Imagine you are facing the following situations. You want to say something in a respected publication about a conflict between the health ministry and private hospitals over reimbursement. You wish to discuss matters that touch local sensitivities, such as mismanagement of health programmes, but you expect blame for showing “dirty laundry” internationally. You publish commentaries about local issues in “high impact” journals but discover that only a few of your local colleagues have read them. You have researched a locally relevant topic that may not interest overseas readers and hope to publish the results locally. What are the appropriate platforms for publishing each of these types of article? You might think that local or regional journals will fulfil the need, but this would be wishful thinking today in many developing countries.
Why can't we upgrade our journals?
Let's take representative examples from my region: the Lebanese Medical Journal (LMJ) and the Eastern Mediterranean Health Journal (EMHJ), which is equivalent to a regional public health journal, may seem to fit the purpose. The LMJ reaches most registered doctors, health professionals, public health and academic institutions, and many healthcare facilities across Lebanon. Numerous health institutions in the region receive the EMHJ. Unfortunately, both journals suffer chronic problems that undermine their usefulness. One is irregular publication: the LMJ has just published its January-March 2003 issue, while the EMHJ's latest issue dates to 2002. With such a backlog any sense of timeliness is lost—and much of the relevance with it. Another problem of these journals is their content. Research and subject reviews dominate, and serious debates and critical reflections on important issues are rare. We desperately need strong local and regional journals, but only international journals get our articles read as we would like. What we actually manage to get published in international journals and its impact locally is a fascinating subject for future reflection.
Who is responsible for the health of our local journals? Public bodies overseeing the journals have the prime responsibility. The LMJ and the EMHJ are backed by powerful, resourceful institutions: the Lebanese Order of Physicians and the World Health Organization's Eastern Mediterranean Regional Office. The current situation is inexcusable, whatever the reasons, and I wonder where the publication of good journals fits in the list of priorities.
Our ministries of health and higher education should support journal publication to stimulate research and promote debate, but don't. Universities pressure their staff—through criteria for promotion—to publish in international rather than local journals. Thus local recognition comes from international exposure rather than appreciation of grounding in local work. Nevertheless, international journals do give a platform for the voices of developing countries. Weak local journals undermine these voices, while European and North American (this is practically what “international” means) journals are strengthened through attracting diverse material and thus readership, sustaining the imbalance.
The health of journals everywhere is an international responsibility. Funders of research, who understandably prefer acknowledgment in international journals, contribute to the imbalance between international and regional journals. The problems of local journals cannot be solved through greater access to journals produced in rich countries. International agencies working with regional and country partners can help to promote local journals. Ultimately, we can't expect change without push from us—local researchers and practitioners. Doctors bear a special responsibility because they continue to dominate the health sector, produce much of the local health research, and have prestige and access to resources. Many local people have rich international expertise in publishing, editing, and reviewing. Why can't we upgrade our journals? Is it the insurmountable institutional factors? Is it because of a lack of vision that we can't see how underdevelopment in health publishing is reproduced or how to change it?
Even when the interests of all stakeholders meet, we may still fail to sustain good journals. We have excellent researchers to make strong editorial boards, but they can't do the job alone. Equally important are competent and accountable management, production, and marketing teams, to address chronic problems in institutional memory and functioning.
Suppose we manage to produce local or regional journals regularly. What would they be about? Would they lead the way, as the BMJ does, by muddying themselves in the dirty waters of social and political realities of health? Or would they confine themselves to the safe terrain of clean research, as more typical international journals do? Most health journals in our region seem to prefer the second approach, leaving little space for critical reflection on health matters as public issues. This should be corrected. Journals are public goods, and so we must have collective oversight and must take on the shared responsibilities of keeping them healthy.