Füsun Sayek
Before I explore why clinical and public health research are not used as widely and as efficiently as we would wish in support of health protection and promotion, let me first describe my context. Turkey is a country of 65 million people, some 64% of whom live in urban areas. The GNP per capita is around US $3000. Some 30% of the population live under the poverty line and 13% have no job. There are huge inequalities, economically, geographically and socially, as shown by the human development index (HDI) values by province. Democracy is not yet fully established in Turkey, and abuses of human rights are common.
One of the biggest problems is individualism and a lack of idealism, dedication and
motivation. We need to find a solution to that. And there is also nationalism, by which I mean negative nationalism or racism. In Turkey, especially the last 15 years, we have experienced a
“silent war” between the racial groups. This promoted racism. Religious fundamentalism is also a problem for Turkey and countries in similar circumstances. I think WHO’s role is becoming much harder because of this fundamentalism and racism.
The birth rate is 22% and death rate is 7%. The infant mortality rate is 43 and the under-5 mortality 52 per 1000 live births. Only 50% of deliveries are assisted by a doctor or midwife. The rate of population increase is 1.6 and the population doubles every 45 years. Life expectancy is only 71 years for women and 66 years for men. Some 6% of the population is over 65, a figure very different from that found in western Europe. About 32% of the population is under 15 years of age, and 40% have no health insurance cover. Health is allocated only 2.7% of GNP (110 dollars per capita), very little compared to western European countries.
Abortion is a common method of birth control, since there is an unmet need for family planning. Knowledge of family planning is universal – according to studies 97% know about methods – but the number practising is low at about 60%. This reveals a lack of provision of materials such as condoms and birth control pills.
Illiteracy is a problem, especially among women, some of whom cannot read and
communicate. Children whose mothers have less than primary education are 1.6 times more likely to die in the first year of life than those of educated mothers, and in rural areas the problem is worse. Only 58% of children are vaccinated and 16% are stunted because of nutritional problems. People die very young owing to preventable diseases, and the quality of life does not compare with that in western European countries.
Public health is defined as the improvement of health through the organised efforts of society and through social intervention. “Social interventions” are those that cannot be undertaken by
individual members of the public or individual clinicians, although of course we need their contributions. These interventions include, for example, immunisation and environmental protection programmes. For all this, primary health care institutes are very important. Without primary health care and a referral-based health care system, it is very difficult to initiate health promotion and prevention activities or to carry out the research that should support them.
In Turkey we have a law that is intended to enforce a referral-based health care system, but there is very little communication between primary, secondary and tertiary care institutes. This problem affects not only patient care but also health protection and promotion and disease prevention activities based on research.
There is an Arabic proverb that says, “He who has health, has hope; he who has hope has everything”. We need hope. We need optimistic examples. In my paper I have presented some optimistic examples from Turkey. These happen to be vertical programmes, but we can fit them into the health for all concept.
All the successful examples are those that involve both the primary and secondary care levels.
As one example, in phenylketonuria screening, academics, primary health care physicians, midwives and the public are all involved together. A second example is education of health care providers and researchers. A third is fostering a culture of teamwork, which has been lacking in our country. A fourth is clinical research, now a preferred type of research for which financing by the pharmaceutical industry has been increasing.
Of course these all need economic resources, infrastructure and information technology. We need to pay attention to the ethical dimension, especially where pharmaceutical and other private companies are involved; and to the dissemination of research results to practitioners, managers and the community, which is still not wide enough. The capacity of the health authorities and the health services to identify priorities for research is not enough, and evidence-based analysis is very seldom used by them. We need a bigger contribution to this field from NGOs and international organisations.
In the Turkish culture people are used to telling the future, if you mean by this fortune telling.
You drink your Turkish coffee, reverse the cup, and see the future. And, as you can imagine, the future is always very dark because that’s the way Turkish coffee is made. I am ready to accept that scenarios can be very useful, especially when you want to scare the politicians.
Unfortunately, you may say, we have recently had some very brave politicians who are not scared by scenarios.
There are good reasons why scenarios written for countries like Turkey are less likely to thrive.
It is because in such countries everything can change drastically and very suddenly, and even natural disasters are common. After we lost more than 20 000 people in an earthquake, the only scenario on our agenda was future earthquakes.
To be able to use scenarios you also need to have a politically and structurally stable system.
Developing countries do not have this stability: for example, the average term of office of a Minister of Health is only 15 months in Turkey. Moreover, we are under the influence of economic globalisation but we do not benefit from the opportunities of that globalisation.
The gap between countries is widening. You say, “human genome”; I say, “salt iodization”. You say, “sophisticated patients” and “intelligent social actors”; I say; “women who do not even
speak Turkish” (they speak their own mother tongue and we cannot communicate). You say,
“AIDS”; I say, “polio”. I notice that when I try to speak at meetings, the gap is widening even in the terminology that we use. I think there is a need for people working in the international arena to do more research that would help reduce the gaps between us, to analyse honestly the reasons for those gaps, and then to think very carefully about possible new approaches.
We need trusted groups to speak more openly, and more loudly. In this meeting we have been talking about different subjects, but we should have talked even more about structures for health care, for public health, for health protection and promotion and for funding health care.
We should say more about privatisation in health care.
I think we have to be more honest than we often are. For example, when we show how much money is spent on arms in an effort to pressure governments to divert funds to health, too often the response is “my government is fine but some other governments are silly”. We have to get more open and we have to support each other more.
Jorma Rantanen
The question as to why the application or implementation of research does not work very well is valid for all of us. Füsun Sayek has identified a number of gaps that I find are equally relevant for Finland, and even for my organisation where we have a combination of research institutes and clinics for occupational medicine. She points to awareness and information, coordination, education, implementation and innovation; and also the lack of incentives for researchers and practitioners. What should we do? I think the first step is to identify whyit does not work well.
I have been surprised by the really poor application of our most recent research in clinical and public health practice. It is a huge gap in terms of both time and substance. Links usually do not work. We are too sectoral and isolated at the different levels of the health service system.
Second, problems tend to be very multidisciplinary in character – not purely medical, not purely technical – but multidisciplinary action does not work. That is a reason for weak functioning.
We have variations in traditions, competence and culture, which are not very easily overcome.
Individualism was mentioned, but lack of agreed priorities may also be a reason, because maybe those who apply science have totally different priorities than the researchers. Then there is poor leadership; usually very junior people are assigned to be responsible for applications and they get no guidance from their seniors. The chief medical officer or senior physician is very busy and does not have time to guide the younger staff.
A lack of information is not usually understood nowadays as an inability to obtain information but one of using and applying the information available. We also have, at least in the Finnish health system, an enormous shortage of time. More than 75% of the people in the health sector in Finland report that they are so busy at work that they do not have time to do the work well. This is the result of cutting resources when needs are growing at every level of the system.
What might be the solutions? One need is to understand the role of the research process in the whole system. This does not apply only to the health system; any societal system needs to analyse how research is really supporting and developing practice. We can trace a certain
continuity in the process that starts with problem identification and continues by studying the mechanisms, generating solutions, making practical trials (not only in the clinical but also the public health field), setting up and running field pilots and evaluating them, and distributing results.
In the distribution exercise we need to show three different types of relevance: scientific, practical and social. If any of these is zero, the whole product is zero. We have to meet all three criteria.
How we try to bridge research and practice is, at the moment, very dependent on the generation of guidelines and codes of good practice. This is a current issue in the whole of Europe. So how do we in occupational health try to bridge the gap between research and practice? We utilise scientific evidence as much as possible. We try to implement the
multidisciplinary approach in finding proper applications. We analyse very carefully the needs in the field and in the system – the needs of clients, populations and workers – in order to respond to the criterion of social relevance. We try to develop a working infrastructure, which is then able to use those applications.
I would like to remind everyone that we also have another continuum. We have “corrective care”, prevention and control, and promotion and development. But these are not separate actions; they are part of a continuum. I think we should find the way to analyse and
understand the rules in the direction within this continuum. I think that’s the weak point we should look at further.