Global health inequalities and the need for solidarity: a view from the Global South

Improving equity and wellness in cancer care with people of Latin American and African Descent: a study protocol

Background

Cancer inequities such as late access to cancer screening and diagnosis affect people of African and Latin American descent in Canada. These inequities in addition to experiences of racism and discrimination and unequal living and working conditions are detrimental to their wellness. We aim to delineate together with people of African and Latin American descent a patient-oriented pathway to improve their equity and wellness in cancer care.

Methods

This is a 3-year community-based and patient-oriented participatory research study. The study will take place in Alberta and Ontario and will involve 125 participants including people with cancer, family and community members of African and Latin American descent, and health care providers. We will conduct in-depth interviews with patients and families and focus groups with community members. Together with patient partners and community collaborators, we will delineate a patient-oriented pathway in cancer care to improve equity and wellness for people of African and Latin American descent in Canada. Finally, we will explore the acceptability of the pathway with a small sample of patients, families and health care providers.

Conclusion

This study will advance our knowledge of equity and wellness in people with advanced cancer from racialized communities in Canada; and increase our understanding of how racialized populations live through a cancer diagnosis. The study will also generate knowledge of how a patient-oriented health equity pathway can contribute to reduce cancer inequities in the care of our study populations.

Solidarity and its decoloniality in global health ethics

Solidarity is one of the emerging values in global health ethics, and a few pieces of bioethics literature link it to decoloniality. However, conceptions of solidarity in global health ethics are influenced primarily by Western perspectives, thus suggesting the decolonial needs to include non-Western perspectives. This article explores a decolonial interpretation of solidarity to enrich our understanding of solidarity. It employs a palaver approach, typical of African (Yorùbá) relational culture, in developing a conception of solidarity grounded in a beehive metaphor. Through a decolonial methodological approach, this article posits that a beehive metaphor allegorically symbolises solidarity. In this decolonial interpretive account, solidarity embeds relational virtues and duties that foster harmony. Solidarity is a positively oriented affective disposition with people with whom one shares similar circumstances for harmonious well-being through concerted efforts. This article addresses five potential objections to this account of solidarity in global health ethics and consequently explores what an African account of solidarity means for global health research funding. This article concludes that the palaver decolonial approach from the Global South has implications for expanding conceptual perspectives on solidarity in global health ethics.

Reimagining global health scholarship to tackle health inequities

•Significant health inequities persist between and within countries, necessitating a paradigm shift in global health scholarship.•Building on the contributions global health experts, this article proposes four key considerations for reframing global health scholarship.•This requires deeper engagement with macrosocial drivers of health and the application of population health science principles.•An evolving field also necessitates innovation in data sources, multidisciplinary engagement, expanded analytical tools, and diverse global perspectives.

An Online Model for Neurosurgical Research in Developing Countries: A One-Year Experience in Mexico and Latin America

BACKGROUND

Mexico is under-represented in global neurosurgical research. High-income countries represent roughly 10% of the world's population but utilize about 90% of the research funding for medical research, highlighting the need for promoting research initiatives in low- and middle-income countries. We present an online-based research initiative in Mexico that aims to reduce the research gap in neurosurgery.

METHODS

Implemented in early 2023, our online-based research initiative included weekly modules covering study types, statistical analysis, meta-analysis, and scientific writing. The first cohort of 22 students completed the 12-week program and then served as tutors for subsequent cohorts. The research model was promoted via word of mouth and social media platforms to medical students, graduates, and specialists across Latin America. Post-program, tutors and the author conducted weekly planning sessions to assist with project planning, analysis, and article writing.

RESULTS

From 833 registrations, over 800 students completed at least 1 training module. The program published 7 articles and presented 12 abstracts at major international neurosurgical meetings. We performed a bibliographic analysis in PubMed and found that from 2021 to 2022, 33,637 neurosurgical articles were published, with 197 involving collaboration from Mexico (0.5%). From 2023 to 2024, 24,121 articles were published, with 205 involving collaboration from Mexico (0.8%), a significant increase (P < 0.001). Our collaboration contributed to 3.4% of these, representing a significant addition in 2023-2024 (P = 0.026).

CONCLUSIONS

This online-based neurosurgical model contributed to 3.4% of the neurosurgical research productivity in Mexico. Our findings suggest that this model can effectively bridge the research gap and enhance scientific contributions in developing countries.

Autonomy-based bioethics and vulnerability during the COVID-19 pandemic: towards an African relational approach

The COVID-19 pandemic has provoked new interest in the notion of vulnerability and in identifying alternative approaches for responding to vulnerable patients and populations during health emergencies. In this paper, I argue that the autonomy-based approach (the most dominant approach in bioethics) to responding to vulnerability during health emergencies is deficient because it focuses only on the interests, values, and decisions of the individual patient. It overly emphasizes respect for autonomy and not respect for the patient as it does not consider the patient as a social and relational agent. Indeed, relational approaches to autonomy like the feminist and indigenous sub-Saharan African ethical approaches are promising alternatives. In this essay, I use the indigenous African relational approach to autonomy as an example of an alternative method which can be used to respond to vulnerability during a global health emergency like COVID-19.

Malaria & mRNA Vaccines: A Possible Salvation from One of the Most Relevant Infectious Diseases of the Global South

Malaria is one of the most dangerous infectious diseases in the world. It occurs in tropical and subtropical regions and affects about 40% of the world´s population. In endemic regions, an estimated 200 million people contract malaria each year. Three-quarters of all global deaths (about 600 per year) are children under 5 years of age. Thus, malaria is one of the most relevant tropical and also childhood diseases in the world. Thanks to various public health measures such as vector control through mosquito nets or the targeted use of insecticides as well as the use of antimalarial prophylaxis drugs, the incidence has already been successfully reduced in recent years. However, to reduce the risk of malaria and to protect children effectively, further measures are necessary. An important part of these measures is an effective vaccination against malaria. However, the history of research shows that the development of an effective malaria vaccine is not an easy undertaking and is associated with some complications. Research into possible vaccines began as early as the 1960s. However, the results achieved were rather sobering and the various vaccines fell short of their expectations. It was not until 2015 that the vaccine RTS,S/AS01 received a positive evaluation from the European Medicines Agency. Since then, the vaccine has been tested in Africa. However, with the COVID-19 pandemic, there are new developments in vaccine research that could also benefit malaria research. These include, among others, the so-called mRNA vaccines. Already in the early 1990s, an immune response triggered by an mRNA vaccine was described for the first time. Since then, mRNA vaccines have been researched and discussed for possible prophylaxis. However, it was not until the COVID-19 pandemic that these vaccines experienced a veritable progress. mRNA vaccines against SARS-CoV-2 were rapidly developed and achieved high efficacy in studies. Based on this success, it is not surprising that companies are also focusing on other diseases and pathogens. Besides viral diseases, such as influenza or AIDS, malaria is high on this list. Many pharmaceutical companies (including the German companies BioNTech and CureVac) have already confirmed that they are researching mRNA vaccines against malaria. However, this is not an easy task. The aim of this article is to describe and discuss possible antigens that could be considered for mRNA vaccination. However, this topic is currently still very speculative.

Health inequalities in Brazilian adolescents: Measuring and mapping gaps in a cross-sectional school-based survey

Background and Aims

This study aims to describe inequalities in health indicators according to gender, area of residence, and socioeconomic position among Brazilian adolescents.

Methods

Cross-sectional study using data from a school-based survey carried out in Brazil in 2019. Twelve health outcomes were evaluated. Dimensions of inequality assessed were gender, area of residence, wealth and subnational region.

Results

This study comprises a sample of 124,898 adolescents. The most prevalent outcome was physical inactivity (71.9%) followed by thinking life is worthless (52.6%) and bullying (51.8%). Gender inequalities were more marked for physical inactivity and thinking life is worthless with girls presenting a prevalence more than 20 p.p. higher than boys. In zero-dose HPV, however, the prevalence in girls was 17.7 p.p. lower than in boys. Area of residence and wealth inequalities were smaller than gender disparities. Context presented a relevant role in inequality with analysis stratified by states of the country, revealing high variability in estimates.

Conclusions

We highlight the need for attention to disparities between subgroups of the adolescent population, especially for gender inequalities that were the most marked for this age group.

Global health governance performance during Covid-19, what needs to be changed? a delphi survey study

BACKGROUND

Covid-19 is not the first pandemic to challenge GHG. Preceding outbreaks and epidemics were sources of continuous debate on GHG leadership and structure resulting in its current structure. However, Covid-19 proved the presence of many deficits in the current GHG. The response to the Covid-19 pandemic is a cumulative result of all policies and actions of different governments and agencies active in global health. Assessing how Covid-19 is being handled globally provides lessons for ensuring better performance in facing upcoming outbreaks. This study has three main objectives: first, to evaluate the performance of GHG during Covid-19 in general and in relation to Covid-19 vaccine equity in particular. Second, to identify the reasons behind this performance; and third, to propose prospective changes in GHG for better performance.

METHODS

A cross-sectional research design using the Delphi method was applied. A panel of experts participated in the three-round Delphi surveys. Their scores were used to perform consensus, performance and correlation analysis.

RESULTS

GHG performance limited the achievement of Covid-19 vaccines' global equity. GHG performance is a product of the existing GHG system, its actors and legal framework. It is a collective result of individual GHG actors' performance. The most influential actors in decision-making regarding Covid-19 vaccine are the vaccine manufacturers and governments. While the most invoked power to influence decision are economic and political powers. Covid-19 decisions underlying value, although had human right to health at the base, overlooked the concept of health as a global public good and was skewed towards market-oriented values. GHG mal-performance along with its underlying factors calls for four main changes in GHG structure: assigning a clear steward for GHG, enhanced accountability, centralized authority, more equitable representation of actors, and better legal framework.

CONCLUSION

GHG structure, actors' representation, accountability system, and underlying priorities and value require future modification for GHG to achieve better future performance and higher health equity levels.

Rethinking solidarity towards equity in global health: African views

When the COVID-19 pandemic first took the world by storm, the World Health Organization (WHO) issued a Solidarity Call to Action to realize equitable global access to COVID-19 health technologies through pooling of knowledge, intellectual property and data. At the dawn of 2022, 70% of rich countries' populations were vaccinated but only 4.6% of poor countries (Our World In Data, Coronavirus (COVID-19) vaccinations, 2022). Vaccine nationalism and rampant self-interest grew and our ineffective global response led to new variants of concern - like Omicron - emerging. Rather than abandon the idea of solidarity in global health, we believe that the international community must embrace it. Solidarity, with its emphasis on relationality and recognition of similarities, could offer fertile ground for building an ethical framework for an interconnected and interdependent world. Such a framework would be better than a framework that focuses principally on individual entitlements. To defend this view, we draw on African relational views of personhood and morality. When humans are conceived of as essentially relational beings, solidarity occupies a central role in moral behaviour. We argue that part of the reason appeals to solidarity have failed may be traced to an inadequate conceptualization of solidarity. For as long as solidarity remains a beautiful notion, practiced voluntarily by generous and kindhearted persons, in a transient manner to respond to specific challenges, it will never be able to offer an adequate framework for addressing inequities in global health in a systematic and permanent way. Drawing on this understanding of solidarity, we propose pathways to respond creatively to the risks we face to ensure equitable access to essential health for all.

Tech sharing, not tech hoarding: Covid-19, global solidarity, and the failed responsibility of the pharmaceutical industry

The Covid-19 pandemic has highlighted the importance of health technologies to mitigate against the spread of the disease and improve care, dominantly including life-saving vaccines. But the pandemic has also highlighted that the current biopharmaceutical business model, based on the enclosure of these technologies and on the immense accumulation of capital it enables, leads to vast inequalities in healthcare particularly in low and middle-income countries. We believe that the pharmaceutical industry has a moral duty to enable and enact global solidarity through tech sharing instead of tech hoarding, but judging by current technology transfer practices we question their willingness to assume their role in organizing healthcare markets through solidaristic principles. In the absence of a voluntary adoption of solidaristic principles and practices by biopharmaceutical firms, the institutionalization of global solidarity as a fundamental organizing principle for healthcare markets is necessary to strengthen resilience and know-how globally. With this call, we add to existing conceptualizations of solidarity by (a) introducing a global level of solidarity and (b) thinking through the concept not as an abstract humanistic stance but as a concrete organizing principle for global healthcare markets.

Malaria-Antigene in der Ära der mRNA-Impfstoffe

Bereits in den frühen 1990er-Jahren wurde erstmals eine durch einen mRNA-Impfstoff ausgelöste Immunantwort beschrieben. Seitdem wurden mRNA-Impfstoffe für eine mögliche Prophylaxe erforscht und diskutiert. Doch erst mit der COVID-19-Pandemie erlebten diese Impfstoffe einen wahren Boom. Die ersten mRNA-Impfstoffe wurden gegen SARS-CoV‑2 zugelassen und zeigten große Erfolge. Es ist daher nicht verwunderlich, dass sich die Hersteller auch auf andere Krankheiten und Pathogene konzentrieren. Neben viralen Krankheiten wie Influenza oder Aids steht Malaria weit oben auf dieser Liste. Viele Pharmaunternehmen (u. a. die deutschen Unternehmen BioNTech und CureVac) haben bereits bestätigt, an mRNA-Impfstoffen gegen Malaria zu forschen. Dabei ist die Entwicklung eines funktionierenden Impfstoffes gegen Malaria kein leichtes Unterfangen. Seit den 1960ern wird an möglichen Impfstoffen geforscht. Die Ergebnisse sind dabei eher ernüchternd. Erst 2015 erhielt der Impfstoff RTS,S/AS01 eine positive Bewertung der Europäischen Arzneimittel-Agentur. Seitdem wird der Impfstoff in Afrika getestet.

Gender inequalities in physical activity among adolescents from 64 Global South countries

PURPOSE

The aims of this study were to (a) describe gender inequalities in physical activity (PA) among adolescents from Global South countries, and (b) investigate the relationship between gender inequalities in PA and contextual factors, such as geographic region, human development index, gender inequality index, and unemployment rates.

METHODS

We analyzed cross-sectional data from the Global School-Based Student Health Survey conducted in Global South countries between 2010 and 2020 among 13- to 17-year-old adolescents. Country-context variables were retrieved from secondary data sources (World Health Organization, World Bank, and Human Development Reports). PA was assessed by a self-administered questionnaire querying the number of days in the past week in which participants were physically active for a total of at least 60 min. PA absolute gender inequalities were evaluated by the differences in the prevalence between boys and girls, 95% confidence intervals (95%CIs) were estimated using the bootstrap method. Relative inequalities were obtained through Poisson regression. Meta-analyses with random effects were used to calculate pooled estimates of absolute and relative inequalities.

RESULTS

Based on 64 Global South countries/surveys, the prevalence of PA was 6.7 percentage points (p.p.) higher in boys than in girls, ranging from 0.5 p.p. in Afghanistan to 15.6 p.p. in Laos (I²= 85.1%). The pooled ratio for all countries showed that boys presented a PA prevalence 1.58 times higher than girls (95%CI: 1.47-1.70) on average. The highest absolute and relative inequalities were observed in high income countries. Countries with higher Human Development Index rankings and lower Gender Inequality Index rankings also presented greater gender differences.

CONCLUSION

Given that girls are overall less active than boys across the globe, the findings of this study reinforce that macro- and micro-level changes should be actively sought if we aim to increase population levels of PA in adolescents and promote equity in PA.

Inequitable access to healthcare in Africa: reconceptualising the "accountability for reasonableness framework" to reflect indigenous principles

Background

The “Accountability for Reasonableness” (A4R) framework has been widely adopted in working towards equity in health for sub-Saharan Africa (SAA). Its suitability for equitable health policy in Africa hinges, at least in part, on its considerable successes in the United States and it being among the most comprehensive ethical approaches in addressing inequitable access to healthcare. Yet, the conceptual match is yet to be examined between A4R and communal responsibility as a common fundamental ethic in SAA.

Methodology

A4R and its applications toward health equity in sub-Saharan Africa were conceptually examined by considering the WHO’s “3-by-5” and the REACT projects for their accounting for the communal responsibility ethic in pursuit of health equity.

Results

Some of the challenges that these projects encountered may be ascribed to an incongruity between the underpinning ethical principle of A4R and the communitarian ethical principle dominant in sub-Saharan Africa. These are respectively the fair equality of opportunity principle derived from John Rawls’ theory, and the African communal responsibility principle.

Conclusion

A health equity framework informed by the African communal responsibility principle should enhance suitability for SAA contexts, generating impetus from within Africa alongside the affordances of A4R.

Relational solidarity and COVID-19: an ethical approach to disrupt the global health disparity pathway

While the effects of COVID-19 are being felt globally, the pandemic disproportionately affects lower- and middle-income countries (LMICs) by exacerbating existing global health disparities. In this article, we illustrate how intersecting upstream social determinants of global health form a disparity pathway that compromises LMICs' ability to respond to the pandemic. We consider pre-existing disease burden and baseline susceptibility, limited disease prevention resources, and unequal access to basic and specialized health care, essential drugs, and clinical trials. Recognizing that ongoing and underlying disparity issues will require long-term correction efforts, this pathway approach is nonetheless helpful to inform ethical responses to this global pandemic. It can facilitate international cooperation during the pandemic to reduce the disparate burdens among different regions without imposing significant burden on any particular contributor. The pathway approach allows international stakeholders in various social positions to respond to different components of the pathway based on their respective strengths and resources to help break the cycle of global health inequity. Guided by the ethical principles of relational and pragmatic solidarity, we argue for a coordinated global division of labor such that different stakeholders can collaborate to foster equitable healthcare access during this pandemic.

Do solidarity and reciprocity obligations compel African researchers to feedback individual genetic results in genomics research?

Background

A key ethical question in genomics research relates to whether individual genetic research results should be disclosed to research participants and if so, which results are to be disclosed, by whom and when. Whilst this issue has received only scarce attention in African bioethics discourse, the extension of genomics research to the African continent has brought it into sharp focus.

Methods

In this qualitative study, we examined the views of adolescents, parents and caregivers participating in a paediatric and adolescent HIV-TB genomic study in Botswana on how solidarity and reciprocity obligations could guide decisions about feedback of individual genetic research results. Data were collected using deliberative focus group discussions and in-depth interviews.

Results

Findings from 93 participants (44 adolescents and 49 parents and caregivers) demonstrated the importance of considering solidarity and reciprocity obligations in decisions about the return of individual genetic research results to participants. Participants viewed research participation as a mutual relationship and expressed that return of research results would be one way in which research participation could be reciprocated. They noted that when reciprocity obligations are respected, participants feel valued and not respecting reciprocity expectations could undermine participant trust and participation in future studies.

Conclusions

We conclude that expectations of solidarity and reciprocity could translate into an obligation to feedback selected individual genetic research results in African genomics research.

Enacting social transformation through occupation: A narrative literature review

BACKGROUND

In occupational therapy and occupational science there is a drive to confront social and health injustices through occupation-based practices with social transformation as a goal. However, scholars acknowledge a lack of theory to support this developing area of practice.

AIM

To explore how occupations have been used to enact social transformation for disadvantaged communities and to elucidate socially transformative outcomes.

METHODS

A narrative literature review was carried out, focussing specifically on arts-based occupations, using seven databases. Thirty-eight items were included.

RESULTS

Three overarching themes emerged: experiences related to giving voice; levels of change and arts-based occupations influence social change.

CONCLUSIONS

Art forms as a means of expression can support people to make demands for change. This was true whether the art form was adopted at grass roots level, or via formalized projects run by researchers or Non-Government Organizations. Whilst personal change and small scale social change outcomes were achievable, larger scale structural change was not evident. Unintended outcomes in the form of risks to participants were reported. How and why change came about was not clearly articulated; leaving a need for further exploration of the mechanisms and contexts supporting change in the growing field of social transformation through occupation.

Ethical issues in global neuroimaging genetics collaborations

Neuroimaging genetics is a rapidly developing field that combines neuropsychiatric genetics studies with imaging modalities to investigate how genetic variation influences brain structure and function. As both genetic and imaging technologies improve further, their combined power may hold translational potential in terms of improving psychiatric nosology, diagnosis, and treatment. While neuroimaging genetics studies offer a number of scientific advantages, they also face challenges. In response to some of these challenges, global neuroimaging genetics collaborations have been created to pool and compare brain data and replicate study findings. Attention has been paid to ethical issues in genetics, neuroimaging, and multi-site collaborative research, respectively, but there have been few substantive discussions of the ethical issues generated by the confluence of these areas in global neuroimaging genetics collaborations. Our discussion focuses on two areas: benefits and risks of global neuroimaging genetics collaborations and the potential impact of neuroimaging genetics research findings in low- and middle-income countries. Global neuroimaging genetics collaborations have the potential to enhance relations between countries and address global mental health challenges, however there are risks regarding inequity, exploitation and data sharing. Moreover, neuroimaging genetics research in low- and middle-income countries must address the issue of feedback of findings and the risk of essentializing and stigmatizing interpretations of mental disorders. We conclude by examining how the notion of solidarity, informed by an African Ethics framework, may justify some of the suggestions made in our discussion.

Global Disparity and Solidarity in a Pandemic

While the domestic effect of structural racism and other social vulnerabilities on Covid‐19 mortality in the United States has received some attention, there has been much less discussion (with some notable exceptions) of how structural global inequalities will further exacerbate Covid‐related health disparity across the world. This may be partially due to the delayed availability of accurate and comparable data from overwhelmed systems, particularly in low‐ and middle‐income countries. However, early methods to procure and develop treatments and vaccines by some high‐income countries reflect ongoing protectionist and nationalistic attitudes that can systemically exclude access for people in regions with weaker health systems. What's needed is a global coordinated effort, based on the principle of solidarity, to foster equitable health care access.

Solidarity and Community Engagement in Global Health Research

Community engagement (CE) is gaining prominence in global health research. A number of ethical goals-spanning the instrumental, intrinsic, and transformative-have been ascribed to CE in global health research. This paper draws attention to an additional transformative value that CE is not typically linked to but that seems very relevant: solidarity. Both are concerned with building relationships and connecting parties that are distant from one another. This paper first argues that furthering solidarity should be recognized as another ethical goal for CE in global health research. It contends that, over time, CE can build the bases of solidaristic relationships-moral imagination, recognition, understanding, empathy-between researchers and community members. Applying concepts from existing accounts of solidarity, the paper develops preliminary ideas about who should be engaged and how to advance solidarity. The proposed approach is compared to current CE practice in global health research. Finally, the paper briefly considers how solidaristic CE could affect how global health research is performed.