The Ethical Crisis in Global Health Research Authorship
Imagine a team of international researchers who have spent years studying a tropical disease in a rural community. Their fieldwork is arduous, their findings groundbreaking, and their potential impact immense. The resulting paper appears in a prestigious international journal, but the lead scientist from a high-income country is listed as first author, while the local researchers who designed the community engagement strategy, conducted interviews in local languages, and provided crucial cultural context appear deep in the author list—or worse, are relegated to the acknowledgments section. This scenario represents an ongoing ethical crisis in global health research that undermines the very partnerships it purports to champion.
Recent research reveals that in publications about decolonizing global health itself, a staggering 70% are authored exclusively by individuals from HICs, with only 7.6% featuring exclusively LMIC-affiliated authors 6 .
of decolonizing global health publications have exclusively HIC authors
of decolonizing global health publications have exclusively LMIC authors
of publications feature mixed HIC and LMIC authorship
In academic research, authorship represents far more than credit for work performed—it is the primary currency of career advancement, influencing hiring, promotions, grant funding, and professional recognition. For researchers in LMICs, equitable authorship provides not just individual recognition but also strengthens institutional capacity and shifts the center of knowledge production toward those who best understand local health challenges.
The International Committee of Medical Journal Editors (ICMJE) has established the most widely recognized authorship criteria, requiring that authors make substantial contributions to the conception, analysis, and interpretation of work; draft or critically revise the manuscript; approve the final version; and agree to be accountable for all aspects of the work 1 .
The fundamental problem lies in what bioethicists call epistemic injustice—the systematic devaluing of certain kinds of knowledge and knowers. When local researchers who contribute crucial cultural understanding, community access, and contextual knowledge are not recognized as authors, their ways of knowing are effectively marginalized within the global knowledge economy.
The dominance of English in scientific publishing creates a significant structural barrier for many LMIC researchers. ICMJE criteria require authors to "draft the work or revise it critically for important intellectual content" 1 . For researchers whose first language isn't English, satisfying this criterion becomes exceptionally challenging, effectively excluding them from authorship despite substantial contributions to research design, data collection, or analysis.
Beyond basic inclusion, authorship order communicates relative contribution, with first and last positions typically carrying the most prestige. Current guidance provides little direction on determining author order, leaving a vacuum where power imbalances often dictate outcomes.
In global health partnerships, HIC researchers frequently occupy the most prominent first and last author positions, while LMIC researchers are relegated to middle positions regardless of their actual contributions 1 .
The "Matthew effect" in science—where recognition tends to accumulate disproportionately to already-established researchers—plays out starkly in global health publishing. Well-known researchers from prestigious HIC institutions may be added as authors primarily to enhance the credibility of manuscripts, a practice known as gift authorship 1 .
Meanwhile, editorial bias may favor submissions from prominent HIC researchers, creating a perverse incentive for their inclusion as authors.
Diverse cultural practices and expectations regarding authorship can create conflict in international collaborations. More collectivist cultures might emphasize group recognition over individual credit, while Western academic systems prioritize individual achievement through precise authorship attribution.
These cultural differences play out within broader power imbalances rooted in historical inequities and colonial legacies. HIC researchers often control research funding, determining budgets, priorities, and ultimately, authorship decisions 3 .
A revealing 2023 cross-sectional analysis examined authorship patterns in publications about decolonizing global health and global health partnerships 6 . Researchers systematically searched multiple databases (Medline, CAB Global Health, EMBASE, CINAHL, and Web of Science) from their inception through November 2022.
They identified 197 relevant publications with 691 total authors. Each author's institutional affiliation was categorized by country income level (HIC or LMIC) using World Bank classifications.
The findings revealed a striking paradox: the literature discussing decolonization of global health is itself dominated by voices from high-income countries 6 .
| Journal | Headquarters Country | Total Editorial Staff | LMIC-affiliated Staff (%) |
|---|---|---|---|
| Clinical Epidemiology and Global Health | India | 37 | 75.7% |
| Frontiers in Global Women's Health | Switzerland | 414 | 41.3% |
| BMC Public Health | UK | 609 | 25.3% |
| BMJ Global Health | UK | 40 | 27.5% |
| Annals of Global Health | USA | 52 | 5.8% |
| Emerging Microbes & Infections | USA | 60 | 0.0% |
The study also found that most publications (89.8%) were viewpoint articles, commentaries, or editorials rather than original research, and nearly three-quarters (74.6%) did not report funding sources 6 . This suggests the discourse around decolonization remains largely theoretical rather than driven by empirical research, and operates with limited dedicated resources.
Fortunately, researchers and institutions have developed practical frameworks to guide more ethical authorship practices in global health research. These tools help partners establish clear expectations and navigate power imbalances from the outset of collaborations.
| Tool or Principle | Function | Application Example |
|---|---|---|
| Authorship Agreements | Clearly define roles, expectations, and authorship order before research begins | Teams create a "science prenup" documenting anticipated contributions and resulting authorship |
| ICMJE Criteria with Accommodations | Ensure all contributors meriting authorship can meet criteria | Provide translation support, writing assistance, or extended timelines for LMIC researchers 1 |
| Equity Guidelines | Journal policies requiring local authorship representation | Global health journals adopting standards that LMIC researchers must be included as authors for studies conducted in their countries 2 |
| Transparent Contribution Statements | Detail each author's specific input | Using CRediT taxonomy to specify contributions to conceptualization, methodology, fieldwork, writing, etc. |
| Regular Check-ins | Monitor collaboration dynamics and adjust as needed | Scheduled partnership reviews to ensure tasks and credit distribution remain fair 7 |
The Swiss Commission for Research Partnerships with Developing Countries (KFPE) has outlined 11 principles for equitable transboundary research partnerships that emphasize mutual learning, shared responsibility, and long-term capacity building 5 . These include developing trust, joint project formulation, ensuring mutual benefit, and committing to capacity strengthening.
Practical guidelines for collaborative writing recommend that researchers discuss authorship order early, share expectations clearly, divide tasks explicitly, establish realistic timelines, and conduct regular check-ins to ensure ongoing agreement 7 . These steps may seem basic, but their consistent implementation can prevent many of the conflicts that plague international research partnerships.
Addressing authorship inequity in global health research requires action at multiple levels. Journals must develop and enforce specific authorship guidelines that recognize the structural barriers facing LMIC researchers. Currently, only 17.8% of global health specialty journals include specific language regarding local authorship representation in research conducted in LMICs 2 . This represents a critical opportunity for reform.
Funding agencies can incentivize equity by requiring detailed collaboration plans and authorship agreements as part of grant applications, and supporting budget lines for capacity strengthening and writing support. Research institutions in HICs must confront their own complicity in these inequities and implement training on ethical partnership practices.
Perhaps most importantly, the global health research community must commit to recognizing diverse forms of expertise—not just technical scientific knowledge but also contextual, cultural, and community knowledge that LMIC researchers bring to partnerships. This requires rethinking what constitutes a "substantial intellectual contribution" beyond manuscript drafting.
The movement toward equitable authorship in global health research is fundamentally about justice—recognizing the essential contributions of all knowledge producers regardless of their geographic location or native language. It's also about effectiveness—research designed and implemented through genuinely collaborative partnerships is more likely to be contextually appropriate, ethically sound, and responsive to local health needs.
The path forward requires what some scholars have called "decolonizing global health"—dismantling the colonial legacies that continue to shape knowledge production and credit. This means not only including LMIC researchers as authors but also valuing their intellectual leadership in setting research agendas, interpreting findings, and communicating results.
As global health faces complex challenges from climate change to pandemic preparedness, we need the full range of human knowledge and experience. This begins with ensuring that the names on our research publications reflect the true diversity of those who contributed to creating that knowledge. The future of equitable global health depends not just on who participates in the research, but on who gets to tell the story.
Ensuring fair recognition across geographic boundaries
Valuing all forms of knowledge and expertise
Transparent and fair authorship practices