The APC Barrier: Silencing Public Health Voices and Marginalizing Case ReportsThe Open Access (OA) movement promised to democratize scientific knowledge. However, two decades later, that promise is only half-fulfilled: while readers enjoy free access, authors—especially workers in public institutions and clinicians from low- and middle-income countries (LMICs)—face economic barriers due to high Article Processing Charges (APCs). This asymmetry silences crucial voices and shapes what is published.
APCs in prestigious medical journals, often ranging from USD 2,000 to 5,000, are unattainable for most public health professionals. Studies confirm a weak correlation between publication cost and prestige and reveal a persistent underrepresentation of LMIC authors in high-impact OA journals (Abdel-Razig et al. 2024, Charpignon et al. 2025, Kilgallon et al. 2023, Tocco et al. 2025). This model creates a two-tiered system of knowledge production: those who can pay to publish and those who cannot. For clinicians in public institutions, who often deal with context-specific or emerging diseases, publishing transitions from a professional goal to an unattainable aspiration.
One of the main casualties of this inequitable system is the Clinical Case Report (CCR). Once fundamental to medical education and progress, CCRs have been progressively marginalized by editorial policies prioritizing large trials and meta-analyses (Cima et al. 2023, Zhao et al. 2022). This reduction is severe: by deprioritizing CCRs, journals diminish the documentation of rare, unexpected, or locally relevant clinical phenomena—observations vital for diagnostic reasoning and contextual learning.
CCRs are pedagogical laboratories that invite students to connect pathophysiology with patient context and reasoning under uncertainty. Their disappearance narrows both the evidentiary and the cognitive landscape. Furthermore, if Artificial Intelligence (AI) tools learn from an incomplete registry of clinical cases, there is a risk of propagating algorithmic biases by training future systems that ignore the clinical reality of much of the world.
This editorial landscape is further complicated by a focus on discourse over nomenclature—from Monkeypox becoming Mpox (Hulland et al. 2025, Klein et al. 2023) to NAFLD evolving into MAFLD (Younossi et al. 2021, Fouad et al. 2020). While valuable, this disproportionate visibility, compared to the marginalization of CCRs, reveals an “editorial hidden curriculum” that prioritizes social visibility and linguistic consensus over clinical insight and diagnostic reasoning.
While APCs are necessary for sustaining peer review, equity cannot depend solely on the ability to pay. The challenge is to reimagine OA to balance financial sustainability with global inclusion and educational purpose. Journals must re-evaluate their editorial priorities, recognizing CCRs not as curiosities, but as essential pedagogical tools that cultivate diagnostic agility, cultural competence, and humility.
Reform must be guided by three principles: Transparency in APC policies; Revaluation of CCRs as explicit educational evidence; and a broader Redefinition of “impact” that values clinical relevance, pedagogical contribution, and geographic diversity over citation accumulation. Only by incorporating these principles can medical publishing fulfill its original promise: not just open access to information, but open participation in knowledge creation.
References
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- CHARPIGNON ML ET AL. 2025. Geographic Diversity and Authorship Representation in High-Impact Medical Journals. BMJ Open 15: e080421.
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- FOUAD Y ET AL. 2020. What’s in a Name? Renaming ‘NAFLD’ to ‘MAFLD’. Liver Int 40: 1254-1261.
- HULLAND EN ET AL. 2025. On the Importance of Communication, Advocacy, and Information Accuracy in Destigmatizing Mpox Disease. Sci Rep 15: 27064.
- KILGALLON J ET AL. 2023. Global Inequities in Access to Medical Knowledge: The Financial Barriers of Publishing and Reading. Ann Glob Health 89: 52.
- KLEIN EJ ET AL. 2023. Mpox “Monkeypox” Virus: The Importance of Inclusive Imagery to Prevent Disease Stigma. J Drugs Dermatol 22: 1235-1236.
- TOCCO G ET AL. 2025. Economic Patterns in Open Access Medical Publishing: APCs and Prestige Gaps. PLoS One 20: e0298451.
- YOUNOSSI ZM ET AL. 2021. From NAFLD to MAFLD: Implications of a Premature Change in Terminology. Hepatology (Baltimore Md) 73: 1194-1198.
- ZHAO Y ET AL. 2022. Trends in Case Reports and Case Series in Medical Literature: A Bibliometric Analysis. Eur J Med Res 27: 21.
Edited by
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Handling editor
Yraima Cordeiro
Data sharing not applicable as no new data generated.
