IMMpress Magazine: International Immunology (Volume 11 Issue 3)

IMMpress Magazine Magazine of the Department of Immunology, University of Toronto

2024 | vol.11 no.3

International immunology Smallpox Eradication A show of worldwide collaborative brilliance

World Health Organization Its inception, success, and pitfalls

Collaborative Crossroads

Examining the successes and setbacks during the COVID-19 pandemic ISSN 2291-2398

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About the Cover In the intricate tapestry of our world, every individual, community, and nation is interwoven into a web of cause and effect where actions and events in one corner of the globe resonate across borders. This interconnectedness is critically highlighted in the global spread of infectious diseases. An outbreak in one part of the world can rapidly cascade into a global health crisis, emphasizing how the well-being of every individual is inextricably linked.

Yet, within this interconnected world lies a positive opportunity. The very same web of cause and effect that magnifies the impact of global challenges also provides the foundation for a collaborative effort to address them. The beauty of interconnectedness lies in the ability to leverage resources globally, tapping into a vast pool of diverse talents. In the context of a pandemic, international research is the cornerstone of curbing the spread of the disease. Efforts across the globe come together to better understand the immunological response to diseases, and this has allowed for novel and effective treatments.

In this issue of IMMpress, the interconnectedness of international research is visually represented in a chord diagram resembling Earth.

A chord diagram is commonly used to illustrate the inter-relationships between entities, with each arc bridging from one point to another to demonstrate their connection. As depicted, research does not occur in isolation; it is intricately connected to not only other research nodes, but to the broader world. In a way, we are all integral parts of a larger network of efforts aimed at creating a better world for everyone.

Design notes

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EDITORS-IN-CHIEF James Pollock Karen Yeung DESIGN DIRECTOR Kitty Liu SOCIAL MEDIA COORDINATOR Tianning Yu SENIOR EDITORS Baweleta Isho Tiffany Kong James Pollock Siu Ling Tai Alara Tuncer Karen Yeung Tianning Yu DESIGN ASSISTANTS Daniah Alkassab Sarvin Fathi Daneshvar Arwa Hilal Baweleta Isho Boyd Johnson Sabah Kahnemuyipour Meggie Kuypers Kitty Liu Jennifer Sahadeo Sophie Sun Nasana Vaidya Karen Yeung Tianning Yu Adriana Zutic CONTENT CONTRIBUTORS Jennifer Ahn Daniah Alkassab Matthew Bianca Zi Yan Chen Irene Fang Sarvin Fathi Daneshvar Mira Ishak Boyd Johnson Rafeed Khan Kitty Liu Jinny Tsang Boyan Tsankov Sila Usta Nasana Vaidya Adriana Zutic

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International efforts and collaboration play an important role in visual art and design. In this issue of IMMpress, our team of diverse talents has created beautiful designs conveying the many layers of international immunology research, with each designer contributing their unique flair and artistic perspective. As we dive into this issue, we would like to thank all of our designers, returning and new, for their incredible contributions. We thank you all for all the creativity and dedication you have poured into your designs.

-Kitty Liu-

IMMpress

YM LL

UST, REC YC

Copyright © 2013 IMMpress Magazine. All rights reserved.

Reproduction without permission is prohibited.

IMMpress Magazine is a student-run initiative. Any opinions expressed by the author(s) do not necessarily reflect the opinions, views or policies of the Department of Immunology or the University of Toronto.

FOUNDING EDITORS Yuriy Baglaenko Charles Tran

CONTENTS VOL 11. NO 3. [2024] › FEATURE ON [ISSUE]

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Smallpox eradication A show of worldwide collaborative brilliance

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World Health Organization its inception, success, and pitfalls Collaborative crossroads examining the successes and setbacks during the COVID-19 pandemic

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8

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The numbers behind the science: how biomedical research varies across the globe

16 Alumni Interview with Nathalia Batista 18 The benefits and challenges of international collaboration

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20 Moving from Brain Drain to Brain Circulation 22 Crossing continents: unveiling insights from Uganda in collaborative research with North American institutes 24 Global health: on a mission to health for all

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25 Helicopter research: a driving force of health disparities between global north and south and how it can be curbed 26 Navigating inequities: the challenges and bias faced by scientific research in lowincome countries

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28 Unhealthy planet = unhealthy people 29 Health data use and misuse: navigating information dissemination and privacy in thedigital age 30 Studying abroad: the immunologist’s perspective 31 A book review on Braiding Sweetgrass: Indigenous Wisdom, Scientific Knowledge and the Teachings of Plants

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LETTER FROM THE

EDITORS

In order of left to right: James Pollock (Co-Editor-in-Chief), Kitty Liu (Design Director), Karen Yeung (Co-Editor-in-Chief), and Tianning Yu (Social Media Coordinator)

Immunology, by its nature, knows no geographical boundaries. In this issue of IMMpress Magazine, we celebrate the diverse tapestry of research and innovation that span continents and highlight the collective efforts of scientists working together to unravel the mysteries of the immune system. Researchers often face unique challenges, depending on where they live, but still share a collective commitment to advancing human health, fostering a unity of purpose that resonates across borders.

We begin, as always, with an infographic comparing research trends by continent (p8). We follow this with a history of smallpox and the global efforts that led to its eradication (p10), an analysis of the triumphs (and failures) of collaboration during the COVID-19 pandemic (p14), and a look at the WHO from its early days to the present (p12). To learn more about immunology research around the world, we interviewed the globetrotting UofT alumnus Dr. Nathália Batista about her worldly scientific training and career path (p16).

We follow this with an article on brain drain: the migration of scientists looking for better opportunities (p20). Next, we delve into the exciting and emerging fields of global health (p24) and planetary health (p28) research. For personal perspectives on “international immunology”, we share stories from international students on the challenges of studying abroad (p30) and as well as a conversation with a Ugandan researcher on his experiences with international collaboration (p22).

We also remember some of the past and ongoing ethical issues in international research, with articles on the inequities faced by researchers in low-income countries (p26), exploitation in “helicopter research” (p25), and patient data privacy in the digital age (p29). Lastly, we end this issue with a review of the book Braiding Sweetgrass by Robin Wall Kimmerer, in which she reflects on the influence of her Indigenous heritage on her work in environmental biology (p31).

As we embrace the theme of “International Immunology,” we hope to inspire our readers to think beyond borders and appreciate the interconnectedness of scientific inquiry. After all, the immune system, in its complexity and adaptability, serves as a metaphor for the global scientific community, where collaboration and shared knowledge are paramount.

Each issue of IMMpress Magazine is assembled by a talented group of student writers, editors, and designers. As we enter the New Year we’d like to thank everyone on the team for their great work in 2023 and look forward what they have in store for us in 2024. As always, we are grateful to the Department of Immunology and our sponsors at BioLegend for their continued support. We hope you enjoy this issue of IMMpress!

James Pollock

Karen Yeung

IMMpress Vol. 11 No. 3 2024

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LETTER

FROM THE CHAIR “Doing science with care and humility is a powerful act of reciprocity with the more-than-human-world” - Robin Wall Kimmerer Reciprocity…That is the word I would use to describe this fantastic new issue of IMMpress dedicated to Global Science. In Kitty Liu’s review of Braiding Sweetgrass by indigenous writer Robin Wall Kimmerer, we learn that reciprocity is about beneficial relationships between us and the world we live in. For us Immunologists, reciprocity can and should also be about our relationships between scientists from different parts of our world – and not just the parts with the most resources. There are beautiful and inspiring examples of reciprocity throughout this issue. Read Boyan Tsankov’s article on the eradication of smallpox, an endeavour that succeeded despite the barriers of the Cold War, or Boyd Johnson’s article about our very own Dr. Rae Yeung who has been busy swapping notes with colleagues around the world so that we may better treat rare diseases in children.

Reciprocal training: For this kind of reciprocal global science to succeed, it must begin at the training stage. Mira Ishak outlines the provocative idea of stemming the tide of “brain drain” by converting it to “brain circulation” through trainee exchanges. This is the mission of Associate Chair in International Collaborations and Initiatives Dr. Eleanor Fish who spearheaded the wildly successful Beyond Science Initiative, a not-for-profit consortium comprised of scholars from around the globe that bring science to trainees no matter where they live. And let’s not forget the hard work of our own Dr. Michelle Letarte who has been supporting trainees in their home countries through her role at the IUIS, as delightfully told in this fun tribute. Lastly, heartfelt testimonies from two Immunology international students helped me to better understand their newcomer experience.

Reciprocal health: While global science is clearly important for our collective health and prosperity, it is not a walk (or airplane ride) in the proverbial international park. As Irene Fang and Daniah Alkassab remind us, conducting research in low- and middle-income countries (LMIC) should be pursued with great care, being ever mindful of what is ethical, what is sustainable, and the ethos of co-discovery. However when done mindfully, such research is very rewarding - “Health For All”, as described by Nasana Vaidya, is a research approach that sits at the intersection of biomedical sciences, epidemiology and public health with the goal of not only disease prevention/treatment but rectifying systemic inequities that create health risks for vulnerable communities. A great example of the challenges and rewards of “Health For All” is depicted in Jinny Tsang’s interview with James Nnamutete, a study coordinator at the Rakai Health Sciences program (RHSP) situated in Kalisizo, Uganda.

Reciprocal data: Of course, a key player in global science is WHO. In Adriana Zutic’s article “Who’s WHO?” I couldn’t help but be reminded of one of Toronto’s previous mayors who, during the SARS pandemic of 2003, infamously stated “Who are these WHO people?” It was a dark time for Toronto, but of course nothing compared to the COVID-19 pandemic which followed and revealed stark global inequities as outlined by Matthew Bianca. Understanding these inequities will not only require team science to work together, but as Ziyan Chen writes, electronic health data can be a major arrow in our quiver.

Imagine a future of secure and ethical health data reciprocity that accelerates co-creation of medical interventions among international colleagues. This is not only important for fighting communicable diseases, but also for dealing with the health consequences of global climate change and pollution, as enumerated by Sila Usta. And as a nod to the earth, with the exception of a small paper run, IMMpress Magazine is now totally digital!

Reciprocal care: Last, but certainly not least, hearing about Dr. Nathália Batista’s efforts as co-chair of the Toronto chapter of the International Women in Science network was very inspiring. I think of all the times I passed Nathália, a scientist from Brazil and true citizen of the world, in the hallway at the MSB and had no idea she was doing this kind of important work. I also think of the female post-docs who have come through my own lab as immigrant scientists – Drs. Olga Rojas, Georgina Galicia-Rosas, Valeria Ramaglia and Ikbel Naouar spring to mind. Sunday February 11th is the 9th International Day of Women and Girls in Science. Enacted annually by UNESCO in collaboration with UN Women, this is a great chance to reach out to women scientists, particularly those who have immigrated to train here in Toronto. These women face more challenges than we realize.

It is a massive honour to write my first Letter from the Chair for IMMpress Magazine. I am exceedingly proud of this student-run publication.

Jen Gommerman, PhD Canada Research Chair in Tissue Specific Immunity Professor and Chair, Department of Immunology IMMpress Vol. 11 No. 3 2024

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The Numbers Behind the Science: How Biomedical Research Varies Across the Globe The importance of global collaboration is the highlight of this issue, and for good reason. Research is driven by collaboration. Some of the world’s most pressing health issues are not limited to one geographical location, and so a global understanding of these issues is essential. One of the greatest public health successes ever achieved was the global eradication of smallpox in 1980. This incredible feat would not have been possible without the collaborative research effort conducted across the globe to develop safe and effective vaccines against the highly contagious disease.

Despite vast increases in the time and money that are spent on health research, solutions to some of the world’s greatest health problems are still lacking.

The driving factor behind this discrepancy is a disparity in the global allocation of health research funding. Focusing specifically on biomedical research, funding varies drastically from continent to continent.

Additionally, not all research topics are investigated to the same extent in all regions. Generally, in higher income regions, such as the Americas (North and South America) and Europe, funding is devoted to research on chronic illness and noncommunicable diseases. These are diseases that do not spread through infection and are not considered contagious.

Meanwhile, lowerincome countries focus their research funding on communicable diseases, such as malaria, tuberculosis, and cholera. Without a common research focus across the globe, and discrepancies in research funding, how can we foster collaboration to look for answers to some of our most pressing issues?

These are some of the global trends across the globe.

Disclaimer: The data presented here is based on biomedical research funding awarded in the form of grants, since grants are a major way that many research organizations obtain the funding necessary for their work, and most of this information is publicly reported. Evidently, this does not encapsulate all research being conducted, but serves to represent the majority of publicly funded research.

For more information and additional measures of health research trends across the globe, check out the World Health Organization’s (WHO) Global Observatory on Health R&D. All data is presented in US dollars.

- Adriana Zutic 8 IMMpress Vol. 11 No. 3 2024

Annual grant amount by income group

Most awarded research topics globally Annual grant amount by health category

Percent female researchers by region

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Smallpox Eradication:

a Show of Worldwide Collaborative Brilliance An infectious disease that had plagued humanity for nearly 3000 years

I

nternational scientific collaboration makes use of the collective experiences, knowledge, and intellect of diverse nations. Through shared knowledge and combined efforts, it pioneers breakthroughs unattainable within the confines of solitary endeavors, propelling innovation to unprecedented heights. One clear instance exemplifying the power of international collaboration is demonstrated in the concerted effort of smallpox eradication.

sponse that eventually contributed to the death of 30% of infected individuals. The severity of this disease can be demonstrated by examination of the 20th century alone, in which a minimum estimate of 300 million people died. The global transmission of smallpox is largely attributed to the rapid expansion of international trade throughout the 13th – 18th centuries period during which smallpox became a pandemic and required massive eradication efforts.

Smallpox is an infectious disease that had plagued humanity for nearly 3000 years. It was caused by the variola virus, and clinically manifested as a progressive skin rash to result in overwhelming viremia and a prolonged immune re-

Prior to the 19th century, variolation was the primary method used to control smallpox. This involved inhalation of smallpox scab material by a healthy, uninfected individual in hopes of inducing a mild but protective infection. Although

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the origins of variolation remain poorly characterized, evidence suggests that it has roots in China or India, and later was adopted by the European subcontinent. Despite its rudimentary nature, variolation decreased the overall mortality

In 1967, the WHO intensified the smallpox eradication program by using Collier’s vaccine storage method, employing more aggressive mass vaccination campaigns, and establishing case surveillance systems throughout the world. of the contracted disease from 30% to 2%. The standard of care did not change from variolation until 1796, during which an English doctor, Edward Jenner, noticed that milkmaids who had been infected with cowpox were protected from smallpox. He postulated that cowpox may be of a similar nature to smallpox, and that exposure to cowpox can protect individuals from smallpox-associated death. To test his hypothesis, Jenner took material from a cowpox pustule derived from an infected milkmaid’s arm and inoculated it into the arm of James Phipps, a 9-year-old boy. Months later, Jenner exposed the boy multiple times to the variola virus, during which the boy never developed smallpox. Jenner later published his results in what would become one of the first modern scientific publications in immunology. Jenner’s work on vaccination became widely accepted in Europe and was published in all of the major European languages.

Two years following Jenner’s publication, Dr. John Clinch subsequently introduced Jenner’s vaccine to North America in Trinity, Newfoundland, Canada. Similar efforts for vaccine administration were seen in the United States of America, in which the first vaccine was administered in 1800. Within the first decade of the 19th century, smallpox vaccination was routine in Europe and the United States. Similarly in 1804, Francisco Javier de Balmis and his deputy José Salvany intoduced the vaccine throughout the Spanish Empire in South America and Southeast Asia.

Despite such early collaborative efforts to spread vaccination throughout Europe, the Americas and Asia, and vaccination becoming mandatory in various regions, total eradication of smallpox was difficult to achieve. This was primarily due to concerns of infections occurring from vaccine contaminants and arm-to-arm vaccination strategies. Thus, the WHO launched the global smallpox eradication program.

However, this initiative struggled with lack of funding and acceptance by some countries resulting in regular outbreaks occurring in South America, Asia, and Africa. The main identifiable issue was the lack of vaccine storage, as there had

not yer been a streamlined method of storing vaccine doses for prolonged periods resulting in loss of vaccine efficacy following shipment.

In the 1950s, an English microbiologist named Leslie Collier discovered that the addition of phenol and peptone to the liquid vaccine prevented bacterial contaminants and protected the virus particles from the freeze-dry process. The process developed by Collier increased the efficacy of the dried vaccine following prolonged storage, which allowed it to be transported to and administered in tropical areas and remote communities. In 1967, the WHO intensified the smallpox eradication program by using Collier’s vaccine storage method, employed more aggressive mass vaccination campaigns, and established case surveillance systems throughout the world.

The efforts exerted by this intensified smallpox eradication program were further enforced by an agreement between the Soviet Union and the United States of America whereby the Soviet Union purchased freeze-dried smallpox vaccines on behalf of Eastern Europe, China, and India. Furthermore, in a concerted effort, America, Britain, Canada, Cuba, France, and the Soviet Union freely gave stored vaccines to the WHO to distribute to countries with regular smallpox outbreaks. In addition, the adoption of knowledge and technical resources by countries in Africa, Asia, and South America resulted in

To this day, smallpox remains the only disease which humanity has completely eradicated. local manufacturing of vaccine supplies. Through this concerted worldwide effort, the last case of naturally acquired smallpox infection was documented in 1977 — Ali Maalin from Somalia. He was isolated by the local Somalian smallpox eradication team led by Jason Weisfeld from the American Centre for Disease Control, and Karl Markvart from Czechoslovakia. Ali Maalin made a full recovery following treatment. The world was declared free of smallpox on May 8th, 1980.

To this day, smallpox remains the only disease which humanity has completely eradicated. This is perhaps unsurprising given the framework of solidarity that was present in the world during that time. It is indeed remarkable what humanity can achieve when it works together.

- Boyan Tsankov

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WHO’S

The World Health Organization –

F

acing the destructive aftermath of World War II, nations around the globe convened to form the United Nation in 1945.

At one of its first conferences, representatives from Brazil and China proposed the concept of a global health organization, which would facilitate collaboration between countries to fight the spread of diseases. Three years of additional conferences, commissions, and proposals later, the constitution of the World Health Organization (WHO) came into effect on April 7th 1948. Armed with an initial budget of 5 million USD and 55 member states, WHO embarked on campaigns to prevent infectious diseases while promoting sanitation, nutrition, and maternal and child health.

Fast forward 75 years, WHO has 194 participating member states and an approved budget of 6.8 billion USD for the upcoming year 2024-2025. Since its inception, WHO has been instrumental in implementing vaccination programs, eradicating smallpox, and reducing global deaths from infectious diseases such as malaria, measles, and tuberculosis.

One of the most successful operations by WHO has been the near-eradication of polio.

Poliomyelitis (polio) is caused by poliovirus, which infects the nervous system and causes a wide range of symptoms including fever, stiffness in the neck, pain in the limbs, and permanent paralysis. During the 20th century, repeated polio epidemics in developed countries left thousands dead and paralyzed. For example, there were more than 21,000 paralytic cases in the United States during the year 1952 alone.

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Fortunately, the invention of polio vaccines by American scientists, Jonas Salk and Albert Sabin, allowed the number of cases to drop significantly. In fact, dissemination of vaccines across the country eliminated polio entirely from the United States by 1979.

However, polio remained a persistent problem in developing countries. Recognizing the need for vaccines in resource-limited regions, WHO launched the Global Polio Eradication Initiative (GPEI) in 1988. In collaboration with other humanitarian organizations such as Rotary International, WHO helped to escalate vaccine production and immunization programs in affected countries. Their concerted efforts eradicated wild poliovirus from the Americas, Western Pacific, and Africa by 1994, 2000 and 2020, respectively. Altogether, wild poliovirus cases have decreased by 99% since 1988. As of 2023, there have been 11 reported cases of wild poliovirus in Pakistan and Afghanistan – and WHO continues its endeavors to achieve complete eradication of polio worldwide.

“WHO

stands as a leader of global health as the international community looks up to the organization for its reports, decisions, and guidance.

Despite its successes, the 75-year-old global health agency has not been exempt from criticisms, accusations, and controversies. For example, WHO was heavily criticized for its

WHO?

– its inception, successes, and pitfalls delayed and insufficient response during the Ebola virus epidemic in West Africa. While the number of lethal and infectious cases rose in March 2014, WHO did not declare Ebola a Public Health Emergency of International Concern until August of that year.

Public health experts claimed that such delay in reporting the risks and scale of the outbreak to international communities was costly – as there were 1,711 more cases and 932 deaths during the five-month period. They also claimed that WHO was not prepared to tackle the various factors that exacerbated the outbreak – including political and economic tensions in West Africa, weak national health systems, and lack of funds allocated for emergency responses. By publishing a formal report in The Lancet, these experts demanded WHO address three main objectives: 1) increase transparency, 2) establish lines of accountability and 3) re-organize its structure so that WHO and its budget are protected from political pressures. In total, the West African Ebola epidemic resulted in 28,000 cases and claimed 11,000 lives from 2013 to 2016. Considering the criticisms WHO received during this time, one cannot help but wonder whether the number of cases and deaths would have been reduced had WHO responded in a timely and effective manner.

Most recently, WHO was embroiled in another controversy during the coronavirus disease related 2019 (COVID-19) pandemic.

More specifically in 2020, then United States president Donald Trump announced his intent to withdraw the country’s membership and funding from WHO. He justified this decision by accusing WHO of mismanagement,

slow actions, and deferential stance towards the Chinese government. The Trump administration and WHO further disagreed on trade and travel restrictions, as the former advocated for imposing these restrictions on affected countries including China while the latter advised against such actions. In the midst of multiple accusations and disagreements, WHO faced potentially massive cuts to its funding and its ability to address rising COVID-19 cases. Luckily, Trump’s withdrawal plans were quickly revoked by the new Biden administration and were never realized.

However, Trump’s actions towards WHO highlighted the extreme vulnerability of the health agency to the whims and fancies of political superpowers.

During the 75 years since its inception, WHO has controlled the spread of diseases and saved countless lives. It has also made mistakes and implicated itself in tense, political situations. Riding through the ups and downs, WHO stands as a leader of global health as the international community looks up to the organization for its reports, decisions, and guidance. Inevitably, new epidemics and pandemics will continue to appear and challenge the human race – and it is imperative that WHO perseveres in its efforts to protect and promote global health.

- Jennifer Ahn

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Collaborative Crossroads – Examining the successes and setbacks during the COVID-19 pandemic

T

he COVID-19 pandemic has had many profound long-lasting effects on our personal and professional lives. It has influenced our views on how we live, where we work, and importantly, the ways which we interact with people and the world around us. Although efforts to curb the spread of the virus limited our physical associations, the necessity to set aside differences and coalesce as a global community was never more important. Collaborative efforts in scientific research and public health played an undeniably important role in addressing the myriad of challenges that were presented throughout the pandemic. During this time of global uncertainty, however, certain aspects of collaboration succeeded while others faltered and fell short of reaching their potential in the face of adversity.

Even prior to the World Health Organization (WHO) declaring COVID-19 a global pandemic on March 11th, 2020, the scientific community had taken advantage of global information sharing capabilities to accelerate our understanding of the virus. Researchers in China sequenced the SARS-CoV-2 genome and made this genetic code available through public databases on January 12th, 2020. This commenced a global surveillance effort, where uploading of SARS-CoV-2 sequences to the Global Initiative on Sharing All Influenza Data (GISAID) platform enabled researchers to monitor viral spread and emerging variants.

Successful public-private partnerships played a pivotal role in the rapid development, testing, and distribution of numerous effective COVID-19 vaccines and diagnostic tests. One notable collaboration which produced the innovative BNT162b2 mRNA vaccine occurred between Pfizer, a multinational pharmaceutical company, and BioNTech, a German biotechnology company specializing in mRNA-based human therapeutics. Project “Lightspeed” combined the expertise and experience of both Pfizer and BioNTech to develop the world’s first authorized mRNA vaccine, being approved for distribution in late December 2020. The urgency of the pandemic prompted rigorous Phase 3 clinical trials of the vaccine to commence in parallel with manufacturing optimization processes. With Pfizer’s infrastructure to conduct such large-scale clinical trials, this approach permitted a faster distribution timeline without compromising safety and efficacy standards.

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With the goal of guaranteeing fair access and equitable distribution of COVID-19 vaccines for people in all countries, COVID-19 Vaccines Global Access (COVAX) was a worldwide initiative launched in April 2020. This collaborative effort between various international organizations, including Gavi, the Vaccine Alliance, the Coalition for Epidemic Preparedness (CEPI), and the WHO, emphasized the interconnectedness of global health. By fostering a coordinated, inclusive, and equitable approach, COVAX placed a strong emphasis on supporting lower-income countries who struggled to independently secure an adequate supply of vaccines and faced logistical challenges with distribution. By pooling funds from wealthier countries using the Advance Market Commitment financial mechanism, the COVAX initiative ensured vaccine manufacturing was supported prior to approval and that dose procurement was arranged for all participating nations. This collective approach between the 184 participating countries of COVAX mitigated disparities in vaccine access and limited vaccine nationalism that may have otherwise exacerbated global health inequalities.

Although the COVID-19 pandemic saw an unprecedented increase in first-time collaborations between research groups, acting as a catalyst of scientific novelty and innovation, there were many instances where collaborative efforts were overshadowed by perpetual shortcomings and missteps. One instance which exacerbated the challenges faced during the pandemic was the lack of a cohesive and coordinated global governance and leadership strategy. The absence of a unified approach and highly divergent regional responses hindered efforts to contain the virus and protect vulnerable populations. Despite effective strategies to limit transmissibility of SARS-CoV-2 being discovered during early months of the pandemic, global epidemiological data was not always translated into a strategic response. The implementation of swift and stringent lockdowns, by countries such as New Zealand, proved to successfully eliminate community transmission for extended periods. In contrast, nations such as Sweden adopted more of a lenient approach to minimize economic disruptions at the cost of a higher per capita death rate compared to neighboring countries. The further absence of an integrated approach implementing travel restrictions and border control measures complicated efforts to contain international spread of the virus.

Contact tracing app technology was extensively developed and implemented throughout the COVID-19 pandemic to help identify and notify individuals who may have been exposed to SARS-CoV-2. In Canada, the federal government collaborated with provincial health authorities to launch the COVID Alert app in July 2020. Despite the nationwide efforts to utilize these technological advancements for disease surveillance, the decentralized nature of public health management and infrastructure across regions in Canada led to many challenges. A drastic lack of standardization and interoperability among provinces and territories limited the effectiveness of contact tracing as gaps in information sharing existed. Further, this federal and provincial collaboration approach to adopt contact tracing apps failed to provide solutions which addressed technological inequalities, typically faced by older individuals or those in lower-income brackets lacking access to smartphone apps. Despite collaborative efforts, a lack of effective solutions were presented to tackle the digital divide within Canada which ultimately limited the effectiveness of contact tracing apps.

As the world prepares for future health crises, it is essential that lessons learned from collaborative efforts during the COVID-19 pandemic are addressed in policy and decision-making strategies. Whether this involves reflecting on the positive power of collective efforts or criticizing cooperative shortcomings, there exists a large opportunity to strengthen collaborative frameworks to ensure that society is best prepared for cohesive and effective action when the time comes.

- Matthew Bianca

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Alumni Interview with Dr. Nathália Batista “Immunology has always fascinated me. Its complexity presents a challenging yet stimulating area of study. Additionally, the direct impact on healthcare and the potential to improve motivates me greatly,” says Dr. Nathália Batista, a scientist at Treadwell Therapeutics.

Her passion for science has led her on a journey all around the world, with the goal of gaining new perspectives in science and improving healthcare. I sat down with Nathália to discuss her academic experience, both before and after her time at the University of Toronto, and how her experiences helped her get to her established position today.

Who is Dr. Batista and where has she been?

Nathália has had a truly enriching academic experience as it has allowed her to travel the around the world. After completing her undergraduate studies in biology at the Universidade. Federal de Minas Gerais (UFMG) in Brazil, she spent a summer at the University of Calgary in Dr. Donna-Marie McCafferty’s laboratory. She then pursued a master’s degree in Cellular Biology at UFMG and spent three months as a visiting fellow at the Université de Rennes in France.

Nathália returned to UFMG to study Immunology for her doctoral degree, during which she spent 18 months as a visiting fellow at Humanitas University in Milan, Italy. Nathália expressed that none of her international experiences were planned. Her few months in France were the serendipitous product of attending a seminar by two professors from Rennes who were interested in collaborating. Nathália says that her 3-month French excursion and year-and-a-half stay in Italy “exposed me to different cultures, traditions, and ways of life…broadened my worldview, enhanced my adaptability, and fostered cross-cultural understanding”.

Travel provided Nathália access to specialized equipment and resources that weren’t readily available for her at UFMG. It was important to foster collaboration, exchange ideas and access diverse perspectives, allowing her to present research findings at international conferences and seminars.

The Alma Mater Experience

Due to the financial constraints faced by scientists in Brazil, Nathália was certain that she would pursue her postdoctoral studies abroad. A position at UofT in Dr. Tania Watts’s lab was her top choice primarily because of its exceptional research program and its location in a highly multicultural city, which she believed would facilitate her life as an immigrant. In 2017, Nathália moved to Toronto to start her postdoctoral research in Dr. Watts’s lab where she later transitioned to the role of research associate. While working there, she focused on T cell activity and antigen-presenting cell (APC)-T cell interaction in viral infections and cancer. She primarily worked on manipulating signals from members of the tumour necrosis factor receptor (TNFR) superfamily and the TNF family ligands to induce long-lived T cell memory to protect against viral infections.

Nathália’s postdoctoral experience was incredibly valuable, allowing for the acquisition of new skills, deepening her expertise in T-cell biology, enhancing her project management and leadership skills, and expanding her professional network. She emphasizes, “Dr. Tania Watts was an exceptional supervisor and mentor. The experience I gained while working with her significantly impacted my future career opportunities. My experience at the Department of Immunology was wonderful as it exposed me to groundbreaking research by esteemed researchers”.

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International Women in Science (IWS) Network: The IWS Network is a grassroots organization dedicated to supporting international and immigrant women in science across Canada. They engage with IWS fellows through monthly meetings, actively participate in equity, diversity and inclusion events, connect across various social media platforms, and advocate for women’s empowerment. This organization plays a crucial role because securing STEM employment can be immensely challenging for new immigrants, where highly skilled immigrants often face barriers due to a lack of Canadian work experience or recognition of their credentials; a challenge particularly daunting for women.

Nathália volunteered with IWS Network from February 2021 to October 2022 where she served as one of the co-leaders for the Toronto chapter. Additionally, she held the position of National Board Member and co-chair of the Communications & Marketing Committee for a year. As a co-leader in Toronto, Nathália organized various events and mentorship programs. While she was the Communications & Marketing Committee co-chair, she managed national events and fundraising campaigns, and developed advertisement and marketing materials. She notes that the volunteering experience was incredibly rewarding, providing her with opportunities to connect with like-minded individuals, industry professionals, and STEM experts, thus expanding her professional network. She made sure to highlight that the most important part of being in an organization like this is that it promotes gender equality in STEM and supports immigrant women in Canada. This was personally rewarding to her as she knew she was contributing to a cause that could have a lasting impact.

Current life and future plans

Nathália currently works at Treadwell Therapeutics as a scientist within their cell therapy program, where their focus involves developing TCR-based therapy for cancer patients. “Working in this field is captivating as it entails groundbreaking research,” Nathália says to me. Most of Nathália’s responsibilities revolve around hands-on laboratory experimentation, protocol development, and conducting assays to evaluate cell function. Despite the challenges this work inherently has, TCR-based therapies prove to have substantial potential in treating diseases like cancer. This kind of research could revolutionize healthcare and proves to be a driving force for Nathália.

For the moment, Nathália envisions herself staying in Canada and working in research- related positions within the field of immunotherapy.

Advice for fellow scientists I asked Nathália if she had any tidbits for those looking to pursue a similar career path as her. She told me that in addition to being very knowledgeable in your field of expertise, networking holds significant importance. Establishing connections with professors, researchers, and professionals in your field can offer mentorship opportunities, collaborations, and valuable insights into career paths.

While Nathália mentions she had a defined plan for her career trajectory, she remained open to possibilities. She states that “opportunities aren’t just stumbled upon; they are created. Most importantly, readiness and the willingness to seek and pursue opportunities are crucial. Embrace new ideas, step beyond your comfort zone, take risks, and embrace new challenges. The journey toward a career in science demands persistence and adaptability”.

- Rafeed Khan

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the benefits and challenges of

INTERNATIONAL COLLABORATION

T

ronto) is a clinician scientist workhe concept of international collabgium) works full time while pursuing ing in pediatric rheumatology, where oration invokes the greatest ideals her PhD. Nayab brings together varshe studies rare childhood diseases of science: working together on global ious groups for a common goal: the through the lens of translational imissues, aligning the agendas of diverse prevention and treatment of cervical munology. There are few scientists that groups, and developing a more robust cancer. Part of Nayab’s job is to orgaexamine ultra-rare diseases this way, understanding of the world. While nize meetings with experts to discuss reflected in limited grant dollars globmany research questions could bentools for HPV prevention, including ally. According to Yeung, it became apefit from the breadth of international implementing HPV vaccines in lowcollaboration, we must considand middle-income countries. er what constitutes a successful This means collaborating with "The concept of international collaboration collaboration. What challenges industry, vaccine manufacturinvokes the greatest ideals of science." do these researchers and trainees ers, and NGOs across contiface when building and mainnents. parent that “none of the investigators taining complex, multifaceted colwould move forward unless they all laborations? Ultimately, what can be Both Nayab and Dr. Yeung face chalmove forward as a collaboration, rathproduced from this work that non-collenges in the pursuit of international er than competition.” With this goal laborative work cannot accomplish? collaboration. According to Dr. Yeung, established, collaboration began with harmonizing procedures is the most biospecimen collection, a fundamental We seek to answer these questions difficult challenge, and the least gloritask upon which all their research was through the perspective of researchers ous. It requires tedious work that will built. “If you cannot harmonize the at different levels of the collaborative not receive high impact attention, and process. Dr. Rae Yeung (SickKids, Tobasic foundations of what you do, you the resulting low-impact publications cannot collaborate,” Yeung says. Dr. are not great for career development.

Yeung went on to develop UCAN (Understanding Childhood Arthritis NetFurthermore, many challenges arise work), an international translational in sharing collaborative data: regularesearch federation encompassing tory, ethical, and legal concerns need 50 countries, in which memto be addressed across institutions bers engage with one another in and all levels of government. For Dr. shared principles of research. Dr. Yeung, this necessitated a full legal Yeung leads UCAN and other consorteam to manage 70+ contracts between tia to achieve her scientific goals, one Canada and the European Union. Lanof which is to bridge the “gap in treatguage differences are also considered, ment approaches and support transas patient questionnaires and consent lational research for all children with forms must be accurately translated. juvenile arthritis.”

To overcome these administrative hurdles, Dr. Yeung is supported by fullAcross the Atlantic, Dur-e-Nayab time project managers, biospeciWaheed (University of Antwerp, Belmen teams, funding agencies,

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a legal team, and “country leads” that are sent to each country to assist in rollouts and personalizing workflows for different sites.

ones. In contrast, Dutch physicians prescribe based on perceived efficacy.

The Dutch found that prescribing the most expensive drug within a specific window of opportunity leads to a high success rate for treatment and avoided drug dependency. In Canada, this drug cannot be started until a year of failing other drugs. In hopes of promoting equity in healthcare, the window of intervention is missed, leading to lifelong pharmaceutical dependency. Thus, international collaboration

Both Nayab and Dr. Yeung emphasize the importance of mentorship for those that wish to pursue careers in international collaboration. Nayab notes that personal connections and In contrast, Nayab sees fewer chalprogress will be highly dependent on lenges. Differing work environments your group and a supervisory princiacross countries can lead to variable pal investigator supportive of your expectations in project timelines. It is goals. She advises to be mindful of difficult to master the nuances of comhow you communicate, and to admunication and its variable features vocate for your ideas. Similarly, Dr. from culture to culture. Nayab notes Yeung encourages prospective trainthat “how you say something and how ees to find mentorship that will build the other person perceives their network of collaborait can be [different]” and tors and nurture functional "...those engaged in international collaborations may cross unknown cultural Successful find their chosen work to be fulfilling, worth years collaborations. boundaries to result in the international collaborations loss of collaborator partici- of investment to build something that impacts lives surmount multiple challengpation in meetings or studies. es to provide reproducible across continents."

One example is the promoand impactful results, with tion of vaccination programs. “You highlights differences in regulatory the potential to provide insights that are an outsider coming in telling peomeasures and allows doctors to proextend beyond the reach of any single ple what to do. That can come off as vide data-driven precision medicine, institute. It is apparent that those enoffensive.” Nayab and her team must benefiting patients while decreasing gaged in international collaborations be careful about what language they lifetime healthcare costs. Dr. Yeung find their chosen work to be fulfilling, use and how they position themselves finds this work incredibly rewarding, worth years of investment to build in the conversation, framing meetings “seeing the perspective and challenges something that impacts lives across as discussion platforms rather than inof other countries opens our eyes to continents.

- Boyd Johnson structional. better questions that we can ask, and how to better translate the science.”

Accounting for these challenges, Dr. Yeung and Nayab still find collaboraNayab finds her collaborative work tion between researchers to be synersimilarly gratifying: “[the work] feels gistic for their work. For Dr. Yeung, more meaningful, motivating me to standardizing protocols significantly come to my job and do challenging aids translational research. The work tasks.” The difficulties of collaboof UCAN presents a compelling case ration are worth the effort to allefor international influence on the acviate the global cervical cancer burcessibility of healthcare, in which den. This endeavor also ensures that studying the biology of disease dicgroups do not replicate data and detates prescribing practices and access vote their resources to novel questions. to medication. Dr. Yeung describes On a professional level, she now has one example in which Canadian regaccess to people in organizations spanulations stipulate that her patients ning the globe, benefiting her network must fail cheaper drugs before when exploring career options beyond they can use more expensive academia.

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Moving from Brain Drain to Brain Circulation B

rain drain is a term coined in the 1950s to describe the emigration of highly skilled personnel, particularly physicians and scientists, from Great Britain to the United States and Canada. During this time, professionals departed their home country in pursuit of better salaries, increased research funding, and more favorable job opportunities. While the landscape has evolved since the 1950s, the concerns surrounding brain drain have evolved into a complex ethical dilemma.

Brain drain has disproportionately affected individuals in developing countries around the world. In order to escape impoverished living conditions, political unrest, and to seek out better educational opportunities, individuals from developing countries flee their homes and seek refuge in places like Canada and the United States. While this offers incredible opportunities to the emigrating individuals, both in their professional life but also for their quality of life, it directly harms their home countries.

Skilled health professionals and researchers are needed in all parts of the world, not just the Western world. When individuals leave their home countries in search for better opportunities, the healthcare systems and scientific institutions of those countries are directly harmed in a way that perpetuates a vicious cycle that is difficult to escape.

The obvious effect of brain drain is the direct loss of skilled personnel, which limits the ability of affected countries to respond to medical emergencies and healthcare crises.

The departure of skilled researchers may also result in the slowing down of scientific and technological progress in these countries, which can limit clinical translation of research findings. Scientific emigration also affects academic institutions directly, by reducing the quality of education students can receive. This in turn reduces the quality of life in developing countries, by increasing patient burdens in hospitals, reducing the accessibility of innovative research, and limiting the educational resources available to students. Because of this, more people are motivated to leave these countries and

search for better opportunities elsewhere, perpetuating the brain drain predicament.

For these reasons, policies are desperately needed to reduce the burden of brain drain on developing countries. Instead of focusing on helping scientists and students flee their home countries for the sake of better opportunities, there should instead be a focus on helping to create these opportunities globally, not just in the Western world.

For example, there are many scholarships available for international students that help financially support them in their pursuit of education outside of their home country.

Again, while this is an incredible support system for the emigrating student, it directly depletes the resources of their home country. Instead, Western countries should work on developing programs that aim to financially support international students at their home institutions, to help strengthen the academic and research infrastructures of these nations.

In turn, countries supporting these programs can set up collaborations with international academic institutions, which can foster scientific dissemination and knowledge exchange, a benefit for all parties involved.

Moreover, there needs to be more emphasis placed on the creation of exchange programs that enable international research collaboration. For example, instead of pushing for the

The World Health Organization (WHO) estimates that the emigration rate of doctors from African countries, especially Nigeria, is as high as 50%, with most leaving to work in the UK and the United States.

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permanent relocation of scientists from their home countries, exchange programs can be put in place to encourage collaboration and expertise-sharing at an international scale. These programs could support scientists and professionals from Western countries to participate in exchange programs with scientists from countries all over the world. This would help prevent brain drain in two ways. First, by preventing the permanent loss of skilled scientists from developing countries, and second, by bringing new expertise to these countries that could help strengthen their research institutions and foster long term collaboration.

Additionally, policies should be put in place to encourage entrepreneurship in developing countries. By creating opportunities for researchers and students in their home countries, there would be less motivation for them to abandon their homes in search of these prospects. This can also provide an avenue for skilled individuals to contribute to the local economy, which in turn can improve the quality of life in their community. For example, in 2010 the Chilean government started a program called ‘Start-Up Chile’, which provided funding, mentorship, and networking opportunities to support early stage startups and entrepreneurs within the country. This program has helped support and retain thousands of skilled professionals within Latin America.

The struggle developing countries face in retaining skilled professionals and researchers is serious.

To address this issue, international organizations and governments should shift their focus from facilitating emigration out of developing countries, to creating opportunities within these countries. Policies should prioritize supporting international students at their home institutions rather than depleting resources through scholarships that encourage migration.

Collaboration between Western and developing countries should be fostered through exchange programs that promote research collaboration and expertise-sharing on an international scale. Moreover, policies aimed at fostering entrepreneurship within developing countries can create local opportunities, reducing the incentive for skilled individuals to seek opportunities abroad. This approach not only prevents the permanent loss of skilled professionals, but also contributes to the strengthening of research institutions globally.

- Mira Ishak

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CROSSING CONTINENTS: Unveiling Insights from Uganda in Collaborative Research with North American Institutes James Nnamutete is a study coordinator at the Rakai Health Sciences program (RHSP) situated in Kalisizo, Uganda. His 17 years of expertise consists of his work with various clinical studies, including those related to human immunodeficiency virus (HIV) risk and transmission within the Ugandan community. This year, I had the privilege to visit RHSP in Uganda to help initiate a clinical study for my PhD project.

James kindly participated in this interview for IMMpress, offering valuable insights into global collaborative research.

Here’s a snapshot of a conversation between James and I, bridging the distance between Kalisizo and Toronto with our discussion.

Hi James, thanks for taking the time to do this interview.

Can you please give an overview of the RHSP organization?

RHSP is a collaborative biomedical research and service delivery organization in South Central Uganda dedicated to enhancing the quality of life of all community members of the district of Rakai through community-based research, services, and prevention strategies. Beyond research, it operates as a public clinic offering medical services, including HIV prevention, alongside additional services like prayer counseling. Through research opportunities, I have personally collaborated with institutes from Canada and the United States.

From your perspective, does international research collaborations benefit RHSP and its community? How does RHSP do that?

There are a few benefits that I see from collaborative research. Each study enhances our international friendships, fosters a union between institutes, and continues to recognize RHSP’s efforts on a global scale. Through collaborations, findings are shared with the Rakai community [through community outreach programs like free soccer matches] to directly inform the health services that we provide. Importantly, international collaborators bring crucial funding to continue supporting active research from our side.

James Nnamutete, Diploma in Medical Laboratory Technology (DMLT) and Bachelor’s Degree in Medical Laboratory Sciences (BMLS) Laboratory Coordinator for Rakai Health Sciences Program

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Internally, new projects allow staff to be trained with novel skillsets, thereby increasing and experience of our team.

Likewise, new equipment purchased for studies remain in our research facility after the study ends, contributing to our resources and benefiting future projects and patient diagnosing. This increase in staff expertise and available equipment creates a positive feedback effect, enhancing our ability to secure more funds for research.

Working with international collaborators must also bring some challenges along the way. Can you tell me about some of these challenges from your experience?

Participant-facing obstacles predominantly concern the language barrier found in international collaborations. Most participants are fluent in Luganda, with English as their second language, posing challenges during surveys conducted by foreign researchers. This can lead to participants being unable to fully express themselves in English. Cultural mistrust emerges when participants perceive foreign researchers as being able to abuse their information outside of Uganda.

Nevertheless, RHSP’s image as a reputable research facility instills community trust. Conducting interviews with our Ugandan staff fosters greater confidence from participants, assuring that their personal information remains confidential and be used to directly benefit our community.

Working with international collaborators also introduces logistical challenges. Uganda is seven hours ahead of the collaborators that we commonly work with in Canada and the United States, and there isn’t much overlap during the day when both of us are working. This limits real time communication and feedback. While scheduling meetings helps, it can slow down work.

Systemic challenges persist in international collaborations. Funding is never guaranteed, and the loss of international funding impacts project sustainability and our global relationships. It is also easy to forget that there is a huge team behind each clinical study. For instance, there is an entire department that performs groundwork for the recruitment of participants for each of our studies. Their efforts are just as important as ours in the lab, but they are often overlooked in research.

Acknowledging the efforts of

all individuals is essential for a comprehensive understanding of the collective contributions to research.

Thank you so much! Okay, last question… Do you enjoy working here at RHSP? Yes! Having spent a considerable amount of time, I still haven’t felt the need to seek other job opportunities. The collective success and achievements of RHSP and the community have created a shared journey that binds me to this organization. Without this unique connection, I might have considered exploring opportunities in other sections or departments.

Collaborating with RHSP provides unique insights into local challenges faced by communities globally in addressing the persistent global health challenge of HIV. International

partnerships foster the exchange of insights on global health systems not readily apparent to other researchers, facilitating widespread knowledge dissemination through study publications. Global collaborations also promote ethical research practices and emphasizes the important of creating culturally sensitive research protocols. Since the questionnaires we use are initially prepared in English, tremendous teamwork and patience from RHSP are required to translate them into Luganda. Extensive international partnerships will not only support active research, but also reward participating institutions that produces research with global-scale social impact through funding and global reputation.

Despite spending an extended time at RHSP, this conversation has been incredibly enlightening, offering deeper insights into the benefits and challenges of working with international institutions. RHSP’s success with international partnerships is not only owed to the knowledge and expertise that each of its members brings, but also their positive and welcoming attitude when working with foreign members. Ugandans exude authenticity and hopefulness, rooted in their religious faith and strong connections with family and friends. I look forward to the possibility of visiting Uganda again and reconnecting with James and other friends and colleagues that I dearly miss. *Conversations have been edited from the original interview for clarity and brevity.

- Jinny Tsang Recent publications and studies based in RHSP1–5: 1. Prodger, J. L. et al. Chemokine Levels in the Penile Coronal Sulcus Correlate with HIV-1 Acquisition and Are Reduced by Male Circumcision in Rakai, Uganda. PLoS Pathog 12, e1006025 (2016).

2. Kigozi, G. et al. Foreskin surface area is not associated with sub-preputial microbiome composition or penile cytokines. PLoS One 15, (2020).

3. Liu, C. M. et al. The Effect of Antiretroviral Therapy Initiation on the Vaginal Microbiome in HIV-Infected Women. Open Forum Infect Dis 6, (2019).

4. Prodger, J. L. et al. Penile bacteria associated with HIV seroconversion, inflammation, and immune cells. JCI Insight (2021) doi:10.1172/jci.

5. Galiwango, R. M. et al. Immune milieu and microbiome of the distal urethra in Ugandan men: impact of penile circumcision and implications for HIV susceptibility. Microbiome10, 7 (2022).

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Glo T

he COVID-19 pandemic is not our first brush with a health crisis that has sounded a call for global action.

In 1988, the Global Polio Eradication Initiative was established in response to the ravages of polio outbreaks. Since its launch, there has been more than a 99% decrease in the incidence for this potentially debilitating disease. In 2001, the Stop TB Partnership undertook a similar goal of eliminating tuberculosis (TB) globally. More recently, the United Nations’ Agenda for Sustainable Development has set out to end the epidemics of HIV, TB, and malaria by 2030.

These concerted efforts, which extend beyond the scope of nation-specific public health, are necessary in this era of global interconnectedness and interdependence.

Global health is a field that has emerged to address health issues that transcend national borders and interests. Noting the lack of consensus on defining ‘global health’, the Consortium of Universities for Global Health Executive Board have put forward the following definition: an area for study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide. Others have since proposed a more pointed amendment – collaborative trans-national research and action for promoting health for all – to further emphasize the need for action-oriented collaboration.

Research efforts in this field spans multiple disciplines, encompassing bio-

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H l ea a on a mission to health for all

medical sciences, epidemiology, economics, sociology, among others. This multidisciplinary approach allows for a holistic understanding of health challenges through consideration of different socio-cultural, economic, political, and environmental factors underpinning health inequities.

Take, for example, TB. It is an infection caused by the bacteria M. tuberculosis, which can be cured with antibiotics. Why, then, does it continue to cause 1.6 million deaths yearly? TB is often called a ‘disease of poverty and inequity’. Social and structural factors such as overcrowded living conditions, poor access to healthcare facilities and stigma associated to TB pose barriers to receiving diagnosis and appropriate care. Consequent underdiagnosis of TB can lead to higher mortality rate from untreated cases and spreading to others. Research efforts towards improving case detection are assessing the use of systemic screening interventions in lieu of relying on self-reporting from different perspectives like regional case studies and cost-effectiveness evaluations.

Global health research has been perceived to be limited to challenges predominantly affecting low- and middle- income nations (LMICs). TB along with HIV and malaria do indeed disproportionately affect individuals in LMICs. However, many of the social and structural determinants described above affect those in marginalized communities in high-income countries (HICs), such as Indigenous people and people experiencing homelessness, as well.

Moreover, current areas of priority in the field are wide-ranging, including the mental health crisis, the climate crisis, and the rising prevalence of non-communicable diseases. Non-communicable diseases like cancer and diabetes that were once considered diseases of HICs are becoming more prevalent globally. Diseases simply cannot be contained within geopolitical boundaries.

The “health for all” commitment of global health is undoubtedly an ambitious one that is contingent on us coming together as global citizens.

- Nasana Vaidya

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W

hile international scientific research is seemingly beneficial to society as it generates new knowledge through collaboration, such collaboration is not always equitable, leading to exploitative, egregious outcomes for disadvantaged populations. This is explicated by a phenomenon called “helicopter research”, otherwise known as “neo-colonial” or “parachute science”, whereby scientists from developed countries travel to under-resourced nations to conduct research and extract samples and data with circumscribed to no engagement of local researchers. Such practices fail to adequately address the needs of local participants, let alone permit them to reap the benefit, if at all, including academic authorship, thereby entrenching imbalances of power within the global community.

Unfortunately, parachute science has not been uncommon in various fields, from geoscience to paleontology; and its occurrence in medical research is no exception. Historically, such practice has lopsidedly focused on the health needs of high-income countries at the expense of those of low- to middle-income nations, exacerbating the already-existing health inequities due to disparate access to healthcare.

This is illustrated in many studies, with an instance being a placebo-controlled trial conducted by the pharmaceutical company Discovery Laboratories of Doylestown, Pennsylvania, to evaluate the effectiveness of Surfaxin, a novel surfactant drug, on premature Latin American neonates in 2001.

Given its ability to enhance lung function, Surfaxin was used to treat respiratory distress syndrome (RDS)—a common breathing disorder and the leading cause of mortality in premature infants worldwide due to the lack of surfactant production in the lungs that led to insufficient absorption of oxygen. However, instead of receiving available, effective comparator surfactants proven by the U.S. Food and Drug Administration (FDA), 325 infants in the control group received an inert placebo that had no therapeutic effect.

The Surfaxin trial had been reprimanded as unethical and unjustified, and rightfully so. Distressingly, the study design was otherwise unapproved in Europe and the U.S. as it infringed the Declaration of Helsinki outlining the ethical principles governing human experimentation, specifically the use of the “best proven interventions” or current standard treatments for RDS in the control group in comparison to the novel intervention should they exist. Such a trial imposed an undue risk of harm on Latin American placebo subjects with preventable death.

Indeed, placebos ought to be used as a control only if they are in clinical equipoise with the experimental treatment. Despite the removal of the placebo arm of the Surfaxin study ultimately, it begs the question of what constitutes “ethical” care. Should the standard of care for high-income countries or host nations be provided in the study? Would the best care be affordable to the under-resourced countries? Would such solutions be sustainable?

Nonetheless, mutual respect, trust, and understanding are the building blocks of equitable, global partnership in science. Scientists must bear in mind that carrying out research abroad is not a right, but a humbling opportunity, and the objective of advancing new insights should never override the rights and interests of research subjects. With awareness enhancement serving as the springboard, synergistic conscious efforts from researchers, regulatory agencies, and governing bodies must be made to restrain parachute science. Potential solutions include involving local partners in processes ranging from study design to data collection and co-authorship, and establishing institutional safeguards against unethical research by rejecting papers involving helicopter research that fails to acknowledge the contributions of local collaborators, by scientific journals. After all, the ultimate goal of international scientific research is to bridge the gulf in health disparities and ensure that all of humanity benefits from it.

- Irene Fang IMMpress Vol. 11 No. 3 2024

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Navigating Inequities: The Challenges and Bias Faced by Scientific Research in Low-Income Countries Curiosity and the eagerness to learn are inherent aspects of human nature, propelling indwividuals to seek answers to various phenomena they observe or experience.

Through rigorous research, our world has undergone significant advancements across multiple fields compared to centuries ago. In fact, scientific research exhibits a positive correlation with the standard of living. Without it, human thriving would falter, and our progress would halt. While in theory, knowledge knows no borders and research should not be limited to a socioeconomic class, the reality contrasts the ideal, evident by the varying landscapes of research between low-income countries (LICs) and their higher-income counterparts.

High-income countries (HICs) have made significant investments in applied research, commonly recognized as research and development (R&D). R&D encompasses innovative activities undertaken by both private companies and the government to advance and discover new products and services, particularly in sectors such as pharmaceuticals and biotechnology. Recognizing the positive impact of R&D on the economy, HICs allocate substantial amounts of funds to this sector. As of 2020, global spending has reached $2.4 trillion. HICs typically invest approximately 3% of their gross domestic product (GDP) in R&D in contrast to the less than 0.5% invested by LICs. This significant disparity in R&D spending can be attributed to the challenges faced by LICs and their varying priorities due to their lower socioeconomic status.

As a result of poverty, LICs struggle with an array of stressors, including food insecurity, malnutrition, and a substantial disease burden. These challenges compel governments to allocate funds predominantly to essential needs, such as providing food, shelter, and medical treatments to citizens. Consequently, there is significantly less financial surplus available for investment in R&D. Limited resources further add to the challenges faced

by LICs, encompassing scarce funding and outdated technology. For instance, a 2021 study conducted on public health graduate students in Liberia revealed that, among 120 participants, 86% owned a computer. However, 18.4% and 39.4% experienced malfunctioning hardware and battery issues, respectively.

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The study also highlighted the students’struggles with poor internet connectivity for approximately 3.4 days per week. Regarding technological knowledge, 47% of students reported never using analysis programs, while 46% had limited knowledge of statistical analysis. On a broader scale, LICs encounter obstacles such as limited access to grant opportunities, outdated laboratory equipment, the high cost and limited accessibility to lab reagents, and inadequate research salaries. Moreover, the funding landscape for cutting-edge research, particularly in R&D, relies heavily on contributions from private corporations, a crucial aspect lacking in many LICs. These limitations collectively impede the capacity of LICs to engage in cutting-edge research, thereby restricting progress across various scientific disciplines.

HICs typically invest approximately 3% of their gross domestic product (GDP) in R&D in contrast to the less than 0.5% invested by LICs. The lack of prioritization for R&D in LICs can also be traced back to the substantial disease burden they face.

Poverty, coupled with issues like unclean water and inadequate sanitation, exposes citizens of LICs to an increased risk of infectious agents. Limited access to medical care and preventative measures exacerbates this vulnerability, leading to the outbreak of communicable diseases such as malaria, HIV, tuberculosis, and most recently COVID-19, in these regions. However, the challenges for LICs extend beyond communicable diseases, encompassing a concerning surge in morbidity and mortality rates due to non-communicable diseases such as hypertension, diabetes, and cancer - also prominent among low-income citizens in middle-income countries and HICs. Of concern, a study conducted by Bollyky et al. (2017) found LICs are underprepared for the shift to communicable diseases.

This warrants the need for research initiatives to address both aspects of the disease burden. Additionally, the situation in LICs explains why research is focused on health rather than R&D.

Despite the numerous challenges, scientists in LICs strive to advance the scientific field. Nevertheless, prevalent bias impedes the broader impact of their research.

This issue is highlighted by the findings of Harris et al.

(2017), who conducted a blinded crossover study involving 347 English clinicians. The study revealed that research abstracts originating from LICs were perceived differently when the source was altered to indicate a HIC. Furthermore, a notable decrease is observed in the citation rates of publications from LICs compared to those from developed nations. This discrepancy not only reflects a potential bias in the acknowledgment of research contributions but also highlights the challenges faced by scientists in LICs in gaining recognition and impacting the global scientific community.

Therefore, HICs must consider the feasibility of their research outcomes in LIC settings. This careful consideration ensures that both collaborative efforts contribute positively to global health without compromising ethical standards or feasible implementation in low-income settings.

Besides the challenges, LICs offer significant research opportunities, especially in clinical settings. These include a diverse patient population and distinctive disease profiles, creating a platform for the development of new therapeutics. HICs possess robust research capacity, funding, and equipment, leading to increased international collaborations with LICs in global health research, benefiting both parties. However, several concerns have been raised, including ethical considerations and the potential for research outcomes to be skewed in favor of HICs. Regarding ethical considerations, the absence of regulatory frameworks poses a risk of exploiting unprotected populations. This issue can be addressed by involving local collaborators to protect the rights of participants. Concerning the potential skewing of research outcomes, HICs may lack insight into the infrastructure of LICs, leading to the development of applications or therapeutics that are impractical in LIC settings.

In conclusion, the disparities in research landscapes between LICs and HICs are evident. Despite the challenges faced by LICs, such as limited resources, a substantial disease burden, and biased recognition of scientific contributions, these nations offer significant research opportunities, particularly in clinical settings.

HICs, with their strong research capacity, funding, and equipment, engage in international collaborations with LICs, providing mutual benefits in global health research. However, ethical considerations and the potential for skewed research outcomes pose challenges.

To address these issues, HICs must involve local collaborators and consider the feasibility of outcomes in LIC settings. The need for a more equitable global scientific community entails ongoing efforts to bridge the research gap and foster collaborative initiatives that benefit all nations.

There is a significant decrease in citation rates of publications in LICs compared to HICS.

- Daniah Alkassab

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Unhealthy Planet = Unhealthy People T

he looming effects of climate change on humans - of rising temperatures and extreme weather phenomena, are no new concern. While the physically destructive conse-

quences of climate change have already begun running their course, the direct impacts of climate change on human health are now being documented in every biosphere.

TMOSPHERE // A

LA

AIR

Outdoor air pollutants, expelled by motor vehicles, factories, powerplants, forest fires and heating systems, all contribute to poor air quality. Inhalation of these pollutants, such as nitrogen dioxide (NO2), carbon monoxide (CO) and fine particulate matter (any solid or liquid droplets of matter that are <2.5 um in diameter including aerosols, smoke, fumes, dust, or ash), can irritate the respiratory tract. Chronic irritant exposure and the associated coughing and wheezing can lead to damage of the lungs (emphysema). In some instances, the respiratory tract produces excessive phlegm to trap and expel irritants, which can trigger the development of chronic obstructive pulmonary disease (COPD). Studies have indicated a rise in the risk of developing asthma with poorer air quality, worsening of symptoms and a rise in respiratory emergency department visits.

// LITHOSPHERE D N

The slow decomposition of plastics is a long-held environmental concern and has led to nation-wide policies on the use of plastic (although the ban on single use plastics in Canada was recently overturned). Why? Microplastic debris can interfere with soil moisture – reducing the fertility of soil and therefore its agricultural capacity. Moreover, toxins slowly released by plastic are taken up by plants and can accumulate up the food chain until they reach human consumption.

Such large-scale impacts leave great uncertainty for future availability and quality of food.

R // HYDROSPHERE E T

WA

Water bodies are often inundated with harsh detergents as a result of surface runoff, leading to uninhabitable conditions for aquatic wildlife. Another downstream effect (no pun intended) is overwhelmed water drainage systems which can lead to flooding, even in urban areas. How does this impact human health? Repeated flooding can compromise the barriers of indoor and outdoor spaces, allowing for mold and fungi growth that can lead to chronic respiratory illness. Further, the retention of water in plastic litter leads to tiny pools of still water which are ideal breeding grounds for mosquitos that can act as vectors for viruses such as dengue, yellow fever and Zika.

Whether by air, water, or sea, the biosphere that humans inhabit is rapidly changing. Expansion of cities means encroachment into forested areas, depletion of resources from wildlife and forced displacement of native wildlife. For example, as temperatures rise around the planet, northern latitudes begin to resemble equatorial climates. Mosquitos, normally non-endemic in these regions, are able to survive at northern latitudes and carry the disease-causing pathogens.

All of this contributes to the rising incidence of zoonotic diseases.

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While the effects of climate change may have been an ominous warning in the hallways of our childhood schools, the consequences are already making appearances on the weather report more often than ever before. It is only a matter of time before climate change-related health effects turn up on medical records.

- Sila Usta

Health Data Use and Misuse Navigating Information Dissemination and Privacy in the Digital Age

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n 2019, Lifelabs, Canada’s largest provider of general dianostic and specialty testing services, experienced a cyberattack, which compromised the health information of 15 million customers in British Columbia and Ontario.

Lifelabs had to make a payment to the perpetrators to negotiate the retrieval of the information, and is now facing a class-action lawsuit settlement. In October 2023, another cyberattack halted services in five hospitals in Windsor, Ontario; the full extent of the impact on patient data is being investigated. In January 2023, the clinical research group, University of Toronto Practice-Based Research Network (UTOPIAN), was criticized for the lack of informed patient knowledge, consent, and transparency during the acquisition of 600,000 full patient records provided by over 1400 family physicians.

These examples raise awareness to the ethical collection and protection of our health data. As we navigate through the Digital Age in the 21st century, dissemination and privacy of our health data are at the forefront of public inquiry and improvement. Creating databases containing patient electronic health records (EHRs) ideally eases transfer of patient information between health care providers and prevents repetitive prescriptions, medical examinations, and error. While efforts to amalgamate digitalized patient data had been hindered by poor management, and is limited to systems within the province/territory, new efforts will bridge institutions nationally and internationally. For instance, the federal government’s proposed plan of the Shared-Pan Canadian Interoperability Roadmap intends to build a secure, digital system that would facilitate patient EHR transfers across the country.

Researchers have also benefitted from the wealth of information harvested from collaborative institutions sharing patient databases. Non-profit organizations, such as the Institute for Clinical Evaluative Sciences (ICES), which is supported by the Ontario Ministry of Health and Long-Term Care, garner information from a large health data repository containing records since 1986. The collected data, which includes population-based health surveys and EHRs of an estimated 13 million Ontarians to date, supports research projects that align with improving the efficiency and effectiveness of Ontario’s health care system and study of chronic diseases.

The recent COVID-19 pandemic stimulated international research

collaborations. The Coalition for Epidemic Preparedness Innovations (CEPI)’s Centralized Laboratory Network (CLN), consists of ten laboratories, including one in Canada, that aim to facilitate the transfer of patient information, knowledge, and technologies (e.g. for vaccine development).

The convenience and comprehensiveness of these databases unfortunately might make them attractive targets for ransomware attacks, or misuse. In Ontario, the Personal Health Information Protection Act (PHIPA) works to define the conditions in which health information can be collected, used, and disclosed. This legislation is enforced by the Information and Privacy Commissioner of Ontario. Organizations, such as ICES, must regularly apply for the privilege to access health information in digital repositories.

Canadian Institutes of Health Research and other similar agencies have recommended some best practices for researchers to follow when collecting participant data. These include:

1 Justifying the use of participant data, the amount of personal data that is 2 Limiting collected,

3

De-identifying the participant by assigning participants “codes” that limited members of the research team (i.e. senior members) can access, and

4 Regular research ethic board approvals and audits.

Researchers must also disclose the type of data that is collected, be clear about the retention period of the collected data, and state whether there are policies in place to protect that data. Patients should be given sufficient information to decide if they would like to opt out of providing their confidential health information. At many research institutes, steps are being implemented to avoid accidental disclosure and mishandling of patient information. For instance, employees may sign a confidentiality letter prior to their start in the workplace, take annual refresher courses on privacy, and in some cases, implement random audits of EHR access.

Establishing public trust is critical to encourage individuals to voluntarily provide their health information that would support the scientific community. Moving forward, it would be in all in our best interests, regardless as a study participant, a health care provider, or a researcher, to understand how this data should be ethically utilized and protected.

- Ziyan Chen

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STUDYING ABROAD The Immunologist’s Perspective

Here are the narratives of newcomers to Canada sharing their experiences navigating the challenges encountered upon entering a different world. The interviewees decided to remain anonymous to feel comfortable sharing their stories. For the interview, they were asked to explain the challenges that come with living and studying abroad.

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mbarking on my journey from Uganda to Canada was a rollercoaster! The initial months? Whew, they were a mixed bag. Here I was, oceans away from home, missing the warmth of family hugs, and tackling emotions that could rival a soap opera. Oh, Canada, your weather! Born and bred in the land of perpetual warmth, I had to cozy up to a climate diametrically opposed to what I knew. Seasonal depression? That was a curveball! I went from “sunshine on my shoulders” to “where’s the sun, though?” But hey, now I’m a seasoned pro, vitamin D and C are my BFFs. Let’s talk language: swapping from speaking my native tongue for over two decades to sud-

B

eing a graduate student in Immunology from Tabriz, Iran, getting to Canada was a wild ride. Visa struggles were a major headache, waiting almost a year to hear back from IRCC about a visa was a test of patience. But bagging acceptances from two departments at UofT was thrilling. With my heart set on Immunology, especially cancer research, I took the leap. But let me tell you, convincing foreign universities that you’re the real deal is no joke.

High TOEFL scores, GPA hustle, and papers, it’s like an endless checklist. And if your home country’s education system is vastly different, buckle up for an even wilder ride.

Now, here’s the kicker: I’ve just landed here, and English is my main battle. It’s crazy, I’m fluent in my head, but sometimes my tongue gets all twisted when I speak. I know it’s normal and nothing to be embarrassed about, but as an idealist, cutting myself some slack ain’t easy. Plus, there’s this fear that people might

denly swimming in English’s deep end? That was like navigating a linguistic labyrinth!

Speaking of Canada: Opportunities? Check.

Education? Check. Diversity? Check, check, check! Canada’s like a melting pot of cultures, and the University of Toronto? It’s a competitive arena where labs scream ‘cutting edge.’

Funny anecdote? Picture me strolling into a snow-covered wonderland wearing regular sneakers, wondering why everyone else seemed to have mastered ice-walking. Let’s just say, slipping and sliding became my new normal until the light bulb moment, special boots were the game-changer!

not see my true smarts and capabilities just because of this language barrier.

Missing my family back home is hitting me hard. I mean, think about it, you’re almost halfway across the planet, facing a whopping 14-hour flight just to see them. Sometimes, it feels like a hopeless endeavor. But Canada’s a beauty! The people here are super friendly, saying “good morning” with the biggest smiles on random streets. And the diversity, man, it’s a treasure trove of cultures that’s a lifesaver when homesickness kicks in.

In the midst of my challenges, I’ve always admired those courageously navigating language barriers to communicate, study, and contribute to science in a non-native tongue. Witnessing someone speaking my language with an accent always intrigues me, it signifies their capability in at least one language that I might not know.

- Sarvin Fathi Danesh 30 IMMpress Vol. 11 No. 3 2024

A Book Review

Braiding Sweetgrass: Indigenous Wisdom, Scientific Knowledge and the Teachings of Plants

by Robin Wall Kimmerer

“The ultimate reciprocity, loving and being loved in return.”

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n her book Braiding Sweetgrass, author Robin Wall Kimmerer, a decorated environmental biology professor and a member of the Citizen Potawatomi Nation – a federally recognized tribe of the Potawatomi people in Oklahoma – weaves together her Indigenous roots and Western scientific expertise. Describing the relationship between people and the land as “the ultimate reciprocity, loving and being loved in return,” Braiding Sweetgrass is written as a collection of essays that read like a love letter to the land. Through her heartfelt personal stories and unwavering hope for the future, she invites readers to rekindle their connection with nature as an effort of restoration.

With tender care and respect, Kimmerer skillfully intertwines Indigenous teachings with Western scientific knowledge in her book, fostering the idea that they can harmoniously collaborate to enrich our appreciation and care for the natural world. This is exemplified in her discussion of the concept of reciprocity, a deep-rooted Indigenous teaching defined as a mutually beneficial relationship between people and the world. She illustrates this effectively using examples in nature such as sweetgrass, a plant sacred to many Indigenous nations. She describes the moderate harvest – and not overharvest nor underharvest – of sweetgrass as a long-standing cultural practice of Indigenous nations, and this approach has ensured the survival of sweetgrass, highlighting the co-dependent relationship of the people and the plant. Scientifically, Kimmerer explains this phenomenon as compensatory growth, in which moderate harvest creates space and light for additional shoots to flourish. Through this, she underscores the value in listening to both worlds of knowledge. While Indigenous practice is centered on listening to the land as the teacher, the Western scientific method of environmental stewardship is to observe the land as a study subject. Despite the differing methodologies, they share a common objective.

Kimmerer proposes a union of both, suggesting that “doing science with care and humility is a powerful act of reciprocity with the more-thanhuman-world”.

While science is often read without emotions, Kimmerer imbues her storytelling with soul, gently drawing you in and instilling in you a deep appreciation of nature, one that mirrors her own.

She does this by seamlessly weaving in her personal anecdotes with stories of nature, often drawing parallels between the two. This is exemplified in the chapter titled “The Consolation of Water Lilies”, in which she shares her sadness when her children leave home. To find solace, she paddles out into a pond and finds comfort in the water lilies. She sees the way daughter lily pads are connected to the mother lily pads via a life-sustaining air-filled capillary system and how they mirror her relationship with her daughters – “forever linked in one long breath, an inhalation that calls for reciprocal exhalation, nourishing the common root from which they both arose”. Through this, she highlights our similarity to the natural world, encouraging us to view nature as part of our own community in need of our care as opposed to a separate entity from which we draw resources.

Kimmerer’s love for nature comes with both joy and grief, yet she remains hopeful. She writes about the grief of loss of connection with the land and her culture as an aftermath of colonization.

Instead of assuaging the grief with anger, she proposes an alternative way of comfort -- through “rebuilding the homeland that was taken”. She is hopeful as she writes about the resilience of Indigenous communities and their efforts to reconnect the land with the people. One example she describes is the ongoing advocacy work by the Onondaga Nation to restore the Onondaga Lake in New York, a once-clear lake full of biodiversity now made unhabitable from wastewater pollution. Despite her grief, she still holds light for the future. Her novel, Braiding Sweetgrass, is a testament to her hope and love for the land. Through her poetic language and tender tone, Kimmerer invites her readers with love and open arms to use their personal strengths to help heal the relationship between people and the land.

- Kitty Liu

Braiding Sweetgrass is available at the Toronto Public Library as physical copies, ebook, and audiobook (narrated by Robin Wall Kimmerer herself!)

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Department of Immunology University of Toronto 1 King’s College Circle Toronto, ON M5S 1A8 Canada

Kay Riddell, director of the International Student Centre, stands in front of the Centre located in Cumberland House on St. George Street. (1965) Photo Credits: University of Toronto Archives.