The role of journals and journal editors in advancing global health research equity

Global health in all its facets – from funding, implementation, education and research – is facing increasing calls to face its colonial history [1-3]. Inequitable practices in global health research have been challenged and brought to light. The field continues to be dominated by researchers from institutions in high-income countries (HIC) to the exclusion of researchers in low- and middle-income countries (LMIC) or communities where the research is conducted. Disparities in first/senior (last) authorship positions have been used to highlight these power imbalances [4-6]. For example, in their systematic review of authorship in global health research in Africa, Hedt-Gautheir et al. found that only about half of research output had a first author from the country of the paper's focus [4]. In the 'publish or perish' paradigm of academic research, authorship presents opportunities for career progression affecting tenure, hiring, award and grant decisions [7]. Academic journals and journal editors hold significant power in the research process as they ultimately make research publication decisions. Given the power they hold in the research process, journals and journal editors have a responsibility to ensure that the research they choose to publish and by extension research of value, does not perpetuate unjust and exploitative research practices. Just like most medical journals require institutional review boards for research involving human subjects [8], journals also ought to develop and adopt guidelines and standards that prevent unethical research practices like 'parachute or helicopter' research in LMICs. In the current issue of Anaesthesia, Morton et al. present a consensus statement on measures to promote equitable authorship in the publication of research from international partnerships in global health [9]. The authors used a robust process, including three workshops and four narrative reviews, followed by an external review by experts in global health and journal editors who were independent of the core writing team. The impetus for a consensus statement was the exclusionary practice of doing research in a host country and publishing the results without adequate recognition of local researchers – a practice that has now come to be termed as 'parachute (or helicopter)' research. Among the recommendations in these guidelines, the reflexivity statements are perhaps the most salient. The statements are to be used by journal editors in decision-making to promote equitable research partnerships in global health research. We welcome this recommendation for several reasons. First, reflexivity statements may prompt those engaging in international global health research partnerships to consider several aspects of equitable research partnership beyond authorship. While authorship has recently been used to gauge equity in research partnerships, the metric is limited as it often does not provide a full picture of the quality of research partnerships and increases the risk of gift authorships [7]. Equitable global health partnerships involving LMIC and HIC partners ought to start from research conceptualisation to ensure that the proposed research accounts for the research priorities and opinions of LMIC researchers who are more cognisant of the local context and needs. Unfortunately, this is often not the case. Researchers from LMICs where the global health research is conducted are often brought into the picture only when the research has been conceptualised and funding sought or obtained. A requirement of prospective authors for reflexivity statements will encourage them to consider other aspects of equitable research partnership from research conception, co-development, authorship and dissemination. As with authorship criteria from the International Committee of Medical Journal Editors, the proposed reflexivity statements may only be considered by authors retrospectively on research completion. We believe, however, that its true utility is revealed when researchers reflect on these statements before research conception and throughout the entire partnership. In other words, the proposed reflexivity statements should be used to guide conception and implementation of research projects prospectively rather than audit collaboration integrity retrospectively. Research institutions in HICs and LMICs should consider adapting and using these reflexivity guidelines during research conception to ensure that all aspects of equitable research partnership are addressed when approaching international research partnerships. To ensure that reflexivity statements are considered before research conception, similar statements could be adapted and required as part of the ethical clearance process by institutional review boards in both LMICs and HICs. Second, research authorship equity requires capacity building with a view to shifting the base of skills and knowledge from 'foreign expertise' to local and indigenous knowledge holders. The emphasis on research capacity building in the reflexivity statements is welcome and we believe that research capacity building for partner institutions in LMICs must become an integral part of every major global health research project. Without such intentional localised research capacity building, it is likely that power asymmetries in global health research will persist. Research output through publications alone cannot be the sole indicator of successful equitable research partnerships. The training of local graduate students, for example, should also be considered as an important objective in global health research partnerships between HICs and LMICs. Just as many global health funding proposals by HIC institutions now include costs for article processing charges for open access journal publications and the training for graduate students at HIC institutions, we recommend that global health funding opportunities also include costs for research capacity building for LMIC partners. If used during research conception, the proposed reflexivity statements should allow international research partnerships to consider capacity building as an integral part of global health research and identify pragmatic solutions. The recommendations are not only pertinent to parachute research, but also 'helipad research', that is research conducted at institutions that are domiciled in LMICs, but owned, led and funded by governments and/or non-profit organisations in HICs. Many of these institutions have a colonial legacy and continue to exert significant influence in the global health research ecosystem through power dynamics embedded within these institutions [10, 11]. In Africa, research capacity can be achieved in part by collaborating with and strengthening existing institutions on the continent such as those listed in Table 1 – all of which are involved in postgraduate education in the health sciences across sub-Saharan Africa. Targeted development assistance directed at these institutions and others, especially in the areas of curriculum design, scientific writing, statistical analysis and leadership, will go a long way to address historic inequities in authorship. Paid internships should be incorporated to provide training positions for candidates selected by these LMIC colleges in HIC institutions. Virtual mentoring and online coaching are also additional educational arrangements that may not be as capital intensive. In the framing of global health decolonisation, institutions in LMICs can sometimes be portrayed as helpless and powerless. However, we believe that this is not the case. Institutions in LMICs technically hold significant power within global health research [12]. Though these institutions may not have the degree of funding available to HIC institutions, they understand the local context including historical, sociological, political and anthropological determinants of health a lot better than HIC institutions. Therefore, they can regulate the kinds of research partnership they get involved in and prevent exploitative research practices. We believe that research institutions in LMICs must work together to develop strategies to prevent exploitative global health research partnerships from continuing. Addressing the factors that drive research authorship inequity requires the involvement of all major stakeholders. The conspicuous absence of experts from the USA and other major HIC funders in the composition of this expert group is notable because, as pointed out by the authors and others, first or senior authorship for LMIC researchers is less likely in research conducted in partnership with or funded by US-based institutions which is the largest funder of global health [4, 13, 14]. Additionally, the purposeful selection of members of the expert panel resulted in selection of members from English-speaking countries in the African Union (AU). This may affect the validity of the consensus statements and recommendations as the experiences of non-English-speaking experts may be different. Perhaps a more diverse group, including countries that were not colonised by Britain, and who speak and write in a language other than English (French, Portuguese and Spanish) would have helped to enhance the validity of these recommendations. This is important because barriers to authorship and publication for an LMIC expert from Senegal, Angola or Mexico may not be the same as those from Ghana, India or Kenya. The hegemony of the English language in science at the exclusion of other languages is important to address [15, 16]. In a recent LMIC study, English grammar was a major barrier to scientific output, and accounted for 43.5% of article rejections, while translation and editing services accounted for between one-quarter and one-half of the monthly salary among Colombian doctoral students [17]. In Africa, only 24 of the 55 countries in the African Union (AU) are English speaking [18]. Even in countries where English is an official language, scientific writing is not a core curriculum at training institutions. It is, therefore, important that journals, reviewers and editors are cognisant of these linguistic limitations and address them by being intentional about creating multilinguistic alternatives and diversifying their editorial boards. Reviewer panels should include non-English speakers with diverse backgrounds by partnering with the institutions within Africa to identify, support, train and mentor these LMIC experts, who possess vital knowledge of the social and cultural context of their homelands and are therefore a potential asset to address health system issues if appropriately engaged. Breaking down linguistic barriers alone will not be sufficient to promote equity, but it will significantly enhance it. The African Union has Arabic, English, French, Portuguese, Spanish and Kiswahili as official languages, representing the diversity of languages spoken in the African Union and this is also reflected in many institutions on the continent. For example, the West African Colleges of Physicians and Surgeons are multilingual Colleges and have specialists who are proficient in one or more of the official languages in the African Union. These experts are a potential pool of reviewers that international global health journals can recruit to diversify their reviewer panel. Furthermore, journals can partner with the respective journals of these institutions that have local reviewers and editorial boards to review submissions, and to also share knowledge and technology that promotes the quality of science published in both HIC and LMIC journals in a mutually beneficial way. HIC journals can also offer translation services and waive editing fees for non-native English-speaking LMIC investigators submitting articles of scientific merit through programs such as the Author Assist Programme by the African Journal of Emergency Medicine (AfJEM) which helps researchers improve the quality of manuscripts before the submission to AfJEM for peer review [19]. In conclusion, the recommendations by Morton et al. represent an important push for advancement in the reduction of authorship inequities in global health research partnerships. We encourage journals and journal editors to build on these recommendations, particularly the adoption of reflexivity statements for global health collaborations. Reflexivity statements could serve as a powerful tool for building equitable global health research partnerships if they are used by both LMIC and HIC institutions during research conception and project implementation. They should not only be considered during manuscript submission. The guidelines by Morton et al. establish a foundation on which other efforts in the global health research ecosystem can be launched to achieve more equitable partnerships in research. No competing interests declared.