Authorship Equity in National Global Surgery Student Working Groups: A Perspective

Eleven years ago, The Lancet Commission on Global Surgery published the landmark paper “Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development,” which identified 5 billion people worldwide who lack access to safe, affordable surgical and anesthesia care when needed.[1] While significant progress has been made since Meara et al.’s call to action, pathologies requiring surgical intervention continue to have a disproportionate effect on low- and middle-income countries (LMICs). For example, mortality after emergency abdominal surgery is three times higher in low-human development index (HDI) countries compared to high-HDI countries, 80% of deaths related to head and neck cancer occur in LMICs, and nearly 95% of all maternal deaths in 2020 occurred in LMICs.[2–4]

Active engagement in local research and policymaking offers medical students, residents, trainees, and practicing surgeons a means to leverage their local experiences to drive meaningful changes in resource allocation and healthcare delivery. Since the disproportionate burden of surgical disease impacts LMIC communities, research tailored to local contexts and led by LMIC stakeholders is essential to offer relevant insights and priorities for creating effective and sustainable policy changes. Historically, there has been a significant imbalance in research output from LMICs, with many publications originating in these settings listing high-income country (HIC) professionals and institutions as the first and senior authors.[5] For example, a review of authorship trends in The Lancet Global Health from 2013 to 2017 found that only 35% of authors were affiliated with or from LMICs.[6]

Several barriers contribute to the disproportionate representation of LMIC authorship teams. Local factors include a lack of institutional research infrastructure (e.g., protected research time, funding, support staff, and access to existing literature for review), language barriers, limited research experience and training during medical school and residency, and a high patient volume.[5] External factors also hinder LMIC research efforts, including high article processing charges, less consideration by reviewers for top-tier journals, and inappropriate credit-sharing when partnering with foreign authors and institutions.[5,7]

Thankfully, several organizations have championed novel models for equitable research practices, shifting the current state of LMIC authorship in a positive direction. For example, the nonprofit Partners in Health/Inshuti Mu Buzima (PIH/IMB) in Rwanda implemented guidelines to ensure the equitable representation of Rwandan authors.[8] As of 2019, PIH/IMB has subsequently published or planned 22 papers, 50% of which have a Rwandan first or senior author, a significant advancement in Rwandan research capacity.[5,8] Similarly, the 501(c)(3) nonprofit organization (NPO), the Global Otolaryngology–Head and Neck Surgery Initiative (Global OHNS Initiative), published formal research equity guidelines for global, collaborative public health research in otolaryngology.[5] Since the publication of these guidelines in 2021, the Global OHNS Initiative has published 33 peer-reviewed papers in high-impact journals, all of which feature equitable representation of LMIC authors. Additionally, the 501(c)(3) NPO, the Association of Academic Global Surgery (AAGS), published a 2024 consensus statement on conference equity.[9] Consensus recommendations include interventions to reduce financial, geopolitical, and physical access barriers, thereby increasing conference attendance among LMIC professionals.[9] Further, the 501(c)(3) NPO, the International Student Surgical Network (InciSioN), developed an objective, point-based system for assigning authorship order, used in tandem with the International Committee of Medical Journal Editors (ICMJE) authorship criteria.[10,11]

To maintain the vision and emerging reality of equitable partnerships as demonstrated by PIH/IMB, the Global OHNS Initiative, AAGS, and InciSioN, it is essential to educate and develop research equity from an early stage. Multiple studies in the medical education literature have demonstrated the impact of early exposure to research on the careers of future physicians. For example, Waaijer et al. found that medical students who published before graduation were 1.9 times more likely to publish after graduation.[12] Additionally, Krupat et al. found that greater research involvement during medical school doubled the likelihood of a future research career for women.[13] Applying these trends to equitable research practices, we anticipate that early exposure to equitable research partnerships may produce more future global surgeons who will continue to engage in equitable authorship practices. However, this is an extrapolated expectation that requires prospective investigation to identify any potential relationship between early engagement in global surgery research and changes in the number of new global surgeons.

The Global Surgery Student Alliance (GSSA) is the United States (US) National Working Group (NWG) of InciSioN. InciSioN is an international NPO for medical and public health students, trainees, and early-career professionals involved in the care of surgical patients worldwide. As an NWG, GSSA strives to educate, inspire, and unite US medical students, residents, and trainees through engagement and mentorship in global surgery. The GSSA community comprises over 70 chapters and more than 1,500 students, residents, and trainees throughout the US, aiming to advance equity in all aspects of global surgical care, particularly in global surgery research. We developed the GSSA Authorship Equity Guidelines (AEGs) in response to the growing trend of equitable engagement in global surgery research to educate and empower our members to take an active role in this positive change.

To identify potential power imbalances on our research team and to ensure the integrity and representativeness of the GSSA AEGs, we employed a community-based approach to their development and approval. Our authorship team included four members of the GSSA National Team, with a 3:1 female-to-male ratio, each representing one of the four US census regions: West, Midwest, South, and Northeast. GSSA members were invited to review and comment on the guidelines, and feedback was incorporated to represent the diverse perspectives, interests, and priorities of our members. The GSSA Board of Trustees provided additional support to ensure all aspects of the guidelines align with the mission, vision, and values of GSSA and InciSioN. Finally, two independent expert physicians – one from an HIC institution and one from an LMIC institution – with substantial experience in global surgery and global health equity provided independent review and suggestions. Expert feedback was incorporated, and a cyclical review process was continued until consensus on the AEGs was achieved. Through this intentional, multifaceted, community-focused approach, the GSSA AEGs represent our shared commitment to equitable partnerships in global surgery research.

The complete text of the final GSSA AEGs is available as a supplemental resource to this publication. A summary of the key points of the research process from beginning to end is provided below (Figure 1):

1. A new project begins with the research team selecting a project category. There are three project categories: GSSA Project, GSSA Affiliated Project, or GSSA Unaffiliated Project. Only GSSA Projects and GSSA Affiliated Projects must follow the GSSA AEGs.
a. GSSA Project: defined as all original projects from GSSA.
b. GSSA Affiliated Project: defined as any project that GSSA members develop at their respective institutions in partnership with GSSA.
c. GSSA Unaffiliated Project: defined as any project that GSSA members develop at their respective institutions, independent of GSSA.
2. The project structure is defined as a single-institution domestic project, a multi-institutional domestic project, a single-institution international project, or a multi-institutional international project.
3. Projects designated as multi-institutional must complete a memorandum of understanding among all partner sites, which will be approved by the GSSA Research Team (GRT) before the project begins.
4. The project team will determine provisional authorship roles using the ICMJE criteria and the American National Standards Institute/National Information Standards Organization (ANSI/NISO) Contributor Roles Taxonomy (CRediT) designations before submitting to the institutional review board (IRB).[14,15] All authorship teams will use the ICMJE criteria inclusively and actively seek opportunities to support the growth and development of all members of the research team throughout all projects.[16,17] Project teams will submit provisional authorship roles to the GRT before the project begins.
5. The project begins, and authorship is revisited and adapted as needed. All members of the project team will meet early in the research process to establish clearly defined roles and responsibilities for each member. All manuscripts completed with LMIC partners are required to have at least one author from the country in which the study was conducted as the first/co-first and/or senior/co-senior author. Additionally, these studies should include authors from the country or countries where the study was conducted, proportional to their contributions to the project.
6. The project concludes, and authorship is finalized in accordance with the ICMJE criteria; all authors approve their final ANSI/NISO CRediT designations, and the GRT is notified.
7. All manuscripts completed with LMIC partners will include a reflexivity statement explaining how authorship equity was addressed. If it is not possible to achieve proportional LMIC author representation, the reflexivity statement should specify the reasons for the lack of representation.
8. The GRT shares the manuscript with the broader GSSA community for feedback.
9. GSSA feedback is reviewed and implemented by the project team, and appropriate credit is given in the acknowledgments section.
10. If the project is a GSSA Project, the project team must meet with the GRT to discuss journal/conference options before submitting an abstract or manuscript.
11. If the project is a GSSA Affiliated Project, the project team is not required to meet with the GRT to discuss journal/conference options, but may do so if desired.
12. First/co-first and senior/co-senior authors will be given priority to present the project. Local authors will be prioritized to present work specific to their context.

If collaborators disagree on authorship order, data use, or any other element of the research project, the principal investigators (PIs) will contact the GRT for guidance. The project team’s PIs and a GRT representative will meet to discuss all concerns and arrive at a final solution. The GRT will serve as an unbiased representative of the GSSA AEGs and GSSA’s institutional mission, vision, and values, and use these as objective metrics for final decisions when resolving disagreements. All members of the project team will support final decisions made through this process.

The finalized GSSA AEGs are designed to ensure that all GSSA research prioritizes equitable engagement for domestic and international projects. These principles will inform, educate, and reinforce the importance of equity in all aspects of the research process, prioritizing authors from the regions of focus in communities in the US and worldwide. We hope that GSSA students, residents, and trainees will adopt these principles and apply them in culturally and contextually specific ways. Beyond authorship, it is important to recognize that research equity requires attention to all elements of the research process, including funding allocation, data governance, and IRB authority. Authorship equity alone is insufficient and must be matched by equity in all aspects of the research process. While the GSSA AEGs focus on authorship, we hope they will serve as a model for developing similar guidance for the equitable implementation of all aspects of global surgery research.

We aim to instill strong values of equity and integrity in our US medical students – regardless of whether projects are domestically or internationally focused – so that they may translate these skills into their future careers as partners in global surgery. Future prospective investigations of the GSSA AEGs are required to illustrate the impact of early engagement in equitable global surgery research on research outputs and early career development. By mentoring students who will become equitable partners, GSSA aims to help produce future global surgeons who will continue to advocate for equity, integrity, and transparent research practices in global surgery, thereby supporting the transformation of knowledge into patient care for people worldwide, regardless of their country of origin.

This article is submitted by members of the Global Surgery Student Alliance (GSSA). GSSA is the United States National Working Group of the International Student Surgical Network. The authors would like to express their gratitude to GSSA for its technical support of this research. The authors would like to thank the following individuals (listed in alphabetical order by last name) for their helpful comments and expertise during the development of the GSSA Authorship Equity Guidelines (AEGs) and this manuscript: Dr. Barnabas Alayande and Dr. Rondi Kauffmann. The authors would like to thank the following individuals from the GSSA Board of Trustees (listed in alphabetical order by last name) for their helpful guidance in developing an implementation strategy for the GSSA AEGs and feedback on this manuscript: Dr. Parisa Fallah and Paul Serrato.