Human existence "threatened by neglect"

Research by developing countries vital, says minister

SUMMARY: At the High-Level Ministerial Meeting on health research in Accra this June, the Minister of Health, Ghana, argued that major issues of vital importance to health in Africa and the developing world, such as local ideas and practices, the cultural effectiveness of the ABC strategy for HIV/AIDS, and traditional medicine, were being under-researched - because low and middle-income countries have too few research resources, and are not driving the international research agenda. "Our very existence" is threatened by this neglect, he said. This is a transcript of the minister's address.

>by Courage Quashigah, Minister of Health, Ghana

Over the last 50 years achievements in science and technology have been phenomenal. We continue to push the frontiers of outer and inner space, and in the effort we have unearthed many discoveries that have increased our knowledge of the environment, ourselves, and the relationship between the two. We have propounded several theories of why diseases occur, and how to treat and avoid them. Indeed we have the answers to most if not many of our health problems. Consequently life expectancy has gone up by 20 years in many low-income countries, and on the average infant mortality has fallen by about half.

We have eradicated smallpox, and are on the verge of eradicating polio. The global population has increased nearly two-fold in the same period. These developments can be attributed to the intensive research and development activities in the health sector, which has led to the previously unimaginable discovery of a large arsenal of drugs and technologies; and to our ability to process large volumes of information in the decision-making process.

But the paradox is that we also live in an era where the foundations of these gains are being threatened by factors both within and outside the health area. We are at a time in the history of mankind where our very existence is being threatened not only by diseases, but also by our own neglect of the knowledge we have accumulated over the years, and our basic social and cultural norms.

The HIV/AIDS pandemic; the resurgence of TB; the persistence of malaria; and other debilitating diseases such as guinea worm, present us with challenges, which can only be met by recognizing that socio-economic and cultural factors are prime determinants of health and health care.

Unfortunately, as scientists we have and continue to place significant emphasis on finding laboratory solutions to our health problems expecting - or rather, hoping - that the social systems will adapt.

There is an increasing need for us as health policy formulators to recognize that peoples' ideas and practices concerning health and illness, as well as social and cultural conditions leading to illness, are critical in the design of interventions.

We need to understand how diseases that afflict us originate in the context of peoples' living conditions and lifestyles. We also need to understand how health problems are communicated in ways that are culturally prescribed, and how they are labelled in accordance with existing cultural concepts and belief systems. Natural scientists can only tell us what happens [physically]. But delivering effective interventions requires much more.

Although this meeting is about health research, the outcome is about how we can formulate effective policies that will reduce the disease burden in developing countries.

To do this, health research must increasingly have a social and ethnocultural outlook. Indeed health research must focus more on health promotion, prevention of diseases, and protection from injuries, by concentrating more on the adaptation of cultural norms in the fight against diseases.

If children are still dying of malaria, mothers are dying in childbirth, and for 25 years HIV/AIDS is showing no sign of burning itself out, we in developing countries must definitely rethink our health policies.

This can only be done if we find the right balance between research and the design of appropriate interventions, and how the majority of us live.

Also, most of us recognize the link between ill health, poverty and underdevelopment.

Indeed in our parts of the world, being poor, female, and adolescent are risk factors for a myriad of health problems ranging from sexually transmitted infections to substance abuse. In many instances these vulnerable groups [are the ones with] less knowledge, fewer resources, and less power to defend or protect themselves, yet many of our research activities are not tailored to answer these questions.

Further, we need to break the vicious circle of underestimation of the value of research for development, the worsening or shortage of resources for research, and the persistence of problems of endemic diseases. It is no longer sufficient to talk about building research capacity and research infrastructure without examining ways of ensuring sustainable funding and significant investment in bridging the gap between research and policy.

It is also important that the issue of coordination, ownership, and relevance begin to take centre stage in our deliberations. In other words we need to have our own independent means of validating the research findings published by the international community, and influencing their focus to address local health concerns as well.

Promotion of research in traditional and alternative medicine is also indispensable, and above all has the potential to provide practical, efficient and low-cost solutions to many endemic diseases. Unfortunately this is an area that most developing countries have left underdeveloped, and remains shrouded in mysticism.

The best legacy we can leave our children is to start a radical revival of this branch of medicine. With an infusion of scientific knowledge accumulated over the years, why have indigenous techniques and practised over many years been left dormant?

Some of us believe that our understanding of traditional and alternative medicine in our parts of the world arises from the limited investments in this direction.

There are many health challenges before us. We need to be broad-minded in our approach, and diversify our interventions. Our success in research and development of traditional medicine will probably be the best contribution that the health sector can make to the economic development of the developing world.

Apart from diseases afflicting individuals and populations, we also have deficiencies in health systems - which receive little or no attention from international and local research institutions. These areas include infection control in our health facilities; integration of health information systems; and improving efficiency in the use of resources available in the public and private health sectors. This underscores the need for us to focus on research that improves the functioning of the health system as a whole.

Yet let me be quick to add that there have been some very good initiatives in this direction. Ghana's Community-Based Health Planning and Services Initiative, which is now a major strategy for improving access to basic health services, was a result of one such piece of research. There may be many more; but the fact remains that judging from the magnitude of the problem this is still under-resourced.

We also need to demonstrate the results of our actions or inactions on the burden of disease. How much does it cost us developing countries to manage diseases such as malaria and other endemic health problems? The fact is that we talk about estimates, and indeed estimates made outside the actual environment where the diseases are experienced.

The long and short of it is that we do not have clear knowledge of the economic burden of the diseases that we are handling. This is an area for intense research - in the short term to make a case as developing countries review our policies towards disease management, prevention and health promotion, we must do this on a cost-benefit basis.

It is only after engaging in such an exercise that we can see more clearly the correlation between health and wealth creation. Such research should point on the one hand at the savings to be made from the reduction in treating and preventing avoidable diseases; and on the other hand the wealth to be created from the high productivity of a healthier population.

We also have to reorganize ourselves to ensure that the right focus is achieved in the international research area. It is not enough to accept research results, conclusions and recommendations done on our behalf. What we must realise is that some of such conclusions and recommendations are not based on real local scenarios. That is to say that many of the confounding factors within our local environments are usually not taken into consideration.

Let me give an example. The HIV/AIDS pandemic is being fought through the ABC campaign - abstinence, faithfulness to one's partner, and condom use. As we speak, there is no substantive evidence that this strategy has led to behavioural change. Yet we have not done any research into why this is so.

There are some countries that claim that condom use has gone up. My question is - was this statistics from the shops, about how many condoms have been bought? Or is somebody going round collecting used condoms? Or is somebody physically witnessing the use of condoms?

Perhaps the low acceptance of condom use may have its roots in our social and cultural values, which may be addressed by fashioning localised strategies based on those values. That is the only way we can develop and implement effective interventions.

If we are to move from our present socio-economic status as developing countries, we should seriously work on improving the health of our people, and we can only do that if we place a high premium on research - which is the core of knowledge. But we must articulate the challenge clearly, and ensure that it can be owned by all.

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