Equity in Global Health Research.

Abstract

Despite its seemingly idyllic setting—Caribbean sun, crystal-clear blue skies, and waves crashing on the beach—the population of Vieques, a small island off the coast of Puerto Rico, faces a grim future. For 60 years, Vieques was used as an explosives test site by the U.S. Navy, leaching toxic chemicals and heavy metals into the surrounding areas for decades. The people of Vieques are eight times more likely to die from cardiovascular disease and seven times more likely to suffer from diabetes—the highest rates of sickness in the Caribbean.1 This is only one example in a long history of high-income countries (HICs) exploiting low- and middle-income countries (LMICs) or territories, such as Puerto Rico. Although overt forms of exploitation have faded, a more nuanced form of neocolonialism is found in some modern public health initiatives. As increased globalization has led to persistent interest in global health research, it is crucial to accept the responsibility of global health equity. To discuss equity in this context, however, requires defining the field of global health itself. Koplan et al. describe global health as “an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide.”2 A focus on collaboration among multiple disciplines to develop and implement solutions to global health problems distinguishes global health from similar disciplines, such as international and public health. Furthermore, global health’s focus on equity—different from equality—is a defining aim. Equity posits that resources are accessible to all communities, whereas equality means that resources are available to all communities. In other words, an equity approach acknowledges different starting points, whether that be geographic inaccessibility or socioeconomic status, and compensates by providing everyone with what they need to be healthy; meanwhile, an equality approach ensures that everyone receives the same treatment, not adjusting for accessibility concerns (Fig. 1). The harmful power dynamics between HICs and LMICs may complicate efforts by global health professionals to achieve equitable outcomes.Fig. 1.: Equality versus equity. In the equality condition, the game is available to all, but there is a significant barrier (fence height) to access for some. In the equity condition, the game is accessible to all, as barriers have been mitigated (crate for shorter individual). From Interaction Institute for Social Change. Artist: Angus Maguire. Available at: http://interactioninstitute.org and madewithangus.com. Accessed April 12, 2022. Creative Commons License: Attribution-ShareAlike 4.0 International (CC BY-SA 4.0).This article will use examples of published global health initiatives to parse out general themes of global health equity and provide context for what equity entails. We will use a framework developed by the Center for Global Health Equity at the University of Michigan to structure a discussion on equitable global health initiatives. This framework includes the “3 Ps”: equal partnerships, sustainable processes, and products that are beneficial for all.3 By describing how researchers can pursue equity in each of the Ps, we will provide insights into equitable approaches to global health research. PARTNERSHIPS A challenge in forming global health partnerships is ensuring that resources and decision-making are shared equitably between HICs and LMICs. The essential characteristics of equitable partnerships are collaboration, sustained funding, and a shared goal. Most importantly, equity in global health seeks the ultimate goal of empowering local researchers to lead initiatives themselves. A joint PhD program between the Karolinska Institutet in Sweden and Makere University in Uganda offers a model for incorporating the essential characteristics of equitable partnerships while working toward that goal. In what are called “sandwich” agreements, Makere students split their time between Uganda and Sweden, permitting them time to research in their home country while completing coursework, data analysis, and supervised work in Sweden.4 This not only facilitates research to improve care in their home country, it ensures their learning and training are on par with peers in HICs. A focus on Ugandan health priorities is crucial considering how Ugandan researchers are more likely to focus on locally relevant topics and better communicate their findings within the cultural context of their home country. In addition, Makere students are funded and collaborate long-term through this partnership. Long-term commitments and sustained funding by Sweden’s international development agency foster the research capacity at Makere by building research laboratories and a central research management system. Direct investment in local research capacities increases opportunity for locally led research, leading to more opportunities to develop the skill base of LMIC scientists and support staff. The support from Sweden facilitates autonomy and participation in research for LMICs. The partnership also encourages interdisciplinary collaboration on Ugandan health issues. This, in turn, creates an environment for mentorship of junior scientists and increases the visibility of resident institutions.5,6 Through long-term collaboration, sustained funding, and a shared vision on responding to local health priorities, the partnership between Makere and Karolinska demonstrates how productive LMIC-led research can be achieved. Inequities in global health partnerships stem largely from the exclusion of LMIC stakeholders in the decision-making process. By empowering LMIC partners and working toward LMIC ownership of future endeavors, equitable partnerships are possible. PROCESS Although universal guidelines do not exist for sustaining equitable global health processes, two overarching themes emerge: trust and continued support. Trust acts as the foundation for an equitable research process, through which continued support may be offered. Establishing trust between researchers and participants may seem elementary, but participants in LMICs have been mistreated and misguided historically. For instance, a clinical trial was conducted in human immunodeficiency virus–infected women in Asia and Africa that included protocols such as a “no-treatment control” group despite the known efficacy of the drug zidovudine in decreasing human immunodeficiency virus spread, and in an assigned study group administering the drug to pregnant women and newborn babies.7,8 This history has sown seeds of distrust throughout LMICs that lead to negative health consequences. For example, an analysis of the Ebola outbreaks in the Democratic Republic of the Congo in 2019 found that citizens had high levels of distrust and thought Ebola was a profit-making ploy for aid workers and researchers.9 This distrust resulted in patients ignoring official advice and enabled the virus to spread. How or why distrust continues to perpetuate within health care systems is not fully understood, yet there are some tangible causes, such as poor implementation of health services and unmet expectations, which may be modified to bolster trust in the health system.9 To change this rhetoric, it is essential that HICs extend LMICs the same basic research principles of informed consent and ethical considerations. This entails following the same safety protocols required in HICs, despite LMIC’s requirements. Many LMICs lack local ethics committees.6 Michigan Medicine’s kidney transplant program in Ethiopia offers a good case study where these principles are applied. The Michigan Medicine transplant surgery team was approached by the Minister of Health to form a partnership with Ethiopian surgeons to start a kidney transplant program.10 This program took years to develop, and continued support is provided by the doctors at Michigan Medicine.10 Mutual trust may be found on an individual level, between the American surgeons and Ethiopian fellows and between the surgeons and their patients, and on an institutional level, such as how oversight entities pursued and aided in the creation of the project. Although the Michigan team gained the trust of the minister of health, other projects may need to build trust within local cultural structures, such as working with village elders who grant permission to activities occurring in their communities. Ensuring that cultural differences are acknowledged and respected would further build trust at the community level. The foundation of trust can be strengthened by providing continued support for LMICs when conducting global health research. Continued support may include long-term projects, access to education, and use of compatible resources. An equitable project emphasizes the long-term nature of a project so that both countries have access to resources. Short-term projects may have unintentional deleterious consequences that may compromise trust and fail to consider root causes. These projects often neglect upstream social determinants of health, such as housing conditions or employment, which may be the main reason for health disparities. In a report, the World Health Organization (WHO) states that most illnesses in LMICs are caused by these upstream factors, indicating that the larger issue is access and wealth accumulation in the modern world.11 To remedy this, providing education and resources for both LMICs and HICs may help the research teams work together toward a mutually beneficial solution. Education may include teaching LMICs to write grants, giving access to scientific resources or databases, and providing training for surgeons or other professionals.12 On the part of the HIC, education may include making a concerted effort to understand equity, learning from previous global research mistakes, and studying the LMIC itself. Both parties can use this education to ensure a feasible and equitable global health project. Feasibility of a study is a crucial piece of planning, especially in a global setting, and may necessitate additional considerations for global health research. LMICs may not have the physical resources necessary for a particular research project; therefore, it is crucial that HICs work closely with LMICs to design a project that is compatible with the local capacity.12 Technology is perhaps the most tangible example of this. If the local community does not have capacity for advanced technology, it would not be appropriate to propose a study that requires it. Once a foundation of trust and support exists, fruitful projects can crystallize. PRODUCTS (OUTCOMES) The products of global health research range from articles published in peer-reviewed journals to policy changes implemented on the ground. These products all face unique challenges with respect to equity. The authorship of peer-reviewed articles provides a measure of LMIC visibility in global research. Unfortunately, issues with authorship, funding, and overall power imbalances manifest in the underrepresentation of LMIC authors.13 The articles published in prestigious journals by HIC researchers who conduct short-term research in LMICs without mentioning contributions from their LMIC colleagues are examples of inequitable outcomes in global health research. However, a variety of other factors contribute to lower representation of LMIC authors. Global health research collaborations are complex and make it difficult to properly rank authors in a way that respects their contributions. Furthermore, language barriers pose a challenge, making it difficult to review articles and meet the standards for authorship. These standards themselves also pose a barrier, given that guidelines on authorship ethics developed in HICs may not apply to the cultural setting of LMICs. For instance, some LMIC researchers are expected to give authorship to their senior colleagues out of respect, despite these colleagues’ lack of participation.14 To ensure the contributions of LMIC researchers are rewarded in an equitable manner, more research on ethical research design, education on authorship, and clear official guidelines are needed. When evaluating the tangible outcomes of global health research, the translation of knowledge to practice through policy implementation or health interventions is critical. The first step is ensuring LMIC partners have access to research findings through equitable ownership of data and resources.15 Ideally, strategies and objectives for the translation of research findings would be built into the initial project plan with relevant stakeholders (ie, researchers, policy makers, administrators, providers, and, most importantly, LMICs) participating in the decision-making process for determining the methods for policy implementation.16 Furthermore, the process of implementation will inevitably encounter real-world challenges. When this occurs, it is necessary to conduct additional follow-up studies to test the effectiveness of practice and policy. The field of implementation research provides a scientific approach to studying global health interventions in a real-world, real-time context to work toward optimal execution.17 Throughout this ever-evolving process, all stakeholders should once again be engaged. With the involvement of the LMIC community, policy makers, and practitioners, health services can be delivered in an effective manner. The general themes of collaboration and trust discussed in previous sections are important for ensuring equity in global health research outcomes. HIC researchers who are aware of cultural differences and willing to collaborate with local stakeholders on an equal footing will be able to deliver knowledge translation that meets the community’s needs. THE SOCIAL JUSTICE APPROACH On the most basic level, social justice “requires equity, fairness, and respect for diversity, as well as the eradication of existing forms of social oppression.”18 This is to say that a patients’ geographic location and socioeconomic status should not determine the quality of care available to him or them. In practice, taking a social justice approach requires accessible health care through the redistribution of resources to disadvantaged people. Applying a social justice approach to global health research requires designing projects that not only satisfy the 3 Ps but also prioritize the most vulnerable populations, even within LMICs. For instance, the kidney transplant project discussed above satisfied the 3 Ps. It created equitable partnerships and sustainable processes, and offered a product not otherwise available to people in Ethiopia. However, this project lacked a social justice approach. The cost, in addition to other factors associated with inaccessibility, made the transplant unattainable for most Ethiopians; Kassa et al. found that higher socioeconomic status was associated with reception of treatment.19 Rather, taking a social justice approach would have meant using the resources dedicated to this project to help the most vulnerable Ethiopians who cannot afford a transplant. When considering what is better for the general population, vaccines, structural interventions, and increased accessibility to primary care may have a greater impact. The 90/10 gap highlights the inequity in global health research. Approximately 10% of global health funding is spent researching diseases that affect more than 90% of the world’s population.20 The WHO notes that although this phenomenon is convenient for emphasizing a disparity in global health, it is not entirely accurate, as there are a number of other factors that perpetuate the cited disparity, such as upstream factors.11 Nevertheless, this is not to say that global health research cannot help improve conditions. There are many tangible ways to take a social justice approach in global health research. First, when designing a project, it is crucial to prioritize equity over equality, such as by prioritizing vulnerable host communities and designing accessible interventions.21 Even within LMICs, some communities are more vulnerable than others. Therefore, an equity-justice approach, with its focus on designating more resources to the most vulnerable, suggests choosing a host community before selecting an intervention or disease. Identifying a disparity in health outcomes first can then highlight underlying causes. Objective outcomes, such as life expectancy and years of life lost to disease, may be helpful when selecting a population for a study.21 Another way to take a social justice approach to global health research is to design interventions that focus on accessibility rather than innovation. The WHO indicates that the medical field has few shortcomings with respect to medical innovation in global research. Rather, it is the inaccessibility of the innovations where the barriers to appropriate health care lie.11 Finally, taking a social justice approach to global health research may also extend beyond one’s actual research. For example, educating oneself on past injustices, systematic issues, and adopting an equitable mindset may help. Nonequitable partnerships have been such the norm for HICs that these patterns often reappear subconsciously. Although recognizing the problems and patterns are the first step, it is essential that a conscious effort be made to change. As the field of global health research continues to grow, it is essential to focus on equity. Equal partnerships, sustainable processes, and research products that are beneficial for all parties are vital to an equity-based approach. However, fulfilling these three conditions may not answer the need for ensuring a basic level of health care for all people in LMICs. Ultimately, a social justice approach will ensure that global health research focuses on interventions that increase accessibility for disproportionately disadvantaged communities, in turn furthering global health equity. ACKNOWLEDGMENT The authors appreciate the peer review and edits from Mike Stokes, staff vice president of communications at the American Society of Plastic Surgeons.