Voices in the wilderness: how exclusionist article processing charge policies of academic journals underscore what is wrong with global health
Authors: Bassey Edem, Esin Nkereuwem, Oghenebrume Wariri
Journal: The Lancet Global Health (2021)

The global health landscape has increasingly come under intense scrutiny in the last two years for diverse reasons, traceable to its colonial and, by extension, Western-dominated structure. From the foreign gaze of global health research, to the poor diversity in the composition of the editorial boards of global health journals, to the tendency of high article processing charges (APCs) of global health journals that exclude the contribution of researchers from low-income countries, these issues have been a subject of public discourse.1Abimbola S The foreign gaze: authorship in academic global health.BMJ Glob Health. 2019; 4e002068Crossref PubMed Scopus (105) Google Scholar, 2Abimbola S Pai M Will global health survive its decolonisation?.Lancet. 2020; 396: 1627-1628Summary Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 3Nafade V Sen P Pai M Global health journals need to address equity, diversity and inclusion.BMJ Glob Health. 2019; 4e002018Crossref PubMed Scopus (23) Google Scholar There is a need for diversity in global health. Who tells the stories counts perhaps as much as what is being said; a concept that might be an essential aspect of the movement to decolonise global health.2Abimbola S Pai M Will global health survive its decolonisation?.Lancet. 2020; 396: 1627-1628Summary Full Text Full Text PDF PubMed Scopus (67) Google Scholar Currently, scholarly articles are mainly published in peer-reviewed journals, and they disseminate the results of experiments or research projects that have been funded through grants that include funds to cover APCs in open access journals. In some cases, manuscripts might be eligible for an APC waiver to encourage scholarly contributions from researchers in low-income countries. However, many researchers continue to face a double jeopardy of not being externally funded by grants and being ineligible for APC waivers to publish their self-funded research. It is therefore not surprising that only 1·3% of annual global research outputs come from Africa, with just three countries (Kenya, Nigeria, and South Africa) accounting for 52% of Africa's output.4Uthman OA Wiysonge CS Ota MO et al.Increasing the value of health research in the WHO African Region beyond 2015–reflecting on the past, celebrating the present and building the future: a bibliometric analysis.BMJ Open. 2015; 5e006340-eCrossref Scopus (71) Google Scholar In this Commentary, we explore the dilemma of such researchers, who we refer to as the voices in the wilderness. In response to The Lancet Global Health's call for articles on what is wrong with global health,5The Lancet Global HealthGlobal health 2021: who tells the story?.Lancet Glob Health. 2021; 9: e99Summary Full Text Full Text PDF PubMed Scopus (21) Google Scholar we reviewed the conditions for an APC waiver or discount in 13 major global health journals. We decided to look at these 13 journals by updating the original list of 12 major global health journals identified by Nafade and colleagues,3Nafade V Sen P Pai M Global health journals need to address equity, diversity and inclusion.BMJ Glob Health. 2019; 4e002018Crossref PubMed Scopus (23) Google Scholar which was based on the subgroup of academic journals that explicitly had 'global health' or 'international health' as part of the journal title. One author (OW) searched the website of each journal and extracted information on the journal's conditions for APC waivers, and this information was crosschecked for accuracy by a second author (EN). We found that three broad conditions were explicitly stated by the 13 journals for authors to qualify for an APC waiver or discount. These conditions include authors' affiliations to an institution from a low-income or middle-income country (LMIC), being a corresponding author from an LMIC, and their availability (or absence thereof) of funding. To capture the range of authorship scenarios, we created eight groups based on a combination of the three major conditions for APC waivers or discounts. The figure shows the conditions for an APC waiver or discount for every journal and the group of authors who qualify or do not qualify. Two (15%) out of the 13 journals explicitly offer full APC waivers for all authorship scenarios. For most journals, when all the authors are from a low-income country (group 1) they qualify for a full waiver, whereas when all the authors are from an LMIC (group 2) they only qualify for an APC discount, irrespective of the availability of funding. Articles that included any author from a high-income country (group 4) do not qualify for any form of APC waiver or discount, and most journals do not offer an APC waiver for articles that included authors from a combination of low-income countries and LMICs (group 3). Four (31%) of the 13 journals explicitly offered an APC waiver if the corresponding author is from a low-income country, and a discount if they are from an LMIC. From the eight different scenarios in our figure, we identify three key implications that these APC policies pose to early career researchers from low-income countries. First, researchers in low-income countries are already faced with many challenges such as scarce funding, scarce governmental and institutional support for science, and poor infrastructure, which substantially hampers their research progress. Having to pay high APCs is seen as exacerbating these existing challenges.6Pai M How prestige journals remain elite, exclusive and exclusionary.https://www.forbes.com/sites/madhukarpai/2020/11/30/how-prestige-journals-remain-elite-exclusive-and-exclusionary/?sh=241e79804d48Date: Nov 30, 2020Date accessed: May 3, 2021Google Scholar Moreover, many of these researchers earn too little from their income or meagre research grants to consider publishing in such top tier open access journals. With some APCs as high as the annual salaries of some scientists in many African countries, these scientists cannot publish and therefore miss out on the visibility needed to compete in the global health research landscape,7Nabyonga-Orem J Asamani JA Nyirenda T Abimbola S Article processing charges are stalling the progress of African researchers: a call for urgent reforms.BMJ Glob Health. 2020; 5e003650Crossref PubMed Scopus (11) Google Scholar which then puts them at a further disadvantage when it comes to competing for research funding, thus resulting in a vicious cycle. Second, the current APC policies hamper the desire for collaboration amongst scientists in LMICs. As early career researchers ourselves, we recognise the need for collaboration with our peers from LMICs. However, even though we are based in a low-income country, we recognise situations when partnering with our peers from LMICs would alter our eligibility for APC waivers and put us in a less favourable position. We acknowledge that we are privileged simply because we are authors living and working in a low-income country as this gives us access to APC waivers in some high impact journals. Nonetheless, we also recognise that these policies hinder our collaboration with peers in LMICs whose voices are not heard simply because of geography. We agree with Abimbola and colleagues8Abimbola S Asthana S Montenegro C et al.Addressing power asymmetries in global health: imperatives in the wake of the COVID-19 pandemic.PLoS Med. 2021; 18e1003604Crossref PubMed Scopus (20) Google Scholar that the crude dichotomies used by these journals to define who gets an APC waiver and who does not, based on country income classifications, might be obscuring more than they reveal. Such policies continue to perpetuate the serious asymmetry of power and privilege, and the global health voices that are heard are not truly representative of the so-called global south. Lastly, these exclusionist APC policies perpetuate the already deeply entrenched imbalance in who tells the story in academic global health. The apparent underrepresentation of authors from low-income countries and LMICs who contribute to articles in mainstream global health journals will continue to tilt the power imbalance, and underscores what is wrong with global health.5The Lancet Global HealthGlobal health 2021: who tells the story?.Lancet Glob Health. 2021; 9: e99Summary Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 9Sumathipala A Siribaddana S Patel V Under-representation of developing countries in the research literature: ethical issues arising from a survey of five leading medical journals.BMC Med Ethics. 2004; 5: E5Crossref PubMed Scopus (130) Google Scholar Even when scientists from low-income countries and LMICs appear in these journals, they are mostly already established researchers who can afford an APC, or if they are early career researchers, they are usually stuck somewhere in the middle of the author list, flanked at both ends by prominent collaborators from high-income countries.10Hedt-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 (71) Google Scholar As these early career researchers from LMICs rarely attain prominent authorship roles, they will continue to miss opportunities to contribute meaningfully to the global health discourse.5The Lancet Global HealthGlobal health 2021: who tells the story?.Lancet Glob Health. 2021; 9: e99Summary Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 11Iyer AR Authorship trends in The Lancet Global Health.Lancet Glob Health. 2018; 6: e142Summary Full Text Full Text PDF PubMed Scopus (39) Google Scholar As early career researchers from a low-income country, we consider ourselves as lucky simply because of our location, a luxury that many of our peers who are doing good quality research in LMICs cannot afford. These voices in the wilderness who make up a large proportion of early career researchers from low-income countries and LMICs will continue to be unheard as they have neither the funding from research grants, the luck of geographical location, nor the prominence to allow their voices to be heard. As expected, the story will always depend on who is telling it. We expect that the global health research landscape should be more equitable and less about luck. But then, what is the way forward to achieve this expectation? We think that addressing the constraints outlined in this Commentary will require a multifaceted approach. Since collaboration remains a crucial aspect of global health, we advocate that journals include an additional eligibility criterion for APC waivers, such as for early career researchers without external funding, to ensure that the dissemination of good quality research is not determined by the ability to pay. Additionally, governments and philanthropists in low-income countries and LMICs must step up funding for global health research, as was done in 2021 by a Nigerian billionaire who announced an annual fund of US$100 million for development priorities, including research.12Rakhetsi A A Nigerian billionaire just announced a $100 million yearly fund for Africa 2021.Available from: https://www.globalcitizen.org/en/content/nigeria-billionaire-abdul-samad-rabiu-fund-africa/#:~:text=Nigerian%20businessman%20and%20philanthropist%20Abdul,to%20help%20boost%20African%20developmentDate: March 26, 2021Date accessed: May 3, 2021Google Scholar This laudable initiative should be encouraged and emulated by other billionaires in Africa. If these issues are not addressed with urgency, the voices of early career researchers from low-income countries and LMICs, like those from a wilderness far away, will be lost. All authors contributed equally to the conceptualisation, writing, and refinement of this Commentary. We declare no competing interests.