Personal Contribution of Dr. Rodolfo Stusser to the Forecast
& Policy
for the World Action Plan in Health Research 2001-2010 .
Questionnaire of
May 25, Issues in International Health Research, prepared by COHRED, GFHR, WHO & World Bank for
the Latin American & Caribbean Consultative Process, previous to the International Conference of Health Research for
Development on October 10-13 at Bangkok.
First, I
want to thank very much the ICHRD 2000 global analytical team and organisers,
for give me this great informal and unique opportunity to offer my experience,
reflections, ideas and approaches of 32 years, to assist them to face these
very complex issues, in this crucial moment of the human being history,
beginning its third millennium.
My studies
on international health research began on 1977 on the global cancer problem,
after having training some years through all the research settings that a physician
can have.
Answering
this opinion questionnaire, I am not pretending to give full explanations and
useful suggestions to all the issues in it. I am not neither using it to
propose my country exceptional pattern of science progress nor mirroring its
official points of view.
Frequently,
in the analyses concerning developing countries, are completely forgotten some
internal political factors determining the logic of the progress of the medical
and health sciences, as well as of the development of their medicine and public health care
systems.
In the one
hand, the fact that it could be a minimum balance between “Differentiation
Science Programs” and “Integration Science Programs”, for the progress of the
sciences of medicine and health at the national, regional and global levels.
In the
other hand, the fact that it could be a minimum equilibrium between the “Health
Primary Care Research Program”, and the Health Secondary-Tertiary Care Research
Programs”, to develop the national, regional and global health care systems.
I have
made a careful evaluation of the progress in the last half-century and decade,
and an outline of premises for the forecast and policy for the World Action
Plan for Health Research 2001-2010. I want to propose them to you as a
concerned citizen of a developing country, scholar and researcher of these
matters.
1)
Funding
for research: what are the present
constraints and what is suggested?
In my
personal opinion, there are usual types of constraints for funding health
research described at the country level. My focus will be put on some unusual
constraints. First, I shall review some usual constraints as follows:
Usual Constraints.
In all the countries, even in
the most developed of the world, to carry out new core or jumbo scientific
programs, for instance, the Human Genome Project, Brain Project, and so forth,
there are main economical, social and political constraints for funding their
research.
They
limit developed countries --USA, Germany, Japan, UK, France, Canada, Italy,
Nordic European countries, Switzerland, within others--, and force them to look
for international collaboration in regional and global health research
strategies.
At the
level of the under-developed countries of Africa, Asia and Oceania, Latin
America and the Caribbean, there are logically the hugest constraints, in any
of their different stages of economic, social and political development.
To obtain
for health research enough funding and to use it properly, they face great
limitations. Still not too less of these countries, do not know exactly what to
assimilate or investigate, even many, do not know well their main health
problems.
In these
countries, generally for historical, environmental, ethnological, educational
and cultural reasons, there are the greatest disproportions between the huge
aims that societies need to fulfil, and the scarce resources that their
economies have to achieve them.
Generally,
they have absence or incipient scientific tradition, few scientists, and
bad-equipped installations, although some of them show a more advanced
situation.
Some
scholars have stated that the constraints of the underdeveloped countries to
fund anything, in essence, are autochthonous due to their primitive or behind
culture. Their inefficiency, waste, and corruption, explain why they stayed
back in progress.
Others
have excluded all the responsibility of these countries and their inhabitants.
They blame their former metropolis for their late situation, demanding them
unconditional subsidies to finance their development in all the spheres of
society.
The causal
web is very complex, and possibly both causal theories are truth, as many
others not well understood yet. The thing is that these countries now depend of
their more or less weak economies, retarded societies, and primitive policies
of the state.
The state
policy influences in the ministries of health and of science, universities, and
academy, which generally not manage well their relative small budgets for
health research. There is less influence of the state in the private
universities and health industry.
Generally, not all of these actors understand nor face
adequately the scientific research required in each country, nor in its
regional group of countries, to give solutions to the main health problems of
each health care system or group of them.
They have insufficient health policy-making,
programming, conduction, monitoring, and evaluation of results, with not enough
space or not space at all for “health research & development”, and “health
research for development” forecast, policy and program.
They have
not linked adequately at a high political level, health research solutions to
the health care system most important problems, as a way to push forward the
integral economic and social development of the whole country.
They
usually are very impressed with the last scientific advances in medicine and
public health achieved and in use in the developed countries. This confuses and
distorts their frequent subjective mechanisms to select their own priorities,
if they already exist, and the high-priority health research is left without
enough funding.
They do not discriminate well between scientific
knowledge and low and high technology assimilation from developed countries for
their necessary health programs of practical actions, and for their necessary
health programs of scientific research.
Some underdeveloped countries even not understand well
that they need first, to begin to walk a stage of an endless adaptive
scientific, organizational and technological strategy. To be able to begin
then, a very selective scientific strategy on the autochthonous health research problems that the
developed countries do not have to face.
They are usually involved in total strategies of
research that only developed countries could afford even with great
difficulties.
For
instance, biomedical research for malaria vaccines and drugs, a regional
research problem exclusively today of the Southern countries, should not have
the same priority and funding in those countries or regions, that biomedical
research for AIDS, since two decades a global research problem, including the
richest countries.
Other
thing are the great health programs of prevention and control of malaria and
AIDS needed, and the health research programs associated with a strong
socio-medical centred unconventional research, addressing the specific
characteristics of a resistant malaria and of an AIDS of the Southern
uncivilised and/or starved countries.
The funds
obtained for high-priority health research problems, are sometimes not well
used or are deviated toward other low-priority health research more attractive,
other health activities, or other activities, due to the lack of a well trained
or committed research labour force, or the pressure of the other great lacks of
the retarded society.
Unusual Constraints.
However,
in my opinion there are also other more unconventional constraints for funding
research, which have negatively influenced in the last half-century. These are
found in extreme in the underdeveloped countries, although they are also mildly
found in the developed too. First, it will be useful to do some historical
reminders.
In 1948,
it appeared for the first time in UK, general practice as a medical speciality,
to be the first line of health care in the community settings of all its
National Health System. In 1966, appeared in USA and Canada, family medicine as
an academic specialty in three state universities, for the same practical
reason.
These
specialties appeared with the complex scientific challenges to research health
in a positive sense, health problems, illnesses not well defined, of the
person, family and community, in a more behavioural, ethnological, cultural,
and sociological context.
In the
last decade, it has been a great challenge to investigate how the doctor can
enable the patient to cope with his health, health problems, illnesses, and
even life, in a psychosocial context, staying for further research, the
enablement effect in the families and communities.
In 1978,
the WHO HQ stated the "Health for All in the Year 2000 (HFA)" main
objectives, to be achieved strengthening the "Health Primary Care
(HPC)" strategy, independently of the degree of economic and social
development of the countries.
General
practice and family medicine academic programs of the last half-century very
much required since their beginnings research to be successful specialties, and
to become an important force in the health care systems.
However,
it has happened even in the above developed countries, as also in Germany,
Australia, New Zealand, within others, that these specialties have not had
enough funding for health research as they need it urgently yet.
Then, what
can be said about general practice and family medicine in the developing
countries, where in many rural areas, at most, only exist alone a general
nurse, a midwife, or even a quack doctor or witchdoctor doing HPC?
Naturally,
that general practice has had very little funding for health research, if it
has existed and had some, and hence, that it has not had opportunity to achieve
enough progress as scientific specialties to push forward the flag of the HPC.
Instead, have been promoted complementary tactics as Health Local Systems with
health services research.
At this
point, it is important to answer some questions: Which have been the main goals
that have been pursued in the developing countries, with the scarce funds for
health research in the last decades? Has been funded research in order to
achieve the HFA objectives in 22 years, strengthening scientifically the HPC
strategy? Or instead,
Has been
funded research to help the developed countries, obtaining high-technology
advances, facing their still less urgent health problems of tertiary and
secondary health care, and/or strengthening the national and/or trans-national
pharmaceutical, biotechnological, equipment industries, to compete for the
world markets?
It has
been the "unfinished health research and development agenda of WHO
HQ", in the case of HPC and general medicine, which in my opinion has
allowed in great part that the HFA goals have not been achieved yet.
The other
causes are economic, social and political underdevelopment. General practice
and HPC need very much research to provide a good quality of health care. It is
insufficient to promote them, only providing the labour and the settings, even
the education of medical students in them, without adequate funds for research.
However,
the most important is that it seems to be not too much probability for most
developing countries to achieve the HFA goals in the next decades of the
21-century, if at least the WHO "unfinished health research and
development agenda" is not well executed and ended in the HPC and general
medicine.
This
is because over the first burden of diseases inherited of the prevailing
backwardness accumulated in the under-developed countries, is appearing in them
the second burden of diseases. The latter is due to the economic development
and some bad lifestyles patterns imported from the developed countries since
fifty years ago and even more.
The
general practitioner is the best prepared professional that use to give HPC. In
these countries commonly give also HPC other professionals registered and non-registered.
Within them are the nurse, pharmacist, dietician, social worker, sanitarian
worker, chiropractor, homeopath, naturalist, midwife, health activist, and even
quack doctor and witchdoctor.
In
these countries, all these professionals that practice conventional or
alternative medicine in HPC, could work first of all, as a civiliser, a social,
sanitarian and health educator of its families and community, together with the
school teachers, missionary priests, and community leaders, within other social
actors of the communities.
The
environmental, economic, social and health problems causing diseases,
eradicated in the first half of the 20-century in the developed countries, now
are claiming for much more scientific knowledge about biological factors.
However,
those diseases are claiming for the first time, for results on behavioural,
ethnological, and cultural risk factors, due to the great economic and social
handicap that have 100 years or more after, the developing countries to
eradicate them.
It should
be remembered that many developing countries are facing these health challenges
already in the 21-century, with standard levels of economic, social and
political life of the 19- or 18-century.
It is
important to be aware that not too less of them have many more centuries of
lag, excepting some cities, if there exist really some, and that still they
have populations or communities living in the prehistory of human being, but
also with famine and misery.
Other
great problem is that in the past half century, present, and even
prospectively, the main efforts in the developing countries have been, and
continue prevailing, in the unilateral approach to manage the biological
aspects of health, illness and disease, through a multitude of conventional biomedical
"differentiation science programs".
These
conventional scientific biomedical programs have been carried out and are being
carried out very successfully, by millions of scientists in all the world of a
hundred of specialties of basic and applied biomedical and bio-health sciences.
However,
these have increased very much the expenses of health care with high-technology
products and devices, specially for health tertiary and secondary care, making
them non affordable by the majority of the countries. This has reached an
extreme situation in USA that it is known its health care as the most
expensive, but not the best.
However,
before the action of all of these bio-factors, we cannot forget that are acting
“ad hoc” with great intensity the behavioural, ethnological and cultural
factors, given by genes and “memes”, in the bio-social environment, as risk
socio-factors of the risk bio-factors, which generally have been stayed outside
of the conventional biomedical programs.
There is a
great lack of unconventional integration scientific health programs, developed
by general practitioners, chiropractors, natural medicine practitioners,
nurses, sanitarians, internists, paediatricians, epidemiologists, health
managers, technicians, and pharmacists.
They are
needed to integrate the enormous amount of scientific results contributed by
the differentiated biomedical programs, with also the great amount of
scientific results that could be achieved investigating within a more
psychological, cultural and social context.
One
concrete proposal to begin such a program like that is my "Integration
Science Program for Global Medicine and Health". It has six
cross-disciplinary research projects, three cross-disciplinary research
training projects, and one cross-disciplinary research and training centre
project, physically and/or virtually.
This
program is e-posted in the web site, which URL is as follows: http://www.fortunecity.com/skyscraper/systems/1000/website1.html
One main
research project designed in the field of the logic and methodology of health
research policy and program is "The Development of New Self and Shared
Disciplinary Research Spaces of General and Family Medicine and Practice".
The URL for this project is:
http://www.fortunecity.com/skyscraper/systems/1000/artfam2.html
It only
needs human brains, high-technology communication, and Internet Second
Generation features, to establish a strength international collaboration with
different cross-disciplinary teams of partners.
It argues
the scientific strengthening of these general medicine disciplines, not only by
a critical assimilation of high-technology of university and industrial
laboratories, but mainly, by the creative anthropological, psychological,
ethnological, cultural, social, health research in their own community
laboratories.
Much more
research projects of content to strengthen these general medicine disciplines,
the HPC, and HFA in the 21-century will become later, through its
meta-scientific results.
The most
general project about the balance of integration and differentiation science
programs is e-posted in the following URL:
http://www.fortunecity.com/skyscraper/systems/1000/pbm2.html
It should
be awareness that the last half-century has known the “Era of High-Technology”,
but that we have in front a new era that have begun with Internet, the “Era of
Information”.
I personally think that the developing countries to
solve their main health research problems need to manage the research capacity
strengthening in a national way as up-to-date, but also they have to begin to
manage them in a regional and global way.
In the last decade, the developed Northern countries
began a globalisation process, integrating their economies in North America and
Europe. In this advanced context, which also involves science, the developing
countries could aspirate to have much more than national capacity strengthening.
The developing Southern
countries could use the experience of the most developed countries in medical
and health research, not only training their scientist in the best centres of
North America and Europe to work after in their national centres in their
countries, generally not at the state of the art. By only this way, they will continue losing scientists going
to the North.
They could also concentrate some of their best brains in the best
regional centres of each region and/or Southern centre, improved with strong
international collaboration for prioritised regional and global health research
problems.
Using this way too, the single country, will guarantee that a proportion
of their best brains, will not go to the North forgetting the Southern main and
urgent health problems of today.
The feedback of these regional and Southern centres will help the
countries to solve great part of the health research problems in the meantime
they achieve scientific experience and tradition. That is why are important the
regional and global capacity strengthening for the single country too.
Another thing is that I conceived that it has to be
a logic and methodological strengthening of all the scientific trainings that
involve medical and health research in developing countries.
I am proposing in the last five years as part of the same “Integration
Science Program for Global Medicine and Health” stated before, some new
approaches.
They consist in different cross-disciplinary models and programs of
scientific training for basic physician and non-physician scientists, for
clinical physicians and non-physician scientists, and for health physician and
non-physician scientists. Their URL are:
http://www.fortunecity.com/skyscraper/systems/1000/artwho9.html
http://www.fortunecity.com/skyscraper/systems/1000/educproject.html
http://www.fortunecity.com/skyscraper/systems/1000/proycur1.html
Also there
is other approach to the national, regional, and Southern research capacity
strengthening, but specifically in the proposal of a physical and/or virtual
centre for cross-disciplinary research & training for medical & health
scientific research and development policy research. Its URL is:
http://www.fortunecity.com/skyscraper/systems/1000/collaplan5.html
This has
been examined implicitly in the anterior answers to this questionnaire. There
could very well co-exist both global/regional/country axes. The problem is much
more than tri-dimensional.
The
strategy of essential national research programs is very important, because it
allows to face the health research specificity of the diversity of countries in
their different stages of development of health care systems in different regions.
Nevertheless,
the strategies of regional and global research initiatives are the complement
to the national specific strategies, taking the most essential and general to
the majority of the countries, to prioritise the most vigorous research programs
at a regional or global level.
The
universality of science promotes the feedback to each country of the most
prioritised scientific research results obtained from regional and global
initiative agendas and efforts.
All are
very important; and the new complement the old ones. I do hope that all of them
could continue doing their job.
Nevertheless,
I would like to ask that I do not know if CIOMS or who should take in its hands
the new issues addressed by me as important too.
They could
be taken as prioritised health research programs by WHO, included in the
methodological principles of COHRED, conformed as new initiatives of the GFHR,
and promoted also by INCLEN as new types of clinical epidemiology research
projects.
·
Political commitment
·
Priority setting
·
Resource mobilization
·
Research output
·
Networking
·
Dissemination of results
·
Utilization of results
·
Coordination of research activities
·
Evaluation of impact
I agree with the organisers that all these
operational elements, components, process and mechanisms of the national health
research systems have to be improved in every country of the South. I have not
special suggestions about them, although I have touched some of them
previously.
·
Equity
·
Ethics
·
Gender
I agree with the organisers that all these conceptual
elements have to be more taken into account when planning health research
programs and projects in every country of the South. I have not special
suggestions about them, although I have touched some of them previously.
It is
obvious that health research at all levels and subsystems have to be an
advanced part of the health care system and programs. I have not special
suggestions about this.
I want
to state two ideas more to contribute to the forecast & policy for the
World Action Plan in Health Research 2001-2010. These are as follows:
A.
Proposal of a “Global Clinical Medicine Scientific Project”, with emphasis in
general medicine, as a non-scientific interface between the Human Genome and Brain
Projects, and Global Epidemiology and Public Health Projects.
Since
1995, and encouraged by the RPS of WHO HQ in 1997, the first preliminary ideas
about such a Global Clinical Medicine Project was stated in the paper: “A
Unified Approach to Medical and Health Research Methodologies”, which could be
examined at the following URL: http://www.fortunecity.com/skyscraper/systems/1000/artwho9.html
I hope to
have enough time in the next months to develop further this Global Clinical
Medicine Scientific Project, before the ICHRD 2000 in Bangkok. I will post it
in the URL:
http://www.fortunecity.com/skyscraper/systems/1000/poachrwho.html
B. Proposal of a Central Idea Reinforcing the WHO
Health for All Goals Achievement & Primary Health Care Strategy Execution:
Non-Whole Patient-Centred and Whole Patient-Centred Medical & Health
Research.
In the
last decade, I have learnt very important lessons from the Canadian and the
British primary medical care research. The first, from many readings of
articles of the Canadian leader Professor Ian McWhinney from the Department of Family Medicine of The University of Western Ontario. The second, from one
important British leader, Professor John Howie from the Department of Community
Health Sciences & General Practice of The University of Edinburgh.
The next
notes that follow are some of the thoughts recently sent to Prof. Howie, in
honour to his retirement of general practice on next September, after 6 years
of continued and fruitful exchange.
Medicine
and Public Health in the last 50 years have needed two kinds of researchers for
their scientific progress. First, the drug, device, organ, cell and/or
molecule-centred investigators, who have not had many problems to receive
funds, sometimes more than necessary, for secondary and tertiary medical care
research and RCT.
The
second, the patient-centred investigators, who have had too many problems in
the same period to receive enough money for primary medical care research and
surveys. However, I think that still (M & PH) require for their progress
much more researchers of the second kind, because unfortunately to general
practice go very few real researchers as you.
Nevertheless,
the complexities of the multidimensional nature of the medical care (i.e.
consultation) of the patients, with its multi cause-effect relationships; the
absence of high-technology in general practice research; and the relative
insufficient scientific methods that exist to study this object in all its
dimensions yet, have been well stated with your very ingenious conceptual
developments for future research in your last papers and monograph
(Patient-Centredness and the Politics of Change, 1999). That is your most
important pioneering contribution in the 20-century to general medical science.
Medical
sciences have progressed very much studying analytically the parts of the
patients for much more than 400 years, and more than ever in the last 50 years
with the aid of several successful biomedical high-technologies and scientific
methods. However, if you examine carefully the unlimited logical possibilities
of the HTML, basic language of the Internet of today, for the multidimensional
interconnection through hyperlinks of trillions and trillions of statements in
hypertexts.
Then, you
will agree with me that we are about a new Era of medical & health research
of synthesis to face the study of the very complex causal webs, the scientific
problems and projects on patient-centredness you left stated, and the science
integration program for global medicine and health, which I am proposing with
much less possibilities than you, and many more that will be imminently
developed in the next years.
I foresee
that in the next 50 years, general practice research will leave the status of a
low-technology medical research. It will be enriched with a very high
technology as have been the other medical practices. It will be developed with
the aid of Internet Second, Third, and next Generations, new high-communication
technologies, and new scientific methods of the basic psychosocial and exact
general sciences.
General
practice research will launch a more social general medicine or general medical
science for primary health care, but so robust scientifically as anyone of the
strongest biomedical sciences of today. It seems that its time is coming... It
will allow a superior integral study of the health of the individual, family,
and community, achieving a closer scientific relation with a general health
science that will be also developed. Perhaps, someday in this new 21-century, it will more attractive to be a researcher of general practice than a researcher of a very special practice, in an academic sense, when “the politic changes to, or much better, when it include much more
patient-centredness”!
Why don't
we leave to the next generations of doctors this new world laboratory
organised?
Integration Science Program for Medicine, Nursing, Technology & Health
Biosketch with Portrait
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