FIC FY2002 President's Budget Request for NIH
Department of Health and Human Services
Gerald T. Keusch, M.D.
John E. Fogarty International Center for Advanced Study in the Health Sciences
On Fiscal Year 2002 President's Budget Request for the National Institutes of Health
May 16, 2001
Mr. Chairman and Members of the Committee, I am pleased to present the President's budget request for the Fogarty International Center for FY2002, a sum of $56,449,000, which reflects an increase of $5,967,000 over the comparable Fiscal Year 2001 appropriation.
The Fogarty International Center (FIC) plays a unique role in the efforts of the United States to improve the health of the American people and of those who live in developing regions in Africa, Eastern Europe, Asia, and Latin America. The wealth of nations depends upon the health of people. A healthy world is a safer world, for our nation and for those less fortunate with whom we share this amazing and beautiful planet. Virtually all FIC research and training efforts are aimed at reducing the disparities in health that exist between the peoples of the developing world and those who live in countries that enjoy the vast advantages of prosperity.
FIC was established in 1968 to honor Congressman John E. Fogarty of Rhode Island. The Center embodies his vision that because "disease knows no boundaries, so also the benefits of medical research and indeed research itself can know no boundaries." FIC is carrying this vision into the 21st Century. Through its leadership role, program initiatives, and analysis of global science and health policy, FIC plays a central role in NIH efforts to harness the fruits of science for global health.
Research advances made abroad often contribute to improvements in health in the United States. For example, research in Bangladesh establishing the physiological basis and practical use of oral rehydration therapy for cholera has led to adoption in the United States of this simple and inexpensive treatment of diarrheal disease, particularly frequent in infants and children. Research to develop diagnostic tests, new drugs, and other therapeutic strategies for HIV/AIDS, tuberculosis, and other diseases present both in the United States and abroad, is beneficial to all, no matter where it is undertaken. Adapting biomedical research advances to populations at home and elsewhere in the world requires a continuing commitment to basic science as well as rigorous clinical research by both American and foreign collaborating scientists. Success in these endeavors requires the creation of a vibrant research infrastructure and trained research staff in collaborating centers internationally. This is what FIC does best.
In carrying out its mandate, FIC supports medical investigators in over one hundred twenty U.S. institutions who collaborate with medical scientists in more than ninety nations. These efforts are multidisciplinary, embracing clinical, epidemiological, basic biomedical, and behavioral research. Although FIC acts to foster collaborative efforts in all parts of the world, it has placed special emphasis on training medical research personnel in those nations with the least resources. Such countries bear a disproportionate burden of illness and premature death, not only from communicable diseases but from non-communicable chronic diseases as well.
Challenges in Global Health
FIC efforts to address the challenges in global health research are carried out through 20 research and research capacity building programs, as well as through policy and coordination efforts. With more than 35 million persons worldwide infected with HIV, AIDS is a global emergency and has been identified as a threat to our national security. In addition to individual tragedy, one person at a time, there are profound societal consequences including economic loss, social disintegration, and political instability. "Each man's death diminishes me," wrote John Donne centuries ago, "because I am involved with mankind." AIDS prevention, treatment, care, and ultimately cure are universal concerns because the people of the world are increasingly connected by trade, travel, and, unfortunately, threats to health.
To address the burgeoning pandemic, FIC launched the AIDS International Training and Research Program (AITRP), now in its 13th year. AITRP has provided research training for more scientists and health professionals from developing countries than any other program, fostering collaborative links between research institutions in the most affected areas in Africa, Asia, and South America and leaders of American medicine. AITRP trainees have been in the vanguard of the most successful efforts to reduce new infection and to keep infection rates low. Their efforts have contributed to numerous scientific discoveries and implementation of programs to reduce HIV transmission. Now that antiretroviral therapy may be within the reach of the highly stricken poor nations, a massive effort to build organizational infrastructure and train the large number of professionals required to assure the safe and appropriate use of these complex drugs is the critical bottleneck to success. Having developed extensive HIV research and training networks among U.S. Schools of Medicine and Public Health and counterparts in developing nations, FIC is in a unique position to enlarge the pool of professionals necessary to support such an effort. We cannot afford not to succeed.
Malaria, once rampant in the United States, including this capital city, has resurged and spread in endemic regions in Latin America, Africa and Asia. An added complication is that the malaria parasite has developed drug resistance. For these reasons, Americans remain at risk when they travel to endemic regions of the world, each year in increasing numbers. New strategies are needed to meet this global challenge that claims approximately 2.7 million lives annually, largely in tropical countries. FIC has implemented a new malaria research and training program to link research to control. In addition, FIC efforts to create a global coalition to address malaria have resulted in the Multilateral Initiative on Malaria (MIM), a new type of international collaboration designed to create research capacity among African scientists and to generate information in the field. As the current MIM Secretariat, FIC has overseen the enlargement of the MIM research portfolio, expanded its training activities, and increased the number of sponsoring partners. Today, MIM is the essential research counterpart for Roll Back Malaria at WHO and together these two initiatives represent the major global collaborations to combat malaria.
Well over ten million people in the United States and 2.1 billion people worldwide are infected with the tubercle bacillus. This ancient infection still results in more than 2 million deaths annually. One third of tuberculosis in the United States is attributed to infection contracted elsewhere and effective treatment is thwarted by the global emergence of TB strains with multiple drug resistance. To meet this threat, FIC started the Tuberculosis International Training and Research Program that focuses on improving clinical and laboratory practices and the training of medical research scientists. Now in its 5th year, it is an essential component of the global strategy to contain the tuberculosis epidemic and has led to important new control measures. One product of this research is a rapid, reliable, simple and inexpensive diagnostic test, which can be adapted to determine drug susceptibility.
Loss of plant and animal biodiversity is a worldwide phenomenon. The medical consequences, though less obvious, are just as serious as the effects on ecology. With the loss of plant biodiversity there is an irrevocable loss of natural products that have traditionally been the source of front line drugs such as quinine for malaria and digitalis for heart disease. The FIC-led International Cooperative Biodiversity Groups Program is a model for ethical bioprospecting in the search for new drugs while it promotes high quality science through multi-purpose partnerships between U.S. and developing country universities, major pharmaceutical companies, and non-governmental organizations. More than 6,000 species have been examined for biological activity in 13 therapeutic areas. Fifty substances of interest have been found and 15 have been selected for further research because initial studies indicate they may prove useful to treat malaria, leishmaniasis, and tuberculosis.
In response to the increasingly complex questions concerning the social and ethical dimensions of international research, FIC initiated and organized the Global Forum on Bioethics in Research, the first international effort to address critical issues related to the bioethics of conducting research in developing countries. FIC also established the first international bioethics training and research program to develop a cadre of qualified ethicists and health professionals from the developing world who can work in partnership with clinical investigators. They will shape and implement research programs and ethical research policies in their home countries to insure that human subjects receive equal protection from research risks, as do participants in research in the United States.
In collaboration with the National Science Foundation, FIC initiated a research program to study the role of ecological factors that influence the emergence of infectious diseases. This program addresses a critical need, to predict and prevent an infection from emerging rather than confront it after the problem appears. It brings together unique research teams composed of climatologists, epidemiologists, ecologists, vector biologists, entomologists, and microbiologists to develop predictive models of emerging infections. For example, the last El Nino preceded an upsurge in diarrheal disease in Latin America and malaria in Africa. To be forewarned is to be forearmed.
Under FIC leadership, innovative research is being initiated to investigate linkages between investments to improve health and economic performance in developing countries. Healthier people living better lives remains an elusive dream and the Alma Ata declaration has fallen far short of its lofty goal of "Health for All by 2000." Research results from FIC's International Studies in Health and Economic Development Program will help the U.S. and other nations working to enhance economic development in the poor countries of the world understand how best to achieve, at lowest cost, the goals of healthier, better educated people living better in politically stable nations around the world.
As we look to the future, FIC will both strengthen existing programs and respond to needs and opportunities with innovative new initiatives.
FY 2002 Initiatives
To address the growing pandemic of tobacco-related illness and death, now shifting from the developed to the developing nations, FIC will explore how to diminish the initiation of smoking by youth and adolescents. The objective of the International Tobacco and Health Research and Capacity Building Program is to generate scientific information on biological, behavioral, and policy factors that will lead to effective control measures to reduce smoking initiation and enhance cessation. The results of these efforts will be applicable in the U.S.
New advances in clinical research are needed to translate basic research into clinical practice and to develop effective public health policy and programs. There are too few well-trained clinical researchers in low- and middle-income countries. Even fewer have policy experience to deal with research and health care. Clinical researchers are needed to address multi-dimensional medical care needs for AIDS patients, and the prudent use of antibiotics to deter the further emergence of antibiotic resistance. Travelers, refugees, and pilgrims spread resistant microbes worldwide with shocking speed. The International Clinical, Operational, and Health Services Research and Training in Communicable Diseases program will train new clinical researchers in developing countries who understand how to translate their research into practice.
Since Biblical times, those afflicted with disfiguring illnesses of body and distortions of mind have been shunned and cast aside. Such stigma is a burden both to the afflicted and the social compact. Stigma, acting through prejudice, diminishes patients' access to care and even their participation in research designed to alleviate suffering. The Stigma Research Initiative will examine the causes of and response to stigmatization of patients with such diseases as HIV, mental illness, epilepsy, drug or alcohol addiction, and physical disabilities, in the U.S. and abroad. Through epidemiological and social science studies on the roots of stigma, its expression and outcomes, new strategies can be identified and tested to relieve its effects and to enhance the well being of patients, communities, and nations.
Publication of the human genome is an extraordinary achievement that creates a wealth of opportunities to identify genetic determinants of susceptibility and resistance to disease. New discoveries to prevent and treat infectious diseases will stem from this knowledge, aided especially by new information on the genomes of microbial pathogens (most recently Strep pyogenes, the cause of "strep throat", rheumatic fever, "flesh eating" necrotizing fasciitis, and toxic shock) and insect vectors. Now for the first time, scientists can target with precision the development of a drug or a vaccine for a specific microbe. For example, over a dozen genes have been identified that relate to the susceptibility to malaria. Efforts in malaria vaccine and drug development are now utilizing this new information.
From the very beginning of research on the human genome there has been concern about ethical issues that relate to medical applications and the protection of the individual. To permit the expansion of genetics research in developing countries, a new program, Incorporating New Genetic Tools into Global Health Strategies, will foster the development of ethically responsible international research and training in the use of modern genetic technologies. U.S. and foreign scientists will forge collaborations to define the genetic influences on conditions that affect both populations, and to discover the ways and means to improve health and reduce disparities at home and abroad.
The pursuit of health through international scientific cooperation is an inherently global enterprise and one that ultimately improves the public health of our nation. Just as trade and communications have tied the world together, advances in biology have demonstrated our social and global interdependence. "Science knows no country", said Louis Pasteur "because it is the light that illuminates the world." The genome project, the recognition that improved health is a determinant of economic development, and the impact of ecological changes on the emergence of infectious diseases all contribute to a deepening consensus that individuals and nations share common interests and responsibilities. The programs of the FIC advance this vision though their support of research and training focused on global health disparities and enabling effective collaborations between American and foreign scientists. FIC leadership and accomplishments enhance our national efforts to achieve better health for Americans and for those less fortunate in the developing world.
The NIH budget request includes the performance information required by the Government Performance and Results Act (GPRA) Of 1993. Prominent in the performance data is NIH's second annual performance report which compares our FY 2000 results to the goals in our FY 2000 performance plan. As performance trends on research outcomes emerge, the GPRA data will help NIH to identify strategies and objectives to continuously improve its programs.
Thank you, Mr. Chairman. I will be pleased to answer any questions.