Populations In Low- And Middle-income Countries Research Articles

Ensuring People Living with HIV Inform the Future of HIV Treatment in Low- and Middle-Income Countries: A Scoping Review and Recommendations for a Community-Led Research Agenda.

The HIV treatment landscape in low- and middle-income countries (LMICs) is rapidly evolving, exemplified by the expansion of differentiated service delivery (DSD) during the coronavirus disease (COVID-19) pandemic. Long-acting products represent a new frontier that will require a significant redesign of health systems. It is critical to understand service delivery and product preferences of people living with HIV (PLHIV) and ensure evidence generation is guided by community priorities. We conducted a scoping review to identify gaps among preference studies and inform future research. Peer-reviewed articles published from January 2014-May 2022 reporting acceptability or preference data from PLHIV or caregivers for one or more service delivery or product attribute were eligible. Service delivery studies were restricted to LMIC populations while product studies had no geographical restrictions. Based on gaps identified, we consulted advocates to develop community-led research agenda recommendations. Of 6,493 studies identified, 225 studies on service delivery attributes and 47 studies on product preferences were eligible. The most frequently studied delivery models were integration (n = 59) and technology-based interventions (n = 55). Among product literature, only 15 studies included LMIC populations. Consultation with advocates highlighted the need for research on long-acting products, including among pediatric, pregnant, and breastfeeding PLHIV, PLHIV on second-line regimens, and key populations. Consultation also emphasized the need to understand preferences on clinic visit frequency, side effects, and choice. While the preference literature has expanded, gaps remain around long-acting regimens and their delivery. To fill these gaps, the research agenda must be guided by the priorities of communities of PLHIV.

Augmented Reality (AR) in Surgery in Low- and Middle-Income Countries (LMICs): A Scoping Review.

Surgical disparities persist in low- and middle-income countries (LMICs). Insufficient access to surgical care places a large burden on these regions, with high mortality rates for otherwise standard procedures performed in high-income countries (HICs). Augmented Reality (AR) and Virtual Reality (VR) now provide us with a platform to improve the delivery of surgical access and training to LMICs. The use of AR technologies to provide additional training to surgeons and residents globally can help bridge the gap and reduce health disparities in LMICs. The goal of this scoping review is to evaluate whether surgical trainees and surgeons from LMICs have access to or use AR software in their training or practice. A systematic search was conducted on seven databases. Inclusion criteria included populations in LMICs with access to AR-based training. Articles using VR software, or those conducted in HICs were excluded from the review. From the 428 records screened, 58 reports were assessed for eligibility, and of these, a total of six studies were included in the review. Five of the six studies used mentors from an HIC, including the United States (US) and the United Kingdom (UK), whereas one study had mentorship from another LMIC. Three surgical specialties were explored: neurosurgery, plastic surgery, and urology. Although the integration of AR in surgical training is promising, the six studies evaluated in this review emphasize that costs and connection issues are major challenges that can set back these technologies in the operating room. Despite these revelations, with certain improvements, AR training programs are promising as they can help to reduce the global disparity in surgical proficiency.

Comprehensive profiling of social mixing patterns in resource poor countries: A mixed methods research protocol.

Low-and-middle-income countries (LMICs) bear a disproportionate burden of communicable diseases. Social interaction data inform infectious disease models and disease prevention strategies. The variations in demographics and contact patterns across ages, cultures, and locations significantly impact infectious disease dynamics and pathogen transmission. LMICs lack sufficient social interaction data for infectious disease modeling. To address this gap, we will collect qualitative and quantitative data from eight study sites (encompassing both rural and urban settings) across Guatemala, India, Pakistan, and Mozambique. We will conduct focus group discussions and cognitive interviews to assess the feasibility and acceptability of our data collection tools at each site. Thematic and rapid analyses will help to identify key themes and categories through coding, guiding the design of quantitative data collection tools (enrollment survey, contact diaries, exit survey, and wearable proximity sensors) and the implementation of study procedures. We will create three age-specific contact matrices (physical, nonphysical, and both) at each study site using data from standardized contact diaries to characterize the patterns of social mixing. Regression analysis will be conducted to identify key drivers of contacts. We will comprehensively profile the frequency, duration, and intensity of infants' interactions with household members using high resolution data from the proximity sensors and calculating infants' proximity score (fraction of time spent by each household member in proximity with the infant, over the total infant contact time) for each household member. Our qualitative data yielded insights into the perceptions and acceptability of contact diaries and wearable proximity sensors for collecting social mixing data in LMICs. The quantitative data will allow a more accurate representation of human interactions that lead to the transmission of pathogens through close contact in LMICs. Our findings will provide more appropriate social mixing data for parameterizing mathematical models of LMIC populations. Our study tools could be adapted for other studies.

Unravelling the complexity of research capacity strengthening for health professionals in low- and middle-income countries: A concept analysis.

Research capacity strengthening (RCS) is crucial in enhancing healthcare outcomes, particularly in low- and middle-income countries (LMICs), which face challenges due to limited resources, unequal access to care and the need for evidence-based decision-making. We seek to move beyond a surface-level understanding of RCS, unearthing the core attributes, the factors that precede its implementation and the transformative outcomes it generates within the LMIC healthcare landscape. This study employs the Walker and Avant approach to concept analysis to comprehensively explore the dimensions and attributes of RCS as it pertains to allied and public health professionals in LMICs, propose empirical referents and suggest an operational definition. Ovid MEDLINE, Embase, CINAHL and Cochrane CENTRAL were searched from inception to 27 July 2023, to identify studies on RCS in LMICs. The Walker and Avant approach to concept analysis was selected because it provides a framework for systematically examining and clarifying the meaning and implications of RCS. This method involves a structured process of defining RCS, identifying its attributes, antecedents, consequences and cases, and ultimately providing a clear understanding of its meaning and implications. Identifying empirical referents offers measurable indicators that researchers and policymakers can use to assess the effectiveness of RCS initiatives in LMICs. RCS for health professionals in LMICs involves a sustainable process that equips them with essential research skills, fostering the ability to conduct high-quality research and improve healthcare delivery in resource-constrained settings. RCS aims to empower health professionals to apply evidence-based practices, reduce disparities and enhance the well-being of populations in LMICs. Ultimately, a concept analysis of RCS empowers us to harness the full potential of research to enhance healthcare delivery, improve patient outcomes and advance the well-being of populations worldwide.

Treatment Access for Gastrointestinal Stromal Tumor in Predominantly Low- and Middle-Income Countries

Gastrointestinal stromal tumor (GIST) is a rare cancer treated with the tyrosine kinase inhibitors imatinib mesylate or sunitinib malate. In general, in low- and middle-income countries (LMICs), access to these treatments is limited. To describe the demographic characteristics, treatment duration, and survival of patients with GIST in LMICs treated with imatinib and sunitinib through The Max Foundation programs. This retrospective database cohort analysis included patients in 2 access programs administered by The Max Foundation: the Glivec International Patient Assistance Program (GIPAP), from January 1, 2001, to December 31, 2016, and the Max Access Solutions (MAS) program, January 1, 2017, to October 12, 2020. Sixty-six countries in which The Max Foundation facilitates access to imatinib and sunitinib were included. Participants consisted of patients with approved indications for imatinib, including adjuvant therapy in high-risk GIST by pathologic evaluation of resected tumor or biopsy-proven unresectable or metastatic GIST. All patients were reported to have tumors positive for CD117(c-kit) by treating physicians. A total of 9866 patients received treatment for metastatic and/or unresectable disease; 2100 received adjuvant imatinib; 49 received imatinib from another source and were only included in the sunitinib analysis; and 53 received both imatinib and sunitinib through The Max Foundation programs. Data were analyzed from October 13, 2020, to January 30, 2024. Demographic and clinical information was reported by treating physicians. Kaplan-Meier analysis was used to estimate time to treatment discontinuation (TTD) and overall survival (OS). An imputation-based informed censoring model estimated events for patients lost to follow-up after treatment with adjuvant imatinib. Patients who were lost to follow-up with metastatic or unresectable disease were presumed deceased. A total of 12 015 unique patients were included in the analysis (6890 male [57.6%]; median age, 54 [range, 0-100] years). Of these, 2100 patients were treated with imatinib in the adjuvant setting (median age, 54 [range 8-88] years) and 9866 were treated with imatinib for metastatic or unresectable disease (median age, 55 [range, 0-100] years). Male patients comprised 5867 of 9866 patients (59.5%) with metastatic or unresectable disease and 1023 of 2100 patients (48.7%) receiving adjuvant therapy. The median OS with imatinib for unresectable or metastatic disease was 5.8 (95% CI, 5.6-6.1) years, and the median TTD was 4.2 (95% CI, 4.1-4.4) years. The median OS with sunitinib for patients with metastatic or unresectable GIST was 2.0 (95% CI, 1.5-2.5) years; the median TTD was 1.5 (95% CI, 1.0-2.1) years. The 10-year OS rate in the adjuvant setting was 73.8% (95% CI, 67.2%-81.1%). In this cohort study of patients with GIST who were predominantly from LMICs and received orally administered therapy through the GIPAP or MAS programs, outcomes were similar to those observed in high-resource countries. These findings underscore the feasibility and relevance of administering oral anticancer therapy to a molecularly defined population in LMICs, addressing a critical gap in cancer care.

The intersectional impact of climate change and gender inequalities in Africa

AbstractThe global pursuit of the United Nations Sustainable Development Goals underscores the importance of combating inequality, with climate change emerging as a significant threat, especially in low‐ and middle‐income countries (LMICs). This commentary explores the profound impact of climate change on the lives of women in Africa, shedding light on a critical issue where 80% of the female population in LMICs grapples with its far‐reaching consequences. Climate change is exacerbating existing gender disparities, particularly within the realms of agriculture, livelihoods, and resource access. Barriers like limited training and technology access hinder effective adaptation, perpetuating discrimination. Rooted deeply in social and cultural norms, the consequences of climate change negatively impact the human rights of women, resulting in increased vulnerability to illnesses, malnutrition, limited housing, and restricted support services. Health risks, including malaria transmission and respiratory diseases, further compound existing challenges, leading to increased rates of anemia, violence against women, alarming spikes in child marriages, and socio‐economic consequences. Integrated policies emphasizing gender mainstreaming, multisectoral approaches, and closing gender gaps in asset ownership are crucial to addressing these challenges. Education, training, and upskilling opportunities are essential to empowering women to confront climate change, further advocating for the development and enforcement of laws and policies recognizing gender differences and safeguarding women's rights. Moreover, there is a need for integrated solutions to foster sustainable development in Africa, as climate change is not a standalone issue but rather intertwines with various aspects of life. By advocating for policies that promote gender equality, education, and resource access, it seeks to pave the way for a more resilient and empowered female population, capable of navigating the complexities of climate change and contributing to the broader goal of sustainable development on the African continent.

Stroke rehabilitation in low resource countries: time to provide an organised service

Introduction: Stroke is one of the leading causes of death and disability in lowand middle-income countries (LMICs). The proven efficacy for rehabilitation interventions in improving stroke outcomes in LMICs supports the need to strengthen the rehabilitation workforce. Low-cost physical rehabilitation interventions requiring minimal resources, self-rehabilitation, tele-rehabilitation and involvement of family and other carers can be a solution and improve functional outcomes.
 Method: A literature search using the terms Stroke and Rehabilitation were carried out by the Chief Librarian at St. Richard’s Hospital, the University Hospital Sussex. Four databases, namely Ovid Medline, EMBASE, CINAHL and Ebsco CINAHL, were searched using appropriate subject headings and free text terms such as stroke and rehabilitation . We used free text terms to look for concepts synonymous with rehabilitation in LMICs. We did not search for individual countries or continents/sub-continents.
 Results: Relevant results from 2015 to current were included. Twenty articles were finally chosen which included the most relevant and useful information for the purpose of this article.
 Conclusion: Populations in LMICs are exposed to health systems which do not include rehabilitation services. In addition, there are personal barriers to accessing quality stroke rehabilitation that could improve stroke survival and functional outcomes. Although there have been some improvements in the development of stroke rehabilitation in some LMICs, further investment is required to ensure that LMICs continue to receive the best quality rehabilitation services. There are measures that can be put in place to reduce these deficiencies. Collaboration between LMICs and developed countries has been growing but this needs to be extended, especially in training doctors in Rehabilitation Medicine and upskilling therapists. The World Health Organisation Rehabilitation 2030 is an action plan to scale up rehabilitation so that countries, especially LMICs, can be better prepared to address the evolving rehabilitation needs of populations by 2030.

Health and health system effects on poverty: A narrative review of global evidence

Ill-health causes poverty. The effect runs through multiple mechanisms that span lifetimes and cross generations. Health systems can reduce poverty by improving health and weakening links from ill-health to poverty. This paper maps routes through which ill-health can cause poverty and identifies those that are potentially amenable to health policy. The review confirms that ill-health is an important contributor to poverty and it finds that the effect through health-related loss of earnings is often larger than that through medical expenses. Both effects are smaller in countries that are closer to universal health coverage and have higher social safety nets. The paper also reviews evidence from low- and middle-income countries (LMICs) and the United States (US) on the poverty-reduction effectiveness of public health insurance (PubHI) for low-income households. This reveals that PubHI does not always deliver financial protection to its targeted population in LMICs. Countries that have succeeded in achieving this goal often combine extension of coverage with supply-side interventions to build capacity and avoid perverse provider incentives in response to insurance. In the US, PubHI is effective in reducing poverty by shielding low-income households with children from healthcare costs and, consequently, generating long-run improvements in health that increase lifetime earnings. Poverty reduction is a potentially important co-benefit of health systems.

A double-bounded risk-risk trade-off analysis of heatwave-related mortality risk: Evidence from India

As climate variability is increasing, extreme events such as temperature fluctuations are expected to become more frequent. Low- and middle-income countries (LMICs) are especially vulnerable to heat-related variability and its ensuing impacts on mortality. Therefore, there is an urgent need to understand how citizens in LMICs trade-off climate-related mortality risks with other risks such as traffic accidents, and what values they place on reducing such risks. As populations in LMICs are income-constrained, we adopt a non-monetary, risk-risk trade-off (RRTO) valuation method instead of the standard willingness-to-pay stated preference-based approach. We estimate the resulting risk premium for heatwave-related mortality risks through an adapted double-bounded, dichotomous choice approach to establish whether, on average, people value avoiding these risks more compared to reducing traffic risks. Using a sample of over 2,300 individuals from across seven states in India, a country with one of the highest heat-related mortality globally, we estimate the heatwave risk mortality premium to be between 2.2–2.9, indicating that on average, individuals weigh reducing heatwave-related mortality risks more than two times that of reducing traffic accident mortality risks. Based on a standard benefit transfer methodology for LMICs, this premium translates to a Value of Statistical Life (VSL) of USD 0.37–2.61 million for India.

Global assessment of healthcare policies and socioeconomic impact of the rapid rising of non-communicable diseases in LMICs: Case study, Cameroon

Background: The rapid transition from communicable diseases (CDs) to non-communicable diseases (NCDs) in low- and middle-income countries (LMICs) presents a global health challenge, impacting healthcare policies and socioeconomic dynamics. Our study assesses how the prevalence of NCDs influences health and economic indicators, like, quality of life and productivity by conducting a comprehensive global assessment of the role of healthcare policies in addressing this disease transition with a specific focus on Cameroon. Methodology: The study examined the literature from a range of sources, such as Science Direct, PubMed, and official reports, in order to analyse both global and Cameroonian healthcare policies and highlight opportunities and problems with effectively managing NCDs. Results: The socioeconomic impact of the rising NCDs is core concern, as they impose substantial economic burdens on both individuals and healthcare systems. Sub-Saharan countries, Cameroon inclusive, stand to suffer most if it is not addressed early enough. Moreover, by understanding the socioeconomic implications of NCDs, strategies can be developed to mitigate their adverse effects and improve the overall well-being of populations in LMICs. Conclusion: The increasing prevalence of NCDs poses a significant risk to the well-being of the younger generation, jeopardizing their quality of life. Thus, a thorough analysis of healthcare policies and socioeconomic consequences is essential. It highlights the pressing necessity of a multifaceted strategy to tackle this health transition and underscores the importance of customized approaches to address the unique challenges encountered by countries such as Cameroon.

Local Sources of Protein in Low- and Middle-Income Countries: How to Improve the Protein Quality?

Protein inadequacy is a major contributor to nutritional deficiencies and adverse health outcomes of populations in low- and middle-income countries (LMICs). People in LMICs often consume a diet predominantly based on staple crops, such as cereals or starches, and derive most of their daily protein intakes from these sources. However, plant-based sources of protein often contain low levels of indispensable amino acids (IAAs). Inadequate intake of IAA in comparison with daily requirements is a limiting factor that results in protein deficiency, consequently in the long-term stunting and wasting. In addition, plant-based sources contain factors such as antinutrients that can diminish protein digestion and absorption. This review describes factors that affect protein quality, reviews dietary patterns of populations in LMICs and discusses traditional and novel small- and large-scale techniques that can improve the quality of plant protein sources for enhanced protein bioavailability and digestibility as an approach to tackle malnutrition in LMICs. The more accessible small-scale food-processing techniques that can be implemented at home in LMICs include soaking, cooking, and germination, whereas many large-scale techniques must be implemented on an industrial level such as autoclaving and extrusion. Limitations and considerations to implement those techniques locally in LMICs are discussed. For instance, at-home processing techniques can cause loss of nutrients and contamination, whereas limitations with larger scale techniques include high energy requirements, costs, and safety considerations. This review suggests that combining these small- and large-scale approaches could improve the quality of local sources of proteins, and thereby address adverse health outcomes, particularly in vulnerable population groups such as children, adolescents, elderly, and pregnant and lactating women.

Integrating population neuroscience and syndemics frameworks to better understand global sex and gender‐based risk in Alzheimer’s disease and related dementias

AbstractAging populations in low‐ and middle‐income countries (LMICs) are growing more rapidly than those in high income countries (HICs). Thus, globally, the burden of Alzheimer’s disease and related dementias (ADRD) profoundly impacts LMICs, with greater burden and risk for late‐life women than men. LMICs are unable to meet diagnostic challenges with underfunded healthcare infrastructure, low numbers of clinicians with training and expertise in ADRD, and a lack of culturally and linguistically sensitive screening assessments. Emerging social and societal factors that are important risk and protective factors for later life ADRD and are differentially experienced by gender/sex are relatively understudied, yet essential in LMICs. Typical samples in neuroscience studies have been small and highly selected. They have been biased toward Western, Educated, Industrialized, Rich, and Democratic (WEIRD) samples and do not apply well to target populations in LMICs. In addition, levels‐of‐analysis across social/societal and biological determinants of disease are not typically integrated, and social/societal factors such as sociocultural (e.g., culture, religion, gender norms, access to education, discrimination, social aspects of pandemics, disability), political (e.g., governments and policies; migrants and displaced persons; war and conflict; reproductive health, justice, and agency), environmental (e.g., climate change and pollution), and economic factors (e.g., poverty), and their co‐occurrence, have been minimally considered for their role and impact on ADRD. To better understand gender/sex differences in ADRD in LMICs, we review how these social and societal factors may be important to ADRD using an integrated Population Neuroscience and Syndemics framework. Population neuroscience considers the brain in context using multiple levels of analyses, a life course perspective, and tools to enhance internal and external validity, while Syndemics suggest that diseases and social conditions may cluster and interact in populations with syndemic risk factors—sociocultural, political, economic, and environmental factors which promote stress pathways. We lay out a model in which syndemic risk and protective factors contribute to or protect from stress and biological aging and ultimately ADRD risk, both directly and indirectly through physical and mental health conditions. We close with recommendations for future aging and ADRD research based on this integrated Population Neuroscience‐Syndemics of ADRD framework.

Patients, Parents and Providers Perspectives Toward Treatment Options for Sickle Cell Disease

Introduction Sickle cell disease (SCD) is the most common hemoglobinopathies in the world. It is more prevalent in malaria endemic areas where most low-and-middle-income countries (LMIC) are found. Because of challenges in accessing care, persons with SCD (PWSCD) in these settings have a poor outcome and up to 50% die before the age of five years in some places. Those who survive early childhood develop complications at a young age causing their families significant emotional and socioeconomic distress. Effort in LMIC is being directed toward screening for SCD and early initiation of treatment which has improved overall survival and quality of life of PWSCD. However, there are concerns about adherence to treatment due to pill fatigue, persistent SCD symptoms, end organ damage despite available treatment, and side effects of medications. With improved care, SCD is evolving into a chronic illness even in LMIC and PWSCD are surviving into adulthood. These countries will soon face the challenge of handling lifestyle and health demands of an emerging adult and aging PWSCD. There have been significant advances in disease modifying (DM) and curative treatment for SCD in high-income-countries (HIC) and the two promising treatment modalities for cure are bone marrow transplant and gene therapy which can be life changing for PWSCD and their families despite treatment related adverse events. Curing SCD may help prevent long-term complications. It is therefore important to explore the perspectives of PWSCD, their parents and SCD providers toward traditional and novel therapies for SCD as the initial step in planning for improved access to SCD treatment in LMIC. Objective To explore the attitudes of PWSCD, Parents (caregivers) of PWSCD and SCD care providers toward traditional and novel therapies for SCD in a LMIC setting. Methodology This was a mixed methods study conducted at a referral facility for PWSCD in western Kenya. It included 5 focused group discussions (FGD) of 6 - 7 consented participants; 2 with patients, 2 with parents and 2 with SCD providers. FGDs were conducted by trained clinicians and lasted 2 hours. A discussion guide which included information on novel therapies was applied to direct the audio-recorded sessions conducted in local dialect. FGD and analysis were iterative with each thematic content analyzed independent of the others and key concepts arising from these sessions explored. Necessary adjustments were made to the discussion guide for subsequent sessions based on emerging themes. The recorded material was then transcribed in verbatim and translated for analysis using a qualitative analysis tool. Results and Discussion This study enrolled 13 PWSCD, 13 parents of PWSCD and 6 SCD providers (n=32). Participants had similar attitudes towards SCD barriers and novel treatments. 96.9% of participants reported using hydroxyurea and folic acid for themselves, their loved one, or their PWSCD. Over the past year, 83.1% of PWSCD reported painful crisis while 33.% had been hospitalized despite adherence to treatment (table 1). Most participants (65.4%) would consider using novel SCD treatments with hesitations being cost, treatment adverse effect, and distance to treatment location. After the educational intervention, participants were more likely to opt for gene therapy (65.4%) than stem cell transplant (19.2%) or remaining on their current regimen (15.6%) (Table 2). Only one SCD providers' FGD was conducted due to their limited availability from competing clinical duties. Some patients who reported being on recommended treatment continued to have health events and complications that made them, their parents or providers want an alternative treatment. Most participants preferred a curative treatment option for their disease despite the challenges mentioned, which highlighted their willingness to participate in clinical trials. While there are infrastructural challenges in LMIC, they have the highest number of PWSCD that would benefit from new DM and curative treatment for SCD despite being underrepresented in clinical trials. They are the most impacted by complications associated with SCD due to sub-optimal care thus need for action to reverse this. Conclusion This study highlights the importance of involving population in LMIC in efforts to find better treatment for PWSCD. There is a need to conduct a similar study involving a larger cohort in future to further explore more perspectives.

Global Surgery Research: An Overview and the Role of Medical Students and Surgical Trainees in Advancing Global Surgery Research in LMICs

Global surgery research is a critical area of study aimed at enhancing access to safe and effective surgical care for patients in low- and middle-income countries (LMICs). It is essential to explore the significance of global surgery research and highlight the potential contributions of medical students and surgical trainees in addressing the pressing needs of LMIC populations. Global surgery research is pivotal in driving progress and fostering innovation by evaluating surgical disease burden, identifying access barriers, developing sustainable solutions, and strengthening health systems. Additionally, integrating sustainability principles into global surgery research endeavors ensures surgical interventions benefit patients while minimizing the environmental impact of surgical care delivery. Medical students and surgical trainees can engage in global surgery research, including collaborating with experienced researchers, developing research projects with local partners, conducting literature reviews, collecting and analyzing data, and disseminating research findings. Despite challenges faced in conducting research in LMIC, such as limited resources and sociopolitical instability, opportunities exist to nurture the interest of medical students and surgical trainees in global surgery research. By actively participating in global surgery research, medical students and surgical trainees can contribute to improving healthcare outcomes in LMICs while honing invaluable research skills for their future careers. Global surgery research is a critical area of study aimed at enhancing access to safe and effective surgical care for patients in low- and middle-income countries (LMICs). It is essential to explore the significance of global surgery research and highlight the potential contributions of medical students and surgical trainees in addressing the pressing needs of LMIC populations. Global surgery research is pivotal in driving progress and fostering innovation by evaluating surgical disease burden, identifying access barriers, developing sustainable solutions, and strengthening health systems. Additionally, integrating sustainability principles into global surgery research endeavors ensures surgical interventions benefit patients while minimizing the environmental impact of surgical care delivery. Medical students and surgical trainees can engage in global surgery research, including collaborating with experienced researchers, developing research projects with local partners, conducting literature reviews, collecting and analyzing data, and disseminating research findings. Despite challenges faced in conducting research in LMIC, such as limited resources and sociopolitical instability, opportunities exist to nurture the interest of medical students and surgical trainees in global surgery research. By actively participating in global surgery research, medical students and surgical trainees can contribute to improving healthcare outcomes in LMICs while honing invaluable research skills for their future careers. Global surgery research is a critical area of study aimed at enhancing access to safe and effective surgical care for patients in low- and middle-income countries (LMICs). It is essential to explore the significance of global surgery research and highlight the potential contributions of medical students and surgical trainees in addressing the pressing needs of LMIC populations. Global surgery research is pivotal in driving progress and fostering innovation by evaluating surgical disease burden, identifying access barriers, developing sustainable solutions, and strengthening health systems. Additionally, integrating sustainability principles into global surgery research endeavors ensures surgical interventions benefit patients while minimizing the environmental impact of surgical care delivery. Medical students and surgical trainees can engage in global surgery research, including collaborating with experienced researchers, developing research projects with local partners, conducting literature reviews, collecting and analyzing data, and disseminating research findings. Despite challenges faced in conducting research in LMIC, such as limited resources and sociopolitical instability, opportunities exist to nurture the interest of medical students and surgical trainees in global surgery research. By actively participating in global surgery research, medical students and surgical trainees can contribute to improving healthcare outcomes in LMICs while honing invaluable research skills for their future careers.

Policy Insights from High-Income Countries to Guide Safe, Nutritious, and Sustainable Alternative Proteins for Low- and Middle-Income Countries

The United Nations has encouraged governments to promote sustainable healthy diets to address undernutrition, obesity, and climate change. This perspective paper examines policy insights from selected high-income countries in Asia, Europe, and North America to understand how traditional and novel alternative proteins (AP) may support sustainable healthy diets in low- and middle-income countries (LMIC) where populations experience malnutrition in all forms. AP products must be affordable, locally sustainable, and culturally acceptable to improve diet quality and health. Food-based dietary guidelines are a policy tool to guide AP product formulation, manufacturing, processing, labeling, and marketing to ensure that these products complement traditional plant- and animal-source proteins in sustainable healthy diets. This paper suggests that a new food categorization taxonomy is needed to guide AP product recommendations. Decision-makers must harmonize multisectoral policies to ensure LMIC populations have access to sustainable healthy diets to achieve a protein transition and food systems transformation by 2050.

Age at diagnosis for lung, colon, breast and prostate cancers: An international comparative study.

Differences in the average age at cancer diagnosis are observed across countries. We therefore aimed to assess international variation in the median age at diagnosis of common cancers worldwide, after adjusting for differences in population age structure. We used IARC's Cancer Incidence in Five Continents (CI5) Volume XI database, comprising cancer diagnoses between 2008 and 2012 from population-based cancer registries in 65 countries. We calculated crude median ages at diagnosis for lung, colon, breast and prostate cancers in each country, then adjusted for population age differences using indirect standardization. We showed that median ages at diagnosis changed by up to 10 years after standardization, typically increasing in low- and middle-income countries (LMICs) and decreasing in high-income countries (HICs), given relatively younger and older populations, respectively. After standardization, the range of ages at diagnosis was 12 years for lung cancer (median age 61-Bulgaria vs 73-Bahrain), 12 years for colon cancer (60-the Islamic Republic of Iran vs 72-Peru), 10 years for female breast cancer (49-Algeria, the Islamic Republic of Iran, Republic of Korea vs 59-USA and others) and 10 years for prostate cancer (65-USA, Lithuania vs 75-Philippines). Compared to HICs, populations in LMICs were diagnosed with colon cancer at younger ages but with prostate cancer at older ages (both pLMICS-vs-HICs < 0.001). In countries with higher smoking prevalence, lung cancers were diagnosed at younger ages in both women and men (both pcorr < 0.001). Female breast cancer tended to be diagnosed at younger ages in East Asia, the Middle East and Africa. Our findings suggest that the differences in median ages at cancer diagnosis worldwide likely reflect population-level variation in risk factors and cancer control measures, including screening.

Palliative Justice Post-COP27.

The climate crisis is a planetary existential threat, disproportionately affecting the poorest populations worldwide. People in low- and middle-income countries (LMICs) experience the most detrimental consequences of climate injustice, endangering their livelihoods, safety, overall wellbeing, and survival. Although the 2022 United Nations Climate Change Conference (COP27) put forth several internationally salient recommendations, the outcomes fall short to efficiently tackle the suffering that exists at the intersection of social and climate injustice. Individuals with serious illness living in LMICs have the highest burden of health-related suffering globally. In fact, more than 61 million people experience serious health-related suffering (SHS) each year that is amenable to palliative care. Despite this well-documented burden of SHS, an estimated 88-90% of palliative care need is unmet, the majority in LMICs. To equitably address suffering at individual, population, and planetary levels in LMICs, a palliative justice approach is crucial. The interplay of human and planetary suffering requires that current planetary health recommendations be expanded to incorporate a whole-person and whole-people perspective that recognizes the need for environmentally conscious and community-based research and policy initiatives. Conversely, palliative care efforts should incorporate planetary health considerations to ensure sustainability in capacity building and service provision. In sum, the optimal health of the planet will remain elusive until we can holistically recognize the value of relieving all suffering due to life-limiting conditions, as well as the value in preserving the natural resources of countries in which all people are born, live, age, suffer, die, and grieve.

Global Health Perspectives on Race in Research: Neocolonial Extraction and Local Marginalization.

Best practices in global health training prioritize leadership and engagement from investigators from low- and middle-income countries (LMICs), along with conscientious community consultation and research that benefits local participants and autochthonous communities. However, well into the 20th century, international research and clinical care remain rife with paternalism, extractive practices, and racist ideation, with race presumed to explain vulnerability or protection from various diseases, despite scientific evidence for far more precise mechanisms for infectious disease. We highlight experiences in global research on health and illness among indigenous populations in LMICs, seeking to clarify what is both scientifically essential and ethically desirable in research with human subjects; we apply a critical view towards race and racism as historically distorting elements that must be acknowledged and overcome.

Suicide in Global Mental Health.

We review recent research on the epidemiology and etiology of suicide in the global context. We focus on data from low- and middle-income countries (LMIC), with the goal of highlighting findings from these under-researched, over-burdened settings. Prevalence of suicide in LMIC adults varies across region and country income-level, but is, on average, lower than in high-income countries. Recent gains in suicide reduction, however, have been smaller in LMIC compared to global rates. LMIC youth have much higher rates of suicide attempts than youth from high-income countries. Females as well as people with psychiatric disorders, those living with HIV, those who are LGBTQ + , and those with poor socioeconomic status are highly vulnerable populations in LMIC. Limited and low-quality data from LMIC hinder clear interpretation and comparison of results. A greater body of more rigorous research is needed to understand and prevent suicide in these settings.

Formulation Studies to Develop Low-Cost, Orally-Delivered Secretory IgA Monoclonal Antibodies for Passive Immunization Against Enterotoxigenic Escherichia coli

Enterotoxigenic Escherichia coli (ETEC) is a common cause for diarrheal infections in children in low- and middle-income countries (LMICs). To date, no ETEC vaccine candidates have been approved. Passive immunization with low-cost, oral formulations of secretory IgA (sIgA) against ETEC is an alternative approach to protect high-risk populations in LMICs. Using a model sIgA monoclonal antibody (anti-LT sIgA2-mAb), the stability profiles of different formulations were assessed during storage and in in vitro digestion models (mimicking in vivo oral delivery). First, by employing various physicochemical techniques and a LT-antigen binding assay, three formulations with varying acid-neutralizing capacity (ANC) were evaluated to stabilize sIgA2-mAb during stress studies (freeze-thaw, agitation, elevated temperature) and during exposure to gastric phase digestion. Next, a low-volume, in vitro intestinal digestion model was developed to screen various additives to stabilize sIgA2-mAb in the intestinal phase. Finally, combinations of high ANC buffers and decoy proteins were assessed to collectively protect sIgA2-mAb during in vitro sequential (stomach to intestine) digestion. Based on the results, we demonstrate the feasibility of low-cost, ‘single-vial’, liquid formulations of sIgA-mAbs delivered orally after infant feeding for passive immunization, and we suggest future work based on a combination of in vitro and in vivo stability considerations.