In some regions, a little funding can make a big difference. Julia Hinde reports on two units in Asia doing ground-breaking work

The Wellcome Trust may be Britain's largest and most influential medical research charity, but today Henry Wellcome's 1936 legacy is having an effect far further afield than the shores of his adopted homeland.

When not funding UK university laboratories or British-based researchers, part of the trust's spending - some Pounds 400 million each year - is being spent in 30 other countries, including Australia, Brazil and Vietnam.

For the past two decades, the trust has supported a research centre in Bangkok, Thailand, as part of its South-east Asian Overseas Unit, with a second base opened more recently in Ho Chi Minh City, Vietnam. The two units study the tropical diseases that cast a shadow over much of the developing world.

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"We investigate diseases that are important causes of death and debility," says Nick White, who has been director of the trust's South-east Asian operations for the past 13 years. "What we study has to be at least regionally important and, hopefully, will lead to some practical, tangible health benefits. Much medical research nowadays does not do that.

"If you read The Lancet or Science of ten years ago, how many of those things have ever transferred into benefits? A lot of what is called medical research doesn't yield clinical benefits," he says. "This is partly because public health in affluent countries is so good now that most people live full and healthy lives and the opportunity for significant medical advances is smaller. Not so of research in less well developed countries where huge and potentially soluble medical problems afflict much of the population. In this context, there are opportunities to make a difference."

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Over the past two decades, the Wellcome Mahidol University Oxford Tropical Medicine Research Programme has spent considerable effort on finding new and achievable ways to treat malaria. Its name reflects the fact that the unit is a link-up between Bangkok's Mahidol University and Oxford University in the UK, though funding is solely from the Wellcome Trust.

Thailand is home both to some of the most drug-resistant malaria in the world and, along its northwest borders with Burma, to refugee camps. Housing some 120,000 displaced people of Karen ethnic origin, these are ideal transmission grounds for malaria.

The Wellcome researchers there are pioneering new malarial treatments, including the use of combinations of drugs, as opposed to single treatments, to combat drug resistance.

"Drug resistance comes about by mutations in the malarial parasites' DNA," explains Professor White. "Already the popular and cheap drug chloroquine is no longer effective against malaria, and other alternatives are both scarce and losing their effectiveness. Current treatment practices have been based on using first one drug then, if that doesn't work, trying another. However, recent studies here indicate that a better approach would be to use a combination of drugs right from the start. We have been one of the leading groups developing this new strategy for dealing with malaria."

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The Thai-based team has also pioneered the use of qinghaosu, a herbal remedy employed by the Chinese for centuries, as part of a multi-drug approach to treating malaria. For the past eight years, they have been trialling extracts. "The real key has been the Chinese drugs," says Professor White. "We were the first outside China to push them clinically." Not only have the extracts, used in combination with other malaria treatments, been effective in combating multi drug-resistant malaria but, unlike many treatments, their effectiveness has not declined with time.

The treatment programmes have been so successful in certain geographic areas that a trial of a local cosmetic, impregnated by the researchers with insect repellent to see if its use cut malarial infection in pregnant women, has been inconclusive. The number of mosquito bites was certainly reduced, but the reduction of malaria in the test area by the qinghaosu combinations was so profound that no conclusions could be reached on the ingenious use of the cosmetic as a malaria prevention.

"The only way to study malaria is to live in the area," says Professor White of his team's attitude. "You have to take a holistic approach. It is no good devising a strategy that's unaffordable. It leaves you with an approach which might not be the most effective, but it is the most applicable and affordable in the local circumstances."

He adds that in many tropical countries, there is less than US$10 per person per year to spend on health. "In tropical countries, more than US$1 per person on malaria treatment is not acceptable."

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As someone with 20 years' experience of tropical medicine, Professor White sees the growth of drug resistance and Aids as the main infectious disease threats for the new millennium, and does not discount other health threats in the tropics, such as smoking and traffic accidents. He believes man has become a little complacent, and warns: "We now face an uncertain future, with bacteria evolving resistance mechanisms faster than new classes of antibiotics are being discovered."

The units' research covers far more than just malaria. Also under their microscope are infantile beri beri, melioidosis, typhoid, tetanus, diphtheria, Japanese encephalitus, dengue and bacterial meningitis.

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