Covid-19 expert committees had links to pharmaceutical companies in Latin America
Gonzalo Basile*
For the past ten years, epidemiologist and social scientist Gonzalo Basile has researched inequality in access to healthcare in Latin America and the Caribbean. In this interview, the Argentine specialist analyzes the successes and failures of the region's responses to COVID-19, as well as the involvement of the pharmaceutical industry and private companies in public health decisions. Basile is among the experts who will analyze the impacts of the health emergency at the international seminar "Peru and Latin America in Times of Pandemic," organized by the IEP in partnership with OjoPúblico , which will be held virtually from August 15 to 19. (Interview by Xilena Pinedo )
Now that the most critical phase of the pandemic has passed, researchers are discussing the need to build a scientific literature to understand the successes and failures of the measures adopted during the crisis and, above all, to help countries prepare for future epidemics. Since the beginning of the health emergency, epidemiologist and social scientist Gonzalo Basile has been investigating how Latin American governments handled the pandemic.
The researcher argues that the recent formation of Latin American and Caribbean health systems, and the blow they suffered from managing a pandemic of the scale of the SARS-CoV-2 virus, underscore the need to rethink how health is conceived in this part of the hemisphere. In this context, Gonzalo Basile highlights the need to fundamentally restructure health systems. “[We must] build a theoretical and policy framework for health that reveals the dependency and theoretical coloniality [present in the reforms of our health systems],” he emphasized.
Currently, Basile serves as director and principal researcher of the International Health Program of the Latin American Faculty of Social Sciences (Flacso) Dominican Republic and as regional coordinator of the International Health and Health Sovereignty working group of the Latin American Council of Social Sciences (Clacso).
In a conversation with OjoPúblico, the researcher also elaborated on how an analysis of the expert committees formed to address the pandemic in fifteen countries—Argentina, Chile, Bolivia, Brazil, Ecuador, Colombia, Uruguay, Paraguay, Puerto Rico, El Salvador, the Dominican Republic, Guatemala, Honduras, Mexico, and Spain—revealed that nearly 50% of their members had ties to the pharmaceutical industry. "Their work in healthcare or their clinical epidemiological studies had been funded by multinational pharmaceutical companies," he stated.
You recently conducted research on the critical links in the epidemiological response to Sars-cov-2 in Latin America and the Caribbean. What common weaknesses can be observed in the region's responses to the pandemic?
SARS-CoV-2 is a global pandemic, but our territories have experienced epidemics of this virus. First, I'd like to move away from the all-encompassing view that the epidemiology of SARS-CoV-2 affected all nations equally. Epidemics occurred in specific territories, at specific times, within particular societies, populations, living conditions, and healthcare systems. That's my initial point.
Now, we [the CLACSO researchers] have constructed an analytical matrix of what we call the critical links of SARS-CoV-2 to try to understand the four movements that led us to think of SARS-CoV-2 as a kind of copy-and-paste scheme. That is, what we saw happening in Europe or the United States, the countries of Latin America and the Caribbean copied and pasted into our peripheral, unequal, and inequitable contexts.
What are these four links they identified, and what do they consist of?
The first point relates to the fact that the WHO's [World Health Organization] strategy during SARS-CoV-2 is not new; it is what is known as the concept of global health security. This geopolitical approach establishes the link between health and security, and a notion that there are dangers that, especially for the Global North, can [mean] new pathogens and crises, what they called emerging or re-emerging diseases.
A second element is a type of epidemiology and public health governed by a kind of biomedical expert, above all, clinical [specialists] who became the decision-makers on public health and epidemiology.
The third critical link is related to taking certain measures without a clear understanding of their consequences. All the technical instruments and tools we saw used in the response to SARS-CoV-2 (lockdowns and the transfer of infection control and prevention protocols from hospitals to the general population) were implemented without informing the public or addressing the implications. Furthermore, they were not explained that the scientific evidence supporting them was actually quite weak.
In other words, we had [almost] no evidence to support quarantines [in which the sick and healthy are confined together]. [Editor's note: According to research conducted over the last 20 years, quarantines have worked in certain contexts, such as the Ebola epidemic, where some families were quarantined in Sierra Leone, and the 2003 SARS-CoV epidemic, where infected individuals were isolated and only certain areas of countries like Canada and China were quarantined.]
And the final link is what I call hybrid shocks of institutional arrangements to health systems. That is, faced with our fragile, precarious, exclusionary, and racialized health systems, we injected them with a kind of amphetamine (more intensive care beds, ventilators and mechanical ventilation, human resources) to respond to severe and acute cases. Consequently, what ended up happening is that COVID-19, as a disease, became an epidemic that spread throughout society, and in which our health systems became external to that society, waiting for the tsunami of severe cases to try to prevent death. These four links explain the concept of biomedicalization.
In his articles he talks about the preeminence of individual clinical biomedical science, what is the problem with the fact that the response to the pandemic has been based mainly on that concept?
Biomedicalization focuses on individual intervention, employing curative and care techniques with medications and technology, within an asymmetrical relationship where I, the healthcare professional, hold the power and knowledge, and the patient is an object upon whom I apply measures and knowledge. And if these measures and knowledge fail, it is not the fault of my care strategy, but rather of the patient or the population that does not follow the prescriptions. This entire approach to clinical biomedicine is what dominated the responses to the SARS-CoV-2 epidemic in Latin America.
What was the result of replicating those measures?
Lockdowns were imposed, and quarantines were implemented. In the first four months of the epidemics in Latin America, we began to talk about 'staying home.' But what home? In exclusionary, unhealthy societies with chaotic, inequitable, and unequal urbanizations, like ours, who could have thought of quarantining and confining the entire population equally? I'm not saying this now, two years later. Many of us [the researchers] were writing this in the midst of the epidemic.
Public health, on the one hand, adopted a biomedicalized logic of individual treatment. But, on the other hand, it repeated what we technically call punitive vigilantism. Essentially, it's the medical police, encompassing lockdowns and neo-hygienism, constantly blaming us for all individual behaviors and actions. Latin American and Caribbean states found it easier to control, monitor, punish, and subject all individual behavior to persecution and punishment than to build collective strategies and care systems or to develop a localized epidemiology based on territory and neighborhood.
Currently, it seems that all those measures could be reactivated if cases or deaths increase drastically…
And these tactics can be reactivated in any other epidemiological crisis because, it seems, we are at risk of having normalized these tools. It's not just with SARS-CoV-2. These logics can be reproduced in any other epidemiological crisis. The SARS-CoV-2 lockdowns had already been tried with Ebola in Africa. I worked on that epidemic, and those who commanded the Ebola confinement centers in Guinea, Sierra Leone, Nigeria, and Liberia in 2015 and 2016 were the military forces, who largely confined and blamed African societies and traditional African medicine for the transmission of the epidemic. Afterward, they took what I call parachute-type measures.
Therefore, I believe it is necessary to conduct a systematic and critical review of what states and health systems did in their responses to SARS-CoV-2. This is not only to critique their actions, but also to generate lessons learned and, furthermore, to establish a logic of health sovereignty. In other words, how our countries learn and make decisions for themselves in these epidemiological crises.
You mentioned earlier that, in response to the increase in Ebola cases more than five years ago, drastic measures were adopted. What do you mean by that?
Parachute measures are deployed, for example, during an epidemiological outbreak or epidemic, arriving like a parachute to inject human resources, funding, health services, beds, ventilators, and other capabilities. [But, at the same time,] I paralyze all the other capacities of my health system. I paralyze public health programs, the care and treatment of chronic communicable diseases, the childcare and women's health strategies, and all the programs and strategies related to Indigenous health. I paralyze everything and am left only with the parachute, responding vertically to that epidemiological crisis.
When the crisis is over, I put out the epidemiological fire, all this equipment is removed, this kind of firefighter withdraws from the epidemiological fire, and all the collateral damage remains, the rubble, the ashes of what was done in the response to the emergency itself.
In 2021, you participated in an investigation on the creation of expert committees as part of the response of Latin American and Caribbean states to the pandemic. What were the main findings about these groups?
What's interesting about this COVID-19 crisis is how a language, a grammar, and a healthcare approach have emerged that are closely linked to this kind of expert-led governance. We [the CLACSO researchers] reviewed 15 expert committees for the SARS-CoV-2 crisis and found two particular issues. The first is that in most of these committees in the Latin American and Caribbean region, we found an overabundance of clinical specialists: virologists, infectious disease specialists, and pulmonologists. While all these clinical specialties may have been important for diagnosis and clinical treatment in hospital settings, they were also involved in public health and community epidemiology decisions.
The second point is that, when we began to trace the connections of these biomedical clinical specialists, we found that almost 50% of them had organic ties to the pharmaceutical-industrial complex. That is to say, their healthcare work or clinical epidemiological studies had been funded by pharmaceutical studies from multinational corporations of all kinds, by the private sector, or by healthcare-related financial institutions. And these experts, some of whom were even on the boards of crisis committees, were making decisions about collective and public health, and governing the public, collective, and common goods of healthcare systems.
How does this link between expert groups and the pharmaceutical industry affect public health decisions in an emergency context like the one we are experiencing?
It is perfectly valid for someone to have a clinical specialty and work for the pharmaceutical industry, conducting industry clinical trials or studies within their own healthcare services. However, the problem arises when that same person is then making collective, common, and public decisions. These experts, along with international organizations, not only constructed a narrative around the epidemic using experimental interventions, but, above all, they represented the economic, ideological, and practical interests of private biomedicine, which they themselves embodied in their approach to medicine and public health. This was rendered invisible by the governance of these crisis committees or expert committees.
In his articles, he details that this dynamic, in addition to occurring within countries, also took place within the World Health Organization. How is the pharmaceutical industry's participation reflected in the meetings of this entity's expert committees?
When you look at the World Health Organization's medicines program, you find that it is 60% funded by the pharmaceutical industry. Germán Velásquez, a Colombian public health expert who was part of the medicines program, publicly denounced, after the 2009 H1N1 influenza epidemic, how the pharmaceutical industry was infiltrating the expert committees of a pandemic like H1N1.
By "colonizing," he means that by funding these expert committees, the pharmaceutical industry ensured its interests were at the heart of the decision-making process. Germán Velázquez then demonstrates how Gilead Sciences, the laboratory that held the patent for Tamiflu, a drug recommended at the time for the treatment of H1N1, had specialists on the World Health Organization's own Expert Committee.
In the case of the pandemic…
With the COVID-19 Vaccines Global Access Facility (COVAX Facility), which was supposed to be the mechanism by which access to the COVID-19 vaccine would be provided to everyone worldwide, what ended up happening is that it transformed into a mechanism to defend vaccine patents and a kind of global vaccine charity. In other words, what the Global North has in excess is given as charity to the Global South, rather than as a right to access the vaccine as a public good.
From the conception of health during the colonial period as a solution to certain diseases that affected trade, through the implementation of the Bismarck social insurance model in the 30s—whereby people access the health system by having formal employment—to the establishment of primary care in the 50s, Gonzalo Basile has studied the changes in the health systems of Latin America and the Caribbean, and concluded that it is necessary to refound them.
The history of the creation of health systems in the region could be described as deficient, precarious, and lacking in resources and funding. However, Basile argues that the problems of our health systems go far beyond the difficulties they face daily and are, rather, associated with their colonial foundations, the logic of replicating proposals from the Global North, and an accumulation of temporary reforms. “In reality, what characterizes health systems in Latin America is what I call Frankenstein systems,” he says.
What has characterized the formation and development of health systems in the region?
What characterizes the healthcare systems of Latin America and the Caribbean throughout the 20th century is the importation of theories and policies from the Global North and their adaptation to our countries. On the other hand, there are the reforms, upon reforms, upon reforms, that have accumulated throughout the 20th and 21st centuries. And finally, there is a certain dependency and coloniality in how we have conceived and structured the purpose and rationale of our healthcare system.
You probably expected me to describe stratification, fragmentation, poor responsiveness to both complex and non-complex problems, chronic underfunding, the loss of public capacity, privatization within the system's architecture itself, and the erosion of citizen participation as common characteristics of Latin American health systems. But, in reality, what characterizes our health systems is what I call Frankenstein systems.
Can you elaborate on what you mean by Frankenstein systems?
In other words, bureaucratic healthcare systems that have become increasingly biomedicalized, increasingly curative and welfare-oriented, and increasingly commodified. In many cases, these healthcare systems are conceived as something external to society. They are systems that, in reality, reproduce a Frankenstein's monster of many of these reforms and institutional arrangements that were modified decade after decade, passing through the colonial framework with which they were initially conceived. This was further complicated in the 30s and 40s by the Bismarck model and the importation of the social insurance model. In the 50s and 60s, other theories emerged regarding primary healthcare and the development of local public health services.
What stage are the region's health systems currently at?
Today we are faced with the latest reform, which is the one that brought classical neoliberal thinking to healthcare. This is what we know as the theory of structural pluralism, which states that the healthcare system reform itself must structure a regulated market for coverage. This is what was implemented in Chile, Colombia, Peru, the Dominican Republic, parts of Argentina, and attempted in Mexico.
What's starting to happen in healthcare systems is that we're all beginning to think of them as insurance systems, as systems of coverage, and the language of coverage is a language of differentiation. In other words, insurance for the poor, insurance for workers, insurance they can pay for out of pocket. What's certain about insurance systems in the 21st century is that they are profoundly insecure.
Regarding this latest reform, which opens up more opportunities for private actors, its articles point out that the State has been ceding ground to these actors and develop two specific concepts: de-citizenization through commodification and de-citizenization through dispossession. How do these concepts differ?
The first point refers to the fact that large social classes, sometimes called middle, upper-middle, or professional classes, have had to resolve most of their material needs in the market. That is, they send their children to private schools, live in gated communities or residential areas, access healthcare through private insurance, and, to some extent, even travel around cities using private transportation.
But at the same time, there is a disenfranchisement through dispossession. Large sectors of the population, which we can call the subaltern or working classes, have become mere objects of public policy. This disenfranchisement through dispossession stems not only from inequalities but also from structural problems in accessing healthcare, quality education, and decent housing. In other words, they lack a range of essential social and public goods for life, which they can only access through survival or through the charity of targeted welfare policies within the most neoliberal and current form of social protection.
Ultimately, the erosion of citizenship generates a survivalist logic for both the rich and the poor. The rich want to earn more, regardless of the consequences for society, the commons, and collective resources. Meanwhile, the poor try to survive, sometimes even falling prey to organized crime or suffering from their own living conditions, which also perpetuate violence and racial discrimination. It is within this explosive cocktail that we find ourselves, reflecting on the challenges to healthcare theories and policies in the 21st century.
You raise the need to abandon the concept of health system reform and talk about refounding.
Yes. Latin America and the Caribbean must understand that the health and social protection systems [imported] from the Global North are theories and policies designed for their problems. For the problems of global capitalism, but not for the sociodemographic, socioeconomic, epidemiological, and socioenvironmental problems faced by Latin American and Caribbean societies on the periphery of capitalism, in the Global South.
We need to take a critical look at this, what we call Latin American critical thinking in health, to critique these reforms and, above all, to build a theoretical and policy framework for health that, on the one hand, reveals the dependency and coloniality in theory and public policy through which we have been importing theories and policies for different problems. But, on the other hand, we need to begin building a theoretical and policy vision for alternative health systems, which in Latin America we call the epistemology of the refounding of health systems.
What is needed to take that step towards reinvention?
First, we must redefine the purpose and rationale of our healthcare system. We must decide whether our healthcare system is merely a response to treat illness and prevent death, or whether our healthcare systems are collective and shared constructions of society and the state to produce comprehensive care.
If healthcare systems are only meant to address illnesses and the social ills of life, we will continue with curative, hospital-centric healthcare systems that are largely unpreventive and lack promotional focus, all within this technologically and pharmaceutically dependent logic. However, if our universal healthcare systems are strategies for addressing the comprehensive care of health and life, this represents a shift not only theoretically, but also conceptually and politically, establishing a new starting point that we [researchers] in Latin America define as the refounding of healthcare systems.
* Director and researcher of the International Health Program FLACSO Dominican Republic / Co-coordinator of the CLACSO Working Group on International Health and Health Sovereignty.
Interview published in Ojo Público, August 7, 2022.
https://ojo-publico.com/3618/muchos-comites-de-expertos-covid-19-tenian-nexos-con-farmaceuticas
[+] Thinking about the pandemic
If you would like to receive more information about CLACSO's training programs:
[widget id=”custom_html-57″]
to our email lists.
