Regulation of the pharmaceutical system is a crucial, yet often neglected, component in ensuring access to safe and effective medicines. The aim of this study was to provide an in-depth analysis of the existing pharmaceutical regulation, including recent changes, in the Republic of Moldova.Data from field work conducted by the World Health Organization (WHO) together with a review of policy documents and quantitative secondary data analysis was used to achieve this aim.This analysis identified several ways in which pharmaceutical regulation affects availability of quality medicines in the Republic of Moldova. These include lack of full implementation bioequivalence requirements for generics registration, incomplete implementation of good manufacturing practices and no implementation of good distribution practices, use of quality control instead of quality assurance as a method to ensure quality of medicines, frequent change of power within the Medicines and Medical Devices Agency (MMDA) leading to lack of long-term strategy and plans, conflict of interest between the different functions of the MMDA, the lack of sufficient funding for the MMDA to conduct its activities and to invest in continuous training of its staff (particularly inspectors) and very weak post-marketing control. Notably, several improvements have been recently introduced, including a roadmap for change for the MMDA, the introduction of good manufacturing practices and the drafting of a quality manual for the Agency.Based on these findings the authors propose a set of priority actions to address existing gaps and draw lessons learned from other countries. The Republic of Moldova is a lower-middle-income country in eastern Europe with a population of 3.5 million  . These iRegulation of the pharmaceutical system is a crucial, yet often neglected, component in ensuring access to safe and effective medicines. While medicines financing, selection and procurement are essential, an effective, transparent regulatory system which manages conflict of interest (COI) and has a well-functioning post-marketing system  is crucial to prevent entry of substandard products. The latter pose a threat to patients’ health and cause wastage of resources spent on ineffective and/or unsafe products. The importance of regulatory control in ensuring equitable access to essential medicines is also included in the World Health Organization (WHO) framework for collective action .Despite the importance of regulatory functions in ensuring access to essential medicines, few studies are available which explore pharmaceutical regulatory issues in countries of the former Soviet Union. These include a 1996 review of the transparency levels across regulatory systems worldwide which looked at Estonia and Latvia , a studyThe objectives of this study are twofold. First, to provide an in-depth analysis of the existing pharmaceutical regulation, including recent changes, in the Republic of Moldova by reviewing gaps and progress in the main pharmaceutical system functions. Second, using the case of the Republic of Moldova, this paper aims to highlight the importance of pharmaceutical regulation in ensuring access to quality medicines. As issues of transparency and gaps in regulatory pharmaceutical functions are common in most low- and middle-income countries, this paper is expected to stimulate the debate in the area and encourage similar analysis in other countries.This analysis is based on two in-country missions (field work) conducted by the WHO and complemented by a desk-review of official reports, policies and regulations, as well as analysis of data on the number of registered medicines vs. available medicines obtained from the national laboratory of quality control and the Medicines and Medical Devices Agency (MMDA). The secondary data analysis was conducted in 2013 and enabled an update on findings from the missions. In 2011, the MMDA was only responsible for pharmaceuticals and was called Medicines Agency. In this paper, we will use the new name of the agency (MMDA) but limit our analysis to issues related to pharmaceuticals.st of July 2011. The aim of this field study was to analyse the centralised procurement process undertaken by the MMDA, through interviews with seven management and staff members of the MMDA. In addition, a number of structured interviews with major stakeholders were undertaken. These included representatives (number of interviewees in brackets) from the Ministry of Health (3), private importers and distributors (2), a public importer (1), the Oncological Institute (1), the central district hospital in the rayon of Calarasi , a primary health care unit in the rayon of Calarasi (2), the Republican clinic hospital , a private pharmacy (1), a manufacturer (1) and an academic with expertise in pharmaceutical policy in the Republic of Moldova (1).The first mission focused on procurement and supply and was conducted by two pharmaceutical experts between the 26th of June and the 1The second mission was an extensive review of the entire regulatory system for pharmaceuticals and was conducted between the 19th and 23rd of September 2011 by three pharmaceutical experts (including a regulator from a European Union (EU) country). The review was performed using a WHO data collection tool for the assessment of regulatory systems ,16. InfoThere is a lack of transparency in the regulation of medicines. This is characterised by low access to information on regulations and procedures for applicants and holders of marketing authorisation and lack of clear standard operating procedures (SOPs) for several regulatory procedures. Although various steps have been taken in recent years to address these gaps, the main challenges are the time needed to introduce the necessary legislative changes and low human resource capacity for their implementation. In fact, despite various guidelines having been drafted, many of them have not been approved yet; and for those approved, their implementation is often limited due to human resource constraints. In the next sections, we will highlight some of the main gaps and achievements across the various regulatory functions.a applications for highly soluble substances and to insufficient attention from authorities to the problem. Good manufacturing practice (GMP) inspections are currently not a mandatory part of the registration process and there is insufficient funding and staff trained with the necessary training to conduct GMP inspections. Due to low salaries and general paucity of skilled professionals in the country, there is an insufficient number of assessors with relevant skills in the registration department and the national reference laboratory. In addition, the objectivity of the decisions taken by assessors is weakened due to lack of approved written procedures on how to assess registration applications.The main issue is the conflicting role of the MMDA which is tasked to register products and also to procure them. In a few cases, this has led to pressure from manufacturers to register products quickly. Further, the legal provision requiring the demonstration of generics’ bioequivalence with the brand product is not implemented. This is mainly due to the lack of assessors trained in reviewing biowaverAnother issue is the lack of stable management or a long-term planning process within the MMDA. In the past two years, there have been seven different directors and despite the staff’s genuine commitment to raise standards and meet internationally accepted requirements, there is very little evidence of planning and targets at the MMDA or department level to achieve these goals. Further, there are no COI guidelines for registration activities, rendering the system vulnerable to vested interests. This can be particularly problematic given the frequent use of external experts. Moreover, the committee’s decisions are not publicly available.On average, about 70% to 80% of all registered medicines by foreign manufacturers were actually imported Figure . HoweverIn most cases when a particular medicine was only registered by foreign manufacturers, even if not all strength were available, at least one strength per INN was imported. In a few cases, mostly cancer medicines, no product for any strength was available for a particular INN. These included bleomycin (not imported in 2012 and 2011), busulfan (not imported in 2012), cetuximab (not imported in 2012 and 2011), cytarabine (not imported in 2012), docetaxel (not imported in 2012), doxorubicin hydrochloride (not imported in 2012), everolimus (cancer indication not imported in 2012 and 2011), fludarabine (not imported in 2012 and 2011), imatinib (not imported in 2012 and 2011) and tamoxifen (not imported in 2012).Unavailability of registered medicines is due to a number of reasons including unsuccessful pricing negotiations between manufacturer and the MMDA and disincentive on the part of distributors who may not have sufficient interest in importing certain medicines because of limited or absent demand. Low demand can be due to different reasons like irrational prescribing, heavy promotion of other medicines ) and limited promotion of essential medicines. Finally, the financing of the MMDA is mainly based on registration fees which is likely to provide an incentive to register more products that actually necessary. Underfunding of the MMDA is a real challenge given that registration fees have not been revised in recent years (and thus does not take into account current expenses and inflation rate). The issue of low availability of registered medicines has been already discussed at Ministry of Health and some measures have been taken. Following the recent introduction of a new regulatory requirement in 2012, if a medicine is registered but it is not available on the market (whether it has never been launched or it stops being available) for three consecutive years, its registration is suspended .b regulatory authorities in a standard format accepted in all ICH member countries [Despite challenges remaining, a number of positive developments have taken place in the past two years. The most important positive development is the introduction of GMP guidelines, which, by December 2014, should be implemented by all local manufacturers . In Julyountries . Since JThe Licensing Chamber, a public organ under the Ministry of Economy is currently responsible for licensing of pharmaceutical enterprises. This leads to fragmentation of responsibilities between the MMDA, the Licensing Chamber and the National Evaluation and Accreditation Office. A transfer of the licensing function to the MMDA was envisaged in the Medicines Agency Road Map for 2012–2014, which was approved by the Government in April 2012. However, a draft document to modify the law on pharmaceutical licensing activities was never approved due to lack of support from the other ministries. In addition to not have the licensing function under a specialised authority, as is the case in other countries, there are also no pharmacists within the licensing Chamber.On the 1st of April 2011, the Parliament approved new rules for opening a pharmacy. The new requirements included a minimal distance between pharmacies and location to be based on demographic criteria. The law also required the Government to approve, within three months, a national plan to determine the location of new pharmacies based on these new criteria. The Ministry of Economy was opposed to this national plan and the idea of involving the Government, mainly arguing that regulating the opening of new enterprises is against free market principles. It thus provided negative feedback on the proposed plan and proposed to instead develop a new revision of the law to cancel all the new criteria. The Ministry of Health developed the new draft law which revoked the demographic criteria for pharmacy opening locations as well as the national plan. However, the final text currently under review by the Parliament will likely result in the removal of all three stipulations as requested by the Ministry of Economy. It is therefore still unclear whether any new criteria on opening new pharmacies will be introduced. Regardless, even if new criteria are approved, complexities in access would still remain and thus further considerations could be needed. For example, based on population criteria, the municipality of the capital Chisinau had too many pharmacies, calling for a moratorium on new openings. In 2012 there were 1,838 inhabitants per pharmacy in the capital rayon (district) of Chisinau vs. an average of 4,488 inhabitants per pharmacy in the other rayons. But in reality, there were certain villages near the capital  or in the recently-built ‘microrayons’ (‘microdistricts’) where the number of pharmacies per capita was too low. However, because the average number of pharmacies in the rayon was too high, it was not possible to open new pharmacies in those undersupplied areas.There are currently no written procedures or mechanisms in place to prevent regulatory capture between inspectors and the manufacturers or distributors that they inspect, rendering the system vulnerable to corrupt practices. While inspectors follow available regulations, these do not provide detailed description of the procedure to conduct inspection (SOPs). Another important gap is the lack of a quality management system for the inspectorate. Written criteria for the selection and recruitment of inspectors are available, requiring inspectors to have passed a specific training in inspection. Once recruited, inspectors are not regularly trained on key areas such GMP, good distribution practices (GDP) or good clinical practice (GCP). Further, there is no documented process on qualification and review to confirm the competencies of existing inspectors.The legislation relating to MMDA inspectors involvement in pre-licensing activities is unclear and inspectors are not involved in any stages preceding the opening of a pharmacy. Further there is no clear legal provision designating the inspectors and their powers. As a result, inspectors do not have adequate powers and authority to carry out their tasks. Another issue relates to the fragmentation problems mentioned previously in that only the Licensing Chamber, and not the MMDA, can initiate the process to revoke a license.Due to an insufficient number of competent staff and underfunding, the MMDA does not have resources to inspect manufacturers with the frequency stated in the law. Importing of low cost medicines from countries like India and China has increased in recent years, yet there is very limited capacity to inspect overseas suppliers and to raise questions about the quality of the products imported. This problem has now been addressed for reimbursed outpatient medicines (as explained in the next paragraphs in the positive developments subsection) but remains a challenge for inpatient medicines and non-reimbursed medicines.The recall system for faulty products is not well described in the law and there are no SOPs. As a result, its implementation does not work well in practice; for example, suppliers who underperform are not blacklisted. Based on doctors’ and patients’ reports, there is evidence of the presence of low efficacy products in hospitals. This leads to overuse, increase of dosage or to patients having to purchase medicines, which they should receive for free at the hospital, in private pharmacies. These circumstances are supported by findings during one of the missions, when three different products with the same batch number from a local manufacturer were found in a hospital. There were also specific reports of low effectiveness in three different medicines: ceftazidime, an antibiotic imported from China which required two to three times the standard dose to elicit the response which is usually obtained with the standard dosage; methyl prednisolone and betamethasone, both locally produced corticosteroids  which were reported to have no effect on patients.The Republic of Moldova has already taken concrete steps to gradually move towards GMP compliance for imported as well as locally produced medicines. The first step was the development and approval of GMP guidelines in March 2013. With the release of the new reimbursement list in May 2013, medicines registered in the EU, the United States of America (USA), Canada, Australia, or Japan (and therefore compliant with GMP) were given preferred supplier status. This is expected to provide a strong incentive, particularly to local manufacturers, to improve their manufacturing practices according to internationally accepted GMP. Yet, in the case no product is registered from a GMP compliant manufacturer, products from manufacturer with national GMP certificates or, as a last resort, non-GMP compliant manufacturer need to be sourced. As a result of this, a number of medicines from non-GMP compliant manufacturer  are still in the reimbursement list. For inpatient medicines, all products tendered should comply with GMP  or Food and Drug Administration (FDA) criteria). The exception is psychotropic and TB medicines for which GMP certification according to either WHO, EMA or FDA is required. Further, by December 2014 all local manufacturers are expected to comply with GMP requirements. This will help to gradually remove existing double standards within the country as revealed during the procurement and supply mission, where an exporting facility was found to have voluntarily developed a quality assurance (QA) system because GMP compliance is required for product registration in the majority of the countries where the company exports its products. On the contrary, a domestically-oriented facility visited did not implement GMP . These efforts were complemented with training organised for inspectors in GMP and GDP.Improvements were also observed in the way inspections are conducted. The new law on state control of entrepreneur activity, implemented in March 2013, includes a provision for inspection of enterprises . It defines the principles of control and the procedures to conduct controls. As of March 2013, the Inspectorate is publishing the schedule of visits to pharmacies and warehouses. Moreover, the old procedure (as per the previous legislation) to inspect the pharmaceutical facilities has been revised; now, to visit a pharmaceutical establishment the inspector has to inform the facility five days in advance of the planned visit.Positive developments in access to narcotics for pain management have also occurred. Previously, the control over the supply chain of narcotic substances used to be too strong and fear of sanction was acting as a deterrent for pharmacists to stock narcotics. This situation was likely to cause problems for patients needing narcotic painkillers, particularly in rural areas where availability is low. In October 2012, the Ministry of Health released an order which introduced important changes in the regulation on dispensing narcotics medicines. Limits on the quantity of medicine prescribed were removed; doctors can now issue prescriptions for up to 30 days. Doctors can now also prescribe additional doses before the 30 day treatment period ends, in case the patient condition has changed.Control on medicines promotion is an important regulatory area in Moldova where doctors are known to be heavily influenced by pharmaceutical representatives through financial incentives. Due to very low salaries  3,500 (US$ 260) in 2012) the latter can easily double physicians’ income making this practice very difficult to eradicate without first addressing the problem of low wages. Beyond financial issues, lack of training in rational prescribing and evidence-based medicine make physicians easy preys of the pharmaceutical industry. This is compounded by a lack of guidance from the public institutions in areas such as patient education and disease self-management which further strengthened industry’s role and influence. For example, doctors are required to run diabetes and hypertension schools but they do not have a standardised curriculum and are not provided with patient education materials to distribute so they rely on the pharmaceutical industry to provide patient education materials.There is a law on medicines (# 1409 from 1997/12/17 in the chapter VI) providing general regulation on medicines’ information and advertising. The draft of regulation and executive order which sets out definitions, requirements, procedures of authorisations, prohibitions, monitoring and complaints procedure on advertising on medicines was presented at the beginning of 2012 to the Ministry of Health for approval and is currently still under discussion. The law on advertising (# 1227 from 22.06.1997) outlines the general principles for advertising, including provisions on adverting medicines and commodities. The provisions on medicine promotion and advertising include explicit mention of the different forms of promotion but post-marketing scientific studies, speakers’ fees and consultancies, promotion of exported medicines and restrictions and limits on gifts and gimmicks. In addition, the provisions do not foresee an enforcement mechanism on promotion and advertisement of medicines, stating the sanctions in cases of violation. In addition to legal gaps, there are also procedural ones. For example, while a formal complaints procedure to report unethical promotional practices exists, there is no evidence that this is used. Further, despite a standard check list for pre-approval and monitoring is available, it does not provide SOPs and there are gaps in the guidelines on COI for committee members or public officials involved in the control of medicine promotion activities.A revision of the law on advertising was launched by a group of deputies in early 2012 with a proposal to prohibit advertising of medicines on television. The Government accepted the proposal but it was refused by the Parliament. As in other regulatory areas, a number of other regulations remain in draft form pending approval the Ministry of Health. These include the number of samples pharmaceutical representatives are allowed to provide, advertisement on the internet, enforcement rules and training of medial or sales representatives.A draft of the quality manual of MA has been developed.The main problem in this area is the COI between the MMDA’s regulatory and procurement functions but there are also various gaps in availability of guidelines, SOPs and monitoring systems. For example, there are no guidelines for staff on tendering processes and although a general law on COI is available, there are no specific guidelines for the procurement process. The regulation on quality control does include requirements for each shipment to be physically checked and samples taken, but there are no SOPs for routine inspection of consignments. There is a computerised management information system to report product problems during the procurement process but it does not include quality assurance information. Further, there is no centralised system to track the status of each order or to compare quantities purchased with orders. Suppliers’ performance is monitored at least annually but there is no system to track suppliers’ lead-time, shelf-life, packaging of products and pre- and post-qualification of suppliers. It is not straightforward to prevent underperforming suppliers to take part in tenders again. In one instance, a supplier who failed to supply the market at the agreed conditions participated again in the tender process the following year under a different corporate name.While the Republic of Moldova has started using morbidity data and treatment guidelines information for forecasting purposes, procurement is still mainly based on previous consumption data which, as a method, has various limitations. To be reliable, this method requires a stable supply system with a relatively uninterrupted supply and a full supply pipeline . It alsoNational tendering is used to procure hospital medicines but there are often very few bidders and sometimes no bidder at all. In a few instances, when only one bidder was available in both rounds, the price in the second tendering round was higher because the bidder took advantage of their monopoly position, forcing the MMDA to accept the second price offer. One of the main reasons is certainly the limited advertising of tenders, only using local channels and in local language. A second possible reason goes back to the regulatory gaps identified previously which can act as a disincentive for manufacturers to launch their products due to non-transparent procedures and decision-making criteria. A third possible reason is the underdevelopment of the regulation ground to allow for the use of procurement methods other than centralised tendering. For specific products with limited market share, alternative methods such as price negotiation or single source procurement from international procurement agencies could be better suited. Finally, the small market size and low income levels are unlikely to make the market particularly attractive.Although it is important from a transparency perspective to have public scrutiny by another body on procurement activities, the need for the Public Procurement Agency under the Ministry of Finance to approve each step in the procurement process and to sign all the contracts has caused delays to the tendering process in the past. This is true also for the very close, and often obstructive, involvement of the Anti-Corruption and Anti-Monopoly agencies at all stages of the tendering process. Another issue due to misplaced transparency is the current practice of sharing bids with bidders. This practice was introduced to increase transparency, but could prove deleterious as it may lead to collusion between manufacturers.Stating in November 2012, new regulations are in place for use of additional public procurement methods including framework agreements, competitive dialogue, negotiation procedure and electronic tender. These were already mentioned in the law but government-approved implementation procedures were missing.There is no consistent procedure and criteria for development of the EML, leading to a copy and paste approach of the WHO standard EML without adjusting it to actual needs of the country. Further, there are no efforts in place to promote prescribing based on EML among physicians. There are several gaps regarding selection of committee members including the lack of a declaration of COI, no definition of the role and responsibilities of committee members and the absence of SOPs to guide the selection committee’s decision-making process.The EML is currently being updated to better reflect the epidemiological profile of the country. Further, the medicines reimbursement list is under increased scrutiny from a number of national and international partners. This could help increasing the level of accountability and transparency in the selection process and, hopefully, the extent to which such criteria are evidence-based and following rational selection principles.The main gap is the lack of GDP which threatens the maintenance of medicines’ quality during the distribution process. Although the country is planning to introduce GDP guidelines, these have not yet been approved. Further, there are no SOPs for stock management at each level of the distribution system and it is unknown to what extent the requirements mentioned in the law are implemented at the warehouse level.Issues related to the use of quality control rather than quality assurance measures have caused delays in availability of medicines because every imported batch had to be tested (which is not necessary and causes work overload for the laboratory). Further, SOPs for quality control are largely not available and a quality policy for the laboratory is missing. Another important gap is the lack of a strong and well-functioning post-marketing quality control system.The country has recently taken some very initial, yet promising, first steps in moving towards a risk-assessment and quality assurance system with the introduction of a new order on quality control of medicines. With the new order, medicines registered by companies from the EU, Australia, Japan, Canada or the USA are tested on a random basis . For medicines registered by companies from a country other than EU, Australia, Japan, Canada, or USA but compliant with national GMP, all the first five batches are tested . If the company passes all these first five tests, all following tests are done on random (but not risk assessment) basis. For manufacturers which are not compliant with GMP, all batches are tested, not only the first five. Transition to quality assurance should hopefully help avoid delays in the future.Currently, price is taken into consideration before granting an import authorisation. This practice should be discontinued as price is not an element which should influence the release of import permissions.Low implementation of drug monitoring poses a considerable risk for patients, as pre-marketing studies cover only a very small and highly selective proportion of all the patients who will use the drug in real life and are therefore not large enough to capture all possible side effects. Despite pharmacovigilance being part of the medical curriculum and the availability of reporting forms on the MMDA website, reporting is very low. This seems to be due to a lack of understanding of the importance of reporting, poor collaboration between medical institutions, a culture of fear of making contact with authorities, lack of pharmacovigilance responsibilities for manufacturers (though a new act is under development), lack, until recently, of SOPs on pharmacovigilance activities and unclear use of the data collected. Another issue is understaffing within the MMDA which is responsible for pharmacovigiliance.After being stable for several years, between 2004 and 2011 the number of reports to the pharmacovigilance department at the MMDA has increased from 72 in 2011 to 180 in 2012 . While these levels are very low even for a country of the size of Moldova, this is still an encouraging signal. In 2012, 30% of all adverse drug reactions (ADR) reports were for TB medicines, 25% for antiretroviral drugs (ARV), 11% for antibiotics, 7% for medicines to induce labour and reduce post-partum haemorrhage, 4% contraceptives, 4% antihypertensives and the remaining percentage for other therapeutic groups . While ic,d,e,f,g,h.Similar issues affecting the medicines regulatory system in the Republic of Moldova have been identified in other former Soviet Union countries. These include fragmentation of regulatory responsibilities across different agencies and unclear coordination mechanisms, lack of sustainable funding for the Medicines Agency, gaps in key regulatory documents  which lead to weak implementation of regulations and lack of transparency in decision-making, absence of COI policy and code of conduct for internal staff and external experts, no or partial implementation of GMP, GDP and GCP, insufficient number of trained staff and lack of continuous training, weak to absent market control function, large gaps in the quality management system in terms of both availability of key documents and implementation, insufficient staff and funding to conduct pharmacovigilance activities and lack of strategic planning for the Medicines Agency (unpublished observations)This review of the Moldovan regulatory system for pharmaceuticals highlighted several gaps but also showed that progress has been made over time in a number of areas. It appears, however, that more effort has been paid to developing regulations and less in assuring the effectiveness of their implementation and their impact. That said, it is important to acknowledge some of the factors which limit the country’s ability to invest in effective implementation. These include the small population size, high levels of emigration (among both the highly skilled and low skilled labour force) and brain drain to the private sector within the country, which means that there is only a very small number of experts available (e.g. inspectors). Further, frequent changes of power, which lead to high staff turnover, undermine the strengthening of existing structures and systems. This is exacerbated by limited resources for public agencies to perform their duties, low salaries  and examples of nepotism within the ruling elite of public agencies.Despite several positive steps forward in addressing regulatory gaps, the existing pharmaceutical legislation remains unstructured and not harmonised with EU requirements. In August 2013, the Ministry of Health approved a working group for revision of medicines legislation. A road map for 2012–2014 was also developed, which includes revision of existing regulations to meet EU requirements. The national drug policy has not been updated since 2002 and awareness among staff at the MMDA seemed to be low during the regulatory mission. Updating the policy is now one of the priorities of the collaborative agreement 2012–2013 between WHO Europe and the Republic of Moldova . A draftFinally, the absence of a well-functioning pharmacovigilance system and the presence of a weak post-market quality control system are jeopardising patient safety and quality of medicines in the Moldovan market. A survey of pharmacovigilance activities in 55 low- and middle- income countries showed that lack of budget, understaffing and lack of training were among the main challenges identified . Low repGaps in regulation and lack of transparent procedures are some of the main reasons for constant interference of other organisations in the work of the MMDA. This often delays the MMDA in carrying out its regulatory functions and, together with other issues such as low salaries, is largely responsible for the very high turnover of the staff. Low levels of transparency in pharmaceutical regulation are an important issue in almost all newly independent states. Low levels of transparency in regulatory procedures provide opportunities for people with vested interests to influence the decision making process. To a large extent that also explains the permanent presence of law enforcement agencies like the Anti-Corruption and Anti-Monopoly agencies, which are also often used by politicians as private vehicles to put pressure on other agencies. Further, lack of transparency weakens the MMDA position, particularly in the eyes of foreign manufacturers, and is likely to act as a deterrent for the latter to do business in the country and participate in tenders.As well free from political pressure, medicines regulation should also dispose of the necessary resources for its operation . Yet, fiThis analysis identified several ways in which pharmaceutical regulation affects availability of quality medicines in the Republic of Moldova. These include lack of full implementation bioequivalence requirement for generics registration, incomplete implementation of GMP and no implementation of GDP guidelines, use of quality control instead of quality assurance as a method to ensure quality of medicines, frequent change of power within the MMDA leading to lack of long-term strategy and plans, COI between the different functions of the MMDA, the lack of sufficient funding for the MMDA to conduct its activities and to invest in continuous training of its staff (particularly inspectors) and very weak post-marketing control.Based on the experience of the Republic of Moldova, the following lessons learned can be drawn for countries facing similar challenges. First, there is a need to address existing regulatory and developing SOPs where missing. This will allow for increased levels of transparency in the system, particularly regarding the objectivity of decision-making processes. Second, it is important to develop a strong quality management system based on quality assurance and implementing GMP, GDP and GCP to ensure the quality of the drugs reaching patients. Third, there is a need to focus not just on developing regulations but most importantly, to ensure that they are implemented. For this to happen, key regulatory agencies need to have sustainable funding and trained people at their disposal, have access to continuous training opportunities and be free from political pressures and finally enjoy stable management which will facilitate long term planning. Fourth, different procurement methods, depending on the drug to be procured, may be needed to ensure availability of essential medicines. Fifth, more efforts are needed to strengthen pharmacovigilance systems. These include financial and human resources but also training for doctors, nurses and patients on the importance of pharmacovigilance along with simplifying reporting requirements and making the necessary reporting forms widely available through different media. Sixth, this analysis showed that there are challenges affecting access to medicines which go beyond the pharmaceutical and health sector such as brain drain and the low level of salaries which affects the entire economy. Joint work with other Ministries is required to address such challenges.aThe term biowaiver is applied to a regulatory drug approval process where the efficacy and safety part of the dossier (application) is approved based on evidence of equivalence other than through in vivo equivalence testing .bInternational Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH).cRaudsepp K, Polishchuk O, Bolokhovets G. Review of the medicines regulatory system in Georgia. Tbilisi, Georgia: World Health Organization Regional Office for Europe, 2013.dAzatyan S, Sautenkova N. Review of the Medicines Regulatory System of Kyrgyzstan. Bishkek, Kyrgyzstan: World Health Organization, 2008.eAzatyan S, Sautenkova N, Polishchuk O. Assessment of the Medicines Regulatory System of Turkmenistan. Ashgabat, Turkmenistan: World Health Organization, 2009.fReggi V, Polishchuk O, Azatyan S. Review of the Medicines Regulatory System of the Republic of Armenia. Yerevan, Armenia: World Health Organization, 2007.gStará D. Review of the Medicines Regulatory System with focus on HIV/AIDS and TB medicines and related commodities in Ukraine. Kiev, Ukraine: WHO/EURO, Delegation of EU Commission in Ukraine and USAID2008.hStará D. Review of drug regulatory system in Republic of Belarus. Minsk, Republic of Belarus: World Health Organization Regional Office for Europe, 2009.ARV: Antiretrovirals; COI: Conflict of interest; CTD: Common technical document; EML: Essential medicines list; EMA: European Medicines Agency; EU: European Union; FDA: Food and Drug Administration; GF: Global Fund to fight AIDS, tuberculosis and malaria GMP, good manufacturing practices; GDP: Good distributional practices; GCP: Good clinical practices; MMDA: Medicines and Medical Devices Agency; SOPs: Standard operating procedures; QA: Quality assurance; TB: Tuberculosis; WHO: World Health Organization.The authors declare that they have no competing interests.AF and PK had the initial idea for the paper and defined its scope. NS and VS collected primary and secondary data during the two country missions supported by JH; RS, ZB and VS collected secondary data from policy reports, registration and quality control data. AF, NS, RS, ZB analysed the data. AF wrote the first draft of the manuscript, redrafted subsequent versions based on all the co-authors comments and finalised the manuscript. All the authors critically reviewed the manuscript and provided inputs on subsequent versions based on their expertise. All authors read and approved the final manuscript.http://nomenclator.amed.md/ (for registration status) and the MMDA (for import status). Notes: Due to lack of data on availability of locally produced medicines, we had to limit the analysis of registered vs. available medicines to imported products.A comparison of medicines registered by foreign manufacturers vs. available ones by therapeutic indications (2012). Source: Authors’ compilation based on data from Click here for file


Proteins participate in information pathways in cells, both as links in the chain of signals, and as the ultimate effectors. Upon ligand binding, proteins undergo conformation and motion changes, which can be sensed by the following link in the chain of information. Nuclear magnetic resonance (NMR) spectroscopy and molecular dynamics (MD) simulations represent powerful tools for examining the time-dependent function of biological molecules. The recent advances in NMR and the availability of faster computers have opened the door to more detailed analyses of structure, dynamics, and interactions. Here we briefly describe the recent applications that allow NMR spectroscopy and MD simulations to offer unique insight into the basic motions that underlie information transfer within and between cells. Signal transduction is firmly rooted in the interactions of proteins with diverse ligands, and in the molecular consequences of these interactions. In the past few years we have accrued a large amount of structural information on how proteins look before and after they bind select ligands, as can be seen in the protein data bank (PDB) Databases . As notein vivo in a biologically relevant time , going from the lock-and-key model to induced fit, conformational selection, and population shift . An impoce versa .Native folded states are not the only players in signaling cascades in the cell, as the studies on intrinsically disordered proteins (IDPs) and intrinsically disordered regions (IDRs) in folded proteins have shown . These pThe actual structures in the local minima of these landscapes and the transformations, structural and/or dynamic, that proteins undergo upon ligand binding are the heart of catalysis , allosteMany eukaryotic proteins are composed of more than one domain, connected by linkers. The role of linkers in information transfer between domains goes beyond a reduction in sampling space; some authors  have sugAn interesting corollary is that each conformation or dynamic state accessible through flexibility could be associated to a different function, selected by particular ligands, leading naturally to selectivity even in the presence of promiscuous interactions at a single or multiple sites: each binding event promotes particular structural and/or dynamic changes in the protein, explaining how small changes in the ligand can transform it from an agonist to an antagonist . SelectiAll of the previous discussion hinges on being able to see both the structures and how they change in time in response to ligands or other perturbations, so the proposed mechanisms can be validated or discarded. The examples we discuss below are aimed at the atomic-level exploration of the conformational landscapes of both folded proteins and IDPs relating to catalysis, binding and signaling, allostery, folding, and aggregation.The molecular complexity of proteins and the span in timescales of their dynamics make their study a daunting task, achievable only through the use of multiple approaches, both experimental and computational. This review is centered in the joint application of NMR and MD simulations to understand information flows in biology. Another computational tool that has been extensively used to study protein dynamics is the elastic network model (ENM), which explores fluctuations around the native structure, and has been used to explain allosteric regulation and conformational changes. We suggest a couple of recent reviews  for the Molecular dynamics simulations work as “molecular microscopes” , yieldinThe sampling issue has made it complicated to escape the anecdotal description of folding and binding processes. A couple of strategies to improve sampling in unbiased full atomic detail simulations are distributed computing using maximum parallelization in the generation of tens or hundreds of thousands of relatively short runs (reaching tens of ms of cumulative sampling for a collection of proteins) followed by the construction of Markov state models (MSMs) to represent the network of protein conformations  of macromolecules [up to 100 kDa for structure and 1 MDa for other studies ]. The re2 are reviewed in Protein dynamics is studied with NMR by measuring relaxation rates , and to follow protein folding as it happens, either by fast data acquisition of heteronuclear single quantum coherence or correlation (HSQC) experiments or by H/D exchange . ComplexGiven the low sensitivity of NMR, there is extensive time and ensemble averaging in the data, a feature to be contrasted with the single molecule character of most MD simulations. The main idea of a combined study is to obtain from the MD simulations the underlying distribution that gives the average value obtained in the NMR experiment Figure . This is2 order parameters, which relate to ps–ns motions . The collaboration of these two approaches brings simulations into the real world, and provides clear and testable molecular mechanisms for the spectral features measured by NMR, getting us closer to understanding the molecular basis for life processes.We describe the result of the improvement on both the NMR and MD fronts over the past three years, as it pertains to information flow in biological systems involving proteins in particular. This is by no means an exhaustive account on all published work on MD or NMR, and builds on decade-long efforts by many groups. We apologize to the colleagues whose work we could not include due to space or scope limitations.These simulations are the easiest to set up and carry out, and assume that the force fields are sufficiently accurate to describe both protein structure and dynamics; ingenuity is manifested in careful data analysis, and in the biological insights that can be obtained from these runs. Most of the stories deal with the dynamics of folded proteins, alone or in complexes, as these relate to catalysis or ligand binding, and are compared to amide and methyl order parameters derived from relaxation data, dispersion experiments, and H/D exchange. The biological problems that are explored by these works range from residual structure in the DSE of an acid-unfolded protein, the effect of crowders on the native structure, identification of allosteric pathways, excited states and aqueducts, characterization of loop motions important for complex formation or catalysis, selectivity due to dynamics, and fibril stability.17O magnetic relaxation dispersion experiments. The simulation reproduces the experimental mean survival times at the four cavities, in the range of 2–5 μs. They find single-file water chains that form transient aqueducts through tunnels or pores with lifetimes under 5 ns. These tunnels are mechanically linked to the conformation of the same disulfide bond described by Simulations of free proteins look at the intrinsic structural plasticity and at the timescales of the motions, to relate them to function. Two papers study the dynamics of BPTI , by anal15N relaxation data with two different approaches, and also carry out four MD simulations of 55 ns each for the wild type inactive dimer, a mutant monomer, and an active complex with Rac1. Three loops are crucial for allostery, and two possible allosteric pathways emerge from their analysis, one for dimerization and the other for GTPase binding, sharing a beta strand at their intersection. Analyzing the changes in dynamics they show that binding at loop three makes it more rigid, but this loss of entropy is gained elsewhere, at the termini of adjacent strands. The nature of protein motions and their response to ligands is an issue of practical importance for the design of inhibitors. Continuing with receptors and ligands, 16 ephrin receptors and their nine ligands are an intriguing example of how the same scaffold can allow for specificity , the binA particular case of protein–protein complexes is the amyloid fiber. Two examples showcasing the interplay of ssNMR and MD involve a prion  and a peStopping amyloid fiber formation is an important goal in the clinic. An interesting case is that of alpha-synuclein (AS) and dopamine, an interaction that avoids amyloid fiber formation. AS is an IDP, so the use of unrestricted MD required clever choices of starting structures for the simulations. D-amino acids and non-standard amino acids (such as Aib) in the flaps covering the active site. The conformational isomerization of two symmetry related flaps (residues 37–61) is correlated with the structural organization of the active site, and this step is rate limiting. The flaps sample conformations that depend on the backbone motion of G51, and exchange in the sub-ns and μs–ms timescales. S2 and car-purcell-meiboom-gill (CPMG) experiments show that the dynamics of the catalytic residues echo the dynamics of the flaps, and the coupling appears to be through water molecules. MD simulations of 300 ns of protonated or unprotonated D25 , and of L-alanine or D-alanine substitutions for G51 recover the interflap distances that were measured with electron paramagnetic resonance (EPR). 2+, which is bound to a loop that changes conformation during the catalytic cycle, so again a conformational change is important for activity. There are four nearby Es, one of which is the general base (E153), one is in the loop that changes conformation and binds Mg2+ (E198), and others bind Mg2+. Methyl-NMR and MD suggest that the loop with E198 is sensitive to the protonation state of E153, so they measured the pKa of E153 with NMR using 13C HSQC in a protein labeled in I, L, and V residues. They confirmed this residue as the general base, and showed that its protonation affects both the conformation and the dynamics of the loop, as I199 has linewidth changes, suggesting dynamics in the μs–ms timescale. They carried out MD simulations (100 ns) of the catalytic domain of Dcp2, with E153, protonated E153, and Q153. The observed structural and dynamic consequences of these modifications explain chemical shift displacements with pH, and the changes in dynamics.Enzymes with loops around the active site are common, and an important question is whether these loops help or hinder catalysis. Two studies of dimeric HIV protease show complementary approaches. Trypanosoma brucei (Tb6PGL), an interesting enzyme as it is a potential drug target. They measured the dynamics of both the apo and holo forms, analyzing relaxation data with the Model Free formalism of Lipari and Szabo , using carbon, nitrogen, and hydrogen chemical shifts as replica averaged constraints (This approach could be considered as the best way to complement the strengths of simulations and experiments. The drawback is that the restrictions are protein-specific, so what works for one need not work for others. Nevertheless, it is very powerful, as the following examples show. A natural problem for this approach is the description of IDPs or of the DSE of proteins. straints , revealeRegarding residual structure in denatured proteins Abandoning disordered structures, the next ensemble of interest is that of folding or functional intermediates. Our last two examples relate to functional dynamics. The first one  describeIn vivo NMR holds great promise to study how proteins work in their natural milieu.From the cell surface and extracellular matrix all the way to the interaction of proteins with DNA, protein dynamics is central to function. Outstanding problems in MD simulations are inaccuracies in the force fields and insufficient sampling for unrestricted MD runs. We are optimistic in that both these problems will become smaller in the near future, as force field refinement continues and computers and algorithms for simulations are improved. This will also allow for the study of larger and more complex proteins. On the NMR side, a common complaint in the works we discussed is the risk of overfitting, and the complications arising from only looking at the backbone of the proteins. On the bright side, better instruments, novel labeling schemes and pulse sequences, the use of metals and other probes, and also the development of the equations to deal with multiple states simultaneously will continue to increase our capacity to study more complex motions in proteins. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Although changes to visual acuity in spaceflight have been observed in some astronauts since the early days of the space program, the impact to the crew was considered minor. Since that time, missions to the International Space Station have extended the typical duration of time spent in microgravity from a few days or weeks to many months. This has been accompanied by the emergence of a variety of ophthalmic pathologies in a significant proportion of long-duration crewmembers, including globe flattening, choroidal folding, optic disc edema, and optic nerve kinking, among others. The clinical findings of affected astronauts are reminiscent of terrestrial pathologies such as idiopathic intracranial hypertension that are characterized by high intracranial pressure. As a result, NASA has placed an emphasis on determining the relevant factors and their interactions that are responsible for detrimental ophthalmic response to space. This article will describe the Visual Impairment and Intracranial Pressure syndrome, link it to key factors in physiological adaptation to the microgravity environment, particularly a cephalad shifting of bodily fluids, and discuss the implications for ocular biomechanics and physiological function in long-duration spaceflight. In order to reach low earth orbit on the Space Shuttle, astronauts were seated on top of a carefully designed but monumentally powerful explosion that could lift a mass of over 4 million pounds (about 1.8 million kg) up into orbit. As they ascended, they were exposed to a hypergravitational field that, at times, reached up to three times earth gravity. After about 9 min, the main engines shut off. At this point, the Shuttle was circling around the earth at an altitude of about 200 miles (320 km) above the earth surface and at an orbital velocity of about 17,500 miles per hour . Under these conditions, the apparent gravitational force on the astronauts was negligible, and they experienced the sensation of weightlessness see . Within The record for longest mission duration on orbit is held by the Russian space station Mir, which hosted individuals for up to 438 days on a single mission throughout its lifespan from 1986 to 2001. Even today, Soviet/Russian cosmonauts still hold the record for the maximum number of person-days in space. Crewed missions conducted research on the US Skylab for up to 3 months in 1973 to 1974, and provided some of the most comprehensive data on fluid shift to date. The pool of astronauts who have served on the US Space Shuttle and the International Space Station (ISS) is much larger than earlier ventures into low earth orbit. Typical mission duration for astronauts expanded from about 10 to 16 days in the Shuttle era to a routine span of ~six months on the ISS. NASA is currently planning one-year missions on the ISS to commence in 2015. At present, 35 countries have participated in human spaceflight. The combined experience of over 500 individuals continues to provide us with a richer understanding of human response to living and working in a spacecraft environment.Physiological conditions of concern that accompany spaceflight are a propensity toward bone loss , muscle IOP) )sc edema ,27. OtheIOPs both before and after flight, and experienced the greatest drop in pre- to postflight IOP, which was nearly 50% more than any other classification )dynamics . In thisdynamics , and knodynamics ,192 and dynamics ,194.A decreased proportionally to the increase in mean velocity V, the mean flowrate Q (which is the product of A and V), was essentially constant in healthy controls. On the other hand, glaucoma patients exhibited three different patterns of response, which may provide useful diagnostic information as to the source of dysfunction and decisions for treatment.In a study with open angle glaucoma patients and healthy controls, Feke and co-workers  measuredet al. )The description of valves in the superior OV  and the 2 concentrations, with periods of exposure to low total pressure and 100% O2 during extravehicular activity,Low humidity and high COIncreased radiation levels with the potential of exposure to high energy ‘cosmic ray’ radiation,A high salt diet resulting from a change in taste acuity, andA disrupted circadian rhythm.The uniqueness of the spaceflight environment may introduce other factors that play an additive role in the etiology of reduced visual acuity. The particular characteristics of a spacecraft environment are dependent on the mission requirements and the balance of engineering and operational risks. Environmental factors include vehicle atmospheric pressure and component concentrations, radiation shielding and solar particle events. Operational parameters include available daily drinking water, and even the mass and storage of food and medical supplies, which constitute potential tradeoffs with engineering parameters. For instance, the engineering and operational requirements to maintain the ISS lead to:Many of these factors, potentially in combination with microgravity fluid and tissue redistribution and individual characteristics, have been hypothesized to influence the progression of visual acuity loss in astronauts .2 concentrations unless there is atmospheric control. External venting or chemical “scrubbing” are used to remove CO2 from the air that the astronauts breathe. Another consequence of microgravity is that naturally occurring atmospheric mixing by gravitational forces is not present, resulting in localized buildup near any CO2 source. Until recently, the CO2 partial pressure in the ISS environment could reach levels up to 5 mm Hg, or approximately 20 times greater than CO2 concentrations at sea level. Terrestrial data does not imply significant acute or long-term effects, even with significantly elevated concentrations [2 is a powerful vasodilator, and hypercapnia can also increase cerebral blood flow, elevate ICP, and increase the formation of cerebrospinal fluid [2 toxicity and the inability of the air-handling system to remove CO2 from confined spaces in a timely manner. From this evidence, it was hypothesized that chronic elevated CO2 exposure, in conjunction with the microgravity-induced fluid shift, could potentially result in an increased susceptibility to the VIIP syndrome [2 levels on ISS have been reduced.Since the ISS is a closed environment, respiration and other sources of formation cause a rise in COtrations ,215. Neval fluid . On orbisyndrome . In respThe characteristics of an individual’s metabolic pathways in space may also play a role in the development of VIIP. A 2012 study of astronauts with and without the ophthalmic changes of VIIP illustrated an altered metabolic pathway involving homocysteines, cystathionine, 2-methylcitric acid and methylmalonic acid that has been linked to affected crewmembers . In thisAstronaut nutrition during spaceflight is also considered a potential influencing factor in ophthalmic changes. In general, astronauts have excellent health and nutritional status in comparison to the general population, however, the typical ISS diet is relatively high in sodium, approaching 5 g per day . This isICP over the 90-day experimental period [Alterations in the radiation environment leading to acute radiation syndrome or postflight degenerative radiation induced diseases are a significant health risk for astronauts. High-energy solar particle events (SPE) and Galactic Cosmic Rays, ranging from hydrogen nuclei (protons) to high-energy iron nuclei, make up the space radiation environment. Among the potential effects, an impact on circulatory diseases and a reduction in central nervous system function are considered the most deleterious , althougl period , which iICP if performed without a Valsalva maneuver [ICP is reduced after aerobic activity [Without intervention, the gravitational unloading of the musculoskeletal system leads to significant loss in bone mineral and muscle mass . A primamaneuver ,222 and activity . These eICP. Astronauts can experience alterations to their circadian rhythms due to changes in exposure to sunlight and changes in working periods [Changes in astronaut sleep patterns may also play a role in changes to  periods , which m periods . This stAlthough intriguing, the evidence supporting the overall importance of each of these factors is inconclusive at this time. The analysis is confounded by sparse data and interrelated influences that hinder the determination of the causal chain from a potential contributor to the observed response. It is clear, however, that many factors related to space travel have the potential to alter the fluid redistribution process, as well as CSF pressure and visual acuity.Over 50 years of human spaceflight has shown that the human body can adapt to the microgravity environment through many functional changes, including fluid and tissue redistribution, allowing humans to live and work in space for extended periods. Unfortunately, these adaptations can lead to short- and long- term loss of physiological function and increased risk of serious medical conditions. At this time, one of the highest perceived medical risks to long-duration spaceflight is the potentially permanent loss of visual acuity. All of the evidence suggests that the Visual Impairment and Intracranial Pressure syndrome exhibited in astronauts is induced by some combination of factors inherent to microgravity and other factors in spaceflight.ICP have not yet become available, however, although this is being actively pursued. ICP is important to ocular biomechanics because, assuming that there are no blockages, it sets the pressure in the retrobulbar subarachnoid space behind the eye.Upon introduction into microgravity, the most obvious effect of spaceflight is the aggressive redistribution of bodily fluids from the legs toward the upper body, including blood, plasma, cerebrospinal fluid, lymph and interstitial fluid. The acute response can be studied within the 20-second intervals of microgravity seen in parabolic flight. The heart becomes more spherical, intraocular pressure spikes, the spine elongates, and the bulk fluid/tissue distribution shifts in the cephalic direction almost immediately. Plasma volume drops sharply and reaches a new equilibrium within about two days. During and after the gross redistribution, regulatory processes, osmotic and transmural pressure gradients and tissue stress gradients continue to refine the compartmental distribution of the fluids. The rearrangement of body mass distribution is essentially complete by the middle to end of the second week of flight. The upper body vasculature, spinal theca, interstitial tissues and possibly the lymphatic system are likely repositories for much of the redistributed fluid. Ground-based experiments suggest that blood displaces some of the cranial CSF, and that intracranial pressure increases in the acute phase. Inflight measurements of As described in this review, the fluid shift causes the body to reach a new “space-normal” homeostatic state, which is driven by the loss of hydrostatic pressure gradients as encountered on earth. This paper introduced simple water-filled balloons to derive insight into the biomechanical stresses applied on membrane geometry and differing orientation and magnitude of the hydrostatic pressure gradient. It also described the means by which such a model could be further developed by incorporating additional tissues such as muscle and fat. This approach could be used to quantitatively examine the impact of factors associated with the spatial distribution of these tissues, including body size and type, gender, BMI, and fitness level. In order to develop a meaningful model, quantitative measurements of tissue material properties and their spatial distribution would also be needed, both to build the model and to validate its predictions.IOP, which would in turn affect the translaminar pressure gradient. The availability of drainage pathways, the compliances of the tissues of the venous, arterial, lymphatic and central nervous systems, and the role of regulation are essential factors to the understanding of blood flow within the cranium. The retinal tissues appear to be governed by effective regulation in gravitationally related fluid shifts in healthy people, but less is known about the response of the choroid.Cerebral and ocular hemodynamics are likely to play a significant role in the biomechanical stress state imposed on ocular tissues in space. The volume of blood in the ocular tissues has a direct impact on the All of the tissues in the human body are subjected to a substantially different set of biomechanical stresses in the spacecraft environment, and they may be in excess of those routinely encountered on earth. Over the course of many weeks or months, some tissues, such as the sclera, have the capacity to remodel in order to realign their biomechanical properties with the new homeostatic state. A better understanding of the relationship between the biomechanical stress state in the eye and tissue remodeling could provide the link between biomechanics and some of the anatomical changes observed in VIIP. In addition to biomechanical responses, these tissues may have increased sensitivity to particular metabolic pathways and environmental factors, leading to increased susceptibility for unfavorable adaptations, such as degraded visual acuity, that are observed in the VIIP syndrome.The cephalic fluid redistribution causes dramatic physiological changes upon entry into microgravity and it is present throughout the mission. Consequently, it is inextricably linked to a cascade of physiological responses to space, which have yet to be fully described. Although no complete pathway from exposure to space to VIIP can yet be determined, the profound impact of fluid shift must be considered as one of the more likely contributors to the condition. It is likely to act in concert with other potential contributing factors such as diet, radiation exposure, atmospheric composition, genetic and physiological or anatomical predispositions.At present, it is unclear if the reduction in visual acuity is progressive with time on orbit or if most of the persistent effects occur early in spaceflight. The level of uncertainty in understanding this condition is relatively high, but that understanding is critical to continued success in long-term spaceflight. The NASA Human Research Program is actively engaged in studying the initiation and progression of the VIIP syndrome through studies on the International Space Station and on the ground, including HDT studies and numerical investigations, as well as the development of new on-orbit diagnostic hardware. Over the next several years, the Human Research Program is poised to make major strides in unraveling the tangled web of processes involved in the etiology of the VIIP syndrome.