Research that Matters, Episode 2:
Collaborations across nations and institutions
Research that Matters is a 9-part podcast series featuring researchers from Torrens University Australia, who are working towards solving complex global problems and propelling innovation. For more information, and to access all other episodes in the series, click here.
In this episode, Professor Simon Stewart explains why he has dedicated his whole life to improving the health outcomes of people with heart and lung diseases. He takes us on a journey from central Australia to South Africa with rare insights into the social drivers of disease.
Host: Clement Paligaru (in bold)
Guests: Professor Simon Stewart (SS)
If Graham Clark and his team hadn't conducted pioneering research in the ‘70s, the world may never have known about an iconic Australian invention. The first bionic ear.
Picture a world without research. It would be a world without the antibiotic penicillin or greyscale ultrasound imaging,
A world without spray-on skin, the cervical cancer vaccine or artificial pacemakers.
Research has the potential to transform lives through the discovery of new medicines, treatments, and devices.
SS: Research matters in my field because we're actually improving people's lives. They're living longer and hopefully they're living happier and that actually benefits us all.
When we're ill and we think about it, it has impacts on the whole family.
So, from a social fabric point of view, the less people who are sick and are able to be productive, actually helps the economy. And I can only reflect on my own circumstance, my father died when I was age 13, my mother was forced to raise four boys alone in really poor socioeconomic circumstances.
This is Research that Matters. I'm Clement Paligaru.
This series explores the work of researchers from Torrens University Australia. We'll take you behind the curtain to hear what drives their passions and the impact their work has on all of us.
In this episode, we'll explore the potential of research when it comes to collaborations across nations and institutions.
SS: We're all human, but we have different cultures, we live in different circumstances, environments, so bringing a harmonious and synergistic collaboration is about embracing diversity, embracing different ideas, and then coming up with solutions.
Hello there, I'm Simon Stewart. I'm a professor here at Torrens University Australia.
I'm a national Health and Medical Research Council, Senior Principal Research Fellow. That is quite a mouthful, I know, but I'm a health researcher looking at people with heart and lung disease and determining whether or not we can improve their health outcomes.
I worked in central Australia, for example, in indigenous communities.
I see so many parallels to what could be done in that part of the world, to that of Africa. It's actually finding a commonality, embracing that diversity, but those collaborations when people are genuinely, warm heartedly committed to a single cause we achieve so much more together than we do alone.
Before a career in research, Professor Stewart worked in the frontline of healthcare, but always had this gnawing feeling that he could be doing more to help.
SS: I was a nurse who looked after people who are very sick. I was intrigued by the fact that the health system didn't quite meet their needs. I guess I was tuned in to their needs and the families and I started to determine in my own mind whether there were ways we could do things better.
I think I was a bit of a rebel as a clinician asking, why are we doing it this way?
And that led me to research. So, the research pathway is a rabbit hole that I entered, and I still haven't found the bottom yet.
I love my research work because I think it makes a difference. Some people do research that's esoteric, if you like, and will lead to future findings, but the work I do has an immediate effect.
Quite consciously, I try to develop programs, in my research that understands the needs of people, and then based on what their experiences are and their poor outcomes, develop programs that then improve their health outcomes.
What drives me is to make sure that people around the world, wherever they are, have the best outcome, because after all we're all human, we experience things the same way.
I feel very deeply for people who have been cheated, I think, by the health system or life and I want to give them the best chance possible.
For the past 20 years, Professor Stewart has dedicated himself to understanding the burden of heart disease across the world.
So, what's changed in that time.
SS: If we were in a time machine, we'd go back to an age of the post war and that would be a colonial past as well, where a world that was maybe a little bit more simpler, but there were factors post-war that drove an epidemic of heart disease - at least in the rich countries around the world.
People were eating lots of butter, people were smoking, but they were at least active and fit. And over that time, we've probably retained those poor diets, we eat more manufactured food - smoking rates have gone down, of course, but the sedentary behaviours meant that the pattern of heart disease has risen and then stayed higher. And then we've got this epidemic of diabetes.
In developing countries, and we should call them low to middle income countries, they didn't have any heart disease, they hadn't picked up those trends. But over the past 20 years or so, that has changed dramatically.
What I was able to do in my work in Africa through a program called the Heart of Soweto study was to dispel the myth that there was no heart disease in places like Africa. In actual fact it's on the rise, but it's different because it affects younger people and women.
At the same time, we developed surveillance programs in high-income countries and showed that the pattern of disease that we initially had - typically middle-aged men dying from heart attacks - had turned into older people with chronic disease, and this costs lots of money to the healthcare system. And of course, still kills people.
With Australia's baby boomers, marching towards retirement, Professor Stewart warns that the health dollar has never been so critical and particularly when it comes to heart care.
SS: It used to be a pyramid of younger individuals, young children then actively working adults - post war baby boomers, and to my chagrin, I'm the last - 1964 is counted as the last of the baby boomers.
We are a bulge in the population moving through who have been productive, worked, paid our taxes, and are now entering a period of retirement and obviously asking back of the community. Now that means our health dollar, the proportion spent on older individuals who develop chronic disease is going to rise.
For governments around the world and particularly Australia, we have to get better bang for our buck, for our health dollar, because we're going to have to spend more - and echocardiography, heart conditions are one of the major drivers of cost. So, if we can provide efficiencies and say, hey, why don't you use the echocardiogram this way and make sure that a better outcome occurs that will actually save dollars.
So, economic modelling is critically important. One of the best ways we can help the Australian government to make wise decisions is expose the areas where there may perhaps be some wastage - where we can become more efficient. But also, to direct them where industry should be supported, where they should invest in those new programs.
Echocardiography is an ultrasound examination of the heart. It's used to accurately diagnose and treat people with symptoms of heart failure, structural heart diseases, and other heart conditions.
It's an important clinical tool, but it comes with an enormous economic cost and there have been concerns about inappropriate use.
SS: The use of echocardiography is typically a wild west of however you want to use it. The number of echocardiograms is actually rising by more than 10 per cent each year, but the amount of follow-up from those echocardiograms is not being matched by that.
So, we are actually going to, through this project, not stop people from using echocardiograms, but ask them to consider the information they get from that in a better way to improve outcomes.
Cost efficiency is the key.
Right now, an area of research that Professor Stewart is focusing on is the National Echo Database of Australia (NEDA). And it could provide major cost efficiencies in healthcare.
This research is about identifying new risks through routine cardiac imaging.
SS: It started with a condition called pulmonary hypertension. Your heart and lungs are very much connected, but they wondered why the machines that we routinely investigated with didn't talk to each other. And over a period of years, they managed to convince the industry to let these machines talk to each other, to share data.
What it's done is created a pool of patients, over a million now, with routine collected data on the function and structure of the heart. So, what we've done with this project is linked that to patterns of mortality and being able to feed back to cardiologists and to the whole healthcare team that some of the conventions, the logic that people apply to management, is wrong.
In an actual fact where you might think of a dichotomy, this person's at risk, this person's not - we've actually identified in areas like aortic stenosis affecting the main valve in the heart, indeed for how the heart pumps and relaxes, that there's a far more complicated picture.
NEDA, the National Echo Database of Australia provides simple messages around who should be treated more proactively, and I'm very confident it will change clinical practice moving forward, and we've already seen that.
NEDA is a classic example of looking at big data and saying, look, we could save this amount of lives if we spent these amounts of dollars and I'm confident in actual fact there’ll be cost savings available and save lives at the same time and that's the win-win situation for everyone.
How significant will this research be for average Australians?
SS: In this area of aortic stenosis, there are now trials underway, based on NEDA, to determine whether or not replacing a valve earlier, in the heart of Australians with this valve disease, gives them benefits.
We've identified a new threshold at which clinicians should, rather than wait for something to happen, should act. So, for average Australians NEDA is providing important information to help their clinicians be more proactive in managing them. I'm quietly confident that will actually save lives in the future.
And there you're talking about the benefits to individuals, but what are the likely social and economic benefits of these findings Simon?
SS: So, the important thing to think about is every time someone is sick, if they're in the economic prime and many of these patients are, they're unable to work, they're unable to provide for their family.
When we're ill and we think about it, that has impacts on the whole family, so from a social fabric point of view, the less people who are sick and are able to be productive, actually helps the economy. The other important point is these conditions we are picking up, commonly result in a premature death and of course, people dying early, it has a profound effect.
And I can only reflect on my own circumstance, my father died when I was age 13, my mother was forced to raise four boys alone in really poor socioeconomic circumstances. It was only through education I sit here as I do.
When I talk about the profound impact of early death, early disease, it's usually people from poor circumstances. It’s people from poor countries who bear the brunt most.
So, our research is extremely important because where we find, a signal, if you like, of where we can improve, it will help the vulnerable the most.
To get to this point in his research has meant working with real world teams and looking for real world patterns and where they might develop new interventions.
Unsurprisingly, this study has already had major support from industry and has attracted commercial interest.
SS: I think the genius there, and I take no credit here, the genius was to convince the people that make these machines, that they should allow us to collect data and then put their outcomes into a common language.
To do that, you have to provide a case for these companies, why it would be beneficial to them for that to happen. Naturally enough, I think we've delivered on that.
The next thing is to think about, okay, who uses the data, which is cardiologists and the healthcare system to make decisions, and to identify areas where you think, for example, that there could be gains in terms of therapeutic outcomes.
A classic example is this aortic stenosis. Aortic stenosis is a disease of the main valve in the heart and the prevalence, the number of cases will inevitably rise because we're getting older, which means more and more people will present with this problem and will die from it without active intervention.
What we did was focus on this aortic stenosis, had a very hard look at the evidence and realised there was a dichotomy of risks. So, in other words, people were only considered at risk and chosen for an intervention, if they reached a threshold. We quickly realised that couldn't and shouldn't be the case.
A dichotomy of risk in biology is extremely rare. In other words, you tend to get a gradient of risk. For example, consider your blood pressure - the higher it gets, then the risk rises.
We approached industry and said, hey, we think we can redefine the risk by looking at big data. It's actually talking to them about enabling them to frame the market and for them to look at their therapeutics, if you like and say, yes, that's a really good idea. And that's how we get supported developing real-world profiling and evidence.
It's about making sure, that you speak in the same language, but really clearly about better outcomes for people. I'm particularly proud of the fact that we're able to engage with manufacturers of the machines, the people that develop devices for heart disease, and also the people that develop pharmacological agents because our evidence enables them to develop more targeted clinical trials, to understand their therapeutics better.
We’ve been extremely fortunate to have the support.
We have this philosophy, and I think it's a good one, that we find the evidence and the vulnerability, then we let the industry work out how they then persuade the government through the PBAC or through the TGA, for example - people approve devices - that they use that information to develop the evidence for the interventions.
Outside of Australia, Professor Stewart's heart lies in Africa. He spearheaded the world-famous Heart of Soweto study alongside other internationally renowned academics. That study was published in The Lancet, the most respected medical journal in the world and exposed a time bomb of cardiovascular risk factors in South Africa.
So, what was it like being part of this transnational effort in Soweto? The home of Nelson Mandela.
SS: It had the largest hospital in the world at the time, it used to be an army barracks, British army barracks, from what I understand - 52 separate buildings filled with a hundred patients each, and you can imagine a chaotic scene in the cardiac clinic.
We ended up examining the heart health of over 15,000 Africans.
We had a row of three echocardiographic machines, ECG machines, a team of nurses and doctors, and what we were able to do in a systematic way - imagine the paperwork, we all did that in paperwork at the time - but setting that up meant that we collected an enormous amount of data.
Up to that point, most people said heart disease and hypertensive heart disease were rare in Africans and Heart of Soweto told us something different. And so, getting into The Lancet was relatively easy compared to other times, but it made a profound impact.
And I do want to mention, we trained in the years we were active there, at least five now luminary cardiologists working in other parts of Africa, doing extremely wonderful things, but they started with the Heart of Soweto.
Africa is a vast continent with a rich and diverse culture, and as to be expected, it has a diversity of health challenges.
Professor Stewart’s current research is anchored in Mozambique.
SS: My main work at the moment is working in Mozambique, one of the poorest countries in the world with a wonderful collaborator who's an Adjunct Professor with us, Professor Anna Makumbi. We're working with a range of communities, the most poverty-stricken communities, living in what we called the boroughs of the inner city, slums people would call them, to understand what are the drivers of disease in those communities?
What we're finding is it's different from the drivers and pattern of disease seen in high-income countries. So, for example, you rarely see someone dying from a heart attack, but on the other hand stroke is devastating because of high levels of high blood pressure. And then there’s factors such as indoor air pollution, because they have to burn wood, charcoal and other contaminants that destroy their lungs.
I do have collaborations of some trials - we're doing interventions to see if they can work in the African context. As an example, we have got to proposed trial - we've now got a program where we're micro-financing cleaner fuel for the home.
When you're poor, sometimes you don't have the necessarily financial availability of cheaper fuel. So, imagine you're going to the supermarket, and you see a shampoo bottle and it's a litre and it tells you that per ml, it's very good. You haven't got the money to buy - it takes a certain amount of money to buy the litre, but there's a sachet in front of you. That small sachet provides you a couple of mls - that's what you will buy.
Microfinancing allows people, a source of income to buy the larger, more efficient product. And in this case, we're trialling a more efficient fuel that gives off less fumes and damages the heart and lungs less. In this trial, we're going to compare households where we micro-finance clean fuel versus those people who have to buy the dirty fuel and see what difference it makes to their cardiopulmonary health.
With the microfinance fuel, they can cook, heat their house with less toxic fumes and their heart and lung health will be better. That's the type of social health interventions we're developing in the African context.
What's the impact of this likely to be?
SS: Nearly every household that we've come across in these poverty-stricken areas has to use horrible fuel to heat and cook, and it has a damaging effect on their lungs and their heart. So, the heart lung health of places like Mozambique could be transformed, if we can fund and provide clean and healthier options in their daily lives.
We work very closely with the Mozambique government. We at Torrens support the Mozambique Institute for Health, and also a number of other agencies who form these collaborations, these partnerships to be there within the community.
We support from a research point of view and also an educational point of view, supporting simple things like statistics, data collection, and even research techniques for surveillance. They're supported by a wider collaboration of international partners -Washington State University, people from Harvard who all have an interest in improving the health and lives of these people.
To bring this research to life. Professor Stewart and his research team have been working very closely with the local Mozambique community.
SS: Obviously we have to work with the local communities where we're going to establish the hub for our research, making sure that we have permission to wander around, if you like, the communities to engage with families.
If you want an intervention, the innovative companies who are developing these healthier solutions - they need to have a partnership, they need to understand that we will use their product and test it in a rigorous way. For financing we're working with a bank who are interested in investing in people from lower economic circumstances to provide the micro-financing.
It's a web of so many pieces that have to be put together, but what's the alternative? Having people die early at a young age, many young women and men? Or do we try to unpick our way through a maze of complexity from financing, from finding the right intervention, from finding whether it works in a household, to better health outcomes.
I know which pathway I'd like to choose.
When you’re working across different cultures and health systems, what do researchers have to be mindful of? What have you discovered?
SS: My mantra is very simple, I always ask myself, why am I there? Is it there for my CV, My glory? Or am I there to help?
You ask the researchers, the local community - what do you need from me? And then you focus on that. So, rather than being arrogant and saying, I know the answer, you seek the answers from them, you enable them to answer the questions and for me, the more you give, the more you get back.
When we talk about community in Australia, and then we talk about community in Africa, they’re totally different, because obviously we lead our lives in totally different ways, but community is everything in Africa.
When you engage with a community, you're engaging with everyone. So, there's a higher level of trust needed and there needs to be continuance. The people I work with, Anna Makumbi's team develop strong community links.
Then for example, we actually go into those communities and provide firstly a level of surveillance and engagement, asking them what they think are the most important health problems and then we take a really close look at their environments.
While there are certainly differences to consider when working across nations, Professor Stewart says there's also strong commonalities.
SS: When I first went to Alice Springs to work with the Indigenous peoples living in town camps, and then in remote communities, the thing that struck me was (A) the sense of community and connectivity that's also common in Africa, but the second part, the (B) part was that when you empowered people to find their own solutions, they could achieve those.
The third thing that struck me was the pattern of disease, the vulnerability, that it was the young and particularly, for example, heart disease is considered a disease for men but in actual fact, it was younger women of childbearing age, of still being the hub of their families who were affected.
That commonality passes through many communities. It's always the vulnerable who ended up being the weakest link in terms of our health chain.
I think I can draw that string across in heart and lung health from central Australia to Africa and I'm pretty sure I could do that across to other communities in southern America and to other vulnerable communities around the world.
A proverb that's common to all African cultures is that a person is a person through persons. This comes from Ubuntu philosophy and sometimes translates as - I am, because you are, or humanity towards others.
Professor Stewart also believes in this universal bond and approaches his research through that lens.
SS: What we aim to be is good collaborators and what I mean by good collaborators is that when someone has a good idea, no matter where it's been generated from, we support that.
We're very much about health services research, so that's an area where we're looking from the bedside to the population, developing new interventions and services that make a tangible difference now.
Engaging with health professionals from the primary care sector, all the way through to tertiary hospitals is what we do. We can't do things alone.
I do worry about the system we have - there's politics in research, like everything else and there are people who would like to keep their little empires, if you like. I've never been one for building those empires, if that's a good analogy.
But I think there are many people around the world who are good researchers who would commit themselves to the best possible health outcomes. Enabling them to collaborate, to share ideas, to work with people on the ground and to empower the people on the ground, the people closest to the communities, is the way to go.
I don't see any other way. I can tell you we've submitted now at least five or six, really worthwhile collaborative programs with north American, European Australian collaborations, with African partners and the powers-that-be that give them money say, well, it can't be done - despite the fact Heart of Soweto was never funded by a grant machine.
We did it with the equivalent of the Kellogg's company in South Africa – they gave us the money and we ended up publishing our results in The Lancet. It was a landmark study, but that was done without official support.
What I'm finding still is this resistance to the idea of investing in African researchers supported by international collaborations, because there's this arrogance that only the Americans or the Europeans or the Australians know how to do good research.
My own finding is the African Researchers I work with are passionate, they're brilliant and they're the best of humanity. We should be supporting them rather than saying, you can't do it.
What is it about Africa that keeps you going back there?
SS: Oh, I see the promise of so many young faces. I think that's the thing that drives me is I can imagine my own self walking along the street there. I see the line of children going to school and having such a happy disposition.
I think it's the optimism of a country, and I say country – I mean countries, that have so many challenges. I'm a sucker for challenge, but I'm also sucker for providing a better future for the millions of children I see who are facing an uncertain future.
At Torrens university, Professor Stewart has been prolific. He's published over 400 peer reviewed research articles and over 10 books that he's either written or edited.
So, what keeps him motivated as a researcher?
SS: One of the things I think you have to be as a researcher, you have to be passionate about what you do.
Most people think they complete a PhD, they've reached the summit of Everest, and then I'm reminded of an analogy, the metaphor, that there's another Everest just around the corner. When you look up, there's another peak above you.
So, you feel satisfied for all of 24 hours and then you move on to the next peak.
I think that's what drives me - it's a bottomless pit of good outcomes that can be achieved. You have to be very resilient because you get more failures than you get successes, so you have to learn from your failures. It's a terrible business to be in because no one really rewards you for success, all you get rewarded with is failure.
But those small wins, like the Heart of Soweto study, like the Mozart study in Mozambique, like NEDA, they're the ones that keep driving me. It's a fuel, it's my cocaine, if you like, of success, that high of achieving that is wonderful because you know, you're making a difference. That's what drives me.
In the next episode of Research that Matters.
James Calvert: We've rebuilt these locations in realistic virtual reality, and so it's not just seeing it on a screen, it's standing there - it's standing in the crevasse of a glacier and seeing it in time-lapse rise up around you and you can actually get a true sense of the scale of climate change.
Research that Matters was produced by Written & Recorded. This is a Torrens University Australia podcast, and I'm Clement Paligaru. To hear more, search for Research that Matters on the Torrens University website or wherever you get your podcasts.