The Paradox of ISGlobal: Reflections on the 25th Anniversary of CISM

[This text has been written by Clara Menéndez and Pedro L. Alonso. This is the first of a series of articles we will be pusblishing in the coming months to commemorate the 25^th anniversary of the Manhiça Health Research Centre (CISM)]

This June marks a quarter of a century since a group of researchers from Barcelona’s Clínic Foundation and the Mozambican Ministry of Health set up shop in Manhiça, a town in southern Mozambique. Thus began the story of the Manhiça Health Research Centre (CISM), a novel initiative of the governments of Mozambique and Spain with funding from the Spanish Agency for International Development Cooperation (AECID). Few could have imagined that this step would eventually lead to the creation of the Barcelona Institute for Global Health (ISGlobal) 15 years later.

This June marks a quarter of a century since a group of researchers from Barcelona’s Clínic Foundation and the Mozambican Ministry of Health set up shop in Manhiça, a town in southern Mozambique

The aim of the “Manhiça project” was to establish a research and development centre in a rural area of Mozambique on the basis of three complementary pillars: creating knowledge through research on the top-priority health issues facing local populations, building human capital by training Mozambican technicians and researchers, and providing health care to local communities.

These goals addressed some of the well-known gaps—which still exist today—between the most and least economically developed countries: the lack of adequately trained human capital and the fact that 90% of the world’s research and development budget is primarily directed towards diseases that affect the richest sectors of the global population. Because of these gaps, some of the diseases that have the greatest impact on humankind—the so-called diseases of poverty—have been neglected. These diseases are both a consequence and cause of poverty and underdevelopment. They also represent a failure that market laws have been unable to resolve.

CISM was founded with the aim of helping to close the intolerable equity gaps derived from the fact that place of birth determines people’s chances of surviving early childhood and having a healthy and productive life. In fact, the risk of dying during pregnancy, childbirth or the postpartum period is 50 times higher in Mozambique than in Spain. The principles and mission of CISM would later inspire the creation of ISGlobal. At the time of CISM’s founding, Mozambique was just emerging from a long civil war, which had followed on the heels of a war of national liberation and the creation of a new independent state in 1974. The country was bringing up the rear of every human development index. It was a paradigmatic example of the challenges of development and global health.

CISM was founded with the aim of helping to close the intolerable equity gaps derived from the fact that place of birth determines people’s chances of surviving early childhood and having a healthy and productive life

Like all human endeavours, the development of CISM has had its ups and downs over the past 25 years. It is no exaggeration, however, to characterise the centre’s short history as a success story. Research programmes developed by CISM have helped to advance knowledge, in some cases influencing national policies and even the global policies of the World Health Organisation (WHO), especially in the field of malaria. CISM has been at the forefront of global health through the evaluation of vaccines, drugs and new strategies to fight malaria, tuberculosis, AIDS, pneumonia, diarrhoeal diseases and other infections prevalent in low-income countries, without neglecting other health issues, such as non-communicable conditions affecting mothers and children, and the quest for better tools to determine cause of death and disease burden.

These problems have been approached from a multi- and interdisciplinary perspective, involving doctors, biologists, entomologists, demographers, geographers, anthropologists, economists and specialists from other scientific disciplines. CISM has contributed to the training of an significant cadre of Mozambican (and Spanish) scientists and technicians, establishing the University of Barcelona (UB) as a key academic partner for the country, especially with regard to training doctoral students.

CISM has made an important contribution to improving health in Mozambique.

Last but not least, quality medical care has been continuously provided to tens of thousands of people through Manhiça Hospital and primary health centres across the district, many of which have been rehabilitated or rebuilt by CISM.

It is no exaggeration to characterise the centre’s short history as a success story. CISM has been at the forefront of global health

In 2008, CISM fulfilled its founding vision by transforming itself into a Mozambican public-utility foundation, constituted by representatives of both countries, together with the Mozambican National Institute of Health, Eduardo Mondlane University, the Foundation for Community Development and the Clínic Foundation of Barcelona (representing both the UB and Hospital Clínic). A novel development on the international scene, the Manhiça Foundation represented a cutting-edge vision of international cooperation. The foundation promoted the effective leadership of civil society, academic institutions and the national government, who assumed ownership and management of a centre that soon emerged as one of Africa’s leading institutions. As Graça Machel—who received an honorary doctorate from the UB in 2008—has often observed, whenever Mozambique has made positive and hopeful headlines in prestigious international media outlets, those stories have often featured Manhiça and CISM.

CISM has contributed to the training of an significant cadre of Mozambican and Spanish scientists and technicians.

The history of medical research centres in Africa often reflects a colonial legacy. In many cases, such centres are merely an antenna or field laboratory for a big-city institution. In this sense, the history of CISM and global health in Barcelona is paradoxical.

The creation of CISM through cooperation between Spain and Mozambique was promoted by a very small group of professionals from the Mozambican Ministry of Health and Hospital Clínic-UB. CISM quickly attracted the attention of many key figures in both founding countries, as well as other places. Literally dozens of presidents, heads of government, ministers, secretaries of state, regional government officials, university rectors, ambassadors, scholars and journalists have visited CISM over the years. Of these numerous visits and events, a handful turned out to be decisive in the development of global health in Barcelona.

CISM quickly attracted the attention of many key figures in both founding countries, as well as other places. Literally dozens of presidents, heads of government, ministers, secretaries of state, regional government officials, university rectors, ambassadors, scholars and journalists have visited CISM over the years

Mozambican President Joaquim Chissano and Queen Sofía of Spain attended the official opening of the new facilities and laboratories in 1998. 

In May 1998, Mozambican President Joaquim Chissano and Queen Sofía of Spain attended the official opening of the new facilities and laboratories. The visit provided political momentum and visibility, laying the groundwork for the prodigious decade that was to follow.

In May 1998, Mozambican President Joaquim Chissano and Queen Sofía of Spain attended the official opening of the new facilities and laboratories. The visit provided political momentum and visibility, laying the groundwork for the prodigious decade that was to follow

In July 2000, just months after catastrophic flooding devastated much of southern Mozambique, Regina Rabinovich, then director of the Malaria Vaccine Initiative, paid a visit to CISM. This marked the beginning of direct cooperation in malaria vaccine (RTS,S) trials through the Bill & Melinda Gates Foundation. In September 2003, CISM became the first African research centre visited by Bill and Melinda Gates, consolidating the centre’s collaboration with the Gates Foundation, which continues to this day. A few weeks earlier, Núria Casamitjana, then vice-rector of the UB, visited the centre and laid the groundwork for cutting-edge strategic action on the part of the university.

CISM Laboratory.

The ”la Caixa” Foundation had already supported several health care and research projects in the field of tuberculosis and HIV/AIDS through its international cooperation programme. Infanta Cristina of Spain, director of international programmes at the ”la Caixa” Foundation, made her first official visit to Mozambique and CISM in May 2005. This visit marked the beginning of a long and fruitful relationship between ”la Caixa” and the world of global health research, care and training.

At the same time, the encouragement of Joan Rodés and Antoni Trilla (now the dean of the Faculty of Medicine and Health Sciences at the UB), the steadfast support of the management of Hospital Clínic (Raimon Belenes, Josep Maria Piqué, Josep Maria Campistol), and the recognition of the opportunity—and need—to strengthen research capacities in Barcelona in order to complement and optimise the activities and opportunities of CISM, led in 2006 to the creation, together with the UB and the Catalan Government, of the Barcelona Centre for International Health Research (CRESIB) , the first Spanish research centre focused on the health problems of the world’s most disadvantaged populations. Marina Geli (then Catalan Minister of Health) and Antoni Plasència (then Catalan Director General of Public Health) visited Manhiça in September 2007, underscoring the Catalan Government’s commitment to global health and the role of research, care and training in the world’s poorest countries.

In 2008, Màrius Rubiralta, then rector of the UB and president of the Clínic Foundation, visited Mozambique and participated in the creation of the Manhiça Foundation. The UB’s involvement, inspired by Núria Casamitjana—the real intellectual force behind global health at the university—deepened with the creation of the Global Health Observatory and the subsequent recruitment of Pedro Alonso (one of the authors of this post) as Professor of Global Health—the first chair in this discipline anywhere in Spain. Around that time, the management of Hospital Clínic also took an interest in this discipline and created the International Health Service, the first of its kind at a Spanish hospital.

Pedro L. Alonso with Pascoal Mocumbi. His tireless support for the Manhiça project, first as Prime Minister of Mozambique and later as the first president of the Manhiça Foundation, were key factors in enabling CISM to reach this 25th anniversary milestone.

The final push came in 2008. First, CISM won the Prince of Asturias Award for International Cooperation, helping to consolidate the concept of global health research as a strategic tool for international cooperation in the eyes of institutions as well as the public. Infanta Cristina’s constant support for CISM and the underlying conceptual framework was instrumental in persuading Isidre Fainé and Jaume Lanaspa, president and director of the ”la Caixa” Foundation, respectively, to join her on a visit to the centre in February 2008. Just one month after their return, Fainé called Pedro Alonso into his office. As it had for many others before him, the visit to Manhiça had revealed to Fainé, in the starkest possible way, the intolerable inequalities that exist on our planet, as well as their causes and consequences for children, adolescents and pregnant women in rural areas, where people are trapped in the vicious cycle of disease and poverty. The conviction, shared by Infanta Cristina, Isidre Fainé and Jaume Lanaspa, that it was necessary to put science, equity and compassion at the service of the world’s poorest countries led to the creation of Spain’s first global health institute in 2010.

We suspectthat few of those currently working for ISGlobal and benefiting from having a global health centre in Barcelona are aware of the institute’s history and roots. It is important to recognise that CISM and its global health activities made it possible to train a large number of Spanish scientists and provided opportunities to carry out projects and attract financial resources that otherwise would not have been available.

It is important to recognise that CISM and its global health activities made it possible to train a large number of Spanish scientists and provided opportunities to carry out projects and attract financial resources that otherwise would not have been available

In short, without a shadow of a doubt, if not for CISM, there would be no ISGlobal. Understanding our own roots and being faithful to the intellectual foundation that inspires our action is essential in all facets of life. In our current moment, as health inequality continues to grow, is important to remember this: your place of birth still determines your future. Global health—especially the health of the poorest and most vulnerable in the world’s poorest countries—remains an ethical imperative and a shared need. “No roots, no fruits,” as Marcel Tanner would say.

Before closing this brief note on the creation of ISGlobal and the decisive role that CISM played in it, we would like to make one clarification. We have not mentioned the central contribution of hundreds or thousands of Mozambicans from all walks of life : residents of the district, health care personnel, researchers at the centre, support staff, and district, provincial and national authorities. A longer and more detailed dispatch will be needed in order to acknowledge and highlight their contributions.

Without a shadow of a doubt, if not for CISM, there would be no ISGlobal. Understanding our own roots and being faithful to the intellectual foundation that inspires our action is essential in all facets of life. In our current moment, as health inequality continues to grow, is important to remember this: your place of birth still determines your future

Perhaps our friend and colleague Eusébio Macete, who has directed CISM for the past 10 years, can take on this task in a future post in this series dedicated to the centre’s 25^th anniversary. But we cannot and will not sign off without highlighting one name among many: Pascoal Mocumbi. His decision to commit to scientific research on diseases endemic to his country and his tireless support for the Manhiça project, first as Prime Minister of Mozambique and later as the first president of the Manhiça Foundation, were key factors in enabling CISM to reach this milestone.