Cheryl R. Dee

 Abstract — Inglés

Although statistical data on medical libraries in the Caribbean and Central America are scattered, incomplete, and even inaccurate, Cheryl Dee has compiled a preliminary survey of medical information resources in that region. After a brief description of various types of medical literature and libraries, she explores many of the common problems that hinder the delivery of medical information, such as inadequate and under–utilized collections; lack of hard currency to support new acquisitions; poor roads and postal systems; old–fashioned telephone networks; not enough computers; and extended electrical blackouts.

Using tables of statistics, Dee offers some broad observations on the medical book and journal collections of libraries in 16 Caribbean and Central American countries, and on their access to online medical data bases, such as MEDLINE and LILACS (Literatura latinoamericana e Caribe en ciéncias de salud). These observations, as well as pertinent facts on medical libraries, are summarized by county in the appendix. Two current projects in the region promise to expand access to medical information&$58; better and cheaper access to MEDLINE through BITNET, and international telecommunications network, using GRATEFUL MED software; and more extensive information retrieval through the outreach project of the Medical Center at the Universidad Central de Caribe (UCC) in Bayamon, Puerto Rico.

Dee proposes basic collection development, online access to MEDLINE, an interlibrary loan network, and a computerized medical expert system as important ways for less developed Caribbean and Central American medical libraries to meet minimum standards. In conclusion, she states that given the incomplete and inaccurate data on medical libraries in the area, a more detailed and comprehensive study must be undertaken before any planning for medical resource networks can begin.

 Abstract — Español

Bibliotecas médicas en el Caribe y Centro América
Aunque los datos estadísticos sobre bibliotecas médicas en el Caribe y Centro América son escasos, incompletos e inexactos, Cheryl Dee ha compilado un estudio preliminar sobre las fuentes de información en la región. Después de una descripción breve de los varios tipos de literatura y bibliotecas médicas, la autora explora muchos de los problemas comunes que impiden la entrega de información médica, tales como el referente a las colecciones inadecuadas y subusadas; la falta de efectivo para apoyar las nuevas adquisiciones; los caminos y servicios postales pobres; las redes telefónicas anticuadas; unas pocas computadoras y los apagones extendidos.

A través de la utilización de tablas estadísticas, Dee ofrece algunas observaciones amplias sobre los libros médicos y las colecciones de revistas en diez y seis países del Caribe y de Centro América, y de su acceso a bancos de datos automatizados y accesibles en línea tales como MEDLINE y LILACS (Literatura Latinoamericana e Caribe en Ciencias de Salud). Los proyectos actuales en la región prometen expander el acceso a la información médica: mejor y más barato acceso a MEDLINE a través de BITNET y una red de telecomunicaciones internacional, usando el programa GRATEFUL MED. Dee propone el desarrollo de las colecciones básicas, acceso automatizado en línea a MEDLINE, y una red de préstamo interbibliotecario, y sistemas expertos computarizados sobre medicina como medios importantes para que las bibliotecas de las áreas menos desarrolladas del Caribe y de Centro América puedan alcanzar el mínimo de normas de calidad.

En conclusión, Cheryl Dee establece que, dados los datos incompletos e inadecuados sobre las bibliotecas médicas del área, un más detallado y completo estudio debe realizarse previo a la planeación de las redes de recursos bibliográficos médicos.

 Medical Information Sources

Medical professionals seek high–quality medical information which consists of a collection of facts and theories that can be integrated and synthesized to care for patients, conduct research, and educate health professionals. Medical information needs vary according to the purpose of the information. Medical researchers need comprehensive, state–of–the–art information. On the other hand, health professionals in a clinical setting need immediate access to synthesized answers to specific patient–care questions at the time of patient contact. Clinical information needs to be concise and up to date, although not necessarily state–of–the–art.[1]

Medical information is available from a variety of sources, including formal and informal communications among colleagues; medical literature in a variety of formats; continuing education components of local, national, and international medical meetings; pharmaceutical representatives; and medical libraries. Medical literature consists primarily of books and journals but often includes information presented on audio tapes, audio or video cassettes, and computers. Medical journals comprise most of the medical literature and provide up–to–date information for research, clinical care and current awareness. Medical books supply health professionals with broad, concise information.

Printed indexes, especially the National Library of Medicine’s (NLM) Index Medicus, furnish access to medical journals. Online search capability, particularly that of NLM’s Medical Literature Analysis and Retrieval System (MEDLARS), remains the primary resource. MEDLINE, the most widely–used MEDLARS database, indexes approximately 360,000 articles in 3,500 journals each year.

The value of medical information resources has been well documented, although obstacles to medical information retrieval are formidable. The information explosion is increasingly an issue in the medical sciences, since physicians frequently lack the time to access this information. Resources, particularly in physicians’ offices, may be poorly organized or inadequately indexed for rapid retrieval. Caribbean and Central American health care professionals face these challenges but must cope with additional demands resulting from socio–economic conditions in the region.

Medical libraries are comprehensive repositories for medical information. The major focus of the medical library collection is on medical books and journals, supplemented by interlibrary loan for resources not available on site. Medical libraries typically include four types: academic, association or institute, hospital and nursing. The academic medical collection supports information for medical teaching and research in the school of medicine. Hospital libraries focus on medical information for clinical practice and public health. Optimally, the hospital library provides information for quality patient care, even to the degree of life–and–death circumstances, which frequently creates a need for rapid delivery of medical information. The medical association library, often funded by non–governmental money, provides specialized medical literature appropriate to the association and may be supplemented by general medical literature. Nursing libraries support nursing education programs.

Medical library personnel ideally consists of a professional librarian with a master’s degree in library and information science with an emphasis on medical librarianship. The medical librarians are best assisted by paraprofessionals with medical terminology and clerical backgrounds. It is obvious that these information needs of health professionals cannot be met without adequate collections in medical libraries. This infrastructure is generally available in the United States, countries of western Europe, and other developed nations, but rarely does it exist to the extent necessary in the newly–developing countries of Asia, Africa, and Latin America.

 Problems of Information Delivery

This paper looks at the situation in one such region, the circum–Caribbean, consisting of the island nations and the countries of Central America (the South American mainland countries of Columbia and Venezuela are excluded, as are Mexico and—for lack of information—Cuba). Medical libraries in the Caribbean and Central America often fall short of meeting information needs. The slow development of health sciences libraries in this area and the under–utilization of health care information follows the cultural tradition that places a low value on all libraries. Information delivery problems stem from difficult economic, social, and political conditions.

Economic problems impede the development of adequate medical library collections. Hard currency to support the library acquisition budget is frequently not available because of foreign exchange difficulties and currency devaluation. Payment in dollars for United States publications requires government agency approval, typically a slow and complicated process; very often approval comes after the subscription renewal period has expired. Required bidding by several dealers also complicates and slows the acquisition procedure.

Inadequate roads and poor postal systems delay delivery of acquisitions from abroad, often by as much as six months. It is not uncommon for Latin American authors to receive reprint requests from colleagues in developed countries several months before their own copy of the journal arrives. Medical libraries are challenged by the telephone’s inadequacy to transmit computer information via modems, too few computers for indexing and research, and extended electrical blackouts. Large numbers of books and journals are only available in English, yet the cost of translation is usually prohibitive.

Most medical schools are government–run and some academic medical libraries contain substantial collections. However, when a national crisis dictates cuts in public expenditure, the already minimal funding for books and journals is threatened. Hospitals in the Caribbean and Central America are modest; many complicated medical or surgical procedures are not performed because of limited medical equipment and specialized staff. Since funds are scarce for even basic medical equipment and drugs, very little money remains for the hospital library. Most hospital libraries are small and poorly organized; many lack professional library services and access to MEDLINE. Collections frequently contain a high percentage of incomplete journal runs and older editions of standard texts.

The staff in a Caribbean or Central American medical library typically consists of one person with a bachelor’s degree and a short course in library science and/or medical library study tour, although some academic medical libraries report up to three professionals and one to three paraprofessionals. Hospital libraries have considerably less staff and rarely have professional librarians.

International organizations may conduct significant medical research studies resulting in relevant medical information; however, librarians report that primary medical data is not valued and therefore not adequately indexed for retrieval. Instead, medical information is sought from the United States and Great Britain, which may or may not be appropriate to the local medical situation.

Natural disasters have curtailed medical information delivery. For example, hurricanes have devastated campus libraries on St. Croix and Jamaica; earthquakes have destroyed or severely damaged libraries in Nicaragua and El Salvador. Obstacles to information delivery in the Caribbean and Central America are substantial.

 Medical Libraries in the Caribbean and Central America

This paper summarizes existing data on the region’s medical libraries presented in a variety of published and unpublished sources. [2] Such data are scattered, often fragmented, and sometimes incorrect. Attempts were made to supplement this information by contacting medical librarians directly, even though researchers have previously reported the difficulty of obtaining statistics in the manner. For example, institutions sometimes report the size of the general library rather than the medical collection, or they fail to indicate that medical resources have been integrated into the general collection. Even attempts to secure data by telephone and FAX were often unsatisfactory. However, it seems safe to assume that the information assembled generally represents the minimum extent of medical resources and that a considerable number of additional libraries do exist, even though the evidence suggests that most of them have small collections, inadequate funding and minimum personnel. Available sources yielded statistical information on medical libraries in 16 countries, including Antigua, Barbados, Curaçao, the Dominican Republic, Grenada, Jamaica, Montserrat, Puerto Rico, St. Croix, St. Vincent and the Grenadines, Trinidad and Tobago, Costa Rica, Guatemala, Honduras, Nicaragua, and Panama. Three countries (El Salvador, Guyana, and Haiti) report the existence of universities with a school of medicine and a university librarian. Presumably medical collections exist at these institutions, but no printed data are available to substantiate this assumption.

The statistical profile developed covers 73 medical libraries in four types of libraries (university, association, hospital, and nursing school) in the 16 countries. Table 1 provides a profile of medical libraries in this study.

TABLE 1

An analysis of resources in individual libraries reveals great differences. Medical journals constitute the primary source of current medical information, and the number of current journal subscriptions frequently serves as a benchmark for the size of the library collection. The number of current subscriptions in the group studied varies from none to over 1,000. But perhaps more significantly, more than half the libraries (41) have fewer than 100 subscriptions. Collections of medical monographs may be as few as 125; only 13 of the 73 libraries report more than 10,000 items. Moreover, the extent to which books are recent publications, and collections are relatively up to date, remains unknown.

Data were further analyzed to ascertain the total resources which would be available to health professionals in a given country if resource sharing were practiced. In at least five countries (Puerto Rico, Costa Rica, Dominican Republic, Jamaica, and Guatemala) the total number of journal subscriptions exceeds 1,000 titles. One should remember, however, that these country–wide totals are quite modest in comparison with journal holdings of individual U.S. libraries; e.g., the Health Science Library, University of Florida, receives 2,395 titles, and the Medical Center Library at Vanderbilt University about 2,000. Monograph collections show similar variation. Between 50,000 and 100,000 volumes are reported in the libraries in five countries: Puerto Rico, Costa Rica, Honduras, Jamaica, and Trinidad and Tobago. (As noted above, these volume counts may refer to general collections in the libraries, not exclusively to medical materials.) Both sets of figures, it must be emphasized, are the minimum, because there are additional health science libraries whose figures could not be included in the present calculations since there were no published statistics. Furthermore, without a study of specific titles we do not know the extent to which resources are complementary and supplementary, rather than merely duplicative.

It is true that several reference sources exist in formats other than printed books and journals. Large academic medical libraries have access to NLM’s MEDLINE databases, particularly on CD–ROM; however, the CD–ROM requires expensive equipment and a large initial purchase plus on–going subscription costs. The number of terminals determines the waiting period for patrons, and staff constraints usually preclude the use of CD–ROM databases for outreach services. Several non–print journal formats provide access to journals if equipment is available. The Comprehensive Information System in Medicine (CISmed) for developing countries provides a microfiche turn–key system with access to 99 journals, including Index Medicus, and a document delivery module. This collection has received a relatively high degree of use at the demonstration sites, suggesting successful operation elsewhere. [3] The ADONIS workstation provides CD–ROM access to articles from 360 biomedical journals; however, the factors in choosing journal titles and the overall cost may limit use. [4]

While smaller medical libraries may have access to the printed Index Medicus or Abridged Index Medicus, few appear to have on–site database searching. Some report that they can obtain searches from large academic libraries. Some large libraries access LILACS (Literature latinoamericana em ciénciase da saúde), which provides online bibliographic control of 450 journals and books and other documents produced by Latin authors and published in the region. Medical Caribbeana: An Index to Caribbean Health Science Literature [5] provides indexing to books, journals, articles, and chapters found in regional and international publications. Many librarians report owning the index but state that it is becoming out of date because they lack supplements.

One current project provides optimism for future information retrieval. A development program using the National Library of Medicine’s user–friendly GRATEFUL MED software to access MEDLINE via BITNET furnishes improved biomedical communication capabilities where telecommunication services are limited and expensive. Thirty–eight countries and territories and more than 300 health science facilities in Latin America and the Caribbean could benefit from linking to BITNET or other academic networks. [6] Patrons search MEDLINE by formulating a search strategy on GRATEFUL MED, which automatically constructs a transmittable GRATEFUL MED file that is sent to NLM in Bethesda via BITNET. NLM receives the search, notifies the sender of receipt, and subsequently returns citations to the sender, again through BITNET.

While it would be foolish to attempt to draw firm conclusions based on the incomplete data on 73 medical libraries in 16 countries, it seems unlikely that further study would contradict the following general observations. The most viable medical collections are located in the universities; association libraries provide significant collections, but hospital and nursing school collections are uniformly small. The size of collections varies dramatically not only from library to library but also from country to country. Even the largest collections in the area do not compare favorably with medical libraries in the United States, and it is probably fair to say that in all countries there is a need to enhance collections greatly.

 Recommendations

Even with the limited data available, there are several courses of action which can be recommended. The first is that an in–depth study should be undertaken in order to make available information which is both more complete and more accurate on the present status of medical libraries in all countries of the circum–Caribbean area. This would go far beyond the compilation of a mere directory, even though names and addresses are necessary. Without the results of such a survey, it would be impossible to develop a good network for sharing medical resources.

Second, medical libraries should be encouraged to meet minimum standards. The top priorities for small medical libraries should include the development of minimum on–site collections, access to database searching, and resource sharing. Building a minimum collection, for example, could begin with the “Selected List of Books and Journals for the Small Medical Library,” prepared biennially by Alfred Brandon and Dorothy Hill. [7] The Brandon–Hill list assembles a well–balanced current collection of authoritative English–language books and journals for the clinical sciences; a complete Brandon–Hill list assembles a well–balanced current collection of authoritative English–language books and journals for the clinical sciences; a complete Brandon–Hill collection would include 607 books at a cost of US $60,000 and 140 journal subscriptions at a cost of $17,700. Brandon and Hill also identify items as first purchase for those libraries that cannot afford or may not need the entire list; this would represent expenditures of $21,700 for 297 books and $7,600 for 58 current journal subscriptions. Of course, each medical library must adapt even the first purchases for specialties and local interest. In the Spanish–speaking countries such adaptation might be significant, even with the emphasis on English in many medical schools.

Access to bibliographic databases online, especially MEDLINE, is essential in order to provide efficient subject access to a medical journal collection. Journal use is extremely limited if comprehensive subject access is not immediately available. Since health professionals usually have limited time or patience to search printed indexes, small libraries must provide access to MEDLINE in some form. The concept of sharing resources must be furthered, so that not only small medical libraries but others as well have access to other sources through interlibrary loan, FAX copies, etc., both in the country and from foreign sources. Of particular importance is an exchange of journal reprints generally from MEDLINE printouts. The possibility of cooperative book and journal purchasing should also be explored. Study of the role of the regional medical library for Latin America (BIREME) in Sao Paulo, Brazil in this area should be reviewed.

Since clinical physicians need immediate access to synthesize answers to specific patient care questions at the time of patient contact, further research should be undertaken on information delivery which goes beyond citations and focuses on delivery of answers to patient care questions. For example, a database composed of selected textbooks with integrated keyword access would be extremely valuable. In addition, a computerized medical expert system on an international basis would help to remedy the existing lack of medical information in the Caribbean and Central America.

Delivery of the medical information needed in Central America and the Caribbean presents a real challenge to medical librarians. It is one that must be met.

 References

1. For a detailed account of the information needs of physicians, see Cheryl Dee, “Information Needs of the Rural Physician” (Ph.D. dissertation, Florida State University, 1990; available from University Microfilms, Ann Arbor, Michigan).
Other useful studies include David G. Covell, Gwen C. Uman and Phil R. Manning, “Information Needs in Office Practice: Are They Being Met?” Annals of Internal Medicine 103 (October 1985): 596–599; E. Ray Stinson and Dorothy A. Mueller, “Survey of Health Professionals’ Information Habits and Needs,” Journal of the American Medical Association 243 (11 January 1980): 140–143; Elliot R. Siegal, “Transfer of Information to Health Practitioners,” Progress in Communication Sciences 3 (1982): 311–334; J. Salasin and T. Cedar, “Information–seeking Behavior in an Applied Research/Service Delivery Setting,” Journal of the American Society for Information Science 36 (March 1985): 94–102; and Theresa C. Strasser, “The Information Needs of Practicing Physicians in Northeastern New York State,” Bulletin of the Medical Library Association 66 (April 1978): 200–209.

2. Sources consulted include World of Learning (London: Europa, 1992); Directory of Information Units in Jamaica: Libraries, Archives and Documentation Services, 2nd ed. (Kingston: National Council on Libraries, Archives and Documentation Services, 1986); Manuel Roas and Lucero Arboleda de Roa, Catálogo colectivo de publicaciones periódicas en biomedicina, 2nd ed. (Santo Domingo: Asociación de Bibliotecas Universitarias Dominicanas, 1990); Laxmi Mansingh, “Challenges to Medical Librarianship in Developing Countries—A Caribbean Experience,” in Proceedings of the Fourth International Congress on Medical Librarianship (Belgrade: NOVI DANI, 1980); Memoria (Universidad Nacional Autonoma de Honduras, 1990); Noticias (Guatemala City: Universidad Francisco Marroquín, 1986); and Ursula H. Poland, World Directory of Biological and Medical Sciences Libraries (Munich: Saur, 1988). [The data reported in the World Directory should be treated with some caution, particularly in regard to Latin American libraries. It appears that in several instances what is reported for the size of medical library holdings is in fact the size of holdings for the university as a whole.]

3. Tefko Saracevic, “Experiences with Providing a Low–Cost High Quality Collection of Journals in Medicine for Developing Countries,” INSPEL 25 (1991): 69–98.

4. John Richardson, “Library User Trials with a CD-ROM Database,” Computers in Libraries 11 (April 1991): 28–34.

5. Laxmi Mansingh, Medical Caribbeana: An Index to Caribbean Health Sciences Literature (Mona: University of the West Indies Library, 1988).

6. Richard K. C. Hsieh and Carlos A. Gamboa, “Using BITNET to Access the National Library of Medicine Databases,” Bulletin of the Medical Library Association 80 (October 1992): 335–338.

7. Alfred N. Brandon and Dorothy R. Hill, “Selected List of Books and Journals for the Small Medical Library,” Bulletin of the Medical Library Association 79 (April 1992): 195–222.

 About the Author

Cheryl R. Dee is Librarian of the Watson Clinic, Lakeland, Florida.

© 1992 Dominican University

Citation

Dee, Cheryl R., “Medical Libraries in the Caribbean and Central America” Third World Libraries, Volume 3, Number 1 (Fall 1992).