The International Research Network for Mother–Child Health (IRN-MCH) Achievements and Prospects 

Colloque organisé par Guy de Thé et Rolf Zettertröm du 2 au 8 avril 2004

Participants

France Agid, Maurice-Antoine Bruhat, Nathalie Charpak, Myron Essex, Richard Hamilton, Elisabeth Heseltine, Jan Lindsten, Philippe Mauclère, Nicolas Meda, Ama Rohatiner, Jacob Sweiry, Guy de Thé, Talal Younes, Rolf Zetterström

Compte-rendu

Introduction
Among the peoples of the developing world, who bear 90% of the global burden of disease, children and mothers are particularly vulnerable. Infant mortality rates in many developing countries can be 30 to 40 times and maternal mortality 20 times those occurring in industrialized countries. These deaths and the high morbidity rates that accompany them have a huge economic cost. In 1990, an international commission concluded that strengthening research capacity in developing countries is one of the most powerful, cost-effective and sustainable means of enhancing health and development (1). It was under the aegis of the Inter-Academy Panel (IAP) and later  jointly with the Inter-Academy Medical Panel (IAMP) that the International Research Network  for Mother–Child Health  (IRN-MCH) was conceived as a means to advance health research capacity and  to promote sustainable Health and Well Being in the  developing countries.
In October 1998, an initial workshop organized  with both the French and the Swedish Academies of Sciences, was held at the Fondation des Treilles, and was attended by participants from Australia, Brazil, Colombia, France, India, Karakalpakhstan (Uzbekistan), Senegal and Sweden. In order to decrease the widening ‘90:10’ gap between global spending on health research and that focused on the diseases prevalent in developing countries, it was decided that a network should be developed to facilitate communication and instigate projects of mutual interest between scientists and clinicians in countries of high, intermediate and low income. This idea was further discussed the following year, on 15–17 October 1999 at the Fondation, where it was suggested that an interactive website should be set up as a priority, to provide a means of communication and a source of information for scientists in developing countries and a forum for exchanges of data, ideas and initiation of international collaboration. At the third workshop at Les Treilles, in March 2001, it was decided to enhance implementation of the interactive website, and consensus was reached to focus the initial activities on mother-to-child transmission of HIV in developing countries.
The present workshop, held at Les Treilles on 3–7 April 2004,   evaluated the progress made in this project and set a strategic plan for its future evolution.

Effectiveness of international collaborations
France Agid of the Foreign Office of the French Academy of Sciences described an international programme for the education of women in developing countries in order to improve maternal and child health in Africa. The programme is to be initiated and implemented under the aegis of the Inter-Academy Panel and in collaboration with the Third World Academy of Sciences. New methods are needed to give women access to the necessary basic knowledge. The tools must be accessible to and affordable by the poorest segments of society, reach women where they live and take into account social and cultural concerns as well as national priorities. The success of the programme will depend on the commitment of the authorities in the countries concerned, real partnerships between experts from the North and the South and the cooperation of local populations. The outcome will be evaluated on the basis of changes that are made in life style and health behavior.
A project to reduce maternal mortality in Africa was described by Maurice-Antoine Bruhat.of the French Academy of Medicine. The main causes of the high rates of maternal mortality in developing countries are undercurrent disease in pregnant women, inadequate childbirth conditions and complications of childbirth. Three categories of dysfunction were defined: managerial, medical and financial, and the appropriate corrective actions defined. After three years, partnerships have been established involving two African regions, three European university hospitals and several international organizations. Support is also provided by the club of first ladies of Francophone Africa and associations of African women.
The Harvard AIDS Institute is carrying a strong programme for prevention of mother-to-child transmission of HIV in Botswana. Max Essex reported that the prevalence of HIV-1 among pregnant women in Botswana in mid-2003 was 37.4%, and that 49.7% of women aged 25–29 were infected. Botswana has a higher per capita income than many other African countries (about US$ 3000), and the President, a trained economist, was eager to cooperate in efforts to halt the epidemic. To enable the Harvard AIDS Institute to run trials to determine the optimal drug regimen for treatment of HIV-positive pregnant women with antiretroviral drugs, the Government provided a building, with 12 technical positions,   and all the drugs needed and transport equipment. The Harvard Institute provides teaching and quality control. The regimen used in the national programme has evolved as a function the results of the various trials, the Government deciding on any changes to the programme on the basis of regular consultations. The treatment of patients is being taken over by Botswanans trained by the Institute. So far, 300 medical doctors, 1200 nurses, 35 laboratory technicians and eight scientists have been trained.
The activities of the Kangaroo Foundation, presented by Nathalie Charpak, are to respond to the need for accurate scientific information about Kangaroo Mother Care, but also to promote and develop other aspects of the care of newborns. The cultural changes introduced by the Kangaroo method into health practices humanize the attitudes of health personnel in charge of fragile newborns and their families. International interest in the technique is seen from the fact that the forum for the Kangaroo Foundation’s work on the International Research Network on Mother–Child Health is visited frequently. Basic research and formal studies on the method are increasingly being conducted in developed countries. Thus, a technique conceived in a developing country has expanded not only in the South but from South to North.
One of the main aims of the International Network of Pasteur Institutes in developing countries, discussed by Philippe Mauclère, is training in research within the framework of research projects. Once their training is completed, the researchers remain in contact with the international scientific community through the International Pasteur Network. With respect to the Mother–Child Network, the first prerequisite is that the www. mother-child.org website be restructured by a competent person to make it attractive and informative. Once the number of members has reached a critical mass, scientists in the International Pasteur Network would participate by providing information and exchanging information with other teams.  Regional workshops in scientific writing, using a series of, to be developed,   CD-ROM,   complemented by activities on the  interactive website, could be included as part of the training provided by the International  Research Network (IRN-MCH).
Burkina Faso is severely affected by the HIV/AIDS epidemic, with a prevalence of infection of 4.2% of the adult population. Nicolas Meda presented the national programme, which was launched in 2000 to reduce mother-to-child transmission of HIV infection, in collaboration with the Muraz Centre. He noted that the International Research Network for  Mother–Child Health could become involved in four main areas: access to updated information on programmes on mother-to-child transmission of HIV, training in research planning and writing, stimulating the translation of research results into policies and programmes supporting small projects.
Rolf Zetterström noted that although much effort is being devoted to the control of mother-to-child transmission of HIV and the prevention of nutritional deficiencies, the clinical consequences of exposure to environmental pollutants have received less attention. Lipophilic organic chlorines, such as pesticides and herbicides used in agriculture and forestry, are released into the air, soil and water, and are taken up by various organisms and enter the food chain, from which they can be stored in human fat for long periods of time. These compounds can be transferred to the foetus, and postnatally to the newborn through breastfeeding. Placental transfer seriously affects offspring, resulting in increased rates of congenital malformations and perinatal death. Further studies on the toxic effects of these compounds on foetuses and infants are urgently needed. In the Aral Sea region in Central Asia, extremely high concentrations of persistent organic chlorines have been found in human milk and in the blood of schoolchildren. Studies of the adverse effects are therefore being performed in pregnant women, newborn infants and children in this area.

Achievements of the  international research network for mother-child health.

Guy de Thé presented a report on the progress achieved  by the IRN-MCH since the last meeting at the Fondation in 2001. With the support of a grant from the–NRJ- Institut de France foundation, an interactive website, www.mother-child.org was developed and hosted by the Scientific Information Centre of the Pasteur Institute. By 2002, it became apparent that the website was too complicated and ill-adapted to the needs of scientists in developing countries, and should be restructured. A full-time webmaster was hired, Nancy Cuervo from Colombia, who had graduated in microbiology at the Pasteur Institute and was interested in working for developing countries, while Adolfo Suarez, with a PhD in informatics, took the responsibility of adapting the website. After a thorough overhaul, the renewed website became operational in late January 2003. By December, it had received 44 005 visits from Europe, Canada and the USA but unfortunately only a small proportion from developing countries.  It was recognized that, while a information website was easy to established, an interactive one was much more difficult to develop and operate especially when involving the developing world.. Suggestions to improve the website were made by  the participantsat (see below).
A series of workshops was organized with the World Federationn of Scientists i n Erice, Italy on the topic of mother-to-child transmission of HIV with participants from both developing and industrialized countries. At the first, in August 2000, a plea was made for use of Nevirapine, an affordable virucidal, to prevent mother-to-child transmission. It was agreed that infants born to HIV-positive mothers would be at lower risk of death if they were breastfed than bottle-fed when clean drinking-water was not available. The conclusions of this workshop were published in Acta Paediatrica 2000;89:1385–6. In August 2001, a second workshop was held in Erice, focusing on antiretroviral therapy and therapeutic vaccines in mother-to-child transmission of HIV. The role of health infrastructure and clinical laboratories in adequate biological follow-up of patients given antiretroviral therapy and for monitoring the emergence of drug-resistant HIV mutants was stressed. The report was published in Acta Paediatrica2001;90:1337–9, and further discussions on use of immunization in preventing mother-to-child transmission of HIV-1 were published in Acta Paediatrica 2002;91:241–3. In August 2003, a third workshop was organized in Erice on ethical issues in HIV/AIDS epidemics and control, raised by the increasing number of interventions being conducted with antiretroviral therapy in developing countries by external organizations. the differing cultural environments and health infrastructures in which the interventions are being conducted are making  application of the terms of the Helsinki Declaration difficult. A report of this workshop is in press in Acta Paediatrica, 2004.
Two Canadian colleagues (R. Hamilton and C. Roy) have been very active in raising the interest of scientists, clinicians and funding agencies. They organized a Canadian committee and held a workshop think tank on 7–9 October 2002 to assess how Canadians could participate in this venture, focusing on nutrition and resistance to infectious diseases, areas of great relevance to developing countries. In 2003, they obtained a grant to provide infrastructure to support a Canadian contribution to the endeavour. In August 2002, Professor Glenda Gray presented the Network at the World Summit for Sustainable Development in Johannesburg, South Africa.
On March 24, 2004 the Inter-Academy Medical Panel (IAMP) held an executive committee meeting in Paris and endorsed the international research network for mother–child health (IRN-MCH) as fitting  well within IAMP’s objectives. The IRN-MCH will therefore develop under the aegis of both  science and medicine, i.e. the IAP and IAMP, which does not imply financial commitment from these institutions. The IAMP further considered that the structure of the Network could reflect that of the IAMP. Hence  an Executive  Committee  would help co-chairs, one from the South, one from the north to manage and develop the Network.

The priorities for future activities of the Mother–Child Network were the major point of discussion at the Fondation des Treilles. We evaluated the complementary role of a scientist-to-scientist network with intergovernmental efforts in health promotion. Recognizing the growing political awareness of the role of  health’s promotion  in   economic growth of developing countries, the group discussed how scientific organizations such as the International Council of Scientific Unions (ICSU), the International Union of Biological Societies (IUBS), the Pasteur International Network, the International Network for Cancer Treatment and Research (INCTR), together with the Mother–Child Network, could promote health research in resource-poor countries. Collaboration among these institutions, creating consortium for specific projects, should attract the interest of international foundations, such as the Wellcome Trust and the Gates Foundation, and was praised as an important step to take.

Needs
A working group composed of Nathalie Charpak (Colombia), Max Essex (USA), Philippe Mauclère (Madagascar) and Nicolas Meda (Burkina Faso) prepared a statement of the needs of scientists in the developing world, as they perceived them. They focused on those needs that the Network might address.
The group agreed that international collaboration is a key asset for scientists in the developing world, providing that all projects (i) meet mutually acceptable scientific and ethical standards; (ii) make provision for local (national) scientists to share leadership and (iii) incorporate measures to promote sustained research capacity in the developing country once the project is completed. To promote such collaborative research in the modern world and to compensate for the scientific isolation experienced by so many scientists in the developing world, an efficient, user-friendly system for electronic communication is a critical necessity. The working group strongly endorsed the potential key role to be played by the Network’s website www.mother-child.org in this context. They considered that revisions to the website were urgently required so that it could adequately fulfill this function.
Further uses for the website were discussed. These include: improved access to the health literature, to search engines and to abstracting services to facilitate evaluation of recent literature, and provision of an updated directory of research training sites. It was agreed that actual training courses on subjects such as project design, study conduct and analysis, statistics, ethics and preparation of grant proposals and papers, for which there is a great need, require personal interactions and real protocols as a basis for curricula. CD-ROMs would be suitable teaching aids for this purpose.
The working group proposed that in the longer term the Network could serve as a valuable advocate to national governments, complementing advocacy from other agencies such as Essential National Health Research, to promote health research and the value of improving health care systems around the world.

Response to needs

Role of academies
Jan Lindsten, President of the Royal Swedish Academy of Sciences, commented on the possible continuing role of academies in furthering the development of the Network. He pointed out that in addition to providing a high and broad level of competence in many areas of science, academies had the advantages of being independent, neutral and sustainable. They cannot be expected to provide funds, but they can serve an important promotional function and can facilitate capacity building. In research, they could provide assistance with evaluation, coordination of donors and identification of specific donors. They are well placed to arrange courses, to facilitate communication and to promote the development of scientific academies and science in general abroad.

A Canadian response
Richard Hamilton outlined a Canadian action plan in response to the needs expressed by the working group and to the very modest level of commitment to the Network ‘ website of scientists both in Canada and in the developing world. A professional website consultant has been engaged, and revisions to the current website are being proposed. These revisions will sharpen the focus of the website to encourage and facilitate registration, so as to develop a critical mass of researchers as a base for future developments. It is understood that a  webmaster will be hired. It is imperative that these efforts succeed within the coming year if this project is to acquire the financial support necessary to sustain the Network.

Scientific communication
Elisabeth Heseltine responded to the clear expression of a need for additional training in scientific communication for scientists in the developing world. Currently, few persons who have completed research-training programmes are capable of writing a clear, logical piece of  scientific prose. Elisabeth has conducted workshops in scientific writing in many countries of the world over the past 20 years; other centres have considerable experience with short-term courses on related topics, including project design, statistics and research ethics. The participants agreed that such teaching programmes are most effective when held with small groups of participants who bring their own pieces of writing for discussion. Interactive CD-ROMs are preferable as a first step, to the internet as teaching devices in view of the unequal global access to the internet, although use of the Network’s website for follow-up could be  highly valuable and merit to be investigated.  Many unresolved issues remain, but the working group agreed that educational programmes in research should be an integral part of the International Network.

Role of other organizations
The International Network for Cancer Treatment and Research (INCTR) based in Brusells and represented at the workshop by Ama Rohatiner, is committed not only to improving the treatment of patients with cancer but also to creating capacity for cancer control through education, training and research in developing countries. The International Research Network  on Mother–Child Health could collaborate with the INCTR with regard to education and research, by providing visiting experts (doctors, nurses, scientists or technicians) who would work for several months in institutes in developing countries.
The Wellcome Trust, represented at the workshop by Jacob Sweiry, is an independent , major research-funding charity, funded from a private endowment and managed for long-term stability and growth. The mission of the Trust is ‘to foster and promote research with the aim of improving human and animal health.’ Its aims are to improve the knowledge base by supporting biomedical research and studying its social impact, supporting careers and equipping researchers, promoting clinical research and encouraging its application and improving public engagement. The Trust supports more than 5000 researchers at 300 locations in 42 countries, with awards, research training fellowships and project and programme grants. A programme on the health consequences of population change study how population growth, migration, urbanization, age and behaviour change the patterns of ill health, and how those changing patterns put pressure on health care providers, thus requiring changes in policy and practice. With regard to mother-and-child health, 55 grants totalling £11.5 million were awarded in 1998–2003, in the fields of nutrition, HIV/AIDS and sexually transmitted infections.  The Trust is ready to consider proposals submitted by the network.
The goals and current activities of the International Council of Scientific Unions and the International Union of Biological Sciences (IUBS), were presented by its Executive Director, Talal Younès. Their  new programme on “Science for Health and Well-Being” appears  well fitted with  IRN-MCH, although the former emphasizes the contributions of basic science. Three levels of potential collaboration can be envisaged. The programme for health education of women in developing countries could be presented to participants in the IUBS conference BioEd 2004. An educational module on the topic might be included in the IUBS Bio literacy Series and published online. Specific IRN-MCH’s proposals for collaboration could be made by IUBS member academies that are also participating in the International Network.  On a global level, collaboration could be followed-up by the participation of Professor Guy de Thé in formal meetings between ICSU and the IAP.

Conclusions
The participants in this workshop reached a strong consensus on the following points.

1. Although the full potential of the International Research Network for  Mother–Child Health (IRN-MCH) has not yet been fully realised, it can fulfil an important role in promoting, supporting and sustaining health research relevant to its field of interests in the developing world. Productive research will result in urgently needed improvements in the health status of this segment of the world’s population, who represent the future of our societies.
2. The Network’s immediate priority is the recruitment of scientists from the developed and the developing worlds to a commitment to the Network. For this recruitment effort to succeed, further revision of the website www.mother-child.org is essential, to sharpen its focus on this high-priority objective and to render it more user-friendly.
3. In addition to conventional training programmes in research, there is an urgent need for short-term courses on subjects such as project design, statistical methods, preparation of grant applications, reports and manuscripts, as well as other scientific writing techniques. Courses in the last field could be implemented immediately, involving small groups and personal contact and work on the participants’ own protocols, data, etc. Materials prepared on CD-ROM could complement such courses.
4. To enhance the Network’s long-term viability, a concise document should be prepared, this year, incorporating data on existing research networks and stressing the aims, achievements and needs of the Network. This brochure would be directed to  scientific  institutions and potential donor foundations, agencies both non-governmental and governmental, deemed capable of providing political or financial support to the Network’ activities and research projects.
5.  To develop the efficacy and means of this scientists-to-scientists network, an executive committee with members from both developing and industrialized countries should be set up, and relations with governmental and private institutions having similar goals  must  be developed.

(1) Health Research Essential Link to Equity in Development. Final Report of the Commission for Health Research for Devlopment, Oxford: Oxford University Press, 1990.