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For some years now it has been the policy of the BMJ Publishing Group, which jointly owns Heart with the British Cardiac Society, to give gratis subscriptions to their journals to applicants from countries in the developing world. However, in practice this has had its difficulties. Many developing countries have either poor or non-existent postal services, and granting a print subscription can often be problematic and expensive—for example, the marginal cost of sending Heart to Africa is around £25 each year.
An editorial in BMJ has set out the arguments very clearly.1 We know that the gap between the rich and poor countries is widening. While those of us in the developed world have information overload, the developing countries have bare library shelves. The internet gives us the opportunity to narrow the gap.
The marginal cost of giving access to the electronic edition ofHeart is much less than sending the paper version. What is more, those in resource poor countries can access electronic journals at exactly the same time as those in the developed world, and they can participate in the debate using the rapid response facility on the web site in a way that was almost impossible with the slowness of print distribution.
Access to the electronic edition of Heartwill be provided free automatically to those from countries defined as poor under the human development index by the United Nations (URLhttp://www.undp.org/hdro/HDI.html/). Digital Island has been installed on all BMJ journal web sites. This software recognises where the user is coming from and will give unrestricted access to the whole web site to users from those developing countries we choose to designate.
The main problem is the lack of access to the world wide web in the developing world. While tens of millions of people have access in the USA, it is only thousands in most African countries; and access in Africa is often painfully slow, intermittent, and hugely expensive relative to access in the USA (where it is often free). Power cuts happen every day in many resource poor countries. Yet there is every reason to expect that access should increase dramatically. India currently has a million people with internet access (0.1% of the population), but this is expected to rise to 40 million within five years. Increases of a similar scale are expected in Nigeria.
The challenge will be sustainability. Enhancing information flow will make no impact on health if projects continue only as long as their funding lasts. Information cannot be separated from the capacity of a healthcare system to work effectively over time. How is it possible to influence the context within which information will flow, the apparently intractable political, economic, and organisational constraints that disable rather than enable information to work for people? Publishers in the rich world have a part to play and we hope that by making access to Heart on line free to those in the developing world we are making our own small contribution.