CHAPTER 7: RESEARCH AND DEVELOPMENT
Attracting Mainstream Investigators
7.68 Training CAM practitioners in research will
undoubtedly increase research activity in this area, but this
will take time. An alternative approach would be to attract mainstream
investigators into CAM research. This has several advantages:
firstly, there would be no time-lag; secondly, such individuals
would bring their experience and expertise to this difficult area;
and thirdly, such a development could establish links between
the conventional and complementary sectors, increasing mutual
understanding.
7.69 NCCAM in the United States has been successful
in attracting mainstream investigators to address some of the
research priorities. The Center's Director, Dr Stephen Straus,
who himself is an eminent and successful mainstream scientist,
told us: "The more immediately successful route is to seduce
your best scientists to join the enterprise, by funding them to
work in areas they are already expert in and, perhaps, inherently
interested in as well. Our largest funding has been going to our
best mainstream investigators. We also need to bring complementary
and alternative medicine experts and practitioners into this.
That is hard because — except for some very isolated
aspects within the chiropractic and the acupuncture communities
in the United States and some experts in botanicals — there
is not a research tradition in those communities" (Q 1734).
7.70 The MRC were also enthusiastic about this approach
to kick-starting CAM research. Professor Sir George Radda, Chief
Executive of the MRC, told us: "The first and, perhaps, most
critical thing is that we do have a number of very distinguished
people who are, if you like, part of the Medical Research Council
who actually take complementary medicine seriously and who are
interested in taking it forward in some way. Professor Tom Meade,
of course, has done one of the pioneering studies on back pain
and chiropractic. We have a number of other scientists who have
served on various committees that are concerned with complementary
medicine…I think people are interested in making sure that
not only do we contribute to the debate but that we will be able
to do something serious about making sure that the way complementary
medicine is used is effective and well-researched" (QQ 1085
& 1086).
7.71 Sir George also explained how the MRC may be
able to aid such associations: "We do have the mechanism
to encourage those sorts of collaborations. For example we have
had, for three years, the co-operative grant system where we encourage
people to tackle individual major problems in a way that different
scientists can contribute different aspects to that. It would
be perfectly reasonable, for example in a co-operative on asthma,
to include a component grant application from somebody who wants
to develop a study on the use of complementary medicine in asthma,
and it would actually then be done in the context of what else
is going on in the way of research in asthma, rather than as an
isolated project which, perhaps, would not stand up in the long
run" (Q 1087).
Research Funding Sources
7.72 Funding for healthcare research, including CAM,
is available from a variety of sources. These include:
(i) the Government
(ii) the medical research charities
(iii) commercial and industrial sources
7.73 We have considered the prospects for CAM research
under each of these options in turn.
The Government
7.74 In their written evidence the Department of
Health explained that the Government supports health research
in the United Kingdom through a number of routes outlined in Box
11. The Government were keen to emphasis that CAM projects may
stand a better chance of funding if they come in under areas that
the Department of Health are making a priority. Professor Sir
John Pattison, Director of NHS Research & Development, told
us: "I think the Government has set some challenging priorities
for R&D and granted some extra resources for that - but it
is in specific areas such as cancer, mental health, cardiovascular
disease and coronary heart disease in particular, and the elderly
and children. It would be in those areas that we would particularly
welcome and look at proposals for complementary and alternative
approaches. Just as an example, we are about to fund a study of
reflexology in patients after surgery for early breast cancer.
I think that reflects that there are opportunities for CAM professionals
and practitioners to come through with proposals to get funded
through our systems" (Q 1866).
Box 11
Government Funding Options
— Medical Research Council.
— Department of Health 'Policy Research Programme' (PRP) - This aims to provide a knowledge base for health services policy. PRP has supported two CAM research projects through the Sheffield University Medical Research Unit.
— NHS Research and Development Levy - Money is allocated following evaluation of bids competing against national criteria. In April 1998 £360 million was allocated in the form of three- year funding arrangements. One CAM bid was successful in April 1998 and received funding of £61,650 for its first year.
— NHS Executive Research and Development Programme - Work is commissioned directly from Universities on behalf of the NHS. There are three main national programmes run under this budget: the Health Technology Assessment Programme, the New and Emerging Applications of Technology Programme and the Service and Delivery Organisation Programme.
— Methodology Programme - Supports all the other programmes by commissioning research into methodology. Several projects of relevance to CAM research (although not directed solely at CAM research) have emerged from this programme.
— Research funded by NHS Regions - Regions can identify their own priorities 12 CAM projects have been successful in obtaining funding through this route.
— Higher Education Funding Councils grants to universities - For those researchers based in academic institutions.
Source: Department of Health written evidence (P 101)
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The Medical Research Charities
7.75 The structure of the medical research charities
means that CAM is often in a difficult position to compete for
their funds. The AMRC point out that "Most medical charities
spend the greater part of their money on understanding the mechanisms
of disease, not efficacy. Usually, efficacy is a smaller part
of the work of medical charities" (Q 1198). They also explained
that as most medical charities are relatively small and only focus
on one or two specific disease areas, it is relatively difficult
for them to participate in large-scale, non-disease-specific research
funding, which is the usual nature of CAM research. "In this
field very few medical charities are general charities. Very little
CAM research would be disease-specific. If most of the smaller
charities are disease-specific the research simply does not fit"(Q
1176). One important exception is the Wellcome Trust which, like
the MRC, will fund research in any area of medical science.
7.76 Currently the AMRC has no plans for special
initiatives into CAM: "We are feeling our way as to the role
in CAM that might be played by AMRC. AMRC does not have any of
its own funding for research. Therefore, the Association is a
facilitator in helping charities to spend their money as effectively
and in as targeted a way as they can. What we will do is probably
take the first step by establishing a special interest group within
AMRC to look at CAM research…For it to work it is very important
for AMRC to work with the professional body concerned…Partnership
with the professional body is important and must be developed
in CAMs" (Q 1175).
7.77 As another example of the perceived need for
more research into CAM accessed by their patients, the Arthritis
Research Campaign has developed an initiative to encourage more
CAM proposals with an appropriate assessment mechanism to ensure
these will address relevant questions with high-quality proposals.
7.78 There are some small charities dedicated to
CAM but, as the RCCM told us, they rarely have the resources to
fund research: "Smaller charities - and we are one of them
- in the health arena almost always focus not on research but
on support for clinics or disadvantaged groups" (Q 117).
Commercial and Industrial Companies
7.79 For much of conventional medicine it is the
large pharmaceutical companies which fund clinical trials. However,
in CAM there is very little industry-based research. This is mainly
because many CAM remedies are natural products which cannot be
patented, and hence companies that research them cannot guarantee
that they will benefit financially from the research. Dr Stephen
Straus, Director of NCCAM in the USA, explained the situation
he has encountered with industry: "There is woefully little
investment on the part of private industry. They have yet to discern
that there is a financial advantage for them to do so…I am
attempting to encourage them to help invest in studies of the
effectiveness of their products as well. By and large, they are
not doing so" (Q 1712).
7.80 The Wellcome Trust pointed out that, despite
the lack of patents on CAM products, industry does make substantial
profits in this area, and Wellcome's view is that some of this
should be ploughed back into research and development. We agree.
They told us: "One interesting matter referred to by Dr Mike
Dexter, the Director of the Trust, in his introduction to a workshop
on CAM run by the Trust, was an article in The Times just
prior to that meeting on 2 March which suggested that £500
million in the United Kingdom was spent on complementary health
products. The pharmaceutical industry would spend some 25 to 28
per cent of the money from sales of conventional medicines on
research and development. Therefore, one might think that in CAM
health products perhaps £150 million a year could be spent
on research and development" (Q 1136). With no patent protection
available for most of CAM such figures may not be easily obtainable
in this area. Nevertheless it should be noted that a Research
and Development budget of 5% of commercial turnover on CAM products,
if this is indeed £500m per annum, would yield £25m
per annum. They also suggested that a new regulatory framework
for CAM products might encourage industry to invest in the area:
"Legislation such as regulations governing pharmaceutical
products would help to promote research into CAM products. Of
the three major funders of biomedical research in the United Kingdom
in conventional medicine, the pharmaceutical industry is by far
the biggest supporter. The Government and charities come lower
down the list. We believe that perhaps a look at the legislation
and regulation of these products may also have a safety spin-off
but also release money for further research and development"
(Q 1136).
7.81 We therefore recommend that companies producing
products used in CAM should invest more heavily in research and
development.
Pump-Priming and Ring-Fencing
7.82 One method of kick-starting research into CAM
is to pump-prime or ring-fence research funds. Ring-fenced funds
are funds specifically directed into a defined area of research,
and are awarded to applications from that area without having
to compete with applications submitted from other areas. Pump-priming
differs from ring-fencing in that funds are only dedicated to
the area for a limited period of time to help develop the infrastructure
needed to underpin substantial high-quality research which will
then attract more substantial funds.
7.83 The issue of ring-fencing and pump-priming is
controversial and the views of our witnesses on this subject were
polarised. Several witnesses suggested that without ring-fencing
or pump-priming, the research infrastructure for CAM will remain
poor, and that bias and lack of expertise (see 5.38 above)
on behalf of research proposal referees will continue to prevent
grants being awarded in the area, with the result that CAM research
will never be adequately supported. However the alternative view,
articulated by several other witnesses, is that ring-fencing and
pump-priming are inherently unfair, and that research proposals
should all be considered on merit. It is further argued that,
by designating funds for a specific area, many problems may arise
largely due to an imperative to spend funds on research irrespective
of its quality or importance.
THE LESSONS OF NCCAM
7.84 Research funds have been ring-fenced for CAM
in other countries, most notably in the USA, where NCCAM received
$70 million this year and expects to receive funding of between
$80 and $100 million next year (Q 1712). This, however, represents
less than 5% of the total budget of the NIH. The history and experience
of NCCAM confirms the possible beneficial effects of ring-fencing
of research funds in this area.
7.85 NCCAM was only established in 1999: it was preceded
by the Office of Alternative Medicine which was set up in 1992.
In the first few years of the Office of Alternative Medicine,
funding was much lower than that which NCCAM receives and the
success of that office in generating good quality research was
perceived to be poor. For example, the Academy of Medical Sciences
told us that the office had run into serious problems, as many
of its research grants resulted in papers being written that were
not published or were not published in reputable peer-reviewed
journals; hence, they argue against ring-fencing. We asked Dr
Stephen Straus to comment on these failures and on the history
of his Center: "The first ring-fenced funding, as it were,
for complementary and alternative medicine began in 1992, with
an allocation of $2m to the then Office of Alternative Medicine,
which was in the office of the Director of the NIH. The attempt
was for that small office to attempt to leverage those funds and
convince the other Institutes to increase their support. The office
also funded a number of very small projects. The average funding
for each of those projects was about £20,000 (i.e. $30,000),
which is somewhat less than one-tenth of the usual size of an
NIH grant. It was not surprising that that amount of funding yielded
very little in the way of powerful science" (Q 1718).
7.86 However, he said that now NCCAM's increased
funding and experience means that they are able to conduct reputable
trials: "I would say the best opportunity we have had is
to have the independent authority to issue grants at the standing
NIH level. We believe we are investing in the kind of research
now that will be in the best journals. I would be stunned if our
study of St John's Wort, that has just recently completed
enrolment, would not be accepted in, perhaps, the British Medical
Journal. Frankly, I would be, personally, gravely disappointed
if we do not do far better" (Q 1718).
7.87 Dr Straus went on to elaborate on how NCCAM
had managed to improve the quality of its research. "There
were approximately 40 small grants given from the Office of Alternative
Medicine in its first few years. With the creation of NCCAM in
early 1999 several things were done. First of all, we have invested
in creating research capacity, by funding eleven centres to date.
Two of the centres fund botanical research. We are funding nine
centres around different diseases and conditions. Each of those
centres is funded with $1.5 million a year for five years. We
are developing research capacity through those centres. We have
called for and are now beginning to fund, for the first time,
major research, training and curriculum programmes in institutions
around the United States. We are attempting to inspire young individuals
who seek careers in research to enter the research area within
complementary and alternative medicine by working under the mentorship
of outstanding investigators. We are funding approximately 80
grant applications at this point, averaging about $250,000 to
$300,000 each. We are funding five large, multi-centre, placebo-controlled,
randomised clinical trials. Our first large studies will not be
completed for little under a year. Our small developmental projects
are now entering their second year. It is still premature to know
what our funding has bought. We have encouraged very good people
to join our enterprise" (Q 1719).
7.88 Dr Straus acknowledged that ring-fenced funding
is always a controversial matter in science: "At the NIH
we believe, as you do here in the MRC and other leading research
funding authorities, the best science is investigator-initiated
application submitted by the best individuals in pursuit of the
best ideas" (Q 1712).
7.89 However, he also told us that "The funding
at the NIH, which this year totals nearly $18 billion is, in many
regards, entirely ring-fenced in that it is allocated and apportioned
to institutes on the basis of the perceived public health needs
in those areas…Our funding is ring-fenced in the broadest
sense. It is in pursuit of a broad field and a broad set of ideas"
(Q 1712).
7.90 Dr Straus explained the advantages of ring-fenced
funding at NCCAM, including the fact that the money does not have
to be used just to fund particular projects but can be used to
strengthen the research infrastructure: "We have the ability
within NCCAM to target our resources in pursuit of the best opportunities.
We are building a research infrastructure and capacity by funding
centres. These are things the other Institutes would not tend
to do for complementary and alternative medicine. We are funding
research training and curriculum development from pre-doctoral
through career awards. We could invest in areas that are still
scientifically unformed but which are matters that are still very
much in the public interest. As you know, homeopathy is less well-established
in the United States than it is here. We do not have the equivalent
of the NHS homeopathy hospitals. We have the ability to fund research.
Through the peer review process, which manages all of our grants
and applications, we attempt to select the best. It is ring-fenced,
in a sense, but it is in response to public need" (Q 1712).
7.91 He went on to elaborate upon how NCCAM decide
which applications to fund and explained that scientific merit
is considered as one of several important factors: "[Judgements
are] made on scientific grounds, while being conscious of the
imperatives that we have. Let me explain further. The applications
that are received are peer-reviewed, as all applications are to
the NIH. They are scored accordingly. It is my responsibility
to meet with an advisory council three times a year to review
the applications and the scores they receive. My council can,
in their best judgement, not change the scoring, but they could
say "although this had an average score we feel this is a
very important area, or a less important area" (Q 1716).
In other words, they can prioritise to an extent.
7.92 Dr Straus also explained how he believed the
NIH managed to avoid ring-fencing distorting the overall priorities
of health research: "Over the past decades public advocacy
has grown in strength and impact…Every important condition
has its advocacy organisations that are calling for support for
their work. To some extent, there is an equalisation through the
process. The US Congress responds to calls on the part of the
public, but also to our testimony and our best judgements as scientists
as to where the opportunities are greatest and investments are
most likely to prove profitable. There is a danger that if that
was the only mechanism by which large funding decisions would
be made, then there would be a distortion. Fortunately, that is
not the only mechanism. Even within that mechanism those are general
guidelines. The NIH is still able to fund the very best peer review
research" (Q 1714).
ATTITUDE OF UK RESEARCH FUNDING
BODIES
7.93 The issue of ring-fenced funds has been raised
as a means of boosting CAM funding in the United Kingdom in several
submissions. Professor Edzard Ernst, who holds the CAM Chair at
Exeter University (P 229), points out that ring-fencing has been
very successful in other countries (e.g. Germany and the USA)
and could be encouraged by the NHS, the MRC, Primary Care Groups
and Trusts, and industry. However our discussions with the main
research funding institutions in the United Kingdom reveal little
enthusiasm for ring-fenced funding for CAM research.
7.94 The MRC do not believe that they should ring-fence
funds for CAM. They told us that they intend to continue to judge
CAM grant applications by merit in competition with all other
grant applications: "The MRC believes that there is no justification
for a different approach to research into complementary therapies
compared to conventional therapies. At present, there is generally
insufficient evidence to prioritise within or between evaluations
of conventional and complementary therapies. In the absence of
well-developed research proposals, we therefore consider the case
for increased research funding for CAM has not been made. Nevertheless,
the MRC will continue to welcome applications for support to evaluate
complementary therapies. These will be judged case-by-case on
their own merits, in competition with other calls on MRC's funds"
(P 139).
7.95 One of the MRC's main arguments against ring-fencing
funds for CAM is that, given that one of the main problems within
CAM is the poor quality of CAM research proposals, ring-fencing
might lead only to more poor quality research. They suggest that
there are better alternatives to ring-fencing to improve CAM research:
"Throwing money at bad science does not help anybody. So
I am not for ring-fencing. Whether one should have an initiative,
or if encouragement is sufficient, I do not know. In view of what
we hear, that the research capacity is not there yet, it seems
to me that you need to start training and you need to start getting
people who themselves would like to do research in complementary
medicine to acquire good research training. That is, train people
in statistical aspects of medicine and train people in how to
evaluate evidence and so on. Then we could, perhaps, build on
that (Q 1095). It is a chicken and egg situation and I believe
that people have to come first before you can do the research.
You need to target individuals who can do research and say to
them: 'this looks now an important enough issue: could you put
together a proposal?' That is one way of bringing in the practitioners
of complementary medicine as part of such a proposal. That they
can, through an individual like Professor Meade, learn how to
do this sort of research" (Q 1097).
7.96 Although the MRC were against ring-fencing,
they were not against prioritising certain research areas: "…If
you say that there are some very, very urgent problems which require
proper scientific study that lead to a long-term solution, I am
sure we would be very willing to consider it. If it is a matter
of comparing one treatment with another, that is more a Health
Department issue. With that proviso, there is no reason why we
could not respond if there was a real demand from the medical,
scientific, or whatever, community for something like that"
(Q 1099).
7.97 The Department of Health told us that they also
believe that CAM research must be considered on the same basis
as conventional research: "The Government views research
into CAM in the same light as that into all other branches of
medical practice" (P 113).
7.98 The Department of Health fund research through
several different programmes and organisational structures (as
reviewed in Box 11) and some of these mechanisms allow the setting
of priorities: "Priorities for R&D are set from time
to time to take account of Ministerial priorities and priorities
for health and social care, and CAM research is considered as
part of this" (P 114). They did describe one time-limited
funding programme that had resulted in some CAM research: "The
National Cancer Programme contained a specific priority on the
comparison of cost-effectiveness of different psychosocial interventions,
including CAM therapies. One CAM project was funded: a randomised
controlled study of the effects of reflexology on mood, adjustment,
quality of life and patient satisfaction" (P 113). There
is also scope for prioritisation within local NHS R&D budgets:
"Regional R&D budgets are intended to allow Regions to
identify and support local priorities and build research capacity.
As part of a Commissioned Research Initiative, South West Region
issued a specific call for proposals in May 1996 into: Which specific
CAM therapies are effective for which conditions? Which specific
conditions may benefit from CAM? What are the resource and other
consequences on the NHS where CAM is not provided or used? As
a result of this call, two projects were funded: a project - now
complete - to evaluate the effectiveness of acupuncture in defined
aspects of stroke recovery (£179,903), and a multi-centre
study of acupuncture for tension headaches (£22,169)"
(P 113).
7.99 As discussed in paragraph 6.81 Professor Sir
John Pattison, Director of NHS Research & Development, and
Yvette Cooper MP, Parliamentary Under Secretary of State for Public
Health, both encouraged CAM proposals to try to come in under
current NHS initiatives, such as those prioritising cancer research.
However, despite these limited initiatives, the general position
of the Department of Health is not one that favours ring-fencing
or pump-priming: "Within the NHS R&D programme there
has been relatively little ring-fencing in any area. The arguments
against ring-fencing are robust. I believe that it would imply
a dual standard and at the end of the day there must be research
that is robust enough to give clear answers, By relaxing the standards
of rigour it is too easy to make research investments that do
not pay off" (Q 5).
7.100 We also talked to non-governmental bodies about
their attitudes to dedicated funding. The Wellcome Trust told
us that, despite their recent conference on CAM and their belief
that it is an important area: "CAM research is not ring-fenced,
and it is probably our policy not to do that" (Q 1104). Although
in the past Wellcome did ring-fence, they explained that "we
now go for open competition and try to reduce the number of schemes
that we fund by bringing them together so that all who apply have
an equal opportunity" (Q 1104). The Trust do have some directly-managed
initiatives, for example on genomes, but they saw this as an unlikely
prospect for CAM (Q 1168).
7.101 The AMRC explained why they did not believe
that ring-fencing was an option for medical charities: "We
would resist the idea of any medical research charity being perhaps
forced to ring-fence money for a particular speciality. In a way,
that money is already ring-fenced for specialities or diseases.
That is not a comment on the need or not for Government to ring-fence;
it is a fact of life for charities" (Q 1194).
7.102 It is our opinion that despite the Department
of Health and the MRC's reservations about dedicating funding,
something must be done to build up the research capacity in CAM;
otherwise the poor state of research and development in this area
will continue. The lessons of NCCAM in the USA show that, if funds
are there, experienced researchers will apply for them, and with
sufficient investment high-quality CAM research can be achieved.
NCCAM's annual budget is about $68.4m: this is 0.4% of the total
budget of the NIH. Without dedicated funds, CAM will struggle
to attract high-quality researchers and it will be hard to build
the infrastructure for the research that needs to be done in this
area to protect the public. In our opinion it will not be long
before CAM research will be able to compete against other bids
for funds in a way that it cannot currently do. We recommend
that the NHS R&D directorate and the MRC should pump-prime
this area with dedicated research funding in order to create a
few centres of excellence for conducting CAM research, integrated
with research into conventional healthcare. This will also help
to promote research leadership and an evaluative research culture
in CAM. Such funds should support research training fellowships
and a limited number of high-quality research projects. This initiative
should be sufficient to attract high-quality researchers and to
enable get them both to carry out large-scale studies and to continue
to train CAM researchers in this area within a multi-disciplinary
environment. We believe ten years would be sufficient for the
pump-priming initiative as, for example, in the case of some MRC
programme grants and various training and career development awards
available in conventional medicine. The Association of Medical
Research Charities may also like to follow this example.
Co-ordinating the Development
of CAM Research
7.103 The discussions in this chapter show that there
are many issues to take into account when considering how to increase
research into CAM. Several of our witnesses have suggested the
need for a co-ordinating body to promote research in this area.
For example Dr Howard Scarffe of the Wellcome Trust felt it may
be sensible to have an "over-arching organisation to co-ordinate
research strategy" (Q 1136). He went on to suggest that "the
Foundation for Integrated Medicine may possibly be an appropriate
organisation to assume that role" (Q 1136).
7.104 A body of this sort could take on various roles
to aid CAM research:
(i) To act as an advice centre on where to
gain research funding;
(ii) To advertise funding programmes;
(iii) To act as an information centre on research
training opportunities and to advertise specific opportunities
in this area;
(iv) To advise on drafting grant applications;
(v) To disseminate research findings and co-ordinate
research strategies.
7.105 FIM told us: "I think our central role
at the Foundation in relation to research is very much encouraging
others to do it. That might involve the Government, it might involve
the Wellcome Trust; it certainly does involve the research charities
which are responsible for nearly £500 million of research,
so we see our role as very much one of influencing and helping.
Part of that may involve us directly funding some research; we
do have a small research programme ourselves but it needs to be
seen within that wider context" (Q 93). FIM are currently
drafting a national strategy for CAM research.
7.106 The RCCM also believe that there is a need
for a national strategy for CAM research. "Given the public
and professional interest in complementary and alternative medicine,
a co-ordinated strategy supported by public funds requires careful
consideration and debate (Q114)… In the absence of a comparable
R&D infrastructure, CAMs do not have a national strategy,
so any research will be carried out in isolation, will be ad hoc
and will not address key priorities. So we feel that a national
strategy is required" (Q 118). They believe that this national
strategy should be "developed and co-ordinated by a body
that is independent of but accountable to Government. It should
have relevant and appropriate multi-disciplinary representation
from both the CAM field and the conventional field, and appropriate
representation from health service researchers, and there is a
current debate in NHS R&D around a lack of good health service
researchers. It should be chaired, or led, by someone who is impartial
and not immersed in a particular tradition, and it should establish
priorities for CAM research, perhaps through a consensus approach
drawing on the multi-disciplinary field. It should commission,
fund and monitor CAM research including the quality of the research
that it is commissioning" (Q 352).
7.107 To maintain impartiality and fairness, but
not at the expense of quality, FIM is in a particularly strong
position to take on these tasks with resourcing from the Government
and possibly the charitable sector. Joint research between different
grant-awarding bodies is gaining acceptance in the United Kingdom
and therefore we see no reason why, with appropriate safeguards
and accountability in place, the Research Councils and the Department
of Health could not drive forward CAM research by operating in
this way, rather than by simply awarding individual grants. There
already exist examples of such mechanisms in the concordat that
the MRC and the Department of Health have developed for joint
working, and the joint initiatives between the United Kingdom
Government and the Wellcome Trust in the Joint Infrastructure
Fund and Joint Proposal Funding Initiative.
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