Scientists gathered at NIH recently to explore frontiers in neuroscience for global health and to mark the 10th anniversary of Fogarty's brain disorders program, which is designed to focus attention and resources on this neglected area.
Photo by Ernie Branson/NIH
NIH leaders discussed a number of significant accomplishments
of Fogarty's brain disorders program, which receives broad
support across the Institutes and Centers.
"There is no health without mental health," observed Dr. Thomas Insel, Director of the National Institute of Mental Health (NIMH), who said it is "critical" this profound public health need is addressed as efforts are made to improve health care globally.
Yet an "unconscionable" gap remains between the care available for neurological conditions for people living in wealthy countries as compared to populations living in low-resource settings, said Dr. Steven Hyman of Massachusetts Institute of Technology and Harvard University. This brings "huge societal costs," not only for patients but also for their caretakers and communities, he said. "It degrades human capital formation."
Research is key to improving patient care and must be conducted in-country to be viable and effective, said Dr. Gwen Collman, a director at the National Institute of Environmental Health Sciences (NIEHS). With community engagement and involvement, she noted, "you can translate the results more quickly."
Recognizing this research need, in 2003 Fogarty launched its program, Brain Disorders in the Developing World: Research Across the Lifespan. With broad support across NIH, the initiative has provided at least $85 million to fund more than 150 projects that investigate conditions afflicting populations in low-resource countries. The disorders range from neurodevelopmental, including autism, to neurodegenerative diseases, such as Alzheimer's, to neuropsychiatric conditions, as in depression.
One grantee who collaborates with researchers on different continents is Dr. Richard Guerrant at the University of Virginia. His projects in Brazil and South Africa have shown how child malnutrition impairs cognition and can be prevented by low-cost interventions such as zinc supplementation and reducing the incidence of diarrhea. Research evidence such as this, Guerrant noted, is essential for "driving future policy decisions."
Indeed, this is what happened in Barbados when researchers, starting in the 1960s, amassed records on malnutrition and child mortality. "We worked very hard with the government of Barbados to make malnutrition a reportable disease," said Dr. Janina Galler of Harvard. The government adopted a comprehensive nutrition program to age 12, and malnutrition was eliminated by 1980.
"All children should have the chance to achieve their full potential," said Dr. Alan Guttmacher, Director of the National Institute of Child Health and Human Development (NICHD). He added this means protecting cognitive development not only prenatally and in the first months of life, but also "well beyond."
Fogarty's brain program covers conditions that strike at all ages, including adult onset neurodegenerative disorders and dementias. National Institute on Aging (NIA) Director Dr. Richard Hodes noted about 15 percent of the world's population will be over 65 in a few years. "The challenges are going to be absolutely enormous, in particular those posed by age-related diseases," Hodes said. To maximize progress, he urged researchers to share their data widely and in interoperable forms.
Photo by Ernie Branson/NIH
More than 350 researchers attended Fogarty's brain
disorders conference to network and share discoveries.
One new arena for brain researchers is HIV/AIDS, where antiretrovirals have dramatically extended patients' lives but little is known about the long-term neurological impact of either the virus or the drugs. Fogarty brain program projects include studies of cognition in children exposed to HIV at birth, and the link between HIV and cerebral malaria.
Many influences on health, such as behavior and societal circumstances, are outside the realm of diseases and drugs, and one speaker urged more research globally to measure their impact, observing even wealthier countries lack good data. Dr. Robert Kaplan, who directs the Office of Behavioral and Social Sciences Research (OBSSR), said, "As populations urbanize, the ability to use sensors or other devices in communities to track people's physical activity and other habits are going to offer new possibilities for research."
The knowledge gleaned from global health research can bring insight into health everywhere, noted Dr. Story Landis, Director of the National Institute of Neurological Disorders and Stroke (NINDS). She cited a Peruvian study of a tapeworm disease transmitted from pigs to people and noted in one U.S. public hospital, a third of patients with epilepsy had eaten infected pork. "So it's not just a developing country issue," she said. "It's also an issue in this country."
Developing country scientists have also come up with health system efficiencies that can transfer back to the U.S., noted NIMH's Insel. He cited the example of a so-called task shifting, whereby nurses screen patients and handle some basic treatments to free up the country’s few psychiatrists to tend the most severe cases, Insel said. "Extending care beyond the limited numbers of MDs is done as a matter of course," and the U.S. can learn from that and improve its own efficiencies, he said. "It's very much a two-way street in the global health arena."
Photo by Ernie Branson/NIH
Fogarty's brain disorders program
trains researchers, such as
Congolese neuroscientist Dr. Desire
Tshala-Katumbay, who produce
local evidence for policymakers
to use in setting health priorities.
Researchers seeking low-cost interventions in developing countries have produced novel, inexpensive approaches relevant for developed countries as well. Dr. Benjamin Warf, a current Fogarty grantee, in earlier research in Uganda devised a minimally invasive procedure for treating hydrocephalus. The procedure, now also adopted in the U.S., has greatly reduced the number of patients receiving brain shunts, which carry a higher infection risk.
In another example of two-way benefit, a study in Latin America compared treatment of traumatic brain injury using the expensive high-tech equipment common in the U.S. with its own practice of clinician monitoring, and found no difference in patient outcome. "It has caused us to rethink our care and ask what really, truly is important," said Dr. Randall Chesnut of the University of Washington. "By corroborating across borders, we can come to a better understanding of what we do."
As well as producing science to expand knowledge about brain disorders and ways to diagnose, prevent and treat them, a key aspect of Fogarty's brain program has been to provide significant training for more than 140 developing country researchers to expand capacity in their countries.
Chesnut's traumatic brain injury project, for example, involves 13 intensive care units in Latin America where many former trainees are conducting their own research and training programs. With Fogarty brain program grants, "you're making researchers as you're doing research," he said. "It's a bit like building the bridge as you're driving across it. We need to integrate the idea that research is not what you read in a journal, it's what you do in the educational process and in the machinery of medicine."