Shaimaa El-Jafaary, a member of the Moving Along Editorial Board, recently sat down for a virtual interview with Mohamad Salama, MD, PhD, Associate Professor at The American University in Cairo, Egypt, to discuss translational research and neuroscience in Africa.
Shaimaa:
Dr. Mohamed Salama is Professor at the Institute of Global Health and in Human Ecology in the American University of Cairo. The founder of the Egyptian Network for Neurodegenerative Diseases. The founder of the Egyptian Genome Project. Awardee of many awards for Parkinson's disease and the founder of many international collaborations, including a steering committee member of the MDS Basic Science Special Interest Group. We are very happy and excited about your presence with us today, talking about the transmission and neuroscience in Africa and the gap between the basic science and clinical science. Let me start by asking, how did you become interested in this field, translational and neuroscience?
Mohamed Salama:
First of all, thank you for the invitation and willingness to have this interview with me. The point here is, why I was interested in transnational neuro disease generation. Initially, I started trying to get engaged with a lab in Europe, in Germany. To be honest, first step I was looking for working as a basic neuroscientist, lab man. But once I entered the lab, My professors there asked me one question, "Why are you wasting all your previous studies as a medical graduate? One of your strengths is, you are a physician, so why are you wasting all your time, study and efforts and so on, and just focusing on basic research?" And he made a model for himself, because his a physician and in the meanwhile he's a professor for neuroscience and he has a very active lab, working with animal models and cell culture. So he said, "Okay you can keep both tracks. You can play the role of crossing the gap between basic scientists, because you will see many of our researchers here, working in the lab, and they have no clues about what's happening in clinics and on the other hand you will find of our neurologists working in the hospital and they don't understand very well the main mechanisms or the main techniques working in the lab. Why not crossing this gap?"
So, I started thinking and the other important point he told me is that, "If you focused mainly on basic science, you will not be competitive to those who are hardcore scientists, those who are working mainly in the lab, and they have all their training as basic scientists. So it's better to gather all your strength points and come up with new model." He was establishing by that time a department called "Translational Neurodegeneration." And I found that according to him, the quality of papers, the quality of research projects, the number of funding, or funded grants he achieved, is increasing or getting higher, because he's targeting this critical point, which is Translational Neurodegeneration. Not mainly working in the lab, not mainly working in the clinic, but crossing this gap between the two areas. And most important, it is a so far unmet need in most of areas, not only in Africa, but everywhere, you will find this missing person, who can cross this bridge.
And I thought, "Why not, since it is still missing also in Europe. Certainly, it will be missing in Egypt and Africa. Let's return to Egypt and start to implement the same model I joined in Germany for a while." This is how I started being interested in translational neuroscience for neurodegenerative disease.
Shaimaa:
I think you have already covered the second question, which is "How do you see the gap between the basic and the clinical research in Africa?"
Mohamed Salama:
When we are talking about active neuroscientists in Africa, you will find that the majority are working in the field of neurology. So they are in fact, neurologists. We do not have this critical mass of neuroscientists who are interested in working in the field of neuroscience, or basic neuroscience. We are not very similar to Europe or America where we have two large groups. Basic neuroscientists and neurologists for example. No, we have, let's say 80% as neurologists and only 20, or even 10% those who are specialized in neuroscience.
The second issue here is that I have been chatting with many of my colleagues, or researchers and when I start talking about translational research in general, they feel very excited and say, "Yes, certainly, it's very important." However, when you start asking them, "Do you know examples for translational research?" they do not answer. Yeah, they think it is something very new, it's a totally new discipline, but they don't know what is it.
And because most of them do not know what is the concept of translational neuroscience, or in general, translational research, they prefer not to approach this vague area. This is another major issue. They think that is a totally different branch of science. So, I am working as basic neuroscientist, why am I changing my career? I am working as a clinical neurologist, why am I changing my career? They do not understand that the idea is, you are not changing your role at all, just you are accepting to work with others. So, instead of working mainly in clinical research, or working mainly in basic neuroscience research, you have the appetite to collaborate with others from different disciplines.
Shaimaa:
How can we decrease this gap between the clinical and the basic neuroscientists in Egypt and in Africa?
Mohamed Salama:
I guess the first thing is to start bringing both sides to this, and we have to invite basic neuroscientists to neurology conferences and start bringing neurologists or clinicians to basic neuroscience conferences. Also, dedicating some sessions for the introduction of this concept translational research, translational neuroscience. Try to introduce concepts to both sides. And to underline the most important point here, is that we are not starting a new research. You are not changing your role at all; just we are making bigger teams. So instead of one person or two persons working in the lab, no we are bringing clinicians, artificial intelligence experts, geneticist, and we are establishing one team.
So, you will still continue doing the same thing you have learned to do for the past 10 years. But we are piecing together those pieces of the puzzle to have the whole picture. So this is the most important to, I do not want to say teach, but at least increase awareness about how it works. How we can do translational research and on the meanwhile, each one is preserving his rights, his quality of work, his type he is doing, or the style he's doing his work.
Shaimaa:
Is this one objectives of the MDS Basic Science Special Interest Group?
Mohamed Salama:
Yes, exactly. And according to last discussion, we thought it's very important to underline or emphasize this, and that is why we are starting holding several meetings and we are trying to even organize separate sessions in different international meetings to increase awareness about this. As I poked them last meeting, we have also the other problem that we don't have enough critical mass of neuroscientists in Africa, so we have at least to understand or evaluate the current situation. How many neuroscientists are working in Egypt, in Tunisia, in other African countries? Start bringing them to the board and trying to attract them or make it more appealing to join their clinical colleagues in one thing.
Shaimaa:
How do you evaluate the infrastructure for translational research in Egypt and in Africa? Are we ready or we are still lacking resources?
Mohamed Salama:
I do not think we are lacking resources in term of equipment or machines or even scientists. Maybe some high-tech specialties, but in general, the experts are there. Most important is that we are lacking the understanding of the concept itself. As I mentioned previously, when you start talking about translational research, they think that it is a totally different way of doing research, a different discipline. No, we have just to emphasize that it is a new concept of how you could do your work through joining bigger groups. We are missing this concept. We are missing the appetite to join big team, for example. Each one will say, "No okay, no I prefer to continue working with my own team, just two or three partners working in this area," and others, same way. So we are missing this interest in expanding, in collaboration, in working with other countries. Maybe I would say, also, somehow we are missing the confidence, the total trust on other partners.
Sometimes I speak with the basic scientists and they feel, "Okay, those clinicians are very arrogant. They don't want to listen to us." On the other hand, when I start talking with clinicians, they said, "Okay, those PHDs are always talking about mechanisms and signaling and genetics, and we feel we are superficial." We are not missing the infrastructure regarding the money, the funding or the equipment. The more part we are missing is the appetite to collaborate, and I think we have to encourage this in the coming years.
Shaimaa:
You are very active about bringing international collaboration into the continent, not only Egypt. What are the values of having this international collaboration, and what are they bringing to us, and how to make good use of this international collaboration?
Mohamed Salama:
We have first to differentiate between international collaboration and exploitation. Because many times, you are eager to bring international collaborators and you feel that, okay they are not after capacity building or bidirectional collaboration, no, they are just aiming at bringing some samples from the African continent and they do their research outside Africa, publish a work and then book your name and that's it. This is not a collaboration. This is not a collaboration. From my perspective, a collaboration means that the international partner, let’s say European or American, has a need to understand, to have better understanding for the disease aspects in Africa, and we as African researcher want to learn more and increase our capacities to do research. In this regard, certainly, it would be a valuable collaboration and we are in need of it. We are in need of money for funding. We still need to learn more in different aspects, especially high tech and cutting-edge technology and so on, and we need to send African junior scientists to get more training. For Europeans or for Western scientists as well, they need to learn more about the disease.
I remember I had a chat many years ago with one expert in Parkinson's disease genetics and he was telling me that, "Okay, we didn't know everything about Parkinson's disease, because we are doing our homework in Europe. We are discovering new genes and new mechanisms of the disease and new risk factors,. But in Africa, for example, and some other areas of the world, it is unexplored disease, so we don't know about the risk factors in Africa genetics, and certainly there should be some changes or differences between genes for difference disease in Africa and in Europe, so they need to learn more about other aspects of disease in order to have the whole picture, and we need to improve our capacities. So, international collaboration or partnership is highly needed, highly required, but as I mentioned, we have to differentiate between a scientific, respectful partnership and we call exploitation. Someone's coming to take few samples and run away back to his country and that's it. This is totally unacceptable. For us the most important, certainly number one is capacity building and also providing expertise and funding. Yes I understand that we cannot do everything inside Africa. 100% of the work tasks, the task needed. However, you have to judge the quality of such collaboration by the increase of the percentage of work you are doing by the time of collaboration proceeding. So, in the first year, I understand that maybe 50% of the work should be done in Europe. In the second year, let's say 30%. In the third year, 10% and that's it. If we are progressing, if we are improving the percentages we are contributing to the work, this means we are improving our capacities. I would say that hopefully in five years or 10 years we should be able to do everything technically. In South Africa, the rule of the European partner would be, the data analysis finally, so we sit together and we say, "We did this part in Africa, you did your work in Europe. We are comparing between both worlds." This should be the ultimate goal of such collaboration.
Shaimaa:
It's a very, very optimistic view for the future and I hope we can establish this in the real world, because it's not impossible.
Mohamed Salama:
Not impossible, and we have a very good example in Latin America. I know my very good friend Agustin Ibañez, he established the ReDLat. It's a Latin America consortium for dementia. Certainly, they depend on expertise in the United States, but step-by-step, now, they have increased their capacities, they have improved their research potentials and they are thinking now of establishing a separate institute inside Latin America that is more or less on equal footage with similar instate in the States. So, this is a model. We can replicate somewhere, it's not a problem. I guess we have brilliant minds and we have excellent minds who have just returned from Europe. They have their PHDs or postdocs, so why not invest on those people?
Shaimaa:
Yes, that is very inspirational. What are the challenges about the international collaboration? Is it a challenge in establishing the collaboration, or implementing the projects from that collaboration?
Mohamed Salama:
No, not stabling the collaboration, because as I know, there is a high tendency among Europeans and Western world now, to start collaboration with Africa, to explore more the unexplored features of the disease, so there is a tendency to start a collaboration. Many of the funding organization are initiating funding programs for underrepresented populations, so there is an opportunity to get money. The challenge as I mentioned, is to differentiate between a real collaboration that's built on equal partnership and the other types of, not collaboration as I said, it's exploitation, where you are trying just to get some data from me and I'm not your partner.
To differentiate between real partners and those who are not looking at African scientists as real scientists. Once we identify those who can really start a partnership, those who are keen to start a capacity building program, those who are happy that you are increasing your percentage of work, you are improving your potentials and those who are looking at you as real scientists, that one day you could do everything inside your continent and then we start discussing and chatting and trying to analyze the data together. Those are real partners.
Those who are the ones who we should invest in their partnerships. So the challenge is to identify those who are the real partners, the real scientists, the real European or American scientists, who are looking for a real or equal footage partnership. This is the main challenge. Another important challenge as well, is to convince authorities in different African countries that international partnership and collaboration is a must. To be honest, we cannot do high quality research without the help. At least in the current stage. So, no harm with collaboration as far as we have the regulations and guidelines and goals that control everything.
So, there's no harm to start collaboration for example in a huge project regarding genetics, regarding risk factors with international experts to understand and learn from them. Guided that everything is approved officially and everything is under control and everything is transparent, the protocols are there available and we have official agreement between different institution. There is no harm from this. To convince authorities that this international collaboration is a step for capacity building. Without such initial step, we cannot move forward.
As I mentioned, we have two major challenges. To differentiate between real and unreal partnership, and to convince authorities with the value of partnerships.
Shaimaa:
Moving to the important project of Parkinson's disease genetics in Africa. Let us talk about the IBDCG Africa: What is the importance of this project for genetics of Parkinson's in Africa?
Mohamed Salama:
Thank you very much for bringing this to the discussion. As we mentioned, the genetics of Parkinson's disease is still understudied. We don't know many things about the genetics and different patterns of Parkinson's Disease, and in world where we are talking about precision and personalized medicine and personalized health and so on, this would be a huge gap, a huge missing group of data that will endanger our ability to enter the precision health. If we don't know the types of patients, if we don't know the genetics of patients, how come we are going to advise individualized patterns of treatments? The IBDGC Africa, International Parkinson's Disease Genomic Consortium African Chapter, is an initiative. A huge project certainly to cover this area. So the plan is that, as I mentioned previously, we will start a capacity building program. Initially, we will try to explore the available capacities all over Africa.
Those who are willing to collaborate in this consortium, I guess now we are talking about ten or eleven African countries willing to collaborate. Step-by-step, the ultimate goal of IBDGC Africa is that all African neurologists working in the area of Parkinson's Disease who are actively working in the area, can conduct research inside Africa. That we eventually have a whole understanding of the genetics of Parkinson's disease inside Africa.
Certainly, we will have several activities. Some of them is training and some internship and some fellowships, and certainly some genotyping activities and analysis. But the very nice thing about IBDGC Africa is that we aim that most of the work is done already by African scientists, clinicians, potential geneticists, neuroscientists, data analysts and now I guess we are starting to offer some potential capacity building programs and activities and fellowships as I mentioned. So, this is the right track to start with. I guess IBDGC Africa is very nice platform to give an example of what is meant by international collaboration. We are collaborating with international partners, European partners but in term of capacity building, in term of improving our potentials, hopefully by the end of five years, we have a much better understanding of generics of Parkinson's Disease in Africa, in addition to a higher capacities of African scientists to conduct similar studies in their own countries, by the end of the five years.
It's a very, very, very strong initiative. Hopefully, it will succeed to bring African neurologists and neuroscientists and geneticists together. Hopefully by the end we would say that we have now the capacity to conduct our research inside the African continent.
Shaimaa:
This takes us to the Egyptian genome project. What is peculiar about the Egyptian genome by itself?
Mohamed Salama:
I like this, but first I have to say that I am one of the partners, or one of those who were working on the research initially, and now I am on with the national project of the reference gene. There is nothing peculiar in term that we have strong genes, or we have better genes or worse genes, certainly not. But the issue here is that each population should have a group of common variants that differentiates them from others. And that's why, for example, you will find that certain gene risks are higher, for example for Parkinson's disease than other countries, and you find this in everywhere. The genes contributing to Parkinson's disease in China is different, is different from America, is different from North Africa and so on. The concept here, is that before we identify the disease genes, we have to identify the normal pattern of gene. And this is a reference genome.
Initially it was thought that, "Okay, we will have a human reference genome, and this will cover everything." And then step-by-step geneticists started to understand that no, it will not cover everything. The reference genome built on European ancestors, are somehow different from the reference genome form North Africa for example. For South African, and so on. And that's why different countries worldwide are starting to establish or assemble their own reference genome. This is the first step to start analyzing the data you have from your patients' cords, to identify risk genes, or genes responsible for this.
First, we have to know our normal pattern of genes, our set of normal variants and then say "Okay, we can now compare the patients' genetics with the normal variants and try to filtrate and try to identify possible pathogenic variants. And this is not something new, as I mentioned, so we have different countries, so even the Middle East started their own project. Our research, our initial research identified, I would say the very early base for such activity, Certainly with the national project now handled by the Minister of Higher Education and Academy of Scientific Research, we hope that we will enlarge this number of recruited subjects and certainly we we'll have more confidence in the data. More robust data that we can finally say that we have a reference Egyptian genome comparable, for example to the UK reference genome, the genome built on 100,000 case. We can do the same in Egypt, I guess. Especially with the resources available now by the Egyptian government.
And for those who have been working in genetics in disease for years, we were missing such a thing. We were facing problems, trying to imputing the data we have done studies or similar studies. Now, I guess we have the first step and on completion of this project, we will have a better idea on the different risky genes for different disease in Egypt, and this even could help in the Middle East area.
Shaimaa:
Talking about the Middle East and Africa, we have this concept of the increasing aging population and we need to start thinking about the concept of active aging and how to promote the healthy aging in Africa and the Middle East. We know that you have stepped toward this project of active aging. Could you please focus on promoting active aging in Africa?
Mohamed Salama:
As you mentioned, for years this was also a missing part in Africa and even Middle East, because we were considered younger population, so the life expectancy was not high as Europe for example, so the concerns of aging populations and how they contribute to society and so on, was missing. We felt that we have a lot of other priorities. Now we are moving to the direction of being somehow older population, now the life expectancy is increasing. Are we already prepared? As an easy answer would be, "No, certainly not." Why? Because we do not know, actually we do not know everything about the current situation. Again, we are not reinventing the wheel. This is something that has been done previously in different countries. We have the aging study in America, in UK, in Ireland and Europe and so on. So why not starting an aging study in Egypt and even in the Middle East?
Recently, I started such initiative, talking about launching, or starting a pilot for understanding the features of aging in Egypt. I am trying to follow up this through [inaudible 00:31:37] study for 10 years. And successfully now, we have initial funding, very good funding from the DRD in collaboration with the European longitudinal study, which is called CHAIR. So, we will start a capacity building program. As I mentioned previously, such studies cannot be done through international partners. The role of an international partner is start capacity building. So the funding we have got from the DRD to collaborate with CHAIR, is just to start improve our capacities to conduct a longitudinal study inside Egypt.
And not only inside Egypt, we called it EMH, which is Eastern Mediterranean Aging Study. The hope here is that we will start collaboration between Egypt, Lebanon and Jordan to better understand the current situations, the capacities, potential stakeholders, potential players and researchers. And then, hopefully we will harmonize, or coordinate activities between the three countries to start or launch a longitudinal studies in the three countries. The aim is to study aging population from 50 to 60 years old, over a ten year period. Every two years, we will have one wave, evaluates the progress of the aging population. What is the difference between you when you were in age of 50 and 52 and 54 and so on. We will evaluate clinically through a questionnaire for socio-economic and demographic values. We will try to have samples for bio-markers studies, genetics and everything. And as I mentioned, we will establish patterns of HRS studies in the States, in the UK and Germany, certainly, because now we are staring this capacity building program.
Hopefully, by the end of the capacity building program, we have the potentials, and we have also the interest of other countries, so why not instead of starting with Egypt and Lebanon and Jordan only, why not include other countries in North Africa and the Middle East? Why not include other countries in Africa and so on? This is an initial start. 2021 is the kick-off of such a project. Hopefully by the end of 2022, we are ready to start a real longitudinal aging study in Egypt.
Shaimaa:
I would like to ask you some personal questions. Who is your role model?
Mohamed Salama:
Let's see. It changed, according to your age, so I remember when I was starting my PHD, I guess every Egyptian researches has a role model, Ahmed Zeweil for example. Certainly a brilliant scientist. He got the Nobel prize and he has brilliant vision. Certainly this was him. But when you grow older, you start to appreciate that we have really here some very good role models inside Egypt, that started to work while they are living here in Egypt.
They start to battle and face the challenge. For me, for example, I have a unique role model, Dr. Mohammed Sobh. He is the founder of Medical Research Center in Mansoura University. I remembered why he is considered a role model, because he kept working from inside Egypt, in Mansoura, in Delta. Where the situations are not very favorable and he start thinking, he has a vision, and I like a man who has a vision. He is a brilliant clinician. He is very successful in his clinical world, however, he mentions that why not, in the school of medicine, why don't we have a basic research lab? Why don't we start encouraging clinician to work somehow, to dedicate some of their time in there.
And by the time he started talking about this, most of the faculty considered him somehow crazy and somehow very over-ambitious, but at certain moment, he established a center. Certainly, at the very beginning, it was not such a high esteemed center for research, but now it is improving and developing international reputation partnership, gaining funding. This is what I liked about the guy, that he had a vision and he struggled, and had many fights until he fulfilled his vision.
And after resigning or leaving the research center, his vision is moving forward. His dream is growing, so this is what I liked about him. This could be one of my role models certainly. Finally, the last one I would mention as a role model is Brian Lawler. Brian was my mentor in Global Brain House Institute, and the most critical thing about him is empathy. He is very helpful, he's very modest. I guess he is my role model from the ethical aspect. He is always there to help you, and you never feel that he is this prestigious and highly esteemed professor. He is a founder of St. James hospital in Ireland, so he is a highly esteemed psychiatrist and scientist.
However, when you start talking with him, he looks like a very, very old friend who you have known for many years. He is very modest, and he is very, as I mentioned, empathetic. Sometimes when you start talking about someone elderly, or those living in less favorable conditions, you feel that he is going to cry.
Shaimaa:
I have two important questions. One of them is about your activity, and how can you achieve this balance between your active life in research and your personal life? How do you find time for your family? How can you achieve this balance?
Mohamed Salama:
No. I am sorry to say, I did not achieve this balance. I cannot say I am achieving this balance, because honestly, I'm taking from the family all the day. Even when I am staying in home as my son is saying, I'm working on my laptop, but I guess, the good thing about this is an understanding wife. My wife can understand the value of what I am doing. She is always pushing me, and most of the time you feel confident. Okay she is backing you and everything is okay in the home, so you can start focusing on your work. So, I guess this is the secret, but no, certainly I didn't achieve this balance.
Shaimaa:
Lastly, what is your advice for the younger generation of clinicians and basic scientists?
Mohamed Salama:
Okay, first for all types of scientists or those who are working in science, dream. And dream high. You have the potential. Now it's much easier, I'm sorry to say, but now though internet and through different free courses and even you can send an email and receive the reply within few minutes, so you have more access. You have better potential and I remember when I was a medical student, we understand that the only source of information is a book, but now you as a student, you can go to PubMed and search and you can even challenge your professor and say, "No you are wrong. I read recently a new paper, saying that x, Y, or Z, are not similar to what you are saying." So this is the point. So why are you not dreaming very high?
For clinicians, I notice that recently many medical students or medical graduates are becoming fascinated by the model of working in lab or doing basic research. My advice is focus on your role as a clinician. There is no harm certainly to understand. There is no harm certainly to get training in labs and to even know how to do experiments. But never abandon your strengths. You are a clinician. You have good training. You have been investing a lot of time and money and effort for seven years, learning about disease and patients and so on, so do not lose this physician-patient relationship.
If you like to do research or basic research, you can adopt this MDPHD model and you have some experience in the lab, but never to abandon your clinical support. Being a physician, a clinician. But for scientists, certainly you have to go outside Egypt for a while. Not forever, but at least you get training, you get in touch with the cutting edge knowledge and technology and then decide whether you want to return back and invest what you learned in your country or you continue your track.
It is very challenging and very difficult at least currently, to continue your research track as a scientist without going outside Egypt for a while. Never say "Okay we have everything." No, we don't have everything here. You have to be honest. You have to learn more. And we actually need those who are traveling abroad and learning more and then returning to their country. That's a brilliant model. But certainly you should have a chance to learn more and see the world. For basic scientists, certainly you have time to go to Europe, to America, to Japan, learn more, and then decide. For clinicians, never forget you are clinician, you are blessed being someone who have a physician-patient relationship. You know better about the needs of a patient, so never abandon this aspect of your career.
Shaimaa:
Thank you for reviewing the current station, challenges, and opportunities for the future. Thank you for your advice for the younger generation, your advice for teamwork and establishing concepts, and for your hard efforts to do all these researches and to establish these newly growing concepts. It was a pleasure to focus on these efforts in Egypt and in Africa. Thank you very much.
Mohamed Salama:
Thank you. The pleasure is mine.