Cause of Life
By Paige Parvin 96G
There are places in the world where children under age five die at a staggering rate—more than fifty of every one thousand live births. And in some areas, including parts of sub-Saharan Africa and south Asia, that number is greater than one in ten. In the United States, the average child mortality rate is fewer than six in one thousand.
In much of the developing world, too many children are being lost, according to public health leaders. That’s why the Bill & Melinda Gates Foundation has dedicated up to $75 million to a new initiative led by Emory’s Global Health Institute that is focused on bringing that number down during the next twenty years.
The Child Health and Mortality Prevention and Surveillance Network, or CHAMPS, is a global health surveillance program created to gather data through a faster, more accurate, and more effective process than current methods. By identifying the most common causes of death for children in high-risk areas, leaders hope to improve health and quality of life, help local health officials address the root problems earlier, and prevent unnecessary deaths.
“For some time, the Gates Foundation has been interested in getting a firmer, more evidence-based grip on the causes of child death,” says Jeffrey Koplan, vice president for global health at Emory and CHAMPS executive director. “There is a belief that many children die of preventable causes, and a better sense of these causes would lead to better policy actions and increased funds allocated to addressing these particular problems.”
After months of study, the Gates Foundation invited fifty institutions to pursue the grant, and twenty-four submitted proposals. Emory was one of two finalists and was selected to spearhead CHAMPS earlier this year.
The initiative involves an extensive network of partners, including the International Association of National Public Health Institutes (IANPHI), with a US office based at Emory and global offices in Mexico, France, and Finland; the Centers for Disease Control and Prevention (CDC); the Public Health Informatics Institute (PHII), a program of the Emory-affiliated Task Force for Global Health; and Deloitte Consulting.
IANPHI is a global network of almost one hundred CDC-like organizations that has established a robust health infrastructure in many developing nations and relationships among governments, health care institutions, and global aid organizations. The Gates Foundation has provided funding support for IANPHI since 2005.
CHAMPS leaders are in the process of reviewing some fifty possible sites in sub-Saharan Africa and Asia based on a range of factors, including what type of health care and laboratory infrastructure, if any, is already in place. The eventual sites will have an area population of at least one hundred thousand with a child mortality rate of at least fifty per thousand live births. Initially, six sites will be identified for the launch of the program, but CHAMPS is envisioned as a twenty-year project that will eventually expand to as many as twenty locations.
In addition to having some of the highest child mortality rates in the world, the places being studied lack reliable techniques for gathering and analyzing data about the reasons for those deaths. Often, by the time a sick child is brought to a health clinic for care—which might require days of difficult travel over long distances—their illness has progressed to the point that secondary symptoms, such as electrolyte imbalance or respiratory distress, may obscure the original problem. It is also common, says Koplan, for “verbal autopsies” to be conducted up to one to three months after a child has died through an interview with the family by local health officials. By then, critical details about the early stages of illness may be forgotten or clouded in the minds of grief-stricken parents and relatives.
The CHAMPS project aims to provide a clearer picture in such cases by collecting tissue samples using a minimally invasive sampling of tissue, or MIST, procedure. The network will collaborate with ISGlobal/Hospital Clinic–University of Barcelona to develop and apply state-of-the-art tissue sampling and multiple diagnostic techniques, reducing guesswork and assumptions in favor of scientific evidence collected immediately and at the source.
“What makes this unique is that we will be able to depend on actual measurements and visualization to find evidence for the cause of death,” Koplan says. “We will not be modeling conclusions on extrapolation from one subject to another, but providing routine delivery of accurate data.”
The network will develop a long-term approach to information management, laboratory infrastructure, and workforce capacity, with the main lab analysis for all sites conducted within the country. As a robust disease surveillance system is established, this system and other aspects of prevention and clinical care will be gradually transferred to local governments and national public health institutes with the help of IANPHI.
“A really important aspect of the structure is that we will be building local capacity to do pathology. Many of the questions we have gotten from people in the field at the potential sites have been about building capacity at the local level,” says Lisa M. Carlson 93MPH, CHAMPS associate director of management and operations. “They understand that the potential long-term benefits are significant.”
Eventually, according to Koplan, the CHAMPS Network hopes to collect tissue from every deceased child at established sites—but he and his colleagues realize there is a challenge to be overcome. Much like the need for education about the benefits of organ donation, advocates of the CHAMPS project will be working to cultivate understanding in local communities that even in the face of shattering loss, there may be an unprecedented opportunity to help other children.
“Seven million children die from preventable causes annually around the world,” says Koplan. “Many of these deaths from diseases such as pneumonia, meningitis, malaria, tuberculosis, and diarrheal diseases, and from poor nutrition and accidents could be prevented with better vaccines, antibiotics, diagnostics, advanced medical procedures, improved nutrition, behavior modification, and access to care.”
As the work of the CHAMPS Network expands, the project will yield a growing body of data that will be analyzed and relayed back to area health authorities. While the CHAMPS Network is focused on surveillance, analysis, and communication, the new information can then be used to educate health officials and workers at every level, retool public health policy, increase awareness in communities, shape research priorities, and help strengthen the case for increased prevention and treatment measures. Information about disease prevalence also will help attract more research funding for vaccines and drugs for the most lethal and widespread infectious diseases.
“We will be gathering very complex data sets that interconnect with each other, and we want this data rapidly accessible,” says Robert Breiman, director of Emory’s Global Health Institute and CHAMPS director of science. “We see this as open access almost immediately, with direct dissemination to a vast array of people who can use it to develop new public health prevention efforts. A fundamental cornerstone of this project will be cultivating leaders at the local level who bring back this data and become champions of new solutions.”
The Public Health Informatics Institute will design, develop, and manage the systems and network needed to help health officials understand causes of death and serious illness in their countries and to have the information they need to intervene effectively.
“Translating data into the language of actions that reduce child mortality guides our thinking about systems and technologies,” says PHII Director David Ross.
The CHAMPS Network team envisions a collaborative, multidisciplinary approach to the project, involving Emory faculty and students in anthropology, environmental health, and business as well as the schools of medicine, nursing, and public health.
“There are enormous opportunities in the field for students,” Breiman says. “For example, for young physicians and nurses in training, exposure to global health challenges helps them become better physicians and nurses. When you do clinical work in the field, you have to develop and rely on your acumen, and you become familiar with diseases that we see less often here. Also, knowledge transfer goes both ways, with clinicians in country also learning from visitors with a different set of experiences.”
The twenty-year commitment by the Gates Foundation—an unusually long span of time for a grant, Carlson points out—puts the CHAMPS initiative in a somewhat unique position of having the time and resources to see outcomes realized.
“The childhood mortality rate is totally unacceptable. That’s why the Gates Foundation is funding this,” Breiman says. “If things go well, there is no doubt that we will be able to provide useful, interesting, and important evidence. We will not get there overnight, however. Knowing that ultimately this work will have a positive, life-saving impact will help to keep our eyes on the prize.”