Strengthening collective health in the face of the coronavirus in Latin America and the Caribbean
Gonzalo Basile1
“I think we are blind, Blind people who see,
blind people who, though seeing, do not see.
Jose Saramago
Since the confirmation of the first case of COVID-19 in Latin America and the Caribbean, an upward epidemiological threshold of cases has been observed for the region, along with a rising curve of collective panic, social vulnerability, invisibility of the fragility of health systems, and public decision-making based on therapy. shock towards society. In understanding and responding to the COVID-19 public health emergency, the doctrine of [the following] is prevailing. shock (Klein, 2017). The eagerness of markets and elites to turn every disaster and emergency into profit, as postulated by Klein (2017), begins to appear in Donald Trump's own declaration of "war on COVID-19," where he ignites the engines of shock. Where there is war, it is difficult to consider strengthening systems of protection and care for society. The medical-industrial-pharmaceutical complex is remarkably similar to the military-industrial complex.
“Disaster capitalism,” adds Klein (2017), uses fear as a dominating effect on the population, to whom the system of commodification of life gives no other solution than a promise of false security.
Health philanthrocapitalism is on the prowl. The Johns Hopkins Center for Health Security, in partnership with the World Economic Forum in Davos and the Bill & Melinda Gates Foundation, organized “Event 201” (CJHHS, 2019), a high-level pandemic exercise held on October 18, 2019, in New York. The exercise illustrated areas where public-private partnerships would be necessary during a severe pandemic response to mitigate the economic and social consequences on a “large scale,” according to the “Event 201, a Global Pandemic Exercise” page. The disease chosen as the pandemic for the modeling was a coronavirus (CJHHS, 2019).
The damage and impact on society's life are being left out of the international public health agenda regarding COVID-19: massive job losses and suspensions, labor market deregulation, food crises, severe economic and social impacts, the freezing of the informal economy, and the overexploitation of service workers. As Klein says, capitalism needs a process of destruction to build its consumption and then destroys it again to rebuild it. This is the link between health and national security. This is also reflected in the approaches to the international epidemiology of COVID-19.
Although global capitalism appears to be inflicting exorbitant damage upon itself, it may also be using the situation to adapt. As Wendy Brown (2017) argues, neoliberal capitalism is capable of transforming every human need or problem into a profitable enterprise. COVID-19 is no exception.
Without denying the epidemiological relevance of the current situation, overreacting to the pandemic can lead to scenarios of even greater inequality, social and health emergencies. Therefore, it is necessary to understand that through health language we not only describe and transmit knowledge, but also define the scope of action. do, and practices in the field of health, which can transform subjectivities, social conditions of life and the world in which we live, or mechanically reproduce instrumental responses of technical-normative intervention (Granda, 2004).
Currently, the ideological underpinnings and technical-political actions expressed by individual clinical biomedical science and vertical public health within the context of COVID-19 have generated a complex spiral of societal pathologization, misinformation/overinformation, individual behaviorism, and a police state as the primary coping strategy. Public decision-making is based on prediction, inference, or social fear, which is difficult to dismantle within a fragmented and sectoralized approach to collective health. This spiral conditions the governance of health policy (and governments in general). Biomedical knowledge becomes an epistemological model that, in the pandemic, transcends the world of disease and presents itself as relevant for producing knowledge about society and life.
Under this spiral, in a quick approach and situation analysis, the first key need would seem to be to move from an understanding of the individual level of the COVID-19 disease to the collective level of a (pre)epidemic stage, where the Latin American and Caribbean society may suffer a health-disease process.
Epidemic (from the Greek) epi, “above”, and demos“People”) means understanding that the impact, by definition, is always collective, and that preventive-promotional, protective, care, and surveillance measures are population-based, directed toward and with society, not exclusively individual, assistance-based, or curative. Adopting a collective health perspective (Paim and Almeida Filho, 1999) in the study of the social determinants of health (Breilh, 2010), which generate patterns of inequality and inequity in how people live, become ill, and die, the response to an emergency ranges from preparing and strengthening the capacities of public health services to universalizing social protections for at-risk populations and the most vulnerable groups in our exclusionary societies, and preserving decent employment and social security in both the informal economy and the general economy.
In a brief characterization of COVID-19, it is important to point out that the available literature on epidemiological research in China and other global journals and research centers is beginning to provide a wealth of knowledge and information on the epidemiology of COVID-19, its crude case fatality rate, its basic reproduction number, risk groups, clinical studies, among others (see the study published by the NCIP Epidemiology Working Group for Epidemic Response in the Chinese Journal of Epidemiology in 2020).
Of the studies published by the Chinese Journal of Epidemiology In 2020, among the 44.672 confirmed cases studied, the majority were between 30 and 79 years old (86,6%), 51,4% were male, 22% were farmers or workers, and 74,7% were from Hubei province. Of the confirmed cases, 1023 died, and the crude case fatality rate was 2,3%. Most cases were mild to moderate (80,9%), severe cases accounted for 13,8% (viral pneumonia), and critical cases represented 4,7%. The highest case fatality rate was 14,8% in the ≥80 age group. The crude case fatality rate was 2,8% for men and 1,7% for women. The crude case fatality rate for patients without comorbidities was approximately 0,9%. The case fatality rate was much higher for patients with comorbidities: 10,5% for patients with cardiovascular disease, 7,3% for diabetes, 6,3% for chronic respiratory disease, and 6,3% for hypertension. 6,0%, [XXXX1] The cancer rate was 5,6%. The basic reproduction number (R0), which is defined as the average number of people who will be infected by each sick person, is 1,4 to 4,9 for COVID-19, higher than for seasonal influenza (1,3).
In South Korea, of the 8413 confirmed cases of SARS-CoV-2, 3240 were male (38,5%) and 5179 were female (61,5%). There were 84 deaths, resulting in a case fatality rate of 1%, with 45 male deaths (53,6%) and 39 female deaths (46,4%), resulting in a case fatality rate of 1,39% for men and 0,75% for women. 90,4% of the deaths occurred in the 60-69, 70-79, and over 80 age groups (KCDC, 2020).
Speaking of the total number of accumulated cases and their case fatality rate based on official global reports from the World Health Organization (WHO, 2020) is a recurring error in current epidemiological analysis. While the total number of accumulated deaths is known, the total number of infected individuals is never known in any ongoing epidemic. This leads to real-time reporting of crude case fatality rates ranging from 4,1% (global average) to 7,9% (Italy), which is neither valid nor should be reproduced or expressed in this way, as it would fuel individual misinformation about the pandemic. To understand case estimates, it would be necessary to know how many people worldwide are tested for COVID-19 daily and how available tests are allocated. Unfortunately, there is no centralized WHO data on COVID-19 testing, and most countries do not provide official reports on the tests performed. Only South Korea, once again, is communicating and implementing mass testing, with 307.024 tests conducted as of March 19 (KCDC, 2020), and only 2,8% of the total tests were positive for coronavirus nationwide.
Currently, there is no epidemiological threshold for SARS-CoV-2 in Latin America and the Caribbean. That is, below a certain threshold of cases for some diseases, an epidemic is declared. This generally means that the current situation is being analyzed more by mirroring what happened in the Global North (mainly Europe and the United States), or through predictive mathematical models (Imperial College COVID-19 Response Team, 2020).
According to the WHO itself, there are four types of influenza/seasonal flu viruses (A, B, C, and D) that, annually, are estimated to cause between 3 and 5 million cases of severe illness and between 290.000 and 650.000 respiratory deaths worldwide (WHO, 2018). Reviewing the annual respiratory disease trends in Italy and Spain is almost a requirement for study. In Italy, according to the daily mortality surveillance system (SISMG) of the National Institute of Health (part of the Ministry of Public Health), an average of 8000 deaths are identified annually due to influenza and its complications (Epicentro, 2020).
50% of COVID-19 cases and 66% of COVID-19 deaths in Italy occurred in the Lombardy region (MS, 2020), where extreme austerity measures on public goods (Karanikolos et al., 2013), the drastic reduction of public health service capacities (including reduction of beds in intensive care units), and the preeminence of private insurance and health establishments in northern Italy could be interpreted as processes and determinants of an over-demanded and under-capacity Italian health system.
In Spain, the correlation between austerity policies (Navarro, 2020) and privatization in the autonomous communities on public healthcare is a well-studied effect (Bacigalupe et al., 2016). The Community of Madrid, in particular, which accounts for 41% of COVID-19 cases and 65% of deaths (MSCBS, 2020), was a prime example of public-private partnerships with privately managed hospitals. Furthermore, precarious living conditions, the breakdown of social support systems, the loneliness of older adults (including energy poverty), and the privatization of nursing homes—managed with profit motives rather than a focus on care, where cases and deaths were confirmed in Madrid—are emerging as key research questions regarding the impact of COVID-19 in Spain.
The United States has perhaps the most expensive, irrational, and inefficient healthcare system in the world in terms of outcomes indicators. It is the only country in the region that does not recognize the right to health provided by the state, where approximately 30 million people lack any health insurance coverage and another 27 million have very inadequate coverage (Navarro, 2020). The Centers for Disease Control and Prevention itself estimates that so far this winter season there have been at least 36 million cases of influenza, 370.000 hospitalizations, and 22.000 deaths due to influenza between the end of 2019 and the first months of 2020 (CDC, 2020).
On the other hand, Latin America and the Caribbean experience a frequent increase in the number of influenza and respiratory infections each year (current circulation of H1N1, H3N2, and Influenza B), as well as influenza at other times of the year in the Caribbean (PAHO, 2020). Latin America, especially the Southern Cone, often sees its healthcare services strained and overburdened by respiratory illnesses. In this context, the devastating epidemiological profiles collectively affecting millions in Latin America and the Caribbean are significant: more than 80% of the population lives in cities with significant overcrowding, precarious housing without shelter or access to safe water or protective and hygiene materials. These are not simply “at-risk groups”; they are societies at permanent risk. Exclusionary societies. The quarantine measures implemented in Europe, in societies with near-full employment and access to social protection systems designed to be universal, will operate differently in societies where informal employment, the informal economy, lack of social protection, the gendered division of care, and the need to generate daily sustenance prevail. The Ecuadorian women's parliament has already popularized the phrase: "the quarantine pill is a class privilege."
Latin American and Caribbean health systems in the midst of the second wave of reforms shock The World Bank and the Inter-American Development Bank defunded their healthcare services and public health programs, leading to a spiral of deterioration, ineffectiveness, inefficiency, and loss of capacity that became a self-fulfilling prophecy: the provider state neither serves nor responds to the collective needs of society. Therefore, the main fear of decision-makers and governments in the region is explaining why healthcare systems are fragmented, weakened, and chronically underfunded. Why are they unable to prevent and control infections within healthcare facilities amidst surges in demand for care for severe respiratory illnesses, or address the exacerbated impacts of respiratory infections (not only in the case of COVID-19) in contexts of social inequality and malnutrition/nutritional deficiencies in certain social classes, or the shortcomings in health surveillance and response with comprehensive protection for individuals, families, and communities, including poor working conditions for healthcare teams? All of these are priorities that remain largely invisible in Latin America and the Caribbean today.
Within this scenario of a systemic crisis in health systems facing emergencies and persistent overdemand, the need to relearn the design and management of emergencies and disasters as a collective public capacity in the 21st century is also an aspect to be reevaluated. The formation of public health emergency operational committees colonized by infectious disease “experts” established individual clinical epistemology regarding epidemics/pandemics as state policy, fueled weak leadership, communication, and public governance in the emergency response, initially weakened centralized decision-making, and delegated responsibility to many countries in the disease of individual medical figures and personalities who appeared almost daily on media channels giving real-time recommendations and responding to their hospital, corporate and clinical society logics; or directly promoting the interests of the pharmaceutical industry itself in their work as “experts” (Ugalde and Homedes, 2009).
The geopolitics of COVID-19 represent a clear example of how the course of a global pandemic generates disproportionate public attention and alertness, largely due to its severe impact on countries in the Global North. Other diseases and epidemics in the Global South never had, nor would they have had, this level of centrality. The Pan-American doctrine (Rapoport, 2008) once again operated in Latin America and the Caribbean as a territory under its control and domination. Countries and states quickly followed the measures emanating from the Trump administration. Pan-American international health and liberal global health in general organically respond to this geopolitics of power and knowledge of the Global North and its world system (Basile, 2018). This partly explains why global health diplomacy and technocracies, even those in Latin America and the Caribbean, uncritically implement the agendas of supposed “consensus” on global health and cooperation set by the global center.
Paradoxically, on the other hand, Latin American and Caribbean government health measures once again exposed regional fragmentation and dependence. Paraguay announces one way. El Salvador, Guatemala, Colombia, the Dominican Republic, Venezuela, Haiti, and Chile another. Argentina and Mexico yet another. And so the list could continue. At the level of regional integration in health in Latin America and the Caribbean, this pandemic once again demonstrated the urgent need to rebuild mechanisms and networks for cooperation, coordination, and joint international health decision-making from the Global South, safeguarding regional health sovereignty (Basile, 2019). The lack of comprehensive coordination and cooperation in the design of joint regional epidemiological strategies became evident, overshadowing a kind of competition to see who could be more radical in the shock to society.
In short, this epidemiological crisis reveals once again that dependency is not merely an external phenomenon (Dos Santos, 2000). It also manifests itself in internal forms and structures (social, ideological, political, and governmental). The agenda—geopolitical and health-related at the international and regional levels—and its national and local impacts have implications for a new character of dependency in the field of health and epidemiology.
Perhaps recovering the best traditions of Latin American and Caribbean critical thought on health and social issues is a priority for rethinking the health geopolitics of SARS-CoV-2. This should be based on reinterpretations that work from the perspective of regional health autonomy and sovereignty in the current international epidemiological crisis.
More than individual measures, these are collective health and protection measures for and with society.
Systems of organization, networks, and collective health management built on universality, comprehensiveness, and interdependence are the most effective way to decommodify health and life and to respond more efficiently to the health needs and emergencies of the complex and inequitable societies that still exist in Latin America and the Caribbean. Universal and comprehensive public systems are the safest option for the collective health of society.
Rather than accepting the colonization of science by the individual, by therapy shock and disaster capitalism, weaving together encounters in and with society to produce (depatriarchalized) care, repoliticizing a dialogue without intermediaries with the State to respond prudently, effectively, and fairly, putting the health of society at the center.
The need for international health from a South-South and decolonial geopolitical perspective (Basile, 2018) has once again emerged as a lesson learned in the post-COVID-19 era. Dependence on Pan-American health policies has again demonstrated that the countries of the region are, at times, importers of replicated and copied measures, of pre-designed packages.
Epidemics can sometimes also serve as an opportunity to reflect on and remember the debts we owe to our societies and states. It is a time to call for calm, to come together and show solidarity, but by no means to remain paralyzed or silent. This is a time for collective health.
1- Argentine epidemiologist and social scientist. Coordinator of the CLACSO Working Group on International Health and Health Sovereignty. Director of the International Health program at FLACSO Dominican Republic. Researcher and professor of master's and doctoral programs in public health in Latin America and the Caribbean.
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[+] Thinking about the pandemic
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