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Interview with Frank Cobelens, professor of Epidemiology and Control of Poverty-Related Infectious Diseases

Foto: Jeroen Oerlemans
Photo: Jeroen Oerlemans

Despite major advances in the field of medicine over the last 50 years, many people across the globe continue to have limited access to adequate healthcare. This fact has been compounded by the process of globalisation, which has not only seen infectious diseases spread more easily across borders, but has also led to a growing inequality in the area of healthcare.

To address these and other issues, the University of Amsterdam, together with a number of partners, created the Amsterdam Institute for Global Health (AIGHD) in 2009. This institute, which forms part of the UvA’s Global Health research priority area, brings together researchers from a wide spectrum of disciplines who work on making high-quality healthcare available in the developing world. Its primary aim is to provide sustainable solutions to major health problems by linking teaching and research to healthcare delivery.  

In this month’s edition of UvA in the Spotlight, we speak to Frank Cobelens, newly appointed chair of the AIGHD executive board and professor of Epidemiology and Control of Poverty-Related Infectious Diseases at the UvA. 

Your area of expertise is epidemiology and infectious diseases, particularly tuberculosis, which remains a killer in resource-poor settings. What are the major obstacles preventing a lasting reduction (or eradication) in the spread of this disease?

Our current approach to dealing with the disease has been successful in lowering mortality but not in preventing new cases. One of the major challenges to reducing new infections, primarily in developing countries, is the lack of access to adequate healthcare and early diagnostics. A large percentage of people who contract tuberculosis remain unaware of the fact until the symptoms become more pronounced. Unfortunately, by that time the disease – which is easily transmitted, especially in poor settings – has had enough time to spread further among the populace. As such, we need better tests that allow for early detection and diagnosis, as well as alternative means of preventative therapy.

A more lasting solution, of course, would be the development of a vaccine. The problem, however, is that as opposed to many other infectious diseases, TB leaves no lasting immunity, so classical concepts of vaccine development do not work. This means we actually have to ‘outsmart nature’ as it were. That said, the search for a new vaccine was recently given fresh impetus through the allocation of resources by the Bill and Melinda Gates Foundation. I’m hopeful that we well make major strides in the coming years. 

But does that mean TB and HIV can be eradicated? And If so, how far are we from making an end to these diseases?

Eradication of tuberculosis is possible, primarily because the disease cannot be reintroduced into the human population from animals. In principle, we also have an effective cure for the disease. It is within this framework that the World Health Organization last year set itself the target of eliminating TB as a health problem by 2050. Although this decision should be lauded, it might also be a bit ambitious. In the meanwhile, we need to ensure that we improve and speed up ways of identifying and treating new cases.

As opposed to TB, HIV/Aids does have an animal reservoir and can be potentially reintroduced into the human population. This difference notwithstanding, the global community (WHO, UNAIDS, etc.) strives for the elimination of both diseases. The main challenge here, as in TB, is to identify new infections at an early stage and ensure people receive effective treatment immediately after diagnosis.

However, whether both TB and HIV/Aids can be eliminated without an effective vaccine or large scale preventative treatment remains to be seen.

You were recently appointed as head of the Amsterdam Institute for Global Health and Development. What will be the most important long-term goal(s) of the institute going forward?

Our mission is to improve access to quality healthcare across the globe through research, education and policy. We want to achieve this objective by addressing the entire healthcare cycle, from development to delivery to evaluation. Our approach is based on the two pillars of research and education, which we implement in practical settings through collaborative projects with, among others, NGOs and our healthcare partners.

When the AIGHD was originally created back in 2009, its main focus was on communicable diseases such as TB and HIV. Throughout the years, however, the focus has shifted towards non-communicable diseases, which are becoming more prevalent in developing countries. These diseases, such as hypertension and diabetes, are partly attributable to the process of urbanisation and the effects of a sedentary lifestyle. Armed with the expertise and knowledge we’ve gained over the last 7 years, the AIGHD is ideally poised to make a valuable contribution in addressing these health concerns. This is why in the coming years we will expand our research and education capacity in such areas as antimicrobial resistance, improved access to healthcare, diagnostics and cardiovascular disease.

What has been the most important lessons the institute has learned over the past six years?

The most important perhaps is that healthcare provision, and the act of making it accessible in resource poor countries, is a process that requires a holistic approach. There are numerous examples of groups who saw their projects fail simply because they didn’t account of the many variables that influence whether an intervention is successful or not. For instance, take my earlier comment about the need for early diagnostic tests for TB. While this sounds easy, one also needs to take account of the entire situation on the ground before devising an intervention strategy. What happens, for example, when a father has to choose between using the little money he has to go to a clinic or rather to pay transport fees for his child to attend school? And are there cultural or social aspects that prevent him from seeking early treatment? How will his immediate neighbours react to the news? While all of this might seem obvious, such aspects are frequently overlooked yet require constant consideration.

In all our projects, from the development through to the implementation stage, we try to take account of all the different variables. That is why our research is multidisciplinary and includes medical professionals, but also epidemiologists, anthropologists and economists, to name but a few. A good example of the efficacy of this approach is our project ARISE, which is aimed at creating independent research capacity in partner countries such as Uganda. We do this by training researchers and ensuring that institutional capacity is strengthened. Our ultimate objective is hereby to help create research groups and institutes that can independently attract grants for health research relevance to the countries concerned.   

Has a multidisciplinary approach been lacking in traditional healthcare programmes in the developing world?

I think so. For too long, biomedical researchers have been talking to biomedical researchers, social scientists to social scientists, and economists to economists. This is something that needs to change, chiefly because each discipline brings something unique to the table. The challenge, of course, is finding a common language in which to coverse with one another. When a medical professional looks at an intervention strategy, she does so from her own unique perspective. The same goes for an economist, who sees a completely different picture altogether. And yet, these different viewpoints are exactly what one needs to devise a comprehensive approach to major questions such as healthcare delivery. That is why we actively foster a culture of interdisciplinary collaboration among our researchers.