Africa's neglected area of human resources for health research - the way forward.

Building the skills for doing, managing and delivering health research is essential for every country's development. Yet, human resources for health research (HRHR) are seldom considered in Africa and elsewhere. Africa's health research capacity has grown considerably, with potential to increase this growth. However, a systemic way of defining, co-ordinating and growing the HRHR needed to support health systems development is missing. Reviewing the status of HRHR in Africa, we assert that it consists of uncoordinated, small-scale activities, primarily driven from outside Africa. We present examples of ongoing HRHR capacity building initiatives in Africa. There is no overarching framework, strategy or body for African countries to optimise research support and capacity in HRHR. A simple model is presented to help countries plan and strategise for a comprehensive approach to research capacity strengthening. Everyone engaged with global, regional and national research for health enterprises must proactively address human resource planning for health research in Africa. Unless this is made explicit in global and national agendas, Africa will remain only an interested spectator in the decisions, prioritisation, funding allocations, conduct and interpretation, and in the institutional, economic and social benefits of health research, rather than owning and driving its own health research agendas.

Evolving values in ethics and global health research.

Over the past 25 years, the ethics of international health research have shifted from addressing narrow issues such as cultural differences in informed consent practices towards a greater emphasis on development and social justice. We anticipate that the next 'era' in international research ethics will involve an intensification of this focus on the role of research in achieving global justice. Three values, in particular, will shape how ethics considerations should evolve: solidarity; respect for Southern innovation; and commitment to action. We expect continuing debate on whether researchers and research sponsors should recognise more than a minimal set of obligations for the care and benefit of research participants and their communities. As the debate about the role of research in development intensifies, we expect to see new and more elaborate mechanisms for financing on-going access to beneficial interventions, ancillary care and other research-related benefits, as well as a greater involvement in research funding by developing country governments and private foundations. Ethics review and oversight need to reflect on these new values and on ways of operationalising them, or risk becoming marginalised in the research process.

National health research system mapping in 10 Eastern Mediterranean countries.

Health research systems in the Eastern Mediterranean Region are not well developed to generate and use knowledge to improve health, reduce inequity and contribute to economic development. This study aimed to provide core data on National Health Research Systems (NHRS) in 10 Eastern Mediterranean countries in order to inform actions to strengthen health research system governance and management. Whilst there were examples of good practice, few countries had a formal NHRS and many basic building blocks needed for an effective system had not been put in place. Although limited in focus, the study provides useful information for countries to initiate action to strengthen their NHRS.

National health research system mapping in 10 Eastern Mediterranean countries

Health research systems in the Eastern Mediterranean Region are not well developed to generate and use knowledge to improve health, reduce inequity and contribute to economic development. This study aimed to provide core data on National Health Research Systems [NHRS] in 10 Eastern Mediterranean countries in order to inform actions to strengthen health research system governance and management. Whilst there were examples of good practice, few countries had a formal NHRS and many basic building blocks needed for an effective system had not been put in place. Although limited in focus, the study provides useful information for countries to initiate action to strengthen their NHRS

Unmet health, welfare and educational needs of disabled children in an impoverished South African peri-urban township.

BACKGROUND: Childhood disability in South Africa has failed to receive adequate attention from governmental agencies, such as the health, education and social welfare departments, despite there being more than 1 million disabled children in the country. This study sought to assess the unmet rehabilitation, education and welfare needs of disabled children living in a peri-urban township. METHODS: As no register of disabled children existed, snowball sampling was used to recruit a convenience sample of 156 disabled children living in Orange Farm township near Soweto, South Africa. Children's impairments, their health and educational needs, and the availability and utilization of services were assessed using a structured interview. RESULTS: Few disabled children attended pre-school (35%) or school (44%). Only a quarter (26%) of children in need of rehabilitation received such services. Children with motor impairments were more likely to receive rehabilitation than those with intellectual impairment (44% vs. 8%, P < 0.0001). Of the 233 assistive devices required, only 64 (28%) had been issued. Less than half (45%) of the children entitled to a social assistance grant were receiving it. Lack of money, limited awareness about available services, and bureaucratic obstacles were the main reasons offered by caregivers for the low utilization of available services and resources. CONCLUSION: Children with disabilities living in Orange Farm are not enjoying the rights and services to which they are entitled. Innovative, co-ordinated service delivery strategies, and better-informed caregivers combined with community recognition of, and support for, the needs of disabled children are required to address these unmet needs.

Mapping Africa's advanced public health education capacity: the AfriHealth project.

OBJECTIVE: Literature on human resources for health in Africa has focused on personal health services. Little is known about graduate public health education. This paper maps "advanced" public health education in Africa. Public health includes all professionals needed to manage and optimize health systems and the public's health. METHODS: Data were collected through questionnaires and personal visits to departments, institutes and schools of community medicine or public health. Simple descriptive statistics were used to analyse the data. FINDINGS: For more than 900 million people, there are fewer than 500 full-time staff, around two-thirds of whom are male. More men (89%) than women (72%) hold senior degrees. Over half (55%) of countries do not have any postgraduate public health programme. This shortage is most severe in lusophone and francophone Africa. The units offering public health programmes are small: 81% have less than 20 staff, and 62% less than 10. On the other hand, over 80% of Africans live in countries where at least one programme is available, and there are six larger schools with over 25 staff. Programmes are often narrowly focused on medical professionals, but "open" programmes are increasing in number. Public health education and research are not linked. CONCLUSION: Africa urgently needs a plan for developing its public health education capacity. Lack of critical mass seems a key gap to be addressed by strengthening subregional centres, each of which should provide programmes to surrounding countries. Research linked to public health education and to educational institutions needs to increase.

Provision of HIV treatment in HIV preventive vaccine trials: a developing country perspective.

HIV treatment for participants who become infected during HIV vaccine trials has been the focus of ethical controversy. The obligations of sponsors to ensure that participants have access to antiretrovirals have been a particular focus of this debate. This paper presents three arguments that have been made in this regard, and some of their limitations, in anticipation of HIV vaccine trials in South Africa. The first argument is that HIV risk behaviour increases in such trials, and HIV infection can be viewed as a research-related injury, justifying sponsor provision of treatment on grounds of compensation for harm. We conclude that risk-behaviour studies to date do not show general increases in risk behaviour that could constitute the basis for a general obligation. Participation may well adversely impact on risk behaviour for some individuals, and conceivably this could be demonstrated. This argument may, therefore, have merit at the individual level; however, it seems a weak platform from which to argue that sponsors should treat all HIV infections acquired during trials. The second argument is that treatment should be provided based on distributive justice. We conclude that traditional concepts of "distributive justice" in research appear limited in justifying obligations of sponsors to ensure access to antiretrovirals. Further, using research initiatives to reduce global health care inequities is controversial, and even proponents may disagree about the fairest use of finite resources. The third argument is that sponsors should ensure antiretroviral access on grounds of beneficence; namely, the maxim that if one can do something beneficial without sacrificing anything of comparable significance, it ought to be done. Thus, sponsors should provide more interventions than those minimally required to conduct the research. However, beneficence may demand levels of altruism that exceeds what is reasonable. While the latter arguments may provide stronger justifications than the first, it is difficult to use these arguments to establish that sponsor provision of antiretrovirals to infected individuals is obligatory.

The pharmacy screening project--an evaluation of pharmacy-based screening programmes.

OBJECTIVES: The purpose of this study was to establish the proportion of pharmacies providing screening tests in the areas of Pretoria, Potchefstroom and Klerksdorp, the types of tests used and their cost to patients, the criteria employed to select high-prevalence groups, the attitudes of pharmacists towards screening, and their knowledge of test characteristics. SETTING: In Pretoria, 155 pharmacies were randomly selected and all 43 pharmacies in Potchefstroom and Klerksdorp were included. METHODS: The pharmacies included in the study sample were first contacted by telephone to identify those providing screening tests. Pharmacies that provided screening tests and agreed to participate in this study were then visited and a questionnaire was administered. RESULTS: 57% of the pharmacies provided at least one type of screening test. Blood pressure measurement, serum cholesterol, capillary glucose and pregnancy testing were the most common screening tests available. With the exception of blood pressure measurement, the screening tests were conducted less than 5 times per week. All respondents referred clients with abnormal results to general practitioners but only 35% of pharmacies kept records of the patients tested and the test results. The knowledge of pharmacists concerning the important features of screening tests, such as false-positive and false-negative rates, was poor. No quality control procedures for the screening tests were employed. CONCLUSIONS: Providing pharmacists with specific training in the application and interpretation of screening procedures, and implementing quality control measures will reduce the number of false referrals or non-referrals, and will improve the quality of the service. If pharmacies are to play a meaningful role in screening for disease, coverage of the population will need to be increased substantially.

Adding alpha-amylase to weaning food to increase dietary intake in children. A randomized controlled trial.

The addition of alpha-amylase to a food supplement for weaning-age children was proposed as an alternative to traditionally prepared Amylase-Rich Foods (ARF) for reducing the dietary bulk of weaning diets. In a self-controlled clinical trial including 30 healthy children, aged 10-24 months, the effect of the addition of alpha-amylase and extra cereal to a diet including three meals, was determined in terms of dietary intake. A mean increased intake of 23.8 per cent in energy and 10.4 per cent in protein was found. The addition of commercial alpha-amylase to maize-based weaning foods is a useful method of increasing the nutritional value of weaning diets.

The year in review

Health was again never far from the headlines during 1996/97. This chapter highlights many of those moments that grabbed the public's attention. It also points out some of the achievements; problems and changes of the health sector that were not so attention grabbing in the eyes of the media; but which were at least important in the long term transformation of the health sector

Desegregating health statistics and health research in South Africa.

OBJECTIVE: This article aims: (i) to re-examine the use and usefulness of categorisation based on 'race', ethnicity and 'population group' membership in public health research; and (ii) to assess the consequences of using these categories for describing, analysing and redressing disparities in health within South Africa. The utility of categorisation based on 'race', ethnicity and 'population group'. Categorising populations and comparing patterns of disease between different groups of people can be a useful technique for identifying potential causes of disease. In this context, ethnicity is a valid social concept that could be used to investigate the consequences of self-ascribed identity on health. Likewise, 'population group', as defined during apartheid in South Africa, represents a valid political concept that could be used for assessing the impact of social discrimination on health. However, both these concepts are often seen, and used, as euphemisms for 'race', even though there are no genetically distinct human subspecies that can be identified and categorised as discrete 'races'. Indeed, 'race' as a biological concept has no validity in human biology. Nevertheless, categories based on 'race', ethnicity and 'population group; continue to be used in health research, and reinforce the perception that differences in disease between different 'racial', ethnic and 'population' groups are the result of heritable biological characteristics. In so doing, they undermine support for health interventions that would otherwise address the social and political origins of 'racial' and ethnic disparities in health. The utility of 'population group' for redressing the consequences of apartheid. Despite these problems, 'population group' classification provides important information for assessing the impact of apartheid on disparities in health within South Africa. Yet, the abolition of apartheid legislation is likely to result in extensive socio-economic and geographical migration that will weaken the sensitivity and specificity of 'population group' as an indicator for identifying inequalities in health. For this reason, targeting corrective action at specific population groups in order to tackle disparities in health, runs the risk of ignoring alternative social causes of inequalities in health, and ignoring disadvantaged individuals from elsewhere in the population. The continued use of 'population group' classification might also perpetuate the root cause of disparities in health, by maintaining the process used to formalise discrimination. CONCLUSION: If the purpose of health research is to monitor inequalities in health and to help target resources aimed at reducing these inequalities, then it should seek, in its language, concepts and methods to undermine the root cause of disadvantage. Health research aimed at monitoring and redressing the consequences of social disadvantage on health should therefore focus on non-biological determinants of social disparities in health. As a general rule, health researchers should avoid using categories based on 'race', ethnicity and 'population group' when collecting and analysing health data; journal editors should not accept articles that use these categories without justification; and health authorities should not collect data routinely segregated by 'race', ethnicity or 'population group'.

An assessment of the statistical procedures used in original papers published in the SAMJ during 1992.

OBJECTIVE: To assess the statistical procedures used in original papers published in the SAMJ. DESIGN: Descriptive study based on a random sample of 100 papers from the 153 papers with methodological content that were published in the SAMJ during 1992. RESULTS: This review showed that 34% (95% CI (25%; 43%)) of papers used no statistical procedure at all or used simple descriptive statistics only. In sampling methods, there was a predominance of the use of the period sampling method as opposed to probability sampling methods. Inappropriate statistical methods were used in 15% (6%; 24%) of papers, while in 16% (9%; 23%) statistical procedures and in 13% (6%; 20%) the sampling methods used could not be identified. Inaccurate graphical methods were used in 17% (6%; 28%) of papers. Confidence intervals and power calculations are used far too infrequently, in 33% (19%; 47%) and 11% (3%; 19%) of appropriate papers respectively. If the Journal's readers are at least familiar with simple descriptive statistics, contingency table analysis, simple epidemiological statistics, t-test procedure and confidence interval calculation and interpretation, they will have a complete understanding of the statistical content of 60% of original articles published in the Journal. CONCLUSION: Guidelines for the statistical treatment of reported data and the statistical review of articles before publication will assist substantially in improving the quality of statistical analysis. More intensive use of available biostatistical and epidemiological expertise at the study design and analysis stages is needed to shift the emphasis from descriptive research to analytical investigation.

The reliability of mortality data in Johannesburg.

Information on deaths in Johannesburg is collected on a voluntary basis by the Johannesburg City Health Department from the Department of Home Affairs regional offices as well as state mortuaries in the area. The reliability of these routinely collected data was assessed. Records of deaths of Asians, coloureds and whites from 1 July 1989 to 31 December 1989 were included in the study. Burial orders obtained from the different cemeteries and crematoria in the area were compared with the routinely collected mortality data. Two thousand eight hundred and thirty-seven deaths were included in the study. One hundred and ninety (6%) deaths in the department's records could not be found among the corresponding burial orders while 1,019 (36%) burial order records were not found among the department's routinely collected mortality data. Underreporting of deaths was greatest among the aged (43%) and infants (39%). When this underreporting was taken into account, the corrected infant mortality rate was 19.1/1,000 live births as opposed to 14.1. Recommendations are made for the improvement of the quality of routinely collected mortality data.

AIDS in South Africa.

PIP: The National AIDS Convention in South Africa (NACOSA) in October 1992 was the first real attempt to address HIV/AIDS. In Soweto, government, the African National Congress, nongovernmental organizations, and organized industry and labor representatives worked for 2 days to develop a national plan of action, but it did not result in a united effort to fight AIDS. The highest HIV infection rates in South Africa are among the KwaZulu in Natal, yet the Inkatha Freedom Party did not attend NACOSA. This episode exemplifies the key obstacles for South Africa to prevent and control AIDS. Inequality of access to health care may explain why health workers did not diagnose the first AIDS case in blacks until 1985. Migrant labor, Bantu education, and uprooted communities affect the epidemiology of HIV infection. Further, political and social polarization between blacks and whites contributes to a mindset that AIDS is limited to the other race which only diminishes the personal and collective sense of susceptibility and the volition and aptitude to act. The Department of National Health and Population Development's voluntary register of anonymously reported cases of AIDS specifies 1517 cumulative AIDS cases (October 1992), but this number is low. Seroprevalence studies show between 400,000-450,000 HIV positive cases. Public hospitals cannot give AIDS patients AZT and DDI. Few communities provided community-based care. Not all hospitals honor confidentiality and patients' need for autonomy. Even though HIV testing is not mandatory, it is required sometimes, e.g., HIV testing of immigrants. AIDS Training, Information and Counselling Centers are in urban areas, but not in poor areas where the need is most acute. The government just recently developed in AIDS education package for schools, but too many people consider it improper, so it is not being used. The poor quality education provided blacks would make it useless anyhow. Lifting of the academic boycott will allow South African researchers to catch up with AIDS research.^ieng

Cancer of the pancreas and drinking water: a population-based case-control study in Washington County, Maryland.

A case-control study was done to assess a potential association between drinking water and pancreatic cancer in Washington County, Maryland. Cases of pancreatic cancer occurring from 1975 through 1989 were identified from the cancer registry. Controls were selected from the private 1975 census of Washington County. There were 101 cases and 206 controls. Chlorinated municipal water was used as a source of drinking water by 79% of cases and 63% of controls, yielding a significant odds ratio of 2.2. Adjustment for age and smoking had almost no effect on the risk, although both age and smoking were independently associated with an increased risk of pancreatic cancer. Although these findings must be interpreted with caution because of limitations in exposure assessment, these results have implications for the prevention of pancreatic cancer because chlorination of water is so widely practiced.