Dating back to 1989, the current Wellcome–KEMRI (Kenyan Medical Research Institute) Research Programme has spent more than a decade developing its research and forging links with local medical and political structures, founded on more than 50 years of Trust activity in Kenya. Reviewed and renewed by the Trust in 2000, the Programme is building on its strengths in malaria to encompass broader issues of severe childhood illness and looking to increase its contribution to capacity strengthening.

Having established its reputation in malaria research, the Programme’s Director, Professor Kevin Marsh, suggests that a narrow focus can be at odds with what is happening on the ground. "The problem that you’ve got to deal with as a clinician or clinical scientist in this environment are people – in our case sick children who come to hospital severely ill. Often malaria plays a significant role, often it plays an interacting part, and sometimes it plays no part. But you can’t necessarily tell the difference at the point at which you are dealing with it." The emphasis of the Programme’s research has therefore shifted, focusing more on the patient and less on the disease, tackling symptoms early to keep a child alive. It has also led the Programme’s research into other infectious diseases, and into the longer-term impact of disease on survivors (see box below).

This approach reflects a key principle of the Programme: research should always be tackling some issue of local relevance, argues Professor Marsh. And while the quality of science is of paramount importance, research has to reflect the realities of everyday life: "It would not be justifiable to build up a research centre whose interests were simply, for instance, developing a malaria vaccine, 10, 15, 20 years down the line, doing lots of good basic science, sat in the middle of rural Africa. The pressure to respond to immediate problems is too great. You can imagine being sat inside your air-conditioned lab looking out of the window watching mums in a queue with sick children."

Such queues are a daily feature of life in Kilifi, the main site of clinical and epidemiological work. Researchers are based in Kilifi District Hospital, a typical African hospital dealing with all the usual problems associated with poor rural life: overcrowding, under-resourcing, a lack of trained personnel. The area itself is one of the poorest in Kenya; malnutrition is common and HIV a growing problem. The Programme is based in the district hospital, and its clinical researchers work on the paediatric ward and associated high-dependency intensive care unit. A constant stream of severely ill young children pass through the ward, with malaria, respiratory tract infections, diarrhoea and other infections.

Exposure to the ward reminds everyone why they are there, emphasises Professor Marsh. "It’s good for you – it’s a reality check. It forces you all the time to evaluate what it is you are doing."

Nevertheless, he adds, it is important not to let day-to-day demands dominate, no matter how great the immediate need. "While it can be uncomfortable sometimes, the tension between the service side and the science, in a way that is the challenge, to make sure what you are doing is immediately appropriate and has benefit but in the long term you can also see where you are going."

Delivering benefits

If application is one plank of the Programme’s work, another is integration – ensuring that research takes account of the practical ways in which it might be applied. Just as clinical research reflects experience in the wards, so all the Programme’s research is designed to be beneficial. The Programme’s extensive basic research, for example, is focused on developing an understanding of basic mechanisms important in disease and its treatment or prevention.

Moreover, none of the studies is considered in isolation. In a sense, researchers need to think at the onset about the broader implications of their research and its potential practical impact. In this respect, the situation is rather different from the UK: "Say you’re working on a gene involved in hypertension. It really doesn’t matter if you haven’t got an overview of public health as applied to cardiovascular disease because you can assume that lots of other people around you have. You can focus in on your gene for ten years, and you can be reasonably confident that if it goes anywhere someone will take it up and do something with it. Whereas that’s just not the case in many poor countries because there just isn’t the critical mass of science and policy to make sure that all that happens."

The most extreme manifestation of this approach is that taken by Professor Bob Snow, who is based in laboratories in Nairobi, the other major location of the Programme. An epidemiologist by training, Professor Snow established a large demographic surveillance system around Kilifi to characteris

e the local population. From these beginnings, Professor Snow became increasingly interested in how research findings filtered through (or didn’t) to influence malaria control. As well as being a Trust Senior Fellow, he also acts as a technical adviser to the Kenyan Government and played a major role in the development of the country’s new malaria control strategy.

Capacity strengthening

The relations with KEMRI, Kilifi District Hospital and the Kenyan Ministry of Health in Nairobi illustrate the Programme’s commitment to embedding itself within local structures. A complementary aim has been to help develop research capabilities. "That was explicit from the start, says Professor Marsh. "But it’s increasing in importance – naturally as you get bigger you’ve got more ability to expand capacity."

In resource-poor countries, capacity strengthening remains a major challenge. The Wellcome Trust takes a long-term view in its major overseas funding, recognising that, realistically, a meaningful impact is going to take decades rather than years to achieve. The Kenya Programme has now reached a size where it can begin to make a significant impact in training people, offering an intellectually stimulating environment and range of opportunities. But this is still only the beginning.

"There’s very much more to it than simply saying, ‘well let’s recruit tons of PhD students’. It’s all about how you identify your high-calibre people, where do you put your investment if it’s going to take 10, 15 years to take someone through to being an independent scientist. You want to start with the best people." This may mean scouring universities, even schools, to identify the potential future scientific leaders.

Professor Marsh sees capacity strengthening as one of the most important aspects of the Programme’s work. But, he warns, it is going to be far from plain sailing. "I think people have underestimated just what needs to be done in terms of developing career structures, and also developing centres with a critical mass: you can’t train people when you’ve got one man and a dog."

A brochure describing the Wellcome–KEMRI Research Programme will shortly be available. Copies can be obtained by e-mailing mailto:marketing@wellcome.ac.uk

External links

• KEMRI, Kenya Medical Research Institute
• Centre for Tropical Medicine at the University of Oxford: Includes details of the research conducted by Professor Kevin Marsh and Professor Bob Snow at the Kenya Unit