Disease knows no borders. In today’s interconnected world, diseases can spread from an isolated, rural village to any major city in as little as 36 hours. The U.S. Centers for Disease Control and Prevention (CDC) works 24/7 to protect Americans and save lives around the world by detecting and controlling outbreaks at their source. Critically, CDC helps other countries increase their ability to prevent, detect, and respond to health threats on their own. In the keynote address, Dr. Eric Dziuban will discuss how the U.S. Centers for Disease Control and Prevention uses innovation and research excellence to be a world-class organization. He will discuss the role of academic organisations in creating new knowledge, and will reflect on what it takes to become a world-class university.
Thank you for inviting me here today. I’m very honored to be invited to this event and asked to give this keynote address. You have an exciting line-up of presentations over the next few days, representing a wide range of challenging and fascinating research topics. I appreciate being a part of this.
I’m quite new to Namibia, having only arrived in Windhoek earlier this year, although I have been working in a number of different African countries prior to that. I have been fortunate to have gotten to see many parts of Namibia this year, both with my family and for work. I’ve been to 11 regions this year, with 2 more planned next month. I’ve learned so much from my time in Namibia so far and appreciate the warm welcome I’ve received from Namibians everywhere I go.
So let me start today by telling you a bit about CDC, or the U.S. Centers for Disease Control and Prevention, to use the full title. CDC is one of the major operating components of the Department of Health and Human Services within the United States Government.
Like all long-established organizations, we have our mission statement, our pledge to the people, our role. Today I want to talk about the role of CDC, and why it is relevant to NUST as you think about “building a world-class university through innovation and research excellence.” The stated role of CDC within the US is:
1. To detect and respond to new and emerging health threats;
2. To tackle the biggest health problems causing death and disability for Americans;
3. To put science and advanced technology into action to prevent disease;
4. To promote healthy and safe behaviors, communities and environment;
5. To develop leaders and training the public health workforce, including disease detectives; and
6. To take the health pulse of the American nation.
How do we achieve these six broad goals? I can think of a few main strategies that are relevant to my talk today. CDC achieves its role:
• By basing all public health decisions on the highest quality scientific data that is derived openly and objectively;
• By being on the cutting edge of health security – that is, confronting global disease threats through advanced computing and lab analysis of huge amounts of data to quickly find solutions; and
• By putting science into action – tracking disease and finding out what is making people sick and the most effective ways to prevent it.
To summarize, the work of CDC is built upon a cutting-edge scientific base, and CDC helps provide that base from which to create more cutting-edge science.
In my profession as a medical doctor, scientific innovations can literally be the difference between life and death. In other fields, there may not always be that clear distinction, but urgency for new knowledge and progress still exists. To quote the great American scientist Albert Einstein, “The world is a dangerous place to live; not because of the people who are evil, but because of the people who don’t do anything about it.” So many things exist today, not because there was specific reason to develop them, but because mankind asked the question “why?”; “how?”, and importantly, “what if?” To again quote Albert Einstein, “the important thing is not to stop questioning. Curiosity has its own reason for existing.” To be a world-class university, it is critical to never stop asking “why?”; “how?”, and “what if?”
Let me tell you more about why cutting edge science matters. CDC started in 1946. It was then known as the Communicable Disease Center and had the primary mission to stop the spread of malaria across America. CDC achieved this goal in just a few years — in 1949 America was declared free of malaria.
But CDC did not stop there. Instead, the organization broadened its scope of work to include other communicable diseases and to provide help to state health departments. It was through the use of innovation and research excellence that disease surveillance became the cornerstone of CDC’s mission of service to the states and over time changed the practice of public health. CDC is now recognized as America’s premiere health promotion, prevention, and preparedness agency.
Today, CDC works 24/7 to protect Americans and save lives around the world, by detecting and controlling outbreaks at their source. Critically, CDC also helps other countries increase their ability to prevent, detect, and respond to health threats on their own.
Indeed, since 2002, the CDC Namibia office has supported the Ministry of Health and Social Services in developing and implementing an integrated comprehensive package of HIV/AIDS prevention, care, and treatment programs. CDC Namibia is helping build the capacity of Namibia’s healthcare workforce and supports a comprehensive portfolio of HIV services in the national public health sector.
The funding for the CDC Namibia office comes from PEPFAR — the United States President’s Emergency Plan for AIDS Relief. PEPFAR is recognized widely for efficiently and effectively investing U.S. taxpayer dollars to save millions of lives and change the course of the HIV pandemic. Through implementation of a carefully designed strategy and use of data, PEPFAR is constantly innovating to generate greater efficiencies, drive down costs, and increase our impact. These efforts have made PEPFAR a model for development programs everywhere, with the ability to deliver clear, measurable, and transformative results. I’ll touch more on that later.
You will note that one of the key characteristics of how PEPFAR describes its work is how it uses data. Data is of course collected through research — whether as complicated as a national study or a randomized controlled trial, or as simple as the daily collection of patient information at a clinic. CDC Namibia supports the Ministry of Health and Social Services to use as much data as possible to build, maintain and strengthen the countries’ public health services. The Ministry of Health and Social Services uses program data on a daily basis to monitor the status of healthcare provision in the country. The Minister himself has dashboard access to the District Health Information System on his tablet and he can use this system to find out what the data says about a particular condition, or what is happening in a particular region. This program data is supplemented by national health surveys — the most recent example being the NAMPHIA survey.
The NAMPHIA survey is an excellent example of how data is being used to improve practice in Namibia. Through the information collected, the Ministry can assess where more HIV care services are needed; where more prevention services are needed; what age groups need changes to their public health HIV services. The NAMPHIA survey was very challenging to implement because it was outside the “comfort zone” of many participants. We are all used to the labor force survey, or the census, where we will be asked questions about our household. But NAMPHIA brought HIV testing to households as part of a survey and some people were uncomfortable with this. A critical discussion by the implementing team — all the way up to the Minister of Health — was how to gain sufficient, voluntary participation to ensure that the results from the survey were valid. This is because when it comes to research excellence, the validity of your data is of paramount important. To be a world-class institution, you have to keep asking those why, how, what if questions — and you need to get the answers accurately.
So how does CDC’s work in Namibia and around the world apply to the work in your university? Today I would like to present three points that I’ve learned from CDC and my experiences in health research that I believe can be applied in all fields.
The first is that all health research is now global health research. This is a different way of seeing the world than what dominated a generation ago, or even what I was taught ten years ago. I received formal training at four different research universities, all in the United States. First my bachelor’s degree in biomedical sciences; then a medical doctorate; then my pediatrics residency; and then even a diploma at the country’s largest academic hospital, in Houston, Texas. I learned about health issues by organ system, such as respiratory diseases in the lungs or neurologic disorders in the brain. I learned about health and disease by developmental stages, such as disorders in pregnancy, in childhood, and in aging adults. I learned about diseases by the most basic category of their pathology, such as inflammatory disorders, infectious diseases, malignant growths, metabolic imbalances, and others.
But the idea of “tropical medicine” was separate. That was the program I did in Texas: a Diploma in Tropical Medicine. What exactly does that mean? At the most basic level, it is focusing on the health conditions that are more common, and sometimes even exclusive, in tropical climates. In this course of study you can spend time learning the details of a disease like malaria that doesn’t occur in the United States or in Europe. And there are plenty of these infections, from viruses to bacteria to parasites, causing exotic illnesses with names like breakbone fever, Chinese liver fluke, or monkeypox. Terrible nutritional conditions are covered in tropical medicine as well, where lack of access to a certain vitamin in a person’s diet will cause specific, and usually awful, symptoms. Missing vitamin A will give you night blindness; a lack of vitamin B3 will cause cracked skin and psychotic episodes, children without vitamin D will have bones that grow crooked, and the list goes on.
But are these all really medical issues caused by being in the tropics: that is, living within a couple of thousand kilometers from the equator? No, not exactly. Tropical climates do not give you diseases in themselves. These are usually conditions of poverty, or lack of access to basic human needs. Malaria, perhaps the most famous of tropical diseases, used to be abundant in the Southern United States. As I have mentioned, that was the reason that CDC was established, and the reason our headquarters is down in Atlanta and not in Washington, DC with the rest of the federal government. A strong public health effort eliminated malaria from our mainland even though the climate was suitable for it. Likewise, the bacterium named Yersinia pestis, known as the plague, caused the Black Death that wiped out around a half of Europe’s population in the 1300s. But today you will find it thriving not throughout Europe, but rather in Madagascar and DRC, the two highest concentrations of the disease. Plague is not about the tropics, but about living in conditions where people and fleas and rodents are all sharing close space.
So if such diseases are driven by conditions of poverty, then we know that they are not limited to tropical latitudes. We see this in the language we use, as now we often talk about ‘international health’ or ‘global health’ instead of tropical medicine. But are even these terms meaningful in separating out medical or research topics? Even diseases that are limited in geography by a certain factor, like Ebola found in certain African ecosystems, near certain animal species that carry the virus, cannot be considered only a problem for those countries where the virus is found.
As the world learned vividly in 2014, in our interconnected world, any city, town, or village is only 36 hours or less from any other part of the globe. Ebola can jump from a village in Guinea to New York City. And it did. Drug resistant tuberculosis from India can arrive in London on an airplane. Even the mosquitoes that carry certain infections can find their way onto our planes and ships and end up in new parts of the world to spread diseases. This trade in pathogens has been occurring for as long as humans have been travelling the world. Europeans in the fifteenth and sixteenth centuries brought devastating outbreaks of measles and smallpox to North America and took syphilis back to Europe in return. And the more that humans both push into natural environments and connect our populations with roads, shipping lanes, and flight routes, the more we can expect to see this trend continue.
It’s not just infectious diseases, of course, and this is the other side of the coin for what I meant when I said all health research is now global health research. All of those other conditions we do not associate with the tropics or extreme poverty, such as Alzheimer’s disease or diabetes or depression or arthritis or asthma: these conditions cause great pain and suffering in all the countries of the world, regardless of climate. Longer lifespans, shared food production practices, and more environmental pollution all make this even more true. Of course, living conditions and main causes of death are not identical in every country, but they overlap a lot more now than they did fifty years ago. Thinking that obesity is a problem that only the West needs to face is just as ridiculous as thinking that only Africa needs to worry about Ebola. Tell me: in your own fields of research, are there similar barriers than need to be broken down? Are there assumptions that you are only answering questions relevant to this part of the world? What are the global questions that NUST is researching? To become a world-class institution you need to recognize how the questions you are researching can impact the countries around the globe — and importantly, tell the story of your research though peer-reviewed publications.
My second point to share is that health development now demands a focus on results. This is a point that I imagine you can all already relate to. With the ever-tightening budgets of both donor countries and recipients, foreign aid and health assistance must have a measurable impact in order to be justified. In the same way, your research is often scrutinized by the impact it will have on the field, on science, on the world. There is something romantic and motivating about pure science, about science for science’s sake: this idea that we seek to expand human knowledge as a goal for itself.
We have to keep asking those questions of why, how, what if. That can be a great internal motivator, but we often know that in order to secure the funding, the human resources, and the time to spend on research, our departments and funding organizations want to know what the real-world impact of the research is going to be. How will this change lives? How will this improve health, or the environment, or society, or industry? How will this be a good return on the investment that is made?
Fortunately, getting results from science-based investments is something in which Namibia has already shown clear leadership.
I told you about PEPFAR and its goals for HIV epidemic control in many countries around the world, especially in Africa. This is by far the program that our staff in the CDC Namibia office spend most of their time working on. There is a good reason for this: the HIV epidemic hit Namibia incredibly hard and has had devastating impacts on the country. Namibia has had one of the six highest prevalences of HIV in the world. Even today, in places like Zambezi region, over 22% of all adults are HIV-infected. Fifteen years ago, having so much HIV in the country also meant vast amounts of suffering and death. I hear stories from Namibians of those days, when every weekend included multiple funerals, and sometimes funerals had to be held during the week because there just wasn’t time for them all. When the hospitals were overcrowded with people suffering the late stages of AIDS and there was little to be done to help them. When casket-building seemed to be the most thriving business in the village.
PEPFAR is not a research program in the strictest sense; it is focused on service delivery. We support the Ministry of Health and Social Services in efforts to prevent new HIV infections and give life-saving treatment for those already infected. But it involves immense amounts of data collection, to guide the programmatic work and deliver best results. Surveillance is performed, quality improvement processes produce standard-of-care data, outcome evaluations identify effectiveness of interventions. This is research too. And I can happily tell you from this stage that Namibia’s results are quantifiably the best in Africa and are a model for the entire world in HIV epidemic control.
As of the end of 2017, when we concluded the NAMPHIA survey, 86% of all Namibians infected with HIV had been tested and knew their status. Of those, 96% were on effective medical treatment, and of those 91% were in viral suppression, basically meaning that the virus was subdued and could not harm their bodies or be transmitted to other people for as long as they properly continued their medications. These are results that my colleagues in CDC offices throughout Africa dream of. They are significantly better than South Africa, or even the United States.
How did it happen? I could spend a whole day describing Namibia’s models of success, from strong political leadership, to locally driven partnerships, to careful data collection that allows resources to go to the exact places they are most needed, and so on. But the point of bringing this up today is to say that results didn’t start in Washington, or London, or even Pretoria, and trickle into Namibia. This country has led the response. This country has illuminated a path that other countries can follow to get similar results.
What is being done in your field of research right now that can be the next example of Namibia showing the rest of the world how to solve a problem? Are you ready to stand in front of the crowd and light the way for others?
Now in a discussion about research that demands results, I do feel like I need to raise two cautions. The first is about the danger of shortcuts. Research ethics have evolved over the decades, and often in response to terrible examples of the wrong way to do things. The idea of research ethics refers to a way of treating participants in a manner that explains to them what the research activity involves, and ensures their participation is voluntary. Participants choose to be part of research. This may involve benefit for themselves or others in their community, region or country. It is the duty of researchers to ensure that participants understand what it means to be part of research and give informed consent.
Researchers have not always behaved with the ethics standards we now apply. There are numerous instances throughout history where research activities occurred where participants did not choose to join and where they did not have a clear understanding of what was happening to them or information withheld from them during the research. The clear message of history is that research that tries to rush to results and bypass ethical processes will do no good and will expose the participants, the researchers, and the wider community to a lot of harm. A fundamental pillar of research excellence is absolute adherence to the ethical principles of research, without it, there is no possibility of excellence.
My other caution is to not be discouraged when you, individually, do not get to see the results of the research you produce. Creating meaningful results and experiencing them firsthand are not the same thing. There is a good chance that as researchers at NUST, you often do not get to see the way your research impacts the world more broadly. The same can be said for the global or national work in program management and policy guidance that CDC Namibia engages in. Once upon a time, I had a different role where I was privileged to experience firsthand the dramatic impact that researchers like you were having. As an HIV doctor for children in Swaziland, I saw some heartbreaking cases. Suffering children with little or no hope of better lives, some of whom I had to watch be buried in their family homesteads. But while I was there, new treatment options became available because of careful and lengthy research performed by scientists in laboratories, and data analysts at their computer screens. Watching children get miraculously healthier on a new medication was a true joy, and it was because of the research work done thousands of miles away, by careful scientists like you.
My final main point to share is that our sectors are stronger together. Universities. Government. NGOs. Private businesses. Local organizations, advocates, multilateral groups like the United Nations and their agencies. We all have our own roles, our own strengths, and if we’re honest, our own agendas. But are those roles incompatible? Are those strengths the same? Do those agendas need to be pitted against each other? My answer for all of these, of course, is no. Different sectors can bring their unique strengths into partnership for the places where our missions are all aligned; the common ground that drives us. Perhaps there is no better example of this than research, where the expertise of the university, the investment of the private business, the community reach of the local civil society organizations, and the government’s charge to protect the public good can all come together to create something new that advances society.
You may remember that at the end of 2015, scary reports were coming from Brazil of large numbers of babies being born with a certain birth defect, causing their heads to be far too small at the time of birth. This was happening at the same time as a rare virus was first being detected in that part of the world, called Zika. Now over the years that followed, including right up until today, a lot of research took place on Zika virus and trying to understand its effects on babies and other people, and much of that research was through the partnerships between different sectors that I just described. But I bring up this virus to tell a story at the more basic, human level. During the very first days of the world realizing what was happening in Brazil, and as it turned out, had already spread to a number of other countries, I was working at CDC headquarters and was part of a very small group at CDC working on the problem of this infection in pregnant women and infants. In an incredibly short amount of time we needed to develop clinical guidance for what should be done for the babies with congenital Zika, which means those born with the effects of this virus.
CDC helps create clinical guidelines all of the time, but typically that is for a disease or condition that we have known about for a long time, and we are seeking new evidence from the research to determine if updated guidelines are recommended. But this was something entirely different. This was a brand new condition that the world had never recognized before. And we were creating brand new clinical guidance where none had existed. The evidence base did not yet exist, and the trials and studies would still be months and years away. But in the meantime, these children were being born with a lot of special needs and providers had nothing to turn to in order to say what services, what testing, what therapies were recommended. It was our job to get something out to them immediately.
You may be able to guess that I’ll say we relied on partnerships to create that guidance, and this is true. But it’s more than that. Because of my work at that time in children’s needs during public health emergencies, I had strong contacts based in university medical centers across the U.S. Much of this was coordinated through the American Academy of Pediatrics, a private group that shares many of the same interests as CDC in helping keep children healthy and safe. I called on some of those colleagues one public holiday weekend, and in less than a day we had a group of experts assembled and focusing on best guidance for these babies based on what we knew from similar conditions. Not a single person complained about being bothered with this during the holiday. And a week later, the guidance was published.
But my point is that those relationships were not developed to address congenital Zika, because nobody even knew that this disease existed at the time. Instead, those partnerships had already been created due to a broader shared vision, and I was able to immediately call on those partners when a new need arose. Without the rapid availability of that broad expertise, many more babies might have suffered without the appropriate care.
So I turn it to you: what partnerships outside the university should you be developing now, not in response to your existing problems but in preparations for the problems that are still to come? You have unique value to add, and you are building the research excellence of NUST, but are there partners in other sectors who can help you get that value to a new audience, to a broader distribution, to a higher level of achievement? It may help you more than you realize. In April of this year, it was reported that infants were being born with congenital Zika in Angola as well, some quite close to the Namibian border. Now I am here at CDC Namibia, and I would have never guessed that I would be glad to have those partnerships from the Zika guidance available to help in this country also, as our office stands ready to help protect Namibian from this possible threat.
I hope that sharing these ideas here today can help inspire some new ideas in your own research efforts today. Your work is more global than it ever was before. The world is demanding results from the research that takes place in a world-class university, and while there are no shortcuts to those results, your focus on the value your work can add to the field will put you in the right direction. That doesn’t mean you need to do it alone though, and seeking partnerships even outside your university may be the new opening that you needed for your next breakthrough. As we launch three days of celebrating the excellent research accomplishments of NUST, be confident that knowing what your university is uniquely positioned to accomplish will allow you to add value to the network of partners around you. And whether you ever get the privilege to see it firsthand, know that excellent research doesn’t just expand knowledge; it changes the world.