From the frontlines to the lab: tackling antimicrobial resistance

This episode of LSTM in Conversation podcast features an interview with Dr. Kennedy Uadiale, an alumnus of Liverpool School of Tropical Medicine and a current PhD student. The discussion explores Kennedy's career journey from a medical doctor to his extensive work with Médecins Sans Frontières (MSF) across Africa and Asia, and his recent return to LSTM. Kennedy's PhD research is part of the NIHR-funded Optimising Antibiotic Usage to Mitigate Antimicrobial Resistance project, with partners in Malawi, Zambia, and Uganda (Opt-AMR). The interview explores the complexities of AMR, discussing its drivers, impact, and the importance of a multidisciplinary approach to tackling this global health challenge.

Transcript

0:06

Hi, I'm Joe Valadez, professor in Global Health at the Liverpool School of Tropical Medicine. It's a pleasure to be hosting this LSTM in conversation podcast with our brilliant guest, Doctor Kennedy Uadiale. Kennedy is an LSTM alumnus, having graduated Masters in Public Health in 2017 that year, he earned a distinction and a prize for highest overall marks. He is now undertaking a PhD at LSTM based at the Malawi Liverpool Wellcome Trust Center in Blantyre, Malawi. He worked in government hospitals, from 2009 to 2011 and with Medicine San Frontier, from 2011 to 2024 rising to the physician and medical coordinator. He's had a brilliant career spanning over a decade in medical and humanitarian work, Kennedy has led emergency medical programs across Africa and Asia with Medicine San Frontier, which many of us know as MSF. Well, Kennedy, you've had quite a journey, and it's just beginning really. What made you go from being a medical doctor to an MSF medical coordinator and now a PhD researcher at LSTM. I had my first touch at working in the government hospital, and from there, after working a while, started working with Medicine San Frontier. And I always had this feeling I was doing a lot of public health practice involving outbreak investigation and and setting up intervention and following the intervention all through and carrying out community based control measures. I was practicing public health, but I felt at the point I needed to master it and have a document that shows that I have the skills, even though I was already being consulted by people at that time, and I felt okay, the best place that this can happen will be the words oldest School of Tropical Medicine. That's Liverpool School of Tropical Medicine. That was how I got a Study Grant from MSF, and then it wasn't enough for me to even pay for the school fees. And I was like, Ah, I was at the verge of giving up. And LSTM came through and offered me the Mamco Selab Scholarship, which paid the complete amount, plus the grant I already had completed the full amount I needed for my studies, that for me was something very special, because I became the inaugural Mamco Selab scholar at that time. Subsequently, other persons got that scholarship. The year after I left LSTM, I was able to go back, after my masters again to the field, but this time, well armed with more skills to do a lot of epidemiological work. Yeah. And then after this was in 2017 then I spent this almost eight years of working again in the field, across different settings, training people, bringing my skills to life. And I got to a point again where I was hungry based on the things I've seen in the field. And I said, Now the the kind of impact I want to make at the next level, we come through going through a PhD process that will make me more skillful in in research and being able to make more impact through evidence based data. So that's my story. It's a really an interesting story too. Now , I'll tell our listeners. I'm I'm your supervisor for your PhD, but I'm very curious, how did you decide to to take up the topic that you now have, and tell us what your topic is as well. How did you make that decision to jump into into this topic with me? So in the course of my work, when I got to becoming a medical coordinator for MSF, and by the way, the medical coordinator position is the highest Field Medical position for MSF. So what that means is I'm completely in charge of the design of the medical program for MSF country programs across the various countries where I worked. So I in the course of my work, I have come across a number of scenarios related to antimicrobial resistance, which, in short, we say, we call AMR. So in one of the countries where I worked, I I noticed there was resistance to Cefixime, and this was the, this was Cefixime was the like the magic drug we were using to treat UTI, especially in pregnant women say what UTI is for. UTI is urinary tract infection. Cefixime was what we're using. And I noticed there were some patients who had resistance to this drug. And I looked at literature in that context, and I see that it was not just my own team that was saying this. It was also it has been reported by a couple of other one or two other persons in the same context. This was concerning to me. So most of my programming at that time also then focused on, how do we address antimicrobial resistance in our context, and MSF at that time, this was a major area of focus. The programming was then channeled in to look at three aspects, looking at infection prevention and control, as well as looking at antibiotic stewardship and by extension, in addition to that, looking at diagnostics and surveillance. So I moved again to another context, and I saw we had one patient who, I think the patient was around 11 years old, and this patient was resistant to all other drugs except one, which was meropenem. And meropenem is like the highest we go to. So this was really, really concerning, and it was evidence that antimicrobial resistance is really becoming a huge problem in low and medium income countries. And I was talking to people around as to antibiotics usage, what are the practices? And I got another shocker. I found that girls in and women in that particular setting, after their menstrual period, they take antibiotics. They just buy across the counter. And I was asking, how do you guys take this? And they said, Oh, well, we just take maybe one or two capsules of ampic locks, which is an antibiotics for two days. I was shocked. Like that can actually be that's one of the drivers, the misuse, at community level, of antibiotics. And when I was walking around in that same setting, and I saw someone with a loud speaker, because I'm medical, when they talk about the medicines, I know what the medicines are. And this guy, this person, was with a loud speaker in a market space, and was talking about the various antibiotics he has, and just calling the names of the medicines and all that it could do. It was at this point, I knew that if I needed to be part of the solution at a more at a higher level, at a more technical level, and this really pushed me to focus on antimicrobial resistance for my PhD. So my PhD is, it's embedded in an NIHR funded project. NIHR is the National Institute of for Health and Care Research. So it's on optimizing antibiotics usage to mitigate antimicrobial resistance, and the hope is that this research will contribute to the knowledge and also contribute to policy change That 's really interesting. Kennedy, now you and I have both Yes, that was that was quite interesting as well. When I was worked in many countries, from ones that are very old cultures, like Nigeria, where you are from, but also in South Sudan, which is the world's newest country. I'm very curious with your experience having worked in South Sudan, did you find antimicrobial resistance in that country as well as a new country? in South Sudan, I was managing one primary health care center, one female friendly center, and around nine community based medical care centers across Unity State in South Sudan. And this also what's what was a concern at that time to we, especially in the in the female friendly Center, where we have. But though we say, if you say, it's a female friendly center, but we also have men coming there for STI treatment. So male and females, they come for STI treatment. But then we do other things, like ANC, in that space, we saw some patients that were actually resistance to the to the first line medications were using to treat that was already, you know, flagging, you know, the scale of this problem at that time, you've referred to your PhD studies a few times. Now, can you tell us what is what is it all about? What are you doing? So for my PhD, it's we want to see, is there an association between the quality of care and AMR, for example. So we have a number of components, of research components we are looking at. The first one is trying to do a health facility assessment to look at the quality of care that is rendered to children who are present, who are present with fever, children who are under fives, and we want to see how do they receive care. Want to look at the antimicrobial prescription practices. We want to be able to understand well, how do the mothers feel in terms of their perception of the services that they get, also looking at infrastructure, looking at the capacity of the team that are providing care. How trained are they? Because we know that at this at the peripheral hospitals, these health centers are where the quality of care can be a high marker for the health of the system, in terms of the quality of the health system and how that drives antimicrobial resistance. So that's one component, and then we want to also extend that to the next component, where we want to be able to identify the prevalence of antimicrobial resistance across the region that we are carrying out this research work, knowing the prevalence can also help us to understand the hotspots. And an additional thing that we will be doing, which I'm also bringing in is the aspect of being able to map this, being able to use geographic information system to be able to enhance, you know, the surveillance for antimicrobial resistance, because even when efforts are being made to address the issue, we also have the issue of surveillance not being adequate. So how can we be able to create that surveillance system that is affordable, that can be implemented easily? And that's where we are looking at using the lots quality assurance sampling method, which Professor Valadez, here you you are one of those who pioneered the use of lQs in public health, you know, public health research, and I'm so quite privileged to be part of this. And, you know, trying out lQs as a surveillance tool for AMR. We are, we're going to be involving the use of geographic information system techniques, and we want to also be able to look at what happens at community level. So we will do a community survey, and I'm also looking at us at doing interviews within the community, including that of the community leaders, the traditional healers, who could be herbalists and so on, and also get to understand their perspective and how they contribute to the health system in in those localities. In the end, I'm hoping that what we want to create, what we want to be able to find, will be something that will be useful for policy, because this the our approach also involves getting community voices. And I, I strongly believe that community voices into the solution to address AMR will be very useful in terms of guiding policy, and in addition, will be useful when these policies come out for community to take ownership. So I'm excited about this project, and I think it is the best time to really come out with this project. Yeah, that's great. Can you delve a little bit deeper into what types of impact do you think our work could have? It's it's very common to make policies and and then implementation, because if the if the people who are supposed to implement the policy. And those who are supposed who these policies are made for, they do not take ownership of it. No matter the amount of resources and time put in, we won't see an impact. So I gave a couple of examples in the various contexts where I've worked. I also dive a bit deeper. There are some some AMR policies already existing in those places, but they are not enforced. Because if they were adequately enforced, someone will not go on the street with a with a speaker and really talking about different types of antibiotics, from teeny dozen to self triazone. And I'm like, I was shocked, really seeing that no so we want to be able to address that kind of situation where there is police our data, we influence policy change, but at the same time, we also influence ownership at community level, because it's even possible for someone who who is a community leader to go to that person who is selling antibiotics o n the street to say, No, this is not allowed because we are aware of the dangers that this will pose to us, even now and in the future. So such impact is what I think I agree with you on that. But is there another dimension as well? our our study, we bring out. That's, Do you think that the prescribing practices of clinicians and health facilities is also a problem in some cases, or is it really just only a community level problem? AMR in itself is a multi dimensional problem, and the challenge indeed has to be looked at on different side, because if two of the key drivers of AMR includes the prescription at irrational prescription at healthcare level, as well as the usage at community level, and addressing these two, these two major markers, can actually go a long way in addressing the problem. So again, we hope that, having gone through this process of carrying out this study, there should be an improvement in prescription practices at the healthcare levels, because we we hope that that will improve. And as well as the surveillance, which, by surveillance, I mean the systematic monitoring of AMR in AI as part of the process of the providing care for patient having antibiotics, prescription being used the normal way. And then we have, we then monitor to see what are the emerging trends we are seeing in terms of antimicrobial resistance. You know, in some areas of primary care, vaccinations, for for instance, once mothers become very knowledgeable about what vaccines are needed for their children and when in certain countries where the vaccination coverage is very high, I've seen this in Central America and in Zimbabwe, actually. Yeah, is that the mothers really drive the quality of the system and are incredibly demanding. And so in this of the of the health system to provide the services they know to be good. So in this, this strategy of affecting improved quality of care at the clinical level and at the community level, maybe that. Do you think the third stool of it is making aiding mothers to become very knowledgeable and competence in managing their own children's health with respect to antibiotic usage. That's part of what will happen eventually, because the more awareness we create and mothers who play specific role, not even just for their children, when husbands are sick, mothers are there as well to provide care. They play a vital role in the community in terms of them becoming knowledgeable and also looking at how that knowledge is applied. Because it's one thing to have the knowledge is another thing to have this changing practices and behavior at community level. So we we have the aspect where there will be a community dialog, and this is where they will the findings of of our studies will be shared at community level, and the mothers and fathers will deliberate on those findings and how solutions can be provided, so that can also go a long way in influencing, you know, the behaviors of mothers and community members as to how the usage of antibiotics should look like because. Ideally, they shouldn't just buy antibiotics across the counter on their own, but go to the health facility and get a prescription or get a proper get properly treated. So I look forward to that aspect as well, where there will be an improved knowledge for mothers, even fathers, and then are translating to proper behavior based on that knowledge. And then, how would you bring together? Do you think the this community voice and experience together with government policy makers, where level where policy is actually made? What I really like about our study is that we have this approach of really trying to get as much from the community level, so the health center level, the community level, and preparing this will help us to prepare a proper policy engagement, you know, meetings with with the government. I believe that when the government knows that the findings and some of the results we are sharing actually is coming from recommendations from the community, it creates a bigger buy in by the government. Creates some sense of being responsible, wanting to be accountable, because the community have actually come out clear through a scientific means to say, this is what we think will be the solution. We might find a situation where the community, what the community thinks may be different from what the government policy makers are thinking that will be a good ground to actually then come to, you know, a reasonable point where everybody is comfortable to say this is what we are going to do as a government and as a people, to control AMR. AMR is a silent pandemic. It's, it's, it's something that is looking like it's going to blow up at some point. And in my opinion, I feel I don't want us to get to that point where having an infectious disease could be translating to a death, you know, certain sort of and that's not where we want to get to. And that's the more reason why it has become really necessary to go this far in terms of addressing antimicrobial resistance, then do you think that the work also can have a broader impact beyond the three countries in which we're working, Uganda, Malawi and Zambia in our case, but can it h ave a broader impact? Oh, yes, I think so. It's quite nice that NIHR provided funding for us to do this research in these three countries. It's a research that is cutting across even in the different countries we have the urban, the peri urban and rural setting. We want to be able to look at also these various settings as to how it influences the use of antibiotics and the various practices that exist there. So I do think that just getting the results from this three country can set the pace for us to to look at scaling up to other countries, but not just scaling up, but looking at how the findings also translates to what happens in other countries. Because we know this is a big issue in Sub Saharan Africa, Southeast Asia, for example, there's been quite a number of reports regarding antimicrobial resistance, and generally all over the world there is there are drivers to this, and that's why the impact of this study will go far beyond these three countries where we are starting now, and I look forward to a more, a bigger multi disciplinary approach in the future, and talking about multi disciplinary approach, maybe it will be nice Joe, because you, you have a bigger scope than me in that regard. But just looking at AMR and the challenge looking at the environmental aspect, talking about sewage, you know, talking about animal health, where antibiotics are indiscriminately, also being used. From animal health, it's, it seems like it's a it is a bigger the scale of the problem is, is bigger than humans, than just focusing on humans, so maybe based on your own approach or scope, if you could also share your thoughts regarding this aspect, in terms of multi disciplinary approach to this problem. Well, AMR is, in my opinion. Is a One Health type of problem, and requires the engagement of a wide variety of disciplines and resource management, for example, in veterinary community, in the farming community, in the agricultural community, and understanding how the constellation of human, animal and vegetable and waterborne life is comes comes together. I think being able to to track this from one to the other is going to be the really large challenge. We're taking initial baby steps right at the moment, by measuring the extent of AMR with our surveillance system, we'll be able to identify areas that are particularly, particularly severe conditions and those not as severe as yet. And those may I do think all hands needs to be on deck. So it's not just the be the areas to focus on, to ring fence them, and work intensely so that the AMR doesn't get to a level where it's very difficult to control it. And the other areas will need to have other types of policies and that are focusing very comprehensively, so that new generations of children as they're born, maybe more protected from from antimicrobial resistance and hopefully over time, creating change in the population as a whole, but it will require constant surveillance of the human level and those also in the animal population and in the water resources as well. I suspect that's why we have our colleagues like Professor Adam Roberts working with us, who's working on on the one health problem comprehensively, or Professor Nicholas Feesey , who's taking the clinical lead on on this in each of the countries, who's seen this in adult health, and probably the one of the Leading microbiologist clinicians in the world on this subject. So I'm looking forward to learning a huge amount from this project as well, quite frankly, by working with such a wonderful, wonderful group of professionals. Where do you see as a clinician and as a very experienced person in humanitarian as well as medical health. Where do you see AMR research heading? Is it this one health approach, or you think it will be? There'll be other tools that will need to be developed over time? research alone, but we want policy makers to also accept that there is a problem, because this, from the look of things, the scale of the problem, if we don't address it now, we will have even a worse situation in the future. And I'm glad that people are beginning to really see this in terms of research and grants that are gradually being given for the purpose of AMR research, I will see it that in the future, we have a more collaborative approach to research. I'm also looking at that multi disciplinary approach where every everyone who can bring their expertise, they can bring their expertise, they can bring their their own knowledge in terms of an ideas, in terms of how we should deal with the problem, I don't think them will be a One system that we fit all most of the findings will be contextualized, and that's why the multi disciplinary approach in AMR research will will be a game changer. I do also want to believe that there will be enough funding to be able to carry out this research, because it's impossible to carry out research of this, of this scale, for a situation that is affecting you know that there's a global impact without adequate funding. So even the funders, I really would encourage that they start looking in this direction to provide more funding for AMR, because every day, we keep seeing reasons to talk about AMR. We keep seeing reasons to zoom in on different practices that drives antimicrobial resistance across various regions of the world. So I think in the future, this should be the approach every hand needs to be on that and in that regard, also, it's engaging the international organizations like World Bank and World Health Organization in UNICEF and other big players like Gates Foundation. And because at least the UN organizations will be strongly influential in affecting the policy of nations and global policy as well, which is where the impact needs to needs to be made. And so we can move from a very abstract to a more concrete understanding of the cycle of AMR and that can be very powerful and have impact in the long run. As as we think about what we've been talking about, I'm putting together, just in my notes here, some two or three take home messages from what we've been talking about, and maybe we can think about those together. One certainly is that AMR is a global problem, and it's driven by the misuse of antibiotics at the at the community level and and sometimes at the clinic level as well, where improper use of antibiotics takes place because of the prescribing practices are informed that's one second is that policies need to focus on these three levels of change. One is improving care, health care at the facility level, and improve the prescribing practices, the counseling mothers at to know how to use the antibiotics that they're given at the health facility so that they correctly use them at home. Secondly, at the community level, where there are medicine vendors who effectively sell but they're individuals who consume it, who demand them at the local level as well. And so change there. And the third is creating and supporting the vital role of mothers to demand improved health care. What would you say could be a third take home message from what we've been talking about, this near and dear to you. For me, I think the additional point will be that we need, we need commitments, so commitment from governments, commitments from funders to be able to push AMR research and all the activities that can address the challenge of antimicrobial resistance, again, looking at it from that multidisciplinary approach, where everybody sees it, sees the burden of the problem as important enough to not to address. So that will be an additional take home for me. Yeah, you're right, aren't you? On that one. Thank Thank you. Kennedy, I want to thank all of our listeners who have tuned in today to listen to Doctor Uadalie's talk and our little chat here. We've really enjoyed chatting to each other, as we always, always do, and we hope to we're glad to have had this opportunity to share his thoughts with you. So thank you very much. Thank you very much for having me was a pleasure.