A PUBLICATION OF ASM | VOL 1 | ISSUE 2 | SPRING 2014
SC I EN C E I N
A NEW AGENDA FOR GLOBAL HEALTH SECURITY CDC Director Tom Frieden Speaks
P. 6
SCIENCE DIPLOMACY IN IRAN - NORTH KOREA - PAKISTAN Hotez, Madani, England, Asghar
P. 12
THE ONLY MICROBIOLOGIST IN CONGRESS Inside Representative Slaughter’s Office
P. 46
1
HOW DOES COLLABORATION OFF THE BEATEN PATH LEAD TO INNOVATION, DISCOVERY AND DIPLOMACY?
CULTURES Vol 1, Issue 2 » Page 1
CULTURES STAFF
BOARD OF ADVISORS
UNITED STATES
BRUCE
Alberts
JASON
Rao
MONGOLIA
KHOSBAYAR
Tulgaa
EGYPT
SANJANA
Patel
ENAS
Newire
PORTUGAL
DIOGO
ProenÇa
KATY
Stewart
PARAGUAY
LAURA
For interactive features and more content, read Cultures on your browser or on your tablet. Visit asm.org/cultures for more information.
Acevedo Ugarriza
UNITED STATES
VAUGHAN
Turekian
UNITED STATES
NATHAN
Wolfe
IN THIS ISSUE LETTER FROM THE EDITOR HAPPENING NOW Q&A with Tom Frieden, Director of CDC
4 6
ACROSS THE DIVIDE Vaccine Diplomacy with the Islamic Nations of the Middle East, North Africa, and Central Asia
14
Peter Hotez Building Bridges with North Korea: Engaging through Health Diplomacy
26
Kathleen England & Edward Desmond Science as a Foundation for Collaboration in Iran and Beyond
34
Navid Madani Pakistan: Public Health Challenges and Opportunities
40
Rana Jawad Asghar
IN CONVERSATION Q&A with U.S. Congresswoman Louise M. Slaughter (D-NY)
46
VOICES A collective response from ASM Young Ambassadors of Science on the challenges and opportunities for science communication
52
ON THE GROUND Narratives from the frontlines of science
60
SHARING THE VISION CRDF Global & NAMRU-3
96
IN YOUR WORDS What are you doing to save the world? PHOTOGRAPHY + ART CREDIT ON PAGE 110 CULTURES Vol 1, Issue 2 Âť Page 3
108
JASON RAO Today, it is easy to become complacent with modern day comforts; instant communication, air conditioned homes, medicines that prevent or cure your ailments. For many, the threats are far away, the diseases are rare, and science is ahead of the curve. It is only after personally confronted with disease, or caught in the tragic events of a catastrophe that we realize the limits of our collective knowledge, and the critical and often desperate need to know more. Drug resistance, epidemics of emerging infectious diseases as well as chronic diseases, thrust each of us to the realization that we have much to learn about mother nature, and for science to get “ahead of the curve”, we must go to those far-away, hard places, to learn what we do not know, and study it. The “modern day” is in fact far from comfortable for most, and progress for all, begins with science, in those hard places. And we often make friends along the way. These hard places are isolated with ever increasing political barriers that fuel misperception, steadily replacing generations of friendship with misunderstanding and hostility. This second issue of Cultures, on “Science in Hard Places,” is a topic that is central to our vision for the magazine, illustrating how science can happen in the most challenging environments—an advancement of our collective knowledge
as well as our common understanding of one another. Science sets aside politics to solve shared problems. Something we can all agree upon. What is a “hard place”? There is no single definition, but here we let the authors illustrate them. From geographic boundaries and political barriers to resource constraints and unstable environments, they form partnerships and together forge a pathway for
Page 4
which is a snapshot of individuals, who work in the field and dedicate their lives to scientific discovery, with little recognition for their daily grind towards progress. From Aisha Jumaan to Peter Luckow to Captain Colleen Gallagher, these are the people closest to action, yet furthest from the limelight.
science to move forward under near impossible circumstances. These stories reflect the true spirit of scientists, who forgo prestige for progress, by working on the front lines instead of the air-conditioned halls of the ivory tower. But this work goes much further; building personal relationships, erasing misconceptions, building cultural understanding.
Finally, we share a rare opportunity to hear from two policymakers in Washington, whose careers embody the theme of working to advocate for science in challenging environments. CDC Director, Tom Frieden, gives us his insights on the new Global Health Security Agenda that brings new emphasis to the global nature of the biological threats we face. Congresswoman Slaughter, one of two scientists and the only microbiologist in Congress, shares her views on the clear and present threat of antimicrobial resistance, as well as inspiration to young people looking to make a difference. Her career path and achievements are a model, and a stark reminder that we need more scientists in the legislative arm of government.
From Iran, Pakistan, and North Korea, “Across the Divide” of this issue proves that science can and should be done—anywhere. The results speak for themselves— none of which could have happened without the network of champions that joined each of our authors—Peter Hotez, Kathleen England, Ed Desmond, Navid Madani, and Jawad Asghar—who make progress in the most trying of environments. Institutions that embody the spirit of collaboration across all boundaries, CRDF Global and NAMRU-3, share their stories in “Sharing the Vision”. We are honored to have these organizations contribute to this issue.
As always, we are grateful to our contributors, and you, the reader, for making Cultures what it is.
We introduce a new section in this issue as well, “On the Ground”, SNAPSHOT OF CULTURES
2,500+
reads online in over 75 countries
22
countries made contributions
35,000+ copies mailed worldwide
Visit www.asm.org/cultures for additional content and interactive features! CULTURES Vol 1, Issue 2 » Page 5
HAPPENING NOW:
TOM FRIEDEN
A Q&A with Tom Frieden, M.D., M.P.H., the director of the Centers for Disease Control and Prevention (CDC)
Q:
There has been a lot of buzz recently about the Global Health Security Agenda. For our readers, could you describe what it is and why it is particularly relevant now?
A: Global health security means keeping both the United States and the world safe and secure from infectious disease threats by preventing, detecting, and responding to outbreaks as early and effectively as possible. On February 13, 2014, leaders from the U.S. government, the World Health Organization, and ministries of health around the world pledged their support to accelerate progress toward a world safe and secure from infectious diseases through the Global Health Security Agenda. Our aim is to improve the response to disease outbreaks and to close the gaps in surveillance, so that we can stop disease threats at the earliest possible opportunity. Right now, we are in a perfect storm of vulnerability. Disease threats can spread faster and more
unpredictably than ever. In today’s interconnected world, people are traveling more often and farther, our food and medical products come from around the globe, and biological threats and drug-resistant microbes pose a growing danger to people everywhere in the world. We are all connected by the food we eat, the air we breathe, and the water we drink, making a threat to health anywhere a threat to health everywhere.
Q: The theme of this issue explores scientific collaboration “off the beaten path” and why this is essential to advancing science and global health in particular. How important are collaborative partnerships in meeting this agenda? A: Global health security cannot be achieved by countries acting alone. A global effort through collaborative partnerships and a variety of programs and strategies will be necessary to make the world safe and secure from infectious diseases.
Page 6
Emerging global disease threats create opportunities for us to forge new global solutions such as the International Health Regulations, which all 194 member states of the World Health Organization have adopted. Although we have made significant progress in the past 10 years, significant gaps remain. Only 20% of countries report that they are able to effectively protect their people against infectious disease threats. One of the goals of the Global Health Security Agenda is to close this gap. That is why the United States is making a commitment to help develop health systems and the necessary workforce to prevent avoidable epidemics, detect threats early, and respond rapidly and effectively to save lives and reduce human suffering.
Q: What do you envision as the outcome of this initiative in 5 years? A: Over the next 5 years, the United States has committed to working with at least 30 partner countries (with at least 4 billion people) to prevent, detect, and respond to infectious disease threats, whether naturally occurring or caused by accidental or intentional releases of dangerous pathogens. As part of this effort, countries will be expected to demonstrate concrete commitment to accelerating the progress on global health security through domestic and external (regional, international, bilateral) activities to support the progress and achievements in other countries.
Health workers in Uganda are disinfected after searching for clues to the Ebola chain of transmission in people’s homes
CULTURES Vol 1, Issue 2 Âť Page 7
Q: Are there any success stories that you hope to replicate? A:
CDC conducted global health security demonstration projects in Uganda and Vietnam last year. During 6 months of intensive collaboration, CDC specialists worked with the ministries of health in both Uganda and Vietnam to conduct several core activities. The first was
to modernize diagnostic testing for high-risk pathogens. The second was to develop real-time information systems capable of tracking outbreaks faster. And the third was to improve emergency operations procedures so these countries could respond to urgent situations faster and more effectively. Both countries have improved their Emergency Operation Centers and laboratory
THE EMERGENCE OF GLOBAL HEALTH SECURITY
UN and World Bank Group formed (important for global cooperation)
SECURITY
Biological Weapons Convention
Geneva Protocol
U.S. Centers for Disease Control & Prevention formed
HEALTH
World Health Organization Created International Sanitary Regulations (pre-cursors to IHRs) Page 8
International Health Regulations amended
systems, which are essential to disease surveillance, analysis, and response. These are health security models that can make their host countries, the United States, and the whole world safer. In 2014, working in partnership with the Department of Defense, we have committed to spending $40 million in 10 additional countries to continue the initial rapid investments in global health security.
Amerithrax Attacks
Select Agent Rule
United Nations Millennium Development Goals revealed
National Biodefense Strategy published (“Biodefense for the 21st Century” document)
Q: History shows that nations are likely to respond to emergencies only after they occur rather than to invest in prevention. The agenda seems to do a bit of both. Is it enough? Should we be doing more? A:
While we have made significant accomplishments in disease prevention, detection, and response, we need to do more to help
National Strategy for Countering Biological Threats
U.S. National Security Strategy
International Health Regulations revised
President’s Emergency Plan for AIDS Relief (PEPFAR) announced
CULTURES Vol 1, Issue 2 » Page 9
IN 2014, GLOBAL HEALTH SECURITY AGENDA LAUNCHED
This human skull was part of a shipment inspected by the CDC San Francisco Quarantine Station, one of 20 stations around the country.
countries around the world build their in-country disease surveillance and response capacities. The Global Health Security Agenda is a focused approach to doing that.
Q: Later in this issue, we hear from Congresswoman Slaughter who strongly believes in evidence-based policy making, particularly for issues surrounding health. From your vantage point, is the United States doing enough to combat the spectrum of global health threats? A: Much has been done, but much more is needed. In 2013, the United States spent approximately $500 million to support global health security activities, but such resources can be spent more effectively if they are more closely coordinated. Efforts to accelerate progress will attempt to improve focus so that
we can use existing resources more effectively. Many U.S. agencies have made important investments in this area, so we are considering ways to better structure and align existing investments to ensure progress in the areas of improved and accelerated prevention, detection, and response. For example, in 2014, the Centers for Disease Control and Prevention and the Defense Threat Reduction Agency have jointly committed to accelerate progress on Global Health Security by codeveloping a strategy and devoting $40 million toward activities leading to the accomplishment of the U.S. government’s global health security objectives in 10 nations. President Obama’s 2015 budget includes $45 million for CDC to further expand global health security activities toward the 5-year goal of protecting 4 billion people from infectious disease threats.
Page 10
Q: The Agenda has ambitious goals, geared toward a global audience. What can our readers do to get involved and to contribute? How can individual scientists contribute? A:
Laboratory scientists can follow protocols to ensure that dangerous organisms are kept securely so that people who work in those laboratories are not harmed and that the organisms are not released. Health professionals interested in being on the public health frontlines – conducting epidemiologic investigations, research, and public health surveillance both nationally and internationally – can explore opportunities with the Epidemic Intelligence Service (EIS, http://www.cdc.gov/eis/). EIS is a
unique 2-year postgraduate training program of service and on-the-job learning for health professionals interested in the practice of applied epidemiology. More than 3,000 EIS “disease detectives” have responded to requests for epidemiologic assistance in the United States and around the world. Health care providers should be aware of reportable disease-reporting systems for infectious diseases such as severe acute respiratory infection, influenza-like illness, viral hemorrhagic fever, and severe acute watery diarrhea, to name a few, and follow reporting guidelines to inform the appropriate health authorities and provide appropriate actions to detect, prevent, and respond.
TOM FRIEDEN, M.D., M.P.H.
DIRECTOR, CENTERS FOR DISEASE CONTROL AND PREVENTION Tom Frieden, M.D., M.P.H., is director of the Centers for Disease Control and Prevention (CDC), our nation’s health protection agency. Since 2009, he has worked to control health threats from infectious diseases, respond to emergencies, and battle the leading causes of death in our nation and around the world. Prior to leading CDC, Dr. Frieden served as New York City Health Commissioner (2002–2009), where helped reduce smoking, eliminate trans fats from restaurants, and initiate the country’s largest community-based electronic health records project. From 1992 to 1996, he led New York City’s tuberculosis control program that reduced multidrug-resistant cases by 80 percent. Learn more at www.cdc.gov/about/cdcdirector/ and follow Dr. Frieden on Twitter: @DrFriedenCDC.
CULTURES Vol 1, Issue 2 » Page 11
Science in Hard Places
In each issue, we ask experts to write an essay from their perspective on one central theme. In this issue, they discuss the challenges and opportunities of collaborations off the beaten path, and how they can lead to innovation and discovery. Page 12 Âť Across the Divide Âť Hotez / Desmond & England / Madani / Asghar
PG 14
ENGAGING IN VACCINE DIPLOMACY WITH ISLAMIC NATIONS
PG 26
BUILDING BRIDGES IN NORTH KOREA
PG 34
FOSTERING SCIENCE PARTNERSHIPS WITH IRAN PG 40
WORKING ON THE FRONTLINES OF PUBLIC HEALTH IN PAKISTAN CULTURES Vol 1, Issue 2 » Page 13
Students at Cairo University listen to President Barack Obama on Thursday, June 4, 2009 (Photo: Pete Souza, The White House)
VACCINE DIPLOMACY WITH THE ISLAMIC NATIONS OF THE MIDDLE EAST, NORTH AFRICA, AND CENTRAL ASIA By: Peter Hotez, M.D., M.P.H. High rates of neglected tropical diseases now found in the most troubled countries in the Middle East, North Africa, and Central Asia could create innovative opportunities for scientific collaborations and diplomacy. On June 4, 2009, U.S. President Obama delivered a landmark speech at Egypt’s Cairo University. He stated “I have come here to seek a new beginning between the United States and Muslims around the world,” and announced the future establishment of scientific centers of excellence in Islamic countries, together with the appointment of new U.S. science envoys (1–3). The President also called for new collaborations with member states of the Organisation of the Islamic Conference (OIC) to eradicate polio through vaccination (1). His call exemplifies a branch of global health diplomacy related to the expanded use of vaccines that has become known as vaccine diplomacy (4). Today, the World Health Organization (WHO) recognizes three remaining polio-endemic nations – Nigeria, Afghanistan, and Pakistan –
CULTURES Vol 1, Issue 2 » Page 15
each of which are OIC member states (5). Moreover, additional polio outbreaks over the past year on the Horn of Africa and extending across a “polio importation belt” to West Africa affected several OIC member countries, as did outbreaks in Syria and Yemen (6–8). The latest threats to the success of U.S. vaccine diplomacy in the Islamic world were the recent targeted killings of polio vaccinators by the Taliban and other extremist groups (4, 9). Here, I describe a second and mostly untapped vaccine diplomacy opportunity focused on a group of highly destabilizing and poverty-promoting tropical diseases now threatening some of the most important OIC nations in terms of their strategic importance to the United States.
MOVING BEYOND POLIO: THE NEGLECTED TROPICAL DISEASES My analysis of the world’s neglected tropical diseases (NTDs) in 2009 strongly reinforced the urgency for large-scale global health interventions and global health diplomacy for Islamic-majority countries (10). NTDs are chronic and debilitating parasitic and related infections that trap people in poverty through their effects on worker productivity, and can even destabilize communities, leading to conflict (11). Because many of the poorest countries in sub-Saharan Africa, as well as Bangladesh and Indonesia, are Muslim-majority countries, the OIC nations were found to account for a disproportionate share of the world’s high-prevalence NTDs (10). For example, up to 40% or more of the world’s helminth infections (including schistosomiasis and intestinal helminth infections such as ascariasis and hookworm) can be found in OIC countries, together with approximately one-fifth of the cases of leprosy and trachoma (10). Thus, NTDs could represent a potent force for poverty and unrest in the Islamic world. Based on such findings, I called for greater U.S. scientific cooperation with the Islamic world through joint efforts in NTD control and elimination (11–13). In parallel, the Honorable Kerri-Ann Jones, Assistant Secretary for Oceans and International Environmental and Scientific Affairs at the U.S. Department of State called for stepped up interventions for HIV/AIDS and pandemic influenza (14). Outside sub-Saharan Africa and Asia, in our previous study, the Middle East and North Africa were also found to exhibit an
Page 16 » Across the Divide » Hotez / England & Desmond / Madani / Asghar
Figure 1: Middle East, North Africa, and Central Asia Genemo Abdela, health professional, is one of a team surveying almost 600,000 people in Ethiopia for the neglected tropical disease trachoma.
unexpectedly high prevalence of NTDs among their estimated 65 million people living on less than $2 per day (15). The major NTDs of this region include widespread parasitic infections such as helminth infections and cutaneous leishmaniasis; bacterial NTDs such as brucellosis and trachoma; and some important viral infections including dengue and Rift Valley fever (15). Today, several OIC countries in the regions of the Middle East, North Africa, and Central Asia stand out for their high visibility, potential for conflict, and strategic importance to the United States, especially in its efforts to combat international terrorism. These OIC “hot-spot” nations include Afghanistan, Egypt, Iraq, Iran, Pakistan, Syria, and Yemen. In the setting of conflict, NTDs have become hyperendemic in some of these countries or they are now imminent threats (15, 16).
CULTURES Vol 1, Issue 2 » Page 17
Specifically in regard to the seven OIC hot-spot nations listed above, cutaneous leishmaniasis is now hyperendemic in Afghanistan, Syria, and Iraq (where, because of its extreme disfigurement when it appears on the face or other exposed parts, is sometimes known as “Aleppo evil”); dengue fever transmitted by Aedes mosquitoes affects millions in Egypt and Pakistan; and polio remains endemic in Afghanistan and Pakistan (15, 16). In addition, intestinal helminth infections are widespread where regular and periodic deworming is not conducted, and important animal infections with zoonotic potential have or could emerge, including rabies and brucellosis (15, 16). Shown in Box 1 is a new summary analysis of three major NTDs – cutaneous leishmaniasis, dengue fever, and intestinal helminth infections – in the seven hot-spot nations based on recent publications since 2012 (17–22). Overall, more than 450 million people live in these seven countries (17), of whom more than one-third live in extreme poverty (18). NTDs are widespread in this setting of conflict and poverty. Up to 500,000 people in these seven countries suffer from cutaneous leishmaniasis, led by Afghanistan, Iran, and Syria (19). Indeed, the seven affected countries account for approximately 40% of the total global cases of this disease (19). Moreover, more than 20 million cases of dengue fever occur, with most of the cases in Pakistan and Egypt (20).
Page 18 » Across the Divide » Hotez / England & Desmond / Madani / Asghar
BOX 1: NEGLECTED TROPICAL DISEASES IN SEVEN KEY ISLAMIC NATIONS OF IMPORTANCE TO THE UNITED STATES: AFGHANISTAN, EGYPT, IRAQ, IRAN, PAKISTAN, SYRIA, AND YEMEN
455 MILLION
163 MILLION
cases of cutaneous leishmaniasis
≈ 400,000*
account for 40% of global cases of leishmaniasis
22 MILLION
59 MILLION
total population of 7 nations referenced
estimated cases of Dengue Fever
live on less than $2 per day
children require regular deworming
*estimated range of 280,500 to 505,200
Water Gathering: A Major Mode of Acquisition & Transmission of Neglected Tropical Disease. In 2008, children collected and carried water from the Savelugu Dam, an area known for a high prevalence of guinea worm.
Almost 60 million children require deworming for their intestinal helminth infections; most of those children are in Afghanistan, Iraq, and Pakistan (21, 22). Despite widespread emerging and neglected diseases in the region, currently, the Global Health Initiative (GHI), which combines U.S. government agencies linked to global health in more than 70 countries (23), does not report any operations in the seven hot-spot countries listed above (24). Similarly, the U.S. Agency for International Development (USAID) NTD Program does not support activities in these nations (25). However, USAID is engaged in important initiatives to strengthen public health systems that emphasize maternal and child health in Afghanistan, Egypt, Pakistan, and Yemen (26–29), while, in Egypt, USAID, partly in collaboration with a U.S. Naval Medical Research Unit, is expanding infectious disease surveillance efforts, with a program to investigate drug-resistant microbes and hospital-acquired infections (29).
INTERNATIONAL COOPERATION ON “ANTIPOVERTY” VACCINES TO COMBAT NTDS Several of the most serious NTDs now affecting the Middle East, North Africa, and Central Asia, especially in the hot-spot seven countries, could potentially be controlled or eliminated through the development, testing, and, ultimately, delivery of new vaccines. For the diseases listed in Box 1, including cutaneous leishmaniasis, dengue fever, and hookworm infection (one of three major intestinal helminth infections), some studies have confirmed the potential cost-effectiveness of new vaccines if they were developed (30–32). Currently, several multinational pharmaceutical manufacturers are developing and testing new dengue vaccines (33), but, for cutaneous leishmaniasis, hookworm infection, and other intestinal helminth infections, the development of these so-called antipoverty vaccines is being led by nonprofit product development partnerships (PDPs), including our Sabin Vaccine Institute and Texas Children’s Hospital Center for Vaccine Development (30, 34, 35). Science vaccine diplomacy is one specific component of vaccine diplomacy, one that I defined previously as “the joint development of life-saving vaccines and related technologies, with the major actors typically scientists,” including scientists
Page 20 » Across the Divide » Hotez / England & Desmond / Madani / Asghar
from “nations that often disagree ideologically or even nations that are actively engaged in hostile action” (4). One of the outstanding historical examples of vaccine science diplomacy is the joint development of the oral polio vaccine between the United States and the former Soviet Union during the late 1950s and early 1960s (4, 12). Today, there is the potential for U.S. scientists to collaborate in vaccine development and production with the five OIC developing country vaccine manufacturers in Egypt (Vacsera), Indonesia (Biofarma), Iran (Razi Vaccine and Serum Institute and Pasteur Institute of Tehran), and Saudi Arabia (Arabio) (36–38). In the hot-spot countries, it would be exciting to explore partnerships for leishmaniasis and helminth vaccines with the vaccine manufacturers located in Egypt and Iran. Together with Mohammad Rokni from the Tehran University of Medical Sciences, we previously highlighted the opportunity for collaborations between U.S.-based PDPs and Iran’s major vaccine developer, the Razi Serum and Vaccine Institute (17), or Tehran’s Pasteur Institute. A key point is, just as Dr. Albert Sabin developed the oral polio vaccine jointly with the Soviets during the Cold War (4), it should be possible for U.S. and Iranian scientists to collaborate for producing vaccines to combat
CULTURES Vol 1, Issue 2 » Page 21
Secretary of State Hillary Clinton recounts a story to President Barack Obama, Senior Advisors David Axelrod and Valerie Jarrett, outside the Sultan Hassan Mosque in Cairo, Egypt, June 4, 2009.
Page 22 Âť Across the Divide Âť Hotez / England & Desmond / Madani / Asghar
diseases affecting the Middle East, North Africa, and Central Asia. Some of these diseases also affect the southern United States and neighboring regions of Mesoamerica (39). Several political hurdles need to be surmounted in order to allow joint vaccine development initiatives to begin. These initiatives might include lifting the embargoes regarding the exchange of the reagents used for medical research and the equipment needed for vaccine production, such as bioreactors and large-scale protein purification equipment. A potential conflict is the observation that reagents, equipment, and research protocols used for vaccine development could, in theory, be used for the production of toxins or other biological threats (38). Therefore, the success of vaccine science diplomacy would require the active participation of both the U.S. and Iranian governments in support of the scientists, to help shape new policies and guidelines for recombinant DNA technologies, and the essential steps of early-stage vaccine pilot manufacture, investigational new drug (IND) submissions with the national regulatory authorities of each country, and phase 1 clinical testing. Vaccine science diplomacy is an exciting new avenue for international scientific collaboration. It could one day also open a new chapter in U.S. foreign policy for the Middle East, North Africa, and Central Asia.
CULTURES Vol 1, Issue 2 Âť Page 23
FOOTNOTES 1. Text: Obama’s Speech in Cairo. New York Times. June 4, 2009. http:// www.nytimes.com/2009/06/04/ us/politics/04obama.text.html?_ r=0&pagewanted=print. Accessed February 8, 2014. 2. Koenig R. 2009. US takes steps to use science to improve ties to Muslim world. Science 326:920–921. 3. Zewall AH. 2010. Science in diplomacy. Cell 141:204–207. 4. Hotez PJ. Vaccine diplomacy: historical perspectives and future directions. PLoS Negl Trop Dis In press. 5. Poliomyelitis. Fact sheet no. 114. April 2013. World Health Organization. http:// www.who.int/mediacentre/factsheets/ fs114/en/. Accessed February 8, 2014. 6. Polio Eradication Initiative. Emergency meeting called in response to the polio outbreak in the Horn of Africa, 9–10 June 2013. World Health Organization. http:// www.emro.who.int/polio/polio-events/ response-polio-outbreak-horn-of-africa. html. Accessed February 8, 2014. 7. Polio Global Eradication Initiative. Infected countries. http://www. polioeradication.org/Infectedcountries. aspx. Accessed February 8, 2014. 8. Polio Eradication Initiative. New polio vaccination round begun in Syria. World Health Organization. http://www. emro.who.int/polio/polio-news/poliovaccination-round-syria-february-2014. html. Accessed February 8, 2014. 9. NcNeil DG Jr. C.I.A. vaccine ruse may have harmed the war on polio. New York Times. July 9, 2012. http://www.nytimes. com/2012/07/10/health/cia-vaccine-rusein-pakistan-may-have-harmed-poliofight.html?pagewanted=all. Accessed February 8, 2014. 10. Hotez PJ. 2009. The neglected tropical diseases and their devastating health and economic impact on the member nations of the Organisation of the Islamic Conference. PLoS Negl Trop Dis 3:e539. 11. Hotez PJ, Thompson TG. 2009. Waging peace through neglected tropical disease control: a US foreign policy for
the bottom billion. PLoS Negl Trop Dis 3:e346. 12. Hotez PJ. 2010. Peace through vaccine diplomacy. Science 327:1301. 13. Hotez PJ. 2011. Unleashing “civilian power”: a new American diplomacy through neglected tropical disease control, elimination, research, and development. PLoS Negl Trop Dis 5:e1134. 14. Jones K-A. 2010. New complexities and approaches to global health diplomacy: view from the US Department of State. PLoS Med 7:e10000276. 15. Hotez PJ, Savioli L, Fenwick A. 2012. Neglected tropical diseases of the Middle East and North Africa: review of their prevalence, distribution, and opportunities for control. PLoS Negl Trop Dis 6:e1475. 16. Hotez P. August 16, 2013. Arab revolutions: ignoring a potential catastrophe. http://www.aljazeera.com/ indepth/opinion/profile/peter-hotez.html. 17. List of countries by population. http://en.wikipedia.org/wiki/List_of_ countries_by_population. Accessed February 10, 2013. 18. List of countries by percentage of population living in poverty. http:// en.wikipedia.org/wiki/List_of_countries_ by_percentage_of_population_living_in_ poverty. Accessed February 10, 2013. 19. Alvar J, Vélez ID, Bern C, et al. 2012. Leishmaniasis worldwide and global estimates of its incidence. PLoS One 7:e35671. 20. Bhatt S, Gething PW, Brady OJ, et al. 2013. The global distribution and burden of dengue. Nature 496:504–507. 21. Neglected Tropical Diseases. PCT databank: soil-transmitted helminthiases. World Health Organization. http://www.who.int/ neglected_diseases/preventive_ chemotherapy/sth/en/index.html 22. World Health Organization. 2013. Soil-transmitted helminthiases: number of children treated in 2011. Weekly Epidemiol Rec 88:145–152.
Page 24 » Across the Divide » Hotez / England & Desmond / Madani / Asghar
23. U.S. Global Health Initiative. What is GHI? http://www.ghi.gov/about/ howWeWork/index.html. Accessed February 8, 2014.
32. Lee BY, Bacon KM, Bailey R, Wiringa AE, Smith KJ. 2011. The potential economic value of a hookworm vaccine. Vaccine 29:1201–1210.
24. U.S. Global Health Initiative. Where we work. http://www.ghi.gov/ whereWeWork/. Accessed February 8, 2014.
33. Wallace D, Canouet V, Garbes P, Wartel TA. 2013. Challenges in the clinical development of a dengue vaccine. Curr Opin Virol 3:352–356.
25. USAID’s NTD Program. Countries supported by USAID’s NTD program. http://www.neglecteddiseases.gov/ countries/index.html. Accessed February 9, 2014.
34. Hotez PJ, Diemert D, Bacon KM, et al. 2013. The human hookworm vaccine. Vaccine 31(Suppl 2):B227–B232.
26. USAID. Afghanistan and Pakistan. http://www.usaid.gov/where-we-work/ afghanistan-and-pakistan. Accessed February 9, 2014. 27. USAID. Iraq. Health. http://www. usaid.gov/iraq/health. Accessed February 9, 2014. 28. USAID. Yemen. Health. http://www. usaid.gov/yemen/health. Accessed February 9, 2014. 29. USAID. Egypt. Global health. http:// www.usaid.gov/egypt/global-health. Accessed February 9, 2014. 30. Bacon KM, Hotez PJ, Kruchten SD, et al. 2013. The potential economic value of a cutaneous leishmaniasis vaccine in seven endemic countries in the Americas. Vaccine 31:480–486. 31. Shepard DS, Suaya JA, Halstead SB, et al. 2004. Cost-effectiveness of a pediatric dengue vaccine. Vaccine 22:1275–1280.
35. Zhan B, Beaumier CM, Briggs N, et al. 2014. Advancing a multivalent ‘pan-anthelminthic’ vaccine against soiltransmitted nematode infections. Expert Rev Vaccines 13:321–331. 36. VACSERA. http://www.vacsera.com/. Accessed February 9, 2014. 37. dcvmn. Developing Countries Vaccine Manufacturers Network. http://www.dcvmn.org/. Accessed February 8, 2014. 38. Hotez P, Rokni M. 2013. Next steps in US-Iran diplomacy: vaccine. Pacific Standard. November 6, 2013. http://www.psmag.com/navigation/ health-and-behavior/next-steps-u-s-irandiplomacy-vaccines-69542/. Accessed February 9, 2013. 39. Hotez PJ, Dumonteil E, Heffernan MJ, Bottazzi ME. 2013. Innovation for the ‘bottom 100 million’: eliminating neglected tropical diseases in the Americas. Adv Exp Med Biol 764:1–12.
PETER HOTEZ, M.D., Ph.D. Peter Hotez, M.D., Ph.D., is president of the Sabin Vaccine Institute and the founding dean of the National School of Tropical Medicine at Baylor College of Medicine, where he is also Professor of Pediatrics and Texas Children’s Hospital Endowed Chair of Tropical Pediatrics. Professor Hotez is also the Fellow on Disease and Poverty at the James A. Baker Institute for Public Policy at Rice University. He is the author of Forgotten People, Forgotten Diseases (ASM Press).
CULTURES Vol 1, Issue 2 » Page 25
BUILDING BRIDGES WITH NORTH KOREA: ENGAGING THROUGH HEALTH DIPLOMACY By: Kathleen England, Ph.D. and Ed Desmond, Ph.D.
A resurgence in tuberculosis (TB) following the famines of the 1990s in the Democratic People’s Republic of Korea (DPRK or North Korea) led to an unprecedented collaboration to address a very serious and expanding epidemic. Before 2008, DPRK worked with the World Health Organization (WHO) and later the Global Fund to Fight AIDS, TB, and Malaria (GFATM), to design and update their tuberculosis control program to provide drugs to patients who were diagnosed with pulmonary TB by clinical assessment or conventional acid-fast microscopy. In 2008, the Ministry of Public Health (MoPH) identified a need to conduct culture and drug susceptibility testing to identify patients with drug-resistant disease. This required a renovation and upgrade of their National Tuberculosis Reference Laboratory (NTRL), building on incomplete initial work begun by WHO. Subsequently, a delegation from the MoPH approached John Lewis and Sharon Perry of the Center for International Security and Cooperation (CISAC), and Dr. Gary Schoolnik of the School of Medicine at Stanford University for assistance. This led to the formation of an unprecedented collaboration, which remains active and effective even in the current political climate. Initial partners included CISAC, members of the Stanford School of Medicine, TB laboratory scientists from the San Francisco Bay Area, and volunteers from Christian Friends of Korea (CFK), a Christian faith-based organization that has worked extensively in DPRK for nearly 20 years, particularly supporting local TB sanatoriums (http://cfk.org/). Initial funding and support for the laboratory development project came from CFK, Stanford’s Walter H. Shorenstein Asia Pacific Research Center, and the Nuclear Threat Initiative (NTI), a nonprofit, nonpartisan organization with a mission to strengthen global security by reducing the risk of use and preventing the spread of nuclear, biological, and chemical weapons in order to build trust, transparency, and security. A description of NTI’s early role in this effort can be found at http://www.nti.org/about/projects/TB-Threat/.
CULTURES Vol 1, Issue 2 » Page 27
Early work in this project included the design and renovation of the NTRL facility in Pyongyang. After the facility was reconstructed, laboratory equipment and supplies were procured, initial training in laboratory techniques and biosafety began, and instructions on the specific responsibilities of National TB Reference laboratories were established. These steps were accomplished with the help of largely volunteer CFK construction crews and facilities engineers and Bay Area microbiology laboratory experts. With help from Jason Rao of the American Society for Microbiology, Stanford University (Dr. Schoolnik) was able to obtain additional funding from the Richard Lounsbery Foundation. Together with funding from Zero TB World, this enabled the hiring of a full-time TB laboratory expert, Dr. Kathleen England. The following text box is a narrative of Dr. England’s work, a description of the challenges, and a glimpse of the rewards of constructive humanitarian engagement.
The DPRK TB program is currently making strong efforts to improve the diagnostic and treatment program for drugresistant tuberculosis. The Ministry of Public Health strongly recognizes the need to improve multidrug-resistant TB (MDR-TB) case detection and treatment for the nation. One of the most successful endeavors over the past five years includes the renovation of, and diagnostic advancements at, the National Tuberculosis Reference Laboratory (NTRL) in Pyongyang. Currently, the NTRL has the ability to perform WHO-recommended diagnostics, which include fluorescent acid-fast microscopy, culture-based TB identification methods, drug susceptibility testing by conventional culture methods, and molecular testing using GeneXpert technology. The laboratory staff are currently undergoing proficiency testing and method validation studies to demonstrate the level of performance required to obtain accurate and reliable results. Once proficiency and competency are attained, the laboratory will be able to implement national surveillance programs for both TB and MDR-TB, properly monitor MDR-TB patients under treatment, and perform a national drug resistance survey. Under direct guidance of Stanford’s technical advisor, the NTRL is working through
Page 28 » Across the Divide » Hotez / England & Desmond / Madani / Asghar
N95 respirator fit testing for staff working with TB cultures.
the laboratory accreditation process outlined by the Global Lab Initiatives sponsored by WHO and the STOP TB partnership. The NTRL and National Taxicology Program are dedicated to achieving international accreditation. Attaining this goal would demonstrate a national commitment to the outside world to “STOP TB” in DPRK. Use of advanced technology like the GeneXpert in limited-resource countries has been proven to be the most effective diagnostic tool for rapid identification of MDR-TB around the world. The method is simple and sustainable; it requires very little infrastructure. The technology demonstrates how modern science can find practical solutions for the diagnosis of epidemic diseases like TB for limited resource countries.
CULTURES Vol 1, Issue 2 » Page 29
CHALLENGES FACING TB PROGRAMS IN NORTH KOREA
INTERNATIONAL TRADEE
4
TRADES DE N I
3
ED
5
THE BANK IN G N O FU N D
1
2
1. Limited national resources 2. Outside donors unable to help 3. Sanctions, sanctions, sanctions 4. Decaying national infrastructure 5. Dated diagnostic technology, expertise Despite these challenges, improvements have been made by the efforts of individuals, local physicians, health care workers, laboratorians, and members of the nation’s public health system, oftentimes at risk to their own health and safety.
Page 30 » Across the Divide » Hotez / England & Desmond / Madani / Asghar
In less than two hours, the GeneXpert assay identifies if a patient has TB and if the organism is carrying a specific genetic marker for resistance to the TB drug rifampicin, which serves as a reliable proxy for MDR-TB. Implementation of this technology in the DPRK could be a “game changer.” Having the ability to rapidly screen patients and identify those susceptible to traditional TB drugs and those who need special MDR therapy provides a critical tool that can significantly affect the course of the current epidemic. The rollout of GeneXpert technology in the DPRK can greatly impact the ability to expedite treatment for thousands of MDR-TB patients. As the program expands over the next year, increasing the capacity for GeneXpert testing will be critical. Progress with current and future laboratory developments is slow, because the DPRK laboratory faces many limitations. The project is particularly impacted by internal infrastructure shortages. One of the most serious at this time is the lack of an uninterrupted supply of power to the NTRL facility. Extended power outages and frequent fluctuations affect culture-based diagnostics, can damage equipment, lead to spoilage of sensitive reagents and testing materials, and disrupt daily workflow. Diagnostic activities are further impeded by limitations on the import of needed equipment and TB diagnostic materials from reputable international vendors into DPRK. Often vendors are reluctant to sell the supplies needed for ongoing operation of the DPRK NTRL for fear of running afoul of export control restrictions. The maintenance of a continuous and reliable supply chain is essential. Also, the development of a national specimen referral program has been impeded by internal logistical challenges because special permits are required for travel between regions in DPRK, transport vehicles and money for gasoline coupons are scarce, and rural road conditions are challenging. At present, the biggest impediment to program development and patient treatment is funding. Expanding diagnostic capacity and increasing the drug supply for MDR-TB is extremely expensive. Because of current politics, there has been a decrease in the level of support from U.S. foundations and philanthropic
CULTURES Vol 1, Issue 2 » Page 31
organizations and individuals for humanitarian aid to the DPRK. Loss of external support for the national TB program could halt progress and allow the TB situation to expand further out of control and beyond the borders of the DPRK. Even with all the external challenges and politics, the Ministry of Public Health continues to regularly allow U.S. partners into the country to work closely and productively with their citizens for extended periods of time. This clearly shows that they recognize the gravity of their situation and are working diligently to control TB in their country. Furthermore, through our collaboration, we have witnessed many individuals, local physicians, health care workers, laboratorians, and members of the nation’s public health system, who dedicate their lives to serving and caring for those afflicted with this debilitating and life-threatening disease, even at great risk to their own health and safety. The work and commitment by the Ministry and all those involved is truly commendable.
Dr. England has worked with many partners in an effort to bring about continuous and lasting progress. The good will and trust established between the MoPH of the DPRK toward the CFK enabled this project to begin and continue on a good footing. Dr. England and Stanford University (Dr. Schoolnik) also work closely with WHO, UNICEF, and Global Fund partners who continue their work in DPRK indefinitely to ensure a lasting impact. Cultural differences in the structure of organizations and systems of quality management have presented a challenge. Dr. England and others have found that the desire of the NTRL staff to seek international accreditation has helped them to accept international standards for quality assurance and to incorporate those standards into their daily practices. The Global Laboratory Initiative (GLI) Stepwise Process Towards Laboratory Accreditation (http://gliquality.org/) has also proven to be a very useful tool in promoting the acceptance and introduction of quality testing.
Page 32 Âť Across the Divide Âť Hotez / England & Desmond / Madani / Asghar
Dr. England’s experiences and activities over the past 2 years have fostered relationships with laboratory staff and Ministry colleagues. On her most recent visit in November 2013, she and other CFK travelers engaged in a volleyball match with mixed members of the Ministry and sanatoria staff. For Mother’s Day, 2012, the laboratory staff at NTRL gave Dr. England a cake in recognition of her being a mother. The staff further implied that she was like a mother to the laboratory, providing the nurturing and support they needed to make significant progress and achieve many of their goals. Through these small interactions and exchanges, person-to-person contacts, and good will, relationships built with trust toward the achievement of a shared goal can be models for building bridges with the DPRK.
KATHLEEN ENGLAND, Ph.D. Kathleen England, Ph.D., a tuberculosis (TB) diagnostics specialist, has worked in international TB programs under the NIH in China, Medicins Sans Frontiers in Mongolia, and Stanford University School of Medicine In North Korea. Kathleen’s position with Stanford involved the management of the DPRK National TB Reference Laboratory project, and she was laboratory advisor for the DPRK National TB Program. Currently, Kathleen serves as the Laboratory Technical Officer for an International TB foundation that supports over 20 countries.
EDWARD DESMOND, Ph.D. Edward Desmond, Ph.D., was involved at the beginning of the North Korea laboratory project and has served intermittently as a volunteer for the project. He is a Diplomate of the American Board of Medical Microbiology.
CULTURES Vol 1, Issue 2 » Page 33
SCIENCE AS A FOUNDATION FOR COLLABORATION IN IRAN AND BEYOND By: Navid Madani, Ph.D. In 1999, shortly after I finished my graduate studies, I traveled to Iran, the country of my birth, after an absence of six years. Born and raised in Iran, I had emigrated to the United States to obtain my undergraduate and graduate training. Upon my return, I was invited to give a scientific seminar at the Chemistry Department at the Alzahra University in Tehran, an all-female institution that was established in 1964. As I was preparing my talk in my native language of Persian (Farsi), I wondered how much of the technical and scientific details the audience would understand. The work was extremely specialized, using electrophysiology in Xenopus oocytes to investigate the G-protein窶田oupled receptors that serve as HIV-1 coreceptors. Some of my slides were very esoteric, with concepts that only scientists with significant exposure to primary literature would understand. My understanding was that, although clinical medicine was fairly up-to-date in Iran, knowledge of basic science research was lagging. I started to eliminate the slides I thought would be too difficult for such an untrained audience to understand, but I soon decided that doing so would take away from the essential message of my story and work. In the end, I kept my talk intact and hoped that, despite the complexity of the science, I would be able to coherently convey my results. The auditorium was packed. The student committee that had issued the invitation to speak had gone out of their way to publicize the talk, advertising in multiple universities in Tehran, resulting in a turnout of more than 200 faculty and students. My presentation went smoothly, and I was interrupted only a few times by requests for more background or technical details. When the talk finished and I asked whether there were any questions, there was silence for a moment and I was sure I had Page 34 ﾂｻ Across the Divide ﾂｻ Hotez / England & Desmond / Madani / Asghar
CULTURES Vol 1, Issue 2 » Page 35
confused them all, but then hands went up. As is the custom in the West, the faculty members asked questions first. Then more hands were raised, and I was surprised to see that so many of the students had questions. What astounded me the most was that so many of their questions referred to the current literature; they quizzed me on the work of my competitors, asked for my opinion about a specific paper in my field, and explored the finer implications of my results. I had rarely faced such probing, insightful questions from younger student populations in the United States. After our time was done in the auditorium, the students followed me outside and questioned me more – about science and technical details and the challenges of being a graduate student in United States. The questions were concise, informed, and filled with sincere curiosity. I found it thrilling, and I happily sat with them for as long as they had questions. I do not know what it feels like to be a rock star like Bono, but, from what I have heard, the feeling I was experiencing while answering questions about the science that had been so intimate to me for five years probably came close to it. The question that remained, however, was why I had so grossly misjudged the intellectual capabilities of my audience. The answer lay in my naïve attitude that equated the big-budget science I knew in the United States with knowledge and innovation. I believed that my experience as a basic scientist in the United States, the best possible place in the world to be trained, was
Madani after a lecture with students at Tehran University of Medical Sciences (TUMS) in March 2013.
Page 36 » Across the Divide » Hotez / England & Desmond / Madani / Asghar
unparalleled, and that I was the one who was bringing expertise and rigorous investigation to the table. I thought that in Iran I was the teacher and had nothing to learn in return, but that attitude changed when I was faced by these bright, inquisitive students. During subsequent trips, I became a learner too. I learned how not to rely on premade science kits and one-step answers to perform the task at hand. I learned to be creative in relaying my message while not avoiding complexity. I learned to not equate science in resource-poor settings with lack of knowledge; indeed, now I believe that necessity is the mother of invention, inquisitiveness, and innovation. The most important lesson has been that two-way, open-minded, and transparent dialogue is necessary for scientific exchanges and collaborations. Since my first talk in Iran, I have been fortunate to go back on a regular basis to give seminars and workshops in my field of HIV/AIDS. As I spoke with more people, I began to see opportunities to nucleate conversations that could go beyond experimental science and potentially have clinical impact. I became convinced that I needed to move beyond the bench, and to use my international ties to bring disparate viewpoints to bear on the HIV/AIDS epidemic in the Middle East. I began to engage with policy makers and politicians, drawing them into discussions with my Iranian clinical and scientific colleagues to address a variety of issues relating to HIV/AIDS. My educational trips led to identifying in-country partners to co-organize the first International HIV/AIDS conference in October 2012 with strong collaborations with UNAIDS-Iran and Tehran University of Medical Sciences. We were able to invite 14 faculty and students from the United States and Europe to travel to Iran for an extremely fruitful five-day conference to discuss current topics in the field of HIV/AIDS. The success of this conference led to other meetings in 2013 and to four new workshops planned over the next two years in Iran. In addition, several collaborations were initiated among participants, including an Iranian clinician training in the United States for two weeks, and students traveling from the United States to Iran to work on part of their thesis proposals. These sorts of collaborations are not without challenges. The political tension between the United States and Iran requires that
CULTURES Vol 1, Issue 2 Âť Page 37
“”
DIALOGUE AND COLLABORATION OPEN UP OPPORTUNITIES THAT ARE VAST AND TRULY REWARDING. – Dr. Navid Madani
such projects obtain special clearance from both governments. Funding is always an issue. However, the benefits derived from these collaborations are worth dealing with the challenges. Such collaborations decrease brain drain and motivate younger scientists to build their careers in-country. Working with Iranian scientists could open so many new doors and new perspectives in the study of atypical genetic diseases, emerging infectious diseases, and rare cancers, which might be more difficult to access in the West. By collaborating, we are enhancing science in resource-poor settings as well as adding the Iranian perspective to the global experimental community. Creating a global scientific community is important and reflects the evolving nature of scientific investigation in general. My last research paper included 16 authors from 9 different institutions. Building and sustaining such a collaboration is sometimes difficult at first; as scientists, by nature, we tend to sequester ourselves. However, modern science no longer favors such behavior, and scientists cannot afford to act like secluded islands. For creativity and innovation to blossom, we need to discuss our findings and engage different perspectives to come up with inventive strategies. Although the
Page 38 » Across the Divide » Hotez / England & Desmond / Madani / Asghar
challenges of working with Iranian scientists might have unique features, the lessons I learned in Iran have broader applications; dialogue and collaboration open up opportunities that are vast and truly rewarding. For me, personally, my Iranian discussions and collaborations have certainly been deeply rewarding. My travels as a scientist in Iran have taken me to health houses in Mashhad, to an oceanography center in Bandar Lengeh by the Persian Gulf, and to virology laboratories in Kashan. Through all my travels to Iran as well as AUTHOR ACKNOWLEDGMENT the rest of the Middle East and North This paper is dedicated Africa, I have come to know that the to the memory of Dr. success of collaborations is more than Kamel Shadpour, a true the presentation of information and the health care genius. exchange of ideas, it is a strengthening of the global scientific community, the building of trust, and a dialogue that expands past science into personal (and international) understanding. These collaborations can change perceptions of what is possible on both sides. The positive ripple effect of specific scientific engagement between Iran and the United States is not yet fully felt or understood, but I know from my personal experience that the rewards are limitless.
NAVID MADANI, Ph.D. Navid Madani, Ph.D., is a biochemist at Dana-Farber Cancer Institute and Harvard Medical School focusing on finding a woman-controlled microbicide that specifically targets HIV-1 viral entry. She is currently on the advisory board of the Network of Iranians for Knowledge and Innovation (NIKI), board of directors of Scientific Association for Public Health in Iran (SAPHIR), and previously was chair of the Global Network of Researchers on HIV/AIDS in Middle East and North Africa (GNR-MENA). She regularly travels to the Middle East to present seminars at various universities, with an emphasis on HIV/AIDS and public health geared toward youth and women, to advance the understanding of reproductive health issues.
CULTURES Vol 1, Issue 2 Âť Page 39
PAKISTAN: PUBLIC HEALTH CHALLENGES AND OPPORTUNITIES By: Rana Jawad Asghar, M.D., M.P.H. Early in my public health career, I received a call about a position in Africa. I reached out to one of my mentors for advice. He replied by saying that, if you would like to work in international public health, then you have to spend your time in Africa.
And, once I was in Mozambique, I realized that my “Child Survival Project” was addressing not a single but multiple disease challenges. After working at Stanford University, London School of Hygiene and Tropical Medicine, and Epidemic Intelligence Service (EIS) of the Centers for Disease Control and Prevention (CDC), I decided to head back to my home country, Pakistan. I was applying to many different open positions, and that was why I applied for the Resident Advisor Position of Field Epidemiology and Laboratory Training Program (FELTP) Pakistan, even without paying attention that this was a CDC program and without learning much information about the program itself. In 2006, I arrived in Islamabad to start a new program with no idea of the challenges and rewards I would experience over the coming years. Recently, Jason Rao (Editor, Cultures), while introducing me at a lecture, narrated a story about when he first met me (which I had completely forgotten). He told the audience that, in 2006, on his visit to Pakistan National Institute of Health, he was told that someone from CDC had arrived there. He came to see me and saw me working in a small room that was also being used for phlebotomy by other Pakistan National Institute of Health staff. He took my statement with a grain of salt when I told him
Page 40 » Across the Divide » Hotez / England & Desmond / Madani / Asghar
that I was here to start a sister Epidemic Intelligence Service (EIS) program. FELTP, similar to EIS, is an in-service training program that improves the capacity in disease surveillance and outbreak response of host countries. It is an integral part of the recently launched Global Heath Security Agenda (http://www.cdc.gov/globalhealth/ security/); CDC helped to build these programs in 50 countries (http://www.cdc.gov/globalhealth/fetp/). For seven years, Pakistan FELTP has faced a continuous struggle over challenges that could not have been foreseen. Not only has the level and extent of terrorism increased over the years, but even the Federal Ministry of Health was decentralized to the provinces in June 2011. The suspicion about U.S.-backed programs in Pakistan kept increasing, and it became difficult for CDC staff in Atlanta to visit Pakistan and assist in training schedules. These were very unique impediments, and FELTP had to find solutions quickly to survive. We realized that we needed to find and groom local faculty for our fellows because Temporary Duty Employees from CDC could not be relied upon. This was quite difficult because there were very few field epidemiologists in Pakistan. Not only did FELTP hire good local faculty (including its own trained fellows), but it also provided them and guest faculty with materials developed by CDC for teaching. This not only helped the program, but also strengthened faculty skills, not only of FELTP Pakistan, but also at our sister institutions here like the Health Services Academy, Islamabad. Because we were working directly with provincial departments of health from day one (because most of our fellows are provincial employees), we kept doing our work even when the Federal Ministry of Health was decentralized into the provinces and many donor programs came to a screeching halt. To address the prevailing lack of confidence in most donor programs, we tried to make the procedures and operations of FELTP transparent, fair, and documented.
CULTURES Vol 1, Issue 2 Âť Page 41
CHALLENGES ON THE GROUND
Federal ministry of health was devolved
Suspicion of U.S.backed programs made it difficult to travel
An increase in terrorist activities
$ Financial sustainability
Page 42 Âť Across the Divide Âť Hotez / England & Desmond / Madani / Asghar
Even the selection process of fellows evolved over the years, and now it includes the senior fellows themselves. We made the program an open program where nothing is hidden and which is happy to collaborate and assist any local program or department. Transparency and fairness resulted in trust to the level that FELTP Pakistan was requested by then Ministry of Health to select and nominate “IF THE GOING their staff for some coveted international GETS TOUGH trainings, represent Pakistan at a very highlevel international meeting, and develop AND THE a deployment plan for swine flu vaccine. FELTP was a new and very small player on the donor-supported programs crowd in Pakistan. However, FELTP Pakistan separated itself from this crowd and built the program as a Pakistani program that operates through the Government of Pakistan (GOP). We kept the trust, and, one after another, highly sensitive outbreaks were entrusted to us for investigations.
ENVIRONMENT BECOMES HOSTILE, WE STILL NEED TO CHECK ONE THING. DO WE STILL HAVE PASSION?”
- DR. RANA JAWAD ASGHAR
Sustainability was a major issue for us from the start. So we became one of the only donorsupported programs that never paid any salary, salary support, per diems, or honoraria to our fellows. The total salary and travel support came from the concerned federal and provincial health departments for the full two years for their training. We started with a shared-room office and now have seven dedicated rooms including training rooms provided rent free by the GOP in kind support of the program. Our fellows have investigated 57 disease outbreaks mostly through GOP local resources. The FELTP Pakistan fellows have presented 100 scientific presentations in international peer-reviewed scientific conferences including four consecutive Epidemic Intelligence Service conferences in Atlanta where acceptance rates are as low as 5%. Pakistan FELTP is successful because it works on local problems and comes up with local solutions. The challenge to eradicate polio has become greater over the years with the added violence that global public health has never encountered. The need for well-trained local staff has grown, and a new concept, National Stop the Transmission of Polio (NSTOP), was born through the need felt by and the wider consultations and collaborations
CULTURES Vol 1, Issue 2 » Page 43
conducted among all stakeholders. This is very different from the well-known STOP program because of the local needs addressed. It started as only a six-month pilot program in 16 districts, and now it is well into its third year and has expanded to 37 districts with the highest risk of polio transmission. It has also inspired similar programs in other polio endemic countries managed by local Field Epidemiology Training Programs. FELTP Pakistan initiated a sentinel surveillance system for acute viral hepatitis to encourage the establishment and networking of public health laboratories. It is now being expanded to add other diseases of local priorities and may one day act as a launching pad for Integrated Disease Surveillance in Pakistan. From this year veterinarians have also been inducted into the program, moving it to a One Health approach (One Health approach recognizes that human health is dependent and linked with animal health and environment) of disease detection and control (http://www.cdc.gov/onehealth/). Pakistan has multiple vertical disease surveillance systems; nearly all of these systems depend on external financing, and they do not share information in a timely manner. Recently, a new division at the Pakistan National Institute of Health was approved with the name of Division of Field Epidemiology and Surveillance. After more than two decades, a new technical division is being initiated, and it is significant because it will house and coordinate all these surveillance systems, ensuring the timely detection and response to disease outbreaks. This division will also house FELTP Pakistan, another major step forward to the sustainability of FELTP. I learned very early in my life that it is not the resources but the passion that takes you to success. When I was in medical school in 1980s, my friends and I started a nongovernmental organization (NGO), Health Education Society, with absolutely no money in our pockets. It became one of the most active NGOs on health education in those days. When I was at the School of Public Health, University of Washington, in 1999, I initiated the South Asian Public Health Forum (a voluntary online forum) that is still going strong with more than 1,000 members across the World and, once again, with almost no dedicated resources [http:// www.saphf.org]). So, if the going gets tough and the environment becomes hostile, we still need to check one thing. Do we still have passion? If we still have passion, then we will find ways to circumvent the challenges we may be facing.
Page 44 Âť Across the Divide Âť Hotez / England & Desmond / Madani / Asghar
RANA JAWAD ASGHAR, M.D., M.P.H. Rana Jawad Asghar, M.D., M.P.H. received his education on three different continents and has lived and worked on four. This has given him an opportunity to work with people of diverse backgrounds and has enriched his life with friendships across the globe.
ISE
OU
NL
OM E M. UG
SLA
HT
ER
(NY -D)
FF
SW
STA
RES
AL RI
NG
O
U.S . CO
CULTURE SE ASM
DI T
Page 46
JASON: Global health security is as important and pressing as ever, and the need to communicate to the public is critical. As the only microbiologist in Congress, and a champion for addressing the antibiotic resistance challenge we face globally, any advice you’d give to our readers on how to effectively communicate science to the public? SLAUGHTER: I find one of the more serious problems is that an awful lot of people do not appear to believe in the germ theory of disease. Since the advent of antibiotics, people believe they are safe from germs because someone will give them a shot and save them. And we are finding out that that is simply not the case. And we are seeing more and more resistant diseases—it is terrifying to me.
In this issue, the Cultures staff informally interviewed Representative Louise M. Slaughter, who is a Congresswoman as well as the only trained microbiologist in the United States Congress.
CULTURES Vol 1, Issue 2 » Page 47
JASON: An underlying theme to your approach in Congress, regardless of the issue, is to rely on evidence-based policymaking. Rep. Slaughter is author of the PRESERVATION OF ANTIBIOTICS FOR MEDICAL TREATMENT ACT which would end the routine use of antibiotics on healthy animals and curb the growing threat of superbugs She played a leading role in crafting and passing the AFFORDABLE CARE ACT, and brought the legislation to the House Floor for final passage She is a strong champion for women’s healthcare issues and equal rights. As a member of the House Budget Committee in the early 1990s, she secured THE FIRST $500 MILLION EARMARKED BY CONGRESS FOR BREAST CANCER RESEARCH at the National Institutes of Health (NIH) She co-authored the historic VIOLENCE AGAINST WOMEN ACT in 1994, and wrote legislation that made permanent the Office on Violence Against Women at the U.S. Department of Justice Rep. Slaughter is the original author of the GENETIC INFORMATION & NON-DISCRIMINATION ACT (GINA), which is now Public Law No. 110-223 In 2007, she was the first women to become CHAIRWOMAN OF HOUSE COMMITTEE OF RULES
SLAUGHTER: Absolutely. That is what scientists are taught. That is the most important thing. You know what is factual; you do not have to wonder or have someone else tell you what you know to be fact. For example, science tells us that Staphylococcus aureus has evolved to become methicillin-resistant S. aureus or “MRSA”, and it can kill you in 24 hours. That’s a fact. SANJANA: Now that the 2014 budget appropriations have passed, what do you think about how science has been prioritized? SLAUGHTER: Oh, we are not paying nearly enough attention to science. And it is very troubling. We have evidence that says we should really pay better attention here. The world around us is becoming more polluted, which means we need better science for public health and sanitation, and in particular a recognition of how important food safety and food security are. There’s much to do. JASON: Preparedness is never an emergency. SLAUGHTER: Yes. KATY: Knowing that many of our readers are young scientists, I think Page 48 » In Conversation
they are going to be inspired that you started off as an undergrad studying basic science and moved on to the policy world. Many scientists are exploring new career opportunities off the bench with the same broad objective of making the world a better place. What advice would you give them?
SLAUGHTER: I didn’t actually plan to be in politics. The opportunity came to me, and I took it. I’ve learned along my long career path that planning everything in advance just doesn’t work. Opportunity comes and, if you want to take it, take it. JASON: So opportunity favors those who are ready for it? SLAUGHTER: Right, I think so. I would say something to women scientists, in particular, who have historically had to fight to be recognized. In fact ever since I’ve been in Congress we’ve had to fight for equal recognition, and we still do. CULTURES Vol 1, Issue 2 » Page 49
So anybody who is looking at this, and goes into science: help us fight this battle. It hurts everyone when women are underpaid and under recognized.
KATY: You have been a champion of women’s rights, for science, and will be remembered for so many accolades, including being the first Chairwoman of the House Rules Committee. Is there anything you want to be remembered for that people might not know of? SLAUGHTER: I have been in three congresses: county, state, and here. And the best part is really being able to right some wrongs. Most of what we do is a lot of individual work for people, and sometimes that individual constituent work is what you remember. However, I think the best part of being in Congress is that you write laws that benefit every man, woman, and child, and maybe in the world—and nobody will ever know your name.
Page 50 » In Conversation
BIO
Rep. Louise M. Slaughter
Congresswoman Louise McIntosh Slaughter is one of the most powerful and unique figures in the House of Representatives. Representing the 25th Congressional District of New York, Louise was first elected to Congress in 1986, and is now serving her 14th term in the House of Representatives. From 2007 until 2011, Congresswoman Slaughter served as the Chairwoman of the Committee on Rules, making her the first woman in history to serve in that role. A member of the House Democratic Leadership, she also serves on the prestigious Democratic Steering & Policy Committee. Congresswoman Slaughter holds a Bachelor of Science degree in Microbiology and a Master of Science degree in Public Health from the University of Kentucky. Prior to entering Congress, she served in the New York State Assembly (1982-86) and Monroe County Legislature (1976-79).
CULTURES Vol 1, Issue 2 Âť Page 51
VOICES 8 YOUNG INTERNATIONAL SCIENTISTS WEIGH IN ON THE QUESTION:
What are the opportunities and responsibilities of scientists to communicate their research at home and abroad?
Check out our video interviews with these Young Ambassadors of Science and more: http://www.youtube.com/ Microbeworld.
In each issue, we highlight diverse unheard voices that bring unique perspective to the conversation.
Page 52 Âť Voices
REUEL BENNETT, M.Sc. PHILLIPPINES
AHMED GRIEBALLA, M.Sc. SUDAN
ASHUTOSH SINGH, Ph.D. INDIA
DIRK TISCHLER, Ph.D. GERMANY
KHOSBAYAR TULGAA, M.D. MONGOLIA
LAURA ACEVEDO UGARRIZA
PARAGUAY
EDNNER VICTORIA
PANAMA
MOSES VURAYAI
BOTSWANA
EDITED BY ASM STAFF MEMBER: NATALIE DEGRAAF, M.Sc., M.P.H. CULTURES Vol 1, Issue 2 » Page 53
“”
GLOBAL ISSUES AND MISCONCEPTIONS AROUND ISSUES LIKE CLIMATE CHANGE, BIOSECURITY, EMERGING INFECTIOUS DISEASES, LIMITED NATURAL RESOURCES, AND BIODIVERSITY CONSERVATION ALL REQUIRE CLEAR COMMUNICATION FROM THE SCIENTIFIC COMMUNITY.
A recent study done by the American Institute of Biological Sciences found that, according to 139 biological societies polled, the greatest challenges facing biology in the coming years will be “the public lack of appreciation for biology, and decision makers not being informed about issues” (http:// www.access.aibs.org/page/Greatchall/). Effective communication of science serves as a challenge in the realm of discerning knowledge and communicating it to the public. When communication is done effectively, there is a great opportunity to contribute to the global good, whether in the form of changing individual human behavior or larger-scale societal shifts. However, conveying this information–both effectively and accurately–from the bench to the public has proved to be a hurdle. Throughout history, effective dissemination of scientific knowledge has been an obstacle. For example, in the 15th and 16th century, Galileo, who played an influential role in the scientific revolution, was banished from the Catholic Church for his unpopular support of heliocentrism based on his observation of sunspots. During the 19th century, Ignaz Semmelweis, an early pioneer of the germ theory of disease, attempted to introduce the value of hand-washing as a way to reduce the mortality rate in obstetric wards. However, the medical community rejected his hand-washing theory, because it did not fit the scientific opinion of the time. Today, for scientists like ourselves, communicating to the public in order to affect public discourse continues to be an Page 54 » Voices See Photography + Art Credit on page 59 for copyright information.
obstacle. During training at the bench, scientists are taught to focus on advancing their research. They communicate their work to other scientists or science-related professionals through platforms such as journal publications, abstracts, oral or poster presentations, and grant writing. The highly technical degree of information used in such media may be intimidating to the public, and thus causes uncertainty leading to misconceptions. As a result, bench scientists have little opportunity (or need) to communicate to nonscientists about the details of their work. The frequent inability to communicate the real-world application of scientific research becomes a barrier to the public understanding of science, which is often coupled with language barriers in the international space. The largest obstacle to ensuring the public’s understanding of science is caused by the scientist’s inability to communicate complex ideas and concepts in a manner that broad audiences can grasp. Ultimately, scientists have a responsibility to work toward addressing this problem with other scientists. With the continued advancement of technology, science has become increasingly complex and subsequently more difficult to communicate. It is scientists’ responsibility to thoughtfully utilize accessible scientific language and media to share information with the public. Global issues and misconceptions around issues like climate change, biosecurity, emerging infectious diseases, limited natural resources, and biodiversity conservation all require clear communication from the scientific community. Communication regarding such global issues requires a multidisciplinary approach that brings together not only scientists but also health care professionals, clinicians, public health experts, economists, politicians, and others.
THE COMMUNICATION CYCLE Communication is dynamic and diverse, and follows the cycle of Input, Process, and Output (IPO). Input involves the sharing of verbal or nonverbal information with recipients. Process involves comprehension of shared information. Output is a response to the receiver. As scientists, we often communicate our research to colleagues and occasionally to the public by using various forms of media that follow the basic principle of input-process-output. CULTURES Vol 1, Issue 2 » Page 55
However, communication between scientists and people with nonscientific backgrounds is commonly hampered by errors in the input or process stage of the communication cycle. Often, such errors involve a lack of interest or attention, difference in perception, jargon, cultural and ethological differences, fictitious assumptions, environmental distractions, and distance. One historical example of communication error is the perception of HIV/AIDS during the 1980s when the condition was thought to be associated solely with homosexual activity, thus enhancing stigma, homophobia, and misperceptions about contracting HIV and its victims among the general public. As such, effective communication largely depends on the process component of the public’s understanding of scientific information. Once scientists are able to appropriately tailor their communication to maximize the public’s effective processing of the information, it may be possible to change the perception and misconceptions of science, as in the case of the HIV/AIDS movement.
SCIENCE COMMUNICATION IN THE INFORMATION AGE Evidence must be the foundation for decisions in society. As a result, scientists have both a social and moral responsibility to communicate their evidence-based knowledge where appropriate. Effective communication to nonscientists requires accurate data that are expressed in a nontechnical manner without compromising the integrity and implications of the knowledge itself. In addition, scientists must communicate both opportunities and limitations of their science without causing undue panic or creating unrealistic expectations. A prime example of inappropriate communication of science that exacerbated the public’s expectations is the Human Genome Project, which the media sensationalized and projected as the key to solving most health issues. This type of media misinformation may buy short-term support for science but will ultimately generate long-term public mistrust of the implications of major scientific projects. Frequently, while social media platforms like Facebook and Twitter have been instrumental in information sharing around the world, they also create complexities in the spread of misinformation. One instance of this is the ill-conceived notion that there is a link between
Page 56 » Voices
CULTURES Vol 1, Issue 2 » Page 57
childhood vaccinations and autism, resulting in widespread vaccine refusal and thus damaging herd immunity and posing deep concern for public health professionals.
A WAY FORWARD: STEPS FOR EFFECTIVELY COMMUNICATING YOUR SCIENCE In the age of rapidly spreading information, which is often exacerbated by social media, it is vital that scientists know how to share their findings with the public in a simple but accurate manner. Focusing on the process component of the IPO model will help scientists understand what is essential when sharing scientific discoveries. These four tips can help scientists around the world better communicate their science to their colleagues and the public: 1.
Tell a story: People like stories. Telling a story gives complicated research data and complex scientific concepts a more humanistic feel.
2.
Use relevant data: This helps avoid the spread of misinformation and public distrust of scientific findings. Data can often be represented in photographs, charts, and graphs that help simplify large findings without compromising their integrity, making the information conceptually easier to understand.
3.
Substitute scientific jargon for layman terms: Imagine explaining the science to your grandmother. Avoid using terminology that you would use with your colleagues. Beware of differences in interpretation of common phrases. For example, to the public, “positive trend” might imply that something is beneficial, but that might not be what you are trying to communicate.
4.
Discuss what the public does not know: Talk about not only the opportunities of your science, but also the limitations. Talk about the questions that have yet to be answered and about how you plan on working toward addressing them. This keeps the public informed and mitigates the risk of the spread of misconceptions about the current science and what is ahead.
Page 58 » Voices See Photography + Art Credit on page 59 for copyright information.
Effective communication is essential to informed decision making and thus advancing scientific innovation and technological development. With innovative research collaborations across the world that address many of today’s misconceived grand challenges, effective and accurate science communication to the public is critical. By engaging scientists with nonscientists, public discussion about science allows a discourse that is essential to the realm of decision making in society.
ASM Young Ambassadors of Science are dynamic young leaders, who represent ASM in their home country, facilitating networking, professional development, and collaboration to strengthen science globally. ASM Young Ambassadors of Science mobilize the next generation of scientists to develop innovative approaches to meet the grand challenges in science. To learn more, visit asm.org/international.
CULTURES Vol 1, Issue 2 Âť Page 59
ON THE GROUND
In each issue, we share a collection of unique narratives from individuals and organizations working on the front lines of science.
1
PG 62
Medicine, Morality, and Economics Paul Collier
2
PG 66
Frontline Microbiology: Pushing Our Field to the Boundaries of Exploration Joseph Fair
3
PG 70
Turning Challenges into Opportunities: Establishing Yemen Epidemiology Field Training Program Aisha O. Jumaan
4
PG 74
5
PG 80
6
PG 84
All Aboard: Treating Patients in the Wake of Disaster
Health System Design for Last Mile Villages
Colleen Gallagher
Peter Luckow,
Doing Science in Haiti: Opportunities, Obstacles, and Successes
Joshua Albert,
Meer T. Alam,
Alice Johnson
J. Glenn Morris, Jr.,
An Excerpt from U.S. Navy Hospital Ship Missions Derek Licina
Anthony T. Maurelli
7
PG 90
A Global Science Odyssey: Adventure and Challenges Leonard F. Peruski
MEDICINE, MORALITY, AND ECONOMICS Paul Collier, Ph.D.
Thirty years ago, to be HIV+ was a death sentence. Thanks to remarkable medical advances, if the disease is detected and treated with antiretroviral therapy (ART), people who are HIV+ can now live near-normal lives. The medication costs only a few hundred dollars a year, and it can be administered within the evolving capacities of most health systems. The existence of this new treatment has fundamentally changed the ethics of treatment and, in consequence, the economics of health care in countries with a high prevalence of HIV+ people.
People who are HIV+ can now live near-normal lives. - PAUL COLLIER
If, with near-certainty, an early death can be averted and replaced by a healthy life at the cost of only a few hundred dollars a year, there is a reasonable presumption that somewhere, globally, there resides a moral duty of rescue. And once a person is being treated, to end that treatment would be tantamount to homicide.
This does not mean that such a duty of rescue is unqualified. Some societies are too poor to meet it. In a world of economic scarcity, many desirable actions are not feasible, and so costs have to be taken into account alongside benefits. In a society where average per capita income is only a few hundred dollars, where a substantial percentage of the population is HIV+, and where there are many other calls on very limited public revenues, people may entirely reasonably refuse to recognize a duty of rescue for HIV+ sufferers. But at the present global average living standard of about $6,000 per capita per year, a cost of $400 to rescue a year of healthy life is sufficiently affordable that globally there is such a duty, wherever it might lie. Another qualification is that the duty of rescue depends on the behavioral choices of the person in jeopardy. If an adult person puts themselves in jeopardy through persistent behavior that a reasonable person would regard as foolhardy, they may reasonably be regarded as having forfeited the right to rescue. However, in Africa and other low-income regions,
Page Page 62 62  On On the the Ground Ground
a large majority of the people who have contracted HIV have done so through the normal routine of sexual intercourse, or sometimes owing to contaminated blood transfusions or inheritance at birth from an HIV+ mother.
AUTHOR BIO Sir Paul Collier, Ph.D., is Professor of Economics and Public Policy at the Blavatnik School of Government, a Professorial Fellow of St Antony’s College, and Co-Director of the Centre for the Study of African Economies, Oxford.
The treatment of the population that is HIV+ generates an economic liability, analogous to the liability of sovereign debt. Indeed, in some high-prevalence countries this liability may even exceed sovereign debt as conventionally conceived. Just as finance ministries need to ensure that debt can be managed within the means available to them, so they need to factor the continuing costs of treatment of HIV+ citizens into their calculations. In most cases, these costs are continuing to increase as the numbers beginning ART each year exceed the numbers who die, presenting a growing burden to the next generation. And this is also an issue for aid donors, who in many cases have met the lion’s share of the costs of treatment to date and need to consider the longer-term implications for their support. Once the duty of rescue is recognized as generating a debt burden, it becomes sensible to spend on prevention at least up to the point at which an extra dollar on prevention programs averts an extra dollar of debt. This principle can guide the scaling up of expenditures on prevention, although turning this into practice requires detailed work on the marginal cost-effectiveness of different approaches to prevention.
Furthermore, for incentives to be compatible, it is important that any partition of the costs of treatment between aid agencies and the governments of the countries affected should be matched by the partition of the costs of prevention. If, for example, governments paid for prevention whereas donors paid for treatment, governments would have insufficient incentive to prevent the spread of infection. For a sustainable outcome, a path needs to be found that will stabilize and eventually reduce the number of people needing treatment. This may require an initial investment in a big push. The cost of such an investment may be beyond the means of poor countries, but it would be appropriate for donors.
CULTURES Vol 1, Issue 2 » Page 63
COLLIER
The triumphs of medical research have created a new agenda for public policy that will require some long-standing silos to be overcome. There is an urgent need for practical engagement between medical research, health care professionals, and economists to inform public policy in affected countries. Health ministries need to work much more closely with finance ministries.
(continued from previous article)
ANTIRETROVIRAL THERAPY IN LOW- AND MIDDLE-INCOME COUNTRIES BY REGION Fifty-five percent of low- and middle-income countries around the world have therapy coverage.
The Caribbean
West & Central Africa
67% THERAPY COVERAGE
35% THERAPY COVERAGE
73,000 RECEIVING THERAPY
1,000,000 RECEIVING THERAPY
110,000 ELIGIBLE FOR THERAPY
2,800,000 ELIGIBLE FOR THERAPY
Latin America
Eastern & Southern Africa
79% THERAPY COVERAGE
64% THERAPY COVERAGE
585,000 RECEIVING THERAPY
5,200,000 RECEIVING THERAPY
740,000 ELIGIBLE FOR THERAPY
8,200,000 ELIGIBLE FOR THERAPY
Latin America & The Caribbean
Sub-Saharan Africa
77% THERAPY COVERAGE
56% THERAPY COVERAGE
660,000 RECEIVING THERAPY
6,200,000 RECEIVING THERAPY
850,000 ELIGIBLE FOR THERAPY
11,000,000 ELIGIBLE FOR THERAPY
Page 64 » On the Ground
[ DECEMBER 2011 ]
Europe & Central Asia 26% THERAPY COVERAGE 137,000 RECEIVING THERAPY 520,000 ELIGIBLE FOR THERAPY
North Africa & the Middle East 16% THERAPY COVERAGE 16,000 RECEIVING THERAPY 100,000 ELIGIBLE FOR THERAPY
46% THERAPY COVERAGE 1,100,000 RECEIVING THERAPY 2,400,000 ELIGIBLE FOR THERAPY
CULTURES Vol 1, Issue 2 » Page 65
COLLIER
East, South, & Southeast Asia
FRONTLINE MICROBIOLOGY: PUSHING OUR FIELD TO THE BOUNDARIES OF EXPLORATION Joseph Fair, Ph.D., M.P.H. In science, as in life, the hardest things to achieve are often the most gratifying. Maybe not to you, but scientists are a “different breed” of people. Perhaps it is inherently the type of personality drawn to science or it is a result of our training, but a pervasive trait among us is the ability to delay our own personal gratification to achieve a greater long-term goal. As microbiologists, we can and often spend our entire careers working toward building research programs that provide insight into our curiosity. The
need to see what is over that next hill is an innate quality of humankind, and the pursuit of that desire has ultimately resulted in the globally interconnected and interdependent world in which we live today. Coupled with advances in technology, we continue to expand our horizons and explore the as-yet-unseen worlds of the deep oceans and space. As microbiologists, we have been and continue to be a part of all of those journeys, because, no matter what the adventure is, we have to explore
Fair arriving in Sierra Leone, 2005.
Page 66 » On the Ground
FAIR
Left: Dr. Joseph Fair, with the people who made his career, including Dr. Marx. The Virology Group at the International Center for Medical Research in Gabon (CIRMF). Right: Joseph Fair and Dr. Randy Schoepp looking for Ebola virus exposure in VHF (viral hemorrhagic) patients in Sierrra Leone 2 years ago.
what we cannot see as well as what we can, both how it affects us and how we affect it.
AUTHOR BIO
We presently face an unprecedented confluence of events on this planet, including an increasing unsustainable human population, the derivative constraints on resources such as water and food, and the consequential effects of our actions including the augmentation of global warming and pollution. The present day interconnectedness of our world, coupled with the increased population, has created a global society in which few events remain “localized.” As evidenced by the recent global financial meltdown created by shortfalls in the U.S. housing market, as well as the incredibly rapid spread of the influenza AH1N1 virus in 2009, things do not ever just happen locally anymore. What happens in one corner of the world can and often does have a ripple effect.
Joseph Fair, Ph.D., M.P.H., is a virologist who specializes in emerging diseases, globally. He serves as the Vice President of Research Development at Metabiota, Incorporated.
In response to our global vulnerability to lethal pandemics, efforts are currently underway to train a global cadre of microbiologists of all disciplines to do science in “hard places.” Many novel infectious disease spillover
CULTURES Vol 1, Issue 2 » Page 67
events occur in disease “hot spots,” where there usually exists a nexus of high biodiversity and increased interaction between wildlife, humans, and livestock due to either cultural heritage, economic constraints, or both. These places are often “hard” places to do science, either due to resource constraints or political wariness of acknowledging public health crises.
Now is our time as microbiologists... This requires science to be done in hard places, not just in industrialized cities and nations.
Visionary global programs are underway by the U.S. Agency for International Development, the U.S. Departments of Defense, Agriculture, and State, and European and Asian initiatives, as well as an unprecedented amount of media attention and social awareness of infectious disease issues and risks, albeit usually misinformed. Infectious diseases and their prevention is coming into an - JOSEPH FAIR age where it is considered a global stewardship, in that every country and society has a responsibility to prevent possible pandemics, and, if not, we have the social and security obligation to help them to do so. This unprecedented confluence of circumstances, funding, and initiative offers us an opportunity unique in history to make the world a healthier place, while, at the same time, it also offers us increased global security and perhaps our best chance yet to achieve an ecological balance between humans and their environments. Now is our time as microbiologists. Perhaps for the first time in human history, microbiologists and their skills are not considered a luxury of industrialized nations, but a necessary component of communal society, where we play key roles in monitoring disease among ourselves, our animals, and the wildlife with which we both come into contact, the safety of our food, our water, our blood supplies, as well as urban planning and environmental regulation. This requires science to be done in hard places, not just in industrialized cities and nations. Right now, you might be thinking of wearing a fedora or trekking through a remote jungle, and those instances can and do happen in international microbiology, but think less
DRC and Cameroonian scientists Epos Ngay and Jean-Michele Takuo, respectively, looking for the Ebola reservoir in Isiro, DRC.
Page 68 » On the Ground
FAIR
“Indiana Jones” and more John Kerry meets an Indiana Jones/Louis Pasteur hybrid. For most of us who were trained in a classical environment, when we start doing science in “hard places,” it feels like we are starting all over again and, in many ways, we must.
rra Leonean scientists Author working with Sie se on Bockarie to diagno Augustine Goba and Bay ne. Leo Lassa fever in Sierra and honse Pema of Guinea Right: Fair with Drs. Alp Emily Jentes of CDC.
A dear mentor of mine, Dr. Preston Marx, gave me my first job working overseas, conducting HIV surveillance in Central Africa. Preston taught me something that has been an invaluable lesson, which I continue to relearn everyday: If you want to keep something in science, you have to give it up. If your goal is do science in a hard place, you must be willing to accept that human relations, cultural understanding, and the ability to not only share, but often to sacrifice credit for the sake of the greater good and the increased development and capacity where you are working, are as important as the science we hope to do there. In my own personal experience, the human bonds I have formed while responding to outbreaks of infectious diseases in Africa and Asia are as important to me as any publications that came out of them. Not surprisingly, because of those relationships and shared experiences – making do when you need to centrifuge a sample and the best option you have is to use a battery-operated screwdriver to spin the rotor, all the while wearing a PAPR (powered air-purifying respirator) in 37°C ambient temperature – we formed bonds that are lifelong. Not only great friendships, but also great science happens, late at night, when you are exhausted and sharing a drink over a cold meal.
CULTURES Vol 1, Issue 2 » Page 69
TURNING CHALLENGES INTO OPPORTUNITIES: ESTABLISHING THE YEMEN EPIDEMIOLOGY FIELD TRAINING PROGRAM Aisha O. Jumaan, Ph.D., M.P.H. In the summer of 2010, I was asked by a former colleague at the Centers for Disease Control and Prevention (CDC) to help in establishing a Field Epidemiology Training Program (FETP) in Yemen. FETP is modeled after the CDC Epidemic Intelligence Service, a two-year training program for health professionals. Knowing the value of the program, I agreed. I knew that this would be a difficult task with many challenges. The country has political and security issues. It was a difficult time to establish a new program and to recruit qualified candidates to ensure the program’s success. Moreover, we had to secure a national commitment to the program and ensure collaboration between different and sometimes competing programs. However, I recognized that this was a great opportunity for the future of public health in Yemen. These challenges, if addressed, could be turned into great opportunities. Here, I outline the process that my colleagues at CDC and I used to move the project forward.
JUMAAN
Garner Support from All Potential Stakeholders We made our first trip to Yemen in the summer of 2010. I arranged for meetings with the leadership of the Ministry of Public Health and Population (MOPHP) to garner support for the program. I made sure to include everyone involved in health programs. My list was large but comprehensive. We needed to seek support of all parties to inform them of the program’s objectives and benefits. We had long days with several meetings with a wide range of professionals including technical Directorates at the MOPHP, finance, human resources, higher education, universities, the World Health Organization (WHO), United Nations agencies, and donors. The meetings were very productive and helped us to proceed with our plans.
Page 70 » On the Ground
AUTHOR BIO Aisha Jumaan, Ph.D., M.P.H., is working with the Department of State as a consultant coordinating health projects in Yemen, focusing on strengthening laboratories, surveillance, and human resources capabilities.
Align Objectives of the Program with Those of the Country I arranged for a second trip to Yemen with several CDC colleagues to work on the curriculum a few months later. We worked closely with a group of professionals representing the major public health programs in Yemen for five days to determine the vision, goals, objectives, and processes for implementing the program. This was essential to ensure that the program met the needs of the MOPHP. I have to admit that some of the discussions were heated and we had some disagreements along the way. However, we all used the health priorities in Yemen to bridge the gap. We were able to finalize our training curriculum to meet the needs of the country.
Develop Trust It was crucial to build trust with our Yemeni colleagues. We were transparent in all our interactions. We outlined the qualifications of candidates to train in the program. We worked jointly on job descriptions and calls for candidates. This common objective allowed us to build a trust with our Yemeni counterparts. We were able to jointly select the first cohort of trainees. The selection process was very transparent and resulted in a great group. All candidates were aware of the selection criteria and were pleased with the process. Clearly, our Yemeni colleagues and the Ministry did not intervene in the selection process, but they made great efforts to seek out Signing the agreement for the collaboration for qualified applicants and the FETP Program, Sana’a, Yemen, June 2012. encourage them to apply; they wanted the program to succeed. In Yemen, connections and political alliances sometimes play a role in the selection of candidates. This was not the case here; the Minister was very supportive and granted all of us the needed freedom to do our job properly. The final selection process involved an initial training for 32 candidates to be included in our basic training that started in January 2011.
CULTURES Vol 1, Issue 2 Âť Page 71
Be Flexible Political unrest and demonstrations started 2 weeks before the end of the basic training. As a result, the CDC trainers were not allowed to travel to Yemen. We had to stop the program, hoping that it would resume soon. However, fighting in Sana’a started and the situation became tense; we all realized that the unrest would take time to resolve. Therefore, we arranged to move the training in November 2011 to a safer location in Yemen. An international expert joined me to complete the training and, with the help of our Yemeni colleagues, made the final selection of the trainees to start the two-year program. We selected 12 trainees based on the interactions and selection criteria. Overall, this was a successful process where everyone came together to ensure that a qualified cadre was selected to be trained. We had to be very flexible and willing to change our plans to overcome the challenges. Our trainees were assigned to work in priority programs within the MOPHP.
It was crucial to build trust with our Yemeni colleagues. We were transparent in all our interactions.
Engage Partners
JUMAAN
Our approach was to engage all partners to ensure the success and sustainability of FETP. The WHO Sana’a office was an important partner and provided technical and financial support for the program. We also held a workshop in Sana’a on January 2012 for the supervisors of the programs where the trainees were assigned. We presented an overview of FETP and the roles and responsibilities of the trainees and super- AISHA JUMAAN visors. This presented an opportunity for the supervisors to meet and raise questions and concerns about the program. Most importantly, we were able to address misconceptions and high expectations.
Page 72 » On the Ground
Provide Constructive Feedback FETP decided to hire a resident advisor to lead the program in-country. This process became difficult as the political and security situation deteriorated. Trainees were immediately immersed in multiple projects including responding to outbreaks, analyzing surveillance data, writing abstracts, and conducting assessments and evaluations of health programs. They needed guidance and support for the work they were conducting. We had to be creative and used various methods to provide feedback including hiring short-term national and international consultants, electronic communications with technical experts, phone calls, and periodic visits to Yemen to work with the trainees. All our efforts were to provide constructive feedback to ongoing work and to help the trainees deliver on their assignments and projects. We were able to sustain the program and support all the activities through these mechanisms until the program hired the resident advisor at the end of 2013.
Recognize Good Work The Yemen FETP Program started during a very difficult time. However, the trainees were successful, not just in completing their assigned tasks, but also in conducting high-priority and urgent activities such as polio and measles mass vaccination, evaluation of polio surveillance, and training of surveillance officers around the country. They worked under very difficult situations, traveled to remote areas, and sometimes to war-torn places, to conduct outbreak investigations, assess programs, train local health care personnel, and conduct research. The supervisors displayed flexibility to the changing environment and expectations during uncertain times. They provided technical support and access to data sets to ensure that the work was done. We created several means to recognize the exceptional work of the trainees, their supervisors, and the support staff. We also arranged for meeting with the Minister and his team to present findings and progress. We ensured that the trainees got the credit they deserve for such an outstanding job in a such a hard situation. Most of the trainees were able to attend international conferences and present their work. It was important to provide feedback to everyone involved about the outstanding jobs they were doing. The first Yemen FETP cohort graduated in February 2014.
CULTURES Vol 1, Issue 2 Âť Page 73
ALL ABOARD: TREATING PATIENTS IN THE WAKE OF DISASTER Colleen K. Gallagher, FNP
In April 2009, I had the privilege of visiting Port-au-Prince, Haiti. I was assigned to the U.S. Navy’s hospital ship, USNS Comfort for Continuing Promise 2009, a 4-month humanitarian and civic assistance mission to Latin America and the Caribbean region providing medical, dental, veterinary, and engineering assistance. I was with a multidisciplinary health care team. We worked in an extremely impoverished area where there was limited access to health care. As a team, we treated severe goiters; untreated congenital anomalies; untreated, invasive, benign, and cancerous tumors; and the effects of tropical diseases such as filariasis. The trip had a profound impact on me, not only as a clinician, but also as a person. In the evening, I would look out from the ship and see the many lights from homes high into the hills and mountains twinkling in the night. On the day we departed, I remember wondering if I would or could ever come back. Nine months later, on January 12, an earthquake measured at 7.0 magnitude killed approximately 230,000 people, injured hundreds of thousands more, and displaced millions. On January 15, I deployed on the U.S. Navy’s hospital ship, USNS Comfort. I had no idea what to expect. Had I seen it all before?
CULTURES Page Page 74 74Vol »» On On 1, Issue the the Ground Ground 2 » Page 74
As the ship sailed in closer to Haiti, I could hear the helicopters flying overhead. Soon they started to land on the flight deck of the ship. I was assigned to our casualty-receiving area. I still remember the first two patients I received in casualty receiving. My first patient was quietly rolled into my trauma bay, his eyes looking around. He was a slender, young adult male. I took a breath. He had his “ABCs.” He was awake. He was breathing. He had a pulse. I had a pulse. I touched his shoulder to introduce myself. My high school French for general introductions was understandable to him, and he nodded. I had a Haitian American Red - COLLEEN GALLAGHER Cross Volunteer with me as a translator. I slowly pulled back the blankets and saw two large bulky dressings. There were no notes or paperwork. One dressing was slightly stained with dried blood on the left lower leg, and the other dressing covering his left arm had a rigid portion to it. He did not yell or cry as I carefully took the dressing down from his left lower extremity. The shape of the dressing hinted at a potential traumatic amputation. I removed the gauze. There was a mid-tibia-fibula compound fracture with a traumatic amputation of the left foot. – Deep breath. – I unwrapped the left arm dressing, and I found superficial abrasions, but a severely displaced distal ulnar fracture. The patient was sent off to X ray and then to orthopedics. AUTHOR BIO
The trip had a profound impact on me, not only as a clinician, but also as a person.
CULTURES CULTURES Vol Vol 1, 1, Issue Issue 22 »» Page Page 75 75
As a Family Nurse Practitioner, Colleen K. Gallagher, FNP, is the United States Navy Liaison to the United States Agency for International Development. The comments contained herein are the personal reflections of the author and are not to be construed as official or reflecting the views of the Department of Defense or the crew of the USNS Comfort.
GALLAGHER
I had no time to process the left lower extremity traumatic amputation. My next patient had rolled in to the next bed. This patient was a young teenage girl. Her right hand had a large bulky dressing that she cradled with her left arm. She let me hold the bandaged arm, and I began to undress the injury. As I began to take the final layer of dressing off, she put her left hand over mine and shook her head “no.” Through the translator I told her I needed to see her injury and would tell her exactly what I was going to do. The bandage removal revealed a crushed right hand with traumatic amputation of the fourth and fifth digits through mid shaft of the metacarpals and a partial amputation of the third digit. She kept her head turned away while I examined it, but finally turned to look at her hand with the appearance of utter sadness.
[continued from page 75] The day continued on in a blur. Each patient had as severe and traumatic injury as the one before. Most patients had not been treated other than receiving a dressing or rag over the wound, which explained the clinical findings of severe wound infections, gangrene of wounds, and maggots in the wounds. The next day, I helicoptered to land with a team for a ground assessment. The destruction was catastrophic. We landed near the once presidential palace and walked to the once University Hospital. Hundreds of patients with quick-and-dirty makeshift dressings and splints were lying on sheets and mattresses in the streets; crude tents shielded the sun. Seeing the structural devastation truly visualized the mechanism of the patients’ crush injuries. Later in the evening, I was back on the ship. I saw the same hills and mountains as I did less than 9 months earlier, with the exception that this time it was all dark; there was no electricity, no twinkling lights. After these 2 days, I was not sure if anything would surprise me. I did know one thing for sure – that I was with an incredible team.
Page Page 76 76 »» On On the the Ground Ground
AN EXCERPT FROM U.S. NAVY HOSPITAL SHIP MISSIONS Derek Licina, Dr.P.H., M.P.H.
CULTURES CULTURES Vol Vol 1, 1, Issue Issue 22 »» Page Page 77 77
LICINA
To assist partner nations in their efforts to build health AUTHOR BIO sector capacity, counter the ideological influence of nefarious groups, and support public diplomacy, the Derek Licina, Dr.P.H., U.S. government deploys Navy hospital ships to perM.P.H., is an active form humanitarian assistance missions. The U.S. Deduty US Army partment of Defense (DoD) currently maintains the Medical Service Corps U.S. Naval Ship (USNS) Mercy based out of San Diego, Officer currently California, and the USNS Comfort based out of Norserving on exchange folk, Virginia. Although the primary mission of these to the Australian hospital ships is to provide rapid medical capability Defence Force. for deployed military personnel, it is their secondary mission of providing humanitarian assistance that has dominated their use. Since 1990, the USNS Comfort has deployed twice in support of deployed military personnel (First Gulf War and Operation Iraqi Freedom), and the USNS Mercy has deployed once (First Gulf War). However, the Comfort and Mercy have collectively deployed on seven humanitarian assistance missions (Pacific Partnership, five times; and Continuing Promise, two times) and five disaster responses (Haitian migrant processing, two times; and Asian Tsunami, Hurricane Katrina, and the Haiti Earthquake). This is a one to four ratio between the primary and TO READ DR. LICINA’S secondary missions of these hospiFULL PIECE, VISIT tal ships – a clear role reversal. WWW. ASM.ORG/CULTURES.
USNS MERCY
DURING THE 2004 TSUNAMI DISASTER RELIEF EFFORT:
DILI, East Timor (July 19, 2008) The Military Sealift Command hospital ship USNS Mercy (T-AH 19) is anchored off the coast of East Timor supporting Pacific Partnership 2008. Pacific Partnership provides humanitarian assistance in cooperation with the government of East Timor, partner nations including representatives from Australia, India, Indonesia, Portugal, Canada, and the Republic of Korea and many nongovernmental organizations.
Page 78 Âť On the Ground
LICINA
This figure is based on the work of Dr. Derek Licina. To read his full piece, visit www.asm.org/cultures.
CULTURES Vol 1, Issue 2 Âť Page 79
LUCKOW, ALBERT, JOHNSON
HEALTH SYSTEM DESIGN FOR LAST MILE VILLAGES Peter Luckow, Joshua Albert, Alice Johnson
Liberia exists on the margins of our global society. Based on health, education, and income data, the small West African nation ranks 174th of 187 nations in achieving human development (1). In 2003, at the conclusion of fourteen years of civil war, Liberia was left with one of the worst health workforce shortages in the world; only 51 doctors remained to serve the country’s four million citizens (2). The majority of these physicians practice in or near Monrovia, Liberia’s capital. Yet, 1.5 million people live in remote villages throughout Liberia, far beyond the reaches of health facilities and physicians (3).
AUTHOR BIO Joshua Albert is currently the Country Director & Chief Operating Officer at Last Mile Health.
For the past six years, Last Mile Health has fought to save lives in the remote villages of southeastern Liberia, a twelve-hour drive from the capital and deep into the rainforest. By employing and training women and men from these villages to serve as frontline health workers, Last Mile Health brings home-based care directly into places previously deemed impossible to reach.
These villages exist on the margins of the margins. When you travel to places like Zeagbay, it is hard to imagine that there is a village at the end of your journey. To get to Zeagbay, you have to travel five hours in a four-wheel drive vehicle, thirty minutes in a canoe, six hours on a dirt bike, and then an hour by foot. Our team made the arduous journey to Zeagbay for the first time this past October. When we arrived, we found a community entirely detached from the fruits of modern science and medicine. Public vaccination campaigns had never reached the village, and not a single mother had given birth in
Page 80 » On the Ground
Frontline health workers travel to a Last Mile village. Š Last Mile Health
LUCKOW, ALBERT, JOHNSON
a facility. Unable to walk impossible distances to the clinic, mothers and children all too often died of treatable and preventable diseases. In the 21st century, distance should no longer determine whether one has access to basic primary care. Indeed, more than thirty years ago, 134 ministries of health committed to achieving universal access to primary care (4). But despite tremendous progress over the past several decades, today, more than one billion people will never see a health worker in their lifetime (5). AUTHOR BIO Alice Johnson serves as the Deputy Frontline Health Worker Program Manager at Last Mile Health, overseeing the training and supervision of the organization’s team of community-based health practitioners.
At Last Mile Health, we rely on some of medicine’s greatest achievements to provide care in Last Mile villages. Handheld anemia screeners allow us to ensure that pregnant women have fewer complications. Rapid diagnostic tests confirm malaria cases without the use of heavy laboratory equipment. These advancements, along with others like them, offer incredible new possibilities for achieving universal primary care.
These tools enabled Markson, one of Last Mile Health’s frontline health workers, to bring primary care for the first time to Zeagbay. In our first weekend, Markson diagnosed and treated every sick child in the community, and his nurse-supervisor, Alice, provided antenatal care to Zeagbay’s pregnant women. Over the course of several days, two-thirds of all children in the community were diagnosed and treated for combinations of malaria, pneumonia, and diarrhea. But, in many ways, the greatest innovation was Markson himself. Unlike most community health volunteers throughout the world, Markson is a
Frontline health worker Zark pa checks up on a young child. © Last Mile Hea lth
Page 82 » On the Ground
trained professional. We recruited Markson after he was vetted by his community and passed a series of aptitude tests and interviews. Then, over the course of several months, we trained him to provide prevention, diagnosis, treatment, and referral services for the top ten killers in his community. And we provided him with point-ofcare diagnostic tools and medicines, along with a supervisor to monitor and coach his performance.
AUTHOR BIO Peter Luckow is a Cofounder and Strategic Advisor of Last Mile Health and is an M.P.H. Candidate at The Johns Hopkins Bloomberg School of Public Health.
The advent of professional frontline health workers offers an opportunity to reenvision new possibilities for rural health delivery. With integrated frontline health workers, rural health systems can provide health care to those who need it most, not just to those who can make it to the clinic. That is why Last Mile Health works in partnership with the Liberian Ministry of Health and Social Welfare to design the continuum of care from the community to government health facilities. Today, in places far beyond the reaches of physicians and facilities, frontline health workers like Markson are saving the lives of rural Liberians who would otherwise go untreated. Without innovative and integrated systems for delivering care to Last Mile villages, medical and technological progress will mean little for those who suffer the most. But by leveraging the power and passion of people like Markson, universal primary care may soon be a reality – even in the most distant villages.
REFERENCES 1. United Nations Development Program. 2013. Human Development Report 2013. The rise of the south: human progress in a diverse world. http://hdr.undp.org/sites/default/ files/reports/14/hdr2013_en_complete.pdf.
2.
World Health Organization. 2013. Global health workforce statistics. http://www.
who.int/hrh/statistics/hwfstats/en/ Accessed February 22, 2013.
3. Republic of Liberia, Ministry of Health and Social and Welfare. 2011. National Health and Social Welfare Policy. https://www.healthresearchweb.org/files/NHPP_July132011.pdf.
4. World Health Organization and United Nations Children’s Fund. 1978. Declaration of Alma Ata: International Conference on Primary Health Care, Alma Ata, USSR, 6–12 September, 1978. Geneva, Switzerland: World Health Organization.
5.
World Health Organization. 2010. Increasing access to health workers in remote
and rural areas through improved retention. Global Policy Recommendations. http://whqlibdoc.who.int/publications/2010/9789241564014_eng.pdf.
CULTURES Vol 1, Issue 2 » Page 83
DOING SCIENCE IN HAITI: OPPORTUNITIES, OBSTACLES, AND SUCCESSES Meer T. Alam, M.Sc., J. Glenn Morris, M.D., Jr., Anthony T. Maurelli, Ph.D.
AUTHOR BIO Tony Maurelli, Ph.D., is Professor of Microbiology and Immunology at the F. Edward Hébert School of Medicine (“America’s Medical School”), Uniformed Services University, Bethesda, Maryland. His research interests include the evolution of bacterial pathogens, and how cell wall synthesis and metabolic pathways contribute to the pathogenesis of intracellular bacterial pathogens.
We are working in Haiti at the University of Florida Emerging Pathogens Institute (UF-EPI) Haiti Lab 1-Gressier. Nestled between the mountains and the sea in a semirural area west of Port-au-Prince, it is an area of great natural beauty. Haiti, one of the poorest countries in the Western Hemisphere, was hit with a massive earthquake on January 12, 2010. Even before the devastating earthquake, Haiti had a limited road network, had inadequate housing, and lacked systems of clean water distribution and sanitary wastewater treatment. The earthquake destroyed much of what existed. The electrical grid is limited and unreliable. Many roads are still in bad shape, and some areas of the country are difficult to reach. During the rainy season, these regions may be impossible to reach by road. These conditions make assuring a supply chain challenging. To contribute to “A better tomorrow for Haitian people,” UF took the initiative to establish an infectious diseases laboratory in Haiti. We received funds from the Department of Defense to purchase equipment, reagents, and supplies to study
Page 84 » On the Ground
ALAM, MORRIS, MAURELLI
malaria and diarrheal disease transmission dynamics and seasonality and the spectrum of diarrheal pathogens in clinical samples in Haiti. UF received NIH funding for a community-based study of cholera using a cohort of school children and their families from the Christianville area in Gressier and for surveillance for Vibrio cholerae in the aquatic environment. Working with collaborators, we hired and trained Haitian laboratory personnel and community health workers. Our ultimate goal is to contribute to better health care for Haitians.
Crucial to the success of a project is the identification and training of techincal staff. Work with collaborators.
The result of the UF initiative is that we now have a fully functioning Biosafety Level (BSL) 2 microbiology/molecular biology laboratory. We also recently commissioned a BSL3 laboratory to study tuberculosis and to train Haitian laboratory technicians in BSL3 procedures. Our success in building and sustaining a research presence in Haiti is due to collaborations large (UF, Armed Forces Health Surveillance Center-Global Emerging Infections Surveillance and Response System [AFHSC-GEIS], Ministère de la Santé et de la Population [MSPP], CDC, NIH, BioBubble, Christianville Foundation, etc.) and small (local MSPP and nongovernmental organization [NGO] clinics, local scientific suppliers, etc.). The research needs and opportunities are plentiful. Haitians are plagued by a multitude of infectious as well as chronic diseases due to extreme poverty, the lack of clean, potable water, a fragmented and uncoordinated health care system, and the presence of agents and vectors of tropical infectious diseases. Cholera quickly comes to mind when one thinks of Haiti. But even before the deadly epidemic that began in October 2010,
CULTURES Vol 1, Issue 2 » Page 85
Haiti already suffered from an enormous burden of diarrhea, malaria, dengue, typhoid fever, lymphatic filariasis, tuberculosis, and HIV. There is almost certainly a high level of non-HIV sexually transmitted infections (STIs), and one of our projects is to measure the prevalence of non-HIV STIs in two regions of Haiti. Since epidemic cholera appeared in Haiti in 2010, it has continued, and, as of February 2014, about 699,000 cases and more than 8,500 deaths have been reported. It is essential to understand the patterns of ongoing transmission and seasonality of cholera in Haiti and to assess the likelihood of future epidemics. This raises the question of whether the microorganism has established in environmental reservoirs in AUTHOR BIO Haiti. We are the first to successfully isolate toxigenic V. cholerae O1 from multiple sites in the environment in Haiti Glenn Morris, M.D., is (http://wwwnc.cdc.gov/eid/article/20/3/13-1293_article.htm). Professor of Medicine This finding is of great importance for guiding public and Director of the health planning. Emerging Pathogens Institute at University Diarrheal disease is an ongoing public health concern of Florida. His major in Haiti, so we are also assessing and monitoring drinkresearch interests ing water quality in the Gressier and LÊogâne regions. are in the molecular Since the earthquake and subsequent cholera epidemic, epidemiology and wells installed by NGOs have provided increased access pathogenesis of to drinking water. We tested more than 500 wells for fecholera and other cal coliforms, salinity, and pH, and found that a sizeable enteric pathogens, and percentage of wells are contaminated. We are working foodborne illness. with local offices of the national water authority and NGOs to explore interventions that can address the problem. The planning, building, commissioning, and operation of a BSL2, and now a BSL3, laboratory in a developing country is no small undertaking. But any research project to do science in hard places means dealing with multiple
Page 86 Âť On the Ground
ALAM, MORRIS, MAURELLI
“Voir faire. Faire avec. Faire seul.” translates to “Watch how it is done. Do it with someone. Do it alone.” in English and is one of the authors’ mantras for scientists working in Haiti.
CULTURES Vol 1, Issue 2 » Page 87
unique issues. While numerous obstacles must be overcome, the main challenges can be summarized in three areas: staffing, supplies, and sustainability. Crucial to the success of a project is the identification and training of technical staff. Work with collaborators to identify candidates to interview to work on the project. Interview them. AUTHOR BIO Speak the language, or have interpreters. Find people with a solid scientific background. Most people are Meer Alam, M.Sc., is not familiar with “research” as a job, so you need to a research scholar be clear about the tasks and the time commitment. in the Department Follow the three-step principle of “Voir faire. Faire of Environmental avec. Faire seul.” “Watch how it is done. Do it with and Global Health someone. Do it alone.” After following these steps in the College of with your trainees, you need to be absolutely certain Public Health and that their tasks are being performed according to your Health Professions, protocol. We have found that there are many wellUniversity of Florida at trained, intelligent, hard-working Haitians who can be Gainesville. The major trained to do world-class microbiology and molecular focus of his research biology. Find a way to get your equipment and supis epidemiology, plies to your study site. Then find another way. Try ecology, and genetic out both ways, and then look for a third way. Talk to characterization of people who have been in the area for a while and pick enteropathogens. their brains. Find out what works and what does not. Then think of other possibilities. Design your research project to extend beyond your specific aims. All of your research activities in the developing world should be designed with sustainability in mind. Central to this are the training and technology transfer components of the laboratory. The mission of the UF-EPI Haiti laboratory is long-term and is not purely research. It is also capacity building. Whenever possible, we encourage project design to take into account these two elements. We are not here to take (research results, survey data, etc.). We give back. We work in partnership. Your project should not be “scientific tourism.” To paraphrase an old maxim: Take only data that have been shared; leave everything else to be continued by the people you train. What are the lessons learned from our experience in Haiti? “Plan ahead” is the first, most Page 88 » On the Ground
ALAM, MORRIS, MAURELLI
obvious piece of advice. An underappreciated part of that planning is to educate your support team back home. You will be working in a different environment. Communications, information technology, finance, grants management, logistics, compliance, institutional review boards, all operate within the bubble of the United States. You will work outside the bubble. The people who support your science need to understand that. Tasks that are routinely performed at your home institution can easily become major timeconsuming proceedings. If things have to be done differently, explain why. Offer solutions. Be creative. Be insistent.
Here is our list of rules for working in Haiti: Adjust your expectations – things will not go according to plan, so see rule II Have a plan A and a plan B for your plan A Be flexible – do not forget your original plan; you may need to use plan B today, but plan A might be possible again tomorrow Be patient: nothing starts on time all the time Understand that when you hear “Yes,” sometimes you need to be persistent to be sure that “Yes” really means “Yes” If you promise something, be absolutely certain you can keep the promise Sustainability – train those who will follow you, and whatever knowledge (and equipment) you bring to Haiti, be prepared to leave it in Haiti. Make sure that all that you do provides “a better tomorrow for Haitian people.”
DISCLAIMER The opinions or assertions contained herein are the private ones of Anthony T. Maurelli and are not to be construed as official or reflecting the views of the Department of Defense or the Uniformed Services University.
CULTURES Vol 1, Issue 2 » Page 89
A GLOBAL SCIENCE ODYSSEY: ADVENTURE AND CHALLENGES Leonard F. Peruski, Ph.D.
My journey into global science was and remains an unexpected one. This journey was not the professional (or personal) life that I envisioned when entering graduate school at the University of Michigan in 1981. The decades since have led to work in the Middle East and portions of Africa, university and government laboratories in the United States, onto Southeast Asia, and now Central and South America. The cultures, climate, geography, and languages AUTHOR BIO change with each new assignment, with each new adventure and challenge. The only constant that Leonard Peruski, is that, despite my education and experience, I Ph.D., is Director, realize how very little I know and that there is still Global Disease much to learn. Detection Center in Central America, of After the usual postdocs, I joined the Navy (partly the U.S. Centers for on a whim) and was offered an international asDisease Control and signment – a two-year stint at the Naval Medical Prevention (CDC) Research Unit No 3 (NARMU-3), in Cairo, Egypt. and has worked and I leapt at this opportunity – a dream of a lifetime! lived in the Middle My wife, Anne, and our children saw this as an East and Southeast amazing adventure, and it was in ways imagined Asia. He joined CDC and not. Our new reality ranged from the perfrom the Indiana sonal: where to live and shop for food and not University School being able to drink the water out of the faucet of Medicine where and please don’t touch that donkey because it is he was an Associate covered with fleas – to the scientific: having the Professor. electricity fail almost consistently in the middle of a PCR analysis or running out of MacConkey’s agar and having to wait six weeks (or more) for supplies. But despite these challenges of living and working, most days were like being a little kid in a candy store with a pocket full of coins – so many choices and opportunities and so little time. Two years came and went, then a third year, and suddenly five years – and, in that time, three
Page 90 » On the Ground
PERUSKI Dr. Peruski with his wife Anne and four kids by the pyramids on the Giza Plateau near Cairo.
CULTURES Vol 1, Issue 2 Âť Page 91
author’s hotos from Personal p vels. foreign tra
major vaccine trials, numerous outbreak investigations, basic science into bacterial virulence factors – all interspersed with the pyramids on the Giza plateau, sandstorms that lasted for days, and water and electricity outages that did the same, felucca rides on the Nile, rabid dogs in the streets, and watching comets in the desert night sky. Egypt remains prominent in my life and shaped the scientist I would become.
After an interlude of a few years in the United States, the next adventure was the tropical heat and humidity of Bangkok, Thailand with the Centers for Disease Control and Prevention (CDC). Like Cairo, Bangkok was a huge, bustling city that never seemed to sleep. My work was again in a microbiology laboratory that I would lead. At home, the challenges were not rabid animals in the streets – our kids biked to a school in an enclosed compound with amazing amenities, but we had to be wary of cobras and other snakes that could emerge from the sewers or in the trees. At work, I went from the vast laboratory resources of NAMRU-3, over multiple floors and buildings, to a small converted office space with only a few electrical outlets and no running water and with the responsibility for two major field sites yet to be built many hours away. It was hot and humid all of the time, seemingly penetrating all aspects of existence – exposed metal rusted in a few short days; molds grew everywhere; when it rained, leaks appeared in what appeared to be impossible places, often flooding home and laboratory. But, as in Egypt, my team was unfailingly patient and hardworking. Over the next six years, we renovated the main laboratory, gutting it completely and expanding it. The remote field sites along the borders
Page 92 » On the Ground
PERUSKI
of Cambodia and Laos became extensions of the main laboratory, boasting real-time PCR systems with panels of multiplexed assays and automated blood culture systems, all linked by computer networks. But best of all, Anne and I had the chance to work together between my position at CDC and hers at the WHO. Our “reach” and support eventually encompassed much of Southeast Asia and beyond – providing technical assistance and site visits, training courses, scientific exchanges, and supporting outbreak responses. If Egypt showed me what was necessary to be a scientist, Thailand made me into the scientist that I had hoped to become.
If Egypt showed me what was necessary to be a scientist, Thailand made me into the scientist that I had hoped to become.
The years in the hot tropics of Southeast Asia with its varied cultures and languages transitioned almost overnight into a part of the world I scarcely knew existed – the Spanish-speaking landscape of Central America and the CDC regional office in Guatemala. Here, my role has evolved from that of a senior laboratory scientist to more of a director or manager. What Egypt and Thailand taught me is now being used to groom the next generation of scientists. - LEONARD F. PERUSKI Some of the challenges are familiar: security issues, the environment (this time earthquakes and volcanoes instead of sandstorms and flooding), the difficulty of getting critical supplies and equipment – while others are different and unexpected: letting others take the lead and develop the science with my role being to guide and advise, or dealing with the policy and evaluation of science programs, and trying to coordinate multiple programs toward common goals and priorities (and yes, managing several gifted and talented scientists and their projects is often like herding cats). But of all of my assignments overseas, this one has perhaps been the best. Partly because of experience and partly because of the position and place, I now have the rare
CULTURES Vol 1, Issue 2 » Page 93
chance to be more introspective and yet look at the scientific directions well beyond the next report deadline or the interminable wait for the next shipment of supplies. Being able to step back and look forward has been refreshing and yet offers new intellectual challenges. These exciting, frustrating, stimulating, and often difficult years of working overseas have taught me that science is truly a global collaboration. Whatever you do individually at the bench or in the field is connected – it builds on the work of those that came before, and others will build on what you do long after. Living and working in remote and challenging locations highlights this global integration. Looking back at the twenty years since I first arrived in Cairo and fast-forwarding through Bangkok and to Guatemala, some key lessons stand out:
You will not have all the answers. In fact, you probably will not even know the questions. Listen and learn, then apply what you know. Embrace and understand the culture and people where you work and live. The pace and scope of science vary by place and the people; in essence, the science takes on the flavor of the culture. At the same time, do not forget where you came from – that is what got you here in the first place. Take advantage of opportunities and the rare occurrence of good luck, but there is no substitute for hard work (and a lot of it). Do not compromise your standards, but whatever you try to accomplish, make it sustainable – something that can be maintained and improved after you are gone. Do not be afraid to make decisions, and if you find a problem, make sure you can also propose a solution (or more than one) – always have some options. Accept that you will fail sometimes. Take on the biggest, most difficult challenges – these will force you to be better than yourself and look outside of yourself for answers.
Page 94 » On the Ground
PERUSKI
I have been so very fortunate to have had this unexpected opportunity of a rather non-traditional career in science. The most humbling lesson is that there are so many very smart people in the world; I honestly learn more from doing science in these “difficult places” than I give in return. And so while the hours are still long and sometimes very frustrating, I love what I do. Most days I am that little kid in a candy store, coins in my pocket and so much in the way of choices and opportunities.
PHOTO DESCRIPTIONS: PAGE 92
(From top to bottom) 1.
Egypt 1997: Peruski’s sons greet him returning from a field site.
2.
USA 1999: Reassigned to the United States from Egypt, this is the first time Peruski has worn his uniform in nearly 5 years.
Personal photos from author’s foreign travels.
PAGE 93
(from top to bottom) 3.
Egypt: Shopping in Khan El Khalili
PAGE 95
(from top to bottom) 4.
Guatemala 2012: Hiking on the Volcano Pacaya, Peruski found this lava cave and went exploring inside.
5.
Egypt 1999: Elizabeth (age 11) is sitting with me on the lower courses of the Great Pyramid.
CULTURES Vol 1, Issue 2 » Page 95
SHARING THE
In each issue, ASM’s sister
VISION
societies share their take on the central theme.
Science Diplomacy in Action: Supporting Capacity Building and Research Partnerships in Iraq BY: CATHY CAMPBELL Cathy Campbell is president and chief executive officer of CRDF Global, an independent nonprofit organization that promotes international scientific and technical collaboration. In this piece, she shares some examples of their work in Iraq, where they have worked closely with that nation’s science and engineering community to support capacity building and research partnerships.
CRDF Global’s unique history began in 1992 when Congressman George Brown outlined a new vision based on his belief that science – research and development – is crucial in the progress of the human race. As a long-time advocate for international science cooperation, Congressman Brown argued for the creation of an endowed foundation to “identify and fund cooperative research and development ventures between engineers and scientists working in industry, academia, and defense in the United States and the former Soviet Union.”
Thanks to legislation passed later that year, and funding provided by the U.S. government and an individual donor, CRDF Global was established in 1995. The late Congressman Brown’s vision was bold. It came at a time of significant geopolitical change overseas and an economic downturn at home. Yet, he recognized that science and technology cooperation can be a critical channel of engagement during a period of economic and political transition. He also understood the value of international science and
Page 96 » Sharing the Vision
technology cooperation as an important tool of U.S. foreign policy, and the value of collaborative research to solve common problems and advance our understanding of the world around us. He argued that an NGO could operate more quickly and with greater flexibility than government agencies, hence, the creation of CRDF Global. While every nation and every engagement requires a unique approach, our work with Iraq illustrates some compelling stories of science diplomacy in action. When CRDF Global began its Iraq engagement in 2004, the country was experiencing tremendous change and enormous challenges as it emerged from years of isolation. Iraq had thousands of highly qualified scientists and engineers who needed new opportunities within Iraq to contribute productively to the rebuilding of their country. Some of these scientists and engineers had knowledge of nuclear, biological, and chemical weapons, and there was an urgent need to redirect their expertise to peaceful uses within Iraq. However, much of the science and technology infrastructure was severely damaged or destroyed in the military conflict. Moreover, the security situation in Iraq was very dangerous for foreigners and Iraqis alike. This made it extremely difficult to encourage the flow of personnel and ideas that is so important to building sustainable research partnerships. But time was of the essence, and it was critical to reach out to scientists in Iraq to try to reintegrate them into the global scientific community. So, in September 2004, CRDF Global took the initiative and arranged for a small group of Iraqi scientists and engineers to travel to the United States for what we called a “familiarization visit.” We wanted these scientists, who because of sanctions had been cut off from the West, to familiarize themselves with the state of science in the United States and with modalities for international science cooperation. We worked very closely with the U.S. government, particularly the Department of State, to organize this delegation visit. CRDF Global did not have staff in Iraq, and, owing to security considerations, we were unable to travel there. So, we had to rely on partners already located in Baghdad to help identify and recruit
CULTURES Vol 1, Issue 2 » Page 97
Iraqi scientists and engineers and to facilitate their travel (in fact, the Department of State funded the travel from Baghdad to Amman – and back to Baghdad at the end of the trip). At that time, it was still extremely difficult to secure visas for Iraqis to travel to the United States. It was essential that we work with the State Department to arrange this visit. The six-person Iraqi delegation included specialists in biology, chemistry, and engineering. They spent a week in the Washington, D.C. area where we hosted meetings at CRDF Global’s headquarters, arranged meetings with numerous U.S. government agencies (State Department, National Science Foundation, National Institutes of Health, and the National Institute of Standards and Technology), local universities, and business associations. The delegation visit was successful in several ways. First, it enabled us to begin building the kind of personal relationships that are so important in international engagement. We had many productive discussions about the situation in Iraq, the scientists’ work, and their ideas for future collaboration. The trip also helped to educate the Iraqis about the state of science and engineering in the United States and globally. Some were able to reconnect with former colleagues, because many Iraqi scientists and engineers had studied in the West, including in the United States. These networks are critically important to advancing international collaboration. The visit helped CRDF Global develop ideas for follow-up program activities. The input from these scientists about the situation in Iraq and the tremendous needs in terms of rebuilding Iraq’s science and engineering infrastructure was invaluable. We quickly identified many needs: equipment, professional skills training, research support, access to scientific journals, and more. In response, over the next few years, CRDF Global launched several new programs for Iraq. Iraq Virtual Science Library The Iraq Virtual Science Library (IVSL) was created to provide Iraqi scientists with access to research information from the world’s leading scientific, engineering, and technical publishing houses and societies. With funding from the U.S. Department of State and the U.S. Department of Defense, CRDF Global launched the IVSL in 2006, at a time when Iraqi scientists still had minimal contact
Page 98 » Sharing the Vision
with the global science and engineering community, little access to scientific journals, and very few opportunities to travel to learn about research abroad. CRDF Global conducted train-the-trainer and users workshops that resulted in significant increases in usage of the digital library. In just four years, there was a 300% increase in article downloads: from 10,000 per month in 2006, to more than 30,000 per month in 2011. In 2013, users downloaded an average of 65,000 research articles per month. We also began to observe an increase in the number of articles published by Iraqi researchers. The IVSL now serves more than 80,000 faculty and students CRDF GLOBAL DIGITAL from more than 37 universiLIBRARY DOWNLOADS ties and research institutions throughout Iraq. It serves all public universities in Iraq (95% of the Iraqi university population), as well as nine government ministries. A major milestone was achieved in March 2010 when CRDF Global turned over the operation of the IVSL to the government of Iraq. Several Iraqi researchers, speaking anonymously, stressed that they cannot imagine conducting research without the IVSL. They had previously undertaken tedious and inefficient publication searches without access to scientific databases. Now, they can increase their knowledge of their fields and learn about new research approaches. Students also use the IVSL to interact with researchers around the world to learn the latest methods and technologies and prepare to contribute their own findings to international journals and conferences. Research Grants In 2006, in partnership with the Arab Science and Technology Foundation (ASTF), CRDF Global launched the Iraq Research and Development Initiative (IRDI). Through this program, CRDF Global funded competitively selected research and development proposals from Iraqi scientists. In three rounds of competition, CRDF Global awarded 35 grants totaling over $1.2 million. Research proposals focused
CULTURES Vol 1, Issue 2 Âť Page 99
CRDF GLOBAL AWARDED 35 GRANTS TOTALING OVER $1.2 MILLION
on materials science, water management, public health, agriculture, and engineering.
IRDI strengthened research capacity and better enabled scientists and engineers in Iraq to address local challenges. The projects engaged scientists at different stages of their careers, from Ph.D. level experts to graduate students, and at a wide variety of institutes. Grantees benefited from follow-on research review conferences, which provided technical feedback on their work, strengthened their presentation and publishing skills, and encouraged networking. Many grantees published or presented their results at international conferences, contributing to Iraq’s reintegration into the international scientific community. Finally, the experience of applying for and administering grants increased each grantee’s ability to compete for funding from other sources in the future. Fellowships Under the 2008 Strategic Framework Agreement between the United States and Iraq, both countries agreed to cooperate to develop Iraq’s scientists and engineers through exchanges, training programs, and fellowships in science, engineering and medicine. In response, the U.S. Department of State launched the Iraq Science Fellowship Program (ISFP). Today, CRDF Global implements the program on behalf of the Department of State, inviting between 10 and 20 Iraqi fellows each year to travel to the United States and conduct research with a U.S. partner conducting similar work. These competitively awarded fellowships enable Iraqi scientists and engineers to be hosted at universities, national laboratories, research centers, or private companies across the United States. The wide variety of host institutions directly speaks to Iraq’s broad range of scientific interests and expertise. For example, the 2013 fellows worked in microbial fuel cells, laser applications, electromyography-controlled prostheses, biologically safety, and water management. Upon returning to Iraq, the fellows are able to share their
Page 100 » Sharing the Vision
new methods and research with students and peers. Many have formed sustained partnerships with their host organizations and mentors and have advanced within their home institutions. CRDF Global recently accepted applications to a new fellowship program: the 2014-2015 Iraq Biosciences Fellowship Program (IBFP). The IBFP is a non-degree seeking program that provides the opportunity for highly-qualified biological scientists, researchers, epidemiologists and experts from the government laboratories under the Iraq Ministry of Health and the Iraq Ministry of Agriculture to spend three to six months working alongside biological scientists, researchers and professionals in the United States. Fellows will be placed at universities, private companies, national laboratories or other U.S. institutions and CRDF Global will award up to 20 fellowships. These are just a few examples of how CRDF Global is engaging in science diplomacy, in these cases through capacity building and research partnerships in Iraq. It is extraordinary to see the impact on these scientists and engineers as they are brought into the mainstream, actively working to solve local and global problems and contributing to the worldwide scientific community.
CRDF GLOBAL INVITES BETWEEN 10 AND 20 IRAQI FELLOWS EACH YEAR TO COLLABORATE
ABOUT CRDF GLOBAL CRDF Global is an independent, non-
to be successful. They offer a range of
governmental organization (NGO) that
programs and services that support
supports international cooperation in
scientific research, build capacity, and
science,
foster
technology,
and
innovation.
entrepreneurship
worldwide.
CRDF Global puts science diplomacy into
They specialize in bringing isolated scien-
action by working in more than 40 coun-
tific communities into the global scientific
tries in Eurasia, the Middle East, North
mainstream where these communities
Africa, and Asia. Over the past 20 years,
can contribute to solving local and global
CRDF Global has continued to empower
problems.
scientists and entrepreneurs worldwide
CULTURES Vol 1, Issue 2 Âť Page 101
SHARING THE
VISION
NAMRU-3: at the intersection of medical research, policy, and global challenges BY: ENAS NEWIRE
In coordination with NAMRU-3 Public Affairs Enas Newire is a Molecular Researcher at the Cairo-based U.S. Naval Medical Research Unit No. 3 dealing with emerging disease threats. She is currently conducting her Ph.D. in Microbial Diseases at University College London in UK.
U.S. Naval Medical Research Unit No. 3 (NAMRU-3), Cairo, Egypt, is uniquely situated in the Eastern Mediterranean region to conduct infectious disease research across the Middle East and Africa. There is also a detachment in Accra, Ghana, which serves as a research hub for activities in West Africa. The research laboratory was formally established as a U.S. Navy entity in 1946 at the invitation of the government of Egypt.
epidemiology, vector biology, clinical infectious disease, and preventive medicine. Our clinicians, public health practitioners, and scientists have a full spectrum of expertise in the areas of study design and analysis, laboratory supervision and management, safe laboratory practice, manuscript preparation, the scientific writing process, and proficiency testing. NAMRU-3 also has College of American Pathologists (CAP) accreditation.
Working in close collaboration with ministries of health in 23 countries, NAMRU-3 specializes in the areas of infectious disease, laboratory diagnostics, and scientific inquiry. In addition, its areas of expertise cover veterinary medicine,
The unit’s research goals are supported by four research programs: bacterial and parasitic disease research, global disease detection and response, vector biology research, and viral and zoonotic disease research. The laboratories include:
Page 102 Âť Sharing the Vision
•
Molecular biology laboratory that has facilities and equipment that allow for advanced molecular testing, including, high-throughput DNA and RNA extraction, PCR, high-throughput real-time reverse-transcriptase PCR, pulsed-field gel electrophoresis, variable number tandem repeat and DNA sequencing. The molecular mechanisms underlying resistance to extended spectrum beta-lactamases (ESBLs) are identified by PCR and DNA sequencing.
•
Mycobacteriology laboratory that has the capacity to grow Mycobacterium tuberculosis on solid or in liquid culture and perform drug susceptibility testing for first line drugs.
•
Parasitology laboratory that utilizes microscopy to detect Plasmodium (malaria) parasites from infected human cases via thick- and thin-smear staining and various intestinal pathogens (e.g., Cryptosporidium, Entamoeba, and Giardia) via direct iodine staining. Follow-up molecular testing can distinguish between malaria species, identify mixed infections, discriminate recrudescence from new infections after treatment failure, and characterize different patterns of drug-resistant parasites. A malaria microscopy training program is taught in-house and as an exportable course.
•
Serology laboratory that contains automated enzyme-linked immunosorbent assay and other serological testing equipment, allowing for rapid, high-throughput detection of the humoral immune (secretory and systemic antibodies) response, antigens and toxins for many pathogens (see below). The laboratory also performs various other serological assays, such as agglutination tests, immunofluorescent assays, protein characterization using SDS-PAGE, immunoblotting, and dot-blots.
NAMRU-3 is totally committed to capacity building in Egypt and provides great opportunities for scientists and students. In the past two years, NAMRU-3 has conducted over 9,000 training hours in workshops at its Cairo-based laboratories, and by sending its laboratory technologists, technicians, and research scientists to conduct training at other sites. Undergraduate and graduate students come CULTURES Vol 1, Issue 2 » Page 103
for internships under professional supervision by NAMRU-3 staff. NAMRU-3 regularly assists local universities with biosafety training at their campuses. These opportunities provide hands-on, cutting-edge technologies to the future leaders in medical research in Egypt. Unlike a full-service commercial clinical medical laboratory, NAMRU-3 is a project-focused research organization whose mission is to study, monitor, and detect emerging and reemerging infectious disease threats of military and public health significance, as well as to develop mitigation strategies against these threats. Its research efforts are in partnership with “MENTORSHIP IS its host nation, Egypt, and with other counONE OF THE BEST tries in the region and in Africa, frequently INVESTMENTS ANY working in collaboration with multiple international agencies such as WHO, Centers ORGANIZATION for Disease Control and Prevention (CDC), CAN MAKE IN ITS U.S. Agency for International Development, STAFF, BECAUSE and ministries of health and their central IT GUARANTEES public health laboratories.
PERSONAL AS WELL AS ORGANIZATIONAL CONTINUITY.”
NAMRU-3’s current laboratory capacitybuilding efforts are linked to the adoption of the 2005 International Health Regulations (IHR), with a mandate from - CAPT. OYOFO the U.S. government to help developing countries implement these regulations. With funding from Global Emerging Infections Systems (GEIS), NAMRU-3 has provided laboratory capacity building to upgrade laboratories and train personnel throughout the areas where it conducts research. NAMRU-3 is a World Health Organization Eastern Mediterranean Region collaborating center for emerging infectious diseases and serves as their regional reference laboratory for rotavirus and other enteric viruses, enteric bacterial and parasitic pathogens, and malaria. NAMRU-3 also supports the capacity building of national influenza centers in 12 countries in the Middle East, Central Asia, and West Africa. Global scientific collaborations are key to NAMRU-3’s success in the region. It is currently undertaking major collaborative research initiatives with the CDC to form the Global Disease Detection and Response Program in Egypt, providing laboratory and interprogram support of surveillance activities, such as the Eastern Mediterranean Acute Respiratory Infection Surveillance Network
Page 104 » Sharing the Vision
About NAMRU-3
ITS MISSION IS TO STUDY, MONITOR, AND DETECT INFECTIOUS DISEASES
BASED IN EGYPT
COLLABORATES WITH 23+ HEALTH AGENCIES GLOBALLY
CONDUCTED 9,000+ TRAINING HOURS OVER THE PAST 2 YEARS
at 29 sites in the region, and an acute viral hepatitis project with the Ministry of Health in Egypt. Not strangers to doing science in hard places, NAMRU-3 staff have conducted capacity building and surveillance activities in Iraq and Afghanistan. Egyptian staff have been instrumental in conducting training and assessments in countries where U.S. staff cannot visit because of security restrictions. Dr. Atef El Gendy, Head of the Bacteriology Section in the Bacterial and Parasitic Disease Research Program, provides training for technologists and scientists throughout the region on safety, biosecurity, and safe laboratory practices. In addition to his NAMRU-3 duties, he has been heavily involved in the ASM regional and international affairs, leading to his selection to lead the recently established the African Biological Safety Association. He has been involved with the ASM Ambassador Program since 2004, participating in various caucuses and establishing five ASM resource centers. NAMRU-3 has successfully coped with challenges from recent political events in Egypt. However, this situation has an historical precedent: NAMRU-3 remained in continuous operation during the break in diplomatic relations with the United States during the 1967 War with Israel. With the Egyptian revolution in 2011, nonessential U.S. staff were evacuated for several months. This occurred again in 2013 for approximately six months. In Cairo, Captain Buhari Oyofo, current commanding officer of NAMRU-3, a seasoned microbiologist led the Egyptian
CULTURES Vol 1, Issue 2 Âť Page 105
staff, who took on leadership roles in Cairo, while working with the evacuated U.S. staff in the United States to continue NAMRU-3’s research mission. Despite these huge logistic and staffing challenges, NAMRU-3 was able to execute more than 63 research projects in multiple sites. Captain Oyofo also believes in mentoring the junior staff at NAMRU-3 to promote professional development, support publication of research findings, and encourage new research initiatives. “Mentorship is one of the best investments any organization can make in its staff, because it guarantees personal as well as organizational continuity,” says Oyofo. Laboratory technologist, Enas Newire, who works in the Bacterial and Parasitic Disease Research Program, commented, “Captain Oyofo has been an inspiring leader, who not only has been a mentor on my research projects, but has also supported me to grow professionally. His mentorship is for lifetime progress. “ Ms. Newire, who completed her Master of Science at the London School of Hygiene and Tropical Medicine through distance learning, is currently a Ph.D. student at University College London, leading a research project on the molecular mechanisms underlying antibiotic resistance of ESBLs. Ms. Newire is also the ASM Young Ambassador for science to Egypt, an Advisory Board Member for Cultures, and Student Ambassador for the University of London. A valued member of NAMRU-3, Ms. Newire is a representative of the caliber of NAMRU-3’s junior staff and serves as a role model for Egyptian women in scientific research.
@asmicrobiology on Instagram
ABOUT NAMRU-3 U.S. Naval Medical Research Unit No. 3
that led to expansion of NAMRU-3 public
(NAMRU-3) was established in 1946, fol-
health activities and capacity building in
lowing work by American scientists and
host countries, leading to the recognition
technicians with Egyptian physicians at
of NAMRU-3 as a WHO Collaborating
the Abbassia Fever Hospital, Cairo, Egypt,
Center for Emerging and Re-Emerging
under the auspices of the United States
Infectious Diseases in 2001.
Typhus
World
also serves as a WHO reference laborato-
War II, the Egyptian Government invited
ry for influenza/H5 and meningitis in the
the U.S. Navy to continue collaborative
Eastern Mediterranean Region (EMRO).
studies of endemic tropical and subtrop-
With modern research laboratories and
ical diseases with Egyptian scientists. Its
a medical library, it is one of only two re-
current mission is to conduct infectious
search institutions in North Africa with a
disease research, including the evalu-
functional Biosafety Level (BSL-3) laborato-
ation of vaccines, therapeutic agents,
ry and the only research institution in the
diagnostic assays, and vector control
region with Association for Assessment
measures, and to carry out public health
and Accreditation of Laboratory Animal
disease surveillance and outbreak re-
Care International (AAALACI) accreditation.
sponse assistance. NAMRU-3 has been a
All human and animal research conducted
WHO Collaborating Center for HIV/AIDS
at this facility is subject to approval by the
since 1987. In 1999, a U.S. Department
NAMRU-3 Institutional Review Board and/
of Defense Global Emerging Infections
or the Institutional Animal Care and Use
System (GEIS) program was established
Committee (IACUC).
Commission.
Following
NAMRU-3
IN YOUR WORDS WHAT ARE YOU DOING TO SAVE THE WORLD?
JOSEPHINE SAN PEDRO
Research Area of Interest: Bacteriology, Mycobacteriology, and Mycology Kenya and Ethiopia
“I assist in building diagnostic capacity of microbiology laboratories in Africa with very limited resources—one inoculating loop, a few petri dishes and test tubes, one rusty metal candle jar, and many more supplies lacking. As a microbiology mentor, I enable our mentees (laboratory technologists and supervisors) to identify their laboratory’s needs and be resourceful. I train them on routine bacteriology bench procedures and, at the same time, help them to develop their confidence and be proud of what they do to be able to provide quality patient care despite the challenges they face on a daily basis. Yes, mentoring is a tough and challenging job, but it warms my heart to witness the progress made over time.”
KATHLEEN GENSHEIMER
Chief Medical Officer, Director, CORE Washington, DC
“Every second counts. Nowhere is that more true than when dealing with illness outbreaks. A faster response to a disease outbreak can mean fewer illnesses. As Chief Medical Officer and Director of the Food and Drug Administration’s (FDA’s) Coordinated Outbreak Response and Evaluation Network (CORE), I am privileged to work with scientists in multiple disciplines to oversee this new FDA concept that accelerates and streamlines the Agency’s foodborne illness response efforts. When President Obama signed the Food Safety Modernization Act into law in 2011, the FDA was tasked with building an integrated national food safety system in partnership with federal, state, and local authorities. The CORE Network is proving to be a successful step in that direction.”
ERICA SIEBRASSE
Ph.D. Candidate at Laboratory of David Wang, Ph.D., at Washington University in St. Louis St. Louis, Missouri
“The Young Scientist Program (YSP) at Washington University in St. Louis is a graduate student organization designed to attract students into scientific careers. YSP partners with local school districts to engage more than 1,000 students annually, sending scientists into the classroom, providing high school students with paid summer research internships, and offering free science activities, supplies, and equipment to teachers. Graduate student volunteers also learn valuable leadership and teaching skills. YSP is changing the world by bringing fun, hands-on science to disadvantaged students and encouraging them to pursue their interests and talents in science careers.” CULTURES Vol 1, Issue 2 » Page 108
IN THE NEXT ISSUE WE ASK:
HOW WILL YOUNG PEOPLE DEFINE THE FUTURE OF SCIENCE? Send us a photo along with a short 100-word statement of your perspective on this question. Submit your response to cultures@asmusa.org or tweet or Instagram @ASMicrobiology using the hashtag #ASMCultures for a chance to be featured in the next issue!
CULTURES Vol 1, Issue 2 Âť Page 109
Photography + Art Credit
Page 36, 39 (2 photos): Courtesy
Page 4: By Lindsey Leger
of Navid Madani Page 6: Courtesy of Tom Frieden Page 40, 42, 45 (4 photos): Page 7: By Justin Williams
Courtesy of Rana Jawad Ashgar
Page 10: By André Berro/CDC
Page 46: Courtesy of Louise M. Slaughter
Page 14: “Students at Cairo University Listen to President
Page 49: Courtesy of
Barack Obama” by Pete Souza,
Sanjana Patel
The White House is licensed Page 50: Courtesy of
under CC BY-NC-ND 2.0.
Elizabeth Stulberg Page 17: © Dominic Nahr/ Magnum Photos/Sightsavers •
Page 53 (8 photos): Courtesy
Published in: Community Eye
of ASM Young Ambassadors
Health Journal Vol. 26 No. 82
of Science
2013 www.cehjournal.org Page 57: Courtesy of Jason Rao Page 18: Water Gathering” by Page 62: Courtesy of Paul Collier
the Gates Foundation is licensed under CC BY 2.0.
Page 66-69 (7 photos): Courtesy Page 22: Official White House
of Joseph Fair
Photo by Pete Souza Page 70, 71 (2 photos): Courtesy Page 25: Courtesy of Peter Hotez
of Aisha O. Jumaan
Page 26, 29, 33 (4 photos):
Page 72 (left): “Sana’a Old City!”
Courtesy of Kathleen England
by 2il org is licensed under
and Edward Desmond
CC BY-NY-ND 2.0. Page 72 (right): “Sana’a, Yemen”
Page 34: “Tehran and Milad
by Marcio Balducci is licensed
Tower (HDR)” by Arash
under CC BY-NY-ND 2.0.
Razzagh Karimi is licensed under CC BY-NC-ND 2.0 https://
Page 73: “Old Town Sanaa – Yemen
www.flickr.com/photos/
49” by Richard Messenger is
arash_rk/2514499557/
licensed under CC BY-NY-ND 2.0. Page 110
Acknowledgments LAURA BELLINGER Page 74, 76 (4 photos): Courtesy of Colleen K. Gallagher
LIZ ROSE CHMELA SCOTT DOWELL
Page 77 (2 photos): Courtesy of Derek Licina
DONDA L HANSEN JIM MCLAUGHLIN
Page 78: U.S. Navy photo by Mass Communication Specialist 2nd Class Joseph Seavey/Released Page 80: Courtesy of Joshua Albert, Alice Johnson, and Peter Luckow
ELIZABETH PRESCOTT JANET SHOEMAKER THOMAS W. SKINNER JAYNE SMITH ELIZABETH STULBERG YODIT TEWELDE
Page 81, 82 (2 photos): © Last Mile Health
NANCY WACHTER NATHANIEL WILDER WOLF
Page 84-86, 88 (6 photos): Courtesy of Meer Alam, Tony Maurelli, and Glenn Morris Page 90-95 (7 photos): Courtesy of Leonard F. Peruski Page 96: Courtesy of
For more information on reuse of any photographs or art featured in this issue, please contact us at cultures@asmusa.org.
Cathy Campbell Page 102: By Rafi George, NAMRU-3 Page 112 (3 photos): By Lindsey Leger © 2014 American Society for Microbiology
Edited by: CPS Communication Production Services, Inc. Designed by: madebywe.org Printed By: Goetz Printing
Special thanks to Christopher Allen, Douglas Koozer, Jason Kreiger and Kara Miller for their artistic contributions to this issue.
© 2014 AMERICAN SOCIETY FOR MICROBIOLOGY ISSN 2332-0907
CULTURES LAUNCH PARTY AT ASM HEADQUARTERS IN WASHINGTON, DC (JANUARY 2014)
If you missed our launch event, don’t worry! Go to www.facebook.com/asmfan and check out the photos and watch the interviews!
HI THERE THANKS FOR READING CULTURES!
Did you know that you can read Cultures’ interactive version as well as additional content on your Web browser or on an app on your tablet device? To learn more, visit us at www.asm.org/cultures.
www.asm.org/cultures American Society for Microbiology 1752 N Street NW Washington, DC 20036