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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
Forty-seventh Meeting
Table of Contents
Attendance
- Call to Order
- Consideration of Minutes of Previous Meeting
- Review of Requirements for Confidentiality and Conflict
of Interest Procedures
- Future Meeting Dates
- Report of the Director
- Disease Control Priorities
- Closed Portion of the Meeting
- Review of Application
- Adjournment
The meeting of the Advisory Board of the John E. Fogarty International Center for Advanced Study in the Health Sciences (FIC) was convened on Tuesday, February 6, 2001, at 8:40 a.m., in the Conference Room of the Lawton Chiles International House, National Institutes of Health (NIH), Bethesda, Maryland. The meeting was open to the public from 8:40 a.m. to 12:20 p.m., followed by the closed session for consideration of grant applications until adjournment at 3:00 p.m. Dr. Gerald T. Keusch presided as Chair.
Board Members Present:
Dr. Margaret A. Chesney
Dr. Cutberto Garza
Dr. Steven E. Hyman
Dr. Mary Claire King
Dr. Cora B. Marrett
Dr. Patricia Marshall
Dr. Theodore Reich
Dr. Jaime Supulveda
Board Members Absent:
Dr. Barry R. Bloom
Dr. Ezekiel Emanuel
Mr. Thomas J. McAndrew
Dr. Jane Menken
Dr. Robert E. Shope
Dr. Catherine M. Wilfert
Members of the Public Present:
Dr. Mariam Claeson, The World Bank, Washington, D.C.
Dr. Joy deBeyer, The World Bank, Washington, D.C.
Dr. Dean T. Jamison, University of California at Los Angeles
Dr. Prabhat Jha, The World Bank, Washington, D.C.
Dr. Chris Lovelace, The World Bank, Washington, D.C.
Dr. Anthony R. Measham, The World Bank, Washington, D.C.
Ms. Angela Sharpe, Consortium of Social Science Associations, Washington, D.C.
Dr. Gavin Wright, Triangle Research Institute, Chapel Hill, North Carolina
Federal Employees Present:
Dr. Martin Alilio, FIC/NIH
Dr. James Lavery, FIC/NIH
Ms. Meklit Berham, FIC/NIH
Ms. Judith Levin, FIC/NIH
Mr. Amar Bhat, FIC/NIH
Ms. Heather Looney, FIC/NIH
Dr. Joel Breman, FIC/NIH
Dr. Jeanne McDermott, FIC/NIH
Dr. Kenneth Bridbord, FIC/NIH
Dr. Kathleen Michels, FIC/NIH
Mr. Bruce Butrum, FIC/NIH
Dr. Heather Miller, NIH/OD
Ms. Jennifer Cabe, FIC/NIH
Dr. Mark Miller, FIC/NIH
Dr. Lois K. Cohen, NIDCR/NIH
Mr. Richard Miller, FIC/NIH
Ms. Nancy Coulter, FIC/NIH
Dr. Rachel Nugent, FIC/NIH
Mr. Eric Dakake, FIC/NIH
Ms. Ruth Orenstein, FIC/NIH
Ms. Irene Edwards, FIC/NIH
Ms. Rachel Park, FIC/NIH
Dr. Andrea Egan, FIC/NIH
Dr. Sherri Park, NICHD/NIH
Dr. Pierce Gardner, FIC/NIH
Ms. Charlotte Quinn, FIC/NIH
Ms. Lee Ann Gschwind, FIC/NIH
Ms. Minerva Rojo, DOS
Dr. Bill Harlan, NIH/OD
Dr. Joshua Rosenthal, FIC/NIH
Dr. Ruth J. Hegyeli, NHLBI/NIH
Dr. Luis A. Salicrup, FIC/NIH
Ms. Anne Hill, FIC/NIH
Dr. Barbara Sina, FIC/NIH
Dr. Karen Hofman, FIC/NIH
Ms. Rita Singer, FIC/NIH
Dr. J. Allen Holt, FIC/NIH
Ms. Janice Solomon, FIC/NIH
Dr. Sharon Hrynkow, FIC/NIH
Dr. Sudha Srinivasan, FIC/NIH
Ms. Chris Keenan, FIC/NIH
Ms. Natalie Tomitch, CSR/NIH
Dr. Gerald T. Keusch, FIC/NIH
Dr. Sandy Warren, CSR/NIH
Dr. Richard Krause, FIC/NIH
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OPEN PORTION OF THE MEETING
I. CALL TO ORDER
Dr. Gerald T. Keusch, Director, FIC, called the open session of the Advisory Board meeting to order at 8:40 a.m. on Tuesday, February 6, 2000. He welcomed and introduced a new Board member, Dr. Jaime Sepulveda, Director General, Instituto Nacional de Salud Publica [National Institute of Public Health], Cuernavaca, Mexico. Two additional new Board members were unable to attend the meeting: Dr. Jane Menken, Professor of Sociology, Institute of Behavioral Science, University of Colorado at Boulder, and Dr. Robert E. Shope, Professor of Pathology, Center for Tropical Diseases, University of Texas Medical Branch, Galveston. Dr. Shope served as a Board member previously. Dr. Keusch also welcomed Dr. Steven E. Hyman, Director, National Institute of Mental Health (NIMH), NIH, who was attending his first Board meeting as an ex officio member of the Board.
Dr. Keusch welcomed two special guests, Dr. Dean T. Jamison and Dr. Prabhat Jha, who spoke on disease control priorities later during the meeting (see section VI below). Dr. Keusch extended a special welcome to several guests from the World Bank: Dr. Chris Lovelace, Dr. Joy deBeyer, Dr. Mariam Claeson, and Dr. Anthony Measham. He also welcomed Dr. Raynard Kingston as the new Director, Office of Behavioral and Social Science Research, NIH. Dr. Keusch further welcomed Dr. Bill Harlan, Associate Director for Prevention Research, Office of the Director, NIH, and two directors of international programs within the NIH: Dr. Ruth J. Hegyeli, Associate Director for International Programs, National Heart, Lung, and Blood Institute; and Dr. Lois K. Cohen, Director, Office of International Health, National Institute of Dental and Craniofacial Research.
In a moment of levity, Dr. Keusch introduced FIC's new opportunity for promoting issues of international health and global science-the FIC "mug." The mug, which FIC is providing to all Board members, conveys two messages: "science for global health" and "FIC-small place, big impact."
II. CONSIDERATION OF MINUTES OF PREVIOUS MEETING
The minutes of the Advisory Board meeting of September 19, 2000, were considered and accepted unanimously.
III. REVIEW OF REQUIREMENTS FOR CONFIDENTIALITY AND CONFLICT OF INTEREST PROCEDURES
Dr. Keusch thanked the Board members for providing their updated Confidential Financial Disclosure Reports to the FIC.
IV. FUTURE MEETING DATES
The following meeting dates were confirmed:
Tuesday, May 22, 2001
Tuesday, September 11, 2001
The proposed meeting dates for 2002 are:
Tuesday, February 5, 2002
Tuesday, May 21, 2002
Tuesday, September 10, 2002
Dr. Keusch asked Board members to inform Ms. Irene Edwards, Executive Secretary, of any scheduling conflicts they may have with the future dates. All subcommittees of the Board will meet on the Monday preceding each Board meeting.
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V. REPORT OF THE DIRECTOR
Dr. Keusch reported on FIC personnel and progress in FIC's programs. Mr. Richard Miller, Executive Officer, FIC, presented an update on the NIH and FIC budgets for Fiscal Year (FY) 2001. The written Report of the Director was distributed previously to Board members, was available at the meeting, and is appended to these minutes as Attachment 2, Written Report of the Director.
FIC Personnel
Dr. Keusch recognized Dr. Kenneth Bridbord, Director, Division of International Training and Research (DITR), who is being honored by the American Association for the Advancement ofScience (AAAS) for his contributions "to the understanding and the development of science across national boundaries." Dr. Bridbord will receive the prestigious AAAS Award for International Scientific Cooperation on February 17 during the AAAS annual meeting in San Francisco. The AAAS has specifically noted Dr. Bridbord's "decisive impact in training researchers worldwide [and]... support of collaborative public health research between scientists in the United States and others countries, especially in expanding international research on AIDS." The Board applauded Dr. Bridbord for his efforts and this particular honor.
Dr. Keusch noted several personnel changes. Dr. Bruce Butrum joined FIC in January as Grants Management Officer, replacing Ms. Silvia Mandes who retired from Government service in December. Dr. Pierce Gardner joined FIC on February 1 as Senior Advisor for Clinical Research and Training. Dr. James Lavery joined FIC in October as a bioethicist in the Division of Advanced Studies and Policy Analysis (DASPA). Ms. Minerva Rojo will join FIC on February 12 as Director, Division of International Relations. Mr. Robert Eiss, Director, DASPA, left FIC in December to become Director of Programs, Research, Budget, and Evaluation, Office of National Drug Control Policy, Executive Office of the President. Dr. Karen Hofman is serving as Acting Director, DASPA, while FIC searches for a new director for this division. Dr. Keusch invited the Board to recommend candidates for this position.
NIH and FIC Budgets
Mr. Miller reported that the NIH received its FY 2001 appropriation in December. Since October 1, the NIH had been operating, under a continuing resolution, at the FY 2000 level. The final appropriation provides approximately $20.3 billion for the NIH, which is about $2.5 billion (or 14.0 percent) more than in FY 2000. This appropriation includes two adjustments: transfer of $5.8 million to the new Office of Human Research Protection in the Office of the Secretary, Department of Health and Human Services (DHHS), and an administrative reduction of about $8.7 million. The NIH budget also includes, for the first time, a separate appropriation for the new National Center on Minority Health and Health Disparities (NCMHHD), which will be headed by Dr. John Ruffin.
For FY 2001, FIC received an appropriation of approximately $50.5 million, or about a 16.5 percent increase over FY 2000. Mr. Miller noted that this percentage increase compares favorably with that of other NIH components, which averaged a 13.5 percent to 14.5 percent increase, but that the dollar amounts are small because of FIC's relatively small base.
With this budget, FIC will be able to launch three new initiatives: the Health and Economic Development Program; the International Clinical, Operational, and Health Services Research Program; and the Epidemiology Program. FIC will continue to develop other programs, for funding in FY 2002. FIC will expand the following existing programs during FY 2001: the AIDS International Training and Research Program (AITRP), Fogarty International Research Collaboration Award (FIRCA) Program, Maternal and Child Health Program, International Research Scientist Development Awards (IRSDA) Program, Environmental and Occupational Health Program, and Medical Informatics Program. Two programs will be phased out during FY 2001: the Senior International Fellowship Program, and the International Research Fellowship Program.
In closing, Mr. Miller noted that the Administration is beginning to develop the FY 2002 budget and that the Senate and House hearings on this budget will probably occur during April.
Progress in FIC's Programs
Dr. Keusch reported on FIC's progress since the Board's September meeting and on directions for the future within the context of a broad review of all FIC activities, visualized as the building of FIC's "house"-a schema introduced by Dr. Keusch when he became FIC Director approximately 2.5 years ago. Dr. Keusch noted that FIC is continually remodeling the "house," which comprises a platform, foundation, current programs, program expansions, and future directions.
The Platform. The platform, or FIC's mission, consists of four main activities: building international research capacity, promoting strategic alliances, creating collaborative international research networks, and conducting appropriate research. Dr. Keusch noted significant progress in all these activities. Exemplifying FIC's success and progress are the AITRP (in building international research capacity); collaboration with the World Bank on the Health and Economic Development Program and with other international organizations and foundations (promoting strategic alliances); a new FIC initiative to increase the participation of scientists from developing countries in the NIH Intramural Program (creating collaborative international networks); and FIC's new research Division of International Epidemiology and Population Studies (conducting mission-appropriate research).
FIC-NIH Intramural Initiative. Dr. Sharon Hrynkow, Deputy Director, FIC, elaborated on the concept of the Intramural Program initiative. Approximately 10 percent of the NIH budget supports the Intramural Program of research conducted by approximately 6,000 scientists, including about 2,000 to 3,000 foreign scientists each year. Only a small percentage of the foreign scientists come from developing countries, especially in sub-Saharan Africa and Latin America. To advance the global research agenda, FIC is pursuing three objectives, to increase the number of developing-country scientists in the Intramural Program, provide training (e.g., in grantsmanship, the peer review process, science presentations) for these scientists on their return to their home countries (re-entry), and consider ways to support their research on re-entry. Dr. Hrynkow reported that FIC staff have had preliminary discussions with Dr. Michael Gottesman, Deputy Director for Intramural Research, NIH; will be consulting with developing-country scientists currently in the program; and will work with other NIH partners and outside groups, such as foundations, to support the initiative. She invited the Board to participate in development of this initiative.
The Board encouraged FIC to continue to develop this concept. Members noted that it presented an exciting opportunity for partnering with international organizations such as the World Bank and the World Health Organization (WHO), to strengthen institutional infrastructures in developing countries, and Dr. Keusch was encouraged to present the concept to the NIH institute and center (IC) directors to enlist their support. The Board highlighted two critical issues: marketing of the program to scientists in developed countries, and provision of re-entry research support. For follow-up discussions, the Board requested summary data on the developing-country scientists currently in the Intramural Program (e.g., individuals participating, countries represented, professional level, research fields, graduate degrees, length of stay, proportion returning, gender). Dr. Hrynkow noted that, as of January, approximately 800 of the 2,400 foreign scientists in the program, and about half of the scientists from some developing countries, were female.
Epidemiology and Population Studies. Dr. Mark Miller, Associate Director for Research, FIC, elaborated on the organization and activities of the new FIC division. Since establishing the division in October 2000, FIC has successfully recruited a medical epidemiologist from the Centers for Disease Control and Prevention and several graduate students for specific projects. Focusing initially on vaccines for diseases prevalent in developing countries, FIC staff have developed a protocol for assessing the economics of vaccine-preventable disease; implemented studies in six countries (mostly in Asia) in collaboration with international organizations; established a collaboration with the London School of Tropical Medicine and Hygiene to study the cost effectiveness and epidemiological parameters for adopting new vaccines; initiated working relationships with the Global Alliance for Vaccines and Immunizations and with the Bill and Melinda Gates Children's Vaccine Program and the Gates Foundation; and considered partnerships with other NIH components and other organizations to assess the introduction of vaccines for human papillomavirus.
The Board addressed the rationale for selecting vaccine research as the initial focus for the division's activities. Dr. Miller noted that FIC selected this research area based on FIC's potential resources, experience, and expertise and the world's major global health problems. The intent is to play a catalytic role in the adaptation and translation of known cost-effective, population-based interventions such as vaccines. This effort will include, and draw on, FIC's expertise in building capacity, developing alliances, and conducting training. Dr. Keusch commented that FIC is proceeding in a measured manner to address critical questions related to creating a demand for vaccines within a broad analytical framework involving economics and the social sciences. By linking with other ICs, FIC can add value to their research and "make a difference" in the global need for vaccines.
The Foundation. FIC's foundation consists of four key areas requisite for conducting capacity building and quality research in the new millennium: bioinformatics; bioethics; clinical, operational, health services research; and genetics. Dr. Keusch noted that FIC is developing expertise and implementing programs in each area. In computer-based bioinformatics, FIC now supports 10 training programs (6 in Africa and 4 in Latin America) and, with additional funding, would expand these into Asia. In bioethics, FIC's significant progress includes initiation of the Global Forum on Bioethics and Research, in partnership with others. Approximately 140 participants (three-fourths from developing countries) attended the second forum, held in Bangkok in October; the third meeting will be in Gambia in November 2001, the fourth in Brasilia in 2002, and the fifth probably in France in 2003. This year, FIC also funded the first set of International Bioethics Education and Career Development Awards to four U.S. institutions extensively involved in developing countries and awarded three planning grants to two South African universities and the University of Chile to develop their bioethics programs and revise their applications for recompetition in FY 2002. FIC intends to fund these awards every 2 years, to develop a cadre of individuals with in-depth understanding of the ethical issues in research and science, and is trying to interest other organizations in making a similar investment.
International Clinical, Operational, and Health Services Research Program. Dr. Bridbord described the concept of a new Request for Applications (RFA) for this program, to be issued on February 13 in partnership with the NIMH and other ICs. Based on assessments of the future global burden of disease, the RFA will focus the NIH effort in this area initially on chronic, noncommunicable diseases, with major emphasis on mental health. Additional RFAs are planned, focusing on other areas, within an overall strategic framework to develop centers of research excellence in developing countries. Dr. Bridbord noted that FIC is discussing this long-term effort with additional ICs, to encourage their participation and leverage FIC's resources. The receipt date for applications to the first RFA is April 27, 2001.
Genetics. Dr. Keusch noted that FIC is considering and discussing FIC's involvement in this area. Dr. Hofman described challenges and opportunities for an FIC genetics program. Areas of potential interest include research; training; ethical, legal, and social issues (ELSI); economics and intellectual property rights (IPR); and databanks. With FIC's expertise, a research and training effort would most likely focus on public health genetics and involve analysis of the implications of genetic variations in health and disease. Dr. Hofman noted that FIC staff met with the Trans-NIH Genetics Group to discuss genetic issues for developing countries and that the group expressed strong support for research training; transcultural studies of ELSI; and careful scrutiny of issues such as confidentiality, privacy, stigmatization of groups, informed consent, and benefit sharing. She anticipated that the FIC genetics program would reflect these interests as well as concerns about IPR. The FIC is currently engaged with the WHO in discussing ELSI globally.
The Board noted that FIC can have a positive impact on genetics research worldwide by helping to extend the capability for this research worldwide. Compared to a decade ago, genetic techniques and tools are simpler to use in the field and require less resources, making genetics research feasible in developing countries, which may be "resource-limited but not intellectually limited." The Board commented that FIC has an opportunity to help developing countries identify genetically related health issues pertinent to their populations and strengthen their capacity for independent research on these issues, while resolving concerns about ELSI on a case-by-case basis. The Board also noted the need for research on gene-environment interactions and epigenetic changes in populations. The Board cautioned FIC to identify specific areas of research where it can make the most impact and add value. Dr. Keusch said that FIC will include a genetics program in its planning and budgeting for FY 2002. He also noted that research and training on gene-environment interactions as they relate to disease susceptibility and health promotion in populations is included in various FIC programs.
Current Programs. Dr. Keusch noted that FIC's current programs are expanding. The malaria program includes a research training effort; a partnership with the National Institute of Allergy and Infectious Diseases, focused on anemia and malaria; serving as the Secretariat for the Multilateral Initiative on Malaria (MIM); planning for the 2002 Pan-African Malaria Conference; and other activities. Additional programs relate to tuberculosis, other emerging infectious diseases, population demography, environmental and occupational health, health disparities, and biodiversity. Specific details on these and other programs are provided in the written Report of the Director (see Attachment 2).
Program Expansions. New areas of FIC activity include the IRSDA Program, Maternal and Child Health Program, International Tobacco Control Research and Training Initiative, Stigma Research Initiative, Environment and Ecology Program, and Health and Economic Development Program. Dr. Keusch noted that the IRSDA Program is being expanded to support additional research scientists, including behavioral and social scientists, interested in international health. The Maternal and Child Health Program, also funded in FY 2000, continues in collaboration with the National Institute of Child Health and Human Development. In collaboration with seven other NIH components, FIC has drafted an RFA for international research and training in tobacco and health, which emphasizes behavioral and social issues contributing to the initiation of smoking, for funding in FY 2002. Dr. Keusch noted that FIC also continues to work closely with WHO on its tobacco-free initiative.
In the environment and ecology area, FIC, in partnership with other ICs and the National Science Foundation (NSF), funded 12 new investigator-initiated (R01) awards for research on the ecology of infectious diseases. This effort is moving the research agenda in this area from improved surveillance and response to prediction and, ultimately, prevention. The partners plan to reissue the RFA during FY 2001 and fund additional awards in FY 2002. Funding of FIC's Health and Economic Development Program was discussed later, during the Board's closed session. This program involves several other ICs and the Global Development Network group at the World Bank. Dr. Keusch noted that the goal of this program is to understand the importance of health in economic development so that appropriate and consistent investments can be made at the country level.
Stigma Research Initiative. Dr. Kathleen Michels, Program Manager, DITR, described FIC's interest in stigma, a national and international public health concern. Stigma is an impediment to research on stigmatized conditions and to the provision of quality health care as well as a barrier to an individual's seeking and obtaining appropriate health care. Dr. Michels noted that stigma is associated with many diseases and disabilities and that FIC started with a focus on stigma in relation to mental health and illness. As other institutes across NIH expressed an active interest, this focus quickly broadened to include other diseases and disorders such as neuropsychiatric disorders, epilepsy, drug and alcohol abuse, HIV/AIDS, and congenital physical abnormalities. A systematic, state-of-the-art review is needed of the theory, methodology, and interventions for stigma, including identification of scientists in developed and developing countries who are studying stigma. In January, FIC convened a working group of representatives from other ICs and the NSF to plan a small meeting of outside experts, which will be held at the Lawton Chiles International House on February 21. At this meeting, invited participants will explore the issues involved, develop an agenda for a larger public meeting to be held on September 5-7, 2001, and provide guidance to FIC on the development of an RFA for stigma research.
Future Directions. Dr. Keusch noted that FIC's goal for the future is to build a foundation for appropriate research on public health topics using the range of science available and then helping countries focus on problems they consider most significant. Taking a thoughtful, strategic approach that includes promotion of alliances with others, FIC has begun to explore some new directions. These potential areas of activity include demography and social science, noncommunicable diseases (especially developmental disorders), nutrition, vector biology and vaccinology, and responsible medical reporting. FIC is consulting with other ICs and with experts on the Board and outside the NIH on these potential topics.
In response to a question from the Board about medical reporting, Dr. Keusch emphasized the importance of trust and dialogue between scientists and reporters and the need to strengthen capacity in science reporting in developing countries. The Board noted the role of reporters and commended FIC for engaging in a positive process of dialogue and communication.
Additional details on personnel changes, the FY 2001 budget, and FIC activities are provided in the Written Report of the Director.
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VI. DISEASE CONTROL PRIORITIES
Dr. Keusch introduced two speakers who addressed aspects of an upcoming revision of a major document in international health, Disease Control Priorities in Developing Countries (Jamison, D. and Mosley, W. H., with Bobadilla, J. L. and Measham, A.R., eds., New York: World Bank and Oxford Press, 1993). The purpose of the session was twofold: to elicit the Board's thinking on international health, and to discuss FIC's potential role in developing components of the report.
Analytic Requirements for Global Health: Overview and Status Report. Dr. Dean T. Jamison, Professor of International Health Economics and Economics of Education, and Director, UCLA Program on International Health and Education, University of California at Los Angeles, described the need to create, maintain, and disseminate specific quantitative, evidence-based databases as an integral part of health policy research to enable health policy analysis. He reviewed the current state of health policy research in developing countries, the types of evidence bases data needed to move this research forward, the sources of data for these bases, and the need for an institute for generating and maintaining evidence bases.
Dr. Jamison noted that the essential elements of health policy have not been defined or agreed upon, to support a broad research agenda, as they have been for economic development. Whereas macroeconomic policy can be discussed globally, health policy is still discussed in relation to specific countries that have different desires, institutions, and epidemiology. Generalizations about health finances or the structure and organization of health systems are difficult to make. However, well-founded generalizations, and tools for making rapid and convincing assessments of country-specific circumstances and appropriate policy responses, are sorely needed to advance health policy research. Currently, this research consists of case studies, anecdotes, theory, and increasing amounts of statistical information, which can be used to form some generalizations, but, overall, health policy today is at a similar transformation point as macroeconomics was 60 years ago.
To move health policy research forward, evidence bases that link determinants, mechanisms, and outcomes of health policy need to be established. The core evidence base currently used in developing countries to measure health outcomes is mortality, which only became available during the 1990s and was supplemented recently by burden of disease. Dr. Jamison emphasized the need for four linked evidence bases to obtain a broader view of health outcomes and health status: quantitative characteristics and descriptions of health systems (i.e., determinants), national health accounts and cost effectiveness of interventions (i.e., mechanisms), and assessments of burden of disease (i.e., outcomes). Sources of data for the data include governments' administrative records, specialized (e.g., disease-specific) health surveys of populations, and systematic and sophisticated household surveys.
Dr. Jamison noted that generating and maintaining these demographic and epidemiological databases are essential. However, the function may be perceived as routine and not sufficiently academic by most of academia. He suggested that the World Bank, WHO, and the NIH would have "comparative advantages" in generating different evidence bases and that the WHO could maintain and disseminate the evidence bases. As a research institution, the NIH, in particular, could be effective in designing methodologies; reviewing the status of the evidence bases periodically; developing alternative methods for assessing the burden of disease; and helping WHO, as needed, to maintain and disseminate the databases.
Dr. Jamison emphasized that research will be needed to develop methodologies and, interactively, evidence data (e.g., the burden of disease in developing countries). For example, data on public and private health expenditures are available for many countries, but not in time series that would allow for comparisons (e.g., between 1990 and 1980), and reasonable data on the demographics of disease (e.g., patterns of death by cause or major risk factors) are needed for low- and middle-income countries to underpin assessments of the burden of disease in these countries. In closing, Dr. Jamison noted that both the World Bank and the NIH and FIC have important roles to play in the revision of Disease Control Priorities in Developing Countries. He suggested that the NIH and FIC could complement the World Bank's economic perspective by maximizing the science input and ensuring a better, more scientific product.
Disease Control Priorities, 2nd Edition: Old Wine in a New Bottle? Dr. Prabhat Jha, Senior Health Specialist, The World Bank, and Senior Scientist, WHO, described the objectives and impact of the first edition of Disease Control Priorities in Developing Countries, the reasons for a second edition, and a possible approach to completing the second edition. He noted that the revision would be worthwhile, but considerably more complex than preparing the initial volume. The presentation was authored also by Dr. Jamison and Dr. Anthony Measham, who were editors for the first edition.
The objectives for the first edition were to assess the current and future public health significance of 25 health conditions and to estimate the cost effectiveness of various preventive and case management strategies in two environments corresponding to, for example, a low-income country in sub-Saharan Africa and a middle-income economy. Dr. Jha noted that the book had broad impact. It was a companion document to the World Development Report of 1993, stimulated wide national and international debates, spurred the estimates of disability and specific interventions, and had a limited effect on the allocation of resources by the World Bank and other organizations. Criticisms of the first edition centered on the failure to use a standardized methodology for estimating burden of disease and cost effectiveness across chapters, the exclusion of key health conditions, the limited discussion of risk factors, the failure to describe pertinent non health-sector interventions (e.g., sanitation, education), and the limited discussion on implementation of interventions.
Three main reasons for considering a second edition are the changes in epidemiology and interventions between 1987 and 2001, the recent availability of sophisticated analytical instruments, and a changing institutional context. Dr. Jha noted, for example, that mortality rates for children under age 5 have declined in some world regions, and particularly in sub-Saharan Africa, during the past 5 years, reflecting interventions such as immunization and improved management of sick children. Other important changes in developing countries include the dramatic increase in life expectancy during the past 40 years and the effects of two epidemics-HIV/AIDS and tobacco use. New methods and data are needed to more completely document the HIV/AIDS epidemic and the impact of interventions, to measure the increasing hazards of a "mature" tobacco epidemic, and to provide evidence to policymakers. Dramatic changes occurring in particular regions (e.g., increased mortality rates between 1992 and 1994 for middle-aged adults in Russia) that have implications for global policy also need to be documented and analyzed.
New analytical tools include recent significant breakthroughs in indirectly estimating global burden of disease, innovative research on cost effectiveness of interventions in high-income countries, methods for conducting systematic reviews, improved randomized trials and meta-analytic techniques, methods for determining research priorities, genetic techniques used mapping the human genome, and emerging research on analyzing the constraints and costs of "scaling up" interventions. Institutional changes include the revitalization of WHO, the launching of disease-specific initiatives (e.g., "roll back malaria"), the development community's increased attention and spending on health outcomes, the WHO's recent focus on controlling communicable diseases (especially HIV/AIDS), philanthropic organizations' growing interest in global health outcomes, and increased Internet access and decreased communication costs.
Dr. Jha suggested that the second edition of Disease Control Priorities in Developing Countries should focus on total burden of disease, rather than on a set of specific conditions, because countries have to confront a wide range of diseases and risk factors that affect health outcomes and costs. Oral health, for example, may not appear to contribute significantly to the burden of disease, but can be very costly for many countries. Other dimensions, besides burden of disease, that are important internationally and need to be explored include interventions by type of disease (e.g., communicable, noncommunicable); the health care delivery framework (e.g., clinics, hospitals); non-service delivery methods (e.g., research and policy interventions); and access of populations to health care (e.g., immunizations), which can vary widely between poor and nonpoor groups within and between countries. Dr. Jha also suggested that the second edition could continue the previous emphasis on improving and standardizing methodologies for estimating burden of disease, analyzing cost effectiveness, including applications of molecular biology (e.g., genetic markers) to measurement of disease, examining levels of delivery (e.g., constraints to insurance coverage, health resource issues), and linking health and poverty (e.g., focusing on absolute versus relative poverty).
To prepare the second edition, certain organizational issues also must be considered. These include ensuring a strong "buy-in" by the scientific and development communities, identifying an appropriate and effective vehicle for disseminating the document (e.g., regionally, on the Internet), and establishing broader advisory and technical expert panels. In closing, Dr. Jha noted that the questions concerning disease control priorities are as relevant as in the past and a new effort to resolve them, although more complex and demanding, would yield great insights.
Discussion
The Board focused on ways to increase the potential impact of the proposed second edition of Disease Control Priorities in Developing Countries. Members suggested that consideration be given to the following: the application of genetic technologies for diagnosis of infectious diseases; the complexity of designing and conducting effective research interventions among populations in "real-life" settings; focusing on the causes (risk factors) of diseases, rather than, or in addition to, the outcomes of diseases; alternative methods for evaluating the efficacy, as well as the effectiveness, of research; including a section on "paradoxically positive models" of health and disease (e.g., among Hispanic populations) and successful interventions; including the concept of health systems performance in the delivery framework; adopting the "inequity gap" as a central theme; including social and behavioral determinants of inequity and of access to, and use and delivery of, health services; emphasizing health services research on the efficiency (e.g., affordability) of care delivery and on the barriers, "pull," and demand for health services; and addressing the broader aspects of public health (e.g., water, sanitation, nutrition).
The Board generally agreed that the World Bank should be the lead organization for this effort and that the FIC could play an effective partnership role. Some concern was expressed about the extent of the Bank's commitment to health versus its emphasis on economic and monetary matters. Dr. Keusch noted that the FIC and NIH could be most helpful in addressing methodological issues and developing, testing, and standardizing alternative methods (e.g., to measures of burden of disease).
There was also a suggestion about placing the second edition within a larger "Disease Control Project." Shortly after the Board's meeting, Drs. Jamison, Jha, and Measham compiled a suggested outline for the second edition of Disease Control Priorities in Developing Countries, which is appended to these minutes as Attachment 3.
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VII. CLOSED PORTION OF THE MEETING
This portion of the meeting was closed to the public in accordance with the determination that it was concerned with matters exempt from mandatory disclosure under Sections 552b(c)(4) and 552b(c)(6), Title 5, U.S. Code and Section 10(d) of the Federal Advisory Committee Act, as amended (5 U.S.C. Appendix 2).
There was a discussion of procedures and policies regarding voting and confidentiality of application materials, committee discussions, and recommendations. Members absented themselves from the meeting during discussion of and voting on applications from their own institutions or other applications in which there was a potential conflict of interest, real or apparent. Members were asked to sign a statement to this effect.
VIII. REVIEW OF APPLICATION
A total of 109 scored competing applications were reviewed by the FIC Advisory Board at the February 6, 2001, Board meeting. The applications were in the following programs:
14 applications for the Senior International Fellowship (SIF) program;
56 applications for the Fogarty International Research Collaboration Award (FIRCA) program;
1 application for the HIV/AIDS Fogarty International Research Collaboration Award (AIDS FIRCA) program;
26 applications for the International Studies on Health and Economic Development (ISHED) program;
12 applications for the International Maternal and Child Health Research and Training (IMCHRT) program.
The Board concurred with the initial review group recommendations for the 109 applications.
IX. ADJOURNMENT
The meeting was adjourned at 3:00 p.m. on February 6, 2001.
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