Correspondence

Pathology, Shaukat Khanum Memorial Cancer reports overall neonatal mortality, *Rashmi D’Souza, Barsha Prakash,
Hospital and Research Centre, Lahore, Pakistan (UH) there is no public system for Nirala Kumari Yadav, Oliver Ross,
1 Das M. Economic crisis in Sri Lanka causing monitoring outcomes within specific Kalpana Subedi
cancer drug shortage. Lancet Oncol 2022;
subgroups at high risk of having rashmi.d’[email protected]
23: 710.
2 Shakil FM. Pakistan awaits an economic SVNs, including prematurity and low Royal College of Paediatrics and Child Health, London
collapse. Al Mayadeen. Dec 9, 2022. https:// birthweight. WC1X 8SH, UK (RD’S, OR); Madhesh Institute of
english.almayadeen.net/articles/analysis/ Health Sciences, Janakpur, Nepal (BP); Nepal Neonatal
pakistan-awaits-an-economic-collapse The landscape of Nepal and its and Emergency Paediatric Care Programme, Janakpur,
(accessed Jan 2, 2023). health system results in challenges Nepal (NKY); Paropakar Maternity and Women’s
3 Statista. Pakistan—statistics & facts. https:// Hospital, Kathmandu, Nepal (KS)
www.statista.com/topics/2666/
in accessing care. First, the range of
pakistan/#topicOverview (accessed Feb 7, 2024). facilities delivering maternity and 1 Ministry of Health and Population. Human
Resources for Health Nepal country profile.
4 United Nations Development Programme. newborn care, including government, August, 2013. http://www.nhssp.org.np/
Human development report 2021/2022.
Uncertain times, unsettled lives: shaping our mission, and private hospitals, creates NHSSP_Archives/human_resources/HRH_
Nepal_profile_august2013.pdf (accessed
future in a transforming world. 2022. https:// difficulty in assuring quality in data April 4, 2023).
hdr.undp.org/system/files/documents/global-
report-document/hdr2021-22pdf_1.pdf
collection and services provided. 2 Ministry of Health, New ERA, ICF. Nepal
(accessed July 26, 2023). Second, the seven provinces of demographic and health survey 2016.
November, 2017. https://www.dhsprogram.
5 World Health Organisation. Cancer Pakistan Nepal span a range of terrains, from com/pubs/pdf/fr336/fr336.pdf (accessed
2020 country profile. https://cdn.who.int/
media/docs/default-source/country-profiles/ Himalayan villages at 4000 m to the April 4, 2023).
cancer/pak-2020.pdf?sfvrsn=ad5509e4_2 most populated and deprived lowland
&download=true (accessed Feb 7, 2024).
areas in Terai—the geography and
6 World Bank. Current health expenditure per
capita (current US$)—Pakistan. https://data. altitude can limit the availability of Living donor liver
worldbank.org/indicator/SH.XPD.CHEX.PC. services. Elsewhere, there is evidence
Published Online
CD?locations=PK (accessed Feb 7, 2024).
of an inverse care law in the ratio of
transplantation:
December 14, 2023
7 Yusuf MA. Pursuing excellence in cancer care
in Pakistan. Lancet Oncol 2022; 23: 1365–66. medical staff to population needs: 35 years of saving lives
https://doi.org/10.1016/
S0140-6736(23)01889-5
8 Business Standard. Pakistan faces shortage of Kathmandu valley has the highest
life-saving medicines including insulin: report.
Dec 21, 2022. https://www.business-standard. number of health workers while The first liver transplantation was
com/article/international/pakistan-faces- peripheral provinces have increased performed by Thomas E Starzl in a child
shortage-of-life-saving-medicines-including-
insulin-report-122122100108_1.html
newborn mortality rates, population with biliary atresia in 1963.1 Despite
(accessed Jan 7, 2023). density, and deprivation.1 initial setbacks, longer survival rates
9 Nazir Z. Pakistan’s brain drain crisis escalates as The 2016 Demographic and followed. The disproportion of donor
thousands leave. https://www.dw.com/en/
pakistans-brain-drain-crisis-escalates-as- Health Survey showed substantial graft size to recipient size initially
thousands-leave/a-65733569 (accessed variation in neonatal mortality posed a problem in paediatric liver
Feb 7, 2024).
rates across the country—15 deaths transplantation. Several techniques
10 Aljazeera. Imran Khan’s party received illegal
funds: Pakistan poll panel. Aug 2, 2022. per 1000 newborns in Province 4 were described to mitigate the issue:
https://www.aljazeera.com/news/2022/8/2/ versus 41 per 1000 in Province 7. first, graft reduction by Bismuth and
imran-khans-party-received-illegal-funds-
pakistan-poll-panel (accessed Jan 9, 2023). The extrapolated variation in SVN Houssin in 1984,2 and then split liver
outcomes is concerning.2 transplantation by Pichlmayr and
In view of the scale of unmet needs colleagues in 1988.3
Small vulnerable for SVN outlined in the Lancet Series, In 1989, Raia and colleagues 4
there is a clear case to record and described the first two living donor
newborns in Nepal: the understand SVN outcomes at a unit, liver transplantations for paediatric
need for data provincial, and national level in Nepal recipients. The technique was followed
and similar settings elsewhere. We by an ethical dilemma,5 with concerns
For the Series see https://www. The Lancet Series on small vulnerable propose the need to integrate SVN for donor safety in a more technically
thelancet.com/series/small- newborns (SVNs) highlights a key categories or similar outcomes into challenging surgery compared with
vulnerable-newborns
issue in Nepal and across low-income established national data reporting living donor kidney transplantation,
and middle-income countries: the pathways. This change will help which was an accepted procedure at
inconsistent data impede the ability reveal disparities and the need to the time.
of health systems to deliver care proportionately allocate funding and Despite these initial concerns,
proactively and proportionately. We resources, guiding policy makers to living donor liver transplantations
would like to share the complexities better care for newborns who cannot gained momentum, especially
of the current system in Nepal and advocate for themselves and have in regions where cultural and
suggested solutions. been, for too long, neglected by the religious barriers did not allow
Although the national Health health system. the use of deceased donor organs.
Information Management System We declare no competing interests. The procedure expanded from

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 Correspondence

paediatric to adult recipients, and 1 Starzl TE, Marchioro TL, Vonkaulla KN, high-income countries recognise as
from selected recipients to patients Hermann G, Brittain RS, Waddell WR. standard science. The incorporation of
Homotransplantation of the liver in humans.
with high urgency criteria, thanks to Surg Gynecol Obstet 1963; 117: 659–76. innovative social science approaches
technical advances. These advances 2 Bismuth H, Houssin D. Reduced-sized from low-income countries into
included the use of left lobe grafts, orthotopic liver graft in hepatic implementation science4 could be a
transplantation in children. Surgery 1984;
right lobe grafts, modified right lobe 95: 367–70. way to show its great possibilities to
grafts, and dual grafts in adults to 3 Pichlmayr R, Ringe B, Gubernatis G, Hauss J, better understand health problems
Bunzendahl H. Transplantation of a donor liver
overcome small-for-size syndrome. to 2 recipients (splitting transplantation)—
and define the best interventions with
Other advancements also supported a new method in the further development of an intercultural approach.
the growth of living donor liver segmental liver transplantation. Some researchers from low-income
Langenbecks Arch Chir 1988; 373: 127–30.
transplantations, including techniques 4 Raia S, Nery JR, Mies S. Liver transplantation and middle-income countries prefer
for graft reduction in paediatric from live donors. Lancet 1989; 2: 497. to be mouse head and not lion tail (a
liver transplantation, such as hyper- 5 McMaster P. Live donors and hepatic popular Spanish adage), and try to
transplantation. Lancet 1989; 2: 1042–3.
reduction and anterior hepatic contribute to science, especially that
resection of the left lateral segment, which can serve to highlight local
and the use of true monosegments to problems and propose solutions.
avoid large-for-size syndrome. Successful local science Perhaps, one day, science and
The success of the procedure technology national systems will
must be attributed, in part, to the
in low-income and recognise the differences in context
attention given to the surgery and middle-income and allow the development of a
the postoperative care of the donors, countries scientific system appropriate to the
as the wellbeing of these altruistic conditions in which science is done.
individuals is essential to any living Richard Horton’s Offline about the I declare no competing interests.
donor programme. A substantial north–south differences in science are
Alvaro J Idrovo
concern is organ trafficking, and the eloquent of a reality that we live with [email protected]
medical community must remain daily at universities in countries with
Public Health Department, School of Medicine,
continuously vigilant to combat these little financial support for research.1 Universidad Industrial de Santander, Bucaramanga
activities to maintain public trust in Although some contributions to elite 680006, Colombia
this procedure. science, ie, science with high global 1 Horton R. Offline: The silencing of the South.
35 years after it was first described, impact and real new knowledge, Lancet 2023; 401: 889.
2 Heinze T, Jappe A, Pithan D. From North
living donor liver transplantation originated from researchers from American hegemony to global competition for
has evolved into an established low-income and middle-income scientific leadership? Insights from the Nobel
surgical procedure, and continues countries, they hardly amount to a population. PLoS One 2019; 14: e0213916.
3 Escobar A. Worlds and knowledges otherwise.
to break new ground, with minimum proportion of scientific Cult Stud 2007; 21: 179–210.
innovations ranging from open and technological advances. A good 4 Boulton R, Sandall J, Sevdalis N. The cultural
donor hepatectomies to laparoscopic example is the Nobel prize,2 for which politics of ‘implementation science’.
J Med Humanit 2020; 41: 379–94.
and robotic liver resections. The rich countries have most of the prizes
technique has proven to be safe and in science, leaving countries with
has saved more than 80 000 lives few financial resources the prizes for China’s philosophy for a
worldwide since 2000, according to literature and peace.
the Global Observatory on Donation Scientific studies that require
healthier population
For more on the Global
and Transplantation. Going forward, expensive technology are difficult Richard Horton’s Offline piece1 fits in Observatory see https://www.
transplant-observatory.org
exercising continuous vigilance to carry out in countries with low well with the Confucianism philosophy
regarding donor health will be financial resources, without the of harmony and diversity advocated
essential to ensure continuity and help of researchers from wealthy by the Chinese society. Both political
future advancements in living donor countries. But the social sciences leaders and the general public believe
liver transplantations. do have novel approaches3 that can that harmony is the most valuable ideal.
We declare no competing interests. improve our understanding of the The same values are held in China’s
social determinants of health. The ancient medicine. The Inner Canon
Silvano Raia, *João Seda Neto
[email protected]
experiences of low-income countries of Huangdi2 (the Classic of Internal
are still scarcely acknowledged by elite Medicine, China’s earliest classic work
Faculdade de Medicina da Universidade de São
Paulo, São Paulo, Brazil (SR); Liver Transplantation, science, which has ignored methods on medicine) believes that harmony
Hospital Sírio-Libanês, São Paulo 01308-050, Brazil and findings because they do not between yin and yang is the key to good
(JSN) conform to what scientists from health and preventing disease.

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