The current COVID-19 pandemic has highlighted inequities in access to health care, even within the borders of high-resource countries (BMJ Open 2020;10:e039849). The global vaccine distribution maps vividly demonstrate the inequities between high- and low-resource regions of our globe (asamonitor.pub/3jORVNw). These inequities are emblematic of decades of systematic underinvestment in health care systems, with surgical and anesthesia care particularly neglected. Greater than 95% of the population of South Asia and Sub-Saharan Africa do not have access to safe, timely ,and affordable surgical care, compared to less than 5% in North America (Lancet Glob Health 2015;3:e316-23). In addition, perioperative mortality rates are many times greater in low-resource regions of the world, human resources for anesthesia care are much lower, and the system impact of advanced surgical pathophysiology in Sub-Sahara African patients is poorly understood (Anesthesiology 2020;132:452-60; Anesth Analg 2017;125:981-90).

“In addition to the baseline state of high surgical needs, Africa is now faced with the current pandemic variant surge as a priority and further shrinks their margin for research time, even though the questions still remain.”

What causes these inequities? Why is the pediatric perioperative mortality rate across Africa 100 times higher than in a high-resource setting? What is the driving force behind physician burnout in Africa? What is the best method to secure a difficult airway in Central Africa with no videolaryngoscope available? Where are the roadblocks for access and what are the most efficient avenues to remove those roadblocks? These are all vital questions that have been asked by African anesthesiologist-researchers in the recent past. However, many roadblocks restrict African research for Africa's anesthesia-related questions. The report from the Council on Health Research for Development revealed the fact that only 10% of the global funding for medical research addresses the 90% of the global burden of disease, and thus the term “10/90 gap” was coined. Between 1966 and 2015, the United States contributed to 48.5 % of the scientific global health, and over 70% of global inequities research papers are from only four high-resource countries (U.S., U.K., Canada, and Australia) (PLoS One 2018;13:e0191901). In contrast, the highest low-income country was Tanzania, which provided 0.21% of the published manuscripts (PLoS One 2018;13:e0191901). Data from the anesthesia literature confirms a similar picture, with almost 90% of publications from high-income countries, 10% from middle-income countries, and less than 0.5% from low-income countries (Anaesthesia 2010;65:799-804). This gap in research funding and capacity is multifactorial and uniquely complex for each individual country's milieu of components. This makes it very difficult to address these questions with scientific medical research. We need to start by considering some foundation pillars in forming a framework for success in strengthening, or developing, a research system that is appropriate for a context that offers obstacles quite different from those of high-resource research environments.

An electronic survey conducted in 2018 by investigators in 27 African countries, the African Surgical Outcomes Study (ASOS) explored barriers to clinical research in Africa and highlighted the primary obstacles. Over 93% of the investigators indicated they were interested in conducting the context-specific research necessary to improve patient outcomes, but that significant barriers exist to do so. Many of these primary barriers appear categorically similar to a high-resource setting, but they are remarkably dissimilar in magnitude such that they are qualitatively quite different, i.e., lack or absence of dedicated research teams, poor funding or absence of funding, poor internet connectivity and IT infrastructure, and lack of institutional research leadership and support (Anaesthesia 2010;65:799-804). The desire to collect data in an environment without electronic medical records, high data cost, and only personal electronic devices available for data collection may prompt a sole anesthesiologist to feel overburdened by the daunting task to even begin the process of seeking answers to their research questions. In addition, with the global burden of surgical disease falling disproportionately on the shoulders of our African colleagues, the massive clinical responsibilities for each clinician will typically take precedence over a possible research education program or project implementation. In addition to the baseline state of high surgical needs, Africa is now faced with the current pandemic variant surge as a priority and further shrinks their margin for research time, even though the questions still remain.

Who is driving global health research in Africa? Bethany L. Hedt-Gauthier, et al. analyzed 7,100 PubMed articles extracted for “health” in Sub-Sahara Africa between 2014 and 2016 to consider international collaborations and authorship position in published research manuscripts. The first authors in 53% of the publications were from the African country where the research was conducted. If the collaborators were from a top U.S. academic institution, only 23% of the first authors were from the research country (BMJ Global Health 2019;4:e001853). Another alarming discovery: out of the 7,100 manuscripts, 13.5% had no authors listed at all from the country where the research had been conducted (Br J Anaesth 2018;121:813-21). This study also found that collaborating with African institutions increases local and country-of-research authorship representation. This manuscript authorship positioning issue is a marker for the lack of focus on building Africa-centric research capacity within high-resource-based global health researchers. The maneuvering certainly may be influenced by the ever-present academic enterprise “rules,” entrenched in U.S. academic structure, that award and promote researchers based upon authorship position. While considering global health and the current pandemic's reminder of our interconnectivity, we must reconsider these “rules” and focus on the more important and sustainable global rules so that Africans can and will solve African health care questions and dilemmas. Partnerships are essential. We must first acknowledge our past and potential colonial-leaning tendencies and seek to collaboratively develop appropriate bidirectional research partnerships.

“We know that medical research, in the appropriate context, can generate and analyze data that can then help promote improved patient outcomes. We must strive to understand the ecosystems of our anesthesia and critical care colleagues who are working in lower-resource regions of the world and join them in their struggle to improve outcomes for their patients.”

Building research capacity in Sub-Sahara Africa must be based upon evaluating outcomes for past programs and innovative Africa-centric new programs that are scalable. Scholarships for Africans to primarily train in the global north have not yet produced a critical mass of locally networked researchers and have not developed sustainable research career structure or produced an environment for robust and funded south-south partnerships within the continent of Africa (BMC Health Serv Res 2017;17:696). Sustainable research-building programs must focus on research skills development, acknowledging the unique contexts in African countries. This should include implementation research, epidemiology, research ethics, network-building, financial management, grantsmanship, research stewardship, information technology, research supervision, and mentoring. Additional pillars to consider must include building clinical capacity to allow for those interested in research to be more free from clinical responsibilities; prioritizing mentoring of mentors to help generate waves of researchers; advocacy, and then funding, for global anesthesia and critical care research both in high-resource countries and in Africa; research infrastructure, including internet; and global South-South partnerships between African institutions to develop research, which will be an early marker for a sustainable research platform strengthening endeavor. We must agree that even if we do not have appropriate numbers of clinical providers, research implementation must be strengthened. The College of Anaesthesiologists of East, Central, and Southern Africa (CANECSA) is an example of a context-specific anesthesia education institution that, in collaboration with other stakeholders, will develop anesthesiology leaders, and potential researchers, within a sustainable model.

The COVID-19 pandemic has highlighted the need for appreciating the relationship between regions of the world, even countries without shared borders, when considering our national health care priorities. We know that medical research, in the appropriate context, can generate and analyze data that can then help promote improved patient outcomes. We must strive to understand the ecosystems of our anesthesia and critical care colleagues who are working in lower-resource regions of the world and join them in their struggle to improve outcomes for their patients. Bidirectional partnerships are valuable to all and are beneficial, enlightening, career fulfilling, and greatly needed if we are to truly understand and influence the power dynamics of global health research. The field of anesthesiology will not grow globally until we address this “10/90” gap. ASA, as a leader in promoting anesthesiology, is clearly positioned to lead this charge for change as we promote patient safety in all regions of the world.

Mpoki Ulisubisya, MD, FCA (ECSA), President, College of Anaesthesiologists of East, Central and Southern Africa (CANECSA).

Mpoki Ulisubisya, MD, FCA (ECSA), President, College of Anaesthesiologists of East, Central and Southern Africa (CANECSA).

Mark Newton, MD, Professor of Anesthesiology and Pediatrics, Vanderbilt University Medical Center, Nashville, and Kijabe College of Health Sciences, Kenya.

Mark Newton, MD, Professor of Anesthesiology and Pediatrics, Vanderbilt University Medical Center, Nashville, and Kijabe College of Health Sciences, Kenya.

M. Dylan Bould, MBChB, Professor of Anesthesiology and Medical Education, Children's Hospital of Eastern Ontario, University of Ottawa.

M. Dylan Bould, MBChB, Professor of Anesthesiology and Medical Education, Children's Hospital of Eastern Ontario, University of Ottawa.

Edwin Lugazia, MD, MBA, Head, Department of Anaesthesiology, Muhimbili University of Health and Allied Sciences (MUHAS), and Consultant Cardiothoracic Anaesthesiologist, Dar es Salaam, Tanzania.

Edwin Lugazia, MD, MBA, Head, Department of Anaesthesiology, Muhimbili University of Health and Allied Sciences (MUHAS), and Consultant Cardiothoracic Anaesthesiologist, Dar es Salaam, Tanzania.