Among western African countries, the Republic of Ghana has maintained an economic growth rate of 5% since the 1980s and is now categorized as a middle-income country. However, as with other developing countries, Ghana still has challenges in the effective implementation of surveillance for infectious diseases. Facing public health emergencies of international concern (PHEIC), it is crucial to establish a reliable sample transportation system to the referral laboratory. Previously, surveillance capacity in Ghana was limited based on Integrated Disease Surveillance and Response, and therefore the “Surveillance and Laboratory Support for Emerging Pathogens of Public Health Importance in Ghana (SLEP)” was introduced to strengthen diarrhea surveillance. The SLEP project started with a sentinel diarrhea survey supported by SATREPS/JICA in collaboration with National Public Health Reference Laboratory (NHPRL) and Noguchi Memorial Institute of Medicine (NMIMR). The base-line survey revealed the limited capacity to detect diarrhea pathogens and to transfer samples from health centers to NHPRL. The involvement of private clinic/hospital facilities into the surveillance network is also crucial to strengthen surveillance in Ghana. The strong and interactive relationship between the two top referral laboratories, NHPRL under the Ministry of Health NMIMR and under the Ministry of Education, enables Ghana Health Services and is critical for the rapid response against PHEIC. In future, we hope that the outcome of the SLEP surveillance project could contribute to building a surveillance network with more timely investigation and transfer of samples to referral labs. The Republic of Ghana is a western African country, facing the Gulf of Guinea, and has maintained an economic growth rate of 5% since the 1980s. In 2010, an offshore oilfield was discovered and Gross National Income (GNI) reached $1,190 in 2019, which categorized it as a middle-income country . Then, dSince the Republic of Ghana is located in a tropical wet climate, tropical diseases such as malaria are endemic, and cholera outbreaks occurred in 2014 and 2016 [The diarrheal surveillance component of the SLEP project targeted Ga West Municipality, which is adjacent to the capital Accra and consists of a mix of densely populated areas where urban residents live along the main road and rural villages with no roads. Taking the geographical characteristics into account, the surveyed medical facilities were selected by balancing densely populated and non-densely populated areas. In addition to evaluating the implementation of IDSR as an indicator of surveillance, the Medical Facility Capacity Assessment Guidelines  prepared by the WHO East Africa Office were employed . FinallyThe IDSR manual was used at only 5 out of 13 public and 1 out of 19 private health facilities Table .Health facilities in the IDSR are expected to submit weekly and monthly surveillance reports. However, no weekly reports were submitted from private facilities. Also, only one of the private facilities received training from upper-level facilities, compared to 9 out of 13 of the public facilities , the project distributed the revised IDSR manual to all health facilities in Ga West.Private health care facilities had fundamentally different attitudes from public ones towards surveillance. Private institutions are legally required to report surveillance records. However, because tax is imposed on the number of outpatients, private health facilities are said not to report all patients, which resulted in incomplete surveillance. Because the number of private health facilities is much bigger than that of public, certain measures to make private health facilities get involved in the surveillance should be taken in the administrative process. Training for health facilities at the grass-roots level from district hospitals would encourage the participation of private health facilities.The smooth and reliable coordination between the top two referral laboratories was crucial. In the surveillance scheme in Ghana, investigations for PHEIC such as Ebola virus are conducted at NMIMR. On the other hand, cholera, HIV, and tuberculosis, which are categorized as priority diseases in IDSR, are inspected at NPHRL under the jurisdiction of the Ministry of Health. Therefore, the NPHRL has a significant role in the surveillance. NMIMR at the University of Ghana has been a key partner for JICA medical cooperation projects for many years, and is recognized as a top referral facility in West Africa. Since the NPHRL performs testing for the pathogens indicated as priority by the IDSR, NMIRM worked together with NPHRL on the SLEP project and performed quality control (double checking) as needed. Although previously cooperation between the NMIMR of Ghana University and the NPHRL was sparse, we are working to strengthen cooperation between the bacteriology department of NMIMR and NPHRL by collecting and storing fecal samples together. It is expected that this close cooperation will overcome administrative jurisdictions and organizational or cultural barriers. In the future, it is hoped that the divisional roles between the two organizations will be appropriately carried out.In addition, NMIMR had a next-generation sequencer used in gut microbiota research that was used in this project, indicating the possibility of using research-based test data to enhance surveillance . This prWhile the SLEP study focused on diarrheal disease, public health emergencies stipulated by IHR2005 include chemical, radiation, and food safety emergencies in addition to infectious diseases. Greater focus on these areas would be critical to strengthen Ghana’s ability to respond to PHEIC, as well as better collaboration with veterinary departments for surveillance against zoonotic diseases.In the face of PHEIC, it is critical to detect unusual events through surveillance and rapidly refer patient specimens to referral laboratories for confirmation. Surveys completed as part of the SLEP project identified key areas for enhancing the surveillance network in Ghana, such as streamlining the specimen transport system. A strong and interactive relationship between the two referral laboratories, NPHRL under the Ministry of Health and NMIMR under the Ministry of Education, will enable GHS to be more effective. In addition, greater involvement of private clinics and hospitals in the surveillance network should be prioritized to improve surveillance in Ghana.


Safe, timely, and affordable surgical care is desirable worldwide, but is largely an unmet need. Surgical care is recognized as an important component of public health. Vision for sustainable surgical development is desirable, and general surgeons can contribute substantially toward this mission.In the absence of surgical care, case-fatality rates are high for common and easily treatable conditions. These include congenital anomalies, hernia, fractures, appendicitis, etc. Solution is surgical care. Results of surgery on time are rewarding.General surgeons, as per the Medical Council of India, are required to (1) recognize the health needs of the community and carry out professional obligations, (2) be competent, and (3) be aware of the contemporary advances and developments in the discipline concerned. All this ensures that the general surgeon should be able to treat almost all surgical conditions effectively.Professional patriotism” in the historic Flexner report.With timely, cautious, careful, and tactful surgeries, general surgeons should be able to deliver robust results both electively and in emergency. All this in the true spirit of “Vayam Sevaamahe – We are for service” the motto of the Association of Surgeons of India. General surgeons should boost the best what was termed “ Surgical care is recognized as an important component of public health.Against this background, our article's aim is to (1) analyze general surgery (GS) requirements, (2) build upon the rationale for the role general surgeons should be playing, and (3) catalyze the results which general surgeons can produce.Strategies for sustainable surgical development are desirable and should aim for quality dividends quantitatively. Access to the full spectrum of health care, including surgical care by all has to be achieved. Surgically treatable conditions account for a significant proportion of the total global burden of disease, and surveys of need have shown that it is largely unmet.Professional approach to health for all and advancing modern surgery, demands wide expertise by all against the present trend of limited expertise by only a few for a limited field—the so-called sub(super)-specialization. Majority of the surgical conditions can be dealt by general surgeons and they are trained in it. Holistic healing requires leadership, understanding of human as a whole, and not just organ- or system-specific superspecialist surgeons.Lancet Commission on Global Surgery estimated need of 5,000 surgeries per year per 100,000 population.In the absence of surgical care, case-fatality rates are high for common and easily treatable conditions including congenital anomalies, hernia, fractures, appendicitis, etc. These conditions are ubiquitous. Solution is surgical care. Results of surgery on time are rewarding.India's doctor-population ratio of 1:854 is better than the World Health Organization (WHO) standard of 1:1,000.With universal coverage of essential surgery in low-income and middle-income countries, 1.5 million deaths per year could be averted, representing 6.5% of all avertable deaths in these countries.Worldwide statistics reveal other aspects as well. Available statistics show that over 44% of WHO Member States report to have less than 1 physician per 1,000 population. Health workers are distributed unevenly across the globe. Countries with the lowest relative need have the highest numbers of health workers, while those with the greatest burden of disease must make do with a much smaller health workforce.It has been commented that essential surgery provisioning in rural and remote areas can be only partly met both in developed and in low- and middle-income countries. It may take years to solve the problem of unmet needs.The scenario of surgeons in the Indian Armed Forces is peculiar. The needs are both peace-time and war-time. In addition, surgeons of the Indian Armed Forces play an important role in relief operations. They also play important role by way of surgical camps like those of Op Sadbhavana, in remote and underserved locations.The World Federation for Medical Education Global Standards 2015 for Postgraduate Medical Education stipulates to base the mission on consideration of the health needs of the community or society.The goal of postgraduate medical education shall be to produce competent specialists. General surgeons awarded MS degrees are expected to have the following competency as per the Medical Council of India First, recognize the health needs of the community, and carry out professional obligations ethically and in keeping with the objectives of the national health policy. Important implication is to meet all the surgical needs of the community.Second, mastered most of the competencies, pertaining to the speciality, that are required to be practiced at the secondary and the tertiary levels of the health care delivery system. All the needs of communities, states, and nations can be met for by general surgeons in these levels of health care.Third, be aware of the contemporary advances and developments in the discipline concerned. Surgeons have the enthusiasm, and with sustained efforts for ongoing training the general surgeon should be able to treat almost all surgical conditions effectively.A meeting of experts for workable solutions for GS workforce shortfalls recommended to enhance the number of GS trainees and the breadth of training. It also recommended that minimally invasive surgery should largely return to GS.http://www.medscape.com/generalsurgery/) and medical media communication  is useful in assimilating the newest evidence.Surgeons have long been considered leaders in adapting and improving their practice.Formal online courses, webinars, and remote telementoring all provide examples of surgical leadership.Professionalization of modern surgery demands wide expertise by all against the present trend of limited expertise by only a few for a limited field—the so-called subspecialization.Professionalism has been defined as “a set of values, behaviors, and relationships that underpins the trust the public has in doctors.”General surgeons need to be energized for excellence: It requires sustained energy for excellence, to achieve the targets, and to stay high on the results. With all this we should be able to meet the unmet needs.Improvements in antisepsis, advanced anesthetic techniques, and sophisticated surgical skills have led to improvement in outcomes for surgical patients. Surgery can be elective or performed in emergency. Identifying predictors of mortality and surgical complications has led to outcome improvements for a variety of surgical conditions.electivehernia repair  are low (≈1%), but rise to as high as 18 to 20% when repair is performed at the time of incarceration. Elective inguinal hernia repair can be safely performed in an outpatient setting with an expectation for full recovery within 48 hours.An illustrative example of need for timely surgical intervention is a common condition—inguinal hernia. A hernia not operated is a cause of morbidity, and complications of hernia are a potential cause of mortality. Risks of surgery are substantially less and results rewarding. Approximately 50% of inguinal hernias manifest clinically in the first year of life, most in the first 6 months. The incidence of complications associated withAdverse events in surgery are an important problem globally. Many are preventable. The WHO Surgical Safety Checklist has been shown to reduce surgical complications and improve communication and teamwork in the operating theatre.An important quality improvement initiative is clinical audit. The process involves comparing aspects of care  against explicit criteria and defined standards. General surgeons should analyze results and compare performance against agreed standards with regular audit. It also documents track of personal clinical results. Rigorous evaluation of even the most simple techniques and conditions should be done. It can help to keep a surgeon stimulated throughout a long career and ensure good outcomes for patients, with cost benefits to the provider and a benefit to society as a whole.With timely, cautious, careful, and tactful surgeries general surgeons should be able to deliver robust results both electively and in emergency. More sophisticated surgical operations with better results are increasingly performed. General surgeons should also continue to increase their skills and sophistication.Advancements in technology hold great promise for the advancement of patient care. Modern technology enriches (1) proper assessment, (2) pertinent management, including surgical intervention, (3) progress monitoring, including for adverse events,The practice of surgery is changing in significant ways, and for the good. Novel techniques often require an entirely novel skill set for surgeons. General surgeons should embrace and master new techniques throughout their careers.The latest trend in training in the context of a larger curriculum of proficiency-based training in surgery is encouraging. It is the best way to achieve good training results.“Vayam Sevaamahe – We are for service” is the motto of the Association of Surgeons of India. Surgical care and cure for all should not be a distant dream in India and worldwide, with dedication and devotion of all the general surgeons. General surgeons should strive for service improvement and innovations in delivery of services for the benefit of patient care. The field of surgery is an ever-evolving one. General surgeons should improvise ways for delivery of all advances for the benefit of all.In the present context the historic Flexner report,Professional patriotism amongst medical men: the regard for the honor of the profession and the sense of responsibility for its efficiency.”“


Physical inactivity and its consequences is a growing problem. Health enhancing physical activity (HEPA) behavior has previously been linked to the characteristics of the physical surroundings. Active Living (AL) is, in that connection, an international concept developed to integrate HEPA into everyday life.The city of Odense located on Funen in Denmark has undergone major urban developments throughout the past 10 years - and will continue to do so prospectively. This has resulted in a possibility to create an AL area to be used by various target groups . Therefore, the University of Southern Denmark (SDU) is involved in a project aiming at creating a 80-hectare AL area with various activity possibilities for the everyday users.Citizen Science (CS) has been the bearing principle from the beginning of the project. Rather than developing such an area ‘behind the desk’, the guiding question throughout the process has been: According to the citizens, what should such area contain of? This has been initiated through expert workshops, student modules in relation to the Sports and Health education at SDU, arranging events together with local media, organizing the Danish Championship in cycle cross, organizing a school festival etc.Using the CS approach, the project has received more than 1.000 inputs and ideas from citizens, associations, students etc. The proposals have formed the basis for the results in a combined PhD project, focusing on AL and principles of landscape architecture. Drawings from this PhD will be presented and principles of Citizen Science will be discussed at the conference.The next project step is to raise external funding to realize the potential of the area.At this time, the project is still at its initial stage trying to raise funding to initiate and carry out the collected ideas. However, this project is a great example on how a CS approach in developing an urban area by integrating various sectors, hopefully, can improve the final product in terms of usability and sustainability.


Echocardiography has evolved the first-line imaging for diagnosis and management of pediatric and congenital heart disease all over the world. While it recognized as essential component of pediatric cardiac care delivery, organization of pediatric echocardiography services is very heterogeneous across the world, mainly related to significant differences in material and human resources in heterogeneous health care systems. In this paper, we focus on the role of pediatric sonographers, defined as expert technicians in pediatric echocardiography. While in some services sonographers are an essential part of the organizational structure, other laboratories operate only with physicians trained in echocardiography. The impact of sonographers on clinical, academic and financial performance will be discussed. Two organizational models (with and without sonographers) will be compared, and the advantages and disadvantages of each model will be evaluated. Different models of care provision are possible and decisions on organizational models need to be adjusted to the demands and available resources.  Since cardiac ultrasound was introduced in the 1950s .As the use of pediatric echocardiography expanded, different organizational systems in pediatric cardiology have evolved around the world. Pediatric echocardiography training became an essential component of pediatric cardiology training programs and all pediatric cardiologists should be competent in performing and interpreting echocardiographic studies in children. In some country’s technician training programs specific for pediatric and adult echocardiography developed and the cardiac sonographer profession was introduced to assist with image acquisition and interpretation. All pediatric cardiology services provide echocardiographic imaging, but the organizational structures can be different between countries or even within countries. Specialized pediatric echocardiography laboratories developed in the 1980s–1990s and pediatric echocardiography became a recognized subspecialty in many countries different organizational models for pediatric echocardiography developed in different healthcare systems. So, for instance, in Canada, image acquisition is mainly performed by specialized pediatric sonographers, with image interpretation mainly done by pediatric cardiologists. In many other countries, pediatric cardiologists do the image acquisition, interpretation and reporting. Each organizational system has its advantages and disadvantages with impact on patient care, training of young physicians, scientific productivity, and financial cost.The objective of this review is to compare the clinical, academic and financial impact of both organizational systems (with or without sonographers). We believe this could help individual centers to choose the model according to their clinical needs, academic objectives, and structural and financial resources.The sonographer profession began appearing in the United States in the early 1960’s around the time as the inception of clinical echocardiography. In 1970, the American Society of Ultrasound Technical Specialists (ASUTS) was founded by the American Institute of Ultrasound in Medicine (AIUM) . With thWhile in many countries around the world sonographers are working in adult cardiology services, fewer institutions employ pediatric cardiac sonographers. To our knowledge, 11 countries use a sonographer-based structure in pediatric cardiology . While iThe complexity of CHD requires extensive specialized training to become a proficient pediatric cardiac sonographer . For exaphysician model) and the Hospital for Sick Children (SickKids), Toronto, Ontario, Canada (sonographer model). Based on the databases of the European Congenital Heart Surgeons Association (ECHSA) and the Society of Thoracic Surgeons (STS), postoperative mortality for CHD is broadly comparable between North America and Europe . Image acquisition is guided by detailed imaging protocol that is disease-specific and differ for different stages. Each sonographer follows the same protocol during the image acquisition to guarantee that all essential cardiac structures are imaged with the same standardized views and the same measurements are obtained. After acquisition, the images are reviewed and discussed with the attending staff and sometimes additional images can be acquired either by the sonographer or the physician. The sonographer drafts a preliminary report that is amended and signed off by the physician who takes the final diagnostic responsibility. Completion of a pediatric echocardiogram in a sonographer-based scanning system involves sonographer and cardiologist interaction and collaboration .Over the past 5 years at SickKids, an average of 13,386 TTE are performed each year. With around 12 full time sonographers, the annual average number of pediatric TTE per sonographer is 1,134. These numbers are comparable with other large North American surgical centers . The sonphysician model, the TTE is more considered as an extension of the clinical examination and every pediatric cardiologist acquires images, interprets and reports the findings. Therefore, the TTE is usually not performed in a dedicated room such as an echo room. For outpatients typically, the TTE is performed during the clinic visit by the patient’s cardiologist, in the clinic examination room. For inpatients, physicians and trainees staffing the wards perform bedside echocardiograms when needed, usually as part of the inpatient round, without approval from an extraneous Echo Lab . Seven pediatric cardiologists are involved in performing the pediatric echocardiography, in addition to their other clinical duties . From 8,500 to 9,000 pediatric TTE are performed each year. The echocardiogram acquisition is protocolized, images are saved, and independent electronic reports provided for all outpatients. The average time spent per echo is much lower than in centers with sonographers, about 20 min per examination for outpatients and about 5–10 min for daily follow-up of hospitalized patients. However, the anatomical studies for the initial diagnosis of congenital heart disease are just as complete as described in the sonographer model, based on segmental analysis and exhaustive study of each anatomical structure.Many centers using a physician-based model transition into a hybrid model by recruiting sonographers to handle part of the scanning workload , 12. TheThe primary contribution of sonographers in the organization of an Echocardiography Laboratory is their impact on the medical practice.First, the ability to perform a large quantity of pediatric echocardiograms, thanks to an optimal sonographer/patient ratio, helps to reduce wait times. Indeed, this is particularly marked for outpatients in comparison with systems where echocardiogram is performed during the medical consultation. In the SickKids setting, the non-urgent echo requests have mean wait times of about 1 week . This is made possible because capacity is built into the schedules to be able to absorb additional requests. For inpatient emergencies where fast access to echocardiographic imaging can be important, the physician-based system is usually more reactive. Typically, an ultrasound scanner is immediately available on the cardiac wards and the physician can perform it without any delays. The introduction of point-of-care ultrasound (POCUS) in intensive care units and emergency departments, indicates the need for immediate access to ultrasound technology and could partially address the need to have imaging information available for immediate decision making . Having Secondly, one of the key parameters to support the sonographer model in pediatric cardiology is the quality of echocardiograms. Echocardiography is a very operator-dependent skill and the ability to perform detailed pediatric echocardiograms requires proficient technical skills. Human performance studies indicated that in order to develop “expert” level performance for certain skills, can take years of dedicated practice  and up ta posteriori interpreted and discussed, as a cross-sectional imaging examination. This is particularly important in a specialty where most medical and surgical decisions are based on echocardiographic findings , which efficiently makes use of the professional component. Given the duration of a pediatric echocardiogram and the current cost of billing in Canada, the sonographer is used as a less expensive workforce to make the most of medical time and save on tasks that could be performed by non-medical technicians. This is particularly attractive in a Canadian system where medical time is preserved and where doctors’ salaries are about three times the salary of French public hospital’s physicians (The full billing cost of a pediatric echocardiogram in Canada is 212.80 Canadian dollars (CAD), with a technical component (116.60 CAD) or image acquisition billing cost and a professional component (96.20 CAD) or image review and reporting. Comparatively, the cost of a cardiac echocardiography Doppler in France is fixed at 96,49 euros (≈ 140 CAD) according to the 68th version of the “The interest of comparing these models is not limited to the financial question. As described above, from a purely qualitative point of view, the echocardiogram acquisitions could appear more complete and protocolized through the sonographer model and the sonographer contribution to quality of care and research has been detailed. However, other points have to be discussed to better understand all the dimensions affected by these organizations .For a system like the one developed at SickKids, the key parameter is the high-quality training and skills of the sonographers. Indeed, the added value can only be imagined if the sonographer has a high degree of autonomy and understanding of pediatric and congenital cardiology. Physicians must be able to analyze the sonographers’ images for the time saving to be real. Our comments are based on the SickKids experience, where the training and competence of the sonographers is a reference. However, sonographer training remains heterogenous according to individual centers and this must be considered in the appreciation of the sonographer model.The question of burn out among physicians is a well-known problem affecting the workforce worldwide. As Scott. W. Yattes wrote in a recent review paper: “Burnout is a system problem, not an individual disease and must be addressed with systematic solutions” . The litIn the sonographer model, the time between the TTE request and the receipt of the signed report by the medical team in charge of the patient is longer than when the physician directly scans his own patients. This can lead to delay in decision-making where the TTE findings are crucial . Thus, tFinally, our opinion is that the system efficiency depends largely on the Echo Lab management rather than on the presence or absence of a sonographer. Efficient team management promotes a safe and fulfilling work environment and results in less turnover and better global skills and productivity.The duration of examination in children can be a significant barrier to compliance, comfort and indirectly image quality. In some centers such as SickKids, this leads to provide sedated echocardiography in patients from 3 weeks to 3 years of age to be able to complete the whole protocol. This means spending at least half a day in the hospital, and even when the echocardiogram is not under sedation, the echo appointment is separated from the medical appointment, which lengthens the patient’s journey. An additional potential consequence of the sonographer system is the multitude of people involved in the care pathway. The experience for the family is necessarily different when the referent physician, following the child in the long term, performs the echocardiograms during the medical consultation and then gives the result immediately after, in the same unit of time and place.The sonographer profession supports the importance of ultrasound image acquisition, not its final interpretation. The shortcoming of past and present ultrasound image acquisition is that it remains mainly operator dependent and therefore, requires a trained and skilled professional. However, with the continued rapid development of technology, including 3-dimensional echocardiography, artificial intelligence (AI) and robotization, it is reasonable to envision a future system where ultrasound image acquisition could be fully automated.3D echocardiography (3DE) has been slow to integrate as a routine diagnostic tool. Historically, the central limitation of 3DE has been its inferior image resolution, both temporal and spatial, when compared with 2-dimensional (2D) imaging. However, improvements in probe technology now allow for higher spatial resolution and volume rates needed for cardiac imaging . In addiThe field of robotization has also begun its integration into echocardiography with the development of tele-operated robots for remote studies. One of the first robot operated echocardiography systems was developed for use in space in order to monitor the effects of space travel on the cardiovascular system. The Tele-echography for the European Space Agency (TESSA) was designed to allow trained experts on the ground to operate a remote echocardiography system and obtain real-time images. The TESSA system consists of an ultrasound machine, an ultrasound probe attached to a robotic arm and a video conferencing system . These rLastly, artificial intelligence (AI) in echocardiography is an ever-expanding field that has the potential to reduce the need for trained sonographers. Artificial intelligence is a computer-based system that can observe its environment and take actions to successfully achieve its goals. Currently there are subsections of AI -machine learning (ML) and deep learning (DL)- that are used to enhance acquisition, analysis and reporting in echocardiography. In its simplest form, ML is centered around computers being able to think and act with minimal human involvement; however, DL is about computers learning to think utilizing structures modeled on the human brain. For the purposes of this paper, we will focus only on the use of AI in image acquisition as this is primarily the sonographer’s role. First, new AI software has been studied and developed to assist the user in acquiring good quality echocardiographic images . RecentlDetermining the superiority of one model over the other is not the goal of this study. This work aims to highlight the advantages and disadvantages of both. What distinguishes these two models does not only imply a different Echo Lab organization but involves a different history, culture and concept of care. Transposition from one system to another is neither desirable nor possible but highlighting areas of progress can help actors analyze their system differently, in order to constantly improve the quality of care and working environment. We believe this work will help teams improve their operations by leveraging the advantages and strengths of each system, possibly evolving toward a balanced hybrid system adapted to each situation.All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Research on innovation has two strands: institutions undertaking innovation as a research and development process and companies commercializing innovative products. We combine these strands, analyzing a sequence going from an innovation supply chain to a product supply chain from laboratory to market. We argue that these supply chains are symbiotic, and the relationship between entities is affected by economic considerations. Our framework allows an understanding of how research, regulatory policies, and economic conditions affect the emergence of innovations, the creation of institutions  to carry out these innovations, and the diffusion of the resulting products. Our approach may improve the design of strategies to induce climate change and food security solutions. We analyze the transition from innovative ideas to final marketed products. This transition occurs through two synergetic supply chains for innovation and products. Basic concepts are developed, tested, upscaled, and introduced to commercial use in the innovation supply chain. Then, the products are produced and delivered to the consumer through the product supply chain. We argue that product markets trace their birth to product innovations. These markets tend to start as noncompetitive, which rewards innovators. Credit access and risk determine the reliance on contracting and product diffusion over space and time. The innovation and product supply chains are encouraged and facilitated by public policies, such as support for research and education, intellectual property rights protection, low barriers to trade, science-based regulation, and well-functioning capital markets. We argue for multidisciplinary research incorporating knowledge from economics, business, and engineering to better understand the evolution of innovative companies and supply chains. This understanding will help the development of policies to address challenges of climate change and food security among others. Policy makers, scientists, and the public are interested in understanding the processes that lead to the transition of ideas to new products and services. We present a framework to analyze this transition consisting of two symbiotic supply chains: the innovation supply chain (ISC) and the product supply chain (PSC). In the ISC, scientific discoveries are made, developed, and adapted into marketable products. In the PSC, the innovating firm forms expectations of the demand for their products, designs a supply chain to produce and market its products, and then, implements its supply chain while adapting it as reality unfoldsThe behavior of these supply chains is not mechanical. Instead, the organizations that manage the different supply chain segments are motivated by economic and political incentives. For example, a firm introducing a new fruit will use profitability considerations to decide how much to market and to what extent to produce the food itself vs. relying on contractors. Supply chains adapt to shocks. For example, the COVID-19 pandemic led ISCs to develop vaccines and PSCs to distribute the vaccines. The pandemic also led to the expansion of food delivery from retailers to consumers. Furthermore, the relationship between the ISC and PSC is symbiotic and synergetic, with multiple feedbacks. Consumer feedback obtained through the PSC may lead to investments in research to improve product quality, and new product properties discovered in the ISC will lead to a modification of the PSC. Our analysis extends, relies on, and complements economic frameworks for analyzing, innovation, diffusion, and industrial organization.Our framework applied to innovations in general, spanning developed and developing countries. Innovations are transformative to varying degrees. Most are incremental; some are radical, but all need supply chains. Our framework is quite general, but its application may vary according to circumstance. For example, the supply chain design may be more challenging for a transformative innovation (such as the cell phone) than for an incremental innovation that relies upon and modifies existing supply chains (such as a new variety of beer). The analysis of the ISC and PSC applies to a large extent for most sectors in high-income countries, for fewer in middle-income countries, and for few sectors in low-income countries.1)We analyze the ISC, emphasizing the division of labor between the public and private sectors and the role of public funding of research that provides public goods.2)We review the PSC. We present a framework for projecting adoption and thus, demand over time. It emphasizes the heterogeneity between consumers and the vital role of learning and marketing in shaping adoption dynamics. Then, we introduce a framework to analyze the dynamics of the PSC. We emphasize that the design of a supply chain is an economic problem. The innovating firm designs and implements a supply chain to procure inputs, produce, and market the innovative product or technology. For example, a firm introducing a new fruit needs to decide how much, how to market, and the extent of reliance on contractors for production. The analysis emphasizes that markets, firms, and products are the endogenous outcomes of innovation and PSCs and suggests that supply and demand are interdependent, with firms engaging in marketing activities to generate demand.3)We analyze the symbiotic relationship between the ISC and PSC and identify feedback loops between the different stages of the two. We suggest that the features of both supply chains depend on polices market conditions using illustrative examples. We argue that government regulations of markets must balance the incentive for innovation with the consequences of excessive market power.4)We present implications for environmental, natural resources, and food management policies, arguing that shocks, like climate change or pandemics, affect firms directly and through their impacts on other economic agents throughout their supply chains. Thus, more attention to supply chain design and function will improve efforts to mitigate climate change and address food security and health challenges.5)The conclusion section identifies directions for future research. It emphasizes the need for collecting data and empirical analysis on supply chains evolutions. It highlights the importance of studying technological change within the context of multistage supply chains, relying on findings from economics, engineering, and other disciplines.The paper includes five sections.Innovation is doing things in a new way. Innovation can include new products, technologies, services, institutions, and policies. In its modern form, the ISC is referred to as the educational–industrial complex. The “upstream” of the ISC is the supplier of “basic science,” which can be a laboratory in a public institution or a private firm. The past two centuries have seen a shift from individual or “small science” teams to large teams and laboratories—“big science” . The outIn the midstream of the ISC, innovative ideas are transformed to inventions, upscaled, and tested for efficacy and impacts by start-ups, firms, and public sector laboratories. Some of the basic research discoveries have implications that can lead to commercially viable innovations (including both tangible technologies and intangible processes) and the rights to use public sector innovations conferred to the private sector by offices of technology transfer (OTTs). The OTTs sell the right to use their patents to companies and assist in their utilization. Patent rights serve as an incentive for investment in product development . While uMost innovations tend to build on existing technologies or processes. Incremental innovations may be introduced and developed within laboratories and by practitioners in companies. Innovators recombine existing innovations and concepts from different fields to generate new products. Major inventors, like Edison and Ford, relied on existing technologies to develop new products. Product design companies, like IDEO in Palo Alto, specialize in designing products or processes for clients .The downstream of the ISC establishes the processes for the product's commercial production. This industrial design requires combining technical knowledge with expectations of demand and input prices.Governments support the ISC directly through support of research. Investment in research is affected by scientific, economic, security, and political considerations. Global expenditure on research and develoment has quadrupled between 1980 and 2016, reaching close to $2 trillion in 2016. The share of the United States in global research and develoment has declined to less than 30%, while the share of Asia has been increasing. The share of private sector research in total research and develoment expenditures has increased to become close to 70%. Private research in agriculture in developed and middle-income countries is close to 60%. It is less than 25% in low-income countries, where donors augment local governments in supporting public research  or continuous variables (share of land planted with a new variety). Adopted innovations may have one component or a package of components: for example, hardware and software of a computer. Diffusion is aggregate adoption and is measured by the share of potential adopters that adopt the product or technology at a given moment or the share of productive capacity utilizing new technology .t, a is a measure of initial adoption, and b parameterizes the rate of diffusion. Griliches , learning by doing (reducing the costs of supplying the new technologies), and network externalities .Second, the firm undertakes an analysis of actual and potential adoption. The applications of the imitation and threshold models can be complementary. The firm may use the threshold model in designing policies and strategies for launching and managing the commercialization of innovations and in integrating marketing mechanisms that can induce adoption. The imitation model has a relative advantage in assessing awareness of an innovation and can be used to estimate diffusion rates.Econometric and statistical analyses aim to identify some of the key elements of the modified threshold model and, in particular, to assess the decision criteria of different potential adopters: to what extent they are affected by risk, are constrained by credit, and deviate from economic rationality. Furthermore, the economic literature aims to identify sources of heterogeneity among potential buyers, as it affects the adoption of specific technologies  as well On the other hand, innovating firms have ex ante analytical tools. Experimentation is key in developing new technologies and institutions. Innovating firms may engage in pilot studies before they fully embark on new technology. They may do demonstrations to potential end users to assess demand and adjust the product attributes .Economists have recognized the value of using experiments to assess the viability of new technologies and practices  and theiMarketing analysts use a broad range of prelaunch predictive tools that are based on finding out the importance of the innovation, the willingness to consider it, the importance of specific attributes and consumers’ willingness to trade off these attributes, and the willingness to pay for the innovations in different forms . MarketiDiffusion patterns are the outcome of choices by both the adopters (who form the demand) and suppliers of technologies. The sellers need to quantitatively assess adoption behavior and how their decisions affect it. These decisions include pricing, selection of marketing tools, and location of supply centers and stores. Firms will make these choices by maximizing expected discounted profits consisting of revenues minus marketing and supply costs. In their design of the optimal strategy, firms adopt the commonly used segmentation, targeting, and positioning principle, which starts by identifying segments, targeting (choosing the right segments and prioritizing the segments), and positioning (matching the product to the specific characteristic of the chosen segment) , 26. TheThe literature on adoption and diffusion identifies constraints to adoption  and emphasizes that “attribute bundling,” whereby producers tailor their product to address customer constraints, can enhance adoption. Because early adoption generates positive informational externalities, as it leads to learning by both suppliers and potential adopters, there is a case for subsidization of early adoption.Traditional expected utility models have shown that attitudes toward risk affect adoption. A high degree of risk aversion may reduce the likelihood, speed, and scale of adoption of risky innovations (where risk is defined as a larger variability of returns around the average). Recent examples from agricultural technology adoption include Karlan et al. , EmerickThe innovating firm accounts for these risk considerations when estimating how the innovation’s risk profile will affect adoption and what “bundling” of services might be needed to encourage adoption. For example, the innovator firm may bundle an insurance mechanism with the product, such as “money-back guarantees” and warranties and/or allowing potential adopters to try the innovation for a limited time by offering product demonstrations . PrepurcMoreover, the innovating firm’s communication (including advertising) to potential end users informs the latter’s perception of the innovation’s risk and utility and can reduce information asymmetry. Innovating firms can employ various marketing tools, such as advertising, branding, product demonstrations, product samples, and warranties, to reduce various risks, as emphasized in the marketing literature. For example, the innovating firm can develop a brand that conveys high quality and low risk to a potential consumer . MoreoveThe capacity of potential adopters affects diffusion. As the threshold model suggests, potential adopters are heterogeneous in their resource availability , demographics, and biophysical conditions. There is ample evidence that larger farmers are likely to be early adopters of indivisible technologies, like tractors and computers , 36, 37.Differences in allocative ability  may leadThe innovating firms sometimes adapt the product to the capacity and needs of the adopter.For example, they may supply a smaller cheaper version of the product to smaller farms or firms, as occurs in the farm machinery sector. They also sometimes “bundle” alternative payment schemes, such as leasing and credit, to enable adopters to overcome credit constraints and transaction costs. The innovating firm recognizes that adoption of the innovation can affect the adopter’s valuation of its assets, such as when irrigation increases the value of irrigated land , and thiInstitutions and policies affect risk , transaction costs , and credit . While scale limitations may prevent individuals from purchasing a new product, technology suppliers may introduce rental or custom service , 42. EmeGovernments can also enact policies that create an incentive for adoption, such as emission taxes or technology standards that favor a pollution-reducing technology  and reneOnce firms have formed their expectations for adoption patterns and demand, they can proceed with designing a supply chain. We present a conceptual framework for the design and management of supply chains to implement innovations. Supply chain design has not been emphasized in economics. Economic theory was formed when agriculture was the dominant industry, and therefore, perfect competition was a natural benchmark. While traditional economies were in a state of static equilibrium, modern economies change through innovation and accumulation of human capital and are in constant disequilibrium . SchumpeOur analysis is based on the assumption that implementation of innovation is through supply chains with multiple stages. While we present evidence that supports this assumption, it should be further investigated. Here, we present a basic dynamic model to obtain decision rules under certainty. We further suggest incorporating more complex aspects of reality into the analysis , mainly relying on the literature. We assume that an entrepreneur has an innovation that is the output of the ISC. The key questions facing the entrepreneur are the scale of operation and the supply chain structure: in particular, the extent and manner of using external suppliers of inputs , 52. Onet, t = 0 to t = T. The entrepreneur uses estimates of the demand for the final product to estimate expected revenues for period t, t, denoted by To describe the innovator firm’s choices in the design of its supply chains, we introduce a simple two-stage dynamic supply design chain model, building on the static framework of Du et al. . We assu•variable costs of processing,•investment costs,•costs of producing inputs internally, and•costs of purchasing inputs from others.The objective of the firm is to maximize net present value of profit over time:Allocation of the sourcing of inputs in house vs. external suppliers is a function of the relative costs of each source adjusted for market power.In particular, if the firm has a relative advantage in input production at every scale, it will be vertically integrated and produce all its intermediate inputs internally. In this case, the optimal output level is at the point where the marginal revenue per unit of input is equal to the sum of the marginal processing cost plus marginal internal production costs.Suppose the firm or external source does not have a clear advantage in producing inputs. In that case, the firm will make some of the inputs internally and buy the rest until the marginal cost of internal production equals the marginal cost of procurement.If the firm does not have an advantage in producing its inputs at any scale, it will buy them. The optimal level will be where the marginal revenue per unit of input equals the marginal processing cost plus marginal purchasing cost.The level of investment at each period will equate the marginal discounted net present value of capital Our analysis suggests that the innovative firm will benefit from market power in both output and input markets. For example, through  innovations, Apple created the iPhone, has market power in smartphones, and charges a relatively high price. Apple has long outsourced the production of the iPhone components and has had sufficient market power in purchasing components to keep its costs low and profits high.The model allows the revenue and cost functions to change over time due to dynamic processes of diffusion and learning. If potential revenues increase over time and costs of processing decline, production will increase. If the costs of external input suppliers decline faster than those of the innovating firm, the share of purchased input will increase. For example, Kenya has become the largest exporter of flowers to Europe. In the late 1960s, Dansk Chrysanthemum Kultur (DCK) established a vertically integrated operation producing flowers in Kenya and shipping them. Over time, DCK began outsourcing to producers as other shippers emerged in Kenya. The Kenyan industry has since automated and digitized much of production, logistics, and marketing , 56. ConOur simple model abstracts away from important considerations. We emphasize endogeneity in the input market, where the extent to which the firm makes rather than buys intermediate inputs may change over time. However, we assumed that the firm is buying in a market, while firms may issue contracts of different types to provide differentiated intermediary inputs. They may use bidding or tournament to select suppliers , 57. OurSecond, the innovator may expect loss of profit and market power by new entrants and engage in defensive strategies, such as predatory pricing and acquisition of potential competitors and intellectual property. For example, to extend its market power in the seed industry, Monsanto acquired several seed companies to become the largest in the world . MonsantThird, continuous research and develoment leading to incremental innovations  reduces the cost of production and improves quality. The innovations allow supply increases and price reductions and thus, enhance adoption.Furthermore, improving quality may lead some early adopters to replace older models of the product with recent models, creating secondhand markets for outdated versions. For example, outdated tractor models are sold from China to Burmese farmers and used cars from Europe are exported to Africa. Dynamic supply chain design allows upgrades that increases profits from later versions.Our model does not consider entrepreneurs’ attitudes toward risk. However, the reliability of the volume, timing, and intermediary input quality may be uncertain. Risk aversion will lead to relying less on riskier external suppliers and producing less total output. Similarly, riskier processing of the intermediary input is likely to lower production . Over tiOur basic model also ignores that, in practice, entrepreneurs operate under credit constraints, which are more restrictive in developing countries and reflect asymmetric information between borrowers and lenders . A crediFirms’ decisions about expansion also have a spatial element. A firm may start at certain locations and expand geographically. Initial locations of production may be affected by access to technology (close to a university where the innovation was made) and access to intermediate inputs and skilled labor. Location of sales may be affected by relative demand as well as transaction costs and regulations. International expansions through foreign direct investment (FDI) to developing countries are associated frequently with “product cycles” . The innThe geographical diffusion of innovations emanating from the home country affects not only the final products available to consumers but also, the market organization and institutions internationally. Globalization over the past several decades, with the associated liberalization of trade and FDI, has led to the spread of market innovations introduced in the United States and western Europe in the 1920s to 1950s, such as supermarkets and fast-food chains, into developing regions in Asia, Latin America, eastern Europe, and Africa .Our analysis is limited, being based mostly on findings in economics and marketing. Further development of our approach should incorporate insight from the rich literature in business and engineering. Beamon  reviews Government policies that support research directly benefit the ISC but also, lead to the establishment of new PSCs. Financial incentives  and regulations that alter the demand for the final product or cost of input affect the performance and evolution of supply chains. For example, carbon pricing can lead to the adoption of greener practices. Investment in infrastructure and education may accelerate the development of supply chains and its use of digital technology. Policies that reduce barriers to trade may result in both globalized supply chains and FDI that will transfer knowledge and capital to developing countries, either expanding existing supply chains or developing new ones.There are feedback loops between the ISC and the product PSC. Recall that the ISC fulfills three functions for a new product or technology: 1) discovery or invention, 2) upscaling, and 3) commercialization. The PSC has three functions to implement the ISC-produced innovation: 1) assessment of market potential, 2) supply chain design and implementation, and 3) marketing.First, there is a feedback loop among the ISC segments. Examples of this are found in agricultural research systems where an initial variety is bred, and then, through testing and initial commercialization attempts, flaws are discovered, forcing the basic research team to adapt. The initial version of high-yield wheat varieties developed in the Green Revolution were tall but top heavy and lodged with wind; the next version was a dwarf variety that was less vunerable to wind .Second, there are ISC–PSC feedback loops. In the implementation and marketing stages of the PSC, the marketing team discovers 1) the need for changes in the design of the initial innovation to better meet consumers’ needs, 2) the need for complementary products to be added to a bundle, and 3) opportunities for product differentiation as part of the product cycle. For example, drip irrigation was introduced originally to save water, but its use was expanded for fertigation and chemigation, leading to the production of complementary chemicals . FurtherThe ISC affects the PSC by introducing new versions of products that utilize new technologies. One example is the movement from vacuum tubes to transistors that radically changed radios in terms of function and capability, eventually leading to significant differentiation. Eventually, the ISC may result in innovations that lead to new product categories with their own PSCs.The ISCs and PSCs can be inseparable. Developments leading to innovations in ISCs may depend on the capabilities of PSCs. There are also financial links. Government investments in research and education may finance the early phases and basic research of the ISC. Development and upscaling may be financed by venture capitalists or corporations, with some government support. The PSC is more likely to be financed by the private sector.However, the public sector may support investment in supply chains for innovations with properties of public goods. The ISC and PSC of radical, large-scale innovations with public good properties may be intertwined in the early stages of their commercialization, supported by the public sector. For example, the internet was conceived and initially implemented by the US Defense Advanced Research Projects Agency.In some cases, the ISC is involved in designing the PSC. For example, the introduction of hydrogen as a fuel requires solving a coordination failure, namely developing supply chains and technologies to refine hydrogen, creating a distribution network, and creating the machinery that consumes hydrogen . NationaThe literature on the policy impacts of innovation would benefit from explicitly accounting for both ISC and PSC. The links between research, innovation, and new supply chains suggest that there are benefits from continuous government support of public research and innovation, especially in the early stages of development. It provides a mechanism for how innovations can start new supply chains and lead to the evolution of new industries. Incumbents may use their political clout to reduce government investment or research and slow the evolution of innovation that endangers their market power. Governments tend to underinvest in research and development compared with socially desired levels . IncumbeThe framework presented here can be used to analyze the impacts of and policy responses to climate change as well as other food, environmental, and health challenges. There is a broad literature on the impacts of climate change on smallholders, especially in developing countries, that emphasizes technology adoption and adaptation at the farm level. However, Reardon and Zilberman  suggest Similarly, the decarbonization of the economy will require continuous research investments as well as the establishment of new industries and conversion of existing sectors to drastically reduce their greenhouse gas emissions. Policy design must account for the industry’s capacity to establish and modify supply chains in addition to the impacts of policy on individual markets. With all their limitations, the US and Brazilian biofuel industries emerged within 15 y because of mandates that assured demand. Through learning by doing, their performance drastically improved, overcoming many of the earlier criticisms . HoweverThe expansion of renewables would not have been possible without early support policies. For example, despite their flaws, subsidies for electric cars and solar energy in the United States and elsewhere have been major contributors to the establishment of these new industries. The development of policies that may lead to the use of hydrogen fuel cells to decarbonize the heavy transportation sector requires understanding the impacts of policies on supply chains.The literature on food security and rural development has begun to recognize the importance of analyzing food systems and food value chains . These fThe recent COVID-19 pandemic led to the introduction of various social distancing policies. Assessing the impact of these policies requires an understanding of the workings of food supply chains. Reardon et al.  argue thThis paper integrates several bodies of literature to develop a framework to analyze the transition from new ideas to final products. This transition is done through two symbiotic supply chains, the ISC and the PSC. These supply chains are affected by policies including support for research and education, intellectual property rights protection, antitrust policies to strengthen competition, low barriers to trade and light regulation, and well-functioning capital markets. The notions of ISP and PSC apply globally, but there are significant differences among locations and sections, reflecting different stages of development and policies. Furthermore, globalization has led to diffusion of institutions and products globally.There is a vast need for more empirical work on supply chains. It may require better documenting and understanding of the behavior of large firms; the evolution of linkages between them; and especially in developing countries, the behavior of small and medium enterprises, especially in the midstream segments of supply chains. Analysis of these patterns can be challenging, as data are rarely well organized or easily available. Analysis of supply chains' evolution may require the development or application of tools to analyze narratives and case studies to supplement traditional data sources used by economists. It will also need to understand the choices of engineers who design supply chains as well as policy makers who provide funding for infrastructure and create regulations that affect supply chains. Economics has evolved to be able to address these challenges. The basic premise of economics is that agents pursue their self-interest subject to constraints of ability and institutions. In the twentieth century, behavioral economics and political economy recognized that the traditional classical economic model has its limitations in analyzing individual behavior and social choice. In the twenty-first century, economic frameworks need to evolve to become multidisciplinary and incorporate political, technological, and engineering considerations and tools.


Accurately counting the human cost of the COVID-19 at both the national and regional level is a policy priority. The Russian Federation currently reports one of the higher COVID-19 mortality rates in the world; but estimates of mortality differ significantly. Using a statistical method accounting for changes in the population age structure, we present the first national and regional estimates of excess mortality for 2021; calculations of excess mortality by age, gender, and urban/rural status for 2020; and mean remaining years of life expectancy lost at the regional level. We estimate that there were 351,158 excess deaths in 2020 and 678,022 in 2021 in the Russian Federation; and, in 2020, around 2.0 years of life expectancy lost. While the Russian Federation exhibits very high levels of excess mortality compared to other countries, there is a wide degree of regional variation: in 2021, excess deaths expressed as a percentage of expected deaths at the regional level range from 27% to 52%. Life expectancy loss is generally greater for males; while excess mortality is greater in urban areas. For Russia as whole, an average person who died due to the pandemic in 2020 would have otherwise lived for a further 14 more years (and as high as 18 years in some regions), disproving the widely held view that excess mortality during the pandemic period was concentrated among those with few years of life remaining–especially for females. At a regional level, less densely populated, more remote regions, rural regions appear to have fared better regarding excess mortality and life expectancy loss–however, a part of this differential could be owing to measurement issues. The calculations demonstrate more clearly the true degree of the human cost of the pandemic in the Russian Federation. Counting the human cost of the COVID-19 pandemic is clearly a demographic, policy and epidemiological priority. The particular circumstances in the Russian Federation have come to international attention because of the especially high levels of mortality compared to other parts of the world . This deIn the Russian Federation (hereafter Russia), there appears to be an especially high degree of uncertainty concerning mortality due to COVID-19 . The numAgainst this backdrop, the concept of ‘excess mortality’ has been set out as a possible ‘gold standard’ of measuring the human cost of the COVID-19 pandemic . This apDespite this consensus on the benefits of the excess mortality approach, there are still variations in the final calculated numbers of such deaths at the global and national level . A recenPart of the reason for the discrepancy in figures of excess mortality presented for Russia above stems from alternative methods of calculating this projected death count. As the recent study by Nepomuceno et al.  describeNeither approach accounts for changes in mortality and population age structure over time and can lead to a biased estimation of excess mortality from the COVID-19 pandemic. This can be especially true for an aging population with an irregular age structure–such as Russia. In each case, the dynamics of mortality and waves in the demographic structure will affect the assessment of deaths in the absence of a pandemic and, accordingly, affect the assessment of demographic losses due to the coronavirus pandemic.For a more accurate assessment of the number of deaths in the absence of a pandemic, it is possible to use predicted values of the number of deaths that consider the peculiarities of the age structure of the population. To estimate the number of deaths in 2020–21 in the absence of a pandemic—and therefore to calculate excess mortality in comparison—it is necessary to make a population forecast for one year from the beginning of 2020 to 2021 or for two years from the beginning of 2020 to 2022. The population forecast can be made either with the mortality rate of 2019 or considering the dynamics of mortality in previous years to predict the expected mortality for 2020/2021. Both versions of the forecast allow us to estimate the number of deaths that would have occurred in 2020/2021 in the absence of the COVID-19 pandemic. Excess mortality, in this vein, is defined as the difference between the recorded number of deaths in 2020/2021 and the projected estimate of the number of deaths in the absence of the COVID-19. In this paper we followed the second approach. Projecting the number of deaths in the absence of the pandemic, we assumed that life expectancy would have increased at the same pace as it has been increasing recently. Such an approach was also performed in Islam et al. . They foIn this paper, using the latest data released from ROSSTAT –22, we aYLL). Following WHO methodology [YLL based on expected remaining years of life from a standard life table for all countries. Such an approach, as useful as it may be for international comparisons, does not adequately express losses of expected years of life in countries like Russia where actual remaining life expectancies deviate substantially from those of the standard life table used in Islam et al. [YLL, we term our indicator Mean Remaining Life Expectancy of the Deceased (RLED).Islam et al.  further hodology , they cam et al. . As suchThe primary sources of data are derived from official ROSSTAT publications for the 2021 –22; the t in population i , bi−population-specific effects, bx−age-specific rates of mortality improvement over time. From the modelling outcomes, we obtained age-specific rates of mortality improvement similar to the bx of the Lee-Carter model [World Population Prospects [Our approach builds on that of Islam et al.  who useder model . The agerospects .A standard cohort-component method-based system for producing multiregional population projections was used. To estimate excess mortality, we needed to project the deaths only for two years: 2020 and 2021. In this short time interval, the influence of migration and fertility on the total number of deaths would likely be insignificant (see below). Although we used a multiregional package to produce the number of deaths, similar results would have been obtained had we applied a cohort-component projection model to each region and urban settlement independently.The population projection approach has several advantages over approaches that average the number of deaths over the previous five years or extrapolate the annual number of deaths from the years preceding pandemics. First, the change in the age structure of the population and its impact on the number of deaths is considered. Second, it is possible to reduce random fluctuations in the expected number of deaths, since the population forecasts produce graduated structures of mortality. In fact, the primary reason why the traditional method uses a five-year interval to average the number of deaths is the need to reduce the random component in estimating the number of deaths. Finally, because of the need to obtain time-series data on which to draw the projections—we used data from 2010- we excluded regions with short series of data available, and with small death count as described below (see Appendix for full list).In this paper, to estimate excess mortality, we use a population forecast for all regions of Russia, that assumes the observed recent trend in life expectancy would have continued in the absence of the COVID-19 pandemic. The base population estimate is taken as of January 1, 2020. To estimate the number of excess deaths in 2020 and 2021, the population forecast is made for two years. As the impact of fertility and migration on the number of deaths in 2020–21 is extremely small, so the baseline scenario of fertility and migration, similar to the level of fertility and migration in 2019, was considered. Finally, to mitigate against high levels of fluctuations resulting from small numbers, we only consider populations where our calculated number of expected deaths is greater than 3,000 per year. Although this particular threshold was chosen rather arbitrarily, our decision was based on earlier experience with sampling errors of life expectancy estimates . Given aRLED in Russia and its regions in 2020 we use the following procedure. For each age group with non-negative excess mortality, we multiply the excess deaths by the corresponding remaining life expectancy in the absence of the COVID-19, sum up those products and divide by the total excess deaths in those age groups:x in 2020, x in 2020, ex is life expectancy at age x from the baseline life table in 2020 which would hold in the absence of pandemic. RLED is calculated for each region, urbanization status, and gender. We do not estimate RLED for 2021 because the required data have not been published yet.To produce estimates of Calculations were produced using packages written by authors in FORTRAN and R.Based on our population projections, we estimate that there were 351,158 excess deaths in 2020 and 678,022 in 2021 in the Russian Federation (see Tables thhighest ranking region (Republic of Sakha). Indeed, the regions with the highest excess mortality in 2021 are to be found around the country: four in the Central Federal District ; three in the Volga Federal District  and one each in the Southern Federal District (Volgorad oblast), Northwestern Federal District (Republic of Karelia) and Far Eastern Federal District (Republic of Sakha). Among the regions with the lowest excess mortality, the majority are to be found in the sparsely populated regions of the Far Eastern Federal District and Siberia. Moscow City, however, is also in this low ranked groups.fallen between 2020 and 2021.Finally, there is a high degree of change both between the two years and across the regions of Russia. In the Republic of Karelia, for example, excess mortality rose from 17.11% in 2020 to 46.3%, propelling it from a middle-ranking position to one of the highest in the country. A further five regions saw increases in excess mortality of greater than 25% . Other states, meanwhile, saw much less dramatic changes. Eleven regions saw increases of 10–15% . Excess mortality in the Republic of Dagestan, meanwhile, stayed almost constant between 2020 and 2021. Because of the sharp increases across the country, this meant the region dropped in the national rankings from second top to eighth last. Mortality in the Chechen Republic appears to have negative excess mortality. However, these data bring out one of the main caveats relating to measurements of excess mortality in rural areas–namely that deaths may have been registered in urban areas. This, then, will lead to an inflation of urban excess mortality, and an undercount of rural mortality. As such, extreme caution should be exercised in the interpretation of these results.Next, we turn to the distribution of excess mortality by age. This is represented in (RLED) for all regions in RLED for 2020. For males in two regions , this RLED was greater than 17 years, and in the Republic of Sakha in the Far East it was 18.4. For females, meanwhile, three regions (Republic of Buryatia and Khanty-Mansi Autonomous Area–Yugra) saw RLED greater than 16 years while, again, the Republic of Sakha had the highest RLED at 17.9 years. Other regions, meanwhile, saw lower levels of RLED. Amongst males, Khabarovsk kray reported a RLED of 12.4 years, while Omsk oblast, Chelyabinsk oblast, Republic of Buryatia and Altai kray all reported RLEDs between 10.9 and 11.8 years. For females, the lower RLED in Omsk oblast, Republic of Tatarstan, Udmurt Republic, Chelyabinsk oblast and Kirov oblast were all rather narrowly distributed between 11.9 and 12.2 years.Finally, we present the results for the Mean Remaining Life Expectancy of the Deceased Our calculations found significant degrees of regional divergence in terms of the experience of COVID-19 related excess mortality. This is important for two reasons. Firstly, this reveals the very unequal experience of COVID-19 across the country and may reflect the heterogeneity of the degree to which medical and public health systems at the regional level may have been affected by the pandemic and other local factors which shaped the regional pandemic experience ,38. SecoOur results point to considerable regional variation in excess mortality that deserves further analysis. Tentatively, one may note several factors that might have played their role in forming the regional differences in losses to the pandemics. First, we find that there is substantial positive correlation between the regional demographic losses and the life expectancy projected in the absence of the pandemic. Both life expectancy loss and excess mortality show correlation with the projected life expectancy of around 0.45 for males and 0.57 for females . On thisSecondly, in addition to purely demographic factors, one may also expect socio-cultural, economic and, perhaps, geographic differentials also to contribute to differences in the impact of the pandemics. Regions of the Northern Caucasus, for example, are known for their tradition of elderly living in larger households of extended families together with their children and descendants. While this is generally considered a health-protective behavior, such a tradition might have contributed to higher social exposure and, hence, higher losses in the Northern Caucasus.A preliminary analysis of association between average regional income in 2019 was performed, and number of beds per capita in regional hospitals in 2019 as independent variables and regional excess deaths as a percent of expected as dependent. We run a multiple regression for 2020, 2021 and a combination of 2020–21 data. In all cases the influence of regional income was statistically insignificant, while number of hospital beds per capita was significant at 0.001 level in 2020 while nonsignificant in 2021. An explanation could be that in 2021, the number of hospital beds drastically increased in the regions due to temporarily organized treatment facilities and thus linking excess death in 2021 with the number of hospital beds per capita loses its meaning. Correlation between the number of hospital beds per capita and excess mortality in 2020 was -0.37 and significant at p-value = 0.001 level. We also found a negative correlation between female education and excess mortality in 2020, but no such correlation with the male education, although these results are preliminary and need further investigation. We intend a thorough study of factors of regional variation in excess mortality in the future.Of course, infrastructure of the region—especially in terms of health facilities—would also contribute to the differences in excess mortality. There is, for instance, a huge disparity in excess mortality between Moscow city and the surrounding Moscow oblast. Life expectancy in Moscow oblast is considerably lower than in Moscow . Moscow city, following the arguments introduced above, should have higher excess mortality. On the contrary, excess deaths measured as a percent of expected for men in 2020 was more than two-time higher in Moscow oblast compared to Moscow (25.7% versus 10.1%). Residents of these two places are not especially different in terms of culture, although that does not mean that there are not large behavioral differences. Health care in Moscow city is more advanced than in Moscow oblast, but under normal circumstances for advanced medical treatments people in Moscow oblast would not need to travel far to get treatment in Moscow city. However, in the case of a pandemic, when most health facilities in Moscow were running at (or near) full capacity, there were fewer opportunities for patients from Moscow oblast to be treated in Moscow city.Policies to prevent the spread of COVID-19 and the implementation of measures also played a role in the number of infections. The central government delegated much of the responsibilities in this field to regional administrations and those policies were diverse in the regions of Russia. At the initial stage of the COVID-19 pandemic, there was a high degree of misinformation related to the spread and severity of COVID-19 in Russian media. Sometimes public figures and even medical doctors on TV programs downplayed the danger of COVID-19 . That inSo, in general there are many social, political, cultural and epidemiological factors and their interactions contributed to the diversity of patterns of excess mortality. In each region, the combination of those factors must be studied. In the Chechen Republic, for example, we observed a sharp drop in excess mortality between 2020 and 2021. This may be related to the hardline rhetoric and measures put in place in 2021 by the Chechen leader Ramzan Kadyrov. In May 2021, for example, it is reported that Kadyrov warned citizens that those who refused to be vaccinated would be treated last and will ‘feel how terrible the lack of oxygen feels’ . MeanwhiRLED measure, however, we clearly disprove the widely held concept that such deaths were ‘going to happen anyway’ because of the relatively large number of remaining years of life expectancy of a deceased. Together, it appears that COVID-19 has further added to traumatic recent history of mortality–especially among males–in Russia [Stepping back, our data presents clear evidence of the very high levels of excess mortality seen in Russia over the past two years; and that this level has significantly accelerated between 2020 and 2021. In a comparative sense, this overall finding accords with previous analyses of Russia which suggest it may come out of the COVID-19 experience with one of the very highest levels of excess mortality in the world. Using our n Russia ,46.Our study does, however, have several limitations. Firstly, the restricted data we have for 2021 means we cannot provide an analysis on the level of granularity which we would wish for this year. Secondly, as with all studies of mortality in Russia, there will inevitably be challenges concerning both completeness of registration as well as discrepancies in the place of registration of a death because of migration and different living/working patterns . This isThe human cost of the COVID-19 pandemic is well known. Quantifying this carefully, however, is a high priority to not only measure this impact, but to ensure adequate policy responses. In this paper, we have identified the high levels of excess mortality in the regions of Russia during the COVID-19 pandemic. To do so, we have deployed a rigorous method which accounts more accurately for underlying demographic change. We estimate that more than a million lives were lost to the pandemic. Contrary to the popular belief that such deaths were ‘likely to occur anyway’, our analysis shows that COVID-19 in Russia has had a significant impact upon remaining life expectancy. We have also, for the first, time, been able to present regional figures of excess mortality for 2021, as well as an analysis by age, gender and urban and rural status. These figures showed a higher impact on life expectancy for males who also had rising excess mortality (as a percent of expected) with age, unlike females where there was a non-linear relationship, and in general higher level of excess mortality in urban areas compared to rural areas and little difference is observed in male versus female excess mortality. Higher urban excess mortality could be driven by a higher density of population in urban areas, and thus higher infection transmission rate. As mentioned earlier, another source of bias towards higher urban excess mortality may be caused by registration of deaths of rural residents transferred to urban hospitals. While there is a wide variation in mortality rates between regions, there is no clear regional distribution (e.g. an east-west gradient).While national figures show that excess mortality in Russia is perhaps amongst the highest in the world, there is a wide degree of regional variation. Such variation–and its interaction with age, gender, and rural/urban status–is key to better consideration and formulation of public health strategies to mitigate both the ongoing impact of COVID-19, and to rebuild and reshape health systems after the pandemic is over. As such, the determinants of mortality and the experience of (and response) to the pandemic at the regional level is a critical future avenue of research. This would enable more precise policy recommendations to be generated from our research. At this stage, however, some outcomes are clear. The regional disparities in infrastructure–especially in health–appear to be a key factor in determining levels of excess mortality. These disparities become amplified when the circumstances of the pandemic disrupted access. Higher levels of excess mortality in urban areas may have resulted from greater levels of infection in spaces of higher population density. This may mean that alternative strategies for infection control and management need to be in pace for urban and rural areas. Finally, we must look at the broader picture of how such mortality is so high in the first place. In this, the role of (mis)information and communication concerning both the severity of the public health emergency appears to have played a critical role. Ensuring the public have access to objective, honest, impartial, and accurate information about their circumstances is of the highest priority. For their part, scientists should be providing clear transparent assessments of mortality to inform government, media and other stakeholders.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.


Body mass index was similar across groups (p = 0.15). Motor performance of indigenous land children was explained by the contextual factors that lead to a more active lifestyle, unsupervised free time, and play outside. In urban areas, behavior was similar, and although indigenous urban children kept some play tradition, it was not strong enough to be a protective factor for the motor performance.This study investigated the contextual factors, motor performance, and body mass index across indigenous land children, indigenous urban children, and non-indigenous urban children. A number of 153 children, both sexes , from 8 to 10 years were assessed. The Test of Motor Gross Development-3 was utilized. Indigenous land children showed higher motor performance ( Several studies have reported lower motor performance (MP) and a high prevalence of overweight and obesity among children across several countries , mainly the grandparents and uncles and aunts. In contrast, indigenous land children and indigenous urban children lived with at the maximum of two adults at home–their parents.Regarding the contextual factors, the linear-by-linear test showed a significantly higher proportion of the non-indigenous urban children living with more than two adults at home  and that the most prevalent space of playing was the inside home  compared to the indigenous children from the forest and the urban area. The activities in the free time were unsupervised for the three groups and involved similar games for the urban area. Indigenous urban children played kite, soccer, and run-and-catch games, and non-indigenous urban children played kite, soccer, and dodgeball, whereas indigenous land children usually played run-and-catch, balance games on lines, and games in the river. Although there was a soccer field in the Ponta Alegre village, the indigenous land children played very little soccer; the field and the ball were reserved for adult men. The inside home activities were similar across the three groups, the girls helped the mother with the home chores and the care of siblings, and the boys helped the fathers chop wood and clean fish.The analysis also showed a significantly higher proportion of the non-indigenous urban children that had <2 h of free time  and using the computer , more than 2 h daily each device; indigenous land children had no screen time.The analysis also showed a significantly higher proportion of the non-indigenous urban children, compared to the indigenous urban children, with screen time–watching television , 6564, 6Urban children, indigenous or not, share a common factor they live in more crowded houses and use more screens; these factors were harmful to their MP. It is even more complex for the indigenous urban children; this was a change in the previous way of living, and although they enjoyed some unsupervised time, this freedom was not used to be outside in contact with nature but spent in front of screens. The lack of physical spaces that allow for outdoor play prevents children from developing motor skills. The results emphasize the need to implement public policy to create physical spaces in urban areas to support children's mobility and outdoor play, exposing children to active contexts that positively influence choices for more active activities in urban areas.Regarding BMI, most of the indigenous children living in the forest village, urban indigenous children, and non-indigenous children  were eutrophic. Although no difference was found for weight status across groups, many indigenous children  were severely thin or thin. Although notably higher, these results are comparable to the previous data from indigenous Sateré-Mawé children from Amazonas, which identified 3.63% with thinness or severe thinness . UnfortuContextual factors experienced by indigenous children living in the forest village were more favorable for adopting an active lifestyle that positively impacted MP. Associated factors with the MP of children in this study were different, demonstrating the strength of contextual factors on motor development across groups. Indigenous children in the village do not have screen time (TV and computer); therefore, they spend more time enrolled in free activities in contact with nature, and they have more space to play than their urban peers. On the other hand, urban children (indigenous or non-indigenous) have less free time, smaller play areas, and more screen time. The unlimited physical space in the forest and being free to explore the environment autonomously is a characteristic of the indigenous culture and a protective factor for MP. These characteristics cannot be exported to other cultures; each investigated group had cultural particularities and values, and social expectations within each investigated context. However, our results support the notion that urban children need to have more free time outside and, if possible, more contact with nature to become more motor proficient. Providing urban children with accessible and challenging experiences to explore their motor repertoire may improve their MP. Regarding indigenous children living in the forest, although they lived with fewer resources in the village, they had what was necessary to develop motor skills–free time and physical space. This study advances by providing a further understanding of a population that has been less investigated and with very restricted access and for a better understanding of contextual factors that promote MP in different sociocultural environments. Following these children for a long time to investigate whether the cultural factors affecting MP would change as different opportunities would be experienced seems to be a future direction to pursue. Understanding the value of indigenous children and parents' place in motor activities was a limitation of this study and a recommendation for future research.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Universidade Federal de Minas Gerais. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.MD and RB participated in the design of the study. MD participated in the design of the study and contributed to data collection. MD, RB, GN, and NV contributed to data reduction/analysis and interpretation of results. All authors contributed to the manuscript writing and have read and approved the final version of the manuscript and agree with the order of presentation of the authors.This research was funded by CAPES  and CNPq .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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.