It is a depressingly familiar story. A group of medics in Indonesia search medical literature in preparation for a study. They want to arm themselves with as much knowledge as possible, so that their own research will build on previous work. But when they go online to access the crucial articles, they are out of luck: reading the papers requires exorbitant pay per view or journal subscription fees which they cannot afford.¹

We are part of a grassroots movement of doctors and researchers who believe that medical research results should be a freely available public resource. Governments worldwide invest billions of dollars in medical research every year—the National Institutes of Health in the United States will alone spend $28bn (£15bn; €23bn) in the fiscal year 2004,² yet the results largely remain in private hands, locked behind access fees and restrictions (figure).

It will cost you $30 to read this important study on diabetes

Why is it so urgent to unlock this treasury of knowledge? Taxpayers deserve free access to the results of research that they have financed. Patients have the right to know the results of studies in which they participated and which are relevant to their condition. Researchers should be able to share knowledge to promote more efficient scientific progress—the Human Genome Project (www.nhgri.nih.gov) is a great example of what can be achieved when researchers worldwide can freely share their data. And giving health workers in developing countries access to reliable health information may be the single most cost effective and achievable strategy for sustainable improvement in health care.³

Medical and scientific publishing companies, however, are reluctant to free their articles, which make them about $7bn a year.⁴ Subscription prices outpace inflation again and again, and many medical libraries have had to cut back on titles. Between 1990 and 2000, medical journal subscription prices rose by 184%.⁵

In the days before the internet, charging readers for paper journals made sense—publishers had to recover the costs of processing articles (editing and peer reviewing them), buying paper, printing journals, and mailing them out around the world. In comparison, the cost of distributing an article online is almost zero (for example, for bmj.com the cost is about 0.3 pence an article⁶). Processing an article and putting it online in a secure repository is a fixed, one time cost. If a publisher can recover this cost up front, there is no reason why an article cannot then be made freely available.

That is the model being adopted by open access journals. These journals provide unfettered online access to all material, as well as the right to copy and redistribute it without restrictions. Open access publishers act as service providers, rather than owners of information. They charge a one time publication fee for what they do—mediating peer review, copy editing, electronic formatting, online hosting, and a few other tasks—and in return they impose no restrictions on viewing and using the articles that they publish. If authors cannot afford the publication fee, it is waived, with no questions asked—inability to pay publication charges should not be a barrier to publishing in open access journals.

Why do we need an open access publishing model, given all the recent initiatives to increase the flow of information to some of the world's poorest nations? The Health InterNetwork Access to Research Initiative (HINARI), for example, brings together many of the largest commercial journal publishers to offer free or low cost online access in countries with a per capita gross national product of less than $3000.⁷ But the gross national product cut-off excludes many of the world's most populous nations where the need for current medical knowledge is especially acute, like Brazil, China, India, and Indonesia. And although initiatives such as HINARI do provide online access to journals, copyright laws restrict readers from reproducing and sharing the material—a particularly severe obstacle in countries in which internet access is unreliable.

The Public Library of Science (PLoS) is one of many publishers working to turn the scientific and medical literature into a public resource. Last year, PLoS published its first open access journal PLoS Biology (www.plosbiology.org)⁸ and in October, it will launch PLoS Medicine (www.plosmedicine.org). As well as being a truly international and inclusive journal, with articles covering many different areas of medicine, PLoS Medicine plans to have a team of medical student advisers, a dedicated section of the journal written by students, lively summaries and commentaries, and explanations aimed at patients.

Most importantly, anyone, anywhere in the world is free to use all articles in PLoS Medicine without any limitations—the only condition is that authors should be given proper credit. Nothing stops a minister of health from making a million copies of an article to send to every medic in the country. Now that is what we call an article that is truly free.

Dan Engber intern
Email: dengber@plos.org
Andy Gass outreach coordinator
Email: agass@plos.org
Gavin Yamey magazine editor, PLoS Medicine, Public Library of Science, 185 Berry Street, San Francisco, CA 94107
Email: gyamey@plos.org
studentBMJ 2004;12:309-348 September ISSN 0966-6494

References:

1. Ham MF, Namtini SS, Luo WJ, Xu JX. Open-access publishing. Lancet 2004;364:24-5.
2. Agres T. NIH budget worries advocates. Scientist 2004 July 7. www.biomedcentral.com/news/20040707/03 (accessed 29 Jul 2004).
3. Packenham-Walsh N, Priestly C, Smith R. Meeting the information needs of health workers in developing countries. BMJ 1997;314:90.
4. Delamothe T, Godlee F, Smith R. Scientific literature’s open sesame? BMJ 2003;326:945-6.
5. House of Commons Science and Technology Committee. Scientific publication: free for all? London: Stationery Office, 2004. www.publications.parliament.uk/pa/cm200304/cmselect/cmsctech/399/399.pdf (accessed 29 Jul 2004).
6. Delamothe T, Smith R. Open access publishing takes off. BMJ 2004;328:1-3
7. Katikireddi SV. HINARI: bridging the global information divide. BMJ 2004;328:1190-3.
8. Public Library of Science. PLoS News. San Fransisco: PLoS, 2004. www.plos.org/news/index.html (accessed 29 Jul 2004).

The Public Library of Science (PLoS) is admirable initiative towards bridging the famous 10-90 gap - also called "health gap" or "digital divide in health"¹. Open Access publication provides its users with unique advantages:

It improves health information accessibility, making the information accessible practically anytime, from any place and to anyone who needs it. In the developing world when e-commerce and instant credits is distant dream, rapid delivery of free information is not just important, it is potentially life saving.

It allows better awareness about hottest research - clinical trials, drug development and so on. "Eyes see only what mind knows" and updated knowledge would help clinicians work with more accuracy and confidence in diagnosing illnesses and suggesting treatment options.

Lastly, multiple sources of open access material and latest smart search technology would always allow the user to find the exact information needed, rather than listing "334296 results for your search ‘Digoxin in CCF"! As more and more viewers get the benefit of the open access material online, it will soon go on in more sophistication, customization and finally on way to amalgamate in the routine life the way a newspaper is today.

Open access is such a buzz word that excites all those who think about perpetual and pervasive nature of information science. Surprisingly those young people who advised Microsoft Corporation on the future think "Open Access" a key to bridge digital divide²! PLoS and other open access journals should focus on developing country reader base which is not just a beneficiary but also a potential creator of quality open source contents.

Reference:

1. Cohen B. PLoS Medicine. PLoS Biology. February 17, 2004 (URL: http://www.plosbiology.org/plosonline/?request=get-document&doi=10.1371/journal.pbio.0020063) (Accessed 26th August)
2. .Presentation of Microsoft Office Information Worker Board of the Future Meeting, Redmond, WA, USA (June 21-25, 2004)

Conflict of Interest: The author is a member of Microsoft Office Information Worker Board of the Future but not an employee of Microsoft Corporation.

It is a laudable effort by the editors to bring the issue of people being deprived of information on medical advancement due to lack of money ¹. When I entered medical school, we used to have timely supply of world’s best medical journals like BMJ, Lancet, NEJM, and JAMA etc. But by the time I was in the mid of second year, reading the print version of such journals became a thing of past. Even if we try to access online journals, it is impossible for many except BMJ and NEJM. I don’t know how do people of developed countries tackled such problems but we were helpless. Then there was HINARI but even with it we get articles of only up to six months back of many journals.

Richard Smith, the former editor of BMJ has said that Journals are in the debate business, not the truth business ². So if that is true how can we participate in such debate when we have access only to journals of six months back as the most recent one? Do the founders of HINARI and for that matter owners of such journal think us unsuitable for such critical thinking. And with HINARI, we have problems in our institute, as the owners don’t find undergraduate students like us suitable to acquire the password ourselves.

The HINARI people should learn from BMJ and NEJM, which provide direct access to people of developing world without the need of password. About the reduction in customers of print journal with provision of free online access, it doesn’t apply to developing countries as potential customers like our institute has not been able to buy it on the ground being unaffordable rather than aforementioned cause.

The launching of the PLoS Medicine is a step ahead to fill the existing information gap but the matter of publication charge can be a barrier in publishing great works provided that there are other options not needing such charge. The access to information only one way with limitation in communication and publishing own work is again a new problem, which needs to be addressed. Though they have promised to waive or defray charge to one who can’t pay ³, but it will have certain limitation in terms of number of good works being published. The editors should have analysed the consequences of this fact.

References:

1. Dan Engber, Andy Gass, Gavin Yamey. Who should own medical knowledge? StudentBMJ 2004;12:309-348 (September)
2. Kamran Abbasi. Lifeline. Lancet 2004;364: pp
3. Frequently asked questions PLoS www.plos.org/faq.html

There are limited number of medical journals which are enjoying international accredation till datee.g Lancet,BMJ,sBMJ,NEJM,JAMA etc.These journals are very much informative for all health professionals.

For the benefit of medical fraternity in general and spread of updated professional informations all over the world, irrespective of privilaged and underprivilaged countries,there is a popular demand to grant free internet access.The Lancet,BMJ,sBMJ etc already accepted the appeal.We do appreciate the generous approach of those publishing groups.

From the business point of view,this is not a viable issue.High quality editorial contributions are often expensive.Good amount of funancial support is needed for maintaining the standard of a journal all through the year.

With the rapid progress of medical research in recent years,it seems difficult to keep space with the everyday developments.Many countries are lying isolated from fast advancing western world.Health professionals of those countries are compelled to remain engaged to their daily workload.Many of them get minimum free time to avail library facilities.For most of the health professionals working in underprivilage countries,it is expensive to buy those acrcedated journals.

Free internet access to reputate journals will help to update the health professionals regarding current developments like Human genome project,SARS,Bird's flue etc.

All the internationally accredated medical publishing groups should at least consider the agony of the health professional,medical students,staffs working in under privilage countries and permit free access their reputate journals.

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