Commentary (version 28th of April of 2005)
Research Enhancing in Primary Care and Health Behaviour Assisted by Electronic Research Collaboration. Complementary Program to Improve Human Global Health1
Rodolfo J. Stusser1,7 stusser@infomed.sld.cu, Richard A. Dickey2 mdrad@charter.net, Thomas E. Norris3 tnorris@u.washington.edu, Linda E. Krach4 LKrach@aol.com, Robert L. Kriel5 kriel001@maroon.tc.umn.edu, Marco J. Albert6 ariocha@infomed.sld.cu, Alfredo Rodriguez7 alfredo@cedisap.sld.cu.
1Primary Care Research Unit, Havana University Vedado Health Community Center, 18 # 163 / 15-13, Plaza, Havana, 10400, Cuba.
2Clinical Endocrinology Section, Wake Forest University School of Medicine, Winston-Salem, NC, 27157-0001, USA.
3Family Medicine Department, University of Washington School of Medicine, Seattle, WA, 98195-6340, USA.
4Department of Physical Medicine and Rehabilitation, University of Minnesota, Minneapolis, MN, 55414, USA.
5Departments of Neurology, Pediatrics, and Pharmacy, University of Minnesota, Minneapolis, MN, 55414, USA.
6General Internal Medicine Department, Havana University Vedado Health Community Center, 18 # 163 / 15-13, Plaza, Havana, 10400, Cuba.
7National Center for Health Informatics and Telecommunications, Soto Building 23 / M y N, Plaza, Havana, 10400, Cuba.
Submitting and corresponding author:
Prof. Thomas E. Norris, Family Medicine Department, University of Washington
School of Medicine, UW Box 356340, Seattle, WA, 98195-6340, USA.
tnorris@u.washington.edu
UW Phone 206-685-3466, UWPN Phone
206-329-8976
Abstract
Since the beginnings of medical and health care many results have been achieved, making use of services of primary health care (PHC) and community and family medicine (CFM). However, research and development (R&D) in these services, have not yet accomplished the best possible results required to improve the equity and quality of care of the poor. This paper offers a pro-equity policy approach to the strategic roles that R&D in PHC and CFM may have within global health R&D problems, and hence, emphasizes the need of a more equitable capacity strengthening and building. It also approaches the slow advance of these R&D in turn as global health R&D problems of their general services and specialties.
The dominant philosophy of biomedical sciences, more focused on the prevention of death, disease and disability, has greatly developed the biomedical and technological R&D differentiation model and programs, but has let little space to the life and health behavior and culture R&D integration programs, based on the philosophy of public health sciences, yet not enough centered on the promotion of better quality of life, well-being, and health. More equity without highest production of goods and services, and more charity without maximum responsibility and honesty to invest it, have proved that do not cut the vicious circle of poverty that drags the anachronic global health problems of the poorest communities and countries. We envision that more balanced investments and results in global health R&D problems, oriented to biomedicine and technology, to behavior and culture of life and health, and to reintegrate both complementary R&D programs, will enhance the equity, quality, efficiency, integrality, impact, and cost-benefit of the global health R&D results. One way to attain this could be building capacities in PHC and CFM assisted by electronic research collaboration, as interface to obtain more basic and applied life and health behavior and culture R&D results, and reintegrate them with the biomedical R&D results in agreement with the bio-psychosocial model. National and world scientific societies, United Nations System, health organizations and sponsors of R&D globalization could promote this.
Key Words: research policy, global health, primary care, family medicine, capacity building, bio-psychosocial integration, equity approach, poverty, charity, electronic collaboration, life behavior, culture.
Support Given to PHC and CFM Research in the Global Health Research Problems.
The great importance of research and development (R&D) in community and family medicine (CFM) and other medical and allied primary health care (PHC) specialties in the global enhancing of the equity and quality of care and the health of the individuals, families and communities, was recognized since the decade before the foundation of the North American --and Caribbean-- Primary Care Research Group (NAPCRG), and the World Organization of Family and General Doctors (WONCA) in 1972 [1-2].
The PHC and CFM have been practiced spontaneously since the beginnings of humanity, and in a more organized way, since the first decades of the XXth century. Either through their initial rudimentary services or by the further more specialized ones, they have contributed with many results in personal and public health in the majority of countries.
In 1978, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) started the promotion of a comprehensive and integral strategy of PHC in order to achieve the goals of “Health for All in the Year 2000”. These efforts in part contributed to enhance the PHC services and the number of CFM professionals, but the initial goals were not attained in many countries due to: scarcity of physicians, nurses, social workers, among many other resources, low community participation, and logical deviation of resources --in low income countries and resource poor areas of high income-countries-- towards selective and vertical strategies of infantile and maternal survival [3].2 The interest in the provision of PHC services and CFM education in CFM, enhanced also their R&D in order to increase the equity and quality of care, but results were limited because they were not appropriately supported by scientific institutions and investments in R&D [2,4].
WHO created in Geneva the Council on Health Research for Development (COHRED) at the beginnings of the 1990s, with the aim to strengthen essential national health R&D strategies, and closing the century, the Global Forum for Health Research Foundation (GFHR), with the goal to help correct the dramatic gap (10/90) of the distribution of funding for R&D destined to global health R&D problems between the South and North. In that very time lag, WHO also created among others, the Alliance for Health Policy and Systems Research (AHPSR) and the Global Alliance for Vaccines and Immunizations (GAVI) [5].With the Conference on Health Research for Development given in Bangkok in 2000, which was a landmark in health R&D worldwide history, an enormous international advisory effort was done with 800 actors of 100 countries in order to organize the almost infinite aspects of the strategy, policy, action plan and financing of global health R&D. Its target was to find new solutions to the more compelling global health problems (new, emerging, re-emerging and old ones) of the South, like AIDS, malaria, tuberculosis and smoking habit, among many others. One of its main results was the development of an acceptable governing team of all the global health R&D, which included WHO, COHRED, and GFHR, among other organizations [6]. In 2000, the United Nations (U.N.) System, the governments, the World Bank, and the International Monetary Fund (FMI), and other agencies, agreed with Eight Millennium Development Goals and a Millennium R&D Project until 2015, for the sustaining and improvement of human life and health, mainly in the poorest countries [7].
In 2000, the Swiss Commission for Research Partnerships with Developing Countries upheld a World Workshop in Bern, and a Regional one in Cartagena de Indias in 2001 [8]. This same year the WHO supported with Rockefeller and other donors an International Workshop on National Research Systems in Cha-am [9]. Afterwards, there was an strengthening of the alliances and creation of new organizations, which allowed an increase in the mobilization of the funds of WHO, governmental agencies, Rockefeller’s and Gates’ Foundations, other charitable organizations from Europe and North America, the World Bank and FMI towards the poorest countries in order to develop mainly biomedical knowledge and health technologies. In 2003, and after a worldwide advisory process, the Gates Foundation selected 14 Great Challenges in Health Research, and a year after started to finance them. In that 2003, WHO also created the Global Fund for the Fight against AIDS, Tuberculosis, and Malaria (GF), and in 2004, WHO celebrated the Worldwide Summit Meeting for Health Research in Mexico, D.F., together with the 8th Global Forum. However, there were scarce references to R&D in PHC and CFM in their agendas and meetings [10-11].
All these tasks were very necessary and valuable, but not enough yet, due to the scarce support to the progress of R&D in PHC and CFM, and non biomedical and technological results for global health R&D problems, which have continue with slow progress.
The important U.N. Millennium Village Project now underway in Africa aims to fight poverty in all its aspects --from health and education to agriculture and energy in one focused area-- one village at a time. Its experimental hypothesis states that if a single village cannot be turned around with focused attention, how can whole poor communities and even countries be revitalized? The enormous problem is that near half 6 billion people in the world are poor, and poverty --with its three degrees: extreme (1.1 billion), moderate and relative--, is causally chained in a vicious circle with global ill health [12].
Objectives and Methods of the Commentary
This paper pursues two main objectives: First, to found through a pro-equity policy approach the new strategic roles that R&D could develop in PHC services and CFM specialties, within the global health R&D problems; second, to lay the foundation of the need of strengthening and building new capacities for PHC and CFM R&D, conceptualizing their slow progresses in turn as global R&D problems in health services as well as in general specialties
This work results from an analysis and reflection since the technological boom after 1945 to the present time, regarding the progress in health and global health R&D policies and programs by approaching aspects as strategies and tactics, functions and financial fluxes, structure and results, integrity and breakthrough, equity, poverty and charity, and cost-benefit. It is important to point-out that this paper does not intend to present in few pages an exhaustive study nor to give any know-how or “know-do” solutions for the immediate practice; neither exalt any of the authors’ country present health R&D organizational models nor of any country, since it starts from the presumption that all of them are disproportionate. We neither want to prescribe what to do in the low income countries nor in the areas with poor resources in high income countries. Instead, we do want to encourage more analysis and meditation in this sense, and the creation of new more balanced and equitable scientific programs of health R&D, better adjusted to the bio-psychosocial scientific needs of the human global health R&D problems nowadays.
Balanced Strategy with R&D in PHC, CFM, Behavior and Culture of Life and Health
Up-to-date most of the financing assigned to health R&D in every country of the world, goes to the biomedical R&D (basic as well as applied), to the industrial laboratories, institutes, and most differentiated hospitals and specialties. There are yet too scarce funds dedicated to the R&D in PHC centers, in CFM consulting rooms, to life and health behavior and culture R&D themes, which constitutes another kind of 10/90 financing gap in health R&D that also needs to be closed. Family doctors and other PHC generalists, can demonstrate to all the governments, health organizations, and donors that their R&D results in life and health behavior and culture, achieved in their “community clinical laboratories”, can be also as reliable, rigorous and useful as the valuable biomedical and technological R&D, as well as capable of being a source of horizontal results that may support solutions of impact on the global health problems, in a similar way as the most vertical results. They can demonstrate this by their presentations and publications in national and international NAPCRG, WONCA, U.N. System, WHO, COHRED, GFHR meetings and journals [13].
It is true that U.N. System, WHO, COHRED, GFHR, the alliances, the GF, and mostly the World Bank, the FMI and other funds donors are conscious of the value of R&D in PHC and CFM [14]. Nevertheless, the worldwide gigantic installed capacities of the successful and useful biomedical and technological R&D, pull millions of full and part time professionals, thousands of specialized biomedical journals in paper and on-line, and so many other annual scientific forums vertiginously developed in the last 60 years, makes to appear of an inferior quality the relatively lesser capacities created for R&D in PHC, CFM, in life and health behavior and culture, with much less professionals dedicated to R&D hardly without time and resources, and a relatively insignificant number of scientific journals and forums for the spreading and discussion of their results. This is cause and effect at the same time that the latter social R&D areas are not yet well represented in the agendas and committees that grant the gross part of the national and international finances for health R&D.
The generalists, who research in PHC and CFM, mostly approach the classic global health R&D problems from the point of view of the epidemiological, clinical and health services R&D. They are in charge of the original R&D of their own fields and specialties, of the problems of R&D in health promotion, protection, control and rehabilitation of risk factors, sickness and incapacities, natural products, alternative techniques, and health services, as well as of the R&D collaboration with biomedical and industrial laboratories and institutes, with the clinical and population trials problems of the critical evaluation of bio- pharmaceutical products, devices, and equipments, and the interrelationship of the health care levels. These PHC and CFM R&D in collaboration with laboratories and institutes, yields very useful complementary links with the researchers of the biomedical and technological R&D problems, who frequently use R&D tactics with information and communication technologies (ICTs), which have not yet been fully employed in PHC and CFM R&D. However, all these original and collaborative R&D leave out many behavioral and cultural life and health R&D problems, not necessarily technological, more linked to the quality of life and health promotion and to the positive factors in favor of good life, health and well-being, their protection and restoration.2 Generally, the latter problems are scarcely investigated due to the still present predominance of the biomedical and technological models of scientific thought over the bio-psychosocial one, which has encouraged the wrong belief that the responsibility of their research does not correspond to the health sector, but to the educational, labor, social welfare sectors, within many others.
For example, nowadays, from a theoretical point of view, AIDS is completely preventable in the populations of the Sub-Saharan Africa and other very poor regions of the world, through appropriate PHC services in which may work family or general doctors --or general nurses. The global initiative of the USA to fight against the AIDS epidemic in the poorest countries is based on this ideal model. However, in practice, there are excruciating behavioral, anthropological, sociological, economical, cultural and communicational life and health problems, which must be investigated and scientifically resolved in order to successfully fight the AIDS epidemic. The definitive solutions to the key global health problems in the poor countries, not only relay on more effective vaccines and chemotherapeutic drugs, but also on excellent PHC and CFM services and new behavioral and cultural knowledge on life, health and well-being. The so extended habit of trying to resolve everything with high technology --since 60 years ago--, although is very good [15], has conditioned the underestimation of the potential scientific role of PHC and CFM R&D in life and health behavior and culture still at the beginnings of the XXIst century. The dominant philosophy of biomedical sciences, more focused on the prevention of death, disease, and disability, has greatly developed the biomedical and technological R&D differentiation model and programs, but has let little space to the life and health behavior and culture R&D integration programs, based on the philosophy of health sciences, yet not enough centered on the promotion of a better quality of life, health, and well-being, in the individual and public health care.
If we go further on through the AIDS example --an apparently very biomedical problem-- this point can be well clarified. The dissemination of the AIDS epidemic could have been much better totally or partially prevented and controlled in the late 1980s in the Northern countries and in the 1990s in the Southern ones, when its causal element, the HIV and its mechanism of transmission, were known in a first level of scientific knowledge. This could have been possible, if only a small percentage of the billionaire annual budget of R&D in AIDS in the last 20 years, would have been invested in more R&D in life and health behavior and culture, for better health promotion and AIDS prevention in PHC and CFM, based on its initial etio-pathogenesis, instead of being mainly invested practically all in scientific deepening into its molecular biological pathogenesis, in the search of new vaccines, antiviral chemotherapeutic drugs, and newer detection tests of HIV.
The great challenge of the current world health research system, particularly in the South, is the need of much more R&D in life and health behavior and culture of the “not very healthy” population groups, villages, communities, civil societies and government systems [16]. These would lead to a better “balance” between the potent biological and technologically R&D, mainly in “tropical diseases” and “reproductive health”, and the weak behavioral and cultural R&D, basic and applied. To accomplish this it is necessary to strengthen and create new R&D capacities in PHC and CFM as interface with powerful institutes for life and health behavior, and culture, which results --although without direct potential commercial value for the profitable biomedical industry-- will cause a quicker “complementary” impact in the AIDS epidemic --in addition to a indirect economically too--, as well as in many other global health problems, including every kind of addictions, violence, corruption, and even fanatic terrorism. Who could finance this? We think that partnerships among national and international public sectors, private charity sectors, and even the public and private biomedical industries.
The great paradox of current PHC, CFM, public health, and bioethics is that low infantile, maternal and infectious mortality, as well as low natality and large life span, even with much equity at the bottom and less inequalities, not necessarily guarantee a healthy survival with a real basic quality of “human life”. This is due to the great number of individuals, families, villages and communities that in spite of their survival remain ill and disable [16] due to chronic disorders or sequels that are frequently more mental, moral, and social than physical, and that are not taken into account by the standard health indexes. In these biological survivors, the R&D in PHC and CFM could focus in more effective scientific behavioral and cultural goals that have been scarcely approached until now. For instance: How to encourage in the person, family, village, and community higher goals and levels of decency, urbanity, values, honesty, ethics, self-discipline and productivity at work and study, modern culture and life-styles and other positive health determinants in order to promote healthy and prosperous lives, in the material, spiritual, moral and cultural sense, taking them off from the misery and poverty’s way and vicious cycle? How to foment in them higher goals and standard levels of life and health that may be also accompanied by basic and integral quality of life and of health?
Currently, there are some basic life and health behavioral and cultural problems, as compelling as the discovery of the human genome was in the late 1980s, whose projects have not been even thought nor designed yet, to support the U.N. Millennium Project like: How to promote a suitable and modern nutrition, housing, urbanization, transportation, energy, communication and recreation, according not to the first industrial revolutions, but to the last scientific and technique revolutions too? How to encourage responsibility, peace, growth, prosperity and economic self adequacy (free of charity), full U.N. political, economical, social, and individual freedoms, integral education and culture, and at least basic levels of material well-being with decorous wages and profits proportionally to individual productivity and results, and spiritual richness in the citizens of a backward, stagnated or developing country, so they can be able to start enjoying an integral and modern life and health too? This is a research and practical challenge for “clinical economics”, a new integral approach and method, which mixed good development economics and good clinical medicine in the U.N. Millennium Village Project [12,16].
Equity without highest production of goods and services, and charity without maximum responsibility and honesty to invest it, have proved that do not cut the vicious circle of poverty that drags the anachronic global health problems in the poor communities and countries. We are dealing here with very complex social and human sciences problems that can not be scientifically minimized in the XXIst century, just mitigating the lack of their scientific solutions with massive investments, engineering works, transferences of newest technologies and unsuccessful opposite socioeconomic and political models from other countries, nor with massive grants, donations and condonations of international debts, because in that non scientific way the wasting of funds for sustainable development will continue in most countries like it has been in the last 60 years, achieving scarce results.
Two examples of the beginnings of the XXth century clearly illustrate the necessity of linking the R&D in PHC, CFM, and in public health with the classic “scientific R&D”. The first case was the yellow fever, eradicated from Cuba between 1901 and 1909, immediately after the confirmation of its etio-pathogenesis, thanks to the first important R&D collaboration between Cubans and Americans. Finally, the Aedes aegypti mosquito and the illness were eliminated through environmental sanitation. Nevertheless, this was only possible as part of the concurrent restoration and development of Cuba after its devastating Independence War against Spain, supported at the end by the United States of America. This control was achieved even before the isolation in 1921 of the specific yellow fever virus, the beginning of the creation in 1937 of the specific anti viral vaccines, and despite the lack even today of effective antiviral drugs against its different strains. The second case was the smallpox only eliminated from Cuba until 1923, after 119 years of vaccination. The solution to the global health problems in the southern countries pre-supposes a higher human development in the villages and communities where the men, women, and children live, study, work and recreate theirselves3, and the R&D in PHC and CFM can make the greatest contribution to this purpose.
It has been told that G8 will give to the Project of AIDS Vaccine a similar support to the one given to the Human Genome Project [18]. In that case, there will an opportunity to assign some global funds to the life and health behavior and culture R&D in PHC and CFM of the high risk groups and populations for AIDS prevention and control, apart of the heavy given to the basic, applied industrial, and more specialized institutes and hospitals, and AIDS sanatoriums R&D to obtain the vaccine. Unfortunately, a “Human Development, Ecology, Behavior and Culture Project”,3 would have to wait some years more, until a taking of awareness of the fact that this may be the most helpful basic research project for the solution of AIDS pandemic may be taken on, and also for the rest of the most serious global health problems in the South, and even in the North, if we want to really develop the “human being health”.
Bio-Psychosocial Integration of Health R&D with Electronic Research Collaboration
Regarding the bio-psychosocial integration of health R&D and its scientific results, the creation of the adequate virtual infrastructure with these tactics of e-research collaboration, may constitute the “central nervous system” of the national and international integration of a R&D collaboration of wide spectrum in every health care level and scientific field, making greatly possible at the same time the development of the own methodological arsenal and a new R&D in CFM, PHC, life and health behavior and culture [23].
With the R&D methodological support of the investigators from biomedical institutes, hospitals and government clinics, universities, industries and private sector, and with the addition of international collaboration and financing, it would be possible to develop reference community health R&D centers in the capital and regions. These centers would be able to make R&D in CFM, PHC, life and health behavior and culture, assisted by e-research collaboration and R&D partnerships and networks with base in community centers and consulting rooms [22] and would conform a more powerful R&D subsystem in CFM and PHC, that may be integrated to the health and science R&D national systems in the countries. Some of them may be designed Collaborative Health Scientific Centers of WHO. They may also be able to lead bottom-up regional and global R&D projects, by the international e-research collaboration, starting with the crucial problems and needs of the R&D in CFM, PHC, life and health behavior and culture, and integrated with the institutes and hospitals in order to integrally improve the equity, quality of the results, health impact, and cost-effectiveness of the national and international health R&D collaboration and results.
Conclusions
We envision that more balanced investments and results in global health R&D problems, oriented to biomedicine and technology, to behavior and culture of life and health, and to reintegrate both complementary R&D programs, will enhance the equity, quality, efficiency, integrality, impact, and cost-benefit of the global health R&D results. One way to attain this could be building capacities in PHC and CFM assisted by electronic research collaboration, as interface to obtain more basic and applied life and health behavior and culture R&D results, and reintegrate them with the biomedical R&D results in agreement with the bio-psychosocial model. National and world scientific societies, United Nations System, health organizations and sponsors of R&D globalization could promote this.
Competing interests
The authors declare that they have no competing interests regarding finances’ sources or statements. No organization financed this study that only expresses the authors’ own ideas and do not represent criteria or policies from the health or university authorities of any country.
Authors' contributions
All authors contributed to the commentary. RJS drafted the manuscript. RAD, LEK and RLK have lively discussed personally with RJS, in 2000-2001 by US People to People Ambassadors Program and Religious Delegations to Cuba, the strengthens and weaknesses of national medical research systems in America, Eurasia, Oceania and Africa, and refined the manuscript for critical content and provided continuous intellectual input by mail, fax and email. TEN assisted RJS to found the national and international e-research collaboration technologically since 2003, with his book and conferences in primary care, and discussed the structural approach to family medicine research by email. MJA and AR introduced RJS to the informatics and telemedicine of primary care, and refined the manuscript for critical content and provided continuous intellectual personally. All authors revised the manuscript and approved the final draft.
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Foot Page Notes
1 This paper was inspired in the presentations and recommendations published on regard to the capacity building for research in primary care and family medicine, in the Wonca Meeting given in Kingston in 2003; and in the Advisory Process that analyzed the fulfillment of the Action Plan of the International Conference on Research for Development given in Bangkok in 2000 (IC2000), and in the new outlooks previous to the World Summit Conference on Health Research given in Mexico D.F., in November 2004.
2Mansourian BP. Global Perspectives in Health. In: UNESCO. Online Encyclopedia of Life Support Systems (EOLSS). Biological and Medical Sciences Chapter. Developed under the Auspices of the UNESCO. Oxford: EOLSS Publishers; 2005. Not yet available to the public: http://www.eolss.net/ Accessed to in 24th of March 2005.
3Stusser RJ. The Unity of Human Being Health Needs a Program of Human Health, Development, Medicine, and Behavior Projects, to Integrate with the Human Genome Project. Project presented in the 4th Global Forum and IC2000 at Bangkok, October 10-13, 2000. Available from: http://members.fortunecity.com/rational/integration2.html Accessed to in 24th March 2005.
Acknowledgements:
It is right to acknowledge the great support we received from MSc. Vivian Stusser and Margarita Graupera, in the detailed revision and redaction of this paper, moreover to Arch. María Dolores Espinosa, whose careful review and conceptual discussions in its several versions allowed us to present this.
