By Rosanne Hertzberger, PhD, Postdoctoral Fellow and Morse Fellowship Recipient in the Lewis Lab of Microbial Glycobiology and Women’s Health
When my abstract was selected to present at the oral trainee session of the third annual Global Health and Infectious Disease Conference, I spent quite some time deliberating on how my research, my daily struggles with microbiology at the bench, could be linked to a grand and all-encompassing theme like global health.
Sure, I study a condition (bacterial vaginosis) that has a strong link with preterm birth, one of the biggest threats to neonatal health worldwide. As a basic researcher it is generally easy to include an introductory slide or two, to explain the costs in dollars and lives of the infectious agent of your interest. But the last slide of an average presentation in our department rarely displays any ambition or even mention of the impact that the presented research could have on overall health. With all the struggles and uncertainties and failures, sometimes improving health of even one person seems a distant reality, let alone do I feel comfortable stating that my work should eventually prevent babies from dying. When planning what I would say, I wondered: if I would have one dollar to spend on improving global health, would I spend it on me?
With that perspective in mind I put down my pipet and walked over to the Eric P. Newman Education Center, hoping to learn more about the role of researchers in global health. And I learned a lot. For instance, how much great science emerges when we try to improve our understanding of the different infectious disease agents. Take the work of Christina Stallings on Mycobacterium tuberculosis, the causative agent of tuberculosis. Those bacteria can reside in the patients’ lung for a lifetime, remaining a permanent threat for new active disease. She presented insights in how environmental cues can influence the bacteria when going from its passive state in the lung, to a full exposure to oxygen when disseminated. Her lab manages to recapitulate several features of those transitions, which she uses to find new compounds to attack the increasingly antibiotic-resistant bacteria.
Or take for instance the work presented during the oral trainee symposium. I was especially impressed by the talk of Priya Pal from the Goldberg lab about how a malaria-parasite can cross the blood-brain barrier in patients and Thomas Kraft from the Hruz lab talking about a protease inhibitor used for HIV/AIDS medication that also reduces the incidence of malaria.
And then there was of course Ebola, the virus killing 10,000 people over the last year. The presentation by Gaya Amarasinghe on the genes that the Ebola virus uses to “sneak, hide and attack” was an absolute highlight of the day.
But then, there were the maps. Naturally, in every presentation at a global health conference there is a map. And regardless of whether the talk was about HIV/AIDS, malaria, parasites, TBC, the maps all looked sadly similar, highlighting the same regions of the world. It is depressing to see how many of the topics discussed during the global health conference are actually not at all that global but confined to the poorest parts of the world, Sub-Saharan Africa and South Asia. Professor Powderly laid it out clearly in his opening talk: the three factors that determine health are economy, demography and environment. And of those, the strongest predictor is economy.
The maps didn’t come alone, they were accompanied by stories, real stories about real projects with real people. Stories by Daniel Colley, from the University of Georgia, who showed a slide on “the spectrum” from the bench, to field epidemiology, to operational research, to policy interventions. They were not one continuum however, according to Colley, they were “little buckets” with people that don’t necessarily talk to each other. “Everybody can do global health”, one of his slide said. But tackling a global health problem with a consortium of people was a different task. He went on to present the work of the SCORE consortium, a Gates foundation project that aims to reduce, and in some areas to eliminate Schistosomiasis. During the second talk, by Edward Pearce, we had already learned that this is one of the so-called “Neglected Tropical Disease.” In total there are 17 of those diseases, affecting 1.2 billion people in 129 countries. The combined global disease burden is greater than the burden of malaria and tuberculosis combined. Clearly, basic researchers had an important role to play, especially in developing new diagnostic tools that are essential to determine the prevalence and thereby the strategy for each region. But equally important were behavioral problems, or in the words of Colley: “little boys pooping and peeing in lakes and rivers.”
What if we could find a way to discourage those boys from doing that, or improving access to drinking water and proper sanitation? What if that meant we would not need any more genomes of worms, or diagnostic tools?
There were many of such examples. Gaya Amarasinghe was ruthlessly realistic, indicating how an important cause of the Ebola epidemic was the tiny health budgets of the countries affected. How other African countries, such as Mali and Nigeria effectively contained the few cases that emerged, thanks to the existing polio infrastructure.
What if our money is best spent on improving health infrastructure in those countries? What if we would never need an Ebola vaccine?
It was of course not entirely novel to me, but what I found striking is the relative importance of health infrastructure, access to clean drinking water and proper sanitation. Not an encouraging thought for the bench researcher. My dollar is maybe better spent on a sewage connection for a house in Sudan than on a new protein gel at Washington University.
At the same time, there were also examples of instances where the fruits of bench work were successfully translated in accessible treatment. Powderly showed how the introduction of anti-retroviral therapy has essentially reversed the drop in life expectancy on the African continent. Nonetheless, one third of the HIV patients remain untreated. Half of the patients that present themselves with tuberculosis were never even tested for HIV. Donor fatigue, marginalization of groups and different social changes threaten the success of anti-retroviral therapy. What is lacking is the magic medicine, the cure. And that cure will most likely originate at the bench of some university or company in a high-income country.
One of the best examples of how a researcher could end up making an important contribution to global health was presented by Helen Fletcher, from the London School of Hygiene and Tropical Medicine. Or at least, she came close to making an important contribution. After her PhD, she worked in the lab of Helen McShane, who was at that moment developing a novel TB vaccine, called MV85A, and as she stated “the reason why I was a postdoc for so long.” It was the first vaccine tested against TB since 1968. A major trial in 2013 showed disappointing results in a large group of South African infants. Still, her talk gave some hope for the bench researcher, a glimpse of what would happen when you find the holy grail, that vaccine, that one molecule that will make the bug go extinct and further research on the topic obsolete.
A last comforting thought came from Colley. When I asked him during the reception if I could not better spend my dollar on general health infrastructure and economic development in the countries most affected by infectious disease, he asked: “and how will you do that? All those slides on how we need to use integrative approaches translating science into practices and policies, those are all common sense on paper. But even if it were possible to accomplish structural reforms, you could spend the entire Gates budget on just three small African countries.”
He is probably right. For us, it is common sense to offer to low- and middle-income countries what we are good at: advanced technology and great science. After the conference, I went straight back to the bench, to change the world.