Estimating shadow prices in economies with multiple market failures.

Approaches to the estimation of shadow prices generally assume that all but one market function correctly. However, multiple market failures are common in developing countries. We present a theoretical model and an empirical strategy to estimate the shadow price of a subsistence good in an economy where labor markets fail. Our results show that: 1) among subsistence producers, the shadow price of this good must be greater than or equal to the market price, and equal to it for surplus growers; and 2) current methods create biases when the otherwise-perfect-markets assumption is violated. The propositions are tested using a representative survey for rural Mexico. We find that the shadow wage is below that of the market (MXN $93.2/day vs. MXN $132.3/day), and that the shadow price for subsistence corn is over ten times greater than its market price (MXN $32.37/kg vs. MXN $3.19/kg). Unbiased shadow price estimates for subsistence goods help to overcome the limitations of current income poverty measures: their overestimation of the purchasing power of subsistence households and their underestimation of the value of subsistence goods. In rural Mexico, current practice underestimates the population in food poverty by 2%; an additional 9% has income above the poverty line yet fail to meet the utilization dimension of food security.

Advantages of a New Low-Cost Negative Pressure Wound Therapy Using the "Turtle VAC": A Case Series.

CASE: We present a clinical case and technique guide demonstrating the use and effectiveness of a novel, low-cost negative pressure wound therapy (NPWT) device to achieve soft-tissue coverage in a 34-year-old patient with failed rotational flap and Masquelet technique on infected tibial nonunion. Local debridement was executed, NPWT initiated, and treatment culminated with complete wound healing. CONCLUSION: The "Turtle VAC" offers an effective low-cost alternative to commercially vacuum-assisted closure systems for post-traumatic wounds in low-resource setting of Haiti. Its use of available equipment makes NPWT accessible and can function as a bridge to definitive closure when primary wound closure is not possible and/or between debridement procedures.

Implementation and Impact Evaluation of a Virtual Orthopaedic Continuing Medical Education Conference in a Low-Resource Country.

OBJECTIVE: The Haitian Annual Assembly of Orthopaedic Trauma (HAAOT) is an annual continuing medical education (CME) conference for Haitian orthopedists and trainees converted to a pilot virtual format in 2020 due to the COVID-19 pandemic. We evaluated this virtual format's effectiveness at teaching, facilitating bilingual discussion, and encouraging cross-cultural exchange of experiences - all aimed at improving orthopedic knowledge in a low-resource country like Haiti. DESIGN: Planned collaboratively between North American and Haitian colleagues, the conference involved 4 bilingual weekly Zoom meetings comprised of 4 to 6 prerecorded presentations and live-translated discussion. Pre- and postmeeting knowledge assessments in French (Haitian language of medical instruction) were administered weekly with results compared via 2-sample t-tests. An online postconference survey evaluated attendee satisfaction with the virtual format. SETTING: Virtual. PARTICIPANTS: Weekly attendance involved approximately 50 Haitian orthopedists and trainees, with 20 to 25 completing pre- and postmeeting assessments. RESULTS: Statistically significant increases between pre/post scores were seen during 3 of 4 sessions. Session-wide significant score increases occurred for residents and attending surgeons with <10 years of experience. 85.7% of attendees reported the virtual platform exceeded expectations and 100% indicated likely or extremely likely participation in further virtual events. CONCLUSIONS: The pilot virtual HAAOT was extremely well received with high desire for future sessions. Beyond short-term knowledge retention among attendees, nonmeasurable benefits included collaboration between orthopedists and trainees in the United States, Canada, United Kingdom, Haiti, and Burkina Faso. As COVID-19 spurs online learning in high-income nations, the successful low-resource context adjustments and local partnership underlying this model attest that travel restrictions need not impede delivery of virtual CME conferences in lower-income nations. Attendee learning and the decreased cost and travel requirements allude to this platform's sustainability and reproducibility in facilitating future international education and capacity building. Further studies will assess long-term retention of presented material.

Cross-Cultural Comparison of Nonopioid and Multimodal Analgesic Prescribing in Orthopaedic Trauma.

BACKGROUND: After musculoskeletal injury, US providers prescribe opioids more frequently and at higher dosages than prescribers in the Netherlands and Haiti; however, the extent of variation in nonopioid analgesic prescribing is unknown. The aim of our study was to evaluate how nonopioid prescribing by orthopaedic residents varies by geographic context. METHODS: Orthopaedic residents in three countries in which residents are the primary prescribers of postoperative analgesia in academic medical centers (Haiti, the Netherlands, and the United States) responded to surveys using vignette-based musculoskeletal trauma case scenarios. The residents chose which medications they would prescribe for postdischarge analgesia. We quantified the likelihood and dose of acetaminophen or a nonsteroidal anti-inflammatory drug prescription. We constructed multivariable regressions with generalized estimating equations to describe differences in nonopiate prescription according to country, the resident's sex and training year, and the injury site and age in the test cases. RESULTS: Compared with residents from the United States, residents from Haiti were more likely to prescribe nonopioids (odds ratio, 3.22 [confidence interval, 1.94 to 5.34], P < 0.0001) and residents from the Netherlands nearly always prescribed nonopioids. Of those cases where one or more opioid was prescribed, providers also prescribed a nonopioid (acetaminophen or nonsteroidal anti-inflammatory drug) in 345/603 (57.2%) of US, 152/152 (100%) of Dutch, and 69/97 (71.1%) of Haitian cases (Fisher exact test P value <0.0001). Finally, providers prescribed only nonopioids for pain control in 3/348 (0.86%) of US, 32/184 (17.4%) of Dutch, and 107/176 (60.8%) of Haitian cases (Fisher exact test P < 0.0001). CONCLUSIONS: When comparing multimodal analgesic patterns, US prescribers prescribed nonopioid analgesics less frequently than prescribers in two other countries, one low income and one high income, either in isolation or in conjunction with opioids.

Cross-Cultural Comparison of Postoperative Discharge Opioid Prescribing After Orthopaedic Trauma Surgery.

BACKGROUND: The extent of variation in analgesic prescribing following musculoskeletal injury among countries and cultural contexts is poorly understood. Such an understanding can inform both domestic prescribing and future policy. The aim of our survey study was to evaluate how opioid prescribing by orthopaedic residents varies by geographic context. METHODS: Orthopaedic residents in 3 countries in which residents are the primary prescribers of postoperative analgesia in academic medical centers (Haiti, the Netherlands, and the U.S.) responded to surveys utilizing vignette-based musculoskeletal trauma case scenarios. The residents chose which medications they would prescribe for post-discharge analgesia. We standardized opioid prescriptions in the surveys by conversion to morphine milligram equivalents (MMEs). We then constructed multivariable regressions with generalized estimating equations to describe differences in opiate prescription according to country, the resident's sex and training year, and the injury site and age in the test cases. RESULTS: U.S. residents prescribed significantly more total MMEs per case (mean [95% confidence interval] = 383 [331 to 435]) compared with residents from the Netherlands (229 [160 to 297]) and from Haiti (101 [52 to 150]) both overall (p < 0.0001) and for patients treated for injuries of the femur (452 [385 to 520], 315 [216 to 414], and 103 [37 to 169] in the U.S., the Netherlands, and Haiti, respectively), tibial plateau (459 [388 to 531], 280 [196 to 365], and 114 [46 to 183]), tibial shaft (440 [380 to 500], 294 [205 to 383], and 141 [44 to 239]), wrist (239 [194 to 284], 78 [36 to 119], and 63 [30 to 95]), and ankle (331 [270 to 393], 190 [100 to 280], and 85 [42 to 128]) (p = 0.0272). U.S. residents prescribed significantly more MMEs for patients <40 years old (432 [374 to 490]) than for those >70 years old (327 [270 to 384]) (p = 0.0019). CONCLUSIONS: Our results demonstrate greater prescribing of postoperative opioids at discharge in the U.S. compared with 2 other countries, 1 low-income and 1 high-income. Our findings highlight the high U.S. reliance on opioid prescribing for postoperative pain control after orthopaedic trauma. CLINICAL RELEVANCE: Our findings point toward a need for careful reassessment of current opioid prescribing habits in the U.S. and demand reflection on how we can maximize effectiveness in pain management protocols and reduce provider contributions to the ongoing opioid crisis.

Education Improves Musculoskeletal Radiology Interpretation by Trainees in a Low-Resource Setting.

OBJECTIVE: The aims of this study were to assess baseline musculoskeletal radiology knowledge among Haitian orthopedists and to determine the impact of an adult and pediatric musculoskeletal radiology lecture series. DESIGN: Participants were given lectures reviewing normal and abnormal elbow radiographs and received assessments before and after the intervention. Bivariate and multivariate analyses were used to identify factors associated with baseline and postintervention scores. SETTING: This study was carried out as part of the 2018 Haitian Annual Assembly of Orthopaedic Trauma. This is an annual continuing medical educational conference in the capital city of Port-au-Prince open to all Haitian orthopedic surgeons and associated care providers, with a strong focus on resident training. PARTICIPANTS: Haitian orthopedic surgery residents and surgeons attending the 2018 Haitian Annual Assembly of Orthopaedic Trauma. RESULTS: Thirty-seven residents and faculty consented to participate in this study and 32 (86.5%) were male with a median age of 33 (interquartile rage: 30-35). On multivariate analysis controlling for the title (resident versus attending), total years of orthopedics (beginning of residency and beyond), and formal radiology teaching in medical school or residency, conference attendance in the past was significantly associated with higher preintervention assessment scores (odds ratio = 1.24, 95% confidence interval = 1.06-1.44, p = 0.010]. The mean total preintervention accuracy for correctly identification of pathology, if present, was 70% compared to 83% at the postassessment (p < 0.001). CONCLUSIONS: Overall, this study demonstrates that a brief lecture series at a continuing medical conference in Port-au-Prince, Haiti improved upper extremity radiographic interpretation based on pre and postassessments, and that prior conference attendance may be associated with higher baseline scores.

Haitian Annual Conference on Orthopaedic Traumatology: Building Surgical Capacity Through Academic Collaboration.

The Assemblée Annuelle Haitienne de Traumatologie Orthopedique (Haitian Annual Conference on Orthopaedic Traumatology) is an international orthopaedic conference, conducted each Spring in Haiti in French and English. It brings together most of Haiti's practicing orthopaedic surgeons, trainees from Haiti's 3 residency training programs, and a visiting faculty from overseas. The Haitian Annual Conference on Orthopaedic Traumatology has become an unexpected cornerstone of 1 program to support and nurture the development of orthopaedic surgery in that country.

A Self-Reported Needs Assessment Survey of Pediatric Orthopaedic Education in Haiti.

OBJECTIVE: The burden of musculoskeletal disease remains high in low-income countries, with a high rate of pediatric disease. Efforts continue for orthopedic education, but there is little guidance on local needs and desires. Our aim was to determine the specific content and modalities that would be most useful for pediatric orthopedic educational programs abroad, and we demonstrate a practical method of identifying country-specific educational deficits through a self-reported needs survey in Haiti. DESIGN: A cross-sectional survey was administered using an automated response system. We obtained demographic information as well as training and practice patterns, comfort levels with pediatric diagnoses, and desired topics for education using a 5-point Likert Scale. SETTING: Haitian Annual Assembly for Orthopaedic Trauma (HAAOT), the only national, continuing medical education conference for orthopedic providers in Haiti. PARTICIPANTS: Of 60 eligible participants, 51 were included in the final analysis. RESULTS: Time spent on pediatric orthopedics varied widely, centered at 10% to 25%. Median comfort level with pediatric orthopedics was 3 of 5. Skills with lowest self-reported competence included spica casting, clubfoot casting, and management of supracondylar humerus fractures. Skills with highest self-reported competence were long-leg casting and Salter-Harris classification. Modes of education highly requested included didactics/lectures, hands-on sessions, dedicated rotations, and exchanges with foreign peers/mentors. Diagnoses most encountered were osteomyelitis, trauma, and clubfoot; lowest comfort levels were in neuromuscular, spine, lower extremity deformity, congenital hip, and clubfoot; and most requested for future teaching were congenital hip, neuromuscular, and spine. CONCLUSIONS: Haitian orthopedic providers express a strong desire and need for ongoing pediatric orthopedic education. They describe a high prevalence of trauma and infection, but convey a requirement for more comprehensive, multimodal teaching that also includes congenital deformities/dysplasias, neuromuscular, and spine. Our results demonstrate the importance of assessing country-specific needs and involving local care providers in curriculum development.

Short-Term Performance Improvement of a Continuing Medical Education Program in a Low-Income Country.

BACKGROUND: The Haitian Annual Assembly for Orthopaedic Trauma (HAAOT) is a CME conference designed to help Haitian orthopaedic surgeons improve their knowledge and skills. The effectiveness of international CME conferences has not been studied. We hypothesized that HAAOT improves participants' short-term performance on knowledge-based assessments. METHODS: Data were prospectively collected from 57 Haitian and 21 foreign orthopaedic surgeons and residents who attended HAAOT using pre- and post-presentation questions. An audience response system was used to capture responses to 40 questions. Five additional demographic questions were used to train participants and to record unique audience member responses. Questions were projected in English and in French. Two-sided paired t tests were used to compare pre- and post-test scores. ANOVA with post-hoc unpaired t tests was used to compare among demographic groups. RESULTS: Response rate Median response rate was 77.4 % per day (Range: 76.5-85.9 % per day). Pre-test scores Pre-test scores averaged 21 % for Haitians and 39 % for foreigners (p < 0.0001), and were similar among Haitian attendings and residents. Pre-post differences Scores improved by 8 % for Haitians (p < 0.0001) and 10 % for foreigners (p < 0.01) after didactic presentations. Among sub-groups, Haitian attendings improved on average by 18 % compared to 6 % for residents (p < 0.0001). Haitian attending improvement trended toward significance when compared to foreign attendings (p < 0.08). CONCLUSIONS: Our study is the first to show improved short-term knowledge performance using an audience response system during a CME conference in a low-income country. CME conferences in low-income countries can be an effective tool to increase surgeon knowledge, and audience response systems can help engage participants and track outcomes.

A novel approach for needs assessment to build global orthopedic surgical capacity in a low-income country.

OBJECTIVE: Visiting surgical teams are a vital aspect of capacity-building continuing medical education (CME) in low-income countries like Haiti. Imperfect understanding of the genuine needs of local surgeons limit CME initiatives. Previous paper-based needs assessment efforts have been unsuccessful because of low response rates. We explored using an electronic audience response system (ARS) during a Haitian CME conference to improve the response rates and better assess needs. METHODS: Data were prospectively collected using an ARS from 78 conference participants (57 Haitian and 21 foreign) about current and desired knowledge of 7 topic and 8 skill areas using a 5-point Likert scale presented in English and in French. The response rates using ARS vs a similar paper survey were compared using a 2-sample test of proportions. The current and desired knowledge levels were compared using paired t tests. Analysis of variance and post hoc unpaired t tests were used to compare between demographic groups. RESULTS: The response rates were significantly greater for ARS vs a paper survey (87.7 vs 63.2%, p = 0.002). The 4 areas of least self-confidence for Haitians were pelvic and articular injury, joint dislocation, and osteomyelitis. The 4 skills of least self-confidence for Haitians were arthroscopy, open reduction and internal fixation-plate, external fixation, and fasciotomy. Haitians desired improvements in knowledge and management of articular, diaphyseal, and pelvic injury, joint dislocation, and osteomyelitis to a greater extent than foreigners (p < 0.05). Participants who previously attended the conference on open fractures felt more knowledgeable about open fractures as a topic (p < 0.05), but not in its management. CONCLUSIONS: We are the first to show that an ARS improves response rates to allow for better characterization of surgeon needs in the developing world. We also demonstrate the importance of skill building paired with topic area teaching. Lastly, we show how a CME conference is an effective tool to build surgical capacity and increase confidence level.

Genetic erosion in maize's center of origin.

Crop genetic diversity is an indispensable resource for farmers and professional breeders responding to changing climate, pests, and diseases. Anecdotal appraisals in centers of crop origin have suggested serious threats to this diversity for over half a century. However, a nationwide inventory recently found all maize races previously described for Mexico, including some formerly considered nearly extinct. A flurry of social studies seems to confirm that farmers maintain considerable diversity. Here, we compare estimates of maize diversity from case studies over the past 15 y with nationally and regionally representative matched longitudinal data from farmers across rural Mexico. Our findings reveal an increasing bias in inferences based on case study results and widespread loss of diversity. Cross-sectional, case study data suggest that farm-level richness has increased by 0.04 y(-1) nationwide; however, direct estimates using matched longitudinal data reveal that richness dropped -0.04 y(-1) between 2002 and 2007, from 1.43 to 1.22 varieties per farm. Varietal losses occurred across regions and altitudinal zones, and regardless of farm turnover within the sector. Extinction of local maize populations may not have resulted in an immediate loss of alleles, but low varietal richness and changes in maize's metapopulation dynamics may prevent farmers from accessing germplasm suitable to a rapidly changing climate. Declining yields could then lead farmers to leave the sector and result in a further loss of diversity. Similarities in research approaches across crops suggest that methodological biases could conceal a loss of diversity at other centers of crop origin.

Inexplicable or simply unexplained? The management of maize seed in Mexico.

Farmer management of plant germplasm pre-dates crop domestication, but humans' role in crop evolution and diversity remains largely undocumented and often contested. Seemingly inexplicable practices observed throughout agricultural history, such as exchanging or replacing seed, continue to structure crop populations across the developing world. Seed management practices can be construed as events in the life history of crops and management data used to model crop demography, but this requires suitable quantitative data. As a prerequisite to addressing the causes and implications of maize seed management, we describe its patterns of variation across Mexico by drawing from the literature and new analysis. We find that rates of seed replacement, introduction and diffusion differ significantly across regions and altitudinal zones, but interactions among explanatory factors can obscure patterns of variation. The type, source, geographic origin and ownership of seed help explain observed rates. Yet, controlling for the characteristics of germplasm barely reduces interregional differences vastly exceeding variation across elevations. With few exceptions, monotonic altitudinal trends are absent. Causal relationships between management practices and the physical environment could determine farmers' wellbeing and crop conservation in the face of climate change. Scarce and inconsistent data on management nevertheless could prevent an understanding of these relationships. Current conceptions on the management and dynamics of maize diversity are founded on a patchwork of observations in surprisingly few and dissimilar environments. Our estimates of management practices should shed light on differences in maize population dynamics across Mexico. Consistency with previous studies spanning over a decade suggests that common sets of forces are present within large areas, but causal associations remain unknown. The next step in explaining crop diversity should address variation in seed management across space and time simultaneously while identifying farmers' values and motivations as underlying forces.

Informal "seed" systems and the management of gene flow in traditional agroecosystems: the case of cassava in Cauca, Colombia.

Our ability to manage gene flow within traditional agroecosystems and their repercussions requires understanding the biology of crops, including farming practices' role in crop ecology. That these practices' effects on crop population genetics have not been quantified bespeaks lack of an appropriate analytical framework. We use a model that construes seed-management practices as part of a crop's demography to describe the dynamics of cassava (Manihot esculenta Crantz) in Cauca, Colombia. We quantify several management practices for cassava--the first estimates of their kind for a vegetatively-propagated crop--describe their demographic repercussions, and compare them to those of maize, a sexually-reproduced grain crop. We discuss the implications for gene flow, the conservation of cassava diversity, and the biosafety of vegetatively-propagated crops in centers of diversity. Cassava populations are surprisingly open and dynamic: farmers exchange germplasm across localities, particularly improved varieties, and distribute it among neighbors at extremely high rates vis-à-vis maize. This implies that a large portion of cassava populations consists of non-local germplasm, often grown in mixed stands with local varieties. Gene flow from this germplasm into local seed banks and gene pools via pollen has been documented, but its extent remains uncertain. In sum, cassava's biology and vegetative propagation might facilitate pre-release confinement of genetically-modified varieties, as expected, but simultaneously contribute to their diffusion across traditional agroecosystems if released. Genetically-modified cassava is unlikely to displace landraces or compromise their diversity; but rapid diffusion of improved germplasm and subsequent incorporation into cassava landraces, seed banks or wild populations could obstruct the tracking and eradication of deleterious transgenes. Attempts to regulate traditional farming practices to reduce the risks could compromise cassava populations' adaptive potential and ultimately prove ineffectual.

Dispersal of transgenes through maize seed systems in Mexico.

OBJECTIVES: Current models of transgene dispersal focus on gene flow via pollen while neglecting seed, a vital vehicle for gene flow in centers of crop origin and diversity. We analyze the dispersal of maize transgenes via seeds in Mexico, the crop's cradle. METHODS: We use immunoassays (ELISA) to screen for the activity of recombinant proteins in a nationwide sample of farmer seed stocks. We estimate critical parameters of seed population dynamics using household survey data and combine these estimates with analytical results to examine presumed sources and mechanisms of dispersal. RESULTS: Recombinant proteins Cry1Ab/Ac and CP4/EPSPS were found in 3.1% and 1.8% of samples, respectively. They are most abundant in southeast Mexico but also present in the west-central region. Diffusion of seed and grain imported from the United States might explain the frequency and distribution of transgenes in west-central Mexico but not in the southeast. CONCLUSIONS: Understanding the potential for transgene survival and dispersal should help design methods to regulate the diffusion of germplasm into local seed stocks. Further research is needed on the interactions between formal and informal seed systems and grain markets in centers of crop origin and diversification.

A crop population perspective on maize seed systems in Mexico.

Improvement of local germplasm through artificial selection is regarded as the main force behind maize evolution and diversity in Mexico, the crop's center of origin. This perspective neglects the larger social context of maize evolution. Using a theoretical approach and Mexico-wide data, we show that farmer-led evolution of maize is largely driven by a technological diffusion and appropriation process that selectively integrates nonlocal germplasm into local seed stocks. Our approach construes farmer practices as events in the life history of seed to build a demographic model. The model shows how random and systematic differences in management combine to structure maize seed populations into subpopulations that can spread or become extinct, in some cases independently of visible agronomic advantages. The process involves continuous population bottlenecks that can lead to diversity loss. Nonlocal germplasm thus might play a critical role in maintaining diversity in individual localities. Empirical estimates show that introduction of nonlocal seed in Central and Southeastern Mexico is rarer than previously thought; prompt replacement further prevents new seed from spreading. Yet introduced seed perceived as valuable diffuses rapidly, contributing variation in the form of type diversity or through introgression into local seed. Maize seed dynamics and evolution are thus part of a complex social process driven by farmers' desire to appropriate the value in maize farming, not always achieved by preserving or improving local seed stocks.