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clinmed/2000110006v1 (December 22, 2000)
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It’s almost midnight in Kampala. Dr. Ulu Melo has had a grueling day seeing patients in his clinic. Nevertheless, he sits down by his computer and checks the Global Alliance for Health Information (GAHI) website. After registering, he goes to the infectious disease discussion group where he posted a query earlier that day regarding a complicated case of tuberculosis. There are seven responses to his query from health care providers in Nigeria, Kenya, China, India, Pakistan, and Thailand. Some of the responses have links to articles in the Journal of Infectious Disease, which Dr. Melo then accesses free of charge through GAHI. Twenty minutes later he has a strategy for treating his tuberculosis patient, and he goes to bed. The next day, he sees the patient again in his clinic and administers the treatment.
The vision of GAHI is to improve global health by making health information available to all health care providers in low and middle income countries.(1)
GAHI is an alliance among scientific and medical journals (including Nature, Science, BMJ, CMAJ, Lancet, and many others), knowledge initiatives in high income countries (including the UK National Electronic Library for Health and US-based PubMedCentral), international institutions (including WHO, World Bank), international foundations (including Gates, Rockefeller, Carnegie), and the UN Health InterNetwork.
The rationale for GAHI is the view that health information should be considered an international public good. As emphasized by the 1999 World Development Report, knowledge is crucial for development. Health information is a form of knowledge wherein "the social returns to an innovation (to all those benefiting from it) far exceed the private returns (to just those investing in it)."(2) Therefore, public action – including the public/private partnership represented by GAHI – is required to reap the full benefits of health information. Promotion of international public goods is a core function of international health institutions.(3)
This view of health information as a public good is not universally accepted, as shown by the way many journals assert and protect copyright over the articles they publish.(4) However, journals participate in GAHI, and contribute their full content without charge, for several reasons. First, it immediately positions the journal as global. Second, it provides public relations benefits to the journal; even journals that refused to join PubMed Central because of their vested economic interests appear altruistic. Third, it represents an enhanced source of articles from health care providers in low and middle income countries.(5)(6) Fourth, it represents a source of increased citations for articles in the journal because of the larger readership, thus bolstering the journal’s impact.(7) Fifth, it doesn’t undermine journal revenues because very few health care providers in low and middle income countries have paid subscriptions. Sixth, these health care providers could not afford to pay for the journal subscription anyway. Seventh, health care workers in high income countries cannot access journal content through GAHI so the journal’s current subscriber base is not eroded. (8) Finally, there is no cost to the journal because the cost of registering access to health care providers from low and middle income countries is borne by GAHI.
GAHI builds on the vision of PubMed Central ("to make results from the world's life sciences research community freely available on the Internet"(9)) and the National Electronic Library for Health ("to provide easy access to best current knowledge, and to help improve health and healthcare, clinical practice, and patient choice" (10)). In contrast to these initiatives, GAHI focuses on health care providers in low and middle income countries, organizes content specifically for this audience. For example, GAHI has focus areas in malaria, tuberculosis, polio, and AIDS where it synthesizes information on these diseases. GAHI also provides a platform for communication among health care providers in low and middle income countries on clinical problems.
GAHI addresses the challenge of information overload by using the knowledge architecture of the UK National Electronic Library for Health, and by fostering the development of online communities around particular topics.(11) To select moderators for these online communities, GAHI uses established survey methods to identify opinion leaders. The surveys are conducted online through GAHI, representing an innovation in capacity building in low and middle income countries. Moderators help to develop an appropriate content interface for their particular area of expertise, and provide input into the ongoing conversations of the online community. GAHI moderators are increasingly recruited to join international research networks funded by the Fogarty International Center of the US National Institutes of Health and other international funding bodies. To avoid "brain drain" from low and middle income countries, GAHI compensates moderators on the condition that they stay in their home country and contribute less than 10% of their time to international networks. Therefore, another spin-off benefit of GAHI is its use as a method of social capital development and networking throughout the world.
GAHI’s technical challenges are mitigated through its partnership with the UN Health InterNetwork which "will establish and operate 10,000 on-line sites in hospitals, clinics, and public health facilities throughout the developing world."(12) Nevertheless, there are still problems to overcome.(13) First, the language of communication in GAHI is English, and so it is not valuable to non-English speaking health care providers. Second, internet communication is still a problem for health care providers in many areas of the world, both in terms of bandwidth and availability of hardware. Third, the culture of applying knowledge to clinical problems may not be as strong in all parts of the world as in the citadels of evidence-based medicine in high income countries.
The main value of GAHI may ultimately be the panel of health care providers it assembles. Because health care providers are required to register for access to the website, GAHI possesses a growing list of email addresses of health care providers in low and middle income countries. During the process of registration, GAHI collects, with permission, information from health care providers. This information is used by GAHI to support international public health initiatives including Roll Back Malaria, the International Partnership against AIDS in Africa, the Global Alliance for Vaccines and Immunization (GAVI), Stop TB, and Making Pregnancy Safer.(14)
GAHI also collects opinion on research priorities in low and middle income countries to support the Global Forum for Health Research. Only 10% of the $50-60 billion spent internationally on health research is used for research on the health problems of 90% of the world’s people. The objective of the Global Forum for Health Research is to help correct the 10/90 disequilibrium and focus research efforts on the health problems of the poor by improving the allocation of research funds and by facilitating collaboration among partners both in the public and private sectors.(15)
While initial funding for GAHI was derived from international institutions and foundations, GAHI has achieved sustainability and growth through revenues from its intellectual property rights division (described below), e-business strategic alliances (such as "globaldrugstore.com", which specializes in drug distibution to low and middle income countries), and banner advertising (from multi-national pharmaceutical companies). Despite growing private sector revenues, GAHI maintains independence and integrity through its governance, ethics infrastructure, conflict-of-interest policies, and commitment to global health and welfare.(16)
GAHI’s intellectual property rights division (GAHI-IPRD) is one of its most visionary elements. The mission of GAHI-IPRD is to educate health care workers and scientists around the world about intellectual property rights, and to facilitate patent applications from low and middle income countries. GAHI-IPRD also advocates for the interests of low and middle income countries regarding Trade-Related Aspects of Intellectual Property Rights at the World Trade Organization, (17) and provides technical assistance to groups developing intellectual property strategies such as the African Agency of Biotechnology. GAHI-IPRD is modeled on technology transfer units of major universities. Patents are assigned to the inventor, but GAHI-IPRD retains a 10% share of patent royalties in exchange for its services. Half of this amount helps fund GAHI, and the other half goes to the Ministry of Health of the country in which the discovery was made. The Ministry of Health share is provided only to governments in compliance with the OECD Principles for Managing Ethics in the Public Service; otherwise, the funds are held in escrow by GAHI to be disbursed when the national government is in compliance.(18)
The GAHI-IPRD strategy, which has become known as "patents for development", is widely admired. It complements other intellectual property rights proposals related to the UN Convention on Biological Diversity (19) or experience with agricultural biotechnology. (20) Challenges remain such as strengthening the university system and raising venture capital. (21) The benefits of GAHI-IPRD flow not only from patent royalties but also regional economic development as spin-off companies are formed in association with universities around the world. (22)
Why has a network analogous to GAHI not been possible in high income countries even though many key people agree that it would be beneficial? This fascinating question was examined in an article published in Nature by famed sociologist of science Prof. Pangloss. His conclusion was that the elements of GAHI in high income countries exist in different entities such as individual journals, national knowledge initiatives such as the UK National Electronic Library for Health, national online communities such as doctors.net.uk, and technology transfer divisions of universities. However, vested economic interests prevented pulling together these entities in a GAHI-like alliance in high income countries.
In addition to improving global health, GAHI exemplifies a culture of solidarity among health care providers around the world. This makes an important statement about global ethics, which requires a commitment to a culture of solidarity, and serves as a stimulus for other professional groups to do the same. (23)
Unfortunately, GAHI does not exist. It should.
Acknowledgments: I am grateful to Julio Frenk for helpful discussions; Solly Benatar, Kerry Bowman, Maxine Clarke, Abdallah Daar, Bill Hoffenberg, Sharon Straus, Sue MacRae, David Naylor, Michael Scholtz, James Till, and David Zakus for comments; and Althea Blackburn-Evans for editorial assistance.
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