P³ | #7 Autumn - Winter 2018

ITM MAGAZINE AUTUMN-WINTER 2018 #7

I TM M AG A Z I N E

#7

AUTUMN-WINTER 2018

EN

OP ZOEK NAAR EXOTISCHE STEEKMUGGEN ALERRT BLIJVEN

JOHN NKENGASONG

AFRIKA NEEMT HEFT IN HANDEN

AFRICA TAKES CHARGE JOHN NKENGASONG I TG - M A G A Z I N E H E R S T- W I N T E R 2 0 1 8 # 7

HERFST-WINTER 2018

I TG - M A G A Z I N E

#7

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STAYING ON THE ALERRT IN SEARCH OF EXOTIC MOSQUITOES

NL 23/08/2018 08:30

23/08/2018 08:30

COLOFON Verantwoordelijke uitgever Bruno Gryseels Hoofdredacteur Roeland Scholtalbers

Redactionele coördinatie Ildikó Bokros, Eline Van Meervenne Redactiecomité Roeland Scholtalbers Nico Van Aerde Eline Van Meervenne Catie Young Maria Zolfo

Lay-out Toech Reclamestudio *P³ - de kern van het ITG in één letter

Fotogra�e Jessica Hilltout, Roeland Scholtalbers Vertalingen Serv-U en Wilkens C.S. Contact communicatie@itg.be +32 (0)3 247 07 29

Contact communicatie@itg.be +32 (0)3 247 07 29

Translations Serv-U and Wilkens C.S.

Ons innovatief en interdisciplinair onderzoek gaat uit van Pathogenen (Departement Biomedische Wetenschappen), Patiënten (Departement Klinische Wetenschappen) en Populaties (Departement Volksgezondheid).

ITG-onderzoekers werken aan een beter begrip van tropische ziekten en ontwikkelen hiervoor verbeterde diagnose-, behandelingsen preventiemethoden. Anderen bestuderen de organisatie en het management van de gezondheidszorg en ziektebestrijding in regio’s waar de nood hoog is maar de middelen beperkt zijn. We focussen ook op de gezondheid van dieren en bestuderen daarbij vooral ziektes die op de mens overdraagbaar zijn

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Our innovative and interdisciplinary research focuses on Pathogens (Department of Biomedical Sciences), Patients (Department of Clinical Sciences) and Populations (Department of Public Health). ITM researchers improve our understanding of tropical diseases, and develop better methods for their diagnosis, treatment and prevention. Others study the organisation and management of health care and disease control in regions where means are limited, but needs are huge. We also focus on the health of animals and the diseases they spread to humans. *P³ - ITM’s essence captured in one letter

Photography Jessica Hilltout, Roeland Scholtalbers Layout Toech Reclamestudio Editorial Committee Roeland Scholtalbers Nico Van Aerde Eline Van Meervenne Catie Young Maria Zolfo

Editorial Coordination Ildikó Bokros, Eline Van Meervenne Editor-in-Chief Roeland Scholtalbers

Responsible Publisher Bruno Gryseels COLOPHON

#7

AUTUMN-WINTER 2018

Dear Reader, In February 2018 the World Health Organization (WHO) has added the mysterious ‘Disease X’ to its list of priority diseases. “Disease X represents the knowledge that a serious international epidemic could be caused by a pathogen currently unknown to cause human disease.” Whether we fear an unknown or an already familiar disease like Ebola, the experiences of recent outbreaks show that it’s time for the world to get ready for coming epidemics.

For this 7th edition of P³ we spoke to the extraordinary Dr John Nkengasong, the head of the newly established Africa CDC, who is leading the efforts to better prepare Africa to deal with health threats. In this issue you can also read about ITM’s new outbreak research team, and about our involvement in the ALERRT network, “a multi-disciplinary consortium building a patient-centred clinical research network to respond to epidemics across sub-Saharan Africa”.

But our offer doesn’t end here. In this P³ we delve into the world of tiger mosquito monitoring and the 30-year history of the Unmet Obstetric Need network. We also get a keepsake about malaria from an expert who has dedicated his entire career to the parasitic disease, and we get to know two members of the extended ITM family a little better.

Happy reading!

Sincerely, The Editorial Committee

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DOSSIER: AFRICA PREPARES INTERVIEW: JOHN NKENGASONG DRAWING LESSONS FROM OUTBREAKS AS THEY OCCUR

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STAYING ON THE ALERRT IN SEARCH OF EXOTIC MOSQUITOES PHOTO STORY EXOTIC SPECIES IN BELGIUM

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REWIND UNVEILING UNMET OBSTETRIC NEEDS

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PORTRAIT: HEILIG HUISKEN MOSQUITOES ARE NOT STUPID ITM AND I: ANNE MUENDI MUSUVA © The contents of this publication may not be reproduced in whole or in part without the express consent of the publisher. Images in this report were taken with full understanding, participation and permission of the people portrayed. The images truthfully represent the depicted situation and are used to improve public understanding of our work.

# Table of Contents 3

# ITM NUMBER

9

ITM has recently set up a multidisciplinary outbreak research team consisting of 9 investigators with profiles ranging from social scientist through epidemiologist to molecular biologist and clinical scientist.

This team will carry out research during an outbreak. The Flemish ministry invests 2.5 million euros in this new ITM venture (see page 12). www.itg.be/E/outbreak-research-team

AFRICA PREPARES The word preparedness has taken centre stage in health circles after the West African Ebola epidemic that started at the end of 2013 in Northern Guinea.

Preparedness is about being ready to deal with the unexpected, an outbreak that could happen anytime, anywhere, starring a known or unknown pathogen. In this P3 we put a spotlight on how Africa is getting ready to deal with future epidemics.

# Dossier 5

AFRICA TAKES CHARGE OF ITS HEALTH AGENDA Alumnus John Nkengasong is the first Director of the Africa Centres for Disease Control and Prevention (Africa CDC) After a spell at ITM, bridging the late 1980s and the early 1990s, Dr John Nkengasong went on to build a successful career at the U.S. Centers for Disease Control and Prevention. Now in his mid50s, Cameroonian Nkengasong is leading the efforts to better prepare Africa to deal with old and new health threats. P3 talked to the fascinating ITM alumnus during his recent visit to Antwerp.

ROELAND SCHOLTALBERS In 2017, you became the first Director of the Africa CDC. Why was this new institution created?

“The Africa CDC was conceived in 2013, predating the Ebola outbreak in West Africa. At a heads of state and government summit in Nigeria, Dr Tedros, the present Director-General of the World Health Organization (WHO), presented a concept of an Africa CDC to complement the WHO initiatives.

There were several reasons for the creation of a new public health agency for Africa. First, the continent’s population is expanding rapidly. In 1940 there were about three hundred million people in Africa. Today, we are at 1.2 billion inhabitants and projections indicate we might be about 2.5 billion by the year 2050. Second, the

patterns of disease are changing. Yes, we still face tropical diseases such as malaria.

HIV is here to stay as many Africans continue to die of AIDS every day. Drug-resistant tuberculosis and antibiotic resistance are causing increased concern. But on top of that, Africa has to deal with an epidemic of lifestyle diseases such as heart disease, obesity and diabetes that so far have been mostly associated with Western countries. If you weigh these factors against the mostly weak health systems across the continent, then you see why action was needed. When Ebola hit West Africa, it added a sense of urgency. A sense that Africa needs to be better prepared.”

How exactly will the Africa CDC complement the role of the WHO? “The Africa CDC is focused on strengthening country capacities, their institutions and systems. We are not directly focused on disease elimination or eradication. I believe that if we strengthen these systems, invest in the workforce, surveillance systems, laboratory networks and information systems, you can actually fight any kind of disease.”

If you had to choose one priority for your directorship, the most important thing to tackle in the years ahead, what would it be?

“We believe that each country should have its own functional national public health institute that can truly be used to respond rapidly when outbreaks occur. We therefore need to rally the continent and encourage member states to develop these institutes. Let me illustrate this with an example from afar. In 2003, SARS hit China.

The local response was inadequate. The WHO and other partners stepped in and helped China to respond to the outbreak.

China learned quickly and then established the China CDC. Today if China is hit by flu or SARS, guess who is going to take the front and centre stage? Indeed, the China CDC. Partners will come in to support, not to take the lead. An enormous change, in a matter of 15 years. That needs to happen in Africa too.”

China has come a long way indeed. What point are African countries at today in terms of public health?

“That’s a fundamental question. For the continent’s health agenda, I think that’s where Africa CDC will be an asset. To help define its direction, as a pan-African organisation. The Africa CDC needs to work with the African Union in order to define the health priorities for the continent. So regardless of whether the international power dynamics are changing or not, people work within the framework that Africa CDC is providing in terms of priorities.

We need to know where we are going to be five years from now and ten years from now. At Africa CDC we developed a fiveyear strategy plan to guide that. Africa has also developed the Agenda 2063 which is the continent’s blueprint for development for the next fifty years. The heads of state have renewed their commitment to implement this agenda.

# Dossier 7

I state all of this to say that partnerships with foreign countries are great, but the partnerships should respect these instruments regardless of whatever they are bringing to the table. I strongly feel that in order to be meaningful for the continent, partnerships should be guided by these new instruments that Africa is putting forward.”

So these are positive developments, which are to be confirmed?

“Yes. And that can only be implemented through partnerships with counterparts like ITM, who respect African-driven initiatives. Because if partners don’t respect the continent’s vision and plans, then you contribute to fragmenting the continent, with many little projects that do not add up to a big mission.”

You and ITM go back a long time…

“I came to ITM in 1989 to do the Master’s in Tropical Biomedical Science. I took an interest in virology and did my dissertation on HIV diagnostics. Subsequently, I went straight on for a PhD in Guido van der Groen and Peter Piot’s team. Between

1993-95, I was Chief of the Virology Lab and the WHO Collaborating Center on HIV Diagnostics at ITM. I was privileged to join the U.S. Centers for Disease Control (CDC) after that. First, I headed the CDC’s Virology Lab in Abidjan, Ivory Coast and then became Chief of the International Laboratory Branch in Atlanta.”

As an alumnus and member of ITM’s Scientific Advisory Committee you have an insider’s view on the Institute. What do you see when you look at ITM today?

“I appreciate ITM’s courage to face the issues head-on and to take a mirror and look at itself and say ‘who are we and where are we going?’. When I was here 25 years ago, it was ITM’s wish to see stronger public health institutions in the South and in Africa in particular. And today, many institutions are indeed emerging, several schools of public health that are functioning and growing. So the question that ITM is asking is a pertinent one. How do we remain relevant as an institute of tropical medicine in a world where health priorities are changing? If your constituency is mainly in developing countries, you cannot re-

Africa CDC staff on a field visit during a recent Ebola outbreak in the DRC, with DRC Minister of Health Dr Oly Ilunga on the left and Dr John Nkengasong in the middle

John catches up with former colleague Ciska Maeckelbergh

main passive. And if you have many inroads in Africa, connections and a lot of shared history, you have to be meaningful to your partners by finding a good balance between your traditional strengths and emerging topics. ITM is doing this with its interdisciplinary focus on antibiotic resistance, for example. Non-communicable diseases are becoming increasingly important for Africa, so ITM needs to make a judgement and see how it can contribute.

To me, ITM’s future looks promising. You have so many assets in terms of strong partnerships, vast experience and a long history. Take your contribution to capacity building in Africa. Not to mention the respect and reputation that you have earned over the years. But still, ITM also needs to scan the horizon and align with the new African instruments I talked about earlier.

In the end, it’s the substance that counts.

What happened because of you, not in spite of you. ITM co-discovered the Ebola virus and you did foundational work on HIV/ AIDS in Africa. We learned so much about

HIV and how it spreads thanks to ITM researchers. Thirty years later we are talking about epidemic control or even ending the HIV epidemic once and for all. And ITM has a lot going for it in that sense. You should look forward with confidence.”

Do you have fond memories of your time in Antwerp?

“I loved the time spent in the lab without managerial responsibilities. In Atlanta I led a large branch and programme, but nothing compares to those early days in the lab where my only responsibility was to do good science. Virus neutralisation took forever. It was rudimental, artisanal almost. New discoveries brought so much joy, such as finding out that HIV had different subtypes, which was foundational because at that time the knowledge of HIV diversity was very limited. I lived in a small apartment overlooking the Institute. In the weekends we would enjoy Belgian beers and fries, it was a wonderful period. I was young and didn’t need to worry about putting on weight!” # Dossier 9

EBOLA RESPONSE Following the announcement on 8 May 2018 of an Ebola virus outbreak by the DRC government, the Africa CDC deployed an assessment mission within 48 hours and activated its Emergency Operational Centre to link, scan and monitor the situation. In the following weeks, Africa CDC deployed 25 epidemiologists, laboratory experts, and anthropologists to support the efforts of the DRC government to control the Ebola virus outbreak in northwestern DRC.

DR JOHN NKENGASONG IN SHORT »» Director Africa CDC »» Previously, U.S. Centers for Disease Control and Prevention, the last 10 years as Associate Director for Laboratory Science and Chief of the International Laboratory Branch at the Division of HIV & TB, Center for Global Health »» 1993-95, at ITM as Chief of the Virology Lab and the WHO Collaborating Center on HIV Diagnostics »» Master’s Degree in Tropical Biomedical Sciences at ITM and a Doctorate in Virology at ITM and the Vrije Universiteit

Brussel, as well as another Master’s Degree in Medical and Pharmaceutical Sciences at the Faculty of Medicine of the Vrije Universiteit Brussel »» His work on HIV diagnosis, pathogenesis, and HIV drug resistance has been extensively published since 1988 and he has published over 200 papers in scientific journals »» Numerous awards for his work and seats on various international advisory boards, including ITM’s Scientific Advisory Committee

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59th ITM Colloquium ANTIBIOTIC RESISTANCE: FROM RESEARCH TO ACTION 5-7 DECEMBER 2018 – Phnom Penh, Cambodia

Antibiotic resistance is a global public health threat. It is a multidisciplinary challenge to communities, patients, health services, laboratories and health policies. The 59th Colloquium of the Institute of Tropical Medicine Antwerp (ITM) and its Cambodian partners will feature the latest clinical, biomedical and public health research on antibiotic resistance.

Check out the website for more info! www.antibiotic-resistance-2018.org

DRAWING LESSONS FROM OUTBREAKS AS THEY OCCUR

In April 2018, ITM presented its dedicated outbreak research team in the presence of Flemish Minister of Science Philippe Muyters.

ILDIKÓ BOKROS The Ebola outbreak in West Africa was a wake-up call as the world found itself unprepared for an infectious disease that would kill over 11,000 people between 2013 and 2016. To be better prepared, the World Health Organization (WHO) has recently added the unknown ‘Disease X’ to its list of priority diseases. Preparedness goes beyond the humanitarian response, and includes research during outbreaks, which can lead to insights that might save lives when a new epidemic occurs.

At ITM, preparedness translates to the creation of a new outbreak research team that will be on stand-by for rapid deployment to conduct research during an infectious disease outbreak anywhere in the world. Nine experts with complementary profiles, including an entomologist, an epidemiologist, a clinical researcher, a health systems researcher and a social scientist will undertake multidisciplinary research projects. In between outbreak interventions, the team will study the drivers of outbreaks, and it will design and evaluate diagnostic tests and strategies for the prevention, early detection and control of infectious diseases.

While in the midst of setting up the team, a new epidemic already came knocking.

E­bola returned to the Democratic Republic of the Congo (DRC) for the ninth time in May 2018. At the request of the Institut National de Recherche Biomédicale (INRB) in Kinshasa, ITM sent an epidemiologist and a laboratory expert to the affected region. Anja De Weggheleire assisted in epidemic surveillance, and Birgit De Smet supported the INRB’s laboratory team in the confirmation of Ebola diagnoses.

ITM’s collaboration with INRB in Kinshasa goes back to the very first Ebola outbreak in 1976, when the virus was first discovered by current INRB head Jean-Jacques Muyembe, Peter Piot, Guido van der Groen and international colleagues.

Outbreak control and emergency preparedness have become increasingly important for governments in the past years.

The Flemish Ministry of Science is investing €2.5 million euro in the new outbreak research team at ITM. Philippe Muyters, the Flemish Minister of Science said: “The Institute of Tropical Medicine is world-renowned for its research into and the fight against tropical diseases. It is therefore the right place for a team of experts that studies epidemics of infectious diseases.

A team that is ready to be deployed during a new outbreak and help save lives. The Ebola outbreak has shown that reacting to an outbreak only is not good enough. We need to be prepared before an outbreak occurs. As Flemish government we are happy to contribute to this effort.” # Dossier 13

STAYING ON THE ALERRT Being prepared for clinical research and data management during any epidemic In May 2018 an outbreak of Ebola in the northwest of the Democratic Republic of the Congo brought to the spotlight once again the necessity for rapid outbreak response. This is another example of why ITM is keenly involved in partnerships across the world that look to better our global efforts to save lives when epidemics hit. Such a coalition is the African CoaLition for Epidemic Research, Response and Training (ALERRT) that was officially launched in March 2018 to span five years.

rience with the Ebola epidemics, we know that being a part of the ALERRT network among others is essential for ITM. Over the next five years, we will focus on the areas that proved difficult at the time. For example in the setting up and conducting of clinical trials where bottlenecks in regulatory and ethics committees proved cumbersome and made us lose precious time.”

CATIE YOUNG

“Unfortunately, historically there has been distrust between humanitarian organisations and researchers. Research was often seen as getting in the way of the key goal of saving lives but recent epidemics have shown we need to be able to conduct research during epidemics to come up with vaccines, new diagnostic tools and treatments and save even more lives. A consortium such as ALERRT is looking to change this dynamic so that we can work together to ensure rapid response on all fronts.”

The 21 partner organisations, including ITM, refer to themselves as “a multi-disciplinary consortium building a patient-centred clinical research network to respond to epidemics across sub-Saharan Africa”.

Out of its seven working groups ITM is co-lead on the ICT and Data Management (DM) working group and is participating in the clinical research platform – two areas where our experience and close historical connections with African partners can have high impact.

Prof Johan van Griensven is representing ITM on the ALERRT general assembly and is leading the ITM team involved in the clinical research platform: “From our expe-

Van Griensven explains that in the past activities in epidemics focused on humanitarian response, disease control and the essential nature of the fact that lives needed saving.

Another front that can greatly enhance reactions during disease outbreaks is information systems and data management.

This is why ITM is co-lead in the ICT and DM Work Package.

Johan van Griensven and Harry van Loen

“

we need to be able to conduct re­search during epidemics to come up with vaccines “Having clean and accurate data sets is essential in any research. For clinical trials you need to ensure also that data handling and management is compliant with Good Clinical Practice and regulations,” says Harry van Loen from ITM’s Clinical Trials Unit. “In our work package we are concentrating on the preparation of DM documentation, this can be for example Standard Operating Procedures or Data Management Plans, and capacity building of African partners. Our biggest challenge is in the areas of existing knowledge and experience and in creating awareness of the whole DM workflow, its deliverables, quality assurance and timelines. That’s why we are looking to build this within our

consortium partners. This will also ensure that the technology systems needed to support clinical trials in resource-poor settings can be put in motion quickly in times of outbreak.”

Working on these two fronts, ITM is looking forward to significantly contributing to the essential objectives of the consortium along with 20 other partner organisations from 13 countries (nine African and four European). The consortium has been awarded a €10 million grant from the European and Developing Countries Clinical Trial Partnership for a five year period.

Find out more about the ALERRT consortium at www.alerrt.global # Dossier 15

TOUR OF BELGIUM: IN SEARCH OF EXOTIC MOSQUITOES Over the past year, ITM researchers have travelled the country in search of exotic mosquitoes, creatures from the South that often arrive here via lucky bamboo and second-hand tyres.

Besides their irritating bite, these species can also transmit diseases such as zika, chikungunya and dengue.

Take, for example, the tiger mosquito.

Thanks to its excellent adaptability, it has permanently established itself in southern Europe and is now advancing towards our regions. Researchers at ITM monitor the likely entry points of these potential newcomers. Isra Deblauwe and her team criss-cross the country in search of these exotic species.

ELINE VAN MEERVENNE “I often switch between office work and field work, especially during the summer,” tells Isra Deblauwe. “Together with my team we monitor 23 places that could be possible entry points for tiger mosquitoes and other exotic species. These points often include garden and tyre centres as the tiger mosquito happily travels with second-hand tyres and lucky bamboo plants.

The water that stagnates in the tyres or in which the plants are transported is an ideal

“

our efforts contribute to the public health of the Belgians

# Dossier 17

environment for the eggs of these insects.

We also monitor ports, airports and car parks along major motorways, “Isra continues.

ITM has been carrying out the surveillance of exotic mosquitoes for many years in various locations in Belgium and nationwide since July 2017 within the “Monitoring of Exotic Mosquitoes in Belgium” project, MEMO for short, financed by the federal, Flemish, Walloon and Brussels authorities.

ITM cooperates with the Royal Belgian Institute of Natural Sciences and the Barcoding Facility for Organisms and Tissues of Policy Concern (BopCo). With support from Avia-GIS, the information system VECMAP is used for the integration of field and laboratory data.

“Our work is very intensive. At all 23 locations we set up mosquito traps and look for larvae. After a few weeks we return to empty the traps. We take the captured

mosquitoes to our laboratories and identify them to find out which species we are dealing with. A colleague at the Royal Belgian Institute of Natural Sciences, one of our project partners, has an extensive collection of mosquito species we have spotted so far. I note down our findings in reports for the outsourcing authorities.

Several of our team collaborators are almost constantly in the field and work long hours. Each location is unique. We have also set up traps on airport runways and are obliged to take our equipment through the detectors and undergo a real security check each time. It makes our work unusual but also incredibly fascinating,” says Isra.

Keeping an eye on exotic mosquitoes pays off. “If we can map the locations where these mosquitoes appear, we can also control them better. We know where tiger mosquitoes are most likely to enter the country and we operate as a watchdog in those areas. Even if those species were to establish themselves here, we must keep monitoring them closely to assess the risk of transmission of diseases,” explains Isra.

“I get a lot of satisfaction from my job,” she says smilingly. “What we do with our team is really useful. We sometimes work long hours, but our efforts contribute to the public health of the Belgians in the long term. We have strong teamwork and everyone is very committed, whereby we achieve good results,” she concludes.

# Dossier 19

PHOTO STORY

EXOTIC SPECIES IN BELGIUM ELINE VAN MEERVENNE The project “Monitoring of Exotic Mosquitoes in Belgium” or MEMO for short, was started by ITM and its partners to look out for exotic mosquito species in spots likely to be entry points to our country. Between August and November 2017, researchers collected 5400 mosquitoes and larvae. Only about 2% turned out to be exotic, nonindigenous mosquitoes.

The following types were most common:

AEDES JAPONICUS The Asian forest mosquito ­Aedes japonicus was first observed in Namur in 2002. Between 2012 and 2015 these mosquitoes were eliminated, but they came back at the same place in Namur in 2017.

The same year they were also caught near the German border. The mosquito is indigenous to Southeast Asia but thanks to its excellent adaptability now also lives in Canada, the United States, and Europe.

The Aedes japonicus, like the tiger mosquito, likes to travel in car tyres.

AEDES KOREICUS

AEDES ALBOPICTUS

Aedes koreicus was first spotted in Belgium in 2008 and is now established in the Maasmechelen area. However, the population is small, poses no threat and is carefully monitored by our researchers. The mosquito is originally from Southeast Asia, and Belgium was its first international destination. Today this species also lives in Italy and Switzerland.

The tiger mosquito (Aedes albopictus) was not detected in our country between August and November 2017. Previously, the mosquito sporadically appeared in Belgium. Thanks to its excellent adapting skills, the Asian tiger mosquito has spread worldwide. The mosquito can be found in Southern Europe and it is increasingly moving towards the North. # Photo Story 21

<<REWIND

UNVEILING UNMET OBSTETRIC NEEDS An invisible but radical contribution to safer childbirth CATIE YOUNG Historically the measure of maternal mortality – women dying in childbirth – was a key indicator used to demonstrate the efficacy of health systems in providing care to prospective mothers. Collecting this data accurately and inexpensively proved no easy task in low-income countries, however. Clinics were more than often rudimentary, if women went to a clinic at all.

Two UON team members collecting data from files classified in a Bangladesh hospital, late 1990s-early 2000s

In 1990, ITM’s Vincent De Brouwere* and the Moroccan INAS (national school of public health) were inspired by the experiences of Wim Van Lerberghe, now retired ITM professor but then WHO expert, and Abdelhaye Mechbal, then of the Moroccan Ministry of Health, when comparing caesarean section rates in urban and rural Agadir. This led them to carry out the first Unmet Obstetric Need (UON) national survey.

Wim Van Lerberghe, Salif Samuke (Director of Planning and Statistics at the Ministry of Health in Mali), Vincent De Brouwere, 1997

In order to do this, De Brouwere and his colleagues built a set of indicators to compare areas where women had all their surgical obstetric needs covered with areas where they were not. This allowed the researchers to draw a clearer picture of maternal health gaps in a given country.

These indicators would go on to be recognised internationally beyond the figure of maternal mortality and were eventually adopted in 2008 in the WHO guidelines for monitoring emergency obstetric care.

“We realised”, says De Brouwere, “that using the simple numbers of mortality rates were not making the situation better for millions of women in the world during, what can be, one of the most trying and precarious experiences of their lives. Through our research we felt that another tool was needed, one that could bring greater awareness to decision makers of the state of obstetric care in their countries so that they could figure out the real number of women in need of life saving surgical care and implement real practical measures to address women’s needs.”

As so aptly put in the summary explaining UON in their 1998 proposal to the Euro-

pean Union: “The concept…refers to the discrepancy between what the health care system should do to deal with the obstetrical problems in a given population, and the care it actually delivers.”

Following many years of its promotion across the world at conferences, with UNICEF, at the World Bank, at Harvard University and the United Nations the team succeeded in securing approximately €450,000 in EU funds for the project in December 1997. During a first official UON Network (UONN) meeting partners coordinated their efforts to test and research UON in varying countries. These initially included Benin, Mali, Niger, Tanzania, Haiti, Pakistan and Burkina Faso with Guinea, Bangladesh, Rwanda and Cambodia later joining the ranks.

The first positive results started to emerge in the early 2000s with health authorities using UON as ethical, robust, understand-

able and accessible indicators that could help them to introduce policy and operational changes for better obstetric care.

Some examples included the clear understanding in Morocco that obstetric hospital care needed to improve for mortality rates to decrease; in Mali UON showed a weakness in communications between health care providers and the community; in Haiti a secretary general used it to stimulate a national maternal mortality reduction programme.

With research proving its effectiveness, the breakthrough came in 2008 as UON was taken on as an all-important WHO guideline. *Prof Em Vincent De Brouwere retired in April 2018 after nearly four decades dedicated to maternal health.

Mother and her newborn baby are resting in a health centre in Morocco, in 2015 Photo by Paolo Patruno

# Rewind 23

PORTRAIT HEILIG HUISKEN

(THE SACRED LITTLE HOUSE) Heilig Huisken in the Kloosterstraat is undoubtedly one of the ITM beacons.

A place where unit heads come for an informal chat, where laboratory technicians hold a farewell party, and where PhD students meet weekly for their “Beer Time”. After 25 years, the café is well-established in Antwerp and among ITM staff. We went in search of the secret behind this modest, but special piece of Antwerp heritage.

NICO VAN AERDE The building is located on the corner of Kloosterstraat and Willem Lepelstraat. Its extensive terrace is not only a refuge for the locals, but also literally isolates the café from the houses around it. “In 1972, the city wanted to demolish the remaining five old houses,” says Jackie Dekeyser, who together with Maria Cauberghs, is the café’s current manager. “Bob Cools, former councillor for urban planning and later Antwerp mayor, managed to foil this plan. The five dwellings that once housed a cobbler, a hairdresser, a coal merchant and a small café were transformed into today’s pub.”

“When I took over the pub with my friends Maria Cauberghs and Maggie Carnas in 1993, the place had been through a difficult period. We were all looking for a career switch and we knew AB InBev brewery

was looking for a manager for the café.”

The three ladies started negotiating with the brewery, which had little confidence in the ladies’ ability to run a pub, because bar manager was still considered to be a male profession at the time. Today’s flourishing business proves the brewery wrong.

“People often underestimate this job. A successful pub is more than just a place that serves drinks. Locals are always welcome for a chat. Although our staff is of Turkish, Moroccan, Georgian and Chechen origin, they all speak Dutch which is very important for establishing a relationship with our customers.”

The colourful crowd proves that this is indeed a winning formula. Lawyers stand shoulder to shoulder with office workers, labourers, police officers and of course ITM staff. “Somehow this diverse crowd still manages to bond at the bar or when watching a football match on the big screen.

Some foreign ITM students still feel somewhat uncomfortable with our café culture.

They sit on our terrace without eating or drinking anything, but we don’t mind. Eve­ ryone is welcome here. Compared to some others, the people of the Tropical Institute are gentle and sweet,” Jackie says with a smile.

Scientists regularly go on scientific missions for weeks or months at a time, or

ITM RESEARCHER WERNER SOORS REMEMBERS MAGGIE leave Belgium altogether after having worked for ITM for a few years. The staff of Heilig Huisken is well aware of this: “People come and go, but when they return after many years, it is always a pleasant reunion.”

Maggie passed away in 2015, but the two other ladies have no plans to stop. The brewery has a lease on the building from the city of Antwerp for 99 years, and Maria and Jackie just renewed their contract with the brewery for eight years. Thankfully, because the Heilig Huisken is the perfect spot to make travel plans, discuss tropical diseases and health care or to muse about the future of our Institute.

“In the nineties I worked as a doctor in Nicaragua. I once had three patients suffering from multidrug-resistant tuberculosis.

The medication was very expensive and not available in Nicaragua. I knew that my old friend Maggie combined her job at Hei­ lig Huisken with a secretarial job at UZA, the Antwerp University Hospital. I contacted her and she made sure the medicines were sent to Nicaragua at purchase price. All three patients survived. The wife of one of them gave birth to a son a year later. They named him Werner. If it had been a girl, she just as well could have been called Maggie.” # Portrait 25

MOSQUITOES ARE NOT STUPID Malaria in 10 bullets, a keepsake from Professor Marc Coosemans

CATIE YOUNG In March 2018, ITM gave Professor Marc Coosemans a party – although festive it had a note of sadness. Even though we will see him again as a volunteer, the Institute had to say an official ‘goodbye’ to an important figure who is leaving

a significant 40-year mark on how malaria is best tackled around the world.

Coosemans shared some highlights of his career and, most importantly, what we need to keep in mind when the infectious disease raises its ugly head.

»» We need to understand disease transmission - how humans are infected – to control the biodiverse vectors that are mosquitoes and have the biggest impact on malaria. Continued research shows that focusing solely on treatment usually brings a rise in malaria prevalence, as it is only a small piece of the puzzle in tackling the disease. »» Malaria is not a tropical disease. It was declared eliminated in Europe only in 1978. This was due to better living standards making environments unfavorable to the disease. Most cases in Europe are brought back after visits to endemic regions. It can come back… »» Mosquitoes are not stupid. All organisms will change their behaviour when faced with challenges. Coosemans researched mosquitoes’ changing behaviour when faced with death by pesticides and learned how to trick them best. »» Malaria mosquitoes don’t make noise!

We all know the sound of a mosquito bothering us in the night – well, not when you’re going to contract malaria. »» The most fascinating place Coosemans has ever been to investigate malaria was the Serra Pelada (or “naked mountain”) – a now closed open gold mine in Brazil where people worked like ants in an anarchic state ruled by guns and gangs. He helped the Brazilian government investigate the source of a huge malaria outbreak there.

»» In the 1970s Coosemans was the first person to test pyrethioids and indoor spraying. The research into vector control started the ball rolling towards impregnated bed nets – a key method shown to bring the significant decrease in malaria cases in the 21st century. »» In 1980 Coosemans took on a research mission in Burundi for ITM. His goal was to understand the epidemiology of malaria in the lowlands. He arrived there with nothing but six months ITM funding, a backpack and no car. By 1988, when he left, the project still running there was a team of 150 people working with 12 vehicles. »» 24/7 was how much he had to work to start in Burundi. Mostly on his own, he did entomological, parasitological, drug pharmacological and serological research. This meant working through the night collecting specimens, dissecting in the morning and running parasitological studies during the day. This initial research allowed him to attract EU funds to continue. Later in his career, Coosemans shifted his attention to Southeast Asia where he supported the successful national malaria control programmes in Cambodia and Vietnam. »» Coosemans published 219 papers during his ITM career and sponsored 19 PhDs. »» The worst thing in life for the malaria expert is fatalism – you can always do something. The saying ‘we don’t have money’ is no excuse, Coosemans believes you can always find it if you need it. # The List 27

ABOUT THE GENERAL COUNCIL The General Council is a newly established statutory council that will ensure that the policy, administration and management of the Institute are in accordance with its purpose, identity and integrity. It has the statutory power to monitor the mission, vision, values and core tasks of ITM, and to appoint, evaluate and dismiss the members of a smaller and more executive Board of Governors.

The General Council includes both voting and non-voting members. The voting members are designated by a number of government agencies and Flemish universities, together with representatives of other stakeholders including staff, students, alumni, as well as institutional partners in South and North. The members of the Board of Governors and the Government Commissioner are the non-voting members of the General Council. The General Council meets at least twice a year.

ITM & I ANNE MUENDI MUSUVA Five years after completing her bachelor’s degree in medicine and surgery at the University of Nairobi, Kenyan native Anne Muendi Musuva embarked on a big journey that took her far away from home: in 2011 she started ITM’s Master in Public Health programme. Today she represents ITM’s vibrant alumni community at the Institute’s newly established General Council.

My year at ITM was transformative on my life and career. Having the opportunity to exchange on health systems related issues with colleagues from 28 different countries greatly impacted my way of thinking.

Upon finishing my masters’ studies, I have returned to ITM several times. In 2012 I undertook a research fellowship at ITM on multidrug-resistant tuberculosis. In 2014 I was an Emerging Voices 4 Global Health fellow and completed the training online and in South Africa. Since 2008 I have been working at Population Services Kenya, currently as Deputy Chief of Party. And now I have returned as a representative of the alumni community to ITM’s General Council!

ITM has been building a critical mass of alumni, particularly from low- and middle-income countries, who are making a difference all over the world, one alumni at a time. It is because of my experience and transformation at ITM that I want to contribute towards ITM’s future. I firmly believe in the mission and vision of ITM and

would like to see the Institute scale even greater heights.

Because of my professional experience in the health sector in Kenya, I know that global health professionals need to learn continuously and expand their knowledge, as the global health scene is changing rapidly with new evidence becoming available.

Professionals in low- and middle-income countries in particular need to be the generators of this evidence, and not just passive recipients of it.

I am also a firm believer in collaboration among health professionals, which needs to happen across regions, institutions and disciplines of global health. A good example of these platforms are communities of practice, where practitioners work together on a certain issue and share their experiences, methods and solutions. Global health professionals should not only be experts in their fields but also advocates for social health justice, immersing themselves in the health systems they seek to improve.

In 2018 the General Council has met three times: in January, March and June. I was forced to miss the last one because I gave birth to my third child, a baby boy. As alumni representative, I will be contributing to ITM’s journey and ambitions to be a leading learning institution in tropical medicine and global health.

# ITM & I 29

CALENDAR 8-12 Oct Emerging Voices 4 Global Health at the Fifth Global Symposium on Health Systems Research, Liverpool, UK 23 Oct 40 years after Alma Ata Symposium, ITM 25 Nov

Flanders Science Day

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5-7 Dec 59th ITM Colloquium on Antibiotic Resistance, Cambodia

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