Forum for African Medical Editors
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By Curtis Abraham
New Scientist Vol. 181 issue 2433 - 07 February 2004, page 44
Into Africa
Can founding a medical journal improve the health of a country?
James K. Tumwine believes it can help, and he has set out to
prove it. Africa, he told Curtis Abraham, needs to be self-
reliant in medical research. He recalls how one of his papers
was rejected when he submitted it from Zimbabwe, but published
when he sent it to the same journal from Oxford
James K. Tumwine is the founding editor of African Health Sci-
ences. When he was at university he wrote revolutionary poetry
and fomented revolt against Uganda's then ruler, Idi Amin. He
became a specialist in paediatric infectious diseases and was
Oxfam UK's Health Adviser for Africa. He is now an associate
professor of paediatrics at Makerere University's Medical School
in Kampala, and president of the Forum for African Medical Edi-
tors.
How did you first get involved in writing and publishing?
When I was 14 I started a school newspaper. Within my home vil-
lage in Kabale district in western Uganda, and even within the
school, there was a lack of information. I thought I had the
skills and I like communicating.
One Friday evening I went with my editor to a jazz dance in the
village. The dance was for teenagers but some of our new teach-
ers were at the dance with their girlfriends. It was a scandal
in our eyes to see adult couples at a children's party. So we
wrote the story in graphic detail naming names. Of course we
handwrote it, since there were no typewriters, and we signed it.
We posted it up on the school notice board very early on the
Monday morning. The headmaster called us up during school assem-
bly and caned us five strokes each. We were suspended from
school, but we were not allowed to go back to our homes - we
were given hard labour, digging, for some weeks.
Somebody was telling me recently that if you don't get into
trouble for publishing that story then it wasn't a good story...
And after that?
At Makerere University I was more into student politics than
writing. I wrote revolutionary poetry for Drumbeat, a university
literary publication.
We staged a revolt - this was during Idi Amin's regime. That was
a very traumatic time. We saw a lot of our friends killed, some
by firing squad. When you have your youth filled with so much
violence it's a terrible thing.
I was on the editorial board of the university's medical jour-
nal, as a representative of the student executive, but not play-
ing a major role.
Why did you choose paediatrics?
Children are the majority of the population in Uganda. The cur-
rent measles immunisation programme targets 12.7 million chil-
dren between 6 months and 15 years - out of a total population
of 25.5 million. They are vulnerable, especially when you are
talking about war-ravaged areas like northern Uganda.
Is that Africa's biggest health issue?
Africa's biggest health issue is lack of education. Look at
cholera. I investigated an outbreak in Kampala several years
ago, to try to locate the source. In wealthy areas like Kololo
there was not a single case. There people are wealthier because
they have good jobs and they have good jobs because they are
well educated.
Many more people are dying from malaria in this country than any
other disease. But there used to be malaria in Italy. It's not
there today. Our environment is similar to certain areas of It-
aly, but we have it and they don't. Why? After malaria and AIDS
we come to malnutrition, which hardly gets reported. But about
half the children we see hospitalised have a history of poor
feeding.
Why doesn't malaria, for example, feature on the global agenda
like HIV?
I think it's because malaria is not going to affect the United
States of America and George W. Bush. It's African children who
are dying. But these deaths go unreported because the interna-
tional community is only interested in what directly affects
them. In Europe people are putting a lot of investment into ill-
nesses such as cardiovascular disease. Malaria is a disease of
the poor.
What, then, should be done?
We need to invest in the brains of our own people. If we can
educate our people we can take care of our own problems. Yes, of
course we need foreign investment in health - but for the long
term Africa needs highly educated people if this continent is to
develop.
In Uganda we used to train our medical doctors in the UK - but
this ended in 1967 when we decided to train our people locally.
Today we have many good young authors like some of my master's
degree students. They have produced very good dissertations,
such as one about giving vitamin A to children who are severely
ill with malaria. It asked whether we actually improve the out-
come of this deadly disease using a vitamin supplement in addi-
tion to the standard treatments.
But what happens to that work?
This is original research but if you send this work to a western
medical journal they will not touch it.
Do you have experience of that?
I wrote an article about health and education in Zimbabwe. I was
trying to emphasise that heavy investment in education was hav-
ing a positive impact, though I wasn't sure this was sustainable
because the International Monetary Fund and World Bank were im-
posing "structural adjustment programmes" on the government.
I submitted it from a Harare address. The journal rejected it.
Later, I went to work in the UK. I waited a couple of months and
then resubmitted it to the same journal, from an Oxford address.
It was published! And it has been quoted numerous times in the
literature.
What effect did the rejection have on you?
Naturally, I was angry. It's like the bursting of a bubble
around you and it hurts your ego. But then you think about
whether it needs corrections, and send it elsewhere.
You're not saying that western journals ignore Africa en-
tirely...
Of course they do publish research that originates in Africa.
But I think they look at the research they believe is relevant
to the interest of their readers, this is what they tell us.
Take for example nodding disease, a mysterious ailment that af-
flicts children in southern Sudan.
If children in Sudan are dying of a mysterious ailment it's more
likely to be of interest to us in Africa than to somebody in the
US.
But there is also plenty of evidence, which Richard Horton, edi-
tor of The Lancet, has pointed out, for bias against non-
Caucasian researchers.
It might stem from the fact that Africans are not represented on
the editorial boards of these publications - and if you are not
represented, who is pushing on behalf of your interest? Horton,
who is a big advocate for African scientists, has also docu-
mented that most of the journals, including his own, have mini-
mal representation from Africa on their editorial boards. It's a
very competitive world and particularly if you are doing bio-
medical research here in Africa and you are not collaborating
with western researchers, you really don't stand a chance.
So my attitude is: why struggle to promote journals that do not
put forward your agenda? Why don't we start our own publication
instead of being in a state of dependency? This is the major
reason why we started African Health Sciences, to have a forum
for African medical researchers.
Tell us more about African Health Sciences.
The journal comes out three times annually. We produced the
first issue in August 2001. It took almost a year to collect ar-
ticles, do the research and to get support. So far we have re-
ceived a small grant of 3 million Ugandan shillings (£1,000) for
printing, ultimately from the fees of private students at Maker-
ere University's faculty of medicine. And the World Health Or-
ganization donated computer equipment and printers.
Wouldn't it have been easier to associate yourself with a more
established journal or organisation?
Personally, I don't like the bureaucracy of medical associa-
tions. I'd much rather create something independent. Our dean at
the medical school has given us the freedom to do things our way
and to push the agenda of promoting African publishing.
As president of the Forum for African Medical Editors I know the
problems others face: finance, delays in publication, conserva-
tism. So we couldn't go starting a new journal and go down the
same route as these publications.
What are the difficulties that you face?
We send our articles to one reviewer here in Uganda and at least
two elsewhere. The Ugandan reviewers are extremely slow. Another
problem is that we don't have many people here with editing
skills - and though our students can write fine dissertations
and get their degrees, they do not have the skills to write
2000-word scientific papers.
What are you doing about that?
We are learning on the job. And the WHO Tropical Disease Re-
search Unit has given us a small grant for training authors, re-
viewers and editors.
This will initially be for Ugandans but later we will do train-
ing for east and central Africa. In the past we followed western
guidelines for things like editing and style of writing, but
during the official launch of the Forum for African Medical Edi-
tors in Addis Ababa, Ethiopia in September 2003, we developed
our own home-grown African guidelines.
And has African Health Sciences gained recognition?
MedLine has indexed our journal since April 2003. It means that
we meet international standards. This is the greatest achieve-
ment of my life.
Now we can sit at the same table with other indexed journals as
equals, and this after only two years.
Does that help researchers in Uganda?
Not immediately. The WHO recently asked me to help investigate
nodding disease, which requires access to research journals,
which these days means having access to the internet. You might
search the MedLine database for abstracts - but when you want to
see the full articles they want your credit card number. In
Uganda the vast majority of the population don't have credit
cards. In the end the full articles had to be faxed to us.
Is access improving?
Kofi Annan, the United Nations secretary general, recently ini-
tiated a programme to make 3,000 electronic journals accessible
to developing countries. But in Uganda you would have to go to
one of the big libraries in Kampala to get them.
Just accessing your email through the medical school connection
can take up to three hours. So recently I installed a satellite
dish outside my office. I'm paying 500,000 Ugandan shillings
(£160) a month, which is more than my salary. Then there are
technical problems like computers breaking down. For some the
internet is just another part of life but for us it is part of a
bigger struggle.
Which is?
I think the issue of addressing social inequality has been lost
and I think it needs to be brought back onto the global agenda.
But this is not a sexy topic for medical researchers. They want
to talk about molecules.
We can address these inequalities through education: equalising
our opportunities; making sure all our children go to school;
and investing in training so that our healthcare workers are up
to standard.
--
James K. Tumwine is the founding editor of African Health Sci-
ences. When he was at university he wrote revolutionary poetry
and fomented revolt against Uganda's then ruler, Idi Amin. He
became specialist in paediatrics infectious diseases and was Ox-
fam UK's Health Adviser for Africa. He is now an associate pro-
fessor of paediatrics at Makerere University's Medical School in
Kampala, and president of the forum for African Medical Editors.