Translation the Topic at NIDDK: ‘Clinic to Community’ Conference Raises Questions, Answers, Hope

Before the seats in the National Institutes of Health Natcher Conference Center were fully occupied, the coffee fully cooled, the whispers fully hushed, Roland “Red” Hiss addressed the auditorium with an inconclusive anecdote that set a tone of uncertainty the two-day conference soon fulfilled.

“Hello. I’m Roland ‘Red’ Hiss,” he said. “There’s a story to the ‘Red,’ but I’m not going to tell it.” The “From Clinical Trials to Community” conference, held January 12-13, 2004 and sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases, was a meeting to solve a riddle as enigmatic as Red’s, though with much larger social implications: How do we translate scientific research into community application?

The question is a complex one that, as complex question are apt to do, spawned yet more questions with each ensuing answer. “Translation is a very powerful concept that is very poorly understood, and rather lightly addressed at enormous social cost,” said Hiss, University of Michigan. Translation is the term for putting science into practice, and it is used interchangeably with translational and dissemination research.

Hiss likened the difficulty of translation to that of an infant learning to walk on its own. It “stumbles unguided towards a very uneven, extraordinarily incomplete and socially disappointing state of affairs. This conference is to generate interest in becoming [translation’s] adoptive parents.”

If translation is adopted as a result of this meeting, it will be nurtured by an inter-disciplinary smorgasbord of ideas. The broad expertise of the speakers – who ranged from clinical researchers to journal editors – was a testimony to the problem’s breadth and complexity. Even the sponsors of the event, which included the Office of Behavioral and Social Sciences Research, or OBSSR, and the Centers for Disease Control and Prevention, or CDC, in addition to NIDDK, hailed from different scientific backgrounds. To Allen Spiegel, director of NIDDK, this diverse showing represented a step in the right direction.

“The future of translational research will take a more inter-disciplinary approach,” Spiegel said. “We need to integrate genomic medicine in a ‘real world’ setting. We need to integrate behavior and biologic research.” Spiegel labeled the divergent approaches of the behavioral and biological spectrums a “false dichotomy.” “Ultimately these two need to be informed by each other,” he said, if translation is to reach its full potential.

NIH Deputy Director Raynard Kington agreed, and said NIH had already taken steps to ensure such collaboration ensued. According to Kington, the former director of OBSSR, research teams of the future will sport public-private partnerships, as well as inter-disciplinary emblems. “[We need] new types of teams, multiple disciplines examining the same problem to gain different, group insights,” he said.

Though not entirely a novel approach – NIH has been steadily moving toward a more inter-disciplinary system since implementing the Roadmap initiative, designed to expedite translation, in 2003 – the move is still a breath of fresh air from traditional, slightly ineffective translational strategies.

Hiss said that traditional approaches to information dissemination, such as medical literature, clinical science conferences, the CME industry, the Internet, and educational programs, “usually fail. [They’re] a useful first step, but only result in a vague awareness that new science exists.” The idea of community awareness, and the need to expand its currently limited existence, permeated many of the talks.

“Translation must take local circumstances into account while still striving for some generalizability,” said Lawrence Green, CDC. To get from “bench-to-beside,” or, in other words, to consummate scientific research with its real world application, Green stressed the need to “complement university based research with more practitioner and community center research.” David Marrero, Indiana University, said translation needs an even bigger boost to get on its feet.

“Once research is out of the ivory tower and into the world, there’s no free lunch,” Marrero said. “This is a major issue as we take efficacy into the real world. There may be no way to bring research to the lower income communities who may need it most without significant external sponsorship or third-party reimbursement.”

Barbara Rimer, University of North Carolina, Chapel Hill, echoed Marrero’s concern for translational funding, which he called “a significant problem.” Rimer feared an aborted transaction between the research lab and the community would all but stultify the groundbreaking research performed in the United States.

“There is no bridge between discoveries and their application, or even between discoveries and dissemination research,” Rimer said. “Thus, while the United States has one of the best discovery engines in the world, we often fail in moving discoveries from research to practice.”

Rimer argued that the best way to nurse a struggling child was to return to the nursery. She advocated redesigning research to include dissemination in every step, from conception to completion.

“Unless there is an explicit, formal model of how dissemination fits into the scientific process, it becomes a land to which no one travels,” she said. “We need to build bridges and highways from discovery to delivery.”

The notion of building a bridge between clinic and community, though an ironically antiquated idea in the face of cutting edge, genome-discovering technology, seemed to infect a convention that made no attempt to ignore or placate the redoubtable problem at hand. And in a conference that constructed many small bridges between questions and answers, the one linking behavior to dissemination effectiveness seemed the Golden Gate of the bunch.

“Of the many disciplines we [the UCLA Medical School] collaborate with, anthropology and behavioral studies have very useful theoretical models of behavioral change,” said Carol Mangione, University of California, Los Angeles. Ken Resnicow, University of Michigan, grabbed this suggestion and took off running.

“Behavior specialists have created the most effective obesity interventions,” he said, likely because the “origins of obesity are largely social and behavioral.”

” ‘To treat malaria, go to a physician. To prevent it, consult a mosquito controller,’ ” he metaphorically quoted. Resnicow went so far as to impugn the current treatment paradigm: “The medical profession has been designated as the primary gatekeepers of this [obesity] epidemic … while behavioral and nutritional professionals have largely been secondary resources. Given the behavioral origins of the condition, perhaps we should reconsider.”

Such a paradigm shift “would require a greater focus on the underlying behavioral and psychological causes, as well as alteration for how the public perceives the role of behavioral and psychological professions. … Perhaps we should recast obesity as a behavioral rather than medical condition, flip the nexus of care to behavioral professionals.”

The problems seemed to pass through solutions only to arrive at another problem. But to many, this meant there was inevitably a new solution, however fleeting, and each new complication did not defeat, but rather aroused an added sense of obligation. “Society has given us this power,” said Frank Vinicor, CDC. “We have got to get more involved.”

At the conference’s denouement, Kington reiterated that it might take the involvement of entire network to alter the infrastructure of clinical research so that it’s more receptive to translation. NIH proposed to create clinical research teams, which will include clinicians, statisticians, health educators, economists, psychologists, and members from the public and the industry. This way, “we won’t have to re-invent the wheel every time we have a new problem to address.”

Perhaps this nationwide, inter-disciplinary bridge will provide the concrete answer so long sought, and then there will be time to focus on the conference’s most elusive mystery – the origin of Red’s nickname.

Presentations from the conference are available in PDF format at www.niddk.nih.gov/fund/other/Diabetes-Translation/presentations.htm.