How Can Research in Low- and Middle-Income Countries (LMICs) Help People in High-Income Countries?
Professor Richard Lilford, Professor of Public Health, CLAHRC WM Director and W-CAHRD Director
International health research is undergoing a renaissance. Universities all over North America, Europe and Australia are establishing ‘Centres for Global Research’. Such centres draw funds from local donors and it is reasonable to ask whether research conducted abroad is completely altruistic in its effect, or whether it might also benefit the high-income countries that sponsor the research. Knowledge exchange is a two-way street and we should expect increasing traffic on the North-bound carriageway. I propose the following classification for the potential local benefits of overseas research:
The most obvious category relates to infectious disease. Research carried out abroad may provide early intelligence on impending risk so that countries may take steps to prevent spread, as in the recent Ebola epidemic (discussed in a previous post), or make preparations to contain the infection, as in the case of influenza, MARS and SARS.
Research carried out in countries where a disease is common may provide information on how to treat it in countries where the diseases is rare. This would obviously apply to all tropical diseases that may affect returning travellers, visitors or immigrants, such as malaria and schistosomiasis. It would also apply to infections, such as leishmaniasis or West Nile fever that can be contracted in Europe, but with less frequency than in tropical countries. This type of knowledge transfer would also benefit people at risk of non-infectious diseases arising from habits imported from abroad, such as use of the areca nut, as discussed in a previous post.
Providing larger populations to evaluate treatments where it would be very hard to accrue sufficient patients locally. Lelia Duley’s trial of magnesium for the treatment of eclampsia [1] and Ian Roberts’ ‘CRASH-2’ trial of tranexamic acid for massive haemorrhage [2] were both carried out over three continents. Yet the results drive practice across the world, including the UK.
Providing a means to explore heterogeneity and thus glean deeper understanding of the role of context. For instance, the Cochrane review of trials of the effectiveness of providing additional support in labour through a layperson (so called doula) show that the service is effective in lowering the Caesarean rate where women are not accompanied by their partner, but not in countries like the UK where they usually are. The experience of two people dying of terminal cancer, one in Kenya, the other in Scotland provides a further vivid example of the role of context.[3]
The success of an intervention in LMIC may encourage people to try it locally. For instance, the success of ‘women’s groups’ in improving perinatal outcomes in India, Nepal and Bangladesh [4] have encouraged a UK-based research team to replicate the method among Bangladeshi communities in East London, as mentioned in a previous post. But we should be alert to the danger of leaping too rapidly to the conclusion that what works in one place will necessarily work in another. Studies carried out in the West Midlands shows that clinical research produces essentially the same results when carried out in North America or Europe,[5] but very different results across Europe and Asia.[6]
Research methodologies of generic utility may be developed to deal with issues in LMIC. The fabled stepped wedge design widely used in applied health research in the West Midlands [7] was first used in West Africa.[8] The lesson that much more can be learned by juxtaposing quantitative and qualitative research in systematic reviews than by either method alone, was ably demonstrated by twin Cochrane reviews on the subject,[9] [10] (mentioned in a previous post).
More speculatively, I posit a category where there is no specific nugget of information that is returned, but rather tacit knowledge about universal features of the human condition. Certain general principles may be derived by examining health improvement projects across many countries, rich and poor, as recently pointed out by previous NHS Chief Executive, Lord Nigel Crisp.[11] More indirect still are the cultural and political benefits of human interaction, and putative benefits of seeing the world in less parochial ways.
Bowater RJ, Hartley LC, Lilford RJ. Are cardiovascular trial results systematically different between North America and Europe? A study based on intra-meta-analysis comparisons. Arch Cardiovasc Dis. 2015;108(1):23-38.
Hartley LC, Girling AJ, Bowater RJ, Lilford RJ. A multistudy analysis investigating systematic differences in cardiovascular trial results between Europe and Asia. J Epidemiol Community Health. 2015;69(4):397-404.
Hemming K, Haines TP, Chilton PJ, Girling AJ, Lilford RJ. The stepped wedge cluster randomised trial: rationale, design, analysis, and reporting. BMJ. 2015; 350: h391.
The Gambia Hepatitis Study Group. The Gambia hepatitis intervention study. Cancer Res. 1987;47:5782-7.
Lewin S, Munabi-Babigumira S, Glenton C, et al. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database Syst Rev. 2010; 3: CD004015.
Glenton C, Colvin CJ, Carlsen B, Swartz A, Lewin S, Noyes J, Rashidian A. Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: qualitative evidence synthesis. Cochrane Database Syst Rev. 2013; 10: CD010414.
Crisp N. Chapter 5: Turning the World Upside Down. In: Commonwealth Health Minister’s Update 2010. Geneva: World Health Organization. 2010. pp.89-933.