A New Paradigm for Global Health Research: Local Needs, Local Teams

The level of collaboration and incorporation of local voices in global health as it stands today is far too low. The unfulfilled promise of the past few decades of global health research must be recognized and corrected for with a willingness to explore new models.
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Co-authored with Dr. Brenda D'Mello

2014-06-09-brenda.jpgA specialist in OBGYN since 1999, Dr. Brenda is currently working as a Technical Advisor at CCBRT, implementing a regional collaborative comprehensive maternal / newborn and disability inclusive capacity building project in Dar es Salaam, Tanzania supporting 16 public health facilities that in total conduct about 80,000 deliveries annually. She is passionate about working to help improve maternal and newborn care for the poor, disempowered, and deeply marginalized pregnant women, especially those with HIV/AIDS and disability.

This spring saw the publication of a study in PLOS One illuminating a problem that anyone who works in healthcare in low-resource countries knows inherently to be true. Despite ubiquitous enthusiasm for Global Health, there is an inconsistency between the popularity of the subject, and its representation in the medical literature. The authors found that there have been strikingly few studies, trials, reviews, or articles published that are applicable to the disease profile and infrastructural circumstances of the developing world. Sadly, published research reflects the priorities of those with the resources, rather than those who need the research. Although the validation of this fact with the publication of an article in an established medical journal is an important milestone, the discrepancy has been glaringly obvious to local health providers for some time.

As a field of study and a philanthropic cause, global health has never been hotter. Yet the impact of this influx of attention is difficult to measure, and the imbalance in research mentioned above is one indication that all this activity in fact has had little success in improving the health and well being of the world's poor. We do not need more academic research to figure out why the Global Health enterprise has yet to live up to its promise, or how we can make it more effective. Instead, we should turn to an extremely powerful, yet mostly untapped resource - the people who spend their lives actually doing global health. These are the doctors, nurses, and health workers who are there when foreign researchers arrive, and who stay long after the research projects conclude. They have an inherent understanding of the systems in which they work, and they have learned valuable lessons from their experiences of seeing lofty research agendas repeatedly fall apart at the implementation stage.

The fact that the voice of these valuable collaborators is missing from published research is easy to explain - they lack sufficient resources to care for their patients, let alone undertake research projects. Global health efforts could be more successful if they used the resources of wealthy nations to support and supplement the priorities of those who engage with these issues every day. I have co-authored this article with my Tanzanian friend and colleague Dr. Brenda D'Mello in an effort to open up the discussion of how global health efforts can be maximized to accomplish goals that are relevant, sustainable, and scalable.

As a specialist in obstetrics and gynecology at Dar Es Salaam's CCBRT hospital, Dr. Brenda D'Mello oversees 80,000 births throughout the region every year. She has watched as waves of global health experts have come to her hospital to conduct expensive and labor-intensive research projects, without any corresponding investment in the implementation and service support needed for tangible results. Dr. D'Mello has a clear understanding of why past approaches have failed, and bold ideas for new models for a collaborative approach to global health interventions. In her words...

"A lack of experience and understanding of existing systems on the part of academics compromises the scale-up of interventions, and too often the focus of the research is not even a relevant country concern. What saddens me the most is that a busy labor ward's best personnel get enrolled as research assistants in these projects, spending hours of their valuable time filling in data collection tools. Since they are paid very little to begin with, these workers are vulnerable to exploitation and often accept a pittance from researchers in exchange for their work. As a result, the acute human resource crisis, which directly contributes to the poor care being targeted for intervention, is exacerbated. As money is poured into the study of a fancy intervention that is most likely inappropriate for the environment for which it was intended, patients continue to die of preventable causes as health workers struggle to meet basic standards of care."

She continues, "A more productive model for research at the hospital level would involve the installation of a research support team, including data collectors, biostatisticians, and writers, to the permanent staff. This team would support the clinicians together with the head of the department to meet targets for publication of studies that have been collaboratively designed and implemented. They would work as a team to develop relevant research questions and feasible methods. Each member of the team would work within their own competencies."

"Once a culture of teamwork is institutionalized and replaces the cutthroat environment inspired by the competitive drive to publish, the incentive to simply churn out research as prolifically as possible will be eliminated. There would be many benefits to this cultural shift including capacity building and the strengthening of professional relationships. But most importantly, this system would foster relevant research that will truly contribute to the body of science regarding implementation of cost-effective interventions for low-resource settings."

The level of collaboration and incorporation of local voices in global health as it stands today is far too low. The unfulfilled promise of the past few decades of global health research must be recognized and corrected for with a willingness to explore new models. There is no better place to start than with the people who have faced the challenges of low-resource health systems day-in and day-out for many years. Their input and expertise are essential for the design and implementation of projects that are truly needed. Dr. D'Mello and I urge a shift in global health towards a collaborative research model. It is time to recognize that a lack of resources does not go hand in hand with a lack of good ideas.

Research and editorial assistance for this article was provided by Ariel Trilling.

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