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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
Fifty-second 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
- FIC Strategic Planning
- World Bank Perspective on the Burden, Treatment, and Prevention of Mental Disorers
- Demographic Factors in East Asian Economic Growth
- 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, May 18, 1999, at 8:38 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 8:38 a.m. to 12:30 p.m., followed by the closed session for consideration of grant applications until adjournment at 1:30 p.m. Dr. Gerald T. Keusch presided as Chair.
Board Members Present:
Dr. Francisco J. Ayala
Dr. Marvin Cassman
Dr. Cora B. Marrett
Mr. Thomas J. McAndrew
Dr. Donald O. Nutter
Board Members Absent:
Dr. Barry R. Bloom
Dr. Margaret A. Chesney
Dr. Rita R. Colwell
Dr. Samuel L. Katz
Members of the Public Present:
Ms. Rachel G. Hunt, Analytical Sciences, Inc., Silver Spring, MD
Dr. Steven Radelet, Harvard Institute for International Development, Cambridge, Massachusetts
Dr. Harvey Whiteford, The World Bank, Washington, D.C.
Federal Employees Present:
Ms. Susan Bettendorf, FIC/NIH
Dr. Sharon Hrynkow, FIC/NIH
Mr. Amar Bhat, FIC/NIH
Dr. Josefa Ippolito-Shephard, FIC/NIH
Ms. Heidi Bishop, FIC/NIH
Dr. Gerald T. Keusch, FIC/NIH
Dr. Joel Breman, FIC/NIH
Dr. Baerbel Koester, FIC/NIH
Dr. Kenneth Bridbord, FIC/NIH
Dr. Richard Krause, FIC/NIH
Ms. Stephanie Bursenos, FIC/NIH
Mr. Richard Miller, FIC/NIH
Dr. Lois K. Cohen, NIDCR/NIH
Ms. Sherri Park, NICHD/NIH
Ms. Irene Edwards, FIC/NIH
Ms. Rita Singer, FIC/NIH
Mr. Robert Eiss, FIC/NIH
Dr. Sudha Srinivasan, FIC/NIH
Dr. Ruth J. Hegyeli, NHLBI/NIH
Ms. Natalie Tomitch, FIC/NIH
Dr. Allen Holt, FIC/NIH
Dr. Sandy Warren, CSR/NIH
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 8:38 a.m. on Tuesday, May 18, 1999. He noted that three new members would be joining the Board in September: Dr. Mary Claire King, from the University of Washington; Dr. Cutberto Garza, from Cornell University; and Dr. Patricia Marshall, from Loyola University of Chicago.
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II. CONSIDERATION OF MINUTES OF PREVIOUS MEETING
The minutes of the Advisory Board meeting of February 9, 1999, were considered and accepted unanimously pending one correction on page 4 to state that Dr. Sharon Hrynkow was named Director, Division of International Relations, FIC.
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, September 28, 1999
Tuesday, February 8, 2000
Tuesday, May 16, 2000
Tuesday, September 19, 2000
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.
V. REPORT OF THE DIRECTOR
Dr. Keusch highlighted several changes in personnel and reviewed recent FIC activities. Mr. Richard Miller, Executive Officer, FIC, presented an update on the budget process for fiscal year (FY) 2000 and 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.
Personnel Changes
Dr. Keusch informed the Board that Ms. Stephanie Bursenos, Deputy Director, FIC, will be retiring from the Federal service on May 28. Ms. Bursenos has served the FIC in several capacities since 1983 and as Deputy Director since 1994. Dr. Keusch noted that it has been a pleasure working with Ms. Bursenos, and he thanked her for all her efforts on behalf of the FIC and especially during the transition of the past 7 months under his leadership. On April 11, Dr. Gary Nabel became the first director of the NIH Vaccine Research Center. The center will be located in the new building under construction at NIH, which is due to be completed in the middle of 2000. The center will include pharmaceutical facilities and 10-12 laboratories for approximately 100 scientists. The first major target vaccine will be for the human immunodeficiency virus (HIV), as intended by Congress when it appropriated funds for the center. Dr. Keusch noted that Dr. Nabel is particularly interested in HIV globally and in including HIV strains and isolates from other countries as well as the United States. The center also has targeted other viral diseases, such as herpesvirus, and is considering other diseases for which vaccines are needed, such as malaria.
In March, Dr. Karen Hofman joined FIC's Office of International Science Policy and Analysis (OISPA) as a special expert. Dr. Hofman, a pediatrician trained in medical genetics, formerly consulted with the Pan American Health Organization, the National Institute of Child Health and Human Development, and the National Human Genome Research Institute. Prior to this, she was on the faculty of The Johns Hopkins School of Medicine. Dr. Keusch noted that Dr. Hofman's expertise will be useful in developing FIC's interest in noncommunicable diseases, which are of major importance in developing countries.
Dr. Keusch noted that the FIC is recruiting additional staff for the OISPA and the Division of International Relations.
FIC Activities
Dr. Keusch reported on FIC's progress toward "building a house," the scheme for charting FIC's new directions which Dr. Keusch presented at the previous Board meeting. He expanded FIC's platform, or mission, to include a third, middle component, "to develop research programs." This component complements, and is integral to, the other parts of the mission, which are "to build research capacity" and "to create collaborative research networks." Dr. Keusch noted that, by invitation, he has spoken to several NIH advisory councils about FIC programs and that discussion with these councils has been helpful in defining ways for FIC to interact in a complementary manner with the scientific objectives of the institutes.
Activities are under way in each of the four areas designated as the foundation of FIC's "house." FIC has added resources for the medical informatics area for FY 1999 and has reissued, with the National Library of Medicine, the Request for Applications (RFA) for International Training in Medical Informatics. In the new RFA, which was released on March 4, 1999, the guidelines have been tightened, specific areas of research have been targeted, training in informatics has been tied to ongoing research programs (e.g., research on malaria in Africa), and the program was expanded geographically to include applicants from the Americas while continuing to focus on sub-Saharan Africa. The FIC expects to receive 14 new applications for the program. Dr. Keusch noted that medical informatics is a potentially important area for expanded international collaborations with the NIH institutes.
In the bioethics area, the FIC is convening a workshop on June 21-22, 1999, on Bioethical Considerations in International Research. With this workshop, the FIC hopes to provide the impetus (a) for organizing a coordinated global program in bioethics in international research to address clinical issues related to international medical activities, and (b) for initiating discussions of the need for, and the objectives of, an international training program in bioethics. Within the NIH, the FIC is addressing opportunities for linkage with The Wellcome Trust to fund a multicentered program with multiple training sites. The FIC anticipates that the training program would be developed further at a subsequent, larger meeting that would include scientists and ethicists from developing countries.
Specific programs in the areas of clinical research and molecular genetics, genomics, and other basic sciences are being developed in discussions with various NIH institutes. The FIC intends to target programs in the clinical research area for implementation in FY 2001.
Referring to the third tier of FIC's "house," Dr. Keusch said that all of FIC's current programs are "alive, healthy, and very productive." The current programs are in medical informatics, biodiversity, environmental and occupational health, population and demography, HIV/AIDS, and emerging infectious disease.
Among the initiatives for FY 2000, Dr. Keusch noted that the FIC plans to issue an RFA in bioethics policy and training in FY 2000, with funding of successful applications in the same year. The concept for the RFA would be refined based on discussions at the second, larger bioethics meeting described above. In the area of environment, ecology, and infectious diseases, the FIC has recently held two program development meetings. The goal in this area is to understand the biological principles and features of ecological environmental interactions that result in the emergence of infectious diseases. The National Institute of General Medical Sciences and the National Science Foundation are collaborating in the development of this program. With these partners, and possibly the U.S. Department of Agriculture's Agricultural Research Services, the FIC hopes to issue an RFA in this area for funding in FY 2000.
In the area of maternal and child health, the FIC issued an RFA for the International Maternal and Child Health Research and Training Program. The response to this RFA, which was released on March 4, 1999, has been overwhelming. Approximately 40 institutions, which have not been funded previously by the FIC, have indicated interest in this program. Dr. Keusch noted that FIC will allocate additional resources to this area in FY 2000.
Dr. Keusch highlighted a new initiative that integrates FIC's program areas. On March 30, 1999, the FIC issued an RFA for International Research Scientist Development Awards for U.S. Postdoctoral Scientists. Dr. Keusch noted that this initiative was developed and launched within a 2-week period, largely through the efforts of Dr. Kenneth Bridbord, Dr. Barbara Sina, and the staff of FIC's Division of International Training and Research. The goal of this RFA is to develop capacity in the United States for conducting international research by supporting career development for U.S. scientists who are committed to international health research. The individual postdoctoral awards are for 3 years, with 2 of the years served in a developing country. The range of research that may be conducted is broad and includes biomedical, clinical, and behavioral studies. Applicants must have significant mentorship from both a U.S. and overseas institution. At the completion of the training period, applicants with a faculty position may apply for a subsequent, separately reviewed component for 2 years of faculty support at a higher stipend level. Dr. Keusch noted that the FIC has received a tremendous positive response from the scientific community regarding this award, the first group of which will be awarded in September.
Regarding strategic alliances, the FIC continues to move ahead in this area. FIC's program of Actions for Building Capacity (ABC) in Support of International Collaborations in Infectious Diseases Research (ICIDR) is one example. Through this program, the FIC supports research training in collaboration with the National Institute of Allergy and Infectious Diseases (NIAID), which funds the overall ICIDR program. Dr. Keusch noted that the FIC will be supporting six of the new ICIDR awards, which include research training for foreign investigators. The FIC anticipated supporting 10 awards. With the additional funds, the FIC has decided to provide administrative supplements to malaria research groups targeting research training in malaria for foreign scientists. The supplements will be provided through two FIC programs, the AIDS International Training and Research Program and the International Training and Research Program in Emerging and Reemerging Infectious Diseases, and will be linked to NIAID-supported malaria research in Africa. The decision to fund these supplements was made, in part, in recognition of FIC's new responsibility as the Secretariat for the Multilateral Initiative on Malaria (MIM), which was recently transferred from The Wellcome Trust.
The FIC continues to pursue strategic alliances and to plan joint initiatives with other Federal agencies (including the U.S. Agency for International Development), foundations (e.g., The Wellcome Trust), and the World Bank (see sections VI and VII below). In collaboration with the World Health Organization (WHO), the FIC is participating in a WHO steering committee to plan a conference to review the role and impact of health and biomedical research on development, scheduled for October 2000. To prepare for this meeting, the FIC is considering the feasibility of conducting an historical study to examine the impact of NIH's investments in international research.
In closing, Dr. Keusch said that FIC's future plans remain on course with the strategic plan presented at the previous Board meeting and that FIC's cross-cutting concerns (e.g., health and economics) apply to the NIH as well.
FIC Budget
FY 2000. Mr. Miller reported that the budget process for FY 2000 was proceeding well and that the House and Senate appropriations subcommittees were preparing their responses to the President's Budget. For FY 2000, the budget request for the NIH is $15.9 billion, or a 2.1 percent increase over the FY 1999 level. Included in this budget is a request of $36.3 million for the FIC, representing a 2.4 percent increase. On February 23, Dr. Varmus testified for the NIH at the Senate Appropriations Subcommittee hearing, accompanied by the institute and center directors. No questions were specifically related to the FIC at this hearing. Dr. Keusch testified for the FIC at the House Appropriations Subcommittee hearings on February 25. Mr. Miller noted that both hearings were positive and supportive of the NIH and that both committees are considering another significant increase for the NIH in FY 2000. At the House hearings, questions addressed to the FIC related to FIC's international leadership role and influence; FIC programs, especially the Biodiversity Program and the new initiative on the ecology of infectious diseases; treatment of tuberculosis in developing countries; the World Health Organization's anti-tobacco program; and the recommendations of the External Advisory Panel to Review FIC-NIH International Activities (the Lederberg-Bloom panel).
FY 2001. Discussion of the themes and priorities for the NIH in FY 2001 will begin at a budget planning retreat scheduled for mid-June. Convened by Dr. Varmus, the retreat will include all institute and center directors; members of the Advisory Committee to the Director, NIH; and members of the newly formed NIH Council of Public Representatives.
The Director's written report includes additional information on FIC's budget, program developments, and activities.
VI. FIC STRATEGIC PLANNING
Mr. Robert Eiss, Director, OISPA, proposed an approach for developing a new FIC strategic plan. This activity will be FIC's second planning effort; the first, conducted 5 years ago, culminated in an FIC long-range plan, entitled International Frontiers in Biomedical Research, which was published in September 1994 and formally presented to the Board at its February 1994 meeting.
Mr. Eiss said that the second effort, like the first, will be undertaken in collaboration with the Board. The impetus for the current planning effort is a request from Dr. Varmus for 3- to 5-year plans from the NIH institutes and centers, which are due at the end of December. This request, in part, is in response to a recent recommendation by the Institute of Medicine; the requirements of the Government Performance and Results Act; and the continuing and deepening discussions with Congress on how the NIH sets priorities.
Mr. Eiss presented a proposed outline of the FIC plan for FY 2000-2003. He envisaged two potential roles for the plan, as a reference document conveying FIC's priorities to investigators and as an informational document describing the needs and opportunities in global health for Congress. The plan would include the following parts: FIC's mission, goals, principles, and means; research opportunities and needs in global health; FIC's program plans by categorical area; priorities, initiatives, and activities in science policy; and FIC's approaches for measuring program results.
Among the initiatives that could be highlighted for FY 2000 are FIC's efforts relating to ecological influences on infectious diseases, health and economic development, and the bioethical dimensions of international research. Mr. Eiss noted that, on June 2, 1999, the FIC is convening the first NIH planning workshop on health and economic development. At this workshop, biomedical scientists and macroeconomists will identify and discuss researchable questions concerning health as a precondition of economic development. In the bioethics area, the FIC may collaborate with the NIH Department of Clinical Bioethics to develop a casebook to assist NIH program officers and grantees in interpreting international ethics codes. The FIC also is canvassing the NIH institutes and centers to elicit the practical and conceptual impediments to the ethical design and conduct of transcultural research, particularly in low- and middle-income economies. This information will be useful empirical background for FIC's June 21-22, 1999, planning meeting on Bioethical Considerations in International Research.
On June 18, 1999, Dr. Keusch will be presenting FIC's potential initiatives for FY 2001 to the directors of the NIH institutes and centers. He will highlight three areas: molecular genetics and genomics; training and career development for clinical investigators from developing economies; and international initiatives relating to mental health disorders. Mr. Eiss noted that Dr. Keusch will be meeting shortly with Dr. Francis Collins, Director, National Human Genome Research Institute, to discuss FIC's directions in the broad field of molecular genetics. Possibilities for FIC might include, for example, support of international research training in the genetics of susceptibility and resistance to infectious disease, or support of broad-ranging fellowships in molecular epidemiology and population genetics.
With regard to training and career development, Mr. Eiss noted that the NIH has instituted a series of new K awards in the past few years to strengthen didactic training in clinical investigation. Data indicate that only 5-7 percent of the 1,900 new clinical faculty appointed each year are research investigators. Mr. Eiss suggested that the FIC could review and potentially adapt NIH's K22 award to support individual clinical research fellowships for foreign scientists.
For mental health disorders, the FIC could support studies to better understand the incidence of these diseases globally. The FIC could, for example, support training and research relating to the use of culturally relevant diagnostic measures; support the expansion of genetic linkage studies to include the interaction of genes and environment on mental and behavioral disorders; investigate the relationship between neurotoxins and behavior in populations with high exposures to toxins; or support research training for physicians in primary care settings.
For FIC's plan beyond FY 2001, two areas could be highlighted: the effects of nutrition (e.g., vitamins, micronutrients) on biological function and health, and establishment of international centers of excellence. Potential activities regarding nutrition may include supporting a longitudinal study of the relationship between nutrition and risk of disease in infants and children in developing countries and expanding ongoing NIH protocols to include measures of nutritional status.
In closing, Mr. Eiss noted that FIC's planning process will involve the Board, the NIH institutes, the broader scientific community, the public, and the Congress. He suggested that one approach may be to ask the Board to participate as an informal "cyber" committee, with which the FIC would communicate electronically to obtain members' guidance on proposals and issues at each step of the process, or more formally through a planning subcommittee that would work with staff to develop draft materials for review by the full Board in late summer 1999.
Discussion
The Board encouraged staff to convey in the plan that the FIC is "open" to new opportunities and is not limiting its efforts only to the initiatives described or suggested in the plan. For example, one important potential area of activity for the FIC is the possibility of an emerging epidemic of cardiovascular diseases worldwide. Dr. Keusch noted that the FIC already is discussing potential collaborations in this area with the National Heart, Lung, and Blood Institute (NHLBI). Dr. Ruth J. Hegyeli, Associate Director for International Programs, NHLBI, noted that the NHLBI has many collaborations with developing countries and that the Director, NHLBI, is enthusiastic about collaborating with the FIC in the future. Recently, the NHLBI has been a major collaborator in developing a pan-American initiative in hypertension that includes participation from government, international organizations, and the private sector. Also, NHLBI scientists are major users of the Fogarty International Research Collaboration Award (FIRCA) for support of international collaborations in cardiovascular diseases.
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VII. WORLD BANK PERSPECTIVE ON THE BURDEN, TREATMENT, AND PREVENTION OF MENTAL DISORDERS
Dr. Harvey Whiteford, Mental Health Specialist, The World Bank, Washington, D.C., described The World Bank's role in health, its interest in mental health, and critical health issues for the Bank and other bilateral and multilateral lenders. He noted that the Bank was formed in 1944, along with the International Monetary Fund and the United Nations, to promote long-term social development and economic growth in countries that were not industrialized at the end of World War II, with the aim of promoting international stability. The World Bank Group consists of five components: the International Bank for Reconstruction and Development (IBRD), the International Development Agency (IDA), the International Finance Corporation, the Multilateral Investment Guarantee Agency, and the International Center for the Settlement of Investment Disputes.
The Bank raises money on the global markets to lend to its member countries at low interest rates (currently around 6.4 percent). This money is underwritten by funds set aside by the Bank's owners, 181 countries, who contribute in proportion to their economic strength. The Bank is organized according to six geographic regions, each headed by a regional vice-president and each including country directors, and five networks or technical support units. Personnel report to a country director and liaise with a network. The Human Development network, created in 1977, consists of three sectors: Health, Nutrition, and Population (HNP); Education; and Social Protection (social security).
Dr. Whiteford said that the role of the Bank is threefold: to give policy advice, provide financing, and conduct analyses of situations in countries. Each year, the Bank lends about US$28 billion. In 1998, the total for health was about US$2 billion. The IBRD, the largest lending component, loans to low- and middle-income countries, and the IDA loans to very poor countries. Some countries (e.g., China, India) are eligible for loans from both components. To be eligible for Bank funds, the country must be a member of the United Nations and must have joined the International Monetary Fund.
Dr. Whiteford noted the following distribution of Bank funds for HNP in FY 1999: 38 percent, health; 43 percent, education; and 19 percent, social protection. The Bank began lending in the health sector in the 1980s, and this sector is currently one of the Bank's fastest growing areas, accounting for about 8 percent of all the Bank's loans. Dr. Whiteford cited three reasons for the Bank's interest in investing in health: health accounts for a large proportion of a country's gross domestic product (GDP), the state can play a key role in the health sector, and health is a critical part of the human capital equation (i.e., health and education are necessary for sustainable economic growth).
Since 1970, the Bank's interest in HNP has shifted from a focus on specific problems (e.g., population control, nutrition, infectious diseases) to include basic health services and, now, broad sector-wide reforms (e.g., reconstruction, capacity building). The amount of loans and the number of projects have increased significantly. Currently, the Bank funds health projects in about 95 of the 161 countries receiving Bank funds. The regions receiving the most funds are, in order, Latin America and the Caribbean, South Asia, Europe and Central Asia, sub-Saharan Africa, East Asia and the Pacific, and the Middle East and North Africa. The countries with the largest number of projects are, in order, India (with 20 projects), Mexico, Brazil, Argentina, and China.
Dr. Whiteford highlighted three critical international health issues: the burden of disease, calculated according to disability-adjusted life years (DALYs); the potential impact of noncommunicable diseases; and neuropsychiatric diseases. Data on the global burden of disease indicate that, for developing countries, infectious diseases are becoming relatively less important and noncommunicable diseases are becoming more important. The three major noncommunicable diseases are cancer, cardiovascular disease, and neuropsychiatric disease. Dr. Whiteford said that there are three types of neuropsychiatric disease: neurological disorders, mental disorders, and substance abuse. Areas of interest for funding are: epilepsy (especially in South Asia), substance abuse (especially alcohol abuse), suicide (including depression and other disorders that precede or predispose to suicide), and primary health care.
Dr. Whiteford noted that the Bank and other major lenders find that neuropsychiatric diseases account for a large and increasing burden of disease worldwide. Many lenders have not been persuaded, however, that this situation can be improved cost effectively in poorer countries. Although many of these diseases can be treated effectively in established market economies, sufficient data on these diseases are lacking in developing countries and trained investigators are not available to conduct the research needed. For the Bank, the opportunities for improvement, as well as the burden, must be large. Dr. Whiteford emphasized that, to interest international lenders such as the Bank in investing in specific projects to reduce the burden of neuropsychiatric diseases, developing countries must be able to demonstrate that sustainable, cost-effective interventions are available to prevent, diagnose, and treat these diseases and could be carried out by primary health care services in these countries. Describing a project to reduce suicide rates in India, Dr. Whiteford suggested that the necessary knowledge for developing an effective preventive method in a developing country may be culturally and community-specific and can be difficult to acquire.
Discussion
Dr. Keusch noted that he and Dr. Whiteford have been participating in an Institute of Medicine effort to develop a study plan entitled, "Nervous System Disorders in Developing Countries." The aim of the study is to assess the burden of disease in five categories of nervous system disorders (epilepsy, stroke, mood disorders, psychotic disorders, and developmental disabilities), to assess the services currently available to developing countries for addressing these problems, and to identify research areas for the future. The FIC, three NIH institutes, and the Global Forum on Health are co-funding this effort.
Dr. Keusch noted that the Bank is not contributing funds for this effort. He also noted that the NIH, and the FIC in particular, have been meeting with various staff at The World Bank over the past 6-8 months to explore possibilities of partnering with the Bank. He asked Dr. Whiteford to suggest ways in which the NIH and the Bank could combine their respective resources, interests, and investments (for example, in mental health) to achieve an effective collaborative interaction.
In response, Dr. Whiteford suggested several factors that hinder this type of collaboration. He noted that the Bank must keep its administrative expenses low in order to keep its interest rates low, the Bank does not view itself as a research organization, and the Bank does not fund projects that do not include an evaluation component. He suggested that some monies are available to address questions of interest to the Bank and that funding may be available to support training, partnering with technically skilled individuals from countries that are members of the Bank or the Organization for Economic Cooperation and Development, or partnering with networks of experts during the establishment or evaluation of projects supported by the Bank.
Dr. Whiteford also noted that the Bank supports mental health programs in developing countries, and, as with all Bank funds, the monies are distributed to the governments, not to individuals or institutions. The loans, however, do include set-aside monies for consultants, technical advisors, and program evaluators. Two possibilities for leveraging FIC support through collaborations with the Bank are (a) to encourage FIC applicants to obtain a commitment from the country, with which they will be involved, to utilize Bank funds for in-country activities such as training, capacity building, and program evaluation, and (b) to utilize former FIC trainees as consultants and advisors on projects supported by the Bank. It was noted that the Bank's professional staff are primarily health economists and public health specialists and that the NIH offers in-depth expertise for developing human capacity in specific areas.
In closing, Dr. Whiteford noted that investments in health may not be viewed as a priority in developing countries, which have many other needs, and that country officials will have to weigh the benefits of gaining a healthier, and therefore more productive, workforce against the costs of a Bank loan that must be paid back with interest. Ministers of finance, as well as ministers of health, will be involved in deciding whether health is included in an country's assistance strategy and, if so, what components of health will be included.
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VIII. DEMOGRAPHIC FACTORS IN EAST ASIAN ECONOMIC GROWTH
Dr. Steven Radelet, Director, Macroeconomics Group, Harvard Institute for International Development, Cambridge, Massachusetts, presented a macroeconomist's perspective of the dynamics of economic growth and key health-related variables affecting this growth. He noted that economists' understanding of economic growth has changed dramatically during the past 10 years. With breakthroughs in theory, information, and data, economists can now begin to explore "channels" that might explain the varying growth among countries and the links between economic growth and other factors such as geography, environment, economic policies, education, and health. Recent empirical studies show, for example, that health contributes to economic growth and is one factor that distinguishes countries that are more successfully developing from those that are less successfully developing.
As theorized by Nobel Laureate Robert Solow, each country has a current level of income and is moving toward a potential level of income. The potential level differs for each country and depends on many factors, such as those suggested above. Using this model, economists can estimate a country's potential level and its growth rate, which will slow down as the country develops and the return on investments diminishes (the law of diminishing returns). Dr. Radelet noted that this model explains the faster growth rate of poorer countries as compared with richer countries.
To demonstrate the contribution of health to a country's potential level of income, and therefore differing growth rates, Dr. Radelet presented the results of a statistical analysis of cross-country growth regressions, estimated for 78 countries. In this analysis, various factors (or independent variables) were matched against growth of real per capita GDP, 1965-90 (the dependent variable). The analysis showed that 87 percent of the variance in growth rates of these countries could be estimated by the factors selected. Several of the factors related to health: location in the tropics, life expectancy at birth, and growth of working-age population versus growth of total population (or demographic shift).
Elaborating on the three health-related variables, Dr. Radelet noted that the growth rates of countries in the tropics is 1.26 percentage points slower per year than those of countries located elsewhere. These growth rates would affect the countries' potential level of income. Across the 25-year-period used for the analysis, the countries in the tropics would gain only 53 percent of the income level of countries located elsewhere. As supportive data, Dr. Radelet noted that all rich countries are located in the temperate zones, except for two recent additions (Hong Kong, Singapore) from the tropics. Factors, or "channels," that may account for the reduced labor productivity in tropical countries include poor soil quality and poor agricultural production, hot climate, and difficult-to-eradicate disease vectors (e.g., for malaria).
Life expectancy is viewed as a general indicator of health. Dr. Radelet noted that data indicate that the greatest gains in life expectancy come early in a country's development and that the rate of return decreases as life expectancy increases. Also, some evidence indicates that, at very high life expectancies, the returns actually tail downward. For a country, the most important aspect is the distribution and concentration of gains in life expectancy at the lowest levels of income. Factors that may account for the higher life expectancy in some countries (e.g., in Asia) include the availability of antibiotics and other medicines, which would have enhanced labor productivity, and the use of DDT and other agricultural pesticides, which would have increased agricultural production. Longer life expectancies stimulate other positive changes, such as investments in infrastructure and education.
Dr. Radelet noted that gains in life expectancy and health in developing countries tend to be concentrated first among infants and children through reduced mortality rates, which trigger demographic changes. Summarizing the classic model of demographic transformation, he noted the effects of falling death rates, and then falling birth rates, on the growth of working-age and total population. As the working-age population increases, savings, investments, and economic growth increase. Dr. Radelet partly attributed the extraordinarily high saving rates among Asian populations to this classic demographic shift, which has occurred in Asia over the past 40 years. Statistical analysis of the changes in both working-age population and total population indicates that each 1 percent increase in the working-age population (while holding overall population growth constant) translates into a 1 percent increase in economic growth per capita. Dr. Radelet noted that this effect (a transitory "demographic gift") demonstrates the importance of demographic shifts, which economists have largely neglected in the empirical growth literature until recently. For Asia, he projected that the ratio of working-age population to nonworking-age population will continue to increase until 2010, after which it will begin to fall, first in East Asia and then later in Southeast and South Asia. The aging of the Asian population will result in slower economic growth rates, reduced savings rates, and new health and retirement programs for its older population.
To summarize the quantitative importance of the three health-related variables, Dr. Radelet presented estimates of their contributions to growth differentials between East/Southeast Asia (the comparison region) and three other regions (South Asia, sub-Saharan Africa, and Latin America) for 1965-90. For sub-Saharan Africa, the data show that the average, annual per capita growth rate is 4 percent less than the comparative region and that the three-health related variables (location in the tropics, life expectancy, and the lack of a demographic shift) account for slightly more than 2 percentage points of the difference, whereas policy variables (e.g., government savings rates, openness to trade) account for 1.7 percentage points of the difference. For Latin America, the differences in the health-related variables are small, but the policy variables account for almost half of the overall difference in per capita growth, which is 3.9 percent. For South Asia, which had a 2.9 percent slower growth rate, the three health-related variables accounted for almost half of the difference.
In closing, Dr. Radelet said that the macroeconomic data are strong and based on empirical evidence. Economists are just beginning to explore the channels that would explain the differences observed, the interactions between and among variables, and the specific relation to economic growth. Many open-ended questions remain. For example, do interventions against malaria affect economic growth? Does economic growth trigger the demographic shift, or vice versa? What actually caused the enormous demographic transition in Asia?
Discussion
The Board expressed the need to apply the model presented by Dr. Radelet to three main categories of health problems for developing countries: infectious diseases, cardiovascular diseases, and neuropsychiatric disorders. Epidemiological data would have to be obtained as needed. Dr. Radelet noted that "off-the-shelf" datasets were used for the analysis presented and that data on health were only recently included. He emphasized that better, more reliable databases are needed that would provide meaningful information for cross-country comparisons. Dr. Keusch also expressed concern about the datasets used and suggested that the FIC could develop an initiative to generate research data that would be appropriate for the intended analyses.
The Board commented on other factors that may account for, or affect, differences between regions and countries. Some of the factors noted, which may be embedded within the variables used in the model, were as follows: war, increased age of retirement, government expenditures on education, HIV infection and HIV prevention programs, agricultural versus industrial or export economies, coastal versus landlocked location, and social cohesiveness and integration. In addition, some members asked for clarification about the variables and other aspects presented.
IX. 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.
X. REVIEW OF APPLICATION
A total of 64 applications requesting $2,560,489 in FY 1999 funds were reviewed by the FIC Advisory Board as follows:
11 applications for Senior International Fellowship (SIF) awards requesting $468,500;
32 applications for FIRCA awards requesting $1,173,775;
5 applications for AIDS-FIRCA awards requesting $177,498;
6 applications for International Research Fellowship (IRF) awards requesting $205,700; and
10 applications for ABC awards, requesting $535,016.
The Board concurred with the initial review group recommendations for 64 proposals, recommending $2,560,489.
XI. ADJOURNMENT
The meeting was adjourned at 1:30 p.m. on May 18, 1999.
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