Blue Books: Global Guidelines, Local Blind Spots

Where I come from matters. I was born and trained in India; a country that, in the 1980s, was still wrestling with the consequences of economic scarcity. In that era, access to advanced diagnostics was limited – medicine lagged far behind the West. Today, India is a nation of extremes: a robust private healthcare sector where the wealthy can access virtually any treatment, juxtaposed with a vast majority who continue to face immense barriers to even basic care.

In that sense, India is a microcosm of the world, and it has profoundly shaped how I think about international pathology standards and, in particular, the World Health Organization (WHO) Classification of Tumors. I now serve as a Professor of Pathology at Harvard Medical School, which is a far cry from the resource-limited settings where I began my medical journey.

The WHO tumor classification system sets out to standardize pathological diagnostics by establishing globally applicable criteria and nomenclature. Its goals include supporting evidence-based clinical management through consistent and reliable diagnostic frameworks. Yet, despite these laudable aims, the current classification fails to serve the diagnostic needs of 85 percent of the world’s population, who live in low- and middle-income countries (LMICs).

I have no personal grievance with the WHO Blue Books Editorial Board. Many of them are my colleagues and friends. I’ve even contributed as an author to several chapters, and I’m certainly not against scientific progress. I practice in a high-income country (HIC) and aim to offer my patients every advanced diagnostic tool and therapeutic modality available to deliver optimal care. Some genetic alterations I’ve helped characterize, such as the EWSR1–PATZ1 sarcomas, are now recognized within WHO classifications.

But should every discovery made in a resource-rich setting automatically become part of a global classification system, irrespective of its clinical utility or feasibility worldwide? The answer is no. Because the issue here goes beyond taxonomy: it’s about equity, access, and trust.

For me, the tipping point was the fifth edition of the WHO Classification of Tumours of the Central Nervous System. Scientifically, it’s brilliant. But it sets diagnostic requirements – such as methylation profiling – that are inaccessible even at my institution. How then, can we expect pathologists working in Nigeria, Indonesia, and India’s public hospitals, to work with tools they don’t have and toward classifications they cannot implement?

There’s been a loud debate on social media about the limitations of the WHO Blue Books, especially for LMICs. Still, the conversation has been respectful and constructive – showing how thoughtful debate can help move the field forward. Here, I want to share one practical recommendation that I believe could help solve many of the issues I’ve raised.

Increase LMIC representation on WHO editorial boards.

LMICs bear about 70 percent of global cancer deaths and house most of the world’s population and patients. WHO Blue Books inevitably reflect the perspectives of their editors, their training, their systems, and their assumptions. And right now, nearly 95 percent of the editors of the sixth Edition are from HICs. One of the most serious oversights is in the breast and gynecologic tumor volumes – there isn’t a single editor from a LMIC. This sends the troubling message that either no qualified experts exist (which is false) or that the needs of women with these cancers in LMICs are being ignored.

Let’s be honest about one of the main arguments often used to justify the lack of LMIC representation: that published research is the gold standard and LMIC pathologists haven’t published enough. But the publishing system itself is biased. Most journal editors are based in HICs – one study found 95 percent of editorial staff and all editors-in-chief were from HICs. Yet journals with more editors from LMICs tend to publish more studies relevant to those regions.

Research funding, infrastructure, and visibility are concentrated in the global North. From my own experience, there’s a subtle but real bias against submissions from LMICs. It’s a circular argument: you can’t publish without access, and you can’t access the WHO process without publications. If WHO selection relies too much on publication metrics, it automatically favors academics from well-funded institutions – while undervaluing the real-world expertise of LMIC clinicians who manage large numbers of complex cases with few resources. That expertise is critical and deserves a place in shaping global guidelines.

To challenge this bias, we need to start by recognizing the vital expertise LMIC pathologists offer. For example, pathologists in sub-Saharan Africa have firsthand experience with infection-related cancers, like Kaposi sarcoma. In India, experts have advanced our understanding of oral cancers linked to local habits. Chinese researchers have valuable data on stomach and liver cancers. Ignoring these perspectives means missing out on low-cost diagnostic solutions and approaches that fit local needs.

If WHO tumor classifications included equal input from LMICs, we’d likely see more adaptable guidelines – like alternate diagnostic pathways for settings with limited resources. The problem isn’t a lack of knowledge – it’s a lack of visibility. LMIC pathologists are often excluded from global conversations not because they’re unqualified, but because the system hasn’t made room for them.

And the unspoken argument, the one no one says aloud but which hangs in the air, is that pathologists in LMICs are not good enough. Let me say, in the strongest terms possible: that is not true. Some of the best pathologists I’ve met are in India, not because it’s my country of birth, but because I’ve seen their brilliance firsthand. They deal with immense diagnostic complexity, staggering volumes, and severely constrained resources – and they do so with rigor and excellence.

Other organizations have shown how to fairly include global voices. For example, the Intergovernmental Panel on Climate Change (IPCC) uses a global nomination process to choose authors, ensuring a good mix of expertise, regions, and genders. Each chapter usually has two lead authors – one from a HIC and one from a LMIC – to bring in different perspectives and keep things balanced.

I’m not suggesting that LMICs make up 85 percent of the group (even though they carry most of the disease burden), but aiming for a 50/50 split would be fair. Importantly, this shouldn’t be just symbolic. LMIC experts should have an equal voice – people who have lived, worked, and trained in LMICs, not just those born there but shaped by high-income institutions.

Fair representation isn’t a new idea. History shows that including marginalized voices in decision-making leads to better outcomes, especially in public health. For example, when women in the US won the right to vote, lawmakers started focusing more on health and social issues. Local health spending increased, programs like hygiene visits were introduced, and childhood death rates dropped by 8-15 percent. Civil rights research also shows that inclusive care matters – one US study found that Black newborns were nearly twice as likely to survive when cared for by Black doctors.

The WHO has taken some steps toward inclusion, such as appointing its first Director-General from Africa, Tedros Adhanom Ghebreyesus. But true equity isn’t just about symbolism – it helps build trust. Health professionals in LMICs are more likely to follow WHO guidelines when they see themselves represented in their creation. Right now, the WHO Blue Book editorial boards are mostly made up of experts from HICs. This lack of diversity could harm both the WHO’s reputation and the usefulness of its tumor classification system over time.

To put it simply, we can do better. We must do better. The status quo is not acceptable. This is our moment – a call, not just for scientific refinement, but for structural equity.

Vikram Deshpande is Professor of Pathology at Harvard Medical School and Pathologist at Beth Israel Deaconess Medical Center, Boston, Massachusetts, US

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