Medical Journals and Authorship in Low-income Countries

The low scholarly output from low-income nations has attracted a considerable amount of international attention in the last 5 years. The visibility of articles published by authors from low-income nations, demonstrated by citations by other authors, is also limited. In a global world, few publications and limited involvement in the global debate means limited input toward the solution of global and national problems (1), especially if the expected standard is that policy decisions should be based on best evidence, especially published, scrutinized information in journal articles.

Although a large part of Africa is having severe limitations in the overall economic development, especially in research infrastructure, Africans have demonstrated an enormous amount of achievement and resilience against all odds – from a change from autocracy to democracy in many countries, the rapid and decisive actions when faced with enormous political challenges and the successful succession of national governments to the establishment of medical schools, ie, in Botswana, laying of a foundation to a proposed school of public health in Malawi, and enabling easier access to antiretroviral therapy for the treatment of AIDS.

Richards and Tumwine (2) have suggested that “difficult circumstances and scant resources fuel innovation, and strong inspirational leadership achieves a lot.” Perhaps no continent in the world can be described as experiencing difficult circumstances as Africa, however whether these difficult circumstances and scant resources have “fuelled innovation” will be interesting to explore. Several reasons have been suggested for the low scholarly output for most of the low income nations. These include limited technical competency in scientific writing, which is compounded by English not being the primary language; lack of health research which would give priority toward research from low-income geographical settings; high teaching burden which does not allow time for research and writing; and biases against low-income countries’ authors by journals editors, editorial boards, and publishers from high-income countries. There is also a lack of funding from international funding agencies, which are largely from the developed nations. Many journals from low-income nations are not indexed in MEDLINE and other global databases, which is both a consequence and a cause of the limited visibility of journals from low income countries (3-7). Publications in languages other than English face particular difficulties in attracting global readers and authors (8). A journal which chooses not to be indexed or fails to be indexed because it does not meet the rigorous, sometimes biased criteria for indexing, will not get high quality manuscripts from authors and it is not going to be cited.

Each specific cause of a problem may necessitate a different solution or approach. For instance, the limited visibility of low-income journals and technical limitations in scientific writing were in part the motivation for the African Journals Strengthening Partnership Project, funded by the National Institutes of Health with technical support from the Council of Science Editors, to launch the initiative for strengthening of African journals. This initiative, under the able leadership of African trend-setters James Tumwine (Uganda), Siaka Sidibe (Mali), David Ofori-Adjei (Ghana) (9), and Muzamose Gondwe (Malawi) has achieved what has never been achieved before. The journal partnership project brought together five journals from the mainstream science (BMJ, JAMA, Environmental Health Perspectives, The Lancet, and The American Journal of Public Health) and four African journals, ie, African Health Sciences, Ghana Medical Journal, Malawi Medical Journal, and Male Medicale. Established in 2003, this partnership had the overall aim of enhancing “the quality and credibility of the African journals and thereby attract high-level research.” The planned activities included providing training for editors and authors in improving sustainability and publishing regularity, improving the peer-review process by recruiting experienced reviewers willing to mentor new reviewers, and offering local researchers guidance in preparing research papers for publication. Ideas for improving the credibility of the African journals included having respected scientists from different countries to serve on the journals’ editorial boards, earning inclusion in major indexing databases such as the MEDLINE, and exploring ways to share the journal’s content, for example, by co-publishing peer-reviewed research articles of high importance to the people in the region (4). African Health Sciences and Mali Medicale are indexed on MEDLINE and Ghana Medical Journal is indexed on PUBMED, while Malawi Medical Journal is yet to be indexed.

The previously reported reasons contributing to limited scholarship output from low-income nations are fully valid, however the debate has neglected other worthwhile reasons for such a situation. The first of the many problems that researchers (and authors) face is limited local or national funding for research. In many countries, there are no national agencies that are responsible for funding research. African researchers in many cases obtain funding exclusively from external sources, such as United States or European funding agencies, since African governments often claim that their small health budget cannot be sliced down further to accommodate research. In an environment where research is perceived as a luxury and often just a means for career advancement for researchers and professors, the researcher looks northward for funding opportunities. While this may not be a bad thing in its own right, northern funding agencies are motivated to solve global or at least regional problems rather than national challenges. Furthermore, the north-south collaboration that is often emphasized by funding agencies and researchers themselves, is sometimes a collaboration between partners with unequal power. Insisting that a “southern” researcher be a co-principal investigator does not always solve the power imbalances, as the “southern” researcher sometimes performs that duty only formally. Real co-principal investigators have executive authority to decide when the manuscript would be sent to a journal, which is not always the case in such collaborations. Also, the co-principal investigators are sometimes not listed as the first authors or the most senior authors (depending on the journal conventions as to who is the senior author). My suggestion is that we may need to ensure that African governments are involved in funding research with an equivalent amount of money to the amount that is allocated to Presidential Palaces. Also, we need to ensure that African co- principal investigators are real and not just formal principal investigators. However, African researchers have to earn these responsibilities and not just be given it. Having northern partners draft almost 100% of the research proposal and then inviting African researchers to be co-principal investigators may be demeaning.

I conclude with Prof. Tumwine’s statement from the Health Policy and Planning (3): “If my salary could pay my children’s fees, help with my extended family obligations, house rent, electricity and all, I would not have to do other work and could concentrate on the job I have been trained to do: teaching, communication, advocacy, much needed research and patient care. What helps me on my job and my life is sense and faith in God, social justice, and in the potential power of my patients and communities to find solutions to their problems and challenges.”