Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Idle no more: del reconocimiento al resurgimiento indígena en Canadá = Idle no more: do reconhecimento ao ressurgimento indígena no Canadá = Idle no more: from recognition to Indigenous resurgence in Canada

Neste artigo se pretende analizar a constituição do movimento indígena No Más Pasividad de Canadá, as ideias que o sustentam, assim como a evolução das práticas políticas do movimento indígena dos anos 1960 à atualidade. Se optou por combinar o conceito de campo de Bourdieu e de colonialismo de colonos para entender como o contexto indigenista e o tipo de recursos ou capitais que os distintos atores disputavam determinam as limitações do reconhecimento liberal. Se defende que o movimento No Más Passividad não apenas se opõe ao reconhecimento liberal da indianidade e dos direitos indígenas, mas também busca reclamar e reconstituir espaços indígenas autónomos do Estado, assim como redefinir a discussão sobre os direitos indígena

The Neoliberal State, Recognition and Indigenous Rights: New paternalism to new imaginings

The impact of neoliberal governance on indigenous peoples in liberal settler states may be both enabling and constraining. This book is distinctive in drawing comparisons between three such states—Australia, Canada and New Zealand. In a series of empirically grounded, interpretive micro-studies, it draws out a shared policy coherence, but also exposes idiosyncrasies in the operational dynamics of neoliberal governance both within each state and between them. Read together as a collection, these studies broaden the debate about and the analysis of contemporary government policy. The individual studies reveal the forms of actually existing neoliberalism that are variegated by historical, geographical and legal contexts and complex state arrangements. At the same time, they present examples of a more nuanced agential, bottom-up indigenous governmentality. Focusing on intense and complex matters of social policy rather than on resource development and land rights, they demonstrate how indigenous actors engage in trying to govern various fields of activity by acting on the conduct and contexts of everyday neoliberal life, and also on the conduct of state and corporate actors

From new paternalism to new imaginings of possibilities inAustralia, Canada and Aotearoa/New Zealand: Indigenous rights and recognition and the state in the neoliberal age

The election of Evo Morales as the first indigenous President of Bolivia in 2005 is widely credited to the Cochamba Water War (Spronk 2007: 8). The Cochamba Water War progressed from an indigenous movement and a specific issue to the creation of an indigenous political party and election of the first indigenous President. The Bolivian water war, the Puebla Panama Plan in Mexico, the Mackenzie Valley pipeline in Canada (Altamirano‐Jiménez 2004) and Māori resistance to the neoliberal agenda from 1984 onwards (Bargh 2007: 26) inspired much theorising about indigenous people successfully contesting neoliberalism (AltamiranoJiménez 2004, Bargh 2007, Spronk 2007: 8, Postero 2007). Bargh and others, for example, documented not only ‘overt Māori resistance to neoliberal policies, but also more subtle stories of activities, which The neoliberal state, recognition and indigenous rights implicitly challenge neoliberal practices and assumptions by their support for other ways of living’ (Bargh 2007: 1). Scholars make visible the persistence of the colonial in the concrete and material conditions of everyday neoliberal governance and life (Howard-Wagner & Kelly 2011: 103). As Bargh (2007), Altamirano-Jiménez (2013), Howard-Wagner (2010b, 2015) and others note, indigenous categorisations of neoliberal practices as a form of colonisation relate to a concern that neoliberalism in its multiple forms poses a threat to indigenous ways of life. This scholarship also critically reflects on the reshaping of the relationship between the state and indigenous peoples under neoliberalism (Altamirano-Jiménez 2004, Bargh 2007, Howard-Wagner 2009). For example, it draws attention to the increasing intervention in the lives of indigenous peoples (Howard-Wagner 2007, 2009, 2010a, 2010b) and the dispossession of indigenous people through privatisation (Wolfe 2006, Howard-Wagner 2012, Altamirano-Jiménez 2013, Coulthard 2014). It does not, however, preclude agency, resistance and decolonisation. Interpretive micro-studies about indigenous peoples’ engagement with neoliberalism provide particular value. They tell us about actually existing neoliberalism in the context of intervention in the everyday lives of indigenous peoples, contests over rights, contests over policy and the complex decisions indigenous people are making about how to protect their rights and navigate diverse economies involving neoliberal policies and practices