9Expanding Boundaries to Advance Medical Research—Lessons Learned at the National Institutes of Health and Ways Forward

Hrynkow S.

Publication Details


Geographic boundaries no longer pose the challenge to scientists who wish to work internationally that they did even 10 years ago. International partnerships and collaborations in medical research are rising steadily and rapidly. This presentation explores models of international collaboration in medical research and training and new approaches to bringing scientists in a variety of disciplines together to address common challenges. Breaking down geographic and disciplinary borders provides new opportunities for support of research and is crucial as the chemical science community takes an increasingly global outlook. Potential subjects of joint pursuit between the chemical sciences and the life sciences are discussed, particularly as related to global health challenges and possibilities for enhancing international training and cross-training.


As a backdrop for this discussion, a word on the international initiatives supported by the National Institutes of Health (NIH) may be useful. NIH's very roots are international. Begun as a one-room laboratory on Staten Island, New York, as the Laboratory of Hygiene, NIH had as its mission in 1887 identification of disease—cholera in particular—on ships entering port to prevent their spread to the broader population. Joseph Kinyoun, the first NIH director, had benefited from training abroad in the laboratories of the leading microbiologists of the day, Koch and Pasteur. From that humble beginning, NIH has grown into the lead agency in the U.S. government for support of biomedical and behavioral research, spanning 27 component institutes and centers and supporting a vibrant intramural research program. Today, NIH extramural and intramural activities involve substantial levels of partnership with foreign scientists.

On the extramural side, NIH supports a variety of research grants, contracts, and training programs involving foreign scientists. Research topics cover the full array of medical research pursuits, from basic research on cell signaling, protein production and degradation, imaging technologies, and underlying mechanisms of disease establishment and progression to behavioral research, disease pathogenesis, and more applied work in vaccine development and clinical research. As with support of domestic research projects, scientific rigor must be demonstrated before any award is made to a foreign scientist. Additional specific criteria are used to assess foreign applications.

Many NIH extramural programs are dedicated to advancing medical research through international cooperation. These include the programs and initiatives of the Fogarty International Center (FIC) whose mission is “to reduce disparities in global health through international cooperation.” Thus, FIC works entirely on global health issues and supports partnerships between U.S. scientists and counterparts abroad as an integral component of its work. Fogarty's 30 extramural research and training programs address critical challenges and training needs related to AIDS; emerging infectious diseases, including malaria and tuberculosis; maternal and child health issues; and the human health effects posed by environmental pollution. Research programs support studies to understand the causes and consequences of being stigmatized by an illness or disease, the linkages between health of populations and economic development, and interventions for brain disorders and mental illness, a growing burden of disease in resource-poor nations.

Fogarty's well-established training programs are dedicated to building expertise and scientific infrastructure in resource-poor nations, whereas newer programs have been developed to provide the next generation of U.S. researchers and physicians with international training experience. Over time, the success of the programs aimed at enhancing science in poor countries has become clear. For example, the AIDS research training program, developed and supported in conjunction with multiple NIH institutes, has contributed to the development of leading AIDS researchers and policy makers in countries most heavily affected by this dreadful disease. Leaders in Uganda, Haiti, Senegal, Brazil, and Thailand, for example, have all received training through the Fogarty program and have made important contributions to reducing the spread of AIDS in their home countries. This new generation of AIDS leaders trained by Fogarty competes successfully for NIH grant support and for support on a competitive basis from other international sources, including the Global Fund to Combat AIDS, TB and Malaria; the Elizabeth Glaser Pediatric AIDS Foundation, and the Bill and Melinda Gates Foundation. Thus, this cadre of scientists and health policy makers serves as the linchpins for tackling AIDS in their home countries, and they do so with a firm foundation of scientific knowledge and understanding of evidence-based medicine.

In addition to its long-term approach, Fogarty training programs are characterized by the following:

  • Close linkage between research and training efforts in individual awards
  • Flexibility to allow scientific collaborators to determine what kind of training is most needed to advance critical research areas (Ph.D., master's, postdoctoral fellows, and allied health professionals)
  • Networking among researchers and trainees across programs
  • Long-term mentoring
  • Empowerment and mutual respect
  • Response to local needs and priorities
  • Individual and institutional partnerships and commitments
  • Support for trainees on their return home on a competitive basis

In addition to the targeted programs of the FIC, specific international programs are supported by other NIH centers and institutes. They include major programs supported by the National Institute of Allergy and Infectious Diseases aimed at development and testing of HIV intervention technologies (such as the Comprehensive International Program for Research on AIDS and HIV vaccine and prevention networks), by the National Institute of Child Health and Human Development aimed at identification of effective strategies to reduce maternal and infant morbidity and mortality (such as the Global Development Network), and by the National Heart, Lung, and Blood Institute to improve detection and treatment of hypertension (the Pan American Hypertension Initiative).

On the intramural side, the NIH visiting program supports training of about 2,500 foreign scientists per year in the NIH laboratories in Bethesda, Maryland, of a total of about 6,000 scientists. Foreign scientists are an integral component of the intramural efforts of NIH. Entry into the NIH visiting program depends on scientific matching between the laboratory chief and prospective trainee.

Over the last few years, NIH support of international partnerships and programs has risen dramatically. In FY 1996, for example, NIH spent about $157 million in support of international cooperation, including about $32 million for research projects for foreign investigators, about $40 million for collaborative research projects for U.S.-foreign teams, and about $67 million for training of foreign scientists on the NIH campus. In comparison, in FY 2002, overall spending was around $400 million, including $90 million in support of direct awards to foreign scientists, $200 million for partnerships between U.S. and foreign counterparts, and more than $90 million for training of foreign scientists in the NIH intramural program.


Several conditions make it likely that international partnerships in medical research, including those supported by NIH, will continue to expand. First is the growing recognition that international scientific partnerships will lead to more rapid understanding of specific diseases or conditions and to development of interventions for critical problems, including AIDS, cancer, and other chronic diseases. The scientific community will respond with increasing numbers of applications, many of them internationally oriented. The World Health Organization (WHO) projects that the global burden of disease in 2020 will reflect an increasing burden because of noncommunicable diseases. This epidemiologic shift from the current pattern, in which communicable diseases are most important, will open new opportunities and rationale for scientists around the world to work together in new ways.

Second, ease of communication with scientists anywhere in the world fosters the development and strengthening of partnerships. The Internet and low-cost air travel will continue to be critical as scientists meet and exchange ideas by whatever means available.

Third, new partners and funding sources, including the Bill and Melinda Gates Foundation and the Civilian Research and Development Foundation, provide new opportunities for international teams of scientists to exchange information and ideas and to partner on projects of joint interest. As awareness grows that health of populations leads to wealth of populations, some governments have begun to make increased investments in health and health research, again increasing the possibilities for research support and potential partnerships.

Fourth, as a global culture of science takes hold—to include shared understanding of values on peer review, bioethics, communication of science and health advances to the public, and public involvement in the scientific enterprise—scientists around the world will find themselves on a more level playing field, which will pave the way for increased international cooperation.


U.S. scientists do not travel abroad for postdoctoral experiences, nor do U.S. senior scientists travel abroad for sabbatical experiences at the same rate as counterparts in Europe and much of the rest of the world. The numbers are stark. For example, of the 7,000 National Research Service Awards (postdoctoral support from NIH) provided in 2 successive years, 1998 and 1999, fewer than 20 people elected to take their postdoctoral fellowship outside the United States. Reasons for electing to remain in the United States during the formative period are many and varied. Some report that fear of being out of the U.S. scientific mainstream is the overriding factor. Some new programs (Fogarty-supported, those of the Human Frontier Science Program [HFSP], and the von Humboldt Foundation—see Chapter 8 of this report—and others) provide a “safety net” on return home in the form of salary support for a permanent position, at least for a couple of years. These awards are made on a competitive basis, and early experience with the programs shows that they are working. Fogarty, for example, now supports 20 postdoctoral fellows in developing-country laboratories—this after 3 years of the program. With the appropriate safety nets and with support and encouragement from mentors and department heads, more junior U.S. scientists will take advantage of opportunities to train overseas during the early stages of their careers. In 10 years, we hope to be able to tell a different story with respect to overall numbers than the one being told today.


Lessons learned from the medical research community on international partnerships, formal and informal, may be instructive to others who are planning to engage in international research initiatives. Among the effective model programs and the features that contribute to their success are the following:

  • Human Genome Project. This public-private project brought U.S. scientists together with foreign scientists, particularly those in the United Kingdom, to conduct the largest sequencing project ever. Among the features that allowed this venture to succeed were adequate funding, common vision, clear leadership, an agreed-upon work program, and regular communication among the partners.
  • Multilateral Initiative on Malaria (MIM). This international initiative, launched in 1997, brought together science funding agencies from around the world with scientists from Africa, WHO, the World Bank, and others to develop an action plan in malaria research and training to implement it. Since that time, the United Kingdom, the United States (NIH), and now a Swedish consortium have led the MIM, and support for its efforts has grown. New resources for malaria have resulted. No formal agreement among partners was signed to launch and implement this initiative. African scientists' participation in all aspects of the MIM has ensured its success and relevance. In addition, the MIM adopted a transparent operating mechanism and voting mechanism to engage all stakeholders in identifying future MIM lead agencies.
  • Fogarty International Center research training programs. As described above, these programs are flexible, meet local needs, are scientifically rooted and rigorous, and are long term. Fogarty works in partnership with many other NIH centers and institutes, with the Centers for Disease Control and Prevention and other Department of Health and Human Services agencies, with foreign science funding agencies, and with private groups to develop and support its programs, which work through U.S. universities and counterparts abroad. The result is enhanced scientific infrastructure and leadership in low- and middle-income nations that translates into evidence-based decision making and improvements in individual, family, and community health.


An array of challenges must be considered before one enters into negotiations or implementation of a joint international project or effort. All are potentially surmountable with planning and with good information. Some of the major challenges are described below.

Exchange of scientists across borders is increasingly difficult. In the post-9/11 era and with heightened security, travel restrictions for foreign scientists and increased security measures require additional planning and time in development of exchanges and partnerships. Delays in receiving appropriate visa documentation to enter the United States can be substantial. In addition, as foreign scientists working in the United States travel abroad for home visits or to attend scientific conferences, anecdotal data show that delays in reentering the United States can also be substantial. As new visa systems are put in place, U.S. scientists and institutions and their counterparts abroad must become familiar with new travel requirements and be prepared to work within existing frameworks to advance international efforts.

Missions and practices vary across agencies. Working in partnership with other institutions, domestic or foreign, may pose challenges if missions and operational practices differ seriously. Gaining an appreciation of what is likely to be supported by other agencies and practical ways for sharing support for a given project is important early in the planning stages. Not all successful partnerships require transfer of funds from one agency to another, but it is critical to determine early how the partners will support the project and leverage each other's resources.

Expectations as to level of formality of international partnerships may vary. NIH is party to more than 90 formal agreements—some at the government-to-government level as part of broader science and technology agreements, others between NIH or component institutes and centers and counterparts abroad. Still other partnerships occur through informal mechanisms in which no agreement has been signed. Understanding the benefits and costs of both formal and informal agreements is crucial in determining whether a signed agreement would most effectively advance a particular research objective or whether no formal agreement is needed.


Many achievements in medical research can be traced back to advances in chemistry, physics, mathematics, and other disciplines. Whether it is the development of microscopic methods whose application has yielded enormous insight into normal functioning and disease states or the development of rapid gene-sequencing technologies to identify new genes involved in disease or protection from disease, the underpinnings have involved a mix of expertise and the ultimate benefits to human health have been enormous. The 2004 Nobel Prizes in Chemistry and Physiology or Medicine, awarded to long-standing NIH grantees, are indicative of the fluidity between the physical sciences and the life sciences. The major advances recognized by these awards-for enhanced understanding of the structure of ion channels and for the development of high-resolution imaging technologies—have already led to applications in health care and medical research.

Opportunities are on the horizon for even stronger cooperation among scientists across disciplines. With recent advances in genome technology, imaging technology, and other fields, opportunities to propel health research forward through strong ties among disciplines have perhaps never been greater. To bring scientists together in new ways for the improvement of human health, the NIH Director announced (September 2003) a new strategy to accelerate medical research progress, the NIH Roadmap for Medical Research. Achieving progress under this roadmap will require strong participation by the chemical sciences community.

One of the chief aims of the roadmap is to improve the understanding of complex biologic systems. Among the tools to be produced to assist in this effort will be libraries of molecules that can serve as probes of biologic networks, innovative tools for capturing real-time images of molecular and cellular events, improved computational infrastructure for biomedical research, and nanotechnology devices capable of viewing and interacting with basic life processes.

A second emphasis of the roadmap is on encouraging scientists to move beyond traditional disciplinary borders to participate in novel interdisciplinary scientific projects. Through the new teams, involving public-private partnerships as needed, it is expected that more high-risk, high-payoff projects may be pursued. More information on how the roadmap initiative was developed and announcements on roadmap-related requests for applications are available at www.nihroadmap.nih.gov.


National Science Foundation indicators show that foreign-born scientists make up a substantial proportion of those working in all fields of science in the United States today. This trend is expected to continue in the coming years. As the United States works to strengthen the science pipeline domestically through programs that engage American children and those entering college in science, the reality will remain that key needs will continue to be met through foreign-born scientists. As we look to the future and consider important gaps that that must be adequately filled to advance medical research, including synthetic organic chemistry and radiochemistry, several trends should be kept in mind.

There is an increased competition for highly qualified personnel, particularly at the postdoctoral level. As other Organisation for Economic Co-operation and Development governments develop attractive research environments, anecdotal evidence suggests that European postdoctoral fellows, for example, may opt to train in Europe or Australia rather than in the United States. Several countries now have major repatriation programs to attract young scientists who have traveled abroad for postdoctoral training to come back. Attractive recruitment packages are contributing to increasing repatriation rates in some countries.

There are many favorable effects of this approach on a long-term basis. The short-term effects must be addressed.

As political conditions improve, living standards rise, and scientific infrastructures are strengthened in some countries, junior scientists may opt to remain in their home countries rather than travel abroad during their formative years.


As the chemical sciences community works to expand its global outlook and outreach, taking into account cross-boundary and cross-disciplinary considerations will be useful. Following are perspectives, practical approaches, and questions that could be considered.

Taking a Global Health Approach

Placing international cooperation on a backdrop of global health needs and opportunities adds a dimension to the discussion that may not previously have been considered. As junior scientists set out on a career path, engaging them to tackle issues of global health import should be presented as a worthy endeavor. There are high-profile endeavors and funding streams to assist in engaging the best and brightest scientists on the global health agenda. For example, the Bill and Melinda Gates Foundation and the Foundation for the NIH announced on October 17 the first 14 “grand challenges in global health” as part of a $200 million effort to solve critical challenges that stymie efforts to improve global health. Among the challenges are several directly relevant to the chemical sciences community, including preparing vaccines that do not require refrigeration, development of needle-free delivery systems for vaccines, and development of a chemical strategy to deplete or incapacitate a disease-transmitting insect population. More information on the challenges and application procedures is available at www.grandchallengesgh.org. As noted previously, the programs of the Fogarty International Center (www.fic.nih.gov) provide additional opportunities for U.S. scientists to work in cooperation with foreign counterparts on issues of global health import.

Raising Awareness in the Global Scientific Community About the National Institutes of Health Roadmap Initiative

Individual initiatives under the broad umbrella of the NIH roadmap should be reviewed carefully to determine the extent to which foreign scientists may participate. Raising awareness priorities among interdisciplinary efforts at NIH may lead other agencies to develop similar programs and approaches.

Increasing Awareness in the Chemical Science Community About National Institutes of Health Mechanisms of Support

In addition to the roadmap initiative, NIH, primarily through its National Institute of General Medical Sciences, supports ongoing programs in research and training for chemists working in medical research. Other medical research funding agencies, including the HFSP, support interdisciplinary efforts that are relevant to the chemical sciences community.

Sharing Lessons Learned

Development of international partnerships between chemical scientists and their institutions (for both research and training purposes) can be informed by lessons learned from both formal and informal efforts involving medical researchers. Many of the principles and lessons learned by the medical research community are directly applicable to other scientific communities.

Preparing the Next Generation—Mentoring Is Key

Encouraging junior scientists to expand disciplinary boundaries and geographic boundaries early in their careers will help to develop the next generation of creative, knowledgeable, and broad thinkers. There is a critical role for mentors in achieving this broad objective and a need for funding agencies to advertise more effectively the programs and opportunities that support junior scientists in venturing beyond geographic and disciplinary borders during formative stages. New kinds of training opportunities should be considered, including short courses in new fields of endeavor and summer programs. Programs involving junior scientists in paired institutions—one in the United States, one abroad—could be considered. New models to identify and support mentors who have international and multidisciplinary experience could be pursued.

Meeting Needs Today and Tomorrow

While efforts continue to strengthen the pipeline of U.S. citizens into the chemical sciences, foreign-born scientists will continue to play an important role in achieving short-term and medium-term objectives. Are existing mechanisms appropriate to meet needs in supporting critical fields, including synthetic organic chemistry and radiochemistry? Could new models be developed to meet critical needs without contributing to brain drain in low- and middle-income nations?

Where Are the Women?

Creating a globally aware workforce will require that we recognize and address issues of underrepresentation, including gender representation at senior levels in academe. At a recent colloquium on “Career Paths for Women in the Health Sciences: A Global Perspective,” sponsored jointly by FIC, the Office of Research on Women's Health (ORWH), and the National Institute of Environmental Health Sciences, NIH Director Zerhouni noted that it will increasingly be teams of scientists that propel medical research forward. He called for a change in mind-set to incorporate team approaches as we work to address critical health challenges and encouraged colloquium participants to identify the most effective means to include the best and brightest, including women, in strategies to tackle these challenges. As FIC and the ORWH move ahead with this agenda, collaboration with counterparts in the chemical sciences community is welcomed and encouraged.


Diverse topics were taken up after Sharon Hrynkow's presentation, including NIH funding of international research, global health, and diversity in science.

Foreign Scientists on National Institutes of Health Study Panels

David Budil, of Northeastern University, asked to what extent the increase in funding of overseas investigators that Hrynkow documented is mirrored by increased participation of foreign scientists on NIH study panels.

Hrynkow responded that to her knowledge there has been no dramatic increase in foreign participation on study sections over the years. A number of Canadian investigators participate on study sections. The most likely contributors to the rise in foreign funding are scientific opportunities, as recognized by both U.S. and foreign scientists, and mechanisms that foster international collaboration. FIC supports some of the mechanisms, such as the small-grant award that Hrynkow mentioned, and these programs are increasingly advertised to wider audiences. For example, FIC and other components of NIH take advantage of major scientific conferences to raise awareness of international opportunities. Fogarty also supports proposal-writing sessions and provides information about how to access and understand the NIH grant process.

National Institutes of Health Funding of International Research

Alvin Kwiram, of the University of Washington, first asked about the figures on external funding for Canada.

Hrynkow stated that Canada receives around $60 million in NIH support each year. Canadian investigators are the most successful among foreign scientists in receiving NIH awards, including direct awards to Canadian investigators and support of U.S.-Canadian joint research projects.

Kwiram then asked whether NIH “catches flak” from Congress about sending funds overseas and how NIH justifies it. Is the program for joint funding of U.S. scientists working with international scientists a separate program or the regular R01 program?

Hrynkow responded that NIH justifies spending abroad on the basis of good science and scientific opportunity or training efforts. The Fogarty mission is to tackle global health challenges, so it must work in partnership with its colleagues abroad. To make strides in research in such fields as AIDS and emerging infectious diseases, FIC must work with partners abroad. The benefits accrue to both the United States and the global community. The particular mechanism for joint funding is called “foreign components of domestic awards.” U.S. scientists may partner with foreign scientists on an NIH grant application. Every component of NIH may use this mechanism to support joint international projects.

Kwiram said that it would be constructive if the participants in the workshop had a mechanism for publicizing the importance of international exchanges and study because there is substantial resistance in institutions and among administrators to spending money this way. Furthermore, if someone published op-ed pieces in various professional magazines, such as Science, it would help to convince some of the leadership that international experiences are important. He challenged the group to think about ways to give greater visibility to the issues and present more compelling arguments to make the chemical community be more receptive to these kinds of activities.

Global Health

George Lorimer, of the University of Maryland, inquired about global health and how NIH goes about capturing the enormous intellectual and scientific power that is represented by the U.S. pharmaceutical industry, bearing in mind that many of the health challenges facing the global community involve diseases. Most of the diseases are infectious diseases, which are certainly not being worked on by Western pharmaceutical companies, largely because they affect people who do not have the money to pay for the research involved. In southern Africa for example, Western pharmaceutical companies are reluctant to lower the prices for their drugs even though large parts of sub-Saharan Africa are infected with AIDS, for example. This is enormously damaging for U.S. public relations and global relations. He wondered whether Hrynkow and colleagues are giving any thought to how this politically and scientifically important aspect could be overcome to reflect better on this nation as a whole and its supposed humanitarian behavior.

Hrynkow confirmed that they are looking at that exact issue because as they look at global health and how to improve the health of people around the world, global public good comes into play. Is it the responsibility of NIH, of academic institutions, and of the private sector to see that drugs are developed and moved to people who need them most in poor countries? Market forces, the investments made by pharmaceutical companies to bring drugs to market, and the enormous needs are all being considered. A number of plans and public-private partnerships have been established to accomplish some of the work, and NIH follows them closely.

Diversity in Science

James Martin, of North Carolina State University, directed some comments to the whole meeting about the statistic Hrynkow gave, that about 2,500 of the 6,000 researchers in NIH laboratories in Bethesda, Maryland were foreign. Despite being an extreme advocate of international exchange, Martin asked where the exchange ends. He does not know of any other nation in the world that would accept that statistic in a national laboratory.

He mentioned a comment that he had heard made on more than one occasion by department heads that foreign students are smarter than American students. He has routinely felt this pressure—that because he is domestic, he is not quite as smart as internationals. If this happens to a white American male, what happens to a woman or an African American? He suspected that there were more foreign-born persons in the workshop than women and definitely more than African Americans.

If the participants of the workshop believe in global education and globalization of the workforce, they have to look at their own resources, and Martin does not think that is happening. The statistic mentioned is disturbing, not because of the number but because of the lack of exchange. He believes that we need exchange and we have to develop our policies so that there will be exchange if we are going to make progress.

Hrynkow said the 2,500 figure is based on scientific matching between prospective postdoctoral fellows and laboratory chiefs. People are accepted in laboratories on the basis of their scientific expertise, the match, and the interest. The system is open, and all are encouraged to try to find appropriate laboratories in which to train.

She agreed wholeheartedly that we should do more to encourage and support Americans to go abroad for training and sabbaticals. As she mentioned, she was a postdoctoral fellow in Norway for almost 3 years. It was formative not only professionally but also personally. She used every opportunity to speak to postdoctoral fellows about the value of going abroad early in one's career. She challenged Martin and others in academic settings to have a role as mentors to encourage young scientists to expand their horizons and professional careers beyond the United States.

Martin agreed but was also getting the impression that countless Americans would love to recruit Asians because they are smart. Who is recruiting Americans because they are smart? There is a cultural question, and it is not completely different from getting women and minority groups members into science. We have to get Americans into science.

Hrynkow supported the need for diversity but pointed out that the best minds are recruited and the best grant applications supported. Good science must be the premise.

Inspiring the Next Generation of Global Scientists

Robert Grathwol, of the Alexander von Humboldt Foundation, mentioned one consequence of the German Chancellor Scholarship Program that may be applicable elsewhere. The German Chancellor Scholarship Program has an alumni web site on which people have profiled their own experience with the program. One of them makes it clear that he is prepared to mentor interested people interested in applying; as a result, there is a flood of applications in the environmental field because he is right there saying that he is prepared to talk about the program. Grathwol stated that everyone at the workshop could create a profile of his or her experience and put it on a web site to promote interest.

Hrynkow declared that she looks forward to this and agreed that people and their stories are what capture other people's interest. Compelling personal stories have a big role to play in inspiring the next generation of global scientists.

This is an edited transcript of speaker and discussion remarks at the workshop. The discussions were edited and organized around major themes to provide a more readable summary.