The United States has been synonymous with innovation. Conducting research to better understand the world and to experiment with new ideas has been an important part of this country’s progress. However, at this critical juncture in history, when chronic noncommunicable diseases (NCDs) (e.g., cancers, diabetes, cardiovascular disease, and mental health disorders) are rapidly becoming the largest global health burdens, affecting human welfare and productivity worldwide, US institutions must better align opportunities, pathways, and resources for 21st century scientists and future leaders in health policy.
To this end, we present lessons for government and academia by citing key innovations from a 21st century icon: Google. Bold and unconventional business and human resources strategies have made Google one of the most valuable companies in the world, and for the past three years, Fortune has listed Google as the “best company to work for.”
These lessons underpin the “Atlanta Declaration,” which emerged from the September 2014 US Investigators’ Global Non-Communicable Diseases Research Network Symposium held at Emory University. Participants, including the authors of this post, established the Global Noncommunicable Disease Network to chart a course for creatively supporting the next generation of scientists in the global NCD arena. The group articulated two main recommendations for achieving this goal—making larger and sustained investments in global NCDs research and encouraging non-traditional career paths to achieve innovation—both of which are described in greater detail below.
The Current Paradigm
The United States is not committing enough resources to the world’s biggest health problems. Worldwide, NCDs account for 66 percent of all deaths, but only 2 percent of overseas donor assistance is budgeted for NCDs. Low- and middle-income countries (LMICs) are disproportionately affected by NCDs. For example, 80 percent of worldwide cardiovascular disease mortality occurs in LMICs, and NCDs account for over US $250 billion annually in lost productivity in these countries.
Furthermore, the greatest barriers to combating NCDs, factors outside the traditional biomedical framework such as weak health systems and insufficient capacity, appear daunting.
Investing In Global NCDs Yields Economic And Scientific Returns
The World Economic Forum projects that NCDs will lead to US $47 trillion in lost global productivity by 2030 and directly threaten economic stability. The World Economic Forum highlights that NCDs affect people in their prime: economically productive years of life, leading to absenteeism, low productivity, and low levels of disposable income, all of which affects the global economic interests of the United States. As with Google’s large-scale investments and free products (e.g., digital applications), US investment in global NCD research may lead to profitable products (by providing a basic research foundation, for example). US NCD investments may also create and maintain foreign markets for our goods, facilitate US soft power and generate goodwill, and provide the prosperity and stability that can help keep extremism at bay.
Conducting research in unique populations and diverse settings provides new opportunities for understanding the basis of disease and health, for evaluating the success (or failure) of new health interventions, and for advancing disease prevention and control in the US and the world alike. An example of successful learning from LMICs is how innovative combination antiretroviral therapy, and an expanded role for community health workers to promote adherence, helped South Africa improve delivery of HIV/AIDS treatments to those in need. This same model has been applied to NCD care in the United States; in Harlem, New York, home-based care for high-risk patients with asthma borrows from the lay health worker example in South Africa.
Atlanta Declaration On Noncommunicable Diseases: Specific Recommendations
Financing US-Based Global NCD Research
Google spent US$2.6 billion on research and development in the third quarter of 2014 and is estimated to realize US $10 for every US $1 invested. Quantifying such returns from investing in global NCD research is difficult and nonlinear. For example, the value of interventions focused on prevention is realized only after decades, far longer than the terms of elected officials who are often in charge of these investment decisions.
That said, scientific evidence suggests that investments in prevention will lower long-term health care costs and preserve quality of life. Therefore, we recommend funding agencies, governments, and foundations adopt a longer-term vision in which their global NCD portfolios include investments in both research and implementation that are sustained over the next few decades. These investments are needed to establish and maintain intercountry institutional partnerships and networks, which are the backbone of global health.
In the face of daunting barriers, Google has excelled. Despite weak infrastructure and capacity in LMICs that impedes economic development, the company went ahead and invested in internet connectivity across the African sub-continent, with the intention of stimulating micro- and macro-economic development. US investments in global health and human capital should be similarly resolute. The National Heart, Lung, and Blood Institute (NHLBI) and the UnitedHealth Chronic Disease Initiative together previously funded a network of 11 Collaborating Centers of Excellence (COE) dedicated to cardiovascular and lung disease research worldwide. The COE network established scientific infrastructure and platform studies in the form of large cohorts and generated swaths of new findings, and it provided opportunities for young scientists in LMIC to learn and establish their own credibility. Global NCD–interested fellows and junior faculty in the COE network maximized this investment and returned numerous scholarly works: 75 manuscripts, 136 abstracts, 110 presentations, three career development awards, and 37 submitted grants, all in a short space of time.
Regrettably, investments in this program were ended after just five years; and much of the United States’ global NCD research remains ad hoc, without an overarching strategy or coordination.
Investing in talent development is necessary to ensure future success. Google’s People Operations (a.k.a. human resources) publicly expresses its goal to “find them, grow them, and keep them.” Career development for those interested in global infectious diseases exist in the form of clinical fellowships, academic support, and related fiscal sponsorships given the long established link between infectious diseases, tropical medicine, and modern “global health.”
In contrast, global NCDs fellowships for young investigators are lacking and global NCD training lags behind global infectious disease training by 20 to 30 years. This is true even on the domestic front, where the much-lauded Robert Wood Johnson Foundation Clinical Scholars program, a leadership pipeline for health policy pioneers to eliminate disparities, will end in the next two years. Even the seminal Fogarty International Clinical Research Scholars and Fellows (FICRS-F) Program offers five infectious disease–focused fellowships for every one NCD-focused fellowship. Both trainers and trainees are interested in more global health research, but there is no outlet to develop and sustain trainees that are interested in addressing the burgeoning field of global NCDs.
By supporting efforts to strengthen clinical research and medical education in LMICs, the United States can demonstrate its leadership role in health and development worldwide. The NHLBI COE program required “twinning,” in which each COE included a research institution in a developing country paired with at least one partner academic institution in a developed country. But this support has eroded over time, with now only 25 percent of funds going to LMIC trainees as mandated by the National Institutes of Health (NIH). An alternative program such as the Medical Education Partnership Initiative, which funds 15 sub-Saharan African countries/institutions to develop research careers, is precisely the kind of initiative that can and ought to be supported, even partially, by our funders and academic medical centers.
We also need creativity and innovative human resource approaches in global health. Google’s division directors give their employees freedom and allocated time—one day a week or more—to work on unconventional problems unrelated to their usual “mission.” This sort of protected time yields (a) loyalty and a higher likelihood of retaining top talent and (b) potentially game-changing innovations. Academic institutions can also play a role in financing global NCD research and allowing young researchers the time and financial freedom to pursue this field. Instead of waiting for trickle-down budgets (from Congress to NIH to academia), we encourage division and program directors at academic medical centers to financially invest in physicians and scientists early in their careers. For example, the Division of Cardiology at Duke University recently created a section for Global Cardiovascular Health to support global health research and training for fellows and faculty; this is the first such section in a clinical cardiology division in the United States.
Valuation Of US-Based Global NCD Research
Business valuations can take many forms, from market capitalization to forecasted future earnings, and they can vary according to the perspective taken. Valuing academic achievement in medicine and public health at universities is far more rigid and narrow in its approach and relies on traditional metrics where counts (e.g., of reports published, of journal impact factors, of grants received)—the most easily obtainable and quantifiable metrics—are routinely tracked and are used to determine promotions and compensation.
Metrics for university promotion in the field of global NCDs should not be bound to traditions. Global NCD research requires teamwork, and implementation of new forms of action. The “publish or perish” model is asynchronous with the frame of global NCDs; scholarship evaluations (and therefore promotions) should not be based solely on the impact factor of one’s paper or the order of authorship, but rather on the impact of one’s ideas and their effect on human health. Academic institutions can help lead the way by individualizing evaluations and considering more than counts.
Funders are providing salutary examples of the way forward. The NIH has recently revised its investigator biosketch format, allowing researchers to describe up to five significant scientific contributions instead of merely listing 15 publications. This revision suggests that the NIH may be valuing actual impact over journal impact factor. The NIH has also begun to view favorably multidisciplinary teams in proposals, stressing its preference for interdependence rather than independence.
US institutions must earmark new and existing resources to support work on global NCDs and can adapt lessons from Google on how to do this. We need macro- and micro-level tactics, as well as more local initiatives from division directors to support the next generation of scientists and give them the opportunity to innovate and flourish. The mechanisms should support not only junior investigators in launching their portfolios, but also mid- and senior-level investigators by protecting time for mentorship and sustaining the platform studies through which trainees can safely dip their toes into the research arena.
We hope this Declaration from the current and next generation of researchers on noncommunicable diseases will contribute to the needed innovations on how we stimulate, do, and value research. Networks and human capital are critical to the success of any endeavor. Social mobilization through HIV/AIDS networks in the United States and abroad generated game-changing insights and lessons for research, implementation science, and advocacy; a similar strategy is immediately needed to curb the rising tide of NCDs that devastate lives and cause health care costs to skyrocket. The time to be bold is now.