Dr. J.M. Ndiritu
Too many negative things are said about Africa every day. Many of these may rightly be dismissed as biased or plain ignorant. In health research, it has become impossible to shake off the negative image.
We cannot dispute that the continent faces some of the worst health care challenges in the world. It is one place where humanity still faces the threat of infectious diseases that are under control elsewhere, where frequent disease outbreaks threaten entire populations and where poverty and its attendant ills continue to plague millions. Increasing prevalence of chronic, non-communicable diseases, poor availability of medicines, and weak health systems are a significant feature in nearly all countries.
If necessity were the driver of creativity, innovation, and a determined search for answers to society’s problems, there should be a great deal of health research going on in Africa. This is not the case. Numerous reports indicate Africa’s participation on the global stage in terms of research output remains dismal1.
Research, understood as a search for answers, as the determined efforts to discover new ways, ought to be a big preoccupation in the minds of African intellectuals as they face greater problems than their peers in other parts of the world. It should also be a priority in terms of education, government funding, and private-public partnerships.
The research under consideration here is which has an impact on both health care policy and practice. There sure are numerous publications emanating from Africa. However, these have had little effect on local health policies and clinical practice. They have also failed to improve Africa’s standing in the world of research. A decade ago, research from sub-Saharan Africa accounted for less than 1% of global health research2. Some progress has since been noted, but it remains insignificant3. A less encouraging side of this progress is that most of the research in Africa is designed, funded, conducted, and published by researchers from developing nations. But research is still research and regardless of who does it is should count in terms of its impact on local problems. The reason why it does solve much is that these visiting researchers mostly spend very little time in the environment where the research is done4. With just a passing understanding of the local realities, it doesn’t matter how good a researcher you are. You will still miss a lot of things. This implies that any improvements in the quantity of research may not contribute to local problems. As such, research has not kept up with both economic and population growth rates. Not only is Africa absent at the table of global research, but she is also not an active driver of her growth. Africa’s research remains so inadequate that it cannot as much as catalyze growth within the continent4.
And that cannot be good. Developing is an active verb. The description of a nation as developing should mean that there are concerted efforts to improve the human condition. This requires creative and innovative solutions to problems, the adoption of new technologies, embracing scientific evidence as the basis for policy and practice. Development is so interlinked to research that cannot occur with it. This is how it has always been. It took dedicated scientific minds to discover new technologies and the knowledge that ushered the world into the modern era. When one contemplates this in the context of Africa’s poor research record, you wonder whether this continent is really developing or stagnant. Development depends on research in a way that without the latter, it is impossible to think of any development at all.
There are understandable reasons for lagging behind in health research. The most compelling arguments include poor and inconsistent research funding, undeveloped research infrastructure, and lack of qualified researchers1. All these issues constitute elements of a major problem in which the system has not been designed to optimize research. At the tail end of this is a lack of interest by the authorities to use scientific evidence from local research as the basis for policy development. If the government is not interested in using research findings as the foundation of development, it will not find it necessary to invest in research, which means no research infrastructure and no training of researchers. The cascading issues form a vicious cycle of a broken system.
The limitation of resources has always excused both governments and individuals from research obligations. When one considers the conditions under which pioneering scientists worked, the excuse can no longer hold. All significant discoveries in health care were made by researchers who had nothing going for them except their determination. Knowledge of diseases and human biology was basic at best, funding channels didn’t exist, and governments were too embroiled in war to care about research. To many of these pioneers, the conditions deemed resource-limited would seem luxurious. It is not any wonder that Africa’s paltry contribution to health research is baffling to many.
Foreign researchers have long filled this gap in health research. Reports indicate that research publication from Africa is mostly by visiting researcher. In some African regions, international researchers contribute more than three-quarters of all research output5. The contribution is both direct and indirect. Indirect involves funding research through academic and research institutions in Africa. Some of these research institutions such as the African Population and Health Research Center (APHRC) were founded and are funded by international organizations. The direct way involves allowing individuals or companies (most pharmaceutical) to conduct research often without local collaborators and with little local oversight.
In a resource-limited setting desperate for research, any help from outside would be actively sought and much appreciated. The researchers bring with them resources and experience not available locally. There is a fundamental flaw in this strategy. It is the genesis of a serious power dynamic in which the odds are stacked against the locals. When outsiders arrive with their expertise and money, it is impossible for the host to play equals with them. The imbalance of power is inescapable. Those arriving to conduct research come with predetermined research objectives which usually serve the needs of their home country or the institution financing the research6. The research will be conducted as per the terms and needs of the funding institution. The findings can only benefit those who designed and carried out the research7. It reduces the African collaborators to merely a pedestrian role, notwithstanding that they are the hosts. This has been such rampant abuse of research collaboration that it has been given various terms. These include “parachute” research, and “mosquito” or “vampire” researchers8,9. These terms highlight the exploitative nature of most collaborative agreements.
From the foregoing, outsourcing researchers or funding is not the means by which research capacity will grow. In the world of research, as in all other aspects of life, you only profit from a venture based on how much you invested in it. Hard decisions have to be made to invest more into research driven by local funding and guided by local research agenda. This may be a slow and costly way to go, but the speed and ease of collaboration appear to have no long-term benefits for us.
African institutions have so isolated themselves from their peers on the continent that few ever highlight anything the other is doing. It is a perfect case of the left, not knowing what the right is doing. Intra-Africa collaboration is so poor that it has been quoted as less than 1%5. This is a sad fact. One would expect that local institutions and individual researchers would be interested in forming close bonds to bolster their research efforts. But this is not the case. More emphasis is placed on forging international collaborations that perpetuate extractive research than fostering local collaborations, which would encourage local growth.
For instance, the University of Nairobi is very proud of its collaboration with some of the best international universities in the world. Its medical school rigidly clings on western textbooks with no mention at all of the publications by Kenyan researchers. Most of the professors are so proud of their international collaboration that they will spend significant time narrating their understanding of the advances in medicine in the developed world. No one highlights, even in passing, the work done by local instructions such as KEMRI, APHRC, and IPR. Perhaps this is because these institutions have themselves so focused on north-south collaboration that they have ignored local players. It is easy to see why African research has not positioned itself on the global stage. If we are constantly piggybacking on more capable players, the fruit of our labor will be taken from our hands to feed those who have invested the most in its production. There is a double tragedy to this narrative. Not only does it fail to uplift global standing but also, tragically, fails to leave a mark on the local mountain of problems. The University of Nairobi is no doubt a great institution. But so are the other institutions in Kenya and other African countries. A battle as big as the one African intellectuals face of mounting problems cannot be fought without local allies.
It may seem as if letting go of the comfortable relationship with the north would be disastrous. We would lose the funding, the expertise, and the opportunities to publish in their journals. But we may gain in greater ways. We may be able to find means of funding research that we haven’t thought of. We shall work harder to develop our own expertise, encourage younger generations to participate and we shall start and support local journals which allow easy access to research for local researchers.
Complete self-reliance in research and development has far-reaching benefits. It will not only find innovative solutions to health problems but is also a matter of upholding sovereign dignity. To achieve this begins with a keen focus on training in research. Currently, very few doctors have been trained in the techniques and ethos of research. In nearly all medical schools, principles of research are not prioritized. Most doctors graduate with barely a passing understanding of research design, statistical inference, and report writing. Some develop these skills early by reaching outside the taught curriculum. This requires great determination on the part of such students. These pro-active minds usually end up leaving their countries to pursue their research passion in environments which offer them better chances of self-development10,11. This is a direct result of lack of infrastructure such as equipped laboratories, well-stocked libraries, and access to research publications. Besides, universities that focus entirely on taught the curriculum and pay little attention to research development cannot attract the brightest minds focused on research.
Mostly, junior researchers have to brave it on their own. Absent the mentorship and support that their peers in the developed world undergo, it becomes an uphill climb for young African professionals. To change this trend requires a serious rethinking of tertiary education. University curricula should focus on imparting research skills. Talented students should be accorded special training to develop their research capacity further. There should be structured mentorship programmes to ensure that young researchers do not drop off for lack of support. Aging professors must ensure that their careers are not marked merely by a list of publications but by capable mentees who can perpetuate their work. Absent the incentives necessary to attract and retain researchers, even those who work hard to break even in research will continue leaving in droves areas with more opportunities for personal and professional growth. Clear and structured mentorship and support so that research can be undertaken full time will go a long way in making the process faster and more productive.
It is better to train locally so that researchers master the local environment than to hope that only those who train abroad can come back to impact local researcher. The majority does not return, and those who do may find themselves unable to use skills learned in a well-endowed environment to one that is severely resource-constrained. Reaching international standards does not simply come from sending some out there to learn then come home. It comes from providing incentives for the best minds locally and creating a competitive environment in which to grow and reach the ideal standards.
When one considers the many failed local journals, you cannot help but feel that too much has been allowed to decay that would have grown to greater capabilities. Trying to access research publications from pioneering African researchers is an impossible task. Research articles from the 1980s and 1990s which were published in local journals which are now defunct have been lost to time. For instance, Prof. Edward G. Kasili wrote extensively about the epidemiology of cancer among Africans. His research disproved the notion that diseases such as cancer were less prevalent among Africans12. Many Kenyans feel that cancer is a new scourge due to increased mortality. This is because earlier research is not accessible, has not been mentioned during training, and no one can thus build upon it. African institutions should collaborate to support their own initiative in conducting and publishing research. Only this way can there be continuity in research from generation to generation. It is easier to perpetuate initiatives that are entirely local than try to sustain foreign initiatives once the foreign collaborators leave.
Difficulties with publishing in international journals has long been a serious drawback to African researches. It is frustrating. Most of the rejections point to poor standards in both research methodology and manuscript writing. Publishing in African journals is a viable alternative. The advantages of this are obvious. First, it becomes easy for local researchers to publish. Second, it makes research articles much more accessible to local researchers. There are credible concerns that local journals would (and do) publish substandard material. If editorial standards were matched with international quality, this problem would be solved. The editors should highlight weaknesses in ways that can be improved so that the publication process bolsters the training of researchers. One must note that even the best research training cannot be complete unless it is tested under rigorous publishing and peer review process. Only by participating in research and going through the rigorous process of publishing does one fully join the research community. If many aspiring African researchers continue to face serious hurdles in publishing, they will never fully mature into confident researchers because that last milestone has remained out of reach.
To provide a structural framework to the conduct of research requires proper legislation. The legislative agenda must be both a catalyst for and a response to research. It should lay the agenda for a nation’s healthcare priorities and provide a legal structure to the conduct of research. The law also strengthens ethical oversight in the conduct of clinical trials and genetic studies. It will also be essential in protecting intellectual property rights of African researchers to end the exploitation by their counterparts in developed nations. If local journals are to prosper, they can only do so with strong legal support
Budgetary allocation for research also needs to be backed by a legislative process. This will also establish the mechanisms of ensuring accountability for funds. Health policy agenda should also respond to the findings of research conducted within the country. This provides a symbiotic relationship between the state and professionals dedicated to research and development.