The history of Medial research in Sudan

A M EL Hassan

Early history of research

• This presentation is about some of the heights of early research in Sudan and the more recent research activities in the country

• Some of the early history is based on a PhD thesis by Dr Ahmed Bayoumi

Early history• The beginning of medical research was mainly

due to Sir Henry Wellcome in 1902 when he donated lab equipment, a library and a museum to Sudan

• In 1903 Sir Andrew Belfour assumed the responsibility of Director of research (Wellcome Research lab). He was also Medical Officer of Health in Khartoum province and sanitary advisor to the Sudan Medical Department. This was the early link between medical research and services in Sudan

Early history

• The objectives of the Wellcome Research Lab was to study health problems of importance in humans and animals in Sudan, particularly infectious tropical disease and to promote technical education in these areas

Early history

• Andrew Balfour succeeded in eliminating mosquitoes and malaria in Khartoum as a result of his applied field research

• Another important disease that was addressed was Visceral leishmaniasis which was diagnosed in Sudan in 1904 but there was no known treatment for it and it was invariably fatal

• JB Christopherson, working in the Khartoum succeeded in treating some VL patients with Sodium Antimony Tartrate but the drug was toxic

A tribute to J B Christopherson • Christopherson was a physician and Director of Khartoum

and Omdurman Hospitals and was also Director of the Department of Health in the early part of the 20th century

• As I mentioned he was the first to treat VL by Sodium Antimony Titrate in 1906 and the first to diagnose Mucosal leishmaniasis in 1914.

• In 1919 he treated Schistosomiasis with Sodium Antimony Tartrate. Until I was a medical student in 1950s we were using this treatment

• He vaccinated 10,000 individuals against small pox in the greater Khartoum area

• He was also involved with others in the research on mycetoma

A tribute to J B Christopherson

• This is how JBC moved around Khartoum and Omdurman: the milkman’s way!

A book about ChristophersonBy his great granddaughter who visited us here and we held A special meeting about Bilharzia in honor JBC

Earl research in mycetoma• Dr. Albert Chalmers, Director of the Wellcome Tropical

Research laboratories (1913-1920), together with Captain R.G. Archibald, pathologist, and Dr. J.B. Christopherson, carried out valuable systemic mycological and pathological studies of the causal organisms of mycetoma.

• Chalmers and Archibald gave quite an elaborative and specific definition of mycetoma.

• For the first time they introduced the terms Maduromycosis and Actinomycosis, described the structure of the grains of Maduromycetoma which are composed of large segmented mycelia and Actinomycetoma whose grains are composed of fine non-segmented filaments.

Stack labs• In 1925 the Wellcome Labs were taken over by

Sudan under the Department of Education and were moved to the Stack Labs near the Khartoum Civil Hospital and the Kitchener School of Medicine. The lab was named after Sir lee Stack Governor General of Sudan who was assassinated in Egypt in 1924

• Malaria entomological surveys were carried out in the Gezira by Louis

• Yellow fever was discovered by Kirk and Louis in Western Sudan in 1934

• I give examples of how research was flourishing in selected institutions in the country and how this has been adversely affected by sanctions.

• Had it not been for some NGOs based abroad who came to our rescue, it would have been impossible to undertake meaningful research that addresses the health problems of the poor marginalized communities.

Mohamed Hamad Sati• In the years that followed, the Stack Labs

undertook epidemiological, operational and basic research in many diseases such as leishmaniasis, Onchocerciasis, meningitis, relapsing fever, Rabies, enteric fever and others

• Notable is the work of Satti, Kirk and Lewis in leishmaniasis that led to the mapping of vectors, and detailed descriptions of the various forms of leishmaniases. This culminated in the discovery of Pentostam for the treatment of VL in 1940. We use the drug till today

Mohamed Hamad Sati and his recommendation to establish a medical research council: a great foresight

• M H Satti was the first to recommend the establishment of a Medical Research Council under the University of Khartoum and the Ministry of Health.

• He stressed that the need for a council was urgent since many clinicians were trained in Europe and were not exposed to tropical diseases and needed training in this area. They also needed training in research

• Unfortunately his recommendation was not implemented at the time

Sudanese Ministry of Health• The Ministry was established in 1949• Mansour Ali Haseeb was appointed Assistant Director of

Research in 1952 and he was also the Director of Stack• One of his main achievements is in establishing training

center of lab assistants at the Stack labs. He sent some of them for further training in Lebanon. Among them was Mohamed Salih EL Faki who establish a tissue culture lab in the mid 1960s. I used this lab for the study of interaction between lymphocytes and infected macrophages

• This shows the standard to which technicians were trained

The National Council or Research (NCR)

• Dr Sati's recommendation to establish a Medical Research Council made earlier saw light when the National Council for Research was established in 1970. The late Dr Elsamany A Yaagoub was the Director.

• The Medical Research Council was one of its five sub-councils of the NCR. MA Haseeb was the Chairman of the MRC followed by A M EL Hassan and M Amin.

• In 1972 an Institute of Tropical Medicine was established by the Medical Research Council. The first Director was AM EL Hassan, followed by Sati. Other staff were Mutamed Amin, Asim Dafaa Allah, and Suaad Suleiman .

• The Institute of Tropical Diseases included a Tropical Diseases Hospital in Omdurman. The first Director was Dr Abdel Ghaffar Abdel Raheem

• Five researchers were trained in Britain. Following the retirement of Dr Abdel Ghaffar Dr Elkadaro became the Director.

• He and his staff in collaboration with Institute of Endemic Diseases started working on leishmaniasis and other diseases. This collaboration is still going on

More recent history of Research in Sudan

• I next review some of the recent developments in research in Sudan and discuss some of the problems encountered

• The research flourished as more graduate students became eager to work on research.

• We started to work closely with colleagues abroad on problems in Sudan, mainly in the are of endemic diseases

Collaboration with foreign research institutions

• The research problems were identified by us and the protocols were developed by both Sudanese and foreign researchers. An important part was the training of both Sudanese and foreign students in these projects and the development of infrastructure in Sudan

• The financing was mainly from International Organizations and the collaborating countries

• We started with North South collaborations but more recently we have South-South collaboration

The start of North-South collaboration: MSF Holland

• In 1990 MSF Holland initiated research and health services in Gedarif State by supporting a group of Sudanese scientists from the Faculty of Medicine and the National Public Health Laboratory to work in remote villages in Gedarif Sate where visceral leishmaniasis and malaria were important health problem.

• The main endemic diseases in Gedarif were malaria, visceral leishmaniasis (kala-azar) and leprosy. Kala-azar was rife. The drug Pentostam for treating Kala-azar was only available in the hospitals.

• In 1993 when the Institute of Endemic Diseases was established with the help of the then VC Prof Mamoun, we started our research on visceral leishmaniasis and PKDL. We continued to be supported by MSF Holland.

• We felt obliged to render services to the community and not limit our work to research.

North-South Collaboration between Denmark and Sudan

• The project covered the period from 1991 to 1999 and was supported by the Danish International Development Assistance (DANIDA). It covered two main health problems: malaria and leishmaniasis, two of the major health problems in the Sudan.

• The work on malaria headed by Ibrahim EL Hassan of the IEND Dr Riyad Bayoumi of the Department of Biochemistry faculty of Medicine U of K, Dr Thor Theander from Denmark and Dr David Arnot from Scotland

• Unfortunately the project was terminated by the Danish Government because of human rights issues in the Sudan.

• The results of this collaboration will be discussed in presentations by Dr A M Musa, myself in and by Prof M Mukhtar in this conference. David Arnot will discuss the malaria part

Collaborations between Sudan and Britain

• Prof M E Ibrahim of the Institute of Endemic Diseases collaborated with three distinguished scientists in Britain: Douglas Barker, Jennifer Blackwell and Dominic Kwiatkowski.

• This is what Dr Ibrahim said: ‘Douglas Barker, Jennifer Blackwell and Dominic Kwiatkowski are three distinguished scientists and wonderful people from distinguished institutions with whom I was more than privileged to work.

• Dr Barker and Prof Blackwell collaborated with the Institute of Endemic Diseases in the molecular diagnosis and genetics of VL and PKDL

• The researchers discovered new facts and trained many students. Dr Hiba Salah from the IEND was awarded a prize by the Royal Society in Britain for her work on genetics of leishmaniasis in humans. She was competing with 50 researchers from different parts of the developing countries

Collaboration between Sudan and the United States in health research:

• An important project was started in the 1980s between Michigan University and the National Public Health laboratory in Sudan.

• The research was on Onchocerciasis. Prof Mamoun. Prof Hashim W Ghalib, Prof EL Hady A EL Shaikh and others were the Sudanese scientist involved with the American scientists.

• The project addressed several issues in onchocerciasis that included epidemiology, clinical manifestations, immunology, prevention and treatment. The drug Ivermectin was used as an effective therapy.

Onchocerciasis in Abu Hamad• Onchocerciasis in Abu Hamad was first described

by the ate Prof H V Morgan in the 1950s. As a little boy I came across this disease in a relative from Abu Hamad that used to visit us in Berber. I sued to prepare the Tagarouga, Ibrigue and a rough stone for scratching! I wondered about what he had. I never dreamt that one day I will be studying the pathology of Oncho !!

• One of the great achievements to control Onchocerciasis is in Abu Hamad area in Sudan.

•

Onchocerciasis in Abu Hamad• Higazi TB, Zarroug IM, Mohamed HA, Elmubark WA, Deran TC,

Aziz N, Katabarwa M, Hassan HK, Unnasch TR, Mackenzie CD, Richards F, Hashim K. Interruption of Onchocerca volvulus transmission in the Abu Hamed focus, Sudan. Am J Trop Med Hyg. 2013 Jul;89(1):51-7. doi: 10.4269/ajtmh.13-0112. Epub 2013 May 20.

• This is what Dr Kamal Hashim, Director of the National Program for the Prevention of Blindness at Sudan Federal Ministry of Health, had to say about the project: “ I am proud that Sudan accepted the elimination challenge in 2006, and it gives me great joy to declare that we've succeeded in interrupting transmission of this ancient scourge in Abu Hamad."

The Blue Nile Health Project (981-1985) and continued till 1990

• This was one of the most successful research projects• Its objective was to control malaria, Schistosomiasis and

other water born diseases in the Gazira and Mangil• It was organized by WHO and Sudan Government. Two

eminent researchers were involved: Prof Mutamed Ahmed Amin, Regional Minister of Health Welfare (Wad Madani) at the time and Prof A A Elgaddal the Project Director

• As a result of this project, Malaria was less than 1% and Schistosomiasis was less than 10% in the area by 1990

• Prof Amin who is now in charge of research at Ahfad University for Women continued to work in Schistosomiasis and found a change in its pattern. In some areas Mansoni infection has changeg to S hematobium

Collaboration in mycetoma research between Sudan and Britain:

• This collaboration was started by Prof Elshieskh Mahgoub in the 9160s

• It culminated in the establishment of the Mycetoma Research Center at Soba University Hospital. The center is headed by Prof A H Fahal. It offers services to mycetoma patients in addition to research

• Soba Center collaborates with scientists in Holland• Mycetoma is now included as a neglected disease by

the Drugs for Neglected Disease Initiative (DNDi) and consequently Prof Fahal has been awarded a grant to develop and evaluate new drugs for mycetomas

• The collaboration with Holland in Mycetoma had enabled several young scientists to be trained in Rotterdam and to transfer some modern technology to Sudan.

• Twenty four high quality articles were published in high impact journals.

South-South collaboration in research

• The Drugs for Neglected Diseases Initiative (DNDi) is a collaborative, patients’ needs-driven, non-profit drug research and development (R&D) organization. It was first established in Sudan in a meeting hosted by the IEND

• It supports research in several endemic diseases including leishmaniasis

• It established research facilities in East Africa with objective of developing new drugs of leishmaniasis as will be discussed by A M Musa

Cancer research• In 1966 a Cancer Registry was established by the late Sayed Daoud

from the Stack lab and AM EL Hassan with funds obtained from the International Agency against Cancer through the help of Denis Burkitt. It continued till 1982 and stopped

• A new Registry was recently planned but it did not function well• The Cancer Hospital in Khartoum and the University of ELgazira

have their own Cancer Registries and have published on the subject• The IEND works on the etiology of some cancers, particularly the

breast and colon• Ibn Sina Hospital is researching gastrointestinal disease. They

disseminate their research findings through publications and meetings every month for the last 30 years

Research in the Sudanese Universities

• Research was pioneered by the University of Khartoum and the University of Gazira

• It is gratifying that the new universities are doing research and training Graduate Students in research. Their research initiatives can be accessed through their Websites.

• One University, Alneelain established a Deanship of research. Prof Mohamed Elamin Ahmed is the first Dean for Research. His main research is in Hydatid disease, one of the neglected disease in Sudan and worldwide. He collaborates with different local institutions including the Faculty of Veterinary Medicine of Khartoum University

• The 25th International Conference on Echinococcosis was organized by Prof Ahmed last month in Khartoum.

Research in Traditional Medicine: Prof Ahmed AL Safi at Maharat Center

• Traditional Medicine Research Institute of the National Council for Research, was founded by Professor Ahmad Al Safi in 1980, and the WHO Collaborating Centre for Research in Traditional Medicine in Khartoum was founded by him in 1983.

• Both Institutes are still functioning under Ministry of Science and Technology.

Other important activities of Maharat

• Professor Safi launched a major ongoing project called Sudan Health Trilogy in 2006. Its main documents include:• The Biographical Dictionary of Health Care Professionals in Sudan documenting the lives and work of the men and women who have served in health care institutions or contributed to health and medicine in service and research in the 20th century.• A Bibliography of Biomedical Literature in Sudan (1900-2000). Six thousand entries reached. (This needs updating)

• Other running activities include:• Al Safi’s most recent publication a book (AL Hakeem)

Introduction of genetics and molecular biology in Sudan: a great highlight

• Recent years have witnessed a very important development. Sate of the art methodologies were introduced in Sudan in the area of genetics and molecular biology by Prof Imad Fadl EL Mula at Alneelain University and Prof Muntaser EL Tayeb at the IEND. These lead to a better understanding of important diseases in Sudan at the cellular and subcellular levels. Many publications attest to this

Introduction of genetics and molecular biology in Sudan: a great highlight

• Prof Imad Fadl EL Mula of Al Neelain was the first Clinical Geneticist in Sudan. He founded the department of clinical genetics at the Radiation and Isotope Center

• His research output was in the fields of molecular biology of cancer, disorders of sex differentiation, urological oncology and molecular biology of Meningiomas

• All these activities improved the diagnosis of important diseases at the cellular and subcellular levels

• He now has a grant to study Leptospirosis. He discovered many cases of meningitis due to Leptospira

Introduction of genetics and molecular biology in Sudan: a great highlight

• Prof Muntaser introduced Molecular biology at first in the National Public health lab and later at the IEND

• He worked on the genetics of endemic diseases and cancer

• He established the first MSc degree in molecular biology. Many scientists and health professionals have been trained and are now active in their own research

Problems after the sanctions

• There was an improvement in research output since 2003 in some Sudanese Institutions, largely as a result of working with foreign colleagues in projects supported by European Universities and NGOs.

• With the sanctions, this collaboration is largely not possible

• There is now a big problem in obtaining equipment and reagents for research and diagnostic purposes. In my own histopathology services lab and at the Instate of Endemic Diseases there are important reagents that we simply cannot obtain. If we write to a firm, they either do not answer or if they do they state that Sudan is under sanctions.

Publications

• There are problems with publication too• Even if we have a paper that has been accepted for

publication we are not able to cover the expenses of the publication. We cannot transfer money from Sudan. Our personal bank accounts in England and other European countries have been frozen.

• We therefore have to publish in local journals or in a WHO, Arab or African periodical.

• However this year some good journal abroad have published papers from Sudan. Indeed some of us are reviewers for high impact journals

Local funds for Research and the poor career structure of researchers

• Lack of funds is a major problem. In several strategic research plans conducted over the last 30 years it was recommended that 1-3% of GNP should be allocated to research. This was never implemented.

• Because of the problems of obtaining funds from outside the country, the meager or lack of local funds and due to the poor career structure of researchers, qualified researchers are leaving the country

A new phenomenon. Research the easy way: Hunters and gatherers

• Because of the constraints faced by potential researchers they fall easy prey to practices that serve them individually but are harmful for research development in the country.

• One of these practices is to team up with a foreign researcher or group of researchers to do research on a problem in the Sudan. It is irrelevant whether this is a priority for Sudan or not. Often the collaboration is not through local institutions. The role of the researcher is then to collect material and data for a project that was conceived, designed and largely implemented abroad. Ethical issues may be ignored and local capacity building is nil.

Brain drain

• On 2/12/012 the Ministry of Labour published the following figures for emigration from Sudan:

• The number of medical Doctors who left the country in the last 5 years was 5028.

• This may be an underestimate

Causes of the exodus

• What are the causes of the exodus? • We have well trained medical professionals

but they are rendered impotent because they lack the facilities to practice their professions.

• the career structure for researchers and medical practitioners is poor and financial rewards are ridiculously low.

A tribute to the Sudanese abroad

• Those who left the country to Europe, the United States or other countries have done extremely well and have contributed to medicine and science in the name of Sudan.

• They never forgot their homeland. They participate in all the annual scientific meetings held by the different Sudanese associations. Some regularly visit the country to render services in the area of their expertise.

• This conference is an example of how the Sudanese abroad are always extending a helping hand to their homeland

• One final problem is the absence of a national body for research policy, a body that sets priorities of research in the country, co-ordinate research activities and most importantly fund research.

• This was the function of the National Council for Research in the 1980s which was dissolved along with its specialized councils.

• Research should address not only endemic diseases but also the emerging or the so called diseases of civilization

Thank you

EL Hassan 2005