The contrast with the spirit of Christmas  could not be greater. Indeed, Christmas –  notwithstanding the excessive and irritating commercialization which envelop its celebration in many parts of the world – is also a time which reminds people of the ethical imperative to care (more) for each other, something that seems very much needed in our current times. From this religious and philosophical inspiration, we take the liberty to extrapolate and reflect on an issue that is (or at least should be) central to public health policies and programmes:   the place of caring in the interface between people and health systems.

We believe that (the concept and practice of) patient-centered care (PCC) – or if you prefer, person-centered care – tries to capture this caring dimension. Essentially, PCC focuses on the quality of the interaction between a patient and a health worker. PCC embraces a holistic approach towards the provision of healthcare to an individual – health care that does not just take  into account biopsychosocial elements, but also a patient’s preferences, ideas, concerns and expectations. PCC aims for an alliance between the health worker and the patient which implies the sharing of power and responsibilities. Central in PCC are mutual respect and empathy.

Providing care that is oriented towards a patient or person may sound obvious, but it was only acknowledged on a global scale towards the turn of the century. For instance, in 2001 the Institute of Medicine in the USA explicitly highlighted patient-centeredness as a key dimension of quality of care. Despite this formal recognition, PCC continues to be a neglected aspect in the delivery of care irrespective of the setting, whether high or low income (although perhaps not to the same extent).  Focusing on low-income countries, we explored this gap in a recent article on PCC in sub-Saharan Africa, in the International journal of Person Centered Medicine. We arrived at the conclusion that the concept and practice of PCC in public first line health facilities are still underdeveloped in that part of the world. The title of the paper summed it up neatly: “Patient-Centered Care and People-Centered Health Systems in Sub-Saharan Africa: Why So Little of Something So Badly Needed?”

From the perspective of health workers, we found – quite obviously perhaps –   that health worker attitudes are influenced by a broad variety of factors related to the socio-cultural environment, the  personality of the health worker but also his/her working conditions, the patient’s characteristics, the structure and organization of the health system, etc.  In an attempt to structure this variety of factors which have an impact on the delivery of PCC, we proposed a simple, three-layered model  to conceptualize  the individual interaction between a patient seeking care and a health worker (a medical doctor, clinical officer,  nurse-practitioner, …).

In the context of high-income countries, even if there’s still room for further improvement (see for instance the care for the elderly in our own country, with shamefully long waiting lists…), substantial progress has been made towards PCC, for example through the increased recognition in academic and health policy circles of the value of Primary Health Care implemented via the practice of Family Medicine delivered by small multidisciplinary teams.  As formulated by the late Barbara Starfield, Primary Care relates to the social integration of health workers in the local community they serve, a biopsychosocial approach to people’s problems, a long term relationship between health workers and people, a sound balance between technicity and human relationships, and an offer of truly integrated care…

In many sub-Saharan African countries, on the other hand, this sort of care is still rare, unfortunately. The reasons for this are many, but the fact that health workers and patients, when they interact in the context of modern health systems ( be it within the frame of educational programmes or when seeking health care) only rarely encounter ‘living models’ of care delivery that match the above-mentioned features, is certainly an important factor.

Against this backdrop, we strongly advocate for more patient-centeredness in health care, and for more research on the impact of socio-cultural, structural and organizational conditions on the development and system-wide recognition of PCC in different contexts. Instruments to measure PCC (or the lack of it) need to be developed and validated in a set of culturally distinct environments. And, perhaps most importantly, possible solutions need to be tested using a participatory action-research framework.

Following in the footsteps of Mahler, Mercenier and Van Balen…

When engaging in end-of-the-year musings on PCC in SSA, it would be inappropriate, almost indecent, not to refer to the recent  loss of Dr. Halfdan Mahler who served as the Director-General of the World Health Organisation between 1973-1988. Dr. Mahler will go down in history as the visionary co-founder of the Primary Health Care (PHC) movement that culminated in the Alma Ata declaration in 1978. Dr Mahler passed away on December 14^th. We honor his tremendous legacy.

At the same time, as faculty of the Public Health Department of the Institute of Tropical Medicine in Antwerp, we also seize the opportunity to pay tribute to the important work done in the domain of PHC and PCC by the late Professors Pierre Mercenier and Harry Van Balen, founders of the Antwerp school of thought. Their emphasis in teaching, practice and research on the famous triad of global, continuous and integrated care (or in French: “des soins globaux, continus et intégrés”) as key characteristics of quality health care, familiar to the many hundreds of students that have attended their classes, has not lost an inch of its relevance.

On that note, we wish all of you some restful and peaceful days ahead, and time with your beloved ones. Our warmest season’s greetings!

Publishing in academic journals is a business. An academic journal employs people, develops and sells a product, much like any other business. However, profit  margins of commercial scientific publishers reach on average 35% and are fairly stable. My big frustration is that for-profit publishers  not only reap the benefits of scientists’ dedication and taxpayers’ money, but they also put their work behind paywalls thereby limiting their readers to those who can afford to purchase articles, or have institutional access to these journals. Such for-profit publishers prioritize their shareholders instead of those who have carried out the research or invested in it.

So what is the benefit of trading a unique commodity? In the case of academic writing, published articles are usually unique in their content – giving publishers a monopoly. Do such monopolies increase efficiency? In the case of publishing, the opposite seems to be the case.  The “true cost” of publishing (profit not included) is significantly lower for open access compared to subscription journals.

Is it fair to make knowledge only available for the ones who are able and willing to pay a high price for it?  Limiting access to information for a wider audience has tremendous consequences for the progress of science and global equity.  Rising costs of such journals mean even the most prestigious universities in the West are not able to keep up. I believe equal access to information is one of the cornerstones to enhance global equity and access to evidence important even from a right to health perspective.

So what will it take to bring about change in how scientific papers are published and accessed in the future? As consumers and producers, scientists have an underutilized voice and authority to influence the nature of academic publishing – especially in the interest of access to information. However, for many scientists such a move might be in conflict with the desire for the status and recognition that comes from having publications in journals which are ranked by their impact factor.

Currently, we are witnessing an important change in the way in which people access and share information and more is to come. The open science movement is flourishing. The concept of open access journals is gaining popularity, and even the trend of open data is successfully emerging.  I believe, in the near future, modern science will not appear in the form of finished products developed by and accessible to mainly western scientists, but rather, it will change into a global open source dynamic and interactive system.

There are, of course, valid concerns on the quality and reliability of open source publications and data.  Take for instance the problematic activities of predatory open access journals which make money from fees for publication while delivering an extremely poor quality of publications.  However, if managed well, examples show that open access can often produce very positive and effective results. For example, R – a software for statistical computing and graphics – is now a powerful and reliable statistical software.  Wikipedia reached a similar or better accuracy than any traditional encyclopedia.

Coming back to the role of scientists in the way in which the academic publishing industry functions, we notice some scientists challenge the rising costs of journals. Recently, 2600 scientists signed a petition, at a collective “cost of knowledge movement” to not publish in Elsevier’s journals, nor undertake any referee or editing work for the company.  In a more unconventional step, Alexandra Elbakyan, a 27 year old neuroscientist from Kazakhstan, made her point on the need for open access clear with her site, Sci-hub. Through her website, Alexandra is making millions of papers accessible to millions of people. This is of course an ethically gray area and has the legal implications of copyright infringement among other issues. She is also risking financial ruin, extradition, and imprisonment, especially after she got sued by Elsevier. Unlawful or not, her “disruptive” site is now quickly growing in popularity and has a fair shot at changing the methodology of ‘global science’.

For the moment though, one can imagine the impact Western scientists could have if they would unite to make science more accessible. Such a movement would strongly contribute to progress in science and global equity. A collective movement of scientists can have an impact on the high costs of access to information, and create an environment where information is accessible to all. Are we as global scientists proactive enough to fight for such a cause or does this go the very core of neoliberalism, more specifically in  21st century academic environments  ?