Viewpoint: Parasites and partnerships

Abstract

This text grew from a series of talks between a young science journalist trained in history and Marcel Tanner, global health expert with forty years of field experience in many countries in sub-Saharan Africa and Asia. At the very core of the series was the question of the successes and failures of global health initiatives at various points in time and in different locations. It also tackled the issue of which of the lessons learned in global health over the past thirty years could possibly be of importance for future scholars and decision-makers in the field. The topics touched upon ranged from new global partnerships to sustain the efforts to eradicate malaria and other diseases to new innovations in personalised health, not least for the world's most neglected populations. The views expressed here are based on scientific findings as well as personal experiences and hence are also inherently subjective. Having said this, we still hope that the rich body of evidence assembled over years of extensive field-work and research partnership is of some value to all those how still dare to embark on the adventure of global health research in a spirit of “mutual learning for change.”

Full text

Viewpoint: Parasites and partnerships
Marcel Tanner, Lukas Meier ⁎
Swiss Tropical and Public Health Institute, Switzerland
University of Basel, Basel, Switzerland
R. Geigy Foundation, Basel, Switzerland
article info abstract
Article history:
Received 8 J anuary 2019
Accepted 9 January 2019
This text grew from a series of talks between a young science journalist trained in history
and Marcel Tanner, global health expert with forty years of field experience in many
countries in sub-Saharan Africa and Asia. At theverycoreoftheserieswasthequestion
of the successes and failures of global health initiatives at various points in time and in
different locations. It also tackled the issueofwhichofthelessonslearnedinglobal
health over the past thirty years could possibly be of importance for future scholars
and decision-makers in the field. The topics touched upon ranged from new global part-
nerships to sustain the efforts to eradicate malaria and other diseases to new innovations
in personalised health, not least for the world's most neglected populations. The views
expressed here are based on scientificfindings as well as personal experiences and
hence are also inherently subjective. Having said this, we still hope that the rich body
of evidence assembled over years of extensive field-work and research partnership is of
somevaluetoallthosehowstilldaretoembarkontheadventureofglobalhealthre-
search in a spirit of “mutual learning for change.”
© 2019 Published by Elsevier Ltd on behalf of World Federation of Parasitologists. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
Keywords:
Plasmodium falciparum
Malaria
Research partnership
Capacity building
Institution building
Tanzania
Côte d'Ivoire
Innovation
1. Fascinating life forms
Considered from a biological point of view, regarding parasites only as life-threatening creatures might give the false
impression. Most of them are in fact of stunning ingenuity and deserve our humblest appreciation. Take for example Plas-
modium falciparum, the single-celled parasite responsible for transmitting malaria in many parts of tropical and subtropical
Africa and South-East Asia. Plasmodium falciparum is responsible for 435,000 deaths per year and often affects society's
most unfortunate and vulnerable members (WHO, 2018, World Malaria Report). But from a biological point of view,
there lies considerable beauty in this life form. Through an infectious bite of a female Anopheles mosquito, plasmodia
enter the body of their hosts. Via the blood stream they travel to the liver where they multiply asexually through cell di-
vision. Plasmodia infest the red blood cells, grow, and multiply exponentially, making the blood cells burst. This is the
cause of the fever episodes an infected person experiences. After a while the plasmodia develop into male and female gam-
etes. During this phase they eagerly await a change of host. During the next blood meal of an Anopheles mosquito, the re-
productive cells enter the mosquito's intestines where male and female gametes merge. Upon entering the mosquito's
salivary gland, the offspring from the fertilised egg are ready to infect a new human victim, thus completing this fascinat-
ing life cycle.
Parasite Epidemiology and Control 3 (2019) e00086
⁎Corresponding author at: Swiss Tropical and Public Health Institute, Switzerland
E-mail address: lukas.meier@swisstph.ch. (L. Meier).
https://doi.org/10.1016/j.parepi.2019.e00086
2405-6731/© 2019 Published by Elsevier Ltd on behalf of World Federation of Parasitologists. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Contents lists available at ScienceDirect
Parasite Epidemiology and Control
journal homepage: www.elsevier.com/locate/parepi

2. Asking the right questions
Considering all the tricks and gimmicks of malaria parasites, this single-cell organism outstrips other pathogens such as viruses
and bacteria in terms of sophistication. Undoubtedly, malaria seriously affects large swaths of the population. It prevents peasants
in Africa or in India from cultivating his field and making a modest living. It causes complications during pregnancy, often leads to
miscarriages, and is frequently the cause of dangerously low birth weights, not to forget that it takes the live of a child under
5 years every two seconds. Malaria inhibits social and economic development and accounts for a high disease burden. Of the
91 countries that reported indigenous malaria cases in 2017, fifteen –14 of them in sub-Saharan Africa and India –carried
80% of the global malaria burden (WHO, 2018, World Malaria Report). These figures have been highlighted for good reason.
The point here is that researchers who only focus on the suffering of the afflicted populations and who, in view of the many ob-
stacles, almost despair at the task of making the world a more inhabitable place, will not discover anything and are probably
doomed to failure. Only by acknowledging the ingenuity of nature and being fascinated by it, one will we be able to raise the
right scientific questions, contribute to the containment of the disease, and improve the performance of health systems to the
benefit of the neglected populations. In our opinion, today's highly specialised research has somehow obscured the issue of
science's social responsibility. For instance, many skilled researchers working in the burgeoning field of personalised medicine
limit their efforts to sequencing new genes to add to the list of risk factors with regard to chronic conditions, without questioning
how the knowledge about all the various risk factors will change human behaviour and the social fabric at large. We believe that
only by putting society centre stage and working along the value chain, from innovation to application, can we address the up-
coming challenges of the 21st century.
3. Mutual learning for change
In a globalised world, research partnership, of course, is the key to such an endeavour. The notion of partnership has had a
stunning career in science and development talks. There is not a single “high-level meeting”where partnership between
North-South, South-South, or whatever direction, is not praised. However, these good intentions evaporate as soon as one
takes a closer at ground level. Partnership is, of course, not when a wealthy donor dictates the scientific agenda. Nor is it partner-
ship when the different partners consider their various duties as tasks to be performed, instead of genuinely searching for a so-
lution to a relevant problem. Partnership is not about helping others but about “mutual learning for change”. What we mean by
partnership is perhaps best expressed in the very simple metaphor of a common journey. Experience has shown that in order to
get far, every member of an expedition contributes what he or she has to share. One member has brought his fishing rod and a
Fig. 1. Babylonian language confusion (Illustration: Pia Valär, Zurich).
2M. Tanner, L. Meier / Parasite Epidemiology and Control 3 (2019) e00086

box of matches for lighting a fire. Another has thought of a map and a compass and has an unfailing sense of orientation, also in
difficult terrain. If everyone is an expert in map reading, the journey will not get very far because the members are most likely to
starve to death during the venture. Thus, the most important feature of a successful partnership is the assignment of clear roles
and responsibilities (Figs. 1 and 2). Without these, research partnership will never materialise. Roles and responsibilities can
change during the journey, but everyone has to be able to tell at any time what his or her role and responsibility is
(Commission for Research Partnership with Developing Countries, 2012).
Research partnership has a lot to do with creative listening. There is a stunning biological fact which, however, we often tend
to forget: human beings have two ears, two eyes, but just one mouth. This means that, before hastily proposing “policy advice”,
one is well advised to listen and watch carefully. One sometimes gets the impression that new results emerging from laboratories
or project sites are heralded too quickly as solutions to societal problems, without having them validated for the various cultural
settings they are destined for. Creative listening requires a considerable degree of sensibility for local contexts. Our work experi-
ence in Tanzania during the 1980s showed that catching snails in potential transmission sites along the TAZARA-railway for the
purpose of studying the epidemiology of schistosomiasis potentially resulted in the suspicion of being a South African terrorist. The
challenge was to explain that this was not the case, and that you were actually not hunting for mere research data but working
for the district authorities to find out how the disease is transmitted. At the time we also learnt that spending nights in the
African bush was as important as forging ties with the district and regional authorities. Gathering around a small fire under
the dark-green canopy of giant trees, you got a feeling for the place where you would be spending a couple years doing field-
work. Moreover, it laid the basis for you being accepted locally because the villagers around you realised that you didn't need
a tent of your own or four o'clock tea as did the colonial masters in the old days, and that you, too, were prepared to sleep around
the campfire like everybody else.
4. Long-term investment
Partnership needs long-term investment. Conducting pilot projects here and there is probably not the right way forward if you
really want to establish a sound research partnership. In the 1950s, the Swiss Tropical and Public Health Institute (Swiss TPH) in
Basel established two research laboratories in Tanzania and Côte d'Ivoire, respectively: The Ifakara Health Institute (IHI) and the
Centre Suisse de Recherches Scientifiques (CSRS) en Côte d'Ivoire. Since then, both organisations have developed into key players
in health, nutrition, and ecosystems research and implementation in the respective countries (Meier, 2014). Four PhD students
graduate at the Ifakara Health Institute annually, while the number of peer-reviewed publications amounts to more than a hun-
dred per year (Irikefe et al., 2011).
Fig. 2. "mutual learning for change" (Illustration: Pia Valär, Zurich).
3M. Tanner, L. Meier / Parasite Epidemiology and Control 3 (2019) e00086

The CSRS employs 170 administrative staff and over 100 researchers. Since 2000, over 25 PhD students have graduated from
CSRS, three-quarter are African academics. As recent research has shown, in 2016 CSRS was the second-most prolific publishing
institute in Côte d'Ivoire, behind Université Félix Houphouet-Boigny (Saric et al., 2018). The IHI and the CSRS are established as
international, autonomous trusts, modelled on the Ifakara Health Institute in Tanzania. This model allows for a flexible mix of
public and private partners embedded within national research agendas and under the guidance of an international board of
trustees. The model has been adopted by other international research organisations across the southern hemisphere, including
the Manhiça Health Research Centre in Mozambique, the African Malaria Network Trust in Tanzania, and the International Clinical
Epidemiology Trust in New Delhi.
Building trust and credibility based on mutual respect through capacity and institution building requires commitment, not
least when things go downhill in political terms. This was also the case in Côte d'Ivoire when, after the coup of 1999, the country
was plagued by civil unrest for many years. Numerous national universities were forced to close down, and scientists holding in-
ternational passports quickly returned to their home countries, leaving the scientific community in tatters. As a centre with dip-
lomatic status, CSRS quickly re-launched several community projects to assess the health and food situation in rebel-controlled
areas of Côte d'Ivoire in an attempt to initiate a new generation of major projects and programmes (Bonfoh et al., 2011).
5. From the laboratory to the field…
Well-performing institutions and highly skilled partners are prerequisites for making scientific results available to those who
need them most. The best science for the most neglected is required, and here we should not compromise. In order to achieve
this, science has to proceed along the value chain from innovation, to validation, to application. Most scientists think of them-
selves as innovative. And probably rightly so. They develop new generations of insecticide-treated mosquito-nets or muse
about new concepts in the social sciences. They leave their laboratories or desks with the intention of quickly applying their in-
novation to real-life settings. What is often is missing, though, is validation. New tools have to be validated whether they scien-
tifically work and whether they are socially accepted in a given context, before being up-scaled. The new malaria vaccine
candidate RTS,S is a case in point. Developed by GlaxoSmithKline (GSK) it proved very promising in laboratory research. However,
extensive multi-site trials in eleven countries across Africa, including the Ifakara Health Institute in Tanzania, have shown that the
vaccine is only partially effective (The RTS,S Clinical Trials Partnership, 2011). These insights are now subject to the debate under
which conditions the vaccine could be applied alongside other preventive measures. The World Health Organisation has
demanded further clinical evidence from trials in Ghana, Kenya, and Malawi. Thus, instead of conducting a single laboratory ex-
periment and believing that one has now made a significant contribution to humankind, one should first have the results thor-
oughly validated. Only through validation together with the people living in diverse social and cultural contexts, does it
become clear whether or not such an innovation could possibly be up-scaled.
6. …and from the field back to the laboratory
As we hope to have made clear: the process from innovation to application is not a one-way street. Laboratory and field re-
search are closely intertwined. Innovation –if it deserves the name –should be tailored to local contexts and integrated into
the respective health and cultural systems. It must be socially acceptable as well as scientifically viable. In order to meet such
high expectations, scientist should every so often leave their comfortable labs in cosy Europe or the US and immerse themselves
in foreign cultures, and simply listen and watch with curiosity. This would sharpen their senses in order to ask the right questions
and become involved in solving the problems really relevant to society. For instance, simple observations of malaria patients ad-
mitted to rural hospitals and dispensaries in Tanzania in the 1980s revealed that the by then widely used antimalarial chloroquine
was no longer effective (Tanner et al., 1987). The vigorous Plasmodium falciparum had developed new mechanisms to circumvent
the drug's mechanisms of action. This first scientific evidence of chloroquine resistance in Tanzania was passed on to the pharma-
ceutical industries back in Europe along with the call that new chemical compounds against malaria were urgently needed. No-
tably, the steps undertaken in the process also won the recognition and trust of the Tanzanian government, resulting in a long-
lasting partnership ever since.
Box 1 Ifakara Health Institute, Tanzania.
Ifakara Health Institute (IHI) in Tanzania
In 1957, the Swiss Tropical and Public Health Institute opened its field laboratory in Ifakara. Over the last 60 years it has devel-
oped into the Ifakara Health Institute (IHI) —one of the most renowned research institutions on the African continent (Tanner
et al., 1994). The IHI combines research, teaching, and training as well as services. It currently employs over 380 staff members,
150 of which are scientists. They are dedicated to developing new strategies against infectious diseases such as malaria, tuber-
culosis, or HIV/Aids. In the 1990s, the Institute conducted the first malaria vaccine trial in sub-Saharan Africa and has been cru-
cial for malaria vaccine development ever since. It has been selected as one of the 11 trials sites for the effectiveness trials of the
4M. Tanner, L. Meier / Parasite Epidemiology and Control 3 (2019) e00086

malaria vaccine candidate RTS,S/AS01 which commenced in 2009. In collaboration withthe Swiss Tropical Institute in Basel, IHI-
scientists achieved a high impact on the health of rural populations when they worked on insecticide-treated bed nets. Large-
scale trials in the Kilombero district reached 500,000 people and reduced infant mortality due to malaria by 30%. Not least
thanks to the work of IHI, Tanzania reached the Millennium Development Goal #4 (Reduce child mortality) already by 2010.
In recognition of its many achievement, IHI was awarded the prestigious Prince of Asturias Award for International Cooperation
in 2008 together with the Manhica Health Research Centre in Mozambique, Malaria Research Centre in Bamako, Mali and the
Kitampo Health Research Centre in Ghana.
Box 2 Centre Suisse de Recherches Scientifiques en Côte d'Ivoire.
Centre Suisse de Recherches Scientifiques (CSRS) en Côte d'Ivoire
Founded in 1951, the Centre Suisse de Recherches Scientifiques (CSRS) was Switzerland's first research institution in Africa.
Covering diverse fields such as health, nutrition, urbanisation, and ecological research it has become one of the major hubs of
Swiss-Ivoirian research partnership under African leadership. Nutrition and especially question of food security has become
an important research branch of the centre. In 1998, CSRS-scientists introduced new yam varieties to Côte d'Ivoire which were
both of highquality andlocally accepted. Primatology and biodiversity in the unique Tai Forest are other important fields of re-
search. Under the paradigm of “one health”, scientists study the health of animals as well as humans to contain the spread of
zoonotic diseases. A recent study on chimpanzees in the Tai forest revealed that several plants eaten by chimpanzees could also
have therapeutic effects in humans (Ahoua et al., 2018). Moreover, health research at CSRS includes innovative approaches to
fight parasitic worm infections, combining chemotherapy, latrine construction, and health education programmes in schools. In
2012, the Centre established the Taabo Health Demographic Surveillance System (HDSS), a unique database comprising eco-
nomic, demographic, and health-related data of 40,000 inhabitants living in south-central Côte d'Ivoire. This platform allows re-
searchers not only to determine theimpact of health interventionsbut also to embark on scientific studies, such as on the causes
of anaemia and local concepts of anaemia-related illnesses.
Acknowledgements
We are deeply grateful to the stimulating and fruitful collaborations with all colleagues from the Swiss TPH, the Swiss and in-
ternational scientific and public/global health community, our public and private partner institutions and populations in Europe,
USA, Africa, Asia, Australia and the Pacific.
The illustrations were created by Pia Valär as a consequence of our discussions on mutual learning and partnership.
References
Ahoua, C., et al., 2018. Chimpanzees eat plants that point to new ways of treating diseases. The Conversation 20.05.2018.
Bonfoh, B., et al., 2011. Research in a war zone. Nature 474, 569–571.
Commission for Research Partnership with Developing Countries, 2012. 11 Principles.
Irikefe, V., et al., 2011. The view from the front line. Nature 474, 556–559.
Meier, L., 2014. Swiss Science, African Decolonization and the Rise of Global Health 1940–2010.
Saric, J., et al., 2018. Research productivity and main publishing institutions in Côte d'Ivoire, 2000–2016. Glob. Health 14 (88), 1–11.
Tanner, M., et al., 1987. In vitro monitoring of chloroquine sensitivity of Plasmodium falciparum in Ifakara, Kilombero District, south-east Tanzania. East Afr. Med. J. 64
(7), 464–470.
Tanner, M., et al., 1994. Developing health research capability in Tanzania: from a Swiss Tropical Field Laboratory to the Ifakara Centre of the Tanzanian National In-
stitute of Medical Research. Acta Trop. 57 (2–3), 153–173.
The RTS,S Clinical Trials Partnership, 2011. First results of phase 3 trial of RTS,S/AS01 malaria vaccine in African children. N. Engl. J. Med. 365 (20), 1863–1875.
WHO, 2018. World Malaria Report. World Health Organization, Geneva.
5M. Tanner, L. Meier / Parasite Epidemiology and Control 3 (2019) e00086