The AfJEM blog
With the year drawing to a close, and 2017 lurking around the corner, I’d like to take the opportunity to thank our authors, author assistants, editors, readers and reviewers for their support during 2016. It has been a tremendous year for the journal. We maintained our second tier ranking, gained Directory of Open Access Journals (DOAJ) indexing and are co-publishing a regular feature with some of the best regional journals in the world (check out the Global research highlights).
Those of you who have met me will know that to me, publication is instrumental to expanding any knowledge economy. And although our local knowledge economy is stronger than it was six years ago (Fig. 1), it is still weak compared to the stronger knowledge economies of the world.
It is difficult to compete in a landscape that unknowingly (or perhaps knowingly) discriminates against non-English first language authors of low- and middle-income backgrounds. Don’t get me wrong, publications from low- and middle-income regions happen fairly regularly, but compared to publications from high-income regions, these are negligible. Let me give you an example: over the last five years there were 725 African emergency care papers published, a tiny number compared to the 13906 emergency medicine papers published out of Europe and 15526 emergency medicine papers published out of North America. If it was a statistic, it would be described as almost insignificant (5% or less). What is concerning about these numbers is that in contrast to publications, low- and middle-income populations dwarf that of high income populations (such as Europe and North America) – high income populations make up only 7% of the world’s population (Fig. 2). Why do I make a big thing about populations? Well, research is meant to inform what we do at the bedside (also called knowledge translation). Given regional differences in systems, resources and income levels, the way we approach this would be different. Fig. 2 shows the substantial bias towards European and North American publications. It makes one think a little different about the representativeness of so-called gold standards, doesn’t it?
In short, poverty is a very clear systemic barrier to publication, which likely has a profound impact on knowledge translation of the available literature in low- and middle-income settings. There are no proven, clear ways to erase these barriers. Author Assist, AfJEM’s free author mentor programme, is one way to improve publication success through collaboration with mostly authors from high-income regions. But Author Assist is quite small and similar initiatives are not practiced by any other journal currently (nor is it likely to be any time soon). Without removing the publication bias that exists internationally, low- and middle-income regions are unlikely to ever catch up. This will have a profound impact as the gulf between publications from high income regions and low- and middle-income regions continue to widen. My wish for the New Year is for each of you to publish your work. If you have a great research idea, come talk to us so we can see where we may be of assistance. I am so encouraged by how much have been achieved over such a short period (Fig. 1). Let’s do even better in 2017.
Seeking healthcare from a general hospital in Uganda following a fracture or a dislocation
(full paper available in French - this is our first paper published with an author-translated French version of the entire publication. For those of you who do not know about this yet, AfJEM will publish an author-translated version of your paper alongside your English-version paper with a view to increase the paper’s knowledge footprint)
The resilience of people in the face of adversity truly astounds me. This paper is proof thereof, although I wish it did not have to be so. Kajja, et al. reports truly horrendous timelines to accessing emergency care for not-so-trivial injuries. A significant gender bias is also highlighted in that it took three times as long as men for women to access emergency care for injuries. Motor vehicle collisions were the main cause (no surprises) for injuries which mainly occurred in the early evening. If you struggle with Table 5 then you should perhaps first read this fantastic blogpost by Charmaine Cunningham about the trade-offs in African health care. This is a must read paper for anyone who has ever doubted inequality in African emergency care. Frankly, I would be really concerned for the time to access care for other illnesses.
The clinical profile and acute care of patients with traumatic spinal cord injury at a tertiary care emergency centre in Addis Ababa, Ethiopia
Continuing our theme on injuries and access to care, the real pearl for me in this paper was the description of the lack of care provided to patients with spinal injuries prior to arrival at the emergency centre. Motor vehicle collisions were the main cause (I will say it one more time, no surprise here). The median time to hospital was 36 hours (seems like Uganda is not the only place where delays in access to care occurs). Furthermore, one has to wonder whether the 41% with complete spinal cord injuries (ASIA class A) started off that way given the number of secondary complications seen in the sample. Around three quarters of patients were the main bread-winners for their families prior to injury. If you have not yet read the blog post I linked to above, now would be a good time.
Development of a trauma and emergency database in Kigali, Rwanda
Anyone who has worked in an African setting will know that finding databases to support audit and research can be very tricky; mainly because it does not exist, and where it does, it does not exist within a functional system that can be easily interrogated. In this paper, Kearney, et al. describe a novel approach to creating a trauma and emergency registry from scratch, by linking existing databases to create a reasonable registry that includes information from pre-hospital to in-hospital. This is a remarkable achievement and to boot, one that can also be replicated in other settings. Of course the set-up will be different, but the principle will remain the same – consider what is available and then link it up. I appreciate the latter sounds easier said than done, but have a look at how the authors did it. The corresponding authors contact details are provided in the paper should you wish to set up your own registry in a similar fashion. “It always seems impossible until it is done” -the late Nelson Mandela.
Epidemiology of injuries and outcomes among trauma patients receiving pre-hospital care at a tertiary teaching hospital in Kigali, Rwanda
Linking on from the previous paper, George, et al. use the registry just described to present the causes for and outcomes of injured patients that attended the emergency centre in Kigali by means of the local pre-hospital service. Motor vehicle collisions accounted for the largest proportion of patients (no surprises here), with nearly half of patients having an injury in more than one anatomical region. Around 5.5% of patients succumbed to their injuries, which is far higher than would be expected in a more developed setting. It should be kept in mind that this was a pre-hospital sample and is therefore skewed towards more serious injuries. It will also miss the injured patients who arrived by private transport. It would be nice to have an understanding what proportion of emergency centre patients the latter demographic contributed. That said, this study provides information that would not be available if not for the make-shift registry described in the previous paper. It is a fantastic start to documenting injuries in Rwanda’s first city and ongoing monitoring of these over time will provide even more useful information. The same will be true when applied elsewhere. Make this your priority for 2017.