Universitätsverlag Göttingen Göttingen International Health Network (GIHN) Martin Kappas, Uwe Groß, Dermot Kelleher (Eds.) Global Health A Challenge for Interdisciplinary Research Martin Kappas, Uwe Groß, Dermot Kelleher (Eds.) Global Health This work is licensed under the Creative Commons License 3 .0 “by - nd”, allowing you to download, distribute and print the document in a few copies for private or educational use, given that the document stays unchanged and the creator is mentioned. You are not allowed to sell copies of the free version. erschienen im Universitätsverlag Göttingen 2012 Martin Kappas, Uwe Groß, Dermot Kelleher (Eds.) Global Health A Challenge for Interdisciplinary Research Universitätsverlag Göttingen 2012 Bibliographische Information der Deutschen Nationalbibliothek Die Deutsche Nationalbibliothek verzeichnet diese Publikation in der Deutschen Nationalbibliographie; detaillierte bibliographische Daten sind im Internet über <http://dnb.ddb.de> abrufbar. Address of the Editor Prof. Dr. Martin Kappas Geographisches Institut Abteilung Kartographie, GIS und Fernerkundung Georg-August-Universität Göttingen Goldschmidtstr. 5 37077 Göttingen e-mail: mkappas@uni-goettingen.de This work is protected by German Intellectual Property Right Law. It is also available as an Open Access version through the publisher’s homepage and the Online Catalogue of the State and University Library of Goettingen (http://www.sub.uni-goettingen.de). Users of the free online version are invited to read, download and distribute it. Users may also print a small number for educational or private use. However they may not sell print versions of the online book. Setting and Layout: Martina Beck, Franziska Lorenz Cover: Franziska Lorenz Cover Picture: Arthckunskap: Painting of African woman carrying child. http://upload.wikimedia.org/wikipedia/commons/d/d2/Painting_of_African_woman _carrying_child.jpg © 2012 Universitätsverlag Göttingen http://univerlag.uni-goettingen.de ISBN: 978-3-86395-047-7 Table of contents Table of contents........................................................................................................................... 1 Acknowledgement......................................................................................................................... 3 1 Editorial by Martin Kappas Global Health A challenge for interdisciplinary research ................................................................................. 5 I. Setting the Scene 2 Knowledge based approaches to international health: The Eurolife International Health Alliance ............................................................................ 11 3 The One Health Concept in a development context .................................................. 21 4 Commitments on a global level translating into actions locally ............................... 33 5 Linkages between economic and health outcomes: Options for interventions for better health ............................................................................ 37 6 Cross-cultural bioethics as an interdisciplinary approach ......................................... 45 7 The role of plant health for human health .................................................................... 57 8 Inter-disciplinary health approaches for poverty alleviation: Control of neglected zoonoses in developing countries ..................................................... 65 9 Arbovirus infections in cattle .......................................................................................... 77 II. Health risks related to maternal and child mortality – examples from Africa and India 10 Maternal mortality: A consequence of a lack of reverence for life? ....................... 109 11 Risk of maternal mortality: Indian scenario ................................................................ 117 12 Neonatal infection in resource-limited countries ...................................................... 133 Table of contents 2 13 Reducing child and maternal undernutrition in the context of food security programmes – Ongoing activities of FAO........................................................................... 147 14 Global policies and local implementation: Maternal mortality in rural India ....... 153 15 Research as a tool to tackle maternal health problems in resource-poor settings .............................................................................................................. 167 16 The agriculture and health program of the International Institute of Tropical Agriculture (IITA), a CGIAR institution in Africa ............................................................ 177 III. Specific initiatives and research topics under the vision of GIHN 17 Aspergillosis : a major challenge for public health .................................................... 191 18 IGHEP – a partnership on health education between Indonesian and German universities .................................................................................................................. 209 19 Usefulness of microbiological laboratories in a rural African setting ................... 217 20 Rapid diagnostics for resource-poor settings ............................................................. 233 21 Urinary tract infections in Tanzania: Diagnosis, pathogens and susceptibility pattern ................................................................................................................. 245 22 Rapid screening and mapping of urinary schistosomiasis prevalence at the village scale in the Sourou Valley, Burkina Faso ..................................................... 255 23 Schistosomiasis around the Lake Victoria, Northwest Tanzania ........................... 283 24 Malaria in Kossi Province, Burkina Faso: An investigation of spatio-temporal incidence pattern.......................................................................................... 305 25 Anemia – What has to be investigated in an African setting? ................................ 321 26 Two weeks cataract surgery in rural Ethiopia ............................................................ 331 27 Ultrasonography at a rural district hospital in sub-Saharan Africa – a mixed blessing? ....................................................................................................................... 339 28 Medical Geography and travel-related health risks in Overseas Tourism ........... 351 BIOS ........................................................................................................................................... 371 Acknowledgement First and foremost, we would like to thank Mrs Heike von der Heide of the Minis- try of Science and Culture of Lower Saxony for the financial support within the Programme “Pro Niedersachsen” which enabled us together with the co -funding of the University Medical Centre Göttingen to complete the present book. Special thanks go to Martina Beck, Assistant to Prof. Martin Kappas, without whose constant support and help the collection of the several articles of this book would not have been possible. We appreciate and admire the patience she showed in reviewing the articles and in maintaining contact with the authors. Christiane Hennecke 1 Editorial Global Health A challenge for interdisciplinary research International health, global health or one health, are in general synonyms for the same holistic view of human, animal and environmental issues which is not really a new idea over the past decades. The first veterinary schools for instance were cre- ated 250 years ago as a response to concerns over food security in and the threat from zoonotic diseases. But over the last decades research lost track of this holistic view on the interconnectedness of all health related issues. In consideration of the fact that climate change is happening and endangering our planet (e.g. AR4-climate report of IPCC 2007) many initiatives have been created to adapt to the projected impacts on the 21 st century. The whole range of requirements for human liveli- hood is at risk and the focus of our future health should be on human, animal and plant diseases together. Most of the new infectious diseases (around 75%) are of animal origin and the cost of controlling outbreaks can be extremely high. In relation to the risk that a major disease outbreak poses, the costs of prevention are negligible. For this reason deci- sion makers have implemented measures for regulation, surveillance and research networks (like Eurolife or GIHN) to promote prevention. The main health risk drivers are at present: Martin Kappas, Uwe Groß and Dermot Kelleher 6 • Non-Communicable Diseases; Allergies • Emerging Diseases • Climate Change, Water Cycle Change and Disturbances of Ecosystem Services • Food and Agriculture • Urban Environment (continuation of urbanization to Mega-Cities) Considering the impact of the above mentioned health risks, a holistic and integra- tive perspective will be a prerequisite for successful management of Global Health risks in an era of climate change, air pollution, emerging allergies and zoonotic diseases, malnutrition and other development challenges. The integrative approach of global health means the consideration of both the environmental/geo-bio- chemo-physical and socio-economic parameters and is visualized in a simple flowchart Public Health Diseases Food And Agriculture Environment Global Change Prevention Financial Tools Health Risk Management Capacity Enhancement International Cooperation The following list highlights important topics (in bold) and their association with health and global change - related keywords that make the whole story of the flowchart above more complex: Global Health – A Challenge for Interdisciplinary Research 7 • Public Health : healthcare services – pandemics - pet animals – pharmaceuticals - vaccination & resistances - sanitation & hygiene - socio-economic determinants • Diseases : allergies - communicable diseases - emerging diseases - lifestyle diseases - mental illnesses - non-communicable diseases - wildlife diseases – zoonoses • Food and Agriculture : agricultural production - agro chemistry – biofuel - food design - food safety & security - genetically modified organisms - livestock • Environment : biodiversity - ecosystem goods & services - fisheries & wildlife - land degradation - logistics & transportation – natural hazards – pollution - re- source – depletion - water & energy • Global Change : climate change – demographics - displacement & migration – globalization – poverty - sustainable development - urbanization • Prevention : early warning - monitoring, surveillance & early detection - predictive modelling - preparedness • Health Risk Management : best practice - ethics & stewardship - integrative risk management - intervention/response - recovery/rehabilitation - resilience & adaptation • Capacity Enhancement : capacity building – education - research, innovation & technology - social learning & behavioural change • Financial Tools : financing methods - funding strategies – insurance - sustainable investments • International Cooperation : alliances & partnerships (Eurolife, GIHN) – communi- cation - corporate social responsibility – institutions - global health strategies - policy & governance - public diplomacy The assigning of keywords from the above indicates the broad field of intercon- nected drivers for global health and illustrates relevant scientific disciplines ranging from medicine to geography, sociology, economy and agricultural sciences. The new G öttingen I nternational H ealth N etwork (GIHN) looks at the emer- gence of “One World, One Medicine, One Health” as the latest instance in a long history of attempts to bring research and treatment of human, animal and plant diseases together. This concept tries to diminish disciplinary and institutional barri- ers of collaboration. On the other side interdisciplinary research is still weakly elaborated and is often not the focus of funding agencies. What is needed here is a new awareness on the part of politics and funding agencies. Therefore this concept is on probation and has first to show if it could deliver solutions for complex envi- ronmental-health problems. GIHN involves various disciplines in establishing how they could interact and what contemporary interests lead to their co-operation and problem solving. Ad- dressing human, animal and plant diseases within the framework of global change issues (climate change, land use change, lifestyle change) is the outstanding topic of GIHN. The background for establishing GIHN in 2011 was the strong wish to create a shared vision and to build up the capability of people and institutions in solving Martin Kappas, Uwe Groß and Dermot Kelleher 8 rising health problems which cannot be handled by a mono-discipline view. The global health approach should become the new norm for addressing these complex health issues. Furthermore GIHN encourages bringing together researchers in the relevant areas and facilitating exchange of experience and development of new projects. Networks work best when legitimate interests of different partners com- bine to further a common goal. Moreover the implementation of global health approaches are seen as a pre- requisite for sustainable life. The adoption of global health itself has a unique value to address health issues at the interface of human and animal ecosystems. For this task cross-sectoral partnerships are needed. The ceremonial launch event of the Göttingen International Health Network on May 24, 2011 was a first response to this challenge. It is no surprise that at the same time other huge joint projects like “Global Strategic Alliances for the Coordination of Research on the Major Infe c- tious Dis eases of Animals and Zoonoses” (STAR IDAZ) were created (STAR IDAZ launched in May 2011). Research questions of today read like “Influenza and other Emerging Zoonotic Diseases at the Human- Animal Interface” or “Risk Assessment on West Nile Virus Infection in the European Union” or “Alternatives to Antibiotics” or “Viruses on the Move”. Just a few exa mples of relevant research questions directly connected to Global Health. The Grand Opening of GIHN was dedicated to the unresolved millennium goal of reducing mother and child mortality in the world. An interdisciplinary re- search group should deliver approaches for improving maternal and child health. In the light of this a few chapters of the book directly focus on maternal mortality. Other chapters deliver a more general view of conceptual vistas or offer infor- mation about very specific health problems such as infectious diseases or the travel behaviour of people and related illnesses. Therefore the book is divided into three sections (I: “Setting the Scene” , II: “Health Risks related to Maternal and Child mortality – examples from Africa and India” , III: “Specific initiatives and research topics under the vision of GIHN” ). The chapters of the book reflect the broad variety of topics under the umbrella of global health presented at the GIHN opening event, May 24 th /25 th 2011 at Göttingen University. Setting up GIHN and the present book was a great challenge and we should like to thank the members of Eurolife and GIHN and all contributing authors to this book. Finally, in the name of the entire network, we should also like to express our gratitude to the outstanding commitment of Ms Christiane Hennecke (Univer- sity Medical Center Göttingen, International Affairs) and Ms Martina Beck (Insti- tute of Geography, Göttingen University) for their help in setting up the Göttingen International Health Network and creating a first joint publication dedicated to the vision of “ global health ”. Göttingen, Juli 2012 Martin Kappas, Uwe Groß, Dermot Kelleher I. Setting the scene 2 Knowledge based approaches to international health: The Eurolife International Health Alliance Dermot Kelleher 1 Introduction The world of biomedical science is rapidly changing at an international level at a rate which is frequently not fully appreciated. Arising out of the genome project, we now understand in a lot more detail both the causes of monogenic disorders and the complexities of the genetic components of common human diseases such as diabetes, inflammatory arthropathies and gastrointestinal diseases such as celiac disease or inflammatory bowel disease. However, the genome project although providing huge quantities of data has only provided us with an introduction and a framework on which to base our understanding of human disease. Most im- portantly, we now appreciate that many diseases occur as a result of an interaction of a series of both environmental and genetic effects. Such interactions could best be illustrated by the example of coeliac disease, a condition also known as gluten- sensitive enteropathy, in which the host’s genetic backgrou nd determines the sus- ceptibility, but exposure to gliadin and related proteins from wheat and other cere- als in the diet is the factor which provokes disease. On this background, we can begin to identify a very complex history of evolution of the condition, which is non-fatal and which has developed in geographically distinct parts of the world, including Punjab, North Africa (1) and Ireland (2). Dermot Kelleher 12 We now have to begin to develop an understanding of the “exposome” (3), ie the disease provoking factors to which we are exposed and to develop the tools to catalogue such interactions and to understand their relationships with the genetic component of disease. The influence of such gene- environment interactions over generations can lead to development of populations which are skewed in a particu- lar direction, as a result of both genetic and environmental factors. Hence, genes which contribute to auto-immune disease might also be favourable in terms of their capacity to skew immune responses towards stronger responses to bacterial or viral infection. In the international health arena conditions such as sickle cell disease represent the outcome of generations of interactions with infectious agents and the processes of natural selection which have enabled survival of the host. 2 The paradigm of gene-environment interactions Therefore, the concept of gene environment interactions in terms of conventional, common diseases in man has led to an evolving understanding of disease. Most notably, in recent times, we have been able to determine that multiple genes are involved in disease causation, through genome-wide association studies (4). Fur- thermore, in recent times, we have also been able to identify the cell biology result- ing from gene-gene interactions and from protein-protein interactions and the potential for pathogenic processes to have clear pathways towards disease causa- tion. We now increasingly, in terms of modern day science, utilise animal models of disease to determine the true extent of gene-environment interactions in an in vivo setting and such models have provided us with very exciting insights into the causation of diseases such as childhood eczema, multiple sclerosis, among others. Ultimately, the process of drug development typically involves the requirement for such animal models, prior to testing of a therapeutic entity in a murine system before our well developed processes for clinical trials. However, we do know that this paradigm, while extremely valuable in coun- tries with economic resources to take advantage, has limited applicability when it comes to the implementation of change in terms of poverty related disease. At this moment in time, the world is seeing an emergence of a range of epidemic diseases, including conditions such as West Nile Fever, SARS coronavirus, multi-drug re- sistant salmonella, multi-drug resistant TB and the factors that determine suscepti- bility and outcome frequently relate to situations over which we have less and less control. Furthermore, the factors that influence health are dependent on such basic environmental issues as the economy, the weather and the food and water supply. Global climate change is emerging as an important factor in the pathogenesis of disease, increasing the migration of disease-causing vectors to areas of the world where they have not been endemic, having substantial effects on water supplies and on food supplies in areas which are vulnerable and hence increasing the poten- tial for food and water borne disease at a global level. Global Health – A Challenge for Interdisciplinary Research 13 3 Millenium development goals For these reasons 193 member states of the United Nations and 23 international agencies agreed in 2000 on eight Millenium Development Goals to be achieved by 2015 all of which have substantial impacts on the health of the global populations (5): - eradicating extreme poverty and hunger, achieving universal primary education, promoting gender equality and empowering women reducing child mortality rates, improving maternal health, combating HIV/AIDS, malaria, and other diseases, ensuring environmental sustainability, and developing a global partnership for development There has been considerable debate as to the best mechanisms to achieve these goals and it is fair to say that political complexities both North and South have not always been conducive to the delivery of these goals. International health has not traditionally been attractive to the pharmaceutical industry or to the biotechnology industry, because the returns on investments in this sphere have been considerably less than the returns with regard to conditions of the more prosperous nations. Hence, although there is enormous scientific interest in the areas of international infectious disease, very strongly supported by funding bodies and by philanthropic sources, there are a series of bottlenecks in the delivery process including for ex- ample a bottleneck at the level of large, controlled clinical trials, which are neces- sary in order to determine efficacy of drugs, prior to implementation of therapeutic processes in terms of poverty-related disease. The ethical issues involved in the construct of clinical trials with regard to conditions impacting on international health have come to the fore in recent years with consensus that common ethical principles apply at a global level (6). In this regard, while pharma and biotech and the global medical and political community are frequently dealing with conditions for which many of the mecha- nisms are known, the outcome does not depend on a simple paradigm, but is strongly influenced by issues such as economics, politics, climate, energy and, in- deed, health systems at a global level. Hence, there is an increasing need for new approaches towards the development of synergies in the international health arena, which can contribute to improved outcomes for patients and populations at a global level. In this regard the global academic community has a substantial role to play in developing the agenda not only for the science but also for delivery in the sphere of international health. Dermot Kelleher 14 4 Biomedical science and international health There is a very pressing need to substantially facilitate our capacity to make mean- ingful interventions in the biomedical space in terms of poverty-related disease. Success in this area will require a concerted approach involving Science, Policy and Implementation (Fig 1) and there are important considerations in how we progress across these three themes. Firstly, discovery science is paramount in terms of iden- tifying new mechanisms of disease and in identifying the types of therapeutic ap- proaches that may make a difference at an international level. Secondly, there is an increasing requirement to look at the continuum of activities in international health and to examine such activities in terms of their capacity to substantially modify outcomes. In this context, the development of North-South partnerships in re- search and education, particularly with regard to the biomedical sciences will have substantial impact on the capacity of countries in the south to develop their own analytical and scientific programmes, which will strongly influence our knowledge of disease. In this context, the barriers are substantial and they include the very high cost of equipment and reagents necessary to perform biomedical science at the highest level and also the education of staff at PhD and postdoctoral level, in addition to the principal investigator level, to create the human resource capacity to perform such studies in a scenario of real critical mass. Hence, we do need to strongly ad- dress our ability to deliver high quality educational programmes at an international level. Fig ure 1: The integrati on of Science, Policy and Implementation is key to success in the International Health arena