Ptolemy was designed to provide access to electronic health information and to analyse whether that service had a positive effect on surgical research, teaching, and practice in east Africa. The interaction between information, knowledge, and behaviour is complex and difficult to measure, but some useful observations can be drawn from our early experience with Ptolemy.
Use of online resources
The usefulness of Western medical journals (compared with evidence based texts, systematic reviews, and the
Cochrane Library) has been questioned,
13 and a recent paper has reported that local journals contain information that is most likely to affect the practice of readers in developing countries.
14 Ptolemy provides free access to local, regional, and international journals, major online texts, and the
Cochrane Library, but our participants clearly preferred journals (75%). In view of debate over the transferability of research findings from the rich world to the poor, it is curious to see that the most requested journals were the
British Journal of Surgery, and the
Lancet. Several reasons may contribute to this. Those who search through either PubMed or Ovid are led preferentially to indexed journal articles with abstracts, rather than local journals, text chapters, or Cochrane reviews, and there may be a social aspect whereby doctors enjoy the cachet of quoting to their colleagues and students from well known journals. Efforts are under way to provide electronic publication of the journal of the Association of Surgeons of East Africa, the
East and Central African Journal of Surgery. Textbooks are more difficult to navigate, particularly for low bandwidth users. This preference for journals may reflect easier access and personal taste rather than their greater usefulness compared with other resources. None of the Ptolemy group reported using the
Cochrane Library, which may reflect unfamiliarity with that database or the dearth of material they find useful in it. We hope to be able to watch this change over time.
The commonest criticism of the utility of electronic health information in the developing world relates to slow, unreliable, and costly or non-existent internet access.15 Three quarters of our respondents used Ptolemy from home only or home and work, rather than from work. This may represent a difference between the speed and convenience of private access compared with institutional access. Nearly all our respondents complained about their internet connections, yet 61% browsed Ptolemy for more than an hour a week, and 68% estimated their total combined internet and telephone costs at ≤ $50 a month. This may seem moderate by Western standards, but it is high in relation to physician income in Africa. Although it is costly to the participants personally, many surgeons valued library access from home. Web access is often faster and more reliable from home, and most academic surgeons prepare grants and papers outside working hours because they are occupied with clinical matters during the day.
There is a waiting list to join Ptolemy, and periodic reviews identify idle accounts, which are transferred to people on the waiting list. Regular use of the medical literature is only a weak surrogate measure of intellectual leadership, but, by slowly refining the membership in Ptolemy, we aim to select those individuals who are or will become the opinion leaders in the east African surgical community. Beyond providing access to the literature, Ptolemy draws them into an electronic community linked by medical curiosity which can identify priorities and find solutions to regional surgical problems. Building surgical research capacity in east Africa requires far more than mere access to the literature, it involves drawing individuals into the larger project of solving problems. Ptolemy participants are presently involved in the East African Surgical Initiative-Delphi (“EASI-Delphi”) process to identify priorities for surgical development in the region.
| Table 1 Comparison of electronic health information sources Ptolemy and the World Health Organization's HINARI |
Comparison with other information sources
We were not able to compare Ptolemy with other electronic health information sources such as the World Health Organization's HINARI, because no Ptolemy participants have yet been able to use it. The table lists the features that distinguish Ptolemy and HINARI. Essentially, Ptolemy links a large university library and a well defined community of end users and provides convenient access to a broad resource collection and assesses how they use the it. HINARI links WHO, publishers, and institutions in a collaboration to make a less broad selection of resources available in institutions all over the developing world. We do not yet know how much of that information is reaching the doctors who need it.
Expanding Ptolemy
Helping 100 surgeons to be better equipped for research, teaching, and clinical practice is a useful end in itself, but can the Ptolemy project grow? Part of the strength of Ptolemy comes from the fact that there are only about 400 surgeons in the countries of the Association of Surgeons of East Africa, so that even such a small project may have considerable leverage. Although our respondents represent a substantial portion of the active academic surgical community there, their 100 proxy server accounts comprise only 0.2% of the University of Toronto's 50 000 proxy server library accounts. The cost of running Ptolemy lies mostly in its evaluation mechanisms.
Large university libraries have the technical capability to establish remote access at minimal extra cost, and mechanisms to monitor and validate user access in order to prevent violation of intellectual property rights. From a technical perspective, therefore, expansion is straightforward. The obstacle is largely one of administration: how many research affiliates is a fair number in the eyes of publishers? Five per cent? Scientific and medical publishers are deeply involved in efforts to expand access to their publications in developing countries, and they should lose no revenue by doing so, as poor countries are unlikely to be able to afford their own subscriptions in the foreseeable future. So long as this use does not threaten the intended use and relationships of the existing infrastructure (a parasite killing its host), there will be the opportunity to provide something of great value to the developing world without a large specific operation or budget dedicated to maintaining it.
Expanding access to health information in the developing world is likely to involve a mosaic of complementary approaches. Ptolemy provides both access for a well defined group of end users and a mechanism for evaluating their response. It may help foster the kind of partnerships that contribute directly to building the research, teaching, and clinical capacity so badly needed in Africa. Might this model, of a large university incorporating designated researcher partners from the developing world within its library community, provide a practical and cost effective means of delivering access to the medical literature for doctors in countries that could not otherwise afford it? University libraries, the publishers' principal clients, should work towards enshrining access for research affiliates from the developing world in the licence agreements they negotiate. If other universities formed partnerships similar to that in the Ptolemy project it would be an effective and economical way to build essential health research capacity in Africa.