Kenya: Tropical Medicine Research Institute Targets Neglected Deadly Diseases
“Our vision is of a world in which aid is finite, but scientific collaboration isn’t.” Wycliffe Muga, Weekend Editor of The Star, and Roeland Scholtalbers (Head of Communications – Institute of Tropical Medicine in Antwerp) met at the World Conference of Science Journalists held in Helsinki, in 2013. The following is the transcript of a subsequent conversation on the work of the ITM:
Wycliffe: Tell me a little about the history, background and founding of the Institute of Tropical Medicine, Antwerp?
Roeland: It was founded in 1906 in Brussels as the School of Tropical diseases. In 1934, it moved to Antwerp, where we are still based and it became the Institute of Tropical Medicine. Why? Because ships to the Congo colony left from the docks of Antwerp’s port.
The Belgians were very much involved in public health in their colony, Congo. In those days, the institute trained people who were going to the tropics, while it also served as a hospital for those returning ill. However, after decolonization in 1960, ITM became a specialized part of the Belgian system of higher education. At that point, it no longer trained colonials, but experts in development cooperation. During this period our contacts with the developing world intensified and staff started to travel to developing countries to teach and train people.
Our educational portfolio grew; we also started working on animal health, for example. At the end of the 1960s, we added a Master in Public Healthto our curriculum and we gradually acquired a more international student population. In the 1970s our research component expanded greatly.
We started setting up research lines in developing countries; medical care, cooperation with scientists, institutes and local authorities. We no longer merely focused on treating diseases as we moved to epidemiology, organization of health systems and those kinds of elements.
This was based on the fact that diseases not only have a biological side, but socio-economical determinants as well. That is how our institute developed from the early period of colonialism through the ’60s and ’70s to the three components we have today; education, research and medical services.
Wycliffe: That’s a very rich history indeed. But I’m sure, in the one hundred and ten years, you must have had some great achievements and some disappointments as everything couldn’t have gone your way. Could you tell us about them?
Roeland: Of course. It would be hard though, and probably unfair, to mention just one achievement for such a multifaceted institute. But there are things that set us apart from other organizations, like our focus on neglected diseases affecting the poorest, or our role as HIV pioneers.
For example, fighting sleeping sickness would not have been possible without diagnostics developed at ITM, whilst since the early days we have contributed to research on the HIV virus and care for HIV/AIDS patients.
Wycliffe: How did your institute’s work on HIV develop?
Roeland: We were in the first line when this new, unknown virus caused a great scare throughout the world at the beginning of the 1980s. Peter Piot, the former director of UNAIDS and current director of the London School of Hygiene and Tropical Medicine, was a young researcher at ITM when the disease broke out. He, and several colleagues still working at the institute today, were closely involved in the discovery of what HIV actually was and how it spread, in Africa.
They set up research lines and provided care to the first patients. That was a very intense period, which laid the foundations for our HIV work today. The HIV virus is a difficult virus; we have learned so much about it, yet it is still impossible to develop a vaccine or a cure.
But our laboratory, clinical and epidemiological research have provided several important insights which have contributed to turn a deadly disease into a chronic one, as long as people stay on antiretroviral treatment. We closely follow-up many HIV patients and we are also a national reference centre for HIV. We also look for ways to make it quicker and easier to perform an HIV test, for example through a swab test which looks for antibodies against HIV in the saliva. Our HIV expertise is multidisciplinary, which is one of our strengths.
Wycliffe: You mentioned your expertise on neglected diseases; could you tell us what they are?
Roeland: We are proud to be at the forefront against diseases like Leishmaniasis, Buruli ulcer, bilharzia and sleeping sickness that few people work on and even less people talk about. Neglected diseases affect millions of poor people worldwide, yet very few medicines or vaccines are being developed for these diseases.
Take Human African Trypanosomiasis, or sleeping sickness, which is caused by the trypanosome parasite transmitted by the bite of a tsetse fly.This parasite then multiplies in the blood and evades the human immune system and settles in our organs; heart, kidneys. It weakens patients, it messes up their sleep patterns – hence the name sleeping sickness – and it causes motor and mental problems. If left untreated, this leads to coma and death. WHO estimates that it claims between 10,000 and 20,000 lives each year, mainly in Central Africa.
Most cases occur in the Democratic Republic of the Congo. Now you might say there is a large gap between 10,000 and 20,000 lives. That is because there is a lot of uncertainty, because most cases go undetected. The people who get the disease live in remote villages with little access to healthcare, one of the main problems of sleeping sickness. The progress made so far in reducing the number of new cases wouldn’t have been possible without the diagnostic tools that were and are still developed at ITM.
Wycliffe: How does that work, diagnosing sleeping sickness?
Roeland: For nearly thirty years mobile teams have used our CATT test, an agglutination test, to screen a lot of people in a short time. Last year, our researchers co-developed individual rapid tests which allow medics to get a diagnosis within 15 minutes and that does not require to be stored in a fridge.
This is important, because if diagnosed in time this disease is easy to treat, but once the brain is invaded it becomes more and more difficult to treat, with some of the medicines required having deadly side effects. The rapid tests are easily administered and every health worker with a bit of instructions and training can perform this test. The rapid tests are produced by companies, but they all contain our antigens used to detect the parasite causing the disease.
Wycliffe: Just to get an idea of how widespread this disease is, you have mentioned 10,000-20,000 deaths. Do you have any estimate of those infected yet survive; or incidence rate?
Roeland: Tens of millions of people are at risk of sleeping sickness across more than 25 countries in Sub- Saharan Africa. In 2009, the number of reported cases for the first time dropped just below 10.000 as a result of the control efforts. The incidence rate is thus low. As mentioned earlier though, many cases go undetected. If diagnosed early treatment is rather straightforward, but the disease is deadly if left untreated.
Wycliffe: DRC is a very poor country in a state of semi-civil war most of the time. Unless someone from outside came to perform this research, I doubt there is capacity within DRC to carry out the research. I would say definitely that is a great achievement, especially since it’s not prompted by monetary considerations but by the mission of the institute.
Roeland: Let me pick on that as that’s where the story gets more interesting, because things are changing.Today, we are in a situation where the prevalence of sleeping sickness is decreasing and the strategy of going out to the field with mobile teams is proving less and less effective. Screening for sleeping sickness should be integrated in the normal health system.
That might not sound too exciting but it is a very important thing to do. Now, the DRC is trying to make this work. On the one hand, we are supporting the operational activities of the national sleeping sickness programme. On the other, we carry out several research projects on diagnostic tools, as well as screening and treatment strategies in close collaboration with the national reference laboratory for sleeping sickness in Kinshasa. I should stress here that this means that the DRC is in the driving seat and we enter into play when our specific expertise is required. This neatly fits in our vision of a world in which aid is finite, but scientific collaboration isn’t.
Wycliffe: The institute has indeed done some pioneering work. But going forward, say 50 or 100 years to come, where will your focus be? Will it still be a focus on the neglected diseases in low income countries or will it be on global challenges such as HIV? What is the vision of the organization?
Roeland: You know what, this question gives me a good entry point to also mention one of our shortcomings, or disappointments you asked about earlier. As an institute, we should perhaps have explicated our vision of “beyond aid” earlier. You might be familiar with this concept aboutgoing beyond the paternalistic concept of northern-driven development aid. That is a formula which has its roots in the past, you could say the colonial past. But it is something we are trying to change, as in the example I mentioned in the DRC.
If you look at our mission in the 1970s, it was to strengthen healthcare in developing countries and it very much read like we were the ones who were going to do that. Then in 1995, it had become strengthening the rationale of healthcare in developing countries and thus helping these countries build up basic healthcare, scientific capacity and we are definitely very much in the process.
I will tell you more about that journey, which we call ‘Switching the Poles’, later. But for 2020 and beyond, we actually want to move to a role where we stimulate scientific research on tropical and poverty-related diseases, whilst developing countries are increasingly able to run their own business. That might sound a little bit like a slogan but it’s really something that we believe in and we put a lot of effort in.
Wycliffe: Why is it so important to move to a different type of cooperation?
Roeland: This is about countries and people taking charge of their own future.Tropical and poverty-related diseases, such as tuberculosis, have the greatest impact in low- and middle-income countries. It does make sense to treat them and deal with them as close as possible as to where they happen. Through an extensive programme funded by Belgian Development Cooperation, we are strengthening the capacity of long-term partners across Africa, Asia and Latin America to enable them to do research, to care for patients, to train professionals and take up a pivotal role in their health system. Maybe an anecdote or an example is in place:
This is something I have seen with my own eyes just a few months ago in Cotonou, Benin, at the Laboratoire de Référence de Mycobactériologie (LRM). LRM specializes in diseases caused by mycobacteria like tuberculosis or Buruli ulcer, which is a disease causing mutilating scars which are very difficult to treat. For years, like other laboratories in Africa and around the world, they have been sending samples to ITM to get them analyzed and receive results from ITM. But we get many, if not too many, requests and it is not really efficient to continue doing that in Antwerp.
We will increasingly focus on quality checks of other institutes, which take over some of our tasks. LRM has been very good in doing so. A former PhD student at ITM, who has learned a lot of the important knowledge on Buruli ulcer, TB and laboratory techniques in Antwerp, heads up the lab at LRM.
The laboratory is now a candidate to become a WHO supranational reference centre for West Africa for these two diseases. That means that other West African countries come to LRM to get their samples analyzed. I think it is a beautiful example of an African country or institute taking ownership of a very important issue.
Every day at LRM you have nearly 100 patients who come with suspected TB. They have an excellent laboratory to make the right diagnosis and for further monitoring during treatment. We are talking about microscopy, sputum culture and modern techniques such as PCR (Polymerase Chain Reaction), including molecular fingerprinting. They perform analyses at the same standard as we do in Antwerp.
Wycliffe: That’s the future as you see it. If I understood you correctly, you are talking of establishing partnerships globally but specifically in the areas where certain diseases are prevalent or widely found so that the research can be done