This year, Radboud university medical center (Radboudumc) joined the Netherlands Centre for One Health (NCOH) in partnership. Heiman Wertheim has taken up a position on the NCOH executive board and represents the Radboud Center for Infectious Diseases.

“A high level of expertise in infectious diseases has been developed at Radboudumc and Radboud University within the research theme ‘infectious diseases and global health’. Our research focusses not only on the patient, but also takes people, animals, environment, policy and behaviour into account. The questions surrounding infectious diseases are, therefore, many and wide-ranging, and we cannot solve them on our own. The challenge can be met through collaboration, and by applying the holistic approach of the NCOH and the available expertise. We will focus on the NCOH themes ‘Emerging Infectious Diseases’ and ‘Antimicrobial Resistance’. Our research program involves twelve PIs from the departments of Internal Medicine, Pharmacy, IQ Healthcare, Medical Microbiology and Pediatric Infectious Diseases. These researchers all play a role in the Radboud Center for Infectious Diseases. With, for example, our expertise in fungal infections including the host response, I believe that we are complementary and can add value to the NCOH.”

Can you give an example of what this added value consists of?

“A lot has happened within Radboudumc in the field of infectious diseases over the last two years. A beautiful milestone was the well-deserved award of the Spinoza Prize to Mihai Netea for his research into innate immunity to infections, including fungal infections. We experience a clear demand for our knowledge in the field of mycology. This need also applies to infections with tuberculous and non-tuberculous mycobacteria. We also have a unique research program for mosquito-borne diseases such as dengue and malaria, with a unique human challenge model, which is very relevant for the ‘Emerging Infectious Disease’ theme within the NCOH. Furthermore, we undertake a great deal of research into antibiotic use and resistance, for example around the implementation of guidelines, but also into the complexity of this problem in low and middle-income countries. Two years ago, when I started as head of department at the Department of Medical Microbiology, I knew that collaboration with Wageningen would form an important link with our work. The announcement of the commencement of the NCOH came just at that time, so we were able to fit in nicely.”

What do you want to tackle first within the NCOH?

“Many people in Radboudumc are involved in infectious diseases research,  It’s a major theme. There are good opportunities for cooperation within NCOH, and we all appear to be on the same page. We were received with open arms when we put in our application to become partner. But now we need to work towards concrete research objectives within NCOH. We already have a PhD within NCOH working on fungal research. It’s wonderful that the Westerdijk Institute at the KNAW is now also NCOH partner. Within the NCOH we can for instance undertake robust research on resistant fungi in relation to agriculture. Often people think of resistance in relation to livestock farming, but many anti-fungal agents are used in agriculture. There is potentially an important component of resistance development in agriculture  that we also see in patients. It is important to gain more insights in this.”

Cooperation isn’t a new concept, of course. What does the NCOH add?

“We have already been cooperating independently for years with several institutes who are also connected with the NCOH. But I expect that new ideas can also develop from our new position within the NCOH. You have mutual access to much more expertise, and solutions can therefore come from very unexpected angles. We’re now going to think collectively with all researchers within Radboudumc about what we can achieve at a higher level on a cross-theme basis within NCOH. We’re now partner, so what are we really going to do? It’s not just about bringing the things we were already doing under the umbrella of the NCOH.”

The research should lead to solutions for One Health problems. Is this feasible?

“I think that the NCOH’s ambitions are realistic. There are top researchers in the NCOH who have really achieved things. The ‘one health’ perspective has led to more understanding of the emergence, spread and prevention of infectious diseases. There is a tendency to sometimes lean too much towards the human side. But there are two sides to the coin, like in antimicrobial resistance. The Netherlands is an agricultural country. Much has been achieved in recent years on reducing antibiotic use in the animal sector, but the resistance problem continues to increase. And questions remain regarding the attribution of drug resistance in animals to the drug resistant infections we see in humans. What else can we do? What are possible solutions? People still need to eat and many will want to eat meat. Possibly there is a solution in producing meat by culture techniques. Meat production causes problems with antibiotic use, but also puts a strain on water resources. In the end it is a sustainability issue, which brings us to human behaviour.”

You mean you have to look further and not just limit yourself to the health problems?

“It’s all interconnected. In the entire value chain, the consumer is ultimately the one who decides. We are responsible as humans. It’s not the system that determines this. If we think that eating less meat is good, there are consequences. It takes some of the pressure off, meaning that fewer antibiotics are needed. But you also have to look at the entire production of antibiotics for both humans and animals. I experienced this up close when I was in Vietnam. Nearly the entire antibiotic production has been shifted to Asia. We put the blame on Asia when their factories dispose of antibiotics into rivers. A sip of river water in India close to a production plant is, in a manner of speaking, the same as a full dose of antibiotics. This is one of many examples that have led to the resistance problem we experience today. But regardless of the fact that we pollute the environment at these locations, we have also created a vulnerable system because only a few companies now make antibiotics. There only needs to be a fire or quality issue in these production facilities, and we are already experiencing that certain antibiotics are difficult to obtain in the Netherlands. We sometimes struggle to get hold of the antibiotics that we need for our  patients. In Europe we are just as responsible for the environmental pollution in India as India. In Europe we decided we want cheap medicine. We’ve outsourced medicine production and with this we have  simply also exported our pollution. If we don’t agree with this, we should say to insurers and the EU that antibiotics should not only be cheap, but also produced in a responsible manner.”

So there’s also a role for politics?

“Certainly. To create solutions we have to be pragmatic. You have to address the interests of all stakeholders. It’s a matter of persevering, motivating good people and reaching out to the right networks. The NCOH can help to provide important evidence that policy makers need for developing intervention strategies. Moreover, the horizon should not be limited to the Netherlands. We’re now making a ‘Delta plan’ for resistance in the Netherlands, but the Netherlands is of course not alone in the world. The problem arrives via other back door channels. Tourists travel to Asia and bring resistant micro-organisms home with them. We must remember that the Netherlands has a good international profile and we carry out a lot of relevant research, but could exert more influence in international politics. There is a great need for our knowledge worldwide. We export our DJs, why not also export our infection expertise?”

Who is Heiman Wertheim?

Since 2016, Heiman Wertheim is professor and head of the Department of Medical Microbiology at Radboud university medical center. Before his appointment in Nijmegen, Wertheim was director of the Oxford University Clinical Research Unit in Hanoi, Vietnam, which is based at the National Hospital for Tropical Diseases. Wertheim studied medicine at Leiden University (1989-1997), and specialised in the field of medical microbiology at the ErasmusMC Rotterdam (1998-2005). He was awarded his PhD for research on the prevention of Staphylococcus aureus hospital acquired infections.