Tag: uncategorized

Red Hot Ice by Frank Kane (1912 – 1968)

A Case of Corpses… They piled up so fast that private-eye Johnny Liddell figured he was ahead if he found them still warm. It started when he was hired as baby-sitter to a wildcat. She was blond and beautiful, and stacked better than a deck of marked cards. And she had a cool $200,000 worth of hot diamonds. There was just one hitch. She used bourbon instead of perfume. (Summary by Rear cover, 1955 Dell paperback edition)

SPIRIT 2025 statement: Updated guideline for protocols of randomised trials – ​An-Wen Chan

by An-Wen Chan, Isabelle Boutron, Sally Hopewell, David Moher, Kenneth F. Schulz, Gary S. Collins, Ruth Tunn, Rakesh Aggarwal, Michael Berkwits, Jesse A. Berlin, Nita Bhandari, Nancy J. Butcher, Marion K. Campbell, Runcie C. W. Chidebe, Diana R. Elbourne, Andrew J. Farmer, Dean A. Fergusson, Robert M. Golub, Steven N. Goodman, Tammy C. Hoffmann, John P. A. Ioannidis, Brennan C. Kahan, Rachel L. Knowles, Sarah E. Lamb, Steff Lewis, Elizabeth Loder, Martin Offringa, Philippe Ravaud, Dawn P. Richards, Frank W. Rockhold, David L. Schriger, Nandi L. Siegfried, Sophie Staniszewska, Rod S. Taylor, Lehana Thabane, David J. Torgerson, Sunita Vohra, Ian R. White, Asbjørn Hróbjartsson

Importance

The protocol of a randomised trial is the foundation for study planning, conduct, reporting, and external review. However, trial protocols vary in their completeness and often do not address key elements of design and conduct. The SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) statement was first published in 2013 as guidance to improve the completeness of trial protocols. Periodic updates incorporating the latest evidence and best practices are needed to ensure that the guidance remains relevant to users.

Objective

To systematically update the SPIRIT recommendations for minimum items to address in the protocol of a randomised trial.

Design

We completed a scoping review and developed a project specific database of empirical and theoretical evidence to generate a list of potential changes to the SPIRIT 2013 checklist. The list was enriched with recommendations provided by lead authors of existing SPIRIT/CONSORT (Consolidated Standards of Reporting Trials) extensions (Harms, Outcomes, Non-pharmacological Treatment) and other reporting guidelines (TIDieR). The potential modifications were rated in a three-round Delphi survey followed by a consensus meeting.

Findings

Overall, 317 individuals participated in the Delphi consensus process and 30 experts attended the consensus meeting. The process led to the addition of two new protocol items, revision to five items, deletion/merger of five items, and integration of key items from other relevant reporting guidelines. Notable changes include a new open science section, additional emphasis on the assessment of harms and description of interventions and comparators, and a new item on how patients and the public will be involved in trial design, conduct, and reporting. The updated SPIRIT 2025 statement consists of an evidence-based checklist of 34 minimum items to address in a trial protocol, along with a diagram illustrating the schedule of enrolment, interventions, and assessments for trial participants. To facilitate implementation, we also developed an expanded version of the SPIRIT 2025 checklist and an accompanying explanation and elaboration document.

Conclusions and relevance

Widespread endorsement and adherence to the updated SPIRIT 2025 statement have the potential to enhance the transparency and completeness of trial protocols for the benefit of investigators, trial participants, patients, funders, research ethics committees, journals, trial registries, policymakers, regulators, and other reviewers.

Improving transparency in clinical trial reporting – ​Alison Farrell

by Alison Farrell, On Behalf of the PLOS Medicine Editors

The power to interpret the results of randomised clinical trial results relies on transparent reporting of the study design, protocol, methods and analyses. Without such clarity, the benefits of the findings, to both healthcare, policy and research, cannot be realized in full. The publication of the updated CONSORT 2025 and SPIRIT 2025 statements for reporting of randomised clinical trials and protocols, respectively, offers the opportunity to reflect on the power that transparent reporting of clinical trial design and data offers to improve the quality of trials and outcomes.

Collections of the State Historical Society of Wisconsin Vol 1 by Lyman Copeland Draper (1815 – 1891)

The Wisconsin Historical Society was founded in 1846, even before Wisconsin achieved U.S. statehood. The Secretary, Lyman Draper, began in the early 1850s to solicit articles from around the state containing early impressions and descriptions of original pioneer settlers. Settlement of the territory was so recent that some authors were personally acquainted with the first settlers in their areas. This first volume of the State Historical Society Collections, edited by Draper and published in 1855, contains accounts by travelers in the 1700s and early 1800s, accounts of early settlements, and information about the Native Americans that inhabited the Territory. – Summary by Ted Lienhart

Low HIV-risk aligned discontinuation among HIV pre-exposure prophylaxis users within public HIV clinics in Kenya: A mixed method study – ​Njeri Wairimu

by Njeri Wairimu, Kenneth Ngure, Vallery Ogello, Emmah Owidi, Paul Mwangi, Lydia Etyang, Winnie Waituika, Margaret Mwangi, Dominic M. Githuku, Simon Maina, Elizabeth Irungu, Nelly Mugo, Kenneth K. Mugwanya

Adherence to oral HIV pre-exposure prophylaxis (PrEP) is crucial for its effectiveness, however, studies have shown that PrEP use wanes within the first six months. We sought to understand reasons for discontinuation among individuals previously accessing PrEP from HIV clinics. Between November 2020 – January 2023, we conducted a mixed methods sub-study within a programmatic study to improve the efficiency of PrEP delivery in four public HIV clinics in Kenya (ClinicalTrials.gov number NCT04424524). We used random simple stratification to select individuals who had discontinued PrEP and completed surveys; we purposively sampled a subset of participants for in-depth interviews. Quantitative data were analyzed descriptively; qualitative data were analyzed thematically guided by the socio-ecological model. Overall, 300 participants completed surveys; median age was 35 years (interquartile range 28-43), 61% were female and 57% were married/cohabiting. Majority (76%) discontinued PrEP because of low perceived risk of HIV acquisition. Nearly half (43.7%) reported not being at risk, 23% had separated from their partners or had partners who were virally suppressed (6%), 3.3% were discontinued by healthcare providers. Other reasons for discontinuation were PrEP use concerns (15.6%) including concerns about side effects (8.7%) and daily pill burden (6%). Accessibility challenges (4%), and opportunity costs such as fear of missing/losing work (1%) were reported less frequently. Similarly in qualitative interviews, participants (n=30) reported PrEP discontinuation was mainly driven by perceived low HIV risk due to changes in relationship dynamics (separation/partner relocation), partner achieving viral suppression for those in serodifferent partnerships and reduced sexual activity (individual and interpersonal factors). Other themes included perceived HIV/PrEP stigma (community factors), frequency of clinic visits and long wait times (structural/institutional factors). PrEP discontinuation was mainly associated with perceived low HIV risk in this study population. Prevention-effective adherence counselling is essential in supporting individuals to correctly assess HIV risk to inform appropriate discontinuation.

Assessing the global implications of the COVID-19 pandemic on the cervical cancer elimination initiative – ​Anisha M. Loeb

by Anisha M. Loeb, Patti Gravitt, Allison Frank, Douglas M. Puricelli Perin, Kalina Duncan, Linda Eckert, Maribel Almonte, Nathalie Broutet, Joseph Rodman, Oyeleke A. Oyebamiji, Prajakta Adsul

The COVID-19 pandemic disrupted many public health programs; understanding these disruptions is critical for directing future resources. In a project studying the implementation of human papillomavirus (HPV) testing-based cervical cancer screening, we queried about the impact of the pandemic on screening programs globally. In consultation with World Health Organization’s Regional Advisors, program managers, government officials, and clinicians involved in the implementation of HPV testing-based cervical cancer screening programs were invited to participate in semi-structured, in-depth, interviews. Interview notes and transcripts were used for inductive analysis, focusing on responses to the impact of COVID-19 pandemic on screening programs. Thirty-two interviews were conducted with participants between the age of 29 and 61 years, representing programs from 25 countries. Six key themes were noted. Regarding disruptions, (1) the entire cancer continuum was affected, leading to delays or, in some cases even cessation of vaccination, screening, and treatment programs; and (2) a heightened sense of fear around contracting and transmitting COVID-19 shifted government priorities and impacted healthcare delivery. Nonetheless, participants noted constructive ways in which programs leveraged the impact of the pandemic: (1) at the community level, participants were able to leverage an increased understanding and acceptance surrounding the importance of preventive health behaviors; (2) for HPV-testing: molecular laboratories became well-equipped with better technician training, increasing overall HPV-testing capacities; (3) the pandemic promoted virtual healthcare systems; and (4) for planning: shutdowns allowed time to plan for program scale-up. In many ways, the pandemic response provided evidence supporting countries’ abilities to mobilize resources. While disruptions were noted, the pandemic provided implementers with opportunities to strengthen screening programs, which should be further assessed in future sustainability research on cervical cancer prevention and control.

A Critical juncture in global health: Leveraging historical institutionalism to examine PEPFAR dependency and inform the development of self-reliant public health systems – ​Alison Wiyeh

by Alison Wiyeh, Patience Komba, Samuel Akombeng Ojong, Charles S. Wiysonge, Bih Moki-Suh, Patricia Sadate-Ngatchou, Ferdinand C. Mukumbang

The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has played an important role in expanding access to antiretroviral therapy (ART) and significantly reducing HIV/AIDS mortality globally. However, policy shifts in the United States(US) aimed at realigning foreign aid with US national interests have introduced significant uncertainty regarding PEPFAR funding in 2025, threatening to undermine decades of progress in the global HIV/AIDS response. Many countries that have long relied on PEPFAR funding are trapped in a cycle where sustained donor aid has limited their transition to self-reliant, country-led HIV programs. We leverage historical institutionalism to examine how past structures, especially colonial-era institutions, have constrained African nations and limited their capacity for self-determination through the phenomenon of path dependency. Foreign aid, often aligned with the geopolitical and economic interests of donor nations, has further undermined institutional resilience in aid-recipient countries. The recent halt in PEPFAR funding, marks a critical juncture in global health, with the potential to catalyze long-overdue systemic reforms in African health systems. As uncertainty around U.S. foreign aid grows, we anticipate an increase in engagement from private and philanthropic funders. Without corrective action, the persistence of inefficient institutional pathways will continue to undermine the impact of financial investments in many African institutions, jeopardizing the effectiveness and sustainability of initiatives aimed at improving national health outcomes. For sustainable reforms in former colonies, countries must first acknowledge the constraints of colonial legacies, decolonize mindsets and institutions, define their own development priorities, and establish transparent, accountable governance, alongside political stability as fundamental pillars for progress. PEPFAR is the first major global health program to be affected, and it is unlikely to be the last. How much longer will recipient countries remain dependent on donor funding to safeguard the health and lives of their populations?

Qualitative study of acceptability, benefits, and feasibility of a food-based intervention among participants and stakeholders of the RATIONS trial – ​Sunita Sheel Bandewar

by Sunita Sheel Bandewar, Madhavi Bhargava, Hema Pisal, Sharanya Sreekumar, Anant Bhan, Ajay Meher, Anurag Bhargava

A qualitative study was conducted during the RATIONS trial to explore the perceptions, experiences, and expectations of participants and stakeholders on the acceptability, benefits, and feasibility of the nutritional intervention to complement the trial findings for deeper exploration into why and how of these findings and other allied themes. Using purposive sampling, we recruited 58 individuals for 22 in-depth interviews (IDI) and four focus group discussions (FGDs) between January and June 2022. These included 12 patients with TB, six household contacts, and other stakeholders (18 trial members, 18 government community workers, and four National TB Elimination Program (NTEP) staff). All IDIs and FGDs were audio-recorded, transcribed, and translated. The codes were generated using an inductive process and categorized manually into themes, with direct quotes describing the themes. The intervention was found to be acceptable in terms of cultural compatibility, quality, quantity, and duration; considered beneficial in helping tolerate the adverse effects of medications, weight gain, and resuming work; and was considered life-saving by many during the COVID-19 pandemic. Other observations included food-sharing in the control arm, inability to regain pre-disease functional status despite weight gain, and preference for in-kind support. Community health workers expressed confidence in its feasibility and willingness to take responsibility for its implementation. The NTEP staff considered it feasible if necessary resources were provided. This qualitative inquiry reflected the perspectives and lived experiences of households experiencing poverty, food insecurity, TB and the stakeholders serving them. Their voices are relevant in framing policy and practice in the NTEP and future research in India and similar low-resource settings. The food-based intervention was perceived as acceptable, feasible, and beneficial for the recipients and the NTEP. Opinion on cash or support in kind was divided; many preferred in-kind support over cash, but others expressed a requirement for both.

Examining national health insurance fund members’ preferences and trade-offs for the attributes of contracted outpatient facilities in Kenya: A discrete choice experiment – ​Jacob Kazungu

by Jacob Kazungu, Edwine Barasa, Justice Nonvignon, Matthew Quaife

Patient choice of health facilities is increasingly gaining recognition for potentially enhancing the attainment of health system goals globally. In Kenya, National Health Insurance Fund (NHIF) members are required to choose an NHIF-contracted outpatient facility before accessing care. Understanding their preferences could support resource allocation decisions, enhance the provision of patient-centered care, and deepen NHIF’s purchasing decisions. We employed a discrete choice experiment to examine NHIF members’ preferences for attributes of NHIF-contracted outpatient facilities in Kenya. We developed a d-efficient experimental design with six attributes, namely availability of drugs, distance from household to facility, waiting time at the facility until consultation, cleanliness of the facility, attitude of health worker, and cadre of health workers seen during consultation. Data were then collected from 402 NHIF members in six out of 47 counties. Choice data were analysed using panel mixed multinomial logit and latent class models. NHIF members preferred NHIF-contracted outpatient facilities that always had drugs [β=1.572], were closer to their households [β=-0.082], had shorter waiting times [β=-0.195], had respectful staff [β=1.249] and had either clinical officers [β=0.478] or medical doctors [β=1.525] for consultation. NHIF members indicated a willingness to accept travel 17.8km if drugs were always available, 17.7km to see a medical doctor for consultation, and 14.6km to see respectful health workers. Furthermore, NHIF members indicated a willingness to wait at a facility for 8.9 hours to ensure the availability of drugs, 8.8 hours to see a doctor for consultation, and 7.2 hours to see respectful health workers. Understanding NHIF member preferences and trade-offs can inform resource allocation at counties, service provision across providers, and purchasing decisions of purchasers such as the recently formed social health insurance authority in Kenya as a move towards UHC.

A comparison of national seasonal influenza treatment guidelines across the Asia Pacific region – ​Ellen Beer

by Ellen Beer, Simon Boyd, Phrutsamon Wongnak, Thundon Ngamprasertchai, Nicholas J. White

Seasonal influenza leads to 2–3 million infections and up to 650,000 global deaths annually, with particularly high mortality in Asia and relatively low annual vaccination rates for prevention. Relatively lower attention is paid to antiviral treatment as a facet of influenza response strategy both in research and national policy. This study compares national influenza treatment guidelines across countries in the Asia Pacific region, and assesses the antiviral recommendations, comprehensiveness, availability, and quality, compared with World Health Organisation (WHO) guidelines. Ministry of Health websites were searched, and key stakeholders were contacted to obtain national influenza treatment guidelines. Official guidelines detailing pharmacologic treatment for seasonal influenza were included. Key data for comparison were extracted and quality appraisal was conducted using the AGREE II instrument. Out of 49 countries and areas in the World Health Organisation Western Pacific and South-East Asia regions, under half (14/49; 28.6%) had established national influenza treatment guidelines. Nine (9/49; 18.4%) reported no seasonal flu guidelines at all, and information could not be obtained for 25 (51.0%). All guidelines recommend oseltamivir in line with WHO recommendations, although rationale and evidence reviews were often missing. There was variation in recommendations for other antivirals, indications for treatment, definitions of severity and recency of publication. The AGREE II tool quality assessments revealed the highest average scores were observed in the ‘presentation’ domain and lowest scores in ‘editorial independence’ and ‘rigour of development’ domains, demonstrating limited evidence-based guideline development. The variability in recommendations and definitions highlight the need for a stronger evidence base with direct comparisons of antiviral treatment for hard and soft endpoints, and improvements in systematic guideline development. Established treatment guidelines are a key component of national influenza response strategy and in the post-covid pandemic era, renewed attention to seasonal influenza management is surely warranted.

Multimorbidity and health system priorities in Zimbabwe: A participatory ethnographic study – ​Justin Dixon

by Justin Dixon, Efison Dhodho, Fionah Mundoga, Karen Webb, Pugie Chimberengwa, Trudy Mhlanga, Tatenda Nhapi, Theonevus T. Chinyanga, Justice Mudavanhu, Lee Nkala, Ronald Nyabereka, Gwati Gwati, Gerald Shambira, Trust Zaranyika, Clare I. R. Chandler, Rashida A. Ferrand, Chiratidzo E. Ndhlovu

Multimorbidity, increasingly recognised as a global health challenge, has recently emerged on the health agendas of many countries experiencing rapid epidemiological change, including in Africa. Yet with its conceptual origins in the global North, its meaning and possible utility in African contexts remains abstract. This study drew together policymakers, public health practitioners, academics, health informaticians, health professionals, and people living with multimorbidity (PLWMM) in Zimbabwe to understand: What is the transformative potential and possible limitations of elevating multimorbidity as a priority in this setting? To bring these different perspectives into conversation, we used a participatory ethnographic design that involved a health facility survey, participant-observation, in-depth interviews, audio-visual diaries, and participatory workshops. We found that multimorbidity was new to many respondents but generally viewed as a meaningful and useful concept. It captured the increasingly complex health profile of Zimbabwe’s ageing population, foregrounded a range of challenges related to the ‘vertical’ organisation and uneven funding of different conditions, and revealed opportunities for integration across entrenched silos of knowledge and practice. However, with capacity and momentum to address multimorbidity concentrated within the HIV programme, there was concern that multimorbidity could itself become verticalized, undercutting its transformative potential. Participants agreed that responding to multimorbidity requires a decisive shift from vertical, disease-centred programming to restore the comprehensive primary care that undergirded Zimbabwe’s once-renowned health system. It also means building a policy-enabling environment that values generalist (as well as specialist) knowledge, ground-level experience, and inclusive stakeholder engagement. We conclude that the ‘learning’ health system represents a promising conceptual lens for unifying these imperatives, providing a tangible framework for how knowledge, policy, and practice synergise within more self-reliant, person-centred health systems able to respond to complex health challenges like multimorbidity.

Fides News – EnglishAFRICA – Pope Francis and his tireless pursuit of peace in the face of African conflicts​

by Luca Mainoldi

Rome – Two images capture more than any others the relentless efforts of Pope Francis to put an end to the wars that are tearing African peoples apart.
The first image shows Pope Francis kneeling in the “Casa Santa Marta,” where he kisses the feet of South Sudanese President Salva Kiir Mayardit and the designated vice presidents present, including Riek Machar, the president’s historic rival, and Rebecca Nyandeng De Mabio. It was April 11, 2019. With this extraordinary gesture, which came at the end of a two-day spiritual retreat attended by civil and church authorities from the African country, Pope Francis seemed to want to act on behalf of the peoples suffering from war, asking those in power who cause and fuel it to stop and give hope for peace.
The Bishop of Rome accompanied this gesture with the following words: “To the three of you who signed the Peace Agreement, I ask you, as a brother, remain in peace. I ask you from the heart. Let us move forward. There will be many problems, but don’t be afraid, go forward, resolve the problems. You have started a process; may it end well. Although struggles will arise, these should stay “within the office,hands united”. “In this way, from simple citizens, you will become Fathers of the Natio”. Allow me to ask this of you from the bottom of my heart, with my deepest feelings.”
South Sudan, a very young country that emerged in 2011 after seceding from Sudan, was plunged into a bloody civil war in December 2013 due to the conflict between the two rivals Salva Kiir and Riek Machar.
When Pope Francis made this gesture, the country was in a delicate phase following the signing of a transitional peace agreement in August 2018. The successor to Peter called on the parties to the conflict to resolve the issues that had led to the conflict in order to finally bring peace to the people. On this occasion, Pope Francis also announced his intention to visit South Sudan. This took place in February 2023. A visit under the banner of ecumenism. Pope Francis was accompanied by the Primate of the Anglican Communion, the Archbishop of Canterbury, Justin Welby, and the Moderator of the Presbyterian Church of Scotland, Pastor Iain Greenshields. An ecumenical pilgrimage of peace, as the Pope himself said: “I come as a pilgrim of peace.” In the ecumenical prayer that took place on February 4, 2023, at the John Garang Mausoleum in Juba, Pope Francis said: “My dear friends, those who call themselves Christians must choose a side. Those who follow Christ always choose peace; those who unleash war and violence betray the Lord and deny his Gospel. The attitude that Jesus teaches us is clear: to love all people because all are loved by our common Father in heaven as his children. The love of Christians is not only for their neighbor, but for everyone, because in Jesus everyone is our neighbor, our brother and sister, even our enemy ; all the more so those who belong to our own people, even if they are of a different ethnicity.”
Another emblematic image of Pope Francis’ concern for the suffering of the peoples of the African continent is the opening of the Holy Door in the Cathedral of Notre Dame in Bangui, the capital of the Central African Republic, on November 29, 2015, with which he anticipated the beginning of the Extraordinary Holy Year of Mercy, which was to begin officially on December 8.
“Today Bangui becomes the spiritual capital of the world,” said Pope Francis in his homily. ”The Holy Year of Mercy comes ahead of time to this country. A country that has suffered for many years from war and hatred, from misunderstanding and lack of peace. But this suffering country also includes all those countries that bear the cross of war. Bangui will be the spiritual capital of prayer for the mercy of the Father. We all ask for peace, mercy, reconciliation, forgiveness, love. For Bangui, for the entire Central African Republic, for the whole world, for the countries suffering from war, we ask for peace!”
Pope Francis’ relentless call for peace concerns not only the conflicts that are present in the media, but also the “forgotten” ones, many of which are scattered across the African continent: South Sudan, Sudan, the Democratic Republic of Congo, the Central African Republic, Niger, Burkina Faso, Mali, Nigeria, Somalia, and Ethiopia. Pope Francis recalled that the repeatedly denounced “world war in pieces” appeals to the conscience of every individual.

by Luca MainoldiRome – Two images capture more than any others the relentless efforts of Pope Francis to put an end to the wars that are tearing African peoples apart. The first image shows Pope Francis kneeling in the “Casa Santa Marta,” where he kisses the feet of South Sudanese President Salva Kiir Mayardit and the designated vice presidents present, including Riek Machar, the president’s historic rival, and Rebecca Nyandeng De Mabio. It was April 11, 2019. With this extraordinary gesture, which came at the end of a two-day spiritual retreat attended by civil and church authorities from the African country, Pope Francis seemed to want to act on behalf of the peoples suffering from war, asking those in power who cause and fuel it to stop and give hope for peace.The Bishop of Rome accompanied this gesture with the following words: “To the three of you who signed the Peace Agreement, I ask you, as a brother, remain in peace. I ask you from the heart. Let us move forward. There will be many problems, but don’t be afraid, go forward, resolve the problems. You have started a process; may it end well. Although struggles will arise, these should stay “within the office,hands united”. “In this way, from simple citizens, you will become Fathers of the Natio”. Allow me to ask this of you from the bottom of my heart, with my deepest feelings.”South Sudan, a very young country that emerged in 2011 after seceding from Sudan, was plunged into a bloody civil war in December 2013 due to the conflict between the two rivals Salva Kiir and Riek Machar.When Pope Francis made this gesture, the country was in a delicate phase following the signing of a transitional peace agreement in August 2018. The successor to Peter called on the parties to the conflict to resolve the issues that had led to the conflict in order to finally bring peace to the people. On this occasion, Pope Francis also announced his intention to visit South Sudan. This took place in February 2023. A visit under the banner of ecumenism. Pope Francis was accompanied by the Primate of the Anglican Communion, the Archbishop of Canterbury, Justin Welby, and the Moderator of the Presbyterian Church of Scotland, Pastor Iain Greenshields. An ecumenical pilgrimage of peace, as the Pope himself said: “I come as a pilgrim of peace.” In the ecumenical prayer that took place on February 4, 2023, at the John Garang Mausoleum in Juba, Pope Francis said: “My dear friends, those who call themselves Christians must choose a side. Those who follow Christ always choose peace; those who unleash war and violence betray the Lord and deny his Gospel. The attitude that Jesus teaches us is clear: to love all people because all are loved by our common Father in heaven as his children. The love of Christians is not only for their neighbor, but for everyone, because in Jesus everyone is our neighbor, our brother and sister, even our enemy ; all the more so those who belong to our own people, even if they are of a different ethnicity.”Another emblematic image of Pope Francis’ concern for the suffering of the peoples of the African continent is the opening of the Holy Door in the Cathedral of Notre Dame in Bangui, the capital of the Central African Republic, on November 29, 2015, with which he anticipated the beginning of the Extraordinary Holy Year of Mercy, which was to begin officially on December 8.“Today Bangui becomes the spiritual capital of the world,” said Pope Francis in his homily. ”The Holy Year of Mercy comes ahead of time to this country. A country that has suffered for many years from war and hatred, from misunderstanding and lack of peace. But this suffering country also includes all those countries that bear the cross of war. Bangui will be the spiritual capital of prayer for the mercy of the Father. We all ask for peace, mercy, reconciliation, forgiveness, love. For Bangui, for the entire Central African Republic, for the whole world, for the countries suffering from war, we ask for peace!”Pope Francis’ relentless call for peace concerns not only the conflicts that are present in the media, but also the “forgotten” ones, many of which are scattered across the African continent: South Sudan, Sudan, the Democratic Republic of Congo, the Central African Republic, Niger, Burkina Faso, Mali, Nigeria, Somalia, and Ethiopia. Pope Francis recalled that the repeatedly denounced “world war in pieces” appeals to the conscience of every individual.