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ICDDR,B
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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