Reflections on the development of health economics in low- and middle-income countries

Health economics is a relatively new discipline, though its antecedents can be traced back to William Petty FRS (1623–1687). In high-income countries, the academic discipline and scientific literature have grown rapidly since the 1960s. In low- and middle-income countries, the growth of health economics has been strongly influenced by trends in health policy, especially among the international and bilateral agencies involved in supporting health sector development. Valuable and influential research has been done in areas such as cost–benefit and cost-effectiveness analysis, financing of healthcare, healthcare provision, and health systems analysis, but there has been insufficient questioning of the relevance of theories and policy recommendations in the rich world literature to the circumstances of poorer countries. Characteristics such as a country''s economic structure, strength of political and social institutions, management capacity, and dependence on external agencies, mean that theories and models cannot necessarily be transferred between settings. Recent innovations in the health economics literature on low- and middle-income countries indicate how health economics can be shaped to provide more relevant advice for policy. For this to be taken further, it is critical that such countries develop stronger capacity for health economics within their universities and research institutes, with greater local commitment of funding.     

Designing research funding schemes to promote global health equity: An exploration of current practice in health systems research

International research is an essential means of reducing health disparities between and within countries and should do so as a matter of global justice. Research funders from high‐income countries have an obligation of justice to support health research in low and middle‐income countries (LMICs) that furthers such objectives. This paper investigates how their current funding schemes are designed to incentivise health systems research in LMICs that promotes health equity. Semi‐structured in‐depth interviews were performed with 16 grants officers working for 11 funders and organisations that support health systems research: the Alliance for Health Policy and Systems Research, Comic Relief, Doris Duke Foundation, European Commission, International Development Research Centre, Norwegian Agency for Development Cooperation, Research Council of Norway, Rockefeller Foundation, UK Department of International Development, UK Medical Research Council, and Wellcome Trust. Thematic analysis of the data demonstrates their funding schemes promote health systems research with (up to) five key features that advance health equity: being conducted with worst‐off populations, focusing on research topics that advance equitable health systems, having LMIC ownership of the research agenda, strengthening LMIC research capacity, and having an impact on health disparities. The different types of incentives that encouraged proposed projects to have these features are identified and classified by their strength (strong, moderate, weak). It is suggested that research funders ought to create and maintain funding schemes with strong incentives for the features identified above in order to more effectively help reduce global health disparities.     

Beyond health care reform: immigrants and the future of medicine

Abstract

I first discuss the fundamental responsibilities of physicians and relate them to an increasingly fragmented medical system made even more complex by government regulations. I focus on trust as a vital component in the doctor–patient relationship, and note the difficult conditions surrounding the treatment of poor and marginal populations. Subsequently, I sketch the elements of a new vision to extend medical services to neglected populations. In that pursuit, the part played by physicians is only as important as the willingness of neighbourhoods and communities to support health as a public good.     

Horizontal and vertical transmission of viruses in the honey bee, Apis mellifera

The most crucial stage in the dynamics of virus infections is the mode of virus transmission. In general, transmission of viruses can occur through two pathways: horizontal and vertical transmission. In horizontal transmission, viruses are transmitted among individuals of the same generation, while vertical transmission occurs from mothers to their offspring. Because of its highly organized social structure and crowded population density, the honey bee colony represents a risky environment for the spread of disease infection. Like other plant and animal viruses, bee viruses use different survival strategies, including utilization of both horizontal and vertical routes, to transmit and maintain levels in a host population. In this review, we explore the current knowledge about the honey bee viruses and transmission routes of bee viruses. In addition, different transmission strategies on the persistence and dynamics of host-pathogen interactions are also discussed.     

Transgenerational effects of childhood conditions on third generation health and education outcomes

This paper examines the extent to which pre-puberty nutritional conditions in one generation affect productivity-related outcomes in later generations. Recent findings from the biological literature suggest that the so-called slow growth period around age 9 is a sensitive period for male germ cell development. We build on this evidence and investigate whether undernutrition at those ages transmits to children and grandchildren. Our findings indicate that third generation males (females) tend to have higher mental health scores if their paternal grandfather (maternal grandmother) was exposed to a famine during the slow growth period. These effects appear to reflect biological responses to adaptive expectations about scarcity in the environment, and as such they can be seen as an economic correctional mechanism in evolution, with marked socio-economic implications for the offspring.     

The effects of haloclines on the vertical distribution and migration of zooplankton

While the influence of horizontal salinity gradients on the distribution and abundance of planktonic organisms in estuaries is relatively well known, the effects of vertical salinity gradients (haloclines) are less well understood. Because biological, chemical, and physical conditions can vary between different salinity strata, an understanding of the behavioral response of zooplankton to haloclines is crucial to understanding the population biology and ecology of these organisms. We studied four San Francisco Bay copepods, Acartia (Acartiura) spp., Acartia (Acanthacartia) spp., Oithona davisae, and Tortanus dextrilobatus, and one species of larval fish (Clupea pallasi), in an attempt to understand how and why zooplankton respond to haloclines. Controlled laboratory experiments involved placing several individuals of each species in two 2-m-high tanks, one containing a halocline (magnitude varied between 1.4 and 10.0 psu) and the other without a halocline, and recording the location of each organism once every hour for 2-4 days using an automated video microscopy system. Results indicated that most zooplankton changed their vertical distribution and/or migration in response to haloclines. For the smaller taxa (Acartiura spp., Acanthacartia spp., and O. davisae), this behavior took the form of accumulating in or below the halocline, while the effects on the larger species (C. pallasi and T. dextrilobatus) were more subtle. C. pallasi yolk sac and 3- to 6-day-old larvae seemed to pause or remain in the halocline during their diel migration, while 14- to 17-day-old larvae appeared to avoid the halocline by remaining in deeper, more saline water. There were very few statistically significant effects of haloclines on the vertical distribution of T. dextrilobatus. Subsequent mortality experiments with Acartiura spp., Acanthacartia spp. and T. dextrilobatus indicated that the behavioral changes seen in the halocline studies were not associated with any salinity-induced mortality per se, although more subtle affects of physiological stress could not be ruled out. These results point to a high degree of flexibility in vertical migration behavior within a given species as well as large variation between species. Such behavioral flexibility is likely to be very important in allowing planktonic organisms generally, and estuarine organisms in particular, to maintain or alter position relative to currents, food, and predators.     

On the measurement of health and its effect on the measurement of health inequality

We examine the extent to which self-reported health measures suffer from income-related reporting heterogeneity and then characterize how this reporting heterogeneity affects the estimation of income-related health inequality. We run a comprehensive set of tests of reporting heterogeneity using several self-reported health measures and several clinical measures of health from the National Health and Nutritional Examination Surveys. We propose the use of a multidimensional measure using clinical indicators of health in the context of measuring income-related health inequality, and we examine the extent of income-related health inequality, as measured by the concentration index, using both self-reported measures of health and the multidimensional clinical measure. Our results confirm the existence of significant, positive, income-related reporting heterogeneity and also suggest that higher income individuals react more strongly to a change in clinical health measures. Using self-assessed health suggests that income-related health inequality is about three times larger than when using more objective, self-reported health measures and ten times larger than when using the multidimensional clinical measure of health.     

Selective mortality and the anthropometric status of children in low- and middle-income countries

Despite a close relationship between the childrens’ anthropometric status and mortality rates, the highest mortality rates are concentrated in sub-Saharan Africa, while the lowest anthropometric indicators, in particular the height-for-age z-scores, are concentrated in South Asia. This discrepancy should, however, be expected to decrease when one accounts for the survivorship bias, i.e. selective mortality. We analyse whether the survivorship bias can explain these observed differences in three standard anthropometric indicators (stunting, underweight and wasting) by using individual data of children from six waves of Demographic and Health Surveys for a large cross-section of 37 low- and middle-income countries between 1991 and 2016. We use both a matching approach and semi-parametric regression to estimate the values for the anthropometric status of deceased children. The results are twofold: first, both methods reveal that the imputed values for the anthropometric indicators are, on average, between 0.10 and 0.25 standard deviations lower than the observed anthropometric indicators. Second, since the share of deceased children in our sample is below ten per cent, the contribution of the anthropometric status of deceased children to overall anthropometric indicators is small and therefore only influences it marginally.     

The effects of joint hypermobility syndrome on the kinematics and kinetics of the vertical jump test

PurposeBiomechanical impairments are not apparent during walking in people with Joint Hypermobility Syndrome (JHS). This research explored biomechanical alterations during a higher intensity task, vertical jumping.Materials and methodsThis cross-sectional study compared a JHS group (n = 29) to a healthy control group (n = 30). Joint kinematics and kinetics were recorded using a Qualisys motion capture system synchronized with a Kistler platform. Independent sample t-tests and standardised mean differences (SMD) were used for statistical analysis.ResultsNo significant statistical or clinical differences were found between groups in joint kinematics and jump height (p ≥ 0.01). Sagittal hip and knee peak power generation were statistically lower in the JHS group during the compression phase (p ≤ 0.01), but not clinically relevant (SMD < 0.5). Clinically relevant reductions were found in the JHS group knee and ankle peak moments during the compression phase, and hip and knee peak power generation during the push phase (SMD ≥ 0.5), although these were not statistically significant (p ≥ 0.01).ConclusionThe JHS group achieved a similar jump height but with some biomechanical alterations. Further understanding of the joint biomechanical behavior could help to optimize management strategies for JHS, potentially focusing on neuromuscular control and strength/power training.     

Individual health and the visibility of village economic inequality: Longitudinal evidence from native Amazonians in Bolivia

Mounting evidence suggests that income inequality is associated with worse individual health. But does the visibility of inequality matter? Using data from a horticultural-foraging society of native Amazonians in Bolivia (Tsimane’), we examined whether village inequality in resources and behaviors with greater cultural visibility is more likely to bear a negative association with health than village inequality in less conspicuous resources. We draw on a nine-year annual panel (2002–2010) from 13 Tsimane’ villages for our main analysis, and an additional survey to gauge the cultural visibility of resources. We measured inequality using the Gini coefficient. We tested the robustness of our results using a shorter two-year annual panel (2008–2009) in another 40 Tsimane’ villages and an additional measure of inequality (coefficient of variation, CV). Behaviors with low cultural visibility (e.g., household farm area planted with staples) were less likely to be associated with individual health, compared to more conspicuous behaviors (e.g., expenditures in durable goods, consumption of domesticated animals). We find some evidence that property rights and access to resources matter, with inequality of privately-owned resources showing a larger effect on health. More inequality was associated with improved perceived health – maybe due to improved health prospects from increasing wealth – and worse anthropometric indicators. For example, a unit increase in the Gini coefficient of expenditures in durable goods was associated with 0.24 fewer episodes of stress and a six percentage-point lower probability of reporting illness. A one-point increase in the CV of village inequality in meat consumption was associated with a 4 and 3 percentage-point lower probability of reporting illness and being in bed due to illness, and a 0.05 SD decrease in age-sex standardized arm-muscle area. In small-scale, rural societies at the periphery of market economies, nominal economic inequality in resources bore an association with individual health, but did not necessarily harm perceived health. Economic inequalities in small-scale societies apparently matter, but a thick cultural tapestry of reciprocity norms and kinship ties makes their effects less predictable than in industrial societies.     

Biological effects of conjugated linoleic acids in health and disease

Conjugated linoleic acid (CLA) is a mixture of positional and geometric isomers of octadecadienoic acid [linoleic acid (LA), 18:2n-6] commonly found in beef, lamb and dairy products. The most abundant isomer of CLA in nature is the cis-9, trans-11 (c9t11) isomer. Commercially available CLA is usually a 1:1 mixture of c9t11 and trans-10, cis-12 (t10c12) isomers with other isomers as minor components. Conjugated LA isomer mixture and c9t11 and t10c12 isomers alone have been attributed to provide several health benefits that are largely based on animal and in vitro studies. Conjugated LA has been attributed many beneficial effects in prevention of atherosclerosis, different types of cancer, hypertension and also known to improve immune function. More recent literature with availability of purified c9t11 and t10c12 isomers suggests that t10c12 is the sole isomer involved in antiadipogenic role of CLA. Other studies in animals and cell lines suggest that the two isomers may act similarly or antagonistically to alter cellular function and metabolism, and may also act through different signaling pathways. The effect of CLA and individual isomers shows considerable variation between different strains (BALB/C mice vs. C57BL/6 mice) and species (e.g., rats vs. mice). The dramatic effects seen in animal studies have not been reflected in some clinical studies. This review comprehensively discusses the recent studies on the effects of CLA and individual isomers on body composition, cardiovascular disease, bone health, insulin resistance, mediators of inflammatory response and different types of cancer, obtained from both in vitro and animal studies. This review also discusses the latest available information from clinical studies in these areas of research.     

肠道菌群代谢作用与人体健康关系的研究进展

人体肠道内寄居的大量共生微生物可以通过多方面作用影响人体健康,特别是肠道内菌群的代谢作用,及与人体自身代谢的交互作用在人类的健康促进与疾病的发生、发展中起着重要作用。本文从正反两面讨论了肠道菌群代谢作用对人体健康的影响,并进一步探讨了肠道菌群代谢在健康监测、疾病的预防与治疗,以及个体化医疗方面的运用。     

The intersection of social determinants of health,the microbiome,and health outcomes in immigrants: A scoping review

In the present scoping review, we explore whether existing evidence supports the premise that social determinants of health (SDoH) affect immigrant health outcomes through their effects on the microbiome. We adapt the National Institute on Minority Health and Health Disparities' research framework to propose a conceptual model that considers the intersection of SDoH, the microbiome, and health outcomes in immigrants. We use this conceptual model as a lens through which to explore recent research about SDoH, biological factors associated with changes to immigrants' microbiomes, and long-term health outcomes. In the 17 articles reviewed, dietary acculturation, physical activity, ethnicity, birthplace, age at migration and length of time in the host country, socioeconomic status, and social/linguistic acculturation were important determinants of postmigration microbiome-related transformations. These factors are associated with progressive shifts in microbiome profile with time in host country, increasing the risks for cardiometabolic, mental, immune, and inflammatory disorders and antibiotic resistance. The evidence thus supports the premise that SDoH influence immigrants' health postmigration, at least in part, through their effects on the microbiome. Omission of important postmigration social-ecological variables (e.g., stress, racism, social/family relationships, and environment), limited research among minoritized subgroups of immigrants, complexity and inter- and intra-individual differences in the microbiome, and limited interdisciplinary and biosocial collaboration restrict our understanding of this area of study. To identify potential microbiome-based interventions and promote immigrants' well-being, more research is necessary to understand the intersections of immigrant health with factors from the biological, behavioral/psychosocial, physical/built environment, and sociocultural environment domains at all social-ecological levels.     

Interactive effects of haloclines and food patches on the vertical distribution of 3 species of temperate invertebrate larvae

In laboratory experiments, we examined the effect of haloclines and determined whether the presence of food patches overrides this effect on larval vertical distribution of the sea star Asterias rubens, the sea urchin Strongylocentrotus droebachiensis and the mussel Mytilus edulis. We experimentally constructed haloclines in which the salinity of the bottom water layer was 35 and that of the top layer was 21, 24, 27, and 30 (21/35, 24/35, 27/35, and 30/35) for A. rubens and S. droebachiensis, and 24, 27, 30 and 32 (24/35, 27/35, 30/35, and 32/35) for M. edulis. For each species and stage, additional halocline treatments (A. rubens: 24/32 and 27/32; 4-arm S. droebachiensis: 21/29 and 24/32; 6-arm S. droebachiensis: 24/29 and 24/32; M. edulis: 27/32 and 30/32) were used to determine whether the larval response to inhibitory salinity gradients was due to the absolute salinity of the top layer or the relative salinity difference between the two layers. Also, we measured the density of A. rubens and M. edulis to determine whether the specific gravity of larvae can explain the observed vertical distributions. Larvae aggregated at and below the halocline and these aggregations were more pronounced with increasing strength of the vertical salinity gradient. Threshold salinities in the top layer which inhibited ~ 100% of the larvae from crossing the halocline were 24 for A. rubens and M. edulis, and 21 for S. droebachiensis. These distributional patterns were not the result of larval density, which was greater than all treatment water densities for M. edulis and S. droebachiensis and lower for A. rubens. The effect of the presence of a food patch at inhibitory haloclines (A. rubens: 24/35 and 27/35; 4-arm S. droebachiensis: 21/34 and 24/34; M. edulis: 27/35) was determined by using three algal densities: 0, 5000 or 10 000 cells ml^- 1Thalassiosira pseudonana in either the top or the bottom water layer. For both A. rubens and M. edulis, the number of larvae at the halocline increased in the presence of a food patch, but this effect did not depend on algal density in the patch. For 4-arm S. droebachiensis, there was no effect of the presence of a food patch on larval vertical distribution. Our results suggest that low salinity may act as a barrier to vertical movement and that the presence of food patches above the halocline may strengthen the larval aggregation response to inhibitory haloclines.     

The local and global mental health effects of the Covid-19 pandemic

This paper investigates the mental health effects of the local and global level Covid-19 pandemic among the UK population. To identify the effect, we use a high-quality dataset and an original strategy where we match the previous day’s confirmed pandemic cases to a four-month panel of individual mental health information observed during the interview next day. The approach suggested in this paper aims to identify the average mental health effect on the overall population for the first and second waves of the pandemic. Using a linear fixed-effects model specification, we report robust findings that the average mental health in the UK is substantially reduced by the local and global pandemic. The total reduction in the average mental health of the UK population during our sampling period (April - June, 2020) is about 1.5% for the local and 2.4% for the global cases, which sum up to a 3.9% reduction. Extrapolating the total reduction in average mental health during the first wave of the pandemic (February - September, 2020) sums up to 2.8% while the effect is as large as 9.6% for the first and second waves together, which covers roughly a year since the start. An extensive robustness check suggests that the findings are stable with respect to alternative pandemic datasets, measures, estimators, functional forms, and time functions. The characteristics of the most vulnerable individuals (e.g., elderly, chronic illness, and job security concerns) and their household conditions (e.g., living alone and no private space) are explored. The paper discusses on the implications of the results.     

Horizontal and vertical distribution of meiofauna on sandy beaches of the North Sea (The Netherlands, Belgium, France)

Sandy intertidal zones were analysed for the presence of meiofauna. The material was collected on six macro-tidal sandy beaches along the North Sea (The Netherlands, France, Belgium), in order to analyse the vertical and horizontal meiofaunal distribution patterns. Eleven higher meiofauna taxa (one represented by larval stage—Copepoda nauplii) were recorded. The maximum total meiofauna abundance was observed on the Dutch beach (4,295±911 ind. 10 cm⁻²) in the Westerschelde estuary, while the lowest values (361±128 ind. 10 cm⁻²) were recorded in France at the Audresselles beach. Meiofauna of the different localities consisted mainly of nematodes, harpacticoids and turbellarians. Nematodes numerically dominated all sampled stations, comprising more than 45% of the total meiofauna density. Meiofauna was mainly concentrated at the sand surface with about 70% present in the uppermost 5 cm. Meiofauna occurred across the entire intertidal zone. A clear zonation pattern in the distribution of meiofauna taxa across the beaches was observed. The present work suggests that designation of exposed sandy beaches as physically controlled (McLachlan 1988) does not explain their biological variability.     

Associations between duration of first trimester intrauterine exposure to genocide against the Tutsi and health outcomes in adulthood

Objectives

Hundreds of thousands of Rwandans were conceived during the 1994 genocide against the Tutsi, including thousands conceived by genocidal rape. We explore whether the duration of first trimester exposure to the genocide is associated with variation in adult mental health outcomes in individuals exposed to varying degrees of genocide-related stress in utero.

Materials and Methods

We recruited 30 Rwandans conceived via genocidal rape, 31 Rwandans conceived by genocide survivors not raped, and 30 individuals of Rwandan-descent who were conceived outside of Rwanda at the time of the genocide (control group). Individuals were age- and sex-matched across groups. Adult mental health was assessed through standardized questionnaires for vitality, anxiety, and depression.

Results

Among the genocide only group, a longer duration of first trimester prenatal exposure was associated with higher anxiety scores and lower vitality (both p < 0.010), and higher depression scores (p = 0.051). Duration of first trimester exposure was not associated with any measures of mental health among the genocidal rape or control group.

Discussion

Duration of exposure to genocide in the first trimester of gestation was associated with variation in adult mental health among the genocide only group. The lack of association between duration of first trimester exposure to genocide and adult mental health in the genocidal rape group may reflect the fact that stress associated with conception through rape persisted beyond the genocide period itself, encompassing all of gestation and likely beyond. Geopolitical and community interventions are needed in the context of extreme events during pregnancy to mitigate adverse intergenerational outcomes.     

Consensus statement understanding health and malnutrition through a systems approach: the ENOUGH program for early life

Nutrition research, like most biomedical disciplines, adopted and often uses experimental approaches based on Beadle and Tatum’s one gene—one polypeptide hypothesis, thereby reducing biological processes to single reactions or pathways. Systems thinking is needed to understand the complexity of health and disease processes requiring measurements of physiological processes, as well as environmental and social factors, which may alter the expression of genetic information. Analysis of physiological processes with omics technologies to assess systems’ responses has only become available over the past decade and remains costly. Studies of environmental and social conditions known to alter health are often not connected to biomedical research. While these facts are widely accepted, developing and conducting comprehensive research programs for health are often beyond financial and human resources of single research groups. We propose a new research program on essential nutrients for optimal underpinning of growth and health (ENOUGH) that will use systems approaches with more comprehensive measurements and biostatistical analysis of the many biological and environmental factors that influence undernutrition. Creating a knowledge base for nutrition and health is a necessary first step toward developing solutions targeted to different populations in diverse social and physical environments for the two billion undernourished people in developed and developing economies.