Clinical emergency care quality indicators in Africa: a scoping review and data summary

Ashley E Pickering; Petrus Malherbe; Joan Nambuba; Corey B Bills; Emilie Calvello Hynes; Brian Rice

doi:10.1136/bmjopen-2022-069494

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Clinical emergency care quality indicators in Africa: a scoping review and data summary

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Persistent systemic neo-colonialism in academic publication
Lauren Lai King, Joseph Bonney, Olurotimi Akinola, Stevan Bruijns, Petra Brysiewicz, Heike Geduld, Clint Hendrikse, Peter Hodkinson, Robert Holliman, Joseph Kalanzi, Peter Mabula, Juma Mfinanga, Colleen Saunders, Willem Stassen and Menbeu Sultan
Published on: 6 June 2023

Published on: 6 June 2023
Persistent systemic neo-colonialism in academic publication
- Lauren Lai King, Emergency Physician, Senior Lecturer in Emergency Medicine, UCT CEO, African Federation for Emergency Medicine Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa African Federation for Emergency Medicine
- Other Contributors:
  Joseph Bonney, Emergency Physician President, African Federation for Emergency Medicine
  
  Olurotimi Akinola, Emergency Physician
  
  Stevan Bruijns, Associate professor, Emergency Medicine, UCT Editor in chief, African Journal of Emergency Medicine
  
  Petra Brysiewicz, Registered nurse, Professor, School of Nursing & Public Health, University of KwaZulu-Natal
  
  Heike Geduld, Emergency Physician, Associate Professor and Head Emergency Medicine, Stellenbosch University
  
  Clint Hendrikse, Emergency Physician Associate Professor and Head Emergency Medicine, UCT
  
  Peter Hodkinson, Associate Professor Emergency Medicine, UCT
  
  Robert Holliman, Emergency Medicine
  
  Joseph Kalanzi, Emergency Physician
  
  Peter Mabula, Emergency Physician
  
  Juma Mfinanga, Emergency Medicine Physician , Lecture of Emergency Medicine
  
  Colleen Saunders, Senior Lecturer in Emergency Medicine, UCT
  
  Willem Stassen, Emergency Care Practitioner, Senior Lecturer in Emergency Medicine, UCT Associate editor, African Journal of Emergency Medicine
  
  Menbeu Sultan, Emergency Physician Vice President, African Federation for Emergency Medicine
Letter to the Editor BMJ Open

Persistent systemic neo-colonialism in academic publication

The recent publication of the paper, Clinical emergency care quality indicators in Africa: a scoping review and data summary(1) has triggered much discussion within our network of emergency care academics and clinicians from various countries across Africa.

The subject matter explored in the publication is crucial, and we would congratulate the authors on tackling this issue. We agree that in many settings of nascent African emergency care systems, it is key to build quality indicators and to use them to improve and measure emergency care. Yet, for a paper that concludes that more needs to be done to improve published work on quality indicators in African emergency care, not including any authors living and working within African emergency care, is a significant oversight.

The problem of excluding African voices
Analysing the African emergency care health system from outside Africa is problematic. Africa is not a country, and we find the approach to dealing with Africa as one unit troubling. Although the authors rightly point out that emergency care systems and resources are at profoundly different ends of the spectrum in different settings within the continent, they chose to perform their search looking for evidence from Africa.(1) Much research done within African settings is done without collaboration or active engagement with the African emergenc...
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Letter to the Editor BMJ Open

Persistent systemic neo-colonialism in academic publication

The recent publication of the paper, Clinical emergency care quality indicators in Africa: a scoping review and data summary(1) has triggered much discussion within our network of emergency care academics and clinicians from various countries across Africa.

The subject matter explored in the publication is crucial, and we would congratulate the authors on tackling this issue. We agree that in many settings of nascent African emergency care systems, it is key to build quality indicators and to use them to improve and measure emergency care. Yet, for a paper that concludes that more needs to be done to improve published work on quality indicators in African emergency care, not including any authors living and working within African emergency care, is a significant oversight.

The problem of excluding African voices
Analysing the African emergency care health system from outside Africa is problematic. Africa is not a country, and we find the approach to dealing with Africa as one unit troubling. Although the authors rightly point out that emergency care systems and resources are at profoundly different ends of the spectrum in different settings within the continent, they chose to perform their search looking for evidence from Africa.(1) Much research done within African settings is done without collaboration or active engagement with the African emergency care community working locally. Emergency Medicine is well established in many countries on the continent, which is described by Sawe et al(2), and many countries have established academic and research capacities.(3, 4) Conducting a scoping review is certainly within the capacities and resources of many African emergency care academics, and we are sceptical of the authors’ statement that structural barriers such as internet connection and institutional library access are barriers to inclusion. There are undoubtedly African researchers who would have been able to and would have welcomed the opportunity to contribute to a scoping review on matters that directly affect them.

The need for decolonising global health
There has been much written about decolonising global health and the lack of Southern voices in publications. There is widespread criticism for the lack of representative authorship from low- and middle-income countries on papers about these settings, generated from high-income settings.(5-7) Another BMJ title, BMJ Global Health, has acknowledged the need for equity in Board representation as a component of decolonising academia in low- and middle-income settings.(8) As contended by other publications, some of the responsibility for publishing without due authorship representation rests with the editorial board.(6, 9) The African Journal of Emergency Medicine specifically requires proportional inclusion of African authors on all submissions to be eligible for peer review.

We recognise several authors in this paper with a significant background in global health, specifically in African emergency care. Given that global health is effectively the global discipline of inclusiveness and equity, choosing not to involve any African affiliated authorship, especially for authors so well connected within African emergency care, was a missed opportunity.

The African Federation for Emergency Medicine acknowledges that even as a regional collective, there exist local power differentials and clusters of privilege that facilitate research and publication from a few centres. The organisation has committed to strengthening mechanisms which acknowledge indigenous perspectives and promote equity and inclusivity in research representation.(6, 10) In transforming away from colonialist research and publication systems, it is imperative to engage with the composition of authors reporting on locations outside of their own, and consider systems designed to promote long-term equitable research relationships with appropriate representativity.(10)

1. Pickering AE, Malherbe P, Nambuba J, et al. Clinical emergency care quality indicators in Africa: a scoping review and data summary. BMJ Open 2023;13(5):e069494. doi: 10.1136/bmjopen-2022-069494 [published Online First: 20230502]
2. Sawe HR, Akomeah A, Mfinanga JA, et al. Emergency medicine residency training in Africa: overview of curriculum. BMC Medical Education 2019;19:1-6.
3. Kannan V, Tenner A, Sawe H, et al. Emergency care systems in Africa: a focus on quality. African Journal of Emergency Medicine 2020;10:S65-S72.
4. Rybarczyk MM, Ludmer N, Broccoli MC, et al. Emergency medicine training programs in low-and middle-income countries: a systematic review. Annals of Global Health 2020;86(1)
5. Contractor SQ, Dasgupta J. Is decolonisation sufficient? BMJ Global Health 2022;7(12) doi: 10.1136/bmjgh-2022-011564
6. Horn L, Alba S, Gopalakrishna G, et al. The Cape Town Statement on fairness, equity and diversity in research. Nature 2023;615(7954):790-93.
7. Naidoo AV, Hodkinson P, Lai King L, et al. African authorship on African papers during the COVID-19 pandemic. BMJ Global Health 2021;6(3):e004612. doi: 10.1136/bmjgh-2020-004612
8. Nafade V, Sen P, Pai M. Global health journals need to address equity, diversity and inclusion. BMJ Glob Health 2019;4(5):e002018. doi: 10.1136/bmjgh-2019-002018 [published Online First: 20191018]
9. Saleh S, Masekela R, Heinz E, et al. Equity in global health research: A proposal to adopt author reflexivity statements. PLOS Global Public Health 2022;2(3):e0000160. doi: 10.1371/journal.pgph.0000160 [published Online First: 20220330]
10. TRUST. Global Code of Conduct for Research in Resource-Poor Settings. 2018; doi: 10.48508/GCC/2018.05
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Conflict of Interest:
None declared.
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