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FIC FY2004 Congressional Justification

Authorizing Legislation and Budget Authority
Introduction
Sciences Advances

Building Research Capacity to Address Global Health Challenges

FIC New Initiatives

Expanding Current Programs and Piloting New Initiatives

Strengthening the Global Culture of Science

Conclusion
Budget Policy

Authorizing Legislation: Section 301 and 307 and Title IV of the Public Health Service Act, as amended. Reauthorizing legislation will be submitted.

Budget Authority:

	FY 2002 Actual	FY 2003 Amended President's Budget	FY 2004 Estimate	Increase or Decrease
FTEs	61	61	60	(1)
BA	$55,534,000	$61,816,000	$64,266,000	$2,450,000

This document provides justification for the Fiscal Year 2004 activities of the John E. Fogarty International Center (FIC), including HIV/AIDS activities. A more detailed description of NIH-wide Fiscal Year 2004 HIV/AIDS activities can be found in the NIH section entitled "Office of AIDS Research (OAR)."

INTRODUCTION

Never have global health and disparities in health care, including access to and affordability of the products of medical research, been more prominent on the world's agenda. The United Nations Millennium Development Goals, which include five goals directly or indirectly related to health (noted below), the efforts to specifically diminish the transmission of HIV from mother-to-infant in the epidemic countries in Africa and Asia, and the Global Fund for AIDS, TB and Malaria are just a few examples of why global health is in the media, and on the minds of the American people. In this, the 35th year since the establishment of the John E. Fogarty International Center (FIC), its work has never been as relevant to these issues nor has the Center been recognized as much as it is today for its leadership in supporting cutting-edge research collaborations with U.S. academic institutions and research capacity building in the most affected countries. These efforts are critical to the Center's mission, succinctly expressed as "Science for Global Health," and to advancing the leadership role of the United States in this endeavor.

Nations around the world have expressed firm commitment toward meeting the eight goals outlined in the United Nations Millennium Declaration. FIC is addressing the five health-related Millennium Development Goals (MDGs). MDG 1 calls for the eradication of extreme poverty and hunger. To assist this process FIC's research program in International Studies on Health and Economic Development will clarify the relationship between improvements in health; i.e., nutritional status and economic productivity. MDGs 4 and 5 call for reduced child mortality, and FIC's Maternal and Child Health program identifies new strategies to improve maternal health and birth outcomes by addressing health challenges around the time of birth to ensure that newborns and mothers thrive. MDG 6 challenges the international community to do more to combat HIV/AIDS, malaria, and other diseases. FIC supports a number of distinct and multi-disciplinary programmatic efforts to address the needs and opportunities for advancements in these fields. Three programs focus specifically on AIDS and Tuberculosis (TB): 1) the AIDS International Training and Research Program (AITRP); 2) FIC-supported training in conjunction with the National Institute of Allergy and Infectious Diseases (NIAID) Comprehensive International Program of Research on AIDS; and 3) the International Clinical, Operational, and Health Services Research and Training Program for AIDS/TB (ICOHRTA). A new Program Announcement on Global Infectious Disease Research Training combines former individual training programs on malaria, TB, and emerging infectious diseases. The Ecology of Infectious Diseases program is developing data to permit the prediction and prevention of infectious disease outbreaks rather than simply identifying the infectious disease as it emerges. MDG 7 sharpens our focus on the needs for ensuring environmental sustainability and is directly supported by two FIC programs; one new one related to Health, Environment and Economic Development, and another existing training program in Environmental and Occupational Health.

Medicine has been called "the last, and certainly the finest, untapped resource of international diplomacy" (Kevin Cahill, President of the Center for International Health and Cooperation). As the Global Forum on Health Research notes, "good health is central for (a) the promotion of development; (b) the fight against poverty; and (c) global security. In turn, health research is central for the efficient and effective promotion of health." (The 10/90 Report on Health Research, 2000-2001). The sections below briefly describe highlights of current FIC programs and present a plan to better build upon their successes in FY 2004.

SCIENCE ADVANCES

Building Research Capacity to Address Global Health Challenges

Partnerships to Address Infectious Diseases.

FIC works with an increasing range of partners, especially Institutes and Centers (ICs) at the National Institutes Health (NIH), and with other U.S. government agencies, to support the training of scientists, nurses, laboratory technicians and other allied health professionals in the methodologies needed to conduct scientific studies in infectious diseases. Major partners include the National Institute of Allergy and Infectious Diseases (NIAID), the National Institute of Environmental Health Sciences (NIEHS), the National Institute on Drug Abuse (NIDA) and the Centers for Disease Control and Prevention (CDC). All told, on the broad global health agenda, FIC works with 21 of the 27 NIH Institutes and Centers. While building capacity, FIC's programs, closely linked to those of our sister Institutes, strengthen foreign and U.S. cooperation on tropical infectious diseases. These efforts assist in the development of early detection mechanisms and response strategies to epidemics internationally.

Fighting Emerging Infectious Diseases.

Approximately one-third of the world's population is infected with TB, and each year more than two million people die of the disease; moreover, millions more live with a chronic form of the infection. Controversy continues to surround the question of whether the disease TB is primarily due to tissue damage induced by the microbe, or rather is a dysfunctional host immune reaction to its presence. This controversy is not simply academic, as a clear answer highlights a pathway to new treatment and prevention strategies. FIC-supported researchers from India and the Johns Hopkins University are increasing our understanding of how TB transforms from a chronic latent infection to an overtly deadly disease. They have developed a modified TB organism containing an altered gene involved in tissue damage to the lungs. This gene is in many ways a master gene, controlling the expression of at least 31 genes, and influencing the expression of 150 others. Drawing on this panel of genes the TB microbe can develop strategies to protect itself from heat, oxidation, and other environmental stresses. The discovery of this newly described mechanism of TB virulence opens up new possibilities for the development of TB vaccines and drugs.

Cryptosporidiosis, another emerging infection caused by the parasite Cryptosporidium parvum, causes severe diarrhea, and frequently death in those whose immune systems are compromised, including the elderly, transplant patients, those undergoing cancer chemotherapy, and individuals infected with HIV. This intestinal parasite is spread through contaminated drinking water, through contact with infected animals or through other infected humans. In the developing world, with no specific drug available and limited access to safe drinking water, the parasite is particularly deadly. FIC-supported scientists at the Wadsworth Center in New York working with partners in the Czech Republic are searching for potential targets in the parasite for attack by new drugs. This would represent a major breakthrough in the treatment of infection for HIV-infected and other immunocompromised patients, and would benefit the global community.

Malaria is a devastating disease transmitted by a mosquito vector that is endemic in much of the tropics. At a consensus symposium in Tanzania,^[1] malaria experts developed a revised estimate of the malaria burden; up to 3 million people per year die, mostly infants (around 5,000 per day), especially in sub-Saharan Africa, where 90% of the deaths occur. Millions, young and old alike, suffer from a chronic form of malaria, and suffer repeated attacks. Resistance to the "ideal" antimalarial drug, chloroquine, is increasing around the world. In many countries it is no longer effective. A high priority is the discovery of affordable alternative anti-malarial treatments. An FIC-supported investigator from the University of California, San Francisco worked with partners at Makerere University in Uganda to study the efficacy of alternative anti-malarial drugs in Africa, either alone or in combination. The results of the trial demonstrated that a combination of amodiaquine, sulfadoxine and pyrimethamine (SP) was more effective in curing malaria than either of the other drugs alone. These patients improved, and blood tests revealed that the infectious form of the parasite was greatly reduced. The paucity of infectious malaria in the blood, in response to amodiaquine or amodiaquine-SP reduces the chance of mosquito transmission to susceptible people. Thus, treatment with a combination of SP and amodiaquine currently offers an effective, low-cost anti-malarial therapy in areas where SP resistance is still low. Because the probability of the parasite developing resistance to two drugs with different biochemical targets is very remote, the combination therapy should delay the development of resistance to both drugs.

One of the greatest challenges facing the world community is the rampant spread of HIV/AIDS. Recognizing that no corner of the world will be safe from this disease until every corner of the world has the information and tools required to prevent and control it, HIV/AIDS remains a top priority for the FIC. With the demonstration that prevention of mother-to-infant transmission of HIV is dramatically reduced by the anti-retroviral drug Nevirapine, in an affordable and cost-effective manner, FIC has supported studies to examine attitudes about its use in the developing world. When given to the mother once during labor and once to her newborn, Nevirapine reduces newborn infections by 50%. Due to the limited supply of the drug, and its current cost of $4 per day, health officials would ideally prefer to know the woman's HIV status before administering the drug in order to target only those who need it. In Lusaka, Zambia, where HIV rates of infection among pregnant women is 30%, and only $5 per patient per year is allocated for obstetrical care, there are no funds available to support either voluntary counseling of women or testing of HIV status prior to delivery. One alternative that may be cost-effective in a high prevalence setting would be to treat all women and their newborns with Nevirapine. This strategy becomes feasible with the manufacturer's recent commitment to donate Nevirapine in low-resource settings. It is however important to understand how this approach would be accepted by the pregnant women themselves. Researchers from the University of Alabama and the Zambian Ministry of Health administered a questionnaire to pregnant women attending a antenatal clinic in an urban area of Zambia to examine their knowledge and attitudes. The results showed that universal treatment without counseling is acceptable to pregnant women under such circumstances. This has major implications for the effective and culturally acceptable use of Nevirapine.

Addressing Environmental Risk Factors on Health.

The health implications of pesticide use and exposure continue to be relevant topics for policy-makers and health officials, as they attempt to reconcile the benefits of using pesticides such as DDT for mosquito control, and the health risks associated with DDT exposure. While DDT is now banned for agricultural purposes in much of the world, its use in public health programs remains contentious, however effective and economical it is in controlling malaria, for example. Indoor residual spraying to control the mosquito within the household represents a fraction of the health hazard posed by agricultural use. To assess the latter, scientists at The Mount Sinai School of Medicine in New York and Mexico have investigated the accumulation of DDT in body fat, a decade following the cessation of large-scale DDT spraying. In previous studies DDT accumulation in body fat tissue was evident in workers who had been occupationally exposed as well as in unexposed populations who presumably ingested DDT through foodstuffs grown in soils to which the pesticide was applied. To better understand how high DDT levels occur in populations not exposed through occupational routes, researchers examined the relationship between adipose DDT levels and eating habits. They found that the chemical is still present in adipose tissue several years after DDT use has been terminated, and in fact, increases over time especially in people who live in coastal areas. Researchers found no significant relationship between DDT levels and specific foods. The results have implications for a policy that would ban the agricultural use of DDT in regions of the world, but would still allow limited and targeted use for malaria control.

In related studies looking at the health effects of agricultural chemicals, FIC-funded researchers from UCLA and Mexico examined the production of abnormal sperm in agricultural workers exposed to persistent organic pollutants (POP) in the state of Durango, Mexico. This is of great concern because a significant proportion of spontaneous abortions and newborns with chromosomal abnormalities are of paternal origin, and agricultural chemicals are among the potential causes of genetically defective sperm. Researchers assessed the frequency of changes in sperm chromosome numbers and their relationship with POP byproducts in urine samples. Samples were obtained before and during the pesticide-spraying season. The researchers found significant associations between the concentration of POP byproducts in urine samples and the frequency of sperm abnormalities, both of which were more evident during the spraying season. The most frequent abnormality encountered was a missing sex chromosome, a defect of major importance. This study is the first to show a correlation between POP exposure and sperm abnormalities in chromosomes that determine gender, indicating that even brief exposure, such as occurs during the spraying season, can cause harm in humans. Further research is needed to assess the prevalence of spontaneous abortions, birth defects, and genetic syndromes in agricultural communities. However, it is clear that identifying factors that can reduce chromosomal abnormalities represents an important step in reducing the risk of genetic mutations and the resultant spontaneous abortions or newborns with birth defects.

New Challenges Posed by Aging of Populations and other Demographic Trends.

In 1990, non-communicable diseases accounted for just over 40% of the global burden of disease and disability. By the year 2020, their share is expected to reach 60%, assuming the control of infections is improved. The increase is attributable to expected advances in child survival strategies most vulnerable to infection, as well as economic and demographic trends, including the aging of populations, in low- and middle-income nations. In the developing world, many of these burdens may be averted by adapting cost-effective interventions that have been applied in industrialized nations. These include primary prevention programs to modify high-risk behavior, including smoking and lack of exercise, as well as environmental risk factors. Culturally specific research is needed to develop appropriate interventions. The results of the research will likely be relevant to minority and recent immigrant populations in the United States, as well as to the broader global community.

Prevention of smoking is one of the most important health interventions that can be conceived in the United States and abroad. According to the World Health Organization, tobacco use is the leading cause of preventable death and disability in adults. More than 1 billion people-about one-third of the world's adult population-smoke tobacco, making its use one of the greatest global health threats. Each year approximately 4 million people worldwide die from diseases caused by tobacco use. They are replaced by young people and increasing numbers of women, especially in developing countries. If current smoking patterns persist, the number of deaths caused by tobacco use is expected to reach 10 million annually by the year 2025, surpassing the death toll from AIDS, TB, automobile accidents, homicide, suicide, and childbirth combined. Seventy percent of this increase will occur in the developing world, where health care systems are currently unable to address tobacco prevention and intervention comprehensively and will be strained by tobacco-caused illnesses. Considering the impact on workers' productivity and those who perform the role of caregivers, unless effective interventions are applied now the toll from early onset smoking will be staggering.

In order to address many of the research issues raised by increased smoking in the developing world, FIC has taken an important step to expand its activities related to chronic obstructive pulmonary disease (COPD) with the establishment of its new International Tobacco and Health Research and Capacity Building Program. Last year FIC and eight partners, including the National Cancer Institute and the National Institute on Drug Abuse made 14 initial awards to institutions involved in nearly 20 developing countries to conduct research on the approaches to reduce the impact of smoking-associated adverse health consequences in low- and middle- income nations. This research and training will enhance the ability of those nations to conduct locally relevant research on epidemiology, behavior, prevention, treatment, communications, health services, and policy. The knowledge gained and interventions developed abroad through this innovative research and training program will benefit the United States as well by building greater understanding of the many socio-cultural issues related to tobacco, such as why young people take up smoking.

FIC Story of Discovery

Progress in Understanding a Rare Form of Male Infertility
and Its Implications for Understanding of Other Conditions

Human infertility is of great concern, and it has been the subject of intense research. Reproduction is controlled by a series of hormonal interactions that ensure both the development of the reproductive organs and the ongoing function of the reproductive system. Failure of any one of the steps in the complex system of regulation can cause infertility, and there are no simple ways to reverse this state. Hypogonadotropic hypogonadism (HH) is an example of a rare form of male infertility, caused by a genetic mutation. In some forms of HH, a hormone, gonadotropin releasing hormone (GnRH), released from one area of the brain, is unable to pass its signal to its target cells in another area of the brain, the pituitary gland. Understanding the cause for this lack of communication would shed light into possible mechanisms to overcome it.

Scientists from the Oregon Health Sciences University and their collaborators in Mexico have now discovered a way in the laboratory to reverse some of the defects that lead to HH. Some HH patients have defects in the pituitary cells with which the hormone communicates. In these patients, the GnRH receptor, a docking protein which is normally located on the surface of pituitary cells where it can bind to GnRH hormones passing through the bloodstream, is either not present on the cell surface or is not able to bind to the hormone because it folds into an abnormal shape when it is first made in the cell. Because the GnRH receptor is a member of a large family of hormone receptors that affect many fundamental processes in humans, defects in these receptors can cause many diseases. For this reason, pharmaceutical companies have intensively studied this family of proteins and have discovered many small chemicals that can bind to these proteins and influence the way they bind to their hormones and transmit signals.

The U.S. Principal Investigator in this FIC-sponsored collaboration was able to obtain a chemical from Merck that influenced the function of the normal GnRH receptor, and by adding this chemical to cells containing the defective receptor, was able to demonstrate that the defect could be reversed. Thus, the receptor could bind to its hormone almost normally and the signal could be passed on properly. Moreover, the same chemical could rescue all receptors from five different patients with HH, each of whom had defects that modified the shape of the protein in different ways. Although these results have been obtained only in cells grown in the laboratory, there is good reason to suggest that similar effects may possibly be obtained in HH individuals with these defective genes, thus reversing the cause of their infertility. Of even greater importance, these findings provide a glimmer of hope that drugs similar to those used in the HH experiments can be developed to rescue abnormal proteins linked to other diseases, such as Alzheimer's disease, cystic fibrosis, and hypercholesterolemia, which also fail to fold normally. Thus it is possible that this finding for HH will ultimately have enormous impact on improving human health.

NEW INITIATIVES

Expanding Current Programs and Piloting New Initiatives

FIC will use available resources to continue to support all existing programs, including AIDS, TB and malaria, while developing new initiatives and expanding existing ones.

Strengthening the Global Culture of Science

For scientists to work as equals in collaboration with colleagues around the world, there must exist a shared culture of scientific ethos and values. FIC will continue to enhance the scientific capabilities of investigators in partner institutions in the developing world to promote a global culture of science and to establish a firm framework upon which equal collaborations can be built. Such efforts benefit both the U.S. partner and the foreign scientist and ultimately the global community through dissemination of research results generated through scientific rigor and the use of a common set of guiding principles. To accomplish the broad objective of strengthening the global culture of science, FIC will expand existing programs in information technology, genetics, and bioethics and will establish new activities in FY 2004 that contribute to the objective through the establishment of:

Pilot International "Glue" Grants.

Biomedical science has entered an era in which new approaches to solving problems is required. Individual laboratories working alone are no longer the only means to move scientific fields forward: at times, new approaches effectively linked together, involving a consortia of laboratories, may lead to success more quickly and efficiently. This model has been demonstrated to work, exemplified by the recent triumph of an international consortium of scientists in the public arena in sequencing the human genome. Another winning example of an international public-private consortium has been the sequencing of both the parasite causing malaria, Plasmodium falciparum, and the most important mosquito transmitting malaria, Anopheles gambiae. In FY 2004, FIC will begin to support consortia of FIC-supported institutions in the U.S. and globally around specific disease topics. FIC could "glue" together regional institutions that are already working on specific disease areas and link them in order to leverage each other's strengths. This same mechanism might also "glue" together various FIC-supported departments within the same foreign institution. With 26 FIC programs working internationally through over 100 institutions in the United States, there are frequently settings where several universities work collaboratively with different departments in the same foreign institution. To "glue" the foreign investigators together in a common framework capable of operating more cost-efficiently and with greater productivity, supplemental funds would be provided in areas of need, linking the diverse departments in the foreign institution into a "virtual center of excellence in global health."

Using Mathematical Modeling to Identify New Health Strategies.

An FIC-based research group principally investigates global patterns of the emergence and transmission of drug resistant organisms, influenza and the potential re-emergence of mosquito-borne diseases. The group creates mathematical models that incorporate biological, socio-behavioral and operational sciences in their analyses in order to identify critical questions to be addressed in informing public health decision-making. Two recent consultations have been held with senior USG policy-makers, the first to show how the analysis of infectious disease transmission patterns could help to prepare for potential bioterrorism events and a second to help shape and broaden public health policies in the event of a smallpox outbreak. Current efforts are focused on modeling the different courses that a pandemic of influenza might take. All these efforts will be continued in FY 2004.

Improve Health and Medical Reporting.

The news media is a major source of health information for large numbers of people around the world. In developing countries, where few individuals have access to the Internet and access to health care providers is often limited, the news media may be the only available source of information about health for both policy-makers and the general public. This underscores how important it is that medical reporting by journalists in the developing world be accurate and easily understood. However, in many if not most developing countries, reporters covering medical stories have little or no training in medicine or public health and only modest or no formal training in journalism. Medical editors of scientific journals also play a critical role in providing health information, because medical practitioners and the scientific research community rely upon these journals to inform their health care decisions as well as their research. Currently, developing country editors lack exposure to their peer groups in the developed world in a manner that can contribute to raising standards in local medical journals and enable developing country medical writers to publish in mainstream developed world publications.

In an effort to increase the accuracy of health reporting in the mass media and to raise the scientific and quality standards of local medical journals in the developing world, FIC will work to raise the levels of scientific sophistication among journalists and improve their abilities to write critical pieces on scientific advances or other health information targeted for the general public. FIC will work with schools of public health and schools of journalism through linked efforts that would result in new public health curricula for journalists in the developing world and with prominent journals and their editors to create opportunities for medical editors from the developing world to increase the quality of peer review, writing, and editing for their journals. Significantly, for long-term sustainability, this program will integrate with existing programs and aim to build capacity within developing countries that will allow them to offer their own training to these critical information sectors.

Focus on Global Health through the Gender Lens.

Issues of gender are receiving increasing attention in all areas of health research. Risk factors in heart disease prevalence, progression and response to drug treatment or surgery for example, differ dramatically between the sexes. FIC, working closely with the Office of Research on Women's Health, will utilize existing programs to further support research and research training on gender issues in priority global health areas in the developing world. The impact of pollution on women's health and related risk factors, the impact of stigma on women with AIDS in seeking health care, and the progression or incidence of cancers in women, including those related to smoking, are just some of the areas that would be relevant for study through FIC programmatic efforts. In addition, recognizing that the relatively low societal status of women in many countries around the world prevents them from initiating, establishing, or advancing careers in the life sciences, FIC will enhance its efforts to bring women scientists from the developing world into medical research, from early professional training to the senior scientist level.

Strengthening Ongoing and Cross-cutting Programs.

In FY 2004 FIC will expand its research training programs in the field of bioethics in research. This program will continue to produce a cadre of highly qualified ethicists in the developing world to lead reviews of human subject research protocols, to pose complex bioethical questions in the context of local norms, and to work with all who are involved in health and health research within and outside the country to reconcile differences in perceptions or practices. Only such a sustained effort can insure that the "supply" can keep up with the "demand."

Continuation of two program areas that support critical technologies underpinning the scientific enterprise in the coming decades, information technology and genetics, are similarly planned. The International Training Program in Medical Informatics and the International Collaborative Genetics Research Training Program already link researchers and training experts in their respective fields into global networks. Enhancement of these programs will allow greater participation of developing country researchers in the scientific enterprise.

Strengthening the culture of science requires that investigators around the globe share a common set of values. In order to foster this common linkage, training programs for foreign scientists and U.S. scientists in the formative stages of their careers are essential. Support for U.S. health professionals to gain developing country research experience, particularly early in their careers, is one of the most effective ways to instill a commitment to remain involved in international research and global health. FIC's International Research Scientist Development Award (IRSDA) program supports young U.S. investigators to gain experience conducting research in the developing world under the mentorship of senior investigators in the field. On-the-ground training provides the opportunity to conduct science in settings with limited research capacity as no other research experience can. The IRSDA contributes significantly to the generation of biomedical information relevant for the U.S. as well as for the site where the research is conducted.

Additionally, FIC, working in partnership with the Ellison Medical Foundation, intends to establish a new initiative for U.S. medical and graduate science and public health students to train in clinical research for one year under close supervision in the developing world. This initiative will expand the pool of future U.S. leaders with the needed skills to design and conduct research in collaboration with developing country researchers on critical global health problems. Recognizing that such programs should benefit the host country, where there is a shortage of qualified, clinically trained investigators, FIC will pair medical, science and public health graduate students from the host country with U.S. students to work together.

To make these collaborations successful, there is a simultaneous need to help launch the next generation of scientists in the developing countries. FIC's program, the Global Health Research Initiative Program (GRIP) for New Foreign Investigators, supports the re-entry of young NIH-trained foreign investigators from the developing world to their home countries following research training in the U.S. In partnership with other NIH institutes and offices, FIC aims to enhance scientific research infrastructure in developing countries while supporting research on critical global health issues, including AIDS, women's health, the impact of environmental pollution, cancer, and the growing burden of neurological and mental illness. The GRIP is an important means of combating "brain drain" or "brain flight" and ensuring that developing countries do not lose the benefit of talented scientists while providing opportunities for U.S. scientists to continue to work with top-notch young investigators in developing countries on topics of relevance for both.

Addressing the Growing Burden of Ill Health due to Trauma and Injuries.

Every day, almost 16,000 people die worldwide from injuries. Many more survive with permanent severe disabilities. In low- and middle-income countries in the Western Pacific, for example, the leading injury-related causes of death are road traffic injuries, drowning, and suicide, while in Africa they include in addition to traffic injuries, war and civil disorders, and crime and interpersonal violence. In the Americas, the leading injury-related cause of death among people ages 15 to 44 years in the higher-income countries is traffic injuries, while in the low- and middle-income countries of the Americas it is interpersonal violence. With the continuing increase in numbers of youth, who are typically uninformed risk-takers, the burden of ill health due to injuries is expected to rise dramatically in the coming decades (Global Burden of Disease Report). FIC is partnering with the National Institute of General Medical Sciences and other interested NIH institutes to develop a multidisciplinary research training program in the field of trauma and injuries of importance to low- and middle-income countries as well as to the U.S. Activities ultimately supported include those aimed at improving the understanding of the body's systemic responses to major injury; fostering more rapid application of this knowledge to wound healing following trauma and burns; developing innovative low-cost and low-maintenance prosthetic devices; and integrating mental and physical rehabilitation into primary care for victims of trauma, and to develop and test effective interventions.

CONCLUSION

FIC programs, seen in the context of the development of multi-disciplinary centers of excellence in developing countries, combine FIC investments in specific disciplines, diseases, and cross-cutting initiatives, linked through research and training efforts with U.S. universities, and with those of other ICs. These linkages will create an integrated package, allowing the expected benefits of all FIC and NIH global investments to become considerably more than their sum. It is in this way that FIC adds value to the whole of the NIH while forging new directions in international research, oriented towards insuring a better world through "science for global health."

A classic Arab proverb says "He who has health, has hope; and he who has hope, has everything." Unquestionably, health and disease are universal concerns-they transcend national boundaries and strike at the core of who we are as individuals, families, and societies. Americans have a strong humanitarian tradition and have long supported efforts to improve the health of people around the world, regardless of social and political circumstances. In fact, the direct interests of the American people are best served when the United States promotes global health because healthy nations are more likely to develop economic prosperity and enjoy political stability. It is critical, then, that we maintain our efforts to improve global health through cooperative actions using our scientific and technical strengths. Improving global health is an investment in human capital and in the future; building research capacity and empowering nations to improve health are critical means to breaking the cycles of poverty and political

volatility. They can only be achieved when nations share intellectual capital and goodwill through cooperation and collaboration in exploring, developing, and implementing ways to improve the human condition. FIC and NIH will continue to lead in these efforts.

BUDGET POLICY

The Fiscal Year 2004 budget request for the FIC is $64,266,000, including AIDS, an increase of $2,450,000 and 4.0 percent over the FY 2003 amended President's Budget Request. A five year history of FTEs and Funding Levels for FIC are shown in the graphs below. Note that Fiscal Years 2001 and 2000 FTEs are not comparable for the NIH Human Resources functional consolidation and the transfer of the International Services Branch.

Column Chart: FTEs by Fiscal Year
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Column Chart: Funding Levels by Fiscal Year
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NIH's highest priority is the funding of medical research through Research Project Grants (RPGs). Support for RPGs allows NIH to sustain the scientific momentum of investigator-initiated research while providing new research opportunities. In FY 2004 NIH policy provides for an aggregate 3.0 percent increase in average cost for RPGs. FIC will provide an aggregate average cost increase of 2.6 percent for RPGs.

Also in FY 2004, FIC will fully fund 1 grant, an R03 called the Fogarty International Research Collaboration Award (FIRCA).

The Fiscal Year 2004 request includes funding for 183 Other Research Grants. Research Management and Support receives an increase of 1.8 percent over FY 2003.

Funding for Biodefense activities continues in FY 2004 at the $500,000 funding level. The budget request also includes $40,000 for the Best Pharmaceuticals for Children's Act studies.

The FIC plays a critical role in ensuring that the United States meets current global health challenges and prepares for future challenges. The increase requested will provide the FIC essential resources to enhance its scientific leadership to meet these challenges.

The mechanism distribution by dollars and percent change are displayed below.

Bar Chart: FY 2004 Estimate Percent Change from FY 2003 Mechanism
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