Summary and Assessment
Infectious diseases continue to threaten individuals and societies worldwide, in industrialized and developing countries alike. The threats take a variety of forms. New diseases emerge, often being passed from animals to humans. Previously unrecognized diseases become apparent. Endemic diseases stage a resurgence. Microbes that once were controllable with antibiotics evolve to become resistant to drugs. A number of chronic diseases are being found to have infectious etiologies. Biological agents may be used intentionally to cause harm. Thus, it is vital for the United States, along with other nations, to develop and support a workforce that is sufficiently large, well trained, and strongly motivated to meet current and future challenges in detecting, controlling, and preventing microbial threats.
The Institute of Medicine’s (IOM) report Microbial Threats to Health (2003a) provides a detailed description of the challenges and recommends actions that will be necessary to meet them. Among its conclusions, the report stresses the need for a global approach (IOM, 2003a). The United States should seek to enhance the global capacity for responding to infectious disease threats, and it should take a leadership role in promoting the implementation of a comprehensive system of surveillance for infectious diseases wherever they arise. Attention should be focused, in particular, on improving response and detection capabilities in the developing world, where infectious diseases are most prevalent and opportunities for spread are considerable.
The report also makes clear the need to better understand the dynamic relationship between microbes and humans, rather than to focus simply on fighting individual microbes. The emergence and spread of microbial threats
are driven by a complex set of factors. Ultimately, the emergence of such threats derives from the convergence of genetic and biological factors; physical and environmental factors; ecological factors; and social, political, and economic factors (IOM, 2003a). Clarifying and addressing these factors will be essential in developing and implementing effective prevention and control strategies.
In recognition of such complexities—both microbial and societal—the report emphasizes that mounting an effective response to infectious disease threats will require multidisciplinary efforts involving all sectors of the clinical medicine, public health, and veterinary medicine communities. Such a multidisciplinary approach must rest squarely on a well-prepared workforce within each of these communities. However, “the number of qualified individuals in the workforce required for microbial threat preparedness is dangerously low,” the report concludes (IOM, 2003a). In addition, there must be open and active communications within and among these communities. Similarly, expanded communications—along with greater coordination and cooperation—should take place among the larger scientific, government, and industrial sectors. This synergy will prove vital in advancing basic knowledge of microbes, in developing and implementing new treatments for infectious diseases, and in fostering measures to control or prevent the spread of microbial threats.
The Forum on Emerging Infections (now renamed the Forum on Microbial Threats) convened a 2-day workshop discussion—the subject of this summary—to examine the education and training needs to ensure an adequate infectious diseases workforce. The workshop considered the workforce in the United States as well as in the developing world. Not only do developing nations deserve attention in their own right, but as people, animals, and goods move around the globe in shrinking amounts of time, infectious agents also have an increasingly easier time spreading around the globe.
EXPLORING THE CHARACTERISTICS OF THE WORKFORCE
Participants at the workshop explored a variety of issues relating to the strength and characteristics of the infectious diseases workforce.
Expanding the Research Workforce1
One key question discussed at the workshop focused on the types of scientists and other workers that will be needed in the research enterprise in
For more information, see Victoria McGovern’s paper in Appendix A, page 156.
order to meet the wide range of microbial threats. Of course, the nation—and the world—will continue to need people trained in fields, including microbiology and immunology, that traditionally have been associated with infectious diseases. But new needs are emerging as well, driven, in part, by the shift toward a more systemic view of infectious disease, in which microbes and humans are intricately entwined. For example, participants highlighted the need to attract more people in the physical, chemical, mathematical, and computational sciences to apply their expertise to biological questions. The field also needs to attract more people from ecology and evolutionary biology to help lay the groundwork for understanding the human–microbe interface, as well as people from the veterinary sciences to help in understanding the flow of diseases between animals and humans.
As the workforce grows more diverse, some practical hurdles likely will arise. How can we get people from various disciplines talking with one another, speaking a common language, visualizing common problems, and valuing each other’s skills and ideas? In other words, how can we promote greater and more productive integration at the interfaces between and among often disparate disciplines? Workshop participants proposed a number of possible strategies.
Within universities, for example, departments can hold regular seminars that bring together researchers from a range of disciplines to share knowledge and generate new ideas. More fundamentally, universities can change their cultures to better foster collaborative, crosscutting research. Tenure systems can be restructured to reward faculty who participate in such research, often as part of a team, and resources can be made available when strong faculty want to move in new directions. Looking beyond academe, workshop participants suggested that local, regional, and national scientific meetings offer opportunities for promoting cross-pollination among a mix of scientists. Networks can be formed to “nucleate” individual researchers and groups around common problems. Foundations can play a particularly important role here by helping to build and support networks to advance a particular field, often by supporting promising young scientists who may lead the field as their careers unfold. Training courses or workshops can bring people together, provide them with shared knowledge, and help them frame new ways of thinking about that knowledge. Professional societies can give new ideas and new connections a boost by bringing people together around emerging issues, and their publishing operations can give a kind of validation that legitimizes, enhances, and encourages innovative but risky work that may yield significant scientific reward.
Participants also discussed potential problems with the educational pipeline that supplies scientists to the research enterprise. Of particular note, concerns were expressed that younger scientists pursuing careers at
universities are facing increasing difficulty. Some participants suggested that the entering salaries of trained scientists are not competitive with other intellectually challenging careers. In addition, it is taking longer to get through the system. Thirty years ago, the average new Ph.D. in the life sciences received his or her degree in 6 years, while today it takes an average of 8 years (NRC, 1998). Some evidence suggests that the period spent in postdoctoral training is getting longer as well. As a result, the pool of young scientists positioned to compete for research funding—a gateway to academic success—is shrinking. Twenty years ago, for example, scientists under the age of 35 represented 20 percent of the pool applying for grants from the National Institutes of Health (NIH), the nation’s major funder of research in the health sciences. Today, this age group comprises less than 5 percent of the pool—and the situation is worse in clinical research (Goldman and Marshall, 2002). Thus, the professorate is graying, with more research dollars going to older scientists, while younger researchers are being left in extended professional adolescence.
Science is bigger than academe, of course. Industry employs a great number of researchers and other technical workers. Workshop participants suggested some new routes for training people in the skills suited to industry’s specific needs. For example, universities might create a “professional doctorate,” akin to the way medical schools train a cadre of people ready to practice medicine. Such students would receive broad-based training across a number of disciplines, and they would participate extensively in team-oriented research. Most people in industry, however, will not need a Ph.D. degree. As an alternative approach, some universities are developing specialized 2-year master’s degree programs that provide students with the educational groundwork and research experience necessary to meet the day-to-day needs of industrial laboratories. Early evaluations of these programs indicate that graduates are finding ready acceptance in the job market.
THE ROLE OF PHYSICIAN–SCIENTISTS
Physician–scientists play an important role in advancing medicine. Workshop participants explored how to take even greater advantage of this segment of the workforce in meeting current and emerging microbial threats (Ganem, 2003). Typically defined as persons who perform biomedical research and hold either an M.D. or M.D.–Ph.D. degree, physician–scientists work in a variety of areas, including basic research, disease-oriented research, and patient-oriented research. They are trained to ask clinically relevant questions that lead to the development of research projects linking basic and clinical research; they also are a vital force in transforming clinical observations into testable research hypotheses and translating research findings into medical advances. Workshop discussions focused heavily on
physician–scientists trained to work in the laboratory. Among their activities, physician–scientists are especially well positioned for studying basic mechanisms of microbial replication and pathogenesis, working with high-level pathogens under strictly controlled conditions, developing new vaccines, and discovering new pathogens.
Several lines of evidence, however, suggest that shortages are developing in the overall supply of physician–scientists (Rosenberg, 1999). For example, a study by Ajit Varki and Leon E. Rosenberg found that in 1983 there were 18,535 physician–scientists in the United States, but by 1998 this number had fallen to 14,479—a 22 percent decline (Varki and Rosenberg, 2002). Workshop participants also reported anecdotal evidence that fewer physician–scientists are applying for fellowships in infectious diseases programs at numerous universities nationwide, and that fewer physician–scientists are reporting research results in professional journals serving the field.
Participants offered a variety of reasons for the declining number of physician–scientists. The list includes financial disincentives, including an increasing debt burden for medical school graduates, which tend to push the youngest members of the medical profession away from research (Rosenberg, 1999). (Some participants argued, however, that financial considerations may be less important than is sometimes suggested.) Other factors include a lack of senior physician–scientist role models engaged in research in infectious diseases, and changes in hospital practices. For example, the growth of managed care has imposed financial constraints on academic health centers, and many leaders of clinical departments now require that their faculty members see more patients, thus reducing the time they have available for research or to train upcoming physician–scientists (Rosenberg, 1999). Such changes mean that there is no reinforcing mechanism to encourage people to continue on the long pathway of clinical training while retaining an interest in laboratory science and pathophysiology.
A number of ways were suggested for recruiting more physician–scientists. For example, medical schools can seek out more students who are interested in and demonstrate an aptitude for research. In this way, promising students can be “bonded” to medicine even before they begin formal medical training. During their training, students can be encouraged to seek intensive research experiences early, and they should be rewarded for their efforts. Some participants suggested that cultivating M.D.–Ph.D. programs may provide an especially useful avenue for bonding students and enriching the pipeline for physician–scientists. Support also can be extended beyond medical school. Residency programs can be augmented—for example, through journal clubs and periodic dinners with senior physician–scientists—to help keep residents interested in continuing a career in research, and development programs can be conducted following residency to help
smooth the transition of new physician–scientists as they enter their new careers.
The Role of Ph.D. Scientists2
In today’s scientific environment, including work in infectious diseases, most Ph.D. scientists concentrate on a single specific discipline—and this system has yielded remarkable advances. But many observers suggest that this approach may be less effective in producing scientists who have the broad perspective and breadth of knowledge that will best equip them to address the complex challenges that lie ahead in handling microbial threats worldwide.
Workshop participants discussed several educational models for producing Ph.D. scientists who possess the palette of skills necessary to help in translating research into everyday clinical practice. Graduates of such programs will be “adaptive” experts who can respond rapidly to changing conditions in research and clinical medicine, and who can help to identify unmet needs in these areas.
One of the models described is represented by the Medical Engineering Medical Physics Ph.D. program conducted by the Harvard-MIT Division of Health Sciences and Technology (Abelman et al., 1997; Wilkerson and Abelman, 1993). This program is designed to educate graduate students at the interface of engineering, the physical sciences, and the biomedical sciences via a flexible structure that permits exploration of all the intersections of those disciplines. It is considered unique in providing students with clinical experience similar to that which second- or third-year medical students would have. Although this program is focused on engineering and the physical sciences, the model on which it is based is considered equally adaptable to trainees in the natural sciences. Other innovative Ph.D. programs are based on a “targeted exposure” model, in which students receive varying amounts of training in pathophysiology, pathobiology, or medical concepts in addition to their regular coursework. In one such program at Washington University, for example, students take a two-semester course in human pathology that focuses on the clinical and basic science aspects of important disease states, and the interactions initiated in the course are sustained via a clinical mentor program that continues through the graduate experience.
Both approaches have demonstrated success (Gray and Bonventre, 2002). Workshop participants noted that the programs attract exceptional candidates and are consistently oversubscribed. Many alumni have entered
For more information, see Martha L. Gray’s paper in Appendix A, page 143.
top-ranked institutions, often obtaining positions of leadership, and they are proving successful in garnering grant support. Importantly, many of them are in positions where they can connect with the patient-care enterprise during the course of their research and thus have the potential to create vibrant links between the laboratory and clinic.
Based on their experiences with such training programs, workshop participants offered a number of lessons that can be used in designing new multidisciplinary Ph.D. programs in areas specifically related to infectious diseases. An institution should begin by firmly establishing the overarching goals of the training program. Students should take a strong core of courses in their chosen discipline, in order to learn one field thoroughly. Providing students with first-hand knowledge of human disease through direct interactions with patients is crucial. Although this can happen passively by bringing patients into classes, a more effective approach is to take students into the clinical setting. As any student making the transition from preclinical to clinical work can testify, there is a world of difference between learning in the classroom and implementation in the wards. Finally, institutions should commit to establishing a truly multiprofessional community and to “institutionalizing” programs that cut across classical organizational structures. Such organization greatly reduces the inevitable barriers that exist between departments or disciplines, and it helps both students and faculty to better understand the various underlying value systems and perspectives. It is this understanding that forms the foundation for the necessarily collaborative work that is required to bring the proverbial bench to the bedside.
Strengthening the Public Health Workforce3
By the very nature of their jobs, public health (PH) professionals will be instrumental in protecting society from microbial threats and in mounting effective responses to disease outbreaks, whether naturally occurring or intentional. PH professionals are defined as people educated in public health or a related discipline who are employed to improve health through a population focus. They receive education and training in a wide range of disciplines, come from a variety of professions, work in many types of settings, and engage in numerous kinds of activities.
As many observers have noted, however, the public health infrastructure at the local, state, and federal levels in the United States has suffered years of neglect. As one result of such systematic lack of financial and policy support, there has developed an overall shortage of qualified work-
For more information, see Margaret A. Potter’s paper in Appendix A, page 176.
ers prepared to prevent or respond to major outbreaks of infectious disease. In recognition of this situation, the IOM report Microbial Threats to Health called for immediate, broad-based efforts to ensure that the nation has an adequately trained and competent PH workforce that can respond quickly to emerging microbial threats and monitor infectious disease trends (IOM, 2003a).
Workshop participants suggested that efforts to buttress the PH system might best begin by obtaining a better understanding of the numbers, locations, and expertise of the various types of people comprising the workforce. In many cases, data are limited. One widely cited analysis found that for the year 2000, there were 448,254 workers in state and local health departments, schools of public health, and a few selected national voluntary organizations (Gebbie, 2003; Gebbie et al., 2000). This total amounts to 158 workers per 100,000 people in the general population—a decline from 219 workers for the same population in 1979, when the PH workforce was at its largest. The workforce is unequally distributed by region, with density differences thought to be related, in part, to state and local funding and policy decisions and to geographic conditions that influence the provision of services (Gebbie, 2003). Among the professionals in the workforce—who make up roughly 44 percent of the total—public health nurses comprise the largest group. Other groups identified, in descending order of size, include environmental professionals, officials and administrators, public health physicians, and public health educators (Gebbie, 2003). These statistics represent only rough counts at best, however, and workshop participants agreed that new national studies are needed to better characterize the workforce and to identify current and future needs.
Within the total PH workforce, two categories of professionals were identified by participants as being particularly relevant to meeting the challenges of emerging microbial infections: epidemiologists and infection control/disease investigators (see Potter in Appendix A). But both groups face significant shortages. In the analysis for the year 2000, these two classifications together contributed less than 0.47 percent of the total workforce (see Potter in Appendix A). This percentage may underrepresent or overcount the actual number of workers in the groups, for several reasons. Still, workshop participants expressed concern that these professionals, both central in the front-line defense against disease outbreaks, apparently are so lacking in the PH workforce. (See the section “Fields of Special Emphasis” for additional details.)
Participants also discussed efforts to assess and improve the core competencies of members of the workforce. At heart, competency is a measure of whether workers have the knowledge and skills to perform their assigned tasks. (A related issue is “capacity,” which is a measure of whether an organization has sufficient resources for delivering to people the services it
is supposed to deliver.) A number of organizations have compiled descriptions of core competencies for the overall PH workforce and for specific groups of PH professionals, such as public health nurses and environmental scientists.
One widely recognized set of recommendations is outlined in the IOM report Who Will Keep the Public Healthy? (2003b). It endorses the five core components of public health that have long been recognized—epidemiology, biostatistics, environmental health, health services administration, and social and behavioral science—but also adds eight more critical areas. The new areas encompass informatics, genomics, communication, cultural competence, community-based participatory research, policy and law, global health, and ethics (IOM, 2003b). In addition to serving as general guidelines for public health, these new competencies also will find application among professionals working specifically in the area of infectious disease.
Strengthening the PH workforce will require a range of efforts, and workshop participants identified schools of public health as having a particularly important role to play. There currently are 33 schools of public health in the United States that are accredited by the Association of Schools of Public Health (ASPH). In 2002, these schools graduated 5,665 people, with roughly two-thirds of them earning a master of public health (M.P.H.) degree, which is the field’s core professional degree. There are an additional 37 accredited M.P.H. programs in community-health and preventive-medicine departments of medical schools, and 15 accredited M.P.H. programs in other types of schools (Council on Education for Public Health, 2003).
Workshop participants discussed the variety of ways that schools of public health can contribute to meeting the challenges of emerging infections. By definition, they can serve as a key link in improving the education of the PH workforce. As evidence of the need for expanded education, the federal Centers for Disease Control and Prevention (CDC) estimated in 2001 that 80 percent of PH workers lacked specific public health training and only 22 percent of chief executives of local health departments had graduate degrees in public health. In addition to training future members of the PH workforce, the schools can reach workers already in the field as well. Indeed, a number of schools already are conducting practical training programs to reach workers by distance-communication media (such as the Internet) and in special on-site programs. For example, two federal agencies, the CDC and the Health Resources and Services Administration (HRSA), now support practical education programs through nearly 50 schools of public health. The training through these centers covers crosscutting topics of relevance to public health practice, as well as specialized topics relevant to emerging infectious diseases.
Schools of public health also can advance research, as scientists pursue
studies into communicable diseases, their vectors, their incidence and prevalence, their prevention, and their treatments. In addition, there is a strong need for expanded practice-oriented research. Such research is needed to help answer fundamental workforce questions—for example, how many professionals the PH system actually requires for optimum performance, and how many students should be trained to satisfy these requirements—and to assess the performance capacity of PH agencies. Without such information, schools cannot target education and training programs, state and local governments cannot develop effective standards for staffing public health agencies, and policy makers cannot allocate resources rationally.
Integrating Public Health and Health Care4
In tandem with strengthening the nation’s public health workforce, it also will be important to better educate all students in the health professions in the basic concepts of public health (Colin-Thomè, 1999). Indeed, recent experiences with both the intentional release of anthrax spores and the natural spread of the West Nile virus serve to reinforce the importance of links between educated, alert health-care workers and a responsive PH system. Strengthening the relationship between public health and clinical medicine also will be important in developing plans to handle the surge of patients that might arise during a large-scale disease outbreak.
One way that workshop participants explored to integrate knowledge of public health concepts into the broader health context is to revise the curricula used in institutions that train health and scientific professionals, including those in the medical, nursing, veterinary, and laboratory sciences. It was suggested that curricula for educating non-specialists in the fundamentals of public health should be built around nine principle areas: evidence-based ethical practice, health-care needs assessment, cultural competency and awareness, epidemiologic transitions, partnership building, health policy analysis, management and leadership, health-care planning, and evaluation of the effectiveness of interventions.
In revising their curricula, institutions can begin by evaluating the strengths and weaknesses within their various departments. Among possible strengths are commitment to change within the overall institution; commitment of a critical mass of staff members to promoting public health education; available baseline information about public health content already in the curricula; and external contacts that some staff members have with national or international networks interested in public health. Weaknesses can include insufficient resources and time; staff members who are inadequately trained to teach or learn epidemiologic/population concepts or who feel un-
For more information, see Walid El Ansari’s first paper in Appendix A, page 76.
reasonably treated by management and are thus unwilling to cooperate with new initiatives in protest; and managers, especially at higher levels, who lack the responsibility to bring about proposed institutional policies.
Within most departments and institutions, committed leadership will be critical in setting change in motion and ushering it to successful conclusion. Thus, initiators of curricula reform might best begin by embracing a dynamic staff development program to explain both the necessity for and the benefits of introducing public health concepts into general study. Some resistance should be expected, and leaders would be wise to learn why such resistance is arising and how it might be reduced without engendering bitterness. Senior management will be required to empower staff members for broad-based action, in order to consolidate gains and ultimately to anchor the new approaches in the institutional culture.
FIELDS OF SPECIAL EMPHASIS
Complementing their explorations of some general issues facing the infectious diseases workforce, workshop participants also examined “case studies” of a number of professions and scientific areas of investigation that are more specific to the field.
Infectious Diseases Physicians5
Physicians specially trained in the area of infectious diseases (ID physicians) comprise an important part of the workforce that is charged with meeting current and future challenges in detecting, treating, and preventing microbial threats. There is a limited amount of data regarding the number and level of expertise of ID physicians in the United States or worldwide. Workshop participants suggested, however, that several lines of evidence indicate that programs to train ID physicians need to be strengthened.
For example, the number of infectious diseases training programs that participate in the U.S. national resident matching program decreased between 1994 and 2002 (from 120 to 105), and the total number of positions offered also declined (from 257 to 251) (see Gorby in Appendix A). Graduates filled a larger percentage of the available slots, however, and the total number of participants increased during this period (from 155 to 198). Still, more than 20 percent of training slots went unfilled in 2002, despite an increased demand for ID specialists. Of interest, the percentage of slots filled with U.S. graduates rose from 34.6 percent to 51 percent. From the U.S. position this trend might be considered positive, as more ID physicians
For more information, see Gary L. Gorby’s paper in Appendix A, page 129.
are being trained who are likely to remain in this country. But from the international perspective the trend may seem less positive, as fewer experts are being trained who may return to their native countries, where emerging infectious diseases often pose even greater problems. As another indication of the need for strengthening training programs, a survey of recent ID graduates found that only 51 percent of respondents felt that their training in infection control was adequate (Joiner et al., 2001). The answer, all participants agreed, is to strengthen training programs to boost the number and skill level of ID physicians from both the United States and other countries, especially in the developing world.
Participants identified a number of factors that may deter physicians from entering careers in infectious diseases and public health. There are monetary drawbacks, as ID physicians and PH physicians rank on the lower end of the income scale when compared with other medical specialties. In addition, few students are exposed at an early stage in their training to career options in infectious diseases or public health. Many physicians who enter these fields also report that they encounter a less than desirable working environment, often marked by understaffing, limited resources, and a frequent turnover of key personnel (including, in state agencies, the chief medical officers who are appointed politically).
Among efforts to strengthen the ID physician workforce, a first step would be to gain a better understanding of the landscape. In the aftermath of the terrorist attacks on the United States on September 11, 2001, there has been a significant increase in funding, especially to states, to improve bioterrorism preparedness and the capacity of hospitals to respond to infectious diseases. Two of the largest funding sources have been the Health Resources and Services Administration and the Centers for Disease Control and Prevention. The HRSA provided $918 million in 2002 and budgeted $542 million in 2003; the CDC provided $918 million in 2002 and $870 million in 2003. It must yet be determined, however, whether this funding has increased the number of physicians working in the areas of infectious diseases or public health. In addition, although such increased funding is welcome, it remains possible that future funding will be reduced if the threat of bioterrorism is perceived to decrease.
Participants also suggested that ID training programs need to ensure that formal didactic training in public health, epidemiology, and infection control practices is included in every fellowship experience. This could be accomplished in a number of ways, including participation in formal month-long rotations or accessing an Internet-based training course. Such a course might best be developed jointly by the Infectious Disease Society of America and others, including the CDC, the Society for Healthcare Epidemiology of America, and the Association for Professionals in Infection Control and Epidemiology (Joiner et al., 2001).
Closer links need to be cultivated between ID physicians in private practice and the relatively small group of ID physicians who work full time in an infection control/public health capacity. Participants suggested that these links should be grown primarily at the local level (and to a lesser degree at the state/territorial health department level) to strengthen the necessary “nuts and bolts” local response network. This may require exploring novel technologies for on-demand interactive training, such as a natural language engine paired with a text-to-speech software application or animated virtual teaching assistant. Such technologies would enable conversation-like interactions by many users simultaneously.
Incentives to encourage students to pursue ID/PH careers must be developed. Marketing of such careers should take place relatively early in the educational process, and certainly prior to the accumulation of a large educational debt. An unusual but possible approach to raise awareness of ID/PH careers might employ “edutainment” venues analogous to recent television series about forensic pathology. As a result of such exposure, premed or high school students who were previously unaware of the career path might give some consideration to the option. In addition, forgiveness of educational loan debts for students who elect to undergo ID/PH training would remove a major deterrent to the pursuit of such careers. In exchange, these individuals would have to agree to work in an ID/PH capacity for several years after their training, and it would be hoped that many of these individuals would remain in the field even after their obligation was met.
Participants also suggested that consideration be given to developing a Public Health Medical Reserve Force analogous to military reservists. This force could be formally and selectively activated, thus ensuring an adequate and competent response team. Membership should carry an obligation for recurring ID training certification for which the reservist would be compensated. Physicians would be joined on this force by other health professionals, and together they would form a multidisciplinary national resource that stands ready to respond to any natural or intentional major disease outbreak.
Epidemiologists/Allied Health Professionals
As the science that studies how often diseases occur in different groups of people and why, epidemiology will play a key role in combating microbial threats, whether they arise naturally in a population or are introduced by terrorism (Perl, 2003; Srinivasin, 2003). Public health epidemiologists will be involved in the investigation and control of infectious diseases, the design and enhancement of surveillance systems to detect diseases, and the analysis and interpretation of surveillance and other data. They also will be central in interacting with physicians, nurses, hospitals, and laboratories.
Workshop participants reported, however, that the United States lacks a sufficient number of epidemiologists who are adequately trained and have enough resources to meet current and emerging microbial threats. The picture is even more bleak in the developing world.
Comprehensive data are lacking on how many epidemiologists the nation has and what their skill levels are—but several studies have pointed to major shortcomings. For example, a survey by the Council of State and Territorial Epidemiologists (CSTE), conducted from late 2001 to early 2002, found that the number of epidemiologists working in state and territorial health departments had declined during the past decade, from 1,700 full-time equivalent positions to less than 1,400 (CSTE, 2003). Approximately 42 percent of current epidemiologists lacked formal academic training in epidemiology. Moreover, most of the respondents thought that their operations had insufficient staff and resources. The lack of workforce growth has occurred despite the significant expansion in the scope of responsibilities for epidemiology during the same period. Another study following the terrorist attacks of September 2001 identified the need for at least 600 new epidemiologists in public health departments nationwide to meet the requirements for biopreparedness alone.
In the event of a disease outbreak, epidemiologists working in hospitals often find themselves at the center of efforts to identify the pathogen, treat patients when therapies are available, and control the spread of infection both within their own hospital and among the public. Thus, workshop participants saw a need for training more people to work in hospital epidemiology and infection control, and, in particular, to train future leaders in these areas. Some participants called for the National Institutes of Health to assume this role, just as it now supports training programs to prepare leaders in other areas related to infectious diseases, such as research on HIV/AIDS and tuberculosis. Schools of nursing also can be provided with sufficient funds to support training programs in these areas. Similar training in the area of hospital epidemiology and infection control is equally important within health-care settings in developing countries. Organizations active in training programs, such as CDC and the World Health Organization (WHO), should consider such elements for program design.
Participants identified additional needs as well. To complement efforts to train more people who specialize in hospital epidemiology, steps can be taken to provide all professionals who work in the area of infectious diseases (including physicians, nurses, and allied professionals) with at least the basic concepts of epidemiology and infection control. Schools of medicine and nursing can do more to incorporate this material into their curricula, and students pursuing fellowships in infectious diseases should certainly be exposed to this material. To support such efforts, accrediting organizations might require that training programs add some element of
formal training in hospital epidemiology and infection control, and professional societies, such as the Infectious Diseases Society of America, can take leadership roles in emphasizing the importance of these issues.
Environmental Health Professionals
There is a clear tie between environmental health and infectious diseases: diseases spread by animals and insects, diseases linked to contaminated water or faulty sewer systems, and diseases that hold potential for being spread deliberately by terrorists. As workshop participants heard, however, the workforce of environmental health professionals is showing signs of weakness.
In 2000, local health departments nationwide employed approximately 19,400 environmental health specialists; this cohort represented roughly 10 percent of the total public health workforce. But even as needs for such specialists are increasing, the numbers of students and graduates in environmental health are declining. Twenty-five U.S. universities currently offer accredited undergraduate programs in environmental health. Between 1993 and 2002, these programs experienced a 42 percent drop in enrollment and a 58 percent drop in the number of students graduating. Compounding problems, increasing numbers of environmental health professionals, including many in upper management, are now retiring from local public health departments.
Workshop participants discussed several efforts under way to strengthen the field. For example, the Centers for Disease Control and Prevention, working with a number of other public and private groups, has been developing a comprehensive action plan. Called “A National Strategy to Revitalize Environmental Public Health Services,” the plan sets out six major goals with related objectives and activities (CDC and National Center for Environmental Health, 2003). The goals include building program capacities at local, state, tribal, and territorial levels; supporting research to identify ways to enhance environmental health services; fostering strong leadership; expanding communications among agencies, communities, and other partners and improving the marketing of environmental health services to policy makers and the public; promoting the development of a competent and effective environmental health work-force; and creating strategic partnerships among agencies, organizations, and interests that influence environmental health services. Reaching these goals will require collaborative efforts and sustained commitment by all stakeholders.
To aid in workforce development, the CDC, working with the American Public Health Association, has developed a set of recommendations for core competencies for local environmental health professionals (CDC and APHA, 2001). The competencies represent a broad set of skills, including
being able to assess and interpret data, manage programs, solve problems, evaluate programs, build collaborations, educate and train coworkers and others, and communicate information about environmental health to a range of audiences. According to workshop participants, a number of local public health agencies are now developing training programs to improve the skill levels of their workers, not only in terms of their technical competencies but also their leadership and management competencies.
Veterinary Public Health
Interactions among humans and animals can have a dramatic impact on public health (King, 2003). Approximately 70 percent of infectious diseases that have newly emerged or reemerged in recent decades were transmitted to humans from animals. Moreover, many of the infectious agents that might be used in bioterrorist attacks originate in animals (King and Khabbaz, 2003). Another potential health threat that arises from human–animal interactions is an increase in the resistance of pathogens to drugs as a result of misuse of antibiotics in animals raised commercially (King and Khabbaz, 2003). These and other concerns are heightened by increasing international movement of people, animals, and animal products; climate and other environmental changes, including those that affect wildlife populations; and issues of national and global security.
Clearly, veterinarians have an important role to play in protecting public health, and workshop participants explored a variety of ways to involve them more fully in this mission. One challenge will be to expand and diversify the core workforce—that is, veterinarians who hold full-time jobs in public health. Today, less than one half of 1 percent of veterinarians are so employed. Possible steps forward include increasing the number of veterinarians who take part in the Centers for Disease Control and Prevention’s Epidemic Intelligence Service, which is a 2-year, hands-on comprehensive epidemiology and public health training program. This program also can serve as a model for developing regional programs in order to expand the number of veterinarians who can participate. In addition, veterinary schools and schools of public health can join together to develop and offer dual degree programs. On a larger scale, the veterinary community is exploring the possibility of developing a federally funded National Veterinary Service to help bring in recruits who will work in public health and related areas.
It also will be important to involve the thousands of veterinarians in private practice, who deal with public health issues with their clients on a regular basis, but often lack significant education or training in even basic public health concepts. Workshop participants offered a variety of suggestions on how veterinary education and training can be improved. As a
foundation, veterinarians will need to develop a new portfolio of skills, knowledge, and aptitudes to meet contemporary problems. Veterinary schools will need to strengthen training in such areas as genomics, bioterrorism, population health, emerging diseases, information technology, risk communications, and cultural differences related to health. Schools also should make greater efforts to change behaviors, not only among their students but also internally. Emphasis should be placed on fostering interdependence, working in teams, and respecting other disciplines. In addition, schools can strive to expand the “professional value” of their graduates. Well-trained veterinarians will be needed to participate in such activities as disease and pathogen surveillance, epidemiology and investigation of infectious diseases, population health and medicine, monitoring antimicrobial resistance, wildlife epidemiology and management, and biomedical research in which they will work hand in hand with scientists from numerous other disciplines.
One key to success, participants agreed, will be to get more students interested in veterinary science—the earlier, the better. Public communication efforts can target younger people, who often have a natural interest in working with animals, and new scholarship and fellowship programs can be developed to provide motivated students with the resources necessary to fulfill their goals. Universities also can develop mentor programs to help students as they pass through their college years. Assistance also can be made available after graduation, through programs such as the proposed National Veterinary Service. As students learn more about the vital link between veterinary medicine and public health, they will be better equipped to handle emerging challenges, whether they are serving directly in public health, working in wildlife epidemiology and management, or serving clients in private practice.
A number of vector-borne pathogens, including malaria and dengue, remain as major health burdens and as obstacles to economic development throughout much of the world’s tropics. Diseases caused by vector-borne pathogens, including Lyme disease and West Nile fever, also continue to emerge in many temperate regions. However, the United States now lacks the capacity, including a sufficient workforce, to confront these agents, according to the IOM report Microbial Threats to Health (IOM, 2003a).
As a first step in addressing this issue, workshop participants explored some of the forces that have helped cause the workforce gap. Many of these
For more information, see Andrew Spielman’s paper in Appendix A, page 183.
forces revolve around the way that the nation funds research in the health sciences (see Spielman in Appendix A). For the most part, it is the research interests of faculty members at universities that largely determine the characteristics of the scientific workforce—and it is the ability of researchers to gain funding for their projects, typically from the National Institutes of Health, that makes it more or less attractive for universities to employ them. Thus, changes in the system that the NIH uses to review investigator-initiated proposals may help redirect health-related research on vectors into promising areas, such as vector microbiology and insect transgenesis. Such changes may come slowly, but participants agreed that they would be worthwhile in helping to rebuild and reshape the workforce.
One goal, in particular, will be to find ways to support research efforts that bring vector biologists into collaborative contact with researchers in a range of other fields, including parasitology, clinical medicine, and public health. Such collaborations might find natural homes in schools of public health or medicine, or in cross-departmental centers at universities. Although the NIH can play an important role in fostering multidisciplinary projects and other innovative research, foundations and private donors have so far proved most aggressive. Several groups, including the Bill & Melinda Gates Foundation, the Burroughs Wellcome Fund, and the MacArthur Foundation, support cutting-edge research and training programs to advance knowledge and increase the field’s human capital.
Vaccines against infectious diseases are one of the major success stories of modern medical science. Yet in the United States and worldwide, many diseases remain for which vaccines either have not been developed or are not readily available. Thus, there is a critical need for more people in a range of disciplines to work in vaccinology, the field that comprises vaccine development as well as the use of vaccines and their effects on public health.
One factor that workshop participants identified as complicating vaccine development is the increasing scientific complexity of the process. For any disease now being studied, there may be four or five strategies, often quite different, being explored. As a result, development efforts typically require a much greater range of expertise than previously was the case. In addition, the targets for vaccination are expanding. Vaccination traditionally has been considered a pediatric task, and pediatricians have been in the forefront of promoting and developing vaccines. But target populations are now expanding to include adolescents and adults, and vaccines are being developed to fight a broader range of diseases, including some diseases, such as cancer and
For more information, see Stanley Plotkin’s paper in Appendix A, page 166.
Alzheimer’s disease, that are linked to infectious agents. New vaccines also are being developed for therapeutic use against some chronic infections, an approach that previously was not considered possible.
This changing nature of vaccine development has led to a need for expanded education and training, and workshop participants identified a number of areas in which more physicians and scientists are needed. The areas include, among others, pathogenesis and the development of animal models that shed light on pathogenesis; immunology, which is needed to better understand a target disease so that appropriate antigens can be identified; and clinical trials, which can range from small to exceedingly large and which require a thorough knowledge of epidemiology to design and conduct. Safety assessments also have become increasingly important, and people with a broad understanding of diseases are needed to analyze immune reactions in studies performed in both laboratory and clinical settings.
Participants suggested that in order to help strengthen the workforce in vaccinology, medical schools can do more to teach their students about vaccinology and disease prevention via vaccines, so that they will consider this a realistic career path. Changing curricula to emphasize prevention rather than treatment may help bring this about. It also is vital that training programs be multidisciplinary and incorporate a range of core subjects, such as pathogenesis, microimmunology, safety regulations, scale-up technology, clinical development, and investigational new drug formulations.
The question then arises: who will teach these courses? Workshop participants proposed that one hitherto overlooked place to seek help is industry. Bringing skilled people from private companies into the early stages of training potential scientists and physicians may be a challenge—involving such issues as confidentiality—but at least some participants were confident that problems could be overcome. Moreover, they stressed that industry has a vested interest in finding innovative ways to improving education. When companies now look to hire people in vaccinology, they often have trouble finding sufficient numbers of qualified candidates. Indeed, some participants suggested that this is one of the reasons why the U.S. vaccine industry is relatively small. Industry also can help by developing and supporting training opportunities in the workplace, to ensure that more students are exposed to career paths in vaccinology.
As vividly demonstrated by efforts to contain West Nile virus in 1999, anthrax in 2001, and severe acute respiratory syndrome in 2003, public health laboratories play a lead role in the detection and response to infec-
For more information, see Scott J. Becker’s paper in Appendix A, page 56.
tious diseases. The laboratories also perform a number of other key services to support and improve testing programs and to manage laboratory data for effective disease surveillance (CDC, 2002). In order to perform at peak effectiveness, laboratories need a highly trained staff—but the nation now faces an ongoing shortage of skilled laboratorians. For example, a 2002 wage and vacancy survey taken by the American Society of Clinical Pathologists (ASCP) found that the average vacancy rate for staff-level medical technologists ranged from 6 to 10.2 percent, depending on geographic region (Ward-Cook, 2003). Of particular concern, laboratories are losing to retirement a significant cohort of senior staff, including laboratory leaders, often before they have a chance to recruit and train replacements.
Workshop participants explored some of the factors behind the workforce shortages. These factors include the need for laboratory scientists to master a large, and expanding, body of knowledge and skills; government hiring practices and legal hurdles that often make it difficult to fill positions; concern about biosafety risks; and relatively low pay compared to other sectors of health professionals. There also has been a drop in the number of students interested in laboratory science, which has led to closure of hundreds of accredited training programs, from roughly 1,000 in 1970 to about 500 today (Painter, 2000).
In order to recruit more laboratory scientists, steps will be needed to increase awareness of laboratory careers among students, beginning even before high school and continuing through the college years. Laboratory skills also should be incorporated in larger measure into the curricula of medical schools and schools of public health. State laboratories can help drive this effort by working with schools. Some state laboratories, for example, now offer rotations to medical students and to other students pursuing degrees in relevant sciences. Steps will be needed as well to make careers in laboratory science more attractive: better wages; improved opportunities for training and advancement for practicing laboratorians; added measures to address biosafety risks; relocation assistance; and, importantly, increased public recognition for laboratory technicians and scientists.
Faced with such challenges, a number of organizations have launched innovative programs to help fill workforce needs. Among the examples described at the workshop is the Emerging Infectious Disease (EID) Fellowship program, conducted jointly by the Association of Public Health Laboratories (APHL) and the Centers for Disease Control and Prevention (see Becker in Appendix A). Begun in the mid-1990s, the program enables college graduates at the bachelor’s, master’s, and doctoral levels to spend 1 to 2 years working in public health laboratories. More than 200 fellows from the United States and abroad have been placed in local, state, and federal laboratories nationwide. Following their training, many fellows accept positions in public health laboratories or continue their education
and pursue careers in medicine or other health-related fields. The APHL also recently established the National Center for Public Health Laboratory Leadership. In the past, laboratorians have lacked any mechanism beyond on-the-job training to gain the managerial, public policy, communications, and other skills essential to oversee the complex workings of a public health laboratory. The new center is identifying and disseminating the knowledge needed for effective decisionmaking in public health laboratories, and it is providing technical assistance—such as workshops in grant writing, media relations, and the regulatory inspection process—to support laboratory leaders.
Efforts also are being expanded to improve the knowledge and skills of current laboratory workers. The National Laboratory Training Network, conducted jointly by the APHL and the CDC, offers a variety of courses and workshops. Since its inception in 1989, the network has delivered more than 3,200 workshops and training activities—including courses in bioterrorism, tuberculosis, virology, and molecular laboratory methods—to more than 100,000 laboratorians. This type of targeted training is not available from any other source.
The complex problems involved in controlling infectious diseases—from emergence and detection to treatment and prevention—will require the involvement of experts from a broad range of disciplines and health sectors. Furthermore, an interdisciplinary, collaborate approach can facilitate the training of the workforce needed to meet these challenges (Cassatt, 2003). As many workshop participants reported, however, the present structure of most academic and public health institutions forces individuals, disciplines, and even entire sectors to operate independently of each other. Thus, opportunities for collaboration—and the synergy that springs from such cooperative efforts—are often lost.
In order to explore ways in which collaborative research might be fostered, participants discussed some current trends within the National Institutes of Health, the nation’s single largest supporter of health-related research. In 2003, the agency issued what is called the NIH Roadmap for Biomedical Research. Intended to guide research over the next decade, the roadmap describes major opportunities and gaps that no single institute at the NIH could tackle alone but that the agency as a whole must address in order to make the biggest impact on the progress of medical research. Within this broad framework, the plan identifies three main areas that offer the most compelling opportunities: new pathways to discovery, research teams of the future, and re-engineering the clinical research enterprise (Zerhouni, 2003).
Within each of these areas, it is clear that life and medical scientists will need to work collaboratively with researchers in a number of other fields, including chemistry, computer science, information science, mathematics, and physics, to name but a few. It also is clear that improving crosscutting research will rest solidly on training more researchers, not only in their individual disciplines but also in how to work creatively across disciplines, often in large, multidisciplinary teams. Workshop participants described this as breaking out of the “silos” that now characterize the structure of the research enterprise. At the NIH, the silos are the individual institutes that focus on targeted areas of research; at universities, they are the departments that focus on individual disciplines. Silos also exist, of course, in other organizations at all levels of government, as well as in many organizations in the health and scientific communities.
In an effort to dismantle such silos, the NIH has launched a number of projects to stimulate new ways of combining skills and disciplines in both the physical and biological sciences. For example, the agency is funding several so-called “glue grants,” which are large grants (providing about $5 million annually for direct costs) to enable interdisciplinary teams to attack in a coordinated manner fundamental biological issues. In addition to their role in advancing science, the grants will serve as experiments to help determine whether such team efforts can, as believed, provide greater returns than can individual scientists operating independently—and if the answer is positive, how such advantages can be maximized. Lessons learned from these grants should help inform how research is funded and conducted not only by the NIH but across other government agencies and in academe.
It should be noted, too, that lessons about collaborative research might be gained by looking to industry. As workshop participants reported, interdisciplinary research is literally the order of the day at pharmaceutical and other health-related companies. Biologists, computer scientists, drug metabolism scientists, medicinal chemists, synthetic chemists, pharmacologists, pharmaceutical scientists, and many other specialists all work together toward a common goal, with little room for squabbles over turf.
The NIH also is exploring innovative ways to train researchers to meet emerging interdisciplinary challenges. Workshop participants described, for example, some efforts under way in the area of biomedical computing, including the creation, in 2001, of the Center for Bioinformatics and Computational Biology. Increasingly, researchers spend less time in their “wet labs” gathering data and more time on computation. As a consequence, more researchers find themselves working in teams to harness the new technologies. A broad segment of the biomedical research community perceives a shortfall of suitably educated people who are competent to support those teams. The problem is not just a shortage of computationally sophis-
ticated associates, however; there also is a need for a higher level of competence in mathematics and computer science among biologists themselves. The center will train scientists in these fields by having them “learn while doing,” while at the same time generating such new developments as mathematical models of biological networks, modeling and simulation tools, and methods for analyzing and storing data.
In addition to the practical challenges to be met in training new generations of scientists to tackle complex biomedical issues, there is a philosophical question as well. It is a matter of breadth versus depth. Is it better to assemble teams of people, each with a deep understanding of an individual discipline, to attack a specific problem? Or better to have people with very broad knowledge who can work across a number of disciplines, but who may not have detailed knowledge in any single discipline? No best answer emerged, but workshop participants generally agreed that for the present, some combination of both approaches, adjusted to the scientific issues being addressed, may prove most practical.
Human behavior, both individual and collective, plays a critical role in disease emergence (Tawfik, 2003). At the same time, programs aimed at influencing human behavior have long proved important in protecting or improving individual and public health. The permutations are varied. People can be encouraged to give up risky behaviors or to adopt new behaviors that promote health. Groups of people can be persuaded to take particular actions or to work with other groups to achieve health goals. Even governments are amenable to change brought about by changing people’s knowledge, perceptions, and attitudes. Although changes in human behavior can be difficult to achieve and maintain, this approach often offers the only way to achieve lasting desired outcomes. In promoting public health, then, behavioral scientists can make important contributions.
As an example of some of the challenges involved in promoting behavioral change, workshop participants discussed a project under way to improve the outcomes of infectious disease control in selected developing countries. The 5-year effort is hosted by the Johns Hopkins University School of Public Health, in partnership with a number of other organizations, and is supported by the U.S. Agency for International Development. The project’s mandate is to use strategic communication to create “health competent” societies in which mothers and children are better protected from a variety of infectious diseases, particularly HIV/AIDS, tuberculosis, and malaria.
Within each of the countries, project staff members work together with local health professionals, who often are employed in health ministries or
schools of public health. The first step is to help these professionals become better able to communicate public health concepts and to advocate for programs designed to improve public health. Working in tandem, project members and local health professionals then target three main audiences.
One audience comprises national policy makers, such as presidents and health ministers, who can directly influence nationwide health policies. The advocacy teams strive, for example, to get policy makers to add more money to national health budgets, to increase allocations for controlling infectious diseases, to adopt policies that will most effectively address health needs, to fill vacant positions in the health workforce, and to take action to reduce the stigma often associated with some of these diseases. The second audience includes health service providers. Much of this effort focuses on equipping them with knowledge and skills that will help them provide better treatment, offer more informed counseling, ensure that their patients adhere to treatment regimens, and participate in surveillance activities to detect disease outbreaks and notify higher-level authorities. The third audience comprises the individuals in local communities. A key component of this effort is to form partnerships with groups of people who are affected, directly or indirectly, by a given disease. This might include, for example, groups of youth who have HIV/AIDS, groups of mothers with sick children, or groups of adults who are sick or know someone who is sick. Engaging communities in this manner will help not only in improving treatment of individuals but also in disease surveillance.
Workshop participants agreed that lessons learned from this and similar programs may well build on each other and help inform future efforts to influence human behavior for the betterment of health—and that more skilled and experienced behavioral scientists will be needed to bring such efforts to fruition.
Bioethics and Genomics9
Recent years have seen remarkable scientific and technological advances, and progress has been especially notable in fields that directly or indirectly touch human health. Biotechnology is yielding new ways to develop drugs and vaccines. The genetic codes of major pathogenic organisms are being unraveled. Perhaps most important, researchers have sequenced nearly the entire human genome. Many observers have commented on the impact that such advances will have on human health. Less attention has been paid, however, to how the nations and peoples of the world will share in this newfound intellectual wealth.
For more information, see Tara Acharya et al. in Appendix A, page 67.
Workshop participants identified some of the ways that genomics and biotechnology can be harnessed to improve health in the developing world, and they explored some of the factors that may slow such efforts. Today, most research in these areas is concerned with the priorities of industrialized nations. But some projects suggest that genomics and biotechnology can make a huge contribution to public health in developing nations within the next 5 to 10 years (Daar et al., 2002). Some participants even suggested that over the longer term, these fields could well have greater impact in the developing world than in the industrialized world, due, in part, to the huge health inequities that exist among nations.
Participants provided a list of the “top ten” biotechnologies for improving health in developing countries. It includes molecular diagnostics, recombinant vaccines, drug and vaccine delivery systems, bioremediation, sequencing pathogen genomes, methods that enable females to protect themselves against sexually transmitted infections, bioinformatics, enriched genetically modified crops, recombinant drugs, and combinatorial chemistry.
A key question, of course, is: how to get from here to there? Who will energize the efforts needed to put these or other promising technologies into action globally? Participants discussed a model that may catalyze action. The Bill & Melinda Gates Foundation has pledged $200 million to the Grand Challenges in Global Health initiative, which is administered by the Foundation for the National Institutes of Health. The intent of the initiative is to engage creative minds from across the world and the breadth of scientific and technology communities, including those who have not traditionally engaged in global health research, to partner in developing solutions to critical scientific and technological problems that, if solved, could lead to important advances against diseases of the developing world. By directing substantial and carefully targeted resources toward key health-related research questions pertinent to developing countries, the initiative is intended to attract talented investigators to address these issues and significantly accelerate the development of affordable, practical solutions.
Workshop participants noted that not only is there a moral and social argument for industrialized nations to move aggressively in sharing emerging scientific knowledge and tools, but there is also an argument based on enlightened self-interest. Since infectious diseases often emerge first in the developing world, controlling them on that “front line” might prevent or at least slow their spread globally. Collective action will be needed by developed nations in many areas—including efforts to build research infrastructure and to improve education and training—to provide developing countries with sufficient capabilities to capitalize on the latest advances. These steps will require a financial commitment by the governments of industrialized countries, along with the sharing of relevant intellectual property, a thorny issue that will demand extensive discussion. Some participants agreed
with the suggestion for a global genomics initiative (Dowdeswell et al., 2003), in partnership with developing countries, to provide a forum to discuss and develop these issues.
ASSESSING DOMESTIC AND INTERNATIONAL TRAINING PROGRAMS AND EDUCATIONAL NEEDS
The need to develop new domestic and international education and training programs to support a workforce capable of dealing with emerging and reemerging infectious diseases, and to continue and expand ongoing training programs that are proving effective, is well recognized. Workshop participants explored a variety of issues related to U.S. and global needs for such programs and examined a number of examples of current efforts.
Public Health Leadership
Public health professionals play key roles in protecting society from microbial threats and in mounting effective responses to disease outbreaks. As numerous reports have observed, however, the PH system at the local, state, and federal levels in the United States has suffered years of neglect and needs to be rebuilt. At the workshop, participants noted that an important step in strengthening the system will be to enhance the leadership capacities of senior public health officials, as these people are well positioned to lead change within organizations and across the broad sweep of the public health community (Woltring, 2003). As added importance, it is expected that 40 percent to 50 percent of the managers and administrators in local, county, and state PH departments will retire in less than a decade.
Meeting this workforce challenge is the goal of the Centers for Disease Control and Prevention/University of California Public Health Leadership Institute (PHLI). Established in 1991 and funded by the CDC, the PHLI’s key objectives are to provide participants (called scholars) with knowledge, skills, and experiences that enhance their commitment and ability to provide leadership; to support scholars in exercising leadership in a variety of contexts, including within their agencies or jurisdictions and within professional organizations and schools of public health; and to strengthen their abilities to form collaborations that contribute to the development of healthy communities. Further aims include developing a nationwide network of senior PH leaders and stimulating leadership development efforts at state and local levels.
The PHLI is a year-long program that offers a variety of coordinated activities, including independent reading, teleconferences and electronic seminars, on-site retreats, personal leadership assessment, and peer consultation, among others. The curriculum focuses on improving skills in per-
sonal leadership, leading organizational change, community building and collaborative leadership, and leadership in training others. Woven throughout are efforts to improve communications skills, to enable scholars to better communicate personally and within and among teams and organizations, and to participate effectively in such broader efforts as media advocacy and social marketing.
More than 500 scholars have graduated from the PHLI. They have come from nearly every state, and they have been drawn from government PH agencies (local, state, and federal), academic PH organizations, national health organizations, and other health-related systems. The question, of course, is: does it work? Interim evaluations suggested that the PHLI program was meeting its objectives and having an important impact on scholars’ leadership skills. At the workshop, participants discussed results of the latest, and most comprehensive, evaluation, which covered scholars who took part through 1999. Conducted with help from outside consultants, the evaluation included a survey of scholars (which had a 67 percent response rate) and a set of 18 in-depth interviews of individuals in four groups, including PHLI management and faculty, respected public health leaders who did not participate in the program, CDC staff, and PHLI scholars (for elaboration of survey responses).
The evaluation demonstrated that the PHLI had a measurable, positive impact on scholars’ leadership effectiveness (Woltring et al., 2003). Among key results, respondents reported great or moderate impact on personal leadership effectiveness by expanding their view of their role as a public health leader (82 percent) and by enabling them to use new approaches and ways of doing things (77 percent). Regarding organizational leadership, respondents reported great or moderate improvement in assessing the need for organizational change (69 percent) and improving their organizations’ performance in accomplishing core functions (67 percent). As to community leadership, respondents reported great or moderate impact in developing coalitions or collaborations (68 percent) and enhancing the capacity of community-based organizations (55 percent).
From a broader perspective, scholars underscored the importance of the relationships and networks they developed as a result of their participation (Woltring et al., 2003). Ninety-four percent of respondents described these relationships as meaningful, and 57 percent reported that the relationships increased their effectiveness as public health leaders. Moreover, the evaluation revealed that scholars have made significant contributions to the public health enterprise. Scholars reported a high degree of involvement in such activities as teaching/mentoring colleagues in the field (65 percent), providing leadership to national professional organizations (55 percent), and participating in the development of state or regional PH leadership groups. Outside public health leaders interviewed during the evaluation
also commented on the impact that the alumni are having on advancing workforce development for the field, as well as on their enhanced leadership of professional PH organizations and their growing ability to influence the national public health agenda.
For example, PHLI alumni have joined together to form the Public Health Leadership Society. Among its activities, the society recently developed a Code of Ethics for public health and is working to help schools of public health incorporate ethics competencies into their curricula. Alumni also have played critical roles in forming and developing state and regional public health leadership institutes. As of April 2002, seven state and seven regional institutes were serving 38 states, and five additional state or regional institutes were under development, to add 5 more states to the total being served.
Beyond providing insight into the performance of the PHLI, the evaluation has forged new ground in applying a solid design and methodology to the difficult task of retrospectively assessing leadership training programs, and it offers an approach from which others may learn. The greater hope is that current and potential funders will be inspired by the evaluation’s positive results to continue—and even expand—their support for leadership training, both nationally and internationally.
The CDC continues to support leadership training. In 2000, the agency launched the National Public Health Leadership Institute, through a partnership headed by the University of North Carolina at Chapel Hill School of Public Health and the Kenan-Flagler Business School. The target audience is mid- and senior-level public health managers in state and local governments. Two to six staff members take part as a team in the nearly year-long program, working together to develop a public health business plan. Teams also are encouraged to include key stakeholders in their community who do not work directly in public health but have an interest in seeing the plan come to fruition. Evaluation efforts to date indicate that the program is succeeding in giving participants needed management skills and improving their job performance. The CDC also conducts a variety of other complementary programs in such areas as mentoring, coaching, and program development and planning.
The workforce necessary to improve U.S. and international capacity to respond to microbial threats must be supported with strong training programs in the applied epidemiology of infectious disease prevention and control. According to the IOM report Microbial Threats to Health (IOM, 2003a), the Centers for Disease Control and Prevention, the National Institutes of Health, and the Department of Defense (DoD) should expand
current and develop new intramural and extramural programs that train health professionals in applied epidemiology and field-based research in the United States and abroad. The agencies should develop these programs in close collaboration with academic centers or other potential training organizations or facilities. In addition, the knowledge and skills needed to confront microbial threats must be better integrated into the training of all health professionals.
One of the largest current efforts in this area is the CDC’s Epidemic Intelligence Service (EIS), which is a 2-year postgraduate training and service program that provides health professionals with an opportunity to “learn while doing”—that is, to play hands-on roles in active epidemiology projects in the United States and abroad. The program enrolls about 70 participants, called “officers,” each year. Most participants are U.S. residents, but recent years have seen increasing numbers of participants from other countries. A typical class comprises primarily physicians, but it also might include nurses, veterinarians, dentists, and doctoral graduates in epidemiology and the social and behavioral sciences. The majority of EIS officers train at CDC headquarters, where they work in specialized disease-or problem-specific areas; some officers go to either a state or large local health department, where they receive broad training in a front-line public health experience. During their training, each officer is required to complete a set of core activities, including the conduct of field investigations, the analysis of large databases, and the evaluation of public health surveillance systems. They also are trained in communications skills and are required to respond to public inquiries.
Since the program’s inception in 1951, more than 2,500 professionals have participated. In recent years, most graduating officers (nearly 90 percent) embark on careers in public health at the local, state, federal, or international level. The majority of foreign officers either return to their country of citizenship or to another international setting, where they typically work in some area of public health.
The EIS’s success has helped foster the development of similar training programs in more than 25 other countries, with EIS graduates and CDC staff often aiding in their development. Two common types of programs currently under way are Field Epidemiology Training Programs (FETPs) and Public Health Schools Without Walls (PHSWOWs). FETPs are typically organized within a country’s ministry of health, while PHSWOWs usually are partnerships between ministries of health and university schools of public health (or departments or institutes of public health within a university). Both models emphasize competency-based field epidemiology, with the PHSWOWs generally providing broader training in management and social sciences than do the other programs (Mock, 2003).
The goal of FETPs is to provide service to the sponsoring government
or health ministry while also training public health workers in epidemiology and disease outbreak investigation. During training, staff members, trainers, and trainees (fellows) seek to provide and enhance core public health functions, including disease control and prevention, surveillance, and supplying information needed to inform government policies and legislation. FETPs have produced more than 900 graduates, and more than 400 more are currently in training. Many observers have concluded that these programs have contributed significantly to improving their nations’ efforts in infectious disease control and prevention.
The Public Health Schools Without Walls program, which began in the early 1990s with support and leadership from the Rockefeller Foundation, aims at helping developing nations increase their capacity to train graduates with technical, managerial, and leadership competencies who will respond to practical health problems and direct health systems that are becoming increasingly decentralized (CDC, 2004a). PHSWOWs seek to break the barriers that often exist between teachers and students, between researchers and communities and government policy makers, between health-care providers and patients, and between traditional public health education and other health and related disciplines. Programs target health professionals in entry- or mid-level positions, and training typically culminates in their receiving a Masters of Public Health degree or some other type of postgraduate certification.
PHSWOWs combine the strengths of rigorous training conducted at the participating academic organizations with extensive supervised practical experience that stresses solving immediate local health needs as much as memorizing knowledge. In addition to gaining technical knowledge and skills, the trainees develop competencies in investigating and evaluating local health problems; designing, managing, and evaluating health programs; assessing and controlling environmental hazards, including those that might arise from bioterrorism; and communicating effectively with colleagues, communities, and government officials.
Workshop participants discussed the performance of some of the first PHSWOWs developed: in Ghana (CDC, 2004b), Uganda (CDC 2004c), Zimbabwe (CDC, 2004d), and Vietnam (CDC, 2004e). Evaluations show that the programs have produced several hundred graduates, and almost all of them are now involved in the management of health services, mostly at the district level. For example, in Uganda, which has a mid-sized program, more than 50 participants have graduated. Some of them have taken managerial positions in the nation’s ministry of health, some have remained at the participating academic institute, and some have assumed managerial positions in various health programs at national and regional levels. Additional training programs have been started or are being developed in a number of other countries in Africa and Asia.
Despite their successes, however, PHSWOWs remain vulnerable. Each of the programs depends heavily on external funds to support its activities, and a limited number of faculty members are responsible for teaching participants. Recommendations for future efforts include expanding faculty development and institutional infrastructure for research; developing more flexible learning tools and making increased use of continuing education; expanding the number and type of professionals served; and incorporating a regional strategy for institutional development, including promoting specialization within public health education systems. Indeed, institutional development is a key issue. Universities and other academic and professional organizations may have an important role to play in this regard, and this role might best be served by their committing to “institutional mentoring” efforts that will be significant in scope and long lasting in duration.
Strategies to improve public health, including efforts to expand the workforce and to combat infectious diseases, increasingly highlight the need and value of forming partnerships. Partnerships can operate at local (Findley et al., 2003), national (Morse, 2003), and international levels (Haroon, 2003; Steenbergen and El Ansari, 2003), and they can comprise a range of participants, including people and groups from government agencies, academic and medical institutions, industry, private philanthropies and non-governmental organizations, and local communities, to name but a few.
A growing body of literature suggests that many partnerships and other types of collaborative projects appear to meet their stated goals, and hence such efforts are widely deemed to be “good.” This may well be the case. But workshop participants observed that much more can be done to evaluate their actual effectiveness and to identify factors that significantly affect their outcomes, and they discussed several studies intended to inform such questions. The studies focused primarily on five academic–community partnerships in South Africa (see El Ansari in Appendix A). Funded by the W. K. Kellogg Foundation, the partnerships are intended to improve health care in the communities by reforming the way that medical, nursing, and health professionals are trained. The projects are joint ventures between local and regional academic institutions and health service providers, on the one hand, and the beneficiary communities and their civic organizations, on the other hand. Their goal is to train health professionals in an interdiscipli-
For more information, see Walid El Ansari’s “Stakeholders’ Perceptions” paper in Appendix A, page 89.
nary, community-oriented, and community-based fashion, and then to develop or expand networks and other mechanisms by which these providers can interact with people and groups in the communities to provide needed services.
Some of the studies described at the workshop offered ideas on how evaluations of community partnerships might best be conducted, while others described how well the partnerships are performing and how they might be improved. A key lesson is that it is important for parties on all sides to respect each others skills, abilities, and contributions. One study, for example, examined how the health professionals as a group and community members as a group viewed each other’s expertise in five areas: educational competencies, partnership fostering skills, community involvement expertise, change agents proficiencies, and strategic and management capacities. It turned out that community members have a positive view of the capabilities of the professionals, particularly their abilities in such areas as budget management, policy formulation, and the introduction and management of change. The professionals, however, had limited appreciation of the capabilities of community members in every aspect of expertise examined. According to the study team, these findings suggest that if joint working is to survive, then professionals will need to increase their valuation of the indigenous proficiencies inherent in their community partners. It is a matter of moving away from a “them and us” mentality toward a sense of “we” that will help foster a partnership of mutual benefit.
Workshop participants also examined ways that distance-learning is being employed to form “virtual partnerships” that foster international education in health-related areas. One project, for example, involves the Emerging Infections Network, a Web-based training tool, operated by the Asia Pacific Economic Cooperative, which links public health professionals in 21 countries that border the Pacific Rim. The network provides up-to-date information about emerging infectious diseases of international importance, and it seeks to encourage timely and effective notification and control of disease outbreaks.
In order to enhance the network’s value, researchers from the University of Washington School of Public Health recently developed and tested a new set of instructor-led learning materials and placed them on the Web site, supplementing a viewer-guided page of electronic links to library resource materials. Access to the site increased substantially after the new training materials were launched, especially among public health workers in Asia. The researchers concluded that expanding this and other such outreach efforts can help overcome the lack of accurate information and the difficulty in establishing real-time communications among international health workers and agencies, problems that often encumber global disease surveillance efforts. As electronic linkages mature, there will be an accom-
panying increase in the speed of interaction and flexibility necessary to respond efficiently to infectious diseases wherever they occur.
ADDRESSING THE WORKFORCE CRISIS IN THE DEVELOPING WORLD11
Infectious diseases are a global problem and therefore require a global response (Culpepper, 2003; Hrynkow, 2003; Duale, 2003). As the IOM report Microbial Threats to Health observed, nations must be concerned not only with diseases that afflict their own citizens, but also with diseases occurring elsewhere (IOM, 2003a). Particular attention needs to be paid to the developing world, where the burden of infectious diseases is greatest. A number of forces at work in developing countries—population growth, urbanization, poverty, malnutrition, climate change, and political instability, among others—have created conditions that can promote the emergence and reemergence of diseases. It is estimated that one of every two people in developing nations will die from an infectious disease.
It is vital to combat infectious diseases in developing countries for the sake of their populations; this mandate should not be minimized. The steady push toward globalization also has catalyzed the speedy long-distance transport of people and animals—prime carriers of infectious microbes—and thus a pathogen emerging in a developing country is only a plane ride or boat ride away from the United States or any other part of the developed world.
It is therefore vital that the United States, along with other developed nations, help developing nations improve their capacity to monitor and address microbial threats as they arise. The IOM report recommended that U.S. investments should include financial and technical assistance, operational research, enhanced surveillance, and efforts to share both knowledge and best public health practices (IOM, 2003a). It also will be important for the United States to coordinate its efforts with key international agencies, such as the WHO. A number of federal agencies, including the Centers for Disease Control and Prevention, the National Institutes of Health, the Department of Defense, the Agency for International Development (USAID), and the Department of Agriculture (USDA), can play central roles. These agencies should communicate amongst themselves and coordinate their programs, and they should collaborate actively with private organizations and foundations. There is an absence of any ongoing investigations into the variable needs within developing countries in infectious disease, and these agencies
For more information, see A. Edward Elmendorf’s paper in Appendix A, page 127.
need to support and develop a needs assessment. It was suggested that these agencies convene an international forum in the near future to examine infectious disease education and training needs in developing countries.
During the workshop, participants made clear that an important part of helping developing nations improve their capacity to handle microbial threats will be to help them to improve their scientific and medical workforces charged with controlling infectious diseases.
Framing the Issue
Data regarding health workforces in developing nations are limited and largely anecdotal, but participants generally agreed that the apparent shortcomings constitute a crisis. By way of illustration, they noted that the United States spends just over $2.20 per capita per year on domestic programs directed solely to infectious disease epidemiology, while numerous developing countries, such as Bangladesh, spend about that amount per capita per year overall for health (see Elmendorf in Appendix A).
As the United States and other developed nations work with developing nations on workforce problems, care should be taken to involve a range of participants from the countries and to respect cultural and social issues (Starling, 2001). Directors of government ministries of health, along with other officials directly responsible for health policies, must be involved. Also to be included are top officials in ministries of education and senior academic administrators in higher education, because of their responsibility for universities and schools of medicine and public health, and leading officials responsible for civil service operations and employment practices, because such a large share of the health workforce in most developing nations is employed in the public sector. High-level representatives of the health professions should be invited as well; they may seem obvious participants, but in fact this group has frequently been ignored in government policy deliberations.
Various international organizations also should help in addressing workforce issues, perhaps in collaborative ventures. Given its mission, the WHO should have a key role. Other key participants might be the World Trade Organization (because of its growing interest in trade in services, which inevitably will include services provided by health professionals), the World Bank and the International Monetary Fund (because of their involvement with developing country macroeconomic issues), and the Organisation for Economic Co-operation and Development (because of its role as a forum for discussing and coordinating economic and social policies). Bringing together these parties—along with their domestic counterparts in various countries—in a targeted international effort will likely be a formidable task, but workshop participants called it a challenge that the global community cannot afford to let pass.
Lessons from Africa
As one way to help illuminate the health challenges in the developing world, participants discussed needs and activities in Africa.
The needs, of course, are great. Some 300 million to 500 million new cases of malaria are diagnosed worldwide each year, and between 1 million and 2 million people die from the disease. Up to 90 percent of the cases and 90 percent of the deaths occur in Africa, primarily among young children. Other diseases, such as AIDS and trypanosomiasis, also are prevalent. In response, numerous international organizations have mounted a variety of health initiatives, often aimed at specific diseases. Although these programs are valuable in their own right, they will perform best if they rest on robust public health systems within each developing country. This will require increasing the size of the workforces, enhancing the skills of health professionals and allied workers, and strengthening motivations for countries to invest in workforce development and for professionals to choose public health as a career (El Ansari and Phillips, 2001).
Again, the needs are clear. Ten countries in Africa have only one doctor per 30,000 citizens—and that doctor nearly always lacks formal training in public health. Twenty-seven countries do not have a school of public health and often do not offer any formal PH training at all. Even in nations that have schools of public health, links are generally lacking among academic training, research, and the everyday practice of public health. Links also are frequently poor between institutions in developing countries and organizations in the developed world that work in public health training and health research.
In light of such needs, some participants offered several recommendations from AfriHealth, a relatively new organization that is working to mount a pan-African effort to improve public health. The group has called for international donors to join together in making a major investment in public health in Africa. Investments should total perhaps 5 to 10 times the amount now being spent, and commitments should cover perhaps 25 to 50 years. New and expanded programs should focus not only on improving the skills of individual PH professionals, but also on improving the infrastructures of PH schools and other institutions that will train professionals, conduct needed research, and generally support the field.
Education and Training Programs
Not to be overlooked, of course, are the workforce education and training efforts, both publicly and privately supported, now under way in the developing world (Breman and LeDuc, 2001). These programs can serve as a foundation on which to build stronger health systems. Workshop
participants explored some of these programs, examining their successes and their continuing needs. For example, the National Institutes of Health’s Fogarty International Center (FIC), whose mission is to promote and support scientific training internationally to reduce disparities in global health, conducts more than two dozen programs. The center’s core concept is to build training on top of research. Its primary, and oldest, effort is the AIDS International Training and Research Program (AITRP). Started in 1988, the program brings foreign scientists and allied health professionals (from the masters level to the postdoctoral level) to the United States for advanced training either at the NIH or at schools of public health or medicine. The AITRP is intended to establish critical biomedical and behavioral science expertise in developing countries affected by HIV/AIDS and the related tuberculosis (TB) epidemic, facilitate new prevention research efforts that supplement or complement NIH and other U.S. research on these diseases, establish long-term cooperative relationships between U.S. and foreign research groups, and support cooperation between U.S. academic research centers and foreign scientists.
The AITRP has trained more than 2,000 scientists from some 60 countries. Complementing its in-depth training, the center also offers short courses on a variety of topics, both in the United States and in developing countries, and more than 50,000 students and health professionals have taken part. Evaluations show that a great majority (80 percent) of the foreign scientists trained in the United States return to their home countries, and many of them ultimately assume leadership positions in government and academic health organizations.
The FIC also conducts the International Training and Research Program in Emerging Infectious Diseases, which was started in 1995 and operates in partnership with several institutes within the NIH. Modeled on the AIDS program, it offers foreign scientists advanced training opportunities at the NIH or U.S. universities (in such areas as epidemiology, basic laboratory practices, and selected social sciences), and conducts short courses in the field, which attract a range of health workers whose jobs involve diagnosis, patient management, and the control and prevention of infectious diseases. The relatively young program already has trained more than 200 scientists who have returned to their countries of origin. As another measure of its success, roughly 10 percent of all presentations at a recent world congress on tuberculosis were authored or coauthored by program graduates.
Indeed, the FIC places high priority on encouraging foreign scientists to return home, and has developed a program tailored to this goal. The Global Health Research Initiative Program, supported by 13 partners across the NIH, provides financial and other types of assistance to help ensure that scientists who complete their training in the United States will be able to continue their research at their home institutions.
Programs such as this may help avoid a “brain drain” from the developing to the developed world (Hilary, 2002). Some workshop participants suggested that a brain drain already is well under way. In Africa, for example, is it estimated that some 23,000 qualified academic professionals emigrate annually. Information from South African medical schools suggests that a third to a half of its graduates immigrate to the developed world. This trend, according to some observers, is worsening the already depleted scientific and healthcare workforces in many developing nations. Some workshop participants noted, however, that the movement of health professionals, though deserving of vigilant scrutiny, may not be all bad, and may even offer some benefits to developing nations. Many of the professionals move to positions in international health organizations, such as the WHO, where they can participate in decisions that affect global health policies. In addition, migrating health scientists can promote research activities relevant to their home countries, thereby helping to improve the allocation of health research funding in these areas.
Another FIC program addresses the recognized need to join together a host of disciplines to understand and control infectious diseases. The Ecology of Infectious Diseases program spans several institutes at the NIH and involves a number of outside agencies, such as the CDC, the USDA, the National Science Foundation, the National Institute for Environmental Health Sciences, and the U.S. Geological Survey. It provides grants to multidisciplinary teams of researchers, in both foreign countries and the United States, who will collect data on a range of topics, with the goal of improving current ability to predict the outbreak of infectious diseases.
The FIC also is stepping up efforts to foster the development of “centers of excellence” in the developing world. The idea is to have scientists in those countries take the lead as principle investigators in research and training programs. Several programs, in such areas as brain disorders and bioethics, already are under way. The latest effort is the International Clinical, Operational, and Health Services Research and Training Award for AIDS and Tuberculosis. Involving numerous partners from within and beyond the NIH, the program is intended to integrate research aimed at improving care and treatment across a range of conditions related to HIV/AIDS and TB. Planning grants have been made to a dozen countries, and plans call for making full awards in 2004.
Encouraging more young U.S. scientists to study in developing nations offers another route to workforce development. Whether they remain in those countries or return to the United States to share their experiences, these scientists can make important contributions. The FIC, with support from the Ellison Foundation, recently launched a fellowship program that will enable advanced students in medicine, dentistry, and nursing, as well as doctoral candidates in public health, to study at institutions in the develop-
ing world. The students will spend a year in mentored clinical research training.
The Department of Defense also supports efforts to improve laboratories, health and scientific workforces, and disease response capabilities in the developing world. Many of these programs are components of the DoD’s Global Emerging Infections Surveillance and Response System (GEIS). Established in 1997, the system is intended to improve the United States’ ability to protect the health of its military and civilian populations, as well as global health interests, through systematic laboratory-based surveillance, research, disease response, training, and capacity building. As part of this effort, the DoD supports infectious disease research laboratories in five developing nations: Egypt, Indonesia, Kenya, Peru, and Thailand. The laboratories have long been in place as basic research facilities, but many of their activities have now been woven into the operations of the GEIS.
These laboratories support disease surveillance and outbreak response in the host countries. But they do more, too, by serving as training facilities. Training takes several forms. For example, lab personnel train scientists and other technical workers from the host countries in the latest diagnostic methods and other bench techniques. The goal is to raise the quality of local laboratories to a uniformly high level. When this happens, the DoD labs redirect their efforts to helping the local laboratories develop quality control programs, to ensure that the high standards are maintained. The DoD labs also hold workshops devoted to outbreak response. Professionals from ministries of public health and workers from local and regional health departments attend the workshops, which may last 2 to 3 weeks, to gain skills that will help them better detect emerging infectious diseases on their own. As an indication of the popularity of these workshops, the laboratories regularly receive more requests to attend than there are spaces available. In other training efforts, the DoD provides funding for some host national laboratory employees and others to attend academic institutions in the United States for advanced degree training, which they can put to work when they return to their home institutions.
The DoD also sends U.S. scientists and physicians to the laboratories to receive advanced training in infectious diseases and other scientific areas, and to experience what it is like to work in public health. Participants in such efforts may spend several weeks to several months in the laboratories, and evidence suggests that they often emerge with heightened interests in pursuing research or public health careers, either in the United States or in the developing world.
IMPLICATIONS OF VISAS AND SELECT AGENT RESEARCH RESTRICTIONS12
As the United States works to improve its abilities and the abilities of other countries to combat microbial threats, it also will be necessary to keep the nation safe from other threats that have emerged in recent years. The terrorist attacks of September 11, 2001, along with the purposeful distribution of anthrax spores through the mail that followed, have raised national concerns about security. In response, the government has initiated a series of measures—and is planning more. Many of these measures directly affect the scientific and health communities.
Workshop participants universally agreed that the nation must be kept safe, but many of them expressed concern that some of the new security measures may unduly interfere with how research and scientific training are conducted, both in the United States and internationally. Most of the discussions focused on two issues: the system that controls how visas are issued to foreign scientists and students wanting to enter the United States; and the system that controls who may work with certain biological agents and toxins that pose a severe threat to public health and safety (“select agents”), what procedures must be followed when working with them, and how the materials may be transferred among laboratory facilities within the United States and internationally (see Atlas in Appendix A) (Flagg, 2003; Barrett; 2003).
In short, the U.S. scientific and health communities have long depended heavily on foreign-born scientists and physicians, including those already accomplished in their fields and those still pursuing their education. A host of reports have documented their numbers, as well as their contributions. The occasional bad apple cropped up. But the government’s visa system was, in general, considered adequate (if sometimes slow) in handling the stream of applications, while prohibiting entry of individuals who posed serious security risks. The terrorist attacks changed everything. Many people, including many in government, became convinced of the need to scrutinize everyone—including, and maybe particularly, scientists and students—who wanted to enter the country. The government put new visa regulations and application procedures in place, and consular officers who decide an application’s fate began taking more time in rendering their decisions, rejecting more applicants or referring them back to the start of the application process. Safety was spelled conservatism.
For more information, see Ron M. Atlas’ paper in Appendix A, page 51.
As workshop participants reported, problems arose almost overnight. Many scientists and students found themselves facing long delays in obtaining their visas, with some of them being prohibited entirely, sometimes with little explanation (White and Peterson, 2003). Individuals from certain countries, including those in the Middle East where tensions and threats of terrorism were judged by some observers as high, seemed to come under sharpest review. As a result, academic institutions found themselves short of faculty and staff, graduate and postdoctoral fellowships went unfilled, research collaborations were put on hold, and major scientific meetings were canceled or went without key speakers or participants, among other problems (Powell, 2002; Alberts et al., 2002). (Similarly, many medical and high-tech industries found themselves short of workers.) Some observers began to suggest that if such shortages were to continue, they might translate into fewer people being trained in science and medicine, fewer research advances being made, and fewer new therapies being transferred into practice (Shouse, 2002). In addition, if fewer students come for training, then there ultimately would be fewer professionals to return to their home countries and enter their scientific and medical workforces.
Foreign scientists and students already in the United States on visas sometimes faced problems as well. In some cases, if a person were to leave the country even briefly—perhaps to attend a scientific conference or to go home for a visit—then he or she would have to obtain a new visa and possibly be subject to the same delays that new applicants faced.
At the time of the workshop, the federal government was reexamining its visa policies and trying to identify and implement steps to speed up the application and approval process. Given that state of flux, participants noted that the scientific community should carefully monitor events and work to ensure that constructive policies and mechanisms are adopted. One important task will be to gather systemic data to document any current and continuing problems. Participants also discussed a series of recommendations developed by the American Society for Microbiology for how the visa processing system should be changed. The overarching principle is that screening procedures should result in a minimum of disruption of educational and research endeavors. Among specific suggestions, the government should ensure that the visa system has sufficient personnel and other resources so that all applications can be processed in a timely manner, and it should explore and possibly develop procedures that expedite, on the basis of objective criteria, the processing of applications from individuals who are least likely to pose a threat. In addition, the process for readmitting trainees who leave the country for brief periods should be simplified, and the requirement that such individuals be re-interviewed should be eliminated.
Participants noted that the scientific community has an important communications role to play as well. Scientists and scientific institutions and
organizations can explain to policy makers and the public that the best defenses against the threat of bioterrorism are advancing the research agenda to produce new vaccines, diagnostic tools, and therapeutic agents, and building a large and well-trained workforce ready to combat any microbial threats that arise, either naturally or as a result of hostile actions. Scientists also can make clear that biomedical research is an international endeavor, and that efforts to control and prevent infectious diseases must of necessity be global. Moreover, the scientific community can promote the underlying principal of the universality of science, and explain to all quarters that this principle requires freedom of association, movement, and communication as well as access to data and information in connection with international scientific activities. These freedoms must obtain without discrimination on the basis of such factors as citizenship, religion, creed, political stance, ethnic origin, or race.
Of course, communications is a two-way street, and some participants called on the scientific community to talk more openly with the national security community in order to better understand the dangers of today’s world. The idea is that with such knowledge, scientists will be better prepared to engage in activities—some of which are likely to involve new constraints and adherence to new regulatory mandates—that will reduce the threat that terrorists might misuse life and medical sciences in tragic ways.
Communications has a thoroughly utilitarian side as well. The scientific community needs to stay informed about visa policies, and scientists (and managers) who are involved in programs that bring foreign scientists and students to the United States need to provide them with up-to-date information about the visa application process. When organizing meetings, staff appointments, collaborative research ventures, or fellowship programs that involve foreign scientists and students, U.S. scientists and managers should build in more lead time, and they should be prepared for delays in the processing of visas and for the possible need to provide more information to consular officers. Above all, they should remember that it is the scientists’ or students’ responsibility to obtain travel documents, and not the government’s responsibility to issue visas without due consideration.
Select Agent Research Restrictions
At the time of the workshop, considerable controversy swirled around the government’s regulations—and proposed regulations—regarding select agents. The Centers for Disease Control and Prevention devised the list of select agents and regulates their possession by government agencies, universities, research institutions, and industry. The Department of Agriculture also assumes some oversight responsibility of select agents. Some scientists
were calling for the government to remove all restrictions and allow the scientific community to determine how best to control research with such agents. Other scientists, perhaps the majority, agreed that restrictions were needed—but even within this group there were differences of opinion about what form such restrictions should take and what their ultimate impact on research likely would be. Workshop discussions reflected these varying views.
Complicating matters is the fact that many of the select agents are not commonly found in the United States, and hence there is a lack of U.S. scientists experienced in working with them. A common custom had been for U.S. laboratories to recruit foreign scientists who have such experience. But following the 2001 terrorist attacks, the government passed the USA Patriot Act, which placed added restrictions on who could have access to select agents within U.S. laboratories. Specifically, the act denies access to people from countries that the United States designates as supporting terrorism. These restrictions subsequently were incorporated into the Biopreparedness Act, and thus into the CDC’s regulatory schemes.
Under the new restrictions, debate continued about their effects on scientific research in academe and industry. Some workshop participants suggested that negative effects would be dramatic, with biotechnology being especially hard hit; other participants saw less of a threat. But there were general agreements that the scientific community should carefully monitor events as they unfold. If problems arise, scientists can bring them to the attention of the relevant government agencies and departments and insist that they be responsive.
One particular challenge will be for the scientific community to develop working relationships with the national security and law enforcement communities (Schatz, 2002). The Biopreparedness Act requires that the Department of Justice clear individuals before they are granted access to select agents, and this responsibility has been assigned to the Federal Bureau of Investigation (FBI). Workshop participants expressed concern about how the FBI will carry out this job. Will it provide appropriate security oversight without interfering with the legitimate pursuit of science, especially as the magnitude of biodefense research increases? The scientific community can watch to see if the FBI proves reluctant to grant clearances to foreign scientists, and whether backlogs arise in granting clearances.
Beyond their concerns about regulations imposed by the Biopreparedness Act, participants also worried that some government agencies—including the Department of Defense, the Department of Health and Human Services, and the Department of Agriculture—might further restrict foreign nationals from entering their laboratories. Participants noted that there may be some areas where classified research is conducted and where restricted access to foreign nationals may be appropriate, but that broad
restrictions of international scientists is neither appropriate nor called for by the select agents regulations. To help ensure that such actions do not happen, the scientific community can highlight for policy makers and the public the value of international scientific exchanges for global health and national security.
IDENTIFYING PRIORITIES FOR THE FUTURE
Workshop participants pointed to a number of priority areas, both large and small (Bond, 2003; Carroll, 2003; Jackson, 2003; Boulton, 2003; Gotuzzo, 2003).
As an overarching principle, they stressed that infectious diseases are a global problem and therefore require a global response. Thus, as the United States and other developed nations work to strengthen their capacities to meet current and new microbial threats, they also must look outward. Special attention should be paid to the developing world, where infectious diseases are most prevalent and opportunities for spread are considerable. Of course, an important part of helping developing nations improve their capacities to meet microbial threats will be to help them strengthen their scientific and medical workforces charged with controlling infectious diseases. Additional U.S. help should include financial and technical assistance, operational research, enhanced disease surveillance, and efforts to share both knowledge and best public health practices.
The United States would be well advised to seek—even catalyze—international assistance in this task. Given its mission, the World Health Organization can play a major role. Help also can come from the World Trade Organization, the World Bank, the International Monetary Fund, and the Organisation for Economic Co-operation and Development. The magnitude of the problems facing developing nations deserves no lesser response from the world community.
In assisting developing countries, developed nations should take care to respect local cultural and social values. To the fullest extent possible, they also should actively involve a range of local stakeholders—national and community government officials, teachers and administrators at academic institutions, health professionals, and members of the public—in order to gain “buy in” and improve the prospects of success.
As another guiding principle, participants emphasized that mounting an effective response to infectious disease threats, in the United States and elsewhere, will require leadership and multidisciplinary efforts involving all sectors of the public health, clinical medicine, basic science, and veterinary communities. Thus, strong workforces need to be developed and sustained in each of these areas. In addition, these communities must expand communications amongst themselves, which too often is lacking today. Similarly,
greater cooperation and coordination is needed among the larger scientific, government, and industrial sectors. Such synergy will help in advancing fundamental knowledge about microbes, in developing and implementing new treatments for diseases, and in improving current abilities to predict disease outbreaks and prevent or control their spread.
In discussing the various components of the U.S. workforce involved in combating microbial threats, it became clear that comprehensive data are lacking. Even fewer data are available for the developing world. Studies have produced at least rough estimates of the U.S. workforce—but participants agreed that compiling an up-to-date, thorough picture of the landscape will be essential to guide future capacity development efforts. Moreover, such data will be needed to underpin efforts to gain more financial support for workforce development. Both governments and private foundations—potential sources for expanded funding—will be most likely to respond positively in the face of convincing data.
As participants explored specific segments of the workforce, a number of trends and needs emerged. For example, the scientific community is adopting a more systemic view of infectious disease, in which microbes and humans are intricately entwined, and this shift is increasing the need to recruit people from previously overlooked disciplines into the biological arena. Physicists and chemists, mathematicians and computer scientists, evolutionary biologists and ecologists—all are joining with traditional microbiologists and immunologists to answer complex questions that once were difficult if not impossible to address. The challenge is for universities and other academic institutions, from departments on up, to develop ways to foster such collaborative research, often conducted by large teams. How can institutions break down their disciplinary “silos” and promote cross-fertilization? How can they encourage people from disparate fields to talk with one another, to speak a common language, to visualize common problems, and to value each other’s skills and ideas? Numerous approaches are being tried and likely more will be needed in order to learn what works and then build on those successes.
Participants also stressed the need to redouble efforts to increase the supply of physician–scientists. Among many roles, physician–scientists are a vital force in translating laboratory research into practical medical advances. But their numbers have dropped significantly in recent years. This decline has been due, in part, to the growth of managed care, which has forced many academic health centers to cut the amount of time that physician–scientists have available for research or to train upcoming physician–scientists. A number of ways were proposed to help grow this population. For example, medical school graduates who pursue careers in research can be forgiven at least part of their accumulated educational debts, and medical schools can
seek out undergraduate students who show an aptitude for research and “bond” them to medicine even before they begin formal training.
Literally by definition, public health professionals will be instrumental in efforts to protect society from microbial threats, whether naturally occurring or arising from terrorist actions. But as numerous reports have observed, the nation’s PH system, including its infrastructure of human resources, has fallen into disarray and must be rebuilt. The challenge will be to rebuild as efficiently as possible. This marks one of the areas where workshop participants saw a pressing need for more data, and they called for new national studies to better characterize the PH workforce in terms of numbers, locations, and levels of expertise.
Even as such national studies proceed, however, steps can begin now to strengthen the PH workforce. As participants noted, for example, efforts are needed to boost the supply of physicians who specialize in infectious diseases. ID physicians are and will remain instrumental in meeting microbial threats, but evidence suggests that their numbers are seriously lacking. One approach is to grab students’ interest in such a career early—perhaps during middle school or high school, but certainly before they begin medical training. Enticement also might come from programs to forgive the educational debts of medical graduates who pursue training in infectious diseases and enter the field of public health, especially as ID physicians often earn less than their counterparts in other medical specialties. In addition, participants highlighted the need to attract and train more epidemiologists to work both in hospitals and in the field. The federal government can help in this effort by expanding current programs and developing new programs, both intramural and extramural, to train health professionals in applied epidemiology and field-based research in the United States and abroad. Also important to assuring a strong public health workforce in the future will be investment in leadership development within organizations in the United States and around the world. One speaker suggested the potential benefit of building a network of global leaders for public health.
In tandem with strengthening the PH workforce, it will be important to better educate all students in the health professions in the basic concepts of public health. As experience has amply demonstrated, health workers outside of the formal PH community are often the first to encounter infectious diseases. Forging tighter links between public health and other health professions will help increase the nation’s “surge capacity” to handle the numbers of people who might be stricken in large-scale disease outbreaks. Thus, workshop participants called on institutions that train health professionals—including medical schools, nursing schools, and veterinary schools—to revise their curricula accordingly. Institutional leadership will be critical in setting such change in motion and seeing it to fruition. Leaders will need to
explain convincingly the necessity for and the benefits of introducing PH concepts into general studies, and they will need to empower staff members to take actions that ultimately will anchor the new approaches in the institutional culture.
A major goal across all diseases, of course, is prevention—and when it comes to infectious diseases, the record already is strong, with vaccines available to ward off many microbial threats. But many diseases remain for which new or better vaccines are needed, and workshop participants noted that more people are critically needed in a range of disciplines to work in vaccinology. Toward this end, medical schools can do more to teach students about vaccines and vaccinology—information often relegated mainly to pediatrics—so they might consider this area as a career path. Training would best be multidisciplinary and incorporate a range of core subjects, such as pathogenesis, microimmunology, safety regulations, and clinical development. Since medical schools now offer so few courses related to vaccinology, they may need to look to industry for teachers. Industry can help in other ways as well, such as by developing and supporting training opportunities in the workplace, to ensure that more students are exposed to career paths in vaccinology.
Similarly, disease prevention is the ultimate goal of vector biologists and entomologists. Many of the world’s most dangerous microbial pathogens are passed to humans by insects or other vectors, and achieving a better understanding of the details of transmission could well help in devising methods to slow or stop the process completely. Here, as in most other areas of research related to infectious diseases, collaboration may hold the key. Thus, workshop participants cited the need for expanding efforts to bring vector biologists and entomologists together with researchers in a number of other fields, including parasitology, clinical medicine, and public health. Both the government (through the National Institutes of Health, among other agencies) and private foundations can play important roles in fostering such multidisciplinary projects.
One major challenge that the nation already faces—and will continue to face—as it strives to strengthen the infectious diseases workforce arises not from science or the microbial world, but rather from the government’s own policies. As a result of the terrorist attacks of 2001, the government has launched a series of security measures that directly affect how science operates. Of particular note are policies that affect how visas are issued to foreign scientists and students who want to enter the United States, and policies that control who may work with a select group of biological agents and toxins that the government deems to be a severe threat to public health and safety. Many members of the scientific community have expressed concern that these and other policies being developed will significantly limit the free and open conduct of science in a variety of ways, not the least by
preventing foreign scientists and students from studying or working in the United States.
Many workshop participants expressed similar concerns. They also noted, however, that the policies were new and their consequences not yet fully known. Thus, it will be important for the scientific community to monitor events carefully as they unfold, document any problems, and then work with the government and other stakeholders to ensure that constructive policies are in place. One suggested guideline is that the best policies will be those that result in a minimum of disruption of educational and research endeavors.
Participants also noted that scientists have an important communications responsibility. They can explain to policy makers and the public that an active research effort and a well-trained health workforce are ultimately the best defenses against the threat of bioterrorism, and that the strength of medical science—indeed, of science itself—rests soundly on the principle of universality. But at the same time, scientists have a responsibility to listen respectfully to the concerns of other groups. This will mean, for example, talking openly with the national security community. The goal of such dialogue will be to arrive at a consistent set of government policies that will protect the nation’s safety while enabling science to perform at peak efficiency and deliver fully on its promises for improving human health and well-being.
Abelmann WH, Nave BD, and Wilkerson L. 1997. Generation of Physician–Scientists Manpower: A Follow-up Study of the First 294 Graduates of the Harvard–MIT Program of Health Sciences and Technology. J Investigative Medicine 45:272–275.
Alberts B, Wulf Wm A, and Fineberg H. 2002. Current Visa Restrictions Interfere with U.S. Science and Engineering Contributions to Important National Needs. [Online]. Available: www4.nas.edu/news.nsf/isbn/s12132002?OpenDocument [accessed January 10, 2005].
Barrett A. 2003 (June 12). Panel Discussion at the Institute of Medicine Workshop on Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century. Washington, DC. Institute of Medicine Forum on Microbial Threats.
Bond Q. 2003 (June 13). Panel Discussion at the Institute of Medicine Workshop on Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century. Washington, DC. Institute of Medicine Forum on Microbial Threats.
Boulton M. 2003 (June 13). Panel Discussion at the Institute of Medicine Workshop on Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century. Washington, DC. Institute of Medicine Forum on Microbial Threats.
Breman J and LeDuc J. 2001. International partnerships in infectious diseases research, training, and control. Emerg Infect Dis 7(3 Suppl):542.
Carroll D. 2003 (June 13). Panel Discussion at the Institute of Medicine Workshop on Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century. Washington, DC. Institute of Medicine Forum on Microbial Threats.
Cassatt J. 2003 (June 12). Panel Discussion at the Institute of Medicine Workshop on Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century. Washington, DC. Institute of Medicine Forum on Microbial Threats.
CDC (Centers for Disease Control and Prevention). 2002. Core functions and capabilities of state public health laboratories: A report of the Association of Public Health Laboratories. MMWR 51(No. RR-14):1–8.
CDC, National Center for Environmental Health. 2003. A National Strategy to Revitalize Environmental Public Health Services. [Online]. Available: http://www.cdc.gov/nceh/ehs/Docs/NationalStrategy2003.pdf [accessed January 12, 2005].
CDC. 2004a. Public Health Schools Without Walls. Department of Health and Human Services, Centers for Disease Control and Prevention, Division of International Health. [Online]. Available: www.cdc.gov/epo/dih/phswow.html [accessed January 6, 2005].
CDC. 2004b. Ghana. Department of Health and Human Services, Centers for Disease Control and Prevention, Division of International Health. [Online]. Available: www.cdc.gov/epo/dih/ghana.html [accessed January 6, 2005].
CDC. 2004c. Uganda. Department of Health and Human Services, Centers for Disease Control and Prevention, Division of International Health. [Online]. Available: www.cdc.gov/epo/dih/uganda.html [accessed January 6, 2005].
CDC. 2004d. Zimbabwe. Department of Health and Human Services, Centers for Disease Control and Prevention, Division of International Health. [Online]. Available: www.cdc.gov/epo/dih/zimbabwe.html [accessed January 6, 2005].
CDC. 2004e. Vietnam. Department of Health and Human Services, Centers for Disease Control and Prevention, Division of International Health. [Online]. Available: www.cdc.gov/epo/dih/vietnam.html [accessed January 6, 2005].
CDC and APHA (American Public Health Association). 2001. Environmental Health Competency Project: Recommendations for Core Competencies for Local Environmental Health Practitioners. [Online]. Available: http://www.apha.org/ppp/Env_Comp_Booklet.pdf [accessed January 11, 2005].
Colin-Thomè D. 1999. Primary care perspectives. In: Griffiths S, Hunter D, eds. Perspectives in Public Health. Oxford: Radcliffe Medical Press:179–189.
Council on Education for Public Health. 2003. Accredited Schools and Programs. [Online]. Available: http://www.ceph.org [accessed September 15, 2003].
CSTE (Council of State and Territorial Epidemiologists). 2003 (March). National Assessment of Epidemiologic Capacity in Public Health: Findings and Recommendations. [Online]. Available: http://www.cste.org/pdffiles/ecacover1.pdf [accessed January 6, 2005].
Culpepper R. 2003 (June 13). Panel Discussion at the Institute of Medicine Workshop on Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century. Washington, DC. Institute of Medicine Forum on Microbial Threats.
Daar AS, Thorsteinsdóttir H, Martin DK, Smith AC, Nast S, and Singer PA. 2002. Top 10 biotechnologies for improving health in developing countries. Naure Genet 32:229–232.
Dowdeswell E, Daar AS, and Singer PA. 2003. Bridging the Genomics Divide. Global Governance: A Review of Multilateralism and International Organization 9(1):1–6.
Duale S. 2003 (June 13). Panel Discussion at the Institute of Medicine Workshop on Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century. Washington, DC. Institute of Medicine Forum on Microbial Threats.
El Ansari W and Phillips CJ. 2001. Empowering healthcare workers in Africa: Partnerships in health—beyond the rhetoric towards a model. Critical Public Health 11(3):231–252.
Findley SE, Iriguyen M, See D, Sanchez M, Chen S, Sternfets P, and Caesar A. 2003. Community–provider partnerships to reduce immunization disparities: Field report from Northern Manhattan. American Journal of Public Health 93(7):1041–1044.
Flagg M. 2003 (June 12). Panel Discussion at the Institute of Medicine Workshop on Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century. Washington, DC. Institute of Medicine Forum on Microbial Threats.
Ganem D. 2003 (June 12). Bridge Building between Medicine and Basic Science: The Role of the Physician–Scientist. Presentation at the Institute of Medicine Workshop on Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century. Washington, DC. Institute of Medicine Forum on Microbial Threats.
Gebbie K. 2003 (June 13). Panel Discussion at the Institute of Medicine Workshop on Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century. Washington, DC. Institute of Medicine Forum on Microbial Threats.
Gebbie K, Merril J, Bitoush R, Cortazzl M, Gebbie E, Cupta M, Hwant I, King M, and Wanger M. 2000. The Public Health Workforce: Enumeration 2000. Rockville, MD: U.S. Health Resources & Service Administration, Bureau of Health Professions, National Center for Health Workforce Information and Analysis.
Goldman E and Marshall E. 2002. NIH Grantees: Where Have All the Young Ones Gone? Science 298:40–41.
Gotuzzo E. 2003 (June 13). Panel Discussion at the Institute of Medicine Workshop on Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century. Washington, DC. Institute of Medicine Forum on Microbial Threats.
Gray ML and Bonventre JV. 2002. Training Ph.D. researchers to translate science to clinical medicine: Closing the gap from the other side. Nature Med 8:433–436.
Haroon A. 2003. Employers encouraged to help control TB: WHO and the International Labour Organisation strengthen public/private partnership for tuberculosis control. Lancet 361(9375):2135.
Hilary J. 2002. Brain drain and health professionals: Developed countries must say no to trade in medical staff. BMJ 324(7336):499–500.
Hrynkow S. 2003 (June 13). Panel Discussion at the Institute of Medicine Workshop on Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century. Washington, DC. Institute of Medicine Forum on Microbial Threats.
IOM (Institute of Medicine). 2003a. Microbial Threats to Health: Emergence, Detection, and Response. Washington, DC: The National Academies Press.
IOM. 2003b. Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century. Washington, DC: The National Academies Press.
Jackson R. 2003 (June 13). Panel Discussion at the Institute of Medicine Workshop on Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century. Washington, DC. Institute of Medicine Forum on Microbial Threats.
Joiner KA, Dsimukes WE, Brigan Be, Cohen MS, Johnson WD, Karchmer AW, Mandell GL, and Stamm W. 2001. Adequacy of Fellowship Training: Results of a Survey of Recently Graduated Fellows. Clin Infect Dis 32:255–262.
King L. 2003 (June 12). Panel Discussion at the Institute of Medicine Workshop on Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century. Washington, DC. Institute of Medicine Forum on Microbial Threats.
King L and Khabbaz R. 2003. Converging issues in veterinary and public health. Emerg Infect Dis 9(4):510–511.
Mock N. 2003 (June 13). Panel Discussion at the Institute of Medicine Workshop on Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century. Washington, DC. Institute of Medicine Forum on Microbial Threats.
Morse SS. 2003. Building academic–practice partnerships: The center for public health preparedness at the Columbia University Mailman School of Public Health, before and after 9/11. Journal of Public Health Management and Practice 9(5):427–432.
NRC (National Research Council). 1998. Trends in the Early Careers of Life Scientists. Washington, DC: National Academy Press.
Painter PC. 2000. What Has Happened to All the Techs? [Online]. Available: www.ivdtrials.com/TechStaff.htm [accessed August 14, 2003].
Perl T. 2003 (June 13). Panel Discussion at the Institute of Medicine Workshop on Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century. Washington, DC. Institute of Medicine Forum on Microbial Threats.
Powell K. 2002. Visa clampdown hits home at US universities. Nature 420(6914):349.
Rosenberg L. 1999. Physician–scientists—endangered and essential. Science 283(5400): 331–332.
Schatz W. 2002. When the FBI Asks, Should Scientists Tell? The Scientist 16(2):52.
Shouse B. 2002. Restrictions threaten science. The Scientist. [Online]. Available: www.biomedcentral.com/news/20021216/08/ [accessed January 10, 2005].
Srinivasin A. 2003 (June 13). Panel Discussion at the Institute of Medicine Workshop on Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century. Washington, DC. Institute of Medicine Forum on Microbial Threats.
Starling C. 2001. Infection control in developing countries. Curr Opin Infect Dis 14(4): 461–466.
Steenbergen G and El Ansari W. 2003. The Power of Partnership. Stop TB Partnership, World Health Organization. Geneva, Switzerland: WHO. WHO/HTM/STB/2003.
Tawfik Y. 2003 (June 13). Panel Discussion at the Institute of Medicine Workshop on Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century. Washington, DC. Institute of Medicine Forum on Microbial Threats.
Varki A and Rosenberg LE. 2002. Emerging opportunities and career paths for the young physician–scientist. Nature Med 8(5):437–439.
Ward-Cook K, Chapman S, and Tannar S. 2003. 2002 wage and vacancy survey of medical laboratories. Part I: Salaries continue to show moderate gains. Laboratory Medicine 34(9):631–638.
White WD and Peterson L. 2003. Visas for Visiting Students: Current Situation. The Physiologist 46(2):47–50.
Wilkerson L and Abelmann WH. 1993. Producing Physician–Scientists: A survey of graduates from the Harvard–MIT Program in Health Sciences and Technology. Academic Medicine 68:214–218.
Woltring C. 2003 (June 13). Panel Discussion at the Institute of Medicine Workshop on Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century. Washington, DC. Institute of Medicine Forum on Microbial Threats.
Woltring C, Constantine W, and Schwarte L. 2003. Does leadership training make a difference? The CDC/UC Public Health Leadership Institute: 1991–1999. J Public Health Manag Pract 9(2):103–122.
Zerhouni, EA. 2003. The NIH roadmap. Science 302:63–72.