Erasing the global divide in health research

Collaboration provides answers relevant to developing and developed countries

Developing and developed countries are often viewed separately with respect to their health problems, health systems, and health services research. So although more than 90% of the world's “potential years of life lost” belong to the developing world, only 5% of global research funds are devoted to studying the developing world's health problems.1 Chronic diseases such as cancer, heart disease, and mental illness are usually regarded as problems of the developed world, but, as people live longer, developing nations will need strategies to cope with the associated health burden. Morbidity and mortality from communicable diseases are largely problems of the developing world but there are notable exceptions, in particular HIV infection. And for many healthcare problems the solutions are the same, irrespective of the developmental stage of the country.

When deciding whether to implement a specific healthcare intervention, in whatever setting, there are certain basic steps that should be taken. These include: appraising local needs and health priorities, evaluating the strength and generalisability of the evidence, and estimating the likely cost-benefit ratio to both the health service and the community. In addition, interventions based on research in developed countries should be put to two further tests by health service planners in developing countries: firstly, an assessment of the feasibility of introducing the intervention within the existing health service, and, secondly, an assessment of its cultural sensitivity. Studies must be relevant to the population in which they are carried out.2

A systematic review of the effect of family intervention strategies for patients with schizophrenia showed that such interventions reduced the relapse rate in patients from Europe, North America, and China.3 However, there were striking variations in the emotional responses and styles of coping adopted by relatives in different countries.4 Use of a standardised intervention across cultures may not always be appropriate. Microethnographic techniques can be used to develop interventions that are more culturally orientated.5

High quality collaborative research conducted in developing countries can provide evidence of relevance and value to the developed world. Many health conditions, such as eclampsia and neurocysticercosis, occur so rarely in developed countries that clinical trials could never be conducted there. In such instances advances in our understanding of the treatment of these conditions are likely to come from developing countries. For example, the use of anticonvulsants in the management of eclampsia has been the subject of controversy for over 70 years, but a recent randomised trial conducted in South America, Africa, and India (though largely coordinated from Britain) demonstrated that magnesium sulphate was the drug of choice.6 The results of this trial have been widely accepted by the international obstetric community; for example, the Royal College of Obstetricians and Gynaecologists (London) is currently incorporating this evidence into its practice guidelines.

There are many advantages to conducting research in developing countries: the availability of patients, the existence of well trained investigators, the lower costs, and the benefit to health systems and other institutions from financial investment. Many trials of international relevance could be effectively carried out in developing countries. Indeed, the number of international publications on health research from developing countries has increased steadily over the past two decades.7

From the examples cited above, it is clear that the future of health services research lies in international collaboration. Aggregating results of well conducted randomised clinical trials from developing and developed countries is both desirable and practical, as has been clearly shown by the work of the Cochrane Collaboration.3 8 People from developing countries are currently producing Cochrane reviews; some are using these as the essential starting point for their own high quality primary research. Such multinational collaboration is the surest way to answer questions of global relevance.