Where in the World Are “Low- and Middle-Income Settings”? : Cancer Nursing

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DEPARTMENTS: Guest Editorial

Where in the World Are “Low- and Middle-Income Settings”?

Challinor, Julia PhD, RN

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Cancer Nursing 46(3):p 171-172, 5/6 2023. | DOI: 10.1097/NCC.0000000000001220
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Historically, global health discourse has spoken of developing or emerging versus developed or industrialized countries; low-, middle-, and high-income countries; the Global South and Global North; resource-limited, resource-poor, or resource-constrained countries; and high- or well-resourced countries, among other terms. None of these terms have been without controversy. Arguments have been made that all countries are developing and include regional disparities in healthcare, welfare, and access to care that are clearly visible and documented. Australians and New Zealanders often bristle at the term Global South to connote on a par with low- and middle-income countries because they are designated as high-income countries by the World Bank and others but happen to be located south of the equator. Resource-limited or resource-constrained can apply to areas of poverty and poor access to resources in all countries because no country currently enjoys universal income equity.

Classification of countries by income level was originally designed to determine the amount of aid received internationally from groups such as the International Monetary Fund and the World Bank.1 Advocates for International Development recently published a comparison of 3 systems of developed/developing country taxonomy: United Nations Development Program, International Monetary Fund, and World Bank. One category example for a less-resourced country includes “developing country,” “emerging and developing country,” and “low- and middle-income countries,” respectively.2 These classifications and terminologies have been adopted by many nongovernmental organizations and professional societies and associations to regulate annual dues and eligibility for scholarships to attend annual conferences, among other uses. However, ranking countries by income level provides an outdated view according to critics.1 Several authors have recently criticized global health and development language as colonialist, reductionist, and exclusionary and often based on wealth and political power.3–5 They suggest that terms such as “developing countries,” “third world,” and “limited resources” all assume an artificial hierarchy according to those with the wealth and power.3 The Organization for Economic Co-operation and Development points out that even countries described by the World Bank as having low income have tremendous resources, “Natural capital [soil, water, fisheries, forests and minerals are the principal sources of income] constitutes a quarter of total wealth in low-income countries.”6

Gapminder, an independent nonprofit located in Sweden, uses data to correct generally accepted misconceptions about multiple topics such as migration, education, and economic growth. Gapminder has suggested categorizing income level by individuals instead of countries. People at level 1 earn <$2 a day (extreme poverty), those at level 2 earn $2 to $8 a day (just less than half of the global population), those at level 3 earn $8 to $32 per day, and those at level 4 earn >$32 a day.7 This approach avoids generalizations as broad as clumping 1.4 billion people living in India in 1 category of lower-middle income (World Bank), when the diversity of wealth is so stark. According to the Indian Forum, over the last 10 years, 10% of the population has more than 60% of the wealth, whereas 6% of the total wealth is shared by 50% of the population.8

Is it reasonable to consider cancer surveillance, treatment, and survivorship in a country in terms as broad as income level or in old and offensive terms based on colonialism and world power? Or does it make sense to apply the precision we use in precision medicine when speaking, writing, and taking action in settings where an individual’s circumstances may actually dictate his/her access to care and the quality of the care delivered?

I propose that instead of using generalized statistics and anachronistic language about income or wealth to categorize countries, we as oncology nurses reframe this discourse and join those looking for a fairer and more neutral taxonomy. We should not succumb to disenfranchising vocabulary that ignores the real challenges of cancer incidence, treatment access, and survival in every country, regardless of income or resource ranking. Efforts to save each patient with cancer, despite cost, are valiant, but not if they direct funds and action away from thousands who are by definition of geography at a higher risk of cancer and even if/when diagnosed unable to access appropriate care and have a reasonable chance at survival. This population is found in all countries, albeit in differing numbers because some countries have universal healthcare benefits, for example, Brazil, Norway, and Denmark, which can narrow the access gap. The time is now to revise our language and shift our attention to those for whom composite statistics are not a reality. By revisiting the taxonomy of existing global oncology discourse about the haves and have nots, nurses can bring the patient with cancer to the fore and this would truly reflect people-centered healthcare as recommended by the World Health Organization.9

Julia Challinor, PhD, RN
School of Nursing, University of California San Francisco


1. Prydz Espen Beer WD. Classifying countries by income. World Bank Web site. https://datatopics.worldbank.org/world-development-indicators/stories/the-classification-of-countries-by-income.html. Accessed December 29, 2022.
2. Gbadamosi A. Understanding the developed/developing country taxonomy. A4ID advocates for international development. https://www.a4id.org/policy/understanding-the-developeddeveloping-country-taxonomy/. Accessed December 30, 2022.
3. Khan T, Abimbola S, Kyobutungi C, Pai M. How we classify countries and people-and why it matters. BMJ Glob Health. 2022;7:e009704.
4. Büyüm AM, Kenney C, Koris A, Mkumba L, Raveendran Y. Decolonising global health: if not now, when? BMJ Glob Health. 2020;5(8):e003394.
5. Müller M. In search of the global east: thinking between north and south. Geopolitics. 2020;25(3):734–755.
6. Organisation for Economic Co-operation and Development. Natural resources and pro-poor growth: the economics and politics. https://www.oecd.org/dac/environment-development/naturalresourcesandpro-poorgrowththeeconomicsandpolitics.htm#:~:text=Natural%20capital%20constitutes%20a%20quarter,the%20principal%20sources%20of%20income. Accessed December 29, 2022.
7. Gapminder. Income levels. https://www.gapminder.org/fw/income-levels/. Accessed January 5, 2023.
8. Ghatak M, Raghavan R, Xu L. Trends in economic inequality in India. https://www.theindiaforum.in/economy/trends-economic-inequality-india#:~:text=For%20the%20most%20recent%20decade,over%20the%20past%2040%20 years. Accessed January 5, 2023.
9. World Health Organization. People-centred healthcare: a policy framework. https://www.who.int/publications/i/item/9789290613176. Accessed January 5, 2023.
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