U.S. ARMY MEDICAL MATERIEL DEVELOPMENT AGENCY, FORT DETRICK, MD -- Historically, illness and disease incapacitate more U.S. troops than enemy weapons. Conversely, healthy soldiers free from disease are an effective fighting force, require less medical support, and need fewer evacuations if they do get sick.
Keeping soldiers healthy is a key focus of Army Medicine, and research is ongoing to develop drugs to treat or prevent diseases. Some of these illnesses, such as malaria, are extremely serious and can be fatal.
Lt. Col. (P) David Saunders, currently at the U.S. Army Medical Materiel Development Agency, is an internal medicine MD specializing in clinical pharmacology. He spent 7 years as part of a research collaboration with the Royal Cambodian Armed Forces in Southeast Asia, starting in 2008, while stationed at the Armed Forces Research Institute for Medical Sciences (AFRIMS). In total, Saunders was involved in malaria research for 10 years.
For Army researchers, malaria control research must occur where it is widespread; malaria is essentially unheard of in the U.S., with the exception of limited numbers of imported cases. Because soldiers may deploy to locations where it is a serious problem, readiness to treat malaria and other infectious diseases must be maintained.
In contrast, the Royal Cambodian Armed Forces have a significant malaria problem. Because Cambodian military forces are exposed to malaria and then travel throughout the country, their soldiers are at risk for getting the disease from infected mosquitoes and spreading it to other areas of the country.
Because of the urgent need to control malaria the Cambodian government was a willing participant in the research; permission of the Ministry of Health in Cambodia was obtained before conducting studies.
The main partners in the malaria control effort were the Cambodian Malaria Control Program and the Cambodian Army. Funding for studies came from multiple sources including the Army, DoD Global Emerging Infections Surveillance program, and the Bill and Melinda Gates Foundation.
The team opened a field site in the west of Cambodia in 2006, Saunders said; the idea was to build laboratories close to the field as possible to build local surveillance capacity. The research team moved in 2010 to the north of Cambodia to a small hospital near the Thai border.
One reason for setting up field sites for malaria control research on the Cambodia-Thailand border is that the strains of malaria found there have been particularly difficult to control because resistance to drugs has developed. "If you can to control it there," Saunders explained, "you should be able to control it anywhere."
The actual field sites were in the forest and set up much like a military encampment--sometimes using tents or even lean-tos, Saunders said.
To add value and credibility to the research, Saunders discussed how the lead investigators ensured the highest ethical principles guided the research.
The same ethical practices in use in the U.S. were also used with the Cambodian study subjects. No study subjects or Cambodian military personnel were required to participate in the study.
Getting the ethical processes and standards in place initially took nearly two years. Written informed consent was obtained from all volunteers in the clinical trials. One of the lead investigators, Dr. Chanthap Lon, translated documents, including informed consent information, into Khmer, the official language of Cambodia.
"Ethical standards are never higher than they are for the U.S. military operating overseas," Saunders said. "We represent the U.S. government. We dealt with any impressions that ethical standards were not being met by being completely transparent."
Although Army Medicine's primary interest is keeping soldiers healthy and safe, this research often translates directly to benefits for civilian populations. "Our efforts had to be good for Cambodia or we weren't going to do it," Saunders said.
In 2010 the first study was conducted testing prophylactic, or preventative, drugs. The U.S. led in developing these drugs. To test medical compounds that act as prophylactics, it is critical to be able to follow study subjects, for months or years.
Some of the study subjects received a placebo, meaning the placebo group could contract the disease. There was risk for exposure for this group regardless; they could contract malaria even if they were not participating in the study. By participating, however, they were under medical surveillance in case individual cases of malaria occurred and then medical care could be provided.
The overall cycle of a clinical research project from start to finish can extend three to five years, Saunders explained. Working with local authorities on a long-term basis helped to ensure success by building trust, with local medical personnel multiplying the capabilities of the relatively small research team.
Several studies were eventually performed using different drugs. In the end, 2,000 subjects were treated over the course of six trials during his tenure.
Saunders finished his tour of duty with the AFRIMS in August 2015, but the nature of collecting and analyzing data and publishing research means he continues to collaborate with the research team in Cambodia. Saunders has written or collaborated on about a dozen research papers since he left.
This effort supports the health readiness of U.S. forces that may eventually deploy to areas where malaria is endemic. The research in Cambodia continues, and both the Army and the Cambodian people are closer to a means to prevent malaria, putting this disease on the road to being one less worldwide problem.
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