There is no standard like gold standard

‘It is a truth universally acknowledged, that a single editor in possession of a new journal, must be in want of a strong drink’

Adapted from Jane Austin’s Pride and Prejudice

Author: Stevan Bruijns

Editor: Jo Park-Ross

Much is written about knowledge translation, or breaking down science from journals so it can benefit real-world, patient encounters.  We want to know more so we can do more, and what we know is published in journals from science we have put together in the hope of serving our patients better.  In short, it is all about the patients (ignoring stuff like promotion, citations and a higher h-index of course).  There are 72 journals registered today that describe themselves as emergency medicine journals (yes folks, 72). Of these, 10 (14%) are registered in low-and middle income countries (in Eastern-Europe, Middle East, Asia and Africa – note there is none in South America) whilst the rest is registered in high-income countries.  Arguably this looks a little heavy on the high-income side.  So let me take it one step further; if we say research is really all about the patients we could express the number of journals in a region as a function of the potential patient population inhabiting that region.  Take a moment or two to soak in the information contained on these two maps before continuing.

Map showing the number of registered Emergency Medicine journals per country and continent.

Map showing number of journals in a region as a function of the potential patient population inhabiting that region.

Sure, I am obviously oversimplifying things.  Journals do not just publish material from their own regions, but from other regions too; however, I would wager that for the majority of out-of-region publications, publications remain largely within the same income band.  But is this really such a problem?  Many would say that several parts of emergency care are universal in their application.  And to some extend this is true, but only to some extent.  Take for instance CPR.  Defibrillator aside, one does not need many resources to bounce up and down on some poor soul’s chest.  But I will tell you what you do need and that is an ICU at the backend for those who have return of spontaneous circulation, and ICUs don’t grow on trees, not in high income settings, and much, much less so in low-and middle income settings.  And the same argument goes for many well-meant standards of care, or gold standards as it is referred to colloquially: stroke, sepsis, injury, acute coronary syndrome to name but a few.   So what is important to understand when we view these maps is that it reveals exactly where gold standards are penned. Gold standard, it turns out, is the top prize you achieve when you do it right in a high income setting and the unachievable, unreachable standard if you practice anywhere else.  To me that does not sound quite right.

Anywhere else is big.  The World bank tells us that 71% of the world’s population live in low income settings (earning less than $1025 per annum) with an additional 22% living in middle income settings (earning less than $12475 per annum).  Imagine trying to publish a study that promotes a bundle of care that only applies to 7%, or at the very most 29% of the affected sample.  It would, to put it quite simply, never see the light of day.  But this is what we do and frankly it is not surprising.  Is it perhaps that when we come to publishing we are not truly altruistic in our motive?  Are the lure of promotion, citations and a higher h-index a stronger motivation?  I do believe it is that, and lots and lots of ignorance.  But the problem does not stop there.  It goes far deeper than a set of skewed reference standards.  If low- and middle income countries were able to access those huge volumes of papers published in journals representing high income settings they might consider the accepted gold standards and attempt to contextualise or adapt it for local use.  It is not the ideal solution, but it is at the very least a start.  All they would need is access.

Publish or perish is not the nicest of prospects to build a career on and I am not fully convinced that fundamentally we understand this fully.  A local undergraduate project I supervised looked at access to African Emergency Care research publications.  Surely if Africa is to provide answers for African problems we should not simply be able to do the research, but also access it.  The study included 668 original research papers and reviews published between 2011 and 2015.  Following a stepwise approach we first identified all open access papers; then from the remaining papers we identified those that could be found in repositories, etc. and finally we identified the papers that authors would provide on request.  Quite unexpectedly the findings showed that African authors preferred open access publication, whilst non-African authors (three out of every ten corresponding authors) preferred subscription.  A full 107 (16%) papers remained inaccessible.  Only a third of authors who were requested for a copy of their paper responded in kind.  I did not anticipate that.

Now you can always trust a country with a worse economy than your own to be a budget destination for a holiday.  Everything tends to be cheaper and you can be sure to get more value for your money than you would back home.  The Big Mac index, published annually by the Economist, describes this phenomenon as a representation of the true currency value, or buying power of a currency.  In short, the reason everything is cheaper at your holiday destination is simply because your holiday destination’s currency is undervalued compared to where you are from.  Should the locals from you holiday destination try to visit your home country the reverse would apply to their detriment.  So in the same, oversimplifying vein we might apply currency value to accessing those 107 papers left behind subscription charges.  Using this argument a researcher from South Africa will feel much more out of pocket spending £23 to access a paper from a certain subscription journal than a researcher from England would spending the same amount.  In fact if we were to equalise the value using the South African charge, the English researcher would have to spend £43 – I know of no-one that desperate to access a paper.

And herein lies the great paradox of international research.  High income countries spend huge amounts on research and development, producing solutions of a high standard that requires significant resources.  But these solutions are limited in their application to only a small proportion of the world’s population; the volume of publications make its contribution appear larger than it really is.  Article access charges largely picked up by research institutions in high income settings are passed to the researcher in low- and middle income settings.  It is a destructive cycle that results in more for those who have more and less for those that don’t.  So what can you do?  Well for starters each time you have a debate about the merits (or not) of stroke thrombolysis, the value of video laryngoscopy or the utility of ECMO, bear in mind that at least 71% of the world are not involved in the conversation.  Publish open access, and if for some reason you cannot, deposit your article in a formal repository such as ResearchGate, Academia.edu, etc.  Get involved in publication mentorship programmes such as Author Assist.  If you are in a position of influence on a national, regional or international conference organising committee, ensure you invite presenters that can speak for the huge low- or middle income group your local speakers are unlikely to do.  Be aware that these speakers will not be able to fund attendance themselves.  If you can afford it, get the low- or middle income speakers to represent themselves.  Support researchers from low- or middle income settings at conferences such as DevelopingEM and the African Conference on Emergency Medicine.  And in doing so promote an awareness to help increase our efforts to improve emergency care irrespective of income band worldwide.  We are all in this together, so it is worth rather than doing the #mostforafew to do the #mostforthemost.