Building Surgical Research Capacity in Africa: The Ptolemy Project

The authors describe the Ptolemy Project, a recently developed model of electronic access to medical literature for surgeons in developing countries.


Bridging Knowledge and Research Gaps in East African Surgical Practice
Research is unthinkable without access to scientifi c literature. The Ptolemy Project attempts to bridge the gap between the literature available to researchers in wealthy developed countries and that available to researchers in developing countries, where researchers are largely deprived of access to essential health information. The project's aim is to improve access for developing country researchers to peer-reviewed medical literature, as well as to journals and documents originating in their part of the world. The Ptolemy Project is an electronic health information access tool designed to be effective, to be easy to use, and to satisfy the need for health information of surgeons in the developing world (K. Burton, A. Howard, M. Beveridge, unpublished data).
Health has improved in developing countries more rapidly over the last half century than it did in Western countries from the 17th century onwards [2]. The chief reason has been advances in technology and not, as many believe, improvement in income or education [2]. Technological advances take many forms: examples include vaccines against childhood diseases, effective short-term treatment of tuberculosis, and better information on the risks and control of diseases such as HIV/ AIDS and tobacco-related illnesses. None of the advances would have been possible without high-quality scientifi c research. Yet despite the promise of knowledge to reduce premature mortality and poverty, only 10% of the world's health research resources go towards the 90% of diseases that burden the poorest countries [3].
Making any serious improvement in mortality, morbidity, and disability among the global poor will require more locally driven collaborative research and wider usage of the scientifi c literature [4]. The fundamental idea underlying Ptolemy is that it is African doctors and researchers who know the right questions to ask in order to discover practicable solutions to the health problems of their regions. While Ptolemy alone is not suffi cient to build a surgical research community, the electronic health information it provides is a fundamental and necessary component to this transformation.
Research capacity is lacking in the developing world, particularly in East Africa, making it vital that up-to-date research information is available to practicing physicians as a means to stimulate locally based and collaborative research. The need for the application of research information and the stimulation of research programs in East Africa is exemplifi ed by the fact that a total of 400 surgeons are responsible for providing care to more than 200 million people. Isolation, burden of practice, and lack of research training and funding are the most common reasons for the dearth of research, and access by surgeons to contemporary scientifi c literature can help [5]. The Health in Action section is a forum for individuals or organizations to highlight their innovative approaches to a particular health problem.

Building Surgical Research Capacity in
All of these problems bring dissatisfaction to doctors, and also to patients, who often travel days to reach medical care facilities only to be placed on a wait list. For example, in Ethiopia the waiting list for elective paediatric surgery/neurosurgery is as long as 8-10 months, and for other elective general surgery disciplines the waiting list is 6-8 months, irrespective of the disease pathology. The situation is similar in the other East African countries. Lack of resources makes surgical practice, surgical education, and research diffi cult in Africa [1].

How Does Ptolemy Work?
Electronic media were introduced to East African surgeons in 2001. The Offi ce of International Surgery at the University of Toronto has provided hands-on training on using these media to East African surgeons, as well as to the current trainees studying to take exams to become fellows or members of COSECSA. COSECSA candidates and surgical trainees are a prime target audience for Ptolemy, we believe, because those who learn to read the literature at an early stage in their careers are more likely to play leading roles in promoting education, research, and training in their regions. Surgeons in East Africa who want to sign up for Ptolemy download the registration and consent forms from the Ptolemy Web site and submit these to the Ptolemy coordinator in Tanzania or the Offi ce of International Surgery in Toronto. The criteria to become a Ptolemy participant are shown in Box 1.
The Ptolemy Project also offers a reading course called "Surgery in Africa", which is designed as a pilot project to train leaders in surgical education from Africa. "Surgery in Africa" is a self-directed, online, journal-based course primarily directed at surgical trainees who are undertaking the COSECSA Fellowship. The course is also available to all surgeons in the East African region, and internationally, who are interested in international surgery. The course started with extensive bibliographies on a selection of controversial topics relevant to practice in Africa, as well as a discussion forum for the participants. With the "Surgery in Africa" reading course, we hope to place online medical information at the disposal of African surgeons. The course reading materials are available online on the Offi ce of International Surgery Web site (http:⁄⁄www.utoronto.ca/ois/SIA. htm), which also has instructions on how to sign up for the full course materials.

How Is Success Being Measured?
Participants' subjective satisfaction has been measured by an ongoing series of surveys, the results of which have been published in the BMJ [6]. Objective data regarding number of active users, their access locations, and journals and papers downloaded are collected from the library servers on a monthly basis. The top 20 journals accessed composed 41.4% of all accesses, and 75% of all users used at least some of the top 20 journals. Popularity of access via Ptolemy bore no relation to the published impact factors of the journals. The list of journals people actually read was far broader than the list generated from a previous selfreport user survey. Examining titles of popular downloads suggests that clinical care for acute surgical problems is the most popular reason for consulting Ptolemy, and education is the next most popular. Box 2 shows the most frequently accessed journals. Note that most East African surgical journals are not available online, but are widely available locally in print form. A formal evaluation of the fi rst four years of the Ptolemy Project is being conducted.

Obstacles and Challenges
Surgeons who use Ptolemy use it frequently and extensively and read from a broad range of journals, both to support clinical care and to prepare educational material. Despite this, only 30 of the 167 registered participants in ten East African countries used the Ptolemy service between January 2005 and September 2005. Potential barriers to use include limited Web access, complexity of the Web, unfamiliarity with the Web, poor user support, diffi culty in fi nding relevant information, a preference for alternative information sources, and a lack of perceived need to access the literature. Those who do use Ptolemy, use it a lot, which suggests they do fi nd it useful, but it appears that there remain signifi cant barriers to uptake of what we continue to feel is a valuable resource.
We propose collaborative work through COSECSA to identify and address important barriers. Two measures have been taken to address the problems of Ptolemy. First, the Offi ce of International Surgery now employs a full-time research assistant based in the offi ce of COSECSA, in

Box 1. Criteria for Participating in Ptolemy
Participants must 5. Agree to participate in surveys to assess their use of the service supplied.
6. Agree not to sell the information they obtain, redistribute it for fi nancial gain, or allow others to use the service provided for fi nancial gain.
7. Acknowledge that the University of Toronto Offi ce of International Surgery retains the right to discontinue their access at any time without any form of compensation.
Arusha, Tanzania, who provides handson training on how to use Ptolemy to COSECSA fellows and in particular to COSECSA trainees. Second, the Offi ce of International Surgery gives scholarships to African educators to train trainers in surgical education in their region. It remains to be seen how successfully these steps are in improving the use of Ptolemy in the target region.

Conclusion
Research is unthinkable without access to scientifi c literature. East African surgeons work with very limited resources, both in terms of manpower and technology, and yet they face a huge burden of health problems. Electronic access to projects such as Ptolemy is likely to be of great help to East African surgeons involved in research, assisting them in dealing with the health problems of their region. Collecting data, scientifi cally analyzing it, and using it to tackle the regional health problems will contribute to global health improvement [6]. We hope in the near feature that several electronic resources similar to Ptolemy will emerge to serve the different regions of low-income countries. Ptolemy can be considered as a collaborative model for other countries or institutions in the developed world who wish to help the global poor.