Publishing Urologic Research from Low- and Middle-Income Countries

Global reach is a key component of the mission of the SIUJ. This pertains primarily to our objective of making all content of the journal accessible to all urologists and researchers around the world—especially in locations that do not have institutional access to the myriad of urologic journals. These urologists and researchers are often, although not always, located in low- and middle-income countries (LMIC), home to 85% of the world’s population [1]. This part of our mission has been achieved with the investment of the Société Internationale d’Urologie (SIU) in our diamond open access journal. There is, however, another side to global outreach at the SIUJ: we would like to publish the work of urologists and researchers in LMIC.

We are pleased to have been able to feature occasional publications from authors in these countries, including, for example, Pakistan, Burkina Faso, and Morocco, but they make up a small fraction of the total number of submissions. It is important to emphasize that all papers in the SIUJ are published based on the merits of the work and not based on the country where they originated. And therein lies a critical barrier to our mission—we would publish more high-quality work from researchers in LMIC if we were able to attract it. Researchers in countries such as India and Egypt have a strong track record of publishing and are of course publishing in many journals beyond the SIUJ. Overall, however, there is a definite need to promote urologic research in LMIC.

The biggest barriers to urologic research in LMIC are obvious to us all. These include limited funding, a lack of research infrastructure and resources, barriers to technology and information access, a lack of skilled allied health personnel to support research, and regulatory challenges. Researchers in LMIC often lack access to cutting-edge technology, the scientific literature, and research databases. Research requires funding for equipment, supplies, personnel, and dissemination. LMIC typically are unable to allocate their already limited resources to healthcare research. Many of these countries face a high burden of infectious diseases and maternal and child health issues, which skews research priorities toward immediate health threats and leaves other areas relatively underfunded. Limited awareness of the importance of research within the healthcare system and among policymakers weakens the research culture. The absence of clear research guidelines and oversight mechanisms may also impede research.

The SIU has made some strides in this regard. SIU-sponsored fellowships undoubtedly expose urologists from LMIC to the practices of clinical research. The SIU uCARE network of clinical researchers includes many individuals from LMIC, and their projects are generally focused on clinical questions that can be answered by researchers in numerous countries [2]. In recognition of the need to develop creative surgical techniques and technologies that will be affordable to people in LMIC, Prof. Daniel Yachia from Turkey launched SANTU (Symposium on Affordable New Technologies in Urology) several years ago and has more recently added BANTUC (Best Affordable New Technologies in Urology Contest), which is held at the annual congress of the SIU. Despite these efforts, urologic research in LMIC continues to face formidable barriers that impede progress and innovation in the field.

None of the obstacles to research in LMIC are necessarily easily overcome. While we would endorse more investment in urologic research by governments, international organizations, and philanthropic foundations in LMIC, funding by itself will not guarantee research productivity without addressing other barriers. Funding research needs to include building capacity (e.g., research training and mentorship) [3] and developing infrastructure to stimulate research activity and innovation in the field. Researchers and institutions from high-income countries (HIC) can provide access to expertise, resources, and funding opportunities for urologic research initiatives. Research can, of course, drive economic growth and national development.

Collaboration between HIC and LMIC represents an opportunity—but also a risk. This is most apparent in the domain of clinical trials, to the degree that the American Society of Clinical Oncology (US) has published a policy statement on global equity in clinical trials. Ethical concerns about clinical trials in LMIC relate primarily to the potential vulnerabilities of research participants. Informed consent may be difficult to obtain due to low literacy rates as well as language barriers and cultural differences. Socioeconomic factors and poor access to healthcare make participants in LMIC more vulnerable to exploitation. Sponsors from HIC need to consider how to fairly share the benefits of research conducted in LMIC with the local communities where the research takes place. There is a risk that the research conducted in LMIC may primarily benefit researchers, institutions, and populations in HIC. Every effort needs to be made to build research capacity within LMIC, empower local researchers, and foster equitable collaborations [4]. Engaging with local communities is essential to ensure that research addresses their priorities and is sensitive to local cultural norms. Any research undertaken must be consistent with local customs and values with full transparency and accountability. While privacy protection is taken for granted in HIC, the same needs to occur in LMIC, which sometimes have limited data protection regulations.

The objective of urologic research is to advance our understanding of urologic diseases, improve diagnostic and treatment modalities, and ultimately enhance patient outcomes. We cannot leave out patients in LMIC in this mission. Overcoming the barriers to urologic research in LMIC is a monumental task that will require collective action and commitment from governments, policymakers, researchers, and healthcare professionals.