Curiously, although it has been suggested that the generation of new knowledge accounts for up to 30% of the gross domestic product (GDP) of a nation (1), much of Africa, including Kenya, appears quite content with spending its limited resources in promoting the GDPs of other countries through unfettered purchase of innovations and inventions created in geographical localities outside of Africa. No sector of the economy is excluded from this reality; it is nevertheless most glaring in healthcare, especially surgery. Sub-Saharan Africa (SSA), which represents 17% of the global population, contributed a paltry 0.7% of the global surgical publications between 1996 and 2022 (2). Even with the myriad of obstacles faced while undertaking surgical research in Africa, the absence of a research culture and the lack of supportive research infrastructure, along with the non-submission of conducted research for publication, are major hindrances to the undertaking of quality surgical research (2-4). While governments must have a vested interest in cultivating a research culture, partnerships between industry and academic institutions are vital for innovation to thrive. Innovation has the potential to reduce the cost, while improving the quality of surgical care.
It is noteworthy that the majority of surgical research in SSA is performed within academia, mostly as a requirement of the Master of Medicine degrees offered by most universities in SSA. For many surgical trainees, this first encounter with research is a double-edged sword—offering, on the one hand, the potential for a good experience that may lead to an enthusiastic path toward publication and a lifelong pursuit of research, or, on the other hand, a bad experience that may destroy any lingering interest in research (5, 6). The trainee is often given a supervisor to provide mentorship. For many university supervisors, the only research experience is their own thesis journey, and thesis supervision is performed as a requirement of their employment, as well as their promotion through the academic ranks. This unfortunate situation is akin to the “publish or perish” culture promoted within academia in which the sole goal of publishing is the number of publications and survival within academia (7, 8). The “publish or perish” phenomenon has led to an explosion in publication volumes with a deteriorating quality of submissions and increasing research misconduct (8). Regarding thesis undertaking, the sole purpose of the exercise for both the trainee and the mentor is survival—graduation for the trainee and promotion for the mentor, respectively. Many trainees, while agreeing that research is important, consider the thesis process burdensome (6). With no lasting positive impact of this process, it is a small wonder that this is the last research undertaking for the trainee. The thesis joins hundreds of others in the university’s repository, where few other people have access to the study, and thereby, potentially useful data remain buried. While the obstacles that hinder the completion of a thesis include lack of funding and dedicated time, prior research experience and a structured research training course contribute to thesis completion (6, 9).
Academic theses are not peer reviewed and are therefore classified as part of gray literature. Authors have decried the low rate of conversion of theses into peer-reviewed publications; Touissi et al. found that only 0.8% of Moroccan theses were published in journals (10). While only 50% of research ends in a publication as a result of non-publication (4), the low rate of theses-to-publication conversion deprives the continent of rightful contribution to medical knowledge. The African Perioperative Research Group (APORG) identified 10 priorities for peri-operative research in Africa; the majority of these priorities have most likely been undertaken in existing or ongoing theses in our universities and therefore can be easily and affordably addressed (11). The challenge lies in gleaning this into scientific manuscripts.
Early exposure to medical research, such as the entrenchment of research requirement within some medical school curricular, exposes future doctors to research (10). In theory, the universities train academic surgeons, with the expectation that they will contribute to research, while the now-entrenched collegiate model trains the clinical surgeon. This is not a luxury that we as a country or continent can afford: we should train every surgeon to carry out research and help create the supportive infrastructure needed to make this a reality. Medical students in many high-income countries (HICs) are active participants in research as early as in their first year. Early engagement in research acts in their favor at the time of selecting their disciplines, so that it is not unusual to see a prospective first-year resident with 10 publications to their credit (12). Early exposure of medical students to research requires organizational structures that prioritize the promotion of research and attainment of a sustainable research culture. This infrastructure should include a national policy on the promotion and support of surgical research and innovation, with a designated state office and budgeted annual meritocratic research awards; research champions, designated as mentors/teachers for whom research is a way of life; a surgical research pathway for the surgical research scientist (empowered through research awards and the support of research laboratories); and medical school curricular that enable third- or fourth-year research gap year, allowing medical students to actively participate in impactful research. Universities must have a research curriculum that empowers students to undertake and write their theses. Further, universities must train all research mentors/supervisors in research methodology to make their role both useful and enjoyable. The low number of surgeons currently trained formally in research means that collaboration, both locally and internationally, is needed in order to build up the local capacity (2, 13).
Emerging technologies such as artificial intelligence (AI) provide excellent opportunities for both surgical care and research within SSA. While responsible use of AI is an important and integral aspect, its early and ethical adoption as a tool for surgical research may help create the research culture that is so desirable (14). The need for data from SSA is even more urgent, as the current data used to train the large language models (LLMs) are primarily from HICs; data will allow LLMs to be more useful in Afro-centric surgical research.
Surgical scale-up is a buzzword in global surgery; however, it will remain thus unless steps are taken to incorporate research capacity within surgical training and to require publications from every graduating surgeon. Where theses are an integral part of training, it should be aequirement that a minimum of one manuscript is published by each trainee. Research provides the evidence that drives policy. Contextual research will provide the data needed to establish policies that address the many surgical needs across the nation and the region—only then can we answer such questions: How many surgeons are needed? In which disciplines? What supportive infrastructure is needed? What equipment is required? The answers to these and many other questions within the realm of quality surgical care provision will remain unanswered until the bar on surgical research is raised and research becomes inseparable from clinical care.

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