A theme issue “by, for, and about” Africa
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7493.684 (Published 24 March 2005) Cite this as: BMJ 2005;330:684
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There is serious under-representation of scientists from developing countries in various areas of health research (1, 2). Capacity building in developing countries is essential to improve health research and reduce health inequity (3, 4). We report a retrospective analysis of original articles that appeared in the British Medical Journal, The New England Journal of Medicine and the Journal of Epidemiology and Community Health between October 2003 and September 2004. We noted information on the number of contributing authors and their country affiliation by income (5). We also classified the scientific contributions of authors from midlle- and low-income countries as being “major and intellectual” (contributing to 2 out of 3: study conception/design, analysis, and intellectual contribution to manuscript drafting) or “operational” (contributing to data collection, routine supervision, etc.).
659 articles were reviewed in the three journals. The median (range) number of authors per article was 5 (1-29). Single-author publications were rare (3.2%). The number of articles which included authors from high- (HIC), middle-(MIC), and low-income countries (LIC) were 646 (97.8%), 49 (7.4%) and 11 (1.6%) respectively. Forty seven (7.1%) of the articles were products of collaborations between authors from different country groups: 38 (between HIC and MIC), 7 (between HIC and LIC) and 1 (between HIC, MIC and LIC). The nature of collaboration was such that the authors from MIC and LIC had mostly “operational” roles in research (Table 1). In two instances (0.3%), research papers had no representation from the low- income countries where the research was conducted.
Equity in health research is important to reduce health inequity. Thus, while the research agenda in developing countries may be partially driven by richer country partners who obtain financial and intellectual capital needed for research, healthy partnerships that foster local capacity need to be pursued. Partnerships that give inadequate representation to scientists from developing countries may in some cases be exploitative. Where represented, scientists from developing countries fulfill largely ‘operational’ roles in research. There is a need to transform such research collaborations into genuine partnerships with the aims of mutual learning and local capacity building. Collaborative research programmes that ‘outsource’ the operational aspects of research while retaining intellectual capital in the developed world cannot fulfill the needs of developing countries or of global health. In addition, editorial boards of journals need to be aware of the potentially exploitative nature of reporting of collaborative research between developed and developing countries. There is no better time than now for us to translate into practice the rhetoric of strengthening research capacity in developing countries.
Table 1. Extent and nature of research collaborations between countries classified by income in the three study journals
Characteristic No. (%) Total no. of articles (N) 659 (100.0%) No. of articles based in a middle/low-income 2 (0.3%) country but with no local representation* No. of research collaborations involving authors from*: Middle-income countries 38 (5.8%) Low-income countries 9 (1.3%) Total (n) 47 (7.1%) Role of the authors from middle/low-income countries in research collaborations**: Predominantly intellectual 12 (25%) Predominantly operational 35 (75%) * percentages are out of ‘N’ ** percentages are out of ‘n’
Competing interests: None declared
Competing interests: No competing interests
Since the first demonstration of the efficacy of antiretroviral drugs in prevention of mother-to-child transmission (PMTCT) of HIV much effort has been devoted in many countries in Africa to implement sustainable regimens (1-4). In order to identify potential reasons affecting uptake we evaluated the 5-year performance of the PMTCT programme at St. Francis Hospital Nsambya in Kampala, Uganda. The programme included voluntary counselling and confidential HIV testing for pregnant women and administration of antiretroviral prophylaxis in the peripartum period (with either zidovudine or nevirapine) for those HIV-positive.
Overall 24,133 women received PMTCT counselling, 76% accepted to be tested and 2,011 were found HIV-positive; 1,341 (66.7% of the HIV-positive) were enrolled in the programme and received antiretroviral drugs.
Our evaluation shows that : a) acceptance of the test increased from 72.7% in 2000-2002 to 79.9% in 2003-2004 when a drug access program became available in the hospital. This indicates that the availability of antiretroviral treatment can influence the willing to know the serostatus; b) acceptance of the test and enrolment in the programme were lower in married or cohabitating women (78%) with respect to single women (70.5%) suggesting that the fear to be identified as HIV+ in the family is still a strong limiting factor and that male involvement could have an important role; c) women belonging to the local tribe in Kampala (Baganda) had a lower acceptance of the test (because of the probable fear of being recognized by known hospital health workers) further underlining the need to address the issue of social discrimination; d) higher education was associated with a lower HIV prevalence and with a higher enrolment in the program confirming that education can have a key role not only in protecting from HIV but also allowing those HIV-positive to benefit of existing measures, such as PMTCT, against the spread of HIV.
REFERENCES
1. Stringer EM, Sinkala M, Stringer JSA, Mzyece E, Makuka I, Goldenberg RL, et al. Prevention of mother-to-child transmission of HIV in Africa: successes and challenges in scaling-up a nevirapine-based program in Lusaka, Zambia. AIDS 2003;17:1377-82.
2. Temmerman M, Quaghebeur A, Mwanyumba F, Mandaliya K. Mother-to- child transmission in resource poor settings: how to improve coverage? AIDS 2003;17:1239-42.
3. Perez F, Orne-Gliemann J, Mukotekwa T, Miller A, Glenshaw M, Mahomva A, Dabis F. Prevention of mother to child transmission of HIV : evaluation of a pilot programme in a district hospital in rural Zimbabwe. BMJ 2004;329:1147-50
4. Painter TM, Diaby KL, Matia DM, Lin LS, Sibailly TS, Kouassi MK, Ekpini ER, Roels TH, Wiktor SZ. Women's reasons for not participating in follow up visits before starting short course antiretroviral prophylaxis for prevention of mother to child transmission of HIV: qualitative interview study. BMJ. 2004; 329:543.
Competing interests: None declared
Competing interests: No competing interests
Editor –The editorial by Volmink, Dare and Clark,1 announcing the BMJ’s special issue on Africa, identifies diabetes as one of the continent’s emerging challenges.
The International Insulin Foundation (IIF) has addressed the problems faced by patients in 3 countries in Africa in accessing diabetes care and insulin. This was done using a Rapid Assessment Protocol (RAPIA), which enabled data to be collected at all levels of the system from the Ministry of Health down to individual patients. The results from Mozambique and Zambia2 highlight the high cost of insulin to the health system and individual patients. While the average price per 10ml vial of U100 insulin in the public sector in Mozambique and Zambia was around US$2-3, supplies were intermittent – and insulin cost over $15.00 per vial (approximately 1 month’s need) in the private sector. There were also problems accessing syringes and diagnostic tools. Only 6% of health facilities surveyed in Mozambique had the facilities for blood glucose measurement in comparison to 25% in Zambia. These hurdles with regards to accessing supplies were combined with a paucity of trained healthcare workers. These factors lead to the life expectancy of a child with newly diagnosed Type 1 diabetes being only 0.6 years in rural Mozambique.2 Differences in life expectancy are found between urban and rural areas and also between countries and mirror the availability of supplies and quality of care.
Diabetes as a major emerging public health problem in Africa needs to be addressed. While numerically this principally relates to Type 2 diabetes, Type 1 diabetes has been used as a tracer condition for effective health care systems.3 The RAPIA has provided the Ministries of Health in Mali, Mozambique and Zambia, with baseline data on how their health system works with regards to the care of diabetes. In parallel it has helped Diabetes Associations gain better knowledge about the situation of people with diabetes in different parts of their countries, and raised the profile of diabetes with the health authorities. The RAPIA is also the first step in the necessary shift from acute to chronic care, proposed by WHO,4 as it identifies the gaps in the health system’s ability to provide care for chronic conditions and proposes concrete actions to address them.
1. Volmink J, Dare L, Clark J. A theme issue "by, for, and about" Africa. BMJ 2005;330:684-685.
2. Beran D, Yudkin J, de Courten M. Access to Care for Patients With Insulin-Requiring Diabetes in Developing Countries: Case studies of Mozambique and Zambia. Daibetes Care 2005;28(9):2136-40.
3. Kessner DM, Carolyn, E.K., Singer, J. Assessing health quality: the case for tracers. N Engl J Med 1973;288:189-94.
4. Epping-Jordan J, Pruitt S, Bengoa R, Wagner E. Improving the quality of health care for chronic conditions. Qual Saf Health Care 2004;13:299-305.
Competing interests: None declared
Competing interests: No competing interests
During 2005, female sex workers who are heroin injectors in Dar es Salaam, Tanzania created a new needle sharing practice they call 'flashblood'. Flashblood is the English term Swahili speakers use to describe drawing blood back in a syringe until the barrel is full, and then passing the syringe to a female companion who injects the blood. By injecting the syringe, about 4 cc’s of blood, women believe that they can avert symptoms associated with heroin withdrawal because the first injector’s blood is thought to have ‘some heroin in it.’ Female sex workers began the flashblood practice amongst themselves in the last couple of months in an altruistic attempt to help their impoverished and more desperate associates. Male injectors interviewed are still unaware of this practice. These data are based on ongoing in-depth interviews with 63 heroin injectors.
The rationale for flashblood may be the price and quality of heroin in Dar es Salaam. During 2003, one kete of high quality, mostly pure white heroin cost US$0.50. One kete was all many injectors needed to get high. Now the price of heroin has increased to US$1 per kete, and the heroin is reportedly adulterated. By the summer of 2005, most injectors claimed they need two kete to get high.
Most female heroin users in Dar es Salaam trade sex for money to support their habits. Women most affected by the increase in cost and decline in quality of heroin are those who are in poor health as the result of chronic heroin abuse. Because of their appearance and obvious poor health, these women are unable to attract enough clients to support their habits. Other female injectors still able to attract customers for sex have begun accommodating women in more desperate circumstances by providing them with flashblood.
Female sex workers in Dar es Salaam prefer to use condoms with their clients, but when desperate for money or drugs will agree to forgo the condom at the clients’ request. Many Tanzanian men prefer not to use condoms and routinely ask female sex workers not to use them. Female heroin injectors who are desperate, like the women who accept ‘flashblood’, are the most likely to agree to forgo condoms. In their sexual relationships with intimate partners most women and men do not use condoms.
Research on the relationship between drug injection and HIV transmission has long focused on the serial use of syringes/needles, practices such as "backloading”, and reuse of paraphernalia used to prepared drugs prior to injecting (Johnson and Williams 1992, Needle et al., 1999; Zhou et al., 1994). The practice of flashblood is a new phenomenon that is, in a sense, a dangerous exaggeration of the practice of needle sharing which magnifies HIV transmission risk beyond backloading. Rather than injecting a very small quantity of blood residue, women who practice flashblood inject several cc’s of blood. If the first injector is HIV or HCV infected, the amount of virus directly transmitted into the bloodstream by the second injector could be quite large.
The only apparent reason for the emergence of flashblood in Dar es Salaam is the idea that blood drawn immediately back into the syringe after injecting contains enough heroin to help a second injector escape the pains of withdrawal. To our knowledge this is a myth, as there is not enough heroin in a syringe of flashblood to do anything other than provide a placebo effect. Myths and rumours, however, are powerful motivators and explanatory devices. During the 1920s in East, Central, and Southern Africa, mumiani rumours circulated about European vampires who used human blood for medical purposes. Tranfusion technology and the concept of blood donation emerged in Africa at the same time that an intensification of colonial efforts at domination were exerted post World War I. At that time, some Africans believed that Europeans drained the blood of Africans to provide it to anaemic Europeans (White, 2000). Some older East Africans still believe that British colonial use of mumiani explains why there was enough blood in blood banks prior to independence, but a lack of supply now (White 2000, McCurdy field notes, 1993). Perhaps traces of these rumours are the source of flashblood.
Injection drug use has now reached almost all developing nations in the world (Aceijas et al., 2004; McCoy and Rodriquez, 2005). The practice has emerged in East Africa in the last 5 to 6 years, and it is spreading rapidly throughout the region (Beckerleg, 2004, Beckerleg and Hundt 2004, McCurdy et al. 2005). If the practice of ‘flashblood’ spreads from Dar es Salaam to other cities in East Africa, its impact on the rate of HIV and HCV transmission could be substantial. The emergence of the practice of flashblood promises only to intensify the AIDS epidemic. Injection drug use in developing countries, and local cultural variations that may exacerbate HIV transmission risk, must be recognised by national governments and international organisations. Further research is desperately needed to develop culturally appropriate HIV/HCV risk reduction interventions and drug treatments programmes.
REFERENCES
Aceijas C, Stimson GV, Hickman M, Rhodes T. (2004). United Nations Reference Group of HIV/AIDS Prevention and Care among IDU in Developing and Transitional Countries. Global view of injecting drug use and HIV infection among injecting drug users. AIDS 18: 2295–303.
Beckerleg, S. (2004). How 'Cool' is heroin injection at the Kenya coast. Drugs: Education, Prevention & Policy (11)1, 67-78.
Beckerleg, S., Hundt, G. L. (2004). The characteristics and recent growth of heroin injecting in a Kenyan coastal town. Addiction Research & Theory (12)1, 41-54.
Johnson J, Williams, M. (1992). Nuance of needle sharing among intravenous drug users in Houston. Southern Medical Journal 85(7), pp. 784 -5.
McCoy, C.B., Rodriguez, F. (2005). Global overview of injecting drug use and HIV infection. www.thelancet.com 365, 1008-1009.
McCurdy, S.A., Williams, M.L., Kilonzo, G.P., Ross, M.W., Leshabari, M.T. (2005). The emerging heroin epidemic in Dar es Salaam, Tanzania: Youth hangouts, maghetto and injecting practices. AIDS Care 17 (Supplement 1): S65-76.
Needle, R.H., Coyle, S., Cesari, H.., Trotter, R., Clatts, M., Koester, S., Price, L., McLellan, E., Finlinson, A, Bluthenthal, R.N., Pierce, T., Johnson, J., Jones, T.S., Williams, M. (1998). HIV risk behaviors associated with the injection process: multiperson use of drug injection equipment and paraphernalia in injection drug user networks. Substance Use and Misuse 33(12), 2403-23.
White, Luise. (2000). Speaking with vampires: Rumor and history in colonial Africa. Berkeley: University of California Press.
Zhuo Z, Williams, M., Bell, D. (1994). An evaluation of drug injection behaviors and HIV infection. National AIDS Research Consortium. International Journal of Addiction 29(12), 1499-518.
Competing interests: None declared
Competing interests: No competing interests
When one thinks of Africa’s health challenges today (1), one’s mind unavoidably turns to the ravages of the HIV pandemic; and then perhaps to operational issues of antiretroviral drug availability. The most tragic consequence of the pandemic is transmission of HIV infection from an infected mother to her child. Interventions currently advocated for reducing the risk of mother-to-child transmission of the infection include a short course of antiretroviral drugs and alternatives to breastfeeding (2). Given that vaginal exposure is an important route of HIV infection (3), interventions targeting the birth canal (such as avoidance of vaginal delivery or vaginal disinfection) might play a key role in reducing the paediatric HIV burden in resource-constrained settings such as Africa.
Caesarean section delivery significantly reduces mother-to-child transmission of HIV by about 50%, but technical and logistical difficulties limit its widespread use in sub-Saharan Africa (4). But does vaginal disinfection reduce the risk of mother to child transmission of HIV infection? A systematic review of randomised controlled trials (5) demonstrates that there is insufficient evidence to either support or refute the use of this intervention. Available data (6,7) show a 6 percent reduction in the risk of mother-to-child transmission, with wide confidence intervals (- 29 percent to +25 percent). Given its simplicity and low cost, there is need for an adequately powered randomised controlled trial to assess the effect of vaginal disinfection on the risk of mother-to-child transmission of HIV or, more appropriately, the additive effect of vaginal disinfection in antiretroviral treated women.
1. Volmink J, Dare L, Clark J. A theme issue "by, for, and about" Africa. BMJ 2005;330:684-685.
2. Volmink J. HIV: mother to child transmission. Clin Evid 2004;11:902-12.
3. Newell ML. Mechanisms and timing of mother-to-child transmission of HIV -1. AIDS 1998;2(8):831-7.
4. Read J, Newell ML. The efficacy and safety of cesarean delivery for prevention of mother-to-child transmission of HIV-1: a systematic review (Cochrane Collaboration). Abstract TuPp0406. 3rd IAS Conference on HIV Pathogenesis and Treatment, 24-27 July 2005, Rio de Janiero, Brazil.
5. Wiysonge CS, Brocklehurst P, Sterne JAC. Vaginal disinfection during labour for reducing the risk of mother-to-child transmission of HIV infection The Cochrane Database of Systematic Reviews 2002, Issue 2: CD003651.
6. Gaillard P, Mwanyumba F, Verhofstede C, Claeys P, Chohan V, et al. Vaginal lavage with chlorhexidine during labour to reduce mother-to-child HIV transmission: clinical trial in Mombasa, Kenya. AIDS 2001;15(3):389- 96.
7. Mandelbrot L, Msellati P, Meda N, Leroy V, Likikouet R, et al. 15 Month follow up of African children following vaginal cleansing with benzalkonium chloride of their HIV infected mothers during late pregnancy and delivery. Sex Transm Infect 2002;78(4):267-70.
Competing interests: None declared
Competing interests: No competing interests
The focus of health services in Africa on maternal and child health, TB, leprosy, and malaria, have been overshadowed more recently by the HIV/AIDS pandemic. Cancer remains relatively neglected in Africa although increasingly prevalent: 70% of people with cancer live in the economically developing world, where by 2020 it is predicted that the annual death toll will reach 20 million.1
In sub-Saharan Africa, measures to prevent cancer, emphasised in the developed world – such as smoking cessation, and screening – are not nationally adopted. One third of African cancers are preventable; but the influence of tobacco companies with mass media advertising and high crop payments are real. Traditional cancers such as gastric and hepatocellular carcinoma, and newer cancers, such as lung, breast and AIDS related Kaposi’s sarcoma are increasing in incidence. 2,3
Patients’ expectations for oncological treatment are low in Africa. Lack of money, or a concern not to place their family in debt, frequently prevents patients seeking medical help.4 Lack of awareness of predisposing factors, warning symptoms or signs of cancer, or treatment options mean that patients present late. Cost and difficulty of travel over rough terrain also discourages service utilisation. Indeed after realising their diagnosis, patients may tend to look for peace of mind and spiritual comfort rather than for a physical cure.
In Africa, disease-modifying cancer treatment and basic symptom control are both largely absent. Even when analgesia is available, patients with cancer may still experience severe and inadequately managed pain, as health professionals under-prescribe strong analgesics, fearing drug-dependency.5 For humane cancer care in Africa, an analgesic “ladder” and other symptom control medications must be available and affordable.
Individual sub-Saharan countries cannot address the challenges of cancer in isolation. A new cooperative approach and research base is being advocated for the prevention, treatment and palliation of cancer to bridge the gap between developed and developing nations. 5 The world’s high income countries should work in partnership with poor countries to help scale up their health systems to provide access for all to a limited number of essential health interventions. Heath has recently called for a shift of health service resources from the worried well in developed countries to the sick in poorer nations, asking “who needs health care- the well or the sick?” 6 Are programmes to prevent, diagnose and treat cancers essential or a luxury Africa still cannot afford?
1. Murray JL, Lopez AD. The Global Burden of Disease. Harvard School of Public Health, Boston, 1996.
2. Morris K. Cancer? In Africa? Lancet Oncology 2004;4, 1:5-6.
3. Walker AR, Adam FI, Walker BF. Breast cancer in black African Women: a changing situation. J R Soc Health. 2004;124(2):81-5.
4 Murray SA, Grant E, Grant A, Kendall M. Dying from cancer in developed and developing countries: lessons from two qualitative interview studies of patients and their carers. BMJ 2003;326:368-71.
5. World Health Organization. National Cancer Control Programs. World Health Organisation, Geneva 2005.
6. Heath I. Who needs health care - the well or the sick? BMJ 2005;330:954.
7. Olweny C. Ethics of palliative care medicine: Palliative care for the rich nations only! Journal of Palliative Care 1994;10:3:17-22.
Competing interests: None declared
Competing interests: No competing interests
The estimation of 80 million AIDS-related deaths in Africa by 2025 is very concerning (1). In the era of expanding access to antiretroviral therapy (ART) in Sub-Saharan Africa, the WHO advocates palliative care integration because pain, other distressing symptoms, and complex psychosocial challenges persist throughout the HIV trajectory (2). The specialism improves HIV patient outcomes (3), and in Africa may compliment ART provision through aiding adherence through side effect management, providing patient and family centred holistic care, and end of life care where necessary (4). However, it brings the challenge of re-integrating what have become distinct disciplines: HIV medicine and palliative care (5). Hospice Africa Uganda was founded to provide affordable pain and symptom control, including oral morphine, and to develop a model of palliative care appropriate to Africa. It provides advocacy and training across Africa, education, and specialist palliative care in rural and urban settings alongside community volunteers and traditional healers. Through links between ART clinics and Hospice, patients are provided with the benefits of ART in controlling disease progression while simultaneously accessing symptom and side effect management, psychosocial support, and end-of-life care as required.
To evaluate the success of integrated care, we aimed to measure both referrals and clinical management. We reviewed patient files for new referrals from March-August 2004. Of 311 referrals to Hospice, 106 had HIV disease (34.1%). 39 were accessing ART at referral (36.8%), a further 12 (11.3%) had accessed ART previously but had defaulted. Among those 39 accessing ART, primary referral reasons were severe pain (n=32, 82.1%), skin rash (n=4, 10.3%), diarrhoea (n=2, 5.1%), and nausea and vomiting (n=1, 2.6%). Morphine had been accessed by 10 patients prior to referral, and was initiated by Hospice for a further 72 patients at first visit (67.9%). Chemoprophylaxis was initiated for 73 patients (68.9%), and 46 required treatment for opportunistic infections. Of 67 patients not on ART at referral, 45 (67%) were referred to an ART clinic for treatment.
Although HAU does not provide ART, our data demonstrate how a palliative care provider can network with HIV/AIDS clinicians for integrated care. It is unnecessary for patients or clinicians to choose between palliative care and ART. This novel African service offers insight into achieving optimal ART/HIV care in other resource-poor countries, and perhaps also offers lessons to resource-rich settings where unresolved symptoms and poor adherence persist.
(1) Volmink J, Dare L, Clark J.A theme issue "by, for, and about" Africa. Br Med J 2005; 330:684-685.
(2) WHO. HIV palliative care. WHO:Geneva. http://www.who.int/hiv/topics/palliative/care/en/ (accesssed 29th April 2005)
(3) Harding R, Easterbrook P, Karus D, Raveis VH, Higginson IJ, Marconi K. Does palliative care improve outcomes for people with HIV/AIDS? A systematic review of the evidence. Sex Trans Infect 2005;81:5-14.
(4) Harding R, Higginson IJ. Palliative Care in Sub-Saharan Africa: an appraisal of reported activities, evidence and opportunities. Lancet 2005;365:1971-1977.
(5) Harding R, Karus D, Raveis VH, Higginson IJ, Easterbrook P, Higginson IJ. Barriers and inequalities in palliative HIV/AIDS care: a review of the evidence and responses. Palliat Med 2005;19, 251-258.
Competing interests: None declared
Competing interests: No competing interests
ADVANTAGES OF REVERSING AFRICAN BRAIN DRAIN ( BRAIN GAIN and BRAIN CIRCULATION)
Recently the President of Nigeria hosted a meeting of the Nigerians in Diaspora Organization of Europe and USA ( NIDOE) in Abuja, the capital city of Nigeria to discuss how the thousands of Nigerian professionals in various fields can assist in the escalating restructuring and rebirth of the social, economic and cultural sectors of the country. In the last decade, the damaging effects of the exodus of Africans from their continent to Europe, America and other parts of the world in search of a better life has been widely documented in the media, books and magazines. No profession is spared but some have more dramatic effects than others. The exodus of doctors, nurses, lecturers, teachers, engineers for instance has led to the near total breakdown of these sectors. Africa today has the highest disease burden but the lowest doctor : patient or nurse ratios. Class sizes are unimaginable when compared to the West where most African teachers emigrate to for greener pastures. As a result products of once world class educational institutions are now dodgy at best and down right semi illiterates in some cases. Town planning and maintenance are pipe dreams leading to increasing environmental degradation, squalor, disease and crime . But as the Nigerian Medical Forum UK, a U.K. based registered charity of Nigerian doctors and health professionals, discussed at the Vision 2010 health committee of the federal government of Nigeria in 1997, emigration of Nigerians to the richer more technologically advanced world is not all bad, especially when such Africans eventually make a re-entry to their African homes. To begin with, these Africans in diaspora remit very large sums of money and goods to their kit and kin back home in Africa , indirectly improving the foreign exchange position of African countries. Only last week the Nigeria National Health Insurance Scheme launched the Diaspora programme to enable Nigerians abroad pay for the health needs of their family and friends back home. More importantly when Africans abroad make the sacrifice to leave their lucrative business to return home, and they are given the opportunity, they usually serve their home country immeasurably, imparting skills and knowledge and also helping to improve the quality of life of the local population.
At a time when Africa, because of democratization, is beginning to unshackle itself from the ravages of decades of dictatorship governments, efforts must be made to tap the massive potentials in Africans abroad either by way of a full return to home or structured, periodic visits ( Brain Circulation). Brain Gain will not occur if there was no brain drain, so after all, the movement of Africans in the 1980s and 1990s to Europe and America is not all bad. With democratization and good governance in Africa, Africans will revert to what happened before the 1980s, when they emigrated only for knowledge and skills, and promptly returned to their home country better equipped and knowledgeable to serve mother Africa.
Dr Joseph Ana, FRCS, DUrology (London) Commissioner for Health Ministry of Health Cross River State of Nigeria ( specialised and practiced medicine / surgery in the UK for 22 years before returning to Nigeria in 2004 to serve)
Competing interests: None declared
Competing interests: No competing interests
As Canadian researchers partnered with Nigerian colleagues, supported by the Canadian Institutes of Health Research Global Health Program, we concur with Dr. Bhutta's 2003 BMJ editorial that more effective funding of health research in the developing world is needed. But how do those who agree convince funding institutions of the importance of reversing the 10/90 gap? We argue that the essential requirements for change are more cultural and political than scientific or medical.
One might expect a Canadian consensus that the world is one community, because so many of us come from other continents and most Canadians cite multiculturalism as a defining “national” characteristic. Yet, we rank relatively low in foreign aid at 0.24% of GDP and health research spending is overwhelmingly on development of drugs to produce corporate profits. While Canadians consider themselves world citizens, our economic system much more strongly influences the definition of research priorities than desire to reduce the global disease burden.
Still, the Canadian experience offers insights about how to create contexts where the profit motivation is not paramount. Although our neighbour to the south is the only rich nation not to offer comprehensive universal medical coverage and we receive aggressive propaganda against “socialized” medicine, Canada’s Medicare system is so popular that governments must defend it or risk political oblivion.
The lesson that should be applied to reducing the 10/90 gap is demonstrating that the research makes a difference in the lives of ordinary people, who have friends and family here in Canada. We must convince our citizens, our taxpayers, that it is in “their” self-interest to do this kind of research. Our Nigerian-Canadian partnership on preventing occupational transmission of bloodborne pathogens can have such an impact. The Canadian defence of universal healthcare proves this sort of self-interest can overcome the profit motive. References
1. Bhutta Z. Practicing just medicine in an unjust world. Initiatives to improve academic medicine in developing countries must come from within. BMJ 2003; 327: 1000-1001.
2. Statistics Canada. Canada’s ethnocultural portrait: The changing mosaic. Available at: http://www12.statcan.ca/english/census01/products/analytic/ companion/etoimm/canada.cfm#proportion_foreign_born_highest. Accessed 30/04/05.
Competing interests: None declared
Competing interests: No competing interests
Africas problems easier to solve
Africa is not a "basket case"; it is those who force Africans to continue to live in poverty and sickness who are basket cases.
Africas problems are much easier to solve than most of the rhetoric implies; remove the reins from the basket cases, who continue to force Africans into poverty and sickness, and place them in the hands of decent honourable Africans themselves.
Billions of dollars can buy sanitation, employment, engineering, clean air, clean water, food and essential medicines aplenty - so why are we not hearing of these simple priorities?
If this is to be Africas year we should ensure that our hard earned monies fall not into the hands of corrupt commercial dealers who generate corrupt African commercial and political pawns, but are targetted at honourable decent Africans to rebuild and re-sanitise their environments, re-nourish their people, and develop their industries to realise the wealth beneath their feet that has been denied them for generations.
Regards
John H.
Competing interests: None declared
Competing interests: No competing interests