Open Access to the Medical Literature

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					Open Access to the Medical
  A Global Health Issue

           Gavin Yamey MD

            Senior Editor
           PLoS Medicine
          Consulting Editor
   PLoS Neglected Tropical Diseases
A depressingly familiar story

• A group of junior doctors in
  Indonesia goes online to search the
• 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.

  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:

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”

Yet another depressingly familiar

• 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
• The work has just been published, so
  he goes online: “Access Denied”

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.”

              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

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

What I’d like to talk about today

• The current medical publishing
• Why that system is broken and
  unsustainable and how it impedes
  global public health
• Open access publishing: a healthier

     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

 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
      Delamothe T et al. BMJ 2003;326:945-946

  Who gets to see the research

• 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

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"

Things are getting worse…..the
        journals crisis

200                                      prices





       Source: Association of Research Libraries
       This is unsustainable

“I call it the pay more, get less model”

     Richard Smith

Not for Public Consumption
Restricted access to
research funded by NIH

• Depression severity and drug
  injection HIV risk behaviors. Am J Psychiatry.
• 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.

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

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

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

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

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
• They rely on reprints to drug companies
• They rely on selling drug ads
• The model means editors hands are tied

    There is a better way: open
        access publishing

• Subscription fees made sense before
• 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

How does open access work?

               Research Funder
Publishing        $
is the final
step in a
research         Publisher


The PLoS Journals

            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 in
 promoting science, policy, and advocacy for these diseases of the poor.”
                          Peter Hotez, Editor-in-Chief
Publishing in a PLoS Journal

• Free, unrestricted online access
• Users are licensed to download,
  print, copy, redistribute, and use
• Author retains the copyright (not the
• Papers are deposited immediately in
  a public database that allows
  sophisticated searches

  Myth 1: “The quality won’t be

 There is nothing intrinsic in open
 access which changes the peer-
 review process. Open access journals
 are committed to stringent peer

  Myth 2: “Unfair to developing
         world authors”

• 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)

    Myth 3: “No impact factor”

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!)

Myth 4: “There are plenty of free
        online journals”

• Most (75%) certainly aren’t free in
  any way whatsoever
• Free access is different from open
• HINARI has a GNP “cut off” of $3000
  (misses out Brazil, China, India,
  Indonesia) and individuals are
• Copyright restrictions!

Myth 5: Abstracts are good

• Does not seem just that developing
  world authors have to just make do
  with abstracts
• In any case, abstracts are usually
• Ward et al, 7 big pharmacy journals:
  61% of abstracts were deficient in
  some way [Ann Pharmacother. 2004 Jul-

Myth 6: OA is unaffordable

• 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!

OA: Expanding the Knowledge

A crucial mechanism for improving human
welfare is expanding the “knowledge
– Health workers and policy makers
– Managing environment
– Agricultural production

  Information as a Global Public

“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”?

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

Once knowledge is truly in the
public domain, the only limit
upon its use is our imagination…

• Public database of DNA sequences,
  freely accessible to all scientists
• 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

  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

Many, Many Other Inspiring
• Global Biodiversity Information Facility
  (universal free access to data on the world's
  biodiversity )
• Human Genome Project
• Science Commons (
  “to remove unnecessary obstacles to
  scientific collaboration by creating voluntary
  legal regimes for research and development”
• DNDi (

And There is Even Open Source

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
• NIH, Wellcome Trust, other funders
• Unstoppable force…..

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

  Anthony Costello & David Osrin, Institute of Child
                  Health, London

Where You Publish Makes a

“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

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,

 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.

Thank you.

Gavin Yamey


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