Building Surgical Research Capacity in Africa: The Ptolemy Project

Abstract

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

Full text

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Health in Action
July 2006 | Volume 3 | Issue 7 | e305
T
he Ptolemy Project (http:/
www.ptolemy.ca) is a recently
developed model of electronic
access to medical literature for surgeons
in developing countries. The program
provides for East African surgeons
to become research affi liates of the
University of Toronto and have access to
the full text resources of the university
library, via a secure system that monitors
and evaluates their usage [1].
The project started in 2001, and the
benefi ciaries of the project so far are
201 doctors, mostly belonging to the
Association of Surgeons of East Africa
(Figure 1) and the College of Surgeons
of East, Central, and Southern Africa
(COSECSA). In this article, we describe
an international collaboration program
between the University of Toronto
and East African surgical communities
through the Ptolemy Project.
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Howard, M. Beveridge, unpublished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].
Building Surgical Research Capacity in Africa:
The Ptolemy Project
Miliard Derbew
*
, Massey Beveridge, Andrew Howard, Niall Byrne
Funding: MD is on sabbatical leave from the Addis
Ababa University, and is funded by the Offi ce
of International Surgery and the Wilson Center,
University of Toronto.
Competing Interests: The authors have declared
that no competing interests exist.
Citation: Derbew M, Beveridge M, Howard A, Byrne
N (2006) Building surgical research capacity in Africa:
The Ptolemy Project. PLoS Med 3(7): e305. DOI:
10.1371/journal.pmed.0030305
DOI: 10.1371/journal.pmed.0030305
Copyright: © 2006 Derbew et al. This is an
open-access article distributed under the terms
of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Abbreviations: COSECSA, College of Surgeons of
East, Central, and Southern Africa
Miliard Derbew is Fellow, Massey Beveridge is
Director, and Andrew Howard is Associate Director
at the Offi ce of International Surgery, University of
Toronto, Toronto, Ontario, Canada. Miliard Derbew
is also Assistant Professor of Surgery, Addis Ababa
University, Addis Ababa, Ethiopia. Massey Beveridge
is also at the Ross Tilley Burn Centre at Sunnybrook
Health Sciences Centre, Toronto, Ontario, Canada.
Andrew Howard is also at the Hospital for Sick
Children, University of Toronto. Niall Byrne is
Emeritus Professor, Faculty of Medicine, University
of Toronto.
* To whom correspondence should be addressed.
E-mail: milliard.derbew@utoronto.ca
DOI: 10.1371/journal.pmed.0030305.g001
Figure 1. The 2005 Association of Surgeons
of East Africa Meeting in Harare
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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.
Beginning with 50 library accounts
in December 2001, the number of
Ptolemy accounts increased to 150 in
2003, and 300 in July 2005 (K. Burton,
A. Howard, M. Beveridge, unpublished
data). Of 167 registered participants
in ten East African countries, 30 used
the service between January 2005 and
September 2005. In the broader fi eld
of 24 developing countries during
this period, 56 users downloaded a
total of 4,469 full-text papers from 672
different journals. The mean number
of accesses per user was 79.8 and 14
users downloaded more than 100
papers each. The mean number of days
users accessed Ptolemy was 15.5.
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 self-
report 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
1. Be surgeons working in countries
ranked less than 65 on the annual
World Health Organization Human
Development Index (preference
is given to surgeons in East Africa,
particularly COSECSA Trainees
and Fellows and members of the
Association of Surgeons of East Africa;
167 of the 201 participants are from
East Africa [Ethiopia, Kenya, Malawi,
Mozambique, Tanzania, Uganda,
Zambia, Zimbabwe, Madagascar, and
Seychelles]).
2. Consent to electronic monitoring of
their library usage.
3. Be prepared to enter into a research
affi liation with the University of
Toronto Offi ce of International Surgery.
4. Have regular access to the Internet.
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.
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PLoS Medicine | www.plosmedicine.org 0979
Arusha, Tanzania, who provides hands-
on 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. 
Box 2. Most Frequently
Accessed Journals
1. American Journal of Surgery (401 papers
accessed)
2. Current Orthopedics (359 papers)
3. The British Journal of Surgery (276
papers)
4. The Journal of the American Association
for Pediatrics (265 papers)
5. Burns (257 papers)
6. Surgical Endoscopy (225 papers)
References
1. Beveridge M (2005) The Ptolemy Project:
Surgical community building in East Africa.
Med Educ Resource Afr 18: vi–vii.
2. Jha P, Stirling B, Slutsky AS (2004) Weapons of
mass salvation: Canada’s role in improving the
health of the global poor. CMAJ 170: 66–67.
3. Jha P, Lavery JV (2004) Evidence for global
health. CMAJ 170: 1687–1688.
4. Jha P, Brown D, Nagelkerke N, Slutsky AS,
Jamison DT (2005) Global IDEA. CMAJ 172:
1538–1539.
5. Burton K, Howard A, Beveridge M (2005)
Is electronic health information relevant to
doctors in the developing world—Results of
the Ptolemy Project’s internet-based health
information study (IBHIS). World J Surg 29:
1194–1198.
6. Beveridge M, Howard AW, Burton K, Holder W
(2003) The Ptolemy Project: A scalable model
for delivery of health information in Africa.
BMJ 327: 790.
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