Nearly 150 years ago, the Tanzanian city of Dar es Salaam was known by another name — Mzizima, meaning “healthy town” in the local language. But over the decades, the city and the country of Tanzania have experienced mounting challenges to that health.
Tanzania’s per capita income is estimated to be $350 a year. Each year, there are 100,000 to 125,000 malaria-related deaths. HIV infection has reached epidemic proportions, with an estimated 1.3 million adults and children living with HIV/AIDS. Tuberculosis casts an ever-growing shadow over the country and hastens the illness and deaths of people with HIV. Rates of chronic diseases are increasing. And there is an estimated shortage of 10,000 health care workers.
Wafaie Fawzi, Harvard School of Public Health (HSPH) professor of nutrition and epidemiology, knows the situation well. For the past 15 years, he has headed a collaboration in Tanzania which includes researchers at Muhimbili University of Health and Allied Sciences (MUHAS) and the Dar es Salaam City Council, that has the overarching goal of improving the public health of people living in one of the world’s poorest countries.
One-year commitment turns into 15 years — and counting
In 1988, Fawzi came to HSPH after earning an M.D. at the University of Khartoum, Sudan. He intended to stay just one year at the School to earn a master’s in public health.
“Then during the M.P.H. studies I thought that one year wasn’t enough, so I did a doctorate in nutrition and epidemiology,” he recalled.
His mentors became HSPH Professors Manuel Herrera and Walter Willett. Fawzi conducted his thesis research in the Sudan investigating how vitamin A affects childhood mortality and morbidity. He graduated, and still interested in multivitamin research, he successfully proposed a postdoctoral project in Tanzania that explored whether vitamin A supplementation helped lessen the severity of pneumonia in hospitalized children.
“I chose Tanzania because on collegiate and professional levels, there are a lot of good people and many opportunities for collaboration on various public health issues,” said Fawzi. He went to Tanzania in 1993 and has divided his time between there and HSPH ever since.
Send an e-mail, wait three days
In the early years, Fawzi recalled, conducting research in Tanzania was just one of the challenges. He said “E-mail was done at one computer at the library at Muhimbili University. It worked via telephone and satellite. The satellite would come over twice a day, and it would pick up messages and drop messages, but because the telephone was not working most of the time, you would have to hope that the message got sent. You’d come back three days later to see if somebody had responded.”
A multifaceted collaboration
Much has changed since Fawzi first initiated a relationship with MUHAS to conduct the pneumonia study. The collaboration now involves HSPH, the Dar es Salaam City Council, MUHAS, Harvard Medical School, and departments in several of Harvard’s affiliated hospitals. The partnership focuses on conducting research, building the capacity of local Tanzanian public health systems, training scientists, and practicing public health.
Fawzi and his Tanzanian colleagues have jointly conducted numerous large randomized clinical trials and epidemiological studies on improving nutrition, curbing infectious diseases, and making mothers and children healthier. Currently 13 research studies are under way and six training grants are in place. Eleven funded research studies have already been completed since the collaboration started.
“While nutrition is the central focus of ongoing research activities, it is considered within a broader public health agenda,” said Fawzi. “We use the funded research projects to develop infrastructure and foster a multidisciplinary approach to understanding the epidemiology of various public health problems.”
Public health in practice
A program called “MDH” supports delivering high-quality treatment and care to HIV/AIDS patients. The city of Dar es Salaam owns and runs the health facilities. “Since the start of the program in late 2004, the MDH program has enrolled more than 45,000 adults and children, including 25,000 patients on antiretroviral therapy,” said Fawzi. “Through provision of laboratory, clinical, and research training, the program aims to strengthen staffing, research, and infrastructure capacity, and to support the development of large-scale epidemiological studies for research into HIV/AIDS, TB, and other endemic infectious diseases in Tanzania.”
MDH derives its name from the first letter of the three collaborating institutions (MUHAS, Dar es Salaam City Council, and HSPH). The program is funded through a U.S. grant from the President’s Emergency Plan for AIDS Relief (PEPFAR) that involves research in Tanzania, Nigeria, and Botswana. HSPH Professor Phyllis Kanki is the principal investigator of the overall grant.
“The infrastructure and training opportunities that we are developing with our PEPFAR program are critical for the success of our overall training and research agenda in Tanzania,” said Fawzi.
Research on nutrition and pregnancy outcomes
Despite good prenatal care coverage, many Tanzanian women experience adverse pregnancy outcomes. The partnership researchers are conducting a series of studies in Dar es Salaam to examine the efficacy of micronutrient supplementation on these outcomes. To date, the researchers have found that giving prenatal vitamins B, C, and E to HIV-infected women has significant benefits in reducing fetal loss, low birth weight, and severe prematurity. The researchers have recently reported that similar beneficial effects were noted among HIV-negative pregnant women who receive multivitamin supplementation.
Research on nutrition and child health
The researchers also are examining whether the health of Tanzanian children can benefit from micronutrients, whether given through direct consumption or through breast milk.
“As an example, we looked at how improving the nutritional status of the mothers during pregnancy and lactation has an impact on child health,” Fawzi said, “and we found that mothers who had better nutritional status during pregnancy tended to have children who are less likely to die in the first two years of life and less likely to have diarrhea and other infectious diseases.”
The team is currently conducting three different randomized trials that examine the effect of direct supplementation of children on their health and survival.
Research on nutrition and HIV/AIDS and TB
The HIV/AIDS problem in Tanzania is exacerbated by a growing tuberculosis epidemic. The virus’s ability to suppress the immune system tends to put HIV/AIDS-infected individuals at risk for contracting tuberculosis and increases the risk that latent TB will reactivate within those already infected, noted Fawzi.
The partnership researchers are examining the effects of multivitamins on clinical outcomes and immune responses among 850 men and women; all of the study’s participants have tested positive for TB and about half are co-infected with HIV. Results so far suggest that micronutrients have significantly decreased the risk of TB recurrence.
Said Fawzi, “We hope to continue to do a number of research studies in the area of infectious diseases and maternal, newborn, and child health. Another area that we would like to do more work in is that pertaining to noncommunicable diseases, particularly cardiovascular disease and obesity.” The team has recently started collaborating with partners in Uganda and India, and intends gradually to expand its links with other developing countries.
“Our vision is to further strengthen training and research in Dar es Salaam and increasingly use the site as a base for research and education at other sites in the African region and beyond,” added Fawzi.
Fulfilling that vision has become even more possible. Fawzi now is the principal investigator of the Fostering Opportunities for Nutrition and Global Health Frameworks Program at Harvard, administered by the Harvard Initiative for Global Health (HIGH). The three-year, $400,000 award from the National Institutes of Health’s Fogarty International Center will be supplemented by an additional $300,000 grant from the University.