African Patients and Trialists Largely Left Out of CV Research

African representation is severely lacking in some of the world’s leading general medical journals, even more so among those focused on cardiology, a multiyear comparison study shows.

Less than 4% of the 2,472 RCTs published in five leading journals between 2019 and 2024 were conducted exclusively in Africa. Among the three leading cardiology-focused journals—Journal of the American College of Cardiology, Circulation, and the European Heart Journal—that number was even smaller, at 0.6%, which corresponds to just two RCTs.

Lead author Bamba Gaye, MD, PhD (Emory School of Medicine, Atlanta, GA, and Cheikh Anta Diop University, Dakar, Senegal), said the aim of bringing this lack of representation to light is to move the conversation from awareness to accountability, specifically addressing what he termed the “structural silence" in global research that leaves medical guidelines scientifically incomplete.

“The underrepresentation of African populations is a crisis of scientific validity,” Gaye said in an email. “Biology, environment, and disease patterns are not universal constants. Research that excludes 20% of the human population (and a region bearing 25% of the global disease burden) is scientifically incomplete.”

In the paper, published recently in JACC, Gaye and colleagues note that over the last 30 years, CVD incidence has risen dramatically in Africa and now accounts for around 38% of all deaths not associated with communicable diseases. The continent and its population also have distinct disease profiles that include high rates of rheumatic heart disease and hypertension, young age, and high prevalence of infectious diseases.

Studies suggest that African populations also may have responses to pharmacotherapy that diverge from those of other populations, including three-to-fourfold higher risks of severe side effects from some antihypertensives, emphasizing the necessary safety aspect of including them in cardiovascular research.

Messages for Funders, Journals, and Societies

Funding is a big part of the problem, which Gaye and colleagues say can be bridged in part by transitioning global research from a “recruitment hub” model to one of strategic co-leadership.

“We expect collaborations to be governed by clear rules that ensure African investigators are decision-making partners from trial conception and protocol leadership to steering committee governance and senior authorship,” Gaye noted.

The study found that African scientists were lead authors in only 3.6% of multinational trials that involved an African site. Additionally, the research design of those trials was often dominated by institutions located in high-income countries.

Their plan for collaboration includes ring-fenced funding, which would protect African-led teams and patients; investment in infrastructure, data units, and biorepositories to build sustainable local capacity rather than one-off projects; and equitable budget and leadership distribution.

To TCTMD, Gaye said journal editors, too, have power to improve the representation of African authors.

“To ensure African science is a central pillar of global discovery, journals should: mandate population diversity reporting and require a scientific justification when African populations are excluded from trials of high-burden diseases,” Gaye said.

Other avenues include enforcing equitable authorship standards by ensuring that African investigators who lead implementation are recognized in first or senior roles, strengthening African editorial participation, and supporting local dissemination of research findings.

Academic societies can play a role by building regional trial networks, providing protected training pipelines and research fellowships for African scientists, embedding Africa in guideline-development planning, hosting annual meetings and conferences in African countries, offering small grants for seed trials, and developing shared registries and data systems.

While infectious disease trials have long been the focus of research in Africa, Gaye and colleagues say it is time for funding agencies and industry to broaden their focus and start prioritizing research on CVD there as well.

“Ultimately, for the world to have truly ‘evidence-based’ medicine, the evidence must finally include the whole world,” Gaye added.