National Council for International Health Governing Board
February 24, 1983
A. Despite the considerable publicity in the international health community about "destruction" of the International
Health Program within the Public Health Service, I am here to tell you that the program is alive and well.
B. To illustrate that point, the following are the areas I plan to include in this presentation:
1. The budget for international health in PHS.
2. How international health is organized in PHS.
3. Our multilateral program involvement
4. Bilateral programs the PHS
5. Activities that may be of particular interest to this group -- selected international activities of the National Institute
of Allergy and Infectious Diseases, NIH, and of the Centers for Disease Control.
II. The budget for international health in PHS
B. PHS does not have a budget for international health as such. Most of the PHS' international or internationally related
activities are funded through:
Funds appropriated for domestic research and related salary and expense items. This has always been the case with funds provided
directly from PHS appropriations and it reflects the fact that the PHS agencies have a legislative mandate to conduct international
research and related activities which will advance the status of the health sciences and thereby the health of the American
people. Indeed, for the past several years, between $50 and $70 million (depending on how you define international activities)
has been spent each year from PHS appropriations for international activities.
(Note: estimates for FY 1983 are not available and, frankly, we do not now know what impact the overall budget cuts will have
on our expenditures for international health activities. The impact will probably be modest, inasmuch as most of the expenditures
are for grants and contracts supported under the NIH research program.)
Another significant source of funding is the Agency for International Development. Examples here include CDC work in Africa
to improve programs for childhood immunizable diseases, and NIH activities to establish regional capabilities for maintenance
of research laboratory equipment. At the present time, there are about 20 active interagency agreements between AID and the
PHS. These range from small participating agency service agreements to provide for the services of a particular expert to
large resources support service agreements which provide for technical assistance in such areas as planning for nutrition
interventions in primary health care programs.
Reimbursable programs with foreign governments. The programs with Kuwait and Nigeria fall into this category. We are now on
our second year of the programs with these two countries and the experience we are gaining may well serve as models for similar
cooperative arrangements with other countries. Indeed, we have received inquiries from at least two other governments (United
Arab Emirates and Saudi Arabia) about the possibility of reimbursable programs.
Reimbursements from the World Health Organization for PHS staff who work in various WHO programs. Also WHO provides financial
support to several components of the PHS, especially CDC and NIH, which serve as WHO international collaborating centers (e.g.
in the areas of influenza and other respiratory diseases, hepatitis, and other viral diseases, immunology, leprosy, to name
Other Special Funding Arrangements -- the joint funds with Poland and Yugoslavia are examples. Similarly, we hope to participate
in the new S & T fund that is being established with Spain under the treaty of friendship and cooperation.
B. The only specifically international line items in the budget of the PHS at this time are:
1. The special foreign currency appropriation, which is administered by the Office of International Health on behalf of the
entire PHS. (FYI -- the current access currency countries are India, Pakistan, Guinea and Poland. You should be aware that
while Poland just went back on the excess currency list, we are not now being permitted to use the money for diplomatic reasons.
Also, there have been indications that Taiwan may become an access currency country.)
2. The budget for the Fogarty International Center of the National Institutes of Health is the second international line item
in the budget.
3. The only international health line item that has been eliminated from the PHS budget is the Office of International Health,
OASH. Yet, the OIH continues to exist as a leaner yet very active office within the Office of the Assistant Secretary for
Health. The reduction in the Office of International Health has apparently given rise to a belief, in some cases, that PHS
has reduced its commitment to international health. That simply is not correct. The PHS has a number of important leaders,
starting with Dr. Brandt and including Bill Foege, Bud Mayer, Jim Wyngaarden, Art Hayes, and Bob Graham who are strongly committed
to international health cooperation.
III. How is international health organized within the PHS?
A. The Office of International Health, OASH, carries out some very important functions within the Office of the Assistant
Secretary for Health. These include:
The official liaison function on behalf of the Public Health Service, the US Government with the World Health Organization
and the Pan American Health Organization. Indeed, the Office of International Health was established in 1945 to deal with
the growing international health involvement of the US Government, but particularly for drafting "charters and position
papers" for the proposed United Nations International Health Organization -- what is now the WHO -- and for cooperation
with such agencies as the Pan American Sanitary Bureau.
Overall health policy development within the DHHS, and oversight and coordination of the international health activities of
the five PHS agencies -- NIH, HRSA, FDA, ADMAHA, CDC -- and of the various programmatic components of the Office of the Assistant
Secretary for health (e.g. NCHS).
Official representation to foreign governments on PHS bilateral health program matters.
B. There are international program offices within each of the PHS agencies. These range from rather small offices playing
a policy, coordination and representation role for their agency (e.g. ADMAHA) to organizations, such as the Fogarty International
Center at NIH, which conduct a variety of programs, such as studies of international health research policy issues, sponsorship
of international conferences, and provision of international fellowships.
D. Within the PHS, is the agencies which are key to planning and implementation of international activities. All of the PHS
international activities reflect the domestic responsibilities and capabilities of the agencies. Indeed, the prevailing view
within the Department is that international cooperation is critical to the fulfillment of our mission. Without such cooperation,
our program of biomedical research would not be what it is today; we would be faced with far more difficult problems in the
food and drug consumer protection area; we would be at a great disadvantage as we attempt to carry out our responsibilities
for protecting the US population from communicable diseases, etc.
IV. Multilateral Program Activities
A. The United States is one of 158 members of WHO and we participate in activities and decisions of the organization throughout
the year in fulfillment of the health responsibilities and obligations as a member government. Many of these decisions are
effected at the sessions of WHO's governing bodies, the World Health Assembly and Executive Board, and at the PAHO Directing
Council, Pan American Sanitary Conference, Executive Committee.
B. We develop, in cooperation with the Department of State, policy regarding health issues which come before the governing
bodies of the other UN agencies, including (in addition to WHO) UNICEF, UNDP, the Narcotic Commission, the UN Fund for Drug
Abuse Control, UN Economic and Social Council, the UN Fund for Population Activities, the UN Environment Program, the UN Food
and Agriculture Organization, and the UN Educational Scientific and Cultural Organization.
C. Important multilateral issues which we have dealt with in recent months or are dealing with at this time include:
1. The recommendatory code for marketing of infant formula. Currently, the PHS task force is reviewing scientific evidence
concerning the relationship between infant feeding and infant health as well.
2. International drug scheduling -- this is a recurring issue regarding the international scheduling of abuse-potential drugs,
including, for example, benzodiazepine drugs.
3. Health for all by the year 2000 -- as a member government, we have a responsibility to develop a national strategy for
HFA and to report periodically on progress toward its achievement. We are currently working on the report on the monitoring
of our national strategy, to be submitted to WHO in March 1983.
4. Efforts to promote effective dialogue between WHO and US industry on pharmaceutical matters and particularly on WHO's
Action Program on Essential Drugs.
IV. Bilateral Programs
A. The PHS has agreements or programs with thirty-five countries. The agreements range from agency-to-agency level agreements
(e.g. FDA agreements with counterpart organization in a foreign government on inspection standards for low acid canned foods
offered for export to the United States) to government-to-government health agreements which identify priorities for cooperation
and provide for a joint structure for oversight of the bilateral program. Additionally, the PHS cooperates with several countries
under the terms of umbrella science and technology agreements or cultural agreements entered into by the Department of State.
B. We currently have formalized bilateral health programs with the following countries:
Egypt, People's Republic of China, Federal Republic of Germany, Finland, France, Hungary, India, Israel, Italy, Japan,
Kuwait, Nigeria, Poland, Yugoslavia
C. Highlights of some of the principal bilateral programs are the following:
The program is actually more than twenty years old, having been initiated in 1962 as part of our Scientific Activities Overseas
(Special Foreign Currency) Program. It is noteworthy that, even during our times when diplomatic relations between the US
and Egypt were suspended in the early 1970s, the program of health cooperation continued to function.
The US-Egypt health agreement S health agreement was signed in 1975 and renewed in 1981.
The program is overseen by a US-Egypt Joint Working Group on Health Cooperation. Members of the Joint Working Group on the
US side are the Assistant Secretary for Health, the Director, Office of International Health, the US Ambassador to Egypt,
the Director of the AID Mission in Cairo, the Commanding Officer of NAMRU 3.
This is been a highly successful program, including many projects of mutual interest and benefit -- schistosomiasis, arthropod
borne diseases, prevention of blindness, hepatitis research, etc.
Funding is now a critical problem.
Program initiated in early 1960s under the PHS Special Foreign Currency Program, although the PHS provided technical assistance
to India during the 1950s as well.
The program encompasses the full range of interests of the PHS agencies, but there is special emphasis on infectious and parasitic
diseases, reproductive physiology and prevention of blindness.
We do not have a health agreement with India, but function under the terms of an umbrella S & T agreement. A health and
medical sciences working group meets during the approximately annual meetings of the US-Indo S & T Subcommission.
A recent development with the establishment of a "Blue Ribbon" panel of outstanding scientists to develop plans to
expand cooperation in several areas -- biomass for energy, selected health areas (immunology, prevention of blindness, and
control of leprosy), and food production. PHS is cooperating in the initiative, including participation on the "Blue Ribbon"
panel. Dr. Richard Krause is a member of that Panel. Their report is expected to be given to the President in March.
3. People's Republic of China
The health protocol with the PRC was signed in 1979.
Agreed areas of cooperation are:
Infectious and parasitic diseases
Public health and health services research, child health and nutrition, and environmental and occupational health
Medical information science
Foods and drugs, including pharmacology
Reproductive physiology and family planning.
The last Joint Health Committee Meeting was held in Bethesda in November 1982.
An example of work with the PRC with the joint study of public health progress in Shanghai County. The results of that study
and of a follow-up symposium were published as a special supplement to the September 1982 issue of the American Public Health
Although the program of health cooperation with Israel is more than twenty years old, a formal Health Agreement was not signed
The principal emphasis is currently in policy related studies and consultations -- e.g. regionalization of health services,
the linkage between epidemiology and health policy, and food and drug consumer protection issues.
Agreement providing for reimbursable technical assistance in health field signed in May 1981.
Sub-agreements for cooperation in five areas signed in 1982:
Emergency medical services
Reduction of infant morbidity and mortality
Health manpower development and utilization
Vital and health statistics
Health agreement signed in 1981 the Federal Ministry of Health of Nigeria.
Agreed areas of cooperation include:
Health professions development
Foods and drugs
Communicable diseases control
The second meeting of the US-Nigeria Joint Task Force on Health Cooperation was held this week in Lagos we are awaiting a
report on that meeting. It is not known whether current economic difficulties in Nigeria will have an impact on this program.
The program with the USSR has been active since late 1950s, although the Agreement for Cooperation in Medical Science and
Public Health was not signed until 1972. A second agreement on Artificial Heart R & D was signed in 1974. Despite the
diplomatic difficulties in recent years, both agreements were renewed in early 1982.
Agreed areas of cooperation are:
Influenza, acute respiratory disease and viral hepatitis
Individual scientist exchange
Despite the general slowdown in S & T cooperation between the US and the Soviet Union, this program has remained quite
active (at about 90% of the pre-Afghanistan level).
Recent benefits to the US have included:
Joint clinical trials of the Q-switched laser for the treatment of glaucoma. With the advice and assistance of the Soviets,
a laser has been constructed in the United States and is being used in these studies.
Useful exchanges of personnel, information and virus strains for joint studies of influenza and acute respiratory diseases
are continuing. Information on a Soviet flu epidemic several years ago enabled the CDC to make an assessment of the disease's
possible epidemic impact in United States.
V. Other Areas of Interest to the NCIH (selected NIAID and CDC program activities)
A. As part of its international activities, the PHS is engaged in or supporting important research on diseases that are prevalent
in developing countries. Included are studies supported by the National Institute of Allergy and Infectious Diseases, NIH;
the Centers for Disease Control; and the National Hansen's Disease Center of the Health Resources and Services Administration.
1. NIAID continues to assign special priority in its Tropical Medicine Program to filariasis, leishmaniasis, leprosy, malaria,
schistosomiasis and trypanosomiasis, six diseases targeted for intensive research by the WHO/UNDP Special Program on Research
and Training on Tropical Disease. The FY 1982 commitment to the six diseases in the NIAID tropical disease program was approximately
2. The NIAID program also includes other infectious diseases in which international collaboration is essential to complement
the domestic research effort. These activities include work in the general categories of parasitology; tropical bacteriology,
mycology and virology; rickettsioses; and vector pathogens.
3. Highlights of recent NIAID support of tropical disease and international research, include the following:
Filariasis - recent research has focused on the development of animal models, in vitro cultivation, improved methods of diagnosis,
and immunologic responses to filarial infection. Significant developments include the axenic in vitro culture at the University
of Notre Dame of third stage larva of Dipetalonema Viaeae from ticks. This technique should increase the production of antigens
for diagnostic or immunization purposes and the potential to screen chemotherapeutic agents.
Several NIAID awardees are using Recombinant DNA technology to determine which gene segments of viruses code for virulence.
In June 1980, the human diploid rabies vaccine originally developed with NIAID support at the Wistar Institute was licensed
for general use in the USA. Current studies there include: (1) the use of monoclonal antibodies to investigate the world-wide
distribution of rabies virus strains; and (2) collaborative analyses of street (wild-type) rabies strains from animals which
died in spite of prophylactic vaccination and of humans who developed disease despite post-exposure vaccine treatment.
Preliminary results indicate that natural antigenic variants of rabies virus, probably of bat origin, exist in many areas.
Thus, traditional rabies vaccines conferred little or no protection.
Research projects involving vectors of public health importance cut across virology, parasitology and rickettsial diseases.
Intramural and overseas projects (including work in Egypt) concentrated on insect vectors of human diseases, particularly
tick-borne diseases. This expertise within NIH is concentrated in the Epidemiology Branch of the Rocky Mount Laboratories.
Several studies have focused on innovative approaches to vector control. A study at Ohio State University, for example, is
investigating strategies to disrupt pregnancy in the Tsetse fly vectors of African sleeping sickness which only lay one egg
after each mating.
In FY 1981, NIAID established a new Enteric Disease Study Center with Johns Hopkins at the Whiteriver Apache Indian Reservation
in Arizona. The Center is studying the epidemiology of diarrhea and the effect of potable water supplies on enteric illness.
NIAID is also concerned with vaccine development. Some of the more promising work is being done on vaccines for hepatitis
B, Meningococcal Meningitis, Hemophilus Meningitis, Chickenpox and Typhoid Fever.
International Collaboration in Infectious Disease Research
The ICIDR (insiders pronounce this as "eye cyder") Program involves awards to US institutions to enable them to have
a linkage of research with institutions overseas. Current awardees include:
Harvard School of Public health which is collaborating with the Federal University of Bahia, Brazil on schistosomiasis and
University of Illinois which is collaborating with the Chiang Mai University in Thailand on immunobiology and epidemiology
Michigan State University which is working with the Central Laboratory of the Ministry of Health in Sudan on schistosomiasis,
onchocerciasis and malaria.
C. Centers for Disease Control
1. Each year CDC cooperates with as many as 100 countries, through various mechanisms, including:
Investigation of the outbreak of disease
Assistance in disease surveillance activities in conducting health surveys in refugee camps
Participating in or conducting courses and workshops on such topics as laboratory management, hematology, immunology, epidemiology,
family planning, immunization, occupational health, and diarrheal, parasitic and venereal diseases.
Collaborating on operation projects with AID and WHO.
2. Important laboratory assistance and support is provided through:
Provision of reference agents (e.g. arbovirus) to other countries for use in surveillance of diseases, diagnostic reagents,
sets the control strains, etc.
Establishment of guidelines and standards for the evaluation and production of reference preparations and tests.
3. CDC facilities serve as 27 different WHO Collaborating or National Centers. These include Collaborating Centers for Reference
and Research on Arboviruses, Influenza, Mycobacterium Leprae, Rabies, Respiratory Virus Diseases, and Viral Hepatitis.
4. Cooperation with AID:
CDC's Family-Planning Evaluation staff provide support to AID to improve the management and evaluation of capabilities
family-planning and maternal-child health programs in less developed countries. Activities include evaluations of contraceptive
distribution systems, including community-based programs; contraceptive prevalence surveys; evaluation of the completeness
and quality of family-planning data systems, etc.
Several CDC officers are now assigned overseas to assist in the development of disease surveillance in 20 countries in West
and Central Africa and in Indonesia to reduce morbidity and mortality of diseases preventable by immunization. Countries involved
include Indonesia, Zaire, Congo, Ivory Coast, Cameroon, and the Gambia.
5. Epidemic Intelligence Service
Cooperating both bilaterally and through WHO, CDC is assisting other countries in the development of training programs for
an Epidemic Intelligence Service type training program. Of particular note is the project now going in Thailand, under WHO
auspices, to establish such a program for that region.
CDC is conducting a broad range of research on problems of international importance, including:
Dengue -- a collaborative study with Mexico has increased our ability to predict areas of higher risk dengue transmission
in the Southeastern US and Puerto Rico.
Malaria - CDC's Parasitic Disease Division serves as a reference laboratory for well characterized strains of Plasmodium
Falciparum used in laboratories worldwide.
Hemorrhagic Fever Viruses - Fieldwork in Sierra Leone of Lassa Fever epidemiology, treatment, and control, has contributed
to our understanding of this disease. Results of the Lassa Fever treatment program to date indicate the treatment of patients
with ribavirin and immune plasma may save lives. Progress has been made in studies on diagnostic aids and sub-unit vaccine
Poliomyelitis - In conjunction with WHO, CDC has been active in addressing polio virus problems of the developing world, including
the respective roles of live and killed vaccines in prevention and control and the advisability of routine individual vaccine
administration versus mass campaign activity.
Treponematoses - A direct fluorescent antibody technique has been evaluated for use in diagnosis of yaws.
7. Dracunculiasis Initiative
The years 1981-90 have been designated as the International Water Supply and Sanitation Decade. Control of Dracunculiasis
has been established as one of the goals of the sponsoring organizations. CDC has undertaken a special initiative, in cooperation
with the World Bank, UNDP, and the NAS Board on Science and Technology for Development, to address this problem.
CDC has an important training program directed toward domestic and international needs. In 1982, over 700 international health
workers from over 100 countries came to CDC to attend special seminars, conferences, and courses or to receive individual