Central Appalachia has been disproportionately affected by the opioid epidemic and overdose fatalities. We developed West Virginia Peers Enhancing Education, Recovery, and Survival (WV PEERS), a program based on peer recovery support, to engage individuals using opioids and link them with a range of services.Community partners providing services to individuals with opioid use disorder (OUD) were identified and collaborations were formalized using a standardized memorandum of understanding. The program was structured to offer ongoing peer recovery support specialist (PRSS) services, not just a one-time referral. A website and cards describing the WV PEERS program were developed and disseminated via community partners and community education sessions.Overall, 1456 encounters with individuals with OUD  occurred in a variety of community settings over 8 months. The majority of referrals were from harm reduction programs. Overall, 63.9% (n=931) of individuals served by WV PEERS accessed services for substance use disorders and/or mental health problems. Over half  of individuals entered substance use and/or mental health treatment, and nearly a third  remained in treatment over six months.Using the WV PEERS model, PRSSs effectively engaged and linked individuals with OUD to mental health and substance use treatment in rural central Appalachia. Future research is needed to determine whether these services reduce the risk of overdose mortality. Since the 1980s, people with a history of mental illness, addiction, and/or trauma have become increasingly involved in systems of care as peer supporters for people with behavioral health conditions.5Despite these positive findings, the majority of these peer support studies18According to the WV Office of Drug Control Policy, WV recorded 871 OD deaths from all drugs in 2019 with 76.8% involving at least one opioid.Monongalia County, the location of the City of Morgantown and the main campus of WVU, experienced an unprecedented 82% increase in OD deaths from all drugs from 2015 to 2016, from 28 to 51 deaths, and a 78% increase in opioid-related overdose deaths, from 23 to 41 deaths.In 2017–2018, the WV PEERS program established standardized memoranda of understanding with a variety of community partners including the Ruby Hospital ED, the Morgantown Police Department, county drug courts, a local syringe services program, educational institutions and social services in Monongalia County, West Virginia . The stuhttps://www.wvcbapp.org/). Certification requires a defined course of study, 500 hours of experience including 25 hours of direct supervision, and at least 2 years of continuous sobriety. PRCs were hired and trained by Morgantown Sober Living, Inc. A policies and procedures manual was developed to standardize methods and materials. Training, coordination, and oversight were provided by an experienced PRC supervisor who also served as the WV PEERS Community Outreach Coordinator, and counselling arrangements ensured that the study did not impair the PRCs’ own recovery.West Virginia PEERS PRCs were certified by the West Virginia Certification Board for Addiction & Prevention Professionals  provided OD prevention education and access to naloxone; (2) assessed interest in accessing an addiction treatment program, medical and/or mental health care; (3) assessed interest in accessing the local syringe services program; and (4) provided follow-up contact to determine possible recurrent overdose, naloxone use, and to continue to offer linkage to prevention and treatment services. Individualized coaching was guided by a motivational interviewing framework. Individuals who did not provide consent for the study were given an IRB-approved card describing WV PEERS services and contact information in case they changed their mind . While tWest Virginia PEERS services were divided into six categories: substance use, harm reduction, infectious diseases, mental health, primary medical care, and social services. The PRC discussed options for which they could provide linkage within each category that were tailored to address the client’s hierarchy of needs and were based on community availability. Clients’ hierarchy of needs was based on Abraham Maslow’s five-tiered approach to needs of humans. These tiers include physiological, safety, love, esteem, and self-actualization, requiring each tier’s needs to be satisfied prior to ascending to the next tier.Utilizing encrypted tablets connected to REDCap as a secure data collection tool, PRCs were able to enter data remotely when engaging and tracking vulnerable populations, using an IRB approved informed consent. The specific survey questions are available as an Peer Recovery Coaches recontacted clients at 1 and 3 months after their initial visit to assess whether the client had accessed the services to which they had been linked. At each follow-up contact, the PRC re-assessed the client’s interest in service referral(s) and all referrals were documented in the study database.Linkages were defined as communication between a third-party provider and the client; linkages may have included services provided by a community stakeholder. These linkages were reported by clients at follow-up or between data collection intervals if the client reached out to a peer specialist for support services.https://www.wvpeers.com/), as well as direct contact information for PRC services.Participants were referred to WV PEERS by the treating physician in the ED or by established partners based on their clients’ reported needs. The inclusion criteria for the WV PEERS pilot program evaluation were: (1) having experienced a nonfatal opioid overdose in Monongalia County, (2) at least 18 years old, (3) English-speaking, and (4) cognitive ability to understand and willingness to provide written informed consent. In addition, any individual with a SUD could be referred by a local agency or could self-refer for support and potential linkage to a range of services. A PRC was located in the ED during shifts identified as having higher OD rates based on a review of ED admissions, and were on-call during other time periods to respond to a new ED admission for OD. A website was developed that provided detailed information on the WV PEERS program  program developed in Seattle,Another program element focused on outreach efforts critical to combatting the opioid crisis at a community level. Led by the Community Outreach Coordinator, WV PEERS staff conducted a targeted, sophisticated effort to reach Monongalia County residents to deliver education about SUD as a chronic, relapsing brain disease, the local resources available for people with SUD, and information on WV PEERS services. Our outreach efforts utilized a combination of public information sessions and social media to alert healthcare providers, lawyers, police, educators other professionals and community members about WV PEERS services and how to access them. As part of this effort, PRCs were available to speak about SUD and the risk of OD in secondary and post-secondary educational settings, community meetings, church functions, and other venues on request.Descriptive statistics were calculated on the overall number of referrals, referral sources, proportions of individuals engaging in substance misuse and/or mental health treatment as well as treatment entry, retention, and completion.Between April and December 2018, WV PEERS PRCs received 1456 referrals for services with an average of 2 encounters per individual . The majAlthough schools represented less than 1% of all referrals, 100% of participant encounters resulted in treatment for substance use and/or mental health, with 7 of 10 remaining in treatment for at least six months. Individuals referred by the drug courts were also highly likely to engage in treatment (8 of 10 encounters) with half remaining in treatment for at least six months .West Virginia PEERS delivered 38 public information sessions about SUD and services offered by the program in a wide range of settings including schools, community meetings, churches, and other community locations .A PRC–led program to provide support and warm handoffs to treatment and other services for individuals with SUD was successfully implemented in a rural central Appalachian county significantly impacted by the opioid crisis. PRCs— people with lived experience of OUD now in long-term recovery—met individuals with SUD in a variety of community settings and successfully linked them to a range of resources to meet their expressed needs, from social services to treatment for SUD and mental health issues.Peer Recovery Coaches have been shown to be successful in a variety of settings.Transportation arrangements made by our peers to treatment sites may also have impacted our linkage rates. A previous study in our rural Appalachian environment reported a much higher linkage to treatment for individuals screening positive for HIV and HCV in an academic emergency department than in other urban settings, in part due to the ability of peer navigators to facilitate transportation to follow-up appointments.Additional information is also needed on the overall quality and cost-effectiveness of this approach to promote sustainability and formal incorporation of these services into the West Virginia Medicaid program. More specifically, West Virginia Medicaid recently implemented a 1115 Substance Use Disorder (SUD) Waiver. This cost-neutral waiver provides reimbursement for methadone and peer recovery support services and expansion of residential treatment services.31Although we were able to effectively implement PRC support in a local ED and other outpatient settings directly affected by the opioid epidemic, these results may not be generalizable to other EDs and outpatient settings in West Virginia or other rural communities. Additional information is needed to assess the long-term impact on successful engagement and linkage to treatment, reducing the rate of opioid ODs, and the cost-effectiveness of peer-provided services.West Virginia Peers Enhancing Education, Recovery, and Survival engaged individuals with SUD in nonurban outpatient and community settings in Monongalia County, West Virginia, generally resulting in successful linkage to substance use treatment and mental health services. The model is likely amenable to replication in other rural areas of Central Appalachia. Communities interested in following the WV PEERS model should consider an approach to engaging and gaining the support of community stakeholders similar to that taken in Monongalia County. First, a small group of academic- and community-based collaborators convened a multisector, multidisciplined planning team comprising participants from public health , emergency medicine, SUD treatment and recovery, and community justice (particularly county drug courts). Then, the planning team conducted a community meeting to present and discuss peer recovery support strategies among a broad set of stakeholders . Subsequently, planners facilitated discussions with leaders in key stakeholder organizations to garner their support and participation and build on or create relationships centered on collaborative care and support of patients, clients, and offenders with SUD. Perhaps the key facilitating factor was early identification of a strong, local recovery program committed to integrating WV PEERS into its mission. Future research should elucidate the specific factors associated with successful retention in substance use treatment, as well as the barriers unique to the rural environment, such as the lack of public transportation, that may blunt the effectiveness of peer services.What is already known on this topic? Previous research has demonstrated the benefit of intervention by individuals with lived experience on cessation of substance use and preventing overdoses. Most of these interventions occurred in urban areas and inpatient settings.What is added by this report? This is the first study to report the implementation of peer recovery support services for individuals in rural, Central Appalachia. Peer recovery coaches successfully engaged individuals in the emergency department and community settings and linked them to a variety of resources including housing and access to treatment. Linkage to treatment rates (63.9%) were significantly higher than have been reported in urban areas.What are the implications for future research? Further elucidation of the facilitators and barriers related to implementation of peer services in the rural, Central Appalachian environment to prevent opioid overdoses is needed. The impact of peer services on linkage to treatment and other social services in the rural environment merit further investigation.


The new reality of cybersuicide raises challenges to ideologies about the traditional form of suicide that does not involve the internet (offline suicide), which may lead to changes in audience’s attitudes. However, knowledge on whether stigmatizing attitudes differ between cybersuicides and offline suicides remains limited.This study aims to consider livestreamed suicide as a typical representative of cybersuicide and use social media data (Sina Weibo) to investigate the differences in stigmatizing attitudes across cybersuicides and offline suicides in terms of attitude types and linguistic characteristics.A total of 4393 cybersuicide-related and 2843 offline suicide-related Weibo posts were collected and analyzed. First, human coders were recruited and trained to perform a content analysis on the collected posts to determine whether each of them reflected stigma. Second, a text analysis tool was used to automatically extract a number of psycholinguistic features from each post. Subsequently, based on the selected features, a series of classification models were constructed for different purposes: differentiating the general stigma of cybersuicide from that of offline suicide and differentiating the negative stereotypes of cybersuicide from that of offline suicide.2χ1=179.8; P<.001). Between cybersuicides and offline suicides, there were significant differences in the proportion of posts associated with five different negative stereotypes, including stupid and shallow , false representation , weak and pathetic , glorified and normalized , and immoral . Similar results were also found for different genders and regions. In terms of linguistic characteristics, the F-measure values of the classification models ranged from 0.81 to 0.85.In terms of attitude types, cybersuicide was observed to carry more stigma than offline suicide (The way people perceive cybersuicide differs from how they perceive offline suicide. The results of this study have implications for reducing the stigma against suicide. Suicide remains one of the leading causes of death worldwide according to the latest estimates released by the World Health Organization . Mental The internet facilitates self-disclosure and social connection, giving rise to an emerging form of suicide . Unlike the traditional form of suicide that does not involve the internet , cybersuicide covers a broad range of internet-mediated suicidal behaviors and phenomena, including livestreamed suicide ,10. The The livestreamed suicide is commonly considered as one of the most notable and representative types of cybersuicide, particularly in China ,19. FromTo address these concerns by analyzing social media data , this study attempts to directly and systematically investigate the differences in stigmatizing attitudes across cybersuicides and offline suicides in terms of attitude types and linguistic characteristics, respectively.It is worth noting that cybersuicide is a new and developing form of suicide. The public may not be equally familiar with different types of cybersuicide. In China, because of the prevalence and media coverage of livestreamed suicide, compared with other types of cybersuicide, the public is expected to be more familiar with and more likely to discuss livestreamed suicide on social media. Therefore, to collect sufficient social media data for further analysis, this study aims to consider livestreamed suicide as a typical representative of cybersuicide and compare it with offline suicide.The research process included the following three steps: (1) data collection, (2) data preprocessing, and (3) data analysis. The data collection and preprocessing procedures are shown in First, a participant pool of active Weibo users was created. According to a previous study, 1,953,485 active Weibo users were identified as potential participants . The appSecond, a database of Weibo posts was constructed. In May 2020, using API, a vast amount of publicly available Weibo posts from 1.06 million active users in the participant pool since their registration , were dlivestreamed suicide (直播自杀 and 自杀直播) and suicide (自杀). It is worth noting that although cybersuicide is a rapidly developing form of suicide, an overwhelming majority of suicide incidents still occur offline. For example, between 2003 and 2016, 193 incidents of livestreamed suicide occurred in China [suicide to refer to traditional offline suicide.Third, several relevant Weibo posts were identified through database searches. To obtain the posts reflecting attitudes toward cybersuicides and offline suicides, two sets of keywords were used to search the database, including livestreamed suicide were searched and obtained (cybersuicide group); (2) a total of 933,172 posts with keywords suicide (but without keywords livestreamed suicide) were searched and obtained (offline suicide group); (3) to balance the number of posts in each group, using simple random sampling, 4500 posts were randomly selected from 933,172 posts in the offline suicide group (cybersuicide: 4460 posts and offline suicide: 4500 posts).The process of database searches included the following three steps: (1) a total of 4460 posts with keywords After data collection, preprocessing was performed on the raw data to prepare them for further analysis.First, to exclude irrelevant posts and reclassify misclassified posts, manual scrutiny of the collected data was conducted.In this study, irrelevant posts were considered as (1) posts that depicted suicides in fictional works , (2) posts that focused on suicides in nonhuman animals , and (3) posts that used suicide-related keywords for nonsuicidal purposes . After the removal of irrelevant posts, 7244 posts (cybersuicide: 4460 – 136 = 4324 and offline suicide: 4500 − 1580 = 2920) remained.game: n=4, 5% posts; prosuicide website and forum: n=2, 3% posts; and internet suicide pact: n=2, 3% posts). As this study primarily focused on livestreamed suicide rather than other types of cybersuicide, 8 posts related to the other 3 types of cybersuicide were excluded from further analysis.Subsequently, 77 posts in the offline suicide group were reclassified as posts related to cybersuicide . The demographic characteristics of the participants in the final sample are presented in Second, to extract psycholinguistic features from each of the 7236 posts automatically, the Simplified Chinese version of Linguistic Inquiry and Word Count software was used. The Simplified Chinese version of Linguistic Inquiry and Word Count is a reliable and valid text analysis tool for the automatic estimation of word frequency in multiple psychologically meaningful categories, including linguistic processes , psychological processes , personal concerns , spoken categories , and punctuation categories  [k coefficient, and disagreements were resolved by the decisions of a researcher (AL). All individuals who participated in developing the coding framework and performing manual coding of posts had considerable experience in coding qualitative materials.To explore the differences in types of stigmatizing attitudes across cybersuicides and offline suicides, a content analysis was performed on all 7236 posts to determine whether each of them reflected stigma. The coding framework was developed based on expert consensus and available evidence. Specifically, in this study, a researcher (AL) reviewed relevant studies ,37 and tTo explore the linguistic differences in stigmatizing expressions across cybersuicides and offline suicides, 2 groups of classification models were built using Waikato Environment for Knowledge Analysis  software. Waikato Environment for Knowledge Analysis provides tools for developing machine learning techniques and applying them to practical data mining problems.t tests were conducted to compare the values of all extracted psycholinguistic features between stigmatizing posts in the cybersuicide and offline suicide groups, and then effect sizes (Cohen d coefficient) were computed from the estimated t values. Features that were statistically significant at .05 and had a Cohen d >0.20 or <−0.20 were considered as key features. Finally, using four different machine learning algorithms , 4 classification models were constructed based on the selected key features. Using a 5-fold cross-validation technique, the classification performance of the established models was evaluated in terms of precision, recall, and F-measure.The first group of classification models was built to investigate whether linguistic differences existed in the expression of stigma in general  between cybersuicides and offline suicides. The human coding results were considered as the ground truth for the validation of the classification models. In this study, an imbalanced data problem existed. For example, the number of stigmatizing posts belonging to the offline suicide class (minority class: 588 posts) was obviously lower than those belonging to the cybersuicide class (majority class: 1556 posts). Imbalanced data sets pose a challenge for machine learning modeling, as this problem may result in models with poor predictive performance, especially for the minority class. To handle this problem, using simple random sampling, a certain number of posts were randomly selected from the majority class to obtain a well-balanced data set. Subsequently, to improve classification accuracy, a subset of psycholinguistic features was selected for use in model construction. Specifically, a series of 2-tailed independent stupid and shallow and glorified and normalized) were examined. Well-balanced data sets, key features, and classification models were obtained using the aforementioned methods.It is worth noting that the good classification performance of models in the first group may be attributed to the existence of differences in the amount and distribution of negative stereotypes across cybersuicides and offline suicides rather than the existence of linguistic differences in stigmatizing expressions across cybersuicides and offline suicides. To clarify this issue, the second group of classification models was built to investigate whether linguistic differences existed in the expression of certain negative stereotypes across cybersuicides and offline suicides. To obtain sufficient data for further analysis, in this study, posts reflecting two negative stereotypes . Informed consent was not obtained, as this study was based on publicly available data and involved no personally identifiable data collection or analysis.k coefficients for attitudes and negative stereotypes reached 0.88 and 0.81, respectively, indicating almost perfect agreement [The Cohen greement . The res2χ1=179.8; P<.001). Similar results were found for different genders and regions, including men , women , North China , East China , Central China , South China , and Southwest China .For stigma in general, posts on cybersuicide were more likely than posts on offline suicide to contain stigmatizing expressions  and false representation , whereas posts on offline suicide were often coded as glorified and normalized  and stupid and shallow . Furthermore, posts on cybersuicide were more likely than posts on offline suicide to be coded as stupid and shallow  and false representation , whereas posts on offline suicide were more likely than posts on cybersuicide to be coded as weak and pathetic , glorified and normalized , and immoral . Similar results were found for different genders and regions. Specifically, significant differences in the proportions of posts coded as weak and pathetic were observed for posts by women  and from NC  and EC . Significant differences in the proportions of posts coded as stupid and shallow were observed for posts by men  and women  and from NC , EC , SC , and SWC . Significant differences in the proportions of posts coded as false representation were observed for posts by men  and women  and from NC , Northeast China (Fisher exact test: P=.004), EC , CC (Fisher exact test: P=.006), SC , SWC , and Northwest China (Fisher exact test: P=.003). Significant differences in the proportions of posts coded as glorification and normalized were observed for posts by men  and women  and from NC , Northeast China (Fisher exact test: P<.001), EC , CC (Fisher exact test: P=.01), SC , and SWC . Significant differences in the proportions of posts coded as immoral were observed for posts by men  and women  and from EC  and Northwest China (Fisher exact test: P=.008). In addition, posts on offline suicide were more likely than posts on cybersuicide to be coded as mad for posts by women  and from CC (Fisher exact test: P=.04) and SC (Fisher exact test: P=.03).For negative stereotypes, posts on cybersuicide were often coded as F-measure=0.85; For exploring linguistic differences in the expression of stigma in general between cybersuicides and offline suicides, to achieve a balanced data set, 600 stigmatizing posts were randomly selected from posts in cybersuicide group (cybersuicide: 600 posts and offline suicide: 588 posts). A total of 6 key features were selected for use in the model construction . A total of 4 key features were selected for use in the model construction , 28 key features were selected for use in model construction , although most posts about either type of suicide were not overtly stigmatizing. Cybersuicide allows people with suicidal intentions to interact with their audience in the last moments before death. If the audience responds appropriately to people with suicidal intentions, the likelihood of death would be reduced [First, it is necessary to confront and reduce stigma against cybersuicide. In this study, a large proportion of cybersuicide-related and offline suicide-related posts were coded as  reduced . The pre reduced ,42-44. T21=179.8; P<.001), implying that the public may react more negatively to cybersuicide than to offline suicide. This is consistent with 2 previous studies that explored audience responses to cybersuicide and offline suicide incidents [stupid and shallow  and false representation  and was less likely to be considered as weak and pathetic , glorified and normalized , and immoral . Similar results were also found for different genders and regions. This indicates that antistigma campaigns targeting offline suicide may not be effective in changing stigmatizing attitudes toward cybersuicide, suggesting the need for public awareness campaigns that specifically target cybersuicide. In addition, the most notable and obvious difference between the two types of suicide was found in false representation stigma . The misbelief that cybersuicide is not real may influence stigmatizing responses elicited mainly by the value judgment of suicide death itself but not by the perception of suicidal motives, causes, and methods. For example, the glorification and immorality of suicide represent two distinct values: that it is right or wrong to deliberately take one’s own life. However, dismissing cybersuicide as a nonreal condition contradicts the assumption of such 2 stigmas that suicide is a real condition. This might be the reason why cybersuicide was less likely to be considered as glorified and normalized and immoral than offline suicide. It is also worth noting that cybersuicide was commonly considered as stupid and shallow  and false representation , whereas offline suicide was commonly considered as glorified and normalized  and stupid and shallow . According to previous studies, inappropriate audience responses are associated with greater false representation stigma [Second, the public reacts differently to cybersuicides and offline suicides. In terms of attitude types, in this study, cybersuicide was observed to carry more stigma than offline suicide . Fifth, because of the lack of information about user types , this study cannot investigate the differences in attitudes across different types of users and cannot compare attitude responses elicited by the deaths by suicide of different types of users.This study used a nonintrusive method to directly and systematically examine the differences in stigmatizing attitudes toward cybersuicides and offline suicides. The results of this study support the conclusion that the way people perceive cybersuicide is very different from the way people perceive offline suicide and offer insight into the reduction of stigma against suicide.


With the increasing amount of environmental and scientific data, energy-efficient and high-performance sensing, processing, and memory technologies for the tremendous data are essentially required  and software , have facilitated the development of artificial sensory neural systems, making continuous progress toward cognitive sensing and computing. We believe that continued efforts in conceiving and exploring novel neuromorphic materials, devices, architectures, and algorithms are essential to achieving the ambitious goal of perceptual and cognitive intelligence.Neuro-inspired sensing and computing: Novel materials, devices, and systems” launched recently aims to highlight the most recent advances and achievements in neuro-inspired intelligent sensing and computing from researchers with multidisciplinary and interdisciplinary backgrounds. Below is the abstract information.This Research Topic “Neuroscience of pain: Neck pain is a worldwide health problem. Clarifying the etiology and providing effective interventions are challenging for the multifactorial nature of neck pain. As an essential component of cervical spine function, the sensorimotor control system has been extensively studied in both healthy and pathological conditions. Qu et al. from Nanchang University in China, Aalborg University in Denmark, and Northumbria University in UK provide a short review on neck pain from perspectives of proprioception, sensorimotor control system, neural plasticity, and potential interventions. This mini review may provide inspirations and new ideas to design artificial tactile and pain perception systems.Reservoir network for image recognition: Liquid state machine (LSM) is a type of recurrent spiking network with a strong relationship to neurophysiology and has achieved great success in time series processing , Cachi et al. from Virginia Commonwealth University in US, Universidad de Córdoba in Spain, and Polish Academy of Science propose a rate-based algorithm equivalent to CSNN but that is much simple and well-suited to be run on regular computers. Based on the test results with MNIST and Fashion-MNIST, CRBA has reduced computational cost by up to three-orders of magnitude without reducing accuracy compared with CSNN. CRBA can be used for efficient deployment of CSNN on neuromorphic computers.Arithmetic memristor: Implementation of arithmetic logic operations taking advantage of the non-linear characteristics of memristor can significantly improve the energy efficiency and simplify the complexity of peripheral circuits. Xin et al. from Northeast Normal University in China demonstrate an arithmetic logic unit function using a lateral volatile memristor based on layered 2D tungsten disulfide (WS2) materials and some combinational logic circuits. Mechanism and performance of the 2D memristive devices are comprehensively studied and characterized, showing a potential way to develop 2D memristive devices for future arithmetic logic applications.Neuro-inspired sensing and computing: Novel materials, devices, and systems” will further initiate fruitful discussions and deep thinking in the community. We look forward to continuous progresses and breakthroughs in this emerging field of cognitive sensing and computing. In the end, we thank all the contributing authors for their novel research works and publications. We also thank the editorial team of “Frontiers in Computational Neuroscience” for their efforts in organizing this Research Topic.These typical research works on the neuroscience understanding of pain, neural network model, algorithm, and memristive hardware are important for developing novel intelligent sensing and cognitive computing technologies. Learning from neuroscience, we believe more and more novel neuromorphic sensing and computing materials, devices, algorithms, and systems will be explored. We hope this Research Topic focusing on “All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.


Patients of African ancestry are not well-represented in cancer clinical trials despite bearing a disproportionate share of mortality both in United States and Africa. We describe key stakeholder perspectives and priorities related to bringing early-stage cancer clinical trials to Africa and outline essential action steps. Increasing Diversity, Market Access, and Capacity in Oncology Registration Trials—Is Africa the Answer? satellite session was organized at 2021 Accelerating Anti-Cancer Agent Development and Validation Workshop. Panelists included representatives of African Organization for Research and Training in Cancer, Uganda Cancer Institute, Uganda Women's Cancer Support Organization, BIO Ventures for Global Health, Bill & Melinda Gates Foundation, the US Food and Drug Administration, Nigeria's National Agency for Food and Drug Administration and Control, Bayer, and Genentech, with moderators from ASCO and American Cancer Society. Key discussion themes and resulting action steps were agreed upon by all participants. Panelists agreed that increasing diversity in cancer clinical trials by including African patients is key to ensuring novel drugs are safe and effective across populations. They underscored the importance of equity in clinical trial access for patients in Africa. Panelists discussed their values related to access and barriers to opening clinical trials in Africa and described innovative solutions from their work aimed at overcoming these obstacles. Multisectoral collaboration efforts that allow leveraging of limited resources and result in sustainable capacity building and mutually beneficial long-term partnerships were discussed as key to outlined action steps. The panel discussion resulted in valuable insights about key stakeholder values and priorities related to bringing early-stage clinical trials to Africa, as well as specific actions for each stakeholder group. Cancer outcomes vary by race and ethnicity because of differences in environmental exposures and cancer incidence,Key ObjectiveWe describe key stakeholder perspectives and priorities related to bringing early-stage cancer clinical trials to Africa and outline essential action steps.Knowledge GeneratedPriorities of patient advocacy representatives, oncology research organizations, pharmaceutical companies, and regulatory agencies included increasing both diversity and equity in early-stage cancer clinical trials to improve generalizability of results and build long-term sustainable collaborations with partners in Africa. Such multisectoral collaboration allowed for leveraging of limited resources and was key to outlined action steps and increasing access to early-stage clinical trials in Africa.RelevanceThe discussion among key stakeholders resulted in valuable insights about key stakeholder values and priorities related to bringing early-stage cancer clinical trials to Africa, as well as specific agreed-upon actions for each stakeholder group to bring registration clinical trials to patients.11 Although countries in Africa account for a very small percentage of worldwide cancer clinical trials,13 including 1,376 trials total and 444 active trials —and promote dialog and joint action among these key stakeholder groups—we convened the satellite session Increasing Diversity, Market Access, and Capacity in Oncology Registration Trials—Is Africa the Answer? at the 2021 Accelerating Anti-Cancer Agent Development and Validation Workshop (Data Supplement). Panelists included three representatives of African research organizations and cancer-focused academic institutions ; one leader of an African patient advocacy organization (G.N.); three representatives of regulatory agencies, one from Nigeria (M.C.A.) and two from the United States (K.A. and L.F.-A.); two representatives of global pharmaceutical companies (C.K. and J.F.); and two representatives of US-based global health nonprofit organizations involved in health care in Africa (T.N. and J.D.). Clinical oncologists representing US-based oncology professional organizations and academic cancer centers (B.C. and J.G.) moderated the session.Themes that emerged from the panel presentations and discussion included diversity, equity, and importance of partnerships and collaborations in including African countries in early-stage cancer clinical trials. In this publication, we describe each theme, enumerate associated action items, and outline potential impacts.31 The representatives of African academic institutions and research organizations emphasized that, on the basis of their clinical experience, the lack of inclusion in registration trials of participants either from Africa or of African descent likely contribute to greater rates of treatment failure and poorer outcomes in African patients.Clinical trials are required to determine the safety and efficacy of new products in all patient populations. Participants agreed that the efficacy of standard-of-care cancer drugs in African patients, and patients of African ancestry more broadly, has not been studied sufficiently. Less than 1% of international trials submitted to the US Food and Drug Administration (FDA) for approval of cancer drugs enroll participants from clinical sites in Africa. Most trials that do enroll patients in sub-Saharan Africa typically focus on postmarketing surveillance. Even in the United States, where 20% to 25% of participants in global clinical trials are enrolled, only 2%-4% of participants are of African descent.Panel participants shared their perspectives about reasons for the dearth of clinical trials in sub-Saharan Africa. Representatives of the African Organization for Research and Training in Cancer (AORTIC) and the Uganda Cancer Institute (UCI) described the low priority placed on research, including by country governments, resulting in inadequate funding, insufficient infrastructure (including internet), and insufficient numbers of teams proficient in good clinical practice. Representatives of pharmaceutical companies Bayer  and Genentech  described previous concerns about regulatory infrastructure, data quality and integrity, and patient safety, currently being addressed by these companies through several novel initiatives. From the patient advocacy perspective provided by the leader of the Uganda Women's Cancer Support Organization , barriers included lack of understanding among patients about clinical trial procedures and benefits, concerns about drug safety, logistical barriers, gaps in treatment capacity, and insufficient engagement of patient advocates by researchers and regulatory agencies.32 and noted that sustainable partnerships and collaboration should be the goal of these efforts.Representatives of Nigeria's National Agency for Food and Drug Administration and Control  and FDA discussed the importance of recruiting a diverse population of patients to cancer clinical trials to ensure applicability of resultsThe panelists underscored the importance of ensuring equitable access to clinical trials for patients in Africa.33 This effort resulted in fast trial accrual and emergency authorization of tocilizumab. Another example was a study of ocrelizumab for multiple sclerosis exclusively among patients of African descent, who are known to have a more severe clinical course and worse outcomes, in both Kenya and the United States.34 This successful effort prompted the company to consider additional clinical trials, including in oncology, in sub-Saharan Africa.Panelists from Bayer and Genentech described their commitment to improving equity in cancer care and drew parallels between ensuring access to new medications for African patients and for underserved minority patients in the United States. Examples cited by the panelist from Genentech included a successful effort to recruit US underserved and racial/ethnic minority patients into a phase III clinical trial of its drug tocilizumab for COVID-19 pneumonia by working directly with these communities.Ensuring sustainable research partnerships and long-lasting health care system improvements was a priority for both regulatory agencies and pharmaceutical companies. The panelist from Bayer described conducting needs assessments in Ghana and engaging local experts for prostate cancer capacity building and health care systems strengthening, to ensure sustainable improvements in cancer care. Both the Bayer and Genentech panelists recognized that the considerations for driving equity do not stop after a trial is completed and that plans for market entry and sustained access should be incorporated into research and business strategies.Panelists agreed that partnerships between African and international stakeholders are critical to expanding high-quality cancer clinical trial activities in Africa. They emphasized the importance of understanding and aligning with priorities and values of key stakeholders in developing and executing collaborations.AORTIC and UCI representatives strived for improved cancer outcomes for African patients through research and clinical trial capacity building, as well as African investigator-led trials that are both clinically and culturally relevant. They advocated for inclusiveness, collaboration, stronger regulatory frameworks, and Afrocentric approaches.The patient representative from UWOCASO emphasized the patient advocacy values of improved access to both novel and standard-of-care treatments for patients and inclusion of patient advocates as equal partners in clinical trial planning.NAFDAC and FDA representatives prioritized ensuring patient health and safety first, followed by data quality, integrity, and applicability to their patients. FDA representatives particularly emphasized compliance with regulations governing clinical trial conduct, including data collection, documentation, and analysis.Industry representatives highlighted the importance of equitable access, capacity building, and sustainable partnerships. They emphasized the need for quality data, strong regulatory systems, market access, local expertise to facilitate trial implementation, ability to mitigate risk, and need to have a sustainable business model.The panelists from BIO Ventures for Global Health  and Bill & Melinda Gates Foundation  described their support of African countries in bringing high-quality, impactful cancer clinical trials to their patients, including by working together with country regulatory agencies and local investigators.35—can serve as models. Capacity and infrastructure developed by the HIV/AIDS community in Africa can be leveraged to build African-led and -driven oncology initiatives, such as UCI . HIV/AIDS collaborations offer important lessons, including (1) the imperative to focus on humanitarian aims and equity; (2) considering a return on investment that recognizes the positive impact of a low-cost treatment on patient mortality and quality of life; (3) ensuring that clinical trials do not exacerbate existing inequalities in health care access; (4) involving local stakeholders as equal partners in protocol design to avoid skewing research agendas to that of the funders; (5) ensuring that true informed consent is collected and that treatment will be available after the study ends and once the drug is approved; (6) considering and mitigating the effects of brain drain, or exodus of trained personnel, to higher-income countries as a result of cancer clinical trials; (7) avoiding postal research  and parachute research (sending researchers to conduct short-term projects); and (8) treating African clinical trial experts as equal partners and giving them credit in international meetings and publications.37Panelists noted that successful multidisciplinary HIV/AIDS research and clinical care collaborations in African countries—in which robust prevention and treatment programming led to a significant decline in HIV incidence43 by the Prostate Cancer Trans-Atlantic Consortium28 and by BVGH in several sub-Saharan African countries.28 Robust and long-standing collaborations to build local cancer research capacity and improve patient care include the Partners in Health—Rwanda Military Hospital,44 University of California, San Francisco—Ocean Road Cancer Institute in Tanzania,45 University of Washington/Fred Hutch—UCI,14 University of Pennsylvania—Botswana Partnership,46 University of North Carolina Chapel Hill—Malawi,16 and University of Chicago—University of Ibadan, Nigeria.Multiple successful initiatives and partnerships that focus on addressing disparities in cancer diagnosis and treatment and increasing access to cancer clinical trials already exist in Africa Table . There aThe panelist from UWOCASO described the key role of patient advocate volunteers in connecting patients to clinical trials at UCI. Such volunteers use their own experience as patients to provide reassurance and accurate information. UWOCASO partners with UCI to provide patient support during treatment and reduce loss to follow-up.47 The UCI-Fred Hutch collaboration provided essential resources for research and clinical trial capacity building and resulted in sustainable investment from the Ugandan Government in cancer care after seeing its success and impact on patient outcomes.The UCI panelist described the mutually beneficial partnership with Fred Hutch, including in designing and implementing early-stage clinical trials that provided critical insights into treatment of Burkitt's lymphoma.NAFDAC and BMGF have partnered to tailor BMGF's online platform to enable expedited and paperless review of clinical trial protocols in Nigeria.BVGH has worked on improving access to cancer clinical trials by evaluating and showcasing cancer clinical trial infrastructure and human capacity, as well as the experience and research interests of individual clinical investigators in sub-Saharan Africa.The Bayer and Genentech panelists emphasized their companies' commitment to corporate responsibility and sustainability. The Genentech panelist shared the company's experience of creating a sub-Saharan Africa leadership team in charge of a 5-year plan to help optimize regulatory and human resource infrastructure, data quality, and patient safety at global sites participating in the company's clinical trials. As a result, in addition to South Africa, the company was able to open cancer clinical trials in Kenya, Uganda, Nigeria, Morocco, and Algeria. A feasibility assessment for a phase I study of lung and colorectal cancer in Kenya is ongoing. The panelist from Genentech also described a coinvestment project with the Government of Côte d'Ivoire that resulted in improved access to cancer drugs for patients and a doubling of sales for the company.The Bayer panelist shared the company's philosophy about the necessity of assessing a site or country before the initiation of clinical trials, including (1) complete adherence to good clinical practice and ethical protocols; (2) regulatory landscape; (3) market access capability and patterns; and (4) intellectual property protection, legal, and compliance landscapes to ensure patient safety, protection of patient rights, and sustained equitable access to novel therapies. Both Bayer and Genentech emphasized the importance of local experts to advise companies about clinical trial design and information on clinical trial site capabilities, quality, and compliance. Both Bayer and Genentech looked to BVGH, AORTIC, and other global health research and nonprofit organizations to bring key stakeholders together for dialog and collaboration.48 and inspections for marketing applications. They voiced eagerness to collaborate with regulatory agencies in sub-Saharan Africa for the same purpose.The FDA representatives described decades of experience of working with other regulatory agencies around the world to share experiences and data and conduct collaborative reviews36 In addition to expanding access to care, such partnerships should focus on building both clinical trial and standard-of-care treatment capacity, empowering more African patients to participate in trials by partnering with patient advocates, and strengthening African regulatory agencies.Session participants agreed that cancer research institutions, professional organizations, pharmaceutical companies, patient advocacy groups, and global health non-profit organizations need to encourage collaboration through creative partnering models and funding mechanisms that prioritize cross-institutional and cross-country alliances Table .36 In adThe ASCO and the American Cancer Society, organizers and moderators of this Accelerating Anti-Cancer Agent Development and Validation satellite session, have a strong commitment to achieving diversity and equity in cancer clinical trials. Using their name recognition and convening power, these organizations were able to stimulate dialog on an international scale through this panel. These organizations are leveraging their influence, networks, and convening power to stimulate dialog across sectors and international borders, including through this panel session. Together, they are committing to continue the momentum for building a robust clinical trials infrastructure in sub-Saharan Africa, through partnerships with African cancer institutions, professional societies, cancer clinicians, researchers, patient advocates, industry, regulatory agencies, and all stakeholders.Action items for each group of stakeholders were based on each group's values and priorities and focused on improving diversity and equity in registration cancer clinical trials by building clinical trial capacity in Africa.African cancer research institutions will collaborate with key stakeholders to lead: (1) building clinical trial capacity, including by incentivizing clinical trial training of and design by local investigators and working with patient advocates to promote patient education and recruitment; (2) working with regulatory agencies to optimize clinical trial initiation and drug approval; (3) ensuring government buy-in by showing impact of clinical trials on patient outcomes; and (4) integrating clinical trial processes into high-quality patient care.Patient advocacy groups will play an essential role in obtaining buy-in for clinical trial participation from patients and advocating for resources for clinical trial capacity building with key stakeholders.Regulatory agencies in Africa will collaborate with other key stakeholders to streamline clinical trial opening and drug approval and ensure data integrity and applicability. The agencies will also encourage pharmaceutical companies and investigators to devise strategies to include racially and ethnically diverse patients, as well as underserved patients, in their trials.Global pharmaceutical companies will focus on: (1) building clinical trial capacity in Africa and including patient advocates early to ensure that trials are appropriate to the local context; (2) prioritizing Africa for clinical trials and considering diversity at the planning stages of clinical trials; (3) connecting cancer clinical trial experts to African clinical investigators for mentorship; and (4) working with country regulatory agencies to meet trial timelines and with governments to ensure drug accessibility and market access after drug approval.37 They will also lend their expertise in price negotiation to ensure drug access after trial ending.Global health nonprofit organizations will connect key stakeholders to funding, training opportunities, and mentors for building clinical trial capacity, including by prioritizing investment in African investigator-led trials.ASCO will (1) facilitate dialog and collaboration of key stakeholders; (2) collaborate to increase clinical trial capacity in the region, including through training; (3) create funding opportunities for cancer research in low- and middle-income countries; and (4) create professional development opportunities and cancer care and research education opportunities, including in Africa.Achievement of the proposed action items will lead to improved access for African patients to locally relevant investigator-initiated clinical trials and to registered products with safety and efficacy that have been validated in African populations, resulting in better clinical outcomes. The knowledge and experience gained in improving equitable access to novel drugs in underserved settings can be leveraged to do the same for underserved patients in high-income countries.In conclusion, diversity, market access, and capacity in oncology registration trials can be improved by implementing trials in Africa in partnership with local investigators, patient advocates, and regulatory agencies. Our panel discussion about strategies for improving diversity and equity in clinical trials, which were priorities for all panelists, resulted in valuable insights about the values and priorities of key stakeholders related to bringing early-stage clinical trials to Africa. The discussion generated specific action items for each group of stakeholders on the basis of their priorities, that, once implemented, will result in increased applicability of trial data to broader groups of patients, more equitable care, and improved patient outcomes in Africa and globally.


Despite the available treatment strategies, ischemic stroke (IS) is still a leading cause of death and disability worldwide. Therefore, novel cellular and molecular targets for potential clinical treatment applications in the future need to be identified. Until two decades ago, IS was mainly understood as the prototype of a mere thrombotic disease; however, nowadays there is clear evidence that IS rather involves the whole neurovascular unit (NVU) and interactions with immune cells and platelets. Innovation in this area of research has led to remarkable discoveries and improved understanding of the pathophysiology of IS. Nevertheless, more work and a tenacious pursuit of basic and clinical sciences in cerebrovascular pathophysiology and pharmacology are still necessary. The aim of this special issue is to present promising findings derived from both animal models and clinical studies of “Cellular and Molecular Targets in Acute Ischemic Stroke”, which might provide potential treatment strategies for future use.A special focus was laid on the role of local vascular responses in acute stroke. The following studies paradigmatically delineate a crucial role of immune cell subsets and associated molecules/proteins on arterial thrombus formation , intravaSeveral other studies focused on potential therapeutic options to reduce ischemia induced neuronal cell death. Hong et al. investigated the role of temperature on apoptosis-mediated neuronal cell death in a rodent model of transient global ischemia, mimicking sudden cardiac arrest in humans. They found equal neuroprotective effects of targeted temperature management at 33 °C and 36 °C . SpecifiFurthermore, cellular and molecular targets for non-invasive, non-pharmacological therapeutic/rehabilitative interventions in acute IS  and the In summary, this special issue offers an interesting background and further insights of IS pathophysiology from both animal and clinical studies, and suggests novel strategies that may help in the ongoing efforts for a better prevention and treatment of cerebral ischemia.


Providing access to quality-assured medicines is a fundamental componentof strengthening health systems. Yet, the World Health Organization(WHO) estimates that 13.6% of all medicines in low- and middle-incomecountries (LMIC’s) may be substandard or falsified (SF) impedingpatient outcomes, imposing financial burden, and contributing toantimicrobial resistance. Circulation of SF medicines also underminestrust in the health system and legitimate health care professionals.It may erode trust in the manufacturers of genuine pharmaceuticalproducts as well as health professionals who prescribe and dispensethem. Failure to address challenges in medicines quality assurance andsupply risks jeopardizing progress towards universal healthcarecoverage. This editorial draws on perspectives from a Ghanaian contextand highlights the importance of ensuring an adequate and stablemedicine supply, specifically through mechanisms to foster localmanufacturing. This will serve to address the problem of SF medicines,as well as providing opportunities for mutual benefit with multiplerelated sectors. The WHO’s mechanism on substandard and falsifiedmedical products 2020 highlights multiple sectors have a key role incombatting SF medicines. Although key considerations and initiativesin other sectors are beyond the scope of this article, localmanufacturing should be viewed with WHO’s a multilevel systemwideapproach. A country’s capacity to implement regulation ofmedicines requires a sufficient regulatory and health professional workforcewith the appropriate level of expertise, oversight, andcommunications,47 underpinned by theefficient administrative system10 and access torobust high-quality testing facilities and screening technologies.11The importance of legal frameworks in enabling regulatory enforcement has beenwidely acknowledged, screening technology advances (examples include in the field testingin China), there remain critical challenges, and many nations are limited intheir capacity to effectively assure the quality of the supply of medicinesthrough their NMRA.26Although progress in strengthening regulatory systems is being made globally,such as through short messaging service (SMS), medicines authenticationtechnology such as serialization and traceability, Moreover, a well-equipped and functioning regulatory system inisolation is not enough without a reliable supply of quality-assuredmedicines. It is critical to consider the consequences of supply issues onaccess for patients. Supply shortages are the result of multiple factors and includeenvironmental, the healthcare delivery service, and the pharmaceuticalindustry that manufactures the medicines. Thus coherent multi-levelapproaches encompassing multiple aspects of medicines regulation and supplyare required including national anti-counterfeit drug laws and legislation,registration and licencing, inspection and quality control, training ofhealth professional personnel, price control, technological interventions,national alert systems, and public education and awareness campaigns incollaboration with multiple stakeholders involved in the medicine supply chain.Strengthening any one aspect of medicines provision alone is unlikely to beeffective at significantly increasing medicines quality assurance. This has been highlighted in Morocco where unaffordable medicineswere implicated in driving medicine’s trafficking from Algeria and sold atmarkets, where the quality and validity were unknown.Quality medicines supply should be considered within the broad context of thehealth system. For example, when medicines are not affordable through theformal regulated health system due to prohibitive costs or lack of nationalhealth insurance schemes, patients will be driven to seek these throughother routes, where regulatory oversight may be compromised and there is agreater risk that the medicine will be substandard or falsified.In addition, when healthcare institutions are not able to procure thequantities to meet their local demands for medicines, it may lead tostockouts. This may hinder the ability of the facilities to serve theirpatients. This can occur against a backdrop of national programmes tosupport equitable access,  if thereis a lack of availability through central or regional medicine stores. Theoutcomes can include one or several adaptive mechanisms:Institutions look to procure medicines from other suppliers such asthrough the open markets but may have to balance conflictingchallenges if there is a higher price or limited capacity toassure quality 10Institutions may have to pay additional costs to obtain medicines,meaning they are either required to charge patients more tocover these costs, or these additional opportunity costs must bepassed on to another domain of their healthcare facilityInstitutions cannot provide medicines, so patients must seekmedicines elsewhereThe outcome is that in many cases patients will not be able to access or affordmedicines or are forced to buy them through an unregulated route, where theyare less likely to be quality assured.produced to meet these demands.Tackling challenges of quality assurance, medicines supply, accessibility, andaffordability is part of a wider need to strengthen the pharmaceuticalindustry in a manner that is oriented to service healthcare systems tobetter meet local demand. Key within this will be increasing awareness,building regulatory capacity, and enhancing mechanisms of supply chainmanagement, incorporating innovations in the supply of medicines, but alsoensuring medicines are  The African pharmaceutical market is expected to reach $45 billion in2020, yet only 30 percent of medicines are produced on the continent withthe rest imported mostly from China and India.The global trade of medicines was estimated at $1.2 trillion in 2018.11 This poses astrain on central medicine stores in many low and middle-income countries(LMIC) to enforce regulations and adhere to WHO recommended procurementprocedures.Imported medicines remain more challenging to stringently control qualityassurance, opening opportunities to ambiguity in quality through additionalvariables in production and supply. For example, there is an asymmetrybetween the regulation of imported and exported medicines enforced byhigh-income countries (HICs) with stronger regulatory capacity. Regulationsfor quality control on exported medicines are often insufficient or simplylacking, relying on goodwill. Conversely, the manufacturing of medicines locally can not onlyincrease a countries autonomy in medicines supply but allow tighter controlof quality assurance and transparency in production.In addition, a review of procurement processes found that medicines supply inLMICs is often dominated by a small number of suppliers and intermediariesresulting in high mark-up and increased cost of generic medicines comparedto HICs.This also opens the opportunity for technology transfer, medical innovation,and research to meet local needs. Targeting the manufacturing of essentialmedicines locally increases supply to sufficiently meet the most criticallocal demands. Thus, patients can access medicines through the routes thatoffer the greatest quality assurance. Across Africa, the proportion oflocally manufactured medicines varies from 20%–30%. However, a viable localpharmaceutical manufacturing industry in Africa will not only impact theAfrican health system and its capacity to respond to the health needs of thepeople but also will contribute to the overall socio-economic development ofthe continent. These benefits become more critical in the wake of theCovid-19 pandemic and may contribute to the preparedness of the continent indealing with future pandemics through improving access to medicines.Despite the clear positive aspects of building a local manufacturinginfrastructure, some obstacles can be challenging to overcome. These includeregulation, supply chain, market size, human resource constraints,inadequate infrastructure, high operating costs, weak links between localand international suppliers, and the high cost of local commercialcapital. identified regulatory harmonization as a critical pillar for localmanufacturing capacity in Africa. Since then, the African Union Commissionhas been at the forefront in galvanizing the necessary political will andproviding the leadership to the broad range of processes required forpromoting a sustainable local pharmaceutical industry. Progress is beingmade to harmonize regulation internationally and across Africa to maintaincross-country quality assurance, such as through the establishment of anAfrican Medicines Regulatory Authority. The need to ‘Expand and maintain the global focal point network amongnational medicines regulatory authorities to facilitate cooperation andcollaboration’ was stated in WHO’s 2020–2021 SF medicines priorities as partof their mechanism to prevent, detect, and response to ensure supply chainsafety, although the role of local manufacturing was not recognized explicitly.The Pharmaceutical Manufacturing Plan for Africa adopted by the Conference ofAfrican Ministers of Health in April 2007 and endorsed by the Heads of Stateand Government in Accra in July 2007 Very useful learnings can be derived from policies adopted by Ghanain comparison to those implemented elsewhere. These present potentialcomparative approaches by analysing the relative strengths, and weaknesses,in order to foster local pharmaceutical manufacturing as a mechanism tostrengthen health systems through medicines access, supply, and qualityassurance.Several countries such as Ethiopia, South Africa, Kenya, and Ghana have madeconsiderable advances to boost the local pharmaceutical manufacturing sector. Ghana’s industrial sector recorded a 10.6 percent growth rate in 2018according to the Ghana statistical services report in April 2019.Ghana is the second-most populous country in West Africa, with a population of27.41 million. This is expected to increase to 36.87 million by 2030. Ghanais a LMIC and aspires to advance to a middle-income economy with a grossdomestic product (GDP) per capita of US$3000 by 2020. However, challenges remain at the health-care facility level insupplying medicines due to delays in repayments from the National HealthInsurance Authority (NHIA) resulting in drug shortages, out-of pocket-payments, and patients risking catastrophic costs.Ghana has made considerable healthcare reforms, establishing a National HealthInsurance Scheme (NHIS) in 2004, which covers several essential medicinesfor acute and some chronic conditions. This is made up of approximately 30% locally manufacturedpharmaceuticals with the rest imported mainly from India and China for bothprescription and over-the-counter medicines. This is despite the Ghanaianpharmaceutical industry being the second largest in the West African regionwith 38 registered pharmaceutical manufacturers.The pharmaceutical sector is the key component of the healthcare system to meetthe varying demand for pharmaceuticals. The total market size of thepharmaceutical market in Ghana is estimated at $329 million. and the Medium-Term National Development Policy Framework (2018–2021). The Ghana Industrial Policy, National Health Policy, NationalMedicines Policy, Health Commodity Supply Chain Master Plan, and IndustrialSector Support Programme all aim at supporting the growth of thepharmaceutical sector.In response to the call of African Heads of State for local production ofessential medicines in Africa and the subsequent adoption of the BusinessPlan for accelerated implementation of the Pharmaceutical Manufacturing Planfor Africa (PMPA BP) in 2012, Ghana has made efforts to improve itspharmaceutical manufacturing capacity to meet local needs and that of theWest African sub-region through the development of several policyframeworks. These include the Coordinated Programme of Economic and SocialDevelopment Policies (2017–2024),With the support of the United Nations Industrial Development Organization(UNIDO), the National Development Planning Commission, the PharmaceuticalSociety of Ghana, and various stakeholders, Ghana has developed the GhanaPharmaceutical Sector Development Strategy (GPSDS) with the vision of makingGhana a world-class pharmaceutical investment and manufacturing hub,producing and supplying high-quality and affordable medicines for the peopleof the whole continent. A coordinated approach to these initiatives, backedby a strong political will has the potential of achieving this objective inthe medium- to long-term.These policy initiatives have also been backed by several efforts by thegovernment includingRestriction of some 49 products with local manufacturing capacityfrom importation ;Expansion of the list of VAT-exempted pharmaceutical raw materialsand inputs used for local pharmaceutical manufacturing to about400 (LI 2218 of 2015);Removal of VAT/import tariffs on equipment for plant upgrades;Access to funding through the Export-Import (EXIM) bank. the planned establishment of an industrial pharmaceuticalmanufacturing park with the support of the Ghana Chamber of Pharmacy and thePharmaceutical Society of Ghana offers the platform to drive localmanufacturing. Other pivotal initiatives include the formation of thePharmaceutical Manufacturers Association of Ghana (PMAG) to serve as a platform for advocacy and to also provide aself-auditing system, a robust national Food and Drug Authority (FDA), and astable democratic climate are key indicators which may ensure theachievement of the goal of becoming a pharmaceutical manufacturing hub.Implementation of other initiatives including a 15% price preference forlocally manufactured products for Government of Ghana procurement,These policies are anticipated to improve medicines supply through supportinglocal manufacturing of medicines, which will in tandem support theacquisition and use of medicines of higher quality assurance.Good Health andWell-being), and also build a prosperous economy to supportpeoples’ well-being as stipulated by SDG 8 (Decent Work and EconomicGrowth) and 9 .However, the impact these policy initiatives have on the supply chain has notyet been formally assessed. This remains an area where greater policy impactresearch is required to ascertain the most effective approaches goingforward. Further light on this topic will highlight the intersectionalitybetween economic development, medicines supply, affordability, and qualityassurance at the point of care, which will support the policymaker lookingfor concrete evidence. This, in turn, will strengthen quality assurance andenable health systems to progress towards universal health coverage (UHC) inline with Sustainable Development Goal (SDG) 3 (


Fraser et al.; Hansen et al.). In fact, Google search trends for “music AND corona” suggest that musical responses to the surging outbreak took off already in February 2020 thus preceding the pandemic declaration by the World Health Organization on 11th March by several weeks .Pandemic musical responses were multifarious, though further work is required to map and fully understand them  or asynchronously producing the characteristic splitscreen videos that became a hallmark of the “coronamusic” phenomenon  and extra-curricular ensembles  to graduate-level classical instrumental studios (de Bruin) moved online, sometimes with institutions commissioning home delivery services to facilitate student access to musical instruments , music was also used in hospitals and intensive-care units to support COVID-19 patients feel emotionally connected to their loved ones despite physical distancing requirements . Many musical initiatives were closely covered by the media  as general consumption of news increased during lockdown  and sometimes gave an overly optimistic view of music's alleged healing powers. This latter positivity bias has been proposed to constitute a potential coping strategy to promote resilience and social cohesion during challenging times .Vidas et al.), via fieldwork as participant-observer (Morgan-Ellis), to analysis of websites, news, music videos, or other public sources . While multiple Research Topics and methods could be associated with any article, a single primary topic and/or method was always assigned.Our thematic analysis revealed eight overall Research Topic categories: Theory/Opinion (represented by three articles), Engaging with conventional formats and repertoires (22), Creating new formats and repertoires (14), Engaging with new formats and repertoires (4), Parent-child interactions (4), Music education (3), Music therapy (3), and Musicians' life circumstances (5). Additionally, five overall methodological categories were identified: Surveys (29), Experiments (4), Interviews (5), Analyses (8), and Literature reviews (2). Experiments were defined as intervention studies–in person or virtually–where an independent variable was systematically manipulated. Analyses spanned from Music Information Retrieval methods applied to audio data  was the most prominently represented discipline with smaller numbers for musicology/sociology (9), music therapy (3), and music education (2). Yet, far from all authors were affiliated with psychology departments. Rather, primary affiliations listed for first authors included departments of psychology/social science/health sciences (17 first authors), musicology/music (12), conservatories/schools of music (5), neuroscience (3), music technology (3), education/pedagogy (2), history (1), and information/media science (1). This alludes to substantial degrees of interdisciplinarity.Frontiers in Psychology (42 articles), Frontiers in Neuroscience (1), and Frontiers in Sociology (1), represented by the Specialty Sections Cultural Psychology (16), Performance Science (12), Auditory Cognitive Neuroscience (7), Emotion Science (7), Cognition (1), and Work, Employment and Organization (1).Disciplinary convergence was similarly reflected in the inclusion of the three parent journals Typically, a team of authors co-wrote articles , and multiple institutions were most often listed amongst each team's affiliations . Although suitable comparison data from pre-pandemic times can be hard to obtain, a working hypothesis would be that music researchers pursued opportunities for multi-author and cross-institutional collaborations during lockdown, as has been observed for other scientific areas  and conduct experiments virtually during lockdown  or physically prior to lockdown (Belfi). We expect that as more sophisticated tools become widely available, music researchers will become increasingly better equipped to collect not only survey data but also valid experimental and interview data online , whereas others focussed on single countries . Another sub-group examined student populations in Australia , Canada , and the USA (Hurwitz and Krumhansl).Across the pandemic, media reports often highlighted musical responses to COVID-19 and social-distancing policies. Changes in musical behaviors and how they might help individuals and groups fight stress, loneliness, and anxiety played a key role. Accordingly, many studies tackled these issues with online surveys. Some were multi-country studies , other studies reported higher levels of daily musical engagement or an increased importance of music . Quantitative reports of decreased audio streaming  accompanied by increased video streaming  of music during lockdown  point toward a possibly accelerated uptake of multimodal media for music consumption and potentially inaccurate introspections about actual use . Interestingly, music seemed more beneficial than watching TV. Although both were equally frequent, watching films and TV did not make it into the group of activities deemed most effective for fighting stress and regulating mood  or was even negatively related to life satisfaction . However, the respective surveys did not always differentiate between watching films and series on the one hand  and watching news on the other.A number of studies compared musical activities with other domestic activities. Here, music was not only one of the most frequently performed activities but also repeatedly found to be as effective or even more effective than exercise, sleep, and changing location , nostalgic music  but also for happy and novel music. Other studies not in this Research Topic found that corona-themed repertoires were especially predictive of successful socio-emotional coping with music , but also to reduce stress, to have positive physical effects, such as relaxation or activation. In line with studies on music's potential role as a social surrogate . In addition to relatively few influencing sociodemographic, personal, and contextual characteristics, the individual importance of music  or the sensitivity to musical reward  were found to be critical factors.Although different numbers of concepts were employed to address potential benefits of musical engagement, a relatively coherent picture emerged. In line with a large body of earlier research on emotional and wellbeing effects of musical activities Hanser, , engagemHenry et al.; Gibbs and Egermann; Carlson et al.; Cabedo-Mas et al.; Hurwitz and Krumhansl's Exp. 1; Vidas et al.; Finnerty et al.; Krause et al.; Ferreri et al.; Ribeiro, Lessa et al.; Mak et al.; Terasawa et al.), restrictions were stringent but also eased a bit as the northern-hemisphere spring and summer progressed. After 1st July 2020 , conversely, restrictions to some extent stagnated with notable individual differences between the surveyed countries. The studies by Granot et al. and Martínez-Castilla et al., for example, surveyed populations that were both far above and far below the world average in lockdown stringency.There is, however, no guarantee that the available survey studies provide a complete account of all aspects of pandemic coping with music. For example, no studies were conducted sufficiently early to capture the time around the pandemic declaration and the initial upsurge in lockdown restrictions  even thoHansen et al. collected and annotated a representative corpus of coronamusic videos and news reports with the help of crowdsourcing from a global audience. Positive emotions like happiness, humor, togetherness, and being moved seemed especially prominent . Communities studied were from the UK, Belgium, The Netherlands, Australia, and USA. Typically, researchers were interested in which online platforms and solutions  ensembles used and how they experienced their online interactions. Although frustration with the technical limitations and the lack of physical co-presence was a frequently raised concern, participants appreciated the possibility to develop their artistry and uphold community, and many experienced some wellbeing benefits. That online group music making can have positive wellbeing effects was also corroborated by an experiment comparing effects on stress, mood, and connectedness of individual and group-based online chanting sessions .How exactly music ensembles such as choirs, orchestras, or dance classes moved their activities online, was examined by several groups of researchers  or regarding the effects of various characteristics of virtual concerts . Given that streamed concerts lack actual physical co-presence, findings regarding if and how virtual concerts can afford feelings of physical and social presence might be particularly relevant for future artistic development using these formats. Here, livestreams exhibited an advantage over on-demand streams ; giving audiences the opportunity to interact via a video-conferencing platform enhanced social presence relative to a non-interactive stream, and virtual-reality headsets induced feelings of physical presence and connectedness with the artist. Another, asynchronous form of virtual interaction, namely YouTube user commenting, was found to be potentially beneficial for social bonding and bridging across intercultural divides .Virtual concerts, i.e., performances streamed live or on demand Cho and Steinberg Ilari et al. in USA and Canada; Ribeiro, Janzen et al. in Brazil). Steinberg et al. demonstrated that parents engaged more frequently in musical activities with their children during lockdown than previously and also used music for their own and their child's emotional regulation. Cho and Ilari found that strategically selected recorded music could maintain or reinforce children's positive mood, but soothing and calming playlists were largely unsuccessful in shifting negative moods. Ribeiro, Janzen et al. also found an increase in music activity, with parents spending far more time with their children indoors, and self-reporting dedicating more hours to singing/playing and listening to music and to watching music videos. While caregivers overall experienced low wellbeing and high stress, those with better mental health and higher education levels made significantly more music with their children. Knowing that young children generally benefit from music for mood regulation . Levstek et al. explored changes in young people's lived experiences of virtual group music sessions during the first and second national lockdowns in the UK, finding that these new formats could assist in emotion management and maintenance of social belonging and musical identities. In Australia, interviews with experienced instrumental music educators revealed that teaching became more student-centered with more energy being spent on building emphatic connections and communicating in a more dialogic fashion, and with the teacher in a more guiding/coaching role to encourage student ownership and empowerment (de Bruin). While these changes were mostly framed as successful, it remains unclear how such approaches worked for less intrinsically motivated and parentally supported students and for new students who did not have a prior history of “in-person” experiences with the relevant educator.Research in music education revealed that the mental health of US teachers deteriorated during extended periods of lockdown and that unplanned changes in mode of instruction during the semester increased psychological pressure . In Brazil, opportunities at the federal, state and municipal level, as well as from the third sector, showed massive decreases in income for more than two thirds of musicians as important opportunities for performing and earning money disappeared . In the UK, while interviewees mourned the temporary suspension of their much-loved music careers causing concerns for current financial stability and future career prospects, mid-career musicians (aged 35–45) suffered more severely than their more seasoned colleagues . Particularly their lower motivation to practice and engage in collaborative music-making during lockdown was suggestive of limited psychological resilience. Physical activity may, however, provide some potential for alleviation . A further survey and interview study in the USA revealed that live music-making decreased and online music-making increased during lockdown, and that music-creation also became less collaborative and more solitary at first . However, music creators later restored their collective work approaches and sometimes even prioritized communal aspects over matching musical genres with collaborators. As primary sources for inspiration during this time, creators drew heavily upon nature, nostalgic topics, social issues, and their personal lives.Research in the UK revealed that for musicians, substantial decreases in work and income were associated with lower wellbeing, and with higher depression and loneliness scores . JD's research was funded by the Creativity and Wellbeing Hallmark Research Initiative at the University of Melbourne.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.