© 2004 American Thoracic Society
American in Name, International in ScopeThe Journal was founded in 1917 as the American Review of Tuberculosis. Since then, its name has been changed more often than that of any other medical journal (1). Only one word, American, has stayed constant. The constancy of this word is uncanny given the geographical origin of submissions to the Journal in 2003, as less than 30% of manuscripts originated within the United States of America. The data presented in Figure 1 and in Table E1 of the online supplement is the first ever detailed analysis of the geographical origin of manuscripts submitted to the Journal. Figure 1 shows that 28.8% of manuscripts came from the United States, 41.5% came from Europe, and 18.1% from Australasia. Manuscripts came from a total of 51 countries, and the percentage coming from each is listed in Table E1.
Intrinsic to science is the need for researchers to interact with one another. And from the earliest days, scientists exhibited a collegiality that transcended national boundaries. When Holland was engaged in successive wars with England in the late seventeenth century, the Philosophical Transactions of London's Royal Society published numerous reports by the Dutch microscopist, Antoine van Leeuwenhoek (2). During the American War of Independence a century later, the Philosophical Transaction published detailed discussion of Benjamin Franklin's single fluid theory of electricity (3). Because of Franklin's disloyalty to the crown, George III wanted the Society to condemn his scientific views. The king thought it a point of national honor and patriotism to deny whatever Franklin proposed. Although personally opposed to American independence, Sir John Pringle resigned as president of the Royal Society rather than yield to the royal demand for censorship (3). The action of George III is unfortunately not some aberration of the distant past. Persons in authority still brand scientists of unpopular views as disloyal to a discipline, and attempt to hold back their work (4). The data in Figure 1 and Table E1 provide vivid evidence of universalism, one of the cardinal norms of science (5). This norm is rooted in the belief that there are no privileged sources of scientific knowledge. Scientific manuscripts are evaluated using impersonal criteria, and acceptance should never be based on the personal attributes of authors, their institutional affiliation, or source of research funding. Nationality, race, and religion are also irrelevant. Allied to universalism is the desire of authors to have their work made freely available to other workers around the world. A researcher finds it intolerable to think that other scholars might be prevented from reading his or her new research findings solely because of political obstacles. The norm of universalism operates at its highest level in clinical medicine. Physicians are allowed to place service to mankind ahead of service to their country. In war, physicians are permitted to believe in human brotherhood: to administer medical care to all men and women without national or ethnic distinction. By permitting this practice, politicians and lawmakers acknowledge that the moral code of medicine operates at a higher level than the moral code of nations (6). A physician can walk into a hospital in any corner of the world and become immediately involved in the diagnosis and management of patients. William Osler judged the extraordinary solidarity among physicians of different countries to surpass that of religion: "Medicine is the only world-wide profession, following everywhere the same methods, actuated by the same ambitions, and pursuing the same ends" (7). And also, "The profession in truth is a sort of guild or brotherhood, any member of which can take up his calling in any part of the world and find brethren whose languages and methods and whose aims and ways are identical with his own" (7). Leadership in medical science has never stayed for long at any location. In Renaissance times, the medical school at Padua in the Venetian Republic had no equal. In the early nineteenth century, preeminence in medical science passed to France, moving to the German states at mid-century, and then crossing to the United States in the twentieth century (8). If the United States leads in medicine, why then did fewer than 30% of AJRCCM's manuscripts come from this country? For years, commentators have been expressing grave concerns about shrinking numbers of clinicians conducting research (9–15). In 1979, a former director of the National Institutes of Health, James Wyngaarden, struck a resonant chord when he wrote that the clinical investigator had become an endangered species (9). A convincing rebuttal has never materialized over the subsequent twenty-five years. On the contrary, early alarms were ignored and the NIH continued to invest disproportionately in basic as opposed to clinical research (12, 13). Today, funding success for clinical research proposals is about half of that for basic science proposals (14). Only time will tell whether or not the new NIH roadmap will resurrect clinical research (16). That the numbers of clinical researchers have failed to increase in proportion to numbers of basic researchers caused Brown and Goldstein (physician Nobel laureates) to caution that, "There is a danger that medical schools will go back to a pre-Flexner era, where physicians are trained only in the practice of medicine, and scientists are constrained to almost separate institutes" (15). Before becoming director of the NIH, Bernadine Healey saw the "triple threat" (a physician trying to excel in patient care, teaching, and research) as no longer a desirable model (17). After completing her term, Healy returned to the subject and commented wistfully: "We have to revise our fundamental notion that the old-fashioned triple-threat is long gone. Just what are we replacing it with?" (18). Crowley and Thier (19) have drawn attention to the absence of an organization that can provide objective data on the size of the decline in clinical researchers. That is one reason why the geographical origin of manuscripts is illuminating. In 1995, Kassirer (20) analyzed manuscripts submitted to the New England Journal of Medicine, and found the proportion coming from the United States declined by 30.6% over the preceding ten years. Scientific quality did not differ for manuscripts submitted from within or outside the United States. Like most commentators, Kassirer attributed the decrease in submissions to the decreased support for clinical research in this country. In the New England analysis of 1995, half of submissions were still originating within the United States as compared with less than a third of submissions to AJRCCM in 2003. The most exciting message from the data on submissions is the broad international base of the Journal. Globalization has taken on negative connotations, and is seen by many in the developing world as simply a later stage in the exploitation of the third world by the rest. The challenge for medical societies is to use globalizing systems to bring advances in medical science to patients in disadvantaged parts of the world. For two years, content of AJRCCM has been available free of charge to readers with Internet access in developing countries. Medical history tells of a journey of medical preeminence, moving from country to country. But national borders have become blurred in the current global era, and instant communication systems now unite researchers and clinicians, like never before, in the fight against a common and ever-present enemy: disease. FOOTNOTES This editorial has an online supplement, which is accessible from this issue's table of contents online at www.atsjournals.org Conflict of Interest Statement: M.J.T. is editor of AJRCCM. He receives a fixed stipend from the American Thoracic Society. He does not receive financial support for research from pharmaceutical, biotechnology, or medical device companies. He does not serve as a consultant to or on the advisory board of any company. He receives royalties for two books on critical care published by McGraw-Hill, Inc. REFERENCES
This article has been cited by other articles:
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
