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The 10/90 Gap Is Holding Rwanda Back

I was in Kigali this past summer with my colleague to help conduct a one-week course in academic writing for Rwandan public health professionals. In short, the data were mostly of very high quality and the men and women marshaling these data were exceptionally bright, hardworking, and well-educated individuals. So why did they need us?

"When you think about university, what do you see?" I asked a woman in Rwanda, a student in a workshop I was co-teaching.

"I see buildings, classrooms, books..." she replied.

"Anything else?"

She struggled. "Papers. Desks. Chairs...." Then she looked at me quizzically.

"Anything else?" I prompted again.

"Professors? Students?"

"Yes!" I rejoiced. "A university is people. All institutions are people." Research foundations are people. So are granting agencies, faceless governments, admissions committees, trade boards and every other seemingly monolithic presence that defines both the subtleties of individual life and the expanse of global learning.

I was in Kigali this past summer with my colleague Dr. Edward Mills and his extraordinary doctoral student Steve Kanters, on invitation from the National University of Rwanda and organized by Dr. Mills, to help conduct a one-week course in academic writing for Rwandan public health professionals.

The approximately 40 attendees were a mix of MPH and PhD students, recent graduates, or seasoned public health professionals, all of whom on excellent career trajectories within the forward-looking Rwandan health ministry or within Rwandan academia. Whether it be from partnerships with well-funded Western researchers, work with large development initiatives funded by the traditional global donors, or local programs conceived, funded, and implemented by the Rwandan government, each participant came to us with that most glorious of resources: data. The nature of those data would make many Western researchers tremble with excitement. (I use the word "Western" here inaccurately to refer to the traditional crop of high-income countries, Canada and USA among them.)

One woman came with perhaps one of the first strong pieces of evidence for the direct measurable impact of climate change on human health in Africa. Another gentleman had evaluated his country's novel method of incentivizing management performance nationally, an experience whose lessons could prove valuable to hundreds of communities struggling with the same issue globally. And another had years of data describing a new, fast-track laboratory and hospital accreditation process that might solve an all-too-common problem preventing rapid positive change in many populations' health status.

In short, the data were mostly of very high quality, representing narratives that would be of interest to thousands of scholars and health workers worldwide. And the men and women marshaling these data were exceptionally bright, hardworking, and well-educated individuals.

So why did they need us?

The answer is complicated, and resonates with much of what underlies the mechanics of global disparities in wealth, health, and opportunity. Part of the answer is reflected in the brief exchange posted at the start of this article. The public conversation I'd had with that particular student quickly segued into an exploration of her perceptions of what constitutes a peer-reviewed academic journal.

After some encouragement, I succeeded in getting her to realize that academic journals, just like governments, universities, and granting agencies, are just groups of people. This is an important realization, since people have biases, agendas, and personalities which manifest in their decision-making, colouring the intents and policies of the institutions they represent.

Low and middle income countries (LMICs), even those with remarkable upward development trajectories like Rwanda, are plagued by the legacy of colonialism. Some would argue that even supposedly altruistic development endeavours are subtly colonialistic. The days of missionaries bringing literacy and medicine in exchange for religious conversion and casual paternalism might be mostly gone. But the very structure of our global research infrastructure is biased toward a Western ethic and Western administrative needs.

The woman to whom I was speaking found it revelatory that Western-constructed institutions can reflect the personalities of the people comprising them. Her feeling, identical to that of other young scholars I've dealt with in LMICs, was that Western institutions must operate entirely ethically, and be based upon merit above all else, wherein only the best are accepted, funded and published. It's an understandably naive position embraced by residents of countries who have historically been made to feel less deserving than representatives of wealthier nations. The simplistic model that they've been fed for generations is that things are done better, fairer and of higher quality in the West.

The truth, of course, is that Western institutions associated with research and scholarship are no more or less ethical or merit-based than most non-Western institutions. In fact, the evidence would suggest that the global research agenda is severely biased in favour of Westerners, even when the data, work and ideas are generated in LMICs.

This is what many writers are calling the 10/90 gap. In its purest form, it refers to a findings by the Global Forum for Health Research that 10 per cent of the world's health research budget is spent on issues that affect 90 per cent of the world's population, while 90 per cent of resources are dedicated to the needs of 10 per cent of the world. Its wider implications have to do with the disadvantaging of science development in poor countries, the exploitation of low income researchers by wealthier partners, and, as noted, the exacerbation of a misdirected perception of Western researchers and research institutions as being better and more deserving.

It has been well explored that the publication gap between rich and poor countries is great and, at least in the basic medical sciences, widening. In addition, most empirical research in the field of global health is conducted in LMICs, on LMIC residents, and is most relevant to the policy needs of LMIC decision-makers. But the papers are written by the Western project leaders, published in Western journals, serve to elevate the global profiles of the Western authors, yet are ironically rarely accessible to the people or decision-makers in those same LMICs.

Many see this as an unintentional, unconscious form of neocolonialism, wherein the vulnerabilities of the global poor are leveraged to promote the interests of the Western rich, however well-intentioned the efforts might be.

To my mind, beyond the Byzantine dance of research funders, the barriers to achieving greater equality on the global research field include: the inability of LMIC workers and institutions to afford the expensive subscription fees of traditional peer-reviewed science journals, the misperception that Western researchers are necessarily better than LMIC researchers, and cultural differences that may inhibit LMIC researchers from seeking recognition on par with their Western brethren.

The cost barrier is being addressed via something called the "open access" revolution. An increasing number of peer-reviewed journals are offering their content for free, mostly online, and are downloading the cost of publishing to the authors and their institutions (with waivers or discounts for authors from LMICs).

The misperception of the superiority of Western minds is a more complicated barrier, but one that is being slowly chipped away by an increasing number of trans-global partnerships. It's a difficult perception to tackle, though, when Western universities are shinier and larger than their poorer cousins, and when their professors are overwhelmingly better published, cited and funded.

The last barrier, that of culture, is a bit more subtle. I will wisely refrain from painting the world with broad brushstrokes, since values are geographically heterogeneous and will change over time. There are few investigations into the attitudes of LMIC residents, compared to those in the West, around the value of academic publishing. However, a recent report from Sage Publications in the UK found that while all parties in LMICs valued academic libraries more than did their cousins in the West, the predominant concern in these poorer countries was securing access to important publications, and not necessarily the production of more content to fill their libraries.

By contrast, the mantra of researchers in the West has always been, "Publish or perish." At all times, we Western academics are writing and publishing. It is how our value is measured, how promotion is secured, and primarily how professional status, however measured, is achieved.

For our students in Rwanda, who were as well educated, hard working and intelligent as their compatriots in the West, publication was traditionally not seen as a priority. It was more important to collect data, and analyze and interpret them for the purposes of informing immediate decision-making. The overt purpose of our workshop was to assist in the cultural change that would help make Rwandan research as well recognized on the international front as that of Western investigators. We were able to make this attempt because local administrators, including Minister of Health Dr Agnes Binagwaho, who gave an inspirational address to our group, had carved out precious protected time for their employees to kickstart the creation of a publishing culture.

The barrier to our progress was a distinct lack of confidence on the part of the students. After all, they were being asked to transform culturally, and to learn to write at a world-class level in a language which, for most of them, was their second or third.

Near the end of the week, Dr. Mills had an inspired idea about how to overcome the confidence issue. He called to me to the front of the room, and the two of us lead the group in putting together a scientific paper on the spot. The suppressed passion of the room came out in spurts. Everyone contributed, since the issue was one that was bubbling, unaddressed, throughout the entire event: how do we build health research infrastructure in Rwanda?

In about 45 minutes, the meat of a paper had been written. It reflected the genuine concern, excitement, expertise, and insight reflective of the shared experience in the room. The revelation was two-fold: that there was important, world-class expertise and perspective in these under-recognized individuals, and that that perspective could be quickly shaped into a tight, urgent story that just might be valued on the world stage. A couple of months later, that particular paper was accepted for publication by the leading global health journal in the world, with all the people in the room listed as co-authors.

The world is in the midst of profound change. Power, expertise, and wealth are flowing from one historic pole to another. Yet great challenges to human health and development persist. The more that the expertise and skills locked within the human capital of low income countries can be tapped and expressed, the better off we all will be.

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