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FY 2002 Statement of the Director
Fiscal Year 2002 Hearing on Special Populations and Health Disparities
Statement by
Gerald T. Keusch, M.D.
Director,
John E. Fogarty International Center for Advanced Study in the Health Sciences
Appearing before the House and Senate Appropriations Committees on the FY 2001 Budget.
April 4, 2001
Mr. Chairman and Members of the Committee, I am pleased to have the opportunity to discuss with you initiatives and priorities of the Fogarty International Center (FIC), particularly as they relate to the broad theme of Special Populations and Health Disparities. I will use selected programs and activities to describe our mission as it relates to the theme and to underscore how we achieve strategic objectives. Since its establishment in 1968, FIC has embodied the vision that "disease knows no boundaries" and, more importantly, that "the benefits of medical research should also know no boundaries." To this end, FIC plays a unique role in the efforts of the United States to decrease disparities in global health status. Virtually all of FIC's research and research training efforts are aimed at reducing health status disparities that exist both within populations in the United States and between industrialized countries and those in the developing world or emerging democracies.
Among other factors that contribute to health disparities are genetic and environmental influences as well as lack of access to proper nutrition or health and education services. The poorest segments of the U.S. population share many similarities with those in the developing world in this regard. Research advances made abroad are therefore directly relevant to improvements in health and reductions in health disparities in the United States. Such advances lead to the development of diagnostics, drugs or intervention technologies of benefit to the U.S. and global communities; the identification of new avenues of research that ultimately lead to new interventions; and the improved understanding of behaviors related to positive or negative health outcomes. Knowledge gained through research studies conducted abroad contributes to the scientific foundation for medical advances in the United States. For example, research conducted in Uganda on the effectiveness of a simplified regimen to interrupt the transmission of HIV from mother to newborn could not have been conducted in the United States because there are too few transmission events to study.
Global Leadership
The interconnectedness of societies around the world through travel, trade, and information technology is readily apparent. Increasingly, this interconnectedness leads to the globalization of health threats. This is perhaps best illustrated by the rapid transmission of infectious agents, many of them new organisms developed through stealthy mechanisms of genetic exchange, across borders and populations.
FIC research and capacity-building programs address global health threats, whatever their nature and origin. Our program on HIV/AIDS, the AIDS International Training and Research Program, or AITRP, provides a critical example. Now in its 13th year, the AITRP tackles AIDS research questions while building capacity in poorer regions of the world where more than 90% of the infected live. Long-term training, leading to advanced degrees for over 2,000 researchers and short courses for more than 50,000 health care workers and scientists to date, usually in their home country, has provided the human resources to begin to effectively address this global threat just when access to life preserving drugs seems within the realm of possibility. Uganda provides an illustrative example of the Program's success.
Ten years ago in Uganda, the health care infrastructure was in a state of collapse after years of civil strife. At that time, Ugandan officials realized that the country was in the throes of a devastating epidemic caused by human immunodeficiency virus type-1 (HIV-1). About 30% of all pregnant women in urban settings were found to be HIV positive. The priorities in public health were to rebuild the Ministry of Health so that it could lead and direct national efforts to deal with the HIV epidemic. The AITRP, working through partners at Johns Hopkins University and Case Western Reserve University, was instrumental in this regard. Today, roughly one-third of all senior Ministry of Health officials in Uganda are former trainees of the AITRP. In addition, AITRP trainees and collaborators played a critical role in the landmark study conducted in Uganda and noted above that demonstrated the efficacy of a relatively inexpensive drug, nevirapine, in reducing mother-to-child transmission of HIV. That study, supported by the National Institute of Allergy and Infectious Diseases (NIAID), was made possible because of long-term human capacity building efforts sponsored by FIC. Based on the success of the AITRP, FIC has developed ten similar programs in other critical areas of global health need, for example: Emerging Infectious Diseases; Maternal and Child Health; Environmental Health and Occupational Health; Medical Informatics; Bioethics in Research; Malaria; and Tuberculosis.
In addressing the global challenge of malaria, which claims close to 2 million lives each year (source: World Health Organization), FIC organized the first planning meeting for a new type of international collaboration which, within 2 years, led to the development of a comprehensive research agenda linked to malaria control efforts. In 1999, FIC was asked by sponsoring agencies and African scientists to lead the collaborative effort, now called the Multilateral Initiative on Malaria (MIM), in its second phase. Today, FIC works on behalf of all sponsoring agencies, including NIAID, the National Library of Medicine, WHO, the World Bank, and scientists in malaria-endemic countries to advance malaria research efforts while building research capacity. Under FIC leadership of the MIM, investments in malaria research and training has increased; new funding partners have joined the MIM; and, critically, research has progressed in priority areas of malaria prevention and control.
The end of the 20th century was a time of increasing prosperity for many countries, but for those in many developing nations, it was a lost decade. Despite gains made in reducing childhood diseases worldwide, many low- and middle-income countries suffered a marked deterioration in health status and conditions of living. To assist in understanding the essential linkage between health status and economic development and to better inform resource allocation decisions, FIC launched a new program in partnership with the World Bank's Global Development Network and four NIH partners. This program will increase our understanding of the economic outcomes linked to health status and will provide new methods, analytic frameworks, and empirical macro- and micro-economic data to plan and to guide development and deployment of health interventions.
In addition to these major programmatic activities, FIC plays a pivotal role on behalf of the NIH in advising international organizations, such as the WHO Commission on Macro-Economics and Health and the WHO Advisory Committee for Health Research. Key to our approach in these forums is that biomedical and behavioral research are critical components of any long-term effort to develop and deploy effective health care interventions. Importantly, career development of scientists and health professionals in the developing world is essential to ensuring that research conducted in those settings is high quality, practical and culturally appropriate and acceptable.
Meeting Future Global Health and Research Needs
In many societies, an AIDS diagnosis is so severely stigmatizing that large numbers of at-risk individuals fail to access diagnostic and counseling services, medical care and support, or enter into the very research studies necessary to identify and test interventions. These individuals fear ostracism or, worse, violence and death. But HIV/AIDS is not the only stigmatizing condition in these settings. Epilepsy, which is often seen as a curse; mental illness, which is often hidden away from view; physical (especially facial) defects; and alcoholism and substance abuse, among others, are also significant stigmatizing conditions. Insufficient attention has been given to these major sources of morbidity, anguish, and social injustice to understand the social and cultural determinants of stigma, the utility of education, appropriate behavioral modifications and the optimal points for intervention. FIC, working in partnership across NIH and with the National Science Foundation, will highlight the stigma research agenda, to include opportunities and needs, in the coming year.
Using stigma as an intervention tool, campaigns that de-glamorize smoking have been successful in some settings. Still, the World Health Organization estimates that 7.5% of the world's 53 million deaths annually are attributable to tobacco use and that the number of tobacco deaths will rise to 10 million deaths annually by 2025, surpassing the combined deaths caused by AIDS, tuberculosis, automobile accidents, and maternal mortality. Seventy percent of this increase will occur in developing nations. FIC, working in partnership with five NIH partners, will focus programmatic and policy efforts on ways to reduce the global burden of disease in the coming decades related to the use of tobacco.
As new drugs and interventions are discovered, their appropriate testing in large populations is key. To expand our recently launched International Clinical, Operational and Health Services Research and Training Program, which focuses on chronic diseases, FIC will work in partnership across NIH to develop expertise in the development and conduct of clinical trials in the developing world with a focus on communicable diseases. This undertaking will contribute to ensuring that trials conducted in those settings are scientifically, ethically, and culturally acceptable.
Conclusion
The population of the United States is a microcosm of the global population, a diverse tapestry of groups, all interconnected by genetics, and sometimes by shared environments and shared experience. The programs and initiatives of the Fogarty International Center reduce the gaps between these groups by developing scientific knowledge and by sharing this knowledge for the benefit of all, our vision of Science for Global Health.
The NIH budget request includes performance information required by the Government Performance and Results Act (GPRA) of 1993. Prominent in the performance data is NIH's first performance report, which compares our FY 1999 results to the goals in our FY 1999 performance plan. As our performance measures mature and performance trends emerge, the GPRA data will serve as indicators to support the identification of strategies and objectives to continuously improve programs across the NIH and the Department.
The following two figures were presented by Dr. Keusch at the FY 2002 Hearing on Special Populations and Health Disparities:
Figure 1
This map of the world indicates the locations where Fogarty-sponsored research and training is currently conducted. The gold stars indicate the hundreds of FIC-sponsored research and training sites outside the United States. The red, white, and blue stars indicate the more than 120 FIC-sponsored research and training sites at U.S. collaborating institutions.
Figure 2
This photo is of a young African boy with severe malaria affecting the brain. This condition, called cerebral malaria, is one of the most dreaded complications of severe malaria. Treatment requires not only drugs to tackle the malaria infection but also skilled management to deal with the emergency problems due to brain swelling caused by the infection. Even if this patient survives, there is a strong likelihood that he will be brain damaged for the rest of his life. This is a serious consequence for family, community, and nation. The research and training topics listed in the boxes around this photo are examples of Fogarty-sponsored programs.
