The Inside Track: Paywalls, Diamonds and Summer Tans

Who gets to read the science, and who pays for it? Fresh back from summer (tans included),  Garry Aslanyan and co-hosts  Catherine Kyobutungi and Ricardo Baptista Leite return for the fifth installment of The Inside Track. This time they're joined by special guest Ashley Farley, Senior Officer for Knowledge and Research Services in Global Health at the Gates Foundation, to dig into open access and the paywalls that keep research away from the people who need it most. They talk about why the Gates Foundation stopped paying article processing charges and the growth of Diamond Open Access. The pundits then pick apart Lithuania's controversial plan to send newly trained doctors to rural areas. They close with kudos for El Salvador eliminating trachoma, promising mRNA cancer vaccine results and the public health thinking behind Addis Ababa's makeover.

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paywalls, diamonds and summer tans ... Welcome to the Inside Track, a series from the Global Health Matters podcast. In this series, we step inside a conversation shaping global health. The debates, the dilemmas, and the decisions that don't always make the headlines. Each episode features two recurring expert pundits, Catherine Kyobutungi and Ricardo Baptista Leite offering informed, independent analysis grounded in lived experience. Consider this your invitation to The Inside. Hi everyone. Welcome back to the Inside Track. So I think this is our fifth episode for recording of Inside Track. For those of you who are just joining us for the first time of Inside Track, a reminder that this is a conversation with two pundits. We usually have three sections in this conversation, one focused on a current important global health issue, then we have a Clipping where we pick an article or news item to tear apart, and then we have Kudos section at the end when we really recognize some developments in global health. And our pundits usually speak in their individual capacity. So be prepared to hear it all. So welcome back. Catherine and Ricardo. Considering the tan on Ricardo's face and maybe Catherine, you had a vacation over the summer or how things are Catherine and Ricardo, say hi. Hi Garry. It’s great to see you! Hi Ricardo. Hi Garry and hi Ashley. I’m still on vacation! Ah you're still on vacation? Okay, well, this is real dedication. Now, last time, we've confirmed, I think, that your family members are watching and listening to Inside Track. We may have a development on that front, because maybe this episode will also be as video on Spotify and Apple Podcasts in addition to YouTube. So maybe there'll be more people watching us. We have a guest with us, Catherine and Ricardo, it's Ashley Farley. Ashley, hi. And quickly you will find out why Ashley is here. She actually is the Senior Officer for Knowledge and Research Services and Global Health at the Gates Foundation. And she really had to wake up really early to join us. And she found some few minutes for us. So we're going to use that time as much as possible and make sure that the discussion is covering it. So as I said, there is a reason why Ashley's here. It's really we want to look at an issue. We say that in Inside Track, we look at a current issue in global health. We're going to discuss something more of a perennial issue in global health, which is Open Access and Paywalls, and how this really drives equity and access in knowledge. We really wanted to pick this topic because in the previous few episodes, Ricardo and Catherine know when we did the Clipping part, we picked an article, but unfortunately we knew that our listeners could not go and read them because they were behind the paywall. Hence, we kind of find that weird, right? And we are going to talk about it. So Catherine and Ricardo, are you ready to talk about this topic? We have two great experts here Garry. We have Catherine and Ashely. So, I’ll try to keep up pace and if I may, also welcome Ashley onto our show OK, Maybe I'll start with Catherine, Catherine, maybe you can kick this off by maybe sharing your views, how the access to scientific evidence really got to the place where some of it is not open, or it really is connected to a lot of different issues around financing and what actually implications are of this kind of system. We have for researchers, for people who work out there in clinics, policy makers in different settings who need to really need to use that information to make decisions. So, Catherine, what do you think of this topic of Open Access and what are your views on this? Yes, thanks, Garry, and nice to see you again, Ricardo, and hi, Ashley. I'm also trying to think when this all began, and I think it began with when scientific publications started getting online. That's when I think it coincided with the whole open science movement, because in the past, all journal articles were published in journals, which were paper, manual. And therefore you needed some kind, we need to have access. So you need to papers and journals in your library. And then in that case, of course, people could go to the library and they could access any paper they wanted. But of course the access wasn't equal because journals are not free. So institutions, academic institutions, research institutions needed to subscribe to certain extent. And then of course these would be shipped to them and then you'd have copies in your libraries that people could access. But then I think about 20, 30 years ago, now the online publication of journals started. I mean, when it started, I think there was a question of if previously people bought journals, paper journals, now what happens if the information is online? So it started with again, with restrictions. You just couldn't get a journal, you know, just by logging onto the internet. And then I think the recognition that this was not fair. Started with the whole open science movement. So there's open data, open publications, open all sorts of things. And that's when now the model for access changed. So in this case, institutions have to subscribe to access a journal, journal articles. But because the subscriptions are very high, then there was this whole thing of, should the publisher, should the scientist who writes the paper pay for this to be accessible? So there are models which when you want to publish a paper, you actually pay the journal a fee. And then once you pay that fee, then the paper is made accessible to anyone who wants to access it. So it's a mix of models. And so is this equitable? No, because not everybody can afford to pay to have their paper published. And therefore it has created also this disparity. Whereby researchers and scientists from low- and middle-income countries don't always have the ability to pay for these journals. And then even after paying, it doesn't mean that every single person will have access to the journal anyway. So it's a very, I would say, complex model that I think puts a lot of power into publishers, into the hands of publishers, and it's, it's model which is actually very weird when you think about it. That scientists sit down to research. Much of it is publicly funded. Then they want to put their research out there for people to read and understand. And then journals make the scientists pay for this science that is a public good to certain extent. And then the journals sell access to the science that scientists did and then put out there for the world to read. And then of course, there's a fact that the production of those papers is supported by a whole peer review mechanism. Which is free. So people review the science freely and put it out there and then the journals sell access to this. So it's a very interesting model, but I don't think it's fair. And because the disparities in access really affect more scientists in low- and middle income countries, both from their ability to publish in certain journals, but also when they publish in their ability for anyone to access their papers. Right, right. Okay. Interesting. Catherine. Ricardo, I'm going to ask you, so does this mean that we need to really reimagine the whole research communication overall? I don't know, do we actually need journals? I'm just making this up as I go. But in fact, one interesting comment was made to me as we prepare for this topic by someone who works at an organization called INASP. Her name is Alice, and she said, when we search for articles, we really don't search for the journal. We search for the topic and things come up. It's like a loss of the album when you can search for whatever song you want on Spotify. So why do you need to know the album? Maybe I'm overdoing this, but what are your views on this? Ricardo? Well, I think we need to acknowledge that having sources of information that are trustworthy and that we know have followed the scientific method is still to be considered critically important. Of course, we're living in a world where some actors and even state actors are undermining the credibility of science itself, yet I think, we as a scientific community need to stand up and be very clear that policy should be based on the best evidence and informed on the best science out there. The truth is, because of the reality that Catherine just described, even on the policy front, many ministries of health don't have access to the full length of the articles we're discussing. And so many public health policies affecting wide communities are being based on abstract. And no one is really looking at the full extent of the science and even making their own judgement beyond the peer review that was done. This allows, I think, and creates room for misinformation, disinformation, and moreover, it creates tremendous inequalities in the world. To be able to publish or to be able to read scientific content should not be based on your postal code. Should not be based on your location in the world, or your social or economic standing, or how wealthy your university or institution is because they can or cannot pay for access to these journals. That being said, I think the journals do play an important role, but we have seen also across the landscape, different types of models appearing and different journals having other approaches, open source approaches, open source peer review approaches, community led peer review. And I think that we're also seeing many funders being less willing to pay for article processing charges at an individual basis and moving towards a model that focuses on the concept and the idea, which is -- these platforms that disseminate science and information should be seen as global public goods. I don't think there's an ideal model yet, but I think that's the direction we have to go towards. One last point I would highlight, also coming from the policies field myself, It's not just about scientific articles. Even when we were talking about searching for policies or legislation, it's very difficult to have access, especially if you go beyond the English speaking world, to do comparison between policies and comparative law is an incredibly important piece of the legislative process. And so initiatives like the Global Health Policy Lab in Berlin are precisely trying to address that because many, much of the information. You can hide information behind a firewall, but you can also hide information by making it non-accessible because the websites are so difficult to deal with or because basically the information is not online. And so there are initiatives like the one I mentioned that is trying to bring all of the policies and legislations from the field of health into one place. So then it can be used, be it for the act of policy making or feeding into language models and so forth. And so I think we have to be creative and thinking about also these new technologies on how we can provide new ideas and new opportunities to put the science out there and to make sure that scientific research that is being done in low and middle income countries is also accessible and that those living in low and middle-income countries or in low resource settings can also have access to the science. And I think the journals would benefit tremendously if they were part of the conversation in trying to find a financial model where everyone could benefit. Maybe Ashley, I can bring you here to unpack another aspect, and then you can tell us why some of the changes you had at Gates Foundation over the past few years, related to really that point that Ricardo made about evidence informed decision making when you don't have the evidence or you can't find it, or if it's not available and it's behind unavailable, and it basically creates a lot of inabilities for a lot of the people who need this information. I don't know, journalists, ministries, civil society organizations, they don't have it and they can't access and they can't make any sense out of it. So tell us how you approach this. And you've been steeped in this, really, and help us add a bit of flavor to that as well. Thank you. Yeah, I'd love to share that by background, I'm a librarian. So that's overall the perspective I bring to this work. I've worked in both academic and public libraries my whole career. I've been at Gates Foundation for a little over a decade now trying to really solve this this issue of open access. And I think, you know, open access initially was really community led meant to just make sure people had access to information and there was really no... Like financial barrier or component to it. Of course, we know it does cost to produce information and of course, people should be paid for their labour. But we've seen over the years just how expensive it's become and what a unique kind of marketplace it is. The top five publishers make a lot of money. Year over year, we still see libraries struggle to be able to pay for subscriptions. I think the latest number I've seen, you know, yearly half of the research content that's produced is openly available. So we have made a lot of strides, but it's also come at a lot cost. And then we're trying to think of like, how do we get that additional 50% of access is a big problem to tackle. And I think there's a sense of urgency. So a lot the work that I do, I'm thinking this from a standpoint of like how do get, you know, it's taken us. 30-some years to get to this point now. How do we get to more open access faster? How do get to evidence and insights faster? So from the Gates Foundation perspective, we want access to information as quickly as possible to help inform decisions and learn from. So when we think about the process of publishing, it's still quite long and I would say not very reflective of how technology is now moving. It can take six months, to a year to have a paper published, if not more. So that was a major kind of component of our thinking of how do we unlock this information and make it available faster. There's something called the preprint, which is kind of the version of an article when researchers have completed their work, they've kind of typed it up, they're ready to submit it to a journal to go through that kind of you know, peer review and which is, you know very behind the scenes kind of process of, of publishing. Um, we, we wanted to leverage the pre-print, the pre print servers, which had been around for a long time. We saw in COVID, that was a really important way to share information quickly. Uh, so we can leverage pre print server so authors can share the information when they're ready to. Uh, pre- print servers are journal agnostic. So really it is the focus on the research itself. We're not tying it to. Journal title to judge any of its trustworthiness or impact and yeah, so that we pivoted to requiring preprints, which then gave us, I think, a really bold and interesting way to kind of push back against the article processing charges and the ever-increasing fees to achieve open access. Open Access does not have to mean, you know, money paid by the authors. There are alternative models and ways, but I think that's we've gotten kind of stuck in that thinking of like there's always publishers are always giving us a price tag. Um, so so we are able to boldly say that we're not going to pay for it this way anymore that we really want to support an ecosystem where especially all researchers not just gates funded researchers can benefit and be able to participate In the research landscape. So those are I think the kind of there's two main pillars here of like What version of the article what piece of information do we need to be made available, and how do we really shift towards that more equitable model of funding it. Ashley, you said we -- I'm assuming that's the Gates Foundation. Things that you fund that you are not paying for it right? Right? Those things funded by the Foundation in that process, you've decided not to fund those fees and not to fund that. Right - we're not paying APCs, we're not requiring that the journal version of record be made open access. If grantees want to, we know that this negatively impacts fully open access journals where there's not a version to just publish behind a paywall. We also know that this means there'll be potentially more paywalled content over time. But we also know the current trajectory just wasn't sustainable. I mean, we were spending $6 million a year on about 3,000, 3,500 papers to be made open access, where you could, you know, you could have a whole publishing platform that a much broader audience, a lot more papers could use. And you I'm sure you're part of different groups and coalitions to look at this. And Catherine mentioned that a lot of this is funded by public money. I mean, in your case, it's a private money in a way. Are there any other funders and what are they thinking around in this area? Do you know? Yeah, we’re part of two major funder groups that are focused on open access and open science policy. So we have cOAlition S, which a lot of primarily Europe, but we're really trying to be as global as possible because we know that's what we need in order to be successful is more of a global movement in policy and support of infrastructure. For open access publishing. There's the Open Research Funders Group, which is a little bit more based here in the U.S., but also has some global participation. So those are the two main groups of funders specifically, and those are both national and private funders. And then I've been really excited about the Diamond Open Access community, which has been around for a long time, but I think really growing in the last several years. And that's more of a larger stakeholder group where we have some funders, but also researchers, advocacy groups, infrastructure, and that's been a great example of more, I think, collaborative effort to make some changes. Diamond? Okay, that's an interesting name, Catherine. You brought this up in terms of public money, etc. Do you think any of these movements are really going to address or be able to address? And also maybe your experience with Covid that Ashley mentioned in terms of how really there was greater openness, faster sharing, but also keeping in mind what Ricardo said about, you know, trying to make sure that what's out there is actually of is actually of of standard quality that is needed. What are your views on this, Catherine? Yes, so there are a lot of initiatives that are actually trying to sort of mitigate this situation of inequity. There are initiatives like Research for Life. Research for life brings together, I would say, initiatives in health, health sciences, I think in the agriculture sciences, some of them actually in the justice publication world. So they were like groups that came together to try to bring medical, health, science journals. Into platforms that were sort of aggregators. And then they were now, they all came together into the so-called Research for Life sort of coalition that allows researchers and people from low and middle income countries to access some of these journals. So for instance, my institution is in a low and middle income country. Therefore we subscribe through the Health Gateway. And as such, there are journals which are already sort of aggregated into these platforms. One of them is called Hinari. Therefore, we have a code and we subscribe. And so we can almost get any journal we want, even though we don't subscribe to that particular journal. However, I know that because I work in a research organisation that actually subscribes to that. There are many academics who don't even know that such a mechanism exists. The academics we get Dissertations for PhDs of people who have used Wikipedia as a citation, or just Google and anything they find they put it as a citations. Newspaper articles. It means that there's a university somewhere out there where a PhD student maybe does not know that this mechanism exists, or perhaps is in a university where the university has not subscribed, or made it known that this kind of access exists. Now let's put that to policy makers. So, I know that because my institution subscribes to Hinari. But I don't think the Ministry of Health in Kenya subscribes to Hinari. So the access I have is still different. So while there are mechanisms to sort of circumvent some of these barriers, these are not like spread across all sectors of institutions and publics that need information, and so it still creates some kind of some kind of inequity. Now let's go to COVID and I think what Ashley mentioned about the preprint mechanism that has, to some extent, democratised Science, but again, not fully. Because again, not everybody has access to these pre-print servers, not everybody knows how they work. And so it's still not optimal. And then of course, eventually the papers get published and then either they go behind a paywall or not. Just to give some perspective, Ashley mentioned how the Gates Foundation is spending what, $6 million on about 3,500 publications. In the past, most of us funders, I would include Wellcome, I would include SIDA for the African Population and Health Research Centre, would allow us to charge and bill them for papers published by either scientists or fellows that they support in our research and capacity strengthening programmes. So as long as you could show that this person is doing research funded by them, then when the person is publishing we cover the cost for the article processing charges, and then we could bill and get reimbursed. But this is actually becoming less and less common. Wellcome is no longer refunding everything, SIDA is no more refunding, everything. So it's becoming increasingly difficult for us to support our fellows in our PhD programmes and our researchers, to publish papers with open access. And the article-processing charges, I think they range from about$2,000 to more than $8,000 for some of the big journals like Nature and Science. I think one of them is$8500. Just imagine $8500 to get your paper published in a journal. When this was announced, people say this in some countries, this is like a salary for a postdoc for the whole year and you're asking them to put it into one paper. You know, so there's, there's those things. So in, in, so that there are even journals we cannot, we can't template publishing in because the, the journal article processing fees are just too high. So there are all these things which are still there in the system. There are some efforts to make it more equitable, but still they've not addressed all the challenges that exist. Having said that, I think open access has made it possible for science to be accessible to a much wider audience. There are journals, once they are open access, you don't need any other gymnastics to access them. You just put in an article, you just go and then it will lead you to the article. Then you can access it, but those are not the majority of journals. So yeah, so things have changed, but we still have a long way to go. Okay Ricardo, can I ask you, you said some of the things are not available because they are not available because there are in places that are not very well accessible, and that's beyond just articles that are published in scientific journals. So does AI have anything to help us here? And can AI access things otherwise that humans, when we search, we can't? Or, um... does it access things behind the paywall? I know it's maybe a stupid question, but tell me. Well, I'll get to that AI question in one sec. Please. I just want to pick up on what Catherine was saying about COVID, if I may, because I think there are some lessons also that if we think how the genome of SARS-CoV-2 was shared in January and that led to tremendous advancements in terms of scientific technologies, those that ultimately led to the development of vaccines. That goes to show the power of sharing Science and sharing it fastly. We also saw during that period, a lot of articles that were presented even pre-peer review to accelerate dissemination. However, it also led, as we may recall, to a lot of retractions on as many statements that were made or many publications that were put out there that were actually not completely correct or contradictory findings that affected deeply trust. And that goes back to the point I made at the beginning where we have to make sure that whatever model we put out there is one that ensures that that trust and the science we disseminate is solid to make that then the decisions that need to be made, be it in policy, in clinical settings, are equally based on science and not just on snippets of science or false information. That being said, it's a good segue to your question, Gary about Artificial Intelligence. And in that sense, the truth is -- not all information is accessible to all platforms, to all machine learning systems. Some platforms do have licencing agreements where they do have access to behind paywall information, others do not. And this raises another issue, which is even depending on the way you're using artificial intelligence can actually lead you to getting access to different levels of information. So this actually is a new potential, there's a new potential here for a widening or a new potential digital divide, if you will, where some AI systems do have access to that information and others don't. That's why it's been debated widely that more and more we, as we assume, and I think it becomes clear and clearer, these technologies will be used more and more in the purposes of research and actually in our day-to-day lives, that certain principles need to be followed. And those principles should be ones that the dissemination of science should also include the idea that that science should be readable by machines. There are these principles that are called and the FAIR principles, so FAIR data, which means that the data needs to be findable, accessible, interoperable, and reusable (FAIR). And so making sure that these AI tools, which can be incredibly powerful actually to synthesising enormous amounts of research, to make sure that they are not amplifying poor quality evidence, but actually disseminating science in a way and translating it into a way that can be useful. So ultimately, I think the next knowledge divide may not be between people who can or cannot read a paper or an article. It may be between AI systems that can or can not access the world's scientific knowledge. And that depends on the way we actually put that knowledge out there. Okay, so I'm just afraid of saying something because we'll let us go down another rabbit hole because I read the other day that some study that about 80% of what was produced had something to do with AI helping it to be produced, to be published. So AI might write and then AI might read and then where is the human? Okay, I won't go there, but maybe Ashley, you still have a second? Yes. Okay, so tell me what the ideal future you think may be, and maybe not just for you, but others, but also what the Foundation is thinking. Yeah, yeah, happy, happy to share. I think this is a bit of a segue, too, from what Ricardo was just saying around, you know, how are these AI systems going to use information? And I loved, Gary, your question earlier of, like, do we need journals? It's one of my favourite kind of provocative conversation starters of, like, I personally don't think we need journals as a container of information. I think articles as a container of information no longer serves the purpose of sharing information. We have a lot of different systems, data sets are huge, a lot different ways to share those components of what makes up an article in ways that I think AI would be able to interact with it more. I do think journals are great at creating communities of people and we still need the human aspect and we need to have those communities and that's what really builds, I think, the trust around research. But I do think, you know, eventually we will stop kind of packaging it up in a journal and an article and like putting a stamp of approval of that is like this is knowledge and I think we'll start to embrace it more widely. And so, you now, I think as that shifts, then we then we also have to think about like what are the kind of financial models behind it and how does that shift and so I, my ideal would see the continued growth in communities being able to own and lead their own platforms and spaces for sharing knowledge. And then that I think would be a way to make sure that it's much more equitable. It can be much more reflective of where researchers are in the world. When we talk about, you know, right now a lot of research is, you know forced to be published in English. And if we had more of that multilingualism reflected in research, I think that's exciting, and AI can also help unlock that as well. So I think the ideal state is kind of having that Diamond open access model where you know funders, private or national, are supporting the knowledge sharing from a financial perspective, and then the community researchers are deciding how they want to share the information. We have less reliance on commercial publishers. I think we have less reliance impact factor or metrics of like you know you have to publish or perish in this one journal. I think hopefully in my lifetime I see a shift away from that over-reliance on kind of prestige and publishing and I'm excited to see a better more equitable future. Great. So Ashley, I'll let you go. Thank you so much. Gladly! For joining us. And for our summary of the discussion we just had, I thought of paywalls, diamonds, and summer tans. Would that make sense for our discussion? Right. I guess so. Okay. So, let's go to Clipping and today's Clipping is, and it will be in the show notes, so listeners please read that. And it's an article on Euronews by someone called Giedre Peseckyte. I think, and it's about Lithuania's plan to send newly trained doctors to rural areas sparks backlash. I think it really feeds into a much broader question about global health and the workforce distribution. Maybe we can discuss that. And a quote from the article is,"what regions need is not doctors assigned for five years, but a system in which doctors want to stay." So maybe we can discuss that a little bit and see what it means for global health and what actually this discussion embodies. Maybe I can start with Ricardo. So this is a very, very common discussion, I would say, that many countries are dealing with. And the reason being is because most of the governments around the world, they tend to look at data from the OECD, for example, that says number of doctors per capita, right, as a metric to understand if they have enough doctors or not. But... I want to say this very clearly. The number of doctors per capita is an absolutely useless metric. Because what is important is, are the number of doctor's per region responding to the needs of the population in those regions? Are the number of doctors per speciality responding to the needs of the populations they are serving? And looking at this just from a doctor's perspective is also, I would say, an old way of thinking, to be nice. I think we need to look at different healthcare professions as being part of an integrated system. Pharmacists, nurses, community health workers, and so forth, they all play a critical role. But the most important thing, I think, is that the discussion is not sufficiently focused on what the needs of the people are. And so once again, the health system is designed based on the perspective of who's managing it from the top and not the bottom up approach where -- what do the people need? And then you build from there. And so I think one call to action that should come from here, more than trying to approach this, you know, by forcing people and coercing people to work in rural parts of the country wherever they are. Is actually starting off by understanding, okay, where do you need the healthcare professionals? And to do that, you probably have to develop some form of healthcare services catalogue or charter and compare that, which basically will summarise all of the health services that do exist in your country per region. And I think this geo-reference element is critical. Adding to that then the epidemiology and social determinants and other realities that are geo-referenced and crossing that information. So that you have a clear matrix of what are the needs of the population. And then based on that, you can determine what kind of healthcare professionals you need in each region and even what kind of technologies because part of the work, triage, diagnostics can be supported with AI, for example, to accelerate the offering of healthcare in parts of each country that is underserved in terms of health. So... at the end of the day, forcing people to go down a certain path to solve an immediate problem is a band-aid. If you want a systematic, sustainable solution, first of all, you need to engage with the healthcare professionals you're dealing with to hear what would motivate them to go. And that would take us down a different path that we can discuss if you want. And then most importantly, how can we build a model that is sustainable responding to the specific need, and sufficiently flexible to adapt to the realities in each part of the country, instead of having these kind of generic approaches, which I think are band-aid approaches that many times do not solve the overarching challenges of the health system. Uh-huh. So Catherine, what did you think of the article? And before I do that, have you been to Lithuania, Catherine? No, I've not been to Lithuania. Um, I read that and those, Just to tell you, Lithuania, yeah, Lithuanian is 6% of one province territory of Ontario. And when I saw that article, I said, hmm, they have issues in terms of moving from one part of the country to another. Imagine some other bigger places like Brazil, Canada, I don't know, Australia. So Catherine, please tell us. Yes, I read the article and I was just smiling because this is an issue that countries like Uganda, Kenya, Nigeria have been fighting with for decades and I don't think they've managed to get a grip on it. So here's the thing, I'll just give a little anecdote. I finished medical school and I was thrown literally into the middle of nowhere. I was 24 years old and here I am. In the, in the middle of nowhere and I'm supposed to work there. So there are other, actually, if they would solve this problem, the problem is not necessarily about the health sector alone, it's about what is it like to live somewhere if you're in your twenties or early twenties or early thirties, what is, what it is like? And I know there's a study which we did a few years back. There was a, it was, there's something called, I think, discrete choice experiment where you ask people, okay, rank these as important factors. And then you come up with some kind of score about your, your willingness to go and work somewhere. Schools, good schools for kids are a very important motivation. So if somebody's in their twenties, late twenties or the early thirties and they have a family and you're telling them to go in the middle of nowhere to work, they, they will either leave the family behind and go alone or they will not go, if they can't leave the family behind, they can't go. If somebody who's with the kids cannot find schools for their kids, they'll not go. Because people need good schools for the children. After they fix the schooling system so that everywhere there's a good school where people feel comfortable, that the kids get high quality education, and they won't be left behind compared to the peers, you might actually solve half of the problem of why people don't want to go there. So there's schools, there's social life. Like, is there a shopping mall somewhere? Is there a place where people can go for a nice dinner at the end of the day? Those are the things that people want. You just want to live, you know what? Because being a doctor is not everything about you. It's a job that you do just like everybody else. So actually the fix for these things is to make sure there's good infrastructure for people to have a good life as doctors and then now force them to go there. But if not, somebody will go, how long can you stay, you know, away from your family for five years because you want to get a Residency? I don't really know. So, there's that, you have to put push. Pull factors, people feel like this is a good thing, I can go there, I know it's far but I can survive. And then of course you have to put, so these are the carrots and then you have to put some sticks. But if you just use sticks, I don't think this is sustainable. People will just decide, okay I want to do Residency, or those that end up doing it are those maybe who are desperate or something like that. So it has to be a balance between carrots and sticks. What they're doing is sticks, like you have go, if you don't this will happen. And then now you need to make it nice, so when people go there you know they can live It isn't life as human beings, and not just to see it from a doctor's that people need services and therefore you're pushing people into places which are not livable. You have to ask yourself, why don't people want to go there in the first instance? And much of it has to do with infrastructure and the social amenities that people feel like with their education and stature and maybe your status, that this is not a place where they are going to have a comfortable life. Yeah. Yeah, so I'm afraid probably, I mean, now listeners can read the article and then compare to their setting and see what does that mean and how does that really compare to where they are. But clearly this issue is probably not going away. I think last week there was an article about looking at the trends of human resources and health, and beyond doctors, I think. And there's a huge really gap in workforce. If the universal health coverage is ever going to materialise. So it's not going to go away. And some options are things like this need to be really discussed. Maybe we can park that one there and let our listeners read the article and reflect. Let's go to our last segment, which is Kudos. Who wants to go first? I want to bring in some positive news that I caught on the news cycle recently about how a Central American country, El Salvador, was validated by the World Health Organization as having eliminated trachoma as a public health problem. It was the first country in Central America and the second in the Americas to achieve this milestone. And, I mean, this is quite incredible. I guess this is where my infectious disease background comes in, but I got extremely excited about hearing about how there are zero cases, a zero percent of active transmission and no advanced blindness-causing cases. Just for people to know, this is a painful late stage form of disease where eyelids turn inward and cause eyelashes to scrape on the eyeball and ultimately cause permanent blindness. Globally, trachoma is still responsible for blindness or visual impairment for nearly two million people around the world and 5.6 million of people are at risk. And of course, this doesn't affect populations in general, it affects high risk populations which are typically associated to poverty, lack of access to water, hygiene and sanitation and so forth. And so... I think this is a source of inspiration for other countries that have still important populations at risk. As I said, 5.6 million people remain at risk in nearby regional neighbours, including Brazil, Colombia, Guatemala, Peru. WHO had announced the goal of eliminating trachoma by 2020. That has been readjusted to 2030. I hope this news from El Salvador will get us in that direction, and the world I think needs positive news from the global health space, so I'll leave you with that. Kudos. Catherine, your kudos! Can I have two kudos? Garry? Sure! Short kudos! Two short kudos. Okay, I think the big news for me has been the results from the phase three trial of the Merck and Moderna, they are calling it the cancer vaccine... I think you just stole my kudos. Yes, I mean, it has been, I don't even know how to describe it. It's just incredible to see how far this technology has advanced and the potential that it has to really transform cancer care. For cancers, which are very, very difficult to treat. And it's not the first one. I think there are about 12 promising things that are already there in phase two, or soon going into phase three. And I think it's been all over the news and it's such, I think a boost to the scientific world, but also to a technology which has been demonised and actually in some countries has been de-funded to see really how transformative this potentially could be. So that is the first Kudos. And then The second kudos is a few weeks back, I was in Addis Ababa. And if you've been to Addis-Ababa 10 years ago, five years ago three years ago and then today, every time you go, the city is getting transformed. And it's just incredible to see like a city literally transforming like before your eyes, you go there today and you go back one year later and they're like, what just happened? But that's like, that's from the aesthetics. It looks really nice. It's clean and it's, you know, wide streets. Everything is nice. So I met the Minister of Health during that short visit to Addis Ababa. And actually behind the scenes, it's something much bigger. It's not just a clean, nice looking city with nice streets and all that. There's actually a public health rationale behind what they're doing. So they've put all these like cycling lanes, they've put pedestrian walkways. I drove for 45 minutes outside the city centre and every single road has a pedestrian walkway, which is unprecedented, I think, for an African city. And they're going beyond that. They're putting public parks. They're cleaning the rivers. They are, it's nice to see, to hear somebody articulate that behind the transformation of the city, after there's a public health consideration and there's public health rationale. They are not just putting, you know, putting nice concrete stuff all over the place, they actually, there's a health expectation behind this transformation. And I found it's incredible that there's a government that's actually looking at public health and not just from the health sector, but also in how cities are built and how cities made livable. So kudos to everyone that is doing a great job in making Addis Ababa. I think a good example of what an African city should look like. Okay, great, Catherine. And as I said, you stole my kudos. Maybe to add that this issue with the the mRNA and it's really I mean the in the news you see a lot of Moderna and Merck they are kind of visible champions of this. But it also goes beyond them. And it really is about this field, right, of research that had a lot of investment for years. And somehow it also links to our first topic we discussed about open science and the investments that are made that then really give us the fruits of that old investment. So maybe we will conclude here. We do want our listeners to give us advice on any topics they want us to cover or questions they want us to Um, touch upon so you know how to find us. Thank you. Ricardo. And thank you, Catherine, and we will see you next time. Thank you. Thank you! Bye-bye. To learn more about the topic discussed in this episode, visit the episode's web page where you will find additional readings, show notes, and translations. Don't forget to get in touch with us via social media, email, or by sharing a voice message, and be sure to subscribe or follow us wherever you get your podcasts. Global Health Matters is produced by TDR, a United Nations co-sponsored research program based at the World Health Organization. Thank you for listening.