Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Mexico Agenda informed by wide consultations
- Tikki Pang (26 November 2004)
-
Reasons to be cheerful, part three
- richard horton (26 November 2004)
-
Health summits and medical conferences: struts, preens, and the politicising of medicine
- Vinod K Gupta (30 November 2004)
-
rich need poor
- Uday A Gupta (30 November 2004)
-
HEALTH-CARE RESEARCH IN DEVELOPING COUNTRIES: ROLE OF THE MEDICAL COMMUNITY
- Stuart Enoch (24 December 2004)
|
|
|||
|
Tikki Pang, Director, Research Policy & Cooperation WHO, 1211 Geneva 27
Send response to journal:
|
We thank Kamran Abbasi for his continuing interest in the recently concluded Ministerial Summit on Health Research in Mexico and would like to respond to three issues he raised. First, he laments the lack of translatable actions but did not mention additional action items related to a call to donors for more substantive support for health systems research, a call to governments to allocate a certain percentage of national health expenditures to research, and to work more closely with countries to better use evidence in health decision making. Second, he was critical of the Mexico Agenda which he states was "drafted largely by representatives of the rich". It should be pointed out that the development of the Agenda was informed by wide ranging consultations and meetings in all WHO regions which involved researchers, policy makers and non-governmental organizations. Ultimately, the Agenda will be discussed at the governing bodies of the WHO where all Member States will have a chance to comment and take ownership. Third, it is not correct to state that "everything under the sun" was tied to the Millennium Development Goals-the Agenda clearly acknowledges the importance of other communicable diseases, non-communicable diseases, sexual and reproductive health, injuries, violence and mental ill health. Together with our Member States we are committed to translating the Agenda into measurable actions. Competing interests: None declared |
|||
|
|
|||
|
richard horton, editor the lancet
Send response to journal:
|
Dear Kamran - I enjoyed your two pieces on the Mexico summit this week. But, as we discussed in passionate terms after the closing session, I believe that you are unduly pessimistic about the outcome of this meeting. Indeed, exaggerated criticism at this formative stage could badly damage the very things that we would both wish to support and nurture. Why was the summit and its Statement important? Because, 1. There was astonishing engagement by ministers in the detail of how health research can strengthen health systems. In the parallel meetings at the summit, ministers of health engaged in the detail of how to translate research into policy. In the individual discussions with ministers and their representatives as we drafted the summit Statement, there was also line-by-line involvement about how governments could be helpful to this agenda. "Political expediency" unfairly characterises the process. 2. There was unprecedented agreement among ministers and their representatives. For seasoned observers of ministerial summits, this came as a surprise. A consensus between politicians, academics, NGOs, and community organisations, all built around health systems research, has matured at just the moment that it is needed - a remarkable confluence of circumstances that was apparent if one sat and listened to ministers discuss their country predicaments in detail. Rather than point to the use of the MDGs as an error, it is the MDGs that provide the political leverage to persuade ministers to take these wider issues seriously. Governments have signed up to the MDGs as stated national strategy. We in the health sphere need to make the most of this opportunity. 3. There are already existing signs of action. In low-income countries - where the results, for example, of the multi-country evaluation of IMCI are now being translated directly into policy - we see real attention being paid to evidence for improving public health. In middle-income countries, such as Mexico, evidence and evaluation are becoming the foundations of national health policies. And in high-income countries, such as the UK, research is increasingly being underlined. In the UK public health white paper published last week, research is identified as a central component of strenghthening our own health service - an incredible and valuable commitment that has not been properly acknowledged in the mainstream or professional media. 4. There is a process, which you hint at, to deliver on the Mexico commitments. First, by taking the Statement to the Executive Board in January, under the capable leadership of its chariman, David Gunnarsson (Iceland's permanent secretary in the ministry of health), who chaired the final ministerial session. And second, through a resolution to be proposed at the World Health Assembly. Again, this is unprecedented. 5. There is an important context, one that you do not explain, which again gives good reason for confidence that this agenda is more than "fine words". That context is the review of progress towards the MDGs to take place next September. Combined with the results of the Millennium Project to be released early next year, the work of the Joint Learning Initiative (see Lancet 2004; 364: 1984-90), and the WHO Commission on Social Determinants of Health, there is a realisation that the MDGs will not be reached in the most resource-poor settings, despite the fact that we know what to do in order to reach them. This know-do gap is not a cliche - it is a reality that can only be bridged by a different approach to research - an approach that most scientist-driven funding bodies have ignored. WHO is leading a movement, now joined by ministers, to change the way scientists and policy makers prioritise their funding decisions - truly to create a research agenda for public health. Your target is wrong - it should not be the summit, it should be the science community, which has such an imbalanced view of the shape of the research enterprise to improve human health. Finally, you say that it was a "folly" to have a drafting team, of which I was a part, include largely "representatives of the rich". But, once again, you have misunderstood the process. The drafting team of three were not the authors of the Statement. The authors were the ministers themselves. As they state at the beginning of the document, "We the Ministers of Health"...The role of the drafting team was to consult with delegations and to translate as accurately as we could the wishes of ministers into a final Statement. Criticism always sharpens debate and helps to improve the way we work. I hope that together we can do more to redefine the meaning of research to improve human health. Best wishes, Richard Competing interests: I was a member of the drafting committee for the Mexico Statement, together with Tikki Pang and Joanne McManus. |
|||
|
|
|||
|
Vinod K Gupta, Physician Dubai Police Medical Services, PO Box 12005, Dubai, United Arab Emirates
Send response to journal:
|
Abbasi must be congratulated by -- not only medical scientists worldwide, but also by the expendable silent have-not dross that make up the majority of humanity – for being able to see through veils developed by practice over much of the twentieth century, the rhetoric of the Mexico Summit, and for that matter, of all previous summits – medical and non- medical -- where elected or self-appointed representatives of the peoples of this world gather to invariably wine and dine and to churn out reams of printed papers promising variations of a rosier dawn tomorrow. The harsh truth is that medicalconferencing and summitry has become a specialty. The Mexican summit is not the last…the beauty of it all -- that has not been mentioned yet -- is that there is always another summit around the corner, maybe just six months later… The success of such summits is always insured in advance by the roping in of intellectuals of some standing into drafting committees. Such learned-and-committed members of drafting committees provide the much- needed gloss to such summits thereby effectively deflecting any criticism that might be raised. Pang and Horton (two respondents with clear conflict of interest, undeclared by Pang) are almost amazed at Abbasi’s “outburst” rocking the boat of an otherwise so-meaningful summit of the “minds”, find no merit at all in the critique, and are quick to respond superficially, argumentatively, and conventionally to an anguished empathic cry from an intellectual of equal standing. Insofar as “political expediency” is concerned, Abbasi has hit the nail on the head. The basis and bane of democracy, both for the elected and the electorate, is political expediency. The result of every election is the expression of a mass hypnosis or hysteria. Before I move onto specifics, every government – democratic or otherwise -- has worked under the overt guise of the will of the people. To transfer this instrument of manipulation to medical research is nothing but tragic. That “health research (can) ensure vibrant health systems and reduce inequity and…social injustice” (1) is one of the gravest Orwellian untruths that has gained prominence through democracy. Inequity and social injustice is inbuilt into capitalist democracies while socialist democracies make feeble (or no) attempts to justify their existence by sops now and then. To survive, a politician must sell an idea. Every summit of politicians sells ideas, very often dangerous ones. Do we really want to place medical research squarely in the hands of salespersons? How many of the people attending the conference, perhaps in the hundreds, paid from their own pockets to attend the conference? Invariably, the conferees – invited or delegated -- misused funds made available by the people to governments through taxes and more dubious modes. Each returning Minister of health, ministerial representative, and delegate must somehow justify the expenditure to his/her country, electorate or constituency, department – and therefore, a draft and a drafting team with action points, firm or vague are a must. Whereas the draft might have been authored by the Ministers of health – a highly unlikely personal accomplishment by politicians of any hue or standing – it bore the stamp of approval of the drafting committee. Horton’s emphasis on the origin of the draft and “line-by-line involvement” about governmental commitment is simplistic and specious. Going by Horton’s analysis, identification of research in a recent “white paper”as a central plank of healthcare in the U.K. is a new revelation that will by itself solve – or begin to solve -- the myriad problems that beset the NHS. Pang believes that translatable action involves persuading more governments to contribute more funds to research and health systems research and closer interaction to use available evidence for health decision making. Most governments have budget deficits, are at each other’s throats in the fierce world of international finance, and take an insidious delight in the discomfiture of other countries. Health decision making is not something as precise as the surgeon’s scalpel, depending as it does on a host of social factors like availability of expertise, expense involved, and education of the masses, besides runaway expectations of the rewards of litigation of both patients and lawyers. Despite alarmingly rising allocations to health budgets, the woes of the NHS in U.K. have been making news from quite some time. The situation is unimaginably worse in less developed nations. Half a century ago, a Nobel Laureate wrote inimitable prose about the contribution of finance to research: “Great sums of money are wasted every year on scientific research, in America as well as in Europe,…Neither laboratories, nor apparatus, nor organization can give to scientists the surroundings indispensable to their success. Modern life is opposed to the life of the mind…”. (2) A sophisticated technical backup and ample funding might be less important than intangibles such as attitudes, motives, character, and perseverance. (3) Migraine is an example of a common human illnesses with an inexhaustible literature and uninhibited application of high technology to its study, but, its pathophysiology remains rudimentary, the classification phenomenological, and the therapy purely empirical. (4, 5) The first tenet of democracy is the vote – the celebration of the lowest common denominator, while the second is to rule through debate, “white papers”, and diffusion of responsibility through creation of commissions of inquiry. Scientific conferences epitomize democratic functioning and the outcome of most such endeavours would, therefore, be self-limited. “A work of art has never been produced by a committee of artists, nor a great discovery made by a committee of scholars. The synthesis needed for the progress of our knowledge of man should be elaborated in a single brain”. (3) Conversely, the adrenaline rush of being noted, quoted, and feted in conferences is an entirely incomparable experience. Pang takes exception to the mention by Abbasi of the prerogatives of the rich. The rich have inherited the Earth – while the poor have inherited the bowels of the Earth – and every Agenda at every conference – past, present, or future – has and will marginalize the poor. Once the demonstrations have held their stage and the media its ounce of flesh, the poor get quarantined in their hovels and quartered by their hunger. There is little scope for argument here but commitment and bias brook no nonsense and can label routine bureaucratic proceedings as “unprecedented” breakthrough in the scientific process, as perceived by Horton. Fancy terms such as “Millenium Development Goals”, “push-pull strategies”, “demanders-suppliers of research works” or “embedding of research” do not reduce in any way the accountability of Member States in “translating the Agenda into measurable actions” but most teams from Member States five years later will comprise different individuals free from the yoke of past conferences and half-promises. Finally, Horton’s target is, most amazingly, the scientific community. In dissociating the “scientific community” from the larger community, we are expecting an organ to function well while general decay is setting in. Scientists are always imbued with the prejudices of their generations. Bludgeoned by the publish-or-perish culture, the research grants circus, and the subjective competitive hostile and anonymous peer- review system, scientists are rendered unable to see beyond more pressing human needs and foibles. The “know-do” gap may be a reality but it is truly breathtaking that it can be bridged by a different approach to research. All it takes is one concrete example to prove that Pang and Horton have got it right. Because politics impacts every aspect of human existence, including scientific research and its field practice, it is too important to be left to career politicians. To embrace criticism in principle and form and then to dilute it in content is certainly not the way forward. To redefine the meaning of medical research to suit in-vogue political thinking is too vague an approach to be productive. Verse can sometimes say it better than prose: Hail the sham, the insatiable craving for power
With the advent of the internet, a meeting of the minds is now just a click away. I predict that medical summits and conferences – markers of herd behaviour -- will become obsolete one day. Given the sway that conferences currently hold, that day does not appear to be proximately imminent. Eventually, commonsense and logic will prevail over this form of medical expediency. References 1. Abbasi K. Mexico summit calls for greater commitment to health research. BMJ 2004;329:1258. 2. Carrel A. Man, The Unknown. Hamish Hamilton Ltd., London: 1959. 3. Burkitt D. How important is IQ in research? BMJ 1992305:1300. 4. Gupta VK. Bureaucratisation of migraine. Lancet Neurology 2004;3:396. 5. Gupta VK. Classification of primary headaches: pathophysiology versus nosology? BMJ 2004; published online Jan 22. Available at: http://bmj.bmjjournals.com/cgi/eletters/328/7432/119. 6. Gupta VK. Ode to Chad. The Best Poems and Poets of 2004. Published by Poetry.com. (In press). Competing interests: None declared |
|||
|
|
|||
|
Uday A Gupta, Juniour Resident, Pulmonary Medicine VP Chest Institute, University of Delhi, Delhi. India
Send response to journal:
|
When the rich nations needed the markets in poor nations we had the world trade organization, and now we have a world health assembly. Why do the rich nations need the poor ones, that too for research? I dont mean to be skeptical, but just as it took decades for the poor to realise what is happening in WTO in Doha summit, I hope nothing of the similarity is repeated here. I hope I am wrong. Competing interests: I am from the developing world |
|||
|
|
|||
|
Stuart Enoch, Surgical Research Fellow (PhD) of the Royal Colleges of Surgeons of Edinburgh and Ireland Wound Healing Research Unit, Department of Surgery, Cardiff University/ Hosp. of Wales, CF14 4UJ, UK
Send response to journal:
|
Dear Sir, I read with great interest your editorial, ‘The Mexico Summit on Health Research 2004’ which aptly emphasises the significance of producing and implementing national research agendas (1). Likewise, The Lancet, in its editorial, recommends that research should be embedded as an integral component into the health systems of national governments (2). Although it is important for rich and poor governments alike to adopt policies for improving public health, it is more imperative for the governments of developing (low- and middle-income) countries to implement appropriate national research strategies to reduce child mortality, prevent infectious diseases (by providing clean drinking water and improving sanitation), and combat AIDS. To achieve this, it is essential for the medical community within these countries to take an active role and adopt reforms within the medical system to face the challenges of the 21st century. Unlike in the developed countries, research training is not integrated into the medical curriculum nor is research considered to be part of routine medical practice. Students seldom have the opportunity to undertake any form of research during their medical training; the training solely emphasises on providing health-care to individual patients (clearly important) but fails to appreciate the significance of research in enhancing the well-being of the population as a whole. Furthermore, there is no incentive or a structured career path (e.g., physician-scientist) to encourage clinicians to undertake medical research, which is vital for the success of biological research being translated into clinical practice – ‘from bench to bedside’ (3). Hence the medical regulatory bodies should attempt to restructure the medical curriculum to encompass research training as part of the programme and also develop appropriate career structures for clinicians undertaking research, both of which would encourage medical research. The other pertinent issue is that medical research has rarely been given a ‘high priority’ in the government’s health care planning; providing basic healthcare for the whole population takes precedence to all other requirements in the national health agenda. Since financial constraint seems to be a significant factor in the governments’ reluctance to support medical research, research is mainly undertaken by pharmaceutical companies and selected private institutions; in these situations, financial gains may take precedence to the health of the nation. When research is undertaken in the few government institutions, it may be hampered by political interference and stifling bureaucracy. Capital investment in new facilities and high technology equipment appeals to politicians, even when these investments may be the least cost- effective and seldom benefit public health. In addition, a small number of individuals at decision making levels in public institutions have vested interests and are keen to influence the distribution of funds. The above issues need to be addressed, and the governments of developing countries should apportion a substantial amount of their national budget towards medical research, mainly public health; this is vital for the health and well-being of both its present and future citizens. The medical fraternity, through their representative organisations, in conjunction with the government, should strive to create appropriate regulatory bodies (research and development directorates, ethical committees etc.) and develop national guidelines to encourage medical research in an ethical and transparent manner. They should also guide the government to develop and implement meaningful research strategies and specific national health policies. References: 1. Abbasi K. Editorial. The Mexico Summit on Health Research 2004. BMJ 2004; 329: 1249-1250. 2. Editorial. The Mexico Statement: strengthening health systems. Lancet 2004; 364 (9449): 1911-12. 3. Kreeger K. From bench to bedside. Nature 2003; 424: 1090-91. Yours truly, Stuart Enoch MBBS, MRCSEd, MRCS (Eng); Surgical Research Fellow (PhD) of the Royal Colleges of Surgeons of Edinburgh and Ireland The author is an Indian citizen and obtained his medical degree from Kasturba Medical College, India. He has completed his Basic Surgical Training in the UK and obtained memberships from the Royal Colleges of Surgeons of Edinburgh and England; he is in the final year of his PhD. Competing interests: None declared |
|||