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For some years now it has been the policy of the BMJ Publishing Group to give free subscriptions to its journals to applicants from countries in the developing world. However, in practice this has had its difficulties. Many developing countries have either poor or non-existent postal services and granting a print subscription can often be problematic and expensive—the marginal cost of sending thePostgraduate Medical Journal to Africa is around £25 each year.
An editorial in the BMJ sets out the arguments very clearly.1 We know that the gap between the rich and poor countries is widening. While those of us in the developed world have information overload, the developing countries have bare library shelves. The internet gives us the opportunity to narrow the gap.
The marginal cost of giving access to the electronic edition of thePostgraduate Medical Journal is close to zero. What is more, those in resource poor countries can access electronic journals at exactly the same time as those in the developed world. Even better, they can access what is relevant rather than what is provided, much of which isn't relevant. Best of all, they can participate in the debate using the rapid response facility on the web site in a way that was almost impossible with the slowness of print distribution.
Access to the electronic edition of thePostgraduate Medical Journal will be provided free automatically to those from countries defined as poor under the human development index by the United Nations and the World Bank (www.worldbank.org/data/databytopic/class.htm). The Fellowship of Postgraduate Medicine, the British Medical Association, and several of our co-owning societies have made funds available for the installation of Digital Island on all our journal web sites. This clever piece of software recognises where the user is coming from and will give unrestricted access to the whole web site to users from those developing countries we choose to designate.
The income that we get from resource poor countries is minimal; facilitating information supply should encourage development, improvement in health care, and eventually create a market.
The problem with this vision is the lack of access to the world wide web in the developing world. While tens of millions of people have access in the United States, it is only thousands in most African countries; and access in Africa is often painfully slow, intermittent, and hugely expensive relative to access in the United States (where it's often free). Power cuts happen every day in many resource poor countries. Yet there's every reason to expect that access should increase dramatically. India currently has a million people with internet access, but this is expected to rise to 40 million within five years. Similarly dramatic increases are expected in Nigeria. Technological developments like access to radio and the proliferation of satellites will render irrelevant the many problems of telephone access in Africa. Rapid progress will also be made because many international organisations such as Unesco, the British government, the World Bank, and the Bill and Melissa Gates Foundation are increasingly interested in helping improve information access in resource poor countries.
The challenge will be sustainability. It is easy for donors to invest money and reap the rewards of short term success. But enhancing information flow will make no impact on health if projects continue only as long as their funding lasts. Information cannot be separated from the capacity of a healthcare system to work effectively over time. How is it possible to influence the context within which information will flow, the apparently intractable political, economic, and organisational constraints that disable rather than enable information to work for people? Publishers in the rich world have a part to play and we hope that by making access to thePostgraduate Medical Journal on-line free to those in the developing world we are making our own small contribution.
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