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October 24, 2003

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Discovering New Ways to Save Lives

Once inside, it's an altogether different world. Spacious tables on which lie complex-looking, unfamiliar machinery and rows of neatly arranged slender--bodied tubes of different sizes containing different-coloured liquids fill the room. The apron-clad, sharp looking young scientists sitting or standing across the tables are absorbed in their work. The only sound that breaks the reigning calmness of the surroundings is the crisp clicking sound coming off the computer buttons. Inside laboratories of The International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), this is the usual picture all year round. The state-of-the-art equipment which is comparable to the most sophisticated laboratories in advanced countries and the talented young scientists, from mainly home and also from abroad, led by world renowned names in their respective fields, have made the research units of the ICDDR,B a “Centre of Excellence”. Such effusive praise is the result of the Centre's scientific achievements in diarrhoeal diseases, nutrition, infectious diseases, population programmes and child survival strategies.

Shamim Ahsan Khan

Not long ago, the discovery of ICDDR,B's Oral Rehydration Therapy (ORT) won the enviable distinction of being described as the most important medical advance of the 20th century by the British journal, The Lancet. The cost-effective, easy to prepare and easily applicable (as it can be swallowed), oral saline, has proved to be one of the biggest life savers by cutting down 3 million diarrhoeal deaths a year across the globe. This remarkable discovery also brought the first ever 'Gates Award for Global Health' for the Centre in May 2001.

Established with the vision of serving “all people, especially the poor”, and to make sure that “people can become healthier and can reach their full potential through the application of new knowledge” ICDDR,B has been relentlessly working to realise its aim since it came into being.

Mohammad Abdus Salam, Associate Director and Head, Clinical Sciences Division, who has been associated with ICDDR,B for the last 14 years, talks about the general pattern of research activities they undertake. Every research involves a well organised network among the centre's hospital, the laboratory and the community. When a particular research is underway, thorough investigation and necessary information are gathered from the hospital as well as from the community. The next step is to pass on the study to the laboratory to find out the remedy, which then is applied to the patients both in the hospital and the community. Sometimes a particular remedy works very well with patients staying in the hospital, but don't yield the same level of satisfactory results when applied in the community. Because of the special condition in the hospital where a patient is under close scrutiny, is forced to strictly follow prescription and is in complete rest, he is more likely to respond to that remedy quickly and effectively. “But these conditions,” Salam explains, “are often non-existent when a patient is at home, so, the effect of the same remedy might differ to a great degree. In the third step thus we try that in the community.”

This is not the end of the story. A particular vaccine doesn't remain effective for years on end. After a certain period the bacteria develops immunity against that vaccine and makes it ineffective. “So we have to always work on for developing newer vaccines as replacements. But this is possible only when there is a continuous flow of statistics and data so that our researchers can work accordingly,” says Salam.

Foreign and local scientists work together at the ICDDR,B, creating a unique opportunity to share knowledge and expertise that ultimately benefit countries all over the globe.

This world-famous research centre had a humble beginning when it kicked off as the Cholera Research Laboratory way back in 1960. In 1978 the institution assumed its international status when it was renamed as The International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) : Centre for Health and Population Research. It was literally a new beginning with a broader range of research programmes. It broadened the circumference of its research areas by including virtually all the major health related problems that affect Bangladesh as well as many other third world countries. Diseases that have been traditionally plaguing the large poor populace of the country include diarrhoea, cholera, measles, influenza, tuberculosis, malnutrition, high child mortality rate as well as the upcoming ones like AIDS or the re-emerging dengue.

Although its prime task has always been research, ICDDR,B has been also providing health care to thousands of patients at nominal cost. Since 1978, the Centre has shared its knowledge and techniques by training more than 20,000 health professionals from over 78 countries of the world. It has arranged various courses and practical training in hospital management of diarrhoeal diseases, epidemiology, biostatistics, family planning, demographic surveillance, child survival strategies, etc.

The different activities of the Centre are conducted through six different divisions : Clinical Sciences Division (CSD), Public Health Sciences Division (PHSD), Laboratory Sciences Division (LSD), Health Systems and Infectious Diseases Division (HSID), Information Sciences Division (ISD), and Director's Division (DD).

The Clinical Services Division operates the Dhaka Hospital of the Centre that is providing treatment to around 110,000 patients each year (about 60% of them are children under five) with uncomplicated- and complicated diarrhoeal diseases, and associated health problems including malnutrition and pneumonia. The hospital also adopts preventive measures through immunisation of children and women, education of mothers on prevention and basic tips on how to deal with diarrhoeal diseases and malnutrition at home or counseling mothers on the merits of exclusive breastfeeding.

The Public Health Services Division evaluates and tests community-based interventions to improve general health of people, particularly of the poor.

The Matlab field site, operated by PHSD, has a small hospital, but, most importantly, Matlab is the only place in Bangladesh with a Health and Demographic Surveillance System (HDSS) that has been running for about 40 years covering a population of over 200,000. The other field site is in Chakaria, a remote rural area in the southeast coast of the Bay of Bengal.

Laboratory based research is another strong area of ICDDR,B. The Laborotary Sciences Division (LSD) has several state-of-the-art laboratories including laboratories for Enteric and Respiratory Microbiology, Environmental Microbiology, Immunology, Molecular Genetics, Nutritional Biochemistry, Parasitology, Reproductive Tract Microbiology, Tuberculosis, Virology and Clinical Diagnostic laboratories. LSD has also taken up activities on HIV surveillance, voluntary counselling and testing and other research projects for investigating the dynamics of a possible HIV epidemic. The mandate of the Division is to apply high quality science to alleviate diseases.

Over the years ICDDR,B's list of achievements has grown quite long. Infact, too long to list all of them. Here goes some of the major ones--

The Matlab Health and Demographic Surveillance System of ICDDR,B is the oldest longitudinal demographic surveillance system in the developing world. The Matlab rural intervention for vaccine trials yielded important findings on the effectiveness of injectable and oral cholera vaccines.

The Centre developed an Epidemic Control Preparedness Programme (ECPP) for rapid response to the outbreak of cholera and Shigella epidemics in emergency settings with teams sent to Goma, Zaire, in 1994 and Peruin in 1991

Family planning strategies developed at the Centre have been adopted nationally that led to Bangladesh's recognition at the Cairo Conference in 1994 as a family planning success story.

Though ICDDR, B is mainly a research centre it also provides treatment to thousands of mainly poor patients every year.

The Centre participated in development of the oral vaccines for cholera and enterotoxigenic E. coli (ETEC), including basic immunological work needed to design the vaccines. The oral cholera vaccine tested by the Centre is now recommended by the World Health Organisation.

Demonstrated the remarkable benefits for immunising women during reproductive age against tetanus and S. pneumoniae.

A comprehensive programme has been developed for studies of rotavirus, cholera and ETEC vaccines, including field, laboratory and epidemiological aspects and project management resources.

Children's health has always received special attention from ICDDR,B and it has some notable achievements in this area. A recent World Health Organisation (WHO) study identifies several childhood illnesses as the primary causes of mortality and morbidity in children between the ages of 0 and 5 years in developing countries including Bangladesh. While almost 19% of the child mortality in this age group is associated with diarrhoeal diseases, malnutrition is another critical component that affects 55% of the children in this age group and vaccine preventable diseases, such as measles and polio that claim a significant number of lives.

Mohammad Abdus Salaam, Associate Director and Head, Clinic Services Division.

Child health, however, is a somewhat complicated issue as it has interlinks with nutrition, infectious diseases, vaccines, reproductive health and the overall health system. As long as the associated areas don't improve it is hard to achieve any notable success, Salam points out. He then refers to the integrated family planning and child health programmes that resulted in a 75% reduction (in 2001) in the number of infant deaths in the Matlab field area since 1978 when the programmes started.

At present, ICDDR,B's greatest concern, as far as child health development is concerned, is neonatal deaths. Neonatal deaths which means death of a child in the first weeks of its birth, continues to keep the child mortality rate very high across the country. “While ICDDR,B's community based intervention has seen a substantial fall in the overall rate of infant deaths we are yet to make any remarkable progress regarding neonatal deaths,” Salam admits. He however reveals the centre's plan to go for an extensive awareness campaign because most infant death are due to early infections. Mothers and the community in general have a major role to play.

The centre always attaches great importance to cost-effective and locally-applicable solutions when it works on the prevention strategies and interventions. Thus the main focus of its research is on developing prevention strategies for pneumonia and other common childhood infections while providing immunisation to save the children from a number of fatal diseases. Salam here mentions how polio and measles was checked through immunisation while Qadri refers to the discovery by the Environmental Microbiology Laboratory last year where a very cost-effective and easily applicable cholera preventing device was invented. All one has to do is to use a 8-fold sari as a filtering device to purify surface water that are extensively used and when applied in 65 villages in the Matlab Health and Demographic Surveillance System area, it yielded a surprising 48% reduction in cholera cases.

Bangladesh has long been considered the prime example of an overwhelming population explosion that was virtually unsolvable because of people's reluctance to accept or even discuss the use of contraceptives. The research and extension programmes at ICDDR,B have shown that the high rate of fertility is a problem, but is one that can be solved. Family planning is another area where ICDDR,B has mentionable accomplishment. Since 1978, the Centre developed its reputation as a field site and an operation research site for family planning and reproductive health activities. The Centre has conducted pioneering research in areas of population dynamics and family planning, maintaining longitudinal data on a population in Matlab that exceeds 210,000 , raising the contraceptive use rate among women of reproductive age in Bangladesh etc. Results are also inspiring -- increased contraceptive use has resulted in a 50% reduction in fertility in the Matlab field area.

Firdausi Qadri (left) senior scientist, Laboratory Sciences Division with a foreign researcher.

In Bangladesh, over 60% of the children aged less than 5 years suffer from second or third degree malnutrition and is still a major cause of mortality in Bangladesh. Treatment and prevention of malnutrition are key to the Centre's child survival strategies, and are critical for maternal health, and in the treatment of most medical problems with which the Centre deals.

Certain areas of the world such as the Ganges Delta, are
efficient incubators of disease-causing agents because of population density, susceptible populations, and ecological factors. Present-day communications and travel make it possible for bacteria and viruses infections to spread very quickly, even across the continent. The Centre is a leader in characterising major infectious diseases, patterns of antimicrobial resistance, and prevalence rates of newly-emerging infectious diseases in Bangladesh. Some of the emerging diseases that have been characterised at the Centre include the following: El Tor cholera V. cholerae 0139 (Bengal), which appeared in Bangladesh and India in 1992, diarrhoea due to enterotoxigenic E. coli and rotavirus, agents causing acute lower respiratory tract infections in children, description of resistance patterns of the certain causes of sexually transmitted diseases (STDs) including N. gonnorrhoea.

In the last few years high level of arsenic in tube wells have resulted in serious health hazards. It is estimated that almost 30 million people in Bangladesh are exposed to dangerous levels of arsenic in their drinking water, and ICDDR,B 's field site in Matlab is situated in one of the most affected areas. The surveillance systems in Matlab offer comparative advantages in studying the health effects, the burden of diseases generated by arsenic in tube-well water, and effect of interventions.

The ICDDR,B scientists have started to screen for skin lesions in a population of 220,000, to assess arsenic concentration in water samples from 15,000 tube-wells of the Matlab surveillance area, and to establish a database for epidemiological studies of the levels of arsenic exposure and manifestations of arsenicosis in the population.

The Global Positioning System co-ordinates will also be linked for spatial analysis, mapping of tubewells, and arsenic concentrations. Immediate analyses of the findings will be performed to determine: if individuals exposed to a certain dose of arsenic in drinking water for a certain duration are at a higher risk of developing skin lesions when exposure starts early in life; if boys and men exposed to a certain dose of arsenic in drinking water for a certain duration are at a higher risk of developing skin lesions than are girls and women; if women who have higher arsenic concentrations in their drinking water have a higher rate of negative pregnancy outcome, i.e. miscarriage, stillbirth, and early neonatal death.

The laboratory in ICDDR,B boasts of state-of-the-art equipment.

Currently, ICDDRB has around 2000 staff including regular and part-time (for different projects). The Centre has a cross-cultural environment with 95% local staff that includes researchers, medical officers, administrators and health workers, and 5% international staff, primarily from academic and research institutions engaged in global health research. The Centre's activities are supported by about 55 donor countries and organisations, including Government of Bangladesh, UN specialised agencies, foundations, universities, research institutes and private sector organisations and companies. The Centre is governed by a distinguished multinational Board of Trustees comprising 17 members from all over the world.

For the last 25 years, ICDDR,B has been the nerve centre for health and population research. Firdausi Qadri, senior scientist and the acting Head of the Laboratory Sciences Division, talks about how ICDDR,B with its institutional set-up and state-of-the-art laboratory facilities gives our young researchers a unique exposure to the high research standards. She says that a good number of Bangladeshi scientists who began their research career with ICDDR,B are now working abroad with repute making the name of both Bangladesh and ICDDR,B uttered with respect. "Even a brief stint of research career with ICDDR,B in your CV will win you the most coveted scholarships from the leading universities across the world," Qadri makes the point with a certain degree of pride. All these young researchers working in the immunology section the section headed by Qadri, as well as those in the other nine units of the Laboratory Sciences Division of ICDDR,B are either going abroad on scholarship or have just returned home after carrying out higher studies and specialised training.

Besides, ICDRR,B with its world-wide fame and a very high standard of research facilities has been successful to attract quite a good number of Bangladeshi scientists who had been working abroad. One thing that holds back many young and promising scientists from coming back home, in spite of their willingness to do so, is the fact that the kind of training and skill they acquire abroad become almost difficult to adjust once they are here. "Coming back may often mean a virtual end to your research career due to the lack of specialised facilities in some research-oriented fields," Qadri observes. The ICDDR,B has broken the shackles, at least in the health sector. Over the years many talented Bangladeshi scientists have joined ICDDR,B after returning home and many of them have ascended to senior positions, she says.

When asked about any shortcomings of this unique organisation Salam takes some time to answer: “Working in an institutional set-up a researcher cannot always do what he would like to do,” Salam says. ICDDR,B is not a government institution and it is run by a whole lot of local and foreign donors. When a donor or an aid agency provides fund for a project it naturally wants the project to be done their way. Sometimes, donors' choices make ICDDR,B take up projects which might not have been in their priority list. Salam then mentions the ill state of the Centre's Dhaka hospital and explains the reason. Donors are interested in research, not in the hospital. “At present we don't have any fund exclusively for the hospital and we are managing it by saving from the various research projects,” he points out.

In an otherwise dilapidated state of our country's health care system ICDDR,B has been like the only bright ray of hope. Where for a large section of people even two meals a day is a daily concern 'health care' never gets into their priority list. Thus easily curable diseases like cholera takes epidemic turn, and easily avoidable diseases inflict huge loss as they cannot follow the daily basics of hygiene because of poverty and lack of knowledge. In this backdrop the ICDDR,B has been working to invent cost-effective remedies so that the poor can be benefited as well as discovering new vaccines to fight new threats to keep people healthy. Not just Bangladesh but the entire world will benefit from ICDDR,B's continuous and commendable work in finding cures for dangerous, infectious diseases.

Who Supports the Centre?

ver the years the work of the Centre has been supported by over 52 nations and organisations that share the Centre's concern for the problems of developing countries and value its proven experience in helping to solve those problems.
Major donors include (in alphabetical order): Australia (AusAID health), Bangladesh, Belgium ( DGDC), Canada (CIDA), Japan, Netherlands, Norway, Saudi Arabia, Sri Lanka, Sweden (SIDA), Switzerland ( SDC), United Kingdom ( DFID), United States of America (USAID health and population) and European Union ; International Atomic Energy Agency (IAEA), UNAIDS, UNICEF, World Bank and WHO UN agencies; International organizations: CARE Bangladesh, International Center for Research on Women, International Development Research Centre, Population Council, and Swiss Red Cross; Foundations: Aga Khan Foundation, Ford Foundation, George Mason Foundation, Novartis Foundation, Rockefeller Foundation, and Thrasher Research Foundation; Medical Research Organizations: International Life Sciences Institute, National Institutes of Health, New England Medical Center, Northfield Laboratories, and Walter Reed Army Institute for Research-USA; a host of universities from across the world The Centre has developed a fund-raising plan to build a Centre Fund totalling some $20 million to provide stable, flexible income and the edge of excellence for the future .

David A Sack has been the Director of ICDDR,B since October 1999. He, however, had worked here earlier from 1977-1980 and 1984-87 as a scientist. Here follows an excerpt from his interview with the SWM.

SWM : What, in your opinion, is the secret behind ICDDR,B's success?
2. There have been several reasons for the success of ICDDR,B. These include:
a) a clear mission to develop and promote realistic solutions to the major health, population and nutrition problems facing the poor people of Bangladesh and other settings;
b) high quality of scientific research, medical services and training,
c) an international character that utilises the talents of Bangladesh and international professionals,
d) high ethical standards,
e) transparent and reliable financial system,
f) dedicated and well trained staff, and
g) consistent support from many donors and most importantly,
h) support of the Government of Bangladesh.

SWM : What are the weaknesses, if there is any, of this institution-- Fund or lab facilities or something else? And what can be done to overcome these problems?
3. The weaknesses mostly relate to lack of financial stability. The Centre survives from year to year due to annual donations, but stability of the Centre depends on building an endowment.

The Centre has a Strategic Plan up to year 2010, and the plan describes several opportunities for major improvements in the health of the poor in Bangladesh. These goals in the Strategic Plan are not someone's dreams, but rather are realistic targets that will improve the lives of children and mothers and families in Bangladesh.



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