• acute
• publishing

The study published by LaGrone et al examines the financial barriers faced by low/middle-income countries (LMICs) in the form of article processing fees (APCs) to publish into, and pay walls to read and access, major surgical journals.1 The study shines a light on two important issues dealing with equity as it applies to surgical science in terms of (1) access to existing knowledge to improve surgical care in LMICs, and (2) the ability to generate, publish and disseminate new knowledge that may be more relevant and applicable to the LMIC environment.

Eighty-six percent of the global population resides in LMICs, and the scale of surgically avertable morality in these countries is staggering. In a World Bank study in 2015, it was estimated that if basic surgical care could be provided to all, approximately 1.5 million lives would be saved in LMICs.2 Despite this grim statistic, LMICs face an almost unsurmountable financial barrier in terms of access to the surgical literature that could help alleviate this burden. For example, it is well-known that implementing simple, low-cost solutions like guidelines, algorithms and protocols reduces variability in care and improves outcomes. These protocols can be used by not only physicians but also non-physician surgical providers who provide an essential service in remote and rural areas of LMICs. However, over 90% of surgical literature is created and published in high-income countries (HICs) and as demonstrated in LaGrone et al’s study, ‘pay walls’ make this literature out of reach for most healthcare providers in LMICs.

On the knowledge creation side, much of the published literature coming out of HICs may not be relevant or applicable in LMICs due to resource constraints and vastly different contexts of care. At the same time, there are likely many low-resource solutions that are being developed and would be directly applicable in LMICs, but due to APCs cannot be published and disseminated for others to emulate. To address some of these issues, open access (OA) was developed to make knowledge freely available to all consumers anywhere in the world. However, although OA addresses the ‘access’ issue, it fails to address the ‘creation’ side of the equation and newer models of knowledge creation and access need to be developed.3

As the editor in chief and deputy editors for Global Strategy/Outreach at Trauma Surgery and Acute Care Open (TSACO), we think it is our moral and ethical duty to address these disparities. Recent changes at BMJ Publishing, publisher of TSACO, abolishing APC for all 125 HINARI A and B countries is a welcome development and a step in the right direction. Articles from these countries will be published OA for the world to read, free of charge. Although this is an important first step, APC waiver in and of itself does not lead to equity in publishing as summarized by Rouhi et al.3 To address this, TSACO has also implemented multiple changes at the highest level including (1) appointing two deputy editors (Drs Malhotra and Gaarder) to oversee global outreach and international inclusion with diverse points of view; (2) expanding the global editorial board by adding international editors from multiple countries across the spectrum of socioeconomic human development; and (3) developing partnerships with international and national professional societies from all over the world. We hope this editorial communicates efforts by TSACO (BMJ) to help overcome some of the barriers. Our waiver policy is fully transparent and available online (https://tsaco.bmj.com/pages/authors%23waivers_and_discounts).

With these initiatives, it is our sincere hope that TSACO will become the ‘go-to’ journal for the international surgical community and help achieve our vision ‘to provide the global trauma and acute care surgery community with free access to top-notch scientific information’.