Tropical Medicine and International Health

volume 2 no 6 pp 511–512 june 1997

Editorial: Clinical research in the tropics

This journal is keen to publish clinical research.What do we mean by that term? ‘Clinical’ is definedas pertaining to, or founded on, actual observationand treatment of patients, as distinguished fromtheoretical or basic sciences. Thus clinical research isclear. Yet we get few papers that satisfy this defini-tion. Many are case reports or retrospective analysesof individual conditions in hospitals. Whilst some ofthese may have international significance, most areof primary interest only to the country, or region, oreven hospital, concerned. Thus we usually rejectthem suggesting local publication. Yet there are newobservations to be made. The excellent study ofsevere malaria in Kenya by Marsh et al. (1995)shows what is possible with deliberate prospectiverecording of clinical information. Much of what weare sent is collected in an unsystematic way, dependson the medical records made at the time (withoutthe research in mind) and adds little to what can befound in textbooks. This at a time when evidence-based medicine is at last seen as the necessary basisfor modern practice.Even in the area of clinical trials we get few

papers. Randomization is of course the key here andwe still get studies of therapy which can not be pub-lished because they do not satisfy the basic rules ofevaluation of a treatment. Reviews of therapy are ofgreat interest to us if they are carried out using theappropriate degree of rigour, such as those elabo-rated by the Cochrane collaboration. They also illus-trate the great need for more trials in tropical prac-tice; for example the review we recently publishedon the treatment of giardiasis (Zaat et al. 1997) wasshocking in the very limited number of well-designedtrials that had been conducted.Beyond these immediate applications of clinical

research to diagnosis and management of patients,there is a huge unmet need for clinical research toaddress public health issues. Let us consider tworecent examples. The World Health Organization(WHO) are pursuing the Sick Child Initiative as oneimportant facet of the control of acute respiratoryinfection, diarrhoea and meningitis. It has become

abundantly clear that the best methods for diagnos-ing sick children under conditions of limitedresources and even more so, the best method oftreatment for these children, are largely unknown.WHO has recently put out a call for proposals toexamine the optimal treatment of children withacute respiratory infection. Here is a vast area forthe hospital-based physician to collaborate withhealth centres in critically important research. Thenew division of Emerging and Other CommunicableDiseases Surveillance and Control at WHO alsorecognizes the need for clinical research. They areproposing the introduction of more intensive surveil-lance of a multiplicity of infectious diseases and alsosyndrome-based surveillance. What are valid casedefinitions for this surveillance? What are the bestpredictors of any one diagnosis? Does this differ atdifferent levels of the health service?Clearly, there is a huge need for good quality

clinical research and yet we get offered few papersand even fewer of high quality. Why is this? Well, itmay be that the papers go elsewhere–to sub-speciality journals or to journals with high impactfactors. However, a scan of these does not suggestthis is true. Maybe clinical research is not importantto tropical physicians. Certainly we are all awarethat many have to diversify their employment toensure a living wage, often entailing large privatepractices which leave little energy for research.Perhaps research is not seen as an essential compo-nent of training, as it is in Europe and northAmerica? This certainly seems to be the case inmany countries. However, judging from the paperswe do receive, there is interest in doing research butit is not usually well conducted and its aims areoften quite unclear.Some of this stems from the situation in medical

schools. We know that in Africa, for example, thereis great emphasis on didactic forms of teaching.There are high drop-out rates in the first two yearsof schooling and so there is enormous emphasis onfacts, facts and more facts. Little time is left forthinking, or wondering if these facts are true. After

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graduation this situation is compounded by the lackof role models. Many of the most talented physiciansobtain international posts and so there are few sen-ior figures to guide young men and women in whatis appropriate research and how to do it. Somegroups are trying to overcome this by pairing youngphysicians from the South with senior researchersfrom the North (for example the Tropical Healthand Education Trust). This has worked in some situ-ations, but inevitably it is an uphill task.We suggest that the time is ripe for this to change.

Public health is beginning to recognize the key roleclinical research plays in an effective service,evidence-based medicine is driving physicians to

re-examine how they practice–surely we can hope tosee some of this reflected in more papers to ourjournal in this area. We hope so.

Andrew J. Hall

References

Marsh K, Foster D, Waruiru C et al. (1995) Indicators oflife threatening malaria in African children. NewEngland Journal of Medicine 332, 1399–1404.

Zaat JOM, Mank TG & Assendelft WJJ (1997) Asystematic review on the treatment of giardiasis. TropicalMedicine and International Health 2, 63–82.

Tropical Medicine and International Health volume 2 no. 6 pp 511–512 june 1997

A. J. Hall Clinical research in the tropics

512 ,C 1997 Blackwell Science Ltd