By Jorge Lazareff, MD, FAANS, Emeritus Professor of Neurosurgery; Director of Latin America Initiatives, UCLA Center for World Health
Although the largest number of patients globally live in low and middle-income countries, much of the world’s leading research and healthcare advances originate in high-income countries. This has created a unidirectional flow of information that hinders low and middle-income countries’ production of medical knowledge when compared to high-income countries.
Closing the Publication Gap
We recently surveyed medical literature, enquiring into the number of papers authored by physicians from Africa, Asia, and Latin America about the implementation of a preoperative surgical checklist (SCL). The SCL is a system recommended by the World Health Organization that improves safety in the operating room. Compliance to the SCL does not depend on any specific surgical equipment, and therefore it is as applicable in Boston as it is in Managua. The survey found that physicians from high-income countries have authored more than 800 papers on this subject, while their colleagues from low and middle-income countries produced a mere 79 articles.
Similar results can be found when looking at any other healthcare related subject, even for diseases that are not prevalent in high-income countries, such as malaria or Chagas.
A large volume of valuable observations by low and middle-income country healthcare workers is lost because of this phenomenon. There are countless clinical events that can apprise us of the many nuances of treatment alternatives, particularly in the face of scarce resources. For example, in high-income countries, children born with open spina bifida are operated on within 24 hours of birth. This is not the case in Guatemala, where there is only one hospital of referral. If there is a difference in outcome between countries, what can this tell us about spinal cord injury?
Another example and current clinical problem in Nicaragua is renal insufficiency among sugar cane workers. Why has this picked up now and not years ago and why is this not seen in Argentina’s cane workers? In essence, what questions about diseases can emerge when looked through the epistemological gaze of a local healthcare worker?
Our thesis is that by assisting health care workers form low and middle-income countries in the process of structuring clinical research, we can incite clinical study and revert the unidirectional flow of information.
While we acknowledge that language and rhetorical style are barriers to bidirectional communication, it is important to stress the colonial history that all low and middle-income countries share. This record of past governance by imperial power and present cultural dominance foments the idea that knowledge generated in low and middle-income countries is not as valuable as that coming from high-income countries.
Evidence-Based Medicine and the Philosophy of Science
In high-income countries, evidence-based medicine (EBM) is the preferred method of clinical discovery. EBM has many virtues, however falls short by relying too heavily on technology for giving accurate diagnoses. The social and economic reality in low and middle-income countries demands a broader range of flexibility and creativity in the medical process.
For that purpose, the principles of the philosophy of science can be instrumental in solving clinical puzzles. For example, Hempel did an excellent analysis of Semmelweis’ thought process when facing puerperal fever outbreaks. We need to perceive the surgeon in Matagalpa as a scientist who is well versed in the power of Modus Ponens or Hill’s Criteria of Causation. We must also be aware that those clinical observations are often different from that of a physician from a high-income country.
Tele-Education Program in Latin American Medical Schools
In 2014, we partnered with one medical school in Central America to conduct a live webinar series of lectures on clinical research, with the goal of assisting healthcare workers from low and middle-income countries in structuring their observations and developing a clinical research program. Each series totals eight hours of lecture, covering the following main topics: Reason in Diagnostic and Treatment, Inductive and Deductive Logic and its Fallacies and Causality, and Designing Hypothesis-Driven Clinical Research.
The course also illustrates the process of discovery, with narratives about the thought processes that lead to the etiology of duodenal ulcer, neural tube defects, and AIDS, among other examples. We aim at emphasizing the value of observation. We link the thought of Popper, Hempel, Quine, and Feyerabend to clinical investigation.
By February 2018, six medical schools have partnered with UCLA and three hundred fifty-six participants have completed the course. Encouraging results include the creation of a medical student-run research society, an online medical journal, and four papers, two of which have been accepted in PubMed journals and two that are in revision.
This program highlights the many ways through which Academic Institutions can collaborate with each other. For us at the Center for World Health, charity is vertical and solidarity is horizontal.