A Proposed Global Medicines Agency (GMA) to Make Biological Drugs Accessible: Starting with the League of Arab States.

Medical anthropology teaches us of historical disparity in the accessibility of medicines in the developing world due to their lack of availability and affordability, more particularly of biological drugs, including therapeutic proteins, gene therapy, CRISPR-Cas9, mRNA therapeutics, CART therapy, and many more. This challenge can be resolved by establishing an independent regulatory agency, proposed as the Global Medicines Agency (GMA), with a charter to allow originators from the Stringent Regulatory Agency (SRA) countries to receive immediate registrations applicable to all member states, expanding the market potential as an incentive. For non-SRA countries, it will be limited to biological drugs that are allowed their copies to be made, only biosimilars. A transparent approval process will involve using a rapporteur, a third-party product-related current Good Manufacturing Practice (cGMP), and assurance of the integrity of samples tested for analytical similarity and clinical pharmacology testing. GMA membership will be open to all countries. Still, it is suggested that the League of Arab States, representing 22 states with a population of 400 million, takes the lead due to their cultural and language homogeneity, which is likely to provide a concurrence among the member states. However, some states, like the Gulf Cooperative Council, are already accustomed to this approach, albeit with a different perspective. The target drugs are biotechnology and gene therapy pharmaceuticals, and their scope can be expanded to any drug.

Case reports in the Lancet: From neurophobia to global pandemics.

While neurology remains the best-represented specialty, it was Hematology and Rheumatology cases that were more often reported by non-specialists. The overall distribution by country has also changed, reflecting recent outbreaks of infectious agents.

Kinetic health: ecologies and mobilities of prevention in Europe, c. 1100-1600.

This article coins and deploys the term kinetic health as part of a broader attempt to historicize the mobilities paradigm from the standpoint of past community prophylactics. It uses the example of Galenic or humoral medicine, which for millennia organized individual and group health as a dynamic systems balance among several spheres of intersecting fixities and flows. The radical situatedness it fostered emerges clearly from tracing preventative health interventions among different communities in 'preindustrial' Europe, including urban dwellers, miners and armies, whose different motilities both bound people to and released them from their immediate environment. Beyond reframing past practices, kinetic health benefits mobilities studies scholars by interrogating stagist narratives of civilization and modernization in two ways. First, as an analytic, because although humoralism and other medical systems continue to inform present-day approaches to health and disease around the globe, they are often obscured by layers of colonialism and biomedicine. And secondly, as a perch for viewing the long-term ebb, flow and mingling of ideas about ill/health as an assemblage of (social) bodies and their natural and social environments.

The global, regional, and national burden of atopic dermatitis in 195 countries and territories: An ecological study from the Global Burden of Disease Study 2017.

INTRODUCTION: Numerous population-based studies have focused on the global prevalence of atopic dermatitis (AD), but there are few studies on the global trends of the burden associated with AD. METHODS: We analyzed the global AD trends in 2017 in 195 countries worldwide using the Global Burden of Disease (GBD) Study database, including prevalence rates, age and sex patterns, and AD burden, using disability-adjusted life years (DALYs). Age-standardized DALYs were also compared to the sociodemographic index values of all the countries in 2017. RESULTS: The age-specific DALYs in 2017 showed a right-skewed distribution, with the highest DALYs between 1 and 5 years of age. Females had a higher burden of AD throughout all age groups and geographic regions. The GBD super region with the greatest burden of DALYs caused by AD was high income (178.63 DALYs per 100,000 males, 231.8 for females), and the country with the highest DALYs was Sweden (326.91). The GBD super region with the lowest age-standardized DALY burden caused by AD was south Asia (84.51 DALYs per 100,000 males, 100.54 for females). CONCLUSION: There is a large GBD caused by AD. The observed burden is the greatest in resource-rich countries, females, and young children.

The global, regional, and national burden of fungal skin diseases in 195 countries and territories: A cross-sectional analysis from the Global Burden of Disease Study 2017.

INTRODUCTION: Fungal skin diseases are highly prevalent worldwide, but few existing studies focus on the burden of dermatomycoses. METHODS: An analysis of fungal skin disease trends in 2017 in 195 countries worldwide was conducted using the Global Burden of Disease Study database, including prevalence rates, age and sex patterns, and fungal burden, using disability-adjusted life years (DALYs). Age-standardized DALYs were also compared to the sociodemographic index values of all the countries in 2017. RESULTS: The age-specific fungal skin disease DALYs in 2017 showed a right-skewed distribution, with a peak between 1 and 5 years of age. The world region with the greatest burden of fungal skin disease was sub-Saharan Africa (DALY rate 89.3 per 100,000 males, 78.42 for females), and the individual country with the greatest DALY rate was Mali (122). The Global Burden of Disease super region with the lowest fungal skin disease burden had high incomes (DALY rate 33.12 per 100,000 males, 30.16 for females), which includes southern Latin America, western Europe, high-income North America, Australasia, and high-income southern Pacific. CONCLUSION: Skin mycoses place a substantial burden on patients worldwide. This burden is the greatest in resource-poor countries, tropical regions, and children between 1 and 5 years of age. DALYs can potentially serve as a purposeful measure for directing health policy resources to improve the global impact of fungal skin disease.

Burden of skin disease and associated socioeconomic status in Asia: A cross-sectional analysis from the Global Burden of Disease Study 1990-2017.

INTRODUCTION: Skin diseases have a significant global impact on quality of life, mental health, and loss of income. The burden of dermatologic conditions and its relationship with socioeconomic status in Asia is currently not well understood. METHODS: We selected Global Burden of Disease Study datasets to analyze disability-adjusted life years (DALYs) in 50 Asian countries, including Central Asia, northern Asia, eastern Asia, western Asia, southeastern Asia, and southern Asia, between 1990 and 2017. We compared DALYs to the socioeconomic status using the sociodemographic index and gross domestic product per capita of a country. Statistical analysis was performed using Pearson's correlation. RESULTS: Some countries had higher or lower than expected age-standardized DALY rates of skin diseases. Asian countries, especially high-income countries, had a high burden of inflammatory dermatoses, including acne, alopecia areata, atopic dermatitis, contact dermatitis, decubitus ulcers, psoriasis, pruritus, and seborrheic dermatitis. The burden of infectious dermatoses was greater in low-income Asian countries. The burden of skin cancer in Asia was relatively low. CONCLUSION: There is a high burden of skin disease, especially inflammatory conditions, in Asian countries, but the burden of individual dermatoses in Asia varies by country and socioeconomic status. DALYs can potentially serve as a purposeful measure for directing resources to improve the burden of skin disease in Asia.

"An epoch-making and blessed moment in the history of medicine" -thoughts on international health equity and the Nobel prize in medicine.

The Nobel Prize in Physiology or Medicine is a prestigious award given every year for ostensibly the most important discovery in the field. Prizes in Medicine have typically gone to honor foundational knowledge rather than measurable impact. Two recent examples from global health (a rotavirus vaccine, child growth standards) offer alternatives for what might be lauded in medicine. These two examples and historical achievements regarding cholera and smallpox are worthy but do not fall within the scope of Nobel awards for Peace or Economics. The COVID-19 pandemic gives a new context for the idea that discovery and implementation are both keys to medicine. New patterns that redefine achievement in medicine could emerge by Nobel Prize precedent to promote greater health equity and international collaboration.

Pulmonary Manifestations of Torture.

Despite international treaties banning torture, it is still widely practiced by state agents and private citizens alike. Pulmonologists may encounter survivors of torture in routine clinical practice or in the context of a forensic medical evaluation. The Istanbul Protocol delineates the general approach to the effective medical examination, investigation, and reporting of an individual alleging torture, but relatively little text is devoted to the specific pulmonary manifestations of torture. This review intends to address this paucity.

The global, regional, and national burden of psoriasis in 195 countries and territories, 1990 to 2017: A systematic analysis from the Global Burden of Disease Study 2017.

BACKGROUND: Few existing studies on the global incidence, prevalence, and burden of disease from psoriasis are of high quality, making reliable data and comparisons difficult to find. METHODS: We analyzed global psoriasis trends from 1990 to 2017 in 195 countries worldwide through the Global Burden of Disease Study database, including age-standardized prevalence rates, percent change in age-standardized prevalence rates, age and sex patterns, and psoriasis burden using disability-adjusted life years. RESULTS: The age-specific prevalence rate in 2017 showed a left-skewed distribution with a peak between 60 and 70 years of age and a roughly equal male-to-female ratio across all ages. Psoriasis burden was greatest in countries with high income and high sociodemographic index. A positive linear relationship between psoriasis prevalence and comorbidities is seen with cardiovascular disease (R = .67), mental health (R = .63), type 2 diabetes mellitus (R = .55), stroke (R = .51), non-Hodgkin lymphoma (R = .84), Hodgkin lymphoma (R = .77), nonmelanoma skin cancer (R = .68), and inflammatory bowel disease (R = .55) across all countries in 2017. CONCLUSION: There is increasing prevalence, burden, and associated comorbidities of psoriasis on a global scale and the need for support to reduce this important global health disparity.

The Unseen Global Burden of Disease.

Due to geographic-specific patient and institutional-related barriers to care, data extrapolation and expert opinion on global burden of disease in otolaryngology-head and neck surgery may under- or overestimate the presence and effect of common head and neck conditions. The group of conditions that fail to present to local physicians and/or missed in data extrapolation methods is the unseen burden of disease. This article presents opinions from otolaryngology-head and neck surgery physicians in high- and low/middle-income countries to help explain the contributing factors and ultimately how to use this unseen burden of disease.

Prevalence of Hearing Loss, and Middle Ear Disease in 1351 School Age Children in Mekelle, Ethiopia.

OBJECTIVES: The objective of this study was to begin to measure the prevalence of elevated hearing thresholds in Ethiopia, with audiometric equipment, including bone oscillators and tympanometers. To that end Ethiopian nationals were trained in audiometric techniques to obtain sensorineural hearing loss (SNHL) and conductive hearing loss (CHL) rates in school age children. METHODS: Five mainstreamed public grade schools in northern Ethiopia were the sites for audiometry campaigns examining 1351 children and testing them with behavioral audiometry. RESULTS: Seven percent of students had SNHL > 20 dB in at least 1 frequency in at least 1 ear, and 0.6% of ears had SNHL > 50 dB. Eighteen percent8% of students had CHL > 20 dB in 1 or both ears. The frequency with the highest incidence of elevated pure tone thresholds was at 8000 Hz. Seven percent of students had an air bone gap at 2000 and/or 4000 Hz of at least 15 dB. Air bone gap is not obtained at 8000 Hz. There were 22 perforated tympanic membranes in 17 children (0.8% of tympanic membranes, 1% of students). CONCLUSION: This study gives a baseline for the prevalence of hearing loss in school age children in mainstreamed northern Ethiopian schools. It is the first of its kind and perhaps can help in estimated hearing health needs there. LEVEL OF EVIDENCE: 2.

Emergency Medicine in Egypt.

BACKGROUND: Egypt plays a pivotal role in North Africa and the Middle East, and has the largest population of any Arab country and serves as a regional cultural hub. Emergency medicine as a field of study was first initiated at Alexandria University in 1978, but it was only formally recognized as a medical specialty in 2002. Since then, the prehospital system and practice of emergency medicine has evolved and grown. OBJECTIVES: This article will outline the development of emergency medicine in Egypt, including infrastructure, education, specialty certification, and future challenges, including those which are common to other specialties in development, and also those which are unique to Egypt. DISCUSSION: Opportunities remain with respect to the development of emergency medicine in Egypt, most notably in a continuing 'brain drain' of physicians who leave the country after receiving training, supervision, and oversight of residency programs, and general public and professional awareness of this new specialty. CONCLUSION: Egypt has made great strides with respect to the delivery of emergency services, physician education and certification within the specialty of emergency medicine. Learning about these developments in Egypt will provide the reader with a compelling example of how an emergency system is developed in an advancing national setting.

Knowledge of and attitudes towards cardiopulmonary resuscitation among junior doctors and medical students in Upper Egypt: cross-sectional study.

BACKGROUND: Cardiopulmonary resuscitation (CPR) is a fundamental skill that should be acquired by all medical community members. This study aims to evaluate the knowledge and attitudes of junior doctors and medical students towards CPR and CPR training at Beni-Suef University Hospital in Upper Egypt, a representative region with conditions common to LMIC settings. PARTICIPANTS AND METHODS: In this cross-sectional study, a total of 205 participants (60 junior doctors and 145 medical students) responded to a self-administered questionnaire assessing their knowledge regarding basic life support (BLS) and CPR techniques in neonates, children, and adults, in addition to attitudes towards the importance and necessity of CPR and CPR training. RESULTS: Of the 60 junior doctors that participated in the study, only 31.7% had adequate knowledge of CPR, but up to 95% reported positive attitudes towards CPR training. Among the 145 medical student participants, only 6.2% had adequate knowledge of CPR, while 91% reported positive attitudes towards training. Deficiencies in CPR knowledge were more apparent in questions related to CPR in children and neonates. Junior doctors and medical students with previous CPR training demonstrated significantly better CPR knowledge than their counterparts without prior training. A statistically significant positive correlation was detected between CPR knowledge and attitude towards CPR training among medical students (r = 0.41, p < 0.001). CONCLUSION: The results of this study demonstrate suboptimal and inadequate CPR knowledge among junior doctors and medical students in a representative hospital in Upper Egypt. However, participants reported overwhelmingly positive attitudes and eagerness towards the implementation of CPR training. Further research needs to be done to establish CPR skill proficiency as well as to investigate barriers to CPR training, effectiveness of available programs, and the potential implementation of such a program in Egypt and other LMICs.

Global Medicine, Parasites, and Tasmania.

Until the 1970s, infectious disease training in most medical schools was limited to those diseases common in the area of instruction. Those wishing to explore a more globalised curriculum were encouraged to undertake specialist postgraduate training at schools or institutes of tropical medicine. However, the increase in global trade and travel from the 1970s onward led to dramatic changes in the likelihood of returning travellers and new immigrants presenting with tropical infections in temperate regions. Furthermore, population growth and the changing relationships between animals, the environment, and man in agriculture accentuated the importance of a wider understanding of emerging infectious diseases, zoonotic diseases and parasitic infections. These epidemiological facts were not adequately reflected in the medical literature or medical curriculum at the time. The orientation on tropical infections needed specialised attention, including instruction on diagnosis and treatment of such infections. We describe key global health events and how the changing field of global medicine, from the 1970s to early 2000, impacted on medical education and research. We describe the impact of global health changes in the Tasmanian context, a temperate island state of Australia. We retrospectively analysed data of patients diagnosed with parasites and present a list of endemic and non-endemic parasites reported during this period. Finally, we reflect on the new approaches to the changing needs of global health and challenges that medical programmes, learners and educators face today.

Dermatoses of the Caribbean: Burden of skin disease and associated socioeconomic status in the Caribbean.

INTRODUCTION: Dermatologic disease represents a significant burden worldwide, but the regional effect of skin disease in the Caribbean and how it relates to socioeconomic status remain unknown. OBJECTIVE: This study aims to measure the burden of skin disease in the Caribbean from epidemiologic and socioeconomic standpoints. METHODS: We selected Global Burden of Disease Study data sets to analyze disability-adjusted life-years (DALYs) and the annual rate of change of dermatoses between 1990 and 2017 in 18 Caribbean countries and the United States. The principal country-level economic factor used was gross domestic product per capita from the World Bank. RESULTS: Countries with lower gross domestic product per capita had higher DALYs for dermatology-related infectious diseases, urticaria, asthma, and atopic dermatitis. Countries with higher gross domestic product per capita had higher DALYs of cutaneous neoplasms, contact dermatitis, psoriasis, and pruritus. Several Caribbean countries were among the top worldwide for annual increase in DALYs for melanoma, nonmelanoma skin cancers, bacterial skin disease, and total skin and subcutaneous diseases. CONCLUSION: Despite promising ongoing interventions in skin disease, better support is needed in both resource-rich and -poor areas of the Caribbean. DALYs can serve as a purposeful measure for directing resources and care to improve the burden of skin disease in the Caribbean.

Burden of skin disease and associated socioeconomic status in Europe: An ecologic study from the Global Burden of Disease Study 2017.

INTRODUCTION: Dermatoses contribute to a large burden of global disease, but the relationship between socioeconomic status and the effect of dermatologic conditions in Europe is not well understood. METHODS: We selected Global Burden of Disease Study data sets to analyze disability-adjusted life-years (DALYs) and the annual rate of change of dermatoses between 1990 and 2017 in 43 European countries. The principal country-level economic factor used was gross domestic product per capita from the World Bank. Statistical analysis was performed with Spearman ρ correlation. RESULTS: Wealthier European countries had higher DALYs for melanoma, basal cell carcinoma, psoriasis, atopic dermatitis, acne, seborrheic dermatitis, alopecia, asthma, contact dermatitis, and viral skin disease. Poorer countries had higher DALYs of squamous cell carcinoma, urticaria, decubitus ulcers, pruritus, scabies, tuberculosis, and syphilis. Thirteen European countries were in the top 10th percentile globally for annual increase in skin and subcutaneous disease burden. CONCLUSION: The majority of European countries have experienced an increase in skin and subcutaneous diseases in recent decades relative to the rest of the world, but the burden of individual dermatoses in Europe varies by country and socioeconomic status. DALYs can potentially serve as a purposeful measure for directing resources to improve the burden of skin disease in Europe.

Needs assessment for a formal emergency medicine residency program in southern Madagascar.

INTRODUCTION: World Health Organization data for Madagascar reveal that the nation's under age five mortality rate is 56/1000, and that its maternal mortality rate is 440/100,000. Malaria, leprosy, plague, and tuberculosis remain significant communicable disease threats. Malnutrition rates are improving but continue to impact negatively on the general health of the Malagasy population, especially in the southern region with its 1.9 million inhabitants. There are no emergency medicine (EM) training programs to serve the southern half of Madagascar, which has a large urban population in Fianarantsoa. This study aimed to assess the need for and potential feasibility of an emergency medicine training program in southern Madagascar. METHODS: We met with the institutional leadership on site at the university hospital in Fianarantsoa. A needs assessment was performed on multiple domains. Domain 1: existing hospital infrastructure and its physical plant and emergency centre (EC) space allotment. Domain 2: existing clinical and technological resources. Domain 3: educational resources and the existing curriculum for EM. Domain 4: medical student educational program and availability of prospective residency candidates. Domain 5: pre-hospital care and emergency medical services. RESULTS: The size of the EC is adequate for the current census. Clinical resources are typical of many developing countries, with significant need for technological advancement and support, which we delineate in the body of our paper. There is an existing curriculum in Antananarivo and in Majanga, as well as one available through the African Federation for Emergency Medicine. The medical school in the area is relatively new, with graduating classes numbering approximately 30. There is no organised pre-hospital care system, no 9-1-1 equivalent, and no pre-hospital treatment from within metropolitan Fianarantsoa. CONCLUSIONS: While the needs assessment indicates substantial need for emergency medicine development in southern Madagascar, the yield (particularly for the metropolitan Fianarantsoa area) would serve the population well.

Emergency medicine in Saudi Arabia: a century of progress and a bright vision for the future.

Although emergency medical services (EMS) and pre-hospital care have existed in the Kingdom of Saudi Arabia (KSA) since 1934, emergency medicine (EM) is a relatively new medical field in the country that was not formally recognized as a medical specialty until 2001. In 2005, the Saudi Board of Emergency Medicine formed to develop, implement, and evaluate a standardized curriculum for EM residents. Since then, EM and the pre-hospital system in the KSA has evolved and grown. This article provides an overview of emergency medicine in Saudi Arabia and the progress it has made in the pre-hospital system, healthcare delivery system, and emergency medicine training. Finally, we will discuss the challenges and opportunities faced as this specialty continues to develop.

Curriculum to Learn Social Determinants of Health at Mie University Faculty of Medicine / 医学教育

Health disparity is an emerging issue in our society. It occurs in connection with an aging population, uneven distribution of health sectors or the collapse of medical care systems in rural communities. Accordingly, future health professionals should learn more about social determinants of health (SDH). Mie University Faculty of Medicine has conducted international health electives in Asian and African countries and education about community-based health profession all over the Mie prefecture. Moreover, a lecture entitled “Global Health and Community Medicine” was launched based on the concept that both topics share common aspects of SDH.　In this article, I will report educational programs at Mie University, that provide medical students with opportunities to learn SDH.