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So I've been thinking the global health in the twenty-first century for
us
represented the aging of the population a worldwide and the company changing
patterns of disease of this brought.
it required in the new solutions and new technologies.
We had to learn how to implement what we know.
We know a lot about hypertension.
We don't know how to get hypertension treatment programs into the field
and how to get people to be adherent to treatment.
Whether it's for hypertension
for statins for cancer therapy for
anti microbial agents
we need to think about the revolution's not only in biomedical science
but engineering
but also health.
information technology and long distance learning.
All of these which would allow us to work more globally
tomorrow
more than we had today.
And multi disciplinary programs that we have a framework grant at
Fogarty one of which came to michigan.
It's not in the school of Public Health and Medical School
it's at the level of the University and it requires that the university bring
together
not only medical schools & nursing schools and schools of them
business schools because of supply chains,
law schools because
the framework convention for tobacco
was a legal document but it was a major importance for human health.
Economics we saw with Dean Jameson, behavioral studies for
implementation; global health must be much broader.
Well I came to NIH I started going around to the different institutes and
center heads.
I started with Tony Fauch who is really the guru of infectious diseases
and he showed me here
it global health for him is emerging infections. The idea that
any infection
anywhere on the world can be on our shores in one plane ride.
So global health was clearly infectious diseases.
Then I went to the head of the cancer institute.
He said well you know eighty five percent of the cancers in the world
today a new cancer deaths
are in low and middle-income countries.
So really cancers are global health issue
and many of those cancers
have an infectious etiology. Papillomavirus EB virus and the like
So cancer is really a global health issue.
And if you see that red area in the map in middle of Africa
Amazing discoveries happened there and i'll tell you about them.
I also spent some time in oxford with sir richard Doll really well known for
the doctors smoking study.
And when I was there in the seventies he had just finished twenty years of the
doctor studies
which documented that
cancer and heart disease were major killers of people who were smokers,
physicians who were smokers.
And we said Sir Richard why don't you say something political? Take tobacco off
the
off the stands. This is the biggest impact that you could have.
He said, "No Roger,
I'm an Epidemiologist I'm not a politician I don't do that. That's for
the politicians."
And consequently
over it took twenty years for smoking to decline
in England.
As you can see here that
lung cancer mortality coming down nicely over the past four years.
Across the english channel
twenty six miles away
in France
you can see just the opposite thing happen.
So
clearly while we have the knowledge we didn't have the knowledge to implement.
And this is clearly a problem globally. And when you think about China today,
they say one-in-three smokers in china
will die of their smoking and something like sixty to seventy percent of
physicians smoke just like in the united states in the fifties.
Isn't there something we should be able to learn and to teach.
And is this smoking problem gone away in the US?
Is that tobacco problem over?
Mike my son who's in college
thinks that smoking a hookah is really in
and yet
twenty percent of americans smoke,
hookah smoking is still hazardous cigarettes are a major US export
and there are new ways to use tobacco that specifically target our young.
We haven't begun to yet fully address the tobacco problem.
Well going back to that red zone in the map of cancers in africa
here's a physician who went out to africa is a young man,
Dr. Dennis Burkitt he ended up at Mulago hospital in Kampala
and found patients
His patient like this with big lymphomas of the jaw.
He founded this was
african lymphoma, was later called Burkitt's lymphoma
Very important because what we think about cancer.
Is cancer problem in the united states?
Sure it is.
And what's the idiology?
Well this was the first demonstration that viruses cause cancer.
In the EB virus was linked to cancer not because of studies in the US to europe
but because
and observer a skilled observer working in a in an African setting with his
colleagues identified a new form of cancer,
linked that to a virus
and opened up the idea that viruses can cause cancer. And now there are a number
of infectious agents that cause cancer that are all addressable by infectious
means if we put our resources to it.
He then went to Sloan-Kettering in the sixties one anti
chemotherapeutic agents were being developed.
He took home some
methotrexate in his pocket,
he gave it to those patients
and two weeks the cancer melted it was the first demonstration of chemotherapy.
that that showed its efficacy. Really charge the community to think
that this was a
an approach to go.
So this is clearly
learning from
african
settings, african problems
adapted to our own work in the united states.
Where we've all learned about
cancer it's ideology it's prevention and treatment.
Well I then went to Francis Cullins who was in charge of the genome institute.
And I said Francis
what is global health to you?
He said Roger
we have a melting pot in the united states of people who've come from all
over & this is that signature
of the united states.
People have brought their genes with them
and we have a hard time figuring out everything from the genes of americans
because they're all mixed but we have them all. And the genetic diseases of the
world they're on our shores
and as I was graduating from college
you remember this guy *** guthrie singing "This land is your
land"
One of my classmates Nancy Wexler she
found that as she graduated her mother came down with huntington's correa.
Just a devastating neurological disesae.
We have a couple hundred thousand people in this country who have the gene of
huntington's,
about twenty thousand new cases a year.
And she had a fifty-fifty risk of having this.
Where did she go to find the genes of huntington's?
To a small area Mericival, Venezuela
where a single woman who migrated from europe in eighteen twenty-four
brought the genes
went through six generations of grandchildren great-grandchildren to the
point where there's such a concentration in patients with huntington's,
that the genes of huntington's were found in this community. And the gene was
actually discovered by Francis Collins but it was because of the epidemiology
and the concern of this community
for people who were developing this that this disease.
Well if you look in the audience and if you look for daily the older people in
the audience
a third of us will come down with alzheimer's before
before we die.
So it's one of the most costly diseases we have.
Where will we find
the cure and the prevention and the studies of alzheimer's that would be
most productive?
Well we have so many cases in the US
there slowly progressive there's a great diversity.
But in this community in Columbia just like the community in Venezuela with
huntington's,
there is a community
that's been studied, well studied
to
going back to a single woman who came to the to
Columbia
in about seventeen forty five.
Here is her family tree.
It's a community that has a high prevalence of alzheimer's disease
It presents early in life, thirty five or so
a high penetrance by age forty.
If we're going to understand biomarkers
for huntington's for alzheimer's disease,
and monitor treatments as it goes forward, this is the ideal community to
work with. Its a devastating public health problem in Colombia.
It's a major problem in the united states as well
and now patients that the genes have been identified as the picha mutation.
Patients from this community or bring brought to the united states
to be able to do find early markers of disease and disease progression
and too begin to think about new treatment of disease.
Not in the American community where the same studies
would take ages we want progression and new genotypes
but here in a group where the genes are very well-known and the treatments could
be worked out.
Another advance word global health research,
and a public health problem locally could help us
globally.
And this goes on to environmental disasters
and Tom worked on these and here at Michigan.
Clearly their global problems we could all suffering nuclear
meltdown. The fact that it's in Japan
doesn't mean it's any less importance to us.
If not
it's really more important because we can understand how we might react if
this were to happen on our own shores.
So I got to Fogarty
and here was my mission
and therefore we mentioned it to address global health challenges
through innovative and collaborative programs
of research and training.
And to support and advance the NIH agenda and mission thru global
partnerships
and science for global health,
and so this is what I've been doing for the really for the last six years.
Fogarty is one of the twenty seven institutes and centers at NIH, we work
with almost all of them.
And when I got there
the issue was
what what is in our portfolio what can we do?
And I learned
and I learned it at NIH many of you look at the NIH catalog
were full of acronyms.
And I was greeted with all of these letters some of which you're familiar
with here in michigan. The framework grant that you have
the a ITRIO grant that
environmental and occupational health.
The AIDS international training and research program
but all of these had some common themes.
One was collaborative research and really good strong partnerships with
with between US and foreign institutions.
Another was research training in both foreign
investigators in US fellows
and the development of institutional capacity
because we see the global community is a community where
it would really on the frontiers of research and where we need to help.
Well we our first signature program was as AIDs international
training and research program.
We took in nineteen eighty eight
AIDS it was a
US problem we didn't think about the tremendous mortality that would be
occurring in Africa over them
the next several decades.
So each of young physicians in infectious diseases we brought them to
the US and trained them
in AIDS because we have the population of patients
and we've been doing the studies of the first drugs were being developed.
They've gone home
and they are now absolute leaders twenty years later
in the research endeavor.
And almost every major advance in drugs
microbisides in circumcision
and vertical transmission studies has been done
through the work of many of these people.
They are really the leaders there are collaborators shoulder to shoulder
working on diseases where we share a common interest
and we value the common results.
So that was really a model to me of what we can do and how we should be doing
things, and the ITRIOS is another program just like that for an environmental and
occupational health
Well who are the leaders of global health in the US?
I did a little landscape analysis and you may know or recognize many of
these people.
And I scratch my head and I said isn't this an interesting picture.
I said first
they're all old white men.
The second is that except for Alan Rosenfield they're all in infectious
diseases.
So this is in the twentieth century but they've had one thing in common and what
they had was that early childhood exposure experience.
They all went overseas early in their careers
they got someone glommed down to a project of interest
that they didn't change their orientation.
And whether they came back to work in the US and
issues of equity or in global health
they've remained as leaders in the field. Doing something that they probably never
thought they would do when they were in medical school learn early training.
So we said how can we change this picture & we do have a very
active program of fellows and scholars we've had many people from michigan
involved,
both medical students
and post doctoral programs. And this has been one of our signature program in a
program that we have been growing since I've been there.
In fact we just re-competed this
we've gone from one center
handled by Fogarty to one center at vanderbilt to five consortiums.
Michigan is part of one of the consortium we have
new fellows this year
and we've had buy-in from seventeen of the
institutes and centers of NIH
who all see this is the way for them to develop
research scholars and partnerships for tomorrow.
We can find infectious disease people who've worked in lower middle-income
countries
all over,
but we don't we have a hard time finding a cardiologists
who's worked and thought about developing country issues
a cancer specialist and beyond.
This is our program we're gonna have about eighty
fellows and scholars this year
and I hope that that will grow in the years to come.
And they'll spend a year in research developing a research proposals
for the fellows and post docs in any specialty and they will use this
experience to build a partnership to start their research activities and to
get further funding to continue
what I would say would be a long term relationship or love affair if you will
in research.
We also moved on for people who are not in the consortium
to have a Fullbright Fogarty fellowships
followed by a fulbright early my career.
that there here's ago they say they'll
biomedicine is something different from what we do with the fulbright
and they really were dismissive of the idea or put less emphasis on the idea of
public health.
We've been back speaking with them for the last several years we now have a
Fulbright Fogarty program
for both medical students
and post docs to spend a year in a lower middle-income country working on a
our health priority.
And it works both ways foreign scientists can come to the US
and the specialties that we will accept
will be almost anything on the NIH scoreboard. Be it engineering
IT
Law related to global health and the like.
and our scholars have done the amazing things and you're going to be hearing from
your own scholars this afternoon.
So I'm not going to dwell on some of the interventions.
Another area that we've seen is a trans NIH and a very important areas
mobile health and using ICT information communication technology
to advance our global health agenda.
so we've had mobile health symposium the next one's in december in
washington.
We started out four years ago thinking we would have about a hundred and fifty
people interested in mobile
phones and their use in medicine.
Last year we had thirty five hundred people this year five thousand!
Incredible
razzle-dazzle technology some of the ideas are absolutely wonderful!
Evaluation
implementation
is really quite major, and there is paucity of the of research in this area.
That's something were NIH
and researchers like you in academia
can really provide as the feedback we need.
For instance Francis collins Dr. Collins was in India
and he demonstrated on tv
he had a i-phone
with an EKG monitor that fed back to his cardiologists in Los Angeles who is
doing your research study.
It seems like a no-brainer to be able to monitor your heart if you have an
arithmya.
Doesn't that sound wonderful?
Well they've been to people of a cardiac surgery because
their monitor picked up by an arythimia
that didn't need to be treated
but first whatever reasons was a complications so we clearly have
something to learn
insist and ideas in innovations
that have to be proven demonstrated limited
then perhaps regulated.
And that the number of these devices
uh... that have come out from mobile technology are fabulous.
Cell phones that are linked to microscope so you can look for sickle
cell in Africa
you can look for infections
of different sorts
they can feed to computers and be read by others fit for confirmation.
Realtime adherence
for our programs for moderate therapy. Be it for
TB for cancer drugs for hypertension heads
the idea that you can identify using compliance programs
people who are good in compliance
and people who are bad in compliance.
So you can you can work through when and put your resources in the proper place.
Physician training and fish position training for the twenty-first century.
Here's what the physician
distribution looks like globally and you can see in sub-saharan africa
a real paucity of physicians.
We have a medical education partnership initiative which is new
and it we're providing grants with the partnership with PEPFAR and with HRSA
to thirteen programs in twelve countries.
and many of the people in the audience or from institutions in Africa that
received grants from this.
The idea here is that with PEPFAR
this was an emergency program to start AIDS treatment
and prevention
lots of ngos were involved
and it was really an emergency basis.
Now that that was the demonstrated successful now that the price of anti
retroviral since came down
now the new strategies for prevention of available,
implementation for this and other programs
needs to be done locally by local researchers by local physicians nurses
paramedics
and the full distribution of health
professionals.
So this program is to build up that capacity in Africa
as well as the research capacity.
I was just at the second annual meeting
of the mapping consortium.
You can see a couple people here with the michigan tag on there
chest next a minister Thedros
Joe Cullers wherever you are
and Senayat
were there specifically working with this group to build up
training in
here in in ob-gyn. And Senayat has done an amazing job to build up the ability to
train obstetricians and an gynocologist
so the problems like fistula and fistula repair
safe delivery, maternal mortality
can be addressed. What an amazing contribution and whatever interesting
research agenda
that's been developed
right here connecting michigan
to Ethiopia.
Well another agenda thats on the horizon clean household air pollution
will and answering in addressing the question will clean stoves
improve health?
You know it's estimated by debbie which other about two million deaths a year
from the indoor air pollution.
And indoor air pollution
really
harms women and children who were indoors at cook stoves
in the contaminated
polluted areas.
So it seems like a no-brainer if we can put in clean cook stoves clean up the
indoor
air pollution
and improve health from a variety of diseases. Be it from low birth weight of
infants
to accute aspiratory disease in children
TB synergism
cancer, cardiovascular disease,
chronic lung disease, heart disease and and the like
it's just like clean water in Bangaladesh.
It seems like a and no brainer to clean up the indoor air pollution
but how we do this is a defective is there a research agenda
which can go hand-in-hand
with implementation?
Well the clean cook stove alliance
is trying to introduce a hundred million cook stoves
by 2020.
And NIH is partnering specifically so we can get the research agenda and
figure out
how much we have to reduce indoor air pollution,
what are the true benefits?
What are the risks? What happens in Tibet where that that warm
cook stove indoors
is part of the heating system, and will this kind of initiative work in those
kinds of settings.
So here we have Tom Robbins
working on just this kind of research and
thinking about environmental health and
and pollution
right here in Michigan.
And another area an opportunity for students
has been this peace corps for doctors.
We've said that in our mapping programs
we do a lot for research we do a lot for undergraduate training in their nurses and
doctors,
how about the clinical training which requires hands-on shoulder to shoulder
demonstration of good techniques of values of,
and the peace corps has been been working with us to get three teams for
next year of doctors and nurses
to go out to our MEPE the schools to start with three schools
and see if we can help stand up to a level of clinical training
so that we can
instill in the next generation of physicians in training
values, ideas a
and bring them into what we would call optimal
clinical training experience.
Implementation science
an area that NIH is that we've been wonderful at NIH to develop new
vaccines new drugs
new ideas for treatment.
We haven't been so creative and how to get these
heidi is implemented.
Is there a research agenda around behavior?
Around sticking points to identify
what would help implementation turn
into action to help implement
many of these interventions as we go forward.
That'll be another area that week
there we see in this in the future.
So at Fogarty were a little bit like the watering can for
for this type of thing
capacity-building.
For research and for interventions
with many collaborative relations.
Our strategic plan has focused now for the twenty-first century not only on the
infectious diseases in *** which is clearly critical in Africa
and around the world,
but also the non-candidate paul disease agenda.
We're thinking about implementation signs and had a bridge that gap.
We're working in a critical area priority for us is developing human
capacity
of fostering sustainable research environments in low-income countries
and in building strategic
partnerships and alliances.
I think in global health today
no one can do it alone and we've been working
closely with
WHO and the world bank now that Jim Kim is there.
With Universities like Michigan
with other government agencies I mentioned the peace corps we have a
program with USAID
called peer health
to partner and support researchers in low-income countries
in implementation studies. With the private sector with public-private
partnerships
foundations
NGOs and of course the other institutes in centers at NIH.
And so I've become an astrologer.
Why an astrologer a scientist? Why I've seen the stars align I've seen the
President with commitment to research
and global health
I have an NIH director who's put this as one of his priorities.
We've had now the development of the consortium of universities for global
health
which is in the sense of interest group of universities that feel the global
health is important
and can support the agenda
the global the agenda
and in so doing supporting us at Fogarty
and with unique opportunities in the world for interventions in
advances.
So I am in astrologer because I really do see this movie stars have been a long
line
and it's true these partnerships that will things good things will happen.
So funding in global health
despite our wildest imagination in nineteen ninety seven
have skyrocketed
and I really can't sustain despite all the politics that we hear
in washington
here we have that first meeting of that consortium cycle interest groups
for global health.
Notice the gender and age
of this group of people.
This has to change in the next generation!
Course the NCD agenda which is taken on global perspective
with the UN general assembly.
Of course the shape of things to come the problems that we're all going to be a
facing as we go for it
not only obesity
addictions, the environmental hazards climate change
health equity at both the abroad and at home and here's doctor collins
who's put on his five topics
expanding research into diseases affecting the developing world.
why would doctor collins
and geneticist
thing so warmly about global health?
Well as a young physician he went out to nigeria,
he worked out he was a michigan actually he went out to nigeria he worked there
as a physician he found patients who came in
with diabetes who weren't the normal phenotype of diabetes
and he said this was something wrong with the something different.
He found through this experience the first genes of diabetes
uh... there were isolated so we've learned something from his work in
global health
and his continued interest even though he's not
on the front lines of
of global health in the sense of being out there doing insulin. He has a
tremendous concern for this in the world
the beneficiaries of this concern.
What can Michigan do for global health?
You're going through a lot and I really applaud you for what's going on already.
Encouraging electives of students and faculty.
Building your partnerships in these
caring twinning relationships.
Encouraging innovation and distance learning. Engaging the larger academic
community like the framework program.
So they're many opportunities available
and the time is really right for this so I applaud you for what you're doing and
I hope that through for reduced programs
and many others
you'll continue.
I'm often asked that I was asked by a congressman
going back to a state with lots of tax cuts and why should we in vesting
global health?
And I told them my story about oral therapy
and I told a bunch of these stories were he never knew that what he was
benefiting from whether it was cancer chemotherapy or or treatment of diareha in
his own children
where the responsible will health research.
So I said really it's good for scientists the next frontiers the genes
and then
environmental exposures and what we've learned. It's
good for diplomacy it's really smart power call by Hillary
leading smart power.
It shows the humanity of the United of Americans and correct health.
We can correct an address health disparities in what we see overseas we
can bring back
and learn at home. It's good for business in competition
school for a war on terrorism
terrorism it's good for our own future it's just the right thing to do.
So with that i want to thank you all for asking me to speak here
unless they have
most impressed by what you're doing a michigan i'm delighted to see so many
students in the audience because
I've just remember
in listening to
the
words of kennedy when he launched the space program is that we're going to put
a man on the moon.
By the end of the decade nineteen sixty nine when they arrive
in nineteen sixty nine when men a little man was landed on the road in houston
the average age of the engineers in that
control center
was about twenty seven to twenty eight.
Those people who were controlling
the moon landing
we're not in college or just entering college when day
when the the the challenge was issued by Kennedy.
So it's really in the youth they were going to see
the fulfillment of these global health ideas and agendas for the future
so lot remains in your hands
and I wish you well and i'm delighted that you have
highlighted this is a priority here in michigan.
Thank you so much for letting me.