Decolonising global health research: Shifting power for transformative change.

Recent debates on decolonizing global health have spurred interest in addressing the power asymmetries and knowledge hierarchies that sustain colonial ideas and relationships in global health research. This paper applies three intersecting dimensions of colonialism (colonialism within global health; colonisation of global health; and colonialism through global health) to develop a broader and more structural understanding of the policies and actions needed to decolonise global health research. It argues that existing guidelines and checklists designed to make global health research more equitable do not adequately address the underlying power asymmetries and biases that prevail across the global health research ecosystem. Beyond encouraging fairer partnerships within individual research projects, this paper calls for more emphasis on shifting the balance of decision-making power, redistributing resources, and holding research funders and other power-holders accountable to the places and peoples involved in and impacted by global health research.

Developing an agenda for the decolonization of global health.

Colonialism, which involves the systemic domination of lands, markets, peoples, assets, cultures or political institutions to exploit, misappropriate and extract wealth and resources, affects health in many ways. In recent years, interest has grown in the decolonization of global health with a focus on correcting power imbalances between high-income and low-income countries and on challenging ideas and values of some wealthy countries that shape the practice of global health. We argue that decolonization of global health must also address the relationship between global health actors and contemporary forms of colonialism, in particular the current forms of corporate and financialized colonialism that operate through globalized systems of wealth extraction and profiteering. We present a three-part agenda for action that can be taken to decolonize global health. The first part relates to the power asymmetries that exist between global health actors from high-income and historically privileged countries and their counterparts in low-income and marginalized settings. The second part concerns the colonization of the structures and systems of global health governance itself. The third part addresses how colonialism occurs through the global health system. Addressing all forms of colonialism calls for a political and economic anticolonialism as well as social decolonization aimed at ensuring greater national, racial, cultural and knowledge diversity within the structures of global health.

Le colonialisme, qui implique la domination systémique de terres, de marchés, de peuples, de ressources, de cultures ou d'institutions politiques dans le but d'exploiter, de détourner et d'extraire des richesses et des ressources, affecte la santé de nombreuses manières. Ces dernières années, la décolonisation de la santé mondiale a suscité un intérêt croissant, l'accent étant mis sur la correction des déséquilibres de pouvoir entre les pays à revenu élevé et les pays à faible revenu, ainsi que sur la remise en question des idées et des valeurs de certains pays riches qui façonnent la pratique de la santé mondiale. Nous soutenons que la décolonisation de la santé mondiale doit également aborder la relation entre les acteurs de la santé mondiale et les formes contemporaines de colonialisme, en particulier les formes actuelles de colonialisme d'entreprise et de colonialisme financiarisé qui opèrent par des systèmes mondialisés d'extraction de richesses et de profits. Nous présentons un programme d'action en trois parties destiné à décoloniser la santé mondiale. La première partie porte sur les asymétries de pouvoir existant entre les acteurs de la santé mondiale des pays à hauts revenus et historiquement privilégiés et leurs homologues des pays à faibles revenus et marginalisés. La deuxième partie concerne la colonisation des structures et des systèmes de la gouvernance mondiale de la santé elle-même. La troisième partie traite de la manière dont le colonialisme se manifeste à travers le système de santé mondial. La lutte contre toutes les formes de colonialisme nécessite un anticolonialisme politique et économique ainsi qu'une décolonisation sociale visant à garantir une plus grande diversité nationale, raciale, culturelle et des connaissances au sein des structures de la santé mondiale.

El colonialismo, que implica la dominación sistémica de tierras, mercados, pueblos, bienes, culturas o instituciones políticas para explotar, apropiarse indebidamente y extraer riqueza y recursos, afecta a la salud de muchas maneras. En los últimos años ha crecido el interés por descolonizar la salud mundial, en particular para corregir los desequilibrios de poder entre los países de ingresos altos y los de ingresos bajos, y para cuestionar las ideas y los valores de algunos países ricos que influyen en la práctica de la salud mundial. Sostenemos que la descolonización de la salud mundial también debe abordar la relación entre los actores de la salud mundial y las formas contemporáneas de colonialismo, en especial las formas actuales de colonialismo corporativo y financiarizado que operan a través de sistemas globalizados de extracción de riqueza y especulación. Presentamos un programa de acción dividido en tres partes para descolonizar la salud mundial. La primera parte se refiere a las asimetrías de poder que existen entre los actores de la salud mundial procedentes de países de ingresos altos e históricamente privilegiados y sus homólogos de entornos de ingresos bajos y marginados. La segunda parte se refiere a la colonización de las estructuras y sistemas de la propia gobernanza de la salud mundial. La tercera parte aborda cómo se produce el colonialismo a través del sistema sanitario mundial. Abordar todas las formas de colonialismo exige un anticolonialismo político y económico, así como una descolonización social destinada a garantizar una mayor diversidad nacional, racial, cultural y de conocimientos dentro de las estructuras de la salud mundial.

Global health security and the health-security nexus: principles, politics and praxis.

The past four decades have seen a steady rise of references to 'security' by health academics, policy-makers and practitioners, particularly in relation to threats posed by infectious disease pandemics. Yet, despite an increasingly dominant health security discourse, the many different ways in which health and security issues and actors intersect have remained largely unassessed and unpacked in current critical global health scholarship. This paper discusses the emerging and growing health-security nexus in the wake of COVID-19 and the international focus on global health security. In recognising the contested and fluid concept of health security, this paper presents two contrasting approaches to health security: neocolonial health security and universal health security. Building from this analysis, we present a novel heuristic that delineates the multiple intersections and entanglements between health and security actors and agendas to broaden our conceptualisation of global health security configurations and practices and to highlight the potential for harmful unintended consequences, the erosion of global health norms and values, and the risk of health actors being co-opted by the security sector.

CVtreeMLE: Efficient Estimation of Mixed Exposures using Data Adaptive Decision Trees and Cross-Validated Targeted Maximum Likelihood Estimation in R.

Statistical causal inference of mixed exposures has been limited by reliance on parametric models and, until recently, by researchers considering only one exposure at a time, usually estimated as a beta coefficient in a generalized linear regression model (GLM). This independent assessment of exposures poorly estimates the joint impact of a collection of the same exposures in a realistic exposure setting. Marginal methods for mixture variable selection such as ridge/lasso regression are biased by linear assumptions and the interactions modeled are chosen by the user. Clustering methods such as principal component regression lose both interpretability and valid inference. Newer mixture methods such as quantile g-computation (Keil et al., 2020) are biased by linear/additive assumptions. More flexible methods such as Bayesian kernel machine regression (BKMR)(Bobb et al., 2014) are sensitive to the choice of tuning parameters, are computationally taxing and lack an interpretable and robust summary statistic of dose-response relationships. No methods currently exist which finds the best flexible model to adjust for covariates while applying a non-parametric model that targets for interactions in a mixture and delivers valid inference for a target parameter. Non-parametric methods such as decision trees are a useful tool to evaluate combined exposures by finding partitions in the joint-exposure (mixture) space that best explain the variance in an outcome. However, current methods using decision trees to assess statistical inference for interactions are biased and are prone to overfitting by using the full data to both identify nodes in the tree and make statistical inference given these nodes. Other methods have used an independent test set to derive inference which does not use the full data. The CVtreeMLE R package provides researchers in (bio)statistics, epidemiology, and environmental health sciences with access to state-of-the-art statistical methodology for evaluating the causal effects of a data-adaptively determined mixed exposure using decision trees. Our target audience are those analysts who would normally use a potentially biased GLM based model for a mixed exposure. Instead, we hope to provide users with a non-parametric statistical machine where users simply specify the exposures, covariates and outcome, CVtreeMLE then determines if a best fitting decision tree exists and delivers interpretable results.

Threats by artificial intelligence to human health and human existence.

While artificial intelligence (AI) offers promising solutions in healthcare, it also poses a number of threats to human health and well-being via social, political, economic and security-related determinants of health. We describe three such main ways misused narrow AI serves as a threat to human health: through increasing opportunities for control and manipulation of people; enhancing and dehumanising lethal weapon capacity and by rendering human labour increasingly obsolescent. We then examine self-improving 'artificial general intelligence' (AGI) and how this could pose an existential threat to humanity itself. Finally, we discuss the critical need for effective regulation, including the prohibition of certain types and applications of AI, and echo calls for a moratorium on the development of self-improving AGI. We ask the medical and public health community to engage in evidence-based advocacy for safe AI, rooted in the precautionary principle.

The impacts of COVID-19 and its policy response on access and utilization of maternal and child health services in Tanzania: A mixed methods study.

The SARS-Cov-2 virus (COVID-19) has had a global social and economic impact. Despite the growing evidence, its effects on access and delivery of maternal and child health services in low-income countries are still unclear. This cross-sectional case study was conducted in Mjini Magharibi, Chake Chake, and Ilala districts in Tanzania to help fill this gap. The study combined qualitative and quantitative data collection methods, providing an account of the evolution of the pandemic and the associated control measures in Tanzania. We drew from 34 in-depth interviews, 60 semi-structured interviews, and 14 focus group discussions with key informants, patients, and health providers, and complemented the findings with a review of pandemic reports and health facility records. We followed the Standards for Reporting Qualitative Research (SRQR) to provide an account of the findings. Our account of the pandemic shows that there was at times an inconsistent policy response in Tanzania, with diverse control measures adopted at various stages of the epidemic. There was a perception that COVID-19 services were prioritized during the epidemic at the expense of regular ones. There were reports of reorganisation of health facilities, reallocation of staff, rescheduled antenatal and postnatal clinics, and reduced time for health education and child monitoring. Scarcity of essential commodities was reported, such as vaccines, equipment, and medical supplies. Such perceptions were in part supported by the routine utilization evidence in the three districts, showing a lower uptake of antenatal, postnatal, family planning, and immunization services, as well as fewer institutional deliveries. Our findings suggest that, although the policy response in Tanzania was erratic, it was rather fear of the pandemic itself and diversion of resources to control COVID-19, that may have contributed most to lower the utilization of mother and child services. For future emergencies, it will be crucial to ensure the policy response does not weaken the population's demand for services.

More than just noise: Association of pulsatile tinnitus with anxiety, depression, and reduction of quality of life.

BACKGROUND: While many of the causes of pulsatile tinnitus (PT) are treatable with endovascular approaches, the risks of treatment must be balanced with the risks of the underlying cause and the psychological impact of symptoms on patients. While many physicians have anecdotal experience, the comorbid relationship of depression and anxiety with PT is unknown. The objectives of this study are to quantify the prevalence of depression and anxiety, and, to identify the demographic risk factors for impactful depression and anxiety in patients with PT. METHODS: Subjects recruited from online PT groups filled out secure online questionnaires that included demographic questions, validated Tinnitus Functional Index (TFI) as well as PHQ-9 and GAD-7 questionnaires to assess the prevalence of concurrent depression and anxiety, respectively. RESULTS: Sample included 515 surveys (84% female, 65% unemployed, mean(sd) age = 46.4 years (14.2)). Median symptom duration was 1.9 years. Data showed 46% and 37% of patients with moderate to severe depression and anxiety, respectively. Higher TFI scores were associated with moderate to severe depression (OR 1.07; 95% CI 1.06-1.09, p < 0.001) and anxiety (OR 1.05, 95% CI 1.04-1.06, p < 0.001), with TFI subscores also independently being associated in a univariate analysis. CONCLUSIONS: The prevalence of moderate to severe depression and anxiety in the PT population, which was previously unknown, is estimated in our study to be 46% and 37%, respectively. Significant association of TFI score with increased depression and anxiety scales adds further evidence of the impact of PT on the psychological health of these patients.

The effects of COVID-19 lockdown measures on health and healthcare services in Uganda.

Many countries across the world instituted lockdowns as a measure to prevent the spread of COVID-19. However, these lockdowns had consequences on health systems. This study explored effects of the COVID-19 lockdown measures on health and healthcare services in Uganda. The qualitative study employed focus group discussions (FGDs), household interviews, and key informant interviews (KIIs) in both an urban (Kampala district) and rural (Wakiso district) setting in central Uganda. Fourteen FGDs were conducted among community members, local leaders, community health workers, and health practitioners. Interviews were conducted among 40 households, while 31 KIIs were held among various stakeholders including policy makers, non-governmental organisations, and the private sector. Data was analysed by thematic analysis with the support of NVivo 2020 (QSR International). Findings from the study are presented under four themes: maternal and reproductive health; child health; chronic disease services; and mental health. Maternal and reproductive health services were negatively affected by the lockdown measures which resulted in reduced utilisation of antenatal, postnatal and family planning services. These effects were mainly due to travel restrictions including curfew, and fear of contracting COVID-19. The effects on child health included reduced utilisation of services which was a result of difficulties faced in accessing health facilities because of the travel restrictions. Patients with chronic conditions could not access health facilities for their routine visits particularly due to suspension of public transport. Depression, stress and anxiety were common due to social isolation from relatives and friends, loss of jobs, and fear of law enforcement personnel. There was also increased anxiety among health workers due to fear of contracting COVID-19. The COVID-19 lockdown measures negatively affected health, and reduced access to maternal, reproductive and child health services. Future interventions in pandemic response should ensure that their effects on health and access to health services are minimised.

The disproportionate case-fatality ratio of COVID-19 between countries with the highest vaccination rates and the rest of the world.

Objectives: The global reported cumulative case-fatality ratios (rCFRs) and excess mortality rates of the 20 countries with the highest coronavirus disease 2019 (COVID-19) vaccination rates, the rest of the world and Sub-Saharan Africa (SSA) were compared before and after the commencement of vaccination programmes. Methods: A time series model was used to understand the trend of rCFR over time, and a generalized linear mixed model was used to understand the effect of vaccination on rCFR. Results: By 31 December 2022, an average of 260.3 doses of COVID-19 vaccine per 100 population had been administered in the top 20 vaccinated countries, compared with 152.1 doses in the rest of the world and 51.2 doses in SSA. The mean rCFR of COVID-19 had decreased by 69.0% in the top 20 vaccinated countries, 26.5% in the rest of the world and 7.6% in SSA. Excess mortality had decreased by 48.7% in the top 20 vaccinated countries, compared with 62.5% in the rest of the world and 60.7% in SSA. In a generalized linear mixed model, the reported number of vaccine doses administered (/100 population) (odds ratio 0.64) was associated with a steeper reduction in COVID-19 rCFR. Conclusions: Vaccine equity and faster roll-out across the world is critically important in reducing COVID-19 transmission and CFR.

Breastfeeding: crucially important, but increasingly challenged in a market-driven world.

In this Series paper, we examine how mother and baby attributes at the individual level interact with breastfeeding determinants at other levels, how these interactions drive breastfeeding outcomes, and what policies and interventions are necessary to achieve optimal breastfeeding. About one in three neonates in low-income and middle-income countries receive prelacteal feeds, and only one in two neonates are put to the breast within the first hour of life. Prelacteal feeds are strongly associated with delayed initiation of breastfeeding. Self-reported insufficient milk continues to be one of the most common reasons for introducing commercial milk formula (CMF) and stopping breastfeeding. Parents and health professionals frequently misinterpret typical, unsettled baby behaviours as signs of milk insufficiency or inadequacy. In our market-driven world and in violation of the WHO International Code for Marketing of Breast-milk Substitutes, the CMF industry exploits concerns of parents about these behaviours with unfounded product claims and advertising messages. A synthesis of reviews between 2016 and 2021 and country-based case studies indicate that breastfeeding practices at a population level can be improved rapidly through multilevel and multicomponent interventions across the socioecological model and settings. Breastfeeding is not the sole responsibility of women and requires collective societal approaches that take gender inequities into consideration.

Marketing of commercial milk formula: a system to capture parents, communities, science, and policy.

Despite proven benefits, less than half of infants and young children globally are breastfed in accordance with the recommendations of WHO. In comparison, commercial milk formula (CMF) sales have increased to about US$55 billion annually, with more infants and young children receiving formula products than ever. This Series paper describes the CMF marketing playbook and its influence on families, health professionals, science, and policy processes, drawing on national survey data, company reports, case studies, methodical scoping reviews, and two multicountry research studies. We report how CMF sales are driven by multifaceted, well resourced marketing strategies that portray CMF products, with little or no supporting evidence, as solutions to common infant health and developmental challenges in ways that systematically undermine breastfeeding. Digital platforms substantially extend the reach and influence of marketing while circumventing the International Code of Marketing of Breast-milk Substitutes. Creating an enabling policy environment for breastfeeding that is free from commercial influence requires greater political commitment, financial investment, CMF industry transparency, and sustained advocacy. A framework convention on the commercial marketing of food products for infants and children is needed to end CMF marketing.

The political economy of infant and young child feeding: confronting corporate power, overcoming structural barriers, and accelerating progress.

Despite increasing evidence about the value and importance of breastfeeding, less than half of the world's infants and young children (aged 0-36 months) are breastfed as recommended. This Series paper examines the social, political, and economic reasons for this problem. First, this paper highlights the power of the commercial milk formula (CMF) industry to commodify the feeding of infants and young children; influence policy at both national and international levels in ways that grow and sustain CMF markets; and externalise the social, environmental, and economic costs of CMF. Second, this paper examines how breastfeeding is undermined by economic policies and systems that ignore the value of care work by women, including breastfeeding, and by the inadequacy of maternity rights protection across the world, especially for poorer women. Third, this paper presents three reasons why health systems often do not provide adequate breastfeeding protection, promotion, and support. These reasons are the gendered and biomedical power systems that deny women-centred and culturally appropriate care; the economic and ideological factors that accept, and even encourage, commercial influence and conflicts of interest; and the fiscal and economic policies that leave governments with insufficient funds to adequately protect, promote, and support breastfeeding. We outline six sets of wide-ranging social, political, and economic reforms required to overcome these deeply embedded commercial and structural barriers to breastfeeding.

What is the current evidence for the relationship between the climate and environmental crises and child marriage? A scoping review.

Environmental crises such as climate change threaten the realisation of sexual and reproductive health and rights. In this scoping review, we examine the evidence for the relationship between environmental crises and child marriage. We conducted a search of Google Scholar, Scopus and MedLine from their origin to 4th June 2021 for both peer-reviewed academic literature and 'grey' literature. A total of 24 relevant articles were identified, including both quantitative and qualitative work. while there are limitations of the current evidence base such as its narrow geographical scope, we find that environmental crises worsen known drivers of child marriage, pushing families to marry their daughters early through loss of assets and opportunities for income generation, displacement of people from their homes, educational disruption, and the creation of settings in which sexual violence and the fear of sexual violence increase. Local socio-cultural contexts such as bride price or dowry practices further shape how these factors affect child marriage. Given many of the areas with the highest current rates of child marriage face the gravest environmental threats, action to tackle child marriage must take account of the link identified in this review.

Predicting the binding of small molecules to nuclear receptors using machine learning.

Nuclear receptors (NRs) are important biological targets of endocrine-disrupting chemicals (EDCs). Identifying chemicals that can act as EDCs and modulate the function of NRs is difficult because of the time and cost of in vitro and in vivo screening to determine the potential hazards of the 100 000s of chemicals that humans are exposed to. Hence, there is a need for computational approaches to prioritize chemicals for biological testing. Machine learning (ML) techniques are alternative methods that can quickly screen millions of chemicals and identify those that may be an EDC. Computational models of chemical binding to multiple NRs have begun to emerge. Recently, a Nuclear Receptor Activity (NuRA) dataset, describing experimentally derived small-molecule activity against various NRs has been created. We have used the NuRA dataset to develop an ensemble of ML-based models to predict the agonism, antagonism, binding and effector binding of small molecules to nine different human NRs. We defined the applicability domain of the ML models as a measure of Tanimoto similarity to the molecules in the training set, which enhanced the performance of the developed classifiers. We further developed a user-friendly web server named 'NR-ToxPred' to predict the binding of chemicals to the nine NRs using the best-performing models for each receptor. This web server is freely accessible at http://nr-toxpred.cchem.berkeley.edu. Users can upload individual chemicals using Simplified Molecular-Input Line-Entry System, CAS numbers or sketch the molecule in the provided space to predict the compound's activity against the different NRs and predict the binding mode for each.