1. www.plos.org Open Access to the Medical Literature: A Global Health Issue Gavin Yamey MD Senior Editor PLoS Medicine www.plosmedicine.org Consulting Editor PLoS Neglected Tropical Diseases www.plosntds.org

2. www.plos.org 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.

3. www.plos.org 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.

4. www.plos.org 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”

5. www.plos.org 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”

6. www.plos.org 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.”

7. www.plos.org 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

8. www.plos.org 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

9. www.plos.org 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

10. www.plos.org 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

11. www.plos.org 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

12. www.plos.org 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

13. www.plos.org 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"

14. www.plos.org Journal prices CPI/inflation Journals purchased Things are getting worse…..the journals crisis Source: Association of Research Libraries

15. www.plos.org This is unsustainable “I call it the pay more, get less model” Richard Smith

16. www.plos.org Not for Public Consumption Restricted 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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19. 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

20. www.plos.org 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

21. www.plos.org 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

22. www.plos.org 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

23. www.plos.org 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

24. www.plos.org 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)

25. www.plos.org Research Funder Publisher Reader $ How does open access work? Publishing is the final step in a research project

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27. The PLoS Journals

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29. 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

30. www.plos.org 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.

31. www.plos.org 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)

32. www.plos.org 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!)

33. www.plos.org 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!

34. www.plos.org 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]

35. www.plos.org 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!

36. www.plos.org 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

37. www.plos.org 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”?

38. www.plos.org 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

39. www.plos.org Once knowledge is truly in the public domain, the only limit upon its use is our imagination…

40. www.plos.org 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

41. www.plos.org 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

42. www.plos.org 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”sciencecommons.org DNDi (www.dndi.org)www.dndi.org

43. www.plos.org And There is Even Open Source Beer!

44. www.plos.org 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…..

45. www.plos.org 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

46. www.plos.org 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

47. www.plos.org And the last word on OA…. 9 th 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”

48. www.plos.org 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.

49. www.plos.org Thank you. Gavin Yamey gyamey@plos.org