Written by Anisa Jafar, ST7 in Emergency Medicine & Houghton Dunn Fellow, North West deanery & University of Manchester 

Edited by Philip Delbridge

Therefore the symposium seemed a great way to revisit some of that content whilst gaining a sense of where the dial was now sitting in some of the broader global health spaces. It was also the very first time I have deliberately maintained focus for an entire 3-day conference, even diligently catching up online for the odd session I had to miss – all with a view to a whistle-stop summary blog. This is a serious commitment for the Emergency Medicine concentration span, so here goes…

Day 1

Introductions

Prof. Laloo was followed by WHO Chief Scientist, Jeremy Farrar, who joined online and was very clear to echo the opening sentiments of historical and modern-day challenges that LSTM needs to address at an institutional level. He also shone a light on the rising external challenges resulting from anti-science populism. His keynote touched on multiple ways to tackle this including:

• interfaces with non-traditional partners
• bringing science back to society
• being at the forefront of upholding governance within the private sector
• forcing interdisciplinarity especially within strongly vertical systems

This big-picture view was followed by three speakers: LSTM Professor of Vector Biology, Janet Hemingway, Emeritus LSTM Professor, David Molyneux, and Director of the Malawi-Liverpool Wellcome Programme, Henry Mwandumba. Key reflections included the requirement for trust, integrity and shared vision to be central within partnership;  the need to embrace a diversity of interests; and placing an emphasis on local priorities derived from genuine understanding.

Tuberculosis

LSTM research uptake manager, Kerry Millington, chaired the TB session – she started by asking whether we thought we’d achieve the end of TB by 2030. The weak audience laughter gave the definitive answer which reminded me that, for the longest time, the disease has felt like one of the litmus tests for the direction of global equity. This session included a real mix. Naomi Walker looked at how a revised understanding of TB immunopathogenesis is being used to inform novel interventions. Some of these interventions were familiar friends: doxycycline as an adjunct in reducing lung cavity formation and also n-acetylcysteine (or NAC, used in paracetamol toxicity) reducing treatment time.

Ben Morton spoke of Controlled Human Infection Model (CHIM) studies to accelerate drug and vaccine discovery, which prompted a question about whether pregnant women were being included in such studies. This comes following recently revised WHO guidance on trial inclusion highlighting the imperative that this under-researched group be included in studies where feasible, otherwise we will continue to under-treat this vulnerable group on the basis of “no safety evidence”.

I was impressed with one economic solution described where 4 peoples’ sputum were pooled and tested, then only if positive, the 4 people’s sputum would be tested individually. With the right prevalence and context, this makes so much sense in terms of resource use.

Rachael Thomson discussed qualitative approaches such as participatory action research to explore the reasons behind gender imbalance toward men in TB burden. Finally, Professor of Global Respiratory Health Jeremiah Chakaya’s keynote brought together all of the challenges facing TB eradication, not least the broader impact of climate change on systems and infrastructure.

HIV

Co-chairs, Senior Lecturer Kondwani Jambo and Professor of Global Health  Frances Cowan led another varied session. Augustine Choko presented on the global scaling up of HIV self-testing, which has been evidenced to result in earlier diagnosis and higher anti-retroviral (ART) demand.

Euphemia Sibanda discussed innovations in self-care for HIV prevention and highlighted the research of the Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) in Zimbabwe. This was followed by Loveleen Bansi-Matharu who explored modelling HIV prevention interventions to guide funding decisions in sub-Saharan Africa. Lilian Otiso took us through some successful large HIV care and treatment programmes in sub-Saharan Africa, but also reminded us of some potential threats to progress such as PEPFAR funding cuts, emerging epidemics and climate change impacting service delivery.

The keynote was delivered by Professor of Global Health Liz Corbett (from the other tropical medicine school) . She took us through HIV elimination goals and the 2030 fast-track strategy. However, she urged caution in taking our eye off the ball given that viral rebound dynamics mean that in 2-4 weeks you can have a viral load as high as it was pre-treatment, so global gains can very easily go into reverse.

Malaria

Vaccine-development was Adrian Hill’s angle, in particular exploring different types of vaccine and considering the up-front economics, which are often more difficult to digest than the longer term positive economic impact, even if the latter might be many-fold greater. Finally, Cristina Donini covered treatment, including chemoprophylaxis in pregnant women, the spread of artemisinin resistance and the idea of rotating drug availability on the market to prevent further cycles of resistance taking hold.

Day 2

Climate

Eric Lucas used a different lens and discussed the implications of anthropogenic change on malaria vector populations and transmission. The message seems to be that malaria in some regions is likely to decline as it becomes too hot for Anopheles species, whilst diseases like dengue will increase as Aedes species thrive in the higher temperatures. Equally, some areas will see a malaria rise as they experience the higher temperatures needed for Anopheles species to proliferate. All this said, predictions in any direction are difficult because vector control behaviour may change. For example, where it is starting to get too hot for Anopheles species to thrive, it may also become too hot for sleeping under bed nets, and so this could increase biting and transmission. At the same time, some species of Anopheles may adapt to the temperature change. Dr Lucas was followed by Rachel Tolhurst and Surekha Garimella, who together focussed on health policy and systems research on climate change and urbanisation. They referred to the disproportionate impact that climate change has on marginalised populations, giving some clear examples of the direct effects of extreme weather events on buildings and infrastructure, especially in informal settlements.

Resilient health systems

LSTM Reader Joanna Raven chaired this much anticipated session, central to the launch of the LSTM’s Institute of Resilient Health Systems.  As someone so invested in (and perhaps biased toward the value of) Emergency Care, it was difficult not to feel a bit of a hole in the introduction, with no mention of it. The utopia is, of course, that no-one ever needs to attend an ED, however the reality is far from this. If we are to invest in resilient health systems, we do need a safety valve for all genuine emergencies – and this safety valve can provide a locally-owned failsafe for when the primary care system/vertical programme is struggling. This doesn’t mean we necessarily stop investing in prevention or that we focus only on “response” mode-thinking, but to imagine that a resilient health system exists without an integral Emergency Care system feels implausible… says the perhaps-biased ED clinician  Food for thought in any case.

It was difficult to shake this thinking when listening to the presentations that followed by Maryse Kok and Jacinta Nzinga. Their discussion evolved around shocks to health systems (caused by such factors as infectious diseases, climate and conflict) alongside chronic stressors (such as food prices, migration, resource capacity and, again, climate). They described resilient systems as being able to “absorb, adapt and transform” and I couldn’t help thinking “isn’t this what the heart of Emergency Care is, day in, day out?”. Surely there is an enormous amount of proxy thinking which could be cross-pollinated? This impression only became more pervasive as resilient research was explored alongside the dimensions of how you can enable a system to be both resilient to shocks but also still function effectively and efficiently: isn’t there huge learning in how we plan, prepare for and enact responses to mass casualty  and other major incidents?

To conclude this session, Sushil Baral from HERD International in Nepal focussed on addressing systemic limitations to create long term capacity, contextual tailoring of approaches that are locally informed, and emphasising equity within a system as a measure of true success.

Antimicrobial resistance (AMR)

If ever there was a buzz-phrase in global health, AMR has taken the crown in recent years (not to be confused with ASMR which has had a similar trajectory in popular parlance over a similar time frame!). ‘Taking the crown’ in global health terms, is a decidedly negative thing as the chair, LSTM Reader in Antimicrobial Chemotherapy and Resistance, Adam Roberts, highlighted, and is the reason antimicrobial resistance is such a huge priority for LSTM and institutions internationally. Catrin Moore’s presentation laid out that AMR will remain the biggest global health threat unless we change our practices. She cited areas such as One Health as a driver to help make these changes, however given that poverty has such a huge influence on maintaining the right conditions for AMR to proliferate, the solutions are utterly multi-factorial.

The hard science got a bit deeper with Patrick Musicha’s presentation on the evolution and spread of AMR, where we got down to the chromosomal level of Extended-Spectrum Beta-Lactamase (ESBL) bacteria. Sabrina Moyo carried on the theme as she presented the use of probiotics in protecting against carriage of AMR ESBL bacteria in new-born babies. The resistance discussion did not stop at bacteria, as Tony Nolan took a deep dive into the use of gene drives to help manage resistant mosquitoes.

Just as I felt I might be getting out of my depth with all the clever science, the University of Oxford’s Professor of Medical Microbiology, Tim Walsh, delivered his keynote. One notable piece of work he referred to took place in Pakistan, where the surgical ward’s resident arthropods (think cockroaches, flies, spiders, ants, moths…) were tested and pretty much all carried resistant bacteria. He raised the question of where best then shall we spend the money to manage AMR: infrastructure, diagnostics, infection prevention & control, access to antibiotics, new antibiotics…? He also sobered everyone up by reminding us that no matter where we spend our few billion, if we keep spending trillions on arms and blowing healthcare infrastructure to pieces then we are probably wasting our time. Now that was a thought for the day worth thinking – and this earned him two photos.

Neglected tropical diseases (NTDs)

Trypanosomiasis came next (I can hear the cogs whirring, depending how long ago any DTM&H alumni reader might have studied it…) from Andrew Hope. He introduced ‘Tiny Targets’ which can accelerate progress towards the elimination of the disease. These are small insecticide-impregnated panels of blue cloth and black net which draw tsetse flies in and kill them. He also updated on oral treatments.

Sian Freer took up the mantle of discussing the elimination of lymphatic filariasis.  Whilst progress has been made, the fragility of this progress was spotlighted such that funding cuts, for example those of the Foreign and Commonwealth Development Office in 2021, create a real risk of reversing the gains. Last up for this section was onchocerciasis delivered by Mark Taylor – Wolbachia got a mention again, but this time because the nematodes responsible for river-blindness are dependent on it for their life cycle. This, ironically, makes Wolbachia a potential target again – this time, for treating Onchocerciasis.

To conclude this eclectic mix of NTDs, Dean for the National School of Tropical Medicine and Professor at Baylor College, Peter Hotez, brought us back to the big picture. In a world where cases of dengue, chikungunya, Zika, malaria, leishmaniasis, hookworm are being reported in the United States, climate change is very much being felt. He echoed previous speakers in driving home the impact of urbanisation, poverty, political instability and anti-science movements.

Future threats

As if the present doesn’t have enough, LSTM Professor of Tropical Disease Biology, Giancarlo Biagini, introduced some future threats to address in Day 2’s final session. In this section, Ana Cubas Atienzar discussed advances in diagnosis of Crimean-Congo Haemorrhagic Fever virus, Alain Kohl asked what are we learning from RNA studies to help understand arbovirus-vector interaction; Christine Goffinet discussed HIV-1 cure strategies, and finally, Jonathan Ball considered how we can prepare for future pandemics by developing bovine-derived monoclonal antibodies.

Day 3

“conceptual framework for understanding diseases or health conditions that arise in populations, and that are exacerbated by the social, economic, environmental, and political milieu in which a population is immersed”

Within this they highlighted the western dominance of knowledge production and the notion of structural violence, using an example from Freetown, Sierra Leone. Rosalind Steege and Bachera Aktar then took the stage to explore responses to intensified inequities and intersectionality using examples of structural inequities within socio-political ecosystems, as demonstrated within Bangladeshi slums.

Maternal, child and newborn health

The final themed session posed challenges and innovation in maternal, child and newborn health, chaired by LSTM Professor of Maternal and Newborn Health, Dame Tina Lavender, and LSTM Professor of International Public Health, Charles Ameh. They presented the current activity and future vision of the Centre for Childbirth, Women’s and Newborn Health. Research work streams include use of mobile apps, bereavement, intrapartum guidelines, and adolescents, adopting a range of methods. Tracey Mills spoke of the development and evaluation of a bereavement care intervention in India, Kenya, Pakistan, and Uganda, whilst Duncan Shikuku spoke of improving midwifery education as a pathway to improving maternal health. Feiko ter Kuile and Lauren Cohee brought us full circle in discussing treatment and control of malaria in pregnancy and children. They took an overall picture of the burden of malaria. For example, they looked at chronically infected school-age children whose anaemia impacts on cognition, and whose blood represents significant reservoirs for human to mosquito transmission. As far as women are concerned, the 1^st trimester is especially risky for pregnancy loss, however lack of safety data has in the past restricted how well this group has been treated. Thankfully, this pattern is now changing and pregnancy outcomes are improving.

The final keynote from Olufemi Oladapo, who has over a decade of experience in WHO and is currently Head of Unit for maternal and perinatal health, really challenged the thinking in the room. Dr Oladapo showed how maternal health progress has flat-lined in many places. Furthermore, in the past 20 years, only 64 countries out of 185 have managed to significantly reduce maternal deaths. With 25% of the world living in fragile health settings, the impact on maternal health is enormous – post-partum haemorrhage is even increasing in some places. He thoughtfully applauded the research being done in the room, but directly questioned the contribution of that research to making an actual positive change. A sobering idea for everyone.

Some excellent early career/postgraduate researcher lightning talks came next, covering everything from TB CHIM, snakebite, structural inequity and AMR, to faecal bacteria, lymphatic filariasis, insecticide resistance, relapsing malaria and mental health. Many researchers had also contributed posters to the symposium, a selection of which are shown below.

This was followed by two panel discussions moderated by Tulip Mazumdar. The theme of the two panels was future-proofing LSTM for the next 125 years and the list of heavy-weights across the panels goes as follows:

• Helen Jamet (Bill & Melinda Gates Foundation)
• Catrin Moore (University of London)
• Peter Hotez (Baylor College of Medicine)
• Professor Liz Corbett (London School of Hygiene and Tropical Medicine)
• Samuel Wanji (University of Buea)
• David Lalloo (LSTM)
• Adrian Hill (Oxford University)
• Sabina Rashid (BRAC University)
• Henry Mwandumba (LSTM/MLW)
• Jeremiah Chakaya (LSTM)

Much of the discussion re-iterated the key points of the preceding days, but one audience member, a fellow senior LSTM academic, had noticed the absence of another key issue (other than the Emergency Care bee in my bonnet). This was the fact that in 2024 we are living through full awareness of genocide and therefore she rhetorically questioned whether LSTM and institutions like LSTM have a role in advocacy, support and dialogue in this regard. BRAC’s Sabina Rashid was quick to point out that there is no question about this depending on which country you are from: at BRAC there are no political qualms over open discussion within such institutions. It left me thinking that whilst it may seem that “science” is distant from such concepts as genocide, we absolutely do have a role. Just as in Tim Walsh’s AMR talk, which, at first glance looks so far removed, he reminded us starkly that if we genuinely care about global health, inequity and solving the world’s biggest health threats, then we simply cannot fall silent in the face of deliberate human destruction: at the very basic apolitical level, forgetting for a moment any humanitarian ethics, it undoes and reverses progress catastrophically.

Musings…