Mali Researcher Shows How to Reverse Brain Drain

Relying mainly on homegrown talent, Ogobara Doumbo leads a network in Mali that does state-of-the-art studies of mosquito genetics, tracks drug resistance, and tests new vaccines.

Fellows Spring 2011

By David Taylor

June 28, 2011

Also published in Science, 24 June 2011: Vol. 332 no. 6037, pp. 1498-1499

On a bluff overlooking a flat Sahelian landscape, evening finds most offices empty at the University of Bamako's Faculty of Medicine. But a few lights remain on in the Malaria Research and Training Center (MRTC), and three Ph.D. candidates wait to speak with the director, Ogobara Doumbo. He leaves in a few days for Geneva to present new research affecting World Health Organization (WHO) guidelines on malaria prevention for children. But he makes space in the lab to discuss with a visitor what makes MRTC a paradox.

Traditionalist. A grandson of healers, Doumbo dreamed of becoming a village doctor.Genome Research Limited

Doumbo, in his mid-50s but still looking like a student, smiles faintly when he speaks about his protégés, who recently led a roomful of top West African scientists through a comprehensive research discussion. Only in Mali, he says, will you find a critical mass of African Ph.D.s, with no loss to brain drain.

Bamako, a capital city of dusty streets on the banks of the Niger River, is not a place you expect to find a world center for research. Serving one of the world's poorest countries, Mali's health system is stretched to the breaking point. Yet on this bluff known as Point G, with a colonial-era hospital from 1906, Doumbo has built MRTC and nurtured, by his count, five generations of researchers committed to solving one of the continent's most intransigent problems.

Since co-founding MRTC with support from the U.S. National Institutes of Health (NIH) in 1992, Doumbo has led it into state-of-the-art research on mosquito genetics, vaccine testing, and drug resistance. Furthermore, MRTC supports a network of research-affiliated clinics throughout Mali in very basic village settings. Doumbo has cultivated this cadre for 15 years, what he calls "the bush doctor initiative," to bring top-quality medical research and practice to villages. The conditions would seem ripe for an exodus of highly trained physicians. In most developing countries, simply keeping capable scientists in the capital is difficult. A 2007 World Bank study noted the accelerated migration of skilled professionals, particularly in medicine, and its important effects on poor countries. MRTC has found another path.

"Quite often many senior researchers who could mentor the younger ones have themselves left," says Wilfred Mbacham, executive director of the Multilateral Initiative on Malaria, based in Yaoundé, Cameroon. Those who aren't lured to higher-paying international jobs get tapped for political appointments away from the university, he adds. A country's political climate"”and its valuation of research"”are contributing factors. Mbacham has known Doumbo since 2003 and says that Doumbo saw the need to create a stable environment. "Very early on, he set up a grant-administration program that was attractive for more funding," Mbacham says.

Mali has many problems shared by other sub-Saharan countries, including minimal infrastructure and corruption. In 2010, the Global Fund to Fight AIDS, Tuberculosis and Malaria suspended its malaria programs in Mali after an internal report found health department officials (not MRTC) had siphoned program funds.

Nor has MRTC been immune to charges that it benefited from donor favoritism. In the early years, says Stephanie James, director of science at the Foundation for the National Institutes of Health, a public charity in Bethesda, Maryland, "I know there were some jealousies in the university." And some predicted that Doumbo "would never relinquish control over projects," recalls Christopher Plowe, a researcher at the University of Maryland School of Medicine in Baltimore and an MRTC collaborator. "Last year I was struck by how wrong that prediction was."

Path to Parasites

Doumbo, a son and grandson of traditional healers, grew up in a Dogon village 965 kilometers northeast of the capital. He first rode in a car as a teenager in 1971, to take his secondary-school certification exam in the town of Bandiagara. He never intended to go into research. "I really wanted to be a doctor and to serve in the bush," he says.

After obtaining an M.D. degree at the University of Bamako and finishing a residency in internal medicine at Point G, Doumbo began to practice in 1981 at a clinic at Selingué, about 2½ hours south of the capital. There he aimed to win over local skeptics of Western medicine. The many C-section deliveries he performed were dramatic proof that his methods could save lives. "He was famous for being the guy who handled complicated obstetric labor emergencies and surgeries," Plowe says.

In Selingué, Doumbo found larger problems: river blindness, schistosomiasis, and malaria. "I saw a lot of people suffering," he says. He realized he could have greater impact by recruiting more young doctors to help. He returned to his studies, earning an M.Sc. in tropical medicine from the University of Marseille studying under parasitologist Philippe Ranque and a Ph.D. in parasitology from the University of Montpellier.

Doumbo also saw a role for indigenous medicine. Pragmatically, he saw traditional healers as scarce health care providers already treating rural dwellers, often with useful local knowledge, and thought it better to gain them as partners. "The best way to promote traditional medicine is to show that both types of medicine can work together to resolve a public health problem. This is what we are doing with malaria."

Choosing Partners

Harold Varmus, Nobel laureate and now director of the U.S. National Cancer Institute, visited Mali when he was NIH director in 1997 and traveled to several remote villages. "Doumbo and his senior colleagues grew up in villages without electricity, worked hard for an education in Mali and France, and decided to build a scientific effort in Mali to combat one of its most difficult diseases," Varmus says. "His determination, deep knowledge of malaria, and positive effects on co-workers and government leaders were quickly evident, even in a short visit.

"One of the great things about this effort was his engagement of villagers in the projects," Varmus recalls. That yielded a better understanding among villagers of how transmission of the malaria parasite Plasmodium takes place. After that, they built "multi-functional" health clinics and wells for clean drinking water. Doumbo aims for "a new way of thinking," he says, "of how we can deal with rural areas," one that involves them as partners.

Home base. The Malaria Research and Training Center in Bamako has fostered, by Doumbo's count, five generations of researchers. Many work today in rural clinics.David Taylor; © MRTC

Since 1997, Karamako Nimaga has been a researcher-clinician in Marka Coungo, a village 2 hours east of the capital. His clinic there collected data for a paper he co-authored with MRTC colleagues chronicling the failure of chloroquine, then the standard antimalarial drug. The findings helped overturn WHO and national policies on malaria prevention: WHO changed its guideline in 2006 from chloroquine to artemisinin-based combination therapy as the main drug treatment. MRTC has also pioneered new treatments for prevention with pregnant women and children and won international awards.

Doumbo's style has sometimes raised hackles, however. Health officials argue that the government's rural clinics, which are village-funded, get overshadowed by MRTC's network of international-funded clinics like Nimaga's with lab facilities. Tensions came to the fore when MRTC recommended that the health department abandon chloroquine, in line with WHO's policy. Doumbo and his staff spent a day explaining to ministry staff the WHO recommendation and supporting data. Some officials, seeking to keep chloroquine, focused their frustration on Doumbo. "As you can imagine, a lot of people are reluctant to make any changes," Doumbo says of that battle. But finally, WHO's policy was adopted.

Bernhards Ogutu, senior scientist with the international INDEPTH Network, who coordinates malaria research from Ghana, notes that MRTC has made remarkable progress for the same reason that makes it controversial: MRTC has "marketed the research agenda to the country's political leadership," getting leaders "to appreciate the importance of research and its long-term impact on Mali."

Doumbo has mastered the metaphors that get politicians' attention. He compares malaria's toll to three tsunamis every year and says: "Africa has lost a lot of Einsteins, a lot of Pasteurs, a lot of Bill Gateses because of malaria. And if you're able to eliminate malaria, you will see it increase the general creativity in a country and the ability of people to innovate and bring science to make their own solutions." This encourages younger scientists, Ogutu says: "They can see that science is valued, up to the highest office."

The Next Generation

Doumbo has shown a knack for nurturing younger scientists. Leaders need to create capable successors. "If this is not done, then scientists will burn out and exit," Ogutu says by e-mail. Mbacham agrees: Doumbo has given responsibility to those Mbacham calls "generation F2, who now begin to have their own teams and success stories."

One star of the younger generation is Abdoulaye Djimdé, who started at MRTC in 1993 after putting himself through the University of Bamako's Pharm.D. program. Djimdé was managing a pharmacy in the mornings and volunteering at MRTC in the afternoons, Plowe recalls. Doumbo assigned the young pharmacist to learn a technique for identifying gene mutations and later, with Plowe, arranged for Djimdé to attend short-term training at NIH. Typically, a director would feel obligated to send a more senior technician, Plowe says, but Doumbo made an exception "for somebody who he thinks has that spark that's going to lead to success."

Plowe and Doumbo helped Djimdé get into a Ph.D. program at the University of Maryland, Baltimore. He returned to Mali in 1999 with a research plan and prospects for a grant. "That collaboration," Plowe says, "led to a lot of good work published over the years." Djimdé heads MRTC's drug resistance unit and is the first person from West Africa to receive a Howard Hughes grant.

"It really is a meritocracy," Plowe says, "which I think is unusual."

As night falls with his Ph.D. students waiting, Doumbo describes the key factors for keeping talent: careful selection of staff from among the medical students, a mentor for each graduate student going abroad, and workshops on subjects such as grant-writing so they can find funding for research on their return. "Malians don't like leaving their country," Doumbo says. "I never even ask them to come back. Never. I say, "˜It's up to you if you want to join the team and help the population.' But they all come back." Varmus says the strategy works well, in part "because the students have a good place to which to return to do research."

Doumbo's emphasis on self-sufficiency, stemming from his own background in a remote village, may be a wave of the future. "I think we're in a period in Africa where you can no longer centralize," he says. "We have no choice but to go toward decentralization for all activities, to give responsibility to people." In community-based medicine, people find their own solutions. "That's why I'm confident that will be the future of Mali and the future of Africa."

David A. Taylor traveled to Mali with support from the International Reporting Project (IRP).