# Presentation: 216427

## Perspectives on the Brain and International RelationsSharon H. Hrynkow, Ph.D.Associate DirectorNational Institute of Environmental Health Sciences, NIHInternational Affairs Committee,Society for NeuroscienceScience Diplomats ClubEmbassy of France, Washington, D.C. June 24, 2008

**Notes:**
Note post doc in Oslo, return to State Department for policy experience.  Young neuroscient, but neuroscience was not on foreign policy agenda!  Chose to work on AIDS, the issue that I felt was most critical to US foreign policy....  

Looking back years later, see that neuroscience may be having its day.... As we appreciate economic impact of mental health disorders and impact on development agenda, he time for neuroscience at State may be coming!

## NIH Consists of 27 Institutes and Centers

**NIH Consists of 27 Institutes and Centers**

**NEI**

**NCI**

**NHLBI**

**NIEHS**

**NINDS**

**NIMH**

**NIAMS**

**NINR**

**NCCAM**

**CIT**

**CC**

**NHGRI**

**NIA**

**NIAAA**

**NICHD**

**NIDCD**

**NIDCR**

**NIDDK**

**NIDA**

**NIGMS**

**NCRR**

**NIBIB**

**NCMHD**

**FIC**

**CSR**

**ROADMAP**

**BLUEPRINT**

**OPASI**

**GEI**

**NIH**

**NIAID**

**NLM**

**Notes:**
Orange discs indicate programs that do not have intramural labs.

## Elements of Neuroscience

- Anatomy, physiology, molecular biology.... of central and peripheral nervous system
- Developmental neurobiology
- Disease onset, progression, treatment
- Understanding behavior
- Social issues
- Training and retaining global neuroscientists

## Global Burden of Disease

**Non communicable diseases are responsible for nearly half of total global deaths. **
**They cause up to 80% of all deaths in industrialized countries and 40% of all deaths in the developing world. **
**By the year 2020, non communicable diseases are expected to account for 70% of deaths in the developing region.**

## The Burden of Disease, 2001

- Source: *Disease Control Priorities in Developing Countries, *second edition, 2006, Table 1.A2

|  | Low- and Middle- Income |  | High-Income |  | World |  |
| --- | --- | --- | --- | --- | --- | --- |
|  | DALYs | DALYs
(Stillbirths included) | DALYs | DALYs
(Stillbirths included) | DALYs | DALYs
(Stillbirths included) |
| Total DALYs (thousands) | 1,387,426 | 1,260,643 | 149,161 | 148,316 | 1,536,587 | 1,412,600 |
| Causes of Death (percent) |  |  |  |  |  |  |
| Communicable diseases, pregnancy outcomes, nutritional deficiencies | 39.8 | 33.6 | 5.7 | 5.4 | 36.5 | 30.5 |
| Non-communicable conditions | 48.9 | 52.4 | 86.7 | 87.2 | 52.6 | 56.4 |
| Injuries | 11.2 | 12.1 | 7.5 | 7.5 | 10.9 | 11.6 |

**Notes:**
 This table presents the burden of disease as measured in disability-adjusted life years (DALYs). A DALY is a unit for measuring the amount of health lost because of a particular disease or injury. It is calculated as the present value of the future years of disability-free life that are lost as a result of the premature deaths or cases of disability occurring in a particular year.
 Because of changes in diet and lifestyle as well as rapid population aging in developing countries, noncommunicable conditions now account for approximately one-half of the worldwide burden of disease. 

## The Global Burden of Disease, 1990

***Nature Medicine*****  4, 1241 - 1243 (1998) ****doi:10.1038/3218**

## Disease Burden of Selected Major Psychiatric Disorders, By Region, 2001

- Source: *Disease Control Priorities in Developing Countries, *second edition, 2006, Table 31.1

|  | DALYs Lost Annually per One Million Population |  |  |  |
| --- | --- | --- | --- | --- |
| Region | Schizophrenia | Bipolar Disorder | Depression | Panic Disorder |
| Sub-Saharan Africa | 1,716 | 1,803 | 4,905 | 777 |
| Latin America and the Caribbean | 2,049 | 1,678 | 9,919 | 777 |
| Middle East and North Africa | 2,247 | 1,830 | 6,544 | 852 |
| Europe and Central Asia | 1,630 | 1,400 | 8,944 | 713 |
| South Asia | 2,087 | 1,612 | 10,507 | 779 |
| East Asia and the Pacific | 2,126 | 1,685 | 7,594 | 757 |
| High-income countries | 1,201 | 1,137 | 9,054 | 577 |
| World | 1,894 | 1,583 | 8,431 | 740 |

**Notes:**
 Add here – Mali Anecdote – dementia, etc....
This table shows the DALYs lost per year for a population of one million for selected psychiatric disorders: schizophrenia, bipolar disorder, depression, and panic disorder. While these disorders are not significant causes of mortality, they account for a substantial proportion of the global disease burden.
 Although schizophrenia is a relatively uncommon disorder, estimates of its disease burden are high (1,200 to 2,200 DALYs lost per one million population) because the condition is associated with early onset, long duration, and severe disability.
 Estimates of disease burden for bipolar disorder range from 1,100 to 1,800 DALYs lost per one million population, largely due to the chronic, recurrent nature of the disorder, significant impairments to functioning, and modest treatment rates.
 Depression is the most common psychiatric disorder. The disease burden estimates for depression are high in all regions of the world (5,000 to 10,000 DALYs lost per one million population) due to its disabling consequences, recurrent episodes, and high incidence.
 Panic disorder imposes an estimated burden of 600 to 800 DALYs per one million population.
 A DALY (disability-adjusted life year) is a unit for measuring the amount of health lost because of a particular disease or injury. It is calculated as the present value of the future years of disability-free life that are lost as a result of the premature deaths or cases of disability occurring in a particular year.

## Today’s Talk

**Recent advances in neuroscience**
**Neuroscience on diplomatic agenda**
**Issues on the horizon**

**The brain exists merely to cool the blood and is not involved in the process of thinking. This is true only of certain persons.**
**The seat of the soul and the control of voluntary movement - in fact, of nervous functions in general, - are to be sought in the heart. The brain is an organ of minor importance.**
**And of course, the brain is not responsible for any of the sensations at all. The correct view is that the seat and source of sensation is the region of the heart.**

##  Icons in Neuroscience

**Rita Levi Montalcini**

**Sir John Eccles**

**Santiago Ramon y Cajal**

## Global Neuroscience: Milestones in Understanding

- Stem cells in the brain
- Ron McKay, NINDS/NIH (Scottish, Lebanese) identifies neurofilament specific to young neurons
- Sets in motion years of work that today shed light on stem cells in the brain and other parts of the body
- Working to understand factors to differentiate stem cells into diverse cell types.

**Notes:**
Give a sense of state of the science, and through an international, global lens
Stem cells --  dogma for many years was that we were born with all the neurons we would ever have. Cause for lament. 
Then it was discvered by scientists like Ron McKay that the brain had stem cells, and that there was likely some turnover...

First observed in hippocaumps, seat of short-termmemory, then other parts of brfain.  

## Fast Forward to 2008

**“****A Visionary Approach Using Stem Cells to Repair Eye Damage. New eye research center in India aims to fix visual impairment with the help of stem cells.”**
- - **Scientific American, January 2008**
**“****Stem cell therapy for eye disease. UK scientists are attempting to restore vision in people with a leading cause of blindness using stems cells.”**
** ****BBC News**
**“****Pfizer Eyes New Use for Stem Cells.”**
- - **Health Care**

## Other Landmark Neuroscience Advances

- Functional MRI --  understanding the awake, functioning brain.  Insights on behavior, addiction, gender differences....
- Identification of genes specific to schizophrenia, other mental illnesses

## Suspect Schizophrenia Genes Act Together to Thwart Working Memory 

- Two gene variants implicated in schizophrenia interact to degrade the brain's ability to process information.
- The interaction impaired working memory — retaining information from moment to moment.
- Such thinking problems are a hallmark of this severe mental illness that affects about one percent of the population.

## Summary thus far...

- Technology moving rapidly to help understand brain function and dysfunction
- Team science is the norm, and teams are increasingly international in scope.

## Neuroscience and the Diplomatic Agenda

## International Neuroscience – formal

- Heads of State  -- The G8 Agenda
- What are some factors considered when placing health/science on the annual agenda?

## G8 and Health Agenda: A Look at AIDS

- AIDS on the 2005 Gleneagles G8 agenda
- Recognition that economic and social impact would be staggering, particularly in poor nations
- Called for universal coverage – AIDS by 2010

## International Neuroscience – formal

- G8 agenda?
- Human Frontier Science Programme – based on Strasbourg, France. Multilateral program for research and training. Neuroscience one of initial areas of priority.
- Healthy Aging
- Health and Equity/Capacity in Africa

## International Neuroscience – formal

- Bilateral agreements in Science and Health – opportunities to share expertise, leverage resources
- US-China Joint Commission
- NIH included neuroscience on agenda, China agrees
- Dr. Ting-Kai Li, Director NIAAA, presents at formal bilateral discussion
- Spurs site visits, further agreements on alcohol-related research with counterparts in Shanghai

## International Neuroscience –formal 

- Letters of Intent
- WHO, International Brain Research Organization, SfN, many other agencies
- Visiting Program at NIH – 3000 of 6000 working scientists at NIH are from abroad, many in the neurosciences

## Summary thus far...

- Neuroscience, mental health included as part of broad global health, capacity building agendas considered by G8.
- With increasing awareness of mental health impacts on society, may see increasing attention to neuroscience and mental health in intergovernmental exchanges.
- Agencies will continue to look for partnerships that will extend scientific knowledge.
- Scientist-to-scientist international cooperation thriving; NGOs dedicated to this field increasing

## Issues on the Horizon - 1

- Low- and mid-income countries have needs to build expertise in neuroscience and in mental health care/delivery.

## Health Expenditures, 2001 By Country Income Level

- Source: *Disease Control Priorities in Developing Countries, *second edition, 2006, Table 1.2

| Country Group | Health Expenditure
Per Capita 
(2001 US$) | Health Expenditure 
(Percent of GDP) | Public Sector Expenditures 
(Percent of Total Health Expenditures) |
| --- | --- | --- | --- |
| Low income | 23 | 4.4 | 26.3 |
| Middle income | 118 | 6.0 | 51.1 |
| High income | 2,841 | 10.8 | 62.1 |
| Countries in the       European Union | 1,856 | 9.3 | 73.5 |
| World | 500 | 9.8 | 59.2 |

**Notes:**
 This table presents the level of health expenditures in 2001 in different income groupings of countries, the fraction of the gross domestic product (GDP) spent on health, and the proportion of health expenditures that are publicly financed.
 Almost 10 percent of the total GDP for the world is spent on health services.
 In the low-income countries, about three-quarters of health expenditures are from private, out-of-pocket payments. 
 In the high-income European countries, only about one-quarter of expenditures is for private health care services.
 Middle-income countries spend about 5 times as much per capita on health services as do low-income countries.

## Cost-effectiveness of Interventions for Mental Disorders in Low- and Middle-Income Countries

- Source: *Disease Control Priorities in Developing Countries, *second edition, 2006, Figures 2.2 and 2.3

| Condition | Intervention | Cost-effectiveness
($ per DALY averted) |
| --- | --- | --- |
| Schizophrenia | Antipsychotic drugs with optional psychosocial treatment (hospital-based) | 4,105-19,736 |
| Schizophrenia | Antipsychotic drugs with optional psychosocial treatment (community-based) | 2,472-17,197 |
| Bipolar Disorder | Mood-stabilizing drugs with optional psychosocial treatment (hospital-based) | 3,590-5,244 |
| Bipolar Disorder | Mood-stabilizing drugs with optional psychosocial treatment (community-based) | 2,498-3,728 |
| Depression | Drugs with optional psychosocial treatment | 657-2,741 |
| Panic Disorder | Drugs with optional psychosocial treatment | 384-1,084 |

**Notes:**
 This is one of a series of slides depicting the cost-effectiveness of selected interventions in low- and middle-income countries. 
 This table illustrates the cost-effectiveness of interventions for mental disorders. The interventions available for preventing and treating mental health problems in developing countries are relatively limited.
 The most cost-effective strategies for addressing schizophrenia or bipolar disorder are antipsychotic or mood-stabilizing drugs with psychosocial treatment delivered through a community-based outpatient service.
 For more common mental disorders such as depression, antidepressant drugs with psychosocial treatment are a cost-effective intervention.
 Depression is a high-burden condition (>35 million DALYs), while schizophrenia, bipolar disorder, and panic disorder are low-burden (<35 million DALYs). A DALY (disability-adjusted life year) is a unit for measuring the amount of health lost because of a particular disease or injury. It is calculated as the present value of the future years of disability-free life that are lost as a result of the premature deaths or cases of disability occurring in a particular year.

## Select Health Research and Development Best Buys

- Source: *Disease Control Priorities in Developing Countries, *second edition, 2006, Table 4.3

| Category | Key R&D Investments |
| --- | --- |
| Maternal and child health | - Increase efficiency in vaccine development and delivery  
- Develop new contraceptive methods (male and female) |
| Microbial threats | - Develop an effective prophylaxis for tuberculosis
- Develop a malaria vaccine and an HIV/AIDS vaccine |
| Noncommunicable diseases and injuries | - Establish research and training programs on noncommunicable diseases, healthy aging, and injuries |
| Health policy | - Establish a research and training program on health systems and policy |

**Notes:**
 This slide shows select best buys in health research and development (R&D).
 For maternal and child health related R&D, new contraceptive research should widen the choice of long-term but reversible methods, post-coital methods, and methods for men.
 Malaria and HIV/AIDS vaccines, while costly to develop, would greatly reduce the disease burden, particularly in Sub-Saharan Africa.

## Fogarty International Center and NIH partners --  Brain Disorders in  the Developing World

- Effects of Malnutrition on Cognitive Development
- University of Virginia – Brazil
- Traumatic Brain Injury in Latin America: Lifespan Analysis
- Univ. of Washington – Bolivia
- Planning Grant -- Preventing FAS in Russian Children --  Univ. of OK - Russia

## Building Capacity in Neuroscience in  Low- and Mid-Income Countries

- International Brain Research Organization
- Schools for Neuroscience
- Human Frontier Science Program – re-entry grants
- Pew Fellowships/Latin America
- Fogarty “GRIP” – re-entry

**Notes:**
W
Technology moving so quickly, fear that the gap between the Haves and the Have Nots will only widen

## Women in World Neuroscience --  International Brain Research Organization

- Increasing awareness of women's issues in the field.
- Advancing interests of women in neuroscience.
- Fostering networking and mentoring opportunities for young women pursuing neuroscience.
- Developing country focus.

## Women in World Neuroscience, IBRO

- Judy Iles (Chair, Canada)
- Rita Balice-Gordon; Connie Atwell, Sharon Hrynkow; Jean King; Joanne Berger-Sweeney (USA)
- KaneezFatima (Pakistan)
- Nouria Lakhdar-Ghazal (Morocco)
- Viji Ravindrinath (India)
- Eva Sykova (Czech Republic)
- Eliane Volchan; Leny Cavalcante (Brazil)
- Orly Weinreb (Israel)
- Parisa Gazerani (Denmark)
- Lisette Blanco (Cuba)

## Issues on the Horizon - 2 

- Stigma of mental health disorders – worldwide challenge
- 		Stymies health seek behavior, contributes to 	under-reporting, under-recognition of 	magnitude of the problem
- Developed and developing countries

## Real Men, Real Depression

- First national campaign to raise awareness that depression affects an estimated 6 million men annually.
- Educating the public about depression in men –
- 		Helping men to help themselves.

## Issues on the Horizon - 3

- Neuroscientists targeted by animal rights groups
- Challenges in the UK and other countries

## Issues on the Horizon - 3

- NIH speaks out
- Deputy Director for Extramural Research issues statements following two incidents involving NIH-supported researchers
- _[http://](http://grants.nih.gov/grants/oer.htm)__[grants.nih.gov/grants/oer.htm](http://grants.nih.gov/grants/oer.htm)_** **

## Issues on the Horizon - 4 

- Social, ethical implications of emerging technologies and treatments
- College students
- Military applications
- 40- and 50-year olds keeping up with GenX
- Privacy issues
- New field emerging – “neuroethics”

## Stunning advances in neuroscience hold promise for treatments and understanding of mental health disordersGiven the burden of illness worldwide and demographic trends, neuroscience and mental illness may increasingly appear as themes for cooperation on the diplomatic agenda.Challenges remain, particularly in developing countries and those in which stigma contributes to under-recognition of the problem and discourages health-seeking behaviorWith advances in technology, societies will grapple increasingly with social and ethical dimensions of neuroscience.

**Conclusions**

**Notes:**
Note post doc in Oslo, return to State Department for policy experience.  Young neuroscient, but neuroscience was not on foreign policy agenda!  Chose to work on AIDS, the issue that I felt was most critical to US foreign policy....  

Looking back years later, see that neuroscience may be having its day.... As we appreciate economic impact of mental health disorders and impact on development agenda, he time for neuroscience at State may be coming!

## Opportunities for international cooperation?Opportunities to advance neuroscience and mental health issues on array of intergovernmental forums, including policy discussions?

**Notes:**
Note post doc in Oslo, return to State Department for policy experience.  Young neuroscient, but neuroscience was not on foreign policy agenda!  Chose to work on AIDS, the issue that I felt was most critical to US foreign policy....  

Looking back years later, see that neuroscience may be having its day.... As we appreciate economic impact of mental health disorders and impact on development agenda, he time for neuroscience at State may be coming!

## Selected References

**  ****Disease Control Priorities Project**
**    **_[http://www.dcp2.org/main/Home.html](http://www.dcp2.org/main/Home.html)__[/](http://www.psych.upenn.edu/~mfarah/)__ _
**  ****World Health Organization - Global burden of disease **
**    **_[http://www.who.int/topics/global_burden_of_disease/en/](http://www.who.int/topics/global_burden_of_disease/en/)__ _
**   ****National Institute of Environmental Health Sciences**
**    **_[http://www.niehs.nih.gov/index.cfm](http://www.niehs.nih.gov/index.cfm)_
**   ****NIH Blueprint for Neuroscience Research**
**     **_[http://neuroscienceblueprint.nih.gov/](http://neuroscienceblueprint.nih.gov/)__ _
**   ****Brain Disorders in the Developing World: Research Across the Lifespan **_[http://www.fic.nih.gov/programs/research_grants/brain_disorder/](http://www.fic.nih.gov/programs/research_grants/brain_disorder/)__ _

**Notes:**
Note post doc in Oslo, return to State Department for policy experience.  Young neuroscient, but neuroscience was not on foreign policy agenda!  Chose to work on AIDS, the issue that I felt was most critical to US foreign policy....  

Looking back years later, see that neuroscience may be having its day.... As we appreciate economic impact of mental health disorders and impact on development agenda, he time for neuroscience at State may be coming!

## Thank you!

**Notes:**
Note post doc in Oslo, return to State Department for policy experience.  Young neuroscient, but neuroscience was not on foreign policy agenda!  Chose to work on AIDS, the issue that I felt was most critical to US foreign policy....  

Looking back years later, see that neuroscience may be having its day.... As we appreciate economic impact of mental health disorders and impact on development agenda, he time for neuroscience at State may be coming!

## Climate Change and Mental Health

**Katrina & Rita: Greatest Impact was Mental Health**
**Louisiana State Poll:**
**In what ways did the hurricanes impact your own health or the health of people in your community? **

- Made people sick

- Wind/roof damage/impact is devastating

- Destroyed homes/properties

- Mental health issues/increased anxiety/stress/depression

- Source: Louisiana Survey, 2008
- Charlton Research Company for Research!America

**8%**

**15%**

**16%**

**20%**