Koplan, Jeffrey P. MD, MPH; Baggett, Rebecca L. MA, MPH
This issue of Academic Medicine illustrates the academy’s growing interest in improving global health and the different directions that universities and academic health centers are taking to build programs that have a significant impact. The academy’s interest, in turn, reflects the attention that global health is receiving by government agencies, nongovernmental organizations (NGOs), and private foundations around the world. We believe several issues have contributed to this escalation of interest in global health. First, we in the developed world increasingly face the same diseases as our global neighbors in developing countries. Infectious diseases such as HIV/AIDS and tuberculosis threaten populations living in all countries around the world. Infectious outbreaks from one region can rapidly appear in a distant site (e.g., SARS, West Nile Fever, Nipah Virus, and, potentially, avian influenza).1,2 These diseases can spread rapidly without regard to geographic boundaries, or they can be spread deliberately to specific parts of the world through acts of bioterrorism. Chronic diseases such as diabetes, cardiovascular disease, cancer, and their risk factors, which have historically been more prevalent in the developed world, are accounting for an increasing proportion of the disease burden in the developing world because of its adoption of unhealthy, “Western” behaviors such as decreased physical activity, high-calorie and high-fat diets, and smoking.3–6
Second, we realize that a population’s health is closely connected to its successful development,7–9 national security,10 and economic stability.11–14 A healthy population is a prerequisite for a nation’s ability to succeed in all three of these areas. In addition, health care delivery systems, despite their disparate origins, varying payer models, and different levels of resources and expenditures, all have priority concerns for cost, quality, and access. These concerns include problems related to access to health care services, the global shortage of health care providers, and the rising cost of health care.
The confluence of issues that has catalyzed this multinational, multiorganizational interest in global health provides academic institutions with great opportunities for both scholarly and service pursuits. Additionally, this growing interest has generated funding that academic institutions can pursue to support global health programs. Funds for global health activities have never been more abundant. Government agencies, private foundations and corporations, and international development organizations like the World Bank have all directed substantial funding to programs that they believe can have a great positive impact on global health and development. Additionally, the influence that the Bill and Melinda Gates Foundation has had and continues to have on the academy’s interest in building successful global health programs cannot be overemphasized. Bill and Melinda Gates have been remarkable advocates for improving global health, and their generous acts alone have created a pool of resources that permits the advancement of global health. Their actions and leadership have also spurred philanthropists, governments, and organizations to address global health issues and make them a top priority. To that end, they have done the world a great service.
Finally, academic institutions recognize that global health programs are good for their own health. Global health programs build bridges for academic institutions both within and beyond their walls. Students and faculty members at North American universities are becoming increasingly focused on international affairs. The issue of health can bring these like-minded members of a university community together despite their different fields, because a place for health-related endeavors can be found in many disciplines. There are the obvious linkages among students and faculty in the health sciences schools, but global health also has relevance for area studies, the basic and social sciences, business, foreign languages, government, history, law, and theology. Extramurally, working with international and local in-country partners with the common goal of improving health breaks down barriers that exist between even the most hostile political adversaries. We in the academy realize that to secure a place at the global table in an increasingly globalized world, we must develop and maintain these partnerships. Global health is a topic that both lends itself to collaborative international work and provides another area in which universities can excel and contribute.
It is important to mention that North American universities gain at least as much as they give when they work with global partners. There is no doubt that the resources academic institutions bring to projects and programs are important to their success and sustainability. However, the knowledge and understanding that universities gain from their partners is just as important, if not more so. An academic institution is much more likely to be successful in both launching and sustaining global health programs if it works with persons who know firsthand what their health concerns are and how to best address these concerns in their communities.
Understanding these issues and recognizing Emory University’s potential to both distinguish itself and do good work around the world, Emory’s president established the Emory Global Health Institute in September 2006. In this article, we describe the steps that led to the institute’s founding and discuss its mission, goals, current programs, and plans for the future.
The Emory Global Health Initiative
In September 2003, James W. Wagner, PhD, became president of Emory University. One of his first acts as president was to reexamine Emory’s vision statement and strategic plan. To accomplish this, he launched a university-wide strategic planning process during which input was sought from Emory faculty, staff, students, and alumni. At the end of this 18-month planning period, he presented Emory’s 2005–2015 strategic plan to the Emory community. The plan includes five strategic themes that will guide Emory’s activities during the next decade, with each theme including specific university-wide initiatives that will help the university reach its strategic goals. One of these themes is called Confronting the Human Condition and Human Experience, with Implementing Pathways to Global Health as one of its key initiatives. Implementing Pathways to Global Health later became known as the Emory Global Health Initiative.
The Emory Global Health Initiative involved a university-wide dialogue regarding global health and the role Emory could play in improving it. The initiative was cochaired by a senior officer of Emory’s Woodruff Health Sciences Center (J.P.K.) and a distinguished professor of anthropology at Emory College. The purpose of the Emory Global Health Initiative was to gather information to determine how Emory, which already had individual schools and departments involved in global health work, could best build on its past successes so that it could (1) better contribute to improving health conditions around the world, and (2) distinguish itself among academic institutions as a world leader in global health research and scholarship.
The process for collecting this information was a series of group and individual meetings with Emory faculty, staff, students, and alumni as well as with representatives from peer universities. (Several of the articles in this issue of Academic Medicine are written by authors from those institutions.) The initiative’s leaders and staff began this 14-month-long discussion in April 2005. On the basis of the information collected during those meetings, in June 2006 the cochairs presented a proposal to the Emory University Ways and Means Committee, which is composed of the president of Emory and its vice presidents for academic affairs, administration, finance, and health affairs. The ways and means committee reviewed the proposal during summer 2006 and approved it in August 2006. This resulted in the founding of the Emory Global Health Institute.
The institute received substantial internal start-up funds from the University with the understanding that it will be self-sustaining within six years of its establishment. Emory set an initial budget of $110 million for the institute, with $55 million of this budget coming from the university’s strategic planning and building funds and the remainder coming from individual Emory schools and departments, foundations, and private and governmental partners. The institute will also aggressively pursue other external funding to sustain and expand its programs beyond the initial six-year budgeted period.
Building on Emory’s strengths
Founding the Emory Global Health Institute was a natural evolution for Emory. The institute builds on a strong foundation in global health research, training, and scholarship that was laid by the Emory University School of Medicine, the Nell Hodgson Woodruff School of Nursing, the Rollins School of Public Health, the Emory Vaccine Center, and other schools and departments such as anthropology, area studies, biology, chemistry, and theology. Emory faculty and students have conducted projects focusing on numerous global health problems including HIV/AIDS and other infectious diseases, unsafe water and poor sanitation, nutrition, the obesity epidemic, environmental health hazards, chronic diseases, and reproductive health issues, to name just a few. Emory faculty, students, and alumni have worked in countries on all continents and have developed strong partnerships with both international and local in-country organizations.
The Nell Hodgson Woodruff School of Nursing is home to the Lillian Carter Center for International Nursing, which trains nurses to improve the health of vulnerable persons worldwide through nursing education, research, practice, and policy development. The Rollins School of Public Health’s Hubert Department of Global Health provides students with the knowledge and skills to develop and implement public health efforts in a variety of settings working with multiple partner organizations. In addition, faculty in its department of behavioral sciences and health education have conducted valuable research on HIV/AIDS-prevention strategies, and faculty in other departments have made significant contributions to the school’s global health efforts. The Emory University School of Medicine is home to world-renowned researchers and clinicians specializing in both infectious and chronic diseases. Researchers in Emory’s chemistry and pediatrics departments have had remarkable success in developing highly effective and widely used antiretroviral agents. Emory’s Yerkes National Primate Research Center has made landmark discoveries in the fields of microbiology and immunology, and faculty in anthropology, area studies, biology, and theology have also engaged in global health projects as varied as bench science research to faith-based health interventions. Researchers at the Emory Vaccine Center have developed an FDA-approved AIDS vaccine that is moving into Phase I clinical trials and have established a formal malaria research partnership with Brazilian scientists. Emory is also home to the subsecretariat of the International Association of National Public Health Institutes, a Gates-Foundation-supported initiative whose goal is to build global public health infrastructure through the creation and expansion of national public health institutes around the world. These are just a few examples of Emory’s involvement in global health activities.
Emory’s relationships with prominent public health organizations and agencies also made it an ideal place to launch an academic center focused on improving global health. The university has long-standing, close working relationships with the Carter Center and the Task Force for Child Survival and Development, organizations that have formal affiliations with Emory. Emory faculty and students also partner routinely with other Atlanta-based organizations such as the American Cancer Society, CARE, and the Centers for Disease Control and Prevention (CDC). Emory is closely linked with the Georgia Institute of Technology, which facilitates Emory’s ability to undertake global health projects whose success depends on engineering expertise, and with the University of Georgia, which has strong programs in agriculture and veterinary medicine. And, finally, Emory faculty and students have partnered with Georgia State University, which has expertise in health promotion, and with the Morehouse School of Medicine, which is home to the Louis W. Sullivan National Center for Primary Care.
The Emory Global Health Institute
Vision and mission
The institute’s vision is to be an internationally recognized catalyst for improving global health through collaborative discovery, scholarship, and service. Its mission is to advance Emory University’s efforts to improve health around the world, with an emphasis on vulnerable populations in the developing world. The institute strives to achieve this mission by providing guidance and financial support to Emory faculty, students, and alumni as they work to find solutions to some of the world’s most critical health challenges.
The institute has a director (J.P.K.) and a small staff composed of an administrator, an administrative assistant, a communications manager, and a student programs coordinator. The staff will remain small as the institute will invest the majority of its resources in global health programs for faculty, students, and alumni. The institute has an internal advisory committee whose members inform its priority-setting process; advise and recommend major investments in global health activities across the university; work with the institute to create, prioritize, and recommend new faculty lines; serve as the institute’s advocates and representatives; assist with institutional development; track and review progress; help foster cross-school/unit cooperation; and help resolve barriers to collaboration. This group consists of Emory deans and selected faculty members with specific interest and expertise in global health. The institute also has an external advisory board whose members provide high-level, global input and guidance on both conceptual and programmatic levels; serve as external evaluators; bring experience, wisdom, and expertise to the institute and the Emory community as a whole; and serve as informal ambassadors to promote and disseminate information about the institute. This board is chaired by Sir George Alleyne, chancellor of the University of the West Indies and director emeritus of the Pan American Health Organization, and it includes seven other distinguished global health luminaries.
Goals and activities
The institute’s primary goals are to
* develop a strong academic infrastructure in global health and an infrastructure to support grants, programs, and faculty collaborations at Emory;
* foster global partnerships in research, training, leadership development, policy, and service that improve access to and the quality of programs for health promotion, disease prevention, and treatment; and
* encourage interdisciplinary global health scholarship both at Emory and around the world.
To achieve these goals, the institute
* identifies high-priority opportunities for strategically aligned faculty growth and provides financial support to individual Emory schools and departments in their hiring of world-class scholars engaged in global health work;
* provides direction and financial support to Emory faculty and their local and global partners to conduct innovative, high-impact global health research studies and programs;
* convenes and sponsors seminars and conferences to share information with the Emory community (faculty, students, alumni, and staff) on effective global health initiatives and to develop global health leaders and partners;
* provides global health training opportunities for undergraduate and graduate students, and supports the expansion of global health curricula across Emory; and
* brings global health experts to Emory to share their knowledge with the Emory community.
The institute evaluates its progress on three levels. First, institute staff examine the specific objectives described in each of its three primary goals, to ensure that they are being achieved. The institute measures the number of new faculty members it has helped hire, the faculty programs and student global learning programs it has funded, the conferences it has sponsored and/or convened, the scholars it has brought to Emory, and the partnerships it has helped Emory establish.
Second, the institute evaluates its funded programs to determine whether they are meeting individual project goals and are making progress toward sustainability after institute funding ends. The institute also assesses the impact that institute-hired faculty have on Emory in terms of the number of external global health grants they received and the publications they authored. Institute staff members completed their first evaluation of these two levels of activities in September 2007, and they plan to conduct similar evaluations annually.
Third, the institute plans to examine the impact that Emory is having on the state of global health since the institute began its work. This will be done by determining whether the knowledge Emory generates with its partners and shares with the global health community is being applied by organizations and practitioners in the field. Although it is clear that measuring this third outcome presents methodological challenges because of the multitude of influences on global health outcomes that are beyond the institute’s sphere, we believe it is worthwhile to develop a metric to evaluate the institute’s impact. Developing such a metric also provides an excellent opportunity for collaboration with other academic global health centers interested in measuring the influence they have on the state of global health.
As of November 2007, the institute had funded 19 initiatives proposed by Emory faculty and provided resources to support the hiring of two faculty members, one at the Rollins School of Public Health and one at the Emory University School of Medicine. The institute had also funded seven projects proposed by Emory students as part of its Global Health Institute Field Scholars Awards Program, which was piloted in summer 2007. This program augments existing Emory programs that typically enable approximately 100 students to conduct global health field projects each year. The institute also helped establish an undergraduate minor in global health, culture, and society at Emory College and is currently working with the school of nursing to expand the global health curriculum for undergraduate students across the four Emory schools with undergraduate programs. Additionally, the institute is developing an alumni grants program and expanding the Global Health Institute Field Scholars Awards Program for Emory students beyond the pilot phase.
At this writing (November 2007), the institute has reviewed letters of intent submitted by Emory faculty members in response to its second university-wide request for proposals, which is the funding mechanism for both its Global Health Partnership Program Grants and its Program Seed Grants. All Emory faculty members are eligible to apply for these grants. From the 64 letters of intent received, the institute invited 23 faculty members to submit full proposals, which will be reviewed and scored by independent faculty reviewers. In September 2007, the institute also convened its inaugural advisory board meeting, which produced helpful and tangible feedback that will be useful as the institute expands its programs during its second year of operations. And, finally, the institute has launched an interim Web site (www.globalhealth.emory.edu) and is in the process of developing a permanent Web site that will serve as its primary communications tool.
Selected Funded Projects
Center for Global Vaccines.
The Center for Global Vaccines (CGV) is a joint venture of the Emory University School of Medicine and the New-Delhi-based International Center for Genetic Engineering and Biotechnology. The primary purpose of the CGV is to conduct research to develop vaccines that will improve the control of infectious diseases around the world. The CGV will place a special emphasis on those diseases that disproportionately affect populations in the developing world.
Community Partners Leadership Fellows Program, Phase I: Scenarios from Africa.
This program, developed by faculty at the Rollins School of Public Health, provides fellowship opportunities at Emory to proven community leaders working for community-based organizations (CBOs) and NGOs in Africa. This fellowship program is unique in that it targets community leaders who are typically not eligible to apply for traditional academic fellowships. The program also helps small- and medium-sized CBOs/NGOs that are partnering with Emory to develop their capacity by training their employees.
Conference: What’s Indian about HIV/AIDS in India?
Emory College’s English department and Asian Studies Program coordinated this multidisciplinary conference, which addressed how economics, culture, and systems of representation have converged to shape the HIV/AIDS epidemic in India. The goal of the conference was to explore comprehensive, context-sensitive responses to public health threats through dialogue about the “Indian-ness” of HIV/AIDS. It featured leading scholars in public health and communications as well as practitioners from organizations such as the CDC, the Bill and Melinda Gates Foundation, and the United Nations Development Programme.
Consortium on Avian Influenza Control.
The Emory University School of Medicine’s Center of Excellence for Influenza Research and Surveillance and the Harbin Veterinary Research Institute (HVRI), a leading Chinese organization specializing in avian influenza surveillance, are partnering to conduct studies that will lead to the development of a universal vaccine against infection by different H5N1 avian influenza strains. Emory is providing training to visiting Chinese scientists, and HVRI is training Emory researchers in avian influenza field surveillance and viral pathogenesis studies.
Ethnographic Research Study to Identify the Decision-making Criteria and Process for Choosing Birth Attendants in Bangladesh.
The institute funded a doctoral student in nursing to conduct this ethnographic study as part of its pilot Global Health Institute Field Scholars Awards Program in summer 2007. The student partnered with the International Center for Diarrheal Disease Research, Bangladesh and the Matlab Health Service Area in Bangladesh. The student has since been awarded a National Research Service Award from the National Institute for Nursing Research of the National Institutes of Health to continue her research on this topic.
Global Government Health Partners Forum 2006.
In November 2006, the Nell Hodgson Woodruff School of Nursing’s Lillian Carter Center for International Nursing hosted a forum addressing the global shortage of health care workers. The conference, entitled Global Government Health Partners Forum 2006: The Breaking Point—Human Resources for Health, addressed the magnitude and impact of the global shortage of health workers. The forum provided direction and guidance to health care leaders as they discussed plans to manage the external forces affecting the shortage and the internal forces (e.g., work conditions) over which they continue to wield a positive influence.
Improving Recognition of and Initial Response to Prolonged/Obstructed Labor and Birth Asphyxia in Settings Characterized by Homebirth with Unskilled Attendants.
Emory’s Nell Hodgson Woodruff School of Nursing is partnering with the International Center for Diarrheal Disease Research in Bangladesh to conduct a research and training project that aims to reduce maternal and newborn mortality and morbidity resulting from life-threatening complications in low-resource settings characterized by home birth with unskilled attendants.
Madras Diabetes Research Foundation—Emory Population-Based Global Diabetes Research Center.
Emory’s Rollins School of Public Health and the Madras Diabetes Research Foundation are partnering to establish the Population-Based Global Diabetes Research Center in Chennai, India. Researchers at the center will work to find solutions to the growing global diabetes epidemic, and the center will serve as the research leader and hub for population-based research and large intervention trials throughout South Asia and globally.
Partners in Global Health.
With this program, the Rollins School of Public Health builds on an existing collaboration it has with the Instituto Nacional de Salud Publica located in Cuernavaca, Mexico. The purpose of the program is to strengthen and significantly expand this relationship and, as a result, create new and innovative opportunities for interdisciplinary global health programs. It establishes formal mechanisms for creating student/faculty collaborative experiences in research, teaching, and service, and it encourages interdisciplinary collaboration by involving multiple disciplines and departments from across the university.
Program in Globalization, Global Migration, and Health.
In this program, Emory researchers at the Rollins School of Public Health developed and conducted a scientific workshop, established a network of global collaborators, and are conducting a literature review focusing on the cardiometabolic risk factors of culturally and ethnically diverse populations living within the United States.
Republic of Georgia Emergency Department Program.
The purpose of this program, developed by the Emory University School of Medicine, is to modernize the emergency departments of the Central Clinical (Republican) Hospital in Tbilisi and the Imereti Regional Hospital in Kutaisi, Republic of Georgia. This program builds on a successful partnership that the Emory University School of Medicine has with the Iashvili Children’s Hospital in Tbilisi, which resulted in the transformation of its emergency services from a Soviet- style “admitting room” to a modern emergency department.
Republic of South Africa Drug Discovery Training Program.
A collaboration between researchers at Emory College’s chemistry department and the Republic of South Africa, this program seeks to train African scientists in early-stage drug discovery with the goal of combating infectious and immunologic diseases that are often neglected by the pharmaceutical and biotechnology industries. The program trains talented African scientists in drug discovery, with posttraining placement in appropriate industry or academic positions in their home countries. The government of South Africa also supports this program and will offer significant incentives to start-up biotechnology companies, thereby creating an environment in which scientists conducting drug discovery in South Africa can develop, thrive, and ultimately take on leadership roles as innovators of global health partnerships.
Tobacco Technical Assistance Consortium Global Tobacco Control Initiative.
Administered by the Rollins School of Public Health, the Tobacco Technical Assistance Consortium (TTAC) has historically fostered strong leadership, increased organizational capacity, and strengthened partnerships in the U.S. tobacco control community by providing innovative trainings, technical assistance, and educational materials. The TTAC Global Tobacco Control Initiative takes the organization’s mission to the global arena by providing technical assistance to countries strategically targeted by the tobacco industry and to countries that are working to decrease tobacco use and increase tobacco-free environments. The first countries that the TTAC Global Tobacco Control Initiative plans to target are Thailand and Uruguay.
Zambia–Emory Research Initiative in Tuberculosis and TB/HIV.
The Emory University School of Medicine, the University Teaching Hospital in Lusaka, Zambia, and the University of Zambia School of Medicine are partnering to develop a research program to improve global control of tuberculosis with a special emphasis on the control of tuberculosis in the HIV-positive population.
As a young organization, the institute plans to build numerous programs during the next several years. The institute will continue to assist individual Emory schools and departments in their hiring of world-class scholars and to fund innovative programs proposed by Emory faculty and students through its Global Health Partnership Program Grants and Global Health Institute Field Scholars Awards funding mechanisms. During its first six years, the institute also plans to
* coordinate and/or sponsor multiple global health conferences and seminars;
* found an Emory global health alumni network and grants program that will enhance partnership-building activities;
* establish an annual speakers series and an annual symposium that bring world-renowned global health experts to Emory;
* initiate a visiting scholars program;
* develop an undergraduate major in global health;
* launch a doctoral program in global health and anthropology;
* institute a postdoctoral teaching program in global health;
* expand global learning opportunities for Emory students;
* create multidisciplinary leadership development training programs for health officials and other health professionals from around the world; and
* develop and implement a comprehensive communications plan that includes a Web site to share the institute’s global health experiences and assist Emory faculty, students, and alumni in their scholarly global health pursuits.
Although we at the institute are pleased that it is one of Emory’s first university-wide initiatives, we realize that we will face challenges as we work to fulfill its mission and meet its goals. One of our greatest challenges will be to forge intramural, collaborative relationships within a university whose schools and departments have historically operated independently of one another. Some collaborations have and will continue to be established naturally, as they have been among schools in the health sciences. However, bringing scholars in the social sciences, law, and the humanities to the global health table will take more time and creative thinking.
Another challenge we face is ensuring that we are good stewards of the generous resources Emory has provided to the institute. Emory’s faculty, students, and alumni are talented, committed, and interested in making a positive difference in the world. The institute will no doubt receive far more excellent proposals than it will have resources to fund. Therefore, the institute must be selective and strategic regarding funding decisions so that it supports programs that have the greatest potential to impact global health in a positive way.
Achieving Success through Partnerships
In six years, we want to have enhanced the institute’s capacity, but, more importantly, we want to have established strong partnerships and see measurable improvements in global health stemming from Emory’s collaborative efforts. The institute’s role at Emory is to broaden and deepen the university’s global health efforts as well as close gaps in expertise that currently exist. We also want to bring more and different Emory players to the global health arena along with new partners from around the world. In that same vein, we have and will continue to engage Emory’s peer institutions in global health partnerships. Although being competitive serves us well at Saturday afternoon sports events, it is better to work collaboratively when trying to find solutions to global health problems.