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cannot read what has previously been written on their topic? Ptolemy directly addresses the 10/90 gap in health research by providing access to the literature for a group of surgeons in East Africa that has considerable leverage despite its small size. The membership of the Association of Surgeons of East Africa comprises 400 surgeons who are responsible for 200 million people in the eight East African countries; of those 400, 100 are Ptolemy participants.

Why is surgery so important in poor countries? The World Health Organization devised the Disability Adjusted Life Year to describe the global burden of disease. In this index, injury accounts for 12 percent of the global burden of disease, more than HIV, or diarrhea, malaria, and TB combined.2 There is a global injury pandemic and in 2001 injury killed just over 5 million people around the world yet world attention remains focused mostly on other health issues. Those who are killed or disabled by injuries would usually benefit from surgical management, and poor outcomes can be related to the lack of surgical care. Ptolemy is a very direct and simple way to improve clinical practice, teaching, and research capacity in Africa and hence the ability to reduce the burden of injury there.

When considering how to build research capacity in Africa, one must remember that doctors are not paid to do research. Doctors are paid to take care of patients, operate, run clinics, and do clinical work. Why do doctors conduct research? In Western countries there exists a system of intangible rewards whereby research work is rewarded with the respect of colleagues and status in their communities. While this system of intangible rewards exists in industrialized countries, it is not present in much of Africa. In order to build research capacity we must build a community of medical curiosity that engages doctors mentally and draws them into the endeavor of doing research. How do we engage African doctors in such a community of medical curiosity? To change behavior we have to get the right information to the right persons at the right time and create the system of rewards that will persuade them to stay up at night working on a research project rather than spending that time in other activities. We have to see that their work gets published and that what has been published is indexed and widely available: only then can we expect to see competition-based research funding begin to flow to African researchers.


The origins of the Ptolemy Project are at the intersection of a surgeon’s interests and a librarian’s. The surgeon had returned from working abroad and recognized the boon that access to the medical literature would be for colleagues who had no access to it and the librarian saw the Internet as perfectly suited to serve as the medium for this transfer of knowledge. There is a series of arguments about the inequity of access to health care information and the necessity for building equality. Sharing access with African doctors is a good thing to be doing. It is beneficial to the university; it enhances its profile internationally and has spawned an interesting research topic about how people actually use the information. Thus was born the Ptolemy Project, named after Ptolemy Sotor, the general assigned by Alexander the Great to found the city of Alexandria, who built the great library there in the third century B.C.

In establishing Ptolemy we also had to consider publishers’ contracts. After examining the wording of the agreements between the big journal publishers and the university library, we found that the university community was defined as “students, staff, faculty, and affiliated researchers.” We therefore decided to establish a mechanism for making researchers in Africa “affiliates” of the Office of International Surgery researchers in order to connect them with our university and facilitate library access. The library has dedicated 100 proxy server accounts for this. The University of Toronto Library has 50,000 existing library accounts, so the number of accounts dedicated to Ptolemy is not large (0.2 percent). Library accounts provide online, full-text access to a total of over 20,000 journals (2,500 medical journals) and several thousand textbooks.

In order not to provide access to those who might be able to afford journal subscriptions independently, we restricted participation to those individuals practicing in countries rated lower than 65 on the Human Development


World Health Organization. 2002. “Annex Table 3: Burden of disease in DALYs by cause, sex and mortality stratum in WHO regions, estimates for 2001,” in The World Health Report 2002: Reducing Risks to Health, Promoting Healthy Life, World Health Organization Press, France, October 30.

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