RESEARCH ON TROPICAL DISEASES (1985) p. 5 of 12
INTERNATIONAL CENTERS FOR MEDICAL RESEARCH AND TRAINING (ICMRT),
INTERNATIONAL CENTERS FOR MEDICAL RESEARCH (ICMR), AND INTERNATIONAL
COLLABORATION IN INFECTIOUS DISEASES RESEARCH (ICIDR)
In the late 1950ís, NIH health strategists were aware that the
capacity of the American medical establishment to deal with tropical
diseases, greatly expanded during the war, was atrophying. Deeming it important to maintain at least a modest level of
interest and competence in tropical medicine among American biomedical
scientists, they made plans to establish several training centers in
port cities in the United States.
The passage of the International Health Research Act in 1960, PL
86-610, allowed NIH to expand its concept and include overseas
authorization provided for international cooperation in health research,
research training, and research planning, in order to advance the status
of the health of the American people. Authority to engage in international cooperation to advance the
international status of the health sciences was also included in the
Act, but reserved to the President. As we noted in the cholera story, the delegation of that
authority is enjoyed at the moment only by the US/Japan Cooperative
Medical Research program, which probably doesnít need it.
The intent of Congress to preclude NIH from participating in
overseas programs for the benefit of non-Americans was reaffirmed in
congressional hearings in 1962. Congress
did not want confusion and duplication to arise from the fragmentation
of the foreign assistance program.
Consequently, the ICMRT program was shaped with benefits to
United States citizens exclusively in mind. The principal purposes of the program were to provide stable,
long-term overseas sites for research and research training on
environmental, ethnic and biomedical conditions of scientific interest
unavailable in the United States. The
program would increase the number of US scientists competent in
biomedical research and knowledgeable on health problems in other
Four grants were made to universities in 1960 and one the
following year for the establishment of overseas centers at cooperating
of California in San Francisco, with its overseas Center at the
Institute for Medical Research in Kuala Lumpur. Units were also located in the Faculty of Medicine, University of
Singapore in the l960s, and in the faculty of Medicine, University of
Malaya from the mid-1960s on;
University School of Medicine, with its overseas Center at the
Universidad del Valle in Cali, Colombia;
Johns Hopkins University School of Medicine
and School of Public Health and Hygiene, with its Center at the Calcutta
School of Tropical Medicine and the All-India Institute of Hygiene in
of Maryland School of Medicine, with its Center at the Institute of
Hygiene and the Medical Institute College at Lahore, Pakistan; and
State University School of Medicine, with its Center at the University
of Costa Rica School of Medicine in San Jose, Costa Rica.
The grants were for five years, averaging approximately $500,000
per year, a figure which continued fairly constant over the years as its
value declined through inflation. One
of the express purposes of the program was to provide stable bases for
work in tropical medicine on which people could plan their careers,
confident of continued employment opportunities. The program was never re-advertised, but the grants to
participating institutions were renewed after periodic reviews. The original four universities each remained active for the full
20-year span of the program. LSU was dropped from the program in 1970 when a reduction in
funding made it necessary to reduce the number of Centers. The total cost of the program was about $45
million. Successful institutions used their grants as core funding and
were able to attract personnel paid from other sources. Thus the total expenditure was always much greater than the total
of the NIH grant.
The grants permitted the universities broad latitude in designing
their programs, depending upon the interests of faculty members and the
medical priorities in the area in which their centers were located. Although most of the work would deal with infectious diseases,
other conditions such as malnutrition, genetic diseases, and population
dynamics were eligible for inclusion. Interdisciplinary approaches were to be employed, including the
social sciences. The
program and activities of each ICMRT may be summarized as follows.
(UC-ICMR). The Center
conducted research on arboviruses, especially dengue because of its
prevalence in Malaysia. Although
usually an urban disease, scientists at the Center demonstrated that
dengue infection occurs in monkeys in the forest canopy and that a
previously unknown mosquito was the probable vector.
Another important segment of the UC program was in parasitology,
especially host-parasite interaction, with special attention to natural
or acquired resistance of vector snails to the larval stage of human
parasites. The long-range
objective was to develop biological methods to control snails, the
vector for schistosomiasis and other parasitic diseases.
UC-ICMR social scientists and epidemiologists collaborated with
IMR scientists in studies of Malaysian community health, ethnomedicine,
socio-medical determinants of disease, demography, and traditional
Malaysian medical care. The variety of peoples in the country provided opportunities
for the study of abnormal hemoglobin occurrence and other genetic
conditions, such as thalassemia. This
work was closely coordinated with similar studies at UC San Francisco.
Some UC-ICMR offices and labs were located in the same building
as USAMRU/Malaysia, both associated with the DIR. The pattern of association was quite different,
however. USAMRU research was generally quite self-contained, its own
personnel working in its own labs, while UC-ICMR people were dispersed
throughout the Institute working as staff members of DIR research
UC-ICMR and IMR collaboration in many fields resulted over the years
from this arrangement. Only
a few UC-ICMR researchers collaborated with USAMRU scientists, possibly
because having come half way round the world they were eager to work
with Malaysians rather than Americans.
The Tulane group conducted a vigorous program on malnutrition,
including clinical research on hospitalized adults and children,
experimental animal studies, and field surveys. This was possible because of an unusually fine group of Colombian
investigators interested in a range of nutrition issues.
The second largest effort by Tulane was on infectious parasitic
diseases, including American trypanosomiasis (Chagas disease),
intestinal parasites in school-age children, and the ecology of insect
vectors of parasites of man and animals. Epidemiological investigations of diarrheal disease and
fungal infections were also conducted.
A third dimension was added later to the Tulane ICMRT program,
with the encouragement of the ICMRT Advisory Committee. It dealt with behavioral sciences and social epidemiology,
including social psychiatry, psychiatric origins of criminal behavior,
health systems, anthropology, and health service utilization.
In 1975, Tulane changed its institutional affiliation from
Universidad del Valle to COLCIENCIAS, the national research council.
are already familiar with the work of the Johns Hopkins team on
diarrheal diseases, although that was not their only, or even their
primary, effort in Calcutta. Other
projects concerned hepatitis, malnutrition and anemia, schistosomiasis,
and the ecology of certain insects and mammals in India.
After the move in 1972 to Dacca, their work was focused primarily
on diarrheal diseases, nutrition and population dynamics. The last two years of the project found the ICMRT in
collaborative research on diarrheal diseases with the Gorgas Memorial
Laboratory in Panama.
The most active studies by the Maryland team were on genetic
variations of mosquitoes, for the purpose of devising methods for
biological control of vectors of malaria and arbovirus infections. Another project dealt with the treatment of drug-resistant
malaria found in Pakistan, and additional work was done on scrub typhus.
Rica. The LSU group focused on the study of parasitic infections
most actively. Some work was also done on viral infections including
In 1973, the training element of the ICMRT program was dropped,
and the Centers became known as ICMRs. This change was precipitated by strong pressures from OMB and the
Congress to reduce training at NIH.The word training in the title of any
program could jeopardize its existence, so it was dropped. The training intended in the program was only meant to benefit
American scholars in any case, so the change in titles may have been
expected to produce little change in practice. Not so, in the opinion of Frederick Dunn, who spent seven years
in Malaysia under the ICMR(T) program. The consequences of the change were enormous, in his view, the
strength of the program lying in the training and developing-country
experience it provided for hundreds of American health science
professionals. Dropping the
training was one step on the road that led to the demise of the program.
An earlier step on the same path was transfer of ICMR funding to
the budget of NIAID in 1968. Previously,
ICMRT had been insulated from the research focus of any single NIH
institute by being administered by the Office of International Research.
Transferring the program to NIAID led to increasing pressures for
emphasis on infectious diseases research, and on research as such,
rather than research training. Thus,
according to Dunn, work by hematologists, geneticists, social
scientists, cancer epidemiologists, psychiatrists, heart-disease
epidemiologists, etc. was increasingly viewed as inappropriate. The program gradually became a tropical disease research program,
instead of a medical research and research training program in the
tropics, as it had begun.
Despite the size and significance of this program, it received no
terminal evaluation when it ended in 1980. An evaluation plan was drawn up and discussed with the Institute
of Medicine, but in the end NIAID decided not to follow through with it.
As a result, we have no balanced, or even biased, document on
which to rely for judgments of the outcome of this relatively large
investment of research funds.
A rather formal mid-course study of the Tulane program was
conducted by Shirley B. Laska of Tulane in 1974.
Each of the grantee institutions negotiated its own arrangements
with its hosts. All found it necessary to make some accommodation to the
professional needs and interests of the host institution, but there was
a good deal of variety in the result. Some ICMRs were in effect American laboratories housed for
convenience abroad. This
was consistent with the terms of the award, but sometimes made it
difficult to demonstrate program benefits to host country institutions. In other cases, such as UC-Malaysia, the ICMR was a highly
collaborative association of American and Malaysian scientists working
in labs and in the field.
Tulane was on the collaborative end of the spectrum. A project advisory committee governed field
activities. Colombians were represented on it beginning in 1965, and for a
time were a majority of the committeeís members. In 1969, the committee was reorganized, with three members
appointed from Tulane and three from Valle. All members had equal voting
power. In addition, the committee had an unusual procedure whereby Valle
members could veto any
research proposal made by someone from Valle, Tulane, or some other
institution. The Tulane
members in turn could veto any proposal approved by Valle members. This arrangement assured that all proposals were deemed
appropriate and important by the host institution, and that Tulane could
remain responsible to NIH for the pertinence and quality of the
Tulane recognized that facilitating Colombian research and
training Colombians was of major importance, not only to ensure their
own welcome, but because of the dearth of other research opportunities
for their colleagues. This
goal was not formally acknowledged, however, because of the terms of the
grant. It would not do to
be perceived as offering foreign assistance.
Even while enjoying a share in the governance of the project, and
access to research funds, some of the Colombians complained that they
did not have equal access to facilities and funds. Some of the Americans, on the other hand, complained about the
selection process being subject to personal biases and about being
somewhat isolated professionally while in Colombia.
In general, however, the project appears to have been successful,
popular and productive. Twenty-five
theses and dissertations were produced in its first 13 years, and 244
publications, 22% of which first appeared in Spanish.
Laska makes the comment that the Valle scientists considered that
one of the principal values of the project was the opportunity to gain a
better understanding of the medical problems of their country -- but
that this ďis not of special concern to the US participants, who as
researchers have a greater concern for the advancement of scientific
knowledge.Ē This may
simply represent the authorís personal judgment, but one suspects that
it reveals an attitude not uncommon in the medical research community. It could account for the fact that nowhere in the rather tortuous
examination of participantsí feelings about personal advantages gained
from the program is there mention of the possible impact of the research
on the disease burden of Colombians. That was not the purpose of the program, nor apparently was it
In addition to the Laska study, evaluative comments on the ICMR
program are found in John Sealís letter of support for the military
overseas laboratories. This letter was written in 1980, when the ICMR program was
already at an end, and the military laboratories were endangered, so
Sealís remarks may tilt somewhat in favor of the military model in the
interests of maintaining national capacity for field research abroad. Also, Seal had had a naval
career. Nonetheless, his points are instructive.
Sealís main point is that there is no career available in U.S.
academic institutions for those with primary interests in international
medical research, and that lasting competence cannot be established
through grant and contract programs which do not produce tenured
As evidence he cites the fact that 20 years of stable support for
four of our better medical schools through the ICMR program failed to
build a continuing capacity for international work on infectious
diseases. Capacity seemed
instead to have declined, as indicated by the failure of three of the
four schools to compete successfully for the ICIDR grant program that
succeeded the ICMR program.
This point is a bit unfair because many in the universities saw
the ICMR program primarily as a training vehicle to prepare people for
careers in other institutions, not their own. As for the ICIDR competition, it was a different ball
game. Many of the ICMR participants were interested in medical issues
in tropical countries, but not in infectious disease problems.
Seal also pointed out that limited opportunities exist in schools
of medicine for entomologists, veterinarians, sanitary engineers, or
other disciplines often needed in overseas research or operations. Nor do physicians with valuable international research experience
tend to stay in the field. NIH
had another program from 1963 to 1969 aimed at giving overseas research
experience to young physicians. By
1979, of the 23 physicians assigned through the program to military
overseas laboratories, ICMRs, or the Cholera Research Laboratory in
Dacca, only one remained in government and only eight in academic
medicine. Of the eight, only three had a current relationship to
overseas research. These
figures are challenged by one participant in the program who personally
knows of eight still very active in tropical medicine. This may reflect
the fact that although many seem to go out of the field immediately
after their initial experience, they later find opportunities for
returning to it.
In 1974, in anticipation of a full-scale review of ICMR program
accomplishments before the fourth round of funding, Howard Minners, a
PHS officer charged with administering the program at NIAID, wrote an
article in which he broached a number of issues concerning operations of
the program. Among them
were the following:
the achievements of the ICMRs be evaluated quantitatively for their
contributions to scientific programs and to individual careers;
participating universities able to maintain a sustained level of high
quality research in the field;
sharp a focus is appropriate; should each ICMR select a single theme;
relevant are ICMR research programs to NIAID objectives;
the size of the critical mass needed for centers abroad; and
the ICMRs be located geographically to cover a broad range of geographic
The anticipated review did not take place. Instead, in 1976, a decision was made to redefine, restructure,
and re-advertise international research grants, with the ICMR allowed to
terminate in 1980. This
decision reflected, in part, renewed interest in the White House and HHS
in international medical research, and a desire to give more support to
a new WHO program of tropical disease research.
also reflected a determination by the new director of NIAID to halt
funding for activities, such as social science research, which were
outside the objectives of NIAID.
The new program, International Collaboration in Infectious
Disease Research (ICIDR), is more narrowly confined to infectious
disease research and immunology. It
emphasizes the six diseases selected by WHO, plus diarrheal diseases. Explicit importance is assigned to building the institutional
research capacity of the host country institution, and 70-80% of the
funds are to be spent abroad on problems relevant to health status of
the local people.
The ICIDR program was announced in 1975 and applications invited.
Of the 14 proposals received, only six were rated average or
better, and five were awarded five-year grants. Tulane was the sole survivor of the competition from the ICMR
University of Maryland project failed the competition but received
continued NIH funding for two years because of State Department pressure
to avoid closing the program in the midst of a period of diplomatic
The five successful applicants and their host institutions were:
School of Public Health - Federal University of Bahia, Brazil;
School of Medicine - The Federal University and the University of
Brasilia; Bahia, Brazil;
State School of Medicine - Central Laboratory of the Ministry of Health,
of Illinois School of Medicine - Chiang Mai University, Thailand;
Tulane University School of Public Health
and Tropical Medicine - Colciencias, Cali, Colombia, and Institute
Francais díHaiti, Port-au-Prince, Haiti.
The first cycle of ICIDR awards ended in September 1984. Four of the regional five competed successfully for the second
round -- Tulane, Harvard, Michigan State and Cornell. Three new projects were also funded:
University - Bogota, Colombia
Hopkins University - Lima, Peru
State University - Addis Ababa, Ethiopia.
In addition to institutional awards, the ICIDR program makes
exploratory grants to individual scientists for work in an area. Five grants totaling $277,000 were made in 1980 for work in
Mexico, India, Nigeria and two in Brazil. In the second round, grants were made for work in Indonesia,
Venezuela, Kenya and Brazil.
Total funding for ICIDR is about $2.8 million, around the same
level as earlier expenditure for ICMR. Each institutional project receives only about half the amount
annually that went to the ICMRs.
ICIDR investigators do not take up residence abroad, generally
making visits of four to six months at a time. ICMR investigators were often abroad for two or more
years. Training is not a primary objective of the ICIDR program, nor was
it of ICMR in the later years. Foreign
investigators are allowed travel funds now, but were not under ICMR.
An informal report to NIH from the Michigan State group in
October 1984 describes a vigorous collaborative program, thriving under
conditions of political uncertainty.
Ten Sudanese scientists are full participants in research in the
field and frequent visitors for varying periods to MSU. Eight senior MSU scientists and six graduate students and
research associates have participated. A number of clinically trained students plan to pursue careers in
tropical medicine and infectious diseases, one of whom hopes to do so in
Research underway includes investigations of genetic and other
sources of immunity to malaria, pathologic changes in schistosomiasis,
the epidemiology of onchocerciasis (which can cause blindness), and
testing of various therapeutics. Research funding supplementary to the ICIDR has been received
from various departments of MSU and from several pharmaceutical
Turning to our comparative framework:
of the program
The ICMR program appeared to extend further along the
problem-solving spectrum of international health than the ICIDR program
because it included a broader range of investigators, such as social
scientists. In practice,
this may be an illusion. The
social scientists in Cali, for example, followed their own research
interests without necessary reference to the diseases of concern to
their medical colleagues. Similarly,
in Malaysia, the ICMR(T) avoided interdisciplinary research. The UC group sought to support people with outstanding research
ideas and plenty of enthusiasm, rather than to find people to fit
predetermined slots in existing research projects.
Investigator freedom to define the research task is of course the
hallmark of the sponsoring agency, NIH. The annual site visits to the ICMRs arranged by NIH were
considered by staff to be a rather unusual intrusion into the affairs of
grantees, made necessary perhaps by the breadth and complexity of the
enterprises. They were also
a major factor in helping the individual field directors maintain
quality and phase out programs and individuals who were unproductive.
The stronger the program, the more the visits were appreciated. The ICMR committee was remarkably stable, competent, and
dedicated, and the annual site visits and meetings in the U.S. with host
institution principal investigators were a major factor in the relative
success and longevity of the program.
It would be unfair to criticize the ICMR program for not being a
tightly knit, targeted attack on a tropical disease when that was not
its stated purpose. It is
legitimate to question, however, whether the approach favored by NIH and
the university community would be the most effective way to use limited
funds if the purpose were to reduce the disease burden on people who
live in the tropics. Perhaps
the optimal pattern of organization for stimulating new discoveries and
for training outstanding researchers is not ideal for carrying the
scientific process to the point where people directly benefit from it.
Close collaboration with host-country scientists was possible
under the ICMR, as we have seen in Cali and Kuala Lumpur, but it was not
universally achieved, nor was it required under the terms of the grant. In some circumstances, such as Lahore, it may not have been
possible, given the level of local medical institutions. The ICIDR program, reflecting changes in the international
climate perhaps, or heightened NIH sensitivity, is meant to be highly
Curiously, the two ICMRTs that achieved the closest collaboration
with host country institutions, Cali and Kuala Lumpur, were both led in
their early years by British expatriates.
Impact on Diseases
In the absence of an evaluation of the ICMR program, it is
difficult to determine the contribution it made to understanding and
controlling tropical disease. We saw in the Cholera story that the Johns Hopkins group in
Calcutta made significant contributions to understanding cholera and
diagnosing E. coli and shigella. They
also contributed to the development of oral rehydration therapy. Other ICMRs may have made similarly vital contributions.
In general, however, as Laska put it, the programs were designed
to advance scientific knowledge and train researchers, rather than to
have an impact on the course of a disease in an area.
The ICMR program was explicitly designed to provide in American
medicine a small core of competence in exotic diseases. Seal argued that the increase in capacity of American
institutions sought through the program did not occur, largely because
tenured positions could not be offered. Itís an important point, if valid, but the evidence is not
available to confirm or refute it. Dunn cites a dozen former participants in the program who are
continuing their involvement in international health at UC San Francisco
and nearby institutions. Tropical
medicine is very strong at UCSF due to the ICMR program. The reasons UCSF did not compete successfully for the ICIDR
program have more to do with the fact that many researchers are not
interested in infectious diseases, some are interested in other parts of
the world, and the jungle dengue project had reached a logical stopping
point by 1980.
Despite this explanation, the lack of success of three of the
four universities with ICMRs in competing for ICIDR grants is
perplexing, given their advantages in field experience. Possibly it is difficult to sustain an interest in tropical
diseases in a university setting.
One indication that this was so is that the universities often
had to reach outside their faculty ranks in order to staff their
overseas centers. Even
those scientists with long-term interest in tropical diseases did not
wish to stay abroad for many of the 20 years of the program. It was professionally costly to be out of the mainstream of
American science for too long, often working in poorly equipped
laboratories. It was also
disruptive of the teaching programs for senior people to spend too much
time away, even on university business.
The results of the ICMR program in terms of institutional
capacity building seem therefore to be disappointing. In manpower terms, the ICMRs may well have been a
success. They provided abundant opportunities for relatively large numbers
of scientists to gain experience in tropical disease research, but they
didnít provide career inducements to keep them engaged for the balance
of their careers.