Research in Family/General Practice is Essential for Improving Health Globally

Dear Distinguished Guest Editors Dr. Walter W. Rosser and Dr. Chris van Weel,

Congratulations for so significant results! To read this online set of so valuable papers has been a great pleasure and a happy surprise very expected by us since the late 1980s. We have enjoyed very much the reading of your editorial and paper as well as the other nine papers of this crucial international supplement of the Annals of Family Medicine dedicated to “Improving Health Globally and the Need for Primary Care Research: Report of the World Organization of Family^{Doctors (Wonca)Kingston, Ontario Conference”. We agree with all the thoughts and recommendations of the eleven papers, and would like to make some late reflections and suggestions, if possible.}

One of us who has made scientific research and research training of postgraduates in family medicine for 15 years is going to attend the Wonca 2004 Conference at Orlando this October 13-17. Maybe he could also attend previously the North American --and Caribbean-- Primary Care Research Group meeting, if he is invited as first Cuban international member of the AmericanAcademy of Family Physicians.

We would like to share some personal points of view to complement your contributions as well as the contributions of the other nine distinguished authors. It is important to notice that we do not want to make a prescription for the low-income countries and lowest-income areas of high-income countries. Very far from that we only would like to encourage more meditations and discussions to help improve this so relevant scientific medical and health care matter of our times: Family Medicine Research.

It is true that the increasing interest in the^{provision of primary health care clinical service and educationhas not been accompanied by investment in researchefforts, as you well said in your editorial. However, family medicine researchers could take more advantage of the new ehealth research methods that began to appear in the medical methodological arsenal in the middle of the 1990s, which could be of great help.}

Our late but sincere comment on this set of important results of the Wonca meeting is as follows:

Primary Care and Family Medicine eHealth Research to Help Achieve the Millennium Development Goals*

In 1978, the World Health Organization (WHO) promoted a comprehensive and integral primary health care (PC) strategy to achieve the unfulfilled goal: “Health for All by the Year 2000”. Those efforts increased PC professionals and services, but results were insufficient due to scarce physicians, nurses, other resources, community participation, and deviation in low-income countries and areas to selective and vertical PC strategies in child survival.[1] PC research and development (R&D) to improve the quality of care was increased, although little useful results were obtained due to limited scientific and financial support.[2] In the 1990s, the WHO created the Council on Health Research for Development to strengthen the national health R&D strategies, and afterwards the Global Forum for Health Research Foundation (GFHR) to help correct a 10/90 funding gap on global health R&D problems. In 2000, the WHO and other international agencies established eight Millennium Development Goals (MDGs) to improve in new terms the health and life of humanity.[3] In 2004, the North American Primary Care Research Group (NAPCRG) and the World Organization of Family/General Doctors (Wonca) recognized that research in family medicine and other general specialties of primary care are essential and need to be increased to improve health globally.[2,4-5]

Ten years ago, ehealth applications through the Internet and other information and communication technologies (ICTs) emerged as new tactics to assist all the levels of health care, education and R&D.[6] They are already integrating “at distance” researchers, research centers, and research designs, observations, experiments, analysis and results as never before in the whole world, through high speed communication channels that each time gives more possibility to a more comprehensive text, image and voice information exchange.[7-8]

In our view the use of the ehealth R&D tactics per se in PC and family medicine (FM), and of the ehealth R&D collaboration in an integrated local, regional, and global health R&D strategy more reoriented to the PC/FM needs, can help strengthen the national R&D strategies, correct the 10/90 funding gap, and finally achieve the eight MDGs.

The ehealth R&D in PC/FM per se made through personal computers, Internet, and other ICTs, could constitute some of the long time desired high-technologies that the general and family physicians have never had for PC/FM research in the last 60 years of biomedical technological boom. With all those ICTs, they are beginning to design and carry out their highly complex general research on their patients, families, and communities, as well as on their health services, even in the most remote areas with bad snail mail.[9] One interesting example of this is the Clinical Assessment of the Reliability of the Examination CARE Collaborative Multipractice Study.[10]  Nevertheless, ehealth R&D perspectives seem wider than to allow the web-based collection and analysis of international data. The ehealth R&D is begining to allow virtual team "hands on" design, conduction, analysis, publication, discussion, and assessment of observational and experimental studies and results online and practically in real time, so far through high-speed web-based exchange of text, images and voice.[7]

The ehealth R&D could allow through automated data mining techniques (ICTs extension of the statistical data-dredging in paper) two types of integrated multiple bioclinical, epidemiological, and sociohealth research methods. 1) The classical hypothesis-driven research in universal scientific databases, as for example PubMed, by discovery support systems as for instance ArrowSmith;[11] and 2) the data-driven research in local, provincial, and national health care databases of electronic health records in PC settings with lab data, images, and text of also secondary and tertiary care settings, through new discovery support systems that could arise to research the multidimensional biological, psychological and social process of the patient, family and community health.[9]

The ehealth research through the ICTs could allow the reintegration research in bigger clusters of scientific knowledge --with new kind of cause-effect relations-- of the atomized human being health issues in the enormous and marvelous amount of very differentiated little pieces of scientific knowledge produced so far by the other technologies of the biomedical and public health specialized sciences in the last 150 years, as well as could promote new kinds of integrated general clinical and health research and sciences.[9]

Also, diverse comprehensive national and international health R&D collaboration networks and partnerships with an integrated policy and system through ehealth R&D tactics could be created.  In them, the secondary and tertiary more specialized care R&D, as well as the industrial R&D, could be more integrated with the PC/FM R&D of the patient and family health and its determinants at their community, nourished also by the world applied R&D results of the human genome and brain projects, within other global, regional and international projects.

This integrated health R&D strategy could help PC/FM to continue addressing its corresponding standard R&D scientific targets to lower infant, maternal and infectious mortality, morbidity and disability, lengthening the life span with basic physical quality of health. But also, in these physical survivors the PC/FM ehealth R&D could help approach more effectively behavioral scientific targets not well achieved up to date. For example: How to encourage in the patient, family and community higher levels of civility, education, culture, and more positive life styles and health determinants to enjoy more healthier and prosperous lives in the material, spiritual and cultural senses taking them out of the vicious circle of poverty? How to promote in them higher quantitative health and life standards, but with basic quality of health and life too? 

With the R&D methodological support of the investigators of the institutes, hospitals, clinics of the government, universities, industry, and private sector, as well as with international collaboration and external financing, it could be started the development of sentinel ehealth R&D community centers with practice-based R&D networks and partnerships in the capital and provinces creating a stronger PC/FM R&D subsystem integrated to the national health R&D system.[9]  Their main tasks could be among others as follows:

The creation of areas or centers of PC/FM clinical and population trials to test assimilable technologies and procedures from institutes, hospitals and other PC settings as: natural products, alternative techniques, behavioral change programs, vaccines, drugs, medical equipment, and biotechnological products for the prevention, diagnosis, prognosis, therapeutics and rehabilitation of risks, deaths, injuries, diseases, and disabilities.

The creation of areas or centers of PC/FM R&D to develop new own research spaces of the FM and other PC community specialties, as general internal medicine, pediatrics, obstetrics, epidemiology, health management, and different research spaces shared with other specialties,[12] as for instances: integrated and dynamic classification of health per se, health problems and disease, including positive health status and its determinants; direct PC, home care and integration of care of patients through new ehealth applications, and standardized electronic health records for PC or unique for all the national health system;[13] new methods for health status measurement and assessment in patients, families, communities and populations, and new methods to assess patients for multiple conditions or pathogens at point-of-care.[14]

Some of these centers of excellence for PC/FM R&D could be made WHO collaborating centers for the low-income countries and lowest-income areas of high-income countries, conducting also bottom-up regional and global health R&D projects through ehealth R&D collaboration, beginning from the crucial PC/FM research problems and needs integrated with the ones of the institutes and hospitals, to increment the health results, social impacts, and cost-effectiveness of the national and international cooperation.

Concluding, the PC/FM ehealth R&D national and international collaboration networks, public-private and civil-society partnerships, which could be also promoted by the NAPCRG and Wonca, can allow the WHO, GFHR, and other international agencies in the low-income countries and areas of high-income countries to strengthen and integrate their PC/FM and all levels of care, education, and R&D to achieve their MDGs goals.

The brightest future of primary care and family medicine research depends of ehealth research too.

Let’s continue openly to new reflections and discussions!

Thank you.

Rodolfo J. Stusser, MD

Primary Care Research Unit, VedadoHealthCommunity Center, Havana, Cuba.

http://familydoctor.org/myhavananpolyclinic/

Richard A. Dickey, MD

Clinical Endocrinology Section, WakeForestUniversitySchool of Medicine, Winston-Salem, NC, USA.mdrad@charter.net

Alfredo Rodriguez, MSc

Public Health Computerization Project, Center for Health Informatics Development,

Havana, Cuba. alfredo@cedisap.sld.cu

* We hope to discuss this paper in the GFHR/WHO/Mexican Health Secretary: “Forum 8 and World Summit in Health Research to Achieve the MDGs”. Mexico City, November 16-20, 2004.

References