Port in a tropical storm

An institution founded through a £350 donation by a Victorian shipping magnate is at the forefront of the battle against Covid-19.

After Sir Alfred Jones signed his cheque in 1898, Liverpool School of Tropical Medicine became the first institute of its kind in the world. Its scientists are now working to improve coronavirus testing in a way that could benefit lower-income countries.

“People who spent decades studying infections say they never imagined it could be this bad.”

Professor David Lalloo, LSTM director and a clinician who is treating Covid-19 patients in hospital, says: “We are looking to develop diagnostics for people with the disease and to see if people have already had the disease. One of our focuses is developing tests which are suitable for low-resource settings such as Africa, where they don’t have big laboratories. We would like to achieve something a bit like a pregnancy test – with a rapid result on a stick. If that was achievable it would be great for the UK and overseas.”

At the time of LSTM’s creation, Liverpool was the key port in the British Empire, with ships docking from the Americas, Africa, India and the Far East. Consequently, the city’s hospitals saw a constant supply of tropical diseases – including 294 malaria cases in 1898.

As well as malaria, LSTM’s regular work today includes researching tuberculosis, HIV/Aids and dengue fever. It has projects and partnerships in more than 70 countries and frequently collaborates with Liverpool University. The two institutions are collaborating on 21 Covid-19 studies, which include diagnostics, treatments and prevention strategies. Together with the NHS they have put £1.1 million into the research – and LSTM has launched a drive to raise more funds to fight the pandemic and build resilience for the future.

The speed with which scientists have reacted to the current pandemic is in large part due to their experiences during the 2014-16 Ebola epidemic, according to Lalloo, who joined LSTM in 1999 and became director last year. During that outbreak, which gripped three West African countries, British clinicians and researchers treated patients and undertook studies that helped bring the epidemic under control.

“Although we’ve seen many deaths from coronavirus now, if you caught Ebola your chance of death was much higher,” he says. “That brought up many issues around how to protect health workers properly, and about local populations being understandably very scared.

“It also highlighted issues about this disease being in countries with health systems which were not equipped for emergencies.”

LSTM sent clinicians and scientists to Sierra Leone, where they set up mobile laboratories and ran clinical drug trials and vaccine studies. Only a small number of Ebola cases ever arrived in the UK – in large part because those who picked up the disease often died and had fewer opportunities to spread the infection. Conversely, there is thought to be a period when Covid sufferers are contagious while asymptomatic – aiding its spread.

Another lesson from Ebola was how diseases that emerge in far-flung countries can be relevant to people’s health closer to home.

He says: “We are now seeing how a disease that emerged in one region of China has had consequences across the world. We are a very connected global community and diseases can spread easily. Even so, I’ve talked to people who have spent decades studying emerging infections, who say they never imagined it could be this bad. I think it’s difficult to be completely prepared for something of this magnitude, which are infrequent occurrences.”

Some LSTM staff – like Lalloo – maintain active clinical roles within the NHS, while others have returned to the health service to help out during the pandemic. The school also employs laboratory scientists, virologists, vector biologists, immunologists, and pharmacologists. Staff provide expertise to Public Health England and the World Health Organisation.

LSTM also attracts more than 600 postgraduate students from 68 countries, and works with health ministries, universities and research institutions worldwide to train doctors, scientists, researchers and health professionals.

One of Lalloo’s biggest concerns at present is what is going to happen in lower income countries when the pandemic peaks. In countries with fragile health systems, the impact is likely to be severe.

Together with the University of Liverpool, LSTM manages the Malawi-Liverpool Wellcome Trust Clinical Research Programme. Malawi has just 350 doctors to treat a population of 18 million, and even its largest hospitals lack the basic equipment needed to treat the most serious cases. There are only a handful of intensive care beds in the country and getting oxygen can be a challenge. It is thought two-thirds of serious Covid-19 cases admitted to hospital in the country could die as a result.

Another problem is the impact of the pandemic on other conditions. Lalloo says: “Even in the UK we’ve heard evidence of people not coming to hospital with serious conditions like cancer because they are worried about Covid-19. We are concerned that in areas like Africa that effect may be even more stark. If, for example, you stop malaria control programmes where people distribute bed nets or spray houses to prevent mosquitos being present, then the disease will come back.

“If women who can’t get to hospital or a health centre have a complicated delivery they could die in childbirth. Many more people died in West Africa from causes other than Ebola than died from Ebola during the period of that epidemic, because they did not receive the healthcare they needed.

“We’ve seen the effect of Covid-19 on our health system and reasonably-resourced systems in the world. When you take a system which is just teetering on the brink of coping normally, something like this is catastrophic. Imagine staff having no gloves, or no running water even in a hospital – health workers just won’t engage and everything will fall apart.”

In nations such as Malawi – where many people live hand to mouth, in large households and often grow their own food – there are also huge challenges when it comes to people’s ability to self-isolate to slow the spread of the virus, should they show symptoms.

Viruses and other pathogens are mutating, or developing resistance, at an alarming rate – and environmental change, urbanisation and increased travel mean diseases are emerging and spreading at unprecedented rates across borders. While LSTM happens to be based in Liverpool, most of its work is overseas and it collaborates with partners all over the world – putting it in a good position to respond to future health emergencies.

Lalloo says: “Clearly it’s important that we get research funded into Covid-19 now but it’s important that we don’t neglect all the other conditions. If we stop researching some of those tropical conditions like malaria, they will ultimately kill many more people. There’s an important balance in terms of getting the funding to deal with this emergency and continuing to do all the other good work which needs to continue both in the UK and overseas.

“Our concern is that as a result of a contracting economy there will be less research funding available in the future, particularly that which comes from government, and it’s important that these are not just diverted to one condition.”

One lesson from the pandemic is the need for good surveillance systems, so new diseases can be detected early. Covid-19 happened to arise in China so was picked up relatively quickly, but there are other parts of the world with less well-developed surveillance systems where a novel disease could become more widespread before being detected.

Lalloo says: “The sooner you identify something the sooner you can put things in place to limit the spread of the disease. I think we need to develop a good detection system and then a co-ordinated system to respond to that. We’ve seen some co-ordination but maybe not as much as we should have done around the world. Certain countries have thought much more about their own population than about the global population. But we need a collaborative approach for a disease which really doesn’t know borders if we’re going to stop these illnesses from becoming pandemics.”

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Manchester shacks up with Kenya

Informal settlements pose specific problems for Covid-19 treatment, says Saskia Murphy

An initiative designed by a Manchester University professor is helping to address the complex challenges of dealing with Covid-19 in informal settlements in Kenya.

Diana Mitlin, of the university’s Global Development Institute, is working alongside longstanding collaborators SDI Kenya to map community responses, develop solutions that work in local environments, and rapidly share its findings within Kenya and beyond.

Mitlin described how global advice to self-isolate and wash hands in a bid to stop the spread of the coronavirus are “simply not possible” in some informal settlements.

Speaking to Big Issue North, Mitlin said: “One of the problems about the way the global world has been responding to this [crisis] is the assumption that all settlements are the same – they are really not. In really dense settlements in Nairobi people live in a shack of about three square metres and there may be one family in each shack. Better-off families have two rooms, or two shacks, but many of them can’t afford that. People live in very close proximity to each other and therefore it is very easy for the disease to spread.

“It’s impossible to practice social distancing, and even the things we take for granted – for example, these families live for the most part without taps in their homes. The way shacks are organised is generally you will have five to 10 shacks on a plot, and that plot would have a tap and a toilet, but there’s not always running water. You might have an informal settlement that only has water three days a week; the other four days there is no running water. Or water is available for five hours a day; the other 19 hours there’s no running water, so hand washing for example is impossible.”

Mitlin’s work with SDI Kenya aims to address the challenges in the country’s slums head on by allowing communities to share data and information about ill health, using multiple informants in each settlement and sharing information with other people in the locality so individual leaders have a better understanding of the situation.

Regular reports and updates are posted on the website of Muungano, an organisation that works with SDI Kenya, in an effort to make sure slum residents are seen and supported during the pandemic.

Over three months, the project, funded by Manchester University and the Global Challenges Research Fund, aims to monitor 400 communities via an accessible, online platform. It will pilot community hand washing stations in areas with little running water, as well as community isolation shacks suitable for a variety of different contexts within a settlement.

At the time of writing Kenya had confirmed 1,471 cases of Covid-19, but at the end of April there were just 5,000 testing kits in a country with over 51 million citizens.

Mitlin described how the virus itself isn’t the only threat to communities living in informal settlements, citing economic and educational impacts that are “considerable”.

“Before you get to the spread, the curfew in Kenya has caused very significant disruption to informal settlements,” said Mitlin.

“People can’t do the work they used to do. Things are being shut down, formal shops are being kept open but informal shops much less, schools have been shut, so there are the economic and educational impacts that are really very considerable.

“[And then] there is a lot of concern about what will happen if it spreads. Hospitals have very limited equipment and lots of people will not be able to access hospitals – community health workers and volunteers will do what they can.

“One of the things to work out now is how to isolate people who are sick, and also isolate those who are vulnerable – for example, old people and people with health conditions. But those things are not straightforward when you have really low income people and limited space in which isolation can take place.”