BMJ  2003;327:1000-1001 (1 November), doi:10.1136/bmj.327.7422.1000

Editorial

Practising just medicine in an unjust world

Initiatives to improve academic medicine in developing countries must come from within

A recent report by the Academy of Medical Sciences highlights the importance of clinical research, and the challenge of translating recent discoveries into clinical practice and public health interventions.¹ As the recommendations were made largely in the context of public health practice and academic medicine in the United Kingdom, how do they relate to the developing world, and are the challenges faced by academia in developing countries markedly different?

Although health systems and research in developing countries have been reviewed, little systematic evaluation has taken place of the problems that academic health professionals face.² Firstly, academic professionals in developing countries work in relative isolation from primary care settings, mostly in urban centres, and fewer still interact with public health policy makers.³ Given the average size of a medical class and the workload in busy public hospitals most have to contend with an enormous load of teaching and clinical care. Barring a few examples and specialised centres most academic salaries are insufficient to support a white collar lifestyle, and thus private practice is the most common means of augmenting earnings.⁴ These economic issues are by far the major factor underlying the academic brain drain in developing countries, but other factors such as security and lifestyle may also play a part.⁵

There is little continuing medical education and even rarer access to recent biomedical information. This information drought is filled largely by the pharmaceutical industry and multinationals with enormous resources for marketing their products, which raises questions about the base of the evidence used to practise in such settings.⁶ The research gap is even more yawning. The 10/90 gap alludes to the fact that less than 10% of the current global funding for research targets diseases that afflict over 90% of the population.² Not only are indigenous sources of funding for research therefore limited but most research models are based on outdated strategies of "colonial" or "parachute" research.⁷ When research does get undertaken few projects bear direct relevance to local public health needs and fewer still relate to health systems research.^w1

As the report indicates the importance of health system research and large effectiveness trials cannot be denied,¹ even in developing countries. Disappointingly, of the recently announced grand challenges in global health,⁸ none relate to the challenge of providing services with limited resources in difficult circumstances. Although many academic staff in developing countries rank locally conducted research as highly relevant and important to their practice,^w2 few are involved in developing and testing public health interventions on a scale that has the potential of contributing to health systems. This lack of connection between academia and public health systems in developing countries creates an environment where inappropriate and ethically questionable research is commissioned,^w3 and existing scientific knowledge and information fail to find its way into practice.⁹ For developing countries unethical research encompasses scientifically unsound research, duplicate studies, and research that does not relate to the health priorities of the population studied. The capacity to conceive, undertake, and evaluate appropriate research is a cornerstone of academic medicine and scholarship anywhere in the world.

What is the way forward in developing countries? Strengthening centres of learning and creating local capacity for conducting and overseeing appropriate research are critical for the promotion of academic medicine in developing countries.¹⁰ Such measures and academic support for research must be coupled with easy electronic access and access to information. In a rapidly globalising world many health interventions and knowledge are truly global public goods and may provide solutions that are applicable to local needs. Recent initiatives such as providing electronic full text access to medical journals in developing countries are welcome and may be coupled with innovative projects such as the Ptolemy project, which links surgeons in Africa with information services at an academic centre in Canada.^w4 Such partnerships between institutions in the developed world and centres of learning in developing countries are important, but most sustainable initiatives for improving academic medicine and clinical research in developing countries must come from within.

Investments towards strengthening academic medicine and scholarship in developing countries are a necessity rather than a luxury. A strong correlation has also been shown between investments in science, health indicators, and economic growth of nations.¹¹ The Commission for Macroeconomics and Health has also recently made a strong case for increased global investments and partnerships in research as a means for stimulating economic growth and promotion of health.¹² The most durable and sustainable way to do this in developing countries is through strengthening academic medicine and the promotion of a culture of essential and relevant national research.

Aga Khan University, Karachi 74800, Pakistan (zulfiqar.bhutta{at}aku.edu)

---

Education and debate p 1041

Extra references w1-w4 appear on bmj.com

Competing interests: ZB is a member of the World Health Organization's Global Advisory Committee for Health Research and an adviser to Pakistan's Medical Research Council.

References

1. Academy of Medical Sciences. Resuscitating clinical research in the United Kingdom. BMJ 2003;327: 1041-3.[Free Full Text]
2. The Global Forum for Health Research. The 10/90 Report on Health Research 2000. Geneva.
3. Krishnan P. Medical education. Health millions 1992;18: 42-4.[Medline]
4. Zaidi SA. The political economy of health care in Pakistan. Lahore: Vanguard, 1988.
5. Siringi S. Kenya government promises to increase doctors' salaries to curb brain drain. Lancet 2001;358: 306.[ISI][Medline]
6. Chakraborty S, Frick K. Factors influencing private health providers' technical quality of care for acute respiratory infections among under-five children in rural West Bengal, India. Soc Sci Med 2002;55: 1579-87.
7. Costello A, Zumla A. Moving to research partnerships in developing countries. BMJ 2000;321: 827-9.[Free Full Text]
8. Varmus H, Klausner R, Zerhouni E, Acharya T, Daar AS, Singer PA. Grand challenges in global health. Science 2003;302: 398-9.[Abstract/Free Full Text]
9. Garner P, Kale R, Dickson R, Dans T, Salinas R. Getting research findings into practice: implementing research findings in developing countries. BMJ 1998;317: 531-5.[Free Full Text]
10. Sitthi-amorn C, Somrongthon R. Strengthening health research capacity in developing countries: a critical element for achieving health equity. BMJ 2000;321: 813-7.[Free Full Text]
11. Bloom D, Canning D. The health and wealth of nations. Science 2000;287: 1207-9.[Free Full Text]
12. World Health Organization. Macroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health. Geneva: WHO, 2001.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Relevant Articles

Five futures for academic medicine: the ICRAM scenarios

Jocalyn Clark for the International Campaign to Revitalise Academic Medicine
BMJ 2005 331: 101-104. [Extract] [Full Text] [PDF]

Academic medicine: time for reinvention: Public health sciences need strengthening in developing countries

Lalit Dandona
BMJ 2004 328: 47. [Extract] [Full Text]

Academic medicine: time for reinvention: Encourage overseas based researchers to return to improve academic medicine in the developing world

Niyi Awofeso
BMJ 2004 328: 47-48. [Extract] [Full Text]

Academic medicine: time for reinvention: Summary of responses

Jocalyn Clark
BMJ 2004 328: 49. [Extract] [Full Text]

Clinical research is dying in the United Kingdom
BMJ 2003 327: 0. [Full Text]

Resuscitating clinical research in the United Kingdom

John Bell
BMJ 2003 327: 1041-1043. [Extract] [Full Text] [PDF]

This article has been cited by other articles:

• Clark, J., for the International Campaign to Revitalise Acade, (2005). Five futures for academic medicine: the ICRAM scenarios. BMJ 331: 101-104 [Full text]  
• Soltani, A, Moayyeri, A, Raza, M (2004). Impediments to implementing evidence-based mental health in developing countries. Evid. Based Ment. Health 7: 64-66 [Full text]  
• Buekens, P., Keusch, G., Belizan, J., Bhutta, Z. A. (2004). Evidence-Based Global Health. JAMA 291: 2639-2641 [Full text]  
• Dandona, L. (2004). Academic medicine: time for reinvention: Public health sciences need strengthening in developing countries. BMJ 328: 47-47 [Full text]  
• Awofeso, N. (2004). Academic medicine: time for reinvention: Encourage overseas based researchers to return to improve academic medicine in the developing world. BMJ 328: 47-48 [Full text]  
• Clark, J. (2004). Academic medicine: time for reinvention: Summary of responses. BMJ 328: 49-49 [Full text]  
• Clark, J., Smith, R. (2003). BMJ Publishing Group to launch an international campaign to promote academic medicine. BMJ 327: 1001-1002 [Full text]  

Rapid Responses:

Read all Rapid Responses

Encouraging motivated overseas medical academics to return – a pre-requisite for improving academic medicine in the developing world

Niyi Awofeso
bmj.com, 3 Nov 2003 [Full text]

Practising just medicine in an unjust world

Atsu Seake-Kwawu
bmj.com, 3 Nov 2003 [Full text]

Re: Encouraging motivated overseas medical academics to return – a pre-requisite for improving academic medicine in the developing world

CELIO LEVYMAN,MD,MSc
bmj.com, 3 Nov 2003 [Full text]

Public health sciences need strengthening in developing countries

Lalit Dandona
bmj.com, 4 Nov 2003 [Full text]

Time to stop the numbers game

Shirley McIlvenny
bmj.com, 5 Nov 2003 [Full text]