Can Global Health Research Add Value to Cancer Prevention and Control: A View from Fogarty

Sudha Sivaram: I thought that was loud enough, but I guess not Good afternoon everyone, welcome to the Center for Global Health Seminar Series This series is meant to simulate discussion of ideas around global cancer research, and we are hoping to invite a distinguished panel speakers, and as we can see, we already have a very distinguished panelist in our midst today who’s going to be talking This is the second in our series we started last month, and thank you for attending I’d like to get things started by introducing Dr. Lisa Stevens Dr. Stevens is the Deputy Director of Planning and Operations at the Center for Global Health at NCI So welcome everyone and Lisa Lisa Stevens: Well thank you Sudha It’s my distinct pleasure to have the opportunity to introduce our speaker today, but before he comes to the microphone I’d like to say a few words about him and the Fogarty International Center So the Center for Global Health is just one year old right now, and I have to say that I think one of our key partners in the standing up of the Center has been the Fogarty International Center Their cooperation and support has been vital to what we’ve been able to do over the year, and I think that speaks to Dr. Glass’ leadership So Dr. Glass has been the Director of the Fogarty International Center since March of 2006, so he’ll be coming up on his seventh anniversary very soon And he asked me not to make the introduction too long, and I don’t want to take away from his remarks, but I just want to highlight where he has continued to maintain field studies while running the Fogarty International Center So he still maintains field studies in India, Bangladesh, Brazil, Mexico, Israel, Russian, Vietnam, and China, and it says, and elsewhere So I’m not sure when he has time to sleep, but I do even more so appreciate the fact that he’s given us his time today So Dr. Glass, please come He’s asked that questions stay to the end and just remind you that all presentation and questions will be recorded So thank you Dr. Glass Roger Glass: Great Lisa, thank you – thank you very much, and I’m delighted to be here You might – my slides are here; a little help The buttons are not – we’ve got to get them going Woman: Here they are Roger Glass: Okay Yes, okay I’ve got my blinders on It’s not there Great – okay Let me just start by – first, I’m delighted to be at NCI and to have your Center for Global Health started It’s been fun to watch this go, and I’ve worked with NCI since I got here And I thought I’d give you a little bit of my background because in fact, I think that global health and NCI and cancer are really part of my early formation and part of the reason I’m so excited to be here I grew up in a small town in Somerville, New Jersey, right near Manville, which was the site of Johns Manville And my father was an orthopedic surgeon, and his friends were all radiologists And in the 1950s they began seeing patients with chronic asbestosis and mesothelioma It was a very rare and almost unknown disease in the United States, and yet here in the middle of New Jersey, in the middle of nowhere if you will– a small town, local radiologists were picking up mesothelioma And the links to, between mesothelioma and asbestosis exposure are now well-known And when I got interested in this in the School of Public Health, I began realizing that this asbestosis came from South African mines and Canada, and this was really a global health problem So my interest in global health really began as a child in a small town in New Jersey, being linked to a global cancer exposure When I finished my internship I then went to Oxford and I worked with Sir Richard Doll, who was really the preeminent epidemiology of the 20th century and really preeminent in cancer His book and his text on cancer in five continents was really the 50-year-old version of The Cancer Genome Atlas and a lot of what’s going on today Because all that we had to distinguish the differences in the distribution of cancers was their epidemiology And the fact that he had made these observations that you had lots of esophageal cancer in the Far East and hepatomas and the like, the distributions were different and that led

to the opportunity to understand environmental influences as well as genetic influences He also, while we were there, was doing – had just completed the 20 years of the doctor’s smoking study You know my parents smoked when I was growing up They smoked Camels, because three out of four doctors recommended Camels You know, you had doctors in white coats recommending it And in 20 years we had, you know, tremendous data on the importance of smoking and lung cancer And when he made these observations we said to him, “Sir Richard, why don’t you go out and do something about it? Why don’t you talk to the Brits? It’s the biggest risk factor for cancer Why don’t you have them reduce smoking in the UK?” And he said, “You know Roger,” he says, “I’m an epidemiologist, I’m not someone in policy And so we don’t do this; you know, I’ve provided the evidence and it’s for the politicians.” And if you look at the slide from Richard Peto you can see that in the UK cancer mortality has come down for lung cancer It’s taken 40 years and literally millions of deaths for that smoking to decrease this much and lung cancer to go away Twenty-six miles across the English Channel and France, people who had the same knowledge and data did nothing to deal with smoking And here in France, lung smoke – lung cancer after – from the 1950s, after the war went up in almost a mirror image to what happened in the UK So there’s some kind of a lesson here that while we do tremendous work in the epidemiology and understanding of these disease and risks, the implementation of these recommendations is hard to introduce in many countries I’ve been working for a long time in China And now, today in China – and Richard Peto has written about this a great deal – the risk of smoking and lung cancer and heart disease related to smoking is huge, and it’s really the epidemic of the 21st century for China The biggest – probably the biggest environmental risk there is today And yet despite the fact that we know so much about the links between smoking and lung cancer and heart disease and the rest – and the fact that one in three Chinese who smoke will die of their disease – we still have a problem So I realized that a lot of global health is not only in the basic research that we do, but in the implementation of the recommendations that come from that research When I was an undergraduate – and how I got involved and interested in global health was that as an undergraduate, I was in the History of Science And I thought about and I was introduced to this Broad Street Pump, the story of John Snow controlling cholera in the city of London And this was really the beginning of descriptive epidemiology It was also the beginning of global health because the quarantine services around the world were set up to prevent diseases like cholera from coming on our borders So in reading this as an undergraduate, I was young and idealistic, and I said, “Well if cholera is spread by bad water and by taking handles off the Broad Street Pump, maybe I should go out in the world and take handles off pump or provide clean water and see if I can do something for cholera.” And I ended up in Bangladesh, which is really the heartland of cholera in the world today for endemic cholera I went out to the community and there were two wells being put in to prevent the spread of cholera and to decrease the incidence And the two wells, after $100 million program to put two wells throughout the field area, made absolutely no impact on the incidence of cholera in that area How can it be that by providing clean water, microbiologically clean drinking water, you have no impact on cholera? And it really meant that while we understand some of the issues of cholera transmission, we really don’t understand people’s behavior and how they would drink from the tank waters and the river waters because the water was sweeter and was not contaminated So, with that I also learned that oral rehydration therapy, which was new at the time, could actually prevent cholera deaths in the field And when people say, what’s the value of investing in global health research for the American public I always come back to this example because here, the U.S. spent about $10 million in research to learn how to prevent cholera deaths in patients who were severely ill But in fact that $10 million has come back to be used by every mother who has a child with acute diarrheal disease, which is almost all mothers And the treatment for that is oral rehydration therapy which is exactly the same treatment

that was developed for prevention of deaths from cholera in Bangladesh Research in Bangladesh that led to a very common treatment for diarrheal diseases – the most common treatment in the United States today So I went on to learn that cholera wasn’t the most common problem in Bangladesh but rotavirus was; a disease that hadn’t been identified when I graduated from medical school And so I spent really 25 years, 30 years working on rotavirus prevention through vaccines We got new vaccines that were licensed in the U.S. They had been put into recommended for routine immunization of our children If any of you had children born after 2006 they would have gotten this vaccine or one of these vaccines It’s led to a 95% reduction in hospitalizations for rotavirus in the United States, which is huge It’s about a 5% decrease in hospitalizations of American children under five It puts me in direct conflict with my wife who’s the Chair of Pediatrics at Emory You know her bottom line is how many kids come into the hospital My bottom line is how many kids don’t come in for diarrheal diseases And so we have an active discussion about this But also in developing countries, the same vaccine is led And here in Mexico you see deaths The vaccine was introduced in 2007, and within two years diarrheal deaths in Mexico, diarrheal deaths have gone down by 40% due to one vaccine for rotavirus So I’ve seen amazing changes in global health and a vaccine that’s been developed for both domestic and global use come into practice And we have global recommendations for use of the vaccine The vaccine is in about 38 countries today, and we have a lot of agenda ahead of us for rotavirus I give this example because to me I learned a bunch of issues about global health messaging, but I think it carried forward for me at Fogarty And when I was asked to lead the Fogarty Center I was really an inch wide – narrow, if you will – in my research interest on diarrheal disease and very broad in – very narrow but very deep Now I’m at Fogarty and I’m a mile wide and about an inch deep, so it’s a completely different mission But what I did learn from this experience – what I did learn was that if you start by training people early — I never thought I’d work on diarrheal disease or global health when I was graduating from medical school — but by getting people involved in research in the lower-middle income countries early in their careers, it could really have a lasting impact on their careers Well also I learned that the simple interventions I thought about like prevention of smoking or like introducing tube wells in clean water don’t always have the impact that you expect I learned that unusual environments lead to unusual innovations And the fact that you have oral rehydration therapy developed in Bangladesh but being widely used in the U.S. is clearly a benefit of global health research I learned that these partnerships and global partnerships are absolutely essential And I’m still working in Bangladesh And I realized finally that you have to take science where the problems are and where their opportunities are And I think that’s really the lesson for all of us here at NIH But when I got to NIH and I got to Fogarty I was, I arrived just when this document — the Disease Control Priority Project — landed on my desk It was a project to address, if you’re a minister of health and you have $1 million, where should you spend $1 million? What are your best buys for global health? And this was led not by a physician, not by a public health guru or an epidemiologist It was led by an economist who said, “What’s the best buy? Let’s look at the value of our different interventions.” He started with this table, sort of a classic table showing life expectancy in the 20th century over time And you can see that in each cohort by age or by timing, our life expectancy has gotten longer despite income And this is really due to lots of interventions and lots of rural electrification, behavior changes technology But the bottom line is that life expectancy, longevity is the most important risk factor for cancer and is the most important risk factor for non-communicable diseases and chronic diseases So we have a lengthening prolonged life expectancy throughout the world

and it’s clearly critical Take for example China, where I’ve been visiting since 1977 Life expectancy has grown from 39 years in 1960 to about 75 years today, 2010, and it’s about 7-1/2 years of prolongation per decade It’s the longest prolongation of life – the largest prolongation of life in the history of mankind And this means that their problems in the 21st century are going to be with non-communicable diseases and with cancer So this really changes the way we think about global health And when we look around the world, with the exception of Sub-Saharan Africa, the prime causes of death are these non-communicable disease issues – cancer, heart disease, and the like So, global health in the 21st century is going to be with this changing pattern of disease due to age The idea that we share common problems and we need to have some common solutions, whether it’s for cancer control or hypertension, smoking addition or environmental hazards, we really need new solutions to the problems we have We need to implement the lessons we know We need to think about new technologies such as the use of mobile phones, information and communication technology, and really some of the most novel solutions are from the bioengineers From the lawyers who negotiated the framework invention for tobacco control, from business folks who know how to deliver drugs and vaccines to the most distant reaches – the same reaches where Coca-Cola can reach in Sub-Saharan Africa When I got here I went around and I talked to each of the IC directors about what they thought was important for global health, and of course I started with Tony Fauci because I’m from an infectious disease background And Tony gave me this lovely slide that, you know, that global health is really infectious diseases, tropical diseases because we’re never more than a plane ride from an infectious disease outbreak And it’s obvious to all of us that this is so Then I went to Francis Collins at the Genome Institute Francis said, “Well you know we’re a melting pot in the United States of people who come from all over the world We’ve all brought our genes together We’ve all mixed our genes here.” It’s very hard sometimes to decipher genes from a mixed pool But if we go back to where these genes came from we can actually find the roots of disease and maybe their cures and causes So I only come to perhaps the most important – one of the most important diseases of our times which a third of us – how many of you are over 50? The third of us who are over 50 will probably end up with Alzheimer’s some time in our later years And how are we going to find biomarkers for Alzheimer’s? Where would we find treatment? Well here’s an interesting area of global health where the National Institute of Aging has gone out to Colombia to a family of people – a woman who moved from Europe to Colombia in 1745 The genetics – she brought with her an unusual mutation for Alzheimer’s that has a presentation of early onset in the 30s in rapid progression in five years or so So that if we want – there’s a concentration of patients with Alzheimer’s who are in their 40s and 50s – young, rapid progression If we want to find biomarkers for this disease, this is where we can go And in fact now there are plans to bring some of these patients to the U.S. to look at biomarkers, to look at progression and to try new Alzheimer’s drugs It’s a really important way that we can get a hand up on advancing research in this critical disease, and it’s where a population in Colombia because of where investigators, unusual population provide extraordinary opportunities for us to work together to solve a common problem And there are many examples of these You know one of – I’ll move on I went to see NCI, and this was six years ago, and I said what’s the problem of global health for NCI? And my comment was, well, 80 to 85% of the cancers in the world today are going to be in low or middle income countries And many of these are diseases, just like Richard Doll identified, that are unusual Where are we going to find enough hepatomas to understand the genetics of hepatomas? Where will we find esophageal cancers except in places like Iran where they have unique populations and exposures?

The red band is the band of Burkitt’s lymphoma And if we want to understand Burkitt’s lymphoma, this is where we have to go So this is really a global problem and we can find – we can clearly understand the geographic distribution You may or may not know of Denis Burkitt, a British surgeon who in the 60s went off to Uganda, the Milagros Center, the same center that Dr. Varmus visited last year, and where Larry Corey has been working for about a decade Denis Burkitt found these children like this with a big jaw full of lymphoma He’d never seen this before He was uncomfortable that this African lymphoma took on the name of Burkitt’s lymphoma, but at the time EB virus had just been discovered by Epstein and Barr, and they didn’t know what diseases it caused And Burkitt made this association in a scientific meeting with these investigators and found that EB virus was associated with Burkitt’s And that was really one of the earliest demonstrations in humans that a virus was the ideologic agent of cancer Okay. So if we’re thinking about the importance of this observation, this scientific breakthrough in knowledge, it didn’t come from the U.S. or the English or whatever, it came from observations made on populations in Uganda He then went to Sloan-Kettering — Burkitt did — when they were beginning the first trials with anti-cancer drugs, and brought back some of the first chemotherapeutic agents, gave them – he put them in this pocket — this is the IRB of the time He gave them to patients and in two weeks this child’s lymphoma went away, the first demonstration of early encouragement that treatment of cancer could be effective Another discovery and advance of knowledge not made in downtown New York or downtown Europe, but in Mulago hospital So if we’re going to find new cures for disease in populations that are unusual, this may be where we have to go It’s clearly obvious for diseases like malaria, but for something like Burkitt’s lymphoma, if we want novel solutions to these problems this is where we’ll find them And the other example – I just mentioned this one because it takes me back to asbestos Here’s a group in Cappadocia where they build their houses with asbestos bricks And so – and they’ve been doing this for only 1000 years and they have the highest incidence of mesothelioma So the molecular understanding of mesothelian, the epidemiology biomarkers in treatment will probably come not from studies in the U.S. but from studies in places like this where the incidence of disease is so high and the treatment is so sorely needed And there’s also the genetics that now can be worked out, something that wouldn’t have been done locally but can be done through international collaborations, and the risk factors for mesothelioma in this particular community through international collaboration And finally on our Board, and I think on the NCI Board as well, Olufunmilayo Olopade who – a Nigerian woman oncologist now working in Chicago at the University of Chicago, who came to inner-city Chicago, found African American women who presented with their breast cancer really formative breast cancer – late When she put them on treatment they didn’t respond as American women did – as White American women did And she said – and many of the physicians, you know, this is just because of access problems — health equity — these women just don’t get access until their disease is formed and they haven’t been screened And when you give them treatment they don’t take it And Funmi said no, that’s not so and she looked at the genomics and she found that these African – the women that she saw in Nigeria who were just like the African American women, were triple negatives for markers of cancer And so the genetic basis of understanding the genetics of breast cancer, coming from an African woman looking at an African American and Caucasian U.S. population – to shake us in our understanding that African American women have to be screened differently and treated differently for their cancers – a vital observation made by an African in her own setting; reverse technology if you will And of course there are lots of environmental disasters that we know of, so that really global health has gone in the 20th century from being a problem of infectious diseases, tropical diseases, diseases that know no borders

to really the full diversity of diseases that come with aging, with exposure, with genetics and behaviors that are changing So the frontiers of biomedical research in the 21st century may really lie in the global arena They are unusual diseases but they’re diseases that we have here in the United States as well They’re unusual exposures like the exposures to asbestos, the exposures to smoking – exposures that we’re not completely sure of that may cause some of these other diseases Unusual populations – I was just with this morning with the NHLBI Centers of Excellence program, and a woman from China said, you know, we haven’t presented but we’re working on the largest salt intervention trial in the world And I said, ‘Why are you doing this in China? What’s the problem?’ And she said, ‘Well stroke is very important The number one cause of death in China is stroke.’ She said, ‘Second, you have a salt problem here as well, but all of the salt that we have is in formulated foods, prepared foods In China every mother makes her own food and puts in salt And if we give them low sodium salt we can actually change consumption of salt and we hope outcomes in terms of disease.’ So this is something we can do in China with larger numbers and with greater compliance than you could ever begin to think of doing in the United States And if we can show that this really works we’ll have a basis to reduce sale exposures in our own foods – a very nice observation Extraordinary partnerships that we have – when I was at CDC the issue of folate in neural tube defects was right on the front burner They went to China – the CDC group went to China – to work with the Chinese on a folate supplementation experiment; an experiment with half a million pregnant women — we would never find that here — to demonstrate that folate for the prevention of neural tube defects could have a massive impact and was a global remedy, if you will And really smart people and good partnerships So there are really unusual opportunities that we see throughout the global – our global partnerships, and this is exactly what NCI is doing through your Center for Global Health Well, coming to the Fogarty mission, our Fogarty mission is to address global health challenges through innovative and collaborative programs for research and training Now we’re about the smallest center on the NIH campus of the 27, so what can we do to help a giant like NCI promote your global health agenda? And I want to speak to this in my final moments Of course we help all of the ICs, but I’m here with NCI We have a portfolio of programs – I call it an alphabet soup, because you know about D-43s and A-trips, and age trainings, and emerging infectious diseases But what comes out of this and what Fogarty does extremely well are setting up collaborative research initiatives between U.S. and foreign sites and training U.S. investigators to work comfortably in low income settings Just like I started out in Bangladesh and am still working there, to have foreign fellows come and train or be part of training programs with U.S. investigators, and developing the institutional capacity through our programs in ethics, in research management, and informatics that allows international collaboration to occur by other institutes and centers at NIH Well when we began our global health programs in 1988, AIDS was a disease of the four H’s – hemophiliacs, heroine addiction, Haitians, and homosexuals — the four H’s But it wasn’t a problem of death in Sub-Saharan Africa in 1988 So we began our first AIDS programs — programs in AIDS — by bringing and training several dozen young investigators from low and middle income countries to come, to work in the states, to learn about HIV treatment and controlled laboratory diagnoses, and to go back home and continue these partnerships with their U.S. institutions This was 25 years ago We just celebrated our 25th anniversary These characters here who were babies 25 years ago, young fellows in infectious disease, are now among the leaders of research in the world today in HIV And almost every major innovation in drug treatment, in microbicide trials, in circumcision, in the prevention of vertical transmission of HIV –

almost all of these have had a PI who’s on this scale or came out of the A-trip program Beyond that, they’ve each trained literally thousands of young investigators along the way – so that in the microbicide trials that was published a year ago, there were six trainees who are co-authors on the trial It’s not just that they’ve learned themselves, but they continue They’re really just an extension of the NIH research network in the field, comfortable in working with their own population, understanding of our ethical rules and guidelines, able to handle financing of NIH grants and global grants, and many of them have sustained their activities in their research through partnership with welcome through other governments through getting the national governments involved It’s been an absolute game changer for the AIDS community We’d like to see that happen for cancer We’d like to see it happen for heart, lung, and blood diseases, diabetes, addictions And so this has been our working model and it’s worked very well Well when I came here I said, ‘Who are the leaders of global health today in the world?’ And I went around and I looked at many of my contemporaries, and I said, ‘this is an interesting picture.’ And I said, ‘first of all, they’re all old White men, okay? Second, they’re all, except for Alan Rosenfeld, involved in infectious diseases, but they’ve all had one thing in common They’ve all had this early childhood experience They’ve all gone overseas for training and research early in their career, and that training globally has stuck with them and kept them in global health for a career and helped them.’ So who are going to be the leaders in the 21st century when the infectious diseases are still with us, but other diseases — the NCDs — need to be with us We’ve had a signature program with the Fogarty fellows and scholars This has been expanded in just this past year so that people in 20 universities are involved We’ll send about 80 fellows and scholars back and forth for training in the next year, and they’re going to be trained in all areas and matters of clinical medicine and public health They’re mostly from T-32 programs, the U.S. fellows They’re from existing U.S. institutions to go overseas to develop a research partnership, to develop a database for which they can apply for NIH grants, and they can come back and hopefully build these relationships in the future This morning I was in the NCI meeting at Centers of Excellence Jerry Bloomfield was there – one of our first, I think our first cardiologist of two Both of those cardiologists – one went to India, one went to Kenya They both had an incredible experience They’ve both come back to get K Awards from NHLBI, and they’re both sending the next generation of fellows in their programs out to their former sites to build those partnerships They’ve also been involved in training the foreign sites, investigators at the foreign sites to do quality research So this is a two-year-old, three-year-old program, but we think that in five years or ten years, we will have that next generation of researchers And so the future leaders are really, hopefully, going to be not only men but women, not only in the infectious diseases but in all areas of biomedical research, and we hope that these people will be the game changers of the future Just as a simple example for cancer, this young woman, Krista Pfaendler, came to us as a medical student 2006 and one of our early grantees She didn’t know where she was going in medical school or what she wanted to do, but we sent her to Zambia to work on HPV, on looking for a screening for papillomavirus She set up in an HIV clinic that was involved in vertical transmission So pregnant women came in She took that clinic space and she set up to do acidic acid staining and visualization to identify cervical cancer lesions and to test for HIV – and she began that She figured out how to do it She started training young nurses and using a cell phone to capture the image of the cervix to have it reviewed by an obstetrician or gynecologist After six months she was halfway done with her project – she decided to stay for another year, and now this program is ongoing in a half a dozen countries In the first year and a half they screened 50,000 women, picked up all numbers of cancers

in HIV positive women, and that went right back into the program And so now she’s in a program in OB/GYN oncology She plans to go back and work in Africa on HPV She might well come to NCI for future help and support We also have introduced – and to expand our budget in these difficult flat line budget times – we’ve expanded our program with the Fulbright Program I was a Fulbrighter early in my career And Fulbright, for 30 years, has not put an emphasis on public health or biomedical research We now have the Fulbright-Fogarty Program for medical students and for post-docs, to go and spend a year in a low or middle income country, and that’s announced on our website We have the MEPI Program that’s been supported by PEPFAR and NIH, where NCI is one of the collaborators on a linked award This is our effort over the next five years to build up African medical institutions, not only to work on HIV but to work on basic medical education; to improve the workforce, workforce capacity for a diversity of diseases including cancer So this is another way that we have platforms where introduction of cancer related issues into the training program would be absolutely critical – would be good places to work Another area and division of Fogarty is the Division of International Relations where we’ve developed and we’ve been working with Dr. Collins and with many of the ICs to build up what we call “partnerships in research.” You know we do have this flat line budget We’re trying to figure out how to extend both opportunities and financing And with the BRICS countries — Brazil, Russia, India, China, and South Africa — but some other countries like South Korea, Turkey, the MENA Regions, the Middle Eastern, and Gulf States, there are opportunities for co-funding NCI has been on the cutting edge of co-funding in China through the NSF in China with the AOR and with NIAID, and now with NINDS So we have opportunities to co-fund grants with the Chinese and with the Indians, so that they pay their part of the research and they see value in this relationship It’s extended in Brazil where Brazilian post-docs — are there any Brazilians here? Well Brazilian post-docs on the NIH campus can now receive half of their stipend from the National Research Council of Brazil So, if you want to hire post-docs, Brazilians are willing and interested in coming to the U.S., and they’re partially funded by the Brazilian government A nice investment for Brazil in the scientific and knowledge base of their future And also in other opportunities – in India we have the same activities that global – the Cancer Genome Atlas is an opportunity to work around the world to think about the genetics of the disease, and NCI and NHGRI have been key But these relations with India we’ve expanded greatly during my tenure Here I am – here we are on a visit with the Secretary Sebelius at the Tata Memorial Institute If you notice the man next to her at the bottom is speaking He was a smoker and an industrialist in India He smoked so long he ended up with esophageal tracheal cancer, and he has a wind tube So he’s talking, he’s covering himself so he can breathe through his vocal chords And they’ve developed advocacy programs for esophageal, oral cancers, not from smoking but from chewing tobacco and from tobacco related disease So with a really outstanding investigator’s huge patient populations, they’re thinking through systems to let care and treatment go out from Tata around India They’re novel models for the delivery of cancer care, and I think we’ll see these in other countries as well Low cost cancer treatment delivered on a widespread basis and with novel opportunities for basic research and research on implementation And of course in China several years back, we had the 30-year anniversary of the first contact between the U.S. government, NIH, and China, and NCI was on the forefront of that So you have a long history of training Chinese investigators who are now leaders It’s now an opportunity to change these relationships to true partnership since China has really come of age in science There are other areas that Fogarty has been involved in such as this;

this cookstove initiative that Francis Collins has become involved with NCI has done some lovely work on cancer from indoor air pollution The concentration of pollutants in that fire that this woman is tending is about 100 to 1000 fold higher than air pollution levels in the community And if she’s in that home for several hours a day, her exposures to indoor air pollution far swamp any exposure she would have outside So the opportunity to think about this Cookstove Alliance and how we will get the evidence for clean cook stoves is going to be key The global program from the UN Foundation and the Cookstove Alliance wants to be 100 million cookstoves in the world by 2020 I scratch by head as an epidemiologist, like I scratch my head with the tube wells in Bangladesh Will those tube wells stop cholera? They didn’t Will cookstoves stop the indoor air pollution problem? What do we need to make that research work, because it’s a very complicated intervention? Not only to have nice cookstoves that are clean, to have women accept cookstoves that work in their environment and for their culture, to have indoor levels of air pollution be reduced low enough so that you have an impact, and to be able to actually monitor exposures in the short-term and monitor impact in the long-term for diseases which have a short incubation period, like low birth weight in infants and ARIs — acute respiratory infections — in children, to long-term exposures like cancer, heart disease, and chronic obstructive lung disease So here’s an initiative that will really, could be a game changer in low and middle income countries Three billion people use indoor fuels and cookstoves Can we make a difference in health through this intervention? There is estimated to be about two million deaths a year from indoor air pollution I don’t know where that figure comes from except from WHO Whether we can impact it is really the question, and how we do this effectively – clearly a research agenda And finally just the mobile health – we’re having this Mobile Health Symposium downtown in December And this has been an area where four years ago we had 150 people on campus for a mobile health symposium We didn’t know who would come Last year there were 3500 people The innovation in this space – they could serve both NCI and all of NIH around chemical sensors of indoor air pollution, as an example, to do microscopy You could diagnose with this Lucas microscope – that we have funded through Fogarty – you could diagnose leukemia, sickle cell disease, make all kinds of CD4 counts in patients in the field – all with a cell phone and a small device as a microscope You can do cellular analyses, ideal for cancer biomarkers Rebecca Richards-Kortum, who’s on our Board, has used a fiber optic scope hookup to a cell phone to do colposcopy and to look at cervical lesions, and to look at the nuclear density in the cervical tissue in the cervical lesion to detect cancer by a nuclear density, as opposed to an antigen or other method in clinical trials now and funded in part also by USAID Adherence to treatment – clearly important through all of our NIH activities, whether it’s for cancer chemotherapy, tuberculosis treatment, treatment for hypertension, treatment for tuberculosis – monitoring adherence through cell phone devices would be another way to identify people who are adherent So, Fogarty provides really the watering pot to bring us together on a bunch of these global health issues In closing I have to tell you I’ve become an astrologer And I’ve become an astrologer because I’ve seen in this administration a lot of commitment to science and innovation at all levels I’ve seen Francis Collins come on board as a champion of global health We’ve seen the growth on university campuses of tremendous enthusiasm for global health activities Some of these students really want to go out overseas to do something in the global health arena We’ve got all kinds of global partnerships that have occurred and unique opportunities for advancing overseas, the G8 GAVI, the global fund for HIV, TB, and malaria Funding has been enormous Here’s the funding that’s come in to global health over the last two decades It’s been enormous despite the problems in the world today When I came, we started and we had the IOM Review,

America’s vital interest in global health Harold led this before he was NCI Chief and he led these recommendations These recommendations have been the guidelines for this administration and will hopefully be with us for years to come They’re clearly (unintelligible) of where we might be going We’ve seen Francis Collins of course; number four is expanding research in diseases affecting the developing world And Francis is interesting, why? I think in part because as a young physician, he went to Nigeria He saw patients who had unusual presentations of diabetes and got interested in this issue and found the first genes for diabetes from these populations So, clearly, good science leading, that’s of global interest How can FIC partner with NCI to support your research in global cancer? A couple of things One is, I think that the future of your global health initiative will be in your ability to train the next generation of investigators in all branches of cancer: diagnostic treatment, prevention, epidemiology, diagnostics and the like; to think and work comfortably in low and middle income countries where opportunities abound; and to train people from low and middle income countries to be your true partners in this extension of research The second is through our International Relations Division to build these partnerships and to expand them with other countries that see research in biomedical science as a priority India, China, Brazil, Russia, Turkey, South Korea, Thailand, Mexico and the like – they’re really wonderful partners They have money to invest in research They need leadership and they need know-how and they need access to knowledge and people And finally, by linking you at NCI with other platforms on the NIH campus that you might not be aware of For us at Fogarty it’s the MEPI Program – these 13 institutions in Sub-Saharan Africa that are really in leadership positions to help you But with NICHD there, they’re global sites for early cancers in childhood NHLBI has its 11 centers of excellence in lower middle-income countries NIAID has its vaccine sites where you might want to think about clinical trials There are lots of opportunities, and through the Global Health Working Group we’re trying to bring you all together So that’s the end of my presentation I’m really delighted to be here I think NCI has wonderful opportunities under Harold’s leadership, and with Ted in the driver’s seat for this Center for Global Health, there are so many areas of cancer that are amenable to global health research and intervention and change And I think that’s what we all hope will happen over the next decade Thanks so much