Inequity is an Iniquity: Speaking Up for Aspiring African Researchers
Adelaide M. Lusambili and Constance S. Shumba
The careers of aspiring low- and middle-income country (LMIC) researchers follow a remarkably similar path. Many of these researchers-in-training are able and eager to understand the dynamics of health issues in their own societies. Many want to undertake research to find solutions to the chronic health problems and service deficits that beset their countries. And many possess great insight about the populations of these countries that could add significantly to the current paltry store of global knowledge about health and health care in LMICs. Yet when they submit papers to quality journals, they are frequently rejected. These young researchers soon drop out of the health research field to look for careers in which they anticipate success.
We have previously discussed some of the barriers facing LMIC researchers, such as gender disparities, language barriers, lack of funding, and inadequate research capacities in academic institutions and strategies for redressing these.[1] In this viewpoint we discuss other barriers while focusing specifically on how principles of human rights are compromised in global health research.
Publication fees
A quick scan through high impact journals dealing with global health reveals a dearth of articles written by researchers from LMICs. Open access journals, even when offering a 50% discount on publication fees, are prohibitively expensive for LMIC authors. Much time is spent asking for discounts.
Take Amy, an intelligent student with a promising research career, who was awarded a small health system research grant to conduct an evaluation in a Kenyan hospital. Her research was of high quality and had the potential to contribute to local health care policy. To be admitted to her doctoral program, Amy needed to get at least one article published in a high impact journal. Seven months after submission, her paper was finally accepted for open access publication, with fees discounted by 50% discount to US $1200 but she had no financial support to cover this cost. Amy identified an international journal that charged her US $120 to publish her paper within a month. Her PhD program, however, considered this a predatory journal and refused to accept her. She switched from a research career to a programmatic one in the development sector.
The publication fees hurdle faced by young researchers in LMICs contributes to inequities between them and peers from high-income countries (HICs). It limits their contributions to knowledge generation and dissemination, perpetuating the dearth of evidence to guide policy and practice. This in turn contributes to persistent health inequalities among their populations, which is a health rights failing. High impact journal editors pay lip service to the issues of publication fees without appearing to realize the direct and indirect impacts on LMIC researchers and communities. For instance, opportunities for doctoral degrees through publication have increased in the past decade, and even where traditional PhDs are offered, students are expected to write two or more papers in order to graduate. Emerging researchers from LMICs cannot afford these fees, creating the risk of falling prey to predatory journals that do not conduct peer review. This has far reaching implications for their research capacity and career development and leads to the paucity of credible research, creating a vicious cycle.[2]
Doctoral and other training programs that require publication for admission need to be aware of prohibitive publication fees. Journals need to recognize the inequities arising from publication fees and waive or substantially reduce fees for researchers from LMICs. Importantly, academic staff and researchers in educational and research institutions in LMICs must educate students and researchers about predatory journals.
Inequitable research partnerships
In our experience, partnerships between LMIC and HIC researchers rarely treat colleagues from LMICs as equals. These partnerships tend to be extractive, with LMIC researchers included as tokens, their contributions not highly valued, and the benefits of research not equitably shared.[3] The superficial engagement of LMIC researchers is discriminatory, it limits the impact of the findings, fails to improve health in the communities where data was collected, and breeds mistrust and resentment. We have personally witnessed situations in which LMIC researchers’ contributions were dismissed by HIC colleagues with demeaning comments, such as: “They do not know how to write anyway.” As well as being unkind and insulting, such elitist attitudes exclude LMIC researchers from contributing to resulting publications.
Research partners from HICs perpetuate a culture of endless “capacity building”. True mentorship fosters growth and independence but the capacity-building culture solidifies chronic low expectations and keeps LMIC researchers in subordinate positions. We see this as a one-two punch that all but guarantees their failure to acquire the skills needed to initiate and conduct robust independent research. Despite this, funders of LMIC research continue to require capacity building in project proposals.
Truly collaborative international research partnerships are not possible without equality. The quest for fairness, respect, accountability, equal participation, and cooperation should be front and center in these partnerships, supporting emerging LMIC researchers to overcome the very real obstacles they face, and enabling them develop skills by making real contributions to ongoing research and publication. Learning by doing is the best way to ensure these young people will initiate and conduct independent research projects in the future.
Incongruence in research prioritization
Global health research priorities are often externally driven due to the power imbalances between the agencies in HICs and LMICs.[4] Although there have been notable exceptions, often resources are dedicated to research that is not a priority for local researchers, but is required by global initiatives, posing ethical dilemmas. One consequence is that researchers from LMICs will apply opportunistically for the available grant, and not undertake the research that interests them, or that is needed. For instance, there is a plethora of research on infectious diseases, however, it is only recently that research on non-communicable diseases has started to emerge and drive policy and practice among vulnerable populations.[5] It is well documented that there is a dual burden of disease in LMICs and research is needed to identify the key determinants of morbidity and mortality.[6] For instance, there are too few journal articles focusing on cardiovascular disease research even though it accounts for 75% of the LMIC disease burden.[7]
This reflects the same pattern of donor-driven global health initiatives in LMICs. The need for evidence-generation across a range of global health research areas is enormous, but resources are few.[8] Therefore, to promote fairness and equity, prioritizing the research focus should be a participatory exercise between LMIC and HIC researchers, reflecting countries’ burden of disease, health sector strategic plans, and emergent pressing needs.[9] This requires reforms on research funding governance including national research governance committees.[10] Similarly, international funding bodies need governance committees to oversee the alignment of their research funding priorities with those of the targeted countries. The match between funding and local research priorities will also likely improve research uptake and ownership of the evidence generated.[11] Regional and interconnected global committees are needed to monitor the inclusion of human rights in research funding, implementing, and dissemination.
Insight into cultural contexts
Global health researchers from HICs can neglect or be unaware of the different ways that communities view health. Research in these cultural contexts requires a nuanced and reflective approach involving critical reflection of the research teams’ own culture and assumptions.[12] A deep insight and respect of local knowledge systems is needed to interpret overall findings.
Any lack of meaningful engagement with local indigenous systems and researchers in the research design means that marginalized populations are not involved in the research process and therefore lack ownership of the results. Such results may not reflect the complex interplay of collective values, assumptions, and practices of the local communities, determinants of inequity, nor uncover the factors that promote health resilience. These findings may not respect nor represent the social and cultural heritage of communities. The concept of health as a human right requires an understanding of the determinants that perpetuate vulnerability in the cultural context.[13] A lack of depth and insight about cultural context does not produce meaningful research results and may only serve to fuel discrimination and ineffective strategies. All people have value systems which intersect with structural and other societal factors to influence health and health outcomes, and these must be acknowledged in research.[14] To promote fairness in health, the notion of ‘health as culture’ must be embraced.
Conclusions
A rights-based approach to equitable global health research is needed to create lasting impact and to confront global health inequalities. Emerging LMIC researchers are needed to generate evidence to redress the imbalances. Researchers, academics, and funders need to be aware of the barriers faced by LMIC researchers. Discriminatory attitudes and practices that are inherent within global health research must be challenged at all levels. Integrating issues highlighted in global health research ethics may be key to building transparency and trust. In an increasingly interconnected and interdependent world, it is clear that the benefits of evidence generation transcend national boundaries and should be woven into the research fabric in a manner that promotes fairness, equity, and human rights. Intentional strategies to support emerging researchers in LMICs are crucial to generate the evidence needed to fulfill the right to health, especially in marginalized populations.
Adelaide M. Lusambili, PhD, is a Social Behavioral Health Research Scientist trained in the US and has conducted research and mentored students in the UK and Kenya. She is a faculty member at the Department of Population Health, Medical College, Aga Khan University, Kenya.
Constance S. Shumba, PhD, is a global health practitioner and researcher trained in the UK who has worked in various parts of sub-Saharan Africa and Asia. She is a faculty member at the School of Nursing and Midwifery, Aga Khan University, Kenya.
References
[1] C. S. Shumba and A. M. Lusambili, “Not enough traction: Barriers that aspiring researchers from low- and middle-income countries face in global health research”. Journal of Global Health Economics and Policy. 2021;1. doi:10.52872/002
[2] D. Vidyasagar, “Global notes: the 10/90 gap disparities in global health research” (2006). Journal of Perinatology 26, pp. 55–56. Available at: https://doi.org/10.1038/sj.jp.7211402
[3] Y. Boum Ii, B. F. Burns, M. Siedner, Y. Mburu, E. Bukusi, and J. E. Haberer, Advancing equitable global health research partnerships in Africa BMJ Global Health 2018;3:e000868; Gautier L, Sieleunou I, Kalolo A. Deconstructing the notion of “global health research partnerships” across Northern and African contexts. BMC Medical Ethics 19, 49 (2018). https://doi.org/10.1186/s12910-018-0280-7
[4] D. Sridhar, Who sets the global health research agenda? The challenge of multi-bi financing. PLoS Med. 2012;9(9):e1001312. doi: 10.1371/journal.pmed.1001312.
[5] D.M. Conalogue, S. Kinn, S., J.A. Mulligan and M. McNeil, International consultation on long-term global health research priorities, research capacity and research uptake in developing countries. Health Research Policy and Systems 15, 24 (2017). https://doi.org/10.1186/s12961-017-0181-0
[6] A. Boutayeb, The Burden of Communicable and Non-Communicable Diseases in Developing Countries. Handbook of Disease Burdens and Quality of Life Measures. 2010;531-546. doi:10.1007/978-0-387-78665-0_32
[7] S. Mendis, D. Yach, R. Bengoa, D. Narvaez, and X. Zhang, Research gap in cardiovascular disease in developing countries. Lancet. 2003;361(9376):2246–7
[8] Shumba (2021, See note 1)
[9] R. Labonte and J. Spiegel, Setting global health research priorities. BMJ (Clinical research ed.), 2003, 326(7392), 722–723. https://doi.org/10.1136/bmj.326.7392.722
[10] D. Sridhar, Who sets the global health research agenda? The challenge of multi-bi financing. PLoS Med. 2012;9(9):e1001312. doi: 10.1371/journal.pmed.1001312.
[11] I. Rudan, Global health research priorities: mobilizing the developing world. Public Health. 2012 Mar;126(3):237-240. doi: 10.1016/j.puhe.2011.12.001.
[12] C. Mews, S. Schuster, C. Vajda, H. Lindtner-Rudolph, L. E. Schmidt, S. Bösner, L. Güzelsoy, F. Kressing, H. Hallal, T. Peters, M. Gestmann, L. Hempel, T. Grützmann, E. Sievers and M. Knipper, Cultural Competence and Global Health: Perspectives for Medical Education – Position paper of the GMA Committee on Cultural Competence and Global Health. GMS journal for medical education, 35(3), Doc28. https://doi.org/10.3205/zma001174
[13]Ibid.
[14] A.D. Napier, C. Ancarno, B. Butler, J. Calabrese, A. Chater, H. Chatterjee, F. Guesnet, R. Horne, S. Jacyna, S. Jadhav, A. Macdonald, U. Neuendorf, A. Parkhurst, R. Reynolds, G. Scambler, S. Shamdasani, S. Z. Smith, J. Stougaard-Nielsen, L. Thomson, N. Tyler, A. M. Volkmann, T. Walker, J. Watson, A. C. Williams, C. Willott, J. Wilson, K. Woolf, Culture and health. Lancet. 2014 Nov 1;384(9954):1607-39. doi: 10.1016/S0140-6736(14)61603-2.