Q and A with NIH Director Dr Francis S Collins: The value of global health research and training

November / December 2016 | Volume 15, Number 6

Headshot of Dr. Francis S. Collins in shirtsleeves

Francis S. Collins, M.D., Ph.D.

Dr. Francis S. Collins has been NIH Director since August 2009. A physician-geneticist, he is noted for his landmark discoveries of disease genes and his leadership of the international Human Genome Project. Previously, he served as director of the National Human Genome Research Institute at NIH from 1993-2008. When he began his tenure as NIH Director, he announced global health research as one of his top five priorities. Collins was recently interviewed by Fogarty Director Dr. Roger Glass at the Center's advisory board meeting. His comments below were edited for space.

What sparked your interest in global health?

I am intensely interested and passionate about global health research and it goes back to 1989. As a faculty member at the University of Michigan, I volunteered to serve as a missionary doc in a small hospital in Nigeria. As anybody who has had that kind of experience knows, it was life changing.

Archived photo of Francis Collins performing surgery while volunteering in Africa early in his career
Photo courtesy of Dr. Francis S. Collins

Dr. Francis S. Collins, who volunteered in a small
hospital in Nigeria early in his career, has long
been interested in global health.

Then I had the chance to lead the Human Genome Project. As a geneticist, the evidence became stronger as we collected more and more data about the genome showing that if you really want to understand genetic variation, you have to go to Africa, since that is where we all came from. It became clear that it was going to be essential to have a real full catalogue of human variation if we were going to learn how it is the differences between us play out, in terms of health and disease.

Why did you make it a top priority as NIH Director?

There are lots of reasons to say doing research in other parts of the world than our country makes a lot of sense. There are opportunities there to build research capacities, to train individuals with exceptional talents, for the United States to exercise its role in what one might call "soft power" instead of hard power, or building relationships, making friends and working on projects together. And of course, also, to understand diseases that don't occur very much in this country but are much more prevalent in other places and that we need to be intensely involved in studying. Infectious disease is, of course, at the top of that list.

The general view, I think, of most NIH grantees or intramural researchers here was yes, that is something we do and it is a good thing to do but really, you are going to make that one of the top five priorities? It surprised people. It made Roger very happy, by the way. I think that is probably true of anybody who was already deeply invested in this. The idea that there is going to be visibility here seemed like a really good thing. Well, I must say, it has been a wild ride and I have to, right now, give a lot of credit to my friend Roger Glass for the reasons that it has been so successful.

Roger is, as all of you know who have gotten to know him, absolutely somebody with boundless energy, with vision, somebody who has got an idea about how to make something happen so quickly and in an idea-needing sort of a world, he is the guy who often comes up with a way to put things together that I wouldn't necessarily have thought of and then that turns into a program. Roger knows everyone in the world. It is just amazing. We would travel with the expectation of people we were going to see, and I might have subsequently met a few of them, but not only would Roger turn out to be best friends with most of the people we met with but other random people who just wandered up sometimes on the street also turned out to be Roger's fans and Roger's friends. I don't know how this came about but it is just amazing to consider the network that this guy has generated. And that is really important, since global health depends on relationships. And to have somebody who is so widely admired and appreciated for his ability to build relationships has been a huge plus for NIH. It is really quite amazing to see what Roger has accomplished and it has been a joy to be part of that.

What progress has been achieved in global health?

I think the Medical Education Partnership Initiative, or MEPI, is one of the major developments over the last six years, in terms of building research network capabilities in Africa. This is a wonderful partnership that has pooled resources to build educational opportunities in multiple medical institutions across Africa that previously had not been linked up together, to learn from each other, to figure out best practices. They had never had the chance to do that. Many of them had more north-south relationships but building south-south connections was new. So, that has been pretty amazing.

While visiting Uganda recently, we were able to tour the facility that is supported by another program called H3Africa, Human Heredity and Health in Africa. The biobank was impressive, but what was really astounding were the dozens of very visionary, smart, young East Africans, men and women, who have great ideas about research that they want to pursue and were beginning to feel like there was a critical mass of capabilities to do that. And so maybe they could, in fact, imagine for themselves a career in their own country and not feel the need to fly away to some other place, avoiding brain drain.

Why should the U.S. invest in global health?

Certainly, disease knows no boundaries. It crosses country lines quite freely. If anybody doubts that, they should remember Ebola and the way that set our country into a total tailspin of anxiety and potential danger from an unexpected development in West Africa. Zika now, of course, comes forward as the next example. And so if anybody is concerned about the health of our nation, they have to be concerned about the health of the world. There is really a famous line, which I love to quote, which is "Global is not the opposite of domestic and domestic is not the opposite of global." We are all in this together. So, for simple self-preservation, we need to make those investments.

It is more than that, though. I think there are other circumstances where we need to learn the things about how life works and how disease happens that are very difficult to do within our own boundaries because we don't have the conditions or the particular frequency of an illness that we find somewhere else. I also think that the investments we make in health research in other parts of the world win us a lot of good will and allow America to be seen as not just the soldier to the world but doctor to the world as well.

How important is human capacity building?

I think the most important resource in global health research is not actually dollars. It is not actually buildings. It is not technologies. It is the people. And the Fogarty fellows have made an amazing contribution for a modest investment. The impact that program has had has been stunning.

My sense is, when I go out and visit universities, increasingly I meet students who say "I am interested in global health. I want to see what I can contribute to this area." Are we doing everything we can to capture this interest? Because if we aren't, we should. As we prepare for Fogarty's upcoming 50th anniversary, if we are going to pick an area where Fogarty has already made a huge contribution in terms of training and sending out all this talent across the globe - and many of them now have critical leadership positions - maybe we could advance that by recognizing A) there is a lot of interest and a lot of demand; and B) every institute at NIH has a reason to think about this and maybe a reason, therefore, to work together.

What do you envision the future of global health?

We can see that many of the world's most rapidly growing economies are in Africa. That means governments have an opportunity to start making investments themselves that previously they could not afford. And I think it is time also to figure out how to encourage more of that, given it is a good way for them to build economies, to wrap their arms around the importance of medical research and health care in general, and to help these countries really advance. It also seems like a great moment to build on what we have learned from MEPI and H3Africa about networking across country boundaries and building on IT to make advances happen more quickly.

So, we have been talking about this idea of trying to nurture and encourage a center of gravity shift in terms of biomedical research in Africa from what it has been likely in colonial model. The U.S. and the U.K. have been figuring out ways to give funds, all with good intentions but oftentimes through subcontracts, which don't necessarily provide those institutions in Africa with a chance for stable growth, but shift that more so that there is more of an investment in the institutions and by their governments so that 10 years from now they might imagine a very different kind of research environment. There are so many opportunities for research and so much talent that is ready to be brought into these kinds of studies.

I do think we are in an exceptional time. I think we have been part of some really amazing things that have occurred in the last five years. But looking forward, particularly now with this much more committed and collaborative attitude across all the institutes of NIH that are interested in global health, in increasing ways to work with all the universities out there that have a great interest in this amongst their staff and their students. I think we can do even more and it will be great to see that continue to grow and flourish and be supported by Fogarty, which punches way above its weight when it comes to the small investments but the big impact.

What has resonated most with you?

I will never forget meeting three young women in Uganda who told their stories about how research made it possible for them to be alive, all of them having participated in clinical trials. One had become HIV-infected early on when there was no treatment available except in trials. Another was able to prevent her baby from becoming infected as part of a PMTCT study. And a third, who was participating in a trial of a female vaginal ring approach to HIV prevention, putting women more in charge of their own destiny, instead of having to depend on men.

With tears in their eyes and sincerity in their voices, the women said "Thank you, America, you saved us." And they meant it. People need to be reminded that the human consequences of what we do are really quite profound.

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