Bringing global hematology research to the forefront

TO THE EDITOR:

Considerable advancements have occurred in the diagnosis and treatment of patients with hematological diseases, including knowledge of the omics of disease, to the development of small molecules, targeted agents, and cellular and gene therapies. Yet, improvements in survival have occurred mainly in well-developed world regions while remaining stable or modestly improved in low- and middle-income countries (LMIC).¹ 

This disparity is driven by historical and geopolitical forces including health systems with restricted resources, lack of optimal diagnostic tools, and limited therapeutic armamentariums. Nonmalignant diseases like nutritional anemias, hemoglobinopathies, and infectious diseases have an uneven distribution across populations, being more prevalent in LMIC. Most humans alive today, >6.6 billion people, live in LMIC, and >90% of the world population lives outside North America and Europe.² 

Paradoxically, most of the scientific advances published in the literature come from investigators working in institutions in wealthier regions. A bibliometric analysis in hematology, a reflection of research capacity, reveals that most indexed journals come from high-income countries (HIC),^3,4 as are ∼70% of publications.^5-14 This is not limited to hematology: from 1995 to 2015, 30 countries generated 93.9% of all publications indexed in PubMed. Of them, 21 are from the Americas and Europe, and 24 from HIC.⁵ Contributing factors to global inequity in research output and distribution are multiple, including the number of health professionals and their clinical workload; a lack in research education and English language proficiency; gaps in training, mentorship, and infrastructure; fewer funding opportunities; regulatory limitations; lack of incentives and recognition; and low government investment.¹⁵ 

Despite these limitations, meaningful research is performed worldwide. Historical examples of hematology research emerging from LMICs include the discovery of the different forms of hemophilia,¹⁶ the use of anabolic steroids in aplastic anemia,¹⁷ the cure for acute promyelocytic leukemia with all-trans retinoic acid and arsenic trioxide,^18,19 dose optimization of effective but expensive drugs, and the implementation of alternative models of care like outpatient hematopoietic cell transplantation.²⁰ Other creative and cost-effective solutions to problems otherwise addressed with approaches too costly for LMIC may have been developed but gone unnoticed or unpublished. How can global hematology contributions be fostered? Systemic inequities in research capacity and output should be improved by increasing investment in research and education. Another key factor is to increase the presence of global hematology contributions in peer reviewed, high impact factor (IF) journals. Contributions published in high-IF journals are widely disseminated and read; they are frequently cited and influential, stimulating further research and shaping policies. Equally excellent global hematology research may, in some instances, affect more lives and decrease global disparities in patient outcomes than scientifically complex or expensive research. Successful examples of international research collaborations aimed at solving global issues across world regions exist (Table 1).

Still, there is a wide geographical imbalance in publications in high-IF hematology journals. According to Journal Citation Reports, the median percentage of publications from countries outside North America and Europe in 2020 to 2022 was 19.4% (interquartile range, 16.6-21.5), and the number of publications in LMICs worldwide was 10.4% (interquartile range, 8.8-11.3; Table 2).

“International” high-IF journals should be congruent with their mission that carries a moral responsibility for the whole world. However, editorial bias may exist. Randomized controlled trials in hematology and oncology, the gold standard for evidence in medical research, are more frequently published in journals with lower IF when they are authored by authors from LMIC than trials from HIC.^34,35 

One possible contributor is the composition of editorial boards. Like most hematology journals, 77% of all hematology editorial roles in 2022 were filled by persons from North America and Europe. Only 7% of editors were affiliated to institutions in South America, Africa, or Southeast Asia.³ The issue is amplified when considering high-IF journals in general, in which ∼80% of editorial roles are filled by those from North America and Europe, with only 1% filled by individuals in LMIC.^4,36 Notably, 71.1% of editorial roles are filled by non-Hispanic whites, and 20% of editors had repeated roles in >1 journal.^4,36 This disparity places the spotlight on issues that are more relevant in parts of the world more widely represented in these boards. Editors direct the narrative and content of journals by selecting in an unblinded manner which submissions are to be published, thus have the potential for biased decision-making.^37,38 It might be more difficult for such members to fully and equitably appreciate the value of contributions addressing issues of relevance to LMIC. Studies should be judged on scientific novelty but also on their potential for advancing diagnostic and therapeutic capacity through cost-effective means. The assignment of contributions to editors who are attuned to the issues presented is thus logical and necessary. Furthermore, the careful selection of blinded peer reviewers who are both experts in the field and familiar with the global problems being addressed, is key.

This does not mean setting a lower bar for investigators from LMIC, or that journals should alter their quality standards. Rather, given that scientific publishing is a highly lucrative enterprise, the playing field could be leveled by offering support to investigators who need it. Examples of support from international journals could include offering education and mentorship opportunities, the exemption of English proficiency as a determinant of acceptance, the offer of affordable language editing services and statistical counseling and support, and the creation of tiered submission and open-access fees based on a thorough assessment of payment capacity based not only on gross macroeconomic indices.

Other solutions to move research performed globally to the forefront include the creation of sibling journals under the umbrella of high-profile academic societies or publishing groups, to expand access without diverting high-impact research to lower IF journals. To advance science and global health, medical journals, editors, and peer-reviewers should work as true partners in science with investigators and physicians worldwide for the betterment of humanity.

Contribution: J.C. designed the project, wrote, reviewed, and edited the manuscript, and approved the final version; A.G.-D.L. wrote, reviewed, and edited the manuscript, and approved the final version; A.N.-P. and L.G.-F. collected data, reviewed and edited the manuscript, and approved the final version; and H.M., V.M., A.E.-B., H.T., and C.P. reviewed and edited the manuscript and approved the final version.

Conflict-of-interest disclosure: A.G.-D.L. received honoraria for talks from AbbVie, Amgen, Astellas, Janssen, Novartis, and Sanofi, and served on the advisory board of Pfizer and Janssen. The remaining authors declare no competing financial interests.

Correspondence: Jorge Cortes, Georgia Cancer Center, Augusta University, 1410 Laney Walker Rd, CN2222, Augusta, GA 30912; email: jorge.cortes@augusta.edu.