IDEAS AND OPINIONS
Global Noncommunicable Disease Research: Opportunities
and Challenges
Lindsay M. Jaacks, PhD; Mohammed K. Ali, MBChB, MSc, MBA; John Bartlett, MD; Gerald S. Bloomfield, MD, MPH;
William Checkley, MD; Thomas A. Gaziano, MD, MSc; Douglas C. Heimburger, MD, MS; Sandeep P. Kishore, MD, PhD;
Racquel E. Kohler, PhD, MSPH; Kasia J. Lipska, MD, MHS; Olivia Manders, MA; Christine Ngaruiya, MD, DTM&H;
Robert Peck, MD, MS; Melissa Burroughs Pena, MD, MS; David A. Watkins, MD, MPH; Karen R. Siegel, PhD, MPH; and
K.M. Venkat Narayan, MD, MSc, MBA
O pportunities for collaboration on global noncom-
municable disease (NCD) research across interna-
tional borders and scientific disciplines are increasingly
available, coinciding with globalization of science and
an unprecedented interest in global health among U.S.
students, clinicians, and early-career investigators (1).
However, challenges to developing and funding a
global NCD research agenda remain. In September
2014, researchers representing 41 institutions, includ-
ing universities, government agencies, private compa-
nies, journals, and foundations in the United States met
to discuss the challenges and identify opportunities for
moving forward on a global NCD research agenda.
Four action items emerged from this conference.
BUILD BRIDGES BETWEEN COMMUNICABLE
DISEASE AND NCD RESEARCH
The conventional dichotomy of communicable dis-
eases and NCDs in global health must be replaced with
a more holistic approach to health. Noncommunicable
disease researchers and governments could leverage
infrastructure and cohorts already established or being
developed for communicable disease research (2).
Collaborations will naturally emerge in 2 domains:
strengthening primary care systems in low-resource
settings to manage various common infections and
chronic conditions and establishing integrated care
models for persons with chronic HIV or AIDS who are
also affected by NCDs (3). Collaborative work in the
second domain is urgently needed given the rapid in-
crease in life expectancy among persons with HIV inter-
nationally after the global distribution of antiretroviral
drug treatment (3). Unfortunately, a major challenge for
such interdisciplinary projects is that most funding
agencies focus on specific conditions. Infrastructure
development, clinical research, and public health re-
search are typically funded through different sources,
and this further complicates matters.
ENCOURAGE RECIPROCAL EXCHANGES OF
HEALTH INNOVATIONS BETWEEN U.S. AND
GLOBAL HEALTH
Investments in global NCD research do not need to
be a zero-sum game in which investment in global
health detracts from U.S. health. Although most global
health efforts have focused on implementing evidence-
based practices from the developed world in develop-
This article was published online first at www.annals.org on 25 August 2015.
712 © 2015 American College of Physicians
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Annals of Internal Medicine
ing countries, adoption of health care innovations from
resource-limited settings (such as use of lay community
health workers for primary care delivery and mobile
phones to improve patient adherence) in the United
States may reduce health care costs and improve pa-
tient outcomes (4). In addition, global NCD research
findings may be directly applicable to the United States
because its population is becoming more ethnically
diverse.
BETTER COMMUNICATE THE BENEFITS OF
GLOBAL NCD RESEARCH INVESTMENT
Global NCD researchers, the National Institutes of
Health (NIH), and other institutions supported by U.S.
taxpayers must clearly communicate the benefits to be
gained by the United States from engaging in global
NCD research (Table). A few of the potential scientific
benefits include gaining a greater understanding of the
health effects of a wider range of exposures to environ-
mental pollutants, particularly high-dose exposures,
and access to large samples from diverse populations
for genomic studies and clinical trials. For clinicians, in-
ternational work offers opportunities to broaden their
medical knowledge, refine their physical examination
and diagnostic skills, and become more culturally com-
petent (5).
Creating incentives for trainees to work abroad can
strengthen their research skills. The 32 U.S. fellows sup-
ported by the National Heart, Lung, and Blood Insti-
tute's Centers of Excellence program for global NCD
research published more than 70 manuscripts, and the
536 fellows supported by the NIH Fogarty International
Clinical Research Scholars and Fellows Program pub-
lished more than 3000 manuscripts (6). This productiv-
ity improves the academic breadth and prestige of
universities.
Promoting health equity around the globe can im-
prove political stability (7). The U.S. Department of
State recognizes this link between global health and
U.S. security and promotes shared responsibility for im-
proving health internationally. The President's Emer-
gency Plan for AIDS Relief exemplifies this soft politi-
cal influence through health diplomacy. Policymakers
should respond to requests from low- and middle-
income country governments, which are beginning to
focus on NCDs.
 Global NCD Research: Opportunities and Challenges IDEAS AND OPINIONS

Table. Summary of Benefits to U.S. Science, Academic Institutions, Investigators, and Others From Engaging in Global
Noncommunicable Disease Research

Science Academic Institutions Investigators Others

Reverse innovation and
opportunities for
implementation science
Unique environmental
exposures and doses
Genetic diversity
Immigrant and minority health
U.S. military, expatriate, and
traveler health
Standardization and validation
of different tools in diverse
populations
Access to diseases or
advanced disease stages
that are rare in the United
States
Unique opportunity to study
interactions with infectious
diseases
Basic science research
cheaper
Drug discovery (traditional
medicines)
Training opportunities for
early-career investigators
Improve reputation and prestige and
thus the strength of faculty and
student applicants
Create sense of solidarity among
faculty
Engage in university mission
Increase visibility with other
organizations
Partnering with other strong
institutions in low- and
middle-income countries extends
reach of limited resources
Diversify student body, trainees, and
faculty from low- and
middle-income countries
Increase breadth of diseases studied
and appeal to prospective students
and faculty
Research drives creativity and
innovation in health care
– –
Personal enrichment U.S. Department of State: soft-power
influence through health diplomacy
Expanded pool of mentors Industry: help feed pipeline of young
investigators; efficiency of clinical
trials; support labor force for U.S.
industries abroad
Develop leadership skills Global academic partners: universities
working together to develop research
infrastructure and skills
Establish partnerships that could last Research investments can be sources of
decades revenue through patentable ideas
Platform for early-career investigators –
to develop their own pathways
Interdisciplinary exchange of ideas, –
new perspectives, and persons
– –
– –
– –
–

SUPPORT EARLY-CAREER INVESTIGATORS institutes and centers as well as other governmental

AND MENTORS
Early-career investigators are the current front line
and future leaders of global NCD research, but their
career pathways are poorly defined. U.S. universities
should adopt new metrics of success that reward public
health effect and team science and recognize that, in
today's globalized scientific community, an interdepen-
dent researcher is more valuable than an independent
researcher.
The increasing difficulty in obtaining funding fur-
ther complicates the pathway for early-career investiga-
tors. Although the NIH once funded 1 out of 3 research
proposals, it now funds only 1 out of 6 (8). Career
Development (“K”) Awards, which are critical for early-
career investigators, are extremely competitive, par-
ticularly for global NCD researchers. The funding path-
ways after “K” Awards are even more competitive, and
investigators often rely on “R” Awards. An increase in
funding devoted to global NCD research would be an
important first step toward supporting talented scien-
tists. Concurrently, universities could increase hard-
money and exploratory grants to encourage these
high-impact endeavors. Global NCD mentors also need
financial support to dedicate time to training and build-
ing NCD research capacity at their universities and in
partnering countries.
Several examples of success are worth noting. The
National Heart, Lung, and Blood Institute Global Health
Strategic Plan highlights the need for global transla-
tional research (9). It will be important for other NIH
www.annals.org
and nongovernmental funding agencies to emphasize
global NCDs in their strategic plans. Investigators in the
United States should seek opportunities to sit on NIH
study sections to ensure that global NCD projects are
reviewed and scored fairly, particularly in light of their
large potential for public health effect. In this regard,
the dramatic misalignment between the global burden
of disease and U.S. funding agency priorities (far more
resources are available for HIV and AIDS than for NCDs,
which cause more deaths) must be addressed (10).
Policymakers in the United States can lead the way to
address NCDs as they did with the Global Fund for
HIV/AIDS and the President's Emergency Plan for AIDS
Relief.
CONCLUSION
Achieving these 4 action items requires comple-
mentary contributions by U.S. global NCD researchers,
funders (both public and private), and universities. In-
creased collaboration across university-based centers
focused on global NCDs is also essential. Finally, global
NCD research must coincide with political efforts to ad-
dress known NCD risk factors and disparities in health.
Advocacy for each of these changes will be critical. The
time for action is now.
From Rollins School of Public Health, Emory University, At-
lanta, Georgia; Duke Global Health Institute and Duke Clinical
Research Institute, Duke University, Durham, North Carolina;
Annals of Internal Medicine • Vol. 163 No. 9 • 3 November 2015 713

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 IDEAS AND OPINIONS
School of Medicine and Bloomberg School of Public Health,
Johns Hopkins University, Baltimore, Maryland; Brigham and
Women's Hospital and Young Professionals Chronic Disease
Network, Boston, Massachusetts; Vanderbilt Institute for
Global Health, Vanderbilt University, Nashville, Tennessee;
Yale School of Medicine, New Haven, Connecticut; University
of North Carolina, Chapel Hill, North Carolina; Center for
Global Health, Weill Cornell Medical College, New York, New
York; and University of Washington, Seattle, Washington.
Acknowledgment: The authors thank Emory University, Office
of the Provost, Rollins School of Public Health, Hubert Depart-
ment of Global Health, and the Emory Global Diabetes Re-
search Center; the Hubert-Yeargen Center for Global Health
at Duke University; and the VECD (Vanderbilt, Emory, Cornell,
Duke) Fogarty Global Health Fellowship Program (R25
TW009337) housed at the Vanderbilt Institute for Global
Health for their financial contribution to the U.S. Investigators'
Network Symposium on Global Non-Communicable
Diseases Research, held in Atlanta, Georgia, on 8 –9 Septem-
ber 2014.
For a list of participants in the U.S. Investigators' Network
Symposium on Global Non-Communicable Diseases Re-
search, see the Appendix (available at www.annals.org).
Disclosures: Disclosures can be viewed at www.acponline
.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15
-1068.
Requests for Single Reprints: Lindsay M. Jaacks, PhD, Rollins
School of Public Health, Claudia Nance Rollins Building,
7040-I, 1518 Clifton Road, Atlanta, GA 30307; e-mail,
ljaacks@emory.edu.
Current author addresses and author contributions are avail-
able at www.annals.org.
714 Annals of Internal Medicine • Vol. 163 No. 9 • 3 November 2015
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Global NCD Research: Opportunities and Challenges
Ann Intern Med. 2015;163:712-714. doi:10.7326/M15-1068
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 Annals of Internal Medicine
Current Author Addresses: Dr. Jaacks: Rollins School of Public APPENDIX: PARTICIPANTS IN THE U.S.
Health, Claudia Nance Rollins Building, 7040-I, 1518 Clifton INVESTIGATORS’ NETWORK SYMPOSIUM ON
Road, Atlanta, GA 30307.
Dr. Ali: Rollins School of Public Health, Claudia Nance Rollins GLOBAL NON-COMMUNICABLE DISEASES
Building, 7040, 1518 Clifton Road, Atlanta, GA 30307. RESEARCH
Drs. Bartlett and Bloomfield: Duke Global Health Institute, 310 Participating institutes provided sponsorship for
Trent Drive, Durham, NC 27710. their junior and senior investigators to attend this
Dr. Checkley: Johns Hopkins University, Suite 9121, 1800 Or- event. Participants are listed alphabetically by affilia-
leans Avenue, Baltimore, MD 21205. tion. They provided perspectives and information, but
Dr. Gaziano: Brigham & Women's Hospital, 75 Francis Street,
the responsibility for writing and developing recom-
Boston, MA 02115.
Dr. Heimburger: Vanderbilt Institute for Global Health, 2525
mendations was that of the authors.
West End Avenue, Nashville, TN 37212.
Abt Associates, Cambridge, Massachusetts
Dr. Kishore: Yale School of Medicine, 333 Cedar Street, New
Pat Shifflett
Haven, CT 06510.
Dr. Kohler: University of North Carolina Gillings School of
American Cancer Society, Atlanta, Georgia
Global Public Health, 135 Dauer Drive, 1101 McGavran-
Farhad Islami
Greenberg Hall, Campus Box #7411, Chapel Hill, NC 27599.
Dr. Lipska: Yale School of Medicine, PO Box 208020, New Brigham & Women’s Hospital, Boston,
Haven, CT 06520.
Massachusetts
Ms. Manders: Rollins School of Public Health, Claudia Nance
Rollins Building, 7040-L, 1518 Clifton Road, Atlanta, GA
Thomas Gaziano
30322.
Case Western Reserve University, Cleveland, Ohio
Dr. Ngaruiya: Yale School of Medicine, 464 Congress Avenue,
Chris Longenecker
Suite 260, New Haven, CT 06519.
Dr. Peck: Weill Cornell Medical College Center for Global Centers for Disease Control and Prevention,
Health, 402 East 67th Street, 2nd Floor, New York, NY 10065.
Atlanta, Georgia
Dr. Burroughs Pena: University of California, 505 Parnassus
Street, 11th Floor, San Francisco, CA 94143.
Michael Ballesteros
Dr. Watkins: University of Washington, 325 9th Avenue, Box Naomi E. Chen
359780, Seattle, WA 98104. Andrea Neiman
Dr. Siegel: Rollins School of Public Health, Claudia Nance Rol- Mona Saraiya
lins Building, 7040-J, 1518 Clifton Road, Atlanta, GA 30322.
Dr. Venkat Narayan: Rollins School of Public Health, Claudia Doris Duke Charitable Foundation, New York,
Nance Rollins Building, 7049, 1518 Clifton Road, Atlanta, GA New York
30322. Betsy Myers

Duke University, Durham, North Carolina

Author Contributions: Conception and design: L.M. Jaacks,
Anubha Agarwal
M.K. Ali, J. Bartlett, G.S. Bloomfield, W. Checkley, T.A. Ga-
John Bartlett
ziano, D.C. Heimburger, S.P. Kishore, R.E. Kohler, K.J. Lipska,
O. Manders, C. Ngaruiya, R. Peck, M. Burroughs Pena, D.A. Janet Prvu Bettger
Watkins, K.R. Siegel, K.M. Venkat Narayan. Cynthia A. Binanay
Analysis and interpretation of the data: L.M. Jaacks, K.M. Ven- Gerald Bloomfield
kat Narayan. Melissa Burroughs Pena
Drafting of the article: L.M. Jaacks, K.M. Venkat Narayan. Kelly Matthews Deal
Critical revision of the article for important intellectual con- Marlee Krieger
tent: L.M. Jaacks, M.K. Ali, J. Bartlett, G.S. Bloomfield, W. Laura Musselwhite
Checkley, T.A. Gaziano, D.C. Heimburger, S.P. Kishore, R.E.
Neha J. Pagidipati
Kohler, K.J. Lipska, O. Manders, C. Ngaruiya, R. Peck, M. Bur-
Uptal D. Patel
roughs Pena, D.A. Watkins, K.R. Siegel, K.M. Venkat Narayan.
Final approval of the article: L.M. Jaacks, M.K. Ali, J. Bartlett, Devon Paul
G.S. Bloomfield, W. Checkley, T.A. Gaziano, D.C. Heimburger, John W. Stanifer
S.P. Kishore, R.E. Kohler, K.J. Lipska, O. Manders, C. Ngaruiya, Nathan Thielman
R. Peck, M. Burroughs Pena, D.A. Watkins, K.R. Siegel, K.M. Eric J. Velazquez
Venkat Narayan.
Obtaining of funding: J. Bartlett, D.C. Heimburger, K.M. Ven- EDC Center for Diabetes Education, Atlanta,
kat Narayan. Georgia
Administrative, technical, or logistic support: G.S. Bloomfield, Mahmoud Ibrahim
O. Manders.
Collection and assembly of data: L.M. Jaacks, R.E. Kohler, C. Emory University, Atlanta, Georgia
Ngaruiya. Mohammed Ali
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 Eeshwar K. Chandrasekar Partners in Health, Boston, Massachusetts
Caroline V. Coburn Nancy Ferguson
Solveig A. Cunningham Maia Olsen
James W. Curran Paul H. Park
Ralph J. DiClemente
Mary Foote Population Services International, Washington, DC
Nicole Ford Heather White
Karla Galaviz Social & Scientific Systems, Silver Spring, Maryland
Theresa W. Gillespie Yvette Delph
Unjali Gujral Andy Menke
Danny Haddad Susan Sepelak
Lindsay M. Jaacks
R.L. Felipe Lobelo Stanford University, Stanford, California
Olivia Manders Andrew Y. Chang
Neil Mehta
K.M. Venkat Narayan The Coca-Cola Company, Atlanta, Georgia
Shivani A. Patel Rhona S. Applebaum
Martha Ryan University of Alabama, Birmingham, Alabama
Nida Shaikh Amanda Willig
Karen Siegel
Lisa Staimez University of California, San Francisco, California
Parminder S. Suchdev Dhruv S. Kazi
Mary Beth Weber Jyoti Mishra

Georgetown University, Washington, DC University of Michigan, Ann Arbor, Michigan

Emily Mendenhall Justin List
Michele Heisler
Georgia State University, Atlanta, Georgia
Matthew Magee University of North Carolina, Chapel Hill, North
Carolina
Harvard University, Boston, Massachusetts Racquel Kohler
Christina P.C. Borba Rita K. Kuwahara
Andrea Feigl Elizabeth J. Mayer-Davis
Project HOPE, Health Affairs, Bethesda, Maryland Michelle A. Mendez
Jonathan Bor Christina Shay

Icahn School of Medicine at Mount Sinai, New University of Pittsburgh, Pennsylvania

York, New York Laurien Sibomana
Rajesh Vedanthan Tushar Singh

Johns Hopkins University, Baltimore, Maryland University Research Co., Bethesda, Maryland
William Checkley M. Rashad Massoud
Phabiola M. Herrera Aldana University of South Carolina, Columbia, South
Catherine H. Miele Carolina
Laura D. Sander Nancy L. Fleischer
Sandra Zaeh
University of Southern California, Los Angeles,
National Institutes of Health, Bethesda, Maryland California
National Cancer Institute: John Flanigan Mellissa Withers
National Heart, Lung, and Blood Institute: Michael
M. Engelgau University of Virginia School of Medicine,
National Institute of Diabetes and Digestive and Charlottesville, Virginia
Kidney Diseases: Andrew A. Bremer Ashley K. Volaric
National Institute of Mental Health: Beverly Pringle Chris Winstead-Derlega

Northwestern University, Chicago, Illinois University of Washington, Seattle, Washington

Mark D. Huffman Catherine P. Benziger
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 Manoj P. Menon Robert Peck
Deepa Rao
David Watkins Westat, Rockville, Maryland
Nancy L. Dianis
Vanderbilt University, Nashville, Tennessee Laura Freimanis Hance
Catherine Lem Carothers Jennifer Huang
Douglas C. Heimburger Tracy L. Wolbach
Amina Merchant
Tecla M. Temu Yale University, New Haven, Connecticut
Sten H. Vermund Evelyn Hsieh
Dana C.N. Walker Kasia Lipska
Jeremy Schwartz
Virginia Commonwealth University, Richmond, Sandeep Kishore
Virginia Christine Ngaruiya
Sudha Jayaraman
Young Professionals Chronic Disease Network,
Weill Cornell Medical College, New York, New Boston, Massachusetts
York Abigail Capobianco
Dan Fitzgerald Jordan D. Jarvis

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