Globalisation of international health

Ethical Frameworks and Global Health: A Narrative Review of the "Leave No One Behind" Principle

The "Leave No One Behind" (LNOB) principle, a fundamental commitment of the United Nations' Sustainable Development Goals, emphasizes the urgent need to address and reduce global health inequalities. As global health initiatives strive to uphold this principle, they face significant ethical challenges in balancing equity, resource allocation, and diverse health priorities. This narrative review critically examines these ethical dilemmas and their implications for translating LNOB into actionable global health strategies. A comprehensive literature search was conducted using PubMed, Scopus, Web of Science, and Semantic Scholar, covering publications from January 1990 to April 2024. The review included peer-reviewed articles, gray literature, and official reports that addressed the ethical dimensions of LNOB in global health contexts. A thematic analysis was employed to identify and synthesize recurring ethical issues, dilemmas, and proposed solutions. The thematic analysis identified 4 primary ethical tensions that complicate the operationalization of LNOB: (1) Universalism versus Targeting, where the challenge lies in balancing broad health improvements with targeted interventions for the most disadvantaged; (2) Resource Scarcity versus Equity; highlighting the ethical conflicts between maximizing efficiency and ensuring fairness; (3) Top-down versus Bottom-up Approaches, reflecting the tension between externally driven initiatives and local community needs; and (4) Short-term versus Long-term Sustainability, addressing the balance between immediate health interventions and sustainable systemic changes. To navigate these ethical challenges effectively, global health strategies must adopt a nuanced, context-sensitive approach incorporating structured decision-making processes and authentic community participation. The review advocates for systemic reforms that address the root causes of health disparities, promote equitable collaboration between health practitioners and marginalized communities, and align global health interventions with ethical imperatives. Such an approach is essential to truly operationalize the LNOB principle and foster sustainable health equity.

How states exerted power to create the Millennium Development Goals and how this shaped the global health agenda: Lessons for the sustainable development goals and the future of global health

Since 2000, the eight Millennium Development Goals (MDGs) provided the framework for global development efforts transforming the field now known as global health. The MDGs both reflected and contributed to shaping a normative global health agenda. In the field of global health, the role of the state is largely considered to have diminished; however, this paper reasserts states as actors in the conceptualisation and institutionalisation of the MDGs, and illustrates how states exerted power and engaged in the MDG process. States not only sanctioned the MDGs through their heads of states endorsing the Millennium Declaration, but also acted more subtly behind the scenes supporting, enabling, and/or leveraging other actors, institutions and processes to conceptualise and legitimize the MDGs. Appreciating the MDGs' role in the conceptualisation of global health is particularly relevant as the world transitions to the MDGs' successor, the Sustainable Development Goals (SDGs). The SDGs' influence, impact and importance remains to be seen; however, to understand the future of global health and how actors, particularly states, can engage to shape the field, a deeper sense of the MDGs' legacy and how actors engaged in the past is helpful.

A New World Health Era

Unprecedented economic progress and demands for social protection have engendered an economic transition in health in many low- and middle-income countries, characterized by major increases in domestic health spending and growing national autonomy. At the global level, development assistance is refocusing on fragile states, the poorest communities, and cooperation on global public goods like health security, technical norms, and innovation. Intergovernmental organizations like WHO need the wherewithal and support to provide leadership and to properly advance this new world health era.

Introduction to "Diversity of Child Health Care in Europe: A Study of the European Paediatric Association/Union of National European Paediatric Societies and Associations"

The field of pediatrics in Europe is characterized by the diversities, variations, and heterogeneities of child health care services provided in 53 European countries with more than 200 million children below 18 years of age. Managing the health care of infants, children, and adolescents in Europe requires balancing clinical aims, research findings, and socioeconomic goals within a typical environment characterized by cultural and economic complexity and large disparity in availability, affordability, and accessibility of pediatric care. Since its foundation in 1976, the European Paediatric Association-Union of National European Paediatric Societies and Associations has worked to improve both medical care of all children and cooperation of their caretakers in Europe. Such a report has been conceived in the strong belief that broadening of the intellectual basis of the European Paediatric Association-Union of National European Paediatric Societies and Associations and creating a multidisciplinary society will be necessary to reduce fragmentation of pediatrics and tackle the legal, economic, and organizational challenges of child health care in Europe.

Comparative effect sizes in randomised trials from less developed and more developed countries: meta-epidemiological assessment

OBJECTIVE

To compare treatment effects from randomised trials conducted in more developed versus less developed countries.

DESIGN

Meta-epidemiological study.

DATA SOURCES

Cochrane Database of Systematic Reviews (August 2012).

DATA EXTRACTION

Meta-analyses with mortality outcomes including data from at least one randomised trial conducted in a less developed country and one in a more developed country. Relative risk estimates of more versus less developed countries were compared by calculating the relative relative risks for each topic and the summary relative relative risks across all topics. Similar analyses were performed for the primary binary outcome of each topic.

RESULTS

139 meta-analyses with mortality outcomes were eligible. No nominally significant differences between more developed and less developed countries were found for 128 (92%) meta-analyses. However, differences were beyond chance in 11 (8%) cases, always showing more favourable treatment effects in trials from less developed countries. The summary relative relative risk was 1.12 (95% confidence interval 1.06 to 1.18; P<0.001; I(2)=0%), suggesting significantly more favourable mortality effects in trials from less developed countries. Results were similar for meta-analyses with nominally significant treatment effects for mortality (1.15), meta-analyses with recent trials (1.14), and when excluding trials from less developed countries that subsequently became more developed (1.12). For the primary binary outcomes (127 meta-analyses), 20 topics had differences in treatment effects beyond chance (more favourable in less developed countries in 15/20 cases).

CONCLUSIONS

Trials from less developed countries in a few cases show significantly more favourable treatment effects than trials in more developed countries and, on average, treatment effects are more favourable in less developed countries. These discrepancies may reflect biases in reporting or study design as well as genuine differences in baseline risk or treatment implementation and should be considers when generalising evidence across different settings.

Training healthcare professionals for the future: internationalism and effective inclusion of global health training

There has been a continuing rise in recent years of the number of medical schools in the developed world offering 'global health' teaching to its students. Yet, the term itself is used in a number of contexts and as yet no clear consensus on what constitutes an appropriate or successful global health education programme has been reached. Approaches to sustainable internationalisation of medical curricula include the expansion of not only opportunities for training in specific global health topics, but also the development of broader generic graduate attributes including global citizenship and ethical, cultural and social responsibility. Key components for successful implementation of such an educational framework includes a breadth of educational approach to effect truly integrated and effective curricular internationalisation. That such programmes can offer benefits is appreciated by both faculty and students alike, but there is also a burgeoning concern about potential negative effects of socially and culturally insensitive programmes. We explore three potential pedagogic approaches to the subject; Model A: an 'additive' or contributory model of global health content (the commonest current approach), Model B: an 'integrated' approach and Model C: the more challenging 'transformative' approach requiring institutional as well as programme flexibility.

The evolution, etiology and eventualities of the global health security regime

BACKGROUND

Attention to global health security governance is more important now than ever before. Scientists predict that a possible influenza pandemic could affect 1.5 billion people, cause up to 150 million deaths and leave US$3 trillion in economic damages. A public health emergency in one country is now only hours away from affecting many others.

METHODS

Using regime analysis from political science, the principles, norms, rules and decision-making procedures by which states govern health security are examined in the historical context of their punctuated evolution. This methodology illuminates the catalytic agents of change, distributional consequences and possible future orders that can help to better inform progress in this area.

FINDINGS

Four periods of global health security governance are identified. The first is characterized by unilateral quarantine regulations (1377-1851), the second by multiple sanitary conferences (1851-92), the third by several international sanitary conventions and international health organizations (1892-1946) and the fourth by the hegemonic leadership of the World Health Organization (1946-????). This final regime, like others before it, is challenged by globalization (e.g. limitations of the new International Health Regulations), changing diplomacy (e.g. proliferation of global health security organizations), new tools (e.g. global health law, human rights and health diplomacy) and shock-activated vulnerabilities (e.g. bioterrorism and avian/swine influenza). This understanding, in turn, allows us to appreciate the impact of this evolving regime on class, race and gender, as well as to consider four possible future configurations of power, including greater authority for the World Health Organization, a concert of powers, developing countries and civil society organizations.

CONCLUSIONS

This regime analysis allows us to understand the evolution, etiology and eventualities of the global health security regime, which is essential for national and international health policymakers, practitioners and academics to know where and how to act effectively in preparation for tomorrow's challenges.

Comércio internacional de serviços e complexo industrial da saúde: implicações para os sistemas nacionais de saúde

Os serviços de saúde evidenciam um padrão de inovação - na forma de expansão para mercados públicos e do comércio internacional - que os credencia a assumir um papel preponderante no complexo industrial da saúde. O comércio internacional e suas bases regulatórias, definidas no General Agreement on Trade in Services (GATS), têm o potencial de gerar desenvolvimento econômico, mas também de reordenar os recursos disponíveis para a saúde em âmbito nacional e global, em direções favoráveis ou não. Onde houver uma combinação de prestadores públicos e privados atuando na saúde pública, como no caso brasileiro, os termos do GATS admitem a interpretação de que a prestação pública recai no âmbito do GATS, criando-se restrições às opções políticas dos países para a saúde. São necessárias informações sistematizadas e específicas para cada país sobre serviços eletrônicos, movimento de pacientes e profissionais, e investimento direto estrangeiro em serviços de saúde para compor evidências que permitam decisões mais informadas sobre adesão ao GATS.

Defining features of the practice of global health research: an examination of 14 global health research teams

Objectives

This paper strives to develop a pragmatic view of the scope of practice and core characteristics of global health research (GHR) by examining the activities of 14 Canadian-funded global health teams that were in the process of implementing research programs.

Methods

Information was collected by a reflective exploration of team proposals and progress reports, a content analysis of the outputs from an all-team meeting and review of the literature.

Results

Teams adopted equity-centered, problem-focused, systems-based approaches intended to find upstream determinants that could make people more resilient to social and ecological factors impacting their health. Long-term visions and time frames were needed to develop and solidify fully functional interdisciplinary, multinational, multicultural partnerships. The implementation of research into practice was a motivating factor for all teams, but to do this, they recognized the need for evidence-based advice on how to best do this. Traditional measures of biomedical research excellence were necessary but not sufficient to encompass views of excellence of team-based interdisciplinary research, which includes features like originality, coherence and cumulative contributions to fields of study, acceptance by peers and success in translating research into gains in health status. An innovative and nuanced approached to GHR ethics was needed to deal with some unique ethical issues because the needs for GHR were not adequately addressed by institutional biomedical research ethics boards. Core competencies for GHR researchers were a blend of those needed for health promotion, population health, international development, sustainable development, and systems science.

Discussion

Developing acceptable and meaningful ways to evaluate the short-term contributions for GHR and forecast its long-term impacts is a strategic priority needed to defend decisions being made in GHR development. Planning and investing to support the underlying GHR elements and competencies that allow for adaptive, innovative, and supportive research partnerships to achieve ‘health for all’ are more likely to have long-term impacts than building research strategies around specific diseases of interest.

Framing and the politics of public health: an examination of competing health narratives in Honduras

According to the World Bank, Honduras is a health and development success story. Over the past few decades, it has experienced economic growth, expanded public health infrastructure, and improved key health indicators. However, these achievements do not serve as evidence of success for global public health agencies, such as the World Health Organisation (WHO) and the Pan American Health Organisation (PAHO). The WHO has identified Honduras as a 'priority country' due to extreme levels of poverty, inequality, indebtedness, and poor health. What accounts for these divergent evaluations, and what are their consequences for vulnerable and marginalised populations? I argue that the framing of health is important and demands examination because it reveals political dynamics and shapes policy options. Furthermore, individual frames are incomplete, differentially inclusive, and ultimately inadequate as explanatory and analytic frameworks.

[The transition from 'international' to 'global' public health and the World Health Organization]

Within the context of international public health, 'global health' seems to be emerging as a recognized term of preference. This article presents a critical analysis of the meaning and importance of 'global health' and situates its growing popularity within a historical context. A specific focus of this work is the role of the World Health Organization - WHO in both 'international' and 'global' health, and as na agent of transition from one to the other. Between 1948 and 1998, the WHO went through a period of hardship as it came up against an organizational crisis, budget cuts and a diminished status, especially when confronted with the growing influence of new, power players like the World Bank. We suggest that the WHO has responded to this changing international context by inititating its own process of restructuring and repositioning as an agent for coordinating, strategically planning and leading 'global health' initiatives.

Atenção primária, atenção básica e saúde da família: sinergias e singularidades do contexto brasileiro

O objetivo deste trabalho é analisar os conceitos de Atenção Primária, Atenção Básica e Saúde da Família, com base em documentos oficiais do Ministério da Saúde, relatórios finais das Conferências Nacionais de Saúde e Conferências Nacionais de Recursos Humanos, da Norma Operacional Básica/Recursos Humanos e de textos disponibilizados on-line pela BIREME. A análise dos dados, feita mediante matrizes de dupla entrada, evidenciou a falta destes referenciais na formulação e implementação das políticas de saúde. A NOB-96 tem papel diferenciado neste aspecto; os relatórios das conferências nacionais demonstram uma lacuna importante neste debate e os artigos publicados apresentam, na maioria, os conceitos de atenção primária e atenção básica com o significado de unidade de saúde ou serviço local. Os artigos sobre Programa Saúde da Família se referem a ele mais como programa do que como estratégia, e entre os artigos que problematizam tais conceitos evidencia-se a influência das racionalidades que são subjacentes às diferentes estratégias de organização dos serviços presentes no cenário brasileiro, que são as da Vigilância à Saúde, das Ações Programáticas de Saúde e da Em Defesa da Vida.

The global burden of non-conflict related firearm mortality

OBJECTIVE

Understanding global firearm mortality is hindered by data availability, quality, and comparability. This study assesses the adequacy of publicly available data, examines populations for whom firearm mortality data are not publicly available, and estimates the global burden of non-conflict related firearm mortality.

DESIGN

The design is a secondary analysis of existing data. A dataset of countries, populations, economic development, and geographic regions was created, using United Nations 2000 world population data and World Bank classifications of economic development and global regions. Firearm mortality data were obtained from governmental vital statistics reported by the World Health Organization and published survey data. A qualitative review of literature informed estimates for the 15 most populous countries without firearm death data. For countries without data, estimates of firearm deaths were made using quartiles of observed rates and peer reviewed literature.

MAIN OUTCOME MEASURES

Non-conflict related firearm deaths.

RESULTS

Global non-conflict related firearm deaths were estimated to fall between 196,000 and 229,000, adjusted to the year 2000. 162,800 firearm deaths adjusted for the year 2000 came from countries reporting data and represent 35% of the world's 186 countries. Public data are not available for 122 of these 186 countries, representing more than three billion (54%) of the world's population, predominately in lower and lower middle income countries. Estimates of firearm death for those countries without data range from 33,200 to 66,200.

CONCLUSIONS

This study provides evidence that the burden of firearm related mortality poses a substantial threat to local and global health.

Towards a Chinese definition of nursing

BACKGROUND

A theory of nursing derived from nurses' experience can reflect indigenous practice values, which in turn can act as a fertile source of ideas and inventiveness in developing a relevant knowledge base to inform practice. However, systematic study of how Chinese nurses articulate nursing in their everyday practice is lacking.

AIM

The aim of this paper is to describe how Chinese nurses conceptualize the practice of nursing; and to arrive at a definition of nursing based on this common understanding.

METHOD

A systematic inquiry using a modified version of Van Kaam's controlled explication was designed. In the prescientific phase, 254 written accounts of nurses' views on nursing as lived in their everyday practice were collected in eight Chinese cities. In the scientific phase, concept analysis based on Aristotle's notion of four causes was adopted to capture the richness of the phrases that explain the multi-dimensionality of Chinese nurses' concepts of nursing. This was followed by a survey of 1782 nurses to verify the findings. The most commonly held views were summarized and a Chinese definition of nursing was drafted.

FINDINGS

Nursing in the Chinese sense means to understand the dynamic health status of a person, to verify health concerns dialectically, and to consider interventions with the goal of assisting the person to master the appropriate health knowledge and skills for the attainment of optimal well-being. The survey findings show that nursing has developed into a professional caring practice in China today. The definition has some similarities with those of Western nurses, but the underpinning epistemic concerns are grounded in the philosophy of traditional Chinese medicine and Eastern ideologies.

CONCLUSION

The findings provide Chinese nurses with a definition of nursing articulated in their own language. The identification of qing, li, zhi, and xin as its epistemic concerns, and the articulation of the process of nursing as 'dialectical verification', provides a perspective for understanding nursing based on Eastern philosophies. The findings can enhance nurses' engagement in a cross-cultural dialogue to promote better understanding of nursing as it is practised in different parts of the world.

Governing the globalization of public health

The number and the scale of transboundary public health concerns are increasing. Infectious and non-communicable diseases, international trade in tobacco, alcohol, and other dangerous products as well as the control of the safety of health services, pharmaceuticals, and food are merely a few examples of contemporary transnationalization of health concerns. The rapid development and diffusion of scientific and technological developments across national borders are creating new realms of international health concern, such as aspects of biomedical science, including human reproductive cloning, germ-line therapy, and xenotransplantation, as well as environmental health problems, including climate change, biodiversity loss, and depletion of the ozone layer. Growth in international trade and travel, in combination with population growth, has served to increase the frequency and intensity of health concerns bypassing or spilling over sovereign boundaries.

Although health has traditionally been seen an area of limited multilateral cooperation, there is growing awareness that contemporary globalization has led to the proliferation of cross border determinants of health status and is undermining the capacity of nation states to protect health through domestic action alone.

International patients: a lucrative market for U.S. Hospitals

Ravaged by diminishing revenues and intense price competition, U.S. hospitals desperately need to find profitable areas of healthcare. International patients that travel to the United States for treatment offer such an opportunity. Marketing directors, administrators and medical staff of leading hospitals are recognizing the value of this market segment. They are making special efforts to attract foreign patients. They have developed tailored services for international patient and are forming alliances with civic and business organizations to support the needs of patients traveling from overseas.

Cholera: a continuous epidemic in Africa

Cholera continues to plague many parts of the world, but has largely been concentrated in Africa, which contributes more than 80% of the total cases worldwide. Natural disasters, like the 2000 floods in Mozambique and the volcanic eruption in the Democratic Republic of the Congo in 2002, generally lead to new outbreaks of the disease. The refugee problem in many countries throughout the world also causes potential threats for disease outbreaks. Case fatality rates are high, and we are not anywhere near curbing new cholera epidemics, especially in Africa. It is thus imperative to renew discussions about the nature of this deadly disease, its treatment, measures for prevention and control, modes of transmission, its physical, social and economic impact, and potential solutions.

Relation between burden of disease and randomised evidence in sub-Saharan Africa: survey of research

OBJECTIVE

To evaluate whether the amount of randomised clinical research on various medical conditions is related to the burden of disease and health needs of the local populations in sub-Saharan Africa.

DESIGN

Construction and analysis of comprehensive database of randomised controlled trials in sub-Saharan Africa based on Medline, the Cochrane Controlled Trials Register, and several African databases.

SETTING

Sub-Saharan Africa.

MAIN OUTCOME MEASURES

Number of trials and randomised subjects for each category of disease in the global burden of disease taxonomy; ratios of disability adjusted life years (DALYs) per amount of randomised evidence.

RESULTS

1179 eligible randomised controlled trials were identified. The number of trials published each year increased over time. Almost half of the trials (n=565) had been done in South Africa. There was relatively good correlation between the estimated burden of disease at year 2000 and the number of trials performed (r=0.53, P=0.024) and the number of participants randomised (r=0.68, P=0.002). However,some conditions-for example, injuries (over 20 000 DALYs per patient ever randomised)-were more neglected than others.

CONCLUSION

Despite recent improvements, few clinical trials are done in sub-Saharan Africa. Clinical research in this part of the world should focus more evenly on the major contributors to burden of disease.

Paediatric oncology in Argentina: medical and ethical issues

The process of globalisation is affecting health and health care in Argentina, as it is in many other countries. The full extent of this effect is still unclear, but winners and losers in the world economy are emerging--not only different countries, but also sectors or populations within those countries. There are serious inequalities in health-care provision in Argentina, so that not all children with cancer receive the best possible therapy. What happens to those children who don't? How do staff feel when they have to turn away new patients? Only by asking these questions and examining and understanding the answers can we begin the process of improving the status of paediatric oncology in Argentina.

Global health assistance: a new perspective

Health care priorities for many emerging economies have undergone a dramatic transition in the recent past because of the rise in chronic illness, increased longevity, and lessened infant mortality. Two additional major societal forces, democratization and the information revolution, will alter the nature of global health assistance. Because of democratization, governments will feel increasing pressure to provide adequate health care. Because of the information revolution, all practitioners will know what is available. The convergence of these three forces will create an enormous financial burden for emerging economies. Adapting to these new realities will be the challenge to donor organizations. What is likely to emerge as a critical health care problem around the world is the need to balance priorities between acute care and prevention or modification of chronic disease. These efforts will be directed at different populations, one manifestly ill and one potentially so, and each will need to be recognized politically as having valid claims on governmental resources. External support will need to include demonstration within the recipient communities that data collection permits an accurate identification of disease burden, that risk factor modification ameliorates the impact of disease, that continuity of care is essential to long term outcomes, and that therapy of developed disease can be rationally carried out utilizing evidence based medicine to insure efficiency and appropriateness.

[The pyramid trap]

This paper discusses the impact of globalization on public health practice. Neoliberal supremacy has resulted in both greater interdependence between countries and increasing inequalities. Globalization of health risks and the dependence of local health conditions on external forces precludes the use of local/national solutions for global problems. In this context, the classical organization of public health services in a hierarchical pyramid based on geographically defined areas (from the local to the regional and national levels) no longer makes sense. We thus suggest some characteristics of a different type of organization based on new information technologies: a transnational network, horizontally shaped, more independent from political power, allowing for exchange of information and good practices, promoting dissemination of knowledge and producing "glocal" solutions. Through the creation of work opportunities between health professionals, the model will permit the creation of common strategies and increase the power of their political demands, perhaps allowing for the collective development of a more equitable world.

Globalization, socioeconomic restructuring, and community health

New trends in global public health have social, economic, and political underpinnings that can be found in three 20th century revolutions: globalization, a new epidemiological transition, and an historical shift in patterns of production and consumption throughout the world. Globalization is more than the internationalization of commerce and manufacture; it represents a new development paradigm that creates new links among corporations, international organizations, governments, communities, and families. Social and economic restructuring is reflected in the emerging health profile in underdeveloped countries, including those in Latin America. This emerging profile defies simple categorization, however; while the prevalence of cardiovascular disease and cancer has increased, the traditional diseases (infectious and respiratory disease) are still the leading cause of death. At the same time, industrialized countries are experiencing the re-emergence of those same traditional diseases. These apparent anomalies can be understood by examining class structures within and among countries and by linking health outcomes at the local level to new patterns of production and consumption in the global system.

Globalization and international trade in the twenty-first century: opportunities for and threats to the health sector in the south

Globalization and international trade are important forces at the turn of the century. This article explores how freer international trade will affect developing countries that are net importers of health care goods and services. Four commodities are used as special cases for discussion: pharmaceuticals, health care technologies, pesticides, and tobacco and its related products. The authors discuss the role of international specialized agencies, such as the World Trade Organization, World Health Organization, and World Bank, that are concerned with international trade and its health and health care consequences, and argue that closer collaboration is required among these agencies if the negative effects of trade liberalization on developing countries are to be mitigated. The authors pose a number of research questions that could help in developing proactive policies for the South on the trade of goods and services with harmful effects on health as well as those with potential health and economic benefits.

Globalization and global health

Along with the positive or negative consequences of the globalization of health, we can consider global health as a goal, responding to human rights and to common interests. History tells us that after the "microbial unification" of the world, which began in 1492, over three centuries elapsed before the recognition of common risks and attempts to cope with them in a cross-boundary effort. In the 19th and 20th centuries, the struggle against epidemics united countries, world health became a common goal, and considerable results were achieved. However, in recent decades the notion of health as a cornerstone of economic development has been replaced by the idea that public health and health services are an obstacle to the wealth of nations. Meanwhile, new common threats are growing: among them, the exacerbation of old infections and emergence of new ones, the impact of environmental changes, drug traffic on a world scale, and destructive and self-destructive violence. New and stronger empirical motives relate the interests of peoples to universal rights and to global health. The author concludes with some proposals for policies.

Neurology without borders: neurological disease in a shrinking world

The last half of the twentieth century has seen social, political, economic, and environmental changes which have altered patterns of health care in all parts of the world. International influences are becoming stronger each year, and the practice of medicine in any single country is becoming more and more influenced by events and practices in others. Environmental degradation may involve widespread dissemination of neurological toxins. Newly emerging or drug-resistant infections include those involving the nervous system. Effective neurological practice is more dependent than ever on knowledge of international health. Neurologists can act as effective advocates for appropriate treatment, allocation of resources, and prevention of neurological diseases.

North-South twinning in paediatric haemato-oncology: the La Mascota programme, Nicaragua

We describe the La Mascota twinning programme between La Mascota paediatric hospital in Managua, Nicaragua, and hospitals in Monza and Milan, Italy, and Bellinzona, Switzerland. The programme was based on the belief that an attempt to reduce the gap in mortality from cancer in childhood between developed and less developed countries should become an integral part of the care and research activity of a haemato-oncological department of a developed country and not simply an exercise in solidarity. This programme for acute lymphoblastic leukaemia shows that intellectual, organisational, and financial resources can be generated by a twinning programme. What is vital for such programmes is a long-term commitment to a comprehensive and holistic strategy that incorporates supply of drugs, training and supervision of health professionals, and the care of the children and of their parents.