Bøger udgivet af National Academies Press

Research and innovation in the life sciences is driving rapid growth in agriculture, biomedical science, information science and computing, energy, and other sectors of the U.S. economy. This economic activity, conceptually referred to as the bioeconomy, presents many opportunities to create jobs, improve the quality of life, and continue to drive economic growth. While the United States has been a leader in advancements in the biological sciences, other countries are also actively investing in and expanding their capabilities in this area. Maintaining competitiveness in the bioeconomy is key to maintaining the economic health and security of the United States and other nations. Safeguarding the Bioeconomy evaluates preexisting and potential approaches for assessing the value of the bioeconomy and identifies intangible assets not sufficiently captured or that are missing from U.S. assessments. This study considers strategies for safeguarding and sustaining the economic activity driven by research and innovation in the life sciences. It also presents ideas for horizon scanning mechanisms to identify new technologies, markets, and data sources that have the potential to drive future development of the bioeconomy.

On September 16, 2019, the Roundtable on Obesity Solutions of the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine, held a public workshop, Advancing Effective Obesity Communications, in Washington, DC. The workshop explored effective communication of obesity-related issues by providing an overview of the current communications environment and addressing the complexity of identifying key audiences and developing targeted messages. Speakers discussed communications strategies to reach specific intermediary audiences, such as the public, decision makers, and policy makers. The workshop also explored challenges in communicating about obesity issues, which include aligning the intended meaning of messages with an individual's perception of and response to those messages, addressing obesity bias and stigma through communications, and addressing misinformation. This publication summarizes the presentations and discussions that occurred at the workshop.

In November 2018, National Academy of Sciences (NAS) President Marcia McNutt visited China for the first time in her official role. As part of this visit, the National Academies of Sciences, Engineering, and Medicine's Science and Technology for Sustainability (STS) program and the Chinese Academy of Sciences organized a one-day workshop relating to urban sustainability in Beijing. The goal of the visit was to begin to explore some areas where the U.S. National Academies and the Chinese Academy might develop collaboration. At the same time, the trip provided an opportunity to develop links to other parts of the science and technology community in China. To further elucidate some of these issues and build upon current partnerships, an expert committee under the STS program, in collaboration with the Chinese Academy of Sciences, organized a one-day public workshop on urban sustainability in China and the United States, held on December 16, 2019. The workshop focused on the intersection of urban climate change mitigation and adaptation, urban health, and sustainable transportation, including green infrastructure and urban flooding in both countries. This publication summarizes the presentations and discussions from the workshop.

Temporomandibular disorders (TMDs), are a set of more than 30 health disorders associated with both the temporomandibular joints and the muscles and tissues of the jaw. TMDs have a range of causes and often co-occur with a number of overlapping medical conditions, including headaches, fibromyalgia, back pain and irritable bowel syndrome. TMDs can be transient or long-lasting and may be associated with problems that range from an occasional click of the jaw to severe chronic pain involving the entire orofacial region. Everyday activities, including eating and talking, are often difficult for people with TMDs, and many of them suffer with severe chronic pain due to this condition. Common social activities that most people take for granted, such as smiling, laughing, and kissing, can become unbearable. This dysfunction and pain, and its associated suffering, take a terrible toll on affected individuals, their families, and their friends. Individuals with TMDs often feel stigmatized and invalidated in their experiences by their family, friends, and, often, the health care community. Misjudgments and a failure to understand the nature and depths of TMDs can have severe consequences -- more pain and more suffering -- for individuals, their families and our society. Temporomandibular Disorders: Priorities for Research and Care calls on a number of stakeholders -- across medicine, dentistry, and other fields -- to improve the health and well-being of individuals with a TMD. This report addresses the current state of knowledge regarding TMD research, education and training, safety and efficacy of clinical treatments of TMDs, and burden and costs associated with TMDs. The recommendations of Temporomandibular Disorders focus on the actions that many organizations and agencies should take to improve TMD research and care and improve the overall health and well-being of individuals with a TMD.--

The Earth system functions and connects in unexpected ways - from the microscopic interactions of bacteria and rocks to the macro-scale processes that build and erode mountains and regulate Earth's climate. Efforts to study Earth's intertwined processes are made even more pertinent and urgent by the need to understand how the Earth can continue to sustain both civilization and the planet's biodiversity. A Vision for NSF Earth Sciences 2020-2030: Earth in Time provides recommendations to help the National Science Foundation plan and support the next decade of Earth science research, focusing on research priorities, infrastructure and facilities, and partnerships. This report presents a compelling and vibrant vision of the future of Earth science research.

Pain is both a symptom and a disease. It manifests in multiple forms and its treatment is complex. Physical, social, economic, and emotional consequences of pain can impair an individual's overall health, well-being, productivity, and relationships in myriad ways. The impact of pain at a population level is vast and, while estimates differ, the Centers for Disease Control and Prevention reported that 50 million U.S. adults are living in pain. In terms of pain's global impact, estimates suggest the problem affects approximately 1 in 5 adults across the world, with nearly 1 in 10 adults newly diagnosed with chronic pain each year. In recent years, the issues surrounding the complexity of pain management have contributed to increased demand for alternative strategies for treating pain. One such strategy is to expand use of topical pain medications--medications applied to intact skin. This nonoral route of administration for pain medication has the potential benefit, in theory, of local activity and fewer systemic side effects. Compounding is an age-old pharmaceutical practice of combining, mixing, or adjusting ingredients to create a tailored medication to meet the needs of a patient. The aim of compounding, historically, has been to provide patients with access to therapeutic alternatives that are safe and effective, especially for people with clinical needs that cannot otherwise be met by commercially available FDA-approved drugs. Compounded Topical Pain Creams explores issues regarding the safety and effectiveness of the ingredients in these pain creams. This report analyzes the available scientific data relating to the ingredients used in compounded topical pain creams and offers recommendations regarding the treatment of patients.

The United States faces a significantly aging population as well as a growing share of the population that is living longer with multiple chronic conditions. To provide high-quality care to people of all ages living with serious illness, it is critical that the nation develop an adequately trained and prepared workforce consisting of a range of professionals, including physicians, nurses, social workers, direct care workers, and chaplains. To explore some of the key workforce-related challenges to meeting the needs of people with serious illness, the National Academies of Sciences, Engineering, and Medicine hosted a workshop on November 7, 2019. This publication summarizes the presentations and discussions from the workshop.

On August 7-8, 2019, the National Academies of Sciences, Engineering, and Medicine hosted a public workshop in Washington, DC, to review the status of current and emerging knowledge about innovations for modern food systems and strategies for meeting future needs. The workshop addressed different perspectives on the topic of food systems and would build on a workshop on the topic of sustainable diets hosted by the Food Forum in August 2018. This publication summarizes the presentations and discussions from the workshop.

The goal of planetary protection is to control, to the degree possible, the biological cross-contamination of planetary bodies. Guidelines developed by the Committee on Space Research (COSPAR) are used by all spacefaring nations to guide their preparations for encounters with solar system bodies. NASA's Science Mission Directorate has convened the Planetary Protection Independent Review Board (PPIRB) to consider updating the COSPAR guidelines given the growing interest from commercial and private groups in exploration and utilization of Mars and other bodies in space. At the request of NASA, this publication reviews the findings of the PPIRB and comments on their consistency with the recommendations of the recent National Academies report Review and Assessment of the Planetary Protection Policy Development Processes.

In 2009 the Institute of Medicine (IOM) began to assess the need for better-defined medical and public health crisis standards of care (CSC) for catastrophic disasters and public health emergencies. Over the next 10 years, the IOM defined templates for those stakeholders responsible for integrated CSC planning and implementation; created a tool kit with guidance on indicators and triggers; provided a discussion kit for stakeholders to use with their own communities to establish appropriate indicators and triggers to guide their planning; disseminated the messages and key concepts of CSC; and built on the initial efforts to refine certain elements and address remaining gaps. This current Proceedings of a Workshop captures the discussions from a 2019 workshop reviewing the successes and gaps over the last 10 years of CSC work, in order to inform the next phases of planning and implementation.

The Social Security Administration (SSA) administers two programs that provide disability benefits: the Social Security Disability Insurance (SSDI) program and the Supplemental Security Income (SSI) program. SSDI provides disability benefits to people (under the full retirement age) who are no longer able to work because of a disabling medical condition. SSI provides income assistance for disabled, blind, and aged people who have limited income and resources regardless of their prior participation in the labor force. Both programs share a common disability determination process administered by SSA and state agencies as well as a common definition of disability for adults: "the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." Disabled workers might receive either SSDI benefits or SSI payments, or both, depending on their recent work history and current income and assets. Disabled workers might also receive benefits from other public programs such as workers' compensation, which insures against work-related illness or injuries occurring on the job, but those other programs have their own definitions and eligibility criteria. Selected Health Conditions and Likelihood of Improvement with Treatment identifies and defines the professionally accepted, standard measurements of outcomes improvement for medical conditions. This report also identifies specific, long-lasting medical conditions for adults in the categories of mental health disorders, cancers, and musculoskeletal disorders. Specifically, these conditions are disabling for a length of time, but typically don't result in permanently disabling limitations; are responsive to treatment; and after a specific length of time of treatment, improve to the point at which the conditions are no longer disabling.

"Speakers at the workshop discussed patient recruitment and selection for gene-based clinical trials, explored how the safety of new therapies is assessed, reviewed the challenges involving dose escalation, and spoke about ethical issues such as informed consent and the role of clinicians in recommending trials as options to their patients"--The National Academies of Sciences, Engineering, Medicine website (viewed September 17, 2020)

The social determinants of mental health involve the economic, social, and political conditions into which one is born that influence a person's mental health - and, in particular, that affect the likelihood a person raised in deficient or dangerous conditions often associated with poverty will develop persistent mental health challenges throughout his or her life. To explore how health professions education and practice organizations and programs are currently addressing social determinants that contribute to mental health disparities across the lifespan, the Global Forum on Innovation in Health Professional Education of the National Academies of Sciences, Engineering, and Medicine hosted a workshop in Washington, DC on November 14-15, 2019. This publication summarizes the presentation and discussion of the workshop. Publisher's website.

Brain health affects Americans across all ages, genders, races, and ethnicities. Enriching the body of scientific knowledge around brain health and cognitive ability has the potential to improve quality of life and longevity for many millions of Americans and their families. The Centers for Disease Control and Prevention estimate that as many as 5 million Americans were living with Alzheimer's disease in 2014. That same year, more than 800,000 children were treated for concussion or traumatic brain injuries in U.S. emergency departments. Each year, more than 795,000 people in the United States have a stroke. Developing more effective treatment strategies for brain injuries and illnesses is essential, but brain health is not focused exclusively on disease, disorders, and vulnerability. It is equally important to better understand the ways our brains grow, learn, adapt, and heal. Addressing all of these domains to optimize brain health will require consideration about how to define brain health and resilience and about how to identify key elements to measure those concepts. Understanding the interactions between the brain, the body, and socioenvironmental forces is also fundamental to improving brain health. To explore issues related to brain health throughout the life span, from birth through old age, a public workshop titled Brain Health Across the Life Span was convened on September 24 and 25, 2019, by the Board on Population Health and Public Health Practice in the Health and Medicine Division of the National Academies. This publication summarizes the presentation and discussion of the workshop.

Since its founding in 1982, the Small Business Innovation Research (SBIR) program has become the largest and most comprehensive public research and development funding program of small business research in the United States. An underlying tenet of the SBIR program, and the related Small Business Technology Transfer (STTR) program, is that small and young firms are an important source of new ideas that provide the underlying basis for technological innovation, productivity increases, and subsequent economic growth. By involving qualified small businesses in the nation's research and development efforts, SBIR/STTR grants stimulate the development of innovative technologies and help federal agencies achieve their missions and objectives. At the request of the Department of Energy (DOE), this report examines the SBIR and STTR programs at DOE, focusing on the effectiveness of DOE's SBIR/STTR processes and procedures on topic and awardee selection; DOE outreach efforts to SBIR and STTR applicants; collaborations created between small businesses and research institutions on account of the programs; a range of direct economic and non-economic impacts to awardees; and the role of SBIR/STTR programs in stimulating technological innovation and contributing to DOE's research and development needs, whether directly from awardees or indirectly through spillovers from other firms.

Biokinetic modeling provides a mathematical technique for estimating absorption, distribution, metabolism, and excretion of chemicals, including particles and metals, in humans. Such models can be used to relate the amount of lead external exposure to the amount of lead found in the blood and other tissues at different points in time. At the request of the Department of Defense (DoD), Review of the Department of Defense Biokinetic Modeling Approach in Support of Establishing an Airborne Lead Exposure Limit evaluates whether the model used by DoD to derive airborne lead concentrations from blood lead levels is appropriate. This report also considers whether DoD's modifications to the model are appropriately justified, and whether the assumptions in and inputs to the model are reasonable.

"The United States is formally represented around the world by approximately 14,000 Foreign Service officers and other personnel in the U.S. Department of State. Roughly one-third of them are required to be proficient in the local languages of the countries to which they are posted. To achieve this language proficiency for its staff, the State Department's Foreign Service Institute (FSI) provides intensive language instruction and assesses the proficiency of personnel before they are posted to a foreign country. The requirement for language proficiency is established in law and is incorporated in personnel decisions related to job placement, promotion, retention, and pay. A Principled Approach to Language Assessment: Considerations for the U.S. Foreign Service Institute evaluates the different approaches that exist to assess foreign language proficiency that FSI could potentially use. This report considers the key assessment approaches in the research literature that are appropriate for language testing, including, but not limited to, assessments that use task-based or performance-based approaches, adaptive online test administration, and portfolios."--

Behavioral health and substance use disorders affect approximately 20 percent of the U.S. population. Of those with a substance use disorder, approximately 60 percent also have a mental health disorder. Together, these disorders account for a substantial burden of disability, have been associated with an increased risk of morbidity and mortality from other chronic illnesses, and can be risk factors for incarceration, homelessness, and death by suicide. In addition, they can compromise a person's ability to seek out and afford health care and adhere to treatment recommendations. To explore data, policies, practices, and systems that affect the diagnosis and provision of care for mental health and substance use disorders, the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine created the Forum on Mental Health and Substance Use Disorders. The forum activities are expected to advance the discussion and generate potential ideas on ways to address many of the most persistent problems in delivering mental health and substance use services. The inaugural workshop, held October 15-16, 2019, in Washington, DC, explored the key policy challenges that impede efforts to improve care for those individuals with mental health and substance use disorders. This publication summarizes the presentations and discussion of the workshop.

"Sharing knowledge is what drives scientific progress - each new advance or innovation in biomedical research builds on previous observations. However, for experimental findings to be broadly accepted as credible by the scientific community, they must be verified by other researchers. An essential step is for researchers to report their findings in a manner that is understandable to others in the scientific community and provide sufficient information for others to validate the original results and build on them. In recent years, concern has been growing over a number of studies that have failed to replicate previous results and evidence from larger meta-analyses, which have pointed to the lack of reproducibility in biomedical research. On September 25 and 26, 2019, the National Academies of Science, Engineering, and Medicine hosted a public workshop in Washington, DC, to discuss the current state of transparency in the reporting of preclinical biomedical research and to explore opportunities for harmonizing reporting guidelines across journals and funding agencies. Convened jointly by the Forum on Drug Discovery, Development, and Translation; the Forum on Neuroscience and Nervous System Disorders; the National Cancer Policy Forum; and the Roundtable on Genomics and Precision Health, the workshop primarily focused on transparent reporting in preclinical research, but also considered lessons learned and best practices from clinical research reporting. This publication summarizes the presentation and discussion of the workshop."--

"The U.S. Department of Energy's Office of Environmental Management is responsible for managing and cleaning up the waste and contamination at the Hanford Nuclear Reservation, the nation's biggest and most complex nuclear cleanup challenge. At the site, 177 underground tanks collectively contain about 211 million liters of waste that includes high-activity and low-activity materials. At the request of Congress, Final Review of the Study on Supplemental Treatment Approaches of Low-Activity Waste at the Hanford Nuclear Reservation: Review #4 focuses on approaches for treatment and disposal of the supplemental portion of the low-activity waste from the tanks. This review report discusses developments since the publication of Review #3 and provides a summary of public comments on the third committee review report. The authoring committee then shares their views on these comments and whether they change any of the findings or recommendations in the third review report"--Publisher's website.

Among the many who serve in the United States Armed Forces and who are deployed to distant locations around the world, myriad health threats are encountered. In addition to those associated with the disruption of their home life and potential for combat, they may face distinctive disease threats that are specific to the locations to which they are deployed. U.S. forces have been deployed many times over the years to areas in which malaria is endemic, including in parts of Afghanistan and Iraq. Department of Defense (DoD) policy requires that antimalarial drugs be issued and regimens adhered to for deployments to malaria-endemic areas. Policies directing which should be used as first and as second-line agents have evolved over time based on new data regarding adverse events or precautions for specific underlying health conditions, areas of deployment, and other operational factors At the request of the Veterans Administration, Assessment of Long-Term Health Effects of Antimalarial Drugs When Used for Prophylaxis assesses the scientific evidence regarding the potential for long-term health effects resulting from the use of antimalarial drugs that were approved by FDA or used by U.S. service members for malaria prophylaxis, with a focus on mefloquine, tafenoquine, and other antimalarial drugs that have been used by DoD in the past 25 years. This report offers conclusions based on available evidence regarding associations of persistent or latent adverse events.

"Beginning in 1979 and in each subsequent decades, the U.S. Department of Health and Human Services (HHS) has overseen the Healthy People initiative to set national goals and objectives for health promotion and disease prevention. At the request of HHS, this study presents a slate of Leading Health Indicators (LHIs) that will serve as options for the Healthy People Federal Interagency Workgroup to consider as they develop the final criteria and set of LHIs for Healthy People 2030."--

During the 20th century, the city of Los Angeles diverted surface water flowing into Owens Lake for water supply, transforming the large, closed-basin, saline lake into a small brine pool surrounded by dry playa. Under high winds, the exposed lakebed produced large amounts of airborne dust, resulting in the highest concentrations of airborne particulate matter with an aerodynamic diameter of 10 micrometers or less (PM10) in the United States. Since 2000, the Los Angeles Department of Water and Power, at the direction of the Great Basin Unified Air Pollution Control District, has been constructing and implementing dust control measures on the dry lakebed, with the objective of meeting the U.S. Environmental Protection Agency National Ambient Air Quality Standards for PM10 and the PM10 standards set by the state of California. Many of the dust control measures used at Owens Lake require large amounts of water, energy, and maintenance to sustain their performance. Effectiveness and Impacts of Dust Control Measures for Owens Lake evaluates the effectiveness of alternative solutions for their degree of PM10 reduction and the extent that they reduce use of water in controlling dust emissions. This report considers the associated energy and environmental and economic impacts of these proposed measures and assesses their durability and reliability.

Social isolation and loneliness are serious yet underappreciated public health risks that affect a significant portion of the older adult population. Approximately one-quarter of community-dwelling Americans aged 65 and older are considered to be socially isolated, and a significant proportion of adults in the United States report feeling lonely. People who are 50 years of age or older are more likely to experience many of the risk factors that can cause or exacerbate social isolation or loneliness, such as living alone, the loss of family or friends, chronic illness, and sensory impairments. Over a life course, social isolation and loneliness may be episodic or chronic, depending upon an individual's circumstances and perceptions. A substantial body of evidence demonstrates that social isolation presents a major risk for premature mortality, comparable to other risk factors such as high blood pressure, smoking, or obesity. As older adults are particularly high-volume and high-frequency users of the health care system, there is an opportunity for health care professionals to identify, prevent, and mitigate the adverse health impacts of social isolation and loneliness in older adults. Social Isolation and Loneliness in Older Adults summarizes the evidence base and explores how social isolation and loneliness affect health and quality of life in adults aged 50 and older, particularly among low income, underserved, and vulnerable populations. This report makes recommendations specifically for clinical settings of health care to identify those who suffer the resultant negative health impacts of social isolation and loneliness and target interventions to improve their social conditions. Social Isolation and Loneliness in Older Adults considers clinical tools and methodologies, better education and training for the health care workforce, and dissemination and implementation that will be important for translating research into practice, especially as the evidence base for effective interventions continues to flourish.

Advanced aerial mobility is a newly emerging industry that aims to develop and operate new air vehicles potentially capable of safe, reliable, and low-noise vertical flight. The world has seen a recent increase in the adoption of electric vertical lift aircraft for urban, suburban and rural operations. These new innovations and technologies change the way that we move cargo and people, affecting industries across the economy. These changes will challenge today's airspace monitoring systems and regulatory environment. The U.S. government and its regulatory agencies need technical guidance to facilitate the development of these technologies, and to create the regulatory framework to foster the growth of this vertical flight industry to the benefit of the aviation industry. Advancing Aerial Mobility evaluates the potential benefits and challenges associated with this emerging industry. This report provides recommendations that seek to foster an environment in which the nation can maintain its leading position in developing, deploying, and embracing these new technologies. This publication presents a national vision for advanced aerial mobility, market evolution, and safety and security management.

Emissions associated with oil and gas exploration, development, and production on the Gulf waters can result in increased levels of air pollutants that contribute to a range of air quality impacts in the Gulf of Mexico Region (GOMR). "Criteria air pollutants", such as carbon monoxide, lead, nitrogen dioxide, ozone, particulate matter, and sulfur dioxide, are considered harmful to public health and the environment. The Bureau of Ocean Energy Management (BOEM) manages the U.S. outer continental shelf oil and gas resources and is required to help manage air quality in the GOMR. Review of the Bureau of Ocean Energy Management "Air Quality Modeling in the Gulf of Mexico Region" Study reviews and provides feedback on the BOEM's Air Quality Modeling in the Gulf of Mexico Region Study. This independent technical review of the study explores whether the study meets its goals, accurately reflects the scientific literature, uses reasonable data and modeling analyses, approaches quantitative modeling appropriately, documents findings in a consistent, transparent, and credible way, and aligns with necessary guidelines.

"Patterns of food consumption and nutritional intake strongly affect the population's health and well-being. The Food Economics Division of USDA's Economic Research Service (ERS) engages in research and data collection to inform policy making related to the leading federal nutrition assistance programs managed by USDA's Food and Nutrition Service. The ERS uses the Consumer Food Data System to understand why people choose foods, how food assistance programs affect these choices, and the health impacts of those choices. At the request of ERS, A Consumer Food Data System for 2030 and Beyond provides a blueprint for ERS's Food Economics Division for its data strategy over the next decade. This report explores the quality of data collected, the data collection process, and the kinds of data that may be most valuable to researchers, policy makers, and program administrators going forward. The recommendations of A Consumer Food Data System for 2030 and Beyond will guide ERS to provide and sustain a multisource, interconnected, reliable data system."--

Careers in science, engineering, and medicine offer opportunities to advance knowledge, contribute to the well-being of communities, and support the security, prosperity, and health of the United States. But many women do not pursue or persist in these careers, or advance to leadership positions - not because they lack the talent or aspirations, but because they face barriers, including: implicit and explicit bias; sexual harassment; unequal access to funding and resources; pay inequity; higher teaching and advising loads; and fewer speaking invitations, among others. There are consequences from this underrepresentation of women for the nation as well: a labor shortage in many science, engineering, and medical professions that cannot be filled unless institutions and organizations recruit from a broad and diverse talent pool; lost opportunities for innovation and economic gain; and lost talent as a result of discrimination, unconscious bias, and sexual harassment. Promising Practices for Addressing the Underrepresentation of Women in Science, Engineering, and Medicine reviews and synthesizes existing research on policies, practices, programs, and other interventions for improving the recruitment, retention, and sustained advancement into leadership roles of women in these disciplines. This report makes actionable recommendations to leverage change and drive swift, coordinated improvements to the systems of education, research, and employment in order to improve both the representation and leadership of women.

Since 2004, the U.S. government has supported the global response to HIV/AIDS through the President's Emergency Plan for AIDS Relief (PEPFAR). The Republic of Rwanda, a PEPFAR partner country since the initiative began, has made gains in its HIV response, including increased access to and coverage of antiretroviral therapy and decreased HIV prevalence. However, a persistent shortage in human resources for health (HRH) affects the health of people living with HIV and the entire Rwandan population. Recognizing HRH capabilities as a foundational challenge for the health system and the response to HIV, the Government of Rwanda worked with PEPFAR and other partners to develop a program to strengthen institutional capacity in health professional education and thereby increase the production of high-quality health workers. The Program was fully managed by the Government of Rwanda and was designed to run from 2011 through 2019. PEPFAR initiated funding in 2012. In 2015, PEPFAR adopted a new strategy focused on high-burden geographic areas and key populations, resulting in a reconfiguration of its HIV portfolio in Rwanda and a decision to cease funding the Program, which was determined no longer core to its programming strategy. The last disbursement for the Program from PEPFAR was in 2017. Evaluation of PEPFAR's Contribution (2012-2017) to Rwanda's Human Resources for Health Program describes PEPFAR-supported HRH activities in Rwanda in relation to programmatic priorities, outputs, and outcomes and examines, to the extent feasible, the impact on HRH and HIV-related outcomes. The HRH Program more than tripled the country's physician specialist workforce and produced major increases in the numbers and qualifications of nurses and midwives. Partnerships between U.S. institutions and the University of Rwanda introduced new programs, upgraded curricula, and improved the quality of teaching and training for health professionals. Growing the number, skills, and competencies of health workers contributed to direct and indirect improvements in the quality of HIV care. Based on the successes and challenges of the HRH program, the report recommends that future investments in health professional education be designed within a more comprehensive approach to human resources for health and institutional capacity building, which would strengthen the health system to meet both HIV-specific and more general health needs. The recommendations offer an aspirational framework to reimagine how partnerships are formed, how investments are made, and how the effects of those investments are documented.