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Clinical Research in North Africa: 5 Reasons Why we Are Behind

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Profile picture of Nihel Klouche
Nihel Klouche
on
Sep 2, 2021

Dear Diary,

I have been struggling with an eating disorder for the past few years. I am afraid to eat and afraid I will gain weight. The fear is unjustified as I was never overweight. I have weighed the same since I was 12 years old, and I am currently nearing my 25th birthday. Yet, when I see my reflection, I see somebody who is much larger than reality.

I told my therapist that I thought I was fat. She said it was 'body dysmorphia'.
She explained this as a mental health condition where a person is apprehensive about their appearance and suggested I visit a nutritionist. She also told me that this condition was associated with other anxiety disorders and eating disorders. I did not understand what she was saying as I was in denial; I had a problem, to begin with. I wanted a solution without having to address my issues.

Upon visiting my nutritionist, he conducted an in-body scan and told me my body weight was dangerously low.

I disagreed with him.

I felt he was speaking about a different person than the person I saw in the mirror. I felt like the elephant in the room- both literally and figuratively. He then made the simple but revolutionary suggestion to keep a food diary to track what I was eating.

This was a clever way for my nutritionist and me to be on the same page. By recording all my meals, drinks, and snacks, I was able to see what I was eating versus what I was supposed to be eating. Keeping a meal diary was a powerful and non-invasive way for my nutritionist to walk in my shoes for a specific time and understand my eating (and thinking) habits.

No other methodology would have allowed my nutritionist to capture so much contextual and behavioural information on my eating patterns other than a daily detailed food diary.
However, by using a paper and pen, I often forgot (or intentionally did not enter my food entries) as I felt guilty reading what I had eaten or that I had eaten at all.

I also did not have the visual flexibility to express myself through using photos, videos, voice recordings, and screen recordings. The usage of multiple media sources would have allowed my nutritionist to observe my behaviour in real-time and gain a holistic view of my physical and emotional needs.

I confessed to my therapist my deliberate dishonesty in completing the physical food diary and why I had been reluctant to participate in the exercise. My therapist then suggested to my nutritionist and me to transition to a mobile diary study.

Whilst I used a physical diary (paper and pen), a mobile diary study app would have helped my nutritionist and me reach a common ground (and to be on the same page) sooner rather than later.

As a millennial, I wanted to feel like journaling was as easy as Tweeting or posting a picture on Instagram. But at the same time, I wanted to know that the information I  provided in a digital diary would be as safe and private as it would have been as my handwritten diary locked in my bedroom cabinet.

Further, a digital food diary study platform with push notifications would have served as a constant reminder to log in my food entries as I constantly check my phone. It would have also made the task of writing a food diary less momentous by transforming my journaling into micro-journaling by allowing me to enter one bite at a time rather than the whole day's worth of meals at once.

Mainly, the digital food diary could help collect the evidence that I was not the elephant in the room, but rather that the elephant in the room was my denied eating disorder.

Sincerely,
The elephant in the room

Introduction

I started my research journey as a young female North African medical student one year ago. 

From the beginning, I noticed that medical researchers are quite rare in my country, and research doesn't get much attention here. 

I wondered if other North African countries face the same problem. One year later, I have a better understanding of why research is lacking in my country; however, I had to have data that reflects research engagement in North Africa.

To my surprise, I realized after an extensive literature search that there isn't any recent data about the matter, so I had to do something about it.

I analyzed 10 years of North African clinical trials listed in clinicaltrials.gov. Here are my 3 main findings, along with the reasons why research should be promoted more in North Africa.

1. North Africa's contribution to research is extremely low

I always feel very alone throughout my ongoing research process in my country Algeria, because it regularly seems to me that very few people around me are interested in scientific publications. 

What I had discovered in my analysis came as no surprise to me: From January 2011 to January 2021, Algeria, Morocco and Libya all registered less than 70 clinical trials in the largest clinical trials database, as you can see in the figure below.


Bar Chart
Infogram


Although I expected this result, these numbers still shocked me because they are really too low. To put this data into perspective, in the same time frame, the USA has listed 82747 clinical trials; North Africa's research contribution is almost nonexistent in comparison with this. 

This low engagement in clinical trials reflects North Africa's poor innovation in the medical sector and its weak research interest, among many other factors.

I find this very unfortunate because most North African countries are wealthier than many other sub-Saharan African countries, they also have quite better healthcare systems. This means that they could be performing a lot better than this in clinical research if they wanted to.

Sadly, This problem isn't new; even in the early 2000s, they were the least contributing countries in Africa in medical sciences.

I believe that working on spreading a solid research culture in this region of the world and promoting it with simple approaches could be an excellent way to spark an interest among potential future North African researchers.


2. Lack of public funding for medical research

Not many medical research projects get funded by universities, even ones that tackle important national public health issues, such as COVID-19 vaccination's engagement. 

I have found that universities and organizations only fund a small part of research in most North African countries; for example, only 10% of clinical studies in the past 10 years in Algeria were funded by universities. 


Copy: Bar Chart
Infogram


Most education systems in this region of the world rely mostly on government institutions; the level of their funding contributions reflects the low public funding policies. 

Research funds across the world are granted from two main resources: through governments and corporations. Both sources need to be available to maximize research projects and publications. 

Many nations globally encourage researchers by supporting them directly through grant-providing agencies or by running research facilities.

I find it awfully sad that there are extremely few public grant-providing agencies in my country. I sincerely hope that this will change in the future to improve the production of North African medical publications.


3. Poor research awareness 

There are great healthcare human resources in most North Africa. It is statistically confirmed that both Algeria and Tunisia have achieved and exceeded the World Health Organization recommendation of doctor to population ratio of 1.1  (1.76 and 1.33, respectively). 

This contrast in the high number of doctors and the low number of scientific publications reflects a serious problem in North African medical education system. Unfortunately,  throughout my whole 6 years of studying in my university, research publications were never a topic that got discussed.

I strongly believe that raising awareness about medical research among doctors and students should be a top priority because every modern physician should be practising evidence-based medicine. It is crucial to invest in these great physician resources and not let them go to waste.


4. Lack of electronic health records

Unfortunately, a lot of basic medical statistics remain unknown in North Africa. For example, unknown public data of people with depression or schizophrenia in some countries.

Believe it or not, almost all medical records in this region of the world are still in physical paper formats in public hospitals; this makes sharing medical data outside of the hospitals very hard.

I have never seen any electronic health records used in hospitals here. Clearly, massive efforts need to be made to invest in modern ways of health data storage to increase its public availability.


5. Negligible paid research jobs

I can tell you that in most local doctor's point of view, there seem to be more disadvantages than advantages of going down a research career path in this part of the globe. I can definitely understand why they think this way.

The reason is there are extremely few paid medical research positions in most North African countries. 

The lack of financial gain discourages scientists from conducting medical studies, particularly clinical trials, as they can take over years to finish sometimes.

The benefits of such time and money investments are simply not worth it in the eyes of the physicians.


Conclusion

I must admit that it is very upsetting to me, as someone who is passionate about science, to see how poorly North Africa is performing in clinical research.

It is the part of the world I belong to; I obviously want to see it strive to contribute more to modern medical knowledge.

Even though I am frustrated, I do not let the barriers stop me from taking an interest in research. Even for a medical student, it is possible to successfully publish in the world's best ranking medical journals, just like I did earlier this year when our article got published in the Lancet. Therefore, I encourage all other medical students to try their best to overcome the challenges if they want to publish research articles too.

 However, all the barriers still need to be addressed by policy-makers or potential investors to seek ways to overcome them.

The call to action to promote research and evidence-based medicine in North Africa feels urgent due to the powerful data of this analysis.

I am truly hoping that we will witness considerable improvements in this regard in the future; meanwhile, I will continue doing my best to raise awareness about the matter in my community because I strongly believe that medical research overall is of the greatest importance to build better healthcare systems, and thus providing better health service to almost 100 million North African population.

If appropriately used in the 21st century, data could save us from lots of failed interventions and enable us to provide evidence-based solutions towards tackling malaria globally. This is also part of what makes the ALMA scorecard generated by the African Leaders Malaria Alliance an essential tool for tracking malaria intervention globally.

If we are able to know the financial resources deployed to fight malaria in an endemic country and equate it to the coverage and impact, it would be easier to strengthen accountability for malaria control and also track progress in malaria elimination across the continent of Africa and beyond.

Odinaka Kingsley Obeta

West African Lead, ALMA Youth Advisory Council/Zero Malaria Champion

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Dear Digital Diary,

I realized that there is an unquestionable comfort in being misunderstood. For to be understood, one must peel off all the emotional layers and be exposed.

This requires both vulnerability and strength. I guess by using a physical diary (a paper and a pen), I never felt like what I was saying was analyzed or judged. But I also never thought I was understood.

Paper does not talk back.Using a daily digital diary has required emotional strength. It has required the need to trust and the need to provide information to be helped and understood.

Using a daily diary has needed less time and effort than a physical diary as I am prompted to interact through mobile notifications. I also no longer relay information from memory, but rather the medical or personal insights I enter are real-time behaviours and experiences.

The interaction is more organic. I also must confess this technology has allowed me to see patterns in my behaviour that I would have otherwise never noticed. I trust that the data I enter is safe as it is password protected. I also trust that I am safe because my doctor and nutritionist can view my records in real-time.

Also, with the data entered being more objective and diverse through pictures and voice recordings, my treatment plan has been better suited to my needs.

Sincerely,
No more elephants in this room

Profile picture of Nihel Klouche

Nihel Klouche

Nihel is a final year medical student at University of Tlemcen, Algeria. Her passion for knowledge drew her to pursuing research in public health and mental health. She has published in well-known international medical journals such as The Lancet, ASCO. Nihel loves sharing her ideas through writing and enjoys working with people from different backgrounds. She believes in the power of science bringing people together to make the world a better place.

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