Back to the future

In 1997, a small group of well-meaning, but rather naïve, paramedics based in Johannesburg established the Gauteng Emergency Care Research Forum (Gauteng is the province in South Africa of which Johannesburg is the capital city – Sesotho for ‘place of gold’). Prehospital emergency care education had branched into the tertiary education sector roughly a decade before this, with a National Diploma in Emergency Medical Care. Amongst the group that established this grand-sounding body was not a single individual with any postgraduate qualification or even one peer-reviewed publication to their name (postgraduate in this context means masters or doctoral qualifications). Yet, even at this early stage there was a basic understanding, at least amongst some, of the importance of research in driving the future development of prehospital emergency care in South Africa.

As you could probably imagine, the Forum struggled to figure out what its purpose was other than to meet regularly and have stimulating conversations about research. After some time, one of the key aims that emerged was that for research to start ‘happening’ support would be needed for nascent researchers – in the form of mentorship, various technical resources and funding. And so members of the Forum set about making connections and knocking on doors to try and see how this could be done. All with fairly limited success. However, for a group that started out knowing nothing at all about research some progress was made and a few key contacts were established that eventually made it clear what a seemingly impossible thing the Forum was trying to do.

The Forum had a few limited successes in spreading awareness about research in the profession and in gaining access to some resources, but it eventually succumbed to the entropy that many efforts held together almost exclusively by idealism do. In some ways, the Forum was a little ahead of its time with postgraduate qualifications in the field of emergency care still roughly a decade away. The most difficult thing, seemingly, was not to find ways and means to support researchers but to find them. At the time, thinking about why we were not successful in keeping the Forum or its aims alive I was reminded of a slogan for the U.S. election campaign in 1992 – ‘it's the economy, stupid’. In this case, it could have been ‘it's the researchers, stupid’. Somebody needs to do the research.

Fast forward roughly five years and a Bachelor's degree was in place in South Africa, followed several years later by the beginnings of a postgraduate programme. These changes happened within a relatively short space of time and in parallel with similar ones in emergency medicine which saw this recognised as a clinical specialty in 2005 along with the establishment of discipline-specific postgraduate programmes. Thus, between the turn of the 21st century and a decade hence the broader academic field of emergency care, in both the prehospital and emergency department domains, made significant progress in areas tightly related to research. It would probably be true to say that with a basic postgraduate framework now in place, there was an expectation of growing returns in research output – output that was for the most part non-existent before this. Surveillance of the scholarly publishing landscape does indeed confirm this growth in outputs, not only in South Africa but in Africa more generally.^1,2

Around 2017, discussions were initiated within the Emergency Care Society of South Africa's Board of Directors of the need to establish a local peer-reviewed journal specific to the discipline of prehospital emergency care. One reason cited for this need was that at least some research being done in South Africa was quite unique to this environment and did not necessarily appeal to a broader international readership (or so some editors of international journals told aspirant local authors when rejecting their manuscripts). Thus, having a local journal in place would facilitate the publication and dissemination of this research. While this seemed to be a fair proposal, from the outset there were concerns voiced about how sustainable such a venture would be in terms of both quantity (mainly) but also quality (less of a worry at the time). Consequently, discussions were had with colleagues from universities with related programmes about this and the feedback was uniformly positive – regarding the need for the journal and also regarding support in terms of submissions. After much deliberation a decision was taken in 2018 to establish the South African Journal of Pre-hospital Emergency Care (SAJPEC) – something that eventually came to pass with the first volume available online in 2020.

At this point it is necessary to digress and briefly explain how the South African government's research funding model affects the viability of scholarly journals, especially new ones. In South Africa, the Department of Higher Education and Training (DoHET) subsidises the research outputs of the 26 universities in the country. Translated, this means DoHET pays each university annually for research published in what it refers to as ‘accredited’ journals (subsidy is also paid for book chapters and conference proceedings, but this discussion will be limited to journal articles). To be accredited, a journal must be indexed in one of several recognised indexes (e.g., Scopus is one of these) or if this is not the case, have been assessed by DoHET after a minimum period of three years of uninterrupted publication. While this may already be sounding perverse (which it is), the biggest problem is that universities rely heavily on this research output subsidy and thus pressurise their academics to publish only in accredited journals. Consequently, publishing in unaccredited journals (by definition, any new journal in its first three years will be unaccredited) is something that most academics will do only very reluctantly making it very difficult for any new journal to attract local submissions.

Despite having the odds stacked against it by not being accredited, SAJPEC started off attracting enough submissions to remain viable for the first two years of its existence. However, submissions dropped off towards the end of 2021 and into 2022. The journal applied for accreditation from DoHET in 2023 (the earliest possible time, according to DoHET's minimum three-year publication rule) but was unsuccessful – based on the fact that the journal was not publishing enough articles per issue. While this was disappointing, it was not entirely unpredicted based partly on the funding dilemma described above. Earlier this year, a decision was taken in consultation with ECSSA to stop publishing SAJPEC because the lack of submissions does not seem to be something that can be changed in the short time-frame required to bring about a successful re-application for accreditation.

I believe that SAJPEC's demise may be related to multiple factors affecting emergency care research in South Africa, but probably elsewhere too. Published research outputs are typically linked to a postgraduate programme. This sounds simple enough, however these outputs are driven mainly by academic staff who supervise, rather than by students. Probably in most cases, postgraduate programmes exist in the same academic departments as undergraduate programmes – an important point because typically the same academic staff perform multiple duties across the two. For a postgraduate programme to perform well I believe requires all other programmes in the same department to be healthy. This can be thought of as a Maslow's hierarchy-like concept, meaning that the basic (undergraduate) academic needs must be met and functioning smoothly to allow for time and focus on the higher-order (postgraduate) outputs, especially publication of completed postgraduate research. A struggling undergraduate programme will leach away resources (time possibly being the most important one) from everything else, including research.

Although a healthy postgraduate programme is pivotal in producing good research outputs, it doesn’t guarantee them. What I mean by pivotal refers more to quantities – numbers of graduates and their work, often measured as ‘throughput’. A critical mass of quantity is a basic, first-order requirement – without it nothing else is possible (SAJPEC found this out). Of course, there is also quality of research – something that Simpson, writing in these pages very recently, claims we have a problem with. ³ I tend to agree with this claim, despite the fact that I am still very unsure exactly what we mean by research quality. I doubt very much that research quality can be reduced to citations, h-indexes or impact factors all of which have serious validity problems, as I am sure you have read before.^4,5 While I struggle with the idea of quality and what it means, I believe it is not that difficult to understand the opposite of quality research in an academic programme and what is associated with it.

The kind of research I mean by ‘not quality’ is the research produced by disinterested, or perhaps just browbeaten, academics (or their students) to meet a target, as is so often required by many universities that have become increasingly corporatised and driven by rankings. Of course, this is only aggravated when each unit of research output (typically a published article) has a well-defined monetary value, as it does in South Africa. In such cases, academics – themselves or through their postgraduate (and sometimes undergraduate) students – seek what has been euphemistically termed the ‘least publishable unit’, that is the smallest, simplest and quickest-to-assemble output that will achieve the goal of meeting a target, which in turn feeds into a unit of subsidy, a performance management point or a fraction of an increment in a ranking. Ironically, universities prioritising output metrics also claim to be committed to enhancing the quality of their research, but this is doubtfully true when virtually every discussion about research turns on metrics.

So, what is the answer to begin moving in a direction opposite to one which produces ever more ‘not quality’ research? There are probably many, but one that I believe is important relates to the researcher themselves (‘it's the researchers, stupid’). Much of what characterises ‘not quality’ research can be counterbalanced by freedom. By freedom I mean the ability of each academic to express and pursue (and have rewarded) their own imprint on the research process. Sadly, young academics seem to have this beaten out of them by university bureaucracies, which insist rather on numbers. I am often interested to notice that very few of my colleagues (broadly speaking, not just institutional ones) have ever published research not linked to a postgraduate student – in other words, their own research whether individually or in collaboration, but not for the purposes of graduating a student. Likewise, many struggle to articulate what their focused research interests are in conversation. Although I have no convincing evidence (or metrics), I believe that when academics have this freedom and can set their own agenda and follow their interests in research, quality will by necessity follow. Sadly, this is something that will not be assumed in many modern universities and will only come, if at all, with much pushback.

In some ways, even after some 27 years have passed, when I think back to the Forum I marvel at how much ground has been covered but at the same time I wonder about what feels like a sense of malaise regarding emergency care research in South Africa. The initial gains came fast and were prominent against an empty backdrop, however it seems there is still a long way to go. Certainly, universities active in the emergency care space carry a great deal of responsibility in ensuring that the research trajectory is set where it can have value for patients and where a new generation of younger academics and researchers can own this and imbue it with their own interests and personal growth. While SAJPEC is no longer publishing, it is great to see that ECSSA has entered into collaboration with Paramedicine. While this could be interpreted as a matter of timing, there are more substantive reasons for this partnership. Paramedicine's commitment to high quality peer-review ⁶ and publication practices, indexing and partnership with an established publisher all contribute to sustainability and growth of the journal over time which is also important for South African researchers. Beyond this, Paramedicine has clearly demonstrated its intent to provide an international platform for collaboration ³ and professional conversations ⁷ that serve as the impetus for improvement and evolution ⁸ of the field. I believe that Paramedicine's commitment to quality emergency care research fits well with ECSSA's mission and that this synergism can be instrumental in furthering advances in clinical care, education and emergency care systems capable of making a difference to our collective populations.