“Science for Global Health: Fostering International Collaboration”

University of Maryland at Baltimore

James Herrington, Ph.D., M.P.H.Director

Division of International RelationsFogarty International CenterNational Institutes of Health

U.S. Department of Health and Human Services

June 5, 2007

Outline

• Global Burden of Disease• Global Health Research• NIH Structure, Function• Extramural Grant Awards• NIH Investments in Intramural Researchers • Fogarty International Center

Global Burden of Disease, Reported Mortality by Cause, 2002

World

32%

59%

9%

Africa Region

72%

21%

7%

Communicable, Maternal, Perinatal, and Nutritional Conditions Non-Communicable Diseases Injuries

Source: World Health Report, 2004; Disease Control Priorities Project, 2006

Pop. ~ 6 billion Pop. ~ 672 million

Global Burden of Disease, Reported Mortality by Cause, 2002

European Region

6%

86%

8%

Africa Region

72%

21%

7%

Communicable, Maternal, Perinatal, and Nutritional Conditions Non-Communicable Diseases Injuries

Source: World Health Report, 2004; Disease Control Priorities Project, 2006

Pop. ~ 880 million Pop. ~ 672 million

Global Burden of Disease, Reported Mortality by Cause, Communicable Diseases, Africa Region, 2002

Source: World Health Report, 2004; Disease Control Priorities Project, 2006

42%

23%

7%

14%

11%2%

1%0% HIV/AIDS

Malaria

Tuberculosis

Diarrhoeal diseases

Childhood-cluster diseases

STDs excluding HIV

Trop diseases, leprosy,dengue total

Intestinal nematodeinfections

DiphtheriaMeaslesPertussisPolioTetanus

Mal Aria (“bad air”) associated with marshes; Female Anopheles mosquito taking blood meal

Global Burden of Disease, Reported Mortality by Cause, Communicable Diseases, European Region, 2002

Source: World Health Report, 2004; Disease Control Priorities Project, 2006

28%

0%

53%

13%

5%

1% 0%0% HIV/AIDS

Malaria

Tuberculosis

Diarrhoeal diseases

Childhood-cluster diseases

STDs excluding HIV

Trop diseases, leprosy,dengue total

Intestinal nematodeinfections

DiphtheriaMeaslesPertussisPolioTetanus

Global Burden of Disease, Reported Mortality by Cause: Non-Communicable Diseases, European Region, 2002

Source: World Health Report, 2004; Disease Control Priorities Project, 2006

22%

60%

5%

5%2%3% 3% Malignant

neoplasmsCardiovasculardiseasesRespiratory diseases

Digestive diseases

Diabetes mellitus

NeuropsychiatricconditionsOther

Mal Alimentation (“bad food”) associated with economic development, longevity, sedentary society

Source: http://en.wikipedia.org/wiki/BK_StackerPhoto credit: Mychal Stanley

'''BK Stacker'''

Serving size 1 sandwich311g

Energy 1000 cal

Energy from fat 620 cal

Total fat 68g

Saturated fat 30g

Cholesterol 240mg

Sodium 1800mg

Dietary fiber 1g

Sugars 6g

Protein 62g

Source www.BK.com

Notes US % Daily Value based on 2000 calorie diet.

Mal Comportment (“bad behavior”) associated with economic development, longevity, mobile society

Source: Tobacco Free Initiative, World Health Organization

Mal Environment (“bad surroundings”) associated with economic stagnation/decline, low female literacy, agrarian society

Photo: G

rameen S

hikka

Global Burden of Disease, Projected Mortality by Cause: Communicable (Group I) Diseases, World, 2002-2030

Source: Mathers, C.D. and Loncar, D. in http://medicine.plosjournals.org/archive/1549-1676/3/11/pdf/10.1371_journal.pmed.0030442-L.pdf

Global Burden of Disease, Projected Mortality by Cause: Non-Communicable (Group II) Diseases, World, 2002-2030

Source: Mathers, C.D. and Loncar, D. in http://medicine.plosjournals.org/archive/1549-1676/3/11/pdf/10.1371_journal.pmed.0030442-L.pdf

Source: Mathers, C.D. and Loncar, D. in http://medicine.plosjournals.org/archive/1549-1676/3/11/pdf/10.1371_journal.pmed.0030442-L.pdf

Global Burden of Disease, Projected Mortality by Cause: Trauma and Injury (Group III), World, 2002-2030

Disease Control Priorities Project (DCPP)The 20th Century Take Off in Human Health, Life Expectancy, 1550-2050

Source: Disease Control Priorities Project, 2006 (http://www.ncbi.nlm.nih.gov/books/bookres.fcgi/dcp2/ch1.pdf)

Disease Control Priorities Project (DCPP)Levels and Changes in Life Expectancy, 1960-2002, by World Bank Region

Source: Disease Control Priorities Project. Burden of Disease in China in 2001 (http://www.dcp2.org/pubs/DCP/1/Table/1.1)

Life Expectancy at Birth

30

40

50

60

70

80

90

1960 1990 2002

Period

Age

in

Yea

rs

Low- and middle-incomecountriesEast Asia and the Pacific

China

Europe and Central Asia

Latin America and theCaribbeanMiddle East and NorthAfricaSouth Asia

India

Sub-Saharan Africa

High-income countries

World

0.7%

0.8%

1.8%

3.3%

3.9%

7.4%

7.6%

9.2%

10.9%

12.2%

Iron deficiency

Unsafe sex

Illicit drugs

Physical inactivity

Low fruit and vegetable intake

Overweight

Cholesterol

Alcohol

Blood pressure

Tobacco

Developed countries

Burden of Disease Attributable to Alcohol Among the 10 Leading Risk Factors for Disease In Developed and Developing Countries - % DALYs*

Source: World Health Organization, 2002

*disability-adjusted life years (years of potential life lost due to death plus

years of healthy life lost to disability)

Alcohol/Tobacco Blood pressure Nutrition

Alcohol/Tobacco Blood pressure Nutrition 1.7%

1.8%

1.9%

1.9%

2.1%

2.7%

3.1%

4.0%

5.0%

6.2%

Unsafe water, sanitation and hygiene

Iron deficiency

Indoor smoke from solid fuels

Low fruit and vegetable intake

Cholesterol

Overweight

Underweight

Tobacco

Blood pressure

Alcohol

Developing countries with low child and

low adult mortality

Examples of Change in China: Adult Per Capita Alcohol Consumption by Development Status: 1960-20001

0

1

2

3

4

5

6

7

1960 1965 1970 1975 1980 1985 1990 1995 2000

Developed countries

Former Soviet Union China 2

(1961-1999)

Developing countries

Lit

ers

of P

ure

Alc

ohol

Per

Per

son

15+

Yea

rs

1Adapted from Room et al. (2002). Alcohol and the Developing World: A Public Health Perspective [Summary]. Helsinki: Finnish Foundation of Alcohol Studies in collaboration with the WHO, p. 12.

2Derived from World Health Organization Health Statistical Database: Apparent Alcohol Consumption. http://www3.who.int/whosis/

Epidemiological, Demographic, and Political Transitions

• Shift from Acute to Chronic Diseases

• Aging Population

• Health Disparities

• Emerging and Re-emerging diseases

• Behavioral and Mental Health diseases

• Biodefense

4.2% ($29.2 billion) of total FY 2007 HHS budget ($698 billion) in research

Administration forChildren and Families

(ACF)

Administration forChildren and Families

(ACF)

Food and DrugAdministration

(FDA)

Food and DrugAdministration

(FDA)

Health Resourcesand Services

Administration(HRSA)

Health Resourcesand Services

Administration(HRSA)

Administration onAging(AoA)

Administration onAging(AoA)

Centers for Medicare and

Medicaid Services (CMS)

Centers for Medicare and

Medicaid Services (CMS)

Indian HealthService(IHS)

Indian HealthService(IHS)

Centers for Disease Controland Prevention

(CDC)

Centers for Disease Controland Prevention

(CDC)

Substance Abuse andMental Health Services

Administration(SAMHSA)

Substance Abuse andMental Health Services

Administration(SAMHSA)

Program SupportCenter(PSC)

Program SupportCenter(PSC)

Agency for ToxicSubstances andDisease Registry

(ATSDR)

Agency for ToxicSubstances andDisease Registry

(ATSDR)

Agency for Health Care Policy

and Research(AHCPR)

Agency for Health Care Policy

and Research(AHCPR)

National Institutesof Health

(NIH)

National Institutesof Health

(NIH)

Michael Leavitt Secretary of Health and

Human Services

Michael Leavitt Secretary of Health and

Human Services

= Institutes and Centers that award grants

Elias Zerhouni, M.D.Director, NIH

Elias Zerhouni, M.D.Director, NIH

National Instituteon Alcohol Abuseand Alcoholism

National Instituteon Alcohol Abuseand Alcoholism

National Instituteof Arthritis andMusculoskeletal

and Skin Diseases

National Instituteof Arthritis andMusculoskeletal

and Skin Diseases

National CancerInstitute

National CancerInstitute

National Instituteof Diabetes andDigestive and

Kidney Diseases

National Instituteof Diabetes andDigestive and

Kidney Diseases

National Instituteof Dental andCraniofacial

Research

National Instituteof Dental andCraniofacial

Research

National Instituteon Drug Abuse

National Instituteon Drug Abuse

National Instituteof Environmental Health Sciences

National Instituteof Environmental Health Sciences

National Instituteon Aging

National Instituteon Aging

National Instituteof Child Health

and HumanDevelopment

National Instituteof Child Health

and HumanDevelopment

National Institute onDeafness and Other

CommunicationDisorders

National Institute onDeafness and Other

CommunicationDisorders

National EyeInstitute

National EyeInstitute

National HumanGenome Research

Institute

National HumanGenome Research

Institute

National Heart,Lung, and Blood

Institute

National Heart,Lung, and Blood

Institute

National Instituteof Mental Health

National Instituteof Mental Health

National Instituteof NeurologicalDisorders and

Stroke

National Instituteof NeurologicalDisorders and

Stroke

National Instituteof General

Medical Sciences

National Instituteof General

Medical Sciences

National Instituteof Nursing Research

National Instituteof Nursing Research

National Libraryof Medicine

National Libraryof Medicine

Center for InformationTechnology

Center for InformationTechnology

Center for Scientific Review

Center for Scientific Review

National Centerfor Complementary

and AlternativeMedicine

National Centerfor Complementary

and AlternativeMedicine

National Instituteof Allergy and

Infectious Diseases

National Instituteof Allergy and

Infectious Diseases

National Centerfor ResearchResources

National Centerfor ResearchResources

Clinical CenterClinical Center

National Center on Minority Health andHealth Disparities

National Center on Minority Health andHealth Disparities

National Institute of Biomedical Imagingand Bioengineering

National Institute of Biomedical Imagingand Bioengineering

FogartyInternational

Center

FogartyInternational

Center

Mission

Address global health challenges through innovative and collaborative research and training programs

Support and advance the NIH mission through international partnerships

“Science for Global Health”

FY 2007 Appropriation $67 million

National Institutes of Health Main CampusBethesda, Maryland, U.S.A.

NIH Mission

Uncover New Knowledge That Leads To Better Health For Everyone By:

Supporting peer-reviewed scientific research at universities, medical schools, hospitals, and research institutions throughout United States and overseas

Conducting research in its own laboratories

Training research investigators

Developing and disseminating credible health information based on scientific discovery

Contemporary NIH

NIH creates research laboratories and recruits outstanding scientists from universities and abroad

Institutes and Centers are created in response to public health needs, most with intramural programs

Many young trainees join NIH and go on to become leaders in science across the US and around the world

117 grantees or trainees are Nobel Laureates (as of 2005)

Appropriated NIH Budget, FY07, $29.2 Billion

SpendingSpendingOutside NIHOutside NIH

$24.2 B$24.2 B

SpendingSpending

at NIHat NIH

$4.9 B$4.9 B

% Amount Expenditure

10% $2.9B 6000 Intramural Scientists & Research Personnel

3.8% $1.1B Research Mgt & Support

3.2% $1.0B NLM, OD, etc.

83% of the total NIH budget supports about 212,000 Extramural Scientists and Research Personnel at 2,800 Institutions Nationwide.

$818 million (~2.8%) of NIH budget is international research and research training awards

Balanced National Biomedical Research Portfolio

NIH - $29 B

Clinical Research

Basic Research

Translational Research

Private Sector - $59B

Clinical Research

Basic Research

Translational Research

NIH – Extramural and Other Grant Awards, by Type

• Research Grant Programs (8 types)• New Investigators Program (2 types)• Multiple Principal Investigators (NEW in Feb 2007)• Research Supplemental Programs (1 type)• Ruth L. Kirschstein

National Research Service Awards (NRSA) (8 types)• Research Ethics and Training Grant Programs (2 types)• NIH Career Development (K) Awards (15 types)• Small Business Awards (1 type)• Other Programs (8 types)

Source: http://grants2.nih.gov/grants/funding/funding_program.htm

NIH – Extramural Awards, by Type

Small Grant (R03)

Research Project Grant (R01)

Independent Scientist Award (K02)

Approx. Stage of ResearchTraining and Development

NIH Pathway to Independence (PI) Award (K99/R00)Mentored Research Scientist Development Award (K01)Mentored Clinical Scientist Development Award (K08)Mentored Patient-Oriented RCDA (K23)Mentored Quantitative RCDA (K25)

Exploratory/Development Grant (R21)

NIH Research Training and Career Development Timetable

Predoctoral Individual NRSA (F31)Predoctoral Individual MD/PhD NRSA

(F30)

Postdoctoral Institutional Training Grant (T32)

Postdoctoral Individual NRSA (F32)

Senior Scientist Award (K05)

Mechanism of Support

GRADUATE/MEDICALSTUDENT

POSTDOCTORAL

EARLY

MIDDLE

SENIOR

CA

RE

ER

Predoctoral Institutional Training Grant (T32)

Midcareer Investigator Award in Patient-Oriented Research (K24)

NIH Extramural Grant Awards, Competitive and Non-Competitive, New and Continuations, FY 2006

46,797 research grants awarded ($20.2 billion)

36,814 research project grants ($14.8 billion)

73% of NIH extramural awards go to institutions of higher education

More than 75,000 grant applications received (all mechanisms)

NIH Intramural Program, Visiting Fellows and Guest Researchers, by E.U. Member/Candidate Countries, 2005

Germany, 170, 18%

Italy, 161, 17%

France, 146, 15%

United Kingdom, 131, 14%

Spain, 76, 8%Poland, 60, 6%

The Netherlands, 46, 5%

Turkey, 32, 3%

Sweden, 29, 3%

Ireland, 23, 2%

Austria, 21, 2%

Czech Republic, 20, 2%

Bulgaria, 14, 1%Denmark, 12, 1%Belgium, 9, 1%

Finland, 5, 1%

Portugal, 5, 1%

Lithuania, 3, 0%

Croatia, 2, 0%

Estonia, 1, 0%

N=966 x average stipend cost $50,000/yr = $48.3 million

Rhode Island CongressmanJohn Edward Fogarty

Congressman Melvin Laird(R-WI) 1967

The Committee “… has provided funds to plan a lasting memorial to a man who, for more than a quarter of a century, worked tirelessly for a healthy America, in a healthier world.”

Mission

Address global health challenges through innovative and collaborative research and training programs

Support and advance the NIH mission through international partnerships

“Science for Global Health”

FY 2007 Appropriation $67 million

FIC Organizational Structure

• Dr. Glass was named Associate Director for International Research, NIH and Director of Fogarty International Center by NIH Director Elias A. Zerhouni, M.D., on March 31, 2006.• Harvard College in 1967• Fulbright Fellowship, University of Buenos, 1967• M.D. from Harvard Medical School • M.P.H. from the Harvard School of Public Health, 1972• Medical officer assigned to the Environmental Hazards Branch Text CDC in 1977 • Ph.D. from the University of Goteborg, Sweden in 1983 and joined NIH Laboratory of Infectious Diseases to work on the molecular biology of rotavirus •1986 returned to the CDC to become Chief of the Viral Gastroenteritis Unit at the National Center for Infectious Diseases

Roger Glass, M.D., Ph.D.Director, Fogarty International Center

Research and Research Training

• ~$50 million in grant awards

• 1/3 Research, 2/3 Research Training

• Awards range $10,000 - $1 million

• Low and Middle Income Countries

• Research Capacity Development and Equity

Extramural Training Grants – 14 Programs

Extramural Research Grants – 8 Programs

International Training Grants for U.S. citizens

- Scientist Development Fellowship (Post-doc)

- Fogarty/Ellison Fellowship (Pre-doc/Pre-med)

Fogarty International Collaborative Trauma and Injury Research Training

International Clinical, Operational, and Health Services Research Training Awards for HIV/AIDS and Tuberculosis

International Maternal and Child Health Research Training

Fogarty-Ellison International Clinical Research Training

Informatics Training for Global Health

International Collaborative Genetics Research Training

International Clinical, Operational, and Health Services Research Training Awards

International Clinical, Operational, and Health Services Research Training Awards for Malaria

Global Infectious Diseases Research Training

International Research Ethics Education and Career Development

International Centers for Excellence in Research Clinical Research and Management Training

International Training Program in Environmental and Occupational Health

Global Research Training in Population Health

AIDS International Training and Research

Framework Programs for Global Health

International Research Scientist Development Awards

Flexible

Long-term commitment

Built on research collaborations

Re-entry support

Response to local needs

Empowerment

Networking

Research Training Program Characteristics

Fogarty International Research Collaboration Award (FIRCA)

International Cooperative Biodiversity Groups (ICBG)

Ecology of Infectious Diseases (EID)

International Studies on Health and Economic Development (ISHED)

Int’l Tobacco and Health Research and Capacity Building Program

Global Research Initiative Program for New Foreign Investigators (GRIP)

Stigma and Global Health Research Program

Brain Disorders in the Developing World: Research Across the Lifespan

Research Grants – 8 Programs

Extramural Training Grants

Generally institutional training grant to U.S. universities and non-profit research institutions in response to a specific request for applications (RFA)

Awardees are generally current NIH grant recipients with demonstrated research collaboration with foreign research institutions

Purpose – support training for research-capacity building for scientists from developing nations

Framework Programs for Global Health

Provides support to educational institutions to develop trans-institutional programs in Global Health

Develops new multidisciplinary curricula in broad range of global health research areas

Develops administrative framework for a Global Health research program

Brings new investigators and students into the Global Health field

Applicants from U.S. or eligible low- and middle-income countries; multiple institutions may work together on a single project

Fogarty International Clinical Research Scholars Program (Pre-doc/Pre-med)Provides mentored clinical research training opportunities for 3rd year U.S. medical and other health profession graduate students in NIH-funded research centers in developing countries; 25-30 per year.

Fellowship stipends approximately $18,000-$20,000 per year (adjusted to cost of living expenses at the foreign site) with an additional $6,000 per year for travel, insurance, and educational materials.

Builds clinical research capacity in developing countries by pairing a peer trainee from the developing country with a U.S. trainee.

Collaboration with Association of American Medical Colleges, Association of Schools of Public Health, National Institute of Allergy and Infectious Diseases, the National Institute of Dental and Craniofacial Research, and the National Institute on Drug Abuse,

http://www.aamc.org/students/medstudents/overseasfellowship/start.htm

Fellowship SitesBangladesh

Botswana

Brazil

China

Haiti

India, Chennai

India, Vellore

Kenya

Mali

Peru, Lima, Johns Hopkins University

Peru, Lima, University of Washington

Russia

South Africa, Durban

South Africa, Pretoria

Tanzania

Thailand

Uganda

Zambia

Trainee Activities

3-week orientation program at NIH (July)

Clinical research at designated site (10 months)

FIC/NIH clinical research training via distance learning and contact with FIC staff

Summary report of activities and research accomplishments at the end of the training year

After completion of the research year, the fellow presents results at the annual NIH meeting (March)

Alumni remain connected via continuing relationship with mentors and collaborators and through an FIC alumni tracking/program evaluation system

NIH Alumni AssociationsBrazil – University of California, Berkeley

Central and Eastern Europe – University of Iowa

China – University of California, Los Angeles

India – Brown University

Malawi – University of Illinois at Chicago

Mexico – Emory University

Russia – Yale University

South Africa – Columbia University

Thailand – University of California, Los Angeles

Uganda – Case Western Reserve University