Beautiful minds working together to save lives
Ashraf Fawzy Nabhan is professor of obstetrics and gynaecology, with an appointment at the Faculty of Medicine, Ain Shams University, Cairo, Egypt. A Cochrane contributor since 2006, he also serves as Middle East and North Africa Co-ordinator of The Cochrane Developing Countries Field, and as Director of the Egyptian Centre for Evidence-Based Medicine. Here he reflects on the importance of evidence-based medicine in improving health care in low- and middle-income countries, the challenges involved, and the role The Cochrane Collaboration does - and could - play.
It is true that “Science is organized knowledge and wisdom is organized life” (Immanuel Kant, German philosopher, 1724-1804). I believe we have a treasure of science and wisdom created and nurtured over years by beautiful minds working together in The Cochrane Collaboration. Developing countries must not lose the opportunity to capitalize on this treasure in order to achieve a meaningful reform of the way we provide health care. We simply cannot afford the cost of lost opportunity.
Evidence-based medicine (EBM) describes a pattern of practice, not a set of substantive opinions. It adopts a paradigm in which numerous individual researchers make contributions to the solution of a set of recognized problems.
Some would argue that evidence-based clinical decisions and policies are not feasible for implementation in developing countries. The desperate situation of health care in many developing countries, coupled with the lack of correct understanding of the essence of EBM, for example, in Egypt, tends to drive many policy makers and healthcare providers to marginalize, alienate and ignore evidence-based clinical decisions and policies as merely another one of those western innovations - extremely expensive and totally unsuitable for developing countries. These are wrong beliefs held with strong conviction, despite proofs to the contrary. In fact, it is exactly this desperate situation which justifies and mandates the practice of EBM in our countries. Most developing countries cannot cover healthcare expenses for the whole population, and the individual patient bears a substantial fraction of the cost. Healthcare providers rely on personal opinion and outdated poorly generalizable knowledge, and tolerate a great deal of uncertainty in their daily practice. Pharmacies, backed by vicious marketing media, are flooded with a myriad of products, listed for doubtful and uncertain indications. Those three factors synergistically translate into less efficient yet more expensive care, exacerbating individuals’ suffering and poverty.
Evidence-informed clinical decisions and policies work by dealing with all three issues of poor-quality health care – namely, overuse, underuse and misuse. We give people care they do not need, we fail to give people care that works, and we make mistakes during provision of care that result in adverse outcomes. Therefore, the plan is simple: we need to use the best available knowledge to create a more efficient, equitable and high-value healthcare system. This not only saves lives but would also save costs. Therefore, where financial resources are limited, as they are in most low- and middle-income countries, the provision of EBM is even more critical.
Consequently, we must work to rectify the false beliefs regarding EBM and its value in developing countries. Then, we must work relentlessly on the major challenge: the lack of correct knowledge and the large knowledge-to-practice gap. We must persistently send the message to create and raise awareness about effective interventions and the potential gains from using valid knowledge in policy and practice. We must use the soft power of The Cochrane Collaboration to encourage individuals and create a critical mass to change the pattern of practice, rather than give in to an existing reality of practice by opinion and personal experience.
Enhancing the contribution from developing countries to The Cochrane Collaboration is one of the ways to develop the soft power. The numbers of authors from developing countries and of systematic reviews relevant to developing countries are still deficient. In many developing countries, for example, in Egypt, the gap between intentions and actual contributions to the Collaboration is wide. Both the frustrated young generation and the resistant old generation contribute to this gap. There is some light at the end of the tunnel: a minority struggling to convince the older and to stimulate the younger. I believe The Cochrane Collaboration is actively encouraging the participation of authors from developing countries, as well as boosting the production of reviews relevant to developing countries. However, we remain ambitious for more. It would be of great impact to include at least one author from a developing country among the authors of every systematic review.
The Cochrane Collaboration has wonderful Online Learning materials available for all authors of Cochrane Reviews. Furthermore, the Collaboration runs fruitful and regular face-to-face training workshops. However, if we look at the location of workshops, for instance, in the last quarter of 2012, we can easily notice that more than 90% of workshops are conducted in developed and high-income countries, and that few training events are taking place in Africa or the Middle East. We need an ambitious, well-defined, co-ordinated training agenda. A group of enthusiastic trainers and mentors should be empowered to one end: to spread knowledge across all developing countries. I believe in the human touch, the personal charisma, and the magic of eye-to-eye contact in the transfer of organized knowledge for an organized life.
Saving lives is a great mission that only beautiful minds can accomplish. But is it “mission impossible”? I hope not.