What a difference a year makes
In a world that is becoming increasingly interconnected through breakthroughs in transportation and information technology, we are beginning to feel both the blessings and challenges of globalization.
Inspired by this changing world, Donna Spiegelman saw the need for a team of researchers who could use existing and innovative epidemiologic methods to learn from populations all around the globe to improve global health. The overarching goal of this initiative has been to develop collaborative research projects with colleagues around the world, with a global focus on research embedded in action. Starting exactly a year ago, Donna Spiegelman (Professor, Departments of Epidemiology and Biostatistics) and Michelle Holmes (Associate Professor, Harvard Medical School) began arranging brainstorms, planning meetings, and conference calls among faculty, postdocs, researchers, and students in the Department of Epidemiology and the wider HSPH community, including representatives from the Departments of Environmental Health, Population and International Health, Society Health and Development, Biostatistics and Nutrition. This collaboration has spread more recently to include colleagues from other Boston-area institutions, as well as non-governmental organizations (NGOs) from around the world.
This Global Epidemiology Initiative has taken on many forms - developing into many smaller groups working on an array of activities that are aimed at bringing epidemiologic methods and research to a much more global perspective. Although the group is still in its infancy, many developments have already begun to make a big impact:
A Notice of Intent to Apply was sent to the Bill and Melinda Gates Foundation by Donna Spiegelman and Wafaie Fawzi on March 31, 2008, in response to the Request for Proposals entitled, "Alive & Thrive: Reducing avoidable death and disability due to sub-optimal infant and young child feeding." This large-scale operational research program seeks to connect multiple partners, including NGOs, the private sector and universities, to scale up known efficacious interventions in infant and child feeding. Universities were sought to provide monitoring and evaluation of the interventions, and design of novel interventions that need to be tested in a rigorous research setting. Drs. Spiegelman and Fawzi, along with Julie Rafferty of the HSPH Development Office, have been active in attempting to form partnerships with NGOs planning to submit proposals.
On March 10, 2008, Donna Spiegelman, Michelle Holmes, and Frank Hu submitted a proposal to the Harvard China Fund entitled: "A Randomized Trial Substituting Brown Rice for White Rice to Lower Markers for Diabetes Risk." This is a randomized intervention study involving replacing the staple carbohydrate (white rice) with one that has a lower glycemic index (brown rice) two meals a day in the cafeteria of a factory in Shanghai, China. Blood lipids and other markers of diabetes risk will be assayed at the beginning and end of the intervention for changes. This research has potential major significance in a country where diabetes cases are rising to unprecedented levels. Passing the first round of evaluations, we await decision for final approval.
On April 21-23, Michelle Holmes traveled to Johannesburg, South Africa to attend a conference entitled "Switching Gears in HIV Research: Building an international research agenda on the impact of HAART on fertility in sub-Saharan Africa," as the guest of Dr. David Bangsberg. Her purpose was two-fold: to deliver a talk on possible interventions to lower maternal mortality (Millennium Development Goal #5) and to meet with colleagues from Mbarara University of Science and Technology. Mbarara is a new university in a rural part of Uganda. Colleagues there are interested in potential research collaborations with Harvard.
On April 9th, Michelle Holmes submitted a proposal to the Radcliffe Institute for Advanced Study to hold an Exploratory Summer Seminar. This internal Harvard program allows faculty to invite scholars to a 5-day summer meeting to explore avenues for future collaborative research. If funded, it would allow 5 scholars from Tanzania, Uganda, Ghana, and Nigeria to visit Harvard this summer to continue the discussions of designing observational and interventional studies in Africa that were begun during our faculty's trip to Africa in January 2008.
In response to a Request for Proposals from the Fidelity Foundation's Boston-India Collaborative Project calling for collaborative projects to further public health in India, Donna Spiegelman's team split up into two working groups to develop two separate proposals addressing the most pressing health issues facing India today - the rapidly growing diabetes epidemic associated with India's nutrition/epidemiologic transition, and the slow progress towards the achievement of Millennium Development Goals 4 and 5 concerning under 5 child mortality and maternal mortality.
The first, with Wafaie Fawzi as the co-PI, entitled "MDG4 Action: Community-based Interventions to Prevent Neonatal Mortality in India" seeks to address Millennium Development Goal #4 (reduce by 2/3 the mortality rate among children under age 5). Epidemiology and nutrition doctoral students Christine McDonald, Saurabh Mehta, Manas Kaushik, Julia Finkelstein, and Shagun Sabarwal played a major role in development of this proposal, and Christine wowed all with her brilliant drafting of the document. In India, more than one million infants die within the first week of life, representing more than one-quarter of the world's neonatal deaths. Patrick Webb, Dean of Academic Affairs at the Tufts University Friedman School of Nutrition, and former Chief of Nutrition at the UN World Food Programme, and his group joined the team, and our partners in India include the NGOs Jan Swasthya Sahyog in Chhattisgarh, Self-employed Women's Association in Bihar, and the Rural Unit for Health and Social Affairs at the Christian Medical College in Vellore.
The group is proposing to design and evaluate a package of interventions to lower neonatal mortality in high-risk, resource-limited communities. The interventions will cover the continuum of care from pregnancy through the neonatal period and will be delivered via local health workers. It is of utmost importance that the interventions not only be novel, inexpensive, and logistically feasible, but also culturally appropriate and sustainable. While we will rely on the experience of our collaborators in India to refine the elements of the package during the planning grant phase, the main components will likely include: calcium supplementation of pregnant women(to lower the risk of pre-eclampsia leading to preterm birth), topical application of antiseptics to the umbilical cord at time of delivery (to lower the risk of neonatal infections), and nutritional supplementation of underweight pregnant women (to lower the risk of low birth weight).
The second proposal, with Walter Willett as co-PI, is a proof-of-concept study aimed at identifying key dietary and lifestyle interventions in India that can be incorporated into diabetes prevention efforts both at the community and national level. India had the highest number of diabetes mellitus cases in the world in 2007 with over 40 million cases and is expected to continue leading the DM pandemic in 2025 with nearly 70 million cases. Epidemiology and nutrition doctoral students Vasanti Malik, Manas Kaushik, Julia Finkelstein and Saurabh Mehta, played a major role in the development of this proposal, this time with Vasanti wowing us with her impressive proposal-writing skills! Additionally, biostatistics post-doctoral research fellow, Xiaomei Liao, provided expert assistance with sample size calculations for this and all the other projects to date. Dr. Margo Woods, an experienced nutritional interventionist, of the Nutrition Unit at Tufts University School of Medicine, and her group joined the team, along with Dr. V. Mohan and his group, one of India's leading diabetes groups, based in Chennai. This study will likely take a similar shape to the Harvard-China Fund Proposal, where the intervention will involve switching the staple carbohydrate to one with a lower glycemic index (replacing white rice with brown, red, or parboiled rice).
Through working with another Boston-area institution (Tufts University) as well as institutions in India (SEWA, JSS, CMC, Dr.Mohan's Diabetes Specialties Centre, the Madras Diabetes Research Foundation, and Madras University), these two proposals have truly been a global collaboration. We look forward to meeting with our new colleagues in Boston as well - already, G. Radhika from Dr. Mohan's diabetes group and Dr. Priyank Jain will be visiting us at HSPH this May.
By establishing new collaborative models, new relationships, and new ideas for research on a global scale, this Global Epidemiology Initiative is developing and establishing innovative ways to conduct epidemiologic studies to address the world's major health needs in this era of globalization. Moving forward, the group hopes to take even bigger strides toward interconnecting existing studies, writing more proposals, and collaborating with colleagues from around the world to improve global health. The time for barriers and borders is over; it is time for a global approach to health, research, communication and action. Let's move forward, together.
No man/woman is an island, entire of itself...any man's/woman's death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee. - John Donne