© The International Society for Neglected Tropical Diseases 2014
What diseases has KEMRI Wellcome initiative concentrated on in terms of research to date and what in your opinion is the future for NTD research in Kenya?
The KEMRI Wellcome Trust Research Programme (KWTRP) has its origins as a set of projects which began in 1989 in Kilifi on the coast of Kenya and have subsequently grown to programme with over 800 people working not only in coastal Kenya but at a range of locations and with a range of collaborators across Kenya and other countries in the region. Our initial focus was entirely on malaria but quite early on we recognised that it didn’t make sense to focus on a single pathogen as there was considerable overlap in both symptoms and pathogens- thus a child presenting with malaria may also have a salmonella bacteraemia, and might be malnourished and HIV infected. Thus our focus shifted to one of the “severely ill child” and began to incorporate research on a range of pathogen and presentations. As we have extended our work into older age groups, this approach has been maintained. A key determinant of what we work on is that it should be an important cause of ill health in the communities we work in. Although historically much of our work has focused on infections, as Kenya undergoes an epidemiological transition the range of things we are working on changes to include more non communicable disease such as sickle cell disease and hypertension. The biggest change in focus right now is probably the increased focus on neonatal morbidity and mortality, and therefore on maternal health, as death rates in other age ranges continues to fall.
How close are we to a scenario of the idea-to-market for an 'African therapeutic'?
Historically most therapeutics research in Africa was late stage i.e. drugs or vaccines developed elsewhere would be brought to the field for testing. This often means that African researchers and institutions have little sense of involvement in the generation of ideas. Obviously a prerequisite for change is to have both the facilities and a cadre of internationally competitive researchers trained in relevant disciplines such as biochemistry, molecular biology, immunology etc. and fortunately this has begun to emerge in many African countries. So now there are very encouraging signs of the ideas emerging from local research contexts. The bit in the middle - the actual development and production of new products - still requires more investment.
Does Africa and Kenya in particular have a future for 'independent' domestic drug discovery and development?
Kenya is fortunate in having a large population, many science graduates, an increasingly strong science base and a culture which supports economic enterprise - so I would say Kenya has a very strong future for this kind of development
In your opinion what areas within drug discovery and development in particular hold the most promise?
This is a difficult one for me- I am not a drugs person, though clearly I’m interested in the testing of new approaches. I think a key area in a general sense is the establishment of the correct regimens for drugs used in childhood. For many years drug dosing in children was extrapolated down wards from adults and yet we know the pharmacokinetics and pharmacodynamics in children are very different from adults. We should not accept a situation where children receive suboptimal treatment. As a malariologist I suppose I am bound to be biased in that direction- I think there is an enormous need for and great potential for new drugs capable of killing gametocytes and therefore stopping transmission. At the moment we only have the 8 aminoquinolines and the problem with G6PD deficiency is a limitation.
Is KEMRI a beacon of best practice for the rest of Africa - if so how so?
I think KEMRI is one of a number of excellent research institutes in Africa and rather than seeing one as a beacon for the others I would prefer to think of them as networking with each other to jointly continually raise standards. Having said that, with the clinical trials facility we have established in the KEMRI Wellcome Trust Research Programme we had a very clear aim to establish the highest standards of practice across the board including laboratory support, trial conduct and monitoring and ethical standards. We have been very happy to link in with other centres both through a programme of reciprocal monitoring and also though working with others groups to establish capacity in a particular area.
How far has this initiative gone to changing perspectives of countries outside of Africa in terms of them viewing Africa as an aid - only channel i.e. is the domestic research that you are overseeing and driving helping to change any negative view of African science. Are there any specific initiatives such as awards that have worked well and are in the pipeline for the future?
There have been enormous changes in African science over the last twenty years. There is still much more that needs to happen but the progress has been really encouraging. The key is establishing critical masses of internationally competitive research leaders. It needs to be recognised that this takes time, anywhere in the world the time from undergraduate degree to heading a large successful research group can be around twenty years. It also takes major investment. In our case we have been very lucky to have long term
Kevin Marsh is Director of the KEMRI Wellcome Trust Research Programme (KWTRP) in Kenya.
He qualified in medicine at the University of Liverpool in 1978 and after undertaking specialist training as a physician began his research career at the Medical Research Council Unit in the Gambia working on the immunology of malaria.
From 1985-89 he was at the Institute of Molecular Medicine in Oxford and in 1989 established with colleagues a series of research projects on the clinical epidemiology and immunology of malaria at Kilifi on the Kenyan coast. These have subsequently developed into an international programme involving around 800 staff working across a number of countries in east Africa. For the last 22 years he has lived in Kenya where as well as being director of the KEMRI Wellcome programme he is the scientific team leader of the KEMRI centre in Kilifi.
Professor Marsh has a broad interest in clinical, epidemiological and immunological aspects of malaria and has authored or coauthored over 400 publications on different aspects of malaria. The research team he leads has made major contributions across these fields and works closely with national and international policy makers. Professor Marsh has a particular interest in developing and strengthening research capacity and scientific leadership in Africa.
As well as leading the KWTRP Kevin Marsh is also professor of tropical medicine at the University of Oxford and is a member of a number of international advisory committees relating to malaria and to global health research. He is a fellow of the Academy of Medical Sciences and was awarded the Prince Mahidol prize for medicine in 2010.
commitment from the Wellcome Trust who have taken a very long term view and invested major resources. This is done on a competitive basis of course, we have to establish that our plans are worth investing in but it is unusual to have such sustained long term support. This has enabled us to build up an increasingly large cadre of researchers who are now leading their on groups, mentoring their own students and bringing in funds for research. A number of centres across Africa have established similar initiatives and there is now a much bigger and more connected network of researchers. This is inevitably changing the international profile of African science for the better. There are a number of international and national awards and prizes and these are an encouragement but probably the most important thing is to have role models to inspire young researcher’s at the beginning of their career.
In terms of clinical trials conducted in Kenya and Africa at large is there enough contribution and knowledge/skill transfer given from EU/USA partners in terms of overcoming challenges such as multi center protocols and regulatory ethical environments?
I think there has been considerable skills transfer but one of the issues is that inevitably a funder or sponsor of a trial wants to get the job done and will tend to support specific training more than generalizable training. Although I would encourage partners and funders to be prepared to invest more widely in capacity building I do think there is a big onus on African researchers and institutions to take the lead in addressing this, i.e. to move from receptive mode to a much more active mode in defining what is needed and making sure that it is done. A key thing for me is that clinical trials should wherever possible be part of a broader research enterprise and culture. I am not keen on the term “trial sites” (although obviously one does need trial sites) because the implication can be that they are places where someone comes and does something and goes away again, not necessarily having improved the capacity for locally initiated research. I think it’s very important that research institutes and centres with critical mass see trials as as one part of their activity so that there can be cross fertilisation between many different scientific disciplines.
What changes if any do you see as paramount to overcome any coordination issues and strengthening capacity at local / national / pan African clinical trial programmes?
I think this follows on from the last question and the key is to have locally established research leadership defining and driving the programmes in a strategic way which looks to the overall development of capacity rather than simply doing any individual trial or looking to where the next grant is coming from. Sharing experience is key and a number of regional networks are now being established . One of the most useful initiatives is something called the Global Health Trials network (I should declare an interest in having been involved with setting this up). It is not aligned to any particular institution or funder but provides a fantastic virtual community for researchers at all levels in less resourced countries all over the world to exchange knowledge and share experiences. I woud strongly recommend anyone involved in trials in Africa in any capacity to take a look at it at www.theglobalhealthnetwork.org. Finally of course increasing local funding, both within the continent and nationally is key.
If you had an open cheque book - what would be the top 5 pieces of technology you would bring into KEMRI today?
There is a risk of sounding complacent here- we have actually been very successful in raising funds to develop a superb research environment in Kilifi. If you had asked me last year I would have put establishing next generation sequencing and proteomics with high quality mass spec on my wish list. But we have now put these in place. So I woud actually not focus on the technology but on the human resource, building up scientific leadership in areas such as bioinformatics. The one area where we would really like to build more capacity is in clinical pharmacology, an area which has been very poorly developed. So if you gave me the open check book I would us it to develop critical expertise on the grounds that good people are more important than technology because they will always be able to bring in the funds for what they need to do.
Where would you see KEMRI in 10 years from now and your role?
Well, its important to recognise that KEMRI is a very large institution with many centres. I would hope to see the institution as a whole flourishing and contributing directly to improving the health of Kenyans. The KEMRi Wellcome Trust Research Programme based at the KEMRI centre in Kilifi is just one part of KEMRI but over the next ten years we plan to continue to develop high quality research in an international research environment where many of the groups are led by Kenyan researchers. We woud aim to play an increasing regional role in capacity strengthening and research, and this is already happening. As to my own role, I still have may new things I would want to drive forward and to do this I would like to increasingly step aside from a direct leadership role in the programme but I hope I will still be supporting it in some way from the side lines in ten years!