In Reply: Can Tanzanian Neurosurgeons Access Tanzanian Neurosurgical Literature? A Systematic Review and Survey of Neurosurgical Publications

To the Editor: We thank Roach and Lu1 for their thoughtful commentary on our recent article highlighting difficulties in access to Tanzanian neurosurgical literature and for broadening the discussion to the global neurosurgical publishing landscape. We agree that equitable authorship, access to published literature and available data, and funding and institutional structures that prioritize low- and middle-income country (LMIC) leadership and strengthening of systems are an ethical necessity for improving neurosurgical care worldwide. Collaborations between LMICs and high-income countries (HICs) are not always equitable in practice, despite their idealized intent. Tanzanian neurosurgeons are underrepresented as lead authors in studies conducted within our own country in our study,2 as were Ugandan authors in Roach and Lu's research,3 and as is consistently found in global health research.4 Authorship as a marker of structural power, current and future grant generation, career development, and population health improvement is well-established.3,4 We join existing calls for journals and funders to adopt guidelines to question authorship parity for research conducted in LMICs.4,5 Editors of all neurosurgical journals questioning or refusing to publish articles concerning LMICs with no or minimal LMIC authorship representation seems a simple start. We fully support the proposal for neurosurgical journals to prioritize full article processing charge waivers for LMIC authors in leadership positions, and to move beyond income-based classifications but consider structural disparities, mirroring trends in the Plan S initiative. Our experience in publishing our systematic review2 was of changing information about the waiver, a lack of clarity, multiple confusing communications, and a lack of understanding from the publisher about the importance of open access publishing. After refusal of an article processing charge waiver for LMIC authorship, our study was eventually published open access using a HIC Wolters Kluwer Read and Publish institutional agreement. This incongruity further highlights the inequalities in publishing - authors in HICs can have easy access to institutional agreements which are unavailable to those in LMICs. The existence of institutional Read and Publish type agreements have been driven by funders mandating open-access publishing. Funding bodies requiring open-access publication, equitable authorship, and local dissemination could aid in decolonizing academic publishing and amplifying LMIC research voices. Roach and Lu1 have highlighted our discussion of the limitations of reliance on the Health InterNetwork Access to Research Initiative (HINARI) and similar programs which provide access to biomedical literature from several publishers for institutions in LMICs. In our study, we found that with a HINARI login plus open-access availability, 73% of neurosurgical studies would have been accessible, but that only one Tanzanian neurosurgeon had a HINARI login.2 Contrast this to almost ubiquitous institutional library access in HICs. Although HINARI is intended to bridge access gaps, its utility is constrained by infrastructural challenges, such as the requirement for institutional support in countries where institutions may not have libraries, intranets, or personnel to support the institutional requirements.5 To be truly effective, initiatives such as HINARI must be supplemented by sustained investment in national and institutional research capacity. Although Roach and Lu1 emphasize structural factors, we also believe that mentorship and role models in academic pipelines can perpetuate access and authorship inequities. A lack of research mentorship within LMIC training programs can restrict early-career clinicians from building the necessary skills to lead research. Poor research and publishing practice across and between HICs and LMICs can also perpetuate inequity. We welcome this opportunity to further the discussion beyond Tanzania and challenge the global neurosurgical community to reimagine what ethical publishing and access truly mean. Equity in global neurosurgical care requires equity in access to data, research skills, grants, publishing, and project leadership and ownership. We advocate for policies that treat access to knowledge not as a privilege or gesture of goodwill but as a right and prerequisite for neurosurgical equity.