Building a legacy? Ambivalent impacts of a malaria vaccine clinical trial

Introduction

This article examines the infrastructure and technology assembled to support a malaria vaccine clinical trial conducted in north-eastern Tanzania between 2009 and 2014, and the affect these material objects generated amongst those involved in running the trial. This clinical trial was funded by a European pharmaceutical company and United States (US)-based non-profit organization working with a Tanzanian para-statal research organization. The infrastructure and technology comprised a research centre with offices, state-of-the-art laboratories and several health care dispensaries in nearby villages. While the clinical trial was ongoing, this infrastructure and technology facilitated medical research and health care provision in a place where malaria was endemic. But what happens to these material objects after a clinical trial ends?

Over the past few decades, there has been considerable growth of transnational medical research, including clinical trials, conducted in low-income countries. Currently, medical research in sub-Saharan Africa (apart from South Africa) largely takes the form of Northern scientific institutions or pharmaceutical companies funding and working with publicly funded para-statal organizations or collaborative research centres (Crane, 2013; Geissler, 2012; Petryna, 2009). Increasingly, these Northern scientific institutions engage in ‘capacity building’ to support research activities in resource-poor settings, which can include material outcomes such as infrastructure, health care provision and employment. This is a marked shift from the colonial and post-independence era when Northern researchers often collected data from resource-poor places and left little in the way of material remains of their activities (termed ‘parachute’ or ‘safari’ research) (Crane, 2013; Street, 2014).

Although the quantity of research infrastructure and technology has increased in Africa, few social scientists have examined what happens to this infrastructure and technology when research ends. Bioethicists (see Cook et al., 2016; Mastroleo, 2016) are aware of this particular temporality of clinical trials when debating post-trial access to pharmaceutical products. Anthropologists have also explored the end of clinical trials, looking at access to health care and drugs (Marcis, 2015; Petryna, 2009), and the impacts of diagnostic devices, drugs (Montgomery, 2017) and trial activities (Kelly, 2011) on resource-poor settings. These anthropologists describe how research institutions and pharmaceutical companies from abroad relinquish responsibility for the care of trial participants and donated medical equipment when research concludes, leaving governments, communities and individuals to assume this responsibility as best they can. Thus, these anthropologists demonstrate that when a clinical trial ends, there are social, political and economic impacts, including the withdrawal of health care and life-saving drugs for trial participants. They decry these social harms and call for them to be minimized by taking into account the context in which research is conducted and, if necessary, for resources to be continued to be provided after trials conclude.

Looking directly at the material remains of scientific research and the affect it engenders, a small but growing number of social scientists (Geissler, 2015; Geissler and Kelly, 2016; Lachenal, 2017; Manton, 2015; Tousignant, 2013) draw attention to the ways in which material objects, temporality and affect are entwined. These scholars examine how the end of research can produce decaying buildings and wrecked machines, as well as feelings of disconnection, peripheralization and abjection as researchers lose a sense of progress and connection to more modern places of science.

In this article, I build on this literature while drawing on ethnographic research carried out at a research centre in north-eastern Tanzania and interviews with those involved in developing a malaria vaccine. ¹ I examine the infrastructure and technology used to support a malaria vaccine clinical trial and how clinical trial staff in Tanzania, vaccine scientists at a pharmaceutical company in Belgium, and clinical trial funders at a non-profit organization in the US reflected on these material objects. The research infrastructure and technology were conceived of as enabling the development of a vaccine and facilitating future medical research and health care provision in Tanzania, thus building a legacy. However, observations and discussions with informants after the clinical trial concluded uncovered a more complicated situation. As the trial drew to a close, the material remains of the clinical trial were repurposed, awaiting another large-scale research study, or decaying, their operability dependent on sustained funding and resources. For trial staff in Tanzania, this brought to the fore a sense of loss, frustration and disappointment about a future not fully realized, evocations that are deeply political (Larkin, 2013).

Examining an extended temporality of a clinical trial beyond its end, I argue that the material objects that supported the vaccine clinical trial had ambivalent impacts. Furthermore, the materials of clinical trials are not simply ambivalent; clinical trials have ambivalence embedded in them due to their abrupt endings when research concludes. In resource-poor places, infrastructure and technology cannot positively impact a place without continued maintenance and provision of resources. Analyzing infrastructure and technology from this position, this article contributes to the study of material culture by demonstrating the need to consider the life of material remains after research finishes, which illuminates important social relationships and processes that might otherwise be missed.

In the following section, I explore the social science literature about materiality and affect, followed by a historical overview of medical research infrastructure in Tanzania. Then I provide an ethnographic description of the infrastructure and technology constructed for the vaccine trial in Tanzania and how some viewed these material objects in a positive light. Subsequently I analyse the infrastructure and technology before and after the trial ended, weaving in reflections from informants. Drawing on literature about material remains and affect, I conclude with an analysis of how informants’ expressions of affect were political and moral calls for sustained funding for health care and research.

Materiality, ruin and affect

There has been a growing interest in materiality – the complex relationship between things and people – in the social sciences. Described as a ‘turn to things’, this study of material culture has encouraged the perception of objects as more than assemblages of metal, concrete or electronic components but also complex arrangements of politics, meanings and social relationships (Larkin, 2013; Olsen and Pétursdóttir, 2014). In the case of infrastructure and technology, social scientists have explored how these material objects are connected to the Enlightenment ideas of the world in movement, in which change and the circulation of people, goods and ideas open possibilities for progress. Infrastructures are structures meant to provide stability that allow for the organization of the market economy, development of technology and the eventual emergence of higher order processes, imagined as civilization, development, progress or freedom. Seen through this lens, the provision of infrastructure and technology is intimately tied to the shaping of modern society and the future. This explains why these material objects provoke deep affectual commitments, particularly in resource-poor countries. In this way, infrastructure and technology are not only material objects; they also encode the hopes and dreams of societies and individuals, thus mobilizing affect, including desire, hope and pride (Hetherington, 2014; Larkin, 2013).

Alternatively, other emotional responses are mobilized when infrastructure and technology fail, are lost, or in a state of decay. Since these material objects convey messages about ‘what it means to be linked to, or cut off from, images of modernity’, the connections and disconnections that arise with infrastructure and technology can reveal hidden issues and truths (Trovalla and Trovalla, 2015: 54). Several social scientists examine modern ruins (Olsen and Pétursdóttir, 2014) and the affect they generate (Geissler, 2015; Lachenal, 2017; Narvaro-Yashin, 2009; Tousignant, 2013), finding that frustration and sadness can arise when infrastructure or technology breaks down or is decaying, leading to forestalled possibilities and futures. As well, abjection can emerge when experiences of infrastructure or technology diverge from the trajectory of technological advancement. In this article, I employ this literature about affect, materiality and ruin to analyse the infrastructure and technology that supported the malaria vaccine trial in Tanzania. Next, I provide some historical context about medical research infrastructure in Tanzania.

Historical background on Tanzanian medical research

Beginning during the German and British colonial eras (c. 1884 to 1961), research stations were established in order to collect data and devise solutions to health issues that affected the colonial economy, European colonists, urban residents, and some African labourers. After independence from British rule, the postcolonial government expanded control over social and economic life as it vowed to create a socialist society through the principles of ujamaa (family-hood) and self-reliance. Health and research institutions were nationalized and medical research was gradually ‘Africanized’, with African researchers assuming control over the operation of research centres by the late 1970s. This process began in 1961 when the East African Medical Research Council (EAMRC) was established in place of colonial institutions and took over the operation of medical research in Tanzania. Once funding ran out for the EAMRC in 1977 in the wake of the collapse of the East African community, the National Institute for Medical Research (NIMR) was founded in 1979 as a para-statal organization and assumed control of medical research in the country (Geissler and Kelly, 2016; Gerrets, 2015; Turshen, 1984). As was the case in many African countries after independence, this expansion of research institutions signalled a progressive move towards a modern, dignified and democratic future, and evoked a sense of future imaginary and shared progress (Droney, 2014; Osseo-Asare, 2013).

However, by the 1980s, much of the fervour of decolonization ended with many of the ambitious goals left unachieved. Economic crisis hit Tanzania that led to a deficit and heavy borrowing from the International Monetary Fund and the World Bank. These organizations instituted structural adjustment programmes, which led to the reduction of state spending for research (Heggenhougen and Lugalla, 2005; Rottenburg, 2009; Shiner, 2003). To make up for the loss of funding, Tanzanian research institutions partnered with Northern research institutions, which improved infrastructure and health care provisions (Gerrets, 2015).

At the same time, with stable government funding for research largely withdrawn across Africa and the establishment of research partnerships with Northern institutions, there has been an increasing reliance on research projects that are conceived elsewhere and brought to Africa to be conducted over circumscribed periods of time. For research centres without ongoing projects and stable funding, this situation has resulted in periods of little activity as researchers attempt to attract more research funding from institutions outside Africa. Thus, although the construction of scientific infrastructure can lead to optimistic periods of growth – which evokes hopes for a better future – periods of activity can also have short temporalities that result in waiting, loss, decaying material remains and foreclosed futures (Okeke, 2017; Tousignant, 2013). Below, I provide a description of the research centre and present some positive reflections on the infrastructure and technology.

Establishing a research centre

From 2009 to 2014, the research centre in north-eastern Tanzania and 10 other sites across Africa assessed the efficacy and safety of a malaria vaccine amongst thousands of children. At the research center in Tanzania, 1,505 children living in 34 villages were enrolled in the trial. In order to conduct the trial, funders constructed research and health care infrastructure and provided resources, including laboratory equipment and medical supplies. And, although not the focus of this article, non-material capacity was built with the over 100 staff members of the clinical trial – including fieldworkers, doctors, nurses, administrators, laboratory technicians and data managers – receiving training to carry out the clinical trial.

An expansive research centre was built near a paediatric ward in a district hospital. The centre was constructed of concrete that was cleanly whitewashed, with a tin roof that captured rain to supply the building with water. Built around an atrium, the research centre held offices, conference rooms and two laboratories for hematology and microbiology located around the outer periphery of the square building. There was an inner courtyard of young orange trees and a large sitting area built out of concrete at the back of the building that overlooked farming fields and a lushly wooded mountain range. During the vaccine trial, staff often met in the hallways to converse or eat lunch together. In the basement of the research centre were data entry offices, a pharmacy and a climate-controlled archive to store paper documents for the vaccine trial. Rather than depending on the unreliable energy and internet sources in the surrounding area, the centre consisted of infrastructure that was self-supporting, which included generators, an incinerator, and a satellite connection to the pharmaceutical company in Belgium. Resources came in to the centre from abroad, and the information and blood samples that were collected from clinical trial participants moved out of Tanzania, to scientific and technological centres in Europe and North America.

In villages near the research centre, eight health dispensaries were newly built and one government dispensary was upgraded, with a new roof installed and two rooms in the back of the dispensary renovated to support vaccination and blood drawing. Each of the newly built trial dispensaries was situated next to a government dispensary. The construction of this infrastructure enabled trial participants and their caregivers to access health care near their homes and to attend key meetings with trial staff, including signing consent forms to enter the clinical trial, receiving doses of the malaria vaccine, and providing blood samples. The collection of information and blood samples and provision of health care also occurred in the paediatric ward of the district hospital where all of its funding for staff, diagnosis and drugs derived from the malaria vaccine trial. In exchange for participation in the clinical trial, trial participants received a mosquito net, emergency pick-ups and health care free of charge. Free health care was also provided to all children in the community who visited a trial dispensary or the paediatric ward of the district hospital.

Reflecting on the infrastructure constructed for the vaccine clinical trial, Michael, a representative of the US non-profit organization funding the clinical trial, said:

I have been doing clinical research for almost 30 years … Back in the day we used to call it ‘safari research’, where teams would fly in [with] their helicopters. They would do the research, take over the whole place and then blow out of there. They didn’t want to leave anything for the physicians and the nurses and the lab people on the ground. We took at the beginning a very different philosophy. We wanted to make sure that we … were going to leave something there that could be built upon to solve problems. Once after this study was done, [people] needed to be able to sustain that.

Michael emphasized that the technology and infrastructure would remain in Tanzania and be sustained after the trial ended, breaking with the history of extractive medical research in Africa. Others expressed similar sentiments: Wilson, a laboratory technician, explained that ‘The infrastructure was built to conduct the trial so that is something that will be left behind … That has improved care, especially for children who are treated at the hospital.’ Robert, a malaria vaccine scientist, said, ‘I think a lot of health infrastructures in and around the villages have benefited from the trial. We hope that will remain and have a positive impact on the community around the trial site.’ The material infrastructure facilitated health care provision and the production of evidence about the malaria vaccine. However, these objects had ambivalent effects, which I will describe below.

Infrastructure frozen in time and repurposed

The clinical trial began in 2009 and the last dose of the malaria vaccine was administered to trial participants by 2011, with analysis conducted over the following two years. I arrived in 2013, two years after the last vial of the vaccine had been administered and yet the impacts of the vaccine were evident in many places I visited. Clinical spaces had been built to hold, move, administer and test the malaria vaccine and people also recalled for me how the trial spaces were once used, situating the vaccine in specific times and places.

In one room of the haematology laboratory, the vaccines were kept cold in two large refrigerators before being administered to participants. When the vaccines had been in the room, the two trial pharmacists regularly monitored the quality of the vaccines and the temperature of the refrigerators. However, since the trial was double blinded (meaning that trial participants and most trial staff did not know who had received the malaria vaccine and who the alternative vaccine), this small room was off-limits to everyone but the pharmacists tasked with maintaining the vaccine cold chain. A sign on the door warned unauthorized people not to enter and this prohibition on others entering the room remained in effect even after the vaccines had long gone. This infrastructure was created to support the cold chain and maintain blinding. However, it was now frozen in time and awaiting another drug trial in need of a cold chain. Thus, this infrastructure was ‘mothballed’, or in a state of disuse, awaiting future medical research and experimentation. This room provided tangible traces of both the past and the future when a new research study may be conducted at the research centre (Geissler and Kelly, 2016).

I spoke to Caroline, a trial pharmacist, one morning at the research centre before the trial ended and she described the movement of the malaria vaccine. Vials of the vaccine arrived in Tanzania from Belgium and were held in the room that was off-limits to most staff. Caroline explained that when trial participants were being vaccinated, trial staff ‘had to transport almost 60 to 80 vials’ at a time to different trial-run dispensaries in surrounding villages. I followed the path of the malaria vaccine to one of the trial-run dispensaries in a village 40 minutes away from the research centre. At the dispensary, it was clear what the different rooms were being used for at the time but its layout was built for its original use: to vaccinate children. The large porch, which was open-air with corrugated metal roofing to keep out the sun and rain, was originally used as a waiting room to monitor participants after they were vaccinated. The dispensary also had three rooms. One of the rooms was large and held two wooden desks and two chairs, a bench for people to sit on as they waited to see a doctor, and tall shelves filled with children’s medicines and medical devices. This space was used for consultations and providing health care to children but it was originally used by caregivers to sign consent forms to enter their child into the clinical trial. The other room held two smaller rooms with a front room leading into a back room. The front room was small with a well-used metal sink and the back room had a permanent concrete and tiled table built out of the back wall upon which nurses prepared the malaria vaccine or the alternative vaccine for administration. A nurse would then bring the vaccine to the front room to administer to a participant. This infrastructure, built to support the vaccination process, was later repurposed for other trial activities, including obtaining blood samples from trial participants and providing health care.

The room in the research centre was in stasis while the dispensary in the village was repurposed and being used in new ways during the trial. Both have the potential to be used at a later time for medical research and health care provision. This makes them terrains of future possibility (Geissler, 2015), contingent upon further funding. I now turn to a description of the trial infrastructure and technology after the trial concluded.

An abrupt ending

On 31 December 2014, the malaria vaccine clinical trial in north-eastern Tanzania ended. The Tanzanian government was unable to fund research activities and attempts to attract another large-scale project to the centre had been unsuccessful. Although few small research studies had been attracted to the research centre after the vaccine trial, these studies only needed the use of a few offices and data management services. This meant that around 70 of the 100 staff members became abruptly unemployed. Joseph, a trial administrator, explained why another research project was not found to replace the vaccine trial: ‘With respect to research, we are trying to diversify. Not only [to] do malaria research but … other areas, other diseases … it’s unfortunate that we were caught before we were adequately prepared to diversify our research.’ Sharon, a representative of the US non-profit organization that funded the trial, explained, ‘We were the sole funder of [this site] … for years this was the contract that kept them operating … There weren’t a lot of opportunities to just pick up another project.’ A British malaria researcher involved in the vaccine trial reflected on this situation: ‘some … African centres which don’t have strong core support … are … very dependent on … big trials, for supporting infrastructure, paying the electricity, and so on.’

In the weeks after the conclusion of the trial, the research centre and dispensaries were quiet and it was discovered that the built spaces were not as functional as expected. After the trial ended, I spoke to Ibrahim, a data manager. He discussed how the trial laboratories provided diagnostic services to people in the community but then questioned the sustainability of this service. ‘It helps the community because we’re here. But I don’t know … after the [trial], I don’t think it helps’, he said.

Wilson showed me around the haematology laboratory, which provided blood testing services to trial participants and children admitted to the district hospital. Finding the laboratory empty of people, I enquired why. Wilson explained that there were few laboratory technicians left at the research centre because people were finding new jobs elsewhere. Very soon there would be no work to do because the substances required to operate the blood analysis machines were running out and cost hundreds of US dollars to replace. The remaining laboratory staff were using supplies from the last shipment that had arrived before the trial ended as they gradually closed down the laboratory. Wilson did not know if they would receive any more supplies. Without them, staff would be unable to continue diagnosing children. Wilson said with resignation, ‘before this project started, the death rate in the paediatric ward was very high but now it has reduced tremendously … So, my worry is, if we won’t have someone to sustain this … it’s going to be a major problem.’

With this statement, Wilson expressed his disappointment and resignation about the situation, an evocation of affect that was a political statement (Larkin, 2013). Wilson had developed a ‘medical imaginary’, a morally charged comparison between what medicine is and what it could be (Wendland, 2012). The trial had offered a first-hand idea of how health care could be provided, shaping Wilson’s ideas of how a public health care system should operate and this led to feelings of loss and frustration at the inability of the vaccine trial to bring about lasting change for the public health care system. But the infrastructure and technology were not part of comprehensive health system strengthening (Street, 2014). At the same time, without a continual flow of resources, Wilson also lost his ability to conduct scientific analysis and the blood analysis machines became functionally useless tools in waiting for further research funding and supplies. This situation disconnected Wilson from playing a role in scientific research and peripheralized the research centre, resulting in abjection from better resourced centres for science (Tousignant, 2013).

As for the dispensaries built for the trial, after the trial ended, they were donated to the Tanzanian Ministry of Health to operate as public health care facilities. Visiting one of the trial dispensaries one morning in early February, a few weeks after the trial had ended, the door to the consultation room was open. I was expecting the room to be empty but instead found three young men taking notes from textbooks. I introduced myself to them and they explained that they were nursing students studying for exams and had found the dispensary provided a light and quiet space to study, an improvement to the dark and busy government dispensary next door. There was no government-funded doctor, clinic officer or nurse on duty at the dispensary to attend to patients who might seek care and during the morning that I visited the dispensary, no one sought care. The shelves in the consultation room that had once held medicines and medical devices during the trial were now empty. Although the space built to support the vaccine trial had the potential to provide health care, it was devoid of the necessities to facilitate that care. After my visit to the trial dispensary, I spoke to a clinic officer who had worked for the vaccine trial. He lamented the loss of medicines in the dispensaries, saying that, ‘The Tanzanian government is poor and relies on donor dollars. Once the trial stopped, that was it.’ ²

Several informants claimed that the infrastructure built for the trial, especially the trial dispensaries, would improve health care delivery in the area. With these newer spaces constructed in nearby villages, it was anticipated that people would access health care and avoid the government dispensaries, which were often in various states of decay. But the buildings alone could not improve health outcomes. These buildings needed trained people and resources – drugs and medical devices – to make health care provision possible. The Tanzanian Ministry of Health struggled to attract health care providers to rural places to work and had trouble even paying them regularly. Often, necessary drugs and medical devices were out of stock. Despite the perception that these dispensaries were a positive impact of the malaria vaccine clinical trial, trial-run dispensaries operated separately from the public health care system and could not easily be linked into it when the trial ended. The dispensaries were essentially litter from global health research, dumped once they were no longer of use. The buildings were gifted to a resource-poor country with no thought for how they might be maintained as health care facilities. This burdened people with expensive and operationally useless medical facilities that lacked the necessary resources to make them functional and beneficial to surrounding communities. Thus, the provision of infrastructure did not directly lead to improvements in the health care system.

Decaying infrastructure and technology

With the utility of the clinical trial technology and infrastructure being of questionable value, this infrastructure had also already begun a slow decline, even before the trial ended. The trial-run dispensaries, although newer than the government dispensaries nearby, showed their age. At each of the dispensaries, built four years previously, the white paint was yellowing and cracks were showing in the walls. The outer walls had begun crumbling where flooding during the rainy seasons had eroded them. Paint had chipped off walls, and the doors and floors of some dispensaries were disintegrating. These features would have been unblemished and new when built but Tanzania’s tropical climate wore away at them quickly. Even so, the trial dispensaries stood in contrast to the surrounding setting, with its decaying and severely underfunded public health care system, evinced by the crumbling dispensaries nearby. The government dispensaries next door provided an idea of how the trial dispensaries would look in a few years’ time if left unmaintained: yellowed walls, dirty and crumbling floors and walls, cracks in the plaster, broken furniture, mouldering paperwork in corners and broken insect screens in windows.

The deterioration was not confined to the trial dispensaries; the research centre was also in a slow state of decay. Some devices needed for the smooth running of the clinical trial were in disrepair as the trial wound down. A few weeks before the trial drew to a close, I found Ibrahim in a data management office taking apart a printer and photocopy machine to see if he could repair a broken part. Although the activities of the data office relied upon printing, Ibrahim said, ‘We are so near the end of the trial so they [trial funders] won’t replace this with a new one’, as his frustration grew. But he was unable to fix the machine and eventually, resigned, he gave up trying. This affective expression demonstrated how Ibrahim felt about the decay of technology at the end of the trial. This complicates the idea that the technology was static and indisputably positive and highlights how dependent staff were on trial funders.

After the trial ended, I visited the data management offices in the basement of the research centre and found them in disarray. All the patient files from the archive had been piled on tables and floors, and the desks and tables from the data management office had been moved away from the walls. A data manager explained that the walls of the archive and data management office required repair because of a termite infestation. The place had been slowly chewed up in the last few years. The research centre was not immune to the elements, like every other building in the area. Despite investments in infrastructure and technology, the environmental conditions made it difficult to prevent ruination.

These findings relate to what Tousignant (2013) found when exploring the narratives of scientists working at a Senegalese university laboratory. This laboratory experienced periods of activity and technological abundance, accompanied by scientists engaging in collective and personal projects to bring about specific futures. However, these periods of activity were punctuated by periods of neglect when there was little funding for research, which resulted in broken machines, a lack of activity, and narratives of abjection and loss as scientists saw the progressive movement towards a brighter future foreclosed. Much like the Senegalese laboratory, the research centre in Tanzania was moving into a period of inactivity and it was uncertain what the future held. When technology and infrastructure broke down, it became glaringly obvious to staff how dependent they were on their wealthy funders for maintenance. In response to the ruination, staff expressed a sense of loss, sadness, frustration and resignation, which were political invocations for a sustained flow of funding and resources to support research and health care provision.

Ambivalent objects

Although under-examined in the social sciences, investigating an extended temporality of material objects can uncover important social process and relations that might otherwise be overlooked. Drawing on literature about scientific research, materiality and affect, this article explored the material remains of a clinical trial in Tanzania and how informants reflected on these materials. Consisting of a research centre, health dispensaries and technology, some informants claimed these material objects would serve as sustainable resources that had the potential to support future medical research and improve health care provision in the region. However, when the clinical trial concluded, the limitations of this technology and infrastructure became evident.

Observations at the end of the trial demonstrated that the research infrastructure and technology was decaying, repurposed or awaiting further funding and resources. This situation led to disconnection, abjection and peripheralization of the trial staff from scientific centres in better resourced places. It also ended the provision of high quality health care for children in surrounding communities, which could result in harm. In response to this outcome, trial staff commented on the ambivalent impacts of the trial and expressed a sense of loss, frustration, disappointment and resignation. These were political and moral expressions about the injustices of global inequality and its social harms to those living in resource-poor settings, and an expression of desire for sustained funding for quality public health care and research.

This finding demonstrates that the infrastructure and technology assembled for the clinical trial had varied impacts and, furthermore, clinical trials ‘brought’ to a place – and which do not have local rooting – are by their nature ambivalent due to their abrupt endings (Okeke, 2017). This is especially true in contexts of scarcity, where it is not economically possible for governments and communities to assume the responsibility of continued research and care. Thus, infrastructure and technology alone cannot bring about sustainable change. However, with a continuation of funding and resources, these material objects have the potential to regain functionality. In sum, this article demonstrates the limitations of temporally circumscribed research in building a legacy in a place of need.