A call for reforms in global health publications
Authors: Dhananjaya Sharma
Journal: The Lancet Global Health (2021)

Global health is all about including the excluded, and researchers of low-income and middle-income countries (LMICs) are its major stakeholders.1Sharma D Agrawal V Agarwal P Roadmap for clinical research in resource-constrained settings.Trop Doct. 2020; 51: 1-5PubMed Google Scholar However, these researchers find themselves excluded and marginalised as authors in global health publications; they are also under-represented within editorial workforces and are recipients of unconscious biases that affect editorial decision-making processes at major journals.2Abimbola S Pai M Will global health survive its decolonisation?.Lancet. 2020; 396: 1627-1628Summary Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 3Harris M Marti J Watt H Bhatti Y Macinko J Darzi AW Explicit bias toward high-income-country research: a randomized, blinded, crossover experiment of English clinicians.Health Aff (Millwood). 2017; 36: 1997-2004Crossref PubMed Scopus (33) Google Scholar, 4The Lancet Global HealthGlobal health 2021: who tells the story?.Lancet Glob Health. 2021; 9: e99Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 5Harris M Macinko J Jimenez G Mullachery P Measuring the bias against low-income country research: an Implicit Association Test.Global Health. 2017; 13: 80Crossref PubMed Scopus (29) Google Scholar, 6Cash-Gibson L Rojas-Gualdrón DF Pericàs JM Benach J Inequalities in global health inequalities research: a 50-year bibliometric analysis (1966–2015).PLoS One. 2018; 13e0191901Crossref PubMed Scopus (63) Google Scholar, 7Hedt-Gauthier BL Jeufack HM Neufeld NH et al.Stuck in the middle: a systematic review of authorship in collaborative health research in Africa, 2014–2016.BMJ Glob Health. 2019; 4e001853Crossref PubMed Scopus (57) Google Scholar Major reforms are required for the decolonisation of global health and for the correction of such disproportionate imbalance of power in global health academia. The epistemic Gordian knot of global health publications is the colonial mindset of researchers from LMICs who feel compelled to seek peer approval from a foreign gaze by trying to publish their work in high impact journals as trophy publications.8Abimbola S The foreign gaze: authorship in academic global health.BMJ Glob Health. 2019; 4e002068Crossref PubMed Scopus (92) Google Scholar These researchers continue to submit their best work to elite journals only to face the 10:90 paradox; their submissions receive a nicely worded rejection mentioning how the journal is encumbered with too many submissions, and that space constraints mean that only less than 10% of articles can be published, and although this is not a reflection of the quality of their submission, regretfully, the journal is unable to accept their paper. Disappointed, the authors then submit their manuscript to their national journals, in which they stand a more than 90% chance of getting published and their peers and fellow stakeholders in global health can access their published work more easily. For example, from an Indian perspective, every issue of The Indian Journal of Surgery is accessible online to roughly 27 000 members of the Association of Surgeons of India,9ASIAbout ASI India.https://asiindia.org/about-us/Date accessed: March 18, 2021Google Scholar as is each edition of the Journal of the Indian Medical Association to the Indian Medical Association's approximately 330 000 members.10IMAAbout IMA.https://www.ima-india.org/ima/free-way-page.php?pid=2Date accessed: March 18, 2021Google Scholar It is widely believed that the content of elite, high impact, journals is accessed mainly by academicians working in a small number of prestigious tertiary teaching institutions. We envisage a utopian world in which journals from LMICs will dominate the field of global health publications and authors from LMICs will not be under-represented.2Abimbola S Pai M Will global health survive its decolonisation?.Lancet. 2020; 396: 1627-1628Summary Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 11The Lancet Global HealthClosing the door on parachutes and parasites.Lancet Glob Health. 2018; 6: e593Summary Full Text Full Text PDF PubMed Scopus (38) Google Scholar A plea has already been made for "local people writing about local issues for local audiences";8Abimbola S The foreign gaze: authorship in academic global health.BMJ Glob Health. 2019; 4e002068Crossref PubMed Scopus (92) Google Scholar however, the time has now come for these publications to appear in local journals. Such a reform is possible if ambition and idealism are combined with pragmatism, and if authors from LMICs strengthen their local journals by submitting their best manuscripts. Moreover, the time has come to ask quis custodiet ipsos custodes, or who guards the guards? The elite global health journals have earned their spurs and can justifiably revel in their stratospheric, impact factor-induced, affluenza. However, in today's egalitarian world, they must move beyond their perceived exceptionalism, where they appear to be out of touch with the public mood for accountability. These journals and their editors can do more to assuage the feeling of discrimination and bias among potential authors from LMICs. In the same way that authors cannot objectively judge the quality of their own submissions, the efforts to reduce this perceived bias by journals will have to be judged externally also; by the submitting authors from LMICs. Importantly, to level the playing field and remove the glass ceiling for these authors, the problem of exorbitant open access article processing fees must be addressed. The modest salary structure of researchers from LMICs and their lack of financial institutional support are too well known to bear repetition, making open access article processing fees an insurmountable barrier to publication. Such reforms are the only viable way to leave behind the baggage of colonial ethos, both for global health researchers and journals. The time for sustainable changes is now and these changes will go a long way to restore the power balance in global health and to vindicate these researchers' amour propre, or self respect. Many researchers feel that tags such as LMICs, developing world, and Global South are politically insensitive and carry pejorative overtones. Instead, these countries might prefer to be known as emerging economies.12Agrawal V Yadav SK Agarwal P Sharma D 'EMERGE': construction of a simple quality appraisal tool for rapid review of laparoscopic surgery guidelines during COVID-19 pandemic.Br J Surg. 2020; 107: e518-e519PubMed Google Scholar To paraphrase Desmond Tutu (South African cleric, theologian, and Nobel Peace Laureate 1984), global health researchers from LMICs are no longer comfortable with picking up crumbs of compassion thrown from the table of someone who considers themself their master; they deserve the full menu of rights.13Brainy Quote. Desmond Tutu quotes.https://www.brainyquote.com/authors/desmond-tutu-quotesDate accessed: January 25, 2021Google Scholar Such a clarion call for reforms should not end as an obiter dictum, but should be used to create the rule without exception. I declare no competing interests.