Together, U of M and Ugandan doctors are waging war on HIV/AIDS and malaria in a disease hot zone
By Barbara Knox
In his laboratory on the University of Minnesota campus, Paul Bohjanen, M.D., Ph.D., has spent more than a decade working to stem the tide of HIV/AIDS. But it wasn’t until he traveled to Uganda, 8,000 miles away from his lab, that he truly came face-to-face with the gut-wrenching realities of that deadly disease.
“I remember, back in 2003, I visited a hospice program for AIDS patients in Kampala with a group of African doctors,” says Bohjanen. “The facilitator asked how many people in our group had a family member who had died of AIDS, and every single African in the group raised their hand. I’ve never forgotten that.”
As Bohjanen knows, the impact of HIV/AIDS is more devastating in sub-Saharan Africa than most Americans can possibly imagine. Likewise, the scourge of malaria, virtually wiped out in the United States, continues to kill hundreds of thousands in Uganda and its neighboring countries. So to work effectively on finding treatments and cures for these diseases, many University doctors have been taking their research to the heart of the problem, setting up shop at Makerere University in Kampala, the capital city of Uganda.
The University of Minnesota’s now long-standing partnership with Makerere has proven to be a model for long-distance academic relationships centered on the exchange of research and education. Dozens of University of Minnesota faculty now spend time working in Uganda. Aaron Friedman, M.D., vice president for health sciences and dean of the Medical School, believes the Uganda partnership has reaped enormous benefits for Minnesota.
“It’s difficult to overstate the importance of the relationship we’ve built in Uganda,” he says. “While we have other relationships with programs around the world, this one is unique because of its extensiveness and the clear, productive work of the science. It’s really borne fruit across the board.”
He ticks off examples quickly: “We’ve been told by our students that our relationship with Uganda is one of the reasons they chose this medical school. Doctors here get grants because of it. And you can’t study things like malaria in Minnesota, which means we wouldn’t have some of our top faculty without having this bridge to sub-Saharan Africa.”
John Finnegan Jr., Ph.D., dean of the School of Public Health and the University’s assistant vice president of public health, couldn’t agree more. “Sub-Saharan Africa is a ‘hot zone’ area,” he explains. “You’re going to find more than its share of emerging infectious disease there.”
He certainly doesn’t overstate the problem: Africa is home to 25 percent of the global disease burden and just 3 percent of the health care workforce. Of the world’s 35 million people infected with HIV, 75 percent live in sub-Saharan Africa. Statistics for malaria are even worse: more than 90 percent of annual malaria deaths occur in Africa — and 85 percent of those who die are children under age 5.
In light of those facts, having a deep connection to East Africa is imperative for University doctors who do research in those areas — and for the Ugandans who benefit from their work.
“Uganda is the regional center of East and Central Africa,” Finnegan says, “and Makerere University is one of the top 10 schools in Africa — and the only one in the top 10 outside of South Africa — so it’s a very important university.”
But taking a deeper look into the work being done by Minnesotans both on the ground in Uganda and in tandem with Ugandan doctors within the University of Minnesota’s walls makes a strong case for this international relationship that has bonded, inspired, and trained so many students, researchers, and doctors over the years.
HIV/AIDS and finding hope
Bohjanen, a professor in the University’s departments of Microbiology and Medicine and director of the Center for Infectious Diseases and Microbiology Translational Research, helped blaze the trail when, almost a decade ago, he went to Makerere University for three months to teach a course about AIDS treatment to physicians from across Africa. He continues to travel to Kampala two or three times a year, and he now has status as professor-in-residence at Makerere, although he’s moved from being primarily in a classroom into hospital and clinic settings, where he provides mentorship to local researchers. He also has a Ugandan medical license so he’s able to actively treat patients at Mulago Hospital, the teaching hospital affiliated with Makerere, when he’s in Kampala.
When Bohjanen first began to spend time in Uganda, the situation was grim. “At that time, there was a very gloomy undertone to AIDS care,” he says. “Everyone knew they were taking care of patients who were going to die.”
Since antiretroviral therapy (ART) has become more widely available, however, the forecast has brightened.
“People get on treatment now and they get better,” Bohjanen reports. “It’s improved the morale of the health care providers and really of society at large. Now there’s hope.”
Bohjanen, who also directs the University of Minnesota research office that opened at Makerere in 2010, is now seeking funding for a “test-and-treat” pilot program that he hopes will fundamentally change the way HIV/AIDS is diagnosed and treated in Africa.
The test-and-treat program is designed to go into a community and test everyone living there for HIV. Anyone testing positive would begin treatment immediately.
“This approach could dramatically decrease AIDS transmission,” he says.
Unfortunately, that approach is also expensive — in the short term, anyway. Says Bohjanen: “Our current approach to this disease isn’t leading to decreases in transmission. So while the test-and-treat approach would be a major investment, if it decreases transmissions, which is our belief, then it will ultimately lead to huge cost savings down the road as fewer and fewer people require expensive treatment and hospitalization.”
Though Africa may be ground zero for the HIV/AIDS epidemic and many related research projects, Bohjanen is quick to point out that the problem is certainly not contained there.
“Minnesota is home to a very large community of African immigrants,” he says, “and some of them are bringing HIV/AIDS with them. Today in medicine, local is global and global is local.”
Malaria: A brighter outlook
Chandy John, M.D., M.S., a University of Minnesota colleague in the departments of Pediatrics and Medicine who directs the Division of Global Pediatrics, is compelled to improve the lives of those who have another devastating disease: malaria, one of the leading causes of death worldwide in children under age 5.
John has been working on various studies in sub-Saharan Africa since 1996 and is internationally known for his work on how malaria occurs and progresses.
“There is a huge burden of disease on children overseas,” says John, “and that’s why I work there.”
He and his team are currently focused on cerebral malaria, one of the deadliest forms of malaria. Twenty percent of children who contract the disease die.
The children who recover from cerebral malaria can look quite well but suffer from long-term brain damage, John says.
In earlier studies, he and his team found that 25 percent of the children who’d had the disease showed cognitive impairment two years after recovery — that’s 200,000 kids a year. Now John and his Ugandan research partner Robert Opoka, M.D., are focused on discovering how and why this happens — and how to stop it.
“Malaria accounts for 45 percent of all pediatric admissions to Mulago Hospital,” says Opoka, a senior lecturer in pediatrics at Makerere University and now an adjunct professor at the University of Minnesota. “There are many, many children affected, and a number of them go on to develop complications like blindness, motor difficulty, and cognition impairment. But this disease is preventable, treatable, and curable. The research we do with Chandy has given us more understanding — clues to how it can be treated better and how it can be prevented.”
Still, Opoka faces an uphill battle in his daily care of patients. In Uganda, inadequate staffing and equipment present a constant challenge. “So our care is not as good as it should be,” he says. “But this cooperation from Minnesota helps us employ more staff on the ward, buy more equipment, and train more people who can provide clinical care and do research.”
For John, balancing a life spent partially in Africa and partially in Minnesota at University of Minnesota Amplatz Children’s Hospital, one of the premier medical facilities in the United States, can be challenging.
“Sometimes it’s hard to wrap my head around the disparities,” he admits. “Being here, at a hospital known for transplants, I see patients who require the most complex thinking, and I have the most sophisticated resources available. There, I see children in such desperate need, and have so few resources to use.
“But I think it’s important to do both,” he adds. “Kids there deserve good care, too. It’s important for me to stay on top of things here, then share that knowledge in Africa.”
That back and forth — the trusted exchange of ideas with Ugandan doctors and researchers — is at the core of the relationship. Those involved stress that this is not about the Americans swooping in with all the answers.
“We come in asking how we can help,” says Finnegan. “In return, we gain the ability to do important research, to exchange students and staff, and to build a strong platform for dealing with global health issues.”
Opoka, who has worked with John since 2003, agrees. “The University of Minnesota’s aim is not to come to Uganda and teach us something,” he believes, “but rather to come here and work with us. We have many things to contribute, and they help us get to the next level.”
Opoka enthusiastically endorses the partnership and says it has helped Makerere become one of the top universities on the continent. “We are now ranked eighth in Africa, primarily because of the important research we’ve done here,” he says. “Our relationship with the University of Minnesota has helped raise our profile greatly.”
Coming together to improve health
Friedman, who made his first trip to Uganda in February, believes that as the partnership matures, the benefits derived increase exponentially.
“There is a whole series of obstacles to creating a successful working relationship like the one we have in Uganda,” he says. “How to maneuver within their legal system, how to work with their bureaucracies, finding physical space, allocating resources. But once you’ve made it across those hurdles, you don’t have to keep rebuilding. Now the doctors can focus on work; now we can exchange students and faculty easily.”
For his part, Finnegan considers such international relationships central to the University of Minnesota’s core mission.
“What does it mean to be a global university with a land-grant mission?” he asks. “A place like Uganda, in many ways, helps us reflect on how that mission should develop. One hundred fifty years ago, with the establishment of the land grant, the University’s mission was to develop new knowledge that could be used to create practical applications to improve lives. Now we’ve extended that same mission across the world to encompass a new place where, with practical applications, lives will improve.”
In the end, though, the University of Minnesota’s strong relationship with Uganda is reflective of the smaller world we live in and the imperative need to work together to solve problems.
“Our relationship with Uganda is especially critical in terms of public health,” Finnegan says. “Seventy-five percent of emerging diseases are coming through animal vectors, and sub-Saharan Africa is at the heart of that. But those diseases that originate in Africa — West Nile disease, Chikungunya disease — sooner or later they’re going to come here. The only way to deal with it effectively is to create partnerships.”
Barbara Knox is a Minneapolis-based writer and editor who covers a wide range of topics for local and national magazines.
Photojournalist Kate Holt has worked extensively in East and Southern Africa for the last 10 years. Learn more at www.kateholt.com.
For more information on how you can support the University of Minnesota’s partnerships in Uganda, contact Courtney Billing at 612-626-1931 or firstname.lastname@example.org, or Adam Buhr at 612-626-2391 or a.buhr@ mmf.umn.edu.