Dr. Greenwood-Lecture at Fukushima.


Professor Brian Greenwood
Department of Infectious and Tropical Diseases,
London School of Hygiene and Tropical Medicine, London, UK.


I first learnt about the career of Dr. Hideyo Noguchi[SLIDE 2](PDF:301KB)when I was a medical student at Cambridge University in England 50 years ago. I have always been interested in infectious disease so it is not surprising that I came across his name in my student days as Dr.Noguchi ranks among the most famous microbiologists of the first part of the twentieth century. However, I never imagined that I would have the opportunity to visit some of the places where he lived and worked and I am very grateful to the many people who have made this possible. I am, of course, equally grateful to the Government and people of Japan for having awarded me a prestigious prize named in his honour and for supporting my visit.
 Dr Noguchi was concerned about the health of those who lived in the poorest parts of the world and he made several visits to what we now call developing countries, including his final visit to West Africa to study the causes of yellow fever. He appreciated clearly that the problems of the developing world, including Africa, could not be overcome without research and he devoted his life to this cause. In this lecture, I will try to reinforce this message.


Most of you will not have had a chance to visit Africa so I will start my talk with a few general words about the continent, in particular the part of Africa that lies to the south of the Sahara[SLIDE 3](PDF:99KB). Sub-Saharan Africa is large, approximately 4,000 miles across and with a surface area about 50 times that of Japan. The population of about 600 million is increasing at a rate of 2- 3% per year. Sub-Saharan Africa is enormously diverse, both geographically and in its people, so that in many ways considering sub-Saharan Africa as an entity is misleading. Its geographical diversity extends from dense, tropical rain forests[SLIDE 4](PDF:64KB)to near desert[SLIDE 5](PDF:90KB), and from snow covered mountains[SLIDE 6](PDF:80KB)to mangrove fringed tropical coasts[SLIDE 7](PDF:34KB)and I have been fortunate in having had an opportunity to work in all of these areas at some stage of my career. The geographical diversity of sub-Saharan Africa is matched by its people who belong to numerous ethnic groups and speak over 2,000 distinct languages; Nigeria alone has nearly 200 distinct languages. This geographical and ethnographical diversity is an important factor that must be taken into account when solutions to health problems are considered - problems in one area may require a completely different solution from those appropriate for another.


Despite their geographical and ethnic diversity, the countries of sub-Saharan Africa are, with few exceptions, united in one respect in being among the poorest in the world.
Approximately 75% of the countries of sub-Saharan Africa have an average income of less than $1,000 per person per year and few spend more than $5 per person per year on health. Thus, it is not surprising that sub-Saharan Africa has the worst health statistics of any of WHO's regions. This applies to almost every aspect of health. Child mortality rates in most sub-Saharan countries are among the highest in the world, as shown in[SLIDE 8](PDF:13KB), and infectious diseases such as pneumonia, diarrhoea and malaria, conditions that can be prevented by vaccination or readily treated with simple medications, are still the main causes of death in African children as shown in the next slide[SLIDE 9](PDF:13KB).
Statistics on maternal mortality show a similar, depressing picture with countries in sub-Saharan Africa having the highest maternal mortality rates in the world[SLIDE 10](PDF:13KB). In some parts of sub-Saharan Africa, one in twenty women die during childbirth. In recent years, the health problems of sub-Saharan Africa have been aggravated by the advent of the AIDS epidemic and Africa is the continent worst affected by the HIV epidemic; the 10 countries with the highest incidence of HIV are all in Africa[SLIDE 11](PDF:13KB). However, HIV is a striking example of the diversity found within sub-Saharan Africa. The HIV epidemic is concentrated in the southern and south-eastern part of the continent where prevalence figures as high as 30% of the whole population are found. In contrast, in most of the countries of the Sahelian and sub-Sahelian regions, such as Senegal and The Gambia, the prevalence of HIV is in the region 1 - 2% and has shown little change during the past few years.


Why are the health statistics of sub-Saharan Africa worse than those of any other region of the world? The causes are complex, interacting and difficult to unravel. As in all parts of the world, there are strong interactions between economic development, education and health[SLIDE 12](PDF:11KB)and it is not possible to dissect out the causes of Africa's health problems without also considering economic development and education, areas in which sub-Saharan Africa has also fallen behind other parts of the world.
  There are, however, some important biological factors that contribute to the poor health of sub-Saharan Africa[SLIDE 13](PDF:69KB), for example the presence in Africa of the most effective vector of malaria in the world Anopheles gambiae  and of tsetse flies, the vector of sleeping sickness, which are found only on the African continent. However, I have little doubt that even these conditions could be overcome if education and economic development were dramatically improved and political stability assured.


I have presented a rather gloomy picture of health in Africa but this is only one side of the picture and there are other positive features to report. When I first started work in The Gambia in 1980, almost 300 out of every 1,000 Gambian newborns died before reaching the age of five years as shown in[SLIDE 14](PDF:14KB). This figure has now fallen by a half and similar changes have occurred in many other countries in Africa - a major achievement. Similarly, with international support through the Global Alliance on Vaccination and Immunization (GAVI), over 70% of children in sub-Saharan Africa now receive their full course of routine infant immunisations and an increasing number are receiving newer vaccines such as the one which provides protection against Haemophilus influenzae type b (Hib), an important cause of pneumonia as well as meningitis in African children. The impact of an improved immunisation programme on deaths from measles has been marked as shown in the next slide[SLIDE 15](PDF:14KB). Malaria control is improving through the provision of more effective treatment and scaling up of the distribution of insecticide treated nets and approximately 1.5 million AIDS patients are now receiving anti-retroviral treatment. However, much more needs to be done before African health statistics can match those of the rest of the developing world.


Some of the steps that could be taken to improve the health of the population of sub-Saharan Africa are summarised in the next slide[SLIDE 16](PDF:13KB). The impetus for these changes must come from within a country and cannot be imposed from outside, although outside agencies may be able to help if a determined start has been made. Steps that could be taken include -

  •  Persuading governments to spend a larger proportion of their national budget on health.
     The target set by the international community is about 10% but spending on health by
     nearly all countries in sub-Saharan Africa is far below this figure, even though the
     economies of many are improving rapidly.
  •  Supporting staff working in the health sector so that they do not leave to work in a
     financially more lucrative job outside the health sector or even outside the country where
     they were trained. There has been a huge movement of doctors and nurses from Africa
     to Europe and the USA, it is estimated that at least a half of the doctors trained recently
     in Ghana have left the country to work elsewhere. Imaginative ways need to be found of
     improving the conditions of staff working in the health sector without damaging the overall national salary structure.
  •  Improving the facilities and equipment needed for health staff to do their job effectively.
     International donors can help in this way, JICA has a good record in this area, but provision
     of buildings and equipment must be accompanied with long term funding that will allow them
     to be properly maintained.
  •  Supporting research to ensure that the limited funds available for health are used to
     maximum effect.



 It might be thought that the health problems of Africa are so obvious that all that is needed is a major investment - both from within country and, when necessary, from outside donors - in the tools that are known to work, such vaccination, insecticide treated bednets and anti-retrovirals and that investment in research is an expensive and unnecessary luxury. I think that this is a dangerous approach and I will give three examples from my own experience in which simple and inexpensive research projects have led to substantial, cost effective gains in health.
 My first example relates to the time when I worked at Ahmadu Bello University, Zaria in northern Nigeria[SLIDE 17](PDF:299KB). In this part of Africa, meningitis, caused by the bacterium Neisseria meningitidis [SLIDE 18](PDF:42KB), is a common problem causing major epidemics, sometimes involving tens of thousands of patients, every few years. Untreated this disease is nearly always fatal. Thus, the introduction of treatment with sulphonamides in the 1940s and 1950s, which reduced mortality from nearly 100% to about 10%, was a dramatic event and the drug used, M and B 693, was attributed with almost miraculous properties by the local population. However, shortly after my arrival in Zaria, my colleagues and I showed, using some simple laboratory tests, that the bacterium causing this form of meningitis had become resistant to sulphonamides which could no longer achieve a cure and that an alternative antibiotic was needed. In spite of substantial resistance from the population and press, the health authorities, backed up by the Military Governor of the state who appeared on television to support our case, agreed to the replacement of sulphonamides with penicillin, and subsequently with an oily preparation of chloramphenicol which could be given as a single injection. Thus, the results of a simple piece of research led to the sparing of many lives.
 Malaria provides another example of the potential benefits of simple, community based research in improving the health of the people of Africa. Bednets (mosquito nets) have been used for hundreds of years to protect against the discomfort of being bitten by mosquitoes when in bed at night but it is only relatively recently that their potential as a malaria control tool has been fully appreciated. Bednets have, in the past, been little used in sub-Saharan Africa. When, I worked in villages in northern Nigeria in the 1970s[SLIDE 19](PDF:68KB)I rarely saw a net in use. Thus, I was surprised when I moved to The Gambia in 1980 to see nets, often quite elaborate ones, as shown in the next slide[SLIDE 20](PDF:34KB), used widely, even in poor rural communities, and to learn that nets had been used extensively in The Gambia for at least 100 years. This observation encouraged me and my colleagues to embark on a series of simple field studies to investigate how effective bedets might be in preventing malaria. Our initial studies with straightforward nets showed that they had some effect but their impact was greatly increased when they were treated with an insecticide, becoming an insecticide-treated bednet or ITN. Initially, nets had to be dipped in insecticide every 3 - 6 months to remain effective[SLIDE 21](PDF:44KB)but the need for this procedure, which was difficult to sustain, has now been overcome by incorporating the insecticide into the fibre of the net to create a long lasting net (an LLIN)[SLIDE 22](PDF:172KB)which is effective for the life of the net, usually about five years. The Japanese firm Sumitomo has taken a leading role in this area and recently opened a factory to produce LLINs on a large scale in Tanzania and I believe that another factory is planned for Nigeria. LLINs have now become one of the main tools for controlling malaria across sub-Saharan Africa.
 The final example of the value of field research in Africa that comes my own experience concerns childhood pneumonia. When I first arrived to work in The Gambia in 1980, it was assumed that the main causes of childhood death in The Gambia, and throughout sub-Saharan Africa, were malaria and diarrhoea, and pneumonia was rarely mentioned. However, when we investigated the causes of childhood deaths in The Gambia, using the simple verbal autopsy technique in which the family of a child who has died is asked about the conditions that led up to the death of the child[SLIDE 23](PDF:50KB)we found, to our surprise, that pneumonia was the most important cause of childhood death., followed by malaria and diarrhoea, as shown in the next slide[SLIDE 24](PDF:23KB). Similar studies undertaken subsequently across sub-Saharan Africa have confirmed this finding. This simple piece of work led to a whole new research programme on pneumonia in children in The Gambia that has contributed to the development of new vaccines against the bacteria that cause pneumonia and which continues until today. Even though pneumonia kills more African children than malaria, it is still a forgotten disease and needs much more attention from the international health community than is currently the case.
 In the examples above, I have focussed on examples of what is often called 'applied' or 'field' research. This does not mean that I believe that African scientists should not be involved in more fundamental and laboratory based research and this is now happening in the increasing number of well equipped laboratories that have been established in African countries[SLIDE 25](PDF:89KB). Undertaking basic health research is fundamental to establishing the creative scientific environment from which innovative ways of tackling major health problems will emerge.


The health problems of Africa are understood best by Africans and research in Africa should be done whenever possible by Africans in African institutions. Unfortunately, in recent years, very few African research universities have had the money to support active research programmes and much of the best health related research has come from research institutes[SLIDE 26](PDF:137KB)such as the MRC laboratories in The Gambia, where I worked for 15 years, and the KEMRI Laboratories at Kilifi in Kenya which receive substantial support from international donors but which have only limited links to a university. An exception to this lack of connections with a university is the Noguchi Memorial Institute of Research in Ghana, which I have visited on many occasions, which is generously supported by the Japanese Government through JICA. These laboratories are situated on the campus of the University of Ghana at Accra and have good links with the university. Medical research in African universities needs to be strengthened and there are some moves in this direction, for example a new initiative for African university research capacity strengthening launched by the UK's Wellcome Trust, but much more needs to be done in this area.

During the past few years there has been generous support from the major international donors for the control of infections such as HIV, malaria and tuberculosis. Much of this money has, correctly, gone on the purchase of commodities such as antimalarials, anti-retroviral drugs and bednets and little has been invested in training the scientists and programme officers needed to plan these control programmes effectively and to monitor their impact. Some small steps in this direction have been taken and during the past seven years I have been responsible for co-ordinating a malaria capacity development programme, the Gates Malaria Partnership[SLIDE 27](PDF:149KB), supported generously by the Bill and Melinda Gates Foundation, which has now trained nearly 30 African scientists to a PhD level in applied malaria research. Many more such programmes in a broad range of medical fields are needed.
 I am often asked whether, as more African scientists are trained, there is still a role for expatriate scientists, such as those who might come from Japan, to help in tackling the health problems of Africa. The answer is yes and some of the ways in which expatriates can contribute are shown in the next slide[SLIDE 28](PDF:72KB). These include -

  • Participating in research consortia such as the large vaccine programmes.
  • Participating in an exchange programme for students or research fellows.
  • Working for a non-governmental organisations such as Medecins sans Frontiere, which will
    often provide experience of working in an emergency or refugee situation.
  • Seeking a staff position with one of international organisations working in Africa that
    operates an open recruitment policy with appointments being based on skills and experience
    rather than place of birth.



In this talk I have I have highlighted the health problems currently facing countries of the sub-Saharan Africa and I have provided some suggestions as to how some of these might be addressed including increased support for African institutions and African scientists undertaking research relevant to the health problems of Africa today[SLIDE 29](PDF:43KB).I am sure that this is a conclusion with which Dr. Noguchi would have concurred.


[SLIDE 30](PDF:174KB)