The Mexico Summit on Health Research 2004
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7477.1249 (Published 25 November 2004) Cite this as: BMJ 2004;329:1249
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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
Competing interests: No competing interests
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
camouflaged in canvassing, the brash babel of democracy;
the swagger, the demagogy, the drum roll, the applause,
the confetti, the victory of style over substance,
again, yet again. (6)
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
HEALTH-CARE RESEARCH IN DEVELOPING COUNTRIES: ROLE OF THE MEDICAL COMMUNITY
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
Competing interests: No competing interests