Endemic circulation of foot-and-mouth disease (FMD) in Africa and Asia poses a continuous risk to countries in Europe, North America, and Oceania which are free from the disease. Introductions of the disease into a free region have dramatic economic impacts, especially if they are not detected at an early stage and controlled rapidly. However, farmers and veterinarians have an obvious disincentive to report clinical signs that are consistent with FMD, due to the severe consequences of raising an official suspicion, such as farm-level quarantine. One way that the risk of late detection can be mitigated is offering non-discriminatory exclusion testing schemes for differential diagnostics, wherein veterinarians can submit samples without the involvement of the competent authority and without sanctions or costs for the farmer. This review considers the benefits and limitations of this approach to improve the early detection of FMD in free countries and gives an overview of the FMD testing schemes currently in use in selected countries in Europe and the Americas as well as in Australia. Picornaviridae. The main clinical signs of FMD are lesions on the tongue, oral mucosa and nasal planum, on the teats and in the interdigital spaces and coronary bands of the feet. Except in very young stock, mortality is generally low, but the reduced productivity and the loss of draft power cause significant economic hardship and food insecurity in endemic areas, which are exacerbated by the costs of control measures, and the forfeiture of trade revenue (Foot-and-mouth disease (FMD) is a highly contagious vesicular disease of cloven-hoofed animals caused by an aphthovirus in the family  revenue .FMDV has not occurred in Europe, North America and Oceania for almost 10 years; the last FMD outbreak in any of these regions was in Bulgaria during 2011 , and hasIt has often been argued by proponents of pen-side testing that the time from sample submission to the return of results from the diagnostic laboratory is a significant obstacle to the rapid detection of an FMD incursion , 6. WhilBy contrast, much longer periods of time can pass between infection, the first occurrence of clinical signs, their recognition by the farmer, and finally the submission of samples for laboratory testing. The first obstacle here is the recognition of clinical signs and the realization that they may be an indication of a larger issue that requires veterinary attention see . The sevAn example of this is the large series of FMD outbreaks that originated in the United Kingdom (UK) in 2001 and ultimately affected four countries in Europe, resulting in the culling of over 6 million animals as well as economic losses of 8 billion Euros . This waIn areas where a particular disease has not occurred in decades, most farmers and practitioners are unfamiliar with its clinical manifestations . There aIn cases where FMD cannot be ruled out based on the clinical picture alone, samples must be submitted for laboratory examination. However, if the collection and examination of these samples is contingent on the declaration of a formal suspicion of FMD, this can set the bar for a submission very high. Except in the most obvious cases, some veterinary practitioners may be reluctant to raise an FMD suspicion because of the consequences that are precipitated by its formal declaration, regardless of whether the suspicion is eventually confirmed by laboratory diagnosis see also . In the Unsurprisingly, official veterinarians may be viewed by practitioners and farmers in an adversarial role. Even though they are required to do so by law in most jurisdictions, practitioners can be reluctant to report diseases that could result in regulatory action and may be afraid of alienating their clients if they raise suspicions that turn out to be false alarms  see als. This isNotwithstanding the critical importance of implementing rapid control measures in the event of a credible disease suspicion, a possible approach to increase FMD surveillance is to allow veterinary practitioners to submit samples for an exclusion of FMD without restrictions for the farm  , 26, eduIn the EU, while samples from suspect cases must always be sent to the designated national reference laboratory (NRL), exclusion testing by real-time RT-PCR (RT-qPCR) can be done in any laboratory designated by the competent authority (cf. Annex XV No. 13 of the “FMD Directive”) . SuitablIf the results of an exclusion test at another laboratory are not clearly negative, the samples must be immediately forwarded to the NRL for clarification see . Under tOverall, when a non-discriminatory exclusion testing scheme is implemented in a country, it is advisable for the veterinary authorities to create guidelines for practitioners. This should include a decision tree to determine whether or not a case is likely to be FMD , standard procedures for sample collection and submission, and any follow-up actions or reporting requirements. The veterinary authorities need to devise a strategy for the ongoing training of practitioners to make sure they know how to recognize FMD and the conditions for applying non-discriminatory exclusion testing. Moreover, an active communication channel from the veterinary authorities to practitioners needs to be established to be able to timely disseminate relevant information. For example, this can be used to update stakeholders about the regional risk of FMD according to its presence in neighboring countries, as this information will influence the decision to consider FMD as a likely or unlikely differential in a given case.Switzerland introduced non-discriminatory exclusion testing in 2011. These examinations are carried out at two central government laboratories and cover not only FMD but also African swine fever (ASF), CSF, avian influenza (AI), and Newcastle disease. Samples are submitted by veterinary practitioners and pathologists and include mostly sera, lesions or swabs; in addition, EDTA blood is requested to test for bluetongue (BT) virus as a potential differential diagnosis. Since the costs are covered by the government through the Federal Food Safety and Veterinary Office, the exclusion examinations are free of charge for the senders. The program is considered a success both by the veterinary services and by practitioners, and it has led to a marked increase in the number of samples tested for foreign animal diseases . From Jaad-hoc basis. Reasons for FMD exclusion testing can be. e.g., a herd problem of unknown etiology, a  positive result in an antibody test for export certification, a lesion at the mouth or foot observed at necropsy or irregularities with animal identification or documentation of origin. In the latter case, the exclusion testing must be paid for by the owner, otherwise it is paid for by the FASFC since laboratory analysis is then done in the context of a—perhaps not (yet) formally expressed—suspicion. On average, there are ≤ 2 clinical suspicions and ≤10 exclusion diagnostics for vesicular diseases per year in Belgium.Belgium is using a risk-based “increased vigilance” scheme. Among others, this increased vigilance is currently applied to BT, ASF, and AI. The criteria that trigger exclusion diagnostics in the absence of a clinical suspicion are very different for each disease: for BT, it is importation of ruminants from risk areas with serotypes other than serotype 8; for ASF, it is 2 or more pigs on a farm with symptoms of general disease; for AI, it is abnormal production parameters . Within the “increased vigilance” scheme, the costs for sampling (or necropsy) are borne by the owner of the animals, whereas laboratory analysis is paid for by the Federal Agency for the Safety of the Food Chain (FASFC). As a result of the aforementioned risk analysis, there currently is no organized system for exclusion testing for FMD and other vesicular diseases, even though these tests are available. Every decision for exclusion testing for vesicular diseases is made on an Austria introduced a non-discriminatory exclusion testing scheme in 2014, which was revised in 2019In routine cases (stage I), any diagnostic laboratory can test for FMDV as a differential diagnosis, but all exclusion testing (stage II), and investigations of FMD suspicions or outbreaks take place at the Austrian NRL. Any veterinarian can submit samples for FMD exclusion testing directly to the NRL or can notify veterinary services. This notification is mandatory if the veterinarian actually suspects FMD! Upon notification, the official veterinarian visits the farm and determines the level of suspicion. If there is only a weak indication of the disease, samples will be submitted for exclusion testing (stage II.B) and no restrictions are imposed on the farm. If the suspicion of FMD (or any other notifiable disease) is confirmed by the official veterinarian, stage III  will be declared and the holding will be quarantined.Exclusion testing in Austria is free of charge for the farmer, since the central competent authority covers the costs of the testing. However, if the farmer wants a test for a non-notifiable disease from the same sample material (in addition to the exclusion testing), they have to cover the costs of this additional testing. Although non-discriminatory exclusion testing has been offered in Austria since 2014, not many samples have been submitted to the NRL. There are <5 cases of exclusion testing for vesicular diseases per year in Austria, for a susceptible population of 1.9 million cattle, 0.5 million sheep, 0.1 million goats, and 3 million pigs.In Germany, the regional veterinary diagnostic laboratories of all federal states , have offered exclusion testing for FMD since 2014, following the earlier implementation of distributed non-discriminatory testing for CSF, AI, and ASF. Private laboratories do not test for FMDV. The participating regional laboratories are enrolled in proficiency tests conducted by the NRLs , 31 and Similar to the situation in Germany, each of the states and territories that make up the Australian federation operate under different animal health legislation and the Chief Veterinary Officer (CVO) of the relevant state determines if any legal restrictions should apply. Legally binding on-farm restrictions are not mandated whenever an FMD laboratory test is conducted. This allows for exclusion testing to be carried out where FMD is not thought to be a probable differential diagnosis however clinical signs such as lameness or salivation are present. This approach applies across all nationally notifiable diseases and aims to encourage exclusion testing for all livestock species. In the 3 years between January 2017 and December 2019, 215 exclusions for vesicular diseases were carried out in Australia . All excIn addition to the laboratory testing being funded by the national government, Australia also has in place a National Significant Disease Investigation Program (SDI) . This prThe UK has adopted a binary perspective for initial report cases of FMD in the country—i.e., either (i) there is credible suspicion of disease and on-farm restrictions are adopted until laboratory results are generated or evidence for disease freedom can be provided from other sources, or (ii) based on the clinical and epidemiological context, the animals are not considered to be infected with FMDV and no laboratory testing is necessary or even desirable. This is achieved by a two-tiered alert system (available 24 h a day with veterinary epidemiology support): in stage 1, where restrictions are immediately placed on the premises (by law), clinical suspicion of FMD leads to a visit of an official veterinarian, who undertakes clinical investigation and assesses whether samples are to be taken. If the veterinary visit cannot rule out FMD, stage 2 involves sample collection, laboratory testing and implementation of full restrictions on the farm as well as the need for area restrictions (considered by the competent authority) until a negative test result is returned.Similar to the UK, France does not employ non-discriminatory exclusion testing for FMD, but its national reference laboratory also has veterinarians and epidemiologists available by phone 24 h a day. Veterinary practitioners who encounter alarming clinical signs can call in and describe and electronically transmit their observations with photos. Taking into account the risk profile of the holding, the epidemiological situation and the clinical signs, the central team will decide if the situation requires laboratory testing or if FMD can be ruled out without it. This relieves the veterinary practitioner of any responsibility for that decision and lowers the bar for reporting possibly suspect cases. If testing is deemed necessary , the holding will be quarantined, and the samples will be forwarded to the NRL with high priority and tested immediately at any time.Istituti zooprofilattici sperimentali (IZS) of the national animal health and food safety network. However, the IZS network is prepared to carry out post-vaccination FMD serology, and it is planned to extend the existing proficiency testing for the serological assays to include FMDV RT-qPCR. This will build up distributed diagnostic capability that will be very useful if there is an FMD outbreak. If low-risk submissions  can be tested at regional laboratories, this frees up testing capacity for critical samples at the NRL during an outbreak and can decrease sample turnaround time in large countries.Italy does not offer exclusion testing for FMD. In case of an FMD suspicion, private veterinarians must inform the veterinary services, which will then visit the suspected herd. The cost of laboratory testing for suspect cases is covered by national funds from the Ministry of Health. Formal FMD suspicions were last declared in 2015 and 2016 (2 each), for a susceptible population of 5.6 million cattle, 0.4 million buffalo, 6.2 million sheep, 1 million goats and 8.7 million pigs. Currently, virological testing for FMD in Italy is only done at the NRL, which is located at one of the ten In Canada, based on the experience of the 1951 outbreak , all susIn the United States, the Department of Agriculture's Animal and Plant Health Inspection Service (APHIS) is the competent authority for the detection of a foreign/transboundary animal disease (FAD/TAD). Samples for suspect vesicular diseases in livestock are sent to an approved laboratory within the National Animal Health Laboratory Network (NAHLN), a network of more than 60 state, university-associated, and federal laboratories across the country that provide both active and passive surveillance, as well as surge capacity support during an outbreak . DuplicaTesting results and reporting will be expedited based on the assigned priority level. The FADD, SAHO, and AVIC will agree on a priority level based on risk and on-site epidemiology of the suspect vesicular case. Four priority levels exist: (i) Priority 3, low suspicion for/unlikely to be an FAD, but cannot be distinguished from an endemic condition. (ii) Priority 2, indication this is possibly an FAD, and cannot be distinguished from an endemic condition. Rapid laboratory confirmation is required; (iii) Priority 1, prompt laboratory confirmation is required because there is a high suspicion for an FAD; and finally (iv) Priority A, which also requires prompt laboratory confirmation and is used in situations where animals in commerce are held pending results for FAD testing . TestingIn some situations, testing for endemic diseases that are clinically indistinguishable from FMD, such as SVA infection , may alsIn Mexico, a specific surveillance program for vesicular diseases of animals—the binational Mexico-United States Commission for the Prevention of FMD and Other Exotic Diseases of Animals (CPA)—has been in place since 1954. Any suspect vesicular disease must be immediately reported. There is an entire program dedicated to promoting such notifications through courses, newsletters, and social networks. All suspect cases are attended to in <24 h, on any day of the year, and are handled exclusively by CPA personnel, who have the necessary equipment and means to respond to any notification of a suspect foreign animal disease. Diagnosis occurs at a single high-security laboratory and all investigations are paid for by the CPA. In 2019, 2,621 samples from 103 cases were tested for FMDV, 702/41 of which were cattle, 1,029/35 goats, 685/20 sheep, 85/4 swine, and 120/3 wildlife.In South America, the epidemiological context and the risk perception is different than in Europe and North America. After its introduction to South America in the 19th century, FMD quickly became endemic in the large cattle population. Only through a tremendous and sustained collaborative effort over several decades has the continent now come close to eradication of the disease . While aAn informal opinion poll of current and former CVOs and NRL directors in South America conducted for this review revealed strong disapproval of making non-discriminatory exclusion testing available as an option for private veterinarians. It was seen as too difficult to define what constitutes “clear” or “less clear” suspicions of FMD, and even more difficult to explain such a difference to farmers and private veterinarians. There also was concern that exclusion testing may allow farmers or practitioners to intentionally delay the notification of exotic animal diseases, ultimately resulting in a failure to implement appropriate control measures in a timely manner. In addition, an epidemiological investigation by the veterinary services is seen as essential for vesicular disease suspicions because negative laboratory results may be obtained from infected herds due to inappropriate sample collection, handling or analysis.In 2018, the 13 countries that are part of the South American Commission for the Fight Against FMD (COSALFA) reviewed the way FMD suspicions are addressed . It was There are, however, exceptions to this procedure. For example, when vesicular lesions are found in pigs at an abattoir in Brazil, slaughter may proceed normally if the batch is accompanied by official documentation from the veterinary services indicating that the farm of origin has been investigated for FMD with a negative result within the last 30 days . This isIn 2018, the last year for which collated data are available from the Pan American Foot-and-Mouth Disease Center (PANAFTOSA) , a totalLike other South American countries, Argentina does not offer exclusion testing. It is free of FMD without vaccination in Patagonia, the southern region of the country, and with vaccination in the rest of the country, where only cattle are vaccinated. The susceptible population includes 55 million cattle, 12 million sheep, 4 million goats, and 5 million pigs. The last FMD outbreak occurred in April 2006. Notification of the disease, including suspicious cases, is mandatory. In the event of a FMD incident, or even when it is only a suspicion, farmers and private veterinarians must immediately make a formal report to the local veterinary services. The latter are solely responsible for collecting and sending the samples to the NRL, which is the only laboratory authorized and accredited to perform the diagnostic tests with the appropriate biosafety and issue the final diagnosis. The costs are entirely covered by the national veterinary services.Although private veterinarians or farmers should not collect and send samples of suspect cases, their participation and contribution to FMD surveillance is very significant. In fact, they receive training from the national veterinary services to recognize an FMD suspicion. Furthermore, farmers are associated to a local animal health association supervised by the National Food Safety and Quality Service SENASA. This association performs activities such as animal surveys, vaccinations, and surveillance. Apart from the concerns listed above, it is important to mention that the countries importing meat from Argentina  regularly review the records of all suspect cases of FMD and would probably not accept an exclusion testing scheme instead of the current system.Non-discriminatory FMD exclusion testing can help to quickly detect an introduction of this devastating disease into a previously free area, which is essential for its effective control. In countries where they are available, exclusion testing schemes are gaining acceptance among veterinary practitioners, but more needs to be done to promote the programs and increase awareness about foreign animal diseases in general.At the same time, the possible pitfalls of exclusion testing should be kept in mind. Concerns about delays in the implementation of control measures are a major reason that many countries do not allow practitioners to submit samples for FMD exclusion. In these countries, any suspicion of FMD must be handled by the veterinary authorities, who will then take measures  based on a risk analysis. The response to suspicions of FMD or other exotic animal diseases is often seen as an inalienable state activity to be carried out by the national animal health service, leading to strong resistance to the concept of non-discriminatory exclusion testing in the hands of private practitioners and laboratories other than the central NRL.considered in the differential diagnosis of a clinical case, it must be reported to the authorities. By contrast, other countries only require the notification of an actual suspicion. Where the lines between “no suspicion,” “weak suspicion”  and “well-founded suspicion” are to be drawn is critical but often left to the individual private practitioner or government official.In this context it is important to emphasize that exclusion testing may complement, but cannot replace formally declared suspicions! A lot of the disagreement about non-discriminatory exclusion testing comes from the fact that in many countries, as soon as FMD is even It is clear, however, that a key step for the success of non-discriminatory FMD exclusion testing is the decision made by the private veterinarian during the farm visit; i.e., whether they consider FMD likely, unlikely or even rule it out completely  can be of great utility in the implementation of non-discriminatory exclusion testing schemes. In addition, farmers and practitioners must have confidence in the official animal health authorities, and must be assured that any notification is immediately responded to, a quick diagnosis is obtained, and preventive regulatory measures are applied for as short as possible. Non-discriminatory exclusion testing is one of a range of measures that can be considered to improve the detection of FMD incursions.MB had the idea for this article. ME wrote the original draft. All authors revised and expanded the original draft and approved the submitted manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The handling editor declared a shared affiliation, though no other collaboration, with one of the authors (DO'B) at the time of the review. The handling editor declared a past co-authorship with several of the authors .


The aim is to outline the underlying epidemiological thinking and mentality in post-materialist and postmodern Sweden behind the Swedish strategy. The aim is not to investigate the handling of the pandemic in Sweden in the long-run. Overconfidence in herd immunity, overconfidence in individual responsibility in a pandemic needing community-centered approaches, overconfidence in evidence-based medicine and neglect to coordinate with the WHO and other countries may be associated with post-materialist values and postmodernism including opposition against modern authority, rationality and science, and also an anti-traditionalist stance towards older generations. COVID-19 epidemiology and postmodernism may be a dangerous combination. The COVID-19 pandemic reached many European countries in terms of a general spread in society in late February and early March 2020, although there are indications that the contagion had been present in some individuals already in December 2019 without being known at the time. The first European country with a general spread in society was Italy. In the initially most severely affected countries Italy and Spain the gravity of the situation had initially clearly been underestimated, and this also rapidly became apparent in e.g. Belgium, France, the Netherlands and the UK. The general response throughout Europe to the outbreak of the pandemic was a lockdown of society in mid-March, with the general exception of vital societal functions, e.g. healthcare, police, fire defense, military defense, food stores, and pharmacies. These lockdowns were not identical in all European countries, but they approximately followed the recommendations regarding isolation, social distancing and mass testing from the World Health Organization (WHO), and included the closure of the entire school system, universities, skiing resorts, and often  restaurants and bars, shops, markets and other facilities judged as non-essential. Most countries closed their borders and firmly restricted meetings and social activities. Still, it seems that the lack of rapid and timely community-centered approaches, and most importantly weak public health infrastructures, may have caused a high number of infected cases and a comparatively high mortality in many European countries compared to the initially affected East Asian countries .karensdag) abolished, sick leave without doctor's certificate extended from 7 to 14 days (14 March), persons 70 and above should stay home and reduce social contacts, employers particularly in Stockholm should encourage work at home (16 March), and distance teaching for secondary schools (gymnasium) and universities (18 March)  (Folkhälsomyndigheten) with great emphasis on individual responsibility. In short, the strategy aimed to protect senior and/or vulnerable citizens, and to slow down the spread of the virus so that the healthcare system would be able to cope and not collapse . Prohibi8 March) .Denmark initiated early lockdown measures. Starting on 13 March, all public sector employees in non-essential functions were ordered to stay home, private employers were urged to allow their employees to stay home and work from home if possible , and all secondary schools, libraries, museums, indoor cultural institutions and similar institutions were closed. Starting on 16 March, all primary school and daycare centers were closed . On 18 MOn 16 March, the Finnish government declared a state of emergency. All schools were closed, except early education. Most public facilities  were closed down. Essential occupations were exempted from the Working Hours and Annual Holidays Acts. A maximum 10 persons was set for public meetings. Seniors above 70 should avoid social contacts. No visitors to hospitals were allowed, except to critically ill patients. The capacity for social and health care were increased, other less critical activities decreased. Borders were shut down . These mOn 12 March, the Norwegian Health Directorate introduced measures such as closure of educational institutions, discontinuation of sports activities, closure of cultural events, sports events, gyms and swimming pools, and the closure of pubs, night clubs and bars. Health care professionals were prohibited from travelling abroad until 20 April. Quarantines were introduced for everyone arriving from travels outside Finland and Sweden since 27 February. Restaurants serving food were kept open with requirements regarding social distancing. The Directorate discouraged travelling to work, by public transport and crowded places. People were requested not to visit institutions. Public transport continued in order to transport key professionals .The long-term effects of the pandemic will only be possible to assess in the future. However, the short-term effects of the Swedish strategy in late May 2020 compared to the closest neighboring countries were apparent. On 21 May, 88 new deaths in COVID-19 were reported from Sweden to WHO, 3 in Denmark, 3 in Finland and 1 in Norway . The same day, a total 3831 deaths had been reported in Sweden, 554 in Denmark, 304 in Finland and 234 in Norway . On 21 JThe British independent sustainability rating agency Standard Ethics, based in London, lowered the ethical rating of Sweden on 21 May:During the first phase of the COVID-19 epidemic, Swedish health policy did not comply with World Health Organization recommendations. Standard Ethics analysts believe that this produced additional risks for the Swedish and European populations. The current health policy seems to be a part of a general strategy that is not collaborative with the European Union .Regeringsformen) in order to install ministerial rule. However, the government never used this paragraph. Furthermore, the major part of the healthcare system is handled by the regions and county councils (regioner och landsting) within the framework of national legislation. Additionally, care of the elderly is mostly handled by the municipalities (kommuner), also within the framework of national legislation , Sweden has during the past decades been the most non-traditional, secularized, post-materialist and postmodern country in the world , 2018. TThe notion of materialist as opposed to post-materialist values is connected with the notion of modern versus postmodern culture. Modern culture entails a belief in authority, rationality, science and engineering. Modern culture repudiates tradition and religion. Postmodern culture regards authority, rationality, science and engineering as connected with the West and western materialist culture, which postmodern culture regards as problematic. Postmodern culture represents a renewed belief in tradition, which modernism repudiates, but only traditions which originate in non-western countries are esteemed by postmodernism. Postmodernism also leads to the appearance of new values and lifestyles and entails increased tolerance of ethnic, cultural, sexual and individual choices regarding how to live, based on an emphasis on individual rights. The postmodern view of science repudiates the modern view that only one objective truth exists to a particular scientific problem, even in medicine and natural sciences. The postmodern view of science also entails an emphasis on subjective personal feelings of what is true rather than the modern belief that there is one objective truth to be found following a research question .A number of specific epidemiological characteristics of the initial Swedish strategy may be discerned: overconfidence in herd immunity , overconfidence in individual responsibility, overconfidence in evidence-based medicine and neglect to coordinate with other countries and the WHO.Herd immunity as an answer regarding how to handle the pandemic was soon dismissed by the UK government  in the mall further discussion. The most critical question was almost never asked by the Swedish mass media: What was the point of very loose restrictions and holding even bars, restaurants and skiing venues open if the goal was not to achieve herd immunity?On several occasions, 22 Swedish researchers criticized what seemed to be a herd immunity strategy . The repThe Swedish government and the PHA took great pride in the part of their strategy to handle the pandemic relying on individual responsibility. Much responsibility of the handling of a global pandemic has been put on the individual citizens/inhabitants of Sweden and their assumed individual sense of responsibility. Restaurants and taverns (as well as many other sectors of society) were allowed to stay open leaving much responsibility to the responsibility of the individual owners and customers to keep distance, even when affected by alcohol consumption in late evenings! In fact, in an interview with CNN, the Swedish foreign minister Ann Linde, when asked by the CNN reporter about the high death rates in Sweden, blamed Swedish winter tourists for going to Italy on skiing holiday in late February when they knew that the coronavirus had spread in northern Italy . In the When asked by interviewers about e.g. mouth protection, masks and a number of other important issues, the current state epidemiologist often answered that no evidence exists. These answers were based on the concept of evidence-based medicine. The former state epidemiologist Johan Giesecke (1995–2005) stated in an interview with CNN on 17 April:We, or the Swedish government, decided early, in January, that the measures we should take against the pandemic should be evidence-based. And when you start looking around at the measures being taken now by different countries, you'll find that very few of them have a shred of evidence …But we know of one that has been known for 150 years or more, that washing your hands is good for you and good for others when you're in an epidemic. But the rest, border closures, school closings, social distancing … there's almost no science behind most of this .Evidence-based medicine suggests that the highest level of evidence (level 1) comes from randomized controlled trials (RCTs). However, this poses a problem when a completely new infectious disease pandemic caused by a previously unknown contagion suddenly occurs. Other considerations such as results from lower level studies with other study designs, based on observational data and even practical experiences, common sense and caution rather than lack of caution not only may but should then be used. It seems from this perspective that the repeated reference to evidence-based medicine in rejecting e.g. masks and mouth protection for the public as well as early closures was misplaced.Swedish governments have for decades consistently prided themselves for their and the country's international orientation. Swedish governments have also prided their country as a “humanitarian great power” internationally . HoweverDagens Industri , contracted by the PHA as adviser, expressed the feeling that everyone else was wrong and that the Swedish strategy was right in an interview in Industri , despiteIndustri . On 23 JIndustri . In accoThe strong emphasis on individual responsibility as a specific trait of the Swedish strategy is closely related the postmodern emphasis on individuality and opposition to authority. The Swedish population was almost supposed to handle a major part of the pandemic by individual action. It may be added that even the emphasis on individual responsibility, instead of extensive restrictive decisions implemented by the government in an authoritative way, stands in direct opposition to empirical observations and practical experience from East Asia .The emphasis on evidence-based medicine entails a major paradox. On the one hand, this emphasis in the initial phase of the pandemic in Sweden led to the rejection of e.g. total social distancing in terms of lockdown, the rejection of strong governmental authority and the effective use of public health infrastructures at the national level, the initial rejection of mass testing, the rejection of face masks, although the implementation of these measures would have been in accordance with empirical observations and practical experience. On the other hand, the emphasis on evidence-based medicine did not stop the leading decision makers from believing in their own scientific truth in the form of an assumption regarding herd immunity which was empirically questionable, assuming the swift and general spread of an assumed airborne infectious disease with characteristics similar to influenza. This paradox also seems to be in accordance with the postmodern view of science as including also alternative truths even in medicine.The neglect to coordinate public health implementation with the WHO, the EU and the other Nordic countries seems to be partly a by-product of the postmodern view of science outlined above. Additionally, a particular sense of Swedish exceptionalism has existed in Sweden since the 1970s. The self-image of the political elite in Sweden entails the view that the Swedish government should lead the way not only in the direction of a developed welfare state but also in the postmodern direction of individual rights, progressivism, globalism, and cultural diversity. The self-image of Sweden as a “humanitarian great power” has in recent decades been adopted also by non-socialist governments . It is tThe Swedish strategy seems to be mostly in accordance with the postmodern view of science. The strategy included overconfidence in herd immunity , overconfidence in individual responsibility, overconfidence in the highest levels of evidence-based medicine regarding protective measures  and neglect to coordinate with the WHO, the EU and the other Nordic countries.Svenska Dagbladet Frode Forland, the Norwegian analogue to the Swedish state epidemiologist, criticized not only the Swedish strategy but also the lack of critical questions from Swedish journalists to the PHA at the daily press conferences in the initial phase of the pandemic (presstöd). Second, it seems that the postmodern view of the existence of multiple truths even in medicine and natural sciences may lead to less openness and less diversity in the public discourse, not more, when the consequences of such an alternative postmodern truth become apparent.As already mentioned, postmodernism and postmodern culture opposes the modernist repudiation of tradition and religion. Paradoxically, postmodernism strongly tends to only embrace the tradition and religion of other peoples and cultures than those of the West. This may help explain the fact that postmodernism and secularism are both strong and positively correlated in Sweden in a comparison with other countries in the WVS. Criticism has been forwarded against the idolization of the current state epidemiologist and the lack of critical questions from domestic journalists regarding the strategy. The most profound critique has even concerned the almost sectarian behavior within the PHA and the mass media regarding the strategy and e.g. the repudiation of face masks without critical questions from the journalists . In factpandemic . This waOverconfidence in herd immunity, overconfidence in individual responsibility in solving a pandemic which calls for contextual and societal solutions, overconfidence in evidence-based medicine, neglect to coordinate with the WHO and other countries, and failure to instantly react to protect its own population may be associated with post-materialist values and postmodernism including opposition against modern authority, rationality and science, and an anti-traditionalist stance towards the experience of older generations.This article does not include empirical data or study participants.I am the sole author of this manuscript.There are no conflicts of interest.


The economic and social burdens it brings upon the population are enormous. To overcome this rapidly rising problem, countries in sub-Saharan Africa (SSA) urgently need rational national cancer control planning.Cancer disproportionately affects patients in low- and middle-income countries, with 70% of newly diagnosed cancer cases occurring in low- and middle-income countries where the survival rate of cancer is 30% to 50% lower than that of high-income countries.Key ObjectiveThe aim of this article is to report on the current status of cancer registration in sub-Saharan Africa and to showcase the various critical strategic roles and applications of cancer registries in cancer research and cancer control programs.Knowledge GeneratedCountries in sub-Saharan Africa need a working cancer control program to help battle the ever-increasing burden of cancer. A rational cancer control program must be built on recent, accurate population-based data on incidence, survival, treatment, and outcome from within its nation.RelevanceCancer registries can play an important role in the evaluation and monitoring of screening programs aimed at detecting preinvasive conditions. The quality and quantity of the data generated by these registries have been used to support research and statistics and have been disseminated globally.The aim of this article is to report on the current status of cancer registration in SSA, particularly the pivotal role of the African Cancer Registry Network (AFCRN) in serving as the regional hub for the International Agency for Research on Cancer (IARC) in coordinating cancer registration in the region. We showcase the various critical strategic roles and applications of cancer registries in cancer research and cancer control programs2 This means that the only available alternative for obtaining real information on the occurrence of cancer is through cancer registrationInformation on cancer burden in a country is a crucial basis for building and monitoring any rational cancer control programs. Data needed may be available from death registration systems, which provide data on mortality rates by cause of death. Such statistics have been available for high-income countries for decades; however, the absence of comprehensive and accurate death registration systems is a major defect in almost all SSA countries—only approximately 0.25% of the SSA population is covered by accurate death registration systems.3 There are three types of cancer registries: hospital-based, specialized, and—the most complex—population-based cancer registries.Cancer registries provide for the systematic collection, storage, analysis, interpretation, and reporting of data on patients with cancer.4 Specialized registries collect and maintain data on a particular type of cancer—for example, the Gilda Radner Familial Ovarian Cancer Registry,5 which collects cancer information on families with ovarian cancer.Hospital-based cancer registries are primarily institution based and are involved with recording information on patients with cancer attending a particular hospital. The main purpose of these registries is to contribute to patient care by providing readily accessible information on patients with cancer and treatment received and its result.4 The main objective of population-based cancer registries is to provide statistics on the occurrence of cancer in that population and to provide a framework for assessing and controlling the impact of cancer in the community. The emphasis here is on epidemiology and public health. Hospital-based and special registries may contribute data to PBCRs, but they have fundamental differences in their core functions and are not a substitute for them.6Population-based cancer registries (PBCRs) seek to collect data on all new cases of cancer occurring in a well-defined population. Usually, the population consists of the residents in a particular geographic region.7 The original function of PBCRs was to calculate the rates of incidence so that the risk of various cancers between populations could be compared. In addition, the activities of PBCRs have expanded to include studies of cancer cause and prevention.7It has been accepted generally that the PBCR has more of a back room role than a front-line role in cancer control. Its particular responsibilities lie in the description of cancer patterns, care, and outcome; in monitoring these variables in relation to control activities; and in providing a research database—often for others to use.Uses of data from PBCRs include:To describe the extent and nature of cancer burden in the community and assist in the establishment of public health prioritiesAs a source of material for etiologic studiesTo help in planning, monitoring, and assessing the effectiveness of national cancer control programs.9 These countries share many characteristics and challenges related, but are not limited, to the possession of one of the weakest public health systems in the world. A large proportion inhabitants lack adequate access to basic health care, resulting in poor health indices and extremely high mortality rates.12 The region has one of the highest prevalence of HIV/AIDS in the world,13 and the subsequent proportion of AIDS-associated malignancies is significantly higher compared with the rest of the world.14 Most parts of SSA are warm and humid, which explains the preponderance of infectious diseases in this part of the world.15 Old diseases—familiar problems in the region, including malaria16 and tuberculosis17—coexist with new emerging and re-emerging diseases, such as Ebola,18 Lassa fever,19 and cholera.20 In addition to these infectious diseases are noncommunicable diseases, such as hypertension,21 diabetes,22 and accidents and violence,23 as well as cancer.SSA is geographically the region of the continent that lies south of the Sahara. The United Nations Development Program lists 46 of Africa’s 54 countries as sub-Saharan.24 Unfortunately, in the decades that followed, progress was slow. For the period covered by Cancer Incidence in Five Continents Volume V (1978 to 1982) there was no representative from Africa. A slow rebirth of cancer registration has been taking place since the 1980s.25 Reasons for this slow progress have been described many times: insufficient coordination of data sources, lack of adequately trained technical staff, lack of up-to-date population census figures, poor health infrastructure, lack of political will, and poor procurement systems marred by mismanagement and corruption.27 Even when a registry is operating, it faces countless challenges, such as generally poor health care infrastructure,25 especially in rural areas28; lack of a regular and accurate census program31; absence of vital statistics; the inability to ensure that all new cases were identified and captured in the databases; lack of adequately trained personnel; and lack of cooperation from other data sources. Computer-based medical information systems remain underdeveloped, which means that any data linkage or observation of patients with cancer are tiresome and expensive—patient observation for calculation of survival involves actively tracing patients and their family by mail, telephone, or home visit.32 Passive follow up is feasible only in the few countries where a reliable death registration system exists.Some information on cancer patterns in Africa was available in the first half of the 20th century though the work of pioneering researchers, who published statistics gleaned from individual hospitals and clinics, and the first population-based registries were founded in the 1950s.33 with support from the Nigerian government, and has facilitated many training courses and consultancy visits to support the development of new population-based registries. A 2014 survey identified 25 functioning PBCRs, and the 23 that took part covered a total population of 90.7 million people, some 10.5% of the SSA population.34Despite these problems, there has been a slow growth in the number of cancer registries and, just as importantly, their quality. In Nigeria, for example, the National System of Cancer Registries was established in 2009,35 A rational NCCP can only be built upon and be monitored using accurate evidence provided by PBCRs from within its own country.36 Sadly, most SSA countries still have not developed a comprehensive NCCP—a 2014 survey by the US National Cancer Institute found that only 11 countries in Africa had a current NCCP.37A national cancer control program (NCCP) is a systematic, equitable, and evidence-based program that, if well implemented, has the capability to reduce the incidence of certain important cancers, such as cancer of cervix, and to improve survival and quality of life for all patients with cancer.38 Unfortunately, a similar projection has not been performed in the SSA region despite cancer registry data being improved and made more available for governments and other stakeholders. In one study, only 23 of 56 countries in Africa, concentrated in the southern and northern extremes of the continent, were shown to have megavoltage therapy.39Cancer registries provide statistical information on the number of cases in the population. Accurate information on cancer occurrence is important for fixing priorities and targeting cancer control activities. Annual numbers of incident cases provide an indication of the resources needed for primary treatment, and the number of prevalent cases describes how many people are in need of regular long-term follow up. Information from cancer registries may be used for the planning and establishment of cancer treatment and care facilities directed toward various types of cancer. Geographic differences in cancer occurrence should be taken into account, as well as changes over time in different cancers—these can be used to make projections of future incidence rates, caseloads, and need for treatment facilities. Cancer incidence information has been used for the planning of radiotherapy services in the United Kingdom.40 or being overweight and obese41—or for the continent-wide burden of cancer as a result of infectious agents.42Linking information on the incidence of cancer in the population with data on the prevalence of risk factors allows for the estimation of the population-attributable fraction—that is, the proportion of cancer cases that might be prevented if the risk factor was eliminated (or reduced to a lower level). This is clearly an important exercise in estimating the potential impact of preventive interventions—how much cancer might be prevented by our efforts. This type of exercise may be done for specific national populations—for example, the fraction of cancers in Nigeria that are caused by alcohol43 Until recently, there was relatively little information for unselected populations; most of the data available are from clinical case series.44Stage at diagnosis is an important statistic to document. For the planner, it is an objective indicator of how early cancer is being diagnosed and thus indicates where improvements can be made. This may be via programs of early diagnosis  or population screening, or by ensuring that the medical system provides for the prompt referral and management of patients with symptoms. Stage is also important in interpreting the outcome of cancer: the proportion of patients who will survive their disease. Clearly, the prospects of cure are much better when cancer is diagnosed early. Increasing efforts are being made to collect information on stage at diagnosis by cancer registries in Africa.45 and children46 in African populations is becoming available.Documenting survival at 1, 3, and 5 years after diagnosis is a standard practice of registries in high-income countries, but this has been difficult to achieve in Africa, because of the difficulties of tracing patients with cancer once they are discharged from the hospital, as described earlier. AFCRN has made a concerted effort to improve the situation, and progressively more information on cancer survival in adults47 Registries will have an important role in monitoring the incidence of cancers associated with these viruses. An example of data from a PBCR used to monitor the effects of a preventive intervention—in the setting of a major epidemiologic research study—is The Gambia Hepatitis Intervention Study, a large-scale vaccination trial in The Gambia instituted in July 1986.48 This was designed as an intervention trial by WHO to reverse the high incidence of hepatocellular carcinoma, the results of which would be monitored by The Gambia cancer registry.Primary prevention programs include tobacco control, as in most high-income countries, but in Africa, the most important interventions will aim to reduce the burden of infection-associated cancers. Vaccination programs against hepatitis B—the most important cause of liver cancer—have been implemented since the early 1990s in many countries, and vaccination against human papillomavirus is being rolled out currently.49 Cervical cancer screening programs have been reported to lower the incidence of cervical cancer in some parts of the world.50The purpose of population-based programs of early diagnosis and screening is the detection of early invasive cancers, reduction in mortality from a particular cancer, and improved quality of life through the use of less toxic treatments with early detection. Cancer registries can play an important role in the evaluation and monitoring of screening programs aimed at detecting preinvasive conditions. Examination of asymptomatic persons to detect cancer at early stages is becoming increasingly important in the control of certain cancers, such as cervical cancer.Similar initiatives could be implemented and extended to most preventable cancers in the region.52 or in subgroups of the population,54 as well as the regional distribution of specific cancers.56 Temporal trends in specific registry populations,57 or for individual cancers in multiple registries continent wide,59 are particularly valuable in following results of the changing profiles of environmental exposures.PBCRs are important sources of educational resources for researchers as they provide unique information on the distribution of cancer in a well-defined geographic population. Researchers can use the available data to elucidate the determinants of cancer in a particular population. As described above, the AFCRN database can be used to conduct research and for planning and implementation of cancer control programs and treatments in the entire region and in an individual country. The basic role of a cancer registry is to provide statistical information on cancer occurrence and outcomes. Registries are widely used to study the incidence of different cancers within registry populations60 or HIV.61Use of cancer registries in formal epidemiologic studies in Africa is much less well developed than in high-income settings. They have been used, however, to detect the occurrence of cancer in cohorts of individuals with specific exposures—for example, infection with Epstein-Barr virus62 , International Association of Cancer Registries, Union for International Cancer Control, and IARC oversees AFCRN’s plans and actions. Over the years, financial support has been received from a variety of organizations, as well as foundations of international pharmaceutical companies, which have helped strengthen the capacity of many member registries. AFCRN research projects are often led by young scientists from Africa, which are funded by various research institutes, such as IARC, the American Cancer Society, the Union for International Cancer Control, the University of Halle, and the University of Oxford (Africa-Oxford Initiative).64 as well as for IARC’s national estimates of cancer incidence, mortality, and prevalence (GLOBOCAN estimates).1 The database is accessible via the AFCRN Research Committee (procedure is available online65).One of AFCRN’s significant achievements is that it has created a unique database for cancer in SSA. The database contains data from all member registries from the year when they started population-based registration. The database has facilitated numerous research studies and provides the material for monographs on cancer in Africa,The data are not perfect, nor is AFCRN. Dedicated African registrars, doctors, nurses, and policymakers, together with international researchers, are working tirelessly to improve the situation. It is a battle worth fighting, they believe.66 The availability of modeled estimates of morbidity and mortality seems reassuring; policymakers get a false impression of certainty about health status and trends, and this detracts from making much needed investments in improving data collection and analytical capacity within countries.67Of the 46 countries of the SSA, only 25 have population-based registries, the data for which can be used to make some sort of estimate of the national cancer profile. Apart from island populations, like Seychelles, Mauritius, and Reunion, these registries cover limited populations, nearly all of which are urban, from which the national profile has to be deduced. For the remaining 21 countries, estimation of the cancer profile has to be based on the picture in neighboring countries or some sort of simulation modeling.68 in most SSA countries, there is an insufficient or no governmental budget for cancer registries. That is because health care policymakers in SSA countries are faced with numerous challenges, but also because cancer registries do not show any immediate impact on cancer prevention so that their necessity is not always recognized and appreciated. Historically, registries have worked in isolation, often operating thanks to the supervision and support of one or two keen medical doctors. Sometimes they are even independent of health departments or universities. Registries have been supported by a wide variety of funding agencies.34 In fact, PBCRs are not expensive. A recent study estimated the cost of cancer registration at the population level as 1 to 2 cents per person in three countries studied, Kenya, Uganda, and Zimbabwe.69Although the cancer registry is an essential part of any rational program of cancer control,Despite all the problems mentioned, thanks to the efforts of international organizations, such as WHO and IARC; SSA governments; AFCRN; and, most importantly, the individual cancer registry staff, the situation is changing remarkably. The number of functioning PBCRs has been gradually increasing in all regions of SSA. In countries like Nigeria, Kenya, Tanzania, Uganda, and Zimbabwe, where there are multiple cancer registries, they have become indispensable. These registries submit their cancer reports to the central government regularly and some registry members sit on the NCCP board for making policies for their countries.Several specially designed international research projects, such as SurvCan 3 (led by IARC) and Treatment and Follow Up , have provided additional resources and expertise to conduct studies aimed at determining the survival and treatment received by patients with cancer. Numerous research papers on trends in cancer incidence, led by young African researchers using AFCRN data, have been published in international peer-reviewed journals. A kernel of experienced cancer registry pioneers and registrars have formed a unique team of trainers for teaching cancer registration methods.Countries such as Kenya, Tanzania, Eswatini, Cote d’Ivoire, and South Africa already have their own national cancer control planning based on their own data, and some of their strategies are being implemented. Improvements in the health care system for patients with cancer will be visible in the next 5 years.70 especially in monitoring the effectiveness of cancer control measures. There is an urgent need to increase investment in primary data collection, especially in low- and middle-income countries, to reduce the reliance on complex statistical models.71Countries in SSA need a working cancer control program to help battle the ever-increasing burden of cancer. A rational cancer control program must be built upon recent, accurate population-based data on incidence, survival, treatment, and outcome from within the nation it serves. A functioning cancer registration program is the unique way to obtain such data. Estimates—based on opaque simulation models—should never be a substitute for actual data,The two major common challenges confronting all PBCRs in the SSA are the lack of funding and poor infrastructure to support cancer registration. We recommend that resources for the development of cancer registries be prioritized urgently by the various governments in SSA. This is important as the current overdependence on donor agencies may not be sustainable in view of the emerging global financial crisis.For nearly a decade, AFCRN has been actively involved in providing needed mentorship, establishing more PBCRs, building capacity, providing funding, and initiating cancer research across the various PBCRs in SSA. PBCRs are no longer the elephant in the room in SSA as a result of the various initiatives by AFCRN which have yielded various improvements in cancer registration on the continent; however, there is still much room for improvement in cancer registration on the continent. With increasing awareness and efforts made across the health care system within countries, marked improvement continues.


Background: Interprofessional education is increasingly recognized as essential for health education worldwide. Although effective management, innovation, and entrepreneurship are necessary to improve health systems, business schools have been underrepresented in global health education. Central America needs more health professionals trained in health management and innovation to respond to health disparities, especially in rural communities.Objective:  This paper explores the impact of the Health Innovation Fellowship (HIF), a new training program for practicing health professionals offered jointly by the Central American Healthcare Initiative and INCAE Business School, Costa Rica. Launched in 2014, HIF’s goal is to create a network of highly trained interdisciplinary health professionals in competencies to improve health of Central American communities through better health management.Methods: The program’s fellows carried out innovative healthcare projects in their local regions. The first three annual cohorts  represented all health-related professions and sectors  from six Central American countries. All fellows attended four 1-week, on-site modular training sessions, received ongoing mentorship, and stayed connected through formal and informal networks and webinars through which they exchange knowledge and support each other. CAHI stakeholders supported HIF financially.Results: Impact evaluation of the three-year pilot training program is positive: fellows improved their health management skills and more than 50% of the projects found either financial or political support for their implementation.Conclusions: HIF’s strengths include that both program leaders and trainees come from the Global South, and that HIF offers a platform to collaborate with partners in the Global North. By focusing on promoting innovation and management at a top business school in the region, HIF constitutes a novel capacity-building effort within global health education. HIF is a capacity-building effort that can be scaled up in the region and other low- and middle-income countries. Education for health professionals in the new century is changing. According to Frenk et al.  three geScholars propose that this new approach be guided by two specific principles: transformative learning and interdependence in education . The forThere is a shortage of health professionals worldwide ,6. The nCentral American countries exhibit high variation in terms of their economic and social development. Social security coverage among those formally employed also varies widely in this geographic area, with 80% coverage in Costa Rica and approximately 30% in Guatemala, Nicaragua, El Salvador and Honduras . ChronicManagement is essential in public health and multinational companies are increasingly represented in this sector . At the Business schools bring a focus of leadership and operational skills that remain highly relevant to today’s needs in global health education . By inclpolicy and organization [Healthcare leaders perceive change and innovation as skills necessary for professionals in the field to develop, so that organizations in this sector can face the future challenges . Academinization . Neverthnization .Global health increasingly recognizes that developed countries can learn from developing countries. Because perceptions of health vary across populations and regions, community-based approaches must define their purpose and value through locally focused perspectives of health and health needs that originate from the community itself . TraditiLessons or best practices that Central America could share with other areas of the world include span community engagement, local healthcare worker training, financing, targeted health information, and innovative communication practices . CountriCAHI is a coalition of Central American and US academic institutions that aims to catalyze major improvements in the quality, efficiency, and delivery of healthcare services in the Central American region by promoting innovation and better management. Robert and Elizabeth Jeffe, a philanthropic American couple living in New York City, who had previously developed a medical school in Tanzania, were interested in supporting healthcare efforts in Central America through their family foundation. Central America was geographically closer to the US than Africa and exhibited many of the greatest health challenges representative of the Global South. Faculty members at New York University and Stanford University with connections and knowledge of the region led the Jeffe Foundation to INCAE Business School, an institution founded by Harvard Business School in 1964. INCAE has two campuses, one in Costa Rica and another one in Nicaragua, but its area of influence included all the Central American countries. INCAE’s mission is ‘to actively promote the comprehensive development of the countries served, educating leaders in key sectors by improving their practices, attitudes, and values.’ This business school had strong relationships and convening power among multiple stakeholders in the region besides the private sector. INCAE often worked with local governments and civil society organizations developing strategic plans and strengthening the management skills of their members.In 2012, CAHI and INCAE organized a local Health Summit, inviting former health ministers, social security authorities, academics, and practitioners. Organizers consulted this group of local senior leaders to determine how its intervention model could best strengthen and develop the healthcare sector in the region, and the necessary capabilities that local health professionals needed to improve healthcare access and delivery in Central America. Three proposals came out of the dialogue process, which later became CAHI’s main components: (1) a Health Innovation Fellowship (HIF), (2) a Healthcare Management Program for public hospitals’ managers, and (3) a Knowledge Center to conduct research and share best practices for effectively delivering healthcare to the poor. This paper focuses on describing and assessing the first three years of the HIF program.CAHI’s HIF program seeks to provide the tools and support needed for social entrepreneurs to implement, scale, and replicate innovative projects that improve healthcare access for the Central Americans in the greatest need. The HIF is geared toward committed local health leaders who propose a concrete, innovative project, or idea. The chosen fellows receive training in leadership, project management, political analysis, negotiation skills, partnership management, determinants of health, and trends in global health, among other topics. They also receive mentorship from senior healthcare leaders and experts in particular fields relevant for their projects. The mentorship component pursues the strengthening of ties between senior healthcare professionals with new generations of leaders, as well as the transfer of knowledge that increases the likelihood of the projects’ success. Finally, they receive one-on-one management advice along the program, to support the development and implementation of their project in the field. In this way, the goal of HIF is to create a network of highly trained interdisciplinary health professionals in competencies to improve health of Central American communities through innovation and better management.CAHI selects its HIF participants based on an outline of their proposed project, its degree of innovation and its relevance to their country’s health needs. The first three cohorts  included representatives from multiple health-related professions, from all sectors , and from six Central American countries. The targeted populations (i.e. beneficiaries) of these projects included rural, urban, and national. Recruitment began with contacts in the public health sector and expanded through CAHI alumni networks. Having a diverse group of students increased the quality of the discussion both inside and outside the classroom, through the exchange of their country-related and professional backgrounds. CAHI fellowship projects can be categorized into four types: (1) strategies for prevention and health promotion; (2) access to health services and medications; (3) hospital management; and (4) training of health professionals .10.1080/The HIF modular program lasts 11 months, combining on-site and online components. During the two-and-a-half-month period between on-site modules, the fellows return to their organizations but stay connected through formal and informal channels . Webinars are scheduled to complement their knowledge on specific areas. The fellows also receive a set of assignments to perform during these months, with clear deliverables and deadlines. The goal of these assignments is for fellows to implement the tools they acquire during the modules in their own projects and report on the progress made during this time.The program uses participant-centered learning and case methodology to deliver most of its content, to develop critical thinking, and to ensure that students learn not only from their professors, but also from their classmates’ backgrounds and perspectives. The diversity of students’ backgrounds, combined with this methodology, results in a stimulating exchange of experiences between fellows, faculty, and participating organizations within the CAHI network.The program is structured in four on-site modules, each with specific learning objectives . Each moTo achieve the above objectives, the program includes specific topics within the different modules. The first module seeks to strengthen the fellows’ leadership skills, to potentiate them as agents of change. Thus, students analyze and reflect on the role they want to play in society, as well as the challenges they would have to face to become agents of change in their countries. Materials to address this personal inquiry include historical cases of effective agents of change (e.g. Gandhi) and the analysis of significant challenges affecting humankind. The module also covers healthcare topics, such as the social determinants of health and global health needs, as well as administrative topics such as innovation management. For the latter, this module introduces students to the business model canvas , a pragmThe second module’s main objective is to provide fellows with tools to implement different components of their projects. It includes a range of project management techniques, from dealing with unexpected events to preparing a timeline for the different steps of the process (e.g. Gantt diagram). The module also provides an overview of functional areas such as accounting, marketing, strategy, and human resource management. Finally, this module provides sessions on impact evaluation to help fellows start thinking about how they will assess the impact of their projects.The third module encourages fellows to consider the institutional environment, which can influence the success of their project. They acquire the capabilities that they will need to perform a political and stakeholder analysis, as well as mechanisms to grow or replicate their project either directly or through partnerships. Training in negotiation and effective communication skills is also included in this module. Finally, classes teach fellows how to leverage their social networks and consider technological trends for the implementation of their projects.In the fourth module, fellows present their projects to a panel of external jurors who evaluate their evolution. Learning assessment includes an exam at the end of each module and a final grade that evaluates participation in class and in webinars, as well as assignment and progress report delivery.Faculty from INCAE, Stanford University, New York University, and Central American public health schools deliver the classes. Throughout the program, mentors were assigned to the fellows, often senior local healthcare professional or academics. Mentorship aims to strengthen the network of CAHI fellows and connect them with senior healthcare leaders who can share with them their experience in implementing their own projects in these countries.To evaluate each module, and as part of INCAE’s protocol, fellows filled an electronic survey upon completion of each topic covered. At the end of the module, participants also complete a questionnaire to provide an overall assessment of the week. Additionally, to assess the HIF program, we conducted an exit survey to the fellows. The survey provides qualitative and quantitative information on the participants’ perceived benefits obtained through the program. The authors coded and analyzed the data with the SPSS statistical program to observe tendencies and generate a descriptive statistical analysis. Finally, CAHI and external researchers compared the fellows’ initial project proposals for the program with the final project presentations to the panel of jurors. This comparison allowed for an objective evaluation of the progress achieved during the 11 months.Evaluations collected did not identify the participant, nor collected any personal health information. CAHI notified the fellows in writing that their responses would be an input to evaluate the program; that they provided consent by proceeding, and that all participation was voluntary and anonymous. This design adheres to the Institutional Review Board Ethics Committee guidelines at INCAE Business School.N = 43). They also perceived that the program gave them access to a network of leaders and innovators, as well as professional status and empowerment   .By comparing the application statements and the final presentations, researchers were able to analyze the evolution of the projects during the 11 months of the HIF. Applications were classified into four categories, depending on the starting point of the proposed initiative. The final reports to the jurors were also classified according to four stages. The authors coded the qualitative data, and four categories were identified: (a) idea; (b) complete business plan; (c) small-scale or pilot project; and (d) institutionalized and pursuing expansion. Institutionalized means that the organization had already embraced the project and was seeking to implement it on a larger scale.HIF contributed significantly to the development and implementation of most of the proposed initiatives. The analysis shows that out of 24 projects that started as an idea, 11 evolved into a business plan; seven were implemented on a small scale; and six became institutionalized . For insThe HIF cohorts also included fellows who applied to the program having already implemented their project on a small scale. For instance, the executive director of Teensmart, an organization that provides health education to teenagers at social risk, sought to consolidate and expand its pilot project into the Brunca region—an area with a high percentage of the country’s indigenous population and one of the poorest regions in Costa Rica. At the application stage, she was working with 10 local organizations and reaching approximately 500 teenagers. By graduation, she reported that 914 teenagers in the area were using the organization’s online platform and that Teensmart had coordinated efforts with eight additional local organizations. During HIF, she also established a strategic approach for reaching out to local organizations and for best working with them, including a fundraising strategy. The goal was to continue expanding the Teensmart operation in Costa Rica and Nicaragua, as well to apply the lessons learned in this pilot to the whole organization.We were writing a proposal to apply for external funds. With the HIF program, we improved the focus of the objectives. Now we have a donor, partners, training, and approval of the Minister’s Office. We are ready to start.We were looking for collaborators outside the institution and learning about the activities of the population. Now there are three groups of instructors trained about strategies related to preventing pregnancy, suicide, and overweight.We had the idea of the project, but with this program, we have implemented it. Objectives are now more concrete and more realistic. We are in the implementation stage.We focus on decreasing turnover of healthcare professionals working in indigenous areas. At the beginning, we thought to launch the project countrywide. Now, the approach is to first conduct a pilot project in a remote geographic area using mobile technology.He developed the mobile application as a preliminary version (pilot) but I was not sure about its business model. Currently, I have a business plan; I revised and improved the app and it is now ready to launch in app stores. I am completing the registration process and institutionalization for the subsequent signing of strategic alliances.A selection of fellows’ quotes about HIF’s perceived value added in the evolution of their proposed initiatives complements this analysis. Fellows expressed these sentiments in the program’s exit survey, which was consistently positive:N = 43)  . These rThe impact evaluation of the three-year pilot training program is positive: fellows improved their health management skills, and more than 50% of the projects have found either financial or political support for their implementation. By focusing on promoting innovation and management with the support of a top business school in the region, HIF constitutes a novel capacity-building effort within the domain of global health education in Central America .One strength of HIF is that most of its faculty and all its fellows come from the Global South. Additionally, HIF offers fellows a platform for collaborating with partners in the Global North—such as faculty from NYU and Stanford—leading to unique knowledge exchange. CAHI documents lessons learned by fellows in the field and shares their best practices with multiple audiences.Fellows perceived the fact that HIF makes them part of a local network of change agents in health, as one of the most valuable contributions of the program. In this network, collaborations develop among people from different countries, who face similar challenges but address them from multiple angles and with various methods. These collaborations include mentorship (e.g. fellows sharing their expertise in a specific area); support to develop a strategy or action in a new project (e.g. replicating the project in another country or jointly developing interventions with other fellows); or participation as speakers to share experiences with new CAHI fellows. For instance, a Costa Rican fellow from the first cohort, who developed a project with mobile technologies, mentored a fellow with a project about the implementation of electronic records in a public hospital. Additionally, this fellow shared his experience implementing his project with HIF’s third cohort participants, in an event organized by CAHI. Such networking practices aim at strengthening knowledge exchange and development of ties among fellows. This example shows that HIF constitutes not only a North–South knowledge exchange platform, but also a South–South platform.Despite its initial positive results, HIF also has opportunities for improvement. For example, an 11-month period program is a relatively short time to generate significant improvements in the health system and to evaluate the outcomes of each initiative. Measuring the impact of many of these projects requires specialized techniques  and a longer-term horizon. In this regard, the multiple health issues addressed by the fellows  makes it difficult to standardize the impact evaluation process and the development of appropriate indicators. Moreover, the fact that projects are not all at the same development stage when submitted for the HIF application process makes it difficult to use parameters to compare them.This preliminary impact evaluation of HIF is positive and encouraging. Nevertheless, Central America and the Global South in general have multiple challenges to face. Change must happen faster if we are to achieve the Sustainable Development Goals by 2030. HIF might explore increasing the number of participants per cohort without jeopardizing the quality of the program, particularly the follow-up process of the fellows’ projects.Train the Trainers program, focused on training an army of these leaders who could have a faster and more direct impact on the populations that need it the most. In this way, strengthening the promotion of innovation and management training among community health workers could help reduce global health disparities and achieve the Sustainable Development Goals in Central America.We believe it is necessary for programs like HIF and initiatives working with local leaders to question whether they are providing the necessary conditions for health workers with limited formal education (e.g. without a university degree) to benefit from such training. Having community health promoters in the cohort would not only bring diversity to the group but also enrich the discussion. It is valuable for hospital directors and physicians to understand the reality that these community leaders face every day on the ground. Although HIF included some local leaders in the program, the strengths of having community health workers in each cohort cannot be emphasized enough. While basic health services in rural areas certainly needed more physicians, nurses, and pharmacists, fellows that worked with community health workers are likely to reach the poorest populations in a shorter term. This point is acknowledged in the field of task shifting, as bringing healthcare to the poorest in the region requires the development and engagement of community leaders to deliver basic healthcare services. Thus, CAHI might explore the possibility of launching a