Discussion

This bibliometric analysis is the first to assess authorship representation within the relatively new field of GEM. Our study highlights disparities in authorship representation between HIC and LMIC authors, similar to previous observations seen in bibliometric studies of other global health fields.2 3 5 Authors affiliated with HICs were the most represented, while those affiliated with LMICs, particularly LICs, were the least represented, despite all articles reporting work conducted in LMICs. Additionally, the proportion of studies with exclusively local authors (those affiliated with the study country only), which may be interpreted as an indirect measure of the amount of locally owned research, decreased with lower study country income levels. More troubling findings from this analysis were that more than 1 in 10 articles had no local author representation, and more than half of multicountry studies did not include at least one local author from each study country.

Our findings that HIC authors were the most represented in all key authorship positions (first, second and last authors) are consistent with recent publications examining authorship in other global health fields. In a 2019 study evaluating collaborative health research conducted in sub-Saharan African countries, inclusion of collaborators from the Global North (USA, Canada, Europe) was associated with a decreased percentage of first author positions belonging to Global South institutions.2 Similarly, a recent study in the global surgery field found that most authors were men, affiliated only with HICs, and held senior positions.5 In our analysis, LMIC-affiliated authors were most commonly in middle authorship positions; these positions have been considered less valuable or tokenistic as a means of improving the perceived diversity of the authorship group.2 Our findings contribute to the growing evidence base, which demonstrates pervasive inequity in research relationships and how authors affiliated with LMIC institutions are represented across subspecialties of global health, including newer fields such as GEM.

Notably, our analysis found evidence that the power dynamics that underlie authorship inequity may be most influenced by financial factors in several respects. First, we found that higher study country income levels were associated with greater odds of having local first or last authors, and that local first and last authors were least common in studies conducted in LICs. The differences in local authorship were also particularly striking between studies conducted in upper MICs versus in LICs, with only 8.9% of studies in LICs having exclusively local authors versus 49.4% of upper MIC studies. Additionally, studies that did not include any local authors were most common in studies conducted in LICs compared with those conducted in lower MICs and upper MICs. Studies of this nature have been referred to in the literature as ‘parasitic’ to reflect the major power imbalances and dispossession of data ownership from LMIC study participants and researchers by HIC researchers and are a highly concerning finding.4 In response, some journals have opted to not publish articles that do not include an author from the study country, although these requirements are not yet the norm.20 21 Second, in regression analysis, we found that having any funding from the study country was associated with greater odds of local first or last authorship. Prior research in the global maternal health literature has similarly shown that local lead authorship was more common among articles that reported funding from national NGOs or governments compared with those that reported funding from HIC–LMIC collaborative agencies (ie, bilateral and HIC research agencies), while HIC authors dominated articles with funding reported from the US Agency for International Development, the US National Institutes of Health, and the European Union.21 Local funders, such as national research agencies, NGOs and academic institutions, may also be more likely to invest in the career development and research capacity of domestic rather than foreign researchers, contributing to greater local research leadership and ownership, and concomitant lead authorship positions. These findings suggest that local control of financial resources for research are key drivers in authorship decision-making.

The fact that the global health field remains heavily dominated by HIC funders and much of global health funding is granted to researchers from HICs has recently been called to greater attention.22 23 This power imbalance is illustrated by HIC institutions and researchers often setting the agenda and making funding allocation decisions without consideration for LMIC partner priorities.8 24–26 This often perpetuates LMIC researcher dependence on HIC counterparts for research opportunities and funding.24 As GEM projects are often funded by HIC institutions, efforts to decolonise the GEM field and restore power to local researchers with respect to funding decisions and priority-setting are needed to increase equity. Increasing the funding opportunities specifically for LMICs researchers may play a large role in recognising the expertise of LMIC researchers and allowing professional growth beyond the role of data collector and collaborator into one of setting the agenda, designing the research and disseminating results.24 27–29 We also found that over-representation of HIC authors was more pronounced in multicounty studies, with less than half of the studies including at least one author from each study country. Potential explanations for this finding are the amount of funding needed for larger multicountry studies may be more likely to come from large HIC funding sources, the more complex and potentially hierarchical power dynamics involved in large international collaborations or that the resources needed for larger studies such as research administration and support tend to be in HICs.

Our regression analysis also sheds light on which factors have the greatest influence on authorship decisions. Our finding that larger authorship groups were associated with lower odds of local first and last authorship may indicate that equitable authorship discussions may be more challenging in larger collaborative groups, or simply that larger research groups require greater funding, which are often obtained from HIC sources. Additionally, prior research on authorship ‘parasitism’ in research conducted in sub-Saharan Africa has found that studies without any local authorship were less likely among articles with >10 authors.3 Together, these findings may be explained by larger authorship groups being more likely to include LMIC authors in token middle authorship positions to ensure formal or informal expectations for local author inclusion are met. Additionally, certain subfields within GEM, such as disaster and humanitarian response appear to have even greater inequities; further research is needed to understand how research within crisis settings may differ from general GEM research, and how long-standing colonial structures in the humanitarian sector may influence authorship decisions.30

Existing guidelines which aim to standardise criteria for academic authorship have been established by the International Committee of Medical Journal Editors (ICMJE) and reflect the degree of author contributions to research conceptualisation, analysis and study ownership.11 More recent efforts aim to repurpose ICMJE guidelines in a way that promotes equitable authorship, particularly within international collaborations.31 32 This includes placing a critical eye to where authorship guidelines have been unable to capture the value of a collaborators lived expert knowledge, which often plays a key role in the knowledge coproduction for publication, yet these voices are not often named as a coauthor.32 Additionally, calls for journal editors to require authorship reflexivity statements in international collaborative research are a step towards more equitable authorship practices.8 Such efforts highlight the need for technical sharing in areas that commonly exclude or minimise the contributions of LMIC authors per ICMJE guidelines—particularly in data analysis and manuscript preparation where local authors are often not writing in their native language for publication.31 However, the impact of these efforts has yet to be determined.

The causes behind the relative paucity of LMIC authorship representation seen in this study are likely multifactorial. First, EM as a formal medical specialty is one of the newest disciplines in medicine, being recognised as a specialty in the USA and Canada in 1979, the UK and Australia in 1993.33–35 LMICs have had shorter experience with the formalised specialty with the Philippines being one of the first to recognise the specialty in 1991, and South Africa the first in sub-Saharan Africa to have an EM specialty training programme since 2003.36 However, the specialty does not exist in many countries today, particularly in lower income countries. Given EM’s roots in HICs, this historical background of the specialty can explain some of the discrepancies in authorship in our analysis.33 37 Academics from HICs have often been supporters for the introduction of EM as a specialty in other countries, leading to previously established mentor/mentee relationships. Research relationships likely mirror the clinical teaching relationship (ie, senior authors on papers often may be the faculty that taught EM during early years of EM specialty development).38–40 However, this historical mentor/mentee relationship can hinder continued growth of LMIC colleagues if they are not allowed to move beyond the role of local partner into higher academic, research and leadership roles.41 Additionally, the resources available to conduct research, such as organised research governing bodies and ethical review boards, are often lacking, coupled with reduced or prohibitively expensive research training opportunities for LMIC scholars.42 ,43 44 This is further compounded by the shortage of human resource for health in LMICs, usually resulting in early career specialists in LMICs having a multitude of competing priorities such as heavy clinical workloads, internal quality improvement projects and the education of trainees.45 The movement of qualified medical personnel including researchers from LMICs to HICs or ‘brain drain’ exacerbates this situation.46 While reasons for this migration include better working conditions and increased income opportunities, studies have estimated that LMICs suffer an approximately US$16 billion loss each year as a result of physician brain drain.46

Building technical exchanges and development of research in LMICs have been made a priority by the Global Forum for Health Research to help correct the 10/90 gap in health research.47–49 To meet this need, research fellowship and scholarships for LMIC researchers have been developed in recent years, but lack of consistent funding from HIC partners can hinder these initiatives.50 51 Overcoming journal paywalls can also present an additional academic hurdle for LMIC researchers and the dominance of English-language publications, which is often not the mother tongue or primary language of LMIC researchers, creates major challenges together with lack of access to reliable, high-speed internet connections.44 This may result in researchers from LMIC needing to depend on HIC partners in order to increase the chance of publication.

As GEM and other newer subspecialties expand globally, it is critical that assessments of equity occur early and often as these fields develop and mature. Recognition of the extent of authorship inequities is only the first step in the process of creating an equitable field of GEM. However, further evaluation into the root causes of inequitable research partnerships between HIC and LMIC in GEM research is needed to begin to address systemic academic power structures at odds with equity, so that we can implement possible solutions. Increasing multidirectional research fellowship and mentorship programmes that cater to LMIC-based researchers and scholars and reimagining funding sources can reduce some of these disparities. Closing this gap also includes revisiting and further reducing open-access article-processing fees and paywalls for journals publishing studies from LMICs, and investing in research infrastructure such as the development of ethical review boards.52 53 Fianally, inequities in academic engagement and advancement opportunities are not limited to authorship representation alone. The global health research landscape is influenced by its colonial origins and with it has created power dynamics that support HIC researchers without advancing LMIC counterparts.8 25 28 As the specialty of EM spreads and GEM research partnerships continue to develop, the field must work towards equitable research collaborations and authorship parity.