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Wie gelooft er nog in de Sint? I N A U G U R E L E REDE D O O R P R O F . DR. A . J . A . M . VAN DER VEN

Radboud Universiteit Nijmegen

in a u g u r ele prof. dr

.

rede

a .j .a .m

.

van der ven

International health is a field of mi'dl'lM' I hal r i a l ' s Io

income countries.

Infec-

h i v / a i d s , account for m ost poverty-related health prob­ lems. Unlike in th e industrialized world, university medical centres in low incom e countries mostly focus on care and education as they lack research capacity. Long-term N orth-South and East-West Academic partnership can help to develop research capacity, strengthening th e position of these centres. These in ­ ternational collaborations can also provide a sound basis for student exchange programmes. Finally, travel medicine is also part of international health. It is in ­ creasing in im portance as m ore and more people w ith underlying medical conditions travel, for whom specialized, accurate tailored medical advice is vital.

Prof Dr Andre van der Ven (Breda 1953) studied medicine in Belgium, where he graduated met onder­ scheiding in 1980. After training as a tropical doctor, he worked in Botswana from 1982 to 1987. He became an internist in 1993 and an infectious diseases spe­ cialist at th e u m c St-Radboud in 1995. Also in 1995 he defended his PhD cum laude at Radboud University Nijmegen. He subsequently worked for a year in the Sophia Hospital in Zwolle and for five years at the academic hospital in M aastricht. In 2002 , he was appointed Associate Professor and specialist in infec­ tious diseases at th e u m c St-Radboud and became head of th e Nijmegen Institute for International Health. Since 2010 he has been head of th e infectious diseases section of the departm ent of General Inter­ nal Medicine.

Radboud Universiteit Nijmegen

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Wie gelooft er nog in de Sint? Rede uitgesproken bij de aanvaarding van het ambt van hoogleraar International Health aan het UMC St Radboud/de Radboud Universiteit Nijmegen op vrijdag 18 februari

door prof. dr. A .J.A .M . van der Ven

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V orm gevin g en opm aak: N ies en Partners bno, N ijm egen Fotografie om slag: Bert Beelen D rukw erk: Van Eck & O o sterin k

ISBN 978-90-9026121-8

© Prof. dr. A.J.A.M . van der Ven, N ijm egen, 2011

N iets u it deze uitgave m ag w orden verm en igvuldigd e n / o f openbaar w orden gem aakt m iddels druk, fotokopie, m icrofilm , geluidsband o f op w elke andere w ijze dan ook, zon der voorafgaan de sch rifte ­ lijke to estem m in g van de copyrighthouder.

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Meneer de rector magnificus Dames en heren Vandaag vertel ik u over in te rn atio n a le gezondheidszorg, een stukje geschiedenis, w at bedoelen we m e t arm oedegerelateerde ziekten, h e t belang van in te rn atio n a le academ i­ sche sam enw erking en w etenschappelijk onderzoek, onze onderw ijs- en patientenzorgactiviteiten. G raag zal ik m ijn oratie, vanwege onze buiten lan d se gasten, to t we aan de Sint toekom en, in h e t Engels voortzetten. also know n as global health, is a field of m edicine, usually w ith a public h ealth em phasis, th a t deals w ith h ealth across regional or n atio n al boundaries. A p articular form of in te rn atio n a l m edicine is travel m edicine. In tern atio n al h ealth also deals w ith global processes th a t influence h u m a n h ealth and as such w ith povertyrelated health problems in low and m iddle-incom e countries. It is a rath er new discipline, alth o ugh th e relationship betw een poverty and disease is well know n. Jeffry Sachs, Bono, Bill and M elinda Gates and others have p u t the concept of poverty-related diseases back on th e agenda. At first sight, in te rn atio n a l h ea lth seems a perfect subject for a public h ea lth expert, w hile th e connection w ith in te rn al m edicine m ay be less obvious. Traditionally, tropical m edicine was p a rt of th e expertise of in tern al m edicine. However, m any infections th a t are classified as “tropical diseases” used to be endem ic in countries located in tem perate or cold areas. I will tell you m ore ab o u t th is shortly. Bear in m in d you th a t it was only in 1970 th a t th e w ho officially declared th e N etherlands free of m alaria (th e last case of endem ic m alaria was detected in Koog aan de Z aan in 1958 ). Im provem ents in housing, diet, sanitation and hygiene as well as environm ental changes contributed to the control of these diseases in our p a rt of th e world. For example, th e straightening of th e Rhine reduced th e breeding grounds for th e m osquito th a t tran sm its m alaria. W ater m anagem ent in n o rth w est Europe co ntributed significantly n o t only to the control of m alaria, b u t also to th a t of various other w ater-borne infec­ tious diseases. As th e clim ate was n o t th e m ain factor, th e discipline tropical m edicine was renam ed “geographical m edicine” or “tropical m edicine and in tern atio n al h ealth ” . in te rn a tio n a l health,

le ss o n s

fro m

th e

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In th e past, Zeeland was a very swampy area, creating excellent breeding grounds for m osquitoes. Those days, m alaria was endem ic in Zeeland. The sea, th e lan d an d the river Scheldt (w hich provides access to th e p o rt of Antwerp) were always in com petition. In July 1809 , as described by Howard in th e British Medical Journal, a large British force of 40.000 soldiers sailed for th e island of W alcheren in th e Scheldt estuary. I quote Howard: French naval activity a t A ntw erp h ad m ade th e D utch coast “a pistol held a t th e head of England,” and th e governm ent was keen to strike a decisive blow at N apoleon’s am bititions. The overall com m ander was Lord C h atham , n icknam ed “th e

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late earl” because of his difficulty in getting up in th e m orning. This late w aking h ab it of Lord C hatham was however n o t th e only problem for th e British troops. The so-called W alcheren expedition tu rn ed o u t to be a disaster as m ore th a n 10,000 soldiers developed a febrile illness w ith in th e first two m o n th s an d m any died (very few as a resu lt of enemy action). There is sufficient evidence to im plicate m alaria as a m ajor co m p o n en t of W alcheren fever, b u t careful review of all sources suggests th a t it was a leth al com bina­ tio n of diseases - m alaria, typhus, typhoid an d dysentery - acting together on a group of m en living u nder pitiable circum stances. The reduced m o rtality in officers com pared w ith th e troops (only 3% com pared w ith over 10 %) was probably as m u ch due to th eir b etter general h ea lth as to th e higher-quality care they undoubtedly received. In London, authorities questioned: How is th is possible? It was concluded th a t m any factors contributed to th e catastrophe b u t one of th e m o st significant was th e lack of com m unication betw een th e physician-general an d th e surgeon-general. These positions were abolished and replaced by a single director-general. Over tim e, Zeeland changed. Dykes were built, swamps were drained an d m alaria was elim inated. W h a t can we learn from this? 1. Poor conditions increase susceptibility to m ultiple (infectious) diseases. 2. Some tropical diseases were previously endem ic in our p a rt of th e world. 3. A central authority should perform disease control, especially w here th ere are epidemics 4. W ater m anagem ent is a useful tool for disease control. w h a t

d o

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to d a y

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te rm

“p o v e r ty -re la te d

d isea se s” ?

Infectious diseases, h ea lth problem s around b irth an d m a ln u tritio n acco u n t for 70 % of all deaths in Africa, 4 0 - 50 % in parts of Asia an d for less th a n 20 % of th e deaths in th e other parts of th e world. Infectious diseases account for m o st of these deaths, especially m alaria, tuberculosis and h i v / a i d s . M alaria is a m ajor cause of death in African children u n d er five years old. Tuberculosis - a public h ea lth th re a t in m any parts of th e world - is one of th e leading causes of m ortality and m orbidity worldwide. It is estim ated th a t ab o u t 10 % of th e world population is infected w ith TB. In Africa, th e incidence of tuberculosis has increased, m ainly as a result of th e burden of h i v infection. Since th e beginning of th e epidemic, m ore th a n 70 m illion people have becom e infected w ith h i v . In m any A frican countries, h i v / a i d s is th e m ain cause of death, and it is th e fo u rth cause worldwide. In m any sub-Saharan countries life expectancy is 47 years (this figure w ould be 62 years w ith o u t a i d s ) . In Asia, th e h i v / a i d s epidem ic is growing faster th a n in any oth er region. M alaria, tuberculosis and h i v / a i d s are called poverty-related diseases, because m ore th a n 95% of new cases occur in low -incom e countries. These infections cause

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trem endous h ea lth problem s, w hich b o th accom pany an d exacerbate poverty because of th eir relationship w ith poor housing, food, hygiene and access to h ealth care. A vicious circle arises, w ith illness and death leading to higher costs for m edical care, loss of incom e, and as a result, m ore poverty. fro m

a b s tr a c t

n u m b e rs

to

a

p e r s o n a l

e x p e rien ce

In th e eighties, w hen I worked in Botswana, th e D utch governm ent had a bilateral technical support program w ith Botswana and D utch doctors were seconded via th e m inistry of h ea lth in G aborone to work in th e various district hospitals in th e country. At th a t tim e, Botswana was alm ost com pletely depend en t on foreign doctors, as only two doctors were Botswana citizens (these were refugees from South Africa) an d there was no m edical faculty in th e country. Scandinavia an d th e N etherlands provided technical supp o rt free of charge. In those days Botswana was ju st doing a b it b etter econom ically speaking, having originally been one of th e te n poorest countries in th e world. H igh-quality diam onds, a growing to u rist in d u stry an d beef exports have secured econom ic grow th over th e last 30 years. Health-w ise, th e picture changed dram atically in a very sh o rt tim e: in 1990 life expectancy a t b irth was aro u n d 64 , w hile in 2004 life expectancy at b irth fell to 35 - th e low est figure in th e world (W orld Bank statistics). A single factor caused this dram atic change in life expectancy: hiv/aids!

A critical audience may feel a b it puzzled now: Botswana becam e one of th e richest countries in Africa, b u t a t th e same tim e one of th e m o st severely affected countries health-w ise. So is it correct to call h i v / a i d s a poverty-related disease? There are various possible views, b u t allow m e to look a t this issue as an academ ic m edical professional. The spread of a deadly infectious disease at a scale and speed as occurred in Botswana in th e nineties dem anded im m ediate action and a m ultidisciplinary group of experts tackling th e problem in a com prehensive way. For this p articular problem , biom edical experts are needed, covering for example infectious diseases, virology an d laboratory m edicine in addition to behavioral scientists such as psychologists an d anthropologists an d h ea lth econom ists. In addition, as th e British learned in 1809 , excellent co m m unication an d a central au th ority are needed. As stated before, Botswana had two m edical doctors, n o m edical faculty and no m edical research in stitu tio n and therefore lacked th e capacity to deal w ith this complex emerging problem. Botswana becam e even m ore dependent on foreign experts w ith good intentions. If a sim ilar situation arises in th e N etherlands, a task force of experts from D utch universities or research in stitu tio n s is form ed and evidence-based in terv entions are quickly im plem ented. The m ain p o in t I w ould like to m ake here is th a t th e fight against poverty related diseases does n o t only require m oney b u t local scientific institutions th a t have the capacity to deal w ith th e (em erging) h ea lth problem s as well. In addition, I w ould like to show

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th a t N o rth -S o u th or East-W est academ ic p artn ersh ip is a useful tool for building such capacity and m ay th u s contribute to b etter global health. a c a d e m ic

p a rtn e rs h ip

Universities and university m edical centres in th e industrialized world play an im por­ ta n t role in accum ulating knowledge th a t contributes to improve h u m a n health. Evidence-based m edicine has contributed significantly to th e large h ea lth gains th a t have been achieved in m any p arts of th e world. The clustering of care, education and research w ith in academ ic centers in in d u s­ trialized countries represents one of th e m ain incubators for “W estern ” m edicine. In th e m eantim e, th e developm ent of h ea lth care in developing countries has n o t kept pace. This is n o t only due to financial constraints, b u t also because of th e weak position of local university m edical centers. These in stitu tio n s o ften lack research capacity and th e activities of the m edical professionals are therefore often lim ited to h ealthcare and education. This is n o t th e ideal environm ent for inquisitive potentially “fro n tier” h ealth professionals. At th e same tim e, N on-G ov ern m en tal O rganizations ( N G O s ) im ple­ m e n t large-scale h ea lth program s w ith significant financial su p p o rt from abroad. Be­ cause there is often little or no co n tact betw een th e N G O s an d local academ ic centers, o pportunities to build local capacity to develop evidence-based m edicine an d evidencebased interventions are n o t seized. Local academ ic centers th u s rem ain powerless, n o t only because they lack financial capacity, b u t also because they have n o t b u ilt up re­ search expertise and because, as a result, am bitious b u t fru strated professionals have gone elsewhere. Some of these universities set up partnerships w ith universities overseas. Radboud University Nijmegen, because of its original C atholic signature, has unique long-term collaborations w ith institutions overseas. Its capacity-building efforts are well recognized in these countries b u t are know n only by few in th e N etherlands. A good example is th e nearly 50 years of collaboration w ith th e Tanzanian h ea lth care system, in w hich th e University M edical C entre St Radboud played a crucial role an d m any Radboud workers contributed, such as van Am ersfoort, Meeuwissen, Tolboom an d D olm ans. At th e tim e of independence, nearly 50 years ago in 1964 , Tanzania had around 100 citizens w ith a university degree, ten of w hom graduated as m edical doctor. This is m u ch b etter th a n in Congo in 1960 , w hich had n o t m ore th a n 16 university graduates (by th e way, no medical doctors and n o lawyers). In 1970 , th e University of D ar es Salaam in Tanzania was estab­ lished w ith its own medical faculty. At first, 35 medical doctors graduated each year in Dar es Salaam, serving a population of about 23 m illion inhabitants. The u m c St Radboud has trained m any Tanzanian professionals - at first for th e university hospital in th e capital, later for k c m c , th e university referral hospital for th e N o rth . The m edical curriculum for k c m c was set up and developed thro u g h close collaboration w ith Nijm egen an d th e m edical curriculum in M oshi is still optim ized in collaboration w ith our university.

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Today, Tanzania has five medical faculties from w hich 350 doctors graduate annually (100 from k c m c and 200 from D ar es Salaam ). N onetheless, Tanzania still has only ab o u t one m edical doctor for every 25,000 inhabitants. This was about educational cooperation. But w h at ab o u t research collaboration? In 2003 , th e long-term collaborations of th e u m c St Radboud w ith Tanzania and Indone­ sia were boosted by a g ran t from th e D utch O rganization for Scientific Research ( n w o ) . O u r m ain objective w ith this g ran t was to establish a netw ork of in stitu tes w ith th e aim of building research capacity for studying infectious diseases in Tanzania an d Indonesia. This netw ork was called p r i o r , w hich stands for Poverty-Related Infection O riented Research. Participating institutes were: in Indonesia Padjadjaran University Bandung an d Eijkman Institute Jakarta and in Tanzania: k c m c an d D utch universities (Nijmegen, Leiden, M aastricht, W ageningen) and th e r i v m . M any enthusiastic professionals from different disciplines from th e three countries contribu ted to th is program , supervising PhD students (14 have defended th eir thesis and three m ore will finish soon). Subse­ quently, follow -up program s were developed: a p r i o r i laid th e foundations for th e K ilim anjaro C linical Research Institute (as it is now officially recognized by th e Tum aini University) and i m p a c t has greatly reinforced th e medical research u n it of th e Padjadjaran University in Bandung. w h a t

a b o u t

Bo

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The school of m edicine was only established in 2009 , w hen 36 students were included in th e Bachelor’s program . In conclusion: Low and m iddle-incom e countries often lack th e capacity to develop or optim ize interventions to improve local h ea lth problem s. 2. Long-term N o rth -S o u th or East-W est academ ic p artn ersh ip s can reinforce th e position of th e university m edical centers, especially if th e p artn ersh ip is accom ­ panied by funds th a t enable th e adm ission of extra students an d th e reten tio n of b rillian t professionals in th e low -incom e institutes. 3. In tern atio n al academ ic p artnership offers unique opportunities for w in-w in situations as one p artn e r gets access to m ore advanced technical knowledge w hile th e other gets access to large num bers of patients. 4. The position of university m edical centers in low and m iddle-incom e countries may be w eakened by foreign initiatives w ith considerable funds operating in th e same area. 5. In tern atio n al academ ic p artnership sets high standards for professional behavior for b o th parties and professionalizes th e societal involvem ent of th e institutes. It adds to th e co n ten t of the educational program an d helps prepare students who 1.

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w ish to address global issues. It th u s contributes to th e prestige, profile an d appeal of b o th institutes. G lobalization causes th e rapid spread of diseases an d professionals from th e N o rth and South can learn from each other on how to deal w ith these - for th em em erging illnesses.

Let me give two examples in je c tin g

d r u g

use a n d

th e

sp re a d

o f

h iv /a id s

It is very well know n th a t h i v / a i d s is a sexual tran sm itted disease. The im portance of injecting drug use ( i d u ) as a route for h i v tran sm issio n has received less atten tio n although outside sub-Saharan Africa, i d u is th e ro u te for tran sm issio n of h i v in 30% of cases. The im portance of supplying clean needles an d m e th ad o n e m ain ten an ce tre a tm e n t to prevent h i v transm ission was well recognized early in th e h i v epidemic in th e N etherlands. The exception was th e South-East of th e N etherlands, w here h i v seroprevalence rates rose to around 20 - 25%, com pared to less th a n 5% elsewhere in th e country. The reason for this is th a t clean needles and a shooting-up area were im ple­ m ented late in Heerlen. Very few Hiv-infected i d u s found th eir way to th e h i v trea tm e n t centre in M aastricht. Access to care is a global issue for these people, as h ealth-care workers ten d to see drug users as incurable, m anipulating, lacking in m otivation and n o t w orthy of care, w hile others th in k th a t addiction leads to personality disorders, a sense of sham e and loss of self-respect. Internists a t th e Academic H ospital in M aas­ tric h t joined forces w ith th e Psychology Faculty a t th e sam e university (Prof. Hospers) to prevent, control and tre a t h i v am ong drug users in Limburg. I learned a lo t working in an h i v policlinic a t th e centre for alcohol an d drugs in Heerlen for five years, for example th a t i d u s indeed have very lim ited access to care, they need “one-stop care”, a lot can go wrong in prisons, adherence to treatm ent is n o t necessarily problematic b u t psychiatric co-morbidity is. Prostitution tu rn ed o u t to be com m on, w hich carries th e substantial risk of spreading h i v in th e general population. The collaboration w ith psychologists tu rn ed o u t to be crucial, effective an d very p leasan t an d we received th e Pearl Award for prevention from ZonMw. In the British Medical Journal in 2003 , about th e tim e th a t I moved from M aastricht to Nijmegen, it was show n th a t 80% of all new h i v cases in Indonesia could be attributed to injecting drug use. Indonesia had undergone recen t political change from a repres­ sive to a dem ocratic political environm ent. Together w ith these changes, Indonesia was facing an enorm ous increase in injecting drug users an d consequent h i v transm ission. Estim ates of th e seroprevalence of h i v am ong i d u s vary in Indonesia, b u t can reach m ore th a n 50 percent. In Bandung, doctors also becam e increasingly w orried as they were - for th e first tim e - confronted w ith a i d s patients an d drug users. We were strongly encouraged to share our knowledge on h i v and injecting drug use by th e team of infectious diseases specialists in Bandung. N ijmegen and Bandung were in fact already

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collaborating on t b research, w ith Dr Bachti A lisjahbana an d D r van Crevel as pioneers. We form ed a m ultidisciplinary team of experts from Bandung, M aastrich t (H ospers), Antw erp (M eheus), N ijm egen (D r Baltussen, de Jonge en van Crevel) and Cordaid and a large EU g ran t was obtained. We were very happy to get th is g ran t since investm ents in h ea lth care for drug users and com m ercial sex workers are n o t always appreciated by th e general public or by all politicians and professionals w ho control budgets. However, they can be th e m ain engine driving th e h i v epidem ic an d it was visionary of th e doctors in Bandung to recognize it in th e early phase and for all stakeholders to work on it! For W est Java, we designed a com prehensive program for prevention, control an d tre a t­ m e n t of h i v am ong drug users, addressing all possible levels. After five years of hard work, w ith support from all im p o rta n t stakeholders such as th e university, hospital, prison, provincial h ealth authorities - and w ith in p u t from European partners - a m ultidiscipli­ n ary team of experts was form ed in Bandung to address th e problem of h i v in W est Java an d offer advice, w here needed, to th e n atio n al a i d s com m ittee. A M aster’s program in addiction and h i v care is m eanw hile being organized in Indonesia, w ith support from Prof. Cor de Jong at our university, ensuring dissem ination of expertise for th e w hole of Indonesia. Drug use starts a t the age of 12 and a special school program has therefore been developed by Prof. Hospers at u m . This program may be introduced in th e whole of W est Java (a t 33,000 schools) and will hopefully form th e basis for real prevention. M eanwhile, a co h o rt of 1500 h i v patients was established in Bandung, offering th e intern ists excellent opportunities for tran slatio n al research. M ore fu n d am en tal questions can also be addressed. For instance, we are studying w h at an opioid m u receptor is doing on cells th a t play an im p o rta n t role in h o st defense. In th e laboratory in Nijmegen, th e im m unom odulating effects of opioids are explored w ith su p p o rt from Profs N etea and Joosten. M eanw hile, we found in our co h o rt th a t th e n atu ra l course of h i v differs in i d u versus non-iDU patients. In addition to th a t, they appear m ore likely to develop tuberculosis and we have evidence th a t biological factors play a m ore im por­ ta n t role th a n exposure. O ur research confirm ed th a t opioids have im m u n e-m o d u latin g effects, som e­ th in g th a t was repeatedly suggested by my drug-using patients in Limburg. I find th is a typical example of how co n tact w ith patients, e.g. working as an in tern ist, can add to basic knowledge in m edicine and be of public h ea lth interest. A careful clinical observation also led to our studies on th e role of platelets in m alaria, carried o u t in collaboration w ith U trecht University. Low p latelet counts are com m on in m alaria, and as internists, we hypothesized th a t platelets b in d to th e blood vessels and th a t m alaria resembles a rare blood disease called t t p where this also happens an d like m alaria causes fever, haemolysis and brain dysfunction an d low p latelet counts. A recent editorial in Blood indeed indicated th a t m alaria is now recognized as a m icrovascular disease. Evidence came, am ong others, from studies by Q uirijn de Mast, who studied this in th e experim ental m alaria m odel set up by Prof. Sauerwein in Nijmegen,

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b u t also included field studies in Tanzania and Indonesia. We are currently focusing on th e role of platelets in dengue virus infections, together w ith colleagues in Indonesia and th e N etherlands. m e d ic a l e d u c a tio n

For m ore th a n 40 years, N ijmegen students have done clinical in tern sh ip s in th e final years of th eir train in g in Tanzania, G hana, N icaragua, El Salvador, Surinam and recently Indonesia. This stu d en t exchange is unique in th e N etherlands as 1 ) we only work w ith designated institutes, 2 ) clinical an d public h ea lth activities are always com bined, and 3 ) students are well prepared before they go. This elective is highly appreciated by th e students and every year aro u n d 70 to 90 - soon maybe 120 - travel abroad. M onique Keuter and H enri van Asten are th e m ain driving forces b ehind th is program th a t has th e objective to broaden medical, social an d cultural horizons. The m andatory preparatory courses are continuously improved by M onique an d H enri, in consu ltatio n w ith Tropico, a com m ittee of students. There are initiatives for profes­ sionalizing th e collaborating doctors and teachers abroad, as was done w ith N ijm egen doctors and teachers (this is good for our students and for th e Tanzanian students). Dear students: intern sh ip s in a developing co untry are very im p o rta n t for our d ep art­ m e n t and we in te n d to give it m axim um sup p o rt in th e future. O ur d ep artm en t also took th e initiative to create a sequential series of electives focused on infectious diseases in w hich biom edical an d public h ea lth courses ru n in parallel. This opened th e door to create an “infectious diseases” track w ith in th e study Biomedical Sciences. We hope th a t this track will n o t only be attractive for D utch students b u t for students from abroad as well. There is considerable global v ariation in th e p attern of infectious diseases, and th e creation of an “in te rn atio n a l classroom ” w ould have clear added value. I hope our in stitu te is w illing to invest in such an in ter­ n atio n al classroom. Finally, our d ep artm en t contributes in different ways to m edical education over­ seas. Cor Postma en Petra van G urp are fu rth e r developing th e m edical curriculum at k c m College in Tanzania, extending th e pioneering work done by Prof. D olm ans. We established a M aster’s program in clinical research in Tanzania using n w o funds and will support th e M aster’s program in addiction care in Indonesia. p a tie n t

c a re

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Patient care, research, education and service are core tasks of a university m edical centre in th e N etherlands. So th e rem aining issue to be addressed is how in te rn atio n a l h ealth is translated in to p atien t care in Nijmegen. The answ er is twofold. First travel m edicine: travel-related h ea lth hazards can be prevented trough im m unizations and prophylactic m edication. There is a proliferation of travel clinics providing these services, b u t I question w heth er they always provide a quality service. At

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th e same tim e, m ore and m ore people are travelling w ith underlying m edical conditions for w hom specialized, accurate, tailored m edical advice is vital. The Radboud know -how on tropical or exotic illnesses is extensive and available 24 hours a day. Specialized knowledge on diagnosis and tre a tm e n t can be supplem ented by expertise on im m u n e deficiencies (w ho may be a t increased risk?) or local factors (various specialists have worked for years in th e tropics). Together w ith th e D ep artm en t of O ccupational H ealth we will establish th e Radboud Travel Clinic, a centre of expertise for travel-related h ea lth issues. Tropical or exotic illnesses are n o t com m only diagnosed in th e N eth er­ lands and, in my opinion, care for these patients should be concentrated in a few specialized centers. Finally, th e D utch travel abroad frequently, b u t foreigners also come an d live in th e N etherlands. We have started collaborating w ith general practitioners in order to improve th e care of non-W estern im m igrants in our country. The title of my oration is: “W ie gelooft er nog in de Sint” . I refer here to different m eanings of th e D utch w ord Sint, w hich is n o t easy to tran slate in to English. I hope you will excuse m e if I now will continue in D utch. w ie

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Een w at mysterieuze titel. Welke Sint w ordt hier bedoeld: Sinterklaas, h e t symbool voor vrijgevigheid of de Sint als heilige, dus iem and zonder zonden. In tern atio n ale gezond­ heidszorg h eeft niets te m aken m e t heiligheid m aar is door de signatuur van de k ath o ­ lieke universiteit Nijm egen en h e t academ isch ziekenhuis Sint Radboud - ik gebruik n u de oorspronkelijke n am en - altijd wel een typisch Nijmeegse activiteit geweest. De w enselijkheid van nauw e contacten m e t derdew ereldlanden (zo noem de m en d at to en ) is jaren vastgelegd geweest in de strategische p la n n en van de universiteit, m aar is er helaas u it verdwenen. Sinterklaas sta at voor vrijgevigheid m aar er zijn recen t terech t veel vraagtekens gerezen of h e t geld voor ontw ikkelingssam enw erking allem aal wel goed is besteed. Sint Radboud, hij leefde van 850 to t 917 - quote com m unicatie van h e t servicebedrijf bezoekt zieken, voedt arm en en geeft zijn verm ogen weg. A nno 2011 is h e t verm ogen van h e t Radboud kennis en ik pleit er vurig voor om onze kennis en m iddelen beschikbaar te blijven stellen om een bijdrage te leveren aan m ondiale problem en. Bovendien: in onze globaliserende wereld zijn er veel studenten die verder willen en m oeten kijken dan de om m uurde achtertuin. De am bities van de infectieziekten/ in te rn atio n a le gezondheidzorg van de algemeen in te rn e geneeskunde voor de kom ende jaren zijn daarom h e t volgende 1. O nderzoek: O nze eigen specifieke expertise w ordt verder uitgebouw d door m eer fundam enteel onderzoek in N ederland te com bineren m e t tran slatio n eel onder­ zoek overzee m e t focus op h i v / t b en D engue/m alaria.

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O nderwijs: H et coschap ontw ikkelingslanden willen we m axim aal blijven onder­ steun en en verder professionaliseren w aar mogelijk. Voor stu d en ten overzee zullen we proberen infectieziektenonderw ijs te creëren of te optim aliseren zowel lokaal als in Nijmegen. Patiëntenzorg: Wij w illen onze expertise op h e t gebied van reizigersgeneeskunde krachtiger neerzetten en m eer aa n d ach t geven aan de in tern istisch e zorg voor niet-w esterse patiënten. D ienstverlening: Wij blijven een duidelijke rol blijven spelen in de langdurige in stitutionele sam enw erking m e t Tanzania en Indonesië. d a n k w o o r d

M et genoegen sluit ik m e aan bij de traditie van onze universiteit om deze rede af te sluiten m e t een dankw oord. Per slot van rekening, h e t so o rt werk d at ik doe is alleen mogelijk door de inbreng van heel veel m ensen M eneer de rector m agnificus, leden van h e t college van b estu u r van de Radboud U niversiteit, leden van de raad van bestuur van h e t u m c S int Radboud, dank voor h et in mij gestelde vertrouw en en in h et belang dat u h ech t aan internationale gezondheids­ zorg. M ijn academ ische carrière ben ik begonnen in België, en ik denk m e t dank terug aan de gedegen opleiding die ik er m o c h t genieten en de w arm te van de m ensen die ik er heb ontm oet. Ik raad u dringend een bezoek aan, mogelijk b estaat België b in n e n k o rt n ie t meer. O ok in Botswana ontm o ette ik veel gastvrijheid, evenals later in Tanzania en Indonesië. Als dank deel ik deze ervaringen m e t u, deze gastvrije ervaringen in h e t b u i­ te n lan d staan in schril co n trast m e t de huidige populistische xenofobie in N ederland. M ijn opleider in te rn e geneeskunde is professor Jos van der Meer, tevens m ijn prom otor. Beste Jos, Je h eb t een opvallende liefde voor de w etenschap en m e t je bezielende en m otiverende houding heb je heel w at m ensen w arm gem aakt voor ons vak, w aaronder m ijn persoon. Prof Paul M ier en Dr Tom Vree hebben m e verder in de w etenschap geïntroduceerd, twee inspirerende en vrolijke w etenschappers. Professor Kullberg is m ijn opleider infectieziekten en h e t is door hem d at ik mij in h a r t en nieren een internist-infectioloog voel. Reinout van Crevel, dank ik d at hij m e in Indonesië h eeft geïntroduceerd en voor zijn enorm e inzet voor i m p a c t , ik verheug m e op verdere samenwerking. N a m ijn prom otie heb ik een jaar in Zwolle gewerkt w aar ik bijzonder onder de in d ru k was van de kw aliteit van de geneeskunde. Beste Ton Tjabbes en Frits Nelis, aan jullie denk ik nog steeds terug als een voorbeeld van een ideale collega. H et onderzoek bleef trekken en daarom zijn we n aa r M aastrich t verhuisd. H et cardiovasculaire onderzoek in M aastricht is uitstekend. Ik heb m e d an ook aangesloten bij prof. C atrien Bruggem an en prof. H arrie Steinbusch, die bestudeerden of m icroorganism en bijdragen aan vaat- of hersenschade; zij hebben daarm ee de basis gelegd

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voor ons huidige m alaria/D en g u e werk In M aastrich t heb ik ook de hoogleraren psychologie G erjo Kok, H erm an Schaalm a en H arm Hospers o ntm oet. Dames en heren, w at een geweldige collega’s om onderzoek m ee te doen. Beste H arm , dank voor je in ­ houdelijke m aar ook persoonlijke bijdrage. Illustratie: aan h e t eind van een lange dag werken overzee en n a h e t voeren van vele gesprekken b ek ru ip t je soms h e t gevoel doen we d it wel goed? D at is steevast h e t m o m e n t w aarop H arm sp o n taan k o m t m e t de m ededeling “W at zijn we to ch goed, he A ndre” en dan spreekt vriend en collega en psycholoog. Er zijn heel veel andere m ensen die door h u n inzet de bu iten lan d se activiteiten to t een succes gem aakt hebben, ik kan ze n ie t allem aal noem en. Ik noem graag de nietNijmeegse kartrekkers zoals O tten h o ff u it Leiden, Savelkoul W ageningen, Van Soolingen (Bilthoven) en M eheus A ntw erpen. I w ould also like to th a n k our collaborators from abroad: I ca n n o t m en tio n th em all, as for m any years we had over 150 people on th e payroll, including 30 PhDs. O ne of our first PhD students was G ibson Kibiki, w ho is now Professor Kibiki and head of th e K ilim anjaro C linical Research Institute! Gibson: w h at a achievem ent! I really hope we can continue working together! In Indonesia I w a n t to m en tio n our co-workers from th e Eijkman Institute b u t especially our collabo­ rators in Bandung. Prof Tri from th e Padjadjaran University an d Dr W ahyudi from H asan Sadikin Hospital, Dr Lucy from th e Provintial H ealth Office and, of course, Dr Hadi, Dr Primal, Drs Lucas Pinxten and D r N ina: th a n k you for your kindness and friendship. According to th e old Chinese saying “th e tru e m aster is invisible”, b u t today I w ould like to p u t th e spotlight on D r Bachti Alishibana: you m ake things h appen as only a tru e m aster can. Tenslotte wil ik heel graag prof de G root en dr Fijnheer u it U trecht danken voor de plezierige en effectieve sam enw erking m e t betrekking to t h e t plaatjesonderzoek. M et de verankering van Q uirijn de M ast hoop ik dat we dit verder gaan uitbouw en. De in te rn atio n a le gezondheidszorg is onderdeel van de sectie infectieziekten en dat valt weer b in n e n de algem een in te rn e geneeskunde. Terecht: als infectiologen zijn en blijven wij nam elijk algem een in te rn iste n en h e t is een plezier b in n e n een afdeling te werken m e t zo’n brede expertise. Professor Tack, Lenders en Stalenhoef en alle andere algem een in te rn iste n dank voor jullie collegialiteit! De in tern atio n ale gezondheidszorg. Carla Y senbrand, Mieke Daalderop, H enri van Asten, Reinout van Crevel, Q uirijn de Mast, M onique Keuter en alle prom ovendi. We hebben de afgelopen jaren bijzondere dingen gedaan en d at was alleen m aar m oge­ lijk dank zij een ieders inzet. O nze verschillende persoonlijkheden hebben zich gevoegd to t een fijn team . Aan alle medewerkers van de sectie infectieziekten: werken als infectioloog b in n en h e t Radboud is n e t als zeilen op zee. Een schip is n e t zo zeewaardig als zijn bem an n in g en to t n u toe hebben we over alle wereldzeeën gevaren, de elem enten trotserend. Ik vind h e t een voorrecht om op ons geweldig schip voor in de w edstrijd te m ogen varen.

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Familie: eerst w at m en n o em t de koude k a n t echter niets is m in d er waar: bij de Zeeuwse fam ilie voel ik m e zeer thu is en Arie Roeland, je huis aan de Karel D o o rm an laan is een heel w arm nest. D ank voor je gastvrijheid en zorgzaam heid. M ijn m oeder w ordt oud, ze is er daarom vandaag niet, ik ben blij en dankbaar d at m ijn zussen goed voor haar zorgen. M enno, Viktor en Oscar: De afgelopen jaren zijn er veel m ensen u it h e t b u ite n ­ lan d bij ons op bezoek geweest en jullie hebben deze bezoekers altijd bijzonder open en hartelijk m ee ontvangen. Ik w eet dat dit door veel buitenlandse gasten erg op prijs w ordt gesteld. Ik ben trots op jullie. Realiseer je dat als er w ordt geapplaudisseerd, d at d it ook voor jullie is. M arjolein: Vandaag zei je tegen me: “als je m e toespreekt krijg ik een boei” en iets later “ik ga dan b ru lle n ” . De associatie brulboei was snel gem aakt... Ik m aak n u een grapje, n ie t toevallig w a n t h u m o r n eem t een vaste plaats in onze verhouding. Toch is dit een heel serieus m om ent! W a n t vergeet nooit: iedereen die ooit in de m ist h eeft gevaren w eet hoe belangrijk brulboeien zijn!

Ik heb gezegd.

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H ow ard MR. Walcheren 1809: a medical catastrophe. BMJ. 1999 D e c i8-25;319(7225):i642-5. López JA. M alignant malaria and microangiopathies: merging mechanisms. B lood. 2010 Feb i8 ;ii5 (7):i3 17-8 . Pisani E, G a r n e tt GP, G rassly N C , B row n T, Stover J, H an k in s C , W a lk er N , G h ys PD. Back to basics in H IV prevention: focus on exposure. BMJ. 2003 Jun 2^ 326(7403)^384-7. Sachs J. The End o f Poverty, economic possibilities for our time. 2005 P in gu in Press ISBN 1-59420-045-9 v an der V en AJ, V erm eu len C M , Schippers JA, B ruggem an C A , Satijn TK, H ospers HJ. Transmural care for HIV-seropositive drug users: experiences from Southeast Limburg, the Netherlands. N ed Tijd schr G en eeskd . 2003 A pr 5;l47(14):662 -5. v an der V en AJ, Ram eckers EM , H ospers H, V erm eu len C . H IV prevalence among injecting drug users in South Limburg, 1994-1998/1999: increasing trend in Heerlen, not in M aastricht. N ed T ijd sch r G en eesk d . 2002 Jun 29;l4.6(26):1253;

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