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Evidence-Based Medicine for developing countries: Are we forgetting the meaning of systematic?
Posted by plosmedicine on 30 Mar 2009 at 23:44 GMT
Author: M Justin S Zaman
Position: Dr/British Heart Foundation Clinical PhD Research Fellow
Institution: University College London Medical School
Additional Authors: Dr J Jaime Miranda Wellcome Trust Research Training Fellow London School of Hygiene and Tropical Medicine
Submitted Date: July 24, 2005
Published Date: July 25, 2005
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.
We in the developed world must remain aware of our own limitations and the danger in exporting failure to the developing world, concerns over which have been expressed over recent years . Chinnock et al. ask: are the systematic reviews that have so far been published relevant and of practical use to those who provide health care in the majority world?  Surely the issue is not only with the systematic product itself, but the fact that it often does not originate from nor is it designed to favour the developing world, a setting which has the majority of sufferers from the condition being reviewed.
The Cochrane collaboration's inclusion of topics is not systematic itself but depends on volunteers based mostly in developed countries who contribute a favoured topic. This is not to undermine how important a contribution Cochrane has made to modern medicine as medicine would be a poorer place without it but highlights a factor as to why such work may not be so relevant to the developing world.
Their paper discusses the lack of low-tech interventions . Let us recall that is not solely the 'tech' that contributes to progress but the yield. In the developed world, there are many high-tech interventions that are of comparatively low yield. This yield does not only refer to clinical end-points but to cost-effectiveness ones amongst others.
In relation to the lack of research originating from and responding to developing countries' needs, such an example is in the secondary prevention of cardiovascular events, including coronary heart disease and stroke, which have been evaluated in developed countries . Yet primary events of coronary heart disease and stroke, as well as the mortality and disability associated with these conditions also entail a heavy burden in developing countries, yet affordable treatments are not always available.
Another important factor that contributes to this lack of relevant research, and therefore undermines the role of systematic reviews in developing countries, is the under-representation of journal editors and authors who hail from this region [4-5].
The conditions in which research take place are never identical, and hence that heterogeneity is a not a bad thing. We should work with differences. As the authors correctly pointed out, the most effective treatment in a randomised controlled trial may not be the most effective treatment when provided in the developing world.
This highlights the problem when systematic reviews become meta-analyses, and the flip side to the notion that trials are a panacea for clinical practice. Systematic reviews need to highlight all evidence that is epidemiologically sound, but conclude with take-home messages that appreciate the limitations of each setting, and the circumstances in which they may or may not work.
It is essential that context-appropriate health research and health interventions take place in developing countries. Exporting research results and intervention methods in from industrialized countries ignores the fact that expectations, costs and burdens of disease vary between developing countries almost as much as between an abstract 'developed' or 'developing' country context.
This transferability issue highlights our own academic deficiencies. Trials are considered the gold standard yet they only change one thing at a time. This may be pure scientifically but may also explain the slow progress in science today. Focusing on individual level determinants of health while ignoring more important macro-level determinants is tantamount to obtaining the right answer to the wrong question . Evidence based assessments are largely restricted to individualised interventions.
We agree that we need appropriate evidence in the developing world as opposed to the best evidence, and that more of this evidence needs to hail from this part of the world in order to ensure truly systematic, evidence-based medicine.
1. Ebrahim S, Davey Smith G (2001) Exporting failure? Coronary heart disease and stroke in developing countries. Int J Epidemiol 30: 201-205.
2. Chinnock P, Siegfried N, Clarke M (2005) Is evidence-based medicine relevant to the developing world? PLoS Med 2: e107.
3. Manktelow B, Gillies C, Potter JF (2002) Interventions in the management of serum lipids for preventing stroke recurrence. Cochrane Database Syst Rev: CD002091.
4. Mendis S, Yach D, Bengoa R, Narvaez D, Zhang X (2003) Research gap in cardiovascular disease in developing countries. Lancet 361: 2246-2247.
5. Sumathipala A, Siribaddana S, Patel V (2004) Under-representation of developing countries in the research literature: ethical issues arising from a survey of five leading medical journals. BMC Med Ethics 5: E5.
7. Schwartz S, Carpenter K (1999) The right answer for the wrong question: consequences of type III error for public health research. Am J Public Health 89: 1175-1180.