These are troubling times for academic publishers. The ability of the Internet to publish information quickly and with the widest possible dissemination has raised questions from universities, authors, librarians and others about the continued domination of commercial publishers in the lucrative business of science publishing. For decades, those in the developing world, and in some parts of the West too, have been excluded from access to published information because of the high cost of journals, which are often only available in large, well-funded university or national libraries. Some eminent scientists, including Harold Varmus, former Director of the US National Institutes of Health, have suggested alternative models for the storage and dissemination of science papers, based on the principle of free access to all. Varmus' idea of a central digital archive of life sciences literature, of which PubMed Central ( is an example, was first suggested by J. D. Bernal in 1939 (Bernal 1939). PubMed Central hosts a slowly increasing number of online journals, including BMJ and Proceedings of the National Academy of Sciences, and also provides links to selected publishers' websites where full-text articles are available free. This idea has blown apart the publishing consensus that information has to be paid for and that authors' copyright has to be rigorously protected. While it cannot be denied that the costs of publishing, marketing and distribution of print journals are high, the same cannot be said of web-based publishing. Access to the Internet in the developing world is now becoming commonplace, at least in major urban areas; the opportunity now exists for health information to be distributed freely without barrier.

Since the establishment of PubMed Central there has been a growing number of websites devoted to the principle of free dissemination of research literature, including the Soros-funded Budapest Open Access Initiative ( and the Free Medical Journals site ( A more direct challenge to publishers is Public Library of Science's open letter ( to scientists to boycott journals which do not make articles freely available online within 6 months of publication; more than 30 000 scientists from 177 countries so far have signed the pledge.

A fundamental principle of journal publishing has been the transfer of copyright to the publisher by the author, ostensibly to protect the author's interests. Publishers' control of authors' intellectual property enables them to control the distribution of the journal and to generate further spin-off income through online journal subscriptions (often at a cost several times greater than the print version) and the granting of licences to institutions to allow tutors to issue reading material to students. This practice is being increasingly challenged by universities in the face of escalating journal costs, particularly as online journal subscriptions are stretching library budgets to a point where subscriptions have to be cancelled and also because of an increasing awareness of the importance of universities retaining intellectual property rights generally. Many see the retention of copyright by publishers as an important barrier to the dissemination of research to as wide an audience as possible (Markovitz 2000). Most research is publicly funded and it is anachronistic that the fruits of this research are not freely available in the public domain, particularly to those areas of the world most in need of it.

An alternative publishing model has recently been introduced by BioMed Central ( in which authors pay a one-off fee of US$ 500 for each article published; an institutional subscription is also available enabling staff to publish without individual charge, and several prestigious institutions have signed up recently, including the WHO and the US National Institutes of Health. Significantly for those authors publishing from the developing world, no charge is made. Articles are peer-reviewed in the normal way and made available speedily on BMC's website in any of a growing number of journals and simultaneously posted on the US National Institutes of Health's PubMed Central site. Crucially, BMC journals are indexed in PubMed/Medline and in ISI's Web of Science databases. Unlike the conventional model, copyright rests with the author, enabling the free distribution of the paper without constraint. Furthermore, there is evidence that articles identified through free access to databases such as PubMed and their availability free online substantially increases their impact both in terms of the size of the audience reached and their subsequent chance of citation (Lawrence 2001).

So how will these changes affect access to health information in the developing world? An interesting series of commentaries and debates on publishing hosted by the journal Nature (Nature 2002) indicates a measure of agreement between the protagonists for change and the publishers that offering free full-text access to online journals is unlikely to pose a threat to publishers' revenue and that more needs to be done to increase access. As confirmation, the WHO announced a ground-breaking 3-year agreement with a group of major publishers which, from January 2002, has made available up to 1500 biomedical online journals free to universities, medical schools and libraries in the 60 poorest countries (Health Internetwork 2002). Access to such a significant number of journals immediately places these countries on a level or above many large biomedical libraries in the West, many of which do not subscribe to anything like this number of journals, whether online or print. If the momentum for change continues at this pace, the current relationship between author and publisher will be forever altered with authors or their employers being the dominant partners. The BioMed Central model of publishing, which already has malaria and filaria journals established, promises to be particularly suitable for authors from the developing world. Journal editors have long bemoaned the difficulty of attracting papers from the developing world; free article publication with free access to papers, together with papers indexed in widely available medical databases, should see a more equitable balance of papers from both the North and the South. In the field of tropical medicine and international public health this is long overdue. The ending of the long-standing scandal of knowledge starvation in the developing world, is at last potentially within our grasp, if only we had the will.


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