By Meghan McCarthy
Malawi, a country approximately 7,826 miles from the Penn Memory Center (PMC), is celebrated for its vibrant culture, striking landscapes, and resilient people. Its diverse terrain is framed by majestic mountains with lively villages echoing with the sounds of children and rivers teeming with wildlife.
Images from 2024 MLSFH Malawi
Despite its beauty, Malawi faces significant challenges. Ranked as one of the poorest countries in the world, over 50% of its population lives below the national poverty line. A prolonged drought in 2024 has further destabilized its agriculture-dependent economy, profoundly affecting the health and opportunities available to Malawians.
For the past 25 years, the Malawi Longitudinal Study of Families and Health (MLSFH) has worked in partnership with local communities to understand the demographic, socioeconomic, and health conditions of this population. Initially focused on social networks and fertility, the study has since expanded to explore the social and contextual factors influencing health across the lifespan.
Now, a team of Penn MLSFH researchers will test the validity of dried plasma spot (DPS) technology amongst Malawi communities to measure the prevalence of Alzheimer’s disease and related dementia (ADRDs) in this aging population.
MLSFH team member carrying materials to study visit
The pilot grant was awarded to Corey McMillian, PhD, co-director of the Penn Frontotemporal Degeneration (FTD) Center and Iliana V. Kohler, PhD, associate director of the Population Studies Center (PSC) and Population Aging Research Center (PARC). Hans-Peter Kohler, PhD, co-director of PARC is also a key team member in the MSLFH project and recently traveled to Malawi in the summer of 2024. Next week, Dr. Iliana V. Kohler will return to Malawi with 16 undergraduate students.
Malawi Health Landscape
Malawi’s rich cultural and geographical diversity significantly shapes community health. However, systemic health challenges persist. Periodic famines, recurring droughts, and past epidemics such as HIV and cholera have left lasting impacts. Chronic malnutrition remains pervasive due to high fertility rates and limited access to healthcare.
Images from 2024 MLSFH Malawi
For many Malawians, clinics are 10 to 15 kilometers from home, and transportation options are typically limited to walking or bicycles. While the country has made strides in addressing communicable diseases, care for older populations, including memory care and geriatric services, remains scarce.
“There is tremendous progress in areas of communicable disease,” Dr. Iliana V. Kohler said. “There are tremendous gaps in healthcare facilities providing care for older people.”
For example, many clinics do not have blood pressure monitors, or access to the batteries required for vital machines. Cancer screening, memory care, and overall gerontology services remain mostly nonexistent.
Cultural beliefs around ADRD also pose challenges, as conditions like Alzheimer’s are sometimes attributed to witchcraft. Nevertheless, Malawian communities exhibit remarkable resilience through physical activity, large family networks, and strong social and religious ties.
“We came across a woman in her mid-seventies,” Dr. Hans-Peter Kohler said. “She had basically ballet shoes on, very thin, and was carrying a pile of wood on her head, coming down the mountains. That is remarkably resilient, right? This is the aging you want to see; it’s quite remarkable.”
Malawi’s geography also reveals stark differences in gender roles. In the northern region, a patrilineal system limits women’s access to land and education. Conversely, the southern region’s matrilineal system grants women greater autonomy, including land ownership and schooling opportunities. These disparities affect health outcomes, with women in the northern women facing higher exposure to indoor air pollution from cooking.
Blood biomarkers pilot
While the initial MLSFH aims addressed questions about contraception and HIV, they did not address age-related topics such as cognitive decline and mental health.
Ten years ago, Dr. Iliana V. Kohler got involved in the MLSFH with the goal of understanding the country’s aging patterns.
Through a National Institute on Aging pilot grant, Dr. McMillan and the MLSFH team will address this gap through blood biomarker analysis of Malawians. Their team is comprised of both local representatives, researchers, and students.
“This project in particular focuses on sources of genetic heterogeneity,” Dr. McMillan said. “We know that genetics don’t explain everything, and that environmental influences and disparities are a major driver of disease progression and risk.”
The two-phase project will first validate blood biomarker methods then measure the prevalence of Alzheimer’s disease among Malawians.
Blood biomarker testing offers a cost-effective alternative to traditional diagnostic tools like PET scans, which are often inaccessible in low-resource settings. The team will employ dried plasma spots (DPS) technology, enabling the collection and preservation of blood samples without refrigeration—a critical innovation for rural areas. Specifically, Nicholas Ashton, PhD, a neurochemist at the Arizona Alzheimer’s Disease Research Center (ADRC), will aid in validating the DPS cards and measurements of plasma AD biomarkers.
“We are seeing a revolution in blood-based biomarkers for Alzheimer’s disease,” Dr. McMillan said. “PET scans are very expensive and require specialized health systems. They aren’t accessible in global populations.”
Plasma is a specific component of the blood and is typically separated in laboratories. To stimulate this, the DPS technology utilizes various filters within the cards.
“We are trying to validate whether we can reliably do this,” Dr. McMillan said. “It has been done in clinic settings, but this project will test it in a real-world environment.”
Relationships anchor research success
The success of MLSFH initiatives stems from long-standing relationships with Malawian communities. Prior to data collection, researchers engage local authorities, such as village leaders, and prioritize informed consent to ensure participants fully understand the study’s goals.
Image of 2024 MLSFH team in Malawi
The team’s dedication is evident. Researchers hike to remote villages, carrying equipment to collect survey data, blood samples, and measurements. Community trust is a cornerstone of the project, with nearly 99% of eligible MLSFH participants consenting to blood biomarker testing. This high level of engagement is the result of decades of collaboration and relationship-building.
“We’re known within the community,” Dr. Iliana V. Kohler said. “We often interview, for different projects, children and grandchildren as well. They show up and allow us to come back years later to collaborate.”
With their pilot study underway, Dr. McMillan, Dr. Iliana V. Kohler, and Dr. Hans-Peter Kohler are committed to advancing global health research. “Understanding the extreme conditions people live in can help us better understand how disparities in our own environment contribute to disease risk,” Dr. McMillan noted.
“If we restrict ourselves to study populations we have easy access to, we miss a big part of the U.S. and the globe,” Dr. Iliana V. Kohler said. “I want to make sure that we capture these individuals who one would easily miss. We are pushing to get them reflected in research.”
The MLSFH team’s efforts highlight the strength and resilience of Malawian communities. They also emphasize the importance of addressing global health disparities to advance collective understanding of ADRDs.
To learn more about MLSFH, please click here.