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Access to medical information in developing countries
CORRESPONDENCE
COMMENTARY
CORRESPONDENCE Access to medical information in developing countries Sir—The Secretary General of the United Nations has recently added his voice to the call for using computer technology to improve access to medical and healthcare information for healthcare workers and medical scientists in developing countries. In many of the world’s poorest countries, the need for debt servicing has decimated both healthcare and education. Muhimbili University College of Health Sciences in Dar es Salaam, Tanzania, is currently receiving government money only for carrying out final examinations, because its parent institution, in turn, is being allocated by central government only 10% of its annual expenses. As a consequence of similar pressures, medical libraries are now frequently devoid of journals because of the prohibitive costs of subscription charges, which are payable in foreign currency. In many of these countries, excellent computing facilities are being installed, often as a result of support from unilateral and multilateral donor agencies. While this is able to provide much useful information from the internet, including access to journal abstracts through the MedLine websites, it does not provide full access to the journals themselves. These are usually available in their electronic form only on payment of the full cost of subscription. For The Lancet, in Tanzania these costs are £375 per year for the University and £119 for a personal subscription. This means that Muhimbili University College and its staff are charged at a higher level than University College London and its staff. We would like to ask you, as a person who has, through The Lancet, spoken out forcibly in support of the developing nations, to set an example for other journal editors by providing the electronic version of The Lancet free of charge, without purchase of a subscription, to educational and healthcare institutions in the developing world. We would also ask that you propose to your fellow editors in the International Committee of Medical Journal Editors that this example might be followed by the other major medical and scientific journals as
2248
a symbolic gesture of millennium debt cancellation. *John S Yudkin, Andrew B M Swai *International Health and Medical Education Centre, University College London, London N19 3UA, UK; and Muhimbili University College of Health Sciences, Dar es Salaam, Tanzania (e-mail: [email protected])
Editor’s reply As the survey published in this week’s Lancet (p 2231) tries to show, the issue of access to medical information in developing countries has for too long been excluded from the narrow horizons of medical journal editors. This matter came before the International Committee of Medical Journal Editors in May this year, and that committee plans to seek ways to work with other editorial organisations to achieve the same goal set out by John Yudkin and Andrew Swai. My personal view is that I would very much like to provide the electronic version of The Lancet free of charge to educational and healthcare institutions in the developing world. The journal already sends material, on request and copyright free, to SatelLife, and has been doing so for some years. Lancet editors have brought the matter of free, full-text access to the attention of our publishers at various times during recent years, and part of the purpose of the survey I undertook was to seek evidence to support our view that publishers and editors together have an important contribution to make to health in the developing world. The responses presented this week help to support not only your argument but also my general claim that journals have “global responsibilities to the communities they serve and profit from”. Richard Horton
increased coronary heart disease (CHD) risk seen in UK Indian Asians compared with Europeans. The implication is that the increased CHD risk in this group may be reduced by dietary vitamin supplementation. However, their conclusion is at odds with their results. Among other results, their study showed in Indian Asians that patients with CHD had significantly higher red cell (35%, p<0·001) and serum folate (11%, p<0·002) concentrations of homocysteine than controls. There was no case-control difference in vitamin B12 concentrations. After adjustment for the vitamins, the small case-control difference in plasma homocysteine increased instead of decreased, as is expected if raised homocysteine concentrations in patients with CHD are due to reduced vitamin concentrations. These findings, not commented on by the investigators, contradict their conclusion that raised plasma homocysteine due to low vitamin B12 and folate may lead to increased CHD risk. As suggested by Christopher Martyn in his commentary,2 raised homocysteine resulting from impaired renal function may have confounded the results. Hypertension and diabetes, both well-known causes of renal impairment, were present more often in patients with CHD than controls, and much more often in Indian Asian controls than in European controls. Therefore, it would be interesting if Chambers and colleagues were to present the main data, adjusted for serum creatinine. Lars Brattström Department of Medicine, Kalmar County Hospital, 391 85 Kalmar, Sweden (e-mail: [email protected]) 1
The Lancet, 84 Theobald’s Road, London WC1X 8RR, UK 2
Homocysteine and heart disease in Indian Asians Sir—John Chambers and colleagues (Feb 12, p 523)1 concluded that raised plasma homocysteine associated with reduced vitamin B12 and folate concentrations may contribute to the
Chambers JC, Obeid OA, Refsum H, et al. Plasma homocysteine concentrations and risk of coronary heart disease in UK Indian Asian and European men. Lancet 2000; 355: 523–27. Martyn CN. Serum homocysteine and risk of coronary heart disease in UK Indian Asians. Lancet 2000; 355: 512–13.
Sir—In their study John Chambers and colleagues1 failed to take into account a wide range of risk factors for CHD— eg, family history and levels of physical
THE LANCET • Vol 355 • June 24, 2000
For personal use only. Not to be reproduced without permission of The Lancet.
COMMENTARY
CORRESPONDENCE Access to medical information in developing countries Sir—The Secretary General of the United Nations has recently added his voice to the call for using computer technology to improve access to medical and healthcare information for healthcare workers and medical scientists in developing countries. In many of the world’s poorest countries, the need for debt servicing has decimated both healthcare and education. Muhimbili University College of Health Sciences in Dar es Salaam, Tanzania, is currently receiving government money only for carrying out final examinations, because its parent institution, in turn, is being allocated by central government only 10% of its annual expenses. As a consequence of similar pressures, medical libraries are now frequently devoid of journals because of the prohibitive costs of subscription charges, which are payable in foreign currency. In many of these countries, excellent computing facilities are being installed, often as a result of support from unilateral and multilateral donor agencies. While this is able to provide much useful information from the internet, including access to journal abstracts through the MedLine websites, it does not provide full access to the journals themselves. These are usually available in their electronic form only on payment of the full cost of subscription. For The Lancet, in Tanzania these costs are £375 per year for the University and £119 for a personal subscription. This means that Muhimbili University College and its staff are charged at a higher level than University College London and its staff. We would like to ask you, as a person who has, through The Lancet, spoken out forcibly in support of the developing nations, to set an example for other journal editors by providing the electronic version of The Lancet free of charge, without purchase of a subscription, to educational and healthcare institutions in the developing world. We would also ask that you propose to your fellow editors in the International Committee of Medical Journal Editors that this example might be followed by the other major medical and scientific journals as
2248
a symbolic gesture of millennium debt cancellation. *John S Yudkin, Andrew B M Swai *International Health and Medical Education Centre, University College London, London N19 3UA, UK; and Muhimbili University College of Health Sciences, Dar es Salaam, Tanzania (e-mail: [email protected])
Editor’s reply As the survey published in this week’s Lancet (p 2231) tries to show, the issue of access to medical information in developing countries has for too long been excluded from the narrow horizons of medical journal editors. This matter came before the International Committee of Medical Journal Editors in May this year, and that committee plans to seek ways to work with other editorial organisations to achieve the same goal set out by John Yudkin and Andrew Swai. My personal view is that I would very much like to provide the electronic version of The Lancet free of charge to educational and healthcare institutions in the developing world. The journal already sends material, on request and copyright free, to SatelLife, and has been doing so for some years. Lancet editors have brought the matter of free, full-text access to the attention of our publishers at various times during recent years, and part of the purpose of the survey I undertook was to seek evidence to support our view that publishers and editors together have an important contribution to make to health in the developing world. The responses presented this week help to support not only your argument but also my general claim that journals have “global responsibilities to the communities they serve and profit from”. Richard Horton
increased coronary heart disease (CHD) risk seen in UK Indian Asians compared with Europeans. The implication is that the increased CHD risk in this group may be reduced by dietary vitamin supplementation. However, their conclusion is at odds with their results. Among other results, their study showed in Indian Asians that patients with CHD had significantly higher red cell (35%, p<0·001) and serum folate (11%, p<0·002) concentrations of homocysteine than controls. There was no case-control difference in vitamin B12 concentrations. After adjustment for the vitamins, the small case-control difference in plasma homocysteine increased instead of decreased, as is expected if raised homocysteine concentrations in patients with CHD are due to reduced vitamin concentrations. These findings, not commented on by the investigators, contradict their conclusion that raised plasma homocysteine due to low vitamin B12 and folate may lead to increased CHD risk. As suggested by Christopher Martyn in his commentary,2 raised homocysteine resulting from impaired renal function may have confounded the results. Hypertension and diabetes, both well-known causes of renal impairment, were present more often in patients with CHD than controls, and much more often in Indian Asian controls than in European controls. Therefore, it would be interesting if Chambers and colleagues were to present the main data, adjusted for serum creatinine. Lars Brattström Department of Medicine, Kalmar County Hospital, 391 85 Kalmar, Sweden (e-mail: [email protected]) 1
The Lancet, 84 Theobald’s Road, London WC1X 8RR, UK 2
Homocysteine and heart disease in Indian Asians Sir—John Chambers and colleagues (Feb 12, p 523)1 concluded that raised plasma homocysteine associated with reduced vitamin B12 and folate concentrations may contribute to the
Chambers JC, Obeid OA, Refsum H, et al. Plasma homocysteine concentrations and risk of coronary heart disease in UK Indian Asian and European men. Lancet 2000; 355: 523–27. Martyn CN. Serum homocysteine and risk of coronary heart disease in UK Indian Asians. Lancet 2000; 355: 512–13.
Sir—In their study John Chambers and colleagues1 failed to take into account a wide range of risk factors for CHD— eg, family history and levels of physical
THE LANCET • Vol 355 • June 24, 2000
For personal use only. Not to be reproduced without permission of The Lancet.