Clinical Field Research in a Post‐conflict Setting
| Author | Marco Boggero |
| Published date | 01 October 2010 |
| Date | 01 October 2010 |
| DOI | http://doi.org/10.1111/j.1758-5899.2010.00027.x |
Clinical Field Research in a
Post-conflict Setting
Marco Boggero
Department of Government, Harvard University
This article describes, from a social science perspective,
some of the challenges of managing a medical research
clinical trial in a post-conflict rural environment.
1
Social
science inputs have contributed much to the ongoing global
fight against malaria
2
and should continue to do so. In this
sense, this article describes some of the ethical challenges
of clinical research as I faced them in Liberia, revisits the
fundamental variance between the ‘two cultures’, that is, of
the sciences and the humanities, and suggests the replica-
bility of such research on the condition that it rests on
strong interdisciplinary foundations.
In 2003, 14 years of civil war in Liberia left the country
devastated and around half a million displaced persons out
of a population of 3.2 million. The weakened health
sector’s infrastructure and personnel face a maternal mortal-
ity rate among the highest in the world at 994 per 100,000
in 2007
3
increasing from 578 per 100,000 in 2000. In this
context, malaria is among the deadliest killers. The malaria
research carried out in Nimba County, Liberia, tested a
new drug called ASAQ.
4
The implementing agency,
Me
´decins Sans Frontie
`res (MSF), was supported by Epi-
centre and funded by the Drugs for Neglected Diseases
Initiative (DNDi).
5
Such research in rural conditions pre-
sents an extreme contrast to the highly controlled,
resource-rich environment of medical research sponsored
by pharmaceutical firms in industrialized countries. A post-
conflict and African setting presents greater challenges for
policy; that is, I argue, the avoidance of attitude polariza-
tion between the disciplines. In this article, I first exemplify
the risk of attitude polarization, and then tackle the episte-
mological question.
From field experience, I chose two sets of problems that
deal with perception and with equity. First, perception
challenges have to be understood within the context of a
country where practitioners and practices related to tradi-
tional medicine are present to a large degree. The explana-
tion of what a clinical trial represents requires accurate
translation in local language and symbols to avoid suspicion
towards researchers. Distinctly foreign concepts, such as
informed consent, are often unlikely to mean much to
these populations. In such a context, the challenge of per-
ception is inevitable, and at times intractable, especially
when faced with the syncretism of beliefs from traditional
medicine, religions or secret societies. The prevalence of
traditional healers and soothsayers is well described by
Stephen Ellis.
6
Traditional doctors, called Nye Ke Mi,
7
and
tribal medical anthropology reveal different conceptions of
the metaphysical world and diseases.
8
Thus, perception
problems are really embedded in a vast array of political,
legal and sociocultural barriers to research that can be over-
come by informing state and local health authorities and
spreading information to the local population.
Yet the most serious incident related to the reimburse-
ment policy to patients. A reimbursement of expenses and
foregone income was considered fair and a certain amount
was chosen, in line with local customs and market prices.
However, the public misperception rose when the tracing
visits performed to follow-up patients were outside of what
MSF had previously been doing in the locality, and the
transportation allowance granted to patients enrolled was
something new to the community. The financial aspect
added to a suspicion that the collection of blood involved a
payment. ‘The hospital is buying and selling blood’, the
rumor spread. It required creativity from researchers and
field teams to overcome superstition and ignorance.
9
Thus,
the policy on reimbursements proved successful by includ-
ing effective damage-control reactivity, but the incident
could have endangered the research and could have created
what I referred to as attitude polarization.
A second set of concerns is related to equity. Some
research involves vulnerable people but is not immediately
applied to their benefit. In order to ensure community ben-
efit, national partners were entirely involved.
10
Yet this
research was conducted in a world of wide disparities of
wealth and health, and two points epitomized this chal-
lenge: one was the above-mentioned question of monetary
compensation; the second dealt with treatment. On the
one hand, reimbursement posed an evident question of
equity and opportunity cost, as mentioned above. On the
other hand, a research team that focuses attention on a
cohort of recruited patients runs the risk of applying differ-
ent standards of care for all the other patients, that is, those
that do not meet the requirement and are not part of the
study (in this case possessing two qualities: being less than
Global Policy Volume 1 . Issue 3 . October 2010
Global Policy (2010) 1:3 doi: 10.1111/j.1758-5899.2010.00027.x Copyright 2010 London School of Economics and Political Science and John Wiley & Sons Ltd.
Practitioner Commentary
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