Addressing disparities and challenges in global health from an LMIC perspective.

Researchers from low-income and middle-income countries (LMICs) who have experience of submitting their manuscripts to internationally acclaimed high-impact journals would reverberate unanimously with Richard Horton's Offline piece, published on May 20, on the case for global health.1Horton R Offline: The case for global health.Lancet. 2023; 4011639 Google Scholar Horton's critique highlights crucial issues surrounding power dynamics, resource allocation, and colonial practices in the field of global health.1Horton R Offline: The case for global health.Lancet. 2023; 4011639 Google Scholar While acknowledging the importance of these discussions, we wish to underscore the disparities and challenges faced by LMIC researchers in global health and suggest feasible alternatives to address them. The roots of the term global health can be traced back to the old-fashioned and outdated term tropical medicine. The term tropical medicine emphasised diseases predominantly found in the countries that were ruled by the colonial nations.2Abimbola S On the meaning of global health and the role of global health journals.Int Health. 2018; 10: 63-65Crossref PubMed Scopus (49) Google Scholar From Indian cholera in the 19th century to the more recent SARS-CoV-2, often called the Wuhan virus, western nomenclature has linked diseases with people and nations predominantly from LMICs. The asymmetries in the power dynamics between the high-income countries (HICs) and LMICs lie at the core of the present-day structure of global health. Large concentrations of resources, expertise, universities, and high-impact journals in the HICs have substantially distanced LMICs from having a better visibility and greater impact.3Sayegh H Harden C Khan H et al.Global health education in high-income countries: confronting coloniality and power asymmetry.BMJ Glob Health. 2022; 7e008501 Crossref PubMed Scopus (7) Google Scholar The word decolonisation is quaint in the sense that the researchers in the LMICs have to depend on the initiatives of HICs to get included and recognised. Global health journals’ policy to waive off article processing charges for researchers from low-income countries has an altruistic connotation. However, this creates an issue for the researchers from middle-income and upper-middle-income countries including India, where the article processing charges are decided on a case-by-case basis. “Your manuscript does not fit the scope of the journal” is another humiliating statement that researchers from LMICs have to bear that subtly questions their ability to judge if the contents of their own manuscript were fit for submission to a particular journal or not. The authors have faced both of these issues while submitting manuscripts on endometriosis and snakebite envenomation to high-impact journals that only publish public health articles. Lack of publications in high-impact journals later jeopardises the individual's chances of acquiring funds, grants, and awards. Journals also often have strict requirements regarding study design, statistical analysis, and reporting formats that can be more aligned with HIC research contexts. These requirements can create a perceived hierarchy in which research from LMICs is undervalued or overlooked if it does not meet certain predetermined criteria. Consequently, LMIC researchers can feel pressured to conform to these standards, potentially compromising the contextual relevance and applicability of their work.4Dimitris MC Gittings M King NB How global is global health research? A large-scale analysis of trends in authorship.BMJ Glob Health. 2021; 6e003758 Crossref PubMed Scopus (37) Google Scholar The best global health education courses and universities lie entirely in HICs. This disparity puts a great deal of additional economic pressure on aspiring LMIC researchers. Such barriers perpetuate the culture of grooming future global health professionals who can afford these courses. Under-representation of LMICs in global health leadership roles further skews the dynamic in favour of HICs. Organisations such as The Consortium of Universities for Global Health, which originated in the USA, were established to support global health academic institutions around the world, but it has only 8·7% and 2·7% of member institutions belonging to LMICs and low-income countries, respectively—about 83% of the institutions belong to HICs.3Sayegh H Harden C Khan H et al.Global health education in high-income countries: confronting coloniality and power asymmetry.BMJ Glob Health. 2022; 7e008501 Crossref PubMed Scopus (7) Google Scholar An unexceptionable aspect of global health education is direct exposure to health issues in LMICs and the affecting factors via facilitated field visits. However, such opportunities are replaced by so-called parachute visits whereby researchers from HICs only conduct small research projects by utilising local resources but miss out on potential future collaborations.5Yozwiak NL Happi CT Grant DS et al.Roots, not parachutes: research collaborations combat outbreaks.Cell. 2016; 166: 5-8Summary Full Text Full Text PDF PubMed Scopus (42) Google Scholar The onus of improving the global health situation lies on LMICs as much as it lies on HICs. Decolonisation starts only when the colonised revolt. Providing research opportunities, supporting data even if they go against the established political narrative, increasing research funding, and promoting evidence-based decision making are the first steps of this rebellion. Global funders and philanthropists should be encouraged only when they support the actual LMIC cause and not when they push for their own agenda. Imposition of HIC norms and solutions should be replaced by priority setting based on people's demands and research needs. Respecting local culture, promoting diversity, investing more, and including LMICs to have a greater say in global health can ensure that decolonisation does not just remain a buzzword.6Olufadewa I Adesina M Ayorinde T Global health in low-income and middle-income countries: a framework for action.Lancet Glob Health. 2021; 9: e899-e900Summary Full Text Full Text PDF PubMed Scopus (10) Google Scholar Another aspect that has to be understood in the context of global health publishing is that the term global denotes the scope of the disease and not the geographical location of the researcher. Not just diseases such as COVID-19 or polio, but also issues such as climate change and migrant health, which are shaped by various international and intra-national determinants, come under the umbrella of global health.7Koplan JP Bond TC Merson MH et al.Towards a common definition of global health.Lancet. 2009; 373: 1993-1995Summary Full Text Full Text PDF PubMed Scopus (905) Google Scholar Global health journals are in a unique position whereby they can publish health disparities in local communities (ie, public health) as well as highlight cross-border issues (ie, international health). Journals must provide support to authors from LMICs, such as help with writing and editing their articles at no additional cost. To ensure fair evaluation, the journal editors must undergo training to sensitise them to the needs of LMIC authors.8Sawleshwarkar S Zodpey S Negin J “Public health is global”: examining Indian stakeholders' perspectives on global health education.BMC Public Health. 2020; 201259 Crossref PubMed Scopus (3) Google Scholar Reviewers, often from HICs, who might have little understanding of the specific challenges faced by LMICs, might not adequately account for contextual nuances. The editorial board as well as the panel of reviewers should be inclusive for gender, race, and ethnicity to reduce unfair assessments and biases against certain research topics or methodologies. For inclusion, journals tend to recruit people who are of LMIC origin but have now settled in positions of power in HICs. This practice should be supplemented by researchers belonging to and actively working in LMICs to better understand the contemporary issues and their determinants. Some journals publish research in Spanish, French, Mandarin, and Arabic as well. Initiating research publication in Hindi, which is the third most spoken language globally and is spoken in eight countries,9WorldDataHindi speaking countries.https://www.worlddata.info/languages/hindi.php#:~:text=Hindi%20is%20the%20official%20language,a%20part%20of%20the%20populationDate accessed: May 25, 2023Google Scholar can boost research activities in these regions. Critical evaluation is not synonymous with cancel culture. Global health has indeed contributed substantially to reducing mortality in LMICs by way of improved vaccination, pharmaceutical supplies, and funding. After a debate that has lasted for many years, it is now time for the well intentioned global health agencies to hand over meaningful roles to emerging leaders from LMICs and squash tokenism.10Guinto R #DecolonizeGlobalHealth: rewriting the narrative of global health.https://www.internationalhealthpolicies.org/blogs/decolonizeglobalhealth-rewriting-the-narrative-of-global-health/Date: Feb 11, 2019Date accessed: May 25, 2023Google Scholar Public, international, global, and planetary health are relevant research movements as long as they stand on the foundation of justice, inclusion, and sustainability. Managing global health initiatives through equitable policies, programmes, and educational discourses can go a long way in achieving universal health coverage in LMICs. We declare no competing interests. Offline: The case for global healthGlobal health has become fashionably unfashionable. The case against global health is strong. Global health is the invention of a largely white and wealthy elite residing in high-income, English-language speaking countries. The discipline claims to be concerned about the health of people living in low-income and middle-income settings. But the resources—human, infrastructural, and financial—underpinning global health are mostly concentrated in those countries already replete with power and money. Full-Text PDF