Universidade Federal Do Sul E Sudeste Do Pará, Marabá, Brazil.
Harvard Medical School, Boston, USA.
BMC Health Serv Res. 2024 Nov 30;24(1):1516. doi: 10.1186/s12913-024-11958-1.
Multidrug-resistant tuberculosis (MDR/RR-TB) is a major global health challenge, disproportionately affecting low- and lower-middle-income countries (LLMICs). The World Health Organization (WHO) generates guidance to address the problem. Here, we explore the extent to which guidance and related knowledge are generated by experts living in the most-affected countries and consider the results in the context of the movement to decolonize global health.
We examined the composition of World Health Organization (WHO) MDR/RR-TB treatment Guideline Development Groups (GDGs) from 2016 to 2022. We classified GDG members according to the MDR/RR-TB burden and World Bank income level of the country of their institutional affiliation. We also searched PubMed to identify peer-reviewed publications from 2016 to 2023 which emanated from individual-patient-data meta-analysis like those done for Guideline review, and classified the publication authors according to the same indicators.
There were 33 high-burden MDR/RR-TB countries during the time period. Of these, 72.1% were LLMICs and none was high-income. In contrast, only 30.3% of WHO GDG members and 10.4% of peer-reviewed publication authors were from LLMICs. Representatives from high-MDR/RR-TB-burden countries comprised 34.3% of WHO GDG members and 14.7% of authors of guideline-related publications.
The important imbalance between the geographical distribution of lived experience with MDR/RR-TB and the distribution of individuals generating knowledge and guidance on treatment of MDR/RR-TB can have clinical and resource implications. Countries may reject or defer guideline adoption because of a mismatch between that guidance and local disease epidemiology. Funding conditioned on compliance with guidelines can exacerbate health inequalities. The movement to decolonize global health considers representation disparities as epistemic injustice, that is unfair treatment in the process of generating, sharing, or receiving knowledge. Reform is possible in many of the institutions involved in generation of global health knowledge, such as: meaningful participation of LLMICs in projects as a requirement for research funding, improved attention to the epistemic and geographical location of journal editorial staff, and broader inclusion in guidelines committees. Better alignment of participation in knowledge generation with burden of disease holds potential for reducing inequality and improving relevance of guidance for the lived experience with MDR/RR-TB.
耐多药/利福平耐药结核病（MDR/RR-TB）是一个重大的全球卫生挑战，严重影响着低收入和中低收入国家（LMICs）。世界卫生组织（WHO）制定了相关指导意见来应对这一问题。在这里，我们探讨了生活在受影响最严重的国家的专家在多大程度上制定了指导意见和相关知识，并结合非殖民化全球卫生运动的背景来考虑这些结果。
我们研究了 2016 年至 2022 年期间世界卫生组织（WHO）耐多药/利福平耐药结核病治疗指南制定小组（GDG）的组成。我们根据国家机构隶属的耐多药/利福平耐药结核病负担和世界银行收入水平对 GDG 成员进行了分类。我们还在 PubMed 上检索了 2016 年至 2023 年发表的同行评议出版物，这些出版物源于类似指南审查的个体化患者数据荟萃分析，并根据相同的指标对出版物作者进行了分类。
在研究期间，有 33 个耐多药/利福平耐药结核病负担高的国家。其中，72.1%为低收入和中低收入国家，没有一个是高收入国家。相比之下，只有 30.3%的世卫组织 GDG 成员和 10.4%的同行评议出版物作者来自低收入和中低收入国家。高耐多药/利福平耐药结核病负担国家的代表占世卫组织 GDG 成员的 34.3%，占与指南相关出版物作者的 14.7%。
耐多药/利福平耐药结核病患者居住地经验的地理分布与治疗耐多药/利福平耐药结核病知识和指导的生成之间存在重要的不平衡，这可能会对临床和资源产生影响。由于指南指导与当地疾病流行病学之间不匹配，国家可能会拒绝或推迟采用指南。以遵守指南为条件的资金可能会加剧卫生不平等。非殖民化全球健康运动认为代表性差距是知识产生、分享或接受过程中的认知不公正，即不公平待遇。在涉及全球健康知识生成的许多机构中，改革是可能的，例如：将低收入和中低收入国家在项目中的实质性参与作为研究资金的要求、更加关注期刊编辑人员的认知和地理位置，以及更广泛地纳入指南委员会。使参与知识生成与疾病负担更好地保持一致，有可能减少不平等，并提高耐多药/利福平耐药结核病患者居住地经验指导的相关性。
