Communicating health information in low and

middle income countries

Richard SmithEditor BMJ

www.bmj.com/talks

Some assumptions• You, the audience, between you know

much more than I do about this• All teach, all learn• In seminars the audience must do most

of the talking• Lao Tzu said: “Those who know do not

speak/Those who speak do not know.”• I talk too much

Two stories from the last week

• Final year medical students in Nigeria have never heard of evidence based medicine

• Calabar in Nigeria had no cybercafes two years ago; now it has 50. The medical school and the hospital do not have internet access. “The problem is ceasing to be access and more how to make sense of all this material.”

What I want to discuss

• The difference between information and knowledge

• The utility of information• Information flow to, from, and within

the poor world• What are the problems now?• What is the role of international

journals like the BMJ?

Information: the poet’s view

• Where is the wisdom we have lost in knowledge?

• And where is the knowledge we have lost in information?

• T S Eliot

The information paradox: Muir Gray

• “Doctors are overwhelmed with information yet cannot find the information they need when they need it.”

Information paradox

• “Water, water, everywhere

• Nor any drop to drink”

• The Rime of the Ancient Mariner

Utility of information

• Utility=relevance x validity x interactivity work to access

Utility of different sources of information

Information Source Relevance Validity Interactivity Work to access Utility

J ournal articles Low High Nil High Low

Textbook Medium Medium Nil Medium Medium

Colleague High Medium High Low High

What’s wrong with medical journals

• Don’t meet information needs• Too many of them• Too much rubbish• Too hard work• Not relevant• Too boring• Too expensive

What’s wrong with medical journals

• Don’t add value• Slow every thing down• Too biased• Anti-innovatory• Too awful to look at• Too pompous• Too establishment

What’s wrong with medical journals

• Don’t reach the developing world• Can’t cope with fraud• Nobody reads them• Too much duplication• Too concerned with authors rather

than readers

A comment on medical journals from Drummond Rennie, deputy editor (west),JAMA

• There seems to be no study too fragmented, no hypothesis too trivial, no literature citation too biased or too egotistical, no design too warped, no methodology too bungled, no presentation of results too inaccurate, too obscure, and too contradictory, no analysis too self serving, no argument too circular, no conclusions too trifling or too unjustified, and no grammar and syntax too offensive for a paper to end up in print.

How much time did you spend reading around your patients in the past week?

Stage of theircareer

Median readingtime (minutes)

% who reportedno reading in theprevious week

Medical students 90 0

House officers 0 75

Registrars 60 40

Consultants whograduated since1975

45 30

Consultants whograduated before1975

30 40

Reading of Bristol general practitioners

Activity Minutes

Reading in the library 35

Driving to and from thelibrary

70

How far behind are you with your reading?

• Number of journals 10 000• New articles a week 40 000• Time to read article 30 mins• A doctor spends all day reading; after

six weeks how far behind is he or she with his or her reading?

•A century

A reason to love economists

•Rational ignorance

Information flow to, within, and from the developing

world

Information flow to developing countries

• Has been desperately poor in the paper world

• Problem could perhaps never be solved in the paper world

• Those in the developing world had limited opportunities to select what they wanted

• High cost; slow distribution

Information flow to developing countries

• Many smallish organisations have tried to help but didn’t speak with a powerful voice

• Until recently little importance given to this by organisations like WHO, World Bank, etc

• Information less important than drugs, but is that true?

• Little evaluation

Information flow to developing countries

• The electronic world offers many new possibilities

• The HINARI (Health Internet Network for Access to Research Information) project involves nearly 30 publishers allowing access to the material free to institutions in the 68 poorest countries

• Over 2000 medical journals, all the major ones

Information flow to developing countries

• 438 institutions in 56 countries have registered

• More than a 100 use regularly• These institutions actually have

access to more journals than the world’s richest medical schools

Information flow to developing countries

• Phase 2 launches on 31 January 2003• Extends to another 42 countries• They pay $1000, but the money is kept

by WHO to pay for training, connectivity, etc

• BMJPG makes access to all of its journals free to everybody in the 100 poorest countries in ther world

Remaining problems with information flow to developing

countries

• Poor connectivity: unavailable, slow, expensive, often down

• No training• Access only in institutions; aimed

mainly at researchers and policy makers

• Mostly in English

Remaining problems with information flow to developing

countries

• Most of the material is not very relevant or useful

• Need to reach frontline healthcare workers with appropriate material

• Need to create a culture of reading, learning, debating, and “creating knowledge”

• How to move from information to knowledge?

Initiatives to respond

• Many initiatives• Bid to Gates Foundation (including

LSHTM, BMJPG) to pilot a project to supply information to third world partners, prepare locally appropriate material, and disseminate

• Health Resource Centre in Calabar, Nigeria--connectivity and training

Information flow within and from the developing world

• Generally poor• Few resources for research• Lack of trained people• Many journals but often with very limited

resources, untrained, lone editors, and not indexed; no electronic versions

• Authors send best research to international journals

Initiatives to improve information flow within and from the developing

world• Local indexes and networks--in Latin

America• WAME (World Association of Medical Editors):

offers resources, training, support, contact• Regional networks of editors• Partnerships with journals from richer

countries• Future phase of HINARI will be about

promoting local publishing

Role of international journals like BMJ

• Provide free electronic access• Increase the amount of material

relevant to the developing world (still low but doing better)

• Increase the proportion of authors and reviewers from the developing world

• Rapid responses and electronic submission systems have helped

Role of international journals like BMJ

• Should we have a special section called “Research from the south”?

• Should we have a quota or target for the proportion of southern authors?

• What about local editions of the BMJ? China, South Asia, West Africa. Are these colonial?

Four key questions• Can the developing world avoid the

informaton paradox of the developed world?• How to encourage cultures of reading,

debating, reseraching, and creating knowledge?

• How to improve flow of information within the developing world and from the developing world to the richer world?

• What is the role of journals like the BMJ?