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Reducing global inequities in medical oxygen access: the Lancet Global Health Commission on medical oxygen security
Get PDFExecutive summary“Oxygen delayed is life denied,” COVID-19 survivor, KenyaMedical oxygen is an essential medicine that has been in clinical use for over 150 years. It is required at every level of the healthcare system for children and adults with a wide range of acute and chronic conditions, and for safe surgery and perioperative care, and must be available to all who need it. The COVID-19 pandemic shone a spotlight on the longstanding inequities in access to medical oxygen globally, and the importance of this lifesaving therapy to people of all ages and in every part of the world. It was against this backdrop that the Lancet Global Health Commission on Medical Oxygen Security was launched in 2022 – to synthesise available evidence and harness expertise into concrete and actionable recommendations for governments, industry, global health agencies, donors, healthcare workforce, and researchers.Our work emphasises that oxygen is a service, not just a commodity, and achieving equitable oxygen access requires a systems approach, addressing multiple domains (production, storage, distribution, supply, clinical use, coordination, regulation, financing) across multiple sectors (health, education, energy, industry, transport). Previous efforts, including the major investments in response to the COVID-19 pandemic, largely focused on the delivery of equipment to produce more oxygen, neglecting the systems and people required to ensure equipment is distributed, maintained, and used safely and effectively. Key findings from this Commission show how future investment in strengthening oxygen systems could have huge impact, saving millions of lives, accelerating progress towards the Sustainable Development Goals (SDGs), and leaving the world much better prepared for future pandemics.Key findingsThe global need for medical oxygen is high. Each year, 373 million newborns, children, and adults need medical oxygen, including 364 million patients with acute medical and surgical conditions, and 9 million patients with long-term oxygen needs due to chronic obstructive pulmonary disease (COPD). Eighty-two percent of patients needing oxygen live in low- and middle-income countries (LMICs), with 70% concentrated in South Asia, East Asia, and Sub-Saharan Africa. Patients with acute medical and surgical needs require a minimum 1.2 billion cubic metres (Nm3) of medical oxygen annually. This need is rising, driven by population growth, unmet surgery and long-term oxygen therapy needs. Efforts to prevent oxygen need are critical, through immunisation, smoking and malnutrition reduction, improved indoor and outdoor air pollution, and climate change mitigation. During emergencies the need for oxygen can increase exponentially, putting enormous pressure on health systems. In 2021, globally an additional 52 million patients needed 1.9 billion cubic meters of oxygen to treat COVID-19.Global access to oxygen is highly inequitable with huge gaps in many LMICs despite pandemic-related investments in recent years. We found over 5 billion people, 60% of the world’s population, do not currently have access to safe, quality, and affordable medical oxygen services. In LMICs, less than one in three (30%) people who need oxygen for acute medical or surgical conditions currently receives adequate oxygen therapy, with the greatest inequities in Sub-Saharan Africa. This equates to a 70% oxygen coverage gap, which far exceeds gaps for HIV/AIDS (24%) and tuberculosis (39%) medicines. Major contributors to the oxygen access gap include: people not reaching a health facility; facilities lacking basic oxygen service capacity; missed identification of oxygen need due to lack of pulse oximetry; interrupted, unsafe, or otherwise low quality oxygen care; and the high costs of oxygen services borne by patients. Pulse oximeters and oxygen are currently available in 54% and 58% of general and 83% and 86% of tertiary hospitals, with frequent shortages and equipment breakdown causing healthcare workers moral distress as they ration care. Pulse oximeters and oxygen are practically nonexistent in primary healthcare facilities.Global costs to fill the oxygen gap are large but represent a highly cost-effective investment that will have wide reaching impacts. We estimate that closing the large acute medical and surgical oxygen access gap in LMICs requires an additional US32.6 billion between 2025 and 2030. This does not include the substantial cost to meet the additional oxygen needed for pandemics ($US6.8 billion for COVID-19 in 2021) or costs for long-term oxygen therapy services. The case for investing in medical oxygen is strong - it is as cost-effective as routine childhood immunization, would enable governments to make progress on eight of the nine SDG 3 goals, and reduce deaths during future pandemics.National Medical Oxygen Plans are essential to facilitate investment and effectively coordinate service delivery, as outlined in the 2023 World Health Organization (WHO) Increasing Access to Medical Oxygen Resolution. Less than 30 countries have developed National Oxygen Plans to date, and we encourage all governments to do so by 2030. Governments should bring together public and private sector partners with a stake in medical oxygen delivery - including health, education, industry, energy, transport, and other sectors - to design the system and institute a governance structure that keeps all parties connected in its management. Oxygen systems must be integrated into broader national health plans and pandemic preparedness and response strategies.Pulse oximetry is the gateway to safe, quality, affordable oxygen care and needs to be integrated in clinical education, guidelines, and all levels of the healthcare system. Pulse oximetry measures an essential vital sign - the peripheral blood (haemoglobin) oxygen saturation (SpO2) - that should be routinely assessed in all patients at all levels of health care. However, healthcare workers are currently poorly equipped or supported to use pulse oximeters effectively and pulse oximetry and oxygen therapy are lacking from many clinical guidelines and health curricula. We found that pulse oximetry was performed for only 19% of patients presenting to general hospitals in LMICs and almost never performed for patients presenting to primary healthcare facilities, with the greatest inequities in small and rural government health facilities and across Sub-Saharan Africa. We recognise an urgent need to make high-quality, robust pulse oximeters more affordable and better used while also working to improve their accuracy for all populations, including those with darker skin pigmentation and infants and young children.Oxygen systems must be designed to suit the context, include operational costs, and be affordable to all patients. There is no one-size-fits-all national medical oxygen system. Rather, governments should define priorities and optimise their systems to suit local conditions. Most health systems and health facilities will benefit from a mixed-source oxygen supply (i.e., liquid, oxygen plant, cylinder, and/or oxygen concentrator), including reliable back-up in case of failure and to meet surges during emergencies. Operational costs account for 50 to 80% of total system costs but have received relatively little investment to date, with catastrophic consequences for the functioning, sustainability, and effective use of oxygen equipment. We particularly highlight the importance of investing in the clinical and engineering workforce. Although there are many different models for managing a national oxygen system, from fully-government- to fully private sector-run, governments should ensure that whatever system they choose, costs are not shifted to the patients. Patient and caregiver testimonies repeatedly told of punishing out-of-pocket costs and we strongly urge governments to include pulse oximetry and oxygen services in Universal Health Coverage (UHC) schemes and to pursue other strategies to minimise user fees.We call for closer collaboration between the medical oxygen industry, national governments, and global health agencies. The medical oxygen industry, like the pharmaceutical industry, is an essential part of the public health and pandemic preparedness and response architecture. Governments are responsible for ensuring that medical oxygen markets function safely, competitively, and with price transparency, and that national regulations defining medical oxygen quality and safety are aligned with the updated WHO International Pharmacopoeia. Companies should adopt specific oxygen access targets and publish progress while global health agencies should regularly assess oxygen industry progress as they currently do for the pharmaceutical industry. We call on global health agencies and donors to maintain oxygen access as a global health priority, including supporting the new Global Oxygen Alliance (GO2AL) and replenishing The Global Fund with a strong oxygen access mandate. Finally, access to medical oxygen and related tools and therapies must be fully integrated into global pandemic preparedness and response architecture.Accurate and timely data on oxygen systems is essential for effective decision making and oxygen service access. We found huge gaps in oxygen access data, major deficiencies in the tools we use to monitor oxygen systems and service delivery, and estimates of cost-effectiveness for different oxygen solutions and patient populations. We present two new tools to help governments, health facilities, and global health agencies make progress. These include 10 Oxygen Coverage Indicators and a national Access to Medical Oxygen Scorecard (ATMO2S), which governments should use to both plan their national oxygen systems and report progress implementing the WHO Oxygen Resolution. We also offer areas for further research that’s needed to close the most critical evidence gaps in medical oxygen access.Finally, we note the robust discussions on the future of global health post SDGs and the calls for an approach that delivers not just for human health but also for planetary health. This Commission provide a path for us to make increasing access to medical oxygen a global health exemplar, centring equity and sustainability through practical action. Integrating oxygen investments into national plans and health systems strengthening will improve health services and benefit all patients, everywhere. Embracing oxygen systems and devices that are energy-efficient and powered by renewable energy will reduce carbon emissions, while investment in local maintenance and repair reduces the financial, human, and environmental costs of device graveyards. National medical oxygen systems can be at the forefront of the future we want – the long-term health and sustainability of our most precious resources – people and planet. But only if we continue investing in closing the wide gaps in access to medical oxygen for all
Entrepreneurship-as-struggle:The crises and politics of entrepreneurial becomings
Get PDFEntrepreneurship among marginalized people in Bangladesh involves social, political, and cultural struggle against immediate crises of poverty and enduring crises of class, caste, religious, and gendered exclusions. Drawing on 25 months of ethnographic research among entrepreneurs in rural Bangladesh and the life stories of 137 entrepreneurs, we argue that the aspirations, relationships, and transformations that emerge with these practices reveal an entrepreneurship distinct from the mainstream development ideas so prevalent in the region about individualized market actors. This article calls attention to the specific forms of politics that entrepreneurship-as-struggle acquires and explores how entrepreneurs mobilize identity formation, accommodating protest, cultural critique, and solidaristic action through their ventures. Paying heed to such forms of politics in entrepreneurship offers insights into what types of crises entrepreneurship is able to confront and what forms of transformation become possible for entrepreneurs and their communities
New systemic treatment paradigms in advanced biliary tract cancer and variations in patient access across Europe: A clinician’s perspective
Get PDFIn recent years, treatment options for patients with advanced biliary tract cancer (BTC) have increased significantly due to the positive results from phase 2/3 clinical trials of immune check point inhibitors, combined with chemotherapy, and molecularly targeted agents. These advances have led to the need for molecular testing to identify actionable alterations and patients amenable to targeted therapies. However, these improvements have brought with them many questions and challenges, including the identification of resistance mechanisms and therapeutic sequences. Another important issue is the significant disparities in access to innovative treatments and molecular testing across European countries, leading to inequalities in the possibilities of treating patients with advanced BTC. This may be related to differences in the healthcare systems and reimbursement within Europe. Ongoing European collaborative projects, such as the COST Action Precision-BTC-Network CA22125, supported by COST (European Cooperation in Science and Technology), linked to the European Network for the Study of Cholangiocarcinoma (ENSCCA), can help overcome these disparities and improve the current scenario.<p/
On the deep-water and shallow-water limits of the intermediate long wave equation from a statistical viewpoint
Get PDFWe study convergence problems for the intermediate long wave equation (ILW), with the depth parameter δ > 0, in the deep-water limit (δ \to \infty) and the shallow-water limit (δ \to 0) from a statistical point of view. In particular, we establish convergence of invariant Gibbs dynamics for ILW in both the deep-water and shallow-water limits. For this purpose, we first construct the Gibbs measures for ILW, 0 < δ < \infty. As they are supported on distributions, a renormalization is required. With the Wick renormalization, we carry out the construction of the Gibbs measures for ILW. We then prove that the Gibbs measures for ILW converge in total variation to that for the Benjamin-Ono equation (BO) in the deep-water limit (δ \to \infty). In the shallow-water regime, after applying a scaling transformation, we prove that, as δ \to 0, the Gibbs measures for the scaled ILWconverge weakly to that for the Korteweg-de Vries equation (KdV). We point out that this second result is of particular interest since the Gibbs measures for the scaled ILW and KdV are mutually singular (whereas the Gibbs measures for ILW and BO are equivalent). In terms of dynamics, we use a compactness argument to construct invariant Gibbs dynamics for ILW (without uniqueness). Furthermore, we show that, by extracting a sequence δ_m, this invariant Gibbs dynamics for ILW converges to that for BO in the deep-water limit (δ_m \to \infty) and to that for KdV (after the scaling) in the shallow-water limit (δ_m \to 0), respectively. Lastly, we point out that our results also apply to the generalized ILW equation in the defocusing case, converging to the generalized BO in the deep-water limit and to the generalized KdV in the shallow-water limit. In the non-defocusing case, however, our results can not be extended to a nonlinearity with a higher power due to the non-normalizability of the corresponding Gibbs measures.<br/
Reflections on avoiding ‘bungalow legs’:Active ageing and the built environment
Get PDFCommentary on earlier paper by other authors referring to older adults wanting to remain active and avoid getting 'bungalow legs
Updating the Scottish national cardiovascular risk score: ASSIGN version 2.0
Get PDFBackground The Assessing cardiovascular risk using Scottish Intercollegiate Guidelines Network (ASSIGN) risk score, developed in 2006, is used in Scotland for estimating the 10-year risk of first atherosclerotic cardiovascular disease (ASCVD). Rates of ASCVD are decreasing, and an update is required. This study aimed to recalibrate ASSIGN (V.2.0) using contemporary data and to compare recalibration with other potential approaches for updating the risk score. Methods Data from Scotland-resident participants from UK Biobank (2006–2010) and the Generation Scotland Scottish Family Health Study (2006–2010), aged 40–69 and without previous ASCVD, were used for the derivation of scores. External evaluation was conducted on UK Biobank participants who were not residents of Scotland. The original ASSIGN predictor variables and weights formed the basis of the new sex-specific risk equation to predict the 10-year risk of ASCVD. Different approaches for updating ASSIGN (recalibration, rederivation and regression adjustment) were tested in the evaluation cohort. Results The original ASSIGN score overestimated ASCVD risk in the evaluation cohort, with median predicted 10-year risks of 10.6% for females and 15.1% for males, compared with observed risks of 6% and 11.4%, respectively. The derivation cohort included 44 947 (57% females and a mean age of 55) participants. The recalibrated score, ASSIGN V.2.0, improved model fit in the evaluation cohort, predicting median 10-year risk of 4% for females and 8.9% for males. Similar improvements were achieved using the regression-adjusted model. Rederivation of ASSIGN using new beta coefficients offered only modest improvements in calibration and discrimination beyond simple recalibration. At the current risk threshold of 20% 10-year risk, the original ASSIGN equation yielded a positive predictive value (PPV) of 16.3% and a negative predictive value (NPV) of 94.4%. Recalibrated ASSIGN V.2.0 showed similar performance at a 10% threshold, with a PPV of 16.8% and an NPV of 94.6%. Conclusions The recalibrated ASSIGN V.2.0 will give a more accurate estimation of contemporary ASCVD risk in Scotland.</p
All’s well that ends well?:A new holism about lifetime well-being
Get PDFIs there more to how well a life goes overall (its lifetime well-being) than simply the aggregate goodness and badness of its moments (its momentary well-being)? Atomists about lifetime well-being say ‘no’. Holists hold that there is more to lifetime well-being than aggregate momentary well-being (with different holists offering different candidates for what this extra element might be). This paper presents and defends a novel form of holism about lifetime well-being, which I call ‘End of Life’. This is the view that the momentary goodness or badness of the end of lives has a disproportionate effect upon lifetime well-being. More precisely: a welfare subject’s level of momentary well-being at the end of their life contributes more to their lifetime well-being than their level of momentary well-being at each other point
How language proficiency and age of acquisition affect executive control in bilinguals:Continuous versus dichotomous analysis approaches
Get PDFResearchers have argued that grouping heterogeneous linguistic profiles under a dichotomous condition might mask the cognitive effects of bilingualism. The current study used two different analysis approaches (i.e., continuous versus dichotomous) to examine inhibitory control in a sample of 239 young adult bilinguals. Dividing the sample into dichotomous groups based on L2 proficiency (i.e., high-proficient versus low-proficient) and L2 AoA (i.e., early versus late) did not lead to reliable group differences in any of the measurements used. However, the use of a continuous measure revealed that higher L2 proficiency predicted better visual inhibition and earlier L2 AoA was associated with better auditory inhibition. Furthermore, the observed differences were limited to tasks involving stimulus–stimulus competition, but not stimulus–response competition. These findings shed new light on the importance of conceptualising bilingualism as a continuous measure rather than a dichotomous measure and previous research on bilingual performance in different cognitive tasks
Abundant clock proteins point to missing molecular regulation in the plant circadian clock
Get PDFUnderstanding the biochemistry behind whole-organism traits such as flowering time is a longstanding challenge, where mathematical models are critical. Very few models of plant gene circuits use the absolute units required for comparison to biochemical data. We refactor two detailed models of the plant circadian clock from relative to absolute units. Using absolute RNA quantification, a simple model predicted abundant clock protein levels in Arabidopsis thaliana, up to 100,000 proteins per cell. NanoLUC reporter protein fusions validated the predicted levels of clock proteins in vivo. Recalibrating the detailed models to these protein levels estimated their DNA-binding dissociation constants (Kd). We estimate the same Kd from multiple results in vitro, extending the method to any promoter sequence. The detailed models simulated the Kd range estimated from LUX DNA-binding in vitro but departed from the data for CCA1 binding, pointing to further circadian mechanisms. Our analytical and experimental methods should transfer to understand other plant gene regulatory networks, potentially including the natural sequence variation that contributes to evolutionary adaptation
On NextG Open RAN as a sensing infrastructure
Get PDFWhile communication and sensing systems have historically evolved independently, there are several compelling reasons for their integrated operation, including reduction in deployment and operational costs. We consider di!erent ways to integrate communication and sensing, and argue that joint communication and sensing (JCAS) paradigm stands out clearly as the preferred alternative, that too from a network-centric perspective. Given the above, we make the case for turning the NextG radio network infrastructure for enabling sensing applications, leveraging the trend towards Open RAN adoption in NextG networks. We outline NextG Open RAN enabled sensing applications spanning both spectrum sensing and wireless signal sensing. We discuss several research challenges that need to be addressed to realize NextG Open RAN based sensing. We consider device positioning as a representative sensing use case in this setting and highlight some challenges for robust positioning through analysis of measurements from a carrier-grade indoor 5G Open RAN testbed
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