To the Editor: We applaud the international effort stemming from Humanitas Clinical and Research Center-IRCCS, Italy; Humanitas University, Italy; The University of Cape Town, South Africa; Addenbrooke's Hospital, United Kingdom; The University of Cambridge, United Kingdom; The University of Bamenda, Cameroon; Universidad El Bosque, Colombia; and Valle-Salud IPS Clinical Network, Colombia and we thank Dr Servadei et al1 for their letter in response to our article “Letter: Operationalizing Global Neurosurgery Research in Neurosurgical Journals.”2 In addition, we thank the authors1 for reading and addressing content from related replies to our original article.3,4 The authors1 raised the important question of why there should be a need for a new “global” section in neurosurgical journals, with supporting evidence that a) less than 10% of neurosurgical publications are produced by members of low-income and lower to middle-income countries, of which Egyptian and Indian authors produce 75%5; b) most publications specific to traumatic brain injury care originate from Australia, China, Europe, Japan, and North America, all the while the traumatic brain injury disease burden is endemic to Africa, Latin America, and South East Asia6; c) published randomized controlled trials, which inform clinical management and influence policy, receive only 9% of contributions from authors in low- and middle-income countries (LMICs).7 We agree with the comments raised forth by the authors and concur that neurosurgeons and scientists from high-income countries (HICs) must work together with colleagues in LMICs to implement policies applicable to their respective terrains. Recommendations of the Colombian Consensus Committee from the Beyond One Option for Treatment of Traumatic Brain Injury: A Stratified Protocol (BOOTStraP)8,9 are indeed effective and appropriate policy implementation measures to improve patient outcomes and quality of life; we agree with the authors.1 Similarly, since 2001, The University of Pennsylvania School of Medicine has partnered with the Government of Botswana Ministry of Health and the University of Botswana to build healthcare and increase research capacity, currently employing more than 120 full-time staff in the country. This growing Botswana–UPenn partnership has allowed for interdisciplinary care, development of postgraduate training programs at the University of Botswana, and joint research programs addressing the health and welfare of the citizens of Botswana. At Harvard Medical School, the Program in Global Surgery and Social Change has helped bridge the gap addressed by the authors through advocacy, capacity building, policy implementation, research endeavors, and systems strengthening. Moreover, at Duke University School of Medicine, the Center for Global Surgery and Health Equity has provided education and research services to improve surgical care, outcomes, and efficient policy implementation in Guatemala, Rwanda, Somaliland, and Uganda. Nonetheless, we must acknowledge the ethical considerations of the modern global surgery landscape. Alongside the opportunity for bilateral academic and clinical growth exists the opportunity for paternalism and exploitation; it is important to concede that the best ethical standards in academic global surgery are not always realized. A recent meta-analysis10 on the literature pertaining to the ethics of global surgery highights multiple ethical conflicts created by global surgical initiatives pertaining to the delivery of culturally competent patient care, the potential for nontransference of knowledge, and the development of sustainable and capacity-building partnerships. For example, as the authors1 astutely point to in their reply, researchers from LMICs are frequently inappropriately credited in publication or furthermore insufficiently involved in planning of global surgery research partnerships, allowing for the potential for exploitation of LMICs by our pervasive publish or perish mentality. An additional meta-analysis of issues in global surgery11 found that 20% of all publications did not include LMIC partners as coauthors; we thus agree with the authors1 in their thoughtful reply—it is critical that we not only make a concerted effort to mitigate inequities in publishing and authorship but also posit similarly critical to build an environment in academic research that fosters literature on global surgical ethics from both HMIC and LMIC partners. Despite this notable growth of international academic partnerships, the current global deficit requires a much larger and coordinated effort, as described by the authors,1 and we agree this collaborative network remains unavailable to a significant portion of surgeons in LMICs.12 To address the evident deficit, the authors1 have suggested a four-part approach: a) careful consideration of guideline development application to LMICs, with the addition of a section specific to LMICs13; b) collaboration with local stakeholders to encourage alternatives assessment measures for publication, such as short-term follow-up in lieu of long-term follow-up and rehabilitation, as the latter is often not a realistic option in most regions of the world14; c) enable authors from LMICs to serve as first and senior authors of landmark publications between HICs and LMICs; and d) continue encouraging and facilitating virtual access to organized neurosurgery for members of LMICs.15 We are in accordance with the authors1 on this four-step strategy, and we have previously proposed methods and measures to allow for recruitment and retainment before and during COVID-19 and beyond.16-20 We express our sincere gratitude to Servadei et al1 along with the World Federation of Neurosurgical Societies, The United Kingdom National Health Service, and the Young Neurosurgeons Committee for their generous contributions to the vehicle of global neurosurgery.