The birth of a child after 9 months of expectancy and alternating hope and despair is a triumph, a source of an inexpressible joy. Yet, very soon after, the evidence must be faced: life is fragile and uncertain. Tension increases when symptoms of disease appear: jaundice, vomiting or diarrhea. Most of the time, fortunately, hope can be quickly restored.
Now, let us imagine the same situation in a different context. The country of the child's birth is in a state of misery because of an economic embargo, a repressive dictatorship or war. The birth of a child may not bring joy but may be an event that increases the uncertainty of life for the family. Ensuring a supply of water and food completely occupies the family and there is little strength and few resources left to cope with disease in a newborn child. There is no reason to look with confidence to the future. Fear suffocates life. This evocation grips us, at least momentarily, as we read about it. Although we are concerned about the exigencies of life for families in the developing world, we must acknowledge our helplessness, and the evocation of the moment passes.
All of us have an opinion on the political, economic and historical causes of conflicts that cause human misery, but they are for the most part beyond our ability to solve. Sometimes, even war may seem to be fair. In that case, we call it a "right to interfere." Isn't it fair to expel by force a dictator oppressing his people? Isn't it fair to limit the power of a rogue state by isolating it through embargo? But...what about the children trapped in these situations? Everyone agrees that they are innocent victims, but who will commit to taking their side? Who will defend their rights, so regularly affirmed by governments of states and even by the United Nations? Why care about the anxiety of Third World parents if they are not voters in the elections of our more privileged countries?
Not only as pediatricians but also as citizens and parents we must assume some responsibility. As I am presently ending my term as ESPGHAN Editor of the Journal after 5 years of collaboration, I think it is important to examine how our Journal can contribute to liberate children from the fear caused by disease. It is obvious that the Journal actively contributes to improving the diagnosis, treatment and prognosis of digestive diseases. Among the topics most frequently considered in these pages are, in descending order, diarrhea and dehydration, inflammatory bowel disease, celiac disease, abdominal pain and Helicobacter pylori infection. Among liver diseases, hepatitis and cholestasis are well covered. The same is true for the organic and metabolic aspects of nutrition, from studies on human milk and its substitutes to the functions of the digestive organs including the pancreas, and the metabolism of macronutrients and micronutrients. A long forgotten partner, the colonic microflora, has been rediscovered with the use of new genetic molecular tools. Digestive diseases and nutritional functions are well covered from pregnancy to adulthood. The Journal provides original articles, reviews and "news and views" in a field that is involved in the treatment of the most prevalent childhood diseases worldwide.
Through publication of the best and most relevant contributions, our community does participate in the relief of disease in children. However, I see two main limitations to our worldwide impact. First, we are not experts in disease prevention. I can cite an example from my own field of expertise: infectious diarrhea. In the late 1960s, as a resident at the Hopital des Enfants in Tunis, I quickly recognized the close link between malnutrition, diarrhea and mortality risk. Later, in Montreal and Paris, I acquired the basics of pediatrics and gastroenterology. In addition, I studied the biophysics of membranes and started my research on the mechanism by which intestinal water absorption and secretion follow the movements of electrolytes, especially sodium and chloride. The World Health Organization, a United Nations agency, then called me to initiate a global program on diarrheal disease control. Oral rehydration therapy has been a great achievement in that area, but it does not prevent infectious diarrhea. Indeed, diarrhea still accounts for 6% 18% of the mortality of the world's children. The most effective way of preventing infection is to provide ready access to clean water and to the simple means of personal hygiene: soap and proper sewage disposal. This simple example shows that pediatrics and public health are two domains with very different, although complementary, skills. Our Journal adequately covers pediatric disease lacks coverage of issues related to public health.
The second limitation is the narrow distribution of the content of the Journal. Approximately 2,000 copies are mailed every month, but nearly 90% are sent to subscribers in North America and Europe. Such a distribution reflects the fact that North American and European Societies sponsor the Journal and require subscription as part of membership. However, most of the 2.2 billion children in the world live outside Europe and North America. In the past 5 years, several initiatives have been taken to allow for an increased distribution of the Journal to low-income countries at an affordable price:
1. The Journal is now available online at www.jpgn.org. At present there are approximately 9,000 visits per month and 4,500 abstracts are read. But we do not know the geographic distribution of the visitors.
2. The World Health Organization and the world's six biggest medical publishers have launched an initiative called Hinari that enables nearly 100 developing countries to gain access to vital scientific information that they otherwise could not afford. JPGN is one of the available journals.
3. Similarly, the enLink program (www.enlink.org) targets individual doctors rather than institutions, providing access to published nutritional information.
4. In addition, access is available through PubMed, although we lack quantitative information regarding this access.
5. Our publisher is working with the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition develop a means to provide discounted electronic subscriptions for society members in that organization.
Until recently, the two Editors who selected the most appropriate contributions from all over the world determined the content of the Journal. However, an additional complexity has arisen. A United States publisher owns and publishes the Journal, and the American government has recently restricted interaction with specific countries. This situation has the potential to jeopardize the free exchange of knowledge between individuals around the world. We need to design new strategies if we want to insure that JPGN is an instrument of freedom from fear, devoted to the children of the world.