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The COVID-19 pandemic accelerated a digital transformation in education across the globe. Almost overnight, schools shifted to online learning to mitigate the disruption to academic activities.

Although this transition was necessary to avoid learning loss, it came with unintended consequences—particularly in low-resource settings. The shift, once hailed as a great equalizer, instead deepened inequalities and introduced physical and mental health burdens on vulnerable student populations.  

Even in the aftermath of the pandemic, many educational institutions continue to adopt hybrid or fully online models of instruction. However, the long-term health effects of prolonged digital learning, particularly on students in under-resourced regions, remain under-explored in public discourse. In countries such as Nigeria—where for 13 years I have taught and mentored students across various universities— the digital divide is not just a technical gap. It is a health emergency in disguise. 

The challenges of digital migration are often measured by infrastructure indicators such as internet access, device availability, and bandwidth. In 2024, a joint study led by the World Health Organization, Europe, and the London School of Economics reported that access to the internet, availability of digital devices, and digital literacy are among the most urgent digital determinants of health.  

Yet, for students in northern Nigeria and similar low-resource environments, the digital learning experience goes beyond technical limitations. It exacts a toll on the mind and body, and the consequent risks toward physical, mental, and social health remain under-addressed. 

Mental Health 

Mental health and digital well-being remain some of the least addressed aspects of the digital education transition in low-resource settings. Cultural stigma and lack of access to psychological services mean that many students suffer in silence. Universities in Nigeria and other low- or middle-income countries typically do not have robust mental health programs, and online counseling remains a luxury available to only a few. 

The abrupt shift to digital platforms caused students to lose access to in-person support systems such as peer groups, academic mentors, and extracurricular activities that traditionally serve as buffers against stress. The World Health Organization, in collaboration with the Health Behaviour in School-Aged Children released a study warning of a growing mental health crisis among children and young people due to pandemic disruptions. However, little has been done to translate these warnings into targeted interventions for university students in low-resource environments. 

The Human Cost of Digital Learning 

Students in low-resource settings often lack access to personal laptops, stable electricity, suitable devices, or quiet environments to study. More than 66% attend online classes and complete assignments using smartphones, and nearly 40% lack a functional, online-ready smartphone for effective participation. Hours spent staring at small screens without ergonomic support have led to increased complaints of eye strain, poor posture, and chronic fatigue.

Postpandemic disruptions and new routines that could be linked to changes brought about by digital learning have contributed to rising reports of anxiety, depression, and stress-related symptoms. Those trends are consistent with emerging global burden of disease literature on the increase in the major depressive and anxiety disorders after the pandemic.

A 2022 study in Brazil indicated that the majority of university students enrolled in online classes experienced heightened levels of stress and anxiety during the pandemic. Although similar data from northern Nigeria remains limited, anecdotal evidence and small-scale surveys indicate that students experience these symptoms due to unstable internet connections, high data costs, and academic disruptions. 

Gendered Disparities 

The pressure to complete classwork without having the necessary learning tools and support systems leaves many students feeling isolated and overwhelmed. For female students, the burden is even greater. Cultural expectations often require women to manage household responsibilities alongside academic demands. Unlike their male counterparts, many juggle care-giving roles, domestic chores, and online classes simultaneously. Although preliminary observations from 36 countries suggest that the cumulative burden of these responsibilities has a negative impact on academic performance and mental well-being, a paucity of robust, population-specific evidence remains. Future research, particularly longitudinal studies and meta-analyses targeting the affected demographic, is essential to substantiate and quantify these effects.  

Such gendered disparities have been documented globally. A UN Educational, Scientific and Cultural Organization report from 2021 noted that the digital shift had a disproportionate effect on girls and young women in developing countries, often limiting their access to education and exacerbating existing inequalities. 

Toward an Equitable Digital Future 

The road to digital equity requires a multidimensional approach. To ensure that students enjoy a seamless transition to online learning, governments and institutions should adopt a comprehensive framework to address the intersection of digital learning and student well-being in low-resource settings.  

Instructors should begin with systematic needs assessments, ensuring that the unique digital and health-related challenges students face are identified and prioritized. Using such evidence, institutions can design awareness and wellness programs [PDF] that provide guidance on issues such as healthy screen time management, ergonomics, and coping strategies for stress and anxiety linked to digital education. At the same time, strengthening the digital infrastructure by incorporating flexibility in learning delivery using asynchronous content and low-bandwidth options, thereby making education more accessible and equitable, is essential.  

Equally important is the need to empower mental health support systems within academic environments. This includes building peer support networks, expanding access to telecounseling services, and training academic staff to recognize and support at-risk students. Finally, a transformative approach requires student codesign, in which students are active participants in shaping digital learning models. By incorporating student voices, experiences, and challenges into decision-making, institutions can ensure that emerging educational models are both contextually relevant and inclusive. 

Digital migration in education was an essential response to an unprecedented global crisis. Yet, in the urgency to go online, the unequal burdens students in low-resource settings carry were too often overlooked. If governments are to create a truly inclusive and sustainable digital future, they should confront those hidden costs head-on. This means integrating health, equity, and student voices into every stage of digital education design.

It is not merely an academic concern: It is a matter of public health, social justice, and global equity. 

Mesothelioma is a rare cancer that affects the tissue that lines many organs of the body. Approximately 30,000 cases are diagnosed every year worldwide, most of them in the pleura, or lining of the lungs. It occurs most often in people who have been exposed to asbestos.

“Mesothelioma is a difficult tumor to treat,” said the study’s lead author Joshua Reuss, MD, a thoracic medical oncologist with Georgetown’s Lombardi Comprehensive Cancer Center. “Our study demonstrated the feasibility and safety of using immunotherapy before surgery for patients who have tumors that can potentially be removed surgically.

“Immunotherapy is making substantial contributions to extending the lives of patients with lung cancer and many other solid tumors. This is an important step in identifying mesothelioma patients who could benefit from immunotherapy in the perioperative period, meaning right before or after their surgery and in choosing patients who are actually candidates for that surgery,” said Reuss, who is also an attending physician at MedStar Georgetown University Hospital.

Reuss designed the clinical trial during fellowship training at the Johns Hopkins Kimmel Cancer Center, the primary site where the study was conducted. He presented the results of the phase II study, Neoadjuvant Nivolumab or Nivolumab plus Ipililumab in Resectable Diffuse Pleural Mesothelioma, at the 2025 World Conference on Lung Cancer in Barcelona, Spain on September 8 and is lead author of the study published concurrently in the journal Nature Medicine (DOI 10.1038/s41591-025-03958-3).

Phase II clinical trials are designed to assess whether it is possible to deliver innovative treatments to specific patient populations, and whether the potential benefits of the therapy outweigh any adverse effects that patients experience.

“When looking at patient outcomes to date, the issue of whether any mesothelioma is truly resectable is controversial,” said Reuss. “Several major studies have not shown improvement in survival when surgery is incorporated into systemic therapy for mesothelioma. This study incorporates immunotherapy into the treatment of patients who might benefit from surgery.

“Since they occur in the tissue that lines the lungs, mesotheliomas don’t grow and spread like other cancers.” Reuss said. “They don’t typically form solid masses or nodules. These tumors are more fluid, or diffuse throughout the lining of the lung. That makes it more difficult to use our usual methods to determine how extensive a tumor is or to measure whether a treatment is effective by standard imaging assessments.”

In this study, the clinical team worked closely with scientists in the laboratory to test a novel approach studying circulating tumor DNA (ctDNA) in their patient’s blood. Tumors frequently shed cancer DNA into the blood stream. Oncologists can test the blood to detect the presence of this ctDNA, but their role in clinical decision-making is an evolving area of interest. This is particularly challenging in mesothelioma, a tumor type that has a low number of cancer mutations that can be detected by traditional ctDNA techniques.

“Imaging doesn’t always capture what’s happening with mesothelioma, especially during treatment,” said the study’s senior author, Valsamo Anagnostou, MD, PhD, the Alex Grass professor of oncology and co-director of the upper aerodigestive cancers program at Johns Hopkins. “By using an ultra-sensitive genome-wide ctDNA sequencing method, we were able to detect microscopic signs of cancer that imaging missed and predict which patients were most likely to benefit from treatment or experience relapse.”

“This approach may give us a baseline to monitor the efficacy of that treatment,” Reuss said. “If the ctDNA decreases or disappears, it is a good indication that the therapy is working, If not, it indicates a change in therapy may be warranted.” Reuss added that further validation of this methodology is required before it can routinely be incorporated into clinical practice.

“These analyses contribute to our understanding of which patients with mesothelioma may be candidates for surgery,” Reuss said. “Up until now, ctDNA assessments have not been part of the clinical landscape in the management of diffuse pleural mesothelioma, but our analyses suggest this may be nearing a change in the future.”

Phase II clinical trials are not designed to measure the clinical efficacy of treatment options but both arms of this trial showed improvements in the time from treatment to when the tumors began to grow again and overall length of survival.

Reuss cautions against drawing conclusions about that data, but notes that the results do provide positive signals about the potential value of neoadjuvant immunotherapy for mesothelioma patients with tumors that can be surgically removed and point the way to future studies.

“This is a small study,” he said, “and it does not tell us whether neoadjuvant immunotherapy will improve outcomes for these patients, but it does open windows of opportunity. We need to take what we learned and do further studies, dig deeper so that we can develop better therapies for patients with mesothelioma.”

The study was conducted across multiple academic cancer centers. The trial was sponsored by Bristol Myers Squibb. The research was supported in part by the Department of Defense Congressionally Directed Medical Research Programs grant CA190755, the Johns Hopkins Kimmel Cancer Center NCI Support Grant NCI CCSG P30 CA006973, the US Food and Drug Administration grant U01FD005942-FDA, National Institutes of Health grant CA1211113, the Bloomberg~Kimmel Institute for Cancer Immunotherapy, the ECOG-ACRIN Thoracic Malignancies Integrated Translational Science Center Grant UG1CA233259, the Robyn Adler Fellowship Award, the Commonwealth Foundation, the Mark Foundation for Cancer Research, and the Florence Lomax Eley Fund.

Reuss reports receives research funding through Georgetown University from Genentech/Roche, Verastem, Nuvalent, Arcus, Revolution Medicines, Regeneron, Amgen, DualityBio, and AstraZeneca, and serves in a consultant/advisory role for AstraZeneca, Bristol Myers Squibb, Daiichi Sankyo, Seagen, Gilead, Janssen, Novocure, Regeneron, Summit Therapeutics, Pfizer, Lilly, Natera, Merck, EMD Serono, Roche Diagnostics, and OncoHost. Anagnostou reports receiving research funding from Astra Zeneca and Personal Genome Diagnostics, Bristol-Myers Squibb, and Delfi Diagnostics, is an advisor to Astra Zeneca and Neogenomics and receives honoraria from Foundation Medicine, Guardant Health, Roche and Personal Genome Diagnostics. Other author disclosures are included in the manuscript.

Additional authors include Paul K. Lee, Reza J. Mehran, Chen Hu, Suqi Ke, Amna Jamali, Mimi Najjar, Noushin Niknafs, Jaime Wehr, Ezgi Oner, Qiong Meng, Gavin Pereira, Samira Hosseini-Nami, Mark Sausen, Marianna Zahurak, Richard J. Battafarano, Russell K. Hales, Joseph Friedberg, Boris Sepesi, Julie S. Deutsch, Tricia Cottrell, Janis Taube, Peter B. Illei, Kellie N. Smith, Drew M. Pardoll, Anne S. Tsao, Julie R. Brahmer, and Patrick M. Forde.