This Traverse City doc’s 29 years of research in a humble African medical clinic has saved hundreds of thousands of children’s lives. Dr. Terrie Taylor isn’t done yet, though.
At this particular moment, Dr. Terrie Taylor is blessedly and blissfully not worried about mosquitoes and the havoc they wreak upon mankind, because she is sitting cradled in the air- conditioned, insect-free and caffeinated ambiance of Brew cafe, in downtown Traverse City.
July 24, 2015, has rolled around, and life is good. Outside, the sun shines bright. The water sparkles blue. TC summer surges at its most summeriest, and Taylor is kicking back, doing an interview in the town where she grew up on the shore of Grand Traverse Bay. She still makes her home here—in that very same childhood house—that is, when she’s not traveling the planet presenting the findings that made her a malaria research rock star, or when she’s not spending six months a year in the African nation of Malawi, where for 29 years she has conducted research that earned her global renown.
Taylor’s reputation was already solid in the malaria research world when in March 2015, she and her team published a paper in the New England Journal of Medicine that elevated her reputation from well-respected clinical researcher to research celebrity. Under her guidance, the team at her Malawi clinic was able to finally prove and show to the world how cerebral malaria kills its victims. The finding does not offer a cure, but it does help researchers zero in on that specific lethal mechanism and focus on treatments that can save lives from a scourge that has beset humans and shaped cultures for 500,000 years, killing untold millions along the way.
For most northerners, malaria is an “other people’s problem” kind of disease, in large part because the U.S. government is so fixated on keeping malaria out of the general population that whenever a case arises, a team is instantly assigned to the area to prevent its spread. Historically, though, Michigan did have an endemic form of malaria, and it spread to the point that in 1858, students at the college that later became Michigan State University took daily doses of quinine to fight the mosquito-borne “ague,” as it was called.
So, yes, we are lucky when it comes to malaria, but half the world’s people are not, because Plasmodium falciparum [pro: fal-SIP-a-rum] thrives among them and in them. The World Health Organization estimates that in 2015 438,000 people died from malaria, with 91 percent of the deaths in sub-Saharan Africa. Adding a dose of cruelty to the story, the vast majority of the people who die are children 5 and under. With such a clear call to action, such an urgent mission, it’s easy to see why Dr. Terrie Taylor is compelled to leave Traverse City’s safe embrace and travel 8,500 miles back to her Malawian clinic year after year. “Irresistible,” is in fact how she describes the pull, that need to know, that need to decipher, that need to deconstruct and disarm this disease. “I don’t want to stop that process until we reach a point at which we understand,” she says.
Taylor grew up with a general practitioner dad who left the house each morning with this declaration: “I’m going out to save lives and stomp out disease!” With that daily dose of indoctrination, it’s perhaps only logical that she would want to go to medical school, but it was an event in her freshman biology class at Swarthmore College that ignited her research instincts, the love of intellectual discovery.
She had to conduct a tricky lab experiment involving the genetics of fruit flies, and she was sketching the problem on a blackboard, when suddenly it became clear to her what the solution was. She ran to the professor’s office, but he was on the phone, with his back turned to his blackboard. Taylor drew the solution out in chalk. “He swiveled around and smiled a BIG smile,” Taylor recalls. “That moment was great. How exhilarating it was to discover something!” she says, channeling the vivid emotions of her 19-year-old self from 41 years back.
Taylor first experienced Africa when she graduated from the Chicago College of Osteopathic Medicine and thought, Why not see the world? “I had this romantic notion of Africa inspired by Isak Dinesen [author of Out of Africa],” she says. She signed on to a medical program through MSU to treat people in Sudan. Though she was immersed daily in three major scourges of mankind—malaria, schistomiasis and onchocerciasis—she says, “I really liked it … REALLY liked it.” One aspect she especially enjoyed: she had to improvise a lot, figure things out in the moment.
But even as a freshly minted doc, Taylor could see that in trying to serve the overwhelming need of the Sudanese, the physicians were too swamped to problem-solve bigger, systems kinds of issues. “There were just queues and queues and queues of patients,” she says. Each day the clinicians would work themselves to exhaustion, go home to crash, and get up and do it all over again. Nobody had time or energy to figure out better ways. Taylor realized that what was needed was somebody to come in and study the situation, develop basic research questions about effective health care and make science-based improvements.
But more important for her personally, Sudan is where Taylor had her moment of clarity about her calling: this was it, working in Africa and doing research in a clinical setting. She returned to the United States to complete a residency and then trained for a year through the Liverpool School of Tropical Medicine, based in Liverpool, England. The only other tropical medicine program at the time was in London, but it required lab work, and Taylor, ever wanting to be close to the patient, was committed to training in the field. She accepted an assignment to a clinic in Malawi.
Taylor contacted the MSU dean, Dean Magan, who arranged her work in Sudan, to share her good news about Malawi. “He said, ‘If you can get a research project going in a developing country that would be hospitable to our students, I will give you a faculty job.’” And the seeds of what would become a long and fruitful relationship were planted.
Soon after she began her training in Malawi, a new faculty member with the Tropical School of Medicine, Malcolm Molyneux, who was her supervisor, stopped in to discuss a research project. The Malawian government wanted the team to study how to stop malaria from killing so many of the nation’s young children. Taylor instantly knew the project was the final piece of the criteria that MSU needed to establish an ongoing research and training program in Malawi. Developing country? Check. A town (Blantyre) that is safe and hospitable to students? Check. A research project that was valuable and worthy? Check.
The year was 1986 and Taylor and Molyneux were hoping to be ready for the 1987 malaria season, which runs December through June each year. And they were, but barely. They had managed to secure just $15,000 for the entire six months of work. What’s more, Molyneux had to leave after two months. “It was definitely a mom-and-pop operation … well, mostly mom,” Taylor says. She took temperatures, read the blood films, hung a hammock in a tiny side room off the lab and often slept there. Early on, the team tried to replicate a study in which researchers had seen benefits of injecting antibodies from monkeys that had malaria immunity into monkeys that were sick. So Taylor’s team did the same, but human to human. They saw no improvement within their patients.
Despite the magnitude of the work-load and lack of staff, Taylor remembers being relatively prepared mentally for that degree of challenge. But the thing that she wasn’t prepared for was the depth of sorrow she witnessed among the families who lost children. “I feel we in the U.S. are told that, ‘Oh, Africans have so many children because they expect a certain portion of them to die.’ But every death is awful, and they are not prepared for it at all. It was crushing. Crushing. It was terrible to be the bearer of that, to have to say, ‘Sorry, your child has not survived.’”
Compounding the magnitude of that blow to the family is that in the Malawian culture it is forbidden to predict or even hint at pending bad news like a death, because when the event happens you are considered somehow at least partially to blame, culpable. So medical teams do not warn families that a child is gravely ill, hence the news arrives completely unexpected. Taylor herself was not aware of this cultural taboo until she was there for maybe five years and started to pick up a bit of Malawian language. She noticed the nurses were not translating her cautioning statements to the family. “Later, over coffee, I brought it up. I said, ‘I noticed you weren’t translating …’ And they said, ‘Oh, yeah, we can’t say that. We would never say that.’ And they still don’t.”
Taylor’s first New England Journal of Medicine research paper came just a few years after she began her Malawi research: her team discovered that about 20 percent of children with cerebral malaria have low blood sugar and that that alone could be putting them into a coma. “So for millennia kids were dying just because their brains didn’t have any glucose,” Taylor says. So, now, standard procedure around the planet is caregivers check glucose levels of malaria children and give dextrose to correct low levels. That single treatment alone has saved hundreds of thousands of children’s lives in the decades since the article was published in 1988.
If you search the U.S. Library of Medicine’s archive for Taylor’s research, you will see a list running nine pages and including 180 articles. Beyond just the sheer magnitude of this body of work, what comes through is a powerful testament to Taylor’s unending focus on the patient, staying close to the sick, being at their bedside, working to save the individual child.
There are two paths researchers can take when dealing with global disease. One is public health, working to stop a disease at a very broad level. The other is clinical level work, studying individual patients. Taylor has earned renown in the latter. When Dr. Alan Magill, former leader of the Gates Foundation’s anti-malaria campaign, wrote his textbook on tropical medicine and emerging diseases, he asked Taylor to write the chapter on clinical care of malaria patients. “She takes care of a lot of patients and she had the ﬁrst-hand experience and perspective for the rest of us,” Magill said. “She is one of the key ﬁgures in the last 20 years. I have marveled at her skill and dedication. And beyond that, she’s just fun to be with.” [Alan Magill passed away suddenly of a heart attack at the age of 61 a month after being interviewed for this article.]
Taylor calls her ﬁrst decade of research in Malawi “the descriptive phase”—10 years of carefully chronicling what children went through as they lived or died battling cerebral malaria. Along the way the clinic performed “some laborious but not earth-shaking drug studies. It paid the rent and allowed us to expand our experiences,” she says.
But after 10 years, the team was no closer to knowing how exactly the disease killed its victims, and Taylor and her partners knew it was time to take the next step. They decided they needed to perform autopsies, to actually study the brain tissue of the deceased victims. “The Africans were used to autopsies for police cases, but they were perplexed a bit because they thought, ‘But you said my child died of malaria, so if you know, why do you need to do an autopsy?’” Ultimately about a third of the parents agreed.
As Taylor tells her story of what led to the discovery of how malaria kills, the narrative thread is anything but a straight line. The apt metaphor is the old “puzzle pieces coming together” thing. The second decade of research proves the point. Ten years of autopsies on children’s brains never revealed how malaria kills. Never answered the question.
A failure? Not really, because the autopsies led to other important ﬁndings that helped get closer to the answer. One unexpected outcome of the autopsies was researchers discovered that a third of the patients were dying not from cerebral malaria, but from other brain afflictions—an early example was a child with a huge blood clot. So that threw the malaria world into a perplexed state because doctors and nurses were left wondering, “Well, we are treating everybody as if they are dying from malaria, but a third of them are not. How do we tell who has cerebral malaria so we can treat patients accordingly?”
But then, another puzzle piece appeared and ﬁt into the emerging picture. An ophthalmologist, Dr. Susan Lewallen, working alongside Taylor, discovered that children with cerebral malaria displayed very specific but extreme abnormalities in the back of the eye. “She saw these wild ﬁndings. And it was actually a pretty intense period because she was so zealous about these ﬁndings, but Malcolm and I couldn’t make sense of them until we paired them up with autopsies, and then it was almost a perfect match,” she says. “The kids with malaria parasites in their brains and who truly died from cerebral malaria all had these eye ﬁndings, and the other kids did not.”
Yet, at the end of Taylor’s second decade in Africa, her team still did not know how malaria actually kills its victims. She convened a conference, a big think, to ﬁgure out how to proceed. “We invited all sorts of specialists, and we put everything to them, all the scientific detail,” she says. The attendees agreed that the autopsies were limited in two key respects. One, they only examined dead patients—you couldn’t compare to those who survived. And two, autopsies revealed nothing about the processes leading up to death. A neuro-imaging machine, an MRI machine, was needed. General Electric donated one, a million dollar donation, and it arrived in Malawi, auspiciously, on World Malaria Day, April 25, 2008.
The machine was up and running by the time malaria season 2009 hit, and in a testament to technology, the very ﬁrst patient revealed the long- elusive killing mechanism. The parasite causes a child’s brain to swell, putting pressure on the breathing center of the brain, in the cerebral cortex. That pressure interrupts neural signals that regulate breathing, and the child stops breathing. “We were all standing there at the MRI, and we all instantly knew what had happened,” Taylor recalls of the moment. The reason the autopsies had not revealed this is when the top of the skull was removed, the pressure on the brain was alleviated and evidence of the swelling disappeared.
The discovery came embedded with a poignant irony. The ﬁnding would have been made years ago if the disease was ravaging a ﬁrst-world nation bejeweled in MRI machines. As Magill summed it up: “Unfortunately the places where modern imaging machines are and the places where children are dying of tropical disease are not often the same. Terrie married them up.”
But of course, work remains, because as mentioned above, knowing the mechanism by which a disease kills is not the same as preventing the deed, but now researchers can focus on that.
Fast forward, and a year has passed since Taylor’s team’s research ran in the New England Journal of Medicine. April 2016 ﬁnds Taylor taking a break from the Malawi clinic, doing a stint embedded back at MSU to help put ﬁnishing touches on yet more research grants. The March 2015 journal article will help the chances of approval, she’s hoping.
What new puzzle pieces will forth-coming research add to the picture? In one major research project Taylor’s team will be working with the Harvard Medical School to examine how the parasite interacts with the lining of the brain’s blood vessel walls to determine how brain swelling is caused in the ﬁrst place.
Taylor is also trying to secure money to bring ventilators to Malawi. In this, Taylor has had some unexpected and very welcome help from Madonna. The biggest-selling female musician of all time is also the adoptive mother of two Malawian children who have, in turn, inspired her to help build a pediatric intensive care unit—just across the road from Taylor’s clinic and its MRI. Taylor hopes to fund ventilators for the Madonna-sponsored clinic. “Two-thirds of kids with swollen brains survive, and their brains resume normal size over two days,” she says. The theory: When kids are nearing the stage where breathing could stop, put them on a ventilator for a few days, let the machine breath for the child, and hopefully by then the brain swelling would subside, the child could breath again on his own and be sent home. The ventilators would be deployed to help children suffering other ailments as well.
Oddly enough, the Madonna connection has a double dose of serendipity … the superstar has close ties to the Traverse City area. Perhaps she and Taylor can meet up during a Traverse City summer, share a coffee in a café, discuss the possibilities of ridding the world of cerebral malaria. This all bodes well for millions of children around the world.
The light from Taylor’s work naturally shines directly back on MSU, a point not lost on leadership there. “Her research is so core to who we are as an institution,” President Lou Anna Simon says. “It so effectively reﬂects the how and the why of our work.” And Simon ﬁnds personal inspiration in Taylor as well. “It’s terrific to watch Terrie, to see she has the same passion, humility and capacity to connect with people that she did at the beginning, even though now she is traveling around the world as an expert on childhood malaria.”
Reﬂecting on her work, in the middle of her 29th malaria season, Taylor says, “This is so much more than a job. It’s so interesting and so compelling. How lucky is that? How many people can say that about their work?” she says. She pauses, thinks for a moment. Her voice goes soft. “And we’re getting close … we’re close …”
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