James K. Tumwine is the founding editor of African Health Sciences. When he was at university he wrote revolutionary poetry and fomented revolt against Uganda鈥檚 then ruler, Idi Amin. He became a specialist in paediatric infectious diseases and was Oxfam UK鈥檚 Health Adviser for Africa. He is now an associate professor of paediatrics at Makerere University鈥檚 Medical School in Kampala, and president of the Forum for African Medical Editors.
How did you first get involved in writing and publishing?
When I was 14 I started a school newspaper. Within my home village in Kabale district in western Uganda, and even within the school, there was a lack of information. I thought I had the skills and I like communicating.
Advertisement
One Friday evening I went with my editor to a jazz dance in the village. The dance was for teenagers but some of our new teachers were at the dance with their girlfriends. It was a scandal in our eyes to see adult couples at a children鈥檚 party. So we wrote the story in graphic detail naming names. Of course we handwrote it, since there were no typewriters, and we signed it.
We posted it up on the school noticeboard very early on the Monday morning. The headmaster called us up during school assembly and caned us five strokes each. We were suspended from school, but we were not allowed to go back to our homes 鈥� we were given hard labour, digging, for some weeks.
Somebody was telling me recently that if you don鈥檛 get into trouble for publishing that story then it wasn鈥檛 a good story鈥�
And after that?
At Makerere University I was more into student politics than writing. I wrote revolutionary poetry for Drumbeat, a university literary publication.
We staged a revolt 鈥� this was during Idi Amin鈥檚 regime. That was a very traumatic time. We saw a lot of our friends killed, some by firing squad. When you have your youth filled with so much violence it鈥檚 a terrible thing.
I was on the editorial board of the university鈥檚 medical journal, as a representative of the student executive, but not playing a major role.
Why did you choose paediatrics?
Children are the majority of the population in Uganda. The current measles immunisation programme targets 12.7 million children between 6 months and 15 years 鈥� out of a total population of 25.5 million. They are vulnerable, especially when you are talking about war-ravaged areas like northern Uganda.
Is that Africa鈥檚 biggest health issue?
Africa鈥檚 biggest health issue is lack of education. Look at cholera. I investigated an outbreak in Kampala several years ago, to try to locate the source. In wealthy areas like Kololo there was not a single case. There people are wealthier because they have good jobs and they have good jobs because they are well educated.
Many more people are dying from malaria in this country than any other disease. But there used to be malaria in Italy. It鈥檚 not there today. Our environment is similar to certain areas of Italy, but we have it and they don鈥檛. Why? After malaria and AIDS we come to malnutrition, which hardly gets reported. But about half the children we see hospitalised have a history of poor feeding.
Why doesn鈥檛 malaria, for example, feature on the global agenda like HIV?
I think it鈥檚 because malaria is not going to affect the United States of America and George W. Bush. It鈥檚 African children who are dying. But these deaths go unreported because the international community is only interested in what directly affects them. In Europe people are putting a lot of investment into illnesses such as cardiovascular disease. Malaria is a disease of the poor.
What, then, should be done?
We need to invest in the brains of our own people. If we can educate our people we can take care of our own problems. Yes, of course we need foreign investment in health 鈥� but for the long term Africa needs highly educated people if this continent is to develop.
In Uganda we used to train our medical doctors in the UK 鈥� but this ended in 1967 when we decided to train our people locally. Today we have many good young authors like some of my master鈥檚 degree students. They have produced very good dissertations, such as one about giving vitamin A to children who are severely ill with malaria. It asked whether we actually improve the outcome of this deadly disease using a vitamin supplement in addition to the standard treatments.
But what happens to that work?
This is original research but if you send this work to a western medical journal they will not touch it.
Do you have experience of that?
I wrote an article about health and education in Zimbabwe. I was trying to emphasise that heavy investment in education was having a positive impact, though I wasn鈥檛 sure this was sustainable because the International Monetary Fund and World Bank were imposing 鈥渟tructural adjustment programmes鈥� on the government.
I submitted it from a Harare address. The journal rejected it. Later, I went to work in the UK. I waited a couple of months and then resubmitted it to the same journal, from an Oxford address. It was published! And it has been quoted numerous times in the literature.
What effect did the rejection have on you?
Naturally, I was angry. It鈥檚 like the bursting of a bubble around you and it hurts your ego. But then you think about whether it needs corrections, and send it elsewhere.
You鈥檙e not saying that western journals ignore Africa entirely鈥�
Of course they do publish research that originates in Africa. But I think they look at the research they believe is relevant to the interest of their readers, this is what they tell us. Take for example nodding disease, a mysterious ailment that afflicts children in southern Sudan. If children in Sudan are dying of a mysterious ailment it鈥檚 more likely to be of interest to us in Africa than to somebody in the US.
But there is also plenty of evidence, which Richard Horton, editor of The Lancet, has pointed out, for bias against non-Caucasian researchers. It might stem from the fact that Africans are not represented on the editorial boards of these publications 鈥� and if you are not represented, who is pushing on behalf of your interest? Horton, who is a big advocate for African scientists, has also documented that most of the journals, including his own, have minimal representation from Africa on their editorial boards. It鈥檚 a very competitive world and particularly if you are doing biomedical research here in Africa and you are not collaborating with western researchers, you really don鈥檛 stand a chance.
So my attitude is: why struggle to promote journals that do not put forward your agenda? Why don鈥檛 we start our own publication instead of being in a state of dependency? This is the major reason why we started African Health Sciences, to have a forum for African medical researchers.
Tell us more about African Health Sciences.
The journal comes out three times annually. We produced the first issue in August 2001. It took almost a year to collect articles, do the research and to get support. So far we have received a small grant of 3 million Ugandan shillings (拢1000) for printing, ultimately from the fees of private students at Makerere University鈥檚 faculty of medicine. And the World Health Organization donated computer equipment and printers.
Wouldn鈥檛 it have been easier to associate yourself with a more established journal or organisation?
Personally, I don鈥檛 like the bureaucracy of medical associations. I鈥檇 much rather create something independent. Our dean at the medical school has given us the freedom to do things our way and to push the agenda of promoting African publishing.
As president of the Forum for African Medical Editors I know the problems others face: finance, delays in publication, conservatism. So we couldn鈥檛 go starting a new journal and go down the same route as these publications.
What are the difficulties that you face?
We send our articles to one reviewer here in Uganda and at least two elsewhere. The Ugandan reviewers are extremely slow. Another problem is that we don鈥檛 have many people here with editing skills 鈥� and though our students can write fine dissertations and get their degrees, they do not have the skills to write 2000-word scientific papers.
What are you doing about that?
We are learning on the job. And the WHO Tropical Disease Research Unit has given us a small grant for training authors, reviewers and editors. This will initially be for Ugandans but later we will do training for east and central Africa. In the past we followed western guidelines for things like editing and style of writing, but during the official launch of the Forum for African Medical Editors in Addis Ababa, Ethiopia in September 2003, we developed our own home-grown African guidelines.
And has African Health Sciences gained recognition?
MedLine has indexed our journal since April 2003. It means that we meet international standards. This is the greatest achievement of my life. Now we can sit at the same table with other indexed journals as equals, and this after only two years.
Does that help researchers in Uganda?
Not immediately. The WHO recently asked me to help investigate nodding disease, which requires access to research journals, which these days means having access to the internet. You might search the MedLine database for abstracts 鈥� but when you want to see the full articles they want your credit card number. In Uganda the vast majority of the population don鈥檛 have credit cards. In the end the full articles had to be faxed to us.
Is access improving?
Kofi Annan, the United Nations secretary general, recently initiated a programme to make 3000 electronic journals accessible to developing countries. But in Uganda you would have to go to one of the big libraries in Kampala to get them.
Just accessing your email through the medical school connection can take up to three hours. So recently I installed a satellite dish outside my office. I鈥檓 paying 500,000 Ugandan shillings (拢160) a month, which is more than my salary. Then there are technical problems like computers breaking down. For some the internet is just another part of life but for us it is part of a bigger struggle.
Which is?
I think the issue of addressing social inequality has been lost and I think it needs to be brought back onto the global agenda. But this is not a sexy topic for medical researchers. They want to talk about molecules.
We can address these inequalities through education: equalising our opportunities; making sure all our children go to school; and investing in training so that our healthcare workers are up to standard.