Sir — Amid much fanfare, the WorldHealth Organization (WHO) announcedlast summer that it had convinced aconsortium of medical publishers to providephysicians and scientists in the developingworld with cheap access to researchjournals, via the Internet1,2. This plan wascharacterized as “a real breakthrough” byWHO director-general Gro HarlemBrundtland, on 9 July 2001 (see www.who.int/director-general/speeches/2001).

But how much of a breakthrough is it?When the eager doctors and investigatorsfinally open their new journals, they willfind the articles inside almost exclusivelygeared to the medical problems of patientsin developed countries, often discussingmedications and technologies not availablein underdeveloped regions of the world.

For example, a recent issue of the NewEngland Journal of Medicine (a publicationalso distributed free over the Internet tolow-income countries, though not amember of the new consortium) presenteda clinical trial demonstrating that HIVpatients responding to antivirus therapy— consisting of at least three powerfuldrugs — may no longer require precau-tionary antibiotics to guard againstpneumonia3. The catch is that in most ofthe world, patients with HIV cannot affordeven one of these medications. As aneditorial accompanying this articleobserved, the results of the study “are goodnews for people living with AIDS but theyalso make the gulf in treatment betweenrich and poor countries that much moreglaring and unacceptable”4.

If journal editors really want to make anenduring contribution to the developingworld, they should focus on the content oftheir publications, not just the distribution.A good first step would be to commit aconsistent number of pages — say 15% —to articles addressing the medical needsand concerns of underdeveloped regions.By acquiring a more global perspective,medical journals would accomplish severalimportant benefits.

First, and most important, the journalswould provide articles of interest andrelevance to doctors, scientists andpatients in these regions of the world,creating a body of data that could guidepractice in the same way that clinicalresearch has improved the treatment ofpatients in developed countries.

Second, articles focused on health carein underdeveloped regions would enablejournal readers to become betteracquainted with the unique needs andproblems of medical care in these areas.

Less than 10% of the world’s health-careexpenditure is said to be devoted toillnesses that account for 90% of the globalburden of disease, and it is likely thatpublished research articles follow a similarpattern5. Increased focus on the health-careneeds of poorer countries might encouragewestern physicians and scientists to thinkabout problems they might not ordinarilyencounter, and to generate fresh insights ornovel approaches.

Finally, the new articles might help toinform the development of ethicsguidelines for clinical research done byNorth American and European scientists in underdeveloped regions. These includethorny questions, such as whether it isethical to conduct a study in which thecontrol group of patients receives nomedicine (the local standard of care) ratherthan an expensive medicine (the best careavailable). Greater familiarity with theneeds and the resources of patients inpoorer nations might help ethicscommittees as they wrestle with thesedifficult but vitally important decisions.

If journals were to commit 15% of theirpages to medicine in the developing world,would their current readers be interested?Surprisingly, the answer may be aresounding yes. Western medical schoolsare reporting a groundswell of interest ininternational medicine; for example, atHarvard, a record number of medical

students — more than 50 — participatedthis past year in international healthexperiences, in countries such as CostaRica, Bolivia, Vietnam and Zambia. TheAssociation of Schools of Public Health,based in Washington DC, reports that thenumber of public-health studentsspecializing in international health is nowat an all-time high6. Meanwhile, organi-zations focusing on international healthare receiving unprecedented recognition,such as Médecins sans Frontières, recipientof the 1999 Nobel peace prize.

By dedicating 15% of their pages to themedical concerns of the developing world,journal editors would not only show theirgenuine commitment to global health, butmight also discover a Western readershipeager for a broadened perspective, and aninternational medical community gratefulfor the opportunity to provide it. David A. Shaywitz, Dennis A. Ausiello Department of Medicine, GRB-740, MassachusettsGeneral Hospital, 55 Fruit Street, Boston,Massachusetts 02114, USA, and Harvard MedicalSchool, 25 Shattuck Street, Boston, Massachusetts02115, USA1. Malakoff, D. Science 293, 189–190 (2001).2. Nature 412, 110 (2001).3. de Quiron, J. N. Engl. J. Med. 344, 159–167 (2001).4. Girard, P. M. N. Engl. J. Med. 344, 222–223 (2001).5. Global Forum for Health Research. The 10/90 Report on Health

Research 2000 (http://www.globalforumhealth.org/).6. Helsing, K. 2000 Annual Data Report: Applications, New

Enrollments and Students, Fall 2000. 41 (Association of Schoolsof Public Health, Washington DC, 2001).

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The 15% solution for majority health concerns Medical journals should devote more space to issues that affect the developing world.

World hasn’t changedfor the dispossessedSir — Understandably, following theoutrages of 11 September 2001, the mainscientific periodicals have covered itsimpact on aspects of science and theresponse of scientists to the fears that itgenerated. The annual News reviews inNature (Nature 414, 836–841; 2001) andScience both headline its aftermath, in termsof the impact on security and the economicdownturn that the attacks have helped toaccelerate. Their central theme is that theworld changed on that day. It did not.

For two thirds of the world’s population,‘business as usual’ involves an ever-widening gap between hope for the futureand expectation of any relief it will bringfrom poverty, disease and disaster. Fear offalling victim to natural calamities — andthose generated by the lifestyles of a highlyprivileged minority — remains as strong asever. Despicable as the perpetrators andthose who motivated their actions were,

the attacks arose from the growingpowerlessness of hundreds of millions ofdispossessed people. Global communi-cations ensure that they are confronteddaily by what they lack, leading to a deepsense of unfairness and victimhood.

Scientists, whose work is enmeshedwith emergence of the possible, shoulddwell on how they might help close thatgrowing human fault line, as you discuss inyour Opinion article “Timely messages forthe South” (Nature 415, 1; 2002), ratherthan raging at or cringing before themonstrosity that they have helped tonurture. Assisting the dispossessed tosecure safe, dependable water supplies; toimprove their agricultural yields; to ridthemselves of endemic disease; to gainaccess to cheap energy and transport; andabove all to acquire knowledge and theability to solve their own problems is not aproblem of cosmological or genomicproportions. It is a simple, human duty. Steve Drury Department of Earth Sciences, The OpenUniversity, Milton Keynes MK7 6AA, UK

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