Omar Siddiqi Interviews Roger Glass for Without Borders December 15, 2016
Dr. Omar K. Siddiqi, MD, of Beth Israel Deaconess Medical Center, a global health researcher currently working in Zambia, interviews Dr. Roger I. Glass, MD, PhD, Director of the Fogarty International Center. Dr. Glass discusses what brought him to work in global health, how The Fogarty Center supports global health as part of the NIH, and what opportunities are available to the neurologist looking to specialize in global health.
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WITHOUT BORDERS PODCAST TRANSCRIPT
Dr. Siddiqi: Welcome, everyone. This is Dr. Omar Siddiqi. I am a neurologist at Beth Israel Deaconess Medical Center and a global health researcher who lives in Zambia, and I get the privilege of interviewing Dr. Roger Glass, who is the director of the Fogarty International Center, which supports global health activities at the National Institutes of Health. I would be remiss not to mention that it’s the John E. Fogarty International Center, and John Fogarty was a congressman from Rhode Island, where I am from, and he was my—represented the district where I lived, and so that doesn’t get—his name doesn’t get probably mentioned enough, and people don’t know it. So, just a plug for Rhode Island in there. But thank you for joining us, Dr. Glass.
Dr. Glass: I’m happy to be with you.
S: Okay. So, I am excited to talk about this, because I think the field of neurology, and for those who are listening, doesn’t get a lot of—it is sort of in its nascent stages in terms of global health and advancing its cause. So I’d like to get some background from you and Fogarty, but then maybe steer the interview more toward neurological disease and global health. So maybe just as a start, to get some context, could you tell us a little bit about your background and how your interest in global health developed?
G: Sure. Thanks, Dr. Siddiqi. I’m a medical graduate from the Graduate School of Public Health, and early in my medical training, and even before I was a Fulbright or an Argentine in Brazil, and I got quite interested in global issues and global science, and then as a medical student, I went to Haiti and Colombia and worked in clinics and met with people, and it was so fascinating to see the diversity of opinions and ideas that people had about their own diseases. And I realized that to be a good doctor, one had to appreciate the different cultures from which people came. And I think that—those early beginnings and that early experience I had, just in visiting and being in different places and different cultures, learning different languages, got me interested. And then I really dipped into global health when I went to Bangladesh with the CDC and started to work on diarrheal diseases in children, a main cause of killers of children. And I got so interested in what you could do simply to prevent diarrheal death and prevent illness, that that’s really led me on to a career in global health, and a nice career dealing with enteric infections, and now more broadly in training the next generation of global health fellows and scholars and researchers.
S: It’s interesting that, even now, just to take my example along with other colleagues, when we say we’re interested in global health, for those not in the know, sometimes we get funny looks. And less now—probably in your time it was truly a novel career path, I’d imagine, back in the early 70s.
G: It was, and you know, when I went to Bangladesh, people said it was a basket case of a country, but because of investments in research and global health, they’ve really become a middle-income country, and diseases that were killers yesterday, like diarrheal diseases, are no longer the threat that they are today, all because of research. And what I learned is also that discoveries in Bangladesh really have helped people and the health profession of diarrheal disease in the United States today. The development of oral therapy is a prime example. Developed to treat children with cholera, and people with cholera in rural areas, it’s now used as the treatment of choice for children in the United States with diarrheal diseases. So we in fact have learned a great deal from research in global health that impacts how we treat and prevent disease in the United States and beyond.
S: Yeah, I think it’s an important point to note that it does inform care here, and you can study unique populations that you don’t necessarily have the critical number of. But, you know, it can be very mutually beneficial.
G: Absolutely.
S: I was wondering if you could—I touched on a little bit that Fogarty International Center is tasked with supporting global health activities at NIH, but could you describe the mission maybe in more detail, and then talk about your role within the Fogarty International Center?
G: Sure. Well, the Fogarty International Center has been on the NIH campus for nearly fifty years now, and we’re the one of the twenty-seven institutes and centers here at NIH that deals with specifically global health training and research, training the next generation of researchers to extend the reach of the American research community, scientific community, into areas where there are unusual exposures, unusual diseases, unusual populations, unusual genetics. There’s so much we can learn by investing in the global health agenda. And if you think about the United States, we are a melting pot of people from all over the world. If we want to really understand their diseases, one of the ways that we can do this is by going back to founder populations and looking at the origins of where our genes and where our exposures have come from. So there’s a lot we can learn from research in global health, and that’s where we put our mark, and that’s why we think that the training that we do is so important.
S: And would it be fair to say that NIH has increasingly made global health an area priority, I guess particularly under the leadership of Francis Collins?
G: Sure. Well, if you look at global health in the twentieth century, it was really a century of thinking about HIV/AIDS and infectious diseases. But now that life expectancy in the world has gone up—if you look at China and India, life expectancy in both countries is seventy years or older—so with longer life expectancies, we really have to think about the non-communicable disease agenda. And that’s an agenda that engages all the institutes at NIH. So I think under the leadership of Dr. Collins, when he came in as director, one of the five points that he wanted to emphasize under his directorship was research in global health. So during his tenure, many of the institutes that had never really thought much about an investment in global health have come to realize that there are great discoveries that can be made, and the new frontiers of research may be well overseas.
S: And did that, in terms of making it one of his five priority areas, did that translate into sort of dollars that were allocated towards global health activities in each of the institutes, or what are the things he did to promote it?
G: Yeah, absolutely. And many of the institutes that first came and got engaged in this were institutes in neurosciences, in part because, when you look at the global burden of disease, the burden for neurologic disease and mental health is absolutely tremendous, and is deserving of greater attention than we’ve ever given it before.
S: So that’s a nice segue into the brain disorders grant mechanism, which has been a bit of—I mean, I think a game-changer for my own part; it’s helped fund some research activities with collaborators. So I was wondering if you could just speak about—when was it recognized that brain disorders should be a priority in the developing world, and maybe some of the value that that particular grant mechanism has provided.
G: Sure, Dr. Sidiqqi. It turns out that in about 2001, the Institute of Medicine did a review of neurologic, psychiatric, and developmental disorders for the developing world, and that study, that investigation by the IOM, led NIH to initiate a “brain disorders across the lifespan” program here at Fogarty. Now, many of the neurologic institutes, and there are about a dozen of them, were not familiar with the opportunities and the exposures in global health. So Fogarty issued a whole bunch of small grants, over 150 in the ten-year period. And from those small grants, we got such interesting ideas and leads that about nine of the bigger institutes came in and issued large RO1 grants, because they felt that what they could learn from these activities and this preliminary research was absolutely conducive to advancing research in their own special areas. So in children, it—they were issues in exposures to fetal alcohol in South Africa and Russia, or seizure disorders throughout Africa—which are easy to treat, in some cases. Discoveries around cysticercosus and parasitic diseases in a variety of countries in the world—but a disease, cysticercosus, that leads to seizures even in Hispanics in the United States. And to the other end of the spectrum, Alzheimer disease in places like Colombia, where because of immigrant populations from Europe carrying a specific mutation, people had an early onset and rapid progression of Alzheimers. So it becomes a population of tremendous interest if we want to understand biomarkers of the disease or conduct clinical trials with early treatments. So this has really opened up the field over the last decade, through programs that began at Fogarty on a small-scale basis, small grants. But where the larger institutes came right in as partners, and picked up areas that they would find particularly interesting.
S: And so the—I know that the Fogarty—that the brain disorders just had a, recently had a ten-year anniversary. And so, as far as I understand it—and you can clarify this—so, Fogarty gets the funding from—does it have its own primary funding for, say, brain disorders? Or then it asks somewhere like NINDS to then help support the various projects that come out of—that someone proposes, then gets a fundable score, for example?
G: Sure. We have a basic budget like all the institutes at NIH, and we brought together the other institutes of the neurosciences to see if they were interested in partnering with us. We began by issuing small grants, and starting a network of partners of researchers around the world that wanted to investigate, on their own, exposures in their countries. But it had to be a partnership with a foreign partner, and often a US partner. And from that preliminary result of small grants, the other institutes would pick off those grants that they thought had opportunities for real discovery. And that’s what happened. So we partnered with all—with many of the larger institutes to advance this whole research agenda. And I must say, it’s been incredibly satisfying. The studies on stroke in Africa, and seizure disorders. Cysticercosus control and treatment. We’ve learned so much about treating and preventing many neurologic diseases from these activities.
S: And I know that in terms of—a lot of people don’t think about it, but, you know, some of the genetic studies related to chronic diseases—Africa, for example, is a rich population; it is quite genetically diverse, and there is an initiative of studying genetics of chronic diseases in Africa, isn’t that true?
G: Absolutely, and one of Dr. Collins’s favorite initiatives, if you will, is human heredity and health in Africa—H3 Africa. And some of the studies there are in the area of neurology. But I think also, Dr. Siddiqi—and you’re a prime candidate—you’re a fellow with the Fogarty program, and we have actually sent out neurologists, epidemiologists interested in neuroscience, and infectious disease folks, and pediatric residents and fellows, to think and study neurologic disease in low-income settings. At the same time, we’ve also trained local investigators in research methods so we can really extend the reach of American science to these frontiers of science where the problems are—taking research where the problems are.
S: And yeah, you had mentioned that I was in the original Fogarty International fellows and scholars class, and I think one of the most gratifying things was when we had our orientation in Bethesda. And you know, it was fifty-fifty; fifty percent fellows and scholars in the United States, but fifty from overseas, and so there was a lot of cross-talk, and, you know, I’m actually still in contact with some of those folks from that original orientation. And it was funny—when I went through that orientation, I got some funny looks as being a neurologist doing global health activities, and it’s still curious—not as prominent, but people think, “What role does a neurologist have in global health activities?” Which, at the time, was very vexing, and now I kind of get a smirk, you know, just kind of being in the field and seeing the devastating—you know, we get both the infectious disease complications along with the chronic disease complications. Do you think that perception exists, or why it might exist? That maybe neurologists don’t have as prominent a role? I don’t think it’s true, obviously, but I felt some of that when I was initially in the early stages of my career.
G: Well, you know, we didn’t really think about other specialties in global health before, really, the twenty-first century. The prolongation of life around the world, including in low- and middle-income countries, has made longevity something that’s global. And with that comes the concern for the non-communicable diseases, which includes neurology. Number-one killer around the world is heart disease, and the key cause of death in different countries changes. It’s stroke in China, for example—isn’t that a neurologic disease? And why is stroke in China so different from stroke in the United States? Stroke in the United States has a lot of large-vessel disease; in China, it’s intracerebral. It has a higher prevalence in heart disease, whereas in the US, heart disease outnumbers stroke. Why should there be these epidemiologic differences? And what can we learn by these investigations? So there’s a lot that we can learn by comparing populations. And do Asians in the United States have more stroke than heart disease? These are issues that can be addressed and thought about by having young people engaged in global health research. It raises questions that will engage them for the rest of their lives.
S: Yeah, I think that’s very true in terms of how it informs the various communities. It’s true that not all strokes are the same, not all neurological diseases are the same across a population. It’s interesting—it seems like, in countries that, within their health system, they start with sort of the “big four” in terms of training—OB/GYN, pediatrics medicine and surgery. And now I think there’s an increasing recognition that there needs to be some specialized care, and so a lot of my colleagues are really beating the drum of getting neurology training programs up and running. There’s nothing more empowering to an individual place than to train local neurologists, say for me in Zambia; to others, it might be in Kenya, might be in South America—you know, various places that don’t have it. What—does Fogarty do anything to promote sort of training programs, or activities around supporting specialized care in resource-limited settings?
G: Well, we do a lot with the research agenda, and training people for research. And there are lots of examples from our brain initiative. For instance, I was recently in Zimbabwe, where, if a patient came into the hospital with a stroke, their chances of leaving the hospital—of dying in the hospital was about one in four. It was incredibly high—and why should that be? So the trainees in the Fogarty program at the hospital at the University of Zimbabwe investigated this. And they found out that these patients died of aspiration pneumonia. When they came in through the emergency room, no one checked their gag reflex, and by not knowing if they had a gag reflex or not, they fed them. And when they fed them, they aspirated. And just by this simple change in the clinical exam at admission for stroke patients, they could actually reduce markedly death from stroke in Zimbabwe, and that has changed a national practice, and it’s a change in practice that’s being used in many of the neighboring countries. So it’s just an area where simple interventions made a huge difference.
S: Yeah, I think most of us in the neurology community feel that there’s a lot of low-hanging fruit, particularly related to reducing mortality in the circumstances you described. You mentioned stroke; I think—
G: It’s not only mortality; it’s also morbidity. In many developing countries, childhood seizures are a stigmatizing event, and a child who’s “possessed by the demon” as demonstrated by seizure disorders is excluded from school, is excluded from friendships; they really are stigmatized in terrible ways, and different ways in each society. Just being able to, as Gretchen Birbeck has done, do research on simple treatments of seizure disorders in children, many of which are outgrown with age, but are incredibly stigmatizing early. And if ninety percent of those can be treated easily, you’re really going to save the lives of many children just by improving and preventing the stigma associated with this not-uncommon pediatric condition. Another example of where research, understanding, and identifying simple solutions can lead to a great benefit for the patients, families, and for global health.
S: And there—I think there’s certainly the treatment gap around—epilepsy’s a really, really prominent example—around stroke as well, just ischemic strokes, just getting people on aspirin, very simple things like that. Are there any sort of gaps—major gaps in knowledge, or unanswered questions in terms of neurological disease worldwide that you think need to be addressed beyond the ones I’ve just mentioned?
G: Well, mental health has become a huge global problem that’s only sort of recently been identified, because it’s not a fatal disease; it’s a disease that accumulates tremendous morbidity. So it’s in the DALY, the Disability Adjusted Life Years, where mental health is a problem. The World Bank and the World Health Organization, just about two months ago, hosted a meeting here in Washington to see what could be done to address the global mental health issues. Many countries have none or very few psychiatrists; they have to think through different ways to provide care, and they have to find deep—more deeply into the ideology of some of the problems that initiate mental illness. And so this has become a priority, and I think we’re going to see a lot more about this in the future. There’s a group—the Global Alliance for Chronic Disease—a consortium of the largest research funders around the world, who get together and try to decide, what are the chronic disease problems that they think the global network should address. Global mental health is on their agenda for one of the next two calls. So it’s actually a huge problem globally, for which we really need, and are searching for, good solutions.
S: Do you get—do you end up getting mental health-related applications for the brain disorders, as far as you know?
G: Absolutely, and the National Institute of Mental Health has a very active program globally, with three centers, in Asia, Africa, and Latin America, specifically to build up and train, for research, young investigators in global mental health. It’s a very active area of research.
S: Yeah, I went to a symposium, and Pamela Collins was there—I remember she also lectured at our Fogarty orientation—so yeah, it just seemed like a huge gap. And you see—it’s interesting, in various places, you end up—neurologists and psychiatrists end up treating the same patients. They’ve sort of morphed into one specialty because, you know, out of need more than anything else.
G: And think about it—you know, you mentioned Pamela Collins, but how many psychiatrists or people in global mental health are there in the United States who have had experience working in low- and middle-income countries? I mean, we have loads of people with HIV experience and infectious disease experience, and we know how to address those burdens from the last century, in part because so many people have had that experience. We have precious few cardiologists and diabetologists and neurologists, and people in all of the many disciplines of medicine who can think in these global terms, and part of what Fogarty can do, and is doing very well, is to train the next generation of American researchers and foreign researchers in these areas that have not traditionally been thought of as global health priorities, but certainly are when you look at the global burden of disease today. S: And could you tell us about—so, in terms of the priorities and your vision for the center in the future—is there—say, the next five, ten years, do you see any plans that you have personally that you want to see, or any changes, or your grand vision for Fogarty in the time that you have there?
G: Oh, well, I think we’re just starting the twenty-first century, and we’re entering our fiftieth birthday party next year for fifty years of the Fogarty Center, so we’re thinking about the future. But I would say that in the last decade, the fact that you’re a neurologist now who’s working in Zambia is a prime example of what we’d like to see more of. We’d love to see more US universities have outreach and collaborative training for training and research in developing countries. We’d like to see training going both ways. We’re in an era of videoconferences and cell phones, so in the next ten years—twenty years ago, no one had a smart phone. In the next decade, everybody in the world—almost everybody in the world—will have a smart phone and access. Does that give them access to knowledge? Can we do telemedicine? Can we train? There’s so much that we can do in the next ten years or twenty years, and I think that our plans at Fogarty include a program in mobile health, for instance. We have programs in ethics, training the next generation of researchers, and building bridges in US institutions and foreign institutions for the benefit of all. So we[’ve] got lots of plans for the future, and they involve the full range of research and activities in global health.
S: Yeah, it’s interesting; a lot—I think a third of all medical students now who come in to training expressing an interest in global health, and a lot of them—you know, they need the right individual, the right mentor, and then they can take off. And a lot of people really just don’t know where to start, and to some degree, it starts with mentorship and meeting the right individuals, and getting—you know, if your institution has it. Any advice, any pearls of wisdom for individuals like this who are—who want to embark on a career in global health?
G: Well, absolutely—first of all, you’re spot on that the next generation of students in public health, in medicine, in nursing, in all of the medical specialties and health specialties, bioengineering, there’s a huge interest on campus in issues of global health. Not only in medicine, but in economics, in law—think of the Framework Convention for tobacco control—in business—think about logistic supply chains for devices in medicines. There’s a huge—there are huge opportunities. My best advice to everyone is to start early, and to get some international experience. Hopefully, or at least in medical school, one that’s mentored, so that you go and you learn not only about the health issues, but about cultures and people—and you open up your heart to the problems of others. Even if you don’t become a global health researcher, it’ll certainly make you more tolerant of patients from other cultures who you see in your own practice. I think that that’s equally important for all American physicians. And I think these contacts and friendships that you build are—can be life-lasting, and incredibly rewarding. So go early, find a place to dig in and do something meaningful, and continue that when you get back home. Research is a wonderful way to do this, and it’ll keep people sustained for life.
S: Thank you very much for sort of—kind of the last words of wisdom. I appreciate it, and I appreciate the time.
G: You’re a role model right there; you’re a neurologist who went to—who’s living in Zambia. How many neurologists do you know that are living in a low-income country like that? How many neurologists are there in Zambia, and can you help train the next generation?
S: Yeah, I mean, I think that’s the—that’s the holy grail, to train sort of local neurologists. And we all know the expertise is there, that the talent pool is enormous, but, you know, it’s just creating the right environment. And, you know, I was—I benefited from Fogarty. I think Gretchen Birbeck is really the matriarch of global neurology, in many ways, and so we all benefit from her perseverance, and really, when it wasn’t a well-established field. So yeah, it’s exciting. It’s exciting to see what’s ahead, and obviously Fogarty’s been a huge part of that. So I appreciate your time; I know you have a busy schedule, but I think it’s nice—it’s nice, actually, this is our first podcast for the global health section and Without Borders, which is an area of the journal Neurology, where Gretchen Birbeck is highlighting global activities, so yet another step in, you know, advancing the cause.
G: So, for young fellows and students interested in neuroscience, there’s a real opportunity for global health research, and opportunities that await you, and I would just seek those out. There’s so many universities now that are part of the Consortium of Universities in [sic] Global Health, and there are opportunities to look and to find places to sit, and begin to think about issues of global neurologic disease. The time has never been better for this, and people won’t raise their eyebrows when you say you want to do a global health elective, because so many of your fellow residents and fellows want to do the same. So that would be my advice—go out and find the proper place, get good mentorship, and get your—get some early field experience. It’ll tee you up for life.
S: Great. I appreciate your time; thank you so much.
G: Thank you, Dr. Siddiqi, appreciate it.