Medical School Hotline

Introduction

In 2009, Salefu Tuvalu, a high school senior from the tight-knit community of American Samoa, traveled to Honolulu to begin an eight-week summer research internship at the University of Hawai‘i John A. Burns School of Medicine. For Salefu, this was a big step into the unknown. She was one of 75 interns selected nationwide to enroll in the NIH/NIDDK STEP-UP (National Institutes of Health/National Institute of Diabetes, Digestive, and Kidney Diseases/Short Term Education Program for Underrepresented Persons) Program (http://stepup.niddk.nih.gov). In that year, two American Samoa students received their research training in laboratories at the John A. Burns School of Medicine, JABSOM (http://209.18.84.241/stories/nih_stepup.php). That summer, Salefu presented her research on the molecular pathogenesis of West Nile Virus at NIH in Washington, DC. The following year, she spent the summer at the NIDDK laboratory in Phoenix, AZ, to investigate the genetics of diabetes in American Indian communities. These experiences were transformative, with an enormous boost of self-confidence. Salefu's goal is to be the first American Samoan scientist at NIH. For her, this was a complete change in perspective and outlook. Just two years ago Salefu had questioned that a nationally run program such as STEP-UP is really intended to benefit students like herself in the remote corners of the Pacific.

In 2010, three high school students from Hana, Maui and from Moloka‘i, all of Native Hawaiian descent, followed the same path to JABSOM. They were not the first STEP-UP students from Hawai‘i. Since 2005, students from each of the Hawaiian Islands spent their summers at JABSOM, with all their travel and living expenses sponsored by STEP-UP. During the 2011 summer, ten high school students each from Hawai‘i, American Samoa, and Guam, together with seven students from the Commonwealth of the Northern Mariana Islands (CNMI), will be research interns under the STEP-UP Program directed by UH JABSOM. Eyes are now set on enrolling students in the program in 2012 from the remaining Pacific communities associated with the United States (ie, The Freely Associated States of Micronesia (FSM), the Republic of Palau, and the Marshall Islands). With these communities coming online, the STEP-UP Program will cover the entire US affiliated communities in the Pacific. These island communities span a geographical area equivalent to the entire continental US.

The STEP-UP Program

Annually, STEP-UP selects from throughout the nation, 75 students from approximately 300 qualified applications to be trained in research laboratories over an 8-week period. Stipends and travel expenses are provided. The typical STEP-UP intern is 16 to 18 year old, who has very little knowledge of what a career in medical research entails, other than perhaps those portrayed in television series in episodes such as the CSI. The common elements in their STEP-UP applications' Personal Statements are a sense of curiosity in medicine and ideas of the ways that modern medicine can make a positive difference in their families and communities. Most importantly, the youngsters see themselves becoming part of the solution, as future “doctors” finding cures for those diseases that they have known all their lives. These are the key ingredients needed to help them excel in the 8-week intensive research internship. With little basic science knowledge, the students typically face a steep learning curve. Ironically, the big hurdle for them is usually not the amount of subject matter materials and laboratory techniques that they have to master but the feeling of intimidation as they are transplanted from the comforts of home and classrooms into research facilities crammed with a jungle of laboratory equipment. Much patience is demanded from the interns' research mentors who are University and JABSOM faculty members accustomed to the fast-paced and sophisticated research in an academic environment. These mentors are all volunteers for the STEP-UP program. They donate their precious time and efforts to coach these young interns through every step of scientific investigations. The mentors' challenge is to teach cutting-edge research at a level that a high school student can comprehend.

At NIH, Washington, DC, STEP-UP interns from the many parts of the nation meet each year to present their research projects. Senior NIH staff scientists have often commented that the level of maturity and sophistication demonstrated by the STEP-UP interns equals that of their own graduate students. They all agree that the enthusiasm radiated by these young interns in their own research projects is unmatched by anyone on NIH campus, including postdoctoral fellows.

High School STEP-UP: Past, Present, & Future

The NIH/NIDDK STEP-UP program was launched in 1994 as the National High School Student Summer Research Apprenticeship Program. The Program was the brainchild of Dr. Lawrence Agodoa at the Office of Minority Health Research Coordination, NIDDK. The rationale for the STEP-UP stemmed from NIDDK's Strategic Plan to address health disparity among minority and disadvantaged populations in the US that bear a disproportionate burden of major severe and costly diseases (http://www.healthypeople.gov/2020/about/disparitiesAbout.aspx) (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497467/pdf/12500958.pdf). It was recognized that to address health disparities, a workforce of health professionals and researchers who are culturally competent and sensitive to the needs of the minority and disadvantaged community is vital to success (Strategy II.C in http://minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_complete.pdf). f It was believed that the most efficient and effective means to alleviate health disparity would be to produce or expand the healthcare workforce within the affected populations/communities. The strategy then was to establish a pipeline of such individuals with career goals in healthcare and medical research, and provide them with the necessary support and tools to succeed. There is no argument that such pipelines should extend from the earliest possible age groups and continue beyond post-graduate education. STEP-UP's mission is to perform outreach and provide biomedical research experience to targeted populations at the earliest possible, and logistically feasible, educational levels. High school students over the age of 16 would “fit the bill.” Since its inception, STEP-UP has recruited close to one thousand high school students (11th and 12th graders) nationwide and has given each student a hands-on research internship experience under the tutelage and mentorship of a research scientist. A recent survey of STEP-UP graduates from the past four years revealed that the majority (>90%) pursued a biomedical science degree in college. A longer follow-up period will be necessary to determine if they will eventually be part of the healthcare and research professional workforce upon graduation.

The NIDDK STEP-UP has not gone unnoticed within NIH. In the past year, several initiatives similar to STEP-UP were issued as Requests for Applications (RFAs) by other Institutes and Centers (ICs) within NIH. For example, the National Institute of Allergy and Infectious Diseases (NIAID) Science Education Awards (http://grants.nih.gov/grants/guide/pa-files/PAR-11-086.html) and the National Institute on Minority Health and Health Disparities (NIMHD) Science Education Initiatives (http://www.nimhd.nih.gov/hdss/nimhd_SE_initiative.html) were launched to support research training at the high school level. The training programs that these new initiatives support are locally focused and do not establish a national network/program. Only some of these initiatives have a focus on minority populations. Nevertheless, they will significantly contribute to expand the pool of young students suitable to contribute to the pipeline of medical researchers.

Plans for the Pacific

Prior to 2009, the furthest geographical reach of the STEP-UP program in the Pacific was Hawai‘i. Most STEP-UP interns were from the continental US. The US-affiliated communities of American Samoa, Guam, the Commonwealth of Northern Mariana Islands (CNMI), Federated States of Micronesia (FSM), the Republic of Palau, and the Marshall Islands did not participate. This omission may have stemmed from the sheer physical distance and isolation of these small islands from Washington, DC, compounded by the often sparse and disruptive nature of electronic communications. Timing was just right when the oversight was noted by Senator Daniel K Inouye and brought ito the attention of Dr. Agodoa and the Institute Director of NIDDK, Dr. Griffin Rodgers, as Congress and President Obama issued the America Recovery and Reinvestment Act (ARRA). ARRA funds were released to JABSOM to support STEP-UP activities that would cover the entire Pacific region.

Potentially facing similar logistical challenges, the JABSOM directed Pacific STEP-UP project launched its activities in American Samoa. This was possible because the initial steps were facilitated by JABSOM's AHEC (Allied Health Education Centers) which had established groundwork in high schools to raise awareness and interests in health related careers. Guam and CNMI soon followed as STEP-UP gained credibility. At each locale, STEP-UP sought collaborations from local colleges, Departments of Education, and Departments of Health. These groups were encouraged to form partnerships, participate, and support research training. This approach has been a key factor in the receptiveness and success of STEP-UP because it promotes a sense of ownership and responsibility in line with the core mission. Completing the Pacific STEP-UP network will be the Freely Associated States of Micronesia (FSM). Historically, JABSOM has had a strong presence here, with the establishment of the Pacific Island Health Officers Association (PIHOA) in the 1960s. With the help of Dr. Gregory Dever from PIHOA, STEP-UP has been enthusiastically welcomed by island health administrators and educators.

For these and most island communities, an alternate approach is being tried. Because of the scarcity of biomedical research infrastructures and budget constraints that prohibit bringing all students to JABSOM to receive training, research training laboratories are being established at the local community colleges. The plan is to enable local faculty mentors to adopt and incorporate molecular techniques in their STEP-UP interns' research projects. Much of the needed research equipment is being donated from NIH's surplus equipment warehouse. It is envisioned that this resource will be available to support future equipment needs for STEP-UP training. Workshops are being conducted by JABSOM faculty and staff at the local colleges to familiarize potential STEP-UP mentors with lab equipment operations and the proper research techniques. With appropriate and adequate support from the local government, it is envisioned that these research-training facilities will become self-sustaining.

Conclusion

With its modest budget of just under $170,000/year to support a handful of students from each Pacific region, one could argue that STEP-UP in the Pacific may be seen as just a symbolic gesture. But on another measure, if STEP-UP can ignite a spark in the life of just one Pacific Islander like Salefu Tuvalu by opening the door to the many possibilities of medical sciences and research, and in doing so win over the support of the local government for STEP-UP's missions, it may just be the nucleus needed to grow the next generation of medical scientists.