Most readers of this journal will know something about global inequalities but may not fully realise their extent. The useful reminder is the ‘nine to one’ rule: 90% of health resources are consumed by 10% of the richest countries (Global Forum for Health Research, 2000). This ratio is beginning to improve a little (the aim is to reach an 80/20 ratio in 10 years), although within-country inequalities may be increasing (Reference GoeslingGoesling, 2001). The same inequality applies to even the humble editorial offices of medical journals; our publication rates mirror closely the nine to one rule, with most of our articles coming from richer countries (Reference Patel and SumathipalaPatel & Sumathipala, 2001). Readers of the Journal will note that the World Health Organization discussed this matter last year (Reference TyrerTyrer, 2004) and a consensus statement has now been issued jointly by that organisation and the editors of scientific journals (World Health Organization & Joint Editors, 2004). The aim of this consensus statement is an attempt to reverse the publication bias that currently favours authors from wealthy countries. Whether it succeeds is for history to note, but whatever the outcome it is worth the attempt.

INSTITUTIONAL RACISM

A term that was never mentioned 10 years ago is relevant to this discussion: institutional racism. It describes any system (usually a combination of institutions and people) that systematically discriminates against others on the grounds of race or creed, and can occur ‘when the policies and practices of an organisation result in different outcomes for people from different racial groups’. The editor of the Lancet, Richard Horton, recently claimed that most journals were institutionally racist (Reference HortonHorton, 2003). Many I have spoken to about this allegation dismiss it out of hand; ‘What do you expect from the Lancet? It's just being aggravating as usual and living up to its name’ is the consensus of these views. However, when we consider what Richard Horton actually wrote, it is difficult to demur. The definition of institutional racism adopted by the Commission for Racial Equality in the UK states that unfair treatment often takes place ‘without intention or knowledge’, so when Horton argues for the widespread existence of editorial institutional racism he does not mean that editors themselves are consciously racist, but that our routine practice promotes it.

Thus we perpetuate the ‘nine to one’ rule by publishing a tiny fraction of papers originating from countries of low and middle income, by having very few representatives of these countries on our editorial boards (Reference Saxena, Levav and MaulikSaxena et al, 2003) and by turning down a greater proportion of papers from these countries than we do from others. The British Journal of Psychiatry comes within the middle range when compared with other leading journals in this respect (Reference Patel and SumathipalaPatel & Sumathipala, 2001); Acta Psychiatrica Scandinavica comes out the best (Reference Patel and SumathipalaPatel & Sumathipala, 2001; Reference Parker and ParkerParker & Parker, 2002) and the major American journals are the least generous in this respect. Only a small number of journals, including our own, promote a minor form of positive discrimination, asking referees to be more generous in assessing articles from the 90%.

ASSESSING PAPERS FROM LOWER-INCOME COUNTRIES

One form of racism in our editorial practice - and it is important to recognise that there are many others - could be found in our attitudes to articles received from countries in the low- to middle-income range. These articles tend to be rejected by the top-ranked journals. This can be for racist reasons, but most editors are unaware of this and are shocked by such an allegation, as the reasons for rejection are covered so effectively in the disguises of perceived impact, methodological rigour or writing style that the journal can feel virtuous in rejecting a worthy paper that has nonetheless been subjected to discrimination. The real difference between the 90% and 10% is in capacity. Although we can go some way towards greater equality of opportunity by ‘meeting researchers from these (90%) countries on “their home ground”, improve submissions by diligent assessment, detailed recommendations for revision and sympathetic consideration of revised versions’, this will not be enough without further training in research methodology and scientific writing, ‘mentoring, personal encouragement, training courses and research collaboration’ together with ‘increased access to mental health research publications’ (World Health Organization & Joint Editors, 2004).

If we do not increase research capacity and ‘manuscript development’ skills, we will continue to take refuge in our open and transparent review process, and convince ourselves that all papers that are accepted are better than those that are rejected. What this process does not acknowledge is that in this contest, to use a sporting analogy, contenders from the 90% are almost always playing uphill and into a howling gale. This is more than a mere question of equity; if we do not acknowledge the contribution of the 90% adequately we may lose essential elements of knowledge in our attempts to develop a complete picture of the aetiology, course and management of mental disorders. The worldwide indexing of psychiatric journals is potentially a great boon and a leveller, but the richer countries could do more to improve regional journals in poorer countries so that their journals can be indexed. Psychiatrists in South Africa, for example, who despite resource problems are carrying out excellent research, have no indexed local journal and so unless they publish elsewhere their contributions will be read by only a few.

ARE WE IMPROVING OUR INTERNATIONAL STATUS?

It is interesting that almost all journals like to describe themselves as international, even if they pursue a narrow agenda that tends to regionalism. At present medical journals tend to pursue excellence rather than fairness and in doing this their eyes are focused far too closely on the impact factor of their journals as the only adequate measure of worth. The publications department of the Royal College of Psychiatrists has been conscious of this subject in recent years but is aware that we have only made modest inroads into being truly international. Nevertheless, we have some reasons to be proud of our international contribution in publication: one of our most successful books (Reference PatelPatel, 2003) is aimed entirely at readers from low- and middle-income countries. International Psychiatry, edited by Hamid Ghodse, is similarly focused and is freely available on the College website (http://www.rcpsych.ac.uk/publications/internationalPsychiatry.htm). We will be introducing our new online journal for continuing professional development under the editorship of Cornelius Katona later this year, and are constantly thinking about ways of expanding this educational opportunity to other countries, particularly those in the 90%. For some time now the online versions of all three journals published by the College (the British Journal of Psychiatry, Psychiatric Bulletin and Advances in Psychiatric Treatment) have been freely available to 75 of the world's lowest-income countries.

In increasing capacity we also need to be aware of the need to foster the development of a reservoir of intellectual talent that has the confidence to set its own agenda in the light of local conditions and not simply follow in the tracks of researchers in richer countries. Although the initiative for this has to be indigenous, journal editors in the rich 10% must be careful not to assume that what is opportune and topical in their own country has any such priority with the remaining 90% (e.g. Reference EmsleyEmsley, 2001).

We also need to celebrate the breadth and quality of papers from low- and middle-income countries in our journal. In 2004 alone we had two papers that were unequivocally international (in that they show no selection in favour of the 10%) describing common mental disorders from a global perspective (Reference Bhugra and MastrogianniBhugra & Mastrogianni, 2004; Reference Üstün, Ayuso-Mateos and ChatterjiÜstün et al, 2004), together with useful epidemiological studies giving interesting cross-national comparisons (Reference Lee, Yip and LeungLee et al, 2004; Reference Noorbala, Bagheri Yazdi and YasamyNoorbala et al, 2004; Reference Okulate, Olayinka and JonesOkulate et al, 2004; Reference Seedat, Nyamai and NjengaSeedat et al, 2004), excellent examples of collaboration and potential capacity-building between researchers in richer and low-income countries (Reference Igreja, Kleijn and SchreuderIgreja et al, 2004; Reference Saravanan, Jacob and PrinceSaravanan et al, 2004; Reference Sumathipala, Siribaddana and BhugraSumathipala et al, 2004), as well as informative accounts of the special problems of psychiatry in India (religious treatment in conflict with conventional mental health services; Reference Thara, Padmavati and SrinivasanThara et al, 2004), unusual variations in Nigeria (low incidence of Alzheimer's disease among the Yoruba tribe; Reference Ayonrinde, Gureje and LawalAyonrinde et al, 2004) and the high rate of dissociative disorders in Egypt (Reference OkashaOkasha, 2004). We have also published a transcultural supplement in which one low-income country, Uganda, was a close participant in the research (Reference Asten, Marks and OatesAsten et al, 2004). Several of these contributions were encouraged or invited, and both the previous editor, Greg Wilkinson, and Andrej Marušič, our ‘round the world’ editor, deserve credit for taking an initiative here in advance of many other journals in the field. I also propose to increase the number of corresponding editors from poorer countries to ensure that we are better able to assess the local context in assessing submitted articles. In addition, we have begun a small research project into the fate of articles submitted to the Journal according to the wealth of the country of origin of their main authors.

Recent world events have served to emphasise our interdependence and remind us that we cannot escape into separate worlds. Perhaps it is this, more than any other perception, that will break down the barriers between the 90% and 10%. I hope that we can continue to pursue this path at the Journal, neither veering too far in the direction of tokenism and political correctness nor lowering our standards in embracing a genuinely more international approach. Often we may have been racist ‘without intention or knowledge’, but we can no longer hide behind ignorance. As McKenzie (Reference McKenzie2003) has reminded us, ‘developing a deeper understanding of possible links between racism and health is a pre-requisite for initiatives to decrease impact at a community and individual level’, and so all should gain in the longer term from this increased awareness. We hope that the World Health Organization will be able to host another meeting in a few years’ time to review the progress of its initiative. We also hope that on the next occasion our colleagues from the Archives of General Psychiatry and the American Journal of Psychiatry will be able to participate. It is a long way to Geneva, but as Mark Twain once observed, ‘travel is fatal to prejudice’.