development and deployment of disparate systems that would become "stovepipes"--unable to communicate with each other. Interoperability and standards thus become key issues, along with ensuring coordination.
IT and health care are the two fastest growing sectors in the economy, he noted. Yet only two or three percent of health expenditures is in IT and vice versa. This is changing, however. As expenditures for health care increase everywhere in the world, IT companies are adding health divisions. The Foundation sees this as a great opportunity, a "higher order vision" to bring the talent of IT professionals and IT corporations to serve public health needs in the developing world and allow it to leap-frog into 21st century communications. Dr. Pablos-Mendez sees this as an incredible revolution that will occur over the next decade.
He outlined multiple levels for action. At the bottom level there needs to be work on the ground: public health information, electronic health records, telemedicine, surveillance, modeling, access to information. At the mid-level analysts need to look at frameworks and standards at national or district levels and promote public-private partnerships in e-health. Evidence of effectiveness is necessary, as well as the means for capacity building in the developing world.
At the top level he described a four-week Global Health Conference to be held this summer in Bellagio, Italy, with each week bringing in 50 participants. The idea of the conference is to "get it right": to bring donors together with the corporate sector and government health ministries to address key issues and policies.
Week one will be organized around interoperability and public health informatics. Week two will focus on e-health capacity building and knowledge. Week three will explore core e-health applications, including electronic health records and phone-based e-health. The last week will discuss policies and markets. We need to capture national e-health policies and markets. We need to capture national e-health policies that are already being developed and identify where there are leaders and the capacity to establish e-health councils to advise governments, he said. The issue of markets in the developing world is tricky, he added. Here we may need to rely on social responsibility and good will, but perhaps new markets will be created with progress.
Dr. Pablos-Mendez concluded by reminding the group that as in so many other health problems, we know the gap, we know what to do, but we are not doing it. In the area of health systems we haven't invested enough in research or developed cadres of expertise around the world, but he was committed to the Bellagio series and invited Board members to join in the e-health movement and add their ideas.
Drs. Barrett-Connor and Antman initiated discussion with questions about updating health professionals and adding curricula components so that current and emerging practitioners are equipped with e-health know-how. Patients themselves might also want to be included and have direct access to records. Dr. Mendez said that patient-centered e-health is a bit remote at present, but that IT companies are moving in that direction. In terms of capacity building he said that companies have already incorporated short courses as well as advance degree training programs.
Dr. Glass mentioned Fogarty's very successful bioinformatics training program and introduced Thomas Mampilly, Chair of Fogarty's Information and Communications Technology Working Group formed last year. In addition to the bioinformatics training programs, Mr. Mampilly said that other Fogarty programs have included ICT in curriculum development, or use the technology in day-to-day networking with grantees across sites. The Working Group has also hosted ICT meetings and worked with sister ICs at NIH to discuss data management issues. Beyond NIH, they have reached out to the World Bank, NGOs, the Gates Foundation, and others to discuss Fogarty's role and potential partnerships in expanding ICT use. The group is planning a conference later this year to air problems and potential solutions as well as collect success stories.
Mr. Mampilly concluded with a series of questions for the Board: How can Fogarty use its strengths to improve ICT for global health research and research training? What types of support can Board members provide for building ICT partnerships? Does the Board have any perspective on the distance learning consultations the Working Group is planning or any other ICT consultations? Finally, can the Board provide any insights or best practices for ICT globally to guide Fogarty's next steps?
Before turning over discussion to the Board, Dr. Glass asked NLM Director Donald Lindberg to describe what the library is doing, saying that NLM has been out in front in getting information on medical literature to all kinds of partners.
Dr. Lindberg gave top priority to the library's training grants, now in 24 institutions. These are long-standing grants based on his understanding that institutional changes are slow-moving and should not be subject to on-again off-again funding. He cautioned patience, noting that in spite of the speed with which technology moves, it takes time to cultivate the understanding and facility of students and institutions to use the technology.
Dr. Glass responded that Fogarty had started with the bioinformatics grants and is moving into long distance learning. He reflected that the issue of scaling up for capacity building in the developing world is huge: We are doing things in tens and twenties but we envision that a major scaling up could happen through the use of ICT. He suggested that Fogarty "ride the tails of the business community," and learn from the Google type of technology or broadband for commercial use. He mentioned Robert Bollinger, a Fogarty grantee at Johns Hopkins, who runs clinical rounds and teleconferences with India. One of Bollinger's students is currently in Uganda and videocasts there have made it possible to have face-to-face interactions with her and her students. On this note he turned to Dr. Black to ask him to comment on some of the other things Hopkins has been doing.
Dr. Black mentioned Hopkins' use of open courseware. He said that many JHU courses are freely available on the web for anybody to use (but not for formal degree programs). While the university has had considerable experience with degree programs and distance learning, he said that the programs have not been fully evaluated nor have they considered scaling up issues.
Web-based instruction for a Master's degree in Public Health program has been in place for 10 years, he noted. The program serves a need but could serve a far greater need if it could be linked to foreign institutions. Indeed, the program could tie in to Fogarty's strategic plan, he suggested, not just in ICT, but in serving the research hubs proposed to build centers of excellence. In addition to Web-based training he mentioned CD-based training in their Bill and Melinda Gates Institute of Reproductive Health. It is not interactive, but the program reaches a very wide audience. These examples are by no means exclusive to Hopkins and he proposed that Fogarty's Working Group, with some input from the Board, gather in-depth examinations of what else is being done and whether such efforts could be expanded.
At this point a member of the audience, Linda Wright from NICHD, described two problems her Institute encountered in their research programs pairing U.S. and foreign institutions around the world. The first was access to journals; the second was access to Internet. Yes, cell phones are common, she said, but the internet is not available and videoconferencing cannot even be considered unless the internet problem is resolved.
Dr. Claudio asked Dr. Pablos-Mendez if any of the projects in e-health were addressing these issues. He replied that they were working with major medical publishers to assemble a collection of literature that would cost one to three million dollars a year but which is available free "if your country is one of the 70 poorest countries in the world." He agreed that connectivity is a challenge, but that the hook-ups of new sites have been growing fastest in Africa. There are also alternative systems such as a library which copies the Web onto a hard drive--copies everything from NIH, CDC, WHO, and which is available free in a local area network.
He also addressed scale-up issues, describing e-learning platforms to scale up nurse training in Kenya, a program which is reaching thousands of nurses. Another great success story is a network of open electronic records in Africa which can be applied to mobile phones.
He proposed that Fogarty consider partnering in a Global Observatory for e-Health. WHO began to plant the seeds for such an observatory, completing the first global survey of e-health last year. One hundred twelve countries participated and a handful of institutions are looking at the evidence and beginning to share best practices. Rockefeller is now trying to support development of these observatories and the networks of people who will look at the evidence.
Dr. Hotez remarked that last year a new Web-based Public Library of Science journal for neglected tropical diseases had been launched, and that half the members of the editorial board come from countries where these diseases are endemic. This has turned out to be a nice capacity-building measure since young investigators from Sub-Saharan Africa, Southeast Asia, and tropical parts of the Americas who have never published in international journals are now doing so. He would be happy to work with Fogarty on how this Web-based service could be expanded beyond simply publishing papers.
Dr. Lindberg commented that the pairwise partnering of members on the editorial board of a journal was a very good approach, but asked why can't there be more first-class journals published in Africa by Africans? Toward that end he acknowledged Fogarty's help in a program in which editors from prime journals like JAMA, The New England Journal of Medicine, and BMJ had mentored editors of African journals with impressive results. The next step will be for these now quite good journals to use the internet for electronic reviews and get record-keeping up and running.
Dr. Dale Williams, an ICOHRTA grantee at the University of Alabama at Birmingham, commented that they were heavy users of the internet in their collaborations with India but there were several unresolved issues. One was paying for local bandwidth. Another was the requirement for the U.S. university to set up a special server so that the Indian investigators could log on and go directly to Medline or other sources for access to journals, just as faculty members do. They found that pricing of software and hardware by IT companies in India was prohibitive.
Dr. Glass asked if there were further comments, adding that he saw IT as a burgeoning area for Fogarty. In connection with Fogarty-sponsored activities in bioinformatics, he mentioned that he and Tom Cook had taken a 750 gigabyte hard drive and equipped it with a complete medical library with updates monthly. The drive has been provided to sites around the world, obviating the need for a connection to the internet. Also, for sites without broadband, Tom Cook has developed a low bandwidth narrow band connection for use in conferencing.
In drawing the discussion to a close, Dr. Glass mentioned the use of IT facilities in the U.S. whereby a university talk can be videocast to all campuses of a state-wide system or where a medical school can beam a basic lecture on infectious disease overseas and have case presentations of patients webcast back to the U.S. site. He said Fogarty has been weighing the issues carefully in planning its IT conference, looking for good ideas that focus on Fogarty's strengths and identify models that could be emulated.
The meeting recessed for lunch at 12:45 p.m. to reconvene at 1:45 p.m.
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VIII. FOGARTY STRATEGIC PLAN: IMPLEMENTATION STRATEGIES
Dr. Linda Kupfer, Fogarty Evaluation Officer
Board members had received copies of the final draft of the Strategic Plan, which had also been posted on the web site. Dr. Glass said that the Board could have a few more days for comments before a final version would go to press. He introduced Linda Kupfer to provide a brief overview, complimenting her for shepherding the plan through a year of strenuous activity and thanked all who had participated.
Dr. Kupfer added her thanks, saying "it takes a whole village!" and that there was no one at Fogarty who had not contributed in positive and insightful ways. She briefly reviewed the staff retreats and national and international meetings of stakeholders that had taken place as well as the listening tour that Dr. Glass had undertaken with NIH directors, NGO leaders, and others in the global health community, at the suggestion of the Board. The latest draft resulted in 50 comments: 9 from NIH ICs, 19 from U.S. P.I.s, 5 from foreign P.I.s., a few from organizations such as PAHO, NAS, and the Wellcome Trust, and many from advocacy groups.
In general people thought the Plan was clear, visionary, focused, concise and up-to-date. They thought it was well-written and well-supported, doable and appropriate and they liked the serious analysis it embodied. They also made recommendations. These were largely suggestions that Fogarty expand in such areas as mental health, the behavioral and social sciences, trauma and injury, and talk more about safety (such as the need for safe environments, safe roads, health lifestyles, safety from violent acts, reduction in health disparities). With regard to the last goal on partnerships, the recommendation was not only to expand partnerships, but add leveraging.
To move the plan forward, Dr. Kupfer said that five interdivisional working groups had been formed, including the ICT group which had reported that morning.
Dr. Kupfer then briefly summarized the five goals in the Plan:
Goal I: Mobilize the scientific community to address the shifting global burden of disease and disability
The point here is to expand Fogarty's investment in non-communicable disease, but continue to invest in infectious disease research and training.
Goal II: Bridge the implementation research training gap
Fogarty will support and expand research training programs for implementation science research and support applications of the research to DCCP recommendations.
Goal III: Develop human capital to meet global health challenges
Fogarty plans to expand early global health research experiences abroad for U.S. health science students and junior faculty. As important, Fogarty will expand research support for foreign investigators and promote their independence when they return home.
Goal IV: Foster a sustainable research environment in low- and middle-income countries
Fogarty is conceptualizing the development of research hubs as a means of strengthening the research enterprise of institutions in low- and middle-income countries. Expanding ICT is part of this goal.
Goal V: Build strategic alliances and funding partnerships in global health research and training
Fogarty recognizes the need to build strategic alliances and forge partnerships based on mutual interest and complementary strengths.
Dr. Glass said he expected the Plan, as amended by recommendations, to be launched in the coming month along with articles in the press, as part of Fogarty's anniversary year events. He welcomed comments from the Board.
Dr. Black liked the Plan and said he agreed with everything in it. He remarked that the emphasis on non-communicable diseases provided opportunities to build on the strengths of the NIH. However, he was particularly attracted to implementation research. He did not think this type of research was an area of NIH strength, and suggested that Fogarty look outside NIH for both funding and expertise. He was concerned that many science students think this is a boring area and instead want to make big discoveries. He did not think that Gates and other foundations understand how to approach the area and it might benefit Fogarty to convene a meeting to better define the field and enhance its stature.
Dr. Glass proposed making Dr. Black Chair of a Board working group to assist in that matter and he asked Karen Hofman, one of the authors of the Science article, to discuss where Fogarty should be going next.
Dr. Hofman said that interest at NIH has been growing and that NCI and NIMH have developed an inventory of implementation research and have also solicited international grants. As far as defining the field, she thought that there needs to be a better understanding of what tools are available, how to develop new tools and methodologies, and how to train people. "We are at the very beginning of the consultative process," she said. The ICOHRTA meeting coming up will touch on health services research, she added, which is one aspect of implementation science research.
Dr. Hofman also noted that NIH interest is evident in the form of a nascent Roadmap group who want to put an implementation research proposal together. A lot has to do with modeling health systems. The NIH office of Behavioral and Social Science Research has taken the lead and there is serious interest on the part of NCI and some other Institutes.
Dr. Kleinman agreed with Dr. Black's comments with regard to NIH strengths and weaknesses and thought Fogarty's move to implementation science can play on Fogarty's comparative advantage in being able to bring things to NIH. He agreed that there is growing interest in social and behavioral science but that what was still missing was managerial science. It doesn't exist at NIH, he said, and yet it is quintessentially a biosocial area that extends social science to management, where there is a very substantial database in the country's top business schools. "I think this is a new intellectual direction and an enormously important field in which Fogarty can play a significant role in building," he said.
Dr. Kleinman also recommended eliminating the term "melting pot" in the Plan, as not applicable to American society, which is essentially multi-ethnic.
Returning to the subject of implementation science Dr. Glass remarked that Board member Dr. Jim Yong Kim was in Africa and unable to attend, but that he had expressed himself as an ardent supporter of implementation science at earlier Board meetings and especially advocated learning from business schools and case studies of management.
Dr. Daar added a comment that in his role as a member of an external group reviewing the WHO TDR programs, the group had recommended efficacy, effectiveness and operational research as one of the strategic directions for TDR to pursue.
Given the Board's interest and insights regarding implementation science Dr. Glass concluded that forming a subcommittee of the Board to examine the issues and advise on how to move the agenda forward was critically important, especially since the field was not a routine part of the NIH mandate.
The group then turned to other comments on the Strategic Plan. Dr. Hotez remarked on the absence of any mention of the NIH Roadmap in the Plan. Dr. Glass replied that Fogarty is multi-collaborative in its operations at NIH, but lacks a specific medical specialty or disease mandate in its authorization. In order to initiate a Roadmap proposal Fogarty must enlist other ICs and will do so in the future. He said that several Roadmap initiatives now include a global health component, so that they are making progress. Dr. Hotez suggested that an implementation science proposal--not included in the original Roadmap draft--would be a good way to interdigitate with the Roadmap, and Dr. Kleinman agreed. There was some discussion to clarify the meaning of implementation science, emphasizing that it went beyond "bench to bedside" to mean adoption of interventions out in the community, which would include prevention efforts.
Dr. Claudio suggested that there ought to be a body comparable to the Council of Public Representatives for Dr. Zerhouni, which would be the voice for the developing world advising Fogarty. She asked Dr. Kupfer if comments from the developing world differed in any respect from others she had received. Dr. Kupfer said that there were no notable differences except greater concerns for supporting returning trainees in their careers. She said that the goal of implementation science resonated well with a broad mix of developing world scientists gathered at the strategic plan workshop in Cairo.
Dr. Reingold asked for some clarification about the idea of developing alumni networks. Dr. Glass responded by given an example: He said that there are some 3,000 postdocs who have trained on the NIH campus with about 500 from China, many of whom have gone back. One use of alumni networks would be to provide a directory of scientists, whether in China or other countries, in order to identify sites, research areas of emphasis, and potential mentors for students wanting global health experience. So it's really about connectivity around scientific experience--a kind of professional scientist resource to help people connect, the way young people use Facebook. He asked Dr. Herrington to comment on his recent trip to China. Dr. Herrington had met with Chinese alumni in Beijing last year and said that they were enthusiastic about an alumni network. They wanted to be able to get together with their counterparts at other Chinese universities, among other things, to identify the best and brightest young researchers and provide a forum where they could talk about their work. They talked about one or two conferences a year with some small grants to encourage young investigators on their career paths. This is not something they could do on their own but would welcome help and that is what Fogarty is considering.
Dr. Reingold raised a question about which groups of alumni Fogarty had in mind and said he still found the network concept daunting. Dr. Kleinman provided a point of clarification saying that major universities--Yale, Johns Hopkins, Harvard--have established alumni associations of foreign scientists in cities in China and that the associations have provided continuing education courses and other useful programs. He cautioned that Fogarty should not re-invent the wheel but recognize existing precedents.
Dr. Glass acknowledged that the concept needed further development and, accordingly, proposed that both Dr. Reingold and Dr. Kleinman advise Fogarty. He also saw the networks as a way of finding qualified foreign alumni who could be tapped as grant reviewers and also benefit, gaining access to NIH videocasts, for example.
Returning to the Strategic Plan as a whole, and alluding to the morning's discussion, Dr. Alleyne made the point that global health--especially with regard to chronic disease--applies to the whole world and not just to low- and middle-income countries. Solutions to developing country problems can come from anywhere. With regard to implementation, he endorsed Fogarty's move in this direction, adding that implementation research was not just about the incorporation of findings into selected programs, but also involved scale-up on a national scale. He again emphasized the need to reach policy makers at high levels. He alluded to a meeting with health and finance ministers in a country where the issue was whether to adopt a particular health program or improve metro stations.
On the subject of networks, Dr. Alleyne stated that the only way they work is when there is commonality of purpose and a real will to keep them alive. You need people with the energy to keep everyone interested and on target. He approved Fogarty's support of foreign scientists, seeing this as critical to building partnerships at the country level.
Finally, he said he was looking forward to seeing the work of the Strategic Plan Implementation Working Groups with respect to detailed measurable targets, quantifiable goals and timelines.
Dr. Glass said that among the challenges the plan faces in the coming years are the budgetary constraints that have affected NIH as a whole in recent years. For that reason, the plan lays out general areas for investment rather than specific initiatives since they will depend on resources available.
With regard to Goal V on partnerships, Dr. Hotez introduced the idea of global health as a bridge to piece--its potential role in diplomacy--something he calls "vaccine diplomacy." This led to a general discussion of the role of medical research in diplomacy. Dr. Glass commented that the State Department had supported some Fogarty programs that were deemed diplomatically interesting. Dr. Alleyne mentioned past meetings which brought together health ministers from countries in contention and had resulted in joint health programs, many of which served as a basis for stopping fighting.
Dr. Glass thanked everyone for comments on the Plan and said he wanted to devote the final minutes of the meeting to discuss how better to engage the Board in Fogarty activities--in building partnerships, raising visibility, and in promoting what Fogarty does. "Now that I have a full staff in house," he said, "I need a full staff on the outside to help us move ahead." He wanted to hear what members had to say, including how to improve Board meetings themselves or engage more in Fogarty activities between meetings.
Dr. Heimberger mentioned Dr. Glass' allusion to "intensive internal discussions" that take place between Board meetings, and he suggested that getting input from Board members by having them included in the Strategic Plan Implementation Working Groups might be an easy way to begin the engagement. He also suggested that Board members could play a role in some of the events and activities the Board hears about through the newsletters and other announcements.
Dr. Glass said that the network meeting of the ICOHRTA that was shortly to take place would be just such an occasion where a Board member might usefully participate. So too, would be the forthcoming HIV meeting in Mexico, which was being planned as one of Fogarty's anniversary events.
Dr. Hotez remarked that global health was "hot" right now--hot in Congress, on college campuses, among the celebrity community, and private foundations. But Fogarty remains a well-kept secret. He thought Board members could serve Fogarty well in an advocacy role. Dr. Glass thanked him for the proposal and proposed that Fogarty's communications staff as well as the legislative liaison be in touch.
Dr. Barrett-Connor said she thought that this meeting was the best she had ever attended in terms of discussion and in particular, discussion of the language and terms we use. She recommended more time devoted to the closed session, after the grant review and said she relished hearing the opinions from such a diverse group.
Dr. Reingold agreed with much of what had been said and he too favored more unscripted time on the Board's agenda to allow for the kind of discussion they had that morning.
Dr. Glass said that it had been his intention to use the dinners with Board members as an unscripted and informal way to mix with each other and Fogarty senior staff.
Perhaps a sit-down breakfast to expand that time might be considered, Dr. Reingold said. The WHO committee he belongs to holds such breakfast/business meetings.
Dr. Peggy Murray of NIAAA commented enthusiastically on including Council members on Institute Working Groups. Council members were made co-chairs of working groups and they reported results at Council meetings. Working group meetings were scheduled for the day before Council so that the member would be physically present.
Dr. Black agreed with previous suggestions and proposed that more of the grant work be done before dinner the night before to allow more time for discussion the next day. (Dr. Glass commented that there was flexibility in the schedule and he would explore changes.)
In terms of advocacy, Dr. Black wondered whether, in addition to working with the external constituencies that Dr. Hotez had mentioned, Board members could interact with the internal constituencies--the other Institutes at NIH. Dr. Glass said that since he has been Director he has added speakers to the open session on topics that allow him to invite other Institutes to attend. He himself will be attending other Institute Council meetings and he said he would be happy to bring Board members with him--such as Dr. Kleinman to the NIMH meeting. He said he would ask Mr. Eiss to draw up a list of members and upcoming Council meetings. As for ideas for interacting with the external constituencies, he asked Drs. Black and Hotez to be in touch with DASPA staff.
Dr. Claudio also supported more open discussion but added that she would prefer more focused questions.
Dr. Kleinman suggested that members be provided with up-to-date slides of Fogarty accomplishments, which they could show when asked to give talks. He said he would also appreciate feedback. He mentioned good discussions at past Board meetings but that it was not clear what the follow-up had been. As a current member of the NIH Council of Councils he said he would also like advice on how best to represent Fogarty.
Dr. Antman said that she wanted to remind everyone that cancer was the second major cause of death in the developing world. She would be happy to accompany Dr. Glass to NCI Council meetings. Further, she believes in medical diplomacy and mentioned that the Mideast Consortium of Egypt, Jordan, Israel and others had kept talks going in spite of the conflicts. She endorsed alumni networks as well, saying that as a Dean, she would love to be able to put students in touch with Fogarty graduates. They can become faculty members, she said, and in that way gain access to journals and the internet. In turn, she has found that students trained abroad are the best advocates for global health; many go on to get their MPH and go into the Peace Corps.
Dr. Glass thanked Dr. Antman and said Fogarty could provide information on all NIH-grants in the developing world as a resource. There was some discussion of the utility of web sites and how to sort out the best contacts for students. Dr. Glass said such topics would be included in the agenda for the Global Health Leaders meeting in June.
As the meeting drew to a close several members commented on the richness of discussion, describing it as an "intellectual feast."
Before adjourning, Dr. Glass reported that the eminent biologist Joshua Lederberg, who co-chaired the Lederberg-Bloom report on Fogarty to then NIH Director Harold Varmus, had died on February 4. Dr. Glass described him as a real friend of Fogarty and a champion of "what we do and who we are."
Dr. Glass thanked the Board members and speakers and all who had participated.
(Whereupon, the meeting was adjourned at 3:10 p.m.)
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Abbreviations Used in the Minutes
Acquired Immunodeficiency Syndrome
British Medical Journal
Centers for Disease Control and Prevention
Division of Advanced Studies and Policy Analysis
Disability-Adjusted Life Years
Disease Control Priorities Project
U.S. Department of Health and Human Services
Division of International Training and Research
John E. Fogarty International Center for Advanced Study in the Health Sciences
Human immunodeficiency virus
Institutes and Centers
Information and Communications Technology
International Clinical, Operational, and Health Services Research and Training Award
Institute of Medicine
Journal of the American Medical Association
National Academy of Sciences
National Heart, Lung and Blood Institute
National Institute of Allergy and Infectious Diseases
National Institute of Biomedical Imaging and Bioengineering
National Institute of Child Health and Human Development
National Institutes of Health
National Institute of Neurological Disorders and Stroke
National Library of Medicine
Pan American Health Organization
The Special Programme for Research and Training in Tropical Diseases, WHO
World Health Organization
Fogarty International Center Advisory Board Roster
(All terms end January 31)
Roger I. Glass, M.D., Ph.D. (Chair)
Director, Fogarty International Center for Advanced Study in the Health Sciences and Associate Director for International Research,
National Institutes of Health
Douglas C. Heimburger, M.D., M.S. (2008*)
Professor, Division of Clinical Nutrition & Dietetics
Departments of Nutrition Sciences and Medicine
University of Alabama at Birmingham
Birmingham, AL 35294-3360
William A. Vega, Ph.D. (2009)
Professor of Family Medicine
Department of Family Medicine
David Geffen School of Medicine at UCLA
Los Angeles, CA 90024-4142
Karen H. Antman, M.D. (2010)
Provost and Dean
Boston University School of Medicine
Boston, MA 02118
Peter Hotez, M.D., Ph.D. (2011)
Professor and Chair
Department of Microbiology and Tropical Medicine
George Washington University & Sabin Vaccine Institute
Washington, DC 20037
Sten H. Vermund, M.D., Ph.D. (2011)
Director, Institute for Global Health
Professor of Pediatrics, Medicine, Preventive Medicine and Obstetrics and Gynecology
Vanderbilt University Medical Center
Nashville, TN 37232
Elizabeth Barrett-Connor, M.D. (2008*)
Professor and Division Chief
Division of Epidemiology
Department of Family and Preventive Medicine
University of California, San Diego
La Jolla, CA 92093-0607
Jim Yong Kim, M.D., Ph.D. (2011)
Head, Department of Social Medicine
Associate Clinical Professor of Social Medicine
Brigham and Women's Hospital
Harvard School of Public Health
Boston, MA 02115
Robert Black, M.D., M.P.H. (2011)
Department of International Health
The Johns Hopkins University
Bloomberg School of Public Health
Baltimore, MD 21205
Arthur Kleinman, M.D., M.A. (2009)
Esther and Sidney Rabb Professor and Chair
Department of Anthropology
Cambridge, MA 02138
Luz Claudio, Ph.D. (2010)
Department of Community and Preventive Medicine
Mount Sinai School of Medicine
New York, NY 10029
Arthur Reingold, M.D. (2011)
Professor and Chair, Division of Epidemiology
Center for Infectious Disease Preparedness
UC Berkeley School of Public Health
Berkeley, CA 94720-7350
*term extended to July 2008
Ting-Kai Li, M.D. (2010)
National Institute on Alcohol Abuse and Alcoholism
National Institutes of Health, Bethesda, MD
Office of the Director
Fogarty International Center
National Institutes of Health
Bethesda, MD 20892
 Members absent themselves from the meeting when the Board discusses applications from their own institutions or when a conflict of interest might occur. The procedure applies only to individual applications discussed, not to en bloc actions.
 Applications that were noncompetitive, unscored, or not recommended for further consideration by initial review groups were not considered by the Board.