AN INEQUITY AND ITS POSSIBLE REMEDIES

Vikram Patel & Athula Sumathipala (Reference Patel and Sumathipala2001, this issue) have shown, through a simple survey of six major Western psychiatric journals, that there is gross under-representation of papers from developing countries. They propose several explanations for this observation, including poor quality of submitted manuscripts and of the research they report. Editors of the six journals surveyed could ease their consciences simply by endorsing this explanation. However, there are other possible interpretations which are as plausible, if not more so.

It is striking that the three American journals publish a much lower proportion of papers from developing countries than the three European journals: 2.2% as opposed to 9.4%. This may well reflect a circular effect: authors seeing a very small proportion of published papers from developing countries are likely to rate their chance of acceptance low and submit to European journals for preference. However, the process must have been initiated by editorial practice, although none of the three American editors was able or willing to provide data on their acceptance rates of papers from developing countries. Anecdotally, few American psychiatrists are aware of research or practice in Europe, let alone developing countries, and editorial policy partly derives from this cultural ethnocentricity.

In the European arena, Acta Psychiatrica Scandinavica stands out from the two British-based journals in publishing almost three times the proportion of papers from developing countries. This is achieved without lowering the standard of the journal as an international periodical, so should be achievable by its competitors.

Patel & Sumathipala propose a number of solutions to the problem. They rightly prioritise the development of a research base of high scientific rigour in developing countries, and note that international research institutions bear a responsibility in this regard. While that is true, it is also essential for governments in developing countries to raise psychiatric research up their list of funding priorities. Given the relatively low mortality of psychiatric illnesses, they tend to be eclipsed by the epidemic killers. However, financial forecasts by the World Bank show that psychiatric conditions are fast rising to the top of the list of most costly diseases because of the long-term disability they often create.

A second suggestion of the authors is that greater collaboration is needed between editors and authors from developing countries to improve the presentation of submitted papers that thus avoid rejection on the grounds of style or language. I have served in an editorial capacity for five editors of the British Journal of Psychiatry, from Ted Hare to the current editor, and I can assure readers that considerable effort has always been directed at this problem, to the extent sometimes of an editor completely rewriting a manuscript in which the text was difficult to understand.

A third proposal is a “high-quality new journal with a specific orientation to world mental health”. While this sounds an attractive solution, I am doubtful that such a venture would be financially viable. Most psychiatric journals are heavily dependent on advertising to stay out of debt. Advertisers are attracted to journals with a high circulation, and few individuals and libraries in developing countries have enough flexibility in their budgets to subscribe to expensive foreign journals. Furthermore, it may lead to exclusion of papers from developing countries from mainstream journals on the grounds that they would be better placed in the new international journal.

An important issue raised by Patel & Sumathipala is the relevance of working conditions in psychiatric services in developing countries to those in Europe and America. It is ironic that community psychiatry, the banner under which professionals in the West are marching forwards, is what has been practised in developing countries for as long as human memory, because of the lack of investment of resources in mental hospitals. In most developing countries, as the authors point out, the existing hospitals were built by the colonial powers and in many of them appalling conditions still persist. On the other hand, psychiatric illnesses have largely been contained in the community with the use of minimal resources. As the World Health Organization studies showed in the case of schizophrenia, the outcome is better in developing countries despite the lack of major investment.

So, with straightened resources in community services, psychiatrists in Europe and America may have a lot to learn from the way community psychiatry is practised in developing countries. This is another argument for promoting papers from these countries in the premier Western psychiatric journals. How this could be achieved remains problematic, but the inequity exposed by Patel & Sumathipala must be addressed.