Samiran Nundy, Atul Kakar, and Zulfi Bhutta have published a book titled How to Practice Academic Medicine and Publish from Developing Countries? A Practical Guide. It’s a book that will be extremely useful to the growing number of academics working in low and middle income countries. The book is published by Springer and will from 30 October be available open access, meaning you can access it for free as often as you want. Hard copies will also be available for a fee. I felt privileged to be asked to write the foreword, and what follows is an edited version of my foreword.
When I became an assistant editor at The BMJ in 1979 and began to process scientific papers submitted to the journal it was extremely unusual to see, let alone publish, a paper from a low income country. I remember being surprised by high quality papers coming from Bangladesh, a country that Henry Kissinger called a “basket case.” Those papers came from the International Centre for Diarrhoeal Disease Research, Bangladesh, which I learnt later was a creature of the Cold War and might cruelly be called a “branch office of Johns Hopkins.”
Years later, in 2013, I became the chair of the board of what was by then called icddr,b. The centre has now published major vaccine trials led by Bangladeshi scientists in the New England Journal of Medicine,1 and I was privileged to be on the steering committee of a major trial, also published in the New England Journal of Medicine, of a system for managing hypertension in rural Pakistan, Bangladesh, and Sri Lanka led by scientists from those countries.2 Last year I was delighted to see a major trial of the polypill for the prevention of cardiovascular disease led from India and also published in the New England Journal of Medicine.3
High quality research relevant to the needs of low and middle income countries is much commoner now than it was 40 years ago, and China has become a scientific leader. But, as the editors of this book describe in the introduction, there is still not nearly as much good research as there should be from the part of the world that carries most of the disease burden. Even worse, the medicine practised in some of these countries is disconnected from research and teaching, and driven more by profit than what is best for patients and the population. I have Indian friends who are terrified of seeing a cardiologist for fear that they will be given treatments they don’t need.
I agree with the editors’ diagnosis that “the main reasons for our having sunk into this deep morass is not because we are poor but because we have not intelligently examined, evaluated and investigated how we could use our own resources more effectively. We have tended to blindly follow what is being done in richer countries instead of trying to provide healthcare to our population which is accessible, affordable and, most importantly, appropriate even if this means deploying and working with informal healthcare providers.”
Other people’s research can be valuable, but it can never be as valuable as your own—addressing the problems that matter to your people with relevant methods and the tools you have. And we know that the very act of researching brings improvement, and (as I know to my cost) you can never learn about research from reading about it: you need to do it.
I’ve never quite understood why people in low and middle income countries would want to replicate the health systems of high income countries. Not only are those systems not relevant to the needs and circumstances of the low and middle income countries, but the systems in high income countries are increasingly unaffordable and unsustainable and not meeting the needs of their own populations.
Health systems in high income countries were developed decades ago and were designed to respond to the infectious disease and trauma that were then the main causes of suffering and death. Those problems could be cured, but now non-communicable disease is the main cause of suffering and death. Such disease cannot be cured and needs a different approach.
Non-communicable disease is now also the main cause of suffering and death in low and middle income countries (apart from some sub-Saharan countries, but even there it will soon be the main cause). The epidemiological transition happened very fast in low and middle income countries: in Bangladesh non-communicable disease caused about 10% of deaths in 1986 but nearer 80% by 2006.4 I spent years working with 11 centres in low and middle income countries that were doing research, building capacity, and advising on policy in relation to non-communicable disease. We envisioned what a better system in low and middle income countries might look like—with an emphasis on public health, the social determinants of health, prevention, primary care, patient empowerment, and widespread use of evidence based guidelines.5 (Such guidelines were developed by academics in South Africa as part of a package that allows good primary care where doctors are few or unavailable.6)
We should have said more about the use of technology. Most people in low and middle income countries, even some of the poorest, now have mobile phones, which has meant that people can communicate without having to connect every house by wires, as happened with terrestrial phone systems in high income countries. Low and middle income countries can in this way “leapfrog” over a stage that was needed in high income countries, and the same can be done for health—not least by using mobile phones to provide access to care. Similarly, health systems in low and middle income countries might create health record systems where patients, not healthcare providers, own and control the records. Health systems in high income countries are just beginning to recognise the importance and inevitability of giving patients ownership and control of their records. (I have a conflict of interest here as I’m the chair of Patients Know Best, a company that gives patients in Britain and some other countries control of their records and data.)
Health systems in high income countries are actually sickness systems, and low and middle income countries would be wise to concentrate more on health. Only a small part of health comes from the health system, but politicians, citizens, and even many health professionals seem unaware of the fact. Consequently, health and healthcare are treated as if they are synonymous. Those countries that currently have poorly developed health systems have the opportunity to build systems that pay more attention to health than healthcare, as indeed was the case in many traditional and ancient health systems. Physicians to Chinese emperors were paid only if the emperor was well.
Such developments in health and health systems can be achieved only through research conducted in low and middle income countries by researchers from those countries. And, I suggest, we need a new way of doing science, and researchers in low and middle income countries should take the lead. I have recently been part of a discussion on the future of the UK Academy of Medical Sciences, and people are advocating a new way of doing science that will be much more transdisciplinary and global with more involvement of citizens. A broader range of methods will be needed, together with a greater willingness to bring together different kinds of studies and data to reach conclusions. Without curiosity-driven research being neglected, there might be more emphasis on research that brings social benefit. Implementation of research findings will become as important as discovery, and the hierarchy of science that ranks genetics above social science will disappear.
Secondary aspects of the new science might be universal data sharing, greater transparency throughout the research process, immediate open access to all research, and the final abandoning of publications and the place of publication as the main way to measure academic success. In addition, scientific integrity (and its dark twin, misconduct) will be taken much more seriously, as will the commitment to explaining science and how it works to the public.
As part of the debate over the future of the academy there has been discussion on priorities, and two of the priorities that are widely advocated—climate change and inequalities—are even more relevant to low and middle income countries than to high income ones. It’s a huge global injustice that most of the greenhouse gases that are causing climate change have been produced in high income countries, but the resulting harm will be experienced mostly in low and middle income countries. A third of Bangladesh, already a densely crowded country, is set to disappear under water, and temperature increase and drought will reduce crop yields in many low and middle income countries, forcing people to migrate. Health academics must pay attention to climate change, which will mean forming new, unfamiliar research partnerships with climate, agricultural, social, and political scientists.
Academics must also recognise the huge role that inequalities in wealth, income, education, and opportunity play in health. The covid-19 pandemic has brutally illustrated the importance of inequality, in both high and low and middle income countries. Most low and middle income countries have even greater inequality within the countries than do high income countries. Health researchers in some high income countries, including Britain, have done a good job of measuring and describing the harm to health from inequalities but have done less well in reducing the harm. Researchers in low and middle income countries have an opportunity to do better.
The world faces considerable problems, and what is clear is that research and teaching will be essential in tackling those problems. It’s also clear that the research and teaching must be undertaken by researchers and teachers within countries, producing responses and using methods that are right for their countries. This book will be a great aid to researchers and teachers. The result should be better health and sustainable health systems. The opportunities are greater than the problems.
Richard Smith was the editor of The BMJ until 2004.
Conflict of Interest: RS is the unpaid chair of Patients Know Best, but he has equity in the company. He is the unpaid chair of the UK Health Alliance on Climate Change, but he has shares in the UnitedHealth Group. He was not paid for writing the foreword to the book and will not benefit from whatever sales there might be.
References
1 Qadri F, Wierzba TF, Ali N, et al. Efficacy of a single-dose, inactivated oral cholera vaccine in Bangladesh. N Engl J Med 2016; 374:1723-1732. DOI: 10.1056/NEJMoa1510330
2 Jafar TH, Gandhi M, Asita de Silva H, et al. A community-based intervention for managing hypertension in rural South Asia. N Engl J Med 2020; 382:717-726. DOI: 10.1056/NEJMoa1911965
3 Yusuf S, Joseph P, Dans A, et al. Polypill with or without aspirin in persons without cardiovascular disease. N Engl J Med 2021; 384:216-228. DOI: 10.1056/NEJMoa2028220
4 Ahsan Karar Z, Alam N, Streatfield P. Epidemiological transition in rural Bangladesh, 1986-2006. Glob Health Action 2009 Jun 19;2. doi: 10.3402/gha.v2i0.1904. PMID: 20027273; PMCID: PMC2779938.
5 Checkley W, Ghannem H, Irazola V, et al. Management of NCD in low- and middle-income countries. Glob Heart 2014;9:431-443. doi:10.1016/j.gheart.2014.11.003
6 Fairall L, Cornick R, Bateman E. Empowering frontline providers to deliver universal primary healthcare using the Practical Approach to Care Kit. BMJ Global Health 2020;3:ek4451rep.