Hemoglobin level was primarily associated with iron status in these Indian toddlers; however, maternal hemoglobin level, family wealth, and food insecurity were also important factors. Strategies for minimizing childhood anemia must include optimized iron intake but should simultaneously address maternal anemia, poverty, and food insecurity.

It is very exceptional that a new disease becomes a true pandemic. Since its emergence in Wuhan, China, in late 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, has spread to nearly all countries of the world in only a few months. However, in different countries, the COVID-19 epidemic takes variable shapes and forms in how it affects communities. Until now, the insights gained on COVID-19 have been largely dominated by the COVID-19 epidemics and the lockdowns in China, Europe and the USA. But this variety of global trajectories is little described, analysed or understood. In only a few months, an enormous amount of scientific evidence on SARS-CoV-2 and COVID-19 has been uncovered (knowns). But important knowledge gaps remain (unknowns). Learning from the variety of ways the COVID-19 epidemic is unfolding across the globe can potentially contribute to solving the COVID-19 puzzle. This paper tries to make sense of this variability—by exploring the important role that context plays in these different COVID-19 epidemics; by comparing COVID-19 epidemics with other respiratory diseases, including other coronaviruses that circulate continuously; and by highlighting the critical unknowns and uncertainties that remain. These unknowns and uncertainties require a deeper understanding of the variable trajectories of COVID-19. Unravelling them will be important for discerning potential future scenarios, such as the first wave in virgin territories still untouched by COVID-19 and for future waves elsewhere.

BackgroundHealth systems interventions, such as capacity-building of health workers, are implemented across districts in order to improve performance of healthcare organisations. However, such interventions often work in some settings and not in others. Local health systems could be visualised as complex adaptive systems that respond variously to inputs of capacity building interventions, depending on their local conditions and several individual, institutional, and environmental factors. We aim at demonstrating how the realist evaluation approach advances complex systems thinking in healthcare evaluation by applying the approach to understand organisational change within local health systems in the Tumkur district of southern India.MethodsWe collected data on several input, process, and outcome measures of performance of the talukas (administrative sub-units of the district) and explore the interplay between the individual, institutional, and contextual factors in contributing to the outcomes using qualitative data (interview transcripts and observation notes) and quantitative measures of commitment, self-efficacy, and supervision style.ResultsThe talukas of Tumkur district responded differently to the intervention. Their responses can be explained by the interactions between several individual, institutional, and environmental factors. In a taluka with committed staff and a positive intention to make changes, the intervention worked through aligning with existing opportunities from the decentralisation process to improve performance. However, commitment towards the organisation was neither crucial nor sufficient. Committed staff in two other talukas were unable to actualise their intentions to improve organisational performance. In yet another taluka, the leadership was able to compensate for the lack of commitment.ConclusionsCapacity building of local health systems could work through aligning or countering existing relationships between internal (individual and organisational) and external (policy and socio-political environment) attributes of the organisation. At the design and implementation stage, intervention planners need to identify opportunities for such triggering alignments. Local health systems may differ in their internal configuration and hence capacity building programmes need to accommodate possibilities for change through different pathways. By a process of formulating and testing hypotheses, making critical comparisons, discovering empirical patterns, and monitoring their scope and extent, a realist evaluation enables a comprehensive assessment of system-wide change in health systems.Electronic supplementary materialThe online version of this article (doi:10.1186/1478-4505-12-42) contains supplementary material, which is available to authorized users.

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