Posted by Alli (188.8.131.52) on February 13, 2002 at 15:11:58:
Nature 415, 575 (Feb. 7, 2002) © Macmillan Publishers Ltd.
"The 15% solution for majority health concerns"
Sir – Amid much fanfare, the World Health Organization (WHO) announced last summer that it had convinced a consortium of medical publishers to provide physicians and scientists in the developing world with cheap access to research journals, via the Internet1, 2. This plan was characterized as "a real breakthrough" by WHO director-general Gro Harlem Brundtland, on 9 July 2001 (see http://www.who.int/director-general/speeches/2001).
But how much of a breakthrough is it? When the eager doctors and investigators finally open their new journals, they will find the articles inside almost exclusively geared to the medical problems of patients in developed countries, often discussing medications and technologies not available in underdeveloped regions of the world.
For example, a recent issue of the New England Journal of Medicine (a publication also distributed free over the Internet to low-income countries, though not a member of the new consortium) presented a clinical trial demonstrating that HIV patients responding to antivirus therapy — consisting of at least three powerful drugs — may no longer require precautionary antibiotics to guard against pneumonia3. The catch is that in most of the world, patients with HIV cannot afford even one of these medications. As an editorial accompanying this article observed, the results of the study "are good news for people living with AIDS but they also make the gulf in treatment between rich and poor countries that much more glaring and unacceptable"4.
If journal editors really want to make an enduring contribution to the developing world, they should focus on the content of their publications, not just the distribution. A good first step would be to commit a consistent number of pages — say 15% — to articles addressing the medical needs and concerns of underdeveloped regions. By acquiring a more global perspective, medical journals would accomplish several important benefits.
First, and most important, the journals would provide articles of interest and relevance to doctors, scientists and patients in these regions of the world, creating a body of data that could guide practice in the same way that clinical research has improved the treatment of patients in developed countries.
Second, articles focused on health care in underdeveloped regions would enable journal readers to become better acquainted with the unique needs and problems of medical care in these areas. Less than 10% of the world's health-care expenditure is said to be devoted to illnesses that account for 90% of the global burden of disease, and it is likely that published research articles follow a similar pattern5. Increased focus on the health-care needs of poorer countries might encourage western physicians and scientists to think about problems they might not ordinarily encounter, and to generate fresh insights or novel approaches.
Finally, the new articles might help to inform the development of ethics guidelines for clinical research done by North American and European scientists in underdeveloped regions. These include thorny questions, such as whether it is ethical to conduct a study in which the control group of patients receives no medicine (the local standard of care) rather than an expensive medicine (the best care available). Greater familiarity with the needs and the resources of patients in poorer nations might help ethics committees as they wrestle with these difficult but vitally important decisions.
If journals were to commit 15% of their pages to medicine in the developing world, would their current readers be interested? Surprisingly, the answer may be a resounding yes. Western medical schools are reporting a groundswell of interest in international medicine; for example, at Harvard, a record number of medical students — more than 50 — participated this past year in international health experiences, in countries such as Costa Rica, Bolivia, Vietnam and Zambia. The Association of Schools of Public Health, based in Washington DC, reports that the number of public-health students specializing in international health is now at an all-time high6. Meanwhile, organizations focusing on international health are receiving unprecedented recognition, such as Médecins sans Frontières, recipient of the 1999 Nobel peace prize.
By dedicating 15% of their pages to the medical concerns of the developing world, journal editors would not only show their genuine commitment to global health, but might also discover a Western readership eager for a broadened perspective, and an international medical community grateful for the opportunity to provide it.
David A. Shaywitz & Dennis A. Ausiello
Department of Medicine, GRB-740, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114, USA, and Harvard Medical School, 25 Shattuck Street, Boston, Massachusetts 02115, USA
References 1. Malakoff, D. Science 293, 189-190 (2001). | PubMed |
2. Nature 412, 110 (2001). | Article |
3. de Quiron, J. N. Engl. J. Med. 344, 159-167 (2001). | PubMed |
4. Girard, P. M. N. Engl. J. Med. 344, 222-223 (2001). | PubMed |
5. Global Forum for Health Research. The 10/90 Report on Health Research 2000 (http://www.globalforumhealth.org/).
6. Helsing, K. 2000 Annual Data Report: Applications, New Enrollments and Students, Fall 2000. 41 (Association of Schools of Public Health, Washington DC, 2001).
World hasn't changed for the dispossessed
Sir – Understandably, following the outrages of 11 September 2001, the main scientific periodicals have covered its impact on aspects of science and the response of scientists to the fears that it generated. The annual News reviews in Nature (Nature 414, 836–841; 2001) and Science both headline its aftermath, in terms of the impact on security and the economic downturn that the attacks have helped to accelerate. Their central theme is that the world changed on that day. It did not.
For two thirds of the world's population, 'business as usual' involves an ever-widening gap between hope for the future and expectation of any relief it will bring from poverty, disease and disaster. Fear of falling victim to natural calamities — and those generated by the lifestyles of a highly privileged minority — remains as strong as ever. Despicable as the perpetrators and those who motivated their actions were, the attacks arose from the growing powerlessness of hundreds of millions of dispossessed people. Global communications ensure that they are confronted daily by what they lack, leading to a deep sense of unfairness and victimhood.
Scientists, whose work is enmeshed with emergence of the possible, should dwell on how they might help close that growing human fault line, as you discuss in your Opinion article "Timely messages for the South" (Nature 415, 1; 2002), rather than raging at or cringing before the monstrosity that they have helped to nurture. Assisting the dispossessed to secure safe, dependable water supplies; to improve their agricultural yields; to rid themselves of endemic disease; to gain access to cheap energy and transport; and above all to acquire knowledge and the ability to solve their own problems is not a problem of cosmological or genomic proportions. It is a simple, human duty.
Department of Earth Sciences, The Open University, Milton Keynes MK7 6AA, UK
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