Building Sustainable Global Health Science Partnerships
May 8, 2009
Michael P. Johnson, M.D., M.P.H
Deputy Director
Fogarty International Center
Canadian Researcher and Genetic Carrier
Prevalent Canadian Genetic Condition
IOM Reports on Global Health
1997
2008
Global Health Leadership and Commitment
Rise in HIV/AIDS Funding - USG
U.S. Public Opinion About Global Health (GH)
How Concerned Are You About GH?
Think US Should Lead In GH Research?
A
tA
ll
N
ot
To
o
N
ot
ha
t
m
ew
So
Ve
ry
60
50
40
% 30
20
10
0
National Global Health Survey, Research America, Nov 2008
U.S. Public Opinion About Global Health (GH)
Would You Pay $1/wk for GH?
Should Congress Prioritize GH?
40%
42%
Yes
No
58%
60%
National Global Health Survey, Research America, Nov 2008
For a Global Generation, Public Health Is a Hot Field
By David Brown
Friday, September 19, 2008
"It took something like HIV/AIDS … to capture our attention
and make us realize that there were such inequities in the
world," said Thomas Coates, head of the global health
program at the University of California at Los Angeles,
describing the new interest in public health.
But the benefits of studying public health go considerably
beyond understanding infectious disease.
Sunday, February 10, 2008
Global Classrooms
U.S. Universities Rush to Set Up Outposts Abroad
Carnegie Mellon University campus in Doha, Qatar
CSIS COMMISSION
ON SMART POWER
A smarter, more secure America
CoChairs:
Richard L. Armitage
Joseph S. Nye, Jr.
CSIS
CENTER FOR STRATEGIC & INTERNATIONAL STUDIES
Disparity in health workers, scientists, and
health worker training institutions
• Consistent correlation between density of health workers and
probability of survival
•Africa has 24% of disease burden, 3% of health workers, 1% of
health expenditure
• Academic model should integrate clinical care, teaching, research,
public health, management
Researchers/Scientists Worldwide
Researchers per million inhabitants, 2005 or latest available year
UNESCO Institute for Statistics, 2007
Technical Assistance/Consultants
Glad I
am here
so that
you can
get it
right
Technical assistance may:
• overpriced
• inappropriate
• distort local systems
• diminish local capacity
Healthcare workforce pyramid
Academic health professionals
Doctors
Others
Nurses
Community health workers
The “tip of the pyramid” are the fewest in number,
yet play key role in training at other levels of the pyramid
Synergy of research, training, service delivery
Service
Delivery
Research
Training
National Institutes of Health
Office of Director
National Cancer
Institute
National Institute
of Dental and
Craniofacial
Research
National Eye
Institute
National Heart,
Lung and Blood
Institute
National Human
Genome Research
Institute
National Institute on Eunice Kennedy Shriver
Deafness and Other
National Institute
Communication
of Child Health and
Disorders
Human Development
National Institute
of Allergy and
Infectious Diseases
National Institute
on Drug Abuse
National Institute of
Environmental
Health Sciences
Fogarty Intl
Center
National Library
of Medicine
National Institute
of Nursing
Research
Clinical Center
National Institute
of Biomedical
Imaging and
Bioengineering
National Institute
of General Medical
Sciences
National
Institute of Aging
National Institute
National Institute
of Arthritis and
of Diabetes and
Musculoskeletal and Digestive and Kidney
Skin Diseases
Diseases
National Institute
of Mental Health
National Center for National Center on
Complementary and Minority Health and
Alternative Medicine Health Disparities
Center for
Information
Technology
National Institute
on Alcohol Abuse
and Alcoholism
Center for Scientific
Review
National Institute
of Neurological
Disorders and Stroke
National Center
For Research
Resources
NIH Global Investment and Regional Distribution
Foreign Awards
or Sub-Awards
2%
98%
NIH International Report, 2008
Fogarty-Supported Training and Research
 1/3 Research, 2/3 Training
~ $55 million/yr
~400 active grants
Degrees awarded by Fogarty-funded training programs
8% 1%
7%
14%
35%
35%
Other
Bachelors
Masters
Other non-degree
training
Post-doctoral
Professional doctorate
Research Doctorate
Short-term training
Fogarty funded trainees’ degree by world bank region,
1988-2009
Latin America & Caribbean
Sub-Saharan Africa
East Asia & Pacific
South Asia
Europe & Central Asia
OECD & High Income
Middle East & North Africa
0
100
200
Bachelor's
Professional Doctorate
Postdoctoral position (>=3 months)
Other non-degree training (>=3 months)
300
400
500
600
700
800
Master's
Research Doctorate
Short-term training
Other
Other non-degree training includes certificate, diploma, sabbaticals
Rakai Health Science Program Fogarty Trainees
6 PhD degrees (2 still in training)
30 Masters degrees
JHU (18), Alabama (3),
Makerere (5) Regional (4)
15 Bachelors degrees,
Makerere
65 Diplomas, Certificate
13 Post doc / Sabbatical
Productivity of Long-Term Partnerships
18.0%
16.0%
14.0%
12.0%
10.0%
8.0% 7.6%
6.0%
6.2%
4.0%
2.0%
0.0%
1993
6.1%
5.6%
3.5%
6.0%
4.5%
1996
HIV
2000
SYPHILIS
3.1%
2003
Fogarty Scholars
“early childhood education”
25 “pairs” of trainees going to 16 medical centers in the developing world
Fogarty 40th Anniversary Dinner
October 15, 2008
Foundation for NIH
•
Awards to
Congressman Payne
and Senator Lugar
• Participation of many
sponsors
•
Many eminent and
experienced speakers
•
Hosted by Italian
Embassy in
Washington, D.C.
Funding
(NIH/
Other)
Human and
Institutional
Capacity
building
Collaborative Long
Term Relationships
Characteristics of Success
• Research, service delivery and training are synergistic
• Locally-controlled training that builds upon existing
research/program support
• Early investments in U.S. and foreign scientists yields
“compound interest”
• High rate of return to home country following U.S. training
when there is local institutional capacity (colleagues, career)
• “Second-generation” training occurs, i.e. foreign scientists
return home contribute to the training of the next cohort
• U.S.-supported global health training produces lasting
collaborations, brings foreign scientists into global community
Health Professional Training Institutions
By Region
Health professionals training institutions, by WHO regions
No. of training institutions
2500
2000
1500
1000
500
0
Africa
Medical
Americas
South-East Asia
Nursing and midwifery
Europe
Dental
Eastern
Western Pacific
Mediterranean
Public Health
Pharmacy
Source: Mercer H, Dal Poz MR. Global health professional training capacity (background paper for The world health report
2006; http://www.who.int/hrh/documents/en/)
Capacity in Research Management
FIC Grants Management Specialist Elizabeth Cleveland, Program
Officer Jeanne McDermott, and Executive Officer Tim Tosten at a
network meeting of East African research administrators in Tanzania
Charles Miuri of Duke, who works with FIC’ International AIDS
Training and Research Program in Tanzania, speaking at FIC
• Advance contributions of research administration to the
research enterprise
• Improve communication between individuals and institutions to
enhance collaboration and dissemination of best practice
• Increase the number of research administrators and establish
Offices of Research Administration
• Provide a model to other regions in Africa and elsewhere
Changes in Life Expectancy
80
Life Expectancy (Years)
1990
1960
70
About 1930
60
About 1900
50
40
0
30
5,000
10,000
15,000
20,000
25,000
Income Per Capita
(1991 International Dollars)
World Development Report 1993 p. 34.
Life expectancy – China, 1960-2000
•Life expectancy in China rose from 39 years
in 1960 to 71 years in 2000
• ~ 8 years per decade for 4 decades
•The most rapid prolongation of life in history
•The consequences on health are enormous
Tropical Medicine  Geographic Medicine 
International Health  Global Health
Infectious diseases - AIDS, TB,
malaria, diarrhea,
respiratory infections, other
childhood infections and
maternal health - the
unfinished agenda
Newly emerging global
epidemics of chronic
disease due to prolongation
of life expectancy - heart
disease, stroke, cancer,
mental illness,
Coming agenda, largely manmade; environmental
hazards, obesity, traffic
accidents, climate change,
addictions, smoking
Discoveries Resulting from Collaborative
International Health Research
• Oral rehydration therapy
• Directly-Observed Tuberculosis Treatment
• HIV prevention – PMTCT, circumcision
• Artemisinin Combination Therapy
• Huntington’s gene discovery
• Viral antecedents of CA - Burkitts lymphoma
• Chemotherapy for Cancer
• Polypill for CVD
Identification of Huntington’s Disease Gene
World's largest family with Huntington's disease, 18,000 individuals
Helped map other disease genes for Alzheimer's disease, kidney cancer, two
kinds of neurofibromatosis, Amyotrophic Lateral Sclerosis (ALS), dwarfism
Aggressive breast cancer in African Americans?
Poor access to health
care, environment, or
genetic profile?
Breast tumors without receptors for estrogen,
progesterone, and HER2, “Triple Negatives”,
are more aggressive
Olufunmilayo Olopade (UIC)
African women
>70%
Science , 314:592-4, 2007
African-American 39%
Causcasians
16%
Science of Implementation and Dissemination
• Jim Yong Kim, MD, PhD gave
keynote talk on Implementation
and Global Health to over
400 attendees
• Consideration of research
methodology in implementation
and dissemination science
• Many sessions addressing
training and curriculum
development in Implementation
Science
Variable Implementation of
Insecticide-Treated Nets (Children < 5)
Source: WHO Statistical Information System
$14,000,000
60
$12,000,000
50
Investment
$10,000,000
40
$8,000,000
30
$6,000,000
20
$4,000,000
Publications
Trends in HIV Prevention Investments and
Related Publications
10
$2,000,000
$0
0
2002
Adult Male
Circumcision
2003
2004
2005
2006
Herpes Suppression
2007
Publications
Total Investment (2002-2007) - $130 Million
* - Publications on male circumcision and herpes suppression
Source: HIV Resource Tracking, 2008
Interventions to Prevent HIV Infection
Estimated Worldwide Access
8% IDU harm reduction
9% Condom access
9% MSM behavior change
10-12% HIV testing for adults
11% Prevention of mother-to-child transmission
< 20% CSW behavior change
0
20
40
60
80
100
PEPFAR HIV Prevention Technical Working Group, 2008
Partnerships to Enhance Capacity
Pfizer Global Health Fellows
• Work with NGOs
• Provide technical training/support
• Receive direct experience of work in global health setting
• Multiple partners; USAID, PAHO, IAVI, Earth Institute, AMREF
Fogarty International Center – 2008 - 2012
•
Train next generation of U.S. &
foreign global health researchers
•
Build institutional capacity for
health science research
•
Continue infectious disease, yet
expand chronic diseases portfolio
•
Support implementation science
– “know-do gap”, scale-up
•
Foster institutional partnerships
Fogarty Intl Center Percent of NIH Budget
0.25%
99.75%
NIH (and other) Co-Funding of FIC Awards
FY 2007
HRSA
1%
US Dept. of State
3%
NIMH
7%
NIGMS
2%
NIEHS
4%
NSF
3%
FDA
<1%
OD
15%
NINDS
3%
NCCAM
1%
NCMHD
3%
CDC
2%
NINR
2%
NLM
1%
NIDCR
3%
NIDA
10%
NCI
17%
NIDCD
<1%
NHGRI
1%
NICHD
3%
NIBIB
1%
NIAID
13%
NIAAA
1%
NIA
<1%
NHLBI
5%
Source: IMPACII
IOM Report on Global Health
Preliminary Report
Policy and Governance
•
•
•
Pillar of US foreign policy
WH interagency committee
High-level WH post
Financial Commitment
•
•
•
Double funding
Balance funding
Respond to NCD challenges
Enhance Investment
•
•
•
•
Support country plans, systems
Rigorous evaluation
Research and research capacity
Support WHO
New U.S. Administration on Global Health
May 6, 2009
Obama Seeks a Global Health
Plan
Broader Than Bush’s AIDS Effort
By Sheryl Gay Stolberg
WASHINGTON — President Obama asked Congress on Tuesday to spend $63
billion over the next six years on a new, broader global health strategy that
would reshape one of the signature foreign policy efforts of his predecessor,
George W. Bush.
Mr. Bush made combating global AIDS a centerpiece of his foreign agenda.
The program he created — the President’s Emergency Plan for AIDS Relief or
Pepfar— is regarded as one of his most significant achievements. But the plan
Mr. Obama outlined Tuesday envisions a more far-reaching approach to
global health that would focus not only on AIDS, but also on tropical diseases
and other treatable and preventable illnesses that kill millions, many of them
children, each year.
“We cannot simply confront individual preventable illnesses in isolation,” the
president said in a statement released by the White House that cited the
swine flu outbreak as an example. “The world is interconnected, and that
demands an integrated approach to global health.”