Episode 5      18 min 07 sec
Malaria Resurgent

Professor Graham Brown discusses the resurgence of malaria, and the role of the Nossal Institute of Global Health in the war on malaria and other global health problems.

Guest: Professor Graham Brown, Foundation Director of the Nossal Institute of Global Health

Topic: Malaria Resurgent

"... probably, at least a million children die each year from Malaria " - Professor Graham Brown




           



Professor Graham Brown
Professor Graham Brown

Professor Graham Brown, Foundation Director of the Nossal Institute of Global Health. Professor Brown is also the James Stewart Professor of Medicine, and Head of the University!|s Department of Medicine at the Royal Melbourne Hospital and Western Hospital.

Credits

Host: Jacky Angus
Producers: Kelvin Param and Eric Van Bemmel
Audio Engineer: Miles Brown
Theme Music performed by Sergio Ercole. Mr Ercole is represented by the Musicians' Agency, Faculty of Music
Voiceover: Paul Richiardi
Photography: Kelvin Param

Series Creators: Eric Van Bemmel and Kelvin Param

Melbourne University Up Close is brought to you by the Marketing and Communications Division in association with Asia Institute, and the Melbourne Research Office.

 

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Malaria Resurgent

VOICEOVER
Welcome to Melbourne University Up Close, a fortnightly podcast of research, personalities, and cultural offerings of the University of Melbourne, Australia. Up Close is available on the web at upclose.unimelb.edu.au That!|s upclose.u-n-i-m-e-l-b.edu.au.

JACKY ANGUS
Hello and welcome to Melbourne University Upclose. I!|m Jacky Angus from the Research Office. Today I!|m talking to Professor Graham Brown. In September of this year Professor Brown was appointed as Foundation Director of an important new centre at the University of Melbourne, the Nossal Institute for Global Health, a University initiative to promote scientific research and improve public health at the global level. For Professor Graham Brown this means collaborating with a range of experts in quite different areas; areas such as engineering, architecture and law, as well as medicine. Previously based at the Walter and Eliza Hall Institute of Medical Research in Australia, he now holds the James Stewart Chair of Medicine at the University of Melbourne where he teaches students about infectious diseases. He!|s also on the staff of the Infectious Diseases Service at the Royal Melbourne Hospital, Victoria, Australia. His special interest is malaria and this has taken him to various tropical countries, in particular Papua New Guinea and Tanzania. Well good morning Professor Brown, welcome to Up Close.

PROFESSOR BROWN
Good morning Jacky.

JACKY ANGUS
Well global health sounds a big project. What are the main issues in health at the global level?

PROFESSOR BROWN
There are many, many issues Jacky, it!|s really hard to know where to start. We have many individuals in the University doing very fine work in international health, from very basic research such as developing vaccines for diseases like HIV and malaria, right through to applied research working in developing countries in educational programs, for example prevention of HIV or programs to treat helminth, that!|s worm infections. So we have so many people working, the University decided could we in fact do more. By having a group of individuals who focus on this activity with some new academic positions to make our contribution to global health in this way.

JACKY ANGUS
Well engineering, architecture, and the law, how will they actually help public health?

PROFESSOR BROWN
It was a good example in our recent symposium when [in] one session we decided to look at low cost technologies for health. And of course improvements in health are not just treatments by doctors, but it!|s to do with environmental sanitation, cleaner cities, cleaner air and of course cleaner water. And the engineers have some very interesting projects looking at water supplies, both in cities and at village level and of course there!|s a very strong interaction between clean water and good health. And we believe that we can work with engineers to have better outcomes. There have been some examples where water projects have had benefits but also they!|ve caused problems in health, for example they may make breeding sites for mosquitoes or if you have wells that become contaminated, things can be even worse. We!|ve taken a view that there!|s a holistic approach to health so it!|s to do with nutrition, it!|s to do with water, it!|s to do with lack of pollution, it!|s to do with education, it!|s to do with gender issues, so that all come together for improved health. And you probably know that throughout the world, where many people are very poor and some on borderline poverty, the most common reason for dropping below the poverty line is ill health and the cost of acquiring treatment for that health. In many situations this can tip people over from just coping to not coping at all.

JACKY ANGUS
You!|re listening to Melbourne University Up Close. I!|m Jacky Angus and I!|m talking to Professor Graham Brown, the director of the Nossal Institute for Global Health. Well Professor Brown you!|ve mentioned malaria, I gather that!|s a longstanding interest of yours. It!|s still a serious disease isn!|t it?

PROFESSOR BROWN
Yes, most certainly Jacky, probably, at least a million children die each year from malaria and of course it!|s a major problem in Africa and recent studies suggest that it!|s a very important project also in other parts of the world, with malaria returning to places like India and Sri Lanka. It!|s amazing to think that was very good control of malaria in some of these countries, but there!|s been a major resurgence. That!|s occurred for a number of reasons, partly because control programs have broken down, partly it was because there was great concern for the environment about use of insecticides such as DDT. I might say that the major problems with massive insectide use were related to agriculture, but because of the harmful effects on the environment they were ceased for human use as well. Then apart from the mosquito control breaking down, the malaria parasites themselves have become resistant to cheap easily available drugs and finally population movements. So there are many reasons why malaria has come back and it remains a very, very major problem.

JACKY ANGUS
But in the 1950s, they thought they!|d actually conquered the problem of malaria. There was talk of a vaccine.

PROFESSOR BROWN
Yes well first to go back to the thought in the 50s. Malaria was eradicated from parts of Europe for example, southern Europe or in our case at the north of Australia by the use of insecticides and also draining swamps where mosquitoes could breed. Those great successses led to supreme optimism that the same technology could lead to eradication of malaria elsewhere. But in places where malaria really had a strong hold in parts of Africa for example, it was possible to eradicate malaria from towns and cities but not able to eradicate it more generally particularly in rural areas.

JACKY ANGUS
So in fact there are more than one parasite and more than one type of malaria?

PROFESSOR BROWN
That!|s correct because malaria can affect animals, and malarias can infect humans and they may be different malarias but within human malarias there are four major species. There!|s the one that we!|re most worried about is so-called Falciparum Malaria, that!|s the one that!|s responsible for the serious cerebral malaria, and also for severe malaria during pregnancy. So that!|s the major problem. Another one called Plasmodium Vivax, this has a troublesome characteristic that can relapse months or years later but not as many deaths from Vivax or from the other ones. So Falciparum is a major problem, but Vivax certainly contributes to morbidity, perhaps, not so much to mortality.

JACKY ANGUS
And do people have an immunity after a while to malaria, and children presumably are more vulnerable than anyone else?

PROFESSOR BROWN
Babies who are born to mothers living in an area that!|s endemic for malaria, acquire some immunity from their mothers, so that it!|s not very common to have serious malaria say in the first six months of life. After that time, with constant challenge, the babies become susceptible and this can be manifest as very serious anaemia, very low blood cell counts or the more serious forms I!|ve mentioned such as cerebral malaria or affecting other organs of the body. However if a child survives in an endemic area say to the age of 3 or 4, the child then is relatively protected from malaria for the rest of their lives. They don!|t have complete projection in that you find the malaria parasites in their body, but they!|re not sick from it. So they have what we call a clinical immunity that protects them throughout their life. What!|s interesting is that they need to have repeated challenges to boost that immunity, so if for some reason they move to an area where there!|s no malaria or there!|s a very good control program, after some years people become susceptible again. Another group at particular risk is women during pregnancy, and particularly during the first pregnancy. So, girls who have acquired the same sort of immunity as the boys during childhood become susceptible during pregnancy.

JACKY ANGUS
Why is that exactly?

PROFESSOR BROWN
Well it!|s [a] most interesting fact that the malaria parasite after being injected by the mosquito first goes to the liver where it lasts for some time, then moves into the blood. And the little malaria parasites actually live inside the red blood cells, and then, when they!|re small, they don!|t really cause a great deal of harm, but as they mature over the 12 to 24 hours, they alter the red cells and they have the ability to stick in the circulation, so that in those young children they tend to stick in the spleen. And that causes children to have a large spleen, [which] can make them very sick. And, as I!|ve said, they normally acquire that immunity. But in pregnancy a placenta appears, and this is a new place where parasites can hide and multiply, and cause problems both for mother and for the baby. And it appears, in later pregnancies that women are then relatively protected. JACKY ANGUS So, in fact, you can!|t really give a pregnant woman any particular drug to help her to build up that immunity?

PROFESSOR BROWN
It!|s not quite true because it!|s not possible to give something that would give immunity, however there are people working towards a vaccine to prevent malaria in a pregnancy. Such a thing doesn!|t exist at the moment. However an important strategy would be to try to prevent malaraia infection during pregnancy and this can be done in various ways. So for example a non immune traveller whose pregnant, we would recommend that they don!|t travel to a malaria endemic area unless they need to. However other ways would be to give safe effective drugs to prevent infection during pregnancy and that can be done or alternatively give the mother an impregnated mosquito net so that she!|s not bitten by malaria but the single most important thing is to have available treatment so that should she become ill, she can be treated rapidly before this serious infection can hurt her or her baby.

JACKY ANGUS
So that!|s quite safe - is it - for the mother, the pregnant mother who then has an attack of malaria to take some sorts of drugs?

PROFESSOR BROWN
Well as in medicine every treatment has risks and benefits. malaria in pregnancy is a very serious disease and without treatment often it !V this leads to premature end to the pregnancy or as I!|ve said damage to the mother or to the baby. The drugs can have some side effects, but on the other hand the side effects of the drugs are far less than the potential downside of serious malaria in pregnancy.

JACKY ANGUS
One of the things obviously that!|s important in these countries where malarias are prevalent, is the knowledge of doctors. Now the medical profession in those countries !V how informed are they about malaria?

PROFESSOR BROWN
I think the level of knowledge is rather variable and of course in most parts of the world where malaria is a major problem there are very few doctors. So the most important approach is to develop understanding of people living in those areas, because often the person that an ill patient first turns to would be a traditional healer. And of course there are many traditional remedies. Part of the problem with malaria is that the symptoms are very non-specific, so fever, sweating, maybe chills and rigor, rather like we might have a respiratory infection or influenza. So it!|s hard to tell at the beginning whether it not it is malaria. However, the important things is to recognise that and obtain medications for it, and these in endemic countries these are available from the local shops. A major problem has occurred, however, and I mentioned previously the resurgence in Malara relates to the fact that some malaria has become resistant to those easily available drugs. And many people are now saying that we absolutely must get better drugs that are available and cheap and effective to be available at that village level. And perhaps more importantly is that we should have available combinations of drugs. If we can have effective combinations, this will prevent the resurgence of further resistance of the parasites to our available drugs. It!|s a major need.

JACKY ANGUS
You!|re listening to Melbourne University Up Close. I!|m Jacky Angus and I!|m talking Professor Graham Brown, Director of the Nossal Institute for Global Health. Well Professor Brown, you!|re talking about malaria as obviously a problem in particular parts in the world. Which are the worst areas infected by malaria?

PROFESSOR BROWN
Malaria occurs wherever the environment is right for those mosquitoes that carry malaria, but particularly tropical Africa, it!|s estimated at least a million people per year die from malaria in those regions. But in the south east Asian region as I!|ve said, countries such as with the resurgence in India, Sri Lanka and other countries of the region where malaria is a major problem, some countries have made major progress in controlling it, but where we work in Papua New Guinea for example, malaria remains a major problem and of course in South America it!|s also a problem.

JACKY ANGUS
Well you!|ve travelled I understand in some of these countries to !V in your work, in your research, particularly in Papua New Guinea and Tanzania. Can you tell us a bit more about your experiences in those countries?

PROFESSOR BROWN
Yes, well, I worked in Tanzania some years ago. I was teaching in the Faculty of Medicine and that!|s what sparked my interest in malaria, trying to understand the variable patterns of malaria. Why are some people protected and why are others completely susceptible. And this really made me wonder what can we, of the developed countries, do to try and help developing countries. It!|s that issue of knowledge not just in an ivory tower, but translating knowledge. And I think round the world there are many people with that same goal, of how do we transfer knowledge, and that!|s what led for example to the global efforts to try to develop a malaria vaccine. The reason being that we!|re developing technologies for !V for example vaccines to prevent human papilloma virus a fairly recent finding that came from Australia. So what about malaria, it!|s a huge challenge but many people around the world are trying to do that, and I think it requires all the knowledge that we have about basic science but also importantly understanding of the disease in the community as well. So we need !V need vaccines of which we have none although there are some prototype vaccines that are showing some efficacy, and of course, until we have vaccines we need drugs. And of course it!|s highly likely we!|ll need a combination of all these methods if we are to control this disease.

JACKY ANGUS
Have you ever found at the village level, perhaps in Tanzania, some resistance to these things. I!|m !V I!|m thinking of alternative medicine that had years and years of support and legitimacy in a village.

PROFESSOR BROWN
I think it!|s very important to recognise that we never tell people what to do. We work with communities from whom we learn, and we learn and work together. The traditional healers have been there a lot longer than outsiders and will be there a lot longer than we will. We also know that many of our best medications are actually derived from plant and traditional products. Some of the ones that we use, for example in my field of malaria, Artemisia or Wormwood has been known as a fever cure for centuries and it turns out that that!|s a very, very important source of the best available drug for cerebral malaria, so called Artemisinine derivatives. So I think it!|s important to always work with communities to gain understanding. Of course all societies are at risk of exploitation by people who wish to make money out of ill health. We see it in all societies throughout the world.

JACKY ANGUS
And does the Nossal Institute have connections with other institutions in the developing world?

PROFESSOR BROWN
Yes, we have people doing studies of malaria in pregnancy, for example, in Malawi; also interested in development of immunity from malaria in East Kenya. We have someone working with a program to prevent anaemia in Vietnam, through treatment of helminth infection. So we have many connections. And of course, the Australian International Health Institute, who has joined us as a partner in the Nossal Institute, has longstanding collaborations in India, through Avahan, the Bill and Melinda Gates Foundation supported program to prevent HIV, and many other programs in our region.

JACKY ANGUS
It certainly sounds an ambitious and worthy program. Thank you very much Professor Brown. All the best to the Institute.

PROFESSOR BROWN
Thank you very much Jacky.

JACKY ANGUS
Melbourne University Up Close is brought to you by the Marketing and Communications Division in association with Asia Institute, and the Melbourne Research office of the University of Melbourne, Australia. Our producers for this episode were Kelvin Param and Eric Van Bemmel. Audio engineering by Miles Brown, theme music performed by Sergio Ercole. Melbourne University Upclose is created by Eric Van Bemmel and Kelvin Param. I!|m Jackie Angus, till next time, thank you for joining us. Goodbye.

VOICEOVER
You!|ve been listening to Melbourne University Up Close, a fortnightly podcast of research, personalities and cultural offerings of the University of Melbourne, Australia. Up Close is available on the web at upclose.unimelb.edu.au, that!|s upclose.u-n-i-m-e-l-b.edu.au. Copyright 2006 University of Melbourne.


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