The role of trust in global health research collaborations

Abstract Collaborations in global health research are on the rise because they enhance productivity, facilitate capacity building, accelerate output and make tackling big, multifactorial research questions possible. In this paper, I examine the concepts of trust and reliance in scientific collaborations in general, but also in the particular context of collaborations in global health research between high‐income countries and low‐and‐middle income countries (LMIC). I propose and defend the argument that given the particular characteristics of collaborations and demands of trust relationships, reliance is a better relational mode for successful collaborations. Although reliance can be difficult to establish in situations where asymmetry of power exists, trust should not be the only relational mode available to LMIC researchers because of the type of vulnerability it introduces to the relationship. I conclude that the promotion of good collaborations requires addressing the power imbalances between partners, and establishing an even playing field in global health research.

researchers to tackle diseases and conditions such as malaria, tuberculosis, HIV-AIDS and malnutrition, 7 and a desire among HIC researchers to work with colleagues from LMIC. The aim of these initiatives is twofold: first, to promote and accelerate the discovery of pharmaceuticals and therapeutics; second, to help build research capacity in LMIC, so local researchers will be able in the future to set their own agendas to pursue innovative and locally relevant healthrelated research without the need of an HIC partner.
HIC and LMIC collaborations do not always work as intended.
It has been observed that these types of collaborations are often structured in ways that favour HIC researchers more than their counterparts in LMIC. 8 For example, research partners from LMIC often find themselves in the role of 'glorified field workers', providing the samples and data, but less involved -if at all -in designing the research and setting research agendas. 9 This relationship curtails LMIC researchers' opportunities to establish themselves in their field and to pursue their own research interests, and results in the perpetuation of the situation it is seeking to address: a situation where LMIC researchers remain dependent on their HIC counterparts for funding and research opportunities.
In 2013, the Council on Health Research for Development (COHRED) issued a report entitled Where there is no lawyer: Guidance for fairer contract negotiation in collaborative research partnerships. 10 The aim of this document is to assist researchers from LMIC to achieve better and fairer collaborations with their HIC partners.
COHRED acknowledges that 'sporadic attempts' to level the scientific playing field between HIC and LMIC, as well as calls for HIC researchers to abide by the principles of fairness when entering into partnerships with LMIC researchers have had limited success. By issuing this guidance, COHRED seeks to 'shift the locus of control of research benefits to the LMIC partner', 11 and ensure that LMIC researchers do not have to trust to their richer colleagues' 'good will'.
Trust is important, says COHRED, but more is needed for good and fair collaborations. So, if LMIC researchers cannot rely on trust for fair collaborations, where should they turn?
In this paper, I examine the concepts of trust and reliance in scientific collaborations in general, but also in the particular context of collaboration in global health research between HIC and LMIC. I propose and defend the argument that, given the particular characteristics of collaboration and demands of trust relationships, reliance is a better relational mode for successful collaborations. Although reliance can be difficult to establish in situations where asymmetry of power exists, trust should not be the only relational mode available to LMIC researchers because of the type of vulnerability it introduces to the relationship. I conclude that the promotion of good collaborations requires addressing the power imbalances between partners, and establishing an even playing field in global health research.
The goal of this paper is not to offer a new account of trust or reliance but rather to extend discussion already in the literature to bear upon the context of collaborations in global health research.

| WHAT IS A COLL ABOR ATI ON?
The existing consensus is that collaborations are good and ought to be promoted. It is argued that they are an efficient and effective way of answering scientific questions, and solving problems.
Collaborations enhance research productivity, facilitate knowledge generation and knowledge transfer, and make tackling big, multifactorial research questions possible (e.g., in genomic epidemiology research Similarly, Mattessich, Murray-Close and Monsey define a collaboration as the coming together of two or more autonomous actors in order to fulfil a common mission that requires comprehensive planning, and communication. 17 What distinguishes collaborations from other types of partnerships is the presence of a common goal, and convergence regarding plans of action and methods used. 18 Collaborations are non-hierarchical structures where the division of labour is based on capacity and expertise rather than on functions or titles. 19 Sharing of decision making and of responsibility is fundamental for this type of partnership. Participation in the decision-making process ensures a higher degree of investment from all members, and also greater commitment to the successful completion of the project. The non-hierarchical structure of collaboration also means that establishing rules of engagement and of problem solving, as well as delegating responsibilities, are tasks that are approached in a collective and democratic manner. where conflict may arise. Also, the drive and desire to achieve the common goal, and recognition of the partners' interdependence in fulfilling this aim means that synergy -the attitude that 'something greater can always emerge out of a process or interaction' 21 -rather than reciprocity 22 is what drives such partnerships. 23 Many scholars have argued that what underpins successful collaboration is a relationship of trust between the partners. 24 D'Amour notes that 'the term collaboration conveys the idea of sharing … in a spirit of harmony and trust'. 25 I would like to turn now to this notion, and ask whether trust is important and necessary for collaborations.

| TRUS T
There are three main characteristics that describe trust relationships: (a) trust can only be conferred by the trustor, and it cannot be demanded by the trustee; (b) the trustor believes that the trustee has good will towards him or her; and (c) the trustor assumes a participant's stance, namely they make themselves vulnerable to the trustee as they acknowledge and accept that the trustee can decisively affect the outcome of the entrusted action. 26 These characteristics explain and validate feelings of gratitude, when trust is confirmed, and of betrayal, when trust is broken. It is important to underline that vulnerability is not a necessary characteristic of the person who is trusting, but a relational property that emerges from the act of trusting. When I confide a secret to my friend and I ask him not to reveal it, I acknowledge that he has the power to either confirm my trust -which will make me feel grateful -or to ignore my request -making me feel betrayed. My vulnerability arises because I have no assurances, other than those bestowed by the trusting relationship, to protect me from his decision. His having good will towards me means being 'directly and favourably' moved by the thought that I am counting on him. 27 It is this assumption or belief that a person has 'good will' towards me that justifies entering a position of vulnerability. 28 It follows that without this belief or assumption my decision to trust him would be unreasonable.
It often takes time to build trust, and when broken, it is difficult to restore. As Baier notes: 'Trust me!' is for most of us an invitation which we cannot accept at will -either we do already trust the one who says it, in which case it serves at best as reassurance, or it is properly responded to with, 'Why should and how can I, until I have cause to?' 29 Being trustworthy means giving others reasons to believe that one can be counted on. Yet demonstrating trustworthiness moves beyond 16 Hord, S. M. (1986). A synthesis of research on organizational collaboration. Educational Leadership,43,[22][23][24][25][26] In order to demonstrate the distinction between different modes of working relationships, Mattessich, Murray-Close and Monsey contrast collaborations with cooperation, which they define as a simple agreement between organizations which furthers their individual aims and goals, but lacks a common mission, structure or joint planning; and coordination, where two parties decide to work together in order to better achieve their independent goals. Mattessich, P. the mere observation of rules and regulations as a tactic to avoid punishment or penalties. 30 Being trustworthy means having an attitude of good will towards the trustor by being responsive to the trustor's dependency upon the trustee. 31 It is not immediately obvious why trust is necessary in collaborations. Ideally, people would not want to enter into a relationship which renders them vulnerable and entirely dependent on their collaborator's good will to counterbalance their vulnerability. Trust can be justified if the trustor has sufficient evidence of the trustee's good will -but it takes time to amass this evidence. One might trust a collaborator if one has known them for a long time and has come to believe that they are trustworthy, i.e., they are not only conscientious but also have good will towards one. In such a situation, trust can be a sufficient reason to enter into a collaborative partnership. However, not all collaborations are established between longstanding partners. When considering a collaboration with a new partner, the partner's reputation might be an indication of their trustworthiness; but again, it is not obvious why anyone would choose to become vulnerable to another person, on the basis of what a third party says about them. So, although in certain circumstances trust can be a sufficient reason for collaboration, it is not a necessary one. 32 Researchers form collaborations to achieve goals that would be impossible to reach by working alone. They seek collaborations with colleagues who are interested in answering the same questions, and who also have the knowledge and skill to achieve it. A relational mode that seeks partners based on these qualities, rather than on the presence of good will, might be more appropriate for research collaborations.
Could reliance provide a better relational mode for collaborations?

| RELIAN CE -A NECE SSARY COMP ONENT OF COLL ABOR ATIONS
The terms 'reliance' and 'trust' are often used interchangeably but a closer inspection reveals that there are significant differences between them. Reliance describes a relationship where the involved parties come together through a process of rational exercise that aims at minimizing the risks and maximizing the benefits of the rela- Everybody knows what is expected of them, and what their role in the relationship is. Partners are required to follow the rules agreed upon, and their adherence to the rules is regulated by policies and penalties. As a relationship mode, reliance is one based on 'reasonable expectations' and 'proven capability '. 34 The crucial difference between a relationship of reliance and one of trust is that reliance does not require the adoption of a participant stance towards the other person. In other words, one does not need to take the risk of having one's trust betrayed or confirmed by acting on the belief that the other person has good will towards one, and that this good will forms a reason for fulfilling the trusted action. 35 One only needs to be convinced that the other person has enough self-interested reasons to reliably fulfil the action. These reasons can take different forms. It can be, for example, because the penalty for failing to keep his or her end of the deal would be too high, or because he or she wants to initiate a reciprocal relationship (prisoner's dilemma). The idea that researchers are motivated by self-interested reasons to behave collaboratively, and that self-interest plays a moderating role in reducing risk in such relationships is not new, and has been defended by a number of scholars. 36 Presence of self-interested reasons does not eliminate all risk in collaborations. Partners can still expose themselves to harm or wrong, but the harm or wrong that results from a reliance relationship would not make the harmed party feel betrayed. I rely on my co-author to contribute to the writing of a manuscript. If she fails to fulfil her duties as a co-author she will incur costs. I will remove her from the author list and might decide not to collaborate with her again. I might even share my experience with other colleagues, which will lead to reputational damage for her. When my collaborator reneges on her duty to keep her part of the deal, I am harmed: the manuscript will take longer to complete, or in the worst case I might even have to abandon this project. I may feel upset and annoyed by her behaviour; I do not, however, feel betrayed -as I would feel if a friend had let me down. 37 This is because I would not expect my collaborator to (necessarily) reflect on my dependence on her, and actively and positively engage with this fact. As Jones explains, reliance and reliability is 'depend[ing] on each other in the sense that the success of our action is vulnerable to the other's choice of action, and often enough we recognize this, but we do not depend on the other responding to that dependency '. 38 There is an affective element in trust, which is not present in relationships of reliance, and I maintain that it is this lack of 30 Ibid.  Ethics,123, It is important to acknowledge that trust and reliance are also relevant to institutions. A discussion of the role of trust in and reliance on institutions and the relationship between institutions in collaborative global health research would be an useful addition to the literature, but falls outside the remit of this paper. 33 Of course, this presupposes trust in the system of accountability that regulates the reliance relationship. It can be argued therefore, that reliance does exist independently, but only emerges in a system where different layers of trust relationships exist. This might be true at a systemic level; at the personal level, however, it is still valid to distinguish between relationships of reliance and relationships of trust. So far, through an examination of collaborations, trust and reliance, I have argued that whereas trust can be a sufficient reason for collaboration, reliance presents as a more appropriate relational mode to guide such partnerships. Reliance is premised on self-interest rather than good will, requires less time to be established between partners, and can be achieved by setting clear rules of engagement and systems of accountability. In research collaborations there is always the possibility that things might go wrong and that people might renege on their responsibilities. Therefore, collaborations based on proven capacity and reasonable expectations, rather than on beliefs of good will seem both reasonable and appropriate. What remains to be examined is whether the same holds for collaborations in global health. Does reliance remain a necessary and sufficient reason for collaboration in situations characterized, as are those in global health collaborations, by substantial power imbalance between partners, and what might be the role of trust in these situations?

| TRUS T AND RELIAN CE IN A SYMME TRIC COLL ABOR ATIONS
Collaborative research in global health has been promoted as an effective way of addressing pressing health issues that predominantly affect communities in LMIC, and also of advancing scientific research within countries where the highest burden of disease lies. 43 As such, the implicit aim is to build capacity in LMIC to correct the Relationships of reliance assume the existence of rational self-interested agents with equal power over each other. In partnerships where symmetric power exists, distribution of risks and benefits is expected to also be symmetrical, and therefore fair. A collaboration between two researchers with the same academic standing, equal access to funding, and equal stakes in the research project can be an example of such collaboration. It is easy to imagine that these two agents would be able to negotiate the terms of the collaboration in an effective and fair way, and also stick to them, as it would be 39 Wagner, C. S. (2005). Six case studies of international collaboration in science. in neither's interest to do otherwise. In situations, however, where power symmetry collapses, reasons for keeping the relationship equal and fair also cease to exist. Where there is power asymmetry the stronger partner has the opportunity, and reason, to tip the balance of risk and benefits to his/her favour and at their partner's expense. Also, as it is often the case, the weak partner, in virtue of his/ her position, lacks the ability to effectively punish the strong partner in case of defection, hence giving reasons to the powerful partner to drop the relationship.

Scientometrics
Another factor that could secure a fair collaboration could be the promise of future reciprocation, i.e., a tit-for-tat relationship.
Partners are motivated to establish a stable relationship to increase the likelihood of being granted access to the desired good/service/ relationship now and in the future. Again, a partner with little to offer has less ability to motivate desire for future reciprocation.
Consider the case of genomic research where the LMIC partner provides the samples and the HIC the DNA extraction, sequencing and analysis. Once the samples are handed over and genomic information extracted, these data can be used again and again for new projects without the need for the collection of new samples. There is now little dependence of the HIC partner on the LMIC partner, who would now fail to motivate the HIC partner's self-interest to collaborate fairly. It seems, therefore, that when it comes to partnerships characterized by asymmetric power, reliance cannot reasonably justify collaboration. So, where does this leave global health research collaborations?
The preclusion of reliance as a sufficient justification for collaboration in global health research raises the question of whether trust could offer a sufficient justification. If one cannot rely on the other's self-interest to collaborate fairly, then could trusting in one's good will offer an adequate reason for collaboration? As explained above, although trust makes the trustor vulnerable towards the trustee, as the trustee can decisively affect the outcome of the entrusted action, a reasonable belief in the trustee's good will can justify and counterbalance that risk. But trust does not, and indeed cannot, always exist. Parties in conditions of vulnerability might be forced by the circumstances to act as if they trust -to enter into a relationship in which the other person can decisively influence the outcome of the action -but this would be the outcome of an empty choice, rather than of a belief in the other person's good will towards them. 45 What needs to be avoided is leaving LMIC researchers in a situation where they have no other option than to appeal to another's good will, particularly when trust has not been or cannot be established. The decision to enter an asymmetric collaborative relationship cannot in itself be seen as a proof of trust. People can behave 'as if they trust' in a situation where they have no other option, or where the only alternative is worse than the risk or cost associated with entering the relationship (think, for example, of a mafia boss asking you to deliver a suspicious parcel in exchange for not harming your family). One should not assume, however, that all collaborative asymmetric relationships are either irrational or coercive, nor think that trust is unimportant or irrelevant in research interests and establish themselves in the academic community. This requires not only the availability of direct funds for LMIC researchers, but also the existence of the appropriate infrastructure for the development and flourishing of research in these countries.
Additionally, it requires changes at an international level to the ways in which research excellence is perceived and measured, and collaborations acknowledged in publications. 51 Schemes have already been initiated to encourage and support LMIC-LMIC collaborations in health research. 52 Of course, it remains to be seen whether these efforts will succeed in levelling the research arena. Empirical research can assist in this task by examining whether targets are achieved, and by revealing areas where more work is needed.
However, the focus and direction towards creating the right environment for LMIC countries to pursue their research agendas and enhance their research capacity should persist.

| CON CLUS ION
Scientific collaborations between HIC and LMIC are an increasing trend in global health. They bring together knowledge, expertise and resources in order to find more effective ways of combating disease and illness. Collaborations between HIC and LMIC are, however, often characterized by asymmetric power distribution, making partnerships more risky and often unfair to the LMIC researchers. In this paper I have argued that in symmetric collaborations reliance, rather than trust, can provide adequate justification for entering a partnership. The term 'collaboration' denotes a non-hierarchical partnership aiming at a common goal, based on reasonable expectations and proven ability. It assumes power parity between partners. In situations where power parity is not present, reliance -belief in the self-interested motivation of the other -cannot provide adequate justification for collaboration. Trust could provide sufficient reason for collaboration in such situations, but trust relationships take time to establish, and also require one partner to become vulnerable, depending upon the other to act in a way that will not hurt or betray them. Power disparity therefore could lead to relationships where LMIC researchers are forced to act as if they trust HIC partners even when trust might not exist or is not reasonable.
In order to ensure that collaborations between LMIC and HIC countries are fair and equitable, the scientific playing field must be levelled. Creating the conditions in which researchers can be equal partners makes possible the formation of relationships of reliance between equal stakeholders, rather than asymmetric relationships in which the only option for the weaker partner is to trust in the other's good will.

ACK N OWLED G EM ENTS
Global health bioethics research at the Ethox Centre is supported by a Wellcome Trust Strategic Award (096527). The Wellcome Centre for Ethics and Humanities and the Ethox Centre are supported by a Wellcome Centre Grant (203132/Z/16/Z).

CO N FLI C T O F I NTE R E S T
The author declares no conflict of interest.