Research Training in Limited-Resource Settings: A Call for Equitable Partnerships

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Kathryn Taylor

Kathryn Taylor

Kathryn Taylor is a Harvard medical student beginning her research year as a Paul Farmer Global Surgery Fellow in Rwanda through the support of the Doris Duke International Clinical Research and Fulbright Fellowships. Her research focus in Rwanda will be surgical education in low- and middle-income countries, app-based learning tools, and perspectives of women in surgery. She plans to pursue a career in global general surgery, and is especially interested in pediatric surgery and surgical oncology. Throughout medical school she has worked with the Global Oncology Young Professional Alliance, and spent a summer as a research assistant in Butaro, Rwanda studying the implementation of a clinical tracking tool for chemotherapy adverse events. Prior to medical school, Kathryn spent six years working to support an agricultural school in rural Nicaragua throughout her undergraduate education and beyond. With Project Nicaragua, she helped to build an agricultural school, create a computer classroom, teach English and computer skills, and establish a bakery run by students of the school. After graduating from the Ohio State University in 2012, Kathryn spent a year in rural Honduras working as a research assistant for Helping Babies Breathe, a neonatal resuscitation protocol for low-resource settings, studying the implementation of the course and skill retention.

Dr. Jim Kim, the president of the World Bank and one of the founders of Partners in Health, recently gave a talk about changing the focus of the World Bank, and cited two leading principles: “A preferential option for the poor and evidence-based medicine.” I could not agree more, and I suspect many in global health are guided by a similar set of values.

Y8206462372_d4b301f9cb_oet, how do we achieve “evidence-based medicine” in global health delivery? Publications, abstracts, and comments (including my own) often cite a lack of data from low- and middle-income countries (LMICs). In my experience, many of the publications in global health often do not involve local stakeholders, and when they do, it is often in name only. In order to create a robust, inclusive body of knowledge contributing to evidence-based medicine relevant for global health, research must be context-specific. We often talk of capacity building in medicine, developing and investing in training programs to increase human resources for care delivery. Shouldn’t we do the same for research?

After my first year of medical school, I worked as a research associate in Rwanda studying the implementation of a tool to track chemotherapy adverse events. I was paired with an internist who recently completed his training as my research partner so that we could both share in the benefit of learning how to design and implement a research study. As a medical student from the US, I had time off from my studies, had received funding to do research abroad, and was paired with a mentor who is a leader in his field. In contrast, my partner had no protected time for research, and had overwhelming full-time clinical duties. He did not receive additional financial support for his involvement, nor was he paired with a mentor in the same way I was. Coming from an institution where research is expected of students and supported, I was able to work efficiently with a team to better understand cancer care delivery at the hospital to influence future policymaking. As a future physician-researcher, I gained invaluable insight into clinical care and research in a variable-resource setting, an experience that will help shape my career. However, it became clear that most local clinicians do not have that same opportunity.

When the keyword “HIV” was searched in PubMed and the first 300 articles mapped by first author home institution, one study found that 37% came from North America, 21% from Western Europe, but only 8% from Sub-Saharan Africa.1 This is despite the fact that Sub-Saharan Africa remains the most disproportionately affected region, with more than two thirds (68%) of all people HIV-positive and where more than three quarters (76%) of all AIDS deaths in 2007 occurred.2

Global HIV prevalence overlaid with 300 PubMed articles (keyword: HIV) published in 2007 on HIV PLoS Med. 2011 Nov; 8(11): e1001118.

Global HIV prevalence overlaid with 300 PubMed articles (keyword: HIV) published in 2007 on HIV. PLoS Med. 2011 Nov; 8(11): e1001118.

The barriers for local clinicians to conduct research are many: lack of research educators and mentors, few facilities for research, inadequate funding, and no protected research time outside of clinical duties. By neglecting to create ways in which local clinicians can be actively involved in every stage of research, we are missing out on a potential resource for knowledge and an opportunity for sustainable development.

Dr. Denis Mukwege, a gynecological surgeon and founder of the Panzi Hospital in the Democratic Republic of Congo, is one example of a medical director purposefully creating a space for research in his training program.3 I spoke with his son, Alain, who described the goal of the International Center for Applied Research and Training (ICART) to create research capacity locally, with the support of international collaborators.ICART is currently developing a research training program, and initial efforts have focused on data collection on issues related to gender-based violence and clinical care. He explained, “the biggest road block is analysis.” While ICART has been able collect data, there is a lack of analytic ability, despite the increasing interest. There is need, but no mentorship.

There are other examples in the literature, including the National Heart, Lung, and Blood Institute – UnitedHealth Collaborating Centers of Excellence partnering early stage investigators from LMICs with research institutions in high-income countries with the goal of improving the infrastructure to conduct locally relevant research.5

Despite these examples, research training has been a low priority in global health. There must be a larger emphasis on research equity as models of care delivery are designed and implemented in low-resource settings. As workforce training programs are developed, research skills should be incorporated as part of formal education and supported by administrations. Especially as non-communicable diseases become a larger disease burden on developing countries, research training and infrastructure is increasingly important for understanding contextual determinants and approaches to treatment. In order to use evidence-based medicine in the delivery of a preferential option for the poor, true research partnerships are necessary so that both local clinicians and visiting researchers may share equal benefit.

Citations:

  1. Kerry VB, Ndung’u T, Walensky RP, Lee PT, Kayanja VF, Bangsberg DR. Managing the demand for global health education. PLoS Med. 2011 Nov;8(11):e1001118. doi: 10.1371/journal.pmed.1001118. Epub 2011 Nov 8. PubMed PMID: 22087076; PubMed Central PMCID: PMC3210750.
  2. UNAIDS epidemic update. Geneva: UNAIDS; 2007. Available:http://data.unaids.org/pub/epislides/2007/2007_epiupdate_en.pdf. Accessed 29 September 2011.
  3. http://www.panzifoundation.org/dr-denis-mukwege/
  4. ICART, http://icart-bukavu.org/
  5. Bloomfield GS, Xavier D, Belis D, Alam D, Davis P, Dorairaj P, Ghannem H, Gilman RH, Kamath D, Kimaiyo S, Levitt N, Martinez H, Mejicano G, Miranda JJ, Koehlmoos TP, Rabadán Diehl C, Ramirez-Zea M, Rubinstein A, Sacksteder KA, Steyn K, Tandon N, Vedanthan R, Wolbach T, Wu Y, Yan LL. Training and Capacity Building in LMIC for Research in Heart and Lung Diseases: The NHLBI-UnitedHealth Global Health Centers of Excellence Program. Glob Heart. 2016 Mar;11(1):17-25. doi:10.1016/j.gheart.2016.01.004. Review. PubMed PMID:27102019; PubMed Central PMCID: PMC4876661.