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Open Access to the Medical Literature:
A Global Health Issue
Gavin Yamey MD
Senior EditorPLoS Medicine
www.plosmedicine.orgConsulting Editor
PLoS Neglected Tropical Diseaseswww.plosntds.org
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A depressingly familiar story
• A group of junior doctors in Indonesia goes online to search the literature
• Most articles are only available as “pay per view” or via subscription
• The current medical publishing system bars them from access
Ham MF et al. Open-access publishing. Lancet. 2004;364:24-5.
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Another depressingly familiar story—from Africa
• The WHO asks James Tumwine to investigate an outbreak of “nodding disease” in Sudan
• Literature review: access denied• Once again, medical knowledge is
locked behind access barriers
Yamey G. Africa's visionary editor. BMJ, Oct 2003; 327: 832.
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Yet another depressingly familiar story—from HIF-NET
“Even as an international NGO, we don't have enough money in our budget to take subscriptions to all the interesting journals we might wish for”
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Yet another depressingly familiar story
• The director of one of the world's largest medical research charities receives notification from one of his funded investigators in Africa reporting exciting progress toward the development of a malaria vaccine.
• The work has just been published, so he goes online: “Access Denied”
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Perhaps the most depressing story of all…..
“I met a physician from SA, engaged in perinatal HIV prevention, whose primary access to information was abstracts online…Based on a single abstract, they had altered their perinatal HIV prevention program from an effective therapy to one with lesser efficacy. Had they read the full text article they would have undoubtedly realized that the study results were based on short-term follow-up, a small pivotal group, incomplete data, and unlikely to be applicable to their country situation. Their decision to alter treatment based solely on the abstract's conclusions may have resulted in increased perinatal HIV transmission.”
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The problem
• Medical research results—a treasury of medical knowledge—are privately owned and sold only to those who can afford it
• Publishers make profits by restricting access• I believe medical research results should be
considered a global public good (indeed most is funded by the public)
• Access to this knowledge is arguably a global public health crisis
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The solution: make all research results freely available online
“It is now possible to share the results of medical research with anyone, anywhere, who could benefit from it. How could we not do it?”
Harold Varmus, Nobel Laureate, PLoS Co-founder
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What I’d like to talk about today
• The current medical publishing system
• Why that system is broken and unsustainable and how it impedes global public health
• Open access publishing: a healthier alternative
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The private ownership of research results
• You write the research paper• You give your work to publishers,
you hand over copyright to them, they then sell it to wealthy readers
• A high profile drug trial can earn a journal $1m in reprint sales
• The work is subject to extremely tight copyright restrictions
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Medical & scientific publishing is big business
• Worth approx $9 billion/year • Elsevier (market leader): profits of $290m/yr
with margins of 40% on its core journal business
• Fastest growing sub-sector of the media industry for the past 15 years
• “Not for profit publishers have also been cashing in on this bonanza, becoming cash cows for the scientific societies that own them.”
Delamothe T et al. BMJ 2003;326:945-946
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Who gets to see the research results?
• Results of billions of dollars of research funding (NIH: $28bn in 2004) may be seen by only a small fraction of the intended audience, because it is published in journals that few individuals or institutions can afford to subscribe to.
• Annual subscription to Brain Research costs $20,000
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The Wellcome Trust’s position
"the publishing of scientific research does not operate in the interests of scientists and the public, but is instead dominated by a commercial market intent on improving its market position"
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-50
0
50
100
150
200
250
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1986
Journal prices
CPI/inflation
Journalspurchased
Things are getting worse…..the journals crisis
Source: Association of Research Libraries
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This is unsustainable
“I call it the pay more, get less model”
Richard Smith
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Not for Public ConsumptionRestricted access to research funded by NIH
• Depression severity and drug injection HIV risk behaviors. Am J Psychiatry. 2003;160:1659-62
• Taste preferences and body weight changes in an obesity-prone population. Am J Clin Nutr. 2004;79:372-8.
• Structure of West Nile virus. Science. 2003;302:248.
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Does the traditional subscription-based model serve science and medicine?
• Most potential audiences (health professionals, teachers) worldwide have no access to primary literature
• Economics based on old print/paper system• Puts limits on searching and data mining• Copyright restrictions limit use• Patients are prevented from reading results
of research they participated in Science and medicine would advance more
quickly if information were freely available
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Impeding global health
“Providing access to reliable health information for health workers in developing countries is potentially the single most cost effective and achievable strategy for sustainable improvement in health care.” Packenham-Walsh et al BMJ 1997 314:90
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Impeding global health [2]
• Impedes research efforts globally—especially in the South
• Gets in the way of capacity building in developing countries
• Harder for researchers in the South to contribute to global discussions
• Health policymakers don’t have all the information they need
• Clinicians and patients can’t make decisions based on all the available information
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Impeding global health [3]
• Health professionals are potentially making harmful policy decisions because they don’t have all the information they need!
• Access to abstracts alone is NOT good enough
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Impeding global health [4]
• Subscription based journals traditionally devote little space to covering health issues of developing world (e.g. NEJM: <3% articles). Why?
• They rely on wealthy readers paying, so they must publish materials that appeal to these readers
• They rely on reprints to drug companies• They rely on selling drug ads• The model means editors hands are tied
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There is a better way: open access publishing
• Subscription fees made sense before Internet• Printing, binding, and mailing each additional
paper copy cost additional amount• But what online publishers do has a one time
fixed cost (cost of 2 readers = cost of 2000 readers, so why charge all 2000 readers?)
• Recover this fixed cost up front• Publisher is just a service provider (like a
midwife)
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Research Funder
Publisher
Reader
$
How does open access work?
Publishing is the final step in a research project
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The PLoS Journals
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World’s first peer-reviewed, open access journal devoted to neglected tropical diseases
Launch supported by Bill and Melinda Gates Foundation
Papers on pathology, epidemiology, treatment, control, prevention
Magazine section devoted to policy and advocacy
International editorial board, half the Associate Editors from endemic countries
Accepting submissions early 2007
“It is expected that the journal will be both catalytic and transformative inpromoting science, policy, and advocacy for these diseases of the poor.”
Peter Hotez, Editor-in-Chief
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Publishing in a PLoS Journal
• Free, unrestricted online access • Users are licensed to download,
print, copy, redistribute, and use (www.creativecommons.org)
• Author retains the copyright (not the publisher)
• Papers are deposited immediately in a public database that allows sophisticated searches
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Myth 1: “The quality won’t be maintained”
Answer:There is nothing intrinsic in open access which changes the peer-review process. Open access journals are committed to stringent peer review.
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Myth 2: “Unfair to developing world authors”
Answer:• If authors can’t pay publication fee,
it is waived—with no questions asked• Editors are blinded• Initiatives to cover publication fees
in resource poor countries (e.g. OSI supports PLoS)
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Myth 3: “No impact factor”
Answer: Any new journal has no impact factor. Open
access journals can provide new ways to measure impact.
PLoS Biology 14.7
PLoS Medicine: 8.4 (same as BMJ which is almost 200 yrs old!)
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Myth 4: “There are plenty of free online journals”
Answer:• Most (75%) certainly aren’t free in
any way whatsoever• Free access is different from open
access• HINARI has a GNP “cut off” of $3000
(misses out Brazil, China, India, Indonesia) and individuals are prohibited
• Copyright restrictions!
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Myth 5: Abstracts are good enough
Answer:• Does not seem just that developing
world authors have to just make do with abstracts
• In any case, abstracts are usually wrong
• Ward et al, 7 big pharmacy journals: 61% of abstracts were deficient in some way [Ann Pharmacother. 2004 Jul-Aug;38(7-8):1173-7]
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Myth 6: OA is unaffordable
Answer:• Money is already in the system!• Wellcome Trust: OA model is
“economically viable, guarantees high quality research and is a sustainable option which could revolutionise the world of traditional scientific publishing”
• Costs would be 30% less overall!
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OA: Expanding the Knowledge Commons
A crucial mechanism for improving human welfare is expanding the “knowledge commons”– Health workers and policy makers– Managing environment – Agricultural production
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Information as a Global Public Good
“Knowledge is not the personal property of its discoverer, but the common property of all”
-Benjamin Franklin
What kind of global development is possible once scientific/health information is made “the common property of all”?
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An Extraordinary Opportunity
• Developing countries: increasingly improving capacity to use scientific/technical knowledge to solve local problems
• Increasing the pool of publicly available knowledge for these countries boost human development efforts
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Once knowledge is truly in the public domain, the only limit upon its use is our imagination…
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Genbank(www.ncbi.nih.gov/Genbank)
• Public database of DNA sequences, freely accessible to all scientists worldwide
• Users are licensed to use the database for product development
• Inspired/enabled scientists worldwide to transform a collection of individual sequences into an incomparably richer resource
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Biological Innovation for Open Society (Bios)
• Effort to develop new innovation systems for disadvantaged communities and neglected priorities
• Aims to free up the rights to patented DNA sequences + the methods needed to manipulate biological material
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Many, Many Other Inspiring Examples…
• Global Biodiversity Information Facility (universal free access to data on the world's biodiversity )
• Human Genome Project• Science Commons (sciencecommons.org): “to
remove unnecessary obstacles to scientific collaboration by creating voluntary legal regimes for research and development”
• DNDi (www.dndi.org)
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And There is Even Open Source Beer!
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So let’s now expand the pool of knowledge that is publicly available….
• United Nations: formally endorses/champions OA as a global health and development tool
• Over 130 science/health organizations have signed the Berlin Declaration (Chinese Academy of Sciences, Indian National Science Academy)
• NIH, Wellcome Trust, other funders• Unstoppable force…..
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Is it ethical to publish in closed access journals?
“Faced with the option of submitting to an open-access or closed-access journal, we now wonder whether it is ethical for us to opt for closed access….”
Anthony Costello & David Osrin, Institute of Child Health, London
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Where You Publish Makes a Difference
“Each author's choice of where to publish adds another brick to a complex publishing structure. Your choice may have a dramatic effect on how accessible, or inaccessible, your research is. Your decision can limit or facilitate others' digital access to significant research.
The stakes are high for all.”Stanford University Lane Medical Library
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And the last word on OA….
9th World Congress on Health Information, Salvador: The Salvador Declaration on Open Access: The Developing World Perspective
“We call on all stakeholders in the international community to ensure that scientific information is openly accessible and freely available to all, forever”
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There are many, many global
inequalities in medicine and
health care. Access to the latest
peer-reviewed research results
doesn’t have to be one of them.
Work with us.
