- Email: [email protected]
Problems Encountered in High-Level Research in Developing Countries
opinions/hypotheses Problems Encountered in High-Level Research in Developing Countries* Moises Selman, MD, FCCP; Rogelio Perez-Padilla, MD; and Annie Pardo, PhD
I
(CHEST 1998; 114:610-613)
n developing countries, scientific and medical research faces many complex problems. While there is a fundamental belief that medicine cannot advance without scientific research, there is also a mistaken belief in many developing countries that research is the sole domain of industrialized nations. This delusory notion defeats us even before we begin. In developing countries there exists a complexity of entrenched limitations that translates into deficient scientific growth and, consequently, scarce biomedical research. These limitations derive from various causes, including scarce government funding and almost zero private investment, insufficient number of scientists as well as medical and graduate students, and inadequate public policies for research and development.
GOVERNMENT INVESTMENT IN RESEARCH
Many of the problems that confront scientific development are directly related to the educational and economical strategies of our governments. In turn, this translates into the small amounts of funding that governments direct toward research activities. The United Nations' Education, Science, and Cultural Organization (UNESCO) recommends that countries dedicate at least 2% of their gross domestic product to research and development. However, developing countries appropriate significantly less. In Latin America for example, the ratio between the expenses assigned to research and development, and the gross domestic product was, at the beginning of the 1990s, approximately 0.4%. This is extremely low *From the Instituto Nacional de Enfermedades Respiratorias, Mexico and Facultad de Ciencias, Universidad Nacional Aut6noma de Mexico. Manuscript received April 24, 1998; accepted April 30, 1998. Correspondence to: Moises Selman, MD, FCCP, Instituto Nacional de Enfermedades Respiratorias, Tlalpan 4502; Col. Secci6n XVI, Mexico DF, CP 14080, Mexico; email: mselman@mailer. main. conacyt. mx 610
compared with the United States and Japan (2.8%), Canada (1.5%), or Israel (1.9%) in the same period. There are also important differences between Latin American countries; for instance, Brazil spent 0.66%, Argentina 0.80%, Mexico 0.30%, and Paraguay 0.03%.1-4 In addition, the participation of private industry is practically nonexistent, and of course it is notably inferior to private participation in industrialized nations, where it is estimated that approximately 30 to 50% of the overall research conducted is funded by the private sector. 4 In general, Latin American countries have inadequate research budgets, and there is a growing gap in the amount of scientific resources of industrialized countries vs those of the developing world. One of the major problems in some developing countries is that the governments must constantly continue to pay off the exorbitant external debt, which lessens the amount of funding that could potentially be used for education and research, and for health-care. Unfortunately, in Latin American countries, biomedical and, in general terms, scientific research are dispensable, and any economical trouble is immediately translated into a reduction of the budget for science. In this sense, the contributions of scientists from Latin America to science and culture would be much more substantial if they were the result of not only the individual talent and effort, but also the consequence of a public policy.
GOVERNMENT OFFICIALS
Administrators who determine the destiny of science, at least economically speaking, are experts in financial planning. They are adept in calculating cost-effectiveness and in optimizing resources, and tend to be lovers of quantity and not of quality. Similarly, when scientists become administrators, they acquire a similar way of thinking, and end up smothering our best intentions. Some of the problems this creates are as follows . Opinions/Hypotheses
Priorities
Lack of Resources
B~reaucrats imagine that biomedical research should resolve all national health problems. However, this belief is based on two assumptions: (1) that all health problems in our countries are recognized; and (2) that these problems can be solved through research. Nevertheless, these assumptions are not based on objective data. In the first place, the process by which we identify all of our health problems is now problematic. In general terms, developing countries can rarely count on reliable information about the exact extent and nature of their indemic diseases. This, in turn, makes it difficult to establish priorities. Naturally, despite these deficiencies, we can infer what the most pressing health problems are in developing countries. The first things that jump to mind are malnutrition and infectious diseases. But it is obvious that a large part of these problems have recognizable solutions. Malnutrition can be cured by . . . eating. Rates of infectious diseases are reduced when levels of hygiene and socioeconomic and cultural status of the population are raised, and when the people are vaccinated and treated against sources of infection. On the other hand, these obvious priorities generate a smoke screen that prevents us from seeing other diseases that require increasingly attention, from both the public health and biomedical research points of view. Given the importance of scientific research in the development of knowledge, science is, per se, a priority and it must grow and stimulate itself separately from the field in which the individual scientist works.
The lack of resources for research create many problems. For example, as researchers we cannot purchase equipment, nor can we react appropriately to new developments. This puts our laboratories at a great disadvantage. Similarly, this situation together with austerity create a drain on current brains that emigrate to industrialized countries, mainly the United States, which limits the formation of new human resources. It is important to point out that in Mexico, for example, the number of scientific researchers in all the areas is 1 per 10,000 inhabitants, while in developed countries it is 20 to 60 per 10,000 inhabitants.4
Government Spending Another significant error is represented by the following thoughts: we are a poor country and the government should not be spending money on such esoteric things as research. This is a dangerous mistake, and it becomes obvious that the problem is based on a conceptual vision of what is needed for the future . If our desire is to become more developed countries, scientific and technological research is a crucial key. Constant dialogue is important to convince governmental authorities that they must carefully measure the consequences of a policy of austerity applied toward education and science. If we do not promote research, the result will surely be that we will continue to flounder in scientific under-development. As a result, the breach that separates us from industrialized countries will reach insurmountable proportions .
ACCESS TO INFORMATION
The search for information occupies a fundamental part in the development of science. However, austerity policies, currency devaluation, inflation, and the cost of research and medical journals, which have increased considerably, provoke a severe problem in this aspect. In this context, visiting the majority of libraries in developing countries is a devastating experience and is most often fruitless because the journals that researchers may or may not find are outdated. Although the development of electronic information systems has notably improved, there is still limited access to these systems in many institutions in developing countries, especially the poorest ones. Moreover, these systems still cannot replace reading complete articles in printed journals. SOCIETY
The idea that scientists are not a part of society doesn't help matters either. In contrast to industrialized countries, people in developing countries look on scientists as strange beings and view them with unchanging stereotypes. Citizens in developing countries often do not really know what scientists do or what purpose they serve. And, therefore, scientists do not register on their scale of values . We need to educate our citizens about the role that their own scientists may play. OUR COLLEAGUES
Although it seems incredible, another great limitation facing biomedical research development is the medical establishment. This factor is very important, and probably the most painful to realize. CHEST I 114 I 2 I AUGUST, 1998
611
The great number of responsible doctors who work in the clinical setting are either indifferent or dismissive of research, especially if it has to do with the so-called basic sciences. This is due in part to the fact that clinicians have a similar vision to that of citizens who, in general terms, believe that research is a subject isolated from reality and such work is not really that important. This attitude is an extremely complex problem that is probably influenced by many factors , most notably being level of education. In the education of a medical doctor, the concept of scientific research fails to exist. When it does exist in a student's academic medical training, it is presented as a separate entity having little to do with the practice of medicine and the care of patients. In general, medical students count the days until they can begin to think where and when, according to them, they will really begin their medical studies. In other words, we are creating doctors without providing training in scientific research, scientific methods, experimental design, analysis of data, and the ways of diverging from conventional knowledge. In this way, the teaching of basic sciences and scientific methodology is reduced to a mere requirement that the students and their teachers pass over as quickly as possible. Another point is our own lack of confidence. This is characterized by our belief that everything that comes from overseas, primarily from tl1e United States, is better than ours. That is why many of our clinicians prefer to be consumers rather than producers of science.
PERSONAL AND INSTITUTIONAL PROBLEMS
Biomedical research generally requires the consensus of a heterogeneous group of scientists that, with different disciplines, increase the efficiency and richn ess of the results. In turn , this requires professional maturity. Moreover, it requires limited jealousy-driven infighting in order to ensure that ideas and technical abilities are fully shared, something which often does not occur. There are also institutional factors that seem to oppose teamwork, including bureaucratic incongruencies and problems in determining how funds and equipment are to be distributed. While many scientists in developing countries are aware that the progress of medicine is associated with the progress of knowledge, there also exists a complex and enormous quantity of inter-related problems that join together to torpedo their development. The result is an infinitesimal amount of written contributions to, and lack of confidence among, the editorial boards of international research 612
and medical journals who would publish the data coming from our countries. 5·6 Regarding this problem, it is important to mention that many scientists and journal editors point to subtle prejudices that prevent researchers in poor nations from sharing their discoveries with the industrial world. 6
RESEARCH IN PULMONOLOGY
The study of pulmonology, a discipline we are currently developing, illustrates additional problems. During the first half of this century, the primary focus of respiratory medicine was the prevalence of tuberculosis. After World War II, the lung was recognized as an organ of multiple and complex functions , as well as a target for many pathologies. As a consequence, the field of pulmonary research in industrialized nations was opened wide and began drawing upon many aspects of research, especially basic science. In our countries, however, tuberculosis remained the primary focus of our specialists, which in tum delayed our specialists from broadening their view to incorporate a more modem view of the respiratory system. This, in turn, stymied comprehensive pulmonary research and necessary teaching programs. Only recently have some contemporary scientific topics been introduced to our pulmonologists. Only now are we seeing a substantial change in the practice of pulmonology and the methods by which we train physicians. Generally speaking, medical practice attracts most pulmonologists, and yet, the medical practitioner does not see him/herself as a scientist. Thus, our pulmonary medicine divisions in most hospitals are neither suitable nor stimulating environments for the physician/scientist, as a bridge between clinical and basic sciences, causing a progressive backwardness. Moreover, the nature of many new disciplines, especially molecular biology with the advent of recombinant DNA technology and genetic engineering, has changed so fast that the field of respiratory medicine in developing countries has been literally bypassed by this scientific revolution. While the tools of molecular biology are now yielding insights into the mechanisms of disease, the new vocabulary generated by this discipline is only now scarcely becoming familiar to our specialists. We hope that, in the near future , our medical schools and residency programs will adopt modern and revolutionary curricula to reflect the profound changes in medical knowledge.
REFERENCES l OECD. Main science and technology indicators. Paris: Organization for Economical and Cooperative Development, 1994 Opinions/Hypotheses
2 United Nations' Education, Science, and Cultural Organization (UNESCO) Division of Statistics. Meeting of experts on the improvement of the coverage, reliability, concepts, definitions, and classification in the field of science and technology statistics. Paris: UNESCO, 1994 3 United N ations' Education, Science, and Cultural Organization (UNESCO) Anuario Estadfstico. Paris: UNESCO, 1994
4 United Nations' Education, Science, and Cultural Organization (U NESCO). Informe Mundial sabre Ia Ciencia. Paris: UNESCO, 1996 5 Institute for Scientific Information (lSI). Science citation index, 1989-1993. Philadelphia: lSI, 1994 6 Gibbs VlW. Lost science in the third world. Scientific Am 1995 (August); 76-83
CHEST / 114 / 2 / AUGUST, 1998
613
I
(CHEST 1998; 114:610-613)
n developing countries, scientific and medical research faces many complex problems. While there is a fundamental belief that medicine cannot advance without scientific research, there is also a mistaken belief in many developing countries that research is the sole domain of industrialized nations. This delusory notion defeats us even before we begin. In developing countries there exists a complexity of entrenched limitations that translates into deficient scientific growth and, consequently, scarce biomedical research. These limitations derive from various causes, including scarce government funding and almost zero private investment, insufficient number of scientists as well as medical and graduate students, and inadequate public policies for research and development.
GOVERNMENT INVESTMENT IN RESEARCH
Many of the problems that confront scientific development are directly related to the educational and economical strategies of our governments. In turn, this translates into the small amounts of funding that governments direct toward research activities. The United Nations' Education, Science, and Cultural Organization (UNESCO) recommends that countries dedicate at least 2% of their gross domestic product to research and development. However, developing countries appropriate significantly less. In Latin America for example, the ratio between the expenses assigned to research and development, and the gross domestic product was, at the beginning of the 1990s, approximately 0.4%. This is extremely low *From the Instituto Nacional de Enfermedades Respiratorias, Mexico and Facultad de Ciencias, Universidad Nacional Aut6noma de Mexico. Manuscript received April 24, 1998; accepted April 30, 1998. Correspondence to: Moises Selman, MD, FCCP, Instituto Nacional de Enfermedades Respiratorias, Tlalpan 4502; Col. Secci6n XVI, Mexico DF, CP 14080, Mexico; email: mselman@mailer. main. conacyt. mx 610
compared with the United States and Japan (2.8%), Canada (1.5%), or Israel (1.9%) in the same period. There are also important differences between Latin American countries; for instance, Brazil spent 0.66%, Argentina 0.80%, Mexico 0.30%, and Paraguay 0.03%.1-4 In addition, the participation of private industry is practically nonexistent, and of course it is notably inferior to private participation in industrialized nations, where it is estimated that approximately 30 to 50% of the overall research conducted is funded by the private sector. 4 In general, Latin American countries have inadequate research budgets, and there is a growing gap in the amount of scientific resources of industrialized countries vs those of the developing world. One of the major problems in some developing countries is that the governments must constantly continue to pay off the exorbitant external debt, which lessens the amount of funding that could potentially be used for education and research, and for health-care. Unfortunately, in Latin American countries, biomedical and, in general terms, scientific research are dispensable, and any economical trouble is immediately translated into a reduction of the budget for science. In this sense, the contributions of scientists from Latin America to science and culture would be much more substantial if they were the result of not only the individual talent and effort, but also the consequence of a public policy.
GOVERNMENT OFFICIALS
Administrators who determine the destiny of science, at least economically speaking, are experts in financial planning. They are adept in calculating cost-effectiveness and in optimizing resources, and tend to be lovers of quantity and not of quality. Similarly, when scientists become administrators, they acquire a similar way of thinking, and end up smothering our best intentions. Some of the problems this creates are as follows . Opinions/Hypotheses
Priorities
Lack of Resources
B~reaucrats imagine that biomedical research should resolve all national health problems. However, this belief is based on two assumptions: (1) that all health problems in our countries are recognized; and (2) that these problems can be solved through research. Nevertheless, these assumptions are not based on objective data. In the first place, the process by which we identify all of our health problems is now problematic. In general terms, developing countries can rarely count on reliable information about the exact extent and nature of their indemic diseases. This, in turn, makes it difficult to establish priorities. Naturally, despite these deficiencies, we can infer what the most pressing health problems are in developing countries. The first things that jump to mind are malnutrition and infectious diseases. But it is obvious that a large part of these problems have recognizable solutions. Malnutrition can be cured by . . . eating. Rates of infectious diseases are reduced when levels of hygiene and socioeconomic and cultural status of the population are raised, and when the people are vaccinated and treated against sources of infection. On the other hand, these obvious priorities generate a smoke screen that prevents us from seeing other diseases that require increasingly attention, from both the public health and biomedical research points of view. Given the importance of scientific research in the development of knowledge, science is, per se, a priority and it must grow and stimulate itself separately from the field in which the individual scientist works.
The lack of resources for research create many problems. For example, as researchers we cannot purchase equipment, nor can we react appropriately to new developments. This puts our laboratories at a great disadvantage. Similarly, this situation together with austerity create a drain on current brains that emigrate to industrialized countries, mainly the United States, which limits the formation of new human resources. It is important to point out that in Mexico, for example, the number of scientific researchers in all the areas is 1 per 10,000 inhabitants, while in developed countries it is 20 to 60 per 10,000 inhabitants.4
Government Spending Another significant error is represented by the following thoughts: we are a poor country and the government should not be spending money on such esoteric things as research. This is a dangerous mistake, and it becomes obvious that the problem is based on a conceptual vision of what is needed for the future . If our desire is to become more developed countries, scientific and technological research is a crucial key. Constant dialogue is important to convince governmental authorities that they must carefully measure the consequences of a policy of austerity applied toward education and science. If we do not promote research, the result will surely be that we will continue to flounder in scientific under-development. As a result, the breach that separates us from industrialized countries will reach insurmountable proportions .
ACCESS TO INFORMATION
The search for information occupies a fundamental part in the development of science. However, austerity policies, currency devaluation, inflation, and the cost of research and medical journals, which have increased considerably, provoke a severe problem in this aspect. In this context, visiting the majority of libraries in developing countries is a devastating experience and is most often fruitless because the journals that researchers may or may not find are outdated. Although the development of electronic information systems has notably improved, there is still limited access to these systems in many institutions in developing countries, especially the poorest ones. Moreover, these systems still cannot replace reading complete articles in printed journals. SOCIETY
The idea that scientists are not a part of society doesn't help matters either. In contrast to industrialized countries, people in developing countries look on scientists as strange beings and view them with unchanging stereotypes. Citizens in developing countries often do not really know what scientists do or what purpose they serve. And, therefore, scientists do not register on their scale of values . We need to educate our citizens about the role that their own scientists may play. OUR COLLEAGUES
Although it seems incredible, another great limitation facing biomedical research development is the medical establishment. This factor is very important, and probably the most painful to realize. CHEST I 114 I 2 I AUGUST, 1998
611
The great number of responsible doctors who work in the clinical setting are either indifferent or dismissive of research, especially if it has to do with the so-called basic sciences. This is due in part to the fact that clinicians have a similar vision to that of citizens who, in general terms, believe that research is a subject isolated from reality and such work is not really that important. This attitude is an extremely complex problem that is probably influenced by many factors , most notably being level of education. In the education of a medical doctor, the concept of scientific research fails to exist. When it does exist in a student's academic medical training, it is presented as a separate entity having little to do with the practice of medicine and the care of patients. In general, medical students count the days until they can begin to think where and when, according to them, they will really begin their medical studies. In other words, we are creating doctors without providing training in scientific research, scientific methods, experimental design, analysis of data, and the ways of diverging from conventional knowledge. In this way, the teaching of basic sciences and scientific methodology is reduced to a mere requirement that the students and their teachers pass over as quickly as possible. Another point is our own lack of confidence. This is characterized by our belief that everything that comes from overseas, primarily from tl1e United States, is better than ours. That is why many of our clinicians prefer to be consumers rather than producers of science.
PERSONAL AND INSTITUTIONAL PROBLEMS
Biomedical research generally requires the consensus of a heterogeneous group of scientists that, with different disciplines, increase the efficiency and richn ess of the results. In turn , this requires professional maturity. Moreover, it requires limited jealousy-driven infighting in order to ensure that ideas and technical abilities are fully shared, something which often does not occur. There are also institutional factors that seem to oppose teamwork, including bureaucratic incongruencies and problems in determining how funds and equipment are to be distributed. While many scientists in developing countries are aware that the progress of medicine is associated with the progress of knowledge, there also exists a complex and enormous quantity of inter-related problems that join together to torpedo their development. The result is an infinitesimal amount of written contributions to, and lack of confidence among, the editorial boards of international research 612
and medical journals who would publish the data coming from our countries. 5·6 Regarding this problem, it is important to mention that many scientists and journal editors point to subtle prejudices that prevent researchers in poor nations from sharing their discoveries with the industrial world. 6
RESEARCH IN PULMONOLOGY
The study of pulmonology, a discipline we are currently developing, illustrates additional problems. During the first half of this century, the primary focus of respiratory medicine was the prevalence of tuberculosis. After World War II, the lung was recognized as an organ of multiple and complex functions , as well as a target for many pathologies. As a consequence, the field of pulmonary research in industrialized nations was opened wide and began drawing upon many aspects of research, especially basic science. In our countries, however, tuberculosis remained the primary focus of our specialists, which in tum delayed our specialists from broadening their view to incorporate a more modem view of the respiratory system. This, in turn, stymied comprehensive pulmonary research and necessary teaching programs. Only recently have some contemporary scientific topics been introduced to our pulmonologists. Only now are we seeing a substantial change in the practice of pulmonology and the methods by which we train physicians. Generally speaking, medical practice attracts most pulmonologists, and yet, the medical practitioner does not see him/herself as a scientist. Thus, our pulmonary medicine divisions in most hospitals are neither suitable nor stimulating environments for the physician/scientist, as a bridge between clinical and basic sciences, causing a progressive backwardness. Moreover, the nature of many new disciplines, especially molecular biology with the advent of recombinant DNA technology and genetic engineering, has changed so fast that the field of respiratory medicine in developing countries has been literally bypassed by this scientific revolution. While the tools of molecular biology are now yielding insights into the mechanisms of disease, the new vocabulary generated by this discipline is only now scarcely becoming familiar to our specialists. We hope that, in the near future , our medical schools and residency programs will adopt modern and revolutionary curricula to reflect the profound changes in medical knowledge.
REFERENCES l OECD. Main science and technology indicators. Paris: Organization for Economical and Cooperative Development, 1994 Opinions/Hypotheses
2 United Nations' Education, Science, and Cultural Organization (UNESCO) Division of Statistics. Meeting of experts on the improvement of the coverage, reliability, concepts, definitions, and classification in the field of science and technology statistics. Paris: UNESCO, 1994 3 United N ations' Education, Science, and Cultural Organization (UNESCO) Anuario Estadfstico. Paris: UNESCO, 1994
4 United Nations' Education, Science, and Cultural Organization (U NESCO). Informe Mundial sabre Ia Ciencia. Paris: UNESCO, 1996 5 Institute for Scientific Information (lSI). Science citation index, 1989-1993. Philadelphia: lSI, 1994 6 Gibbs VlW. Lost science in the third world. Scientific Am 1995 (August); 76-83
CHEST / 114 / 2 / AUGUST, 1998
613