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 Requirements for Confidentiality
- Review of Applications
- Minutes of Previous Meeting
- Update on FIC Activities and Plans
- Making e-Health Connections: Global Partnerships, Local Solutions
- Public–Private Partnerships: The Potential Role of FIC
- Plans and Activities of the FIC Division of International Relations: Regional Initiatives
- Concluding Remarks
The John E. Fogarty International Center for Advanced Study in the Health Sciences (FIC) convened the seventieth meeting of its Advisory Board on Tuesday, September 9, 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 10:15 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 2:48 p.m. Dr. Roger I. Glass, Chair, FIC Advisory Board, and Director, FIC, presided. The Board roster follows the minutes of the meeting.
Board Members Present:
Dr. Karen H. Antman
Dr. Douglas C. Heimburger
Dr. Peter J. Hotez
Dr. Arthur Reingold
Board Members Absent:
Dr. Robert A. Black
Dr. Luz Claudio
Dr. Jim Yong Kim
Dr. Arthur Kleinman
Ting-Kai Li, M.D. (ex-officio)
Dr. William A. Vega
Dr. Sten H. Vermund
Members of the Public Present:
Ms. Danielle Altares
Policy and Advocacy Associate,
Dr. Gail Cassell
Vice President for Scientific Affairs,
Eli Lilly Foundation
Dr. Lois K. Cohen
Lois K. Cohen and Associates, LLC
Ms. Janis Mullaney
Senior Advisor for Public–Private Partnerships,
Foundation for the National Institutes of Health
Dr. Ariel Pablos-Méndez
Rockefeller Foundation Dr. Roscoe M. Moore, Jr.
Founder and President,
PH RockWood Corporation Dr. Bonita Stanton
Chair of Pediatrics,
Wayne State University
Federal Employees Present:
Dr. Barbara Alving, NCRR/NIH
Dr. Christine Bachrach, OBSSR/NIH
Mr. Kevin Bialy, FIC/NIH
Ms. Danielle Bielenstein, FIC/NIH
Ms. Katrina Blair, FIC/NIH
Dr. Joel Breman, FIC/NIH
Dr. Ken Bridbord, FIC/NIH
Mr. Bruce Butrum, FIC/NIH
Ms. Stacey Chambers, NINDS/NIH
Ms. Tina Chung, FIC/NIH Ms. Elizabeth Cleveland, FIC/NIH
Mr. Robert Eiss, FIC/NIH
Dr. Dan Gerendasy, CSR/NIH
Dr. Roger I. Glass, FIC/NIH
Dr. Gray F. Handley, NIAID/NIH
Dr. Joe Harford, NCI/NIH
Dr. Karen J. Hofman, FIC/NIH
Ms. Rhea Hubbard, FIC/NIH
Mr. Sean Jeffrey, FIC/NIH
Dr. Flora Katz, FIC/NIH
Dr. Linda Kupfer, FIC/NIH
Dr. Vesna Kutlesic, OD/NIH
Ms. Judy Levin, FIC/NIH
Dr. Donald Lindberg, NLM/NIH
Dr. Yuan Liu, NINDS/NIH
Dr. Thomas Mampilly, FIC/NIH
Dr. Jeanne McDermott, FIC/NIH
Dr. Kathleen Michaels, FIC/NIH
Dr. Peggy Murray, NIAAA/NIH
Dr. Aron Primack, FIC/NIH
Dr. Josh Rosenthal, FIC/NIH
Mr. Julia Royall, NLM/NIH
Dr. Lana Shekim, NIDCD/NIH
Ms. Angela Smith, FIC/NIH
Dr. Katharine Sturm-Ramirez, FIC/NIH
Dr. Manana Sukhareva, CSR/NIH
Mr. Timothy J. Tosten, FIC/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, February 10, 2009
Tuesday, May 19, 2009
Tuesday, September 8, 2009
III. REVIEW OF REQUIREMENTS FOR CONFIDENTIALITY
Mr. Robert Eiss reviewed the rules and regulations, which were maintained.
IV. REVIEW OF APPLICATIONS
Dr. Glass chaired the Closed Session review of applications, during which the Research Awards Working Group reported its activities. The Board concurred with the working group's recommendations for all applications. The program actions are summarized below.
- AIDS International Training and Research Program (AITRP) Supplement Awards (HIV-related malignancies) – 11 applications out of a total of 15 applications, for $1,963,865
- International Research Ethics Education and Curriculum Development Award (BIOETH) – 9 applications out of a total of 22 applications, for $5,904,092
- Fogarty International Research Collaboration Award (FIRCA) – 12 applications out of a total of 21 applications, for $653,217
- International Research Scientist Development Award for U.S. Postdoctoral Scientists (IRSDA) – 11 applications out of a total of 11 applications, for $1,123,247
- Planning Grants for International Malaria Clinical, Operational & Health Services Research Training Programs (MALARIA ICOHRTA) – 2 applications out of a total of 2 applications, for $45,000.
The Board concurred with the initial review recommendations for each program.
V. Minutes of Previous Meetign
The minutes of the FIC Advisory Board meeting of May 20, 2008, were considered and approved unanimously
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VI. Update on FIC Activities and Plans
Dr. Roger Glass, Director, Fogarty
Dr. Glass welcomed everyone to the open session. He noted that Dr. Douglas Heimburger is completing his term on the Board, and he thanked him for all his efforts. Dr. Glass welcomed Ms. Julia Royall, National Library of Medicine (NLM), who recently returned from serving as a Fulbright scholar in Uganda. He introduced and welcomed the following four individuals whose appointments to the Board will soon be official: Dr. Gail Cassell, Vice President for Scientific Affairs, Eli Lilly Foundation; Dr. Roscoe M. Moore, Jr., Founder and Director, PH RockWood Corporation; Dr. Pablo-Méndez, Managing Director, Rockefeller Foundation; and Dr. Bonita Stanton, Chair of Pediatrics, Wayne State University.
Dr. Glass presented an update on FIC plans, developments, and program activities over the past 4 months since the Board’s May 2008 meeting. He then asked FIC staff to update the Board on three topics: a report on NIH-wide international activities, the FIC Strategic Plan, and the FIC Budget. In his presentation, Dr. Glass reported the following.
Recent Activities. In June 2008, FIC participated in the first Foundation for NIH (FNIH) meeting on public–private partnerships in global health [see section VIII below for Dr. Cassell’s report on this meeting]. In July, Dr. Lincoln Chen, president, China Medical Board, visited FIC to discuss opportunities for collaboration [see section IX below]. Also in July, FIC hosted an information and communications technology (ICT) consultation on distance learning. The consultation, which was videocast, involved 14 FIC grantees who are studying how best to apply ICT to long-distance learning and e-health, to extend the reach of FIC’s research training programs and facilitate research. FIC is collaborating with the Rockefeller Foundation in this initiative [see section VII below]. Dr. Flora Katz, Program Officer, Division of Training and Research (DITR), co-chairs FIC’s ICT Working Group.
In July, FIC hosted a 2-week orientation for 100 Fogarty International Clinical Research Scholars. This FIC program, which is supported by seed monies from the NIH institutes and centers (ICs), enables U.S. and foreign medical students and new research investigators to receive 1 year of training in global health. This year, the program was expanded to include postdoctoral investigators.
In August, FIC participated in the 2008 International AIDS Conference, held in Mexico City, Mexico. The conference events included celebrations of FIC’s 40th anniversary and AITRP’s 20th anniversary. On September 2 at Brown University, Dr. Glass, with Senator Jack Reid (D-RI), announced a new round of competition for FIC’s Framework Programs for Global Health (FRAME). These grants support the creation of administrative frameworks for bringing together multiple schools within a university to focus on global health and the development of multidisciplinary curricula in global health.
Partnerships. Dr. Glass reported that FIC continues to build many partnerships to expand the “footprint” of global health at NIH. Since April 2008, FIC contributed expertise to research conferences hosted by the Institute of Health Metrics and Evaluation, Global Health Council, Bill & Melinda Gates Foundation, and The Rockefeller Foundation. Staff contributed to the review of grant proposals in population health submitted to the Doris Duke Charitable Foundation. And, FIC participated in a university consortium on global health, held at the University of California at San Francisco, and in a World Health Organization (WHO) meeting to develop a research agenda for prevention and control of non-communicable diseases.
FIC Trans-NIH Initiatives. Dr. Glass noted four recent trans-NIH initiatives. These include the FIC-led preparation of the NIH Report of International Activities and Expenditures, Fiscal Year (FY) 04–05 [see below for more detail] and the convening of an inaugural meeting of the Trans-NIH Working Group on Climate Change, held in September. The working group, which is chaired by FIC’s Dr. Josh Rosenthal, Deputy Director, DITR, will identify NIH-relevant research questions in climate change and global health. In this regard, Dr. Glass referred the Board to TIME Magazine’s special report on global warming, entitled “Be Worried, Be Very Worried” (April 3, 2006). In addition, in September, FIC collaborated with the National Institute of Allergy and Infectious Diseases (NIAID) to prepare a white paper on NIH’s role in global health, which has been disseminated to all IC directors as an NIH position paper. Also in September, FIC collaborated with the Office of Director, NIH, to chair the International Data Working Group, which will monitor NIH’s future involvement in global health.
Grant Announcements. During the summer, FIC announced several grant competitions. In June, FIC announced the availability of Millennium Promise Awards: Non-communicable Chronic Diseases Research Training Program (NCoD). In July, FIC invited applications for planning grants for MALARIA ICHORTA and for FIRCAs in Basic Biomedical and Behavioral and Social Science. In August, FIC announced its partnership with other ICs to support Ruth L. Kirschstein National Research Service Award (NRSA) Institutional Research Training Grants.
Focus on Africa: Upcoming Events. Dr. Glass highlighted two activities to increase African participation in research and research training. On November 5, 2008, FIC will host the NIH Sub-Saharan Africa Summit, at the Lawton Chiles International House, NIH. Dr. Glass and Dr. Elias Zerhouni, Director, NIH, will co-chair this seminal meeting. Also in November, Dr. Zerhouni will give a presentation at the 2008 Global Ministerial Forum on Research for Health, in Bamako, Mali. Dr. Glass noted that African participation in NIH activities is currently minimal: fewer than 20 postdoctoral scientists in the NIH Visiting Program are from Africa (and most of these are from South Africa), and approximately 13 percent of NIH grants are awarded to researchers in Sub-Saharan Africa (and most of these are to South African researchers focusing on HIV/AIDS).
Networking Meetings: Fall and Winter 2008. FIC will host the annual meetings of FIC’s Bioethics Network (October 1), Population and Health Network (October 31), BRAIN Network (November 13–14), Global Infectious Disease (GID) Network (December 8), and TRAUMA network (December 11–12). At each meeting, FIC grantees will review their activities and suggest ways in which FIC could improve the overall program. Dr. Glass invited and encouraged Board members to participate in the meetings.
Fall 2008 Consultation. On October 15, two events will mark FIC’s 40th anniversary: the second FNIH public–private partnerships meeting on global health and an anniversary dinner at the Italian Embassy. On November 12, FIC will participate in the Global Health Diplomacy Symposium, at Georgetown University Law School. Also in the fall and with the involvement of the Board, FIC will initiate the first scientific evaluation of its Division of International Epidemiology and Population Studies (DIEPS).
Other Issues. Dr. Glass said that FIC is planning for the government transition that will occur in January with the change in administration. As across NIH, the budget has been flat for several years. To prepare for the next 4–8 years, staff are addressing FIC’s uniqueness and contributions to global health, as well as research training, and how best to use FIC resources to promote the agenda for global health. As for other ICs, Dr. Glass noted that the National Heart, Lung, and Blood Institute (NHLBI) recently committed $48 million to support research on heart and lung diseases in centers in developing countries, the National Cancer Institute (NCI) is presently reviewing its strategic plan in global health, the National Institute of Biomedical Imaging and Bioengineering (NIBIB) will be holding its first international conference in India on bioengineering, and the National Institute of Environmental Health Sciences (NIEHS) is publishing its strategic plan in global health.
REPORT ON NIH INTERNATIONAL EXTRAMURAL INVESTMENTS (FY 04–05)
Dr. Karen J. Hofman, Director, Division of International Science Policy, Planning, and Evaluation (DISPPE), FIC
Dr. Hofman reported that, for the past 18 months, FIC has been developing a Report on NIH International Extramural Investments (FY04–05). Still in draft, this report compiles expenditures for international health research and research training across the NIH. Dr. Hofman thanked the ICs for their input and contributions. Previously, from the 1970s until 2000, FIC issued an annual, largely narrative report of NIH international activities. At Dr. Zerhouni’s request, FIC has reinvigorated this process in a new way to capture data on how much NIH spends on international health research. The aim is to establish a baseline for tracking trends and to understand the NIH investment geographically and across ICs and disease areas to increase the transparency, accountability, assessment, and leveraging of NIH’s investments internationally.
Dr. Hofman noted that statistics on the funding of health research internationally, in general and at NIH, are inconsistent and poorly defined, as has been noted by the Global Forum for Health Research and the Global Health Council. Better information is needed by national governments, multilateral agencies, and advocates for global health.
The new report captures data on NIH support of (i) researchers in foreign research institutions, through direct awards and foreign components of domestic awards, and (ii) training of foreign or U.S. researchers at foreign sites. These data, which are publicly available from the NIH Office of Extramural Research, show that research support for either direct foreign awards or foreign components of domestic awards has grown consistently from 1992 through 2004 and that most of this support has gone to researchers in foreign institutions in high-income countries. In 2005, for the first time, NIH support for foreign components of domestic awards was distributed equally between high-income countries and low- to middle-income countries.
Dr. Hofman illustrated several uses for the FY 04–05 data. For example, one can relate the burden of disease (e.g., projected world disability-adjusted life years, or DALYs) to NIH’s foreign investment by topic. In FY 04–05, NIH invested 18 percent of its foreign research dollars into HIV/AIDS (which is projected to account for 12 percent of DALYs in 2030), but no foreign research dollars into psychiatric disorders (which are expected to account for 15 percent of DALYs in 2030). One also can see the distribution of NIH’s investment by world regions. In FY 04–05, most of NIH’s foreign support (68 percent) went to researchers in high-income countries and those in the Organization for Economic Cooperation and Development (OECD), while only 12 percent went to researchers in Sub-Saharan Africa and almost none to researchers in the Middle East and North Africa. Of the top 15 countries receiving foreign research support from the NIH, only 4 are developing countries (Brazil, China, South Africa, and Thailand).
Elaborating on Sub-Saharan Africa, Dr. Hofman stated that NIH invested $137.9 million in this region in FY 04–05, out of a total NIH budget of approximately $28.5 billion. NIAID provided most ($91 million) of this research support, by far, followed by the National Institute of Mental Health (NIMH) ($14 million) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) ($12 million). The FIC provided slightly more than $7 million, and eight other ICs provided lesser amounts. Of the $137.9 million NIH invested in the region, most of the monies (more than $60 million) went to researchers in South Africa, and most (slightly less than $50 million) was for research on HIV/AIDS.
Dr. Hofman noted the top 10 research institutions in Sub-Saharan Africa receiving NIH research support. As for FIC-supported research training, this region received the highest percentage of dollars (35 percent), followed by Latin America and the Caribbean (27 percent), and East Asia and the Pacific (13 percent). Across the world, the Middle East and North Africa is the only region not receiving FIC research training support. In the NIH Visiting Program, only about 20 Visiting Scientists are from Sub-Saharan Africa, and the top five countries with the greatest participation continue to be China, Japan, Korea, India, and Italy.
In conclusion, Dr. Hofman noted that the FY 04–05 report is a first attempt to accurately collect, analyze, and communicate NIH’s international investment and to establish a baseline for tracking trends. The major limitations are that the report reflects flawed data systems that yield probably a minimum dataset, rather than a full picture of NIH’s international investment, and data collection for the report is a non-replicable, labor-intensive effort. A centralized data system is needed to capture information accurately, comprehensively, and in real time. Therefore, as a next step, FIC is convening a trans-NIH group to develop and implement a data management system for NIH international activities. This group will be led by Dr. Glass and Dr. Lana Skirboll, Director, Office of Science Policy, Office of the Director, NIH.
The Board complimented FIC for undertaking a worthwhile analysis. Dr. Glass noted that the extensive effort yielded controversial data and that a main issue is how to use the data. In response to a question from Dr. Cassell, Dr. Hofman confirmed that, as in FY 05, approximately one-fifth of current NIH trainees are foreign investigators. She said that FIC had not specifically addressed the distribution of clinical trials worldwide and that data on which diseases the Visiting Scientists are focusing would be important to obtain. Dr. Joe Harford of NCI said that, among the ICs, NCI supports the most clinical trials and, of these, only a few are at non-U.S. sites and none are in developing countries.
UPDATE: PATHWAYS TO GLOBAL HEALTH RESEARCH, STRATEGIC PLAN 2008–2012
Dr. Linda Kupfer, Deputy Director, DISPPE, FIC
Dr. Kupfer presented an update on the actions FIC has taken thus far to implement the five goals of the Strategic Plan for 2008–2012. She highlighted the robustness of the planning process and the vision and mission statements presented in the plan. A full copy of the plan is available online.
Dr. Kupfer emphasized a point made in the plan—that global health has reached the tipping point at which there is broad international recognition that science is very important for global health, and global health is very important for the economy. For each goal set forth in the plan, she listed the following.
GOAL I: To mobilize the scientific community to address the shifting global burden of disease and disability. Actions: (a) FIC established a new initiative, the Millennium Promise Awards: Non-communicable Chronic Diseases Research Training Program, and (b) FIC recompeted all of its infectious diseases research training programs [AITRP, GID, ICOHRTA AIDS/TB, Ecology of Infectious Diseases (EID)].
GOAL II: Bridge the training gap in implementation research. Actions: (a) FIC is sponsoring the 2nd Annual NIH Conference on the Science of Dissemination and Implementation: Building Research Capacity to Bridge the Gap From Science to Service, at NIH, on January 28–29, 2009, and (b) FIC has increased the emphasis on implementation research in all its research training programs.
GOAL III: Develop human capital to meet global health challenges. Actions: FIC expanded its Scholars program to include fellowship opportunities for U.S. health scientists and for foreign scientists.
GOAL IV: Foster a sustainable research environment in low- and middle-income countries. Actions: (a) FIC expanded the number of direct foreign awards and allowed planning grants under AITRP, and (b) held some ICT consultations, including the one in July with grantees.
GOAL V: Build strategic alliances and partnerships in global health research and training. Actions: (a) FIC collaborated with the FNIH in June to convene the first public–private partnerships meeting on global health, and (b) FIC and FNIH will hold a follow-up, second public–private partnerships meeting in October 2008 to focus on implementation science. [See section VIII below.]
Dr. Kupfer noted that the FIC Strategic Plan will not “just sit on the shelf” in that FIC is creating interdivisional working groups to develop implementation plans and performance targets for each goal. The proposed topics for the working groups are: Sustainable Research Environment, Implementation Science, Non-Communicable Diseases, ICT, and Partnerships/Outreach. Each group will offer creative guidance for implementing the strategic plan, respond to inquiries and provide information for communications and presentations about the group’s topic, and increase communication and coordination among FIC divisions, offices, and staff. In addition, FIC will create flexible, shorter-term interest groups, as needed, to address more-specific topics. The proposed topics for two interest groups are: Malaria, and FIC/NIH Database Needs. Dr. Kupfer encouraged the Board members to participate in the groups.
UPDATE: FIC BUDGET
Mr. Timothy J. Tosten, Executive Officer, FIC
Mr. Tosten presented an overview of the FIC budget. He noted that, over the past 20 years, the FIC appropriation has increased from approximately $15 million in FY 1988 to approximately $66 million in FY 2008 (consisting of approximately $43 million for non-AIDS and approximately $23 million for AIDS-related research and research training). However, for the past 4 years, the appropriation has been flat-lined, a situation that challenges FIC’s ability to develop new programs. In addition, the amount of co-funding that FIC receives from other ICs and agencies has been declining since FY 2004—FIC’s peak budget year, when appropriations approximated $51 million and co-funding approximated $25 million.
Mr. Tosten reported that FIC received an overall budget increase of $137,000 for FY 2008. In August 2008, Congress passed a supplemental bill and FIC received an increase of $354,000, which will become part of the FIC base budget in future years. The entire 2008 budget of approximately $66.8 million was distributed as follows: $50.6 million for extramural activities [e.g., research project grants (RPGs), training grants, fellowships], $12.9 million for research management and support (RMS) (e.g., salaries, administrative costs), and $3.2 million for research and development (R&D) (e.g., contracts, interagency agreements). One-half of the supplement was distributed to RPGs and the remainder to RMS and R&D.
Mr. Tosten noted that the President’s Budget for FY 2009 increases the FIC budget by $65,000, to approximately $66.8 million, out of a total NIH budget of approximately $29.4 billion. He also noted that the FY 2008 supplement ($354,000) will eventually be added to the FY 2009 base. FIC plans to allocate the budget similar to the allocation in FY 2008. Mr. Tosten anticipated that the NIH will operate under a Continuing Resolution at least until spring 2009 and possibly for the entire year.
Dr. Stanton asked about the decline in co-funding since FY 2004. Dr. Kenneth Bridbord, Director, DITR, FIC, noted that there is no simple answer and that co-funding for some FIC programs may have increased, while that for others may have decreased. The final co-funding levels for FY 2008 are not yet available.
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VII. Making e-Health Connections: Global Partnerships, Local Solutions
Dr. Dr. Ariel Pablos-Méndez, Managing Director, Rockefeller Foundation
Dr. Pablo-Méndez discussed the importance of health systems in the framing of the overall NIH international health program. He focused on e-health as part of the solution to building integrated and interoperable health systems in countries and globally. More than just connectivity to access content for distance learning, e-health offers capability for transforming health systems. Dr. Pablo-Méndez addressed three topics: the global challenge of health systems, e-health in the global South, and the Bellagio conference series on global e-health, held this past summer.
The Global Challenge of Health Systems. The past century and, particularly, the past decade have brought great advances in health, but also great inequalities. Nearly 10 million children under 5 years of age die each year, almost all from poor families, and although HIV/AIDS only accounts for 3 percent of these deaths, 80 percent of the United States’ overseas development aid (ODA) is directed to HIV/AIDS. The Millennium Development Goals to reduce infant mortality by 2015 are simply not going to be met. The reason is, in part, because the global health problem has changed, such that health systems are at the center of and the solution to the challenges we now face—access, affordability, and quality of care. These new problems are not disease-specific, but are cross-cutting and universal and, to date, science has not contributed enough to meeting these challenges. Even in the United States, one-half of bankruptcy cases are due to medical bills and, globally, 25 million families who are not poor become poor each year because of health spending. In Africa, only 3 percent of the population has health insurance.
Dr. Pablo-Méndez shared data which showed that (a) countries’ total health spending tracks with their gross domestic product (GDP), regardless of whether health spending is largely public or private, and (b) total health spending, for all countries, has been rising exponentially and faster than GDP—a phenomenon that has been termed “the economic transition of health.” For example, over the past 25 years, China’s health spending has increased 50-fold and, by 2080, the United States is projected to devote 50 percent of its GDP to health. The view of this transition from a macroeconomic perspective is that richer countries will continue to spend more on health than will poorer countries. From an individual level, however, it means that in regions and countries where most health spending is private (e.g., 60 percent in Africa, 80 percent in Asia), poorer families will be spending an increasing proportion of their incomes for health, compared with richer families. This discrepancy between the macroeconomic vs. individual view is important—for, without social protection policies and health insurance to gain equity, the micro-inflationary pressures that will arise could lead to a global disaster in developing countries over the next 20 years.
Dr. Pablo-Méndez also summarized data on childhood (under-5) mortality rates which showed that good health exists across countries with a range of GDP, but poorer countries have poorer health outcomes, in general, and poor countries vary widely in health outcomes (viz., Rwanda vs. Kenya). The data strongly indicate that (a) how much money is spent on health is not the main concern, but, rather, how that money is used, and (b) although health policy has little effect on total health spending, it can have a paramount effect on how the money is spent. In the United States, for example, the attempt to control health care costs has had no effect on the percentage of citizens insured and costs continue to rise.
Dr. Pablo-Méndez emphasized that the economic transition of health is really an opportunity for social justice and equity to converge with economics—and for science leadership in building good health systems, from health infrastructures to service delivery, workforces, technologies and drugs, financing, and stewardship. The components on which the Rockefeller Foundation is focusing are health stewardship, leveraging of the private sector for service delivery and financing, health service professionals (in health economics, health policies, health management), and ICT as the new frontier. The goal is to broaden access to affordable and quality health services by suggesting new and innovative strategies to improve health systems’ performance.
Dr. Pablo-Méndez noted that only 0.3 percent of the $6 trillion spent in global health annually is ODA, which leaves “99.7 percent” for leveraging good ideas to improve health systems. For its part, the foundation is focusing on three regions (Sub-Saharan Africa, South Asia, and Southeast Asia) and three strategies (improving countries’ health systems capacity, harnessing the private sector, and leveraging e-health) that are guided by separate working groups. The foundation will present a 1-year report of the groups’ activities, at the Bellagio Center in October 2008, and a 5-year plan to the foundation’s Board of Trustees this fall.
e-Health in the Global South. Dr. Pablo-Méndez noted that e-health is broadly defined as the use of ICT to improve health—in primary care informatics, public health informatics, and systems support. Evidence indicates that e-health can improve access, affordability, and quality of health services. Whereas e-health was impossible 10 years ago, it is realizable today because of the ongoing revolution in connectivity and ICT infrastructure in most of the world. In Africa, for example, use of cell phones and the Internet is “leapfrogging” across countries (e.g., 80 percent to 90 percent of villages in South Africa have cell phones).
A major emerging problem with this amazing progress, however, is the “1,000 flowers blooming” at local to global levels across the world—a broad range of initiatives, fragmentation, and few large-scale, interoperable systems. Yet, less than 2–3 percent of health spending is for ICT, compared with 10-12 percent for health financing. In the United States, despite high health spending, there are no interoperable systems, scale of efficiency, or R&D on ICT. Yet, all ICT companies (e.g., Intel) have a health division. Avoiding an interoperable “mess” in Africa is key, because the capability for e-health is surging and the promise is high.
Dr. Pablo-Méndez noted that the true value of e-health is connectivity to a larger network. As according to Metcalfe’s law, the value of a network is proportional to the square of the number of users of the system. In e-health, the network must be interoperable across several dimensions—programs, geography, points of care and prevention, technology. Now is the time to preempt the problem of interoperability, for 10 years from now will be too late. e-Health is key to addressing health system weaknesses, and the ICT infrastructure and applications are available in many countries.
Bellagio Conference. From July 13 to August 8, 2008, the foundation hosted the conference series “Making the e-Health Connection: Global Partnerships, Local Solutions” at the foundation’s Bellagio Center in Bellagio, Italy. The conference objectives were to develop and define an e-health agenda, promote the importance of interoperability, and catalyze the formation of new partnerships and collaborations. For each of the 4 weeks, participants could attend two conferences focused on a particular topic—national health information systems, knowledge and capacity for e-health, core e-health technologies, and policy and markets for e-health. Case studies, commissioned papers, and videos were prepared and are available on the conference website, www.ehealth-connection.org.
More than 200 participants attended the series. They came from approximately 40 countries and represented a strong cross-section of e-health stakeholders. Approximately 70 percent represented research and academia, and others represented 26 corporations, 30 donor organizations, non-governmental organizations (NGOs), government, and the media. Dr. Pablo-Méndez reported that the conference achieved a significant alignment on key e-health challenges. Capacity building in e-health was the most critical challenge identified by all constituents, followed by awareness creation among ministries of health and policymakers. The next four challenges that were identified are fragmentation, funding, poor infrastructure, and prohibitive policy or lack of policy.
Dr. Pablo-Méndez noted that the series ended with a Bellagio Call to Action for e-Health—that is, “better health for all through integrated e-health systems” (with a motive of moving from silos to systems). With the support of the president of Rwanda, who envisaged “an economic future with portals,” Rwanda will be a pilot laboratory for developing a fully integrated e-health system (a model already exists in São Paulo, Brazil). The participants identified a set of leaders, both donors (e.g., FIC) and partners, and specified their roles for implementing the call to action. And, the community is mobilizing behind specific e-health initiatives globally and nationally. For example, with regard to setting a global e-health agenda, Archbishop Tutu will champion e-health at the 2008 Global Ministerial Forum on Research for Health, in Bamako, Mali, and the G8 countries have established a working group on information systems. In closing, Dr. Pablo-Méndez noted that the Bellagio conference has generated new momentum and new partnerships. He welcomed further collaboration in this arena between FIC and the Rockefeller Foundation.Discussion
The Board members commented on the Bellagio conference. Dr. Cassell encouraged greater integration of biopharmaceutical companies into e-health initiatives in the future, noting that only two of these companies were represented at Bellagio. Dr. Hotez commented on the minimal threshold of infrastructure needed for e-health initiatives to be effective. Noting that a strategy working group is defining maturity models for different stages of infrastructure development, he encouraged prompt action utilizing existing capabilities (e.g., the cell phone networks already in place in African countries).
Dr. Moore asked about encryption of patients’ medical records. Dr. Pablos-Méndez commented that this very important issue is a major challenge. Many policies are being developed (e.g., concerning electronic access to records), but the issues are still controversial.
Dr. Glass mentioned that FIC grantees were well represented at the Bellagio conference (e.g., ¬most of the presenters in the session on foreign capacity building were FIC grantees). He asked Dr. Flora Katz, to elaborate on FIC’s activities in bioinformatics.
FIC’s Bioinformatics Program. Dr. Katz listed the activities of FIC’s ICT working group, which she co-chairs with Dr. Thomas Mampilly. She noted that FIC established the Informatics Training for Global Health (ITGH) program in FY 1999 and, in November 2008, held a third round of competition for grants. Through this program, FIC is training the human resources needed to help develop integrated health systems globally. As reported by Dr. Glass earlier, FIC held a videocast consultation in July 2008 involving 14 FIC grantees and 21 world leaders with expertise in distance learning. The consultation included a Web collaboration that is available to all trainees using the Elluminate™ software. As followup, FIC has identified resources for grantees to evaluate distance-learning models.
FIC has allocated increased ICT monies to the DIEPS research program for population-level analyses and mathematical modeling of the burden of diseases. In addition, and as already noted, FIC is collaborating with FNIH on the second public–private partnerships meeting. Also, FIC staff are members of various trans-NIH committees related to ICT and participated in the Bellagio conference and the Rockefeller Foundation’s public health informatics meeting in Seattle.
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VIII. Public–Private Partnerships: The Potential Role of FIC
Dr. Gail Cassell, Vice President for Scientific Affairs, Eli Lilly Foundation
Ms. Janis Mullaney, Senior Advisor for Public–Private Partnerships, FNIH
Dr. Cassell reported on the June 2008 public–private partnerships meeting coordinated by FNIH with FIC. Drawing from her former experience in academia and now in the private sector, she noted that the need and opportunities for public–private synergy in research and research training are greater now than ever before for addressing communicable and non-communicable diseases. She highlighted the possibilities for synergy in discussions and action on cross-cutting issues, non-competing interests, and areas of private-sector expertise (e.g., clinical trials, clinical management, information technology, drug distribution, supply-chain management, and demand forecasting).
Ms. Mullaney elaborated on the June meeting. She noted that the aim was to identify industrial entities interested in global health, particularly in relationship to FIC’s Strategic Plan and to health services delivery. At this first “get to know you” meeting, FIC outlined its vision in three areas: implementation science, information technology (IT) and ICT for health research, and chronic diseases. Ms. Mullaney commented that approximately 20 of the companies participating did not know about FIC previously.
The aim of the second public–private partnerships meeting, in October 2008, is to develop a dialogue on how to enhance research and research training in implementation science. At this meeting, FIC will describe its programs, and FIC grantees will present “on-the-ground” research and training needs. Several companies have been invited to discuss their programs and needs and, particularly, their experience with intervention packages. The intended outcome is to specify program initiatives and efforts in implementation science that FIC, in coordination with FNIH, could subsequently propose and support, with industry participation.
Ms. Mullaney invited the Board to comment on other areas that FIC should consider addressing with FNIH and industry.Discussion
Dr. Reingold asked about the nature of the upcoming October meeting. Ms. Mullaney noted that the invited companies will describe their recent experiences in relating to communities in developing countries and that, in earlier years, companies had attended only to their in-country employees. Dr. Cassell noted that the meeting will offer an opportunity to learn about the companies’ corporate social responsibility programs in relation to implementation activities and to probe the potential synergies between the companies and FIC. She agreed with Dr. Pablo-Méndez’s suggestion that FIC also could pursue opportunities for collaboration with private R&D enterprises. He offered that The Rockefeller Foundation could link FIC with other ongoing public–private partnerships.
Ms. Mullaney and Dr. Cassell agreed with Dr. Stanton on the importance of monitoring and evaluating implementation initiatives and the need to identify whether companies are pursuing evidence-based programs. They noted further that several large consulting firms that support global health activities are interested in participating in the meeting. Dr. Cassell noted that companies such as PricewaterhouseCoopers and McKinsey and Company allow employees to undertake one pro-bono activity a year, which could be in global health, for example. Dr. Pablo-Méndez encouraged FIC and FNIH to harness ongoing research in nutrition, and Drs. Cassell and Glass mentioned two companies, Mars and Pepsico, as potential partners with FIC.
Dr. Glass commented that the June 2008 meeting elicited many examples of potential synergy that would not have been envisaged otherwise. He anticipated that the FIC meeting on ICT for global health, to be held in spring 2009, would be equally effective.
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IX. Plans and Activities of the FIC Division of International Relations: Regional Initiatives
Dr. Glass introduced the session by noting that DITR includes six project officers who administer FIC activities in different world regions and that, at each Board meeting henceforth, two project officers will be describing their portfolios. For the present meeting, two project officers described FIC’s initiatives in India and China—two countries that comprise approximately 50 percent of the world’s population.
Dr. Thomas Mampilly, Regional Officer for South Asia, DITR, FIC
Dr. Mampilly stated that FIC’s definition of South Asia accords with the WHO classification and comprises Afghanistan, India, Indonesia, Pakistan, and Thailand. Focusing on NIH activities in India, he summarized the rationale for NIH involvement, the burden of disease in India and South Asia, NIH partners and activities, and future opportunities and action items.
Dr. Mampilly said that NIH’s involvement with India offers an opportunity to answer scientific questions that perhaps could not be answered elsewhere. With a population of more than 1.1 billion, India contains more than 15 percent of the world’s total population. The population is both genetically diverse and consanguine, and the nation bears a large burden of communicable and non-communicable diseases (e.g., HIV/AIDS, diarrheal diseases, acute respiratory infections, diabetes, cancer), some of which are associated with environmental exposures.
Dr. Mampilly noted that the research, political, and economic environment in India are advantageous for collaboration. India has world-class research institutions in government, academic, and private sectors; a large pool of highly educated, highly motivated, English-speaking scientists; and a substantial and growing political commitment and public investment in science and technology. In addition, India already has a strategic partnership with the United States. It is the largest democracy worldwide, has a stable government and rapidly expanding economy, and is a global leader among developing nations.
WHO 2005 data show that, in India, (a) communicable diseases account for approximately one-third of the overall disease burden, (b) non-communicable diseases are among the most important public health issues emerging and collectively account for approximately 50 percent mortality in adults ages 30–59 years, and (c) maternal and child health continues to be a significant challenge. Large variations in each category occur across the states. The 2006 Disease Control Priorities in Developing Countries ranks the leading causes of disease burden in South Asia in the following order: perinatal conditions, lower respiratory infections, ischemic heart disease, diarrheal diseases, and unipolar depressive disorders.
Dr. Mampilly reported that NIH partners broadly with government agencies, NGOs, academia, and private corporations in India. Government partners include various components of the Ministry of Health and Family Welfare, Ministry of Science and Technology, and Indian Council of Medical Research. Examples of NGO partners include Y.R.G.Care and the Tata Institute of Social Sciences. Within academia, NIH partners, for example, with CMC Vellore, the All India Institute of Medical Sciences, and the Public Health Foundation of India. Private-sector collaborations are with biotechnology and pharmaceutical firms.
NIH partnerships with India currently include nine bilateral agreements involving seven ICs and the Office of the Director. In addition, India has begun to participate in the co-funding of bilateral research with NIH (e.g., in HIV/AIDS), and the Government of India is supporting initiatives to increase science and technology in India. Five Indo–U.S. Joint Working Groups of medical research policymakers and scientists meet annually in the following program areas: Vaccine Action Program, Contraceptive and Reproductive Health Research Program, HIV/AIDS and STD [Sexually Transmitted Diseases] Prevention Research Program, Maternal and Child Health Human Development Research Program, and Vision Research Program.
Dr. Mampilly reported that the number of NIH extramural awards to researchers and institutions in India has increased steadily since 1990, to approximately 130 in 2006. Most of these awards are foreign components of domestic U.S. awards. At any given time, more than 300 Indian scientists participate in the NIH Visiting Program. In fact, India is among the top five countries sending scientists to participate in this program, preceded by Japan, China, and Korea.
Dr. Mampilly noted that FIC has made substantial investments in India over the past several decades and that most of his investment has been in research training. A primary aim has been to build local capacity by “twinning” major U.S. academic institutions with Indian institutions. The FIC research training programs in which Indian researchers are currently engaged include AITRP, GID, BIOETH, and IRSDA, and the Global Research Training in Population Health (POP) and International Training and Research in Environmental and Occupational Health (ITREOH) programs. In addition, Indian scientists have received FIC research awards under FIRCA, the Global Research Initiative Program for New Foreign Investigators (GRIP), International Tobacco and Health Research and Capacity Building Program (TOBAC), and Brain Disorders in the Developing World: Research across the Lifespan (BRAIN). Other activities include alumni associations, trainee tracking, public–private partnerships, and strategic planning.
Listing several future opportunities and action items, Dr. Mampilly reported that NIH and the Department of Biotechnology (DBT), in India’s Ministry of Science and Technology, signed two new bilateral agreements in March 2008, one pertaining to neurosciences and one to the Visiting Program. In addition, NIH and DBT are actively discussing potential collaboration with DBT’s Institute of Translation Research in Health Sciences. Of particular note, the Indian Council of Medical Research (ICMR)—an important NIH partner—is being elevated to a “Department of Health Research,” which may imply increased funding and changes in leadership. Specific to FIC’s role, Dr. Mampilly said that FIC continues to act on behalf of NIH in U.S. Government-wide policy discussions on the $30 million Indo-Binational Endowment Fund and is addressing procedural delays by the Government of India’s Health Ministry Screening Committee (HMSC).
Dr. Mampilly suggested an opportunity for examining the role of FIC investments in science diplomacy in India or China, given the substantial FIC investment in these countries. He noted that the transition to a new U.S. administration in January 2009 may raise other opportunities as well.
The Board members expressed great interest in DBT’s new Institute of Translation Research in Health Sciences. Drs. Glass and Mampilly noted that several ICs, including NCI, NIAID, and NICHD, are very interested in potential collaborations with the new institute insofar as perhaps $10 billion to $20 billion will be spent on clinical trials conducted in India during the next decade and NIH collaboration could help assure the conduct and quality of the trials. Dr. Cassell noted the opportunity for public–private partnerships in these efforts. She encouraged consideration of a case study of FIC’s role in science diplomacy in India, particularly given the potential involvement of two NIH employees as advisors on the development of DBT’s new institute.
Dr. Hotez asked about the possibility of NIH harnessing, through FIC, the growing number of Indian medical students in the United States who are interested in global health, particularly in India. Dr. Glass mentioned the availability of FIC’s GRIP award, and a similar Indian award modeled after the GRIP, for this purpose. In response to Dr. Antman’s suggestion that FIC could foster collaborations in biomedical engineering, Dr. Mampilly noted that NIBIB will participate in the first U.S.–India bilateral meeting on low-cost diagnostics, to be held in India in November 2008. He offered to connect Dr. Antman with Dr. Roderic I. Pettigrew, Director, NIBIB.
Ms. Tina Chung, Regional Officer for East Asia and the Pacific, DITR, FIC
Ms. Chung summarized the reasons why China is important for NIH, trends in NIH awards to scientists in China, bilateral agreements with China, and items in progress. She noted that China’s population of approximately 1.3 billion resides equally in rural and urban areas and offers a unique research population with complex disease patterns reflective of both an industrialized and developing country. Striving to attain international standards of health, the Central People’s Government of the People’s Republic of China is promoting international participation and collaboration in research that is conducted in China, with the aim of developing its research infrastructure and long-lasting partnerships. Data (2001) from the Disease Control Priorities Project indicate that non-communicable diseases account for the greatest burden of disease and disability in China. The leading risk factors are high blood pressure, tobacco and alcohol use, indoor smoke, and poor nutrition. The leading causes of death are stroke (17.9 percent) and chronic obstructive pulmonary disease (13.0 percent).
At NIH, China has the second largest participation in the Visiting Program, after Japan, and had almost 500 researchers working at NIH in February 2008. In addition, 18 ICs have ongoing activities with China and two NIH scientists are stationed in China. Dr. Ray Chen, NIAID, has been in China for 4 years, and Dr. Julie Schneider arrived in August 2008 for 2 years as NCI’s first full-time staffer in China. The U.S. Department of Health and Human Services (HHS) supports a health attaché at the U.S. Embassy and is recruiting for this position.
Ms. Chung noted that bilateral agreements in health and medical sciences with China are at two levels: HHS has two broad agreements, with the Ministry of Science and Technology and the Ministry of Health, and a Memorandum of Understanding (MOU) with the Ministry of Health in each of three areas: emerging and re-emerging infectious diseases, HIV/AIDS, and integrative and traditional Chinese medicine. The NIH has a broad MOU with the Chinese Academy of Sciences for cooperation in basic biomedical research, and ICs have agreements with various Chinese institutions for cooperation in research (e.g., on alcohol use, vaccines, HIV/AIDS), research training, and research support (i.e., indexing of Chinese literature for Medline).
Across NIH, the number of direct foreign research grants to Chinese scientists at Chinese institutions rose from 9 in FY 2004 to 18 in FY 2006 and then declined slightly to 16 in FY 2007. The number of foreign components involving Chinese scientists as part of domestic U.S. awards has decreased, from 90 in FY 2004 to 70 in FY 2007. Across FIC, Chinese scientists participate in five research training programs [AITRP, POP, ITREOH, ICOHRTA, and Fogarty International Collaborative Trauma and Injury Research Training Program (TRAUMA)] and four research programs (EID, FIRCA, GRIP, TOBAC).
Ms. Chung highlighted five collaborative items, currently in progress. (i) FIC may consider convening a collaborative workshop for NIH alumni in China, to build on the large pool of Chinese scientists who have participated in the Visiting Program and may wish to network in an NIH Alumni Association. (ii) FIC is following up on its July 2008 meeting with Dr. Lincoln Chen, of the Chinese Medical Board, to discuss opportunities for Chinese support of Chinese-side activities in collaborations with NIH. (iii) The directors of several ICs [e.g., NHLBI, NIBIB, National Center for Complementary and Alternative Medicine (NCCAM), and National Institute of Neurological Disorders and Stroke (NINDS)] have been discussing with Chinese counterparts the potential for collaboration. (iv) FIC is collaborating with the Chinese Academy of Sciences (CAS) to organize a workshop on Cancer and Environmental Health, to be held in Beijing in spring 2009, to foster research relationships and applications (e.g., to the FIRCA and GRIP programs). (v) FIC has proposed three options to CAS for extending the GRIP program, whereby CAS would fund awards to Chinese scientists seeking renewal of their GRIP award, jointly fund awards, and/or support a “reverse” GRIP, whereby return to China would be a condition of an award to Chinese scientists coming to the United States.
In conclusion, Ms. Chung posed three questions for the Board’s discussion: How can FIC help NIH engage and build a long-term and sustained approach with China and ensure that the best research partners are identified? How could/should FIC help facilitate establishment of NIH Alumni Associations in China? What is the appropriate role for FIC in international relations, science diplomacy, and the transition to a new administration?
The Board’s discussion covered six topics pertaining to research and research training collaborations with China and India.
Returning Grantees to China and India. Dr. Reingold asked whether NIH had current data on the return rates for Chinese and Indian scientists participating in the NIH Visiting Program. Ms. Chung said that there are no data on this issue, but scientists have indicated a hesitancy to return to their countries because of a difficulty in replicating their research there. Dr. Reingold noted that most African trainees in AITRP return to their home countries and that Indian scientists’ return may be compromised by India’s top-down science hierarchy and bureaucracy and by scientists’ desire to have their children receive schooling in the United States.
Public–Private Partnerships. Dr. Heimburger suggested that recent increases in private-sector support and funding of emerging health systems and networks in China and India may encourage U.S.-trained Chinese and Indian scientists to return to their home countries and may present opportunities for creating effective public–private partnerships.
NIH Alumni Associations. Dr. Glass mentioned that returning grantees, in general, want to maintain linkages with NIH and that many Chinese and Indian scientists who have been trained in the United States during the past 20 years are now in leadership positions in their country. Applauding the idea of creating NIH alumni associations, Dr. Cassell mentioned that Chinese and Indian scientists who are being offered attractive packages to return from the United States to their country may be interested in funding these associations. Dr. James Herrington, Director, Division of International Relations, FIC, noted that there is broad interest among FIC grantees in having alumni associations and that the reverse GRIP program would offer one way to monitor the return of grantees to their home countries. Dr. Hotez emphasized that U.S. institutions are fast losing Chinese faculty and staff to their home country and Singapore and that the primary need is to create a mechanism to maintain linkages with these scientists, rather than to incentivize their return.
Co-funding and Joint Funding of Chinese and U.S. Grantees. Dr. Glass noted that FIC would like to convene NIH and Chinese funders to discuss new approaches to co-funding and parallel funding of Chinese and U.S. scientists conducting peer-reviewed research in China or the United States. Dr. Gray F. Handley, Associate Director for International Research Affairs, NIAID, mentioned that NIAID has entered into a new agreement with the China National Center for Biotechnology Development (CNCBD) that includes co-funding and/or matching of NIH funding for Chinese grantees. Dr. Cassell suggested that the longstanding and effective U.S.–Japan Cooperative Program is a good model to consider for China and India’s co-funding of research and research training.
Clinical Trials Database for China and India. Dr. Glass asked Dr. Donald Lindberg, Director, National Library of Medicine (NLM), to comment on NLM’s collaboration with China. Dr. Lindberg noted that 102 countries, including China and India, participate in the Web initiative www.clinicaltrials.gov, which was founded by U.S. law, and that as of September 27, 2008, the website will include results of clinical trials. Although WHO has suggested that every country should have its own clinical trials registry, the U.S. position is that a central database presented in English and encompassing all clinical trials worldwide is more effective.
NCI Activities in China. Dr. Glass asked Dr. Joe Harford, Director, Office of International Affairs, NCI, to comment on NCI’s collaboration with China. Dr. Harford noted that, although NCI supports the largest number of grants in China of any IC, most of the funding is for foreign components of U.S. domestic awards, rather than direct foreign grants to Chinese scientists. He said that environmental and industrial pollution is a major concern in China currently and that NCI’s two bilateral agreements with China are for collaborative research on breast cancer and traditional medicines, respectively.
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X. Concluding Remarks
Dr. Glass invited and encouraged Board members to participate in the upcoming networking meetings that FIC is convening for principal investigators and grantees in selected program areas. FIC will provide a list of these activities to the Board members. Commenting on his completion of 2 years as Director, FIC, he noted that FIC is moving forward now with a Strategic Plan, preliminary data on international activities across the NIH, a robust set of programs, and emerging partnerships with other ICs, the private sector, and foundations. He thanked the Board for its contributions and noted that, with much still to do, FIC will continue to depend on the Board’s input and will build on its participation.
The meeting was adjourned at 2:48 p.m. on September 9, 2008.
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