A conversation with Barbara Aronson about global access to medical journals

If you doubt that a librarian can change the world, listen to what Barbara Aronson has to say in this week’s installment of my ITConversations podcast. As the librarian for the World Health Organization, she’s been the driving force behind HINARI, a publisher partnership that’s making thousands of otherwise unaffordable medical journals available to researchers in poor countries — at no cost to the poorest 70 (“band 1”) countries, and at nominal cost to the next-poorest 43 (“band 2”) countries.

I first heard about HINARI from Lee Dirks, Microsoft’s director of scholarly communication, whom I met last month at the EDUCAUSE Seminars on Academic Computing. “She’s doing amazing work,” Lee told me. Wow, is she ever. Her mission to democratize access to medical knowledge challenges our assumptions about the nature of open access, the economics of publishing, and the research priorities of the developed world.

In response to criticism that HINARI isn’t “pure” open access, because of the token fees paid by band 2 countries, she says:

I think that most people who live in wealthy countries have no idea about what incomes are like in poor countries, and how many countries are poor. There are 72 countries whose gross national income per capita is less than a thousand dollars. There are 43 who are in the one- to three-thousand-dollar range. These countries bear the highest burden of disease in the world. These are places where most of the wars in the world are taking place, where they have the highest unemployment, and the most precarious life. Now most of the health research in the world is done on the problems of the richest people, because the money for health research comes from the wealthy countries. So you’ve got these very poor countries with the worst health problems, they’re trying to train doctors and nurses to take care of their populations, they’re trying to train researchers to find out the information that doesn’t exist to solve their problems, and they’re doing all this with no access to scientific and technical information.

Is HINARI open access? Not according to anybody’s strict definition of open access, but those definitions are made in the developed world. The open access argument, or discussion, as it’s going along in the places where it is going along, is too narrow, and it needs to be expanded if we’re going to be truly global about this.

What’s fascinating here, from the perspective of publishing economics, is the way in which publishers seem to be using HINARI to prototype a tiered pricing model that Barbara Aronson suggests may be applicable to their customers in the developed world too:

Maybe if the publishers could find a way to manage tiered pricing, which is a big question, maybe then they’d be able to address issues like: What about poor institutions in rich countries? What about underfunded individuals in rich countries?

But I don’t want to leave the impression that this conversation was all about publishing economics. There’s much more at stake. As she points out, researchers don’t just consume the information that HINARI makes available, they refract it through their own experiences and then contribute important new knowledge.

Two weeks ago I heard from the International Center for Diarrheal Diseases Resarch, in Bangladesh. They’re big users of HINARI. These are the people who pioneered the absolutely brilliant way of treating diarrhea in small children. Diarrheal diseases are one of the two biggest killers of children under five in the world. And this means in the developing world, because in the developed world people don’t die of this. These are the people who developed groundbreaking approaches to dealing with that, and to dealing with acute respiratory infection which is the other big killer. Bangladesh is one of the poorest countries in the world, and yet it has produced world-class research that has helped way beyond its borders.

I tip my hat to Barbara Aronson, to the World Health Organization, and to the hundred-plus publishers who’ve joined the WHO in this inspirational project.

10 Comments

  1. Hi Jon,

    There’s another angle on this. I’ve lived and worked in seven different countries, and variations in medical practices are remarkable. Most dramatically, when we were in Austria my wife was given a cerclage to prevent the premature birth of our second child. While pregnant she returned to Canada, where we were told that had we been in Canada they never would have given her the cerclage. A few hours after the cerclage was removed, her waters broke and our son was born shortly thereafter. Had we not been in Austria earlier in the pregnancy, she almost certainly would have had a miscarriage instead.

    Sharing medical practices would be a good idea worldwide. Why is a highly effective and widely used medication in one country, for example, virtually unknown and unavailable in another country? I hope very much that the doctors and medical researchers will begin talking across borders and language barriers and learn from each other.

  2. I am bothered by the convolution of economic support for developing countries and open access. In my view these are very different things that seek to address an overlapping set of problems. HINARI provides access. This is a great thing, but there is nothing “open” about it.

    Open access is often seen as inexpensive in much the same way that open source is seen as inexpensive. This is certainly possible, but not inherent to either open access or open source. There are real costs associated with publishing a journal or developing software. The distribution model may obscure these costs for many people, but they do not go away. Open access and open source are about freedom of information. (In less lofty terms, they protect intellectual property from those who would hold it for ransom.)

    Co-mingling economic support for developing countries and open access is part of a strategy of some who oppose open access. By conflating these ideas, they attempt to claim that they are addressing the issues championed by the open access movement when they lower economic barriers. Developing nations certainly need this help, but we should not be fooled into thinking that this has anything to do with open access.

  3. “There are real costs associated with publishing a journal or developing software. The distribution model may obscure these costs for many people, but they do not go away.”

    Agreed. FWIW it is Barbara’s belief, based on her observation of open access publishing in developing countries, that governments can and should bear those costs.

    “Developing nations certainly need this help, but we should not be fooled into thinking that this has anything to do with open access.”

    On the one hand it has nothing to do with open access. On the other hand, if our definition of open access can have nothing to do with a project that is revolutionizing access to critical information in the way that HINARI is, then that definition seems a bit narrow.

  4. As registered ‘band 1’ users, clinicians in our partner clinics in Malawi use Hinari and other online medical journals on a daily basis for crucial help with both case diagnosis and continuous professional development. Sites like Hinari are gradually replacing the under-resourced and outdated medical libraries in Malawi. The government clinics in townships are staffed entirely by nurses and clinical officers. There are no doctors. By providing access to the Interent, the Twinning of Scottish and Malawian Clinics Project has allowed colleagues in the developing world to communicate on an equal platform with those in resource-rich countries.

    And therein lies the paradox: the so called ‘worse’ can teach the so called ‘best’ many lessons. Perhaps we should look to our colleagues in Malawi and other resource poor environments to help us re-connect with the core values of patient respect, health education, integration of public health with clinical care, and above all pride in caring for patients. Online journals and social networking sites allow us to do this.

  5. I believe it is a logical step that will be borne out be evidence, that the majority world has more to teach the privileged world than the other way around. This is where the vast share of the burden of problems is borne, and experience and motivation make for the best contributions so long as people have the tools to do so.

    The journal article is a form of communication that has stood the test of time, and one that can be modified to all the advantages of the internet age. While the printing press was a great step forward, with the coincidence of that technology and the journal article within the European world with centuries of colonialism, it contributed to the monopoly of knowledge that concentrates the power of knowledge in a very small number of hands relative to the world. The digital is a global technology, or at least it can be.

    The task for the South is now not simply to get access to apply to training and knowlege needs, but to transform knowledge, transform the journal article, publish open access and allow knowledge development to flourish South-South-North flow of communication, in a global flow. The North is unable to shoulder the density and magnitutde of contemporary human problems, most of which were created by some blind spot in their colonial or post-colonial consciousness in the first place, there are too few individuals and too few perspectives.

    So to face climate change, to face the global burden of infectious disease, to eradicate malaria, to reverse the spread of HIV/AIDS, to provide quality, contextual, free primary education, to direct the shape of curriculi from quaternary to primary, to participate in the global discourse about the form of accreditation of knowledge, it’s relationship to culture and it’s spectrum of universality to plurality, to determine the development agenda locally and extract the global lessons, to realize the right to self-determination, to end the extreme disparity in the world, to correct one’s own biases and blind spots, to throw off cultural baggage and retain traditional strengths, to broadcast African, South American, Asian cultural and intellectual content, and to own the means of media production, to reconcile a global history, to adopt, integrate and hybridize every contribution of the good of any other culture, and to take responsibility for the future, to recognize culture as dynamic while able to transmit wisdom across generations – and to strengthen the majority world, reduce corruption and restore confidence in institutions, to abandon racial and ethnic prejudice and negotiate and manage resources – to equalize the world and make it sustainable – this is not possible unless people have control over and generate knowledge in context, and today that context stretches local to global, today that context is educational, scientific and cultural and problems require communication of all modes of knowing in order to solve them. every society has to be a learning society.

    Is this not the task for all? How can all contribute if there are barriers to knowledge? Who should hang their heads in shame are the subscription-based publishers who in the first place accept donations from the research author whose patron is the public, who accept donations of peer-review, and who then turn around and charge exorbitant rates to view public research, and then turn around and pat themselves on the back for making concessions to poor countries. They can change their business model but won’t do it. This is not about charity, this is about enlightened self-interest on the global level, perhaps about survival for which you need all corners of the globe to be active in solving problems instead of suffering them.

    Don’t get me wrong, HINARI is good, has to be done. Good for the WHO for arranging this, but I do believe that closed-access publishing is going to evaporate because it is, after all, not a model that intelligent people can accept.

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