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



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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century 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

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century 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 1   For more information, see Victoria McGovern’s paper in Appendix A, page 156.

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century 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

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century 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

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century 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

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century 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 2   For more information, see Martha L. Gray’s paper in Appendix A, page 143.

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century 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- 3   For more information, see Margaret A. Potter’s paper in Appendix A, page 176.

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century 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

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century 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

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century 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- 4   For more information, see Walid El Ansari’s first paper in Appendix A, page 76.

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century 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 5   For more information, see Gary L. Gorby’s paper in Appendix A, page 129.

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century 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

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century 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

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century 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

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century 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,

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century 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

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century 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

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century 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

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century 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. REFERENCES 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.

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