[This article was published in 2009 and updated in May 2012. Read the update here.]
The Infectious Diseases Institute is gaining international prominence; can the lessons learned to fight AIDS be used in treating malaria and vice versa?
Malaria is a devastating disease that claims a child’s life every 30 seconds and kills more than one million people each year. In sub-Saharan Africa, which accounts for more than 90 percent of all malaria cases worldwide, the disease is particularly brutal on the young; there, malaria is responsible for nearly 20 percent of all deaths in children under the age of five.
World leaders have come together with a comprehensive plan to eradicate malaria by 2015 and have pledged $3 billion to meet this goal. In addition to providing research funding for a vaccine, the plan aims for a reduction in deaths in the next two years by providing mosquito nets, indoor spraying, diagnosis and treatment.
“Several organizations have made a claim that if everyone in malaria endemic zones had a bed net, we could eradicate the disease. I wish it were that simple,” says Carol Spahn, executive director of Accordia Global Health Foundation, a nonprofit working to overcome the burden of infectious diseases by building health care capacity and strengthening academic medical institutions in Africa.
Could malaria be eliminated simply by expanding the use of bed nets? “The answer is no. The reason is, mosquitos can still bite you when you’re not in bed,” says Alex Coutinho, M.D., M.P.H., executive director of the Infectious Diseases Institute (IDI), Accordia’s flagship program in Kampala, Uganda.
Bed nets are one very important piece in the arsenal of proven interventions that can help prevent malaria. Others include indoor insecticide spraying and intermittent preventative treatment for pregnant women. But clinical training to enhance the quality of care and counseling is an equally essential component of any effective prevention strategy.
Recognizing this reality, Accordia, ExxonMobil and IDI joined forces over the past four years to create the Joint Uganda Malaria Program (JUMP), an ambitious partnership that also includes I-Tech, Makerere University, University of California San Francisco, the Uganda Malaria Surveillance Program and the Ugandan Ministry of Health. The JUMP program is aimed at reducing the burden of malaria by implementing innovative training approaches that teach health care workers to correctly diagnose malaria. The team-based training has shown dramatic results in improving fever case management and reducing the over-prescription of antimalarials — thereby reducing the problem of drug-resistant malaria — and building the capacity of Uganda’s health workforce.
“The reason why an energy company is involved in a global health partnership follows a multi-step logic,” says Steven Phillips, M.D., M.P.H., medical director for Global Issues and Projects at ExxonMobil. “First of all, ExxonMobil has a large footprint in Africa. We’ve been on the continent for more than 100 years, and we’ve been present in 25 sub-Saharan countries historically,” he says, noting that ExxonMobil now does business in six countries there.
Additionally, investment in oil and gas resources in Africa has been growing. Africa now represents about eight percent of the world’s oil supplies, but that number is expected to grow to about 12
“Starting in about 2001, we developed a very comprehensive workplace malaria control program. However, we have to address the reservoir for mosquitos, which is [all] human beings, not just company people,” he says.
JUMP is an integral part of ExxonMobil’s overall corporate responsibility program and commitment to the African continent. ExxonMobil has funded the project at the $500,000 level each year for the past four years, but the company’s overall commitment to the fight against malaria is much larger.
That said, it may be the Ugandan government’s commitment that is the real indicator of the program’s success, as the government has adopted JUMP’s curriculum as a national standard for training health care workers.
The JUMP program has evolved significantly since it was initially developed. “JUMP started as a classroom-based, five-day training program. But we discovered that sites did so much better in terms of health outcomes after we conducted on-site support and supervision visits that we decided that that had to be an essential component of any training,” says Kelly Willis, M.B.A., senior vice president for program development at Accordia Global Health Foundation. “In doing so, we found it was more cost efficient to have peer leaders conduct the courses, so we created a training-oftrainers module, which has proven to be tremendously effective,” Willis adds. As of the end of 2008, the JUMP program had trained 803 individuals in fever case management and effective diagnosis and treatment of malaria.
A Center of Excellence
While malaria has long been a medical problem throughout sub-Saharan Africa, the impetus behind the founding of IDI was not malaria, but AIDS.
In 2001, a group of North American and African physicians, who had experienced the AIDS epidemic firsthand, recognized that Africa lacked the infrastructure to deal adequately with the problem, so they reached out to Hank McKinnell, Ph.D., the former president and CEO of Pfizer, who now is chairman of the board of Accordia.
“The result was what we originally called the Academic Alliance, which quickly became the Accordia Global Health Foundation,” McKinnell says. That group established IDI at Makerere University in Kampala, Uganda. To date, IDI has trained more than 4,500 health care workers from 29 countries in HIV/AIDS, malaria, laboratory practices, research methods and other critical infectious disease topics.
While IDI is an autonomous institution, it is integrated into Makerere University, which, having been founded in 1932, is one of the oldest universities in Africa. “For a long time Makerere was the only university for doctors in the whole of eastern Africa,” says IDI’s Coutinho.
Makerere University, which has a student body totaling around 30,000 students, produces roughly 100 doctors a year. In the medical school, there are 23 professors, as well as 500 undergraduate and 200 graduate students, according to Coutinho. While IDI’s development and subsequent reputation as a center of excellence are a relatively recent phenomenon, Makerere University has a long and accomplished history, which includes discovery of new diseases like a tumor called Burkitt’s lymphoma, among others. “The vision for IDI was that the driving force to combat diseases that primarily impact Africa needs to be firmly rooted in Africa, and Makerere was the natural place to locate it,” says Accordia’s Spahn.
The number of IDI’s trainees has grown substantially since its inception in 2004 to around 1,600 trainees in 2008 alone. With this expansion, the training methods have also evolved. In addition to the trainees who come from across Africa to participate in specific training programs, Makerere medical students also cycle through IDI for a two-week period and follow a patient through the clinical care process and into their homes. This is intended to enable the students to understand the patient’s psychosocial and socio-economic circumstances as part of the HIV/AIDS treatment and care process.
Accordia also sends visiting scholars to IDI, to give lectures and do rounds with medical students, Spahn explains. “These scholars play a critical mentoring role with young African scientists doing research at IDI,” she says. In the last four years, IDI scholars have published 71 articles and presented 92 research abstracts at major infectious disease meetings around the world.
While originally focused on AIDS through contributions from Pfizer, ExxonMobil’s generous support allowed IDI to expand to malaria research, prevention and care. In the first year of the JUMP program, activity focused on building relationships and jointly developing a comprehensive curriculum for use in multidisciplinary team training for the care and prevention of malaria.
The second year saw the implementation of the core malaria training program and demonstration of the value of its multidisciplinary team-based approach to malaria training. In 2008, the program was adapted for national scale by adding modified field-based components for facilities with and without laboratory capacity, external funding was secured for program expansion, and the JUMP curriculum was formally endorsed by Uganda’s Ministry of Health.
A New Model of Treatment
According to ExxonMobil’s Phillips, the company found that the training approaches being developed at IDI for HIV/AIDS could be leveraged to address malaria as well.
“We wanted to develop a module that complemented what IDI was already doing, by developing a new curriculum for training health professionals in malaria and disseminating it, not only in Uganda, but throughout the continent of Africa,” says Phillips.
“But how do you test — how do you export — that technique, and make sure that it is generalizable to other parts of Africa? Malaria is a totally different disease, and it’s not like you can turn on a dime. You have to spend substantial financial resources and figure out who the curriculum is for. Malaria is primarily taken care of by people who work in very, very remote health centers, by people who have very little medical training,” he adds.
Another part of the problem with malaria in sub-Saharan Africa is that, while the disease is readily treatable, resistance has spread, in part because of frequent misdiagnosis. Treatment can take as little as three to five days if the patient is properly treated with drugs like artemisinin, chloroquine or primaquine. “However, the new products are much more expensive, so we have to train the health workers to much higher levels so they don’t waste treatment,” says IDI’s Coutinho. “That’s because malaria is a disease that cycles through the body, and, at different phases of the cycle, different drugs are able to block the propagation of the parasite. For instance, chloroquine is able to block it in the blood cells, while primaquine blocks malaria in the liver cells,” he continues.
“In a country like Uganda, you can often find shopkeepers, or what you would call pharmacists, filling the need for local treatment, and we need to be sure we work with them so that they dispense treatment in the correct fashion. We need to make sure we constantly teach and train people on the front line,” Coutinho says.
Resistance has mainly been a problem in the last decade or so, as doctors have encountered chloroquine resistance in as many as 30 percent to 40 percent of cases. Malaria is often confused with hepatitis or typhoid or one of a number of other tropical diseases when the patient has a fever.
To deal with the problem, the JUMP partnership developed a new field training model to deliver the most effective care for malaria. The model includes a six-day intensive course in advanced care for and prevention of malaria and targets doctors, nurses, clinical officers and laboratory technicians. The JUMP team includes a medical officer, training coordinator or curriculum specialist, laboratory technician, training assistant, data manager and a driver. Once core teams are trained at the institute itself, they return to their home communities to continue training and teaching others. The JUMP team then provides on-site follow-up support.
“We found that the extra investment in providing on-site support helped solidify the training and resulted in a stronger impact,” Accordia’s Spahn says.
Expanding Activities and Diversifying Resources
Because of the success of the JUMP program, Accordia and IDI hope to pilot the JUMP program outside of Uganda, to demonstrate the model’s success in other settings. “The program has been proven to have a positive effect on patient outcomes in Uganda, and we believe it has strong applicability throughout sub-Saharan Africa,” says Spahn. “It is imperative that we scale this up as quickly as possible as a part of the broad plan to eradicate malaria and its impact.”
Accordia and IDI are also exploring the potential replication of the IDI model in another country. “We are trying to replicate the institute in West Africa, perhaps in Nigeria,” Coutinho says. “Tanzania, Zambia and South Africa already have similar institutes, but in West Africa, there are none,” he adds.
Additionally, IDI hopes to acquire land for a new building. “We are fundraising and identifying land; we hope to construct a new building very soon, because the demand for training is so huge,” Coutinho says. “The new building will be used mainly for training, but we could also use some space for additional research. In just five short years, we have outgrown our space.”
As part of its visionary investment in IDI, Pfizer constructed a state-of-the-art facility in Kampala. “The building is something you might find around the corner from you in the United States, with a bustling level of activity,” says Lisa Foster, M.B.A., senior director in the corporate responsibility/philanthropy team at Pfizer.
The multi-level building comes complete with an award-winning research lab and hosts as many as 40 physicians and researchers from the region at one time, she adds. In addition, the on-site computer server is protected from fire or explosion by a heatsensing device, and the building features an air-circulation system. “Our clinic treats up to 300 HIV-positive people per day,” says Coutinho, adding that the building has 40 rooms, three pharmacies, a records office and one of only six labs in Africa that are certified by the College of American Pathologists.
Despite the fact that Pfizer solely financed construction of the building, it has welcomed multiple partners in an effort to build long-term sustainability. “The many different partner organizations work very well together,” says Accordia’s McKinnell. “The reason for diversifying is that we did not feel it was appropriate for a major institute anywhere in the world to be dependent on a single source of funding. Once established, like any other organization, it has to develop its own funding sources,” he adds.
“In the early years, it was very critical that Pfizer provide a solid base of core funding to establish IDI’s relevance, so that when the executive director approaches other organizations to ask for funding, donors will be receptive,” says Pfizer’s Lisa Foster.
By John Otrompke, J.D.