We wanted to know how far Internet-based initiatives have come, and how open access has fared, in meeting the information needs of surgeons in LIC. We found that HINARI has come a very long way with a large library accessed with increasing frequency. However, we found that surgeons who have access to an even larger library (Ptolemy) make regular and repeated use of an even broader range of journals. If Ptolemy users were limited to only those higher impact factor journals available through HINARI, nearly 50% of their clinically relevant reading would be curtailed. We also found that the open access journal with the highest impact factor, “PLoS Medicine”, is widely read in Africa and is read in a manner that very closely mirrors the burden of disease in Africa. This is encouraging evidence that these Internet-based initiatives are achieving their goals of improving access to the peer-reviewed medical literature in LIC.
We draw attention to several limitations. First, in our comparison between Ptolemy and HINARI, we used the theoretical list of journals available through HINARI rather than confirming they were actually downloadable in Africa. Previous publications have shown 57% of the 150 HINARI journals with the highest impact factors could not actually be accessed from Peru in 2007 [21
]. According to Smith’s survey of postgraduate doctors in four African teaching hospitals, only 24–73% of physicians were even aware of HINARI, and as many as 90% usually access the Internet from a café, but HINARI is only available through an institution [19
Second, “PLoS Medicine” is a general medical journal, not a surgical journal. We recognize that the reading patterns of surgeons likely do not match those of internists and therefore our conclusions cannot be applied specifically to the information needs of orthopaedic surgeons. However, “PLoS Medicine” is the most frequently cited (and thus highest impact factor) open access journal, so we chose to analyze its readership. Surgically relevant public health, musculoskeletal and trauma topics are often well-represented in subscription-based general medical journals, and given the preponderance of musculoskeletal complaints to primary caregivers, we believe that journals such as “PLoS Medicine” should be covering musculoskeletal topics. For comparison, of the nearly 4000 papers published in “PLoS ONE” in 2009, only 21 specifically concern surgery [16
]. Public Library of Science publications may not be overflowing with orthopaedic information, but there is a burgeoning of surgery- and orthopaedic-specific open access journals, some of which cater specifically to the needs of LIC [7
A third limitation is the lack of quantitative data about additional free Internet-based sources of orthopaedic knowledge. Smith et al. found that across 333 postgraduate doctors in four African teaching hospitals, “90% had heard of PubMed, 78% of BMJ on line, 49% the Cochrane Library, 47% HINARI, and 19% BioMedCentral” [19
]. Surgeons in low- or middle-income countries may need more basic information than that provided in peer-reviewed journals, but one survey of surgeons in LIC found that the most sought-after electronic resource was journal articles, while electronic textbooks were a distant second [4
]. None the less, useful free Internet-based resources may include (but are not limited to) Wheeless [22
], eMedicine [8
], Global HELP [9
], orthopaedic case discussion sites [14
], or free patient information resources [1
]. These services are of variable value and quality, and most LIC surgeons we know are sophisticated enough to value peer-reviewed sources.
Language of publication is another limitation when assessing utility and accessibility of online medical resources. English has a wider dispersion than any other language and is commonly considered the lingua franca of the modern world, but the number of English speakers in various regions or countries is extremely difficult to define. “PLoS Medicine” readership data lumps North, Central and South America, but one might surmise that the greatest usage takes place in the English-speaking north. Likewise, though English is a common second language in Europe, preference for materials in one’s native language may explain the lower readership per healthcare worker in Europe.
While free access to peer-reviewed journals has been shown to provide clinically- and academically-relevant resources to surgeons in LIC [2
], substantial barriers of Internet connectivity and awareness must be addressed before healthcare workers will fully benefit from online resources. Obviously, development of local infrastructure will be necessary to improve the reliability of electricity and connectivity. In addition to HIC efforts such as those reviewed in this paper, other efforts may bridge the digital divide in the meantime. For instance, Global HELP (Health Education using Low-cost Publications) creates and distributes affordable health education materials, including PDFs, posters and CD libraries [9
Medical publishing is a high value-add business. Two business models (and a number of hybrids) exist: the subscriber pays or the author pays. Open access, the author pays model, accounts for a very small minority of overall publishing. It is, however, the most rapidly growing publishing paradigm. The next decade will be interesting; will the publishing industry find a balance between placing the financial burden on the author or the subscriber, or will a tipping point be reached at which the entire industry moves toward open access?
Open access publishing has several advantages over the traditional subscription-based industry. For example, open access has the potential for wide and rapid dissemination of new findings. On the other hand, more traditional media may be perceived as having greater longevity, a higher impact factor with a higher profile editorial board, and a more exclusive readership. Currently, there seems to be a positive attitude among researchers regarding the idea of open access, and yet, this does not necessarily translate to an intention to publish one’s own research in an open access journal [10
]. Open access does seem to increase the number of article downloads, but that does not translate into an increased rate of citation of those articles [5
]. Based on the readership of Ptolemy users, we know surgeons in LIC read a wide variety of clinical journals when given the opportunity. For the time being, access to such a breadth of medical literature will rely on projects such as Ptolemy and HINARI that are able to legitimately provide free access to subscription-based journals. The scalability and expansion of Ptolemy-type projects has been previously addressed [2
The publishing field is moving toward open access, but nobody knows how quickly or completely open access journals will take over from subscriber-based journals. Within a specific open access journal, we have shown readership in Africa is as high as the Americas and higher than Europe when compared with the healthcare worker density and that the readership corresponds more closely to the burden of disease in Africa than in higher-income regions. The open access publishing model presents a substantial increase in the availability of research information in LIC, as long as healthcare workers are aware of the ever-growing free resources as catalogued on sites such as Directory of Open Access Journals [7
]. Some authors may be hesitant to submit publications to newer, less well-known open access journals [10
], so an alternative to simply creating new open access journals is to encourage already-existing, prestigious, subscription-based journals to move to some version of the open access model. Should open access take over the scientific publishing industry, initiatives like Ptolemy and HINARI will no longer be needed to bridge the gap in access to the body of published literature, but it is a double-edged sword. The ability of African surgeons to publish in the open access journals they read will only be maintained if the current enlightened policies regarding waiving author fees for papers from LIC can be systematically maintained [3