Public Disclosure Authorized PERSPECTIVES ON GLOBAL Public Disclosure Authorized PUBLIC HEALTH AND OTHER Public Disclosure Authorized ISSUES
Collected Blogs II Public Disclosure Authorized October 2019—December 2020
Patricio V Marquez Perspectives Of Global Public Health And Other Issues October 2019—December 2020 CONTENTS
A Few Reflections to Close the Year of COVID-19 | December 23, 2020 http://www.pvmarquez.com/reflectionsend2020
Some Reflections on World AIDS Day 2020 Amidst COVID-19 | November 30, 2020 http://www.pvmarquez.com/hivaids2020
What We Know About the New COVID-19 Vaccines: Are We There Yet? | November 24, 2020 http://www.pvmarquez.com/covid19vaccine
How to Strengthen Health Care Systems to Support COVID 19-Vaccination? | November 16, 2020 http://www.pvmarquez.com/covid-19vaccination
Health Systems Fit for the Future: How to Promote Better Health, Economic Growth, and Social Cohesion? | October 23, 2020 http://www.pvmarquez.com/romehsystems
The World Bank’s health response to COVID-19 (Coronavirus) | October 19, 2020 https://blogs.worldbank.org/health/lets-invest-mental-health-inclusive-and-resilient- recovery-covid-19
Let’s Invest in Mental Health for an Inclusive and Resilient Recovery from COVID-19 | October 8, 2020 https://blogs.worldbank.org/health/lets-invest-mental-health-inclusive-and-resilient- recovery-covid-19
Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | September 6, 2020 http://www.pvmarquez.com/alcoholuse
Let’s Not Forget About Mental Health during COVID-19! | August 22, 2020 http://www.pvmarquez.com/mentalhealandthcovid-19 Perspectives Of Global Public Health And Other Issues October 2019—December 2020
Taxes on tobacco, alcohol, and sugar-sweetened beverages reduce health risks and expand fiscal space for Universal Health Coverage post-COVID 19 | August 11, 2020 https://blogs.worldbank.org/health/taxes-tobacco-alcohol-and-sugar-sweetened- beverages-reduce-health-risks-and-expand-fiscal
While waiting for a COVID-19 vaccine, it’s time to focus on gaps in vaccine distribution, cold chain, and uptake | July 26, 2020 http://www.pvmarquez.com/vaccinationsystems
Improving Health Services: A Global Imperative Amidst COVID-19 | June 22, 2020 http://www.pvmarquez.com/qualityimprovement
Sustaining Essential Health Services during the Covid-19 Pandemic: A Social Imperative | June 15, 2020 http://www.pvmarquez.com/essentialhealthservices
Have South and Central America become the new coronavirus (COVID-19) epicenter? | June 3, 2020 https://blogs.worldbank.org/health/have-south-and-central-america-become-new- coronavirus-covid-19-epicenter
Tobacco use and coronavirus (COVID-19): A deadly but preventable association | May 27, 2020 https://blogs.worldbank.org/voices/tobacco-use-and-coronavirus-covid-19-deadly- preventable-association
Social distancing in the time of COVID-19 in Latin America and the Caribbean: Costs and Benefits | May 14, 2020 http://pvmarquez.com/socialdistancing
Do BCG Vaccinated People Have Some Immunity Advantage Over Non-Vaccinated People? | April 21, 2020 http://www.pvmarquez.com/bcg
Searching for Evidence in the COVID-19 Era: The BCG Case | April 17, 2020 http://www.pvmarquez.com/bcgcovid19 How to Prevent Jails and Prisons from Becoming New Hotspots for the Spread of COVID-19? | April 13, 2020 http://www.pvmarquez.com/prisoncovid19
Does Tobacco Smoking Increases the Risk of Coronavirus Disease (COVID-19) Severity? the Case of China | March 3, 2020 http://www.pvmarquez.com/Covid-19
The Unpredictable Social and Economic Cost of the Coronavirus (COVID-19) Outbreak | February 27, 2020 http://www.pvmarquez.com/coronavirus
Public Health Investments and Economic Gains: Learning from Latin America and Caribbean History in the Time of Coronavirus | February 10, 2020 http://www.pvmarquez.com/disease_control
Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported | February 7, 2020 http://www.pvmarquez.com/Galapagos_CDF
Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | February 2, 2020 www.pvmarquez.com/tobacco_taxes
High Prices for Essential Drugs: A Risk for Public Health, Catastrophic Health Spending, High-Debt Levels, and Impoverishment | January 28, 2020 http://pvmarquez.com/drug_prices
Mental Health and Healthy Futures: A Priority Theme at WEF Davos 2020 | January 22, 2020 http://www.pvmarquez.com/mental_health_davos
How to Accelerate Universal Health Coverage in Latin America and the Caribbean? | January 16, 2020 http://www.pvmarquez.com/health_reform Perspectives Of Global Public Health And Other Issues October 2019—December 2020
Is the Growing Attachment to Smartphones and Digital Media Bad for Our Health? An initial exploration | December 12, 2019 http://www.pvmarquez.com/digital%20media_impacts
Plastic Pollution: A "Clear and Present Danger" to the Galapagos Islands | November 27, 2019 http://www.pvmarquez.com/plastic_pollution_galapagos
Retracing Darwin’s Footsteps in the Galapagos | November 24, 2019 http://www.pvmarquez.com/node/5
An Ode to Halloween, Birthdays and Aging | October 30, 2019 http://www.pvmarquez.com/halloween_aging
Social Disparities Among Indigenous Peoples in the Americas: A Legacy to Overcome | October 27, 2019 http://www.pvmarquez.com/legacy_to_overcome
1/12/2021 A Few Reflections to Close the Year of COVID-19 | Patricio V. Marquez
A Few Re ections to Close the Year of COVID-19 Submitted by Patricio V. Marquez on Wed, 12/23/2020 - 01 35 PM
A Few Re ections to Close the Year of COVID-19
Posted by Patricio V. Marquez on Wed, 12/23/2020 - 01 35 PM
“It was undoubtedly the feeling of exile—that sensation of a void within which never left us, that irrational longing to hark back to the past or else to speed up the march of time, and those keen shafts of memory that stung like re.” Albert Camus (1957 Nobel Prize Laureate for Literature). The Plague. Vintage, 1991.
As we approach the end of 2020, perhaps a few re ections are warranted on a period unlike any other in our global collective memory. While the ceaseless movement of time, manifested in the passing of days and months, is mostly an unconscious fact in our lives, only made visible by calendars, birthdays, and other celebrations, during this year it was different. The sameness of the days, with their now well-established routines, fears, frustrations, rebellions, and hopes, superseded our recent past by rmly imposing a very tangible present that continues to entrap us.
COVID-19 in the historical context of public health crises
Since the beginning of March, when the “Great Lockdown” gradually extended its tentacles across the world, as an initial response to the exponential spread of a novel coronavirus, SARS-CoV-2, few may have thought that come December we were going to still be ensconced as if in a state of siege. Indeed, this overwhelming reality has separated us from our loved ones, friends, and coworkers, and has imposed rigid norms that have forced us to alter and adapt our behaviors and routines to strict social distancing.
But paradoxical, our COVID-19 norms are not so different from the isolation and con nement measures followed in Europe to control infectious disease outbreaks in the Middle Ages. Or that beginning in 1519, were also used in parts of my native region, Latin America and the Caribbean, in accordance with the 1423 Venetian quarantine control system, to detain ships and isolate their crews and passengers outside harbors until suf cient time had elapsed without the outbreak of “pestilences.”
www.pvmarquez.com/reflectionsend2020 1/3 1/12/2021 A Few Reflections to Close the Year of COVID-19 | Patricio V. Marquez The onslaught of COVID-19 has been relentless worldwide, with a growing accumulated damage painfully measured as of today with close to 80 million infected people – and about 1.7 million premature deaths (not counting the excess mortality due to other conditions), and millions of people unemployed or underemployed that has resulted from the disintegration and slowdown of economic activity, trade, and the ow of people and capital across countries.
Exposing inequalities – and an opportunity for renewal
This catastrophe has exposed and brought to the fore with great clarity the manifestations and impact of glaring, pre-existing inequalities in our societies, where minorities and others at the bottom of the economic ladder, the frail and the sicker, have been hit hardest, while the well-off, although still at risk and working from home, have been able to resist better.
In our daily lives, like in a shipwreck, we have continued to hold on to memories of times past, as a way to recharge and remind ourselves that this too shall pass, and we can look forward to future times when we can hug and laugh with family and friends, work in close proximity to others, and travel and discover other geographies and people, without the fear that COVID-19 is waiting for us “just around the corner”. But, more importantly, I think, we are realizing and learning to accept that change is needed in our lives and in the existing social contracts of countries and between countries.
Rising to the challenge – and looking forward with solidarity
We, as a global collective, have resisted, mounted a strong response, and have seen the potential wonders that cooperation and solidarity can bring to enrich our arsenal against COVID-19. In an unprecedented historical feat, we have new vaccines produced in less than a year (good to keep in mind that the eradication of smallpox through a vaccine took several centuries, while the development of vaccines to deal with measles, in uenza, and yellow fever, took several decades), as well as new diagnostics and treatment protocols that have reduced signi cantly the risk of severity and death among the infected.
These scienti c leaps should amaze us: they have resulted from a mixture of accumulated knowledge and technologies, and the human capacity and capability to learn (an initial milestone was the publication of the genome sequence of the new virus on January 29, only weeks after the rst case was noti ed), innovate, develop new knowledge, and translate that knowledge into applications to solve our needs. Also, we have come to realize that the adoption of basic public health measures such as wearing masks, washing hands, and social distancing, are once again helping us to keep the novel coronavirus virus at bay by preventing its uncontrolled spread as they have done over the centuries in similar outbreaks of infectious diseases.
During the past 10 months, we have been able to come together not only as a duty imposed by present challenges, but more importantly, we are realizing that the pandemic is offering us the opportunity to take stock and rebuild better our collective lives. As we enter the holiday season and gaze with hope into 2021, perhaps it will do us good to look back into history to learn that in the face of all types of past calamities – war, famine, and plagues – the resilient human spirit has triumphed when acting as a collective and not as isolated individuals and countries.
Going forward, particularly in the face of the momentous task of having to vaccinate entire populations in the new year, without leaving the most vulnerable and poor behind as our moral obligation, we could start planting the seeds of a better world that is rooted in cooperation, solidarity, and respect for others, accepting our differences as a source of strength and not of con ict, and trying every day to be there as men and women for others, giving our best effort for the betterment of all.
www.pvmarquez.com/reflectionsend2020 2/3 1/12/2021 A Few Reflections to Close the Year of COVID-19 | Patricio V. Marquez Indeed, together, as the gospel song (https://www.bing.com/videos/search? q=bruce+springsteen+we+shall+overcome&docid=608005599646253213&mid=5C988E6B548AE2F887725C988E6B548AE goes, “We shall overcome, We shall overcome, We shall overcome, some day!”
Photo: Long, socially-distanced lines to access services in Lima, Peru. © Victor Idrogo / World Bank The original version of this blog was posted at the World Bank Group Investing in Health site on December 23, 2020:
A few re ections to close the year of COVID-19 (worldbank.org) (https://blogs.worldbank.org/health/few- re ections-close-year-covid-19)
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/reflectionsend2020 3/3 1/12/2021 Some Reflections on World AIDS Day 2020 Amidst COVID-19 | Patricio V. Marquez
Some Re ections on World AIDS Day 2020 Amidst COVID-19 Submitted by Patricio V. Marquez on Mon, 11/30/2020 - 10 07 PM
Some Re ections on World AIDS Day 2020 Amidst COVID- 19
Posted by Patricio V. Marquez on Mon, 11/30/2020 - 10 07 PM
A lot has been accomplished over the past 20 years in the ght against HIV and AIDS. According to UNAIDS data (https://aids2020.unaids.org/report/), of the 38 million people living with HIV, 25.4 million people are now on treatment. New HIV infections have been reduced by 23% since 2010, largely due to a substantial decrease of 38% in Eastern and Southern Africa.
Yet, challenges persist. HIV infections have increased by 72% in Eastern Europe and Central Asia, by 22% in the Middle East and North Africa, and by 21% in Latin America. Across the world, there were 1.7 million new infections, and still 690,000 AIDS-related deaths in 2019. The 2020 targets of reducing AIDS-related deaths to fewer than 500,000 and new HIV infections to fewer than 500,000 will not be met. And the impact of the COVID-19 pandemic stands to further slow the required progress to end AIDS as a public health threat by 2030.
The Basis for Optimism
Looking back on what has been achieved in the past two decades, however, should ll us with optimism that momentum will be regained. As recounted by Dr. Peter Piot, the former Executive Director of UNAIDS, in his memoire, No Time to Lose (https://www.goodreads.com/book/show/13554374-no-time-to-lose), after overcoming many obstacles and naysayers, the United Nations (UN) system, with its many organizations and agencies, working www.pvmarquez.com/hivaids2020 1/3 1/12/2021 Some Reflections on World AIDS Day 2020 Amidst COVID-19 | Patricio V. Marquez together with governments, civil society and religious leaders, groups representing people living with AIDS, and eventually the pharmaceutical industry, came together in the rst decade of the XXI Century to rede ne existing HIV and AIDS prevention and treatment paradigms.
There were also some landmark political events in this period, such as the UN Security Council Session held in January 2000 (https://www.un.org/press/en/2000/20000110.sc6781.doc.html) that for the rst time focused on AIDS as a global health challenge, and the UN Special Session on AIDS held in June 2001, which paved the way for establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria (https://www.theglobalfund.org/en/)and the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) (https://www.state.gov/pepfar/), a great legacy of former United States President George W. Bush (https://www.bushcenter.org/explore-our-work/support-our- work.html). Not only was the power of scienti c and technological developments leveraged to confront the global epidemic, but an unprecedented commitment of funds helped scale up the international response.
In the early 2000s, I was blessed to be working in the Caribbean Region, at a time when it became a trailblazer in the ght against HIV and AIDS. Beginning with a meeting at the World Bank Group (WBG) in Washington DC in June 2000, Caribbean nance ministers and of cials from international organizations placed the disease and its threat in a sobering context. This was followed by a gathering in Barbados later that year where the international community, heeding former Prime Minister Owen Arthur’s call— “We do not have a choice in the matter—we must act now”— pledged millions of dollars to support a regional response. With the establishment of the Pan Caribbean Partnership Against HIV/AIDS (PANCAP) (https://pancap.org/pc/pcc/media/pancap_document/UNAIDS-BEST-PRACTICE- COLLECTION_A-Study-of-PANCAP.pdf) in 2001, spearheaded by Sir George Alleyne (https://www.amazon.com/Grooming-Chancellor-George-Alleyne/dp/9766406510/ref=sr_1_3? dchild=1&keywords=sir+george+alleyne&qid=1606788737&sr=8-3), the Director Emeritus of the Pan American Health Organization (https://www.paho.org/en), and the Caribbean Community (CARICOM (https://caricom.org/)), the regional political umbrella organization, an international best practice evolved as a unique example of collective action to strengthen a regional response to a health crisis. The World Bank Group contribution to that effort was framed within the US$150 million multi-country program (http://documents1.worldbank.org/curated/en/971971468238478200/pdf/709730WP0HIV0i0Box370064B000PUBLIC that funded for the rst time globally, beginning in Barbados in 2001, antiretroviral treatment, (http://documents1.worldbank.org/curated/en/287781468770370735/pdf/307240en0breve0450Barbados0HIV.pdf) along with related health system strengthening investments and intersectoral prevention efforts.
As more and more HIV-infected people began to bene t from access to treatment, some cof n-makers were put out of business as told in a story about Lesotho published in 2012 by the New York Times (https://www.nytimes.com/2012/07/08/opinion/sunday/the-cof n-maker-benchmark.html), and HIV and AIDS de facto became a chronic condition that requires long-term care across the world.
Some Lessons for the Future
In the face of newly emerging infectious diseases of animal origin such as COVID-19, and the still high prevalence of old scourges such as HIV and AIDS, malaria, yellow fever, and tuberculosis, coupled with the rapid increase in the relative importance of non-communicable diseases as a growing global health challenge, a major rethinking is needed globally and sustained action is required to transform how health services are organized, funded, and delivered to meet the changing health needs of the population in an interconnected world.
The social and economic devastation brought by the COVID-19 global crisis has shown that disease prevention and public health preparedness can no longer be an afterthought in the universal health coverage agenda. Rather, they need to be an integral element of a care continuum to anticipate, detect, and prevent the spread at the
www.pvmarquez.com/hivaids2020 2/3 1/12/2021 Some Reflections on World AIDS Day 2020 Amidst COVID-19 | Patricio V. Marquez national, regional and global levels of uncontrolled infectious disease outbreaks that do not respect national borders, and to facilitate timely access to quality health services when required by the population.
This also calls for integration and resource-sharing, leveraging resources, experience, and models of existing programs to place greater emphasis on primary health care and community-based interventions that serve any health condition and comorbidities. We must also advocate for the adoption of inclusive and sustainable schemes to fund the effort at the country level, offering nancial protection to the population (https://openknowledge.worldbank.org/handle/10986/31930) from the impoverishing effect of ill health, premature mortality, and disability.
And, as the response to the HIV and AIDS epidemic clearly demonstrated over the past twenty years, knowledge generation and sharing across the world and their adaptation to local conditions, are paramount to advance the global health agenda in the future.
Indeed, the scienti c developments that helped understand, treat, and prevent HIV infection and AIDS, and the unprecedented scienti c collaboration unleashed in 2020 to develop a safe and effective COVID-19 vaccine in a record eight months (http://pvmarquez.com/covid19vaccine), bode well for the promise of a world free of the threat of HIV and AIDS, and the improvement of people’s health and healthy longevity globally.
Photo Credit: AnomaliStudio (https://www.istockphoto.com/portfolio/AnomaliStudio?mediatype=illustration) Stock illustration ID:1069507882
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/hivaids2020 3/3 1/12/2021 What We Know About the New COVID-19 Vaccines: Are We There Yet? | Patricio V. Marquez
What We Know About the New COVID-19 Vaccines: Are We There Yet? Submitted by Patricio V. Marquez on Tue, 11/24/2020 - 02 09 PM
What We Know About the New COVID-19 Vaccines: Are We There Yet?
Posted by Patricio V. Marquez on Tue, 11/24/2020 - 02 09 PM
Patricio V Marquez and Betty Hanan
Typically, the development of new vaccines requires years of research and testing before being deployed. In the case of the new COVID-19 vaccines, scientists have been racing to produce a safe and effective vaccine in record time (https://www.sciencemag.org/news/2020/11/covid-19-vaccine-trial-complete-p zer-and-biontech-update- their-promising-result). In a historical feat, the trials of some of the vaccines have taken less than a year.
As of today, (https://www.nytimes.com/interactive/2020/science/coronavirus-vaccine-tracker.html) researchers are testing 54 vaccines in clinical trials on humans, and at least 87 preclinical vaccines are under active investigation in animals.
In contrast, history shows that in some cases it took decades of work to develop vaccines (https://www.businessinsider.com/how-long-it-took-to-develop-other-vaccines-in-history-2020-7). For example, the eradication of smallpox through a vaccine--one of the biggest achievements in public health history —took www.pvmarquez.com/covid19vaccine 1/7 1/12/2021 What We Know About the New COVID-19 Vaccines: Are We There Yet? | Patricio V. Marquez several centuries. After a decade of work, Max Theiler, developed the rst safe and effective yellow fever vaccine in 1937, for which he receive the Nobel Prize in Physiology or Medicine in 1951. Similarly, it took years of research to understand the complexities of the in uenza virus, before the rst vaccine was approved for use in the United States in 1945. And then, two years later in 1947, researchers concluded that seasonal changes in the composition of the virus rendered existing vaccines ineffective--there are two main types of in uenza viruses that cause epidemic seasonal infections nearly every year, in uenza A and in uenza B, along with multiple new strains of the virus. Because of this, scientists have had to adjust the in uenza vaccine every year.
In this blog, we provide a snapshot of the development of some leading COVID-19 vaccines based on a quick review of available literature.
The Frontrunner COVID-19 Vaccine Candidates
1. Genetic Vaccines
P zer/BioNTech and Moderna have developed new COVID-19 vaccines using a new technology that has never before been approved for human use. Both use a synthetic version of coronavirus genetic material, called mRNA, to program a person’s cells to churn out many copies of a fragment of the virus. That fragment sets off alarms in the immune system and stimulates it to attack as if the person were exposed to the real virus. The two companies are the rst to announce interim data from large studies.
P zer/BioNTech Vaccine
The companies announced on November 18, 2020 that the vaccine was safe. Its 95% ef cacy was consistent across age, race, and ethnicity, and it worked well in older people to prevent severe COVID-19 disease, well above the 50% ef cacy level that the U.S. Food and Drug Administration (FDA) had said it would accept in order to grant emergency approval for vaccines. The most common serious adverse event was fatigue, with 3.7% of volunteers reporting tiredness after they took the second dose. Two percent of volunteers reported a headache after the second dose.
P zer submitted trial data and a request for emergency authorization for its COVID-19 vaccine to the FDA on November 20, 2020, with the expectation that a decision by the FDA for the vaccine’s use will be made by mid- December 2020.
The application will be reviewed by teams of the FDA’s Center for Biologics Evaluation and Research. Key moments in the process are: the rst comes two days before members of the FDA Advisory Committee meet, when the FDA typically releases its staff report on the clinical trial data, offering an insight into whether the agency is leaning toward authorizing the vaccine; and the second is at the end of the Committee process scheduled for December 10, 2020, when the Committee will take a non-binding vote on whether the FDA should clear the vaccine for public use.
P zer has also begun regulatory submissions in Australia, Canada, the European Union, Japan and the United Kingdom (UK). It has announced also that it plans to apply in other countries as well.
Moderna Vaccine
Positive interim results from a nal-stage trial have been released. The next step will be submission to the FDA of a request for emergency authorization. This would follow shortly after the review of P zer’s vaccine. The Moderna vaccine uses similar technology to the one from P zer and BioNTech. It is reported to have a 94.5% ef cacy, and
www.pvmarquez.com/covid19vaccine 2/7 1/12/2021 What We Know About the New COVID-19 Vaccines: Are We There Yet? | Patricio V. Marquez appears to prevent the COVID-19 disease, including severe cases. A big unknown, however, is how long the immunity provided by the vaccine will last.
Emergency Authorization Process
Both of the companies’ vaccine candidates began large human trials on July 27, 2020. Emergency authorization (https://www.bloomberg.com/news/newsletters/2020-11-21/covid-vaccines-still-face-a-few-hurdles? utm_campaign=news&utm_medium=bd&utm_source=applenews)allows drugs and vaccines targeting COVID-19 to reach limited groups of people in the United States (US) much faster than through standard approval channels. The FDA review process normally takes about six to ten months, depending on the candidate’s priority status.
P zer (https://www.nytimes.com/2020/11/18/health/p zer-covid-vaccine.html?referringSource=articleShare) has indicated that if the FDA authorizes the two-dose vaccine, up to 50 million doses could be available by the end of the 2020, and up to 1.3 billion by the end of 2021. It is estimated that once the P zer/ BioNTech and the Moderna vaccines are authorized for emergency use, there will be enough doses to immunize about 20 million people in the United States before the end of 2020, a group that would most likely include health care workers and nursing home residents (there are an estimated 17 million to 20 million health care workers in the United States, and about a million people living in nursing homes). The 50 million doses would also allow older people with co-morbid conditions to be immunized.
P zer/BioNTech and Moderna have arranged deals with the U.S. Government so that the vaccines will be free to the population (https://www.nytimes.com/2020/11/20/health/p zer-covid-vaccine.html? referringSource=articleShare) and distributed according to plans worked out between the federal government and the states.
Cold Chain Requirements
After the FDA authorizes the use of the P zer/BioNTech and Moderna vaccines, the critical next step is vaccine deployment. The P zer/BioNTech vaccine must be stored at minus 94 degrees Fahrenheit, colder than any other vaccine in development. P zer will ship the vaccine in special boxes of 1,000 to 5,000 doses that are stuffed with dry ice and equipped with GPS-enabled sensors. The vaccine can be stored in conventional freezers for up to ve days, or in the special coolers for up to 15 days, as long as the dry ice is replenished and the boxes are not opened more than twice a day. The Moderna vaccine must also be stored in a freezer long-term, but at minus 4 degrees Fahrenheit. The company has indicated that its vaccine could be stored at standard refrigerator temperatures of 36 to 46 degrees Fahrenheit for up to 30 days, which could make it easier to store than the P zer vaccine.
2. Viral Vector Vaccines
These vaccines contain viruses engineered to carry coronavirus genes. Some viral vector vaccines enter cells and cause them to make viral proteins. Other viral vectors slowly replicate, carrying coronavirus proteins on their surface. And the viral proteins stimulate the body's production of antibodies to confer immunity.
AstraZeneca Vaccine
The British-Swedish company AstraZeneca and the University of Oxford have developed a vaccine based on a chimpanzee adenovirus (these are common viruses that cause a range of illness, such as cold-like symptoms, fever, sore throat, bronchitis, pneumonia, diarrhea, and conjunctivitis).
www.pvmarquez.com/covid19vaccine 3/7 1/12/2021 What We Know About the New COVID-19 Vaccines: Are We There Yet? | Patricio V. Marquez In a press release on November 23, 2020 (https://www.astrazeneca.com/media-centre/press- releases/2020/azd1222hlr.html), the company reported interim ndings from two of their ongoing trials — one in the UK and one in Brazil. The trials used different approaches to inoculating the more than 11,000 people who participated, and found two levels of ef cacy, which they averaged to 70 percent. The researchers also found no severe cases or hospitalizations in the study participants who got the vaccine.
According to the press reports (https://ca.news.yahoo.com/astrazeneca-covid-19-vaccine-highly-073721980.html? guccounter=1&guce_referrer=aHR0cHM6Ly93d3cuYmluZy5jb20v&guce_referrer_sig=AQAAAHK_GSFSL_VNzYKlDK3 CfAuM5Vixnq_c-5FO7d4VkoJJeFzU4eu-WS9a13JUMbZqQzWsR_SeZCsjeHbBEn_jIFwnNz- ICgQAcJo7YhZfYv2xTArKHBEoDnDUW4xOyDlE4WgUb68R), AstraZeneca, has pledged it will not make a pro t on the vaccine during the pandemic. It has reached agreements with governments and international health organizations that its cost will be $3 to $4 a dose. In contrast, P zer’s vaccine is likely to cost about $20, while Moderna’s is $15 to $25, based on agreements the companies have struck to supply their vaccines to the U.S. Government.
The preliminary analysis (https://www.nytimes.com/2020/11/16/health/Covid-moderna-vaccine.html? referringSource=articleShare) also indicates that the vaccine did not just reduce cases of COVID-19 with symptoms, it also reduced the number of asymptomatic cases. This latter nding may mean that the vaccine will be good at reducing the transmission of the virus from person to person. Another advantage of the vaccine is that it can be kept in a refrigerator for up to six months, unlike P zer and Moderna’s vaccines, which have to be frozen.
AstraZeneca has secured a series of agreements to provide vaccines to governments should they prove effective, including 300 million doses to the United States and 400 million doses to the European Union. The company has noted that its total annual manufacturing capacity for the vaccine stands at three billion doses.
However, since unveiling the preliminary results and after the original version of this blog was posted, AstraZeneca acknowledged on November 25, 2020, a key mistake in the vaccine dosage received by some study participants, adding to questions about whether the vaccine’s apparently spectacular ef cacy will hold up under additional testing (https://www.msn.com/en-us/money/companies/after-admitting-mistake-astrazeneca-faces- dif cult-questions-about-its-vaccine/ar-BB1bmqfQ?ocid=msedgdhp). Scientists and industry experts said the error and a series of other irregularities and omissions (https://www.nytimes.com/2020/11/24/world/what-we-know- about-astrazenecas-head-scratching-vaccine-results.html) in the way AstraZeneca initially disclosed the data have eroded their con dence in the reliability of the results. Of cials in the United States have noted that the results were not clear. The head of the agship federal vaccine initiative suggested that the vaccine’s most promising results may not have re ected data from older people.
China’s CanSino Biologics Vaccine
The Chinese company CanSino Biologics has developed a vaccine based on an adenovirus called Ad5, in partnership with the Institute of Biology at the country’s Academy of Military Medical Sciences. After publishing promising results from a Phase 1 safety trial, and reports that Phase 2 trials that demonstrated the vaccine produced a strong immune response, the Chinese military approved the vaccine on June 25, 2020 for a year as a “specially needed drug”, but it is not clear whether vaccination would be mandatory or optional for soldiers. Starting in August 2020, CanSino began running Phase 3 trials in a number of countries, including Saudi Arabia, Pakistan, and Russia.
Russia’s Sputnik V Vaccine
www.pvmarquez.com/covid19vaccine 4/7 1/12/2021 What We Know About the New COVID-19 Vaccines: Are We There Yet? | Patricio V. Marquez The Gamaleya Research Institute, part of Russia’s Ministry of Health, launched clinical trials in June 2020 of a COVID-19 vaccine. It is a combination of two adenoviruses, Ad5 and Ad26, both engineered with a coronavirus gene. On August 11, 2020, President Vladimir V. Putin announced that a Russian health care regulator had approved the vaccine, named Sputnik V, before Phase 3 trials had even begun. However, it was later indicated that the approval was a “conditional registration certi cate,” which would depend on positive results from the Phase 3 trials. Those trials, initially planned for just 2,000 volunteers, were expanded to 40,000. In addition to Russia, volunteers were recruited in Belarus, the United Arab Emirates, and Venezuela. On October 17, 2020, a phase 2/3 trial was launched in India. On September 4, 2020, Gamaleya researchers published the results of phase 1/2 trials. (https://www.nytimes.com/live/2020/11/11/world/covid-19-coronavirus-live-updates? referringSource=articleShare#russias-vaccine-proves-effective-in-early-trial-data-company-says) In a small study, they found that Sputnik-V yielded antibodies to the coronavirus and mild side effects. On November 11, 2020, the Russian Direct Investment Fund announced preliminary evidence from the Phase 3 trial indicating that the vaccine has a 92% ef cacy.
Russia has negotiated agreements to supply the vaccine to several countries including Argentina, Brazil, Mexico, and India.
China’s Sinovac Biotech Vaccine
Sinovac Biotech’s CoronaVac is in Phase 3 of clinical trials (https://www.bloomberg.com/features/2020- coronavirus-drug-vaccine-status/). It uses inactivated virus, which can help the body develop antibodies to the pathogen without risking infection. The shot had already been approved in China for emergency use for doctors, customs of cials, and other frontline workers, while simultaneously in Phase 3 trials in multiple other countries.
How do Pharmaceutical Companies Determine the Ef cacy of a Vaccine?
Clinical trials (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/effectiveness.html)provide data and information about how well a vaccine prevents an infectious disease and about how safe it is. The fundamental logic behind today’s vaccine trials was worked out by statisticians over a century ago. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2004181/) Researchers vaccinate some people and give a placebo to others, and then wait for participants to get sick and look at how many illnesses occur in each group. From these numbers, researchers calculate the proportion of volunteers in each group who get sick. They determine the relative difference between those two fractions and express that difference with a value they call ef cacy. If there is no difference between the vaccine and placebo groups, the ef cacy is zero. If none of the sick people had been vaccinated, the ef cacy is 100%.
A 95 percent ef cacy is compelling evidence that a vaccine works well (https://www.nytimes.com/2020/11/20/health/covid-vaccine-95-effective.html?referringSource=articleShare), but it does not tell what the chances are of a person becoming sick after being vaccinated. Also, it does not say how well the vaccine will reduce COVID-19 across a country.
Difference Between Ef cacy and Effectiveness
Ef cacy and effectiveness are related to each other, but they are not the same thing (https://www.sciencenews.org/article/coronavirus-what-does-covid-19-vaccine-ef cacy-mean). Both terms refer to the ability to produce a desired or intended result, with a difference. While ef cacy refers to a result acquired under ideal or controlled conditions (e.g., in a clinical trial where the patient population and other variable factors can be controlled), effectiveness refers to how well a drug or vaccine works out in real-world situations, where the
www.pvmarquez.com/covid19vaccine 5/7 1/12/2021 What We Know About the New COVID-19 Vaccines: Are We There Yet? | Patricio V. Marquez patient population and other variables cannot be controlled (e.g., differences in the underlying medical conditions of people vaccinated in the real-world compared to those in the clinical trials, how a vaccine is transported and stored, or even how patients are vaccinated).
It is therefore possible that the effectiveness of coronavirus vaccines will or will not match their impressive ef cacy in clinical trials. But if previous vaccines are any guide, effectiveness may prove somewhat lower.
The Importance of Pharmacovigilance
Post-vaccine surveillance needs serious attention given the risk of possible adverse vaccine effects. Clinically important, adverse events following any vaccination must be reported by healthcare providers to the Pharmacovigilance System (PVS) as required of all vaccination providers. Adverse events can also be monitored through electronic health record and claims-based systems.
This is important because before a vaccine is marketed, its safety and ef cacy exposure are limited to its use in clinical trials. Generally, clinical trials cover a limited number of patients with strict inclusion criteria, often excluding special patient groups like those with co-morbid conditions, children, elderly, and pregnant women. Hence, they do not re ect the experience in larger populations and in different geographical regions. People from different geographical regions differ from one another with respect to genetics, nutritional habits, lifestyle, and clinical practices. This makes it obligatory to maintain a constant vigilance on the use of new vaccines during the post-marketing period.
Strong testing systems are essential for vaccine surveillance. Testing is a critical tool to be used alongside vaccines, given that: (i) vaccine-induced immunity must be monitored with testing at a population level; (ii) the real-world effectiveness of COVID-19 vaccines will be largely uncertain and possibly variable across settings and populations; and (iii) vaccine coverage will be incomplete and focused on priority populations.
It is also of paramount importance to get a baseline sero-surveillance study done - representative samples of target populations to receive the COVID-19 vaccine to be able to distinguish between infection and vaccine-acquired immunity.
Moving Forward
Vaccines not only protect the people who get them, but also, they can help drive down new infection rates and protect society as a whole by slowing the spread of the virus. However, as observed in an editorial at The Lancet (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32472-7/fulltext), it should be clear that whether the COVID-19 vaccines prevent transmission of the coronavirus or mainly just protect against illness is still largely unknown. If the latter, achieving herd immunity through immunization becomes a dif cult prospect.
While the good news that a coronavirus vaccine could be available by late December 2020 should help boost our optimism about “returning to normal times” in a not-too-distant future, it is imperative that we continue to follow COVID-19 safety guidelines and remain vigilant about the risks posed by the pandemic. Indeed, as noted by Dr. Tedros Adhanom Ghebreyesus, WHO Director-General, “while a vaccine will be essential for bringing the pandemic under control, it is important to emphasize that a vaccine will complement the other tools that we have, not replace them.” (https://twitter.com/AFP/status/1328314929741504513?s=20)
Until vaccines become widely available, therefore, it should be clear to all that basic public health measures, such as disease surveillance, testing, contact tracing, medical isolation and quarantines, wearing masks in public spaces, social distancing, and hand hygiene, will continue to be our best rewall against the spread of the coronavirus and www.pvmarquez.com/covid19vaccine 6/7 1/12/2021 What We Know About the New COVID-19 Vaccines: Are We There Yet? | Patricio V. Marquez to save lives.
Another key point to highlight, as shown in a recent study in Health Affairs (https://www.healthaffairs.org/doi/10.1377/hlthaff.2020.02054), is that when it comes to cutting down on COVID- 19 infections, hospitalizations, and deaths, a well-coordinated and timely deployment of vaccines matters just as much as their ef cacy. So, as we discussed in a previous post (http://www.pvmarquez.com/covid-19vaccination), the urgent preparation for the massive deployment of the vaccine in the months to come is a public health, social, and economic imperative in countries across the world that cannot wait.
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/covid19vaccine 7/7 1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez
HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19- VACCINATION? Submitted by Patricio V. Marquez on Mon, 11/16/2020 - 06 56 PM
HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19- VACCINATION?
Posted by Patricio V. Marquez on Mon, 11/16/2020 - 06 56 PM
Patricio V. Marquez, Betty Hanan, Sheila Dutta, Mary Mulusa
www.pvmarquez.com/covid-19vaccination 1/12 1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez The announcement (https://www.nature.com/articles/d41586-020-03248- 7) last week by P zer and the German company BioNTech, and early this week by Moderna, that their COVID-19 vaccines are 90% and 94% effective, respectively, is making the world optimistic about the possibility that we may overcome the pandemic in a not too distant future. The optimism was further reinforced by news that Russia’s Sputnik V vaccine may be as effective as these two candidate vaccines.
While waiting for peer-reviewed data from the phase III clinical trials and the formal approval of the vaccines by regulatory bodies, the critical challenge facing all countries is how to ensure that “ (https://www.theguardian.com/world/2020/nov/16/us-coronavirus- vaccine-distribution-challenges)the most logistically dif cult vaccination campaign in history (https://www.theguardian.com/world/2020/nov/16/us-coronavirus- vaccine-distribution-challenges)” (https://www.theguardian.com/world/2020/nov/16/us-coronavirus- vaccine-distribution-challenges) is conducted in the face of a “hesitant and weary public”, and at least one vaccine with “unprecedented cold chain requirements.”
So, what needs to be in place at the country level to move from vaccine promises to actual vaccination? On the basis of an initial review of available literature, we prepared a summary that highlights some key structural and process building blocks.
1. An integrated approach to healthcare delivery is key for a successful immunization campaign effort
Accumulated experience with the delivery of vaccines under the essential program of immunizations (EPI) suggests that a strong public health and primary care partnership is vital to achieving national vaccination coverage
www.pvmarquez.com/covid-19vaccination 2/12 1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez targets and control the spread of disease. While primary care bene ts from public health’s role in policy, population health, health equity, and education, public health bene ts from primary care’s ability to provide individual patient assessment, disease management, screening of patients, care coordination, and quality improvement.
To articulate this partnership for the delivery of a new COVID-19 vaccine, sustained effort is needed to support governments in strengthening some key Core Activity Areas, in accordance to country-speci c context and epidemic status.
2. Core Activity Areas
Four core activity areas are identi ed and discussed below.
Core Activity Area 1 Planning and Management
Activities in this Area include:
Development of national deployment and vaccination plans. Since at this time there are not as yet COVID-19 vaccines that have been approved for use, the focus of national plans may center on two major phases of vaccine availability and distribution: Phase 1 will be when there is limited vaccine availability and will focus on target/priority groups to receive vaccination. Phase 2 will be wide scale distribution vaccine associated with broad availability to the general population. Identi cation of target populations and development of micro-plans. This is an important activity as it would help identify and prioritize critical populations for the different phases of vaccine availability, consistent with the World Health Organization (WHO) Fair Allocation Framework (https://www.who.int/publications/m/item/fair-allocation- mechanism-for-covid-19-vaccines-through-the-covax-facility). More speci cally, it would help estimate numbers for priority groups, and www.pvmarquez.com/covid-19vaccination 3/12 1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez establish a transparent allocation. For example, in some countries vaccination could focus initially in the workforce that provides healthcare and maintains essential functions of society, staff and residents in long-term care facilities, elderly people and those with two or more co-morbidities that put them at high risk for complications from COVID-19. Use and deployment of real-time monitoring tools such as RapidPro (https://www.unicef.org/innovation/rapidpro), a free, open source software, used by UNICEF, governments, and civil society partners. RapidPro collects data via short message service (SMS) and other communication channels (e.g. voice; social media channels, such as Facebook Messenger, Telegram, WhatsApp) to enable real-time data collection and mass-communication with target end-users, including bene ciaries and frontline workers. Strengthening national immunization budgeting and budget tracking capacity. This would need to include the identi cation of options to address the investment cost implications, including recurrent costs, associated with the introduction of the vaccine for country health spending, and how the vaccine can be sustainably deployed moving forward. We should be clear that additional health workers/staff will be required to carry out this unprecedented effort and their salaries should be budgeted and funded. The new vaccine and its administration, therefore, will require a substantial increase in public health nancing in many countries.
Core Activity Area 2 Supply and Distribution
Key activities under this Area include:
Procurement and distribution of COVID-19 vaccine and ancillary supplies
www.pvmarquez.com/covid-19vaccination 4/12 1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez Some countries may choose to purchase vaccines through multilateral mechanisms such as the COVAX Facility (https://www.gavi.org/covax- facility#what.), which is co-led by Gavi, the Coalition for Epidemic Preparedness Innovations (CEPI) and WHO. Other countries may choose to purchase vaccines directly via bilateral deals or may choose to pursue multiple mechanisms for vaccine purchase.
In undertaking this activity, due consideration needs to be given to the threshold for eligibility for vaccine purchase either: (i) approval by Stringent Regulatory Authorities (SRAs) (https://www.who.int/medicines/regulation/sras/en/), or (ii) WHO prequali cation and approval by SRAs.
The procurement of ancillary supply kits may also be necessary, including needles, syringes, alcohol prep pads, COVID-19 vaccination record cards for each vaccine recipient, and a minimal supply of PPE, including surgical masks and face shields, for vaccinators.
COVID-19 Vaccine Allocation
Support is needed to develop country-speci c mechanisms for the allocations of the COVID-19 vaccine to jurisdictions in accordance with multiple factors, including, but not limited to, priority populations, current local spread and prevalence of COVID-19, and COVID-19 vaccine production and availability. This would include coordination with manufacturers and procurement agents on freight, logistics, insurance and storage to deliver COVID-19 vaccine doses.
Key activities include:
www.pvmarquez.com/covid-19vaccination 5/12 1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez Ensuring adequate logistics and transportation capacity, including conducting eet assessments; and procurement and deployment of trucks (e.g. cold trucks) and vehicles.
Strengthening immunization supply chain system, including capacity building with respect to both supply chain systems and training of health sector human resources; and adoption of global tools and best practices.
Leveraging innovations and technology to: test and pilot track & trace technology; strengthen remote temperature monitoring systems; and strengthen logistics information systems to accommodate COVID-19 vaccines
Ensure Quality of Vaccination Services
Quality assurance is very important for vaccine delivery. Vaccines must be stored at correct temperatures and safely handled to ensure the best protection. Training and technical assistance are needed to support health personnel effectively implement vaccination programs. Also, support is needed to conduct monitoring and supervision activities to ensure appropriate vaccine storage and handling practices, and to identify opportunities to improve vaccination coverage of target populations. To this end, support would be required to further strengthen vaccine distribution and cold chain systems while awaiting vaccine availability.
If current cold chain gaps and new requirements are addressed in a timely way, it will facilitate widespread administration, not only of a new COVID-19 vaccine, but will also help revamp the delivery of routine vaccines, particularly those for children. The latter task is of critical importance since the pandemic has disrupted national immunization programs.
Core Activity Area 3 Program Delivery
www.pvmarquez.com/covid-19vaccination 6/12 1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez Key activities to be supported under this Area include:
Community Engagement and Advocacy
Vaccine hesitancy is expected to be high, so public communication efforts should focus on building a foundation of trust. Public communication about COVID-19 vaccinations should aim to in uence the population in a country to: trust the information that they receive from national and local public health institutions, increasing knowledge of vaccine and the process of COVID-19 vaccine development; understand the bene ts and risks, setting and managing expectations by clearly informing about limited availability of vaccines at the onset of the vaccine delivery and on the need to prioritize administration of available vaccines to high risk group; make informed decision; and know how and where to get a COVID-19 vaccination.
To this end, support would be needed to strengthen risk communication and community engagement could be expanded, with a focus on increasing awareness for COVID-19 prevention and to strengthen strategic communication addressing demand-side challenges for vaccine uptake. Such communications efforts need to address speci c national/subnational knowledge, attitudes, and beliefs about vaccination.
Ensure vaccines reach the target populations. This will require: (i) adequate amount of vaccinators / health workers; (ii) support training of vaccinators and health workers; (iii) adopting global tools to local context; and (iv) funding of targeted outreach to ensure prioritized population know where and when to receive vaccinations.
De ne Access Points for Vaccine Administration
www.pvmarquez.com/covid-19vaccination 7/12 1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez This would include identi cation and enrollment of providers into the COVID-19 vaccination program for early narrow and later broad vaccination plans, such as broad-based healthcare partners (primary and specialty care providers, skilled nursing facilities, other long-term care settings, local public health agencies, hospitals and health systems, pharmacies, mobile vaccination providers, occupational health for large employers, providers serving incarcerated populations, and payers); preparations for vaccinations through regular healthcare channels and new mobile or community-based mass vaccination sites; community partners to increase accessibility, uptake, and reach by creating a transition plan from low supply/high demand to high supply/low demand.
Support would also be provided for: creation of a registry to identify priority target populations and develop strategies for outreach, speci cally a list of front-line healthcare workers, the elderly, and those with pre-existing conditions.
Adequate Waste Management System in Health Facilities
Good practices for safely managing health care waste and infection prevention and control should be followed, including assigning responsibility and suf cient human and material resources to dispose of such waste safely. All health care waste produced during the care of COVID-19 patients should be collected safely in designated containers and bags, treated, and then safely disposed of or treated, or both, preferably on- site. This also would be an opportunity to ensure that health facilities possess at least a minimum level of WASH facilities.
Core Activity Area 4 Supporting Systems and Infrastructure
Key interventions under this Area include:
www.pvmarquez.com/covid-19vaccination 8/12 1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez COVID-19 Vaccine Safety Monitoring
A comprehensive and effective vaccination program requires a robust data infrastructure at different levels of a health system. This is needed to: (i) further strengthen vaccination practices in both the public and private sectors; (ii) assesses the impact of vaccination programs through disease surveillance; (iii) provide credible evidence-based information to healthcare consumers; (iv) support outbreak investigation and control; and (v) monitor vaccine coverage, effectiveness, and safety.
Post-vaccine surveillance needs serious attention given risk of adverse vaccine effects. Clinically important, adverse events following any vaccination must be reported by healthcare providers to the Pharmacovigilance System (PVS) as required of all COVID-19 vaccination providers. Adverse events will also be monitored through electronic health record and claims-based systems.
This is of importance because before a medicinal product is marketed, its safety and ef cacy exposure are limited to its use in clinical trials. Generally, clinical trials cover limited number of patients with strict inclusion criteria, often excluding special patient groups like those with co- morbid conditions, children, elderly and pregnant women. Hence, they do not re ect the experience in larger population sand in different geographical regions. People from different geographical regions differ from one another with respect to genetics, food habits, life style, or clinical practices. This makes it obligatory to maintain a constant vigil on the use of medicinal products during the post-marketing period.
Strong testing systems are essential for vaccine surveillance. Testing is a critical tool to be used alongside vaccines, given that: vaccine induced immunity must be monitored with testing on a population level; the real- world effectiveness of COVID-19 vaccines will be largely uncertain and
www.pvmarquez.com/covid-19vaccination 9/12 1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez possibly variable across settings and populations; and vaccine coverage will be incomplete and focused on priority populations. To this end, support may be required for: developing/adapting the national diagnostic strategy and plans as new diagnostic technologies become available, selecting of diagnostic tests for appropriate use following international guidelines and national priorities, and, training on infection prevention and control (IPC) measures, provision of IPC supplies (e.g. hand hygiene products, disinfectants), biosafety measures (e.g., safe specimen collection and handling and appropriate disposal of diagnostic tests and supplies), and availability of protocols for proper testing at facility and community levels.
It would also be of paramount importance to get a baseline sero- surveillance study done - representative samples of target populations to receive the COVID-19 vaccine to be able to distinguish between infection and vaccine acquired immunity.
WASH in health care settings
Existing recommendations for water, sanitation and hygiene measures in health care settings are important for providing adequate care for patients and protecting patients, staff and caregivers from infection risks. Hand hygiene is also extremely important. Cleaning hands with soap and water or an alcohol-based hand rub should be performed according to instructions. Functional hand hygiene facilities should be present for all health care workers at all points of care and in areas where PPE is put on or taken off.
3. How are governments going to address compensation issues related to the liability shield offered to pharmaceutical rms that will be supplying the COVID-19 vaccines?
www.pvmarquez.com/covid-19vaccination 10/12 1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez This question is of particular importance for middle-income countries that have to assume this obligation, including under COVAX arrangements. Low- and lower middle-income countries are expected to be covered under a proposed scheme co-led by WHO to set up a compensation fund for people in poor nations who might suffer any side-effects from COVID-19 vaccines, aiming to allay fears that could hamper a global rollout of shots.
The public sector guarantors of the liability shield offered to pharmaceutical rms will have to look at how to manage this. It is critical, therefore, to have clarity about this now, i.e. before vaccines start owing. With the scale of distribution of the vaccines even rare side effects could end up affecting thousands.
A recent review (https://journals.plos.org/plosone/article? id=10.1371/journal.pone.0233334) (https://journals.plos.org/plosone/article? id=10.1371/journal.pone.0233334)of existing compensation programs in the world shows that the bene ts most referred to in existing no-fault compensation programs were: fair compensation for individuals inadvertently injured by a vaccine meant for public good and increasing con dence in public vaccination programs. The most notable operational challenge of existing programs was identi ed to be lack of public awareness of programs existence, strict requirements for standard of proof that vaccine caused injury, and long timelines for ling claims and receiving compensation.
Conclusion
It should be clear to all that the approval of effective COVIX-19 vaccine is only the rst step in the process to reverse the global pandemic. We also have to realize that multiple vaccines to meet demand would add complexity of the delivery effort. Besides the supply of vaccines, a key challenge to
www.pvmarquez.com/covid-19vaccination 11/12 1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez deal with is gaining public trust, including among healthcare workers who will be asked to take the vaccine rst as part of the priority population groups.
Hence, the activities outlined above will need to be undertaken sooner, rather than later, to address the logistical and cold chain challenges enabling the rapid distribution and administration of COVID-19 vaccines.
Photo credit: Luca Lorenzelli Stock photo ID:1212565443
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/covid-19vaccination 12/12 1/12/2021 Health Systems Fit for the Future: How to Promote Better Health, Economic Growth, and Social Cohesion? | Patricio V. Marquez
Health Systems Fit for the Future: How to Promote Better Health, Economic Growth, and Social Cohesion? Submitted by Patricio V. Marquez on Fri, 10/23/2020 - 04 47 PM
Health Systems Fit for the Future: How to Promote Better Health, Economic Growth, and Social Cohesion?
Posted by Patricio V. Marquez on Fri, 10/23/2020 - 04 47 PM
I recently had the honor of serving as a panelist in plenary session 5 “Health systems t for the future: promoting better health, economic growth, and social cohesion”, that was held virtually as part of the 16th World Congress www.pvmarquez.com/romehsystems 1/8 1/12/2021 Health Systems Fit for the Future: How to Promote Better Health, Economic Growth, and Social Cohesion? | Patricio V. Marquez on Public Health: “Public health for the future of humanity: analysis, advocacy and action” (https://wcph2020.com/), on October 15th, 2020.
While all the participants in the Congress regretted not having been able to travel to Rome, the Eternal City, and participate in person due to the COVID-19 pandemic, the organization of the virtual event was awless. So, our sincere congratulations are conveyed to the organizers for a job well done!
My session was chaired by Prof. Walter Ricciardi and Prof. Sheila Dinotshe Tlou, Co-chairs of the 16th World Congress on Public Health, and included as my fellow panelists Natasha Azzopardi Muscat, Director for Country Health Policies and Systems at the WHO Regional Of ce for Europe and Immediate Past President of the European Public Health Association (EUPHA); Sara Cerdas, a Portuguese medical doctor and since July of 2019 a Member of the European Parliament; Katie Gallagher, Senior Policy Adviser, European Patients’ Forum; Rüdiger Krech, Director, Department of Health Promotion, World Health Organization; and Gita Sen, Director of the Ramalingaswami Centre on Equity and Social Determinants of Health at the Public Health Foundation of India and Adjunct Professor of Global Health and Population at the Harvard T. H. Chan School of Public Health.
In my presentation, I conveyed three action points to address the overarching questions guiding the discussion in the session. These were:
Question 1 How can we improve health, wealth, and societal well-being by investing in health systems?
Action 1 Prevent, detect, and respond to the threat posed by zoonotic diseases and strengthen national systems for public health preparedness
www.pvmarquez.com/romehsystems 2/8 1/12/2021 Health Systems Fit for the Future: How to Promote Better Health, Economic Growth, and Social Cohesion? | Patricio V. Marquez The worldwide spread of COVID-19 is demonstrating the impact that infectious diseases of animal origin can exert on global health and development. More than 70% of new infectious diseases are zoonotic. The COVID-19 pandemic is currently affecting 188 countries and territories across all regions. As of mid-October 2020, (https://coronavirus.jhu.edu/) more than 37 million con rmed cases and more than 1 million con rmed deaths have been reported.
Besides growing numbers of infected people and loss of life, the pandemic has caused an economic free-fall not experienced since World War II. International Monetary Fund (IMF) estimates show that 170 countries will see income per capita go down. (https://www.imf.org/en/Publications/WEO/Issues/2020/09/30/world- economic-outlook-october- 2020#Full%20Report%20and%20Executive%20Summary) And World Bank Group projections (https://www.worldbank.org/en/news/press- release/2020/10/07/covid-19-to-add-as-many-as-150-million-extreme- poor-by-2021) suggest that rising unemployment and loss of income, including in some countries a signi cant drop in remittances, could push between 88 million and 115 million people back into extreme poverty as a result of the pandemic, with an additional increase of between 23 million and 35 million in 2021, potentially bringing the total number of new people living in extreme poverty to between 110 million and 150 million.
The pandemic is also putting at risk the past decade's progress in building human capital, including gains in health, survival rates, school enrollment, and reduced stunting. The economic impact of the pandemic has been particularly deep for women and for the most disadvantaged families, leaving many vulnerable to food insecurity and poverty.
www.pvmarquez.com/romehsystems 3/8 1/12/2021 Health Systems Fit for the Future: How to Promote Better Health, Economic Growth, and Social Cohesion? | Patricio V. Marquez The COVID-19 pandemic, therefore, is a stark remainder of the ongoing challenge of emerging and reemerging infectious diseases and the need for (//blogs.worldbank.org/health/regional-disease-surveillance-globalized- world) (https://blogs.worldbank.org/health/regional-disease-surveillance- globalized-world)constant disease surveillance, prompt diagnosis, and robust research (//blogs.worldbank.org/health/regional-disease- surveillance-globalized-world) to understand the basic biology of new organisms and our susceptibilities to them, as well as to develop effective countermeasures to control them.
A critical long-term aspect of the response (https://blogs.worldbank.org/health/world-banks-health-response-covid- 19-coronavirus) is strengthening and building a resilient health system able to manage similar future health system shocks by supporting the realization of the universal health coverage (UHC) agenda, which includes timely access to health care when needed, nancial protection, and disease prevention and preparedness. To this end, the universal health coverage agenda needs to strengthen its focus on prevention to help guide investments, identify and prioritize the biggest risks, and promote pandemic preparedness for future outbreaks building upon the One Health Strategy. (https://blogs.worldbank.org/health/one-health-approach-critical-de- risk-human-animal-and-environmental-health)
Question 2 Which investments inside and beyond the health system should be performed to increase quality and reduce inequities?
Action 2 Avoid the false dichotomy between physical health and mental health
In this midst of a global pandemic, this year’s World Mental Health Day campaign (https://www.who.int/campaigns/world-mental-health- day/world-mental-health-day-2020) called for greater investment in mental
www.pvmarquez.com/romehsystems 4/8 1/12/2021 Health Systems Fit for the Future: How to Promote Better Health, Economic Growth, and Social Cohesion? | Patricio V. Marquez health. This is timely and justi ed. Recent estimates suggest that most low- and middle-income countries spend less than $2 per person on the treatment and prevention of mental and substance use disorders – and this was prior to the global outbreak of the novel coronavirus.
A fundamental rethinking is needed to overcome the false dichotomy between physical health and mental health in health services. Mental health parity must be placed at the core of human capital development. The social cost of mental illness and substance use disorders – which compound the impact of poor physical health – are terribly high for individuals, families, communities, and the economy. Yet the cost of effective treatments is surprisingly low.
We must be wary of siloed approaches to increased mental health funding. Rather, governments can mobilize new resources and leverage existing funding streams by integrating mental health interventions (https://blogs.worldbank.org/health/lets-invest-mental-health-inclusive- and-resilient-recovery-covid-19? CID=WBW_AL_BlogNoti cation_EN_EXT)into existing service delivery platforms across sectors.
There are numerous potential cross-sectoral entry points that would align funding, service provision, and population needs:
(i) Integrating mental and physical health services at primary health care and community levels
(ii) School-based and youth interventions are critically important because 75 percent of mental and substance use disorders begin before age 25, and suicide is a leading cause of death among youth
www.pvmarquez.com/romehsystems 5/8 1/12/2021 Health Systems Fit for the Future: How to Promote Better Health, Economic Growth, and Social Cohesion? | Patricio V. Marquez (iii) Integrating mental health into wellness programs in the workplace can mobilize private companies to invest in health promotion activities
(iv) Programs in fragile and con ict-affected settings can be leveraged to mainstream integrated physical and mental health interventions alongside other social services to address the needs of displaced populations and refugees
(v) Microcredit schemes to provide low-interest, small business loans, training, and mentorship to entrepreneurs with a history of mental health or addiction challenges (including former prisoners), facilitate reintegration into the community
Question 3 How can we guarantee that health systems are sustainable, resilient, and accessible?
Action 3 Pro-health taxes reduce health risks, expand scal space for universal health coverage, and enhance equity
Taxes on tobacco, alcohol, and sugar-sweetened beverages (https://blogs.worldbank.org/health/taxes-tobacco-alcohol-and-sugar- sweetened-beverages-reduce-health-risks-and-expand- scal) are effective but underused policies of disease prevention and health promotion, that could also help mobilize additional government revenue to fund investments and programs that bene t the entire population and enhance equity.
Raising taxes on tobacco, in particular, can do more to reduce premature mortality than any other single health policy. The evidence across a wide range of countries shows that a 50% increase in cigarette price typically leads to a 20% decline in cigarette consumption. Lowering consumption reduces tobacco-attributable sickness and death: about half of this effect comes from current smokers quitting and the other by reducing smoking
www.pvmarquez.com/romehsystems 6/8 1/12/2021 Health Systems Fit for the Future: How to Promote Better Health, Economic Growth, and Social Cohesion? | Patricio V. Marquez initiation among young people. Taxing alcohol and sugar-sweetened beverages helps to reduce consumption and prevent the onset of related chronic diseases such as cardiovascular diseases, cirrhosis of the liver, obesity, and diabetes. Moreover, taxation to increase the price of alcohol products, along with strict enforcement of drunk-driving laws, can help reduce the high human and economic cost of road traf c injuries, fatalities, and domestic violence.
Emerging evidence shows positive health impacts from sugar-sweetened beverages taxes by reducing consumption and hence helping to control the growing obesity epidemic and its impact on NCDs. Tobacco, alcohol, and sugar-sweetened beverage taxes can substantially boost government revenues. This is of critical importance during COVID-19, as policymakers must maintain their public health responses while also mobilizing domestic revenue for investment in future pandemic preparedness and other essential health services.
These health tax increases would have the additional advantage of reducing future health care costs by curbing the growth of the non-communicable diseases that tobacco, alcohol, and sugar-sweetened beverages can cause. Elimination of fossil fuel subsidies, which impose large scal costs while adding to negative environmental and health impacts, could also help expand scal space for health.
Projections presented in a World Bank Group report for the G-20 meeting in Osaka, Japan in 2019 (https://openknowledge.worldbank.org/handle/10986/31930) showed that the substantial UHC nancing gap in low- and lower-middle-income countries (now exacerbated by COVID-19), can be attenuated by excise tax increases on tobacco, alcohol, and sugar-sweetened beverages. These calculations showed that a 50% increase in prices for these products could
www.pvmarquez.com/romehsystems 7/8 1/12/2021 Health Systems Fit for the Future: How to Promote Better Health, Economic Growth, and Social Cohesion? | Patricio V. Marquez generate additional revenues of approximately $24.7 billion in 54 low- and middle-income countries by 2030. Importantly, the revenue raised can additionally bene t poorer households when it is used progressively.
Take Away Message
As voiced by my fellow panelists during the session, it should be clear to all going forward that high-quality health systems include not only the right to quality health care but also equity. Evidence-based, cost-effective investments and rigorous assessment are key to guarantee high quality health systems for all.
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/romehsystems 8/8 1/12/2021 The World Bank’s health response to COVID-19 (Coronavirus)
Learn how the World Bank Group is helping countries with COVID-19 (coronavirus). Find Out
Publish d on Inv stin in H lth (/h lth)
Th World B nk’s h lth r spons to COVID-19 (Coron virus)
PATRICIO V. MARQUEZ (/TEAM/PATRICIO-V-MARQUEZ), SHEILA DUTTA (/TEAM/SHEILA-DUTTA) & BETTY HANAN (/TEAM/BETTY-HANAN) | OCTOBER 19, 2020
This page in: English
Freetown City Council community engagement to prevent the spread of COVID-19 in Sierra Leone. © Valena McEwen, World Bank Health team in Sierra Leone
In response to the rapid spread of the COVID-19 pandemic, and building on accumulated experience with health crises in the past 20 years, the World Bank Group sprang into action in late February 2020. (https://twitter.com/intent/tweet? text=In+response+to+the+rapid+spread+of+the+COVID- 19+pandemic%2C+and+building+on+accumulated+experience+with+health+crises+in+ banks-health-response-covid-19-coronavirus/? https://blogs.worldbank.org/health/world-banks-health-response-covid-19-coronavirus 1/8 1/12/2021 The World Bank’s health response to COVID-19 (Coronavirus) cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) Working closely with national teams, WHO, UNICEF and other international partners to support countries’ responses, the World Bank prepared the $6 billion (https://www.worldbank.org/en/news/press-release/2020/03/17/world-bank-group- increases-covid-19-response-to-14-billion-to-help-sustain-economies-protect- jobs#:~:text=WASHINGTON%2C%20March%2017%2C%202020%20%E2%80%94,rapid% COVID-19 emergency health response in just a few weeks.
The Bank currently provides emergency health and social support to 111 countries (https://www.worldbank.org/en/news/speech/2020/10/16/remarks-by-world-bank- group-president-david-malpass-to-the-annual-meetings-2020-development- committee), covering about 70% of the world’s population, including millions who live in places a ected by con ict and fragility.
The progress has been fast and signi cant
The Bank’s goal is to assist countries in their e orts to prevent, detect and respond to COVID-19, and to strengthen national public health preparedness systems. (https://twitter.com/intent/tweet? text=The+Bank%E2%80%99s+goal+is+to+assist+countries+in+their+e orts+to+prevent 19%2C+and+to+strengthen+national+public+health+preparedness+systems.+&url=http banks-health-response-covid-19-coronavirus/? cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) A menu of options allowed World Bank country teams to tailor projects to the speci c circumstances of each country.
Country examples illustrate how funding allocated under the program is aligned to service provision and population needs.
Case detection, con rmation, contact tracing, recording, reporting
In Ghana, support has been provided to recruit and train 4,410 health professionals, 1,385 contact tracers and 318 laboratory technicians. Drone delivery of samples from remote areas to test centers has also been initiated, along with the potentially time saving practice of “pool testing,” in which multiple blood samples are tested together and processed separately only if a positive result is found. This has led to the identi cation and testing of 361,542 persons as of July 2020. x This site uses cookies to optimize functionality and give you the best possible experience. If you continue to navigate this website beyond this page, cookies will be placed on your browser. To learn more about cookies, click here. (https://www.worldbank.org/en/about/legal/privacy-notice) https://blogs.worldbank.org/health/world-banks-health-response-covid-19-coronavirus 2/8 1/12/2021 The World Bank’s health response to COVID-19 (Coronavirus) In Georgia, support is being provided to strengthen public health laboratories and epidemiological capacity. As of the end of September 2020, an average of 9,000 polymerase chain reaction (PCR) tests and 1,700 rapid tests were being performed daily.
In Cambodia, the Bank supports decentralized laboratories and helps strengthen services in remote and underserved areas.
In Yemen, six central public-health laboratories have opened, and 930 health professionals have been trained in COVID-19 case management.
In Ethiopia, in the rst 100 days after project approval, more than 11 million households nationwide were screened, lab professionals trained, and about 23 laboratories throughout the country are now conducting COVID-19 tests. A parallel project is also supporting the Africa Center for Disease Control’s region-wide response.
Health system strengthening
In Afghanistan, initial support has included procurement of emergency supplies, including 555,000 personal protective equipment (PPE) kits. These supplies have enabled health care workers to improve clinical management of about 10,000 hospitalized COVID-19 patients.
In Papua New Guinea, 6,846 infection, prevention and control (IPC) supplies and 31,200 PPEs arrived in June 2020 for nationwide use.
In India, the Bank’s operation helps cover salaries of more than 50,000 contractual frontline sta operating across the country’s 35 states and union territories.
In Argentina, Ecuador, Indonesia, Haiti, Iran, Senegal, Somalia, and Ukraine, the Bank has been supporting the acquisition of medical equipment to enhance service delivery capacity.
In Mongolia, as well as in China, support is being provided to strengthen capacities for a multi-sectoral response, particularly the interface of environmental, veterinary, and public health services to contain the spread of new viruses of animal origin at their source.
Water, sanitation and hygiene (WASH) x This site uses cookies to optimize functionality and give you the best possible experience. If you continue to navigate this website beyond this page, cookies will be placed on your browser. To learn more about cookies, click here. (https://www.worldbank.org/en/about/legal/privacy-notice) https://blogs.worldbank.org/health/world-banks-health-response-covid-19-coronavirus 3/8 1/12/2021 The World Bank’s health response to COVID-19 (Coronavirus) Many projects include actions on water and/or sanitation in health facilities. 57 projects include components of behavior change, hygiene and handwashing in health facilities, and 47 projects include support for medical waste management.
In Senegal, for example, the project supports a mix of water supply, hand washing, and sanitation activities in urban, peri-urban, and rural areas, including the connection of unserved localities to existing water supply systems.
Social and nancial support to households
In Sri Lanka, additional nancing of $89 million supports temporary scaled-up cash transfers under existing programs for registered elderly and disabled people and those with chronic diseases.
In Pakistan cash support covers 15 million vulnerable families. Additional support is being provided to 4 million female bene ciaries who were already receiving direct income support under this program.
In Kosovo, under the government’s existing social assistance program, cash transfers are being provided to 24,000 poor families, and to an additional 29,000 newly poor families.
In Rwanda, emergency cash transfers support 19,000 vulnerable households in Kigali, 8,400 other vulnerable households, and 7,700 vulnerable agricultural households (to enable access to seeds and fertilizers).
In Argentina, COVID-19 services are free when are delivered by public hospitals and health centers.
In Paraguay and Uruguay, testing and treatment services for COVID-19 are free of charge to the bene ciaries of the country’s public health and social health insurance programs.
Mental health interventions
In many countries, including Bosnia and Herzegovina, Cambodia, Ecuador, Guatemala, India, Lesotho, Liberia, Mali, Marshall Islands, Morocco, Mongolia, Niger, Nigeria, Republic of Congo, Senegal, Sri Lanka, Turkey, and Yemen, Bank projects support psychosocial interventions to help people deal with the negative psychological e ects from stressors such as lockdowns, self-isolation and quarantines, infection fears, inadequate information, job and nancial losses, and stigma and discrimination. https://blogs.worldbank.org/health/world-banks-health-response-covid-19-coronavirus 4/8 1/12/2021 The World Bank’s health response to COVID-19 (Coronavirus) Community engagement
In Egypt, when movement was restricted, virtual communication tools helped to prepare the project. These tools enabled consultations with a wide range of stakeholders including governmental o cials, frontline health workers and NGO partners. Virtual hospital visits guided by hospital sta equipped with PPE helped to gather information on how projects were being implemented and to get stakeholder feedback.
In Sierra Leone, building on the Ebola experience, the project has supported the Freetown City Council and the mayor to implement risk communication campaigns by forming teams of volunteers in each of the city’s wards, teamed with local councilors, chiefs, tribal heads, Mammie Queens and youth leaders, to conduct outreach activities and house visits to foster community engagement and in uence behavior change.
In the Democratic Republic of Congo, a community-centered approach has been successful to counter misinformation, with feedback mechanisms to communicate critical risk and event information to all communities in the local languages.
As the COVID-19 pandemic continues to evolve, with new diagnostics and therapeutics developed, and vaccines trials progressing, the exibility and agility of the World Bank’s health response will continue to be critical to support the next phase of country responses.
It is important to ensure that programs are adjusted and aligned with the spread of COVID-19, the level of pandemic preparedness, the capacity of health and social support systems, and lessons learned from the early phase of the pandemic response. (https://twitter.com/intent/tweet? text=It+is+important+to+ensure+that+programs+are+adjusted+and+aligned+with+the+ 19%2C+the+level+of+pandemic+preparedness%2C+the+capacity+of+health+and+socia banks-health-response-covid-19-coronavirus/? cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank)
For a full list of the World Bank Group’s COVID-19 projects, please refer here https://www.worldbank.org/en/about/what-we-do/brief/world-bank-group- operational-response-covid-19-coronavirus-projects-list https://blogs.worldbank.org/health/world-banks-health-response-covid-19-coronavirus 5/8 1/12/2021 Let’s Invest in Mental Health for an Inclusive and Resilient Recovery from COVID-19
Learn how the World Bank Group is helping countries with COVID-19 (coronavirus). Find Out
Publish d on Inv stin in H lth (/h lth)
L t’s Inv st in M nt l H lth for n Inclusiv nd R sili nt R cov r from COVID-19
PATRICIO V. MARQUEZ (/TEAM/PATRICIO-V-MARQUEZ) | OCTOBER 08, 2020
This page in: English
/ Mental health parity must be placed at the core of human capital development.
https://blogs.worldbank.org/health/lets-invest-mental-health-inclusive-and-resilient-recovery-covid-19
“I believe more than ever that we have the power to help change the world for people who have mental illnesses and addictions, and for all of those whose lives are touched by these brain diseases—which is to say, all of us.”- Patrick J. Kennedy x
1/7 1/12/2021 Let’s Invest in Mental Health for an Inclusive and Resilient Recovery from COVID-19 In this midst of a global pandemic, this year’s World Mental Health Day (https://www.who.int/campaigns/world-mental-health-day/world-mental-health-day- 2020) campaign is calling for greater investment in mental health. This focus is timely and justi ed. Recent estimates (https://documents.worldbank.org/en/publication/documents- reports/documentdetail/270131468187759113/out-of-the-shadows-making-mental- health-a-global-development-priority) suggest that most low- and middle-income countries spend less than $2 per person on the treatment and prevention of mental and substance use disorders – and this was prior to the global outbreak of the novel coronavirus.
The pandemic has brought social isolation, bereavement, nancial hardship, and interrupted health care services – which are negatively impacting the mental well- being of people. (https://twitter.com/intent/tweet? text=The+pandemic+has+brought+social+isolation%2C+bereavement%2C+ nancial+ha being+of+people.+&url=https://blogs.worldbank.org/health/lets-invest-mental- health-inclusive-and-resilient-recovery-covid-19/? cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank)New research also shows that substance use disorders (https://www.nature.com/articles/s41380-020-00880-7), including opioids, alcohol, and smoking, are tied to an increased risk for COVID-19 and serious adverse outcomes, including hospitalization and death. A fundamental rethinking is needed to overcome the false dichotomy between physical health and mental health in health services. Mental health parity must be placed at the core of human capital development. The social cost (https://www.goodreads.com/book/show/37651095-the-origins-of-happiness) of mental illness and substance use disorders – which compound the impact of poor physical health – are terribly high, for individuals, families, communities, and the economy. But the cost of e ective treatments (https://www.thelancet.com/pdfs/journals/lanpsy/PIIS2215-0366(16)30024-4.pdf) is surprisingly low. Integrating mental and physical health services Faced with the global economic fall-out as the COVID-19 pandemic rages, budgetary capacity of governments and international assistance co ers are stretched. What can be done to deliver on this year’s World Mental Health Day call? x
https://blogs.worldbank.org/health/lets-invest-mental-health-inclusive-and-resilient-recovery-covid-19 2/7 1/12/2021 Let’s Invest in Mental Health for an Inclusive and Resilient Recovery from COVID-19 We must be wary of siloed approaches to increased mental health funding. Rather, governments can mobilize new resources and leverage existing funding streams by integrating mental health interventions into existing service delivery platforms across sectors. (https://twitter.com/intent/tweet? text=governments+can+mobilize+new+resources+and+leverage+existing+funding+stre invest-mental-health-inclusive-and-resilient-recovery-covid-19/? cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) There are numerous potential cross-sectoral entry points that would align funding, service provision, and population needs:
Experiences in Chile, Colombia, Ghana, and the United States demonstrate that national mandates to cover mental and substance use disorders prevent the use of preexisting conditions clauses (https://www.penguinrandomhouse.com/books/317536/a-common-struggle- by-patrick-j-kennedy-stephen-fried/) to deny health insurance coverage. In Peru (https://blogs.worldbank.org/health/paradigm-shift-peru-leading-way- reforming-mental-health-services), the inclusion of mental health services as part of the bene ts package o ered by the Integrated Health Insurance (SIS) scheme was an important step towards the achievement of mental health parity, and for helping vulnerable people access these services when needed without incurring high out-of-pocket expenditures. This measure was complemented by the development of a fee schedule to reimburse health facilities for services rendered, and a 10-year results-based budget allocation by the Ministry of Economy and Finance exclusively to support community- based mental health services. Projects funded under the World Bank Group’s $6 billion COVID-19 Global Health Emergency Response Program (https://www.worldbank.org/en/topic/health/coronavirus) in countries such as Bosnia and Herzegovina, Cambodia, Ecuador, India, Lesotho, Liberia, Morocco, Marshall Islands, Mongolia, Nigeria, Sri Lanka, and Turkey support psychosocial interventions to help people deal with negative psychological e ects associated with stressors such as lockdowns, self-isolation and quarantines, infection fears, inadequate information, job and nancial losses, and stigma and discrimination. Existing funding streams for maternal and child health, such as those under the Global Financing Facility (GFF) in support of Every Woman, Every Child, (https://www.global nancingfacility.org/)can be leveraged to deal with maternal https://blogs.worldbank.org/health/lets-invest-mental-health-inclusive-and-resilient-recovery-covid-19 3/7 1/12/2021 Let’s Invest in Mental Health for an Inclusive and Resilient Recovery from COVID-19 depression, especially postnatal, and the associated stunting in children. School-based interventions are critically important because 75 percent of mental and substance use disorders begin before age 25 and suicide is a leading cause of death among youth. Programs of social and emotional learning along with promotion of physical health, work and study support, and alcohol and other drug services, have a positive impact on healthy development, well- being, and academic performance. Integrating school and clinic-based services is an e ective approach to improve human capital (https://www.worldbank.org/en/news/press-release/2020/09/16/pandemic- threatens-human-capital-gains-of-the-past-decade-new-report-says) outcomes by investing earlier in life. Similarly, integrating mental health into wellness programs in the workplace (https://blogs.worldbank.org/health/case-physical-and-mental-wellness- programs-workplace) can mobilize private companies to invest in health promotion activities such as cognitive-behavioral therapies to reduce stress. These programs generate signi cant bene ts for workers, their families, and employers, improving productivity and competitiveness, and tackling stigma surrounding mental disorders. Programs in fragile and con ict-a ected settings (https://blogs.worldbank.org/voices/ida-securing-more-resilient-future-fragile- and-con ict-a ected-settings) can be leveraged to mainstream integrated physical and mental health interventions (https://documents.worldbank.org/en/publication/documents- reports/documentdetail/916131486730755271/mental-health-among- displaced-people-and-refugees-making-the-case-for-action-at-the-world-bank- group) alongside other social services to address the needs of displaced populations and refugees who have been exposed to high levels of stress. For example, in the Horn of Africa (https://documents.worldbank.org/en/publication/documents- reports/documentdetail/483981467990370653/africa-horn-of-africa-emergency- health-and-nutrition-project), a World Bank Group-funded project supported counseling services for Somali women and children impacted by gender-based and sexual violence as part of a primary care package o ered in refugee camps in Kenya and Ethiopia. Likewise, in Afghanistan
https://blogs.worldbank.org/health/lets-invest-mental-health-inclusive-and-resilient-recovery-covid-19
4/7 1/12/2021 Let’s Invest in Mental Health for an Inclusive and Resilient Recovery from COVID-19 distress-afghanistan) and Yemen (https://projects.worldbank.org/en/projects- operations/project-detail/P161809), psychosocial support services are provided to people who have personally experienced or witnessed traumatic events. Pro-health taxes (https://blogs.worldbank.org/health/taxes-tobacco-alcohol- and-sugar-sweetened-beverages-reduce-health-risks-and-expand- scal), such as those on tobacco, alcohol, and sugar-sweetened beverages can help expand the tax base and collect additional public revenue for priority social investments and programs, including mental health services at primary care and community levels, and reduce health risks associated with substance use disorders. Botswana, Colombia, Moldova, Philippines (https://documents.worldbank.org/en/publication/documents- reports/documentdetail/491661505803109617/main-report), and Ukraine o er good examples of the use of this scal policy for public resource mobilization and health objectives. Microcredit schemes, such as Rise Asset Development in Canada (https://risehelps.ca/), which provides low-interest, small business loans, training, and mentorship to entrepreneurs with a history of mental health or addiction challenges (including former prisoners), facilitate reintegration (https://blogs.worldbank.org/health/mental-health-prisons-how-overcome- punishment-paradigm) into the community.
As the saying goes, a crisis should not go to waste. During the COVID-19 pandemic and beyond, renewed e orts and dedicated funding are needed to achieve mental health parity across sectors. A sustained focus on mental health will contribute to a more resilient recovery and develop more equitable societies. (https://twitter.com/intent/tweet? text=+A+sustained+focus+on+mental+health+will+contribute+to+a+more+resilient+rec invest-mental-health-inclusive-and-resilient-recovery-covid-19/? cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank)
HEALTH (/SEARCH?F[0]=TOPIC:297&F[1]=LANGUAGE:EN), COVID-19 (CORONAVIRUS) (/SEARCH? F[0]=SERIES:881&F[1]=LANGUAGE:EN)
https://blogs.worldbank.org/health/lets-invest-mental-health-inclusive-and-resilient-recovery-covid-19 5/7 1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez
Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID- 19 Submitted by Patricio V. Marquez on Sun, 09/06/2020 - 11 05 AM
Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID- 19
Posted by Patricio V. Marquez on Sun, 09/06/2020 - 11 05 AM
“Taxes should be levied not with the idea of lling the public treasury at whatever cost to public morality and e ciency, but as method of reducing the consumption of alcohol” ---Raymond B. Fosdick and Albert L. Scott, Toward Liquor Control (1933)
For many of us who have experienced alcohol use disorders involving ourselves or family members, the remembrance of these events brings painful memories of behaviors that negate everything that we have done well, accomplished, or stand for; shattered dreams and aspirations; unintended damage to relationships with loved ones and friends; and feelings of guilt and frustration that the temptation to have “one more” cannot be controlled despite promises made of “never again.”
In some cultures, like the one that I grew up in, high tolerance of heavy alcohol use and binge drinking was not only accepted but expected of men and peer-reinforced, both as a rite of passage from adolescence to adulthood, and later in life as a sustained behavior. Common expressions, such as “por qué te vas, si todavía estás bien” (“why are you leaving the party if you are still sober”), clearly portray these deep-rooted social norms.
Some may identify this condition as a social deviance, an outlier of what is considered “good behavior.” But more than that, we need to be clear that alcohol abuse and dependency, with all their causes and manifestations, is a damaging “social disease” affecting not only the mental and physical well-being of individual people, but also the lives of others. Let’s elaborate on this topic. www.pvmarquez.com/alcoholuse 1/12 1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez The Nature of Alcohol Use Disorders
Alcohol use disorder (AUD), including alcoholism, is a chronic relapsing brain disorder (https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-use-disorders), characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences. The severity of the disorder is determined by speci c symptoms, including problems controlling drinking, being preoccupied with alcohol, continuing to use alcohol even when it causes problems, having to drink more to get the same effect, binge drinking, or having withdrawal symptoms (e.g., trouble sleeping, shakiness, irritability, anxiety, depression, restlessness, nausea, or sweating) when a person rapidly decreases or stops drinking.
The impact of alcohol consumption on chronic and acute health outcomes in populations is largely determined by two separate but related dimensions of drinking: the total volume of alcohol consumed, and the pattern of drinking. Moderate alcohol consumption (https://health.gov/our-work/food-nutrition/2015-2020-dietary- guidelines/guidelines/) is up to 1 drink per day for women and up to 2 drinks per day for men. Patterns of drinking associated with AUD (https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge- drinking) include:
binge drinking, a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 percent (or 0.08 grams of alcohol per deciliter - or higher). For a typical adult, this pattern corresponds to consuming 5 or more drinks (male), or 4 or more drinks (female), in about 2 hours. heavy alcohol use as more than 4 drinks on any day for men or more than 3 drinks for women.
Alcohol Consumption
A study in The Lancet (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32744-2/fulltext) that analyzes trends in alcohol intake in 189 countries from 1990–2017 and estimates the rates through 2030, shows that between 1990 and 2017, global adult per-capita consumption (consumption in L of pure alcohol per adult [≥15 years]) in a given year) increased from 5.9 L to 6.5 L, and is predicted to reach 7.6 L by 2030. Globally, the prevalence of lifetime abstinence decreased from 46% in 1990 to 43% in 2017, albeit not a signi cant reduction, while the prevalence of current drinking increased from 45% in 1990 to 47% in 2017. The study forecast both trends to continue, with abstinence decreasing to 40% by 2030 (annualized 0·2% decrease) and the proportion of current drinkers increasing to 50% by 2030 (annualized 0·2% increase). In 2017, 20% of adults were heavy episodic drinkers (compared with 1990 when it was estimated at 18·5%), and this prevalence is expected to increase to 23% in 2030. Overall, men (70%) are more likely to drink than women (30%). The observed increase in alcohol use globally may be explained by increased purchasing power of consumers due to grow in per capita income, particularly in China and India.
Data compiled by Our World in Data (https://ourworldindata.org/alcohol-consumption), show that while alcohol consumption across North Africa and the Middle East is particularly low — in some countries, close to zero, alcohol use across Europe is highest at around 15 liters per person per year in the Czech Republic, Lithuania, and Moldova (equal to around two bottles of wine per person per week), and high in Germany, France, Portugal, Ireland, and Belgium – at around 12 to 14 liters. Outside of Europe, the only other country in this category of high per capita alcohol use is Nigeria.
When looking at consumption data within countries, it is observed that high-income people tend to drink more frequently. While those in lower income or educational status groups often drink less overall, they are more likely to have lower-frequency, higher-intensity drinking patterns.
www.pvmarquez.com/alcoholuse 2/12 1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez Data on alcohol expenditure from North America, Europe, and Oceania show that it typically ranges from 0.5 percent up to 7.7 percent (in Ireland) of household expenditure.
Globally, 107 million people or 1.8% of the total population are estimated to have an alcohol use disorder. The share of the population with alcohol use disorders across countries is shown in the map below, ranging from as low as 0.5 percent to almost 5 percent of the population.
Among youth, a study (https://ghrp.biomedcentral.com/articles/10.1186/s41256-018-0070-2) that reviewed alcohol consumption patterns and alcohol-related social and health issues among 15–29-year olds in Asian countries, found that in a majority of the selected countries, over 15% of total deaths among young men and 6% among young women are attributable to alcohol use. Alcohol use among young people was also found to be associated with a number of harms, including stress, violence, injuries, suicide, and sexual and other risky behaviors.
In Canada (https://www.partnershipagainstcancer.ca/topics/key-statistics-alcohol-consumption-largest-cities- canada/), approximately 80% of adults, aged 18 or older, consumed alcohol in the past year, with the proportion of the adult population with alcohol consumption rates above cancer guidelines ranging from 5% of adults in Toronto, Ontario to 15% of adults in Sherbrooke, Quebec (Canada’s Low-Risk Alcohol Drinking Guidelines for cancer recommends no more than 2 drinks per day for men and no more than 1 drink per day for women).
Mental health disorders are a major risk factor for developing alcohol dependency. The results of a study (https://www.sciencedirect.com/science/article/abs/pii/S104727970700021X) on mental health and alcohol use in developing countries showed that the consumption of alcohol is heavily gendered and is characterized by a high proportion of hazardous drinking among men. Hazardous drinkers not only consume large amounts of alcohol, but also do so in high-risk patterns, such as drinking alone and binging, which are associated with depressive and anxiety disorders as well as suicide and domestic violence. In the Americas (http://www.pvmarquez.com/legacy_to_overcome), in countries such as Bolivia, Canada, Ecuador, Mexico, Peru, and the United States, indigenous peoples, who account for some 13% of the region’s population, suffer substantial alcohol use-induced conditions yet have limited access to care and other interventions.
Health Consequences
According to the World Health Organization (https://www.who.int/news-room/fact-sheets/detail/alcohol) (WHO), alcohol use is a risk factor in more than 200 disease and injury conditions. It is associated with the development of mental and behavioral disorders, including alcohol dependence, major noncommunicable diseases such as liver cirrhosis, some cancers, and cardiovascular diseases. A signi cant proportion of the disease burden attributable to alcohol consumption arises from unintentional and intentional injuries, including those due to traf c injuries, violence, and suicides, and fatal alcohol-related injuries tend to occur in relatively younger age groups. Also, there is
www.pvmarquez.com/alcoholuse 3/12 1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez a causal relationship between harmful drinking and incidence of infectious diseases such as tuberculosis as well as the incidence and course of HIV/AIDS. Alcohol consumption by an expectant mother may cause fetal alcohol syndrome and pre-term birth complications, impacting human capital development.
Worldwide (https://www.who.int/news-room/fact-sheets/detail/alcohol), about 3 million deaths every year result from harmful use of alcohol, which represent 5.3 % of all deaths. More than three quarters of these deaths were among men. Overall, 5.1 % of the global burden of disease and injury is attributable to alcohol, as measured in disability-adjusted life years (DALYs), which re ect both mortality and morbidity.
WHO data (https://www.who.int/substance_abuse/publications/global_alcohol_report/en/) for 2016 also show that of all deaths attributable to alcohol consumption worldwide, 28.7% were due to injuries, 21.3% due to digestive diseases, 19% due to cardiovascular diseases, 12.9% due to infectious diseases, and 12.6% due to cancers. Additionally, alcohol use was responsible for 7.2% of all premature deaths (among persons 69 years of age and younger), with younger people aged 20–39 years old disproportionately affected (13.5% of all deaths among this group are attributed to alcohol use).
The age-standardized alcohol-attributable burden of disease and injury (https://www.who.int/substance_abuse/publications/global_alcohol_report/en/) globally was 38.8 deaths and 1758.8 DALYs per 100 000 people, with the highest burden in the WHO African Region (AFR) (70.6 deaths and 3044 DALYs per 100 000 people). This is in contrast to the level of alcohol consumption which was highest in WHO’s European Region (EUR). The alcohol-attributable burden of disease and injury in Africa was due, in part, to the large burden of disease caused by tuberculosis, cardiovascular diseases, digestive diseases, and injuries (to which alcohol is a contributing factor). This explains why Africa has the highest age-adjusted burden of disease and injury attributable to alcohol consumption. The age-standardized burden of disease and injury attributable to alcohol consumption was lowest in the Eastern Mediterranean Region (EMR) (7.0 deaths and 322 DALYs per 100 000 people). Data for the other regions are: Europe, 62.8 deaths and 2726.5 DALYs per 100 000 people; Americas, 34.1 deaths and 1821.9 DALYs per 100 000 people; South East Asia, 36.8 deaths and 1718.3 DALYs per 100 000 people; and Western Paci c, 24.3 deaths and 1132.9 DALYs per 100 000 people.
The proportions of all deaths and DALYs caused by alcohol consumption were highest in the European Region, where 10.1% of all deaths and 10.8% of all DALYs were attributable to alcohol consumption, and were lowest in the Eastern Mediterranean Region, where 0.7% of all deaths and 0.7% of all DALYs were attributable to alcohol consumption. Data for the other regions are: Africa, 5.1% of deaths and 4.1% of DALYs; Americas, 5.5% of deaths and 6.7% of DALYs; South East Asia, 4.6% of deaths and 4.6% of DALYs; and Western Paci c, 4.1% of deaths and 4.9% of DALYs.
Social Impact
Broader negative social impacts of alcohol use are re ected in the statistics for road traf c-related injuries and fatalities, violent crimes, and gender-based and sexual violence.
Drunk driving is an important risk factor (https://openknowledge.worldbank.org/bitstream/handle/10986/27840/516670v20WP0P110Box345565B01PUBLIC1.p for all road users, and young drivers aged 18–25 are particularly at risk of crashing. As blood alcohol concentration (BAC) increases, so does the likelihood of crashing, particularly above a BAC of 0.04 grams per deciliter (g/dl). WHO estimates that nearly 2 million people are killed on the world’s roads annually, with an additional 20-50 million people seriously injured. The share of all road traf c deaths attributed to alcohol consumption above the national legal limit for alcohol consumption was estimated in 2013 to vary from a high 57.5% in South Africa to a low of 3.8%
www.pvmarquez.com/alcoholuse 4/12 1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez in China. In 2014, alcohol-impaired driving fatalities (https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812219) accounted for 31% percent of total driving fatalities in the United States.
A recent World Bank Group report, “The High Toll of Traf c Injuries: Unacceptable and Preventable,” (https://openknowledge.worldbank.org/handle/10986/29129) showed that besides preventing loss of life of people and the resulting pain and misery for families and communities, there are signi cant long-term economic gains to be achieved from the adoption of simple, sustainable, affordable, and effective traf c safety policies and interventions, including hiking up taxes to increase the price of alcohol products and regulating their marketing and selling practices. The estimated impact in an initial set of ve countries (China, India, Philippines, Tanzania, and Thailand) ranged from a 7% to 22% increase in GDP per capita over 24 years – that could be achieved through substantial reduction in road traf c injuries and deaths in line with the target set under the UN’s Sustainable Development Goals 2030 Agenda. This nding sends a clear message (https://blogs.worldbank.org/health/preventable-traf c-injuries-and-deaths-hold-back-development-countries) to governments: there is a signi cant economic loss associated with every year of inaction when LMICs fail to adopt effective policies and interventions to substantially reduce road traf c injuries and deaths.
Research (https://www.tandfonline.com/doi/abs/10.1080/19371918.2013.759005) on the effects of alcohol abuse on families shows that alcohol abuse and addiction play a role in intimate partner violence, cause family nancial problems, impair decision-making skills, and contribute to child neglect and abuse.
The share of all crimes which are considered to be alcohol-related (https://ourworldindata.org/alcohol- consumption#alcohol-related-crime), including both offenses in which the alcohol consumption is part of the crime such as driving with excess alcohol, liquor license violations, and drunkenness offenses, and all those crimes in which the consumption of alcohol is thought to have played a role of some kind in the commission of the offense (e.g., assault, criminal damage, and other public order offenses), is estimated to vary signi cantly: in some countries – including Iran, Chile, and Scandinavian countries – the share is well below 5%, while in the UK, it is over 50%.
Additional country evidence illustrates the wider social and impact of AUD. As documented back in the mid-2000s in the report “Dying Too Young,” (http://documents.worldbank.org/curated/en/867131468094164661/Main-report) alcohol abuse contributed signi cantly to the dramatic decrease in life expectancy among males and the shrinking of the total population experienced in Russia during rst decades of the post-Soviet period (1990-2000).
Are people drinking more amidst the COVID-19 pandemic?
Alcohol misuse is already a public health concern in many countries, and it has the potential to further complicate the COVID-19 pandemic (https://www.niaaa.nih.gov/directors-blog-alcohol-poses-different-challenges-during- covid-19-pandemic) in multiple ways. Excessive alcohol consumption can in uence COVID-19 susceptibility and severity, as it both activates the immune system, causing in ammation, and interferes with the body’s immune response to viral and bacterial infections. And, in a vicious cycle, the broad effects of the pandemic are also likely to lead to excessive alcohol consumption. As documented in a previous post (http://www.pvmarquez.com/mentalhealandthcovid-19), people are more likely to drink more as a coping mechanism "during times of uncertainty and duress", particularly in the face of raising unemployment and loss of income. The COVID-19 crisis is not an exception. For example, with bars and restaurants closed in the United States, sales of alcohol in the United States (https://www.nielsen.com/us/en/insights/article/2020/rebalancing- the-covid-19-effect-on-alcohol-sales/) have spiked nearly 27% since the start of the pandemic, with consumers gravitating to larger pack sizes.
www.pvmarquez.com/alcoholuse 5/12 1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez Also, COVID-19 stress due to lockdown and isolation has the potential to increase the risk of developing AUD and of relapses among people struggling to overcome this disorder. Studies have shown that there is a clear relationship between anxiety and AUD. Both prolonged drinking and alcohol withdrawal (https://www.ncbi.nlm.nih.gov/books/NBK64178/) are associated with an increased incidence of anxiety; people with general anxiety and panic disorders (https://www.sciencedirect.com/science/article/abs/pii/S0887618508000856) often self-medicate their condition with alcohol; and people with anxiety who self-medicate with alcohol often develop AUD (https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1107248).
How to control this problem?
The most cost-effective policies or “best buys” (https://www.jsad.com/doi/abs/10.15288/jsad.2018.79.514? journalCode=jsad) to reduce alcohol use include increasing taxes on alcoholic beverages, enacting and enforcing bans or comprehensive restrictions on exposure to alcohol advertising across multiple types of media, and enacting and enforcing restrictions on the retail availability of alcohol.
Other effective interventions include the enactment and enforcement of drunk-driving laws and blood alcohol concentration limits via sobriety checkpoints. Indeed, the number of countries reporting the adoption of these measures increased substantially between 2008 and 2016 the majority (97) of countries studied by WHO (https://www.who.int/substance_abuse/publications/global_alcohol_report/en/) have a maximum permissible blood alcohol concentration (BAC) limit to prevent drunk driving at or below 0.05%; 37 countries have a BAC limit of 0.08; and 31 countries have no BAC limits at all. Seventy countries (41%) reported using sobriety checkpoints and random breath-testing as prevention strategies, but 37 (22%) used neither strategy.
Taxing alcohol
As observed by Richard M. Bird (https://openknowledge.worldbank.org/bitstream/handle/10986/23464/Tobacco0and0al0ing0sin0and0virtue00.pdf sequence=1&isAllowed=y), excise taxes on alcohol as well as on tobacco have long been a dependable and signi cant revenue source in many countries globally. In recent years, increased attention has been paid to the way in which such taxes may also be used to achieve public health objectives by reducing the consumption of products with adverse health and social impacts.
Alcohol taxation and pricing policies have public health and economic bene ts: 1) control of alcohol consumption and public health problems caused by alcohol consumption, 2) prevention of drinking initiation, and 3) tax revenue generation.
Several types of alcohol excise taxation methods are employed around the world, including: uniform tax methods – such as speci c taxation (where the tax is calculated based on the amount of ethanol a beverage contains), ad valorem taxation (where the tax is based on the price of the alcoholic beverage), and unitary taxation (where the tax is based on the volume of the alcoholic beverage) – and combination tax methods such as mixed speci c and ad valorem taxation and ad valorem with speci c oor taxation. These methods have different attributes that may be appropriate to different contexts and different alcohol control objectives (https://www.researchgate.net/pro le/Kevin_Shield/publication/318233753_The_need_for_alcohol_taxation_and need-for-alcohol-taxation-and-pricing-policies.pdf). For example, speci c taxation may be appropriate for high- income countries that have a high prevalence of drinkers since it promotes consumption of beverages with low alcohol content instead of beverages with high alcohol content, resulting in a reduction in total alcohol consumption. Ad valorem with speci c oor taxation and mixed speci c and ad valorem taxation may be appropriate for low- and middle-income countries since they promote consumption of medium alcohol content www.pvmarquez.com/alcoholuse 6/12 1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez beverages, which are expected to reduce total alcohol consumption among heavy drinkers and prevent drinking initiation among young people. The government may also apply a minimum price measure to control problems caused by inexpensive alcoholic beverages.
Hiking tax rates to increase the price of alcoholic beverages is one of the most cost-effective and cost-saving approaches to reducing alcohol consumption and harm. As such, it is important to note that alcohol and tobacco taxation may differ with respect to their public health goals. While there is no safe level of smoking, in terms of alcohol consumption, the public health goal is moderation (except in the case of road safety, where no level of drunk driving is safe). Hence, the public health goal for taxing alcohol beverages (https://www.worldcat.org/title/alcohol- consumption-and-taxation/oclc/20754456) is to limit the harm caused by alcohol consumption, either by reducing or preventing increases in the overall average consumption per person.
The WHO’s Global Strategy to Reduce the Harmful Use of Alcohol (https://www.who.int/publications/i/item/9789241599931) recommends that countries establish a system for speci c domestic taxation which may take into account the alcohol content of the beverage. The strategy also encourages countries to review prices regularly in relation to in ation and income levels; to ban or restrict sales below cost and other price promotions; and to establish minimum prices for alcohol where applicable. According to the ndings of the 2015 WHO Global Survey on Progress in Alcohol Policy (https://www.who.int/substance_abuse/publications/global_alcohol_report/en/), 59% of 164 reporting countries indicated that they had established or increased the excise tax on alcohol since 2010, covering 5 billion people.
The results of a study (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4764336/#pmed.1001963.ref011) that compared the scale and distribution across society of health impacts arising from alternative alcohol tax and price policy options have shown that, compared to taxation based on product value, alcohol-content-based taxation or minimum unit pricing would lead to larger reductions in health inequalities across income groups. The study also estimated that alcohol-content-based taxation and minimum unit pricing would have the largest impact on harmful drinking, with minimal effects on those drinking in moderation.
While the excise tax rate is an important factor in determining the price of alcoholic beverages, an important variable to in uence consumption, as is also the case in tobacco taxation, is the extent to which increases in excise taxes are passed along to consumers as opposed to being absorbed by rms, as people are sensitive to changes in the price of alcohol products. Pricing policies therefore can be used to in uence demand and reduce underage drinking, heavy drinking, and binge drinking. Consumer preferences and choice, per capita income variations, alternative sources of alcohol in the country or in neighboring countries, the presence or absence of other alcohol control policy measures, as well as opposition of industry groups, may in uence the effectiveness of this policy measure. To help realize the bene ts of alcohol tax policies, strengthened tax administration, including control of illicit tobacco and alcohol trade (https://documents.worldbank.org/en/publication/documents- reports/documentdetail/677451548260528135/confronting-illicit-tobacco-trade-a-global-review-of-country- experiences), plays a critical role.
Health impact of alcohol taxation
A recent study (https://doi.org/10.15288/jsad.2018.79.514) provided evidence on the comparative cost-effectiveness of alcohol control strategies. The results of the study showed that increasing alcohol excise taxes by 50% is the most cost-effective policy to reduce harmful alcohol use, as it has a low cost (< $0.10 per capita) and a highly favorable ratio of costs to effects (< $100 per healthy life year gained in both low- and high-income settings). This measure is more ef cient than alternative options in the same price category. Availability and marketing restrictions are also highly cost-effective (< $100 per healthy life year gained in low-income settings and < $500 per
www.pvmarquez.com/alcoholuse 7/12 1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez healthy life year gained in high-income settings), while enforcement of drunk-driving laws and blood alcohol concentration limits via sobriety checkpoints had cost-effectiveness ratios in the range of International (I) $1,500– 3,000 and brief psychosocial treatments were Different studies (https://www.who.int/substance_abuse/publications/global_alcohol_report/en/) also provide evidence that increasing the price of alcohol is associated with reductions in harmful use of alcohol and alcohol- related morbidity and mortality, including liver cirrhosis deaths, violence, teenage pregnancy, and sexually transmitted diseases. There is also evidence that suggests that the bene ts of higher alcohol prices also extend to the education sector, increasing the likelihood of secondary school graduation as well as post-secondary enrollment and graduation. Another recently-published study (https://gh.bmj.com/content/bmjgh/5/3/e002143.full.pdf) that simulated the health and economic effects of alcohol, as well as tobacco and sugar-sweetened beverages (SSB) over 50 years for 30–79 years old populations, shows that alcohol taxation generate a health bene t of years of life gained (YLG) over 50 years of 227million and 547million for 20% and 50% price increases, respectively. It also shows that consumer expenditure increases by US$2958 billion and US$1549 billion over 50 years, and tax revenues increase by US$9428 billion and US$17778 billion for the 20% and 50% price increases, respectively. Results from studies focusing on the State of Maryland (US) experience provide speci c evidence that alcohol tax increases are an effective strategy for reducing health risks. One study (https://www.ajpmonline.org/article/S0749-3797(15)00627-3/fulltext) showed that after the sales tax rate for alcoholic beverages increased from 6% to 9% in 2011, on top of the existing state and federal excise tax rates that are collected from manufacturers or wholesalers of alcoholic beverages which are passed on directly to the consumer in the form of raised alcohol prices, per-capita alcohol consumption and sexually transmitted diseases were reduced. Gonorrhea rates, for example, decreased 24% during the 1.5-year post-increase period. This implied that an estimated 2,400 cases of gonorrhea were prevented, saving more than US$500,000 in direct medical expenses. Another study showed that there was a signi cant though gradual annual reduction of 6% in the population-based rate of all alcohol-positive drivers, and a more pronounced 12% reduction for drivers aged 15–34 years following the 2011 alcohol sales tax increase. The ndings suggest that young drivers tend to be alcohol price-sensitive. The sales tax increase, which has also raised about US$70 million a year for health and education programs, has proved to be an important but often neglected intervention to reduce alcohol-impaired driving. In the case of China (https://www.worldbank.org/content/dam/Worldbank/document/NCD_report_en.pdf), modelling work has shown that for a few additional cents (US) or around 0.07 yuan per capita, a combination of anti- tobacco measures with interventions for controlling alcohol abuse, e.g., increasing tax and banning advertising, would help avert an additional 40 million DALYs lost annually. The experience of Russia since 2010 is illustrative of the potential signi cant impact of raising alcohol and tobacco taxes on good health outcomes. Over the past decade, life expectancy (https://www.thelancet.com/action/showPdf?pii=S0140-6736%2818%2931485-5) for men in Russia increased to 65.4 years in 2016, up from 58 years in 2003, and among women it reached 76.2 years in 2016, up from 72 years in 2003. A big factor (http://www.euro.who.int/en/countries/russian-federation/publications/tobacco-control-a- comprehensive-approach-at-country-level-in-the-russian-federation-2017) in this improvement was the effective measures adopted to control the consumption of alcohol and tobacco. It is worthwhile looking at the European Union (EU) experience, which shows that even countries in the same economic block governed by a partially restrictive legal framework enact very different alcohol taxation policies. A recent study (https://onlinelibrary.wiley.com/doi/full/10.1111/add.14631) found only limited evidence that alcohol duties in the EU are designed to minimize public health harms by ensuring that drinks containing more alcohol are www.pvmarquez.com/alcoholuse 8/12 1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez taxed at higher rates. The ndings of the study indicate that only 50% of EU Member States levy any duty on wine, and several levy duties on spirits and beer at or close to the EU minimum level. Duty rates are generally higher for spirits than other beverage types and are generally lowest in Eastern Europe and highest in Finland, Sweden, Ireland, and the United Kingdom. Public revenue impact of alcohol taxation When assessing the scal impact of alcohol taxation, it is important not only to focus on the generation of public revenue but also on the expenditures required to address the social consequences of alcohol use disorders. This consideration is of great importance, as total alcohol tax revenue collection tends to account for only a small share of the total economic cost to the government of alcohol-related harm, and even a lower share of the total economic cost of excessive drinking. For example, a CDC study (https://www.cdc.gov/media/releases/2015/p1015- excessive-alcohol.html) showed that excessive drinking cost the United States US$249 billion in 2010, or US$2.05 per drink, a signi cant increase from US$223.5 billion, or $1.90 per drink, in 2006. Most of these costs were due to reduced workplace productivity, crime, and the cost of treating people for health problems caused by excessive drinking. As shown by data from another on the situation in the United States (https://www.jsad.com/doi/10.15288/jsad.2019.80.408), speci c excise taxes accounted for a weighted median of 20.1% of total state alcohol tax revenue, and the median total alcohol tax per drink (based on all federal and state taxes) was US$0.21, which accounted for 26.7% of the median cost to government and 10.3% of the median total economic cost of excessive drinking. The heavy burden of alcohol-related conditions on the health system is illustrated by data from 100 emergency departments of 33 countries presented in a recent study (https://movendi.ngo/reports/alcohols-healthcare- burden-during-covid%E2%80%9019-pandemic/). In most countries, alcohol’s contribution is in the realm of 20% of all presenting injuries, while alcohol’s contribution to non‐injury emergency department admissions averages 11.5%. From a public revenue perspective, building on the experience in the Philippines (https://openknowledge.worldbank.org/handle/10986/24617) with the “Sin Tax Law” adopted at the end of 2012, considerable attention has been paid in recent years to promoting alcohol and tobacco tax increases as a policy option to help mobilize additional resources to nance development priorities, particularly the expansion of universal health coverage schemes. In large measure, the experience of the Philippines over 2013-2017 is one of the most compelling examples of ambitious national alcohol and tobacco tax reform. It involved a fundamental restructuring of the country’s tobacco excise tax structure, including reduction in the number of tax tiers; indexation of tax rates to in ation; and substantial tax increases that generated more than US$5.2 billion additional revenues or 1.1% of GDP in the rst 4 years of implementation, which expanded the scal space to increase the number of low-income families enrolled in the health insurance scheme from 5.2 million primary members in 2012 to 15.3 million in 2017. Likewise, as part of a broad scal reform package approved by Colombia’s Congress on December 23, 2016, excise tax increases on alcohol and tobacco were adopted (http://documents1.worldbank.org/curated/en/491661505803109617/pdf/119792-REVISED-v2- OctFINALWBGTobaccoTaxReformFullReportweb.pdf) to achieve public health and revenue objectives. In addition, the scal reform law mandates the earmarking of these tax revenues to nance health insurance coverage and education programs at the departmental level. Similar scal reforms were enacted over the 2016-2019 period in countries such as Armenia, Gabon, Lesotho, Montenegro, and Nigeria, with technical support from the World Bank Group. www.pvmarquez.com/alcoholuse 9/12 1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez The “win-win” scal/public health nature of raising taxes on alcohol is further illustrated by the experience of other countries. In the United States (https://www.cbo.gov/budget- options/2018/54815#:~:text=Beginning%20in%202020%2C%20distilled%20spirits%20will%20be%20taxed,about%202 federal collections from taxes on alcoholic beverages totaled about US$11 billion in 2017. Distilled spirits are taxed at a at rate of US$13.50 per proof gallon (a proof gallon denotes a liquid gallon that is 50 percent alcohol by volume), which translates to about 21 cents per ounce of pure alcohol. Beer is generally subject to a tax rate of US$18 per barrel, which is equivalent to about 10 cents per ounce of pure alcohol (under the assumption that the alcohol content of the beer is 4.5 percent), and the excise tax on wine that is no more than 14 percent alcohol is US$1.07 per liquid gallon, or about 6 cents per ounce of pure alcohol (assuming an alcohol content of 13 percent). As part of options for reducing the federal government de cit over 2019-2028, a Congressional Budget Of ce simulation showed that by increasing all taxes on alcoholic beverages to US$16 per proof gallon from current level and indexing for in ation would increase revenues by US$83 billion from 2020 through 2028, while reducing costs for society that are not re ected in the pretax price of alcoholic beverages---e.g., external costs including spending on health care that is related to alcohol consumption and covered by the public, losses in productivity stemming from alcohol consumption that are borne by entities or individuals other than the consumer, and the loss of lives and property from alcohol-related injuries and crime. The above ndings provide a strong justi cation for raising excise taxes on alcoholic beverages to levels where revenues match or at least cover a larger share of the economic cost of alcohol use disorders. If this is not done, the disparity that exists between alcohol-related costs to government and the collected alcohol tax revenue will be perpetuated, which is tantamount to a large taxpayer-funded subsidy of excessive drinking. (https://www.usnews.com/news/health-news/articles/2019-09-11/booze-taxes-dont-make-up-for-societal- costs-of-excess-drinking-study) Is alcohol taxation a regressive policy measure? A common objection to increasing alcohol excise tax is that even if it is an effective public health measure, it is poorly focused, in effect punishing all drinkers regardless of whether their drinking is problematic. As eloquently argued by Prof. Philip J Cook of Duke University (https://press.princeton.edu/books/hardcover/9780691125206/paying-the-tab), in a landmark book on the cost and bene ts of alcohol control, alcohol taxation tends to be well focused on negative externalities of drinking. That is, in the case of a price increase per drink that results from raising taxes on alcohol, those who abstain (a signi cant proportion of most populations) would pay nothing and would be just a few extra dollars per year for light/moderate drinkers (the majority of those consuming alcohol). The bulk of the additional excise revenue would come from the top 15% of the drinkers (who average 8 or 9 drinks per day) who consume 75% of all the alcohol and consequently would pay 75% of a new tax. That is also the group that accounts for most of the alcohol- related harm, consequently yielding a well-targeted tax increase. Additionally, even if the direct effect of prices are on the consumption habits of relatively moderate drinkers, heavy drinkers can be affected indirectly. There is reliable evidence that alcohol consumers across the spectrum in uence each other. So, if alcohol prices affect the drinking patterns at the median, then the upper tail of the distribution will shift inward - in other words, a reduced prevalence of heavy drinking would be expected. Seizing the COVID-19 crisis to reduce public health risks and mobilize public funding The COVID-19 pandemic has impacted countries with an unprecedented double shock, public health and economic, that is constraining the scal capacity of countries in the short- and medium-term. As argued in a previous post (https://blogs.worldbank.org/health/taxes-tobacco-alcohol-and-sugar-sweetened-beverages- reduce-health-risks-and-expand- scal), pro-health taxes, including excise tax increases on tobacco, alcohol, and sugar-sweetened beverages, are a potential tool to help alleviate the ongoing health crisis and contribute to www.pvmarquez.com/alcoholuse 10/12 1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez recovery. While this scal measure can help reduce health risks associated with the onset of non-communicable diseases and injuries and their nancial and economic impacts, it can also help mobilize public revenue to expand scal space for health and other essential programs that bene t the entire population of countries. Indeed, projections presented in a World Bank Group report (https://openknowledge.worldbank.org/handle/10986/31930) for the G-20 meeting in Osaka, Japan in 2019 showed that the substantial universal health coverage nancing gap in low- and lower-middle-income countries (now exacerbated by COVID-19), can be attenuated by excise tax increases on tobacco, alcohol, and sugar-sweetened beverages. These pro-health taxes can help further mobilize public revenue while mitigating the affordability of these products by regularly adjusting the excise tax and sale tax increases in accordance with in ation and per capita income growth. It should be clear, however, that thus far governments have failed to take advantage of taxation (https://newbooksinpolitics.com/political/phishing-for-phools/) as a cost-effective and cost-saving method of alcohol control, despite the evidence that it could help generate signi cant public revenue to keep down taxes elsewhere. In some measure this outcome is due to the in uence of powerful interest groups—from the alcohol industry to owners of bars and restaurants, as well as doubts about the harms of alcohol among the general public as alcohol use is associated with deep-rooted and well-accepted social and cultural norms and traditions. Dealing with this reality, active community engagement, as exempli ed by the work of organizations such as Mothers Against Drunk Driving (https://www.madd.org/history/) (MADD), could be galvanized to lobby for the adoption of tax increases and other measures to moderate alcohol abuse and prevent ruining the lives of alcohol-dependent people and their loved ones, as well as of those people impacted or killed as a result of alcohol-impaired driving or acts of violence. As we move forward containing and mitigating the impact of the COVID-19 pandemic, the most significant global public health crisis of the past 100 years, we need to be clear that disease and injury prevention is not only a public health goal, but more importantly, a broad social goal that should matter to all of us since it is a key requirement for building healthy, resilient, and productive societies. Measures such as alcohol taxation, as shown by the evidence presented above, can contribute to this end by helping reduce the short- and long-term public health and economic harms caused by destructive drinking. Source of image: "Colorful drawing: father drinking alcohol and crying child", Stock photo ID:507843974. (https://twitter.com/pvmarquez1956) www.pvmarquez.com/alcoholuse 11/12 1/12/2021 Let’s not forget about Mental Health during COVID-19! | Patricio V. Marquez Let’s not forget about Mental Health during COVID-19! Submitted by Patricio V. Marquez on Sat, 08/22/2020 - 09 42 AM Let’s not forget about Mental Health during COVID-19! Posted by Patricio V. Marquez on Sat, 08/22/2020 - 09 42 AM “Thus the rst thing that plague brought to our town was exile…….It was undoubtedly the feeling of exile—that sensation of a void within which never left us, the irrational longing to hark back to the past or else to speed up the march of time, and those keen shafts of memory that stung like re.” Albert Camus (1957 Nobel Prize Laureate for Literature), The Plague, 1947 Growing numbers of infected people, loss of life, and an economic free-fall not experienced since World War II, are some of the casualties of the COVID-19 pandemic. IMF estimates (https://blogs.imf.org/2020/04/20/a-global- crisis-like-no-other-needs-a-global-response-like-no-other/) show that 170 countries will see income per capita go down, and World Bank Group projections (https://blogs.worldbank.org/opendata/updated-estimates-impact- covid-19-global-poverty) suggest that rising unemployment and loss of income, including in some countries a signi cant drop in remittances, could push between 71 and 100 million people into extreme poverty. Daily personal routines have been altered by social distancing measures adopted to prevent the spread of the novel coronavirus, impacting people in many different ways. The lack of interpersonal contact with loved ones and peers is contributing to feelings of isolation and loneliness; detachment from our communities is depressing us; and fear of becoming infected or of loved ones falling ill worries and makes us anxious. In large measure, a sense of being in “exile” has engulfed us as we drift through the sameness of days, feeling unmoored and uncertain about the repercussions of the pandemic. Given the intense disruption brought by COVID-19 to our everyday life, it is of great importance to understand how the pandemic is affecting mental well-being and what can be done to help people cope and deal with its consequences in the short- and medium-terms. In answering this question, we need to learn from past crises as well as to look at the emerging evidence from the current pandemic. The Impacts of Unemployment and Loss of Income www.pvmarquez.com/mentalhealandthcovid-19 1/6 1/12/2021 Let’s not forget about Mental Health during COVID-19! | Patricio V. Marquez The layoffs and job losses brought on by lockdowns have been enormous, particularly for people with only basic levels of education and in the poorer segments of society, while telework arrangements have protected the employment of highly skilled and educated people. Across countries, ILO estimates (https://news.un.org/en/story/2020/04/1061322) show that full or partial lockdown measures are affecting almost 2.7 billion workers – four in ve of the world’s workforce. In particular, workers in sectors such as food and accommodation (144 million workers), retail and wholesale (482 million), business services and administration (157 million), and manufacturing (463 million), which account for up to 37.5 per cent of global employment, are feeling the “sharp end” of the impact of the pandemic. COVID-19 has had disproportionate effects on women (https://blogs.imf.org/2020/07/21/the-covid-19-gender-gap/)and their economic status, since women are more likely than men to work in social sectors — such as service industries, retail, tourism, and hospitality, that require face-to-face interactions, and hence, are hit hardest by social distancing and mitigation measures. As discussed in a paper by researchers from the Urban Institute (https://www.urban.org/research/publication/consequences-long-term-unemployment/view/full_report), the experience from previous global crises, such as the Great Recession of 2008, shows than being out of work for six months or more is associated with lower well-being among the unemployed, their families, and their communities. While scal stimulus and targeted social transfer programs can help mitigate the consequences of long-term unemployment, a decline in family income due to a worker’s lack of earnings directly reduces the quantity and quality of goods and services the worker’s family can purchase and exacerbates stress as well. The erosion in the tax base used to fund essential public services, such as essential medical care, can negatively affect individuals and families by constraining access to these services when needed. Impact on Mental Health The devastating impact of COVID-19 disease on people’s physical health is well documented, with more than 22 million people infected, almost 800,000 deaths (https://coronavirus.jhu.edu/), and many that survived infection left experiencing persistent symptoms long after hospital discharge. Much less understood is the impact of high levels of stress on people resulting from the adoption of social distancing measures to contain and mitigate COVID-19 and from the economic downturn and income loss to households. The graph below depicts a COVID-19 physical and mental health impact timeline. www.pvmarquez.com/mentalhealandthcovid-19 2/6 1/12/2021 Let’s not forget about Mental Health during COVID-19! | Patricio V. Marquez Fear, pervasive anxiety, frustration, and anger (https://academic.oup.com/qjmed/article/113/8/531/5860841)experienced by adults and children can be overwhelming and aggravated by social isolation and loneliness (https://www.nap.edu/catalog/25663/social- isolation-and-loneliness-in-older-adults-opportunities-for-the) among the elderly, who are a higher risk of developing severe symptoms or die from COVID-19 disease. These negative psychological effects are associated with stressors (https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930460-8) such as long duration of quarantines, infection fears, frustration, boredom, sadness, grief, inadequate supplies, inadequate information, nancial loss, and stigma and discrimination (https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30498-9/fulltext). Some of the symptoms of mental health problems include changes in sleep or eating patterns; dif culty sleeping or concentrating; worsening of chronic health problems and mental health conditions; and adoption of risky behaviors such as increase in tobacco use, alcohol abuse, and substance use. More speci cally, research in countries is showing how the pandemic is impacting the general population. A health tracking poll (https://www.kff.org/coronavirus-covid-19/report/kff-health-tracking-poll-early-april-2020/) conducted in April 2020 in the United States indicates that an increasing share of people reported worrying about economic impacts, with more than half now reporting being worried that their investments will be negatively impacted for a long time (59%) and that they will be laid off or lose their job (52%), nearly half worried they will lose income due to a workplace closure or reduced hours (45%), more than half (53%) worried that they or a family will get sick from coronavirus, and nearly six in ten adults (57%) being worried they will put themselves at risk of exposure to coronavirus because they cannot afford to stay home and miss work. More troubling, the results of the poll indicate that more than four in ten adults overall (45%) feel that worry and stress related to coronavirus have had a negative impact on their mental health, up from 32% in early March 2020. Similarly, research (https://doi.apa.org/fulltext/2020-52963-001.html)that examined whether intolerance of uncertainty and coping responses in uence the degree of distress experienced by the U.K. general public during the COVID-19 pandemic, indicates that around 25% of participants demonstrated signi cantly elevated anxiety and depression, with 14.8% reaching clinical cutoff for health anxiety. Further research from China (https://gpsych.bmj.com/content/33/2/e100213) found that 35% of people experienced mental distress, such as panic disorder, anxiety, and depression, during the rst month of the COVID-19 outbreak and that these levels continued as the disease spread over the following months. How are Lockdowns Impacting Children and Young Adults? The Great Lockdown has affected close to 1 billion children and adolescents worldwide, upending their daily routine and isolating them from their social structures. A recent study (https://psyarxiv.com/5bpfz/)examining the psychological impact on youth from Italy and Spain, shows that 85.7% of the parents perceived changes in their children´s emotional state and behaviors during this period. The most frequent symptoms identi ed included dif culty concentrating (76.6%), boredom (52%), irritability (39%), restlessness (38.8%), nervousness (38%), feelings of loneliness (31.3%), uneasiness (30.4%), and worries (30.1%). The study also reported that children of both countries used electronic devices more frequently, spent less time on physical activity, and slept more hours. Moreover, when family coexistence became more dif cult, the situation was more serious, the level of stress was higher and parents tended to report more emotional problems in their children. Death of parents or other family members due to COVID-19 may also spur a great amount of grief among children that would need to be dealt with. In addition, long-term school closures may further impact negatively the well-being of school-age children (https://www.cdc.gov/coronavirus/2019-ncov/downloads/considerations-for-school-closure.pdf) as they lose access to meal programs, academic support, physical and social activities, and reduced face-to-face engagement with peers. www.pvmarquez.com/mentalhealandthcovid-19 3/6 1/12/2021 Let’s not forget about Mental Health during COVID-19! | Patricio V. Marquez It has also been suggested (https://theconversation.com/the-long-term-biological-effects-of-covid-19-stress-on- kids-future-health-and-development-140533) that stressors from the pandemic, such as reduced family income, food insecurity, parental stress, and child abuse, can negatively impact children’s developing brains, immune systems, and ability to thrive. While some effects will be immediate, many will surface decades from now (https://theconversation.com/the-long-term-biological-effects-of-covid-19-stress-on-kids-future-health-and- development-140533) in the form of mental, social, and physical health problems (e.g., higher risk of metabolic syndrome (https://journals.lww.com/psychosomaticmedicine/Abstract/2017/06000/Early_Life_Socioeconomic_Disadvantage and physical health problems in adulthood (https://srcd.onlinelibrary.wiley.com/doi/abs/10.1111/cdep.12021)). A related study in China (https://onlinelibrary.wiley.com/doi/full/10.1111/jsr.13142?referringSource=articleShare) has highlighted the importance of the link between sleep, health, and family factors, even during a period in which families are confronted with dramatic lifestyle changes and grappling with heightened health concerns related to the pandemic. Disrupted and insuf cient sleep has been linked to immune system dysfunction (e.g., increase in cytokines, such as interleukin), impeding resilience to infection in young children during the COVID‐19 pandemic. Isolation and lack of interaction with other people are also negatively impacting the mental health of young adults ages 18-24. Existing mental illness among adolescents may also be exacerbated by the pandemic, and with school closures, they may have limited access to mental health services. Recent data from the CDC (https://www.baynews9.com/ /tampa/news/2020/08/15/cdc--young-adults-disproportionately-affected-by- mental-health-impacts-of-covid-19) illustrate this problem by showing that young adults in the United States are among the groups disproportionately affected by the mental health impacts of the COVID-19 pandemic, struggling with issues such as anxiety/depression (31%), trauma/stressor-related disorders (26%), starting or increasing substance use (13%), and seriously considering suicide (11%). Preliminary results of a study carried out by Uribe and team at the Ponti cia Universidad Javeriana (Personal communication with Miguel Uribe, June 2020) focusing on mental health and resilience in young adults in Bogota, Colombia during the COVID -19 lockdown, also evidence the high mental health toll that social distancing measures are having on young adults aged 18-24 years. While 59% of males and 70% of females presented depressive symptoms, 47% of males and 56% of females had anxiety symptoms. Substance use and addiction (https://www.cdc.gov/ncbddd/fasd/features/teen-substance-use.html), in particular, can have long-term impacts on young people, as they can affect brain development, occur more frequently with other risky behaviors, such as unprotected sex and dangerous driving, and contribute to the development of adult health problems, such as heart disease, high blood pressure, and sleep disorders. The daily attachment to laptops, desktops, and the multi-functional smartphone, which have become “virtual bridges” for interacting with the outside world during the pandemic, may pose additional risks, particularly to children and adolescents (http://www.pvmarquez.com/digital%20media_impacts). Hyper connectivity (http://www3.weforum.org/docs/WEFUSA_DigitalMediaAndSociety_Report2016.pdf) has the potential to further change patterns of social interaction, as online interaction may become a “new normal,” substituting for face-to- face interaction--essential to the give-and-take functioning of families, communities, and workplaces. Digital media consumption may also facilitate bullying, harassment, social defamation, and hate speech because potential costs of such behavior are reduced and the ease of engaging in behaviors that harm others or ourselves is increased. And, excessive digital media use can negatively in uence the development of cognitive (thinking, imagining, reasoning, and remembering abilities) and behavioral (reactions or actions that we take in response to stimuli present in our environment) skills and even mental and physical health. Impact on Frontline Health Workers In many countries, as COVID-19 cases surged, hospitals were overwhelmed, and work demands on frontline health care workers increased signi cantly, particularly in facilities with lower physician-or nurse-to-patient densities. As a result, they are at increased risk of burnout and suffer from mental health issues www.pvmarquez.com/mentalhealandthcovid-19 4/6 1/12/2021 Let’s not forget about Mental Health during COVID-19! | Patricio V. Marquez (https://blogs.worldbank.org/health/supporting-mental-health-and-resilience-frontline-covid-19-coronavirus- health-care-workers), including depression and substance use. Risk of Suicides Suicide is a terminal outcome in the spectrum of mental health problems. Accumulated evidence from countries around the world indicates that global crises, that lead to severe social and economic disruptions, similar to those caused now by the COVID-19 pandemic, are associated with increases in suicide, particularly in males of working age. This occurs (https://pubmed.ncbi.nlm.nih.gov/24903684/) as the result of the negative effects of unemployment and job insecurity, as well as effects of nancial loss, bankruptcy, and home repossession on individuals and households, which may lead directly or indirectly to mental health problems such as depression, anxiety, and binge drinking and then to suicidal behavior. A study (https://jech.bmj.com/content/73/4/311#article-bottom)that estimated what the suicide rates would have been during and one year after economic/ nancial crises of the 1970-2011 period in 21 Organization for Economic Co-operation and Development (OECD) countries if the suicide rates had followed the pre-crisis trends, found that all the crises led to excess suicides. Among males, the excess suicide rate (per 100 000 persons) varied from 1.1 to 9, and among females, from 0 to 2.4. In terms of actual numbers, these crises caused more than 60,000 excess suicides in OECD countries. Another study (https://journals.sagepub.com/doi/pdf/10.1177/0020764019879946? casa_token=4hQ4Y4FwCiMAAAAA 6w3FYw1j44NqzVbCOIlBGycQgkT_SysZxVSweojU7BSaNLhngL8vMn0pmCJbaVBugT that after the Great Recession of 2008 in the United States, the number of suicides increased due to the negative effect of the crisis on the mental health of individuals and the decrease in their future expectations. These ndings are corroborated by studies done in Ireland (https://pubmed.ncbi.nlm.nih.gov/26082406/), that showed that ve years of economic recession and austerity had a signi cant negative impact on rates of suicide in men and on self- harm in both sexes, and in Greece (https://bmjopen.bmj.com/content/5/3/e007295), that found a clear increase in suicides among persons of working age that resulted from the economic crisis of 2011-2013. What to Do? While a vaccine and new diagnostics and therapies are on the horizon, it seems that we are at the cusp of a transition from a world that we knew well at the beginning of 2020 and that in many ways has now been shattered, to a yet unknown “new normal”. Should we despair, or use this time as a “window of opportunity” to re ect, learn from the fact that no country, not even the richest one in the world, was prepared to deal with the onslaught of the fast-spreading novel coronavirus, and perhaps start thinking on how to build better for the long term? Looking at the glass half full, we will discover that not everything is lost. As human beings we have the capacity to assess reality, learn from past experiences and accumulated knowledge, and chart a path forward. The mental health toll of the COVID-19 pandemic is only beginning to show itself. Although we cannot predict the scale of its impact, lessons from past crises can offer guidance on how to mitigate and address this challenge. Moving forward, it is crucial that we ensure that along with health and economic emergency response programs, social and psycho-social support interventions are included to provide required support to people in need, both those already suffering from mental disorders pre-pandemic and those newly affected. This would require the allocation of resources targeted to develop effective communication to the population and improve the quality and quantity of mental health services integrated as part of primary health care and social support service delivery platforms at the community level. It will be of critical importance that these platforms include mechanisms for surveillance, reporting, and intervention www.pvmarquez.com/mentalhealandthcovid-19 5/6 1/12/2021 Let’s not forget about Mental Health during COVID-19! | Patricio V. Marquez (https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2764404), particularly to track and address gender and domestic violence and child abuse during lockdowns, and that services delivered be organized following stepped-care approaches (https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2656183)—the practice of delivering the most effective, least resource-heavy treatment to people in need, and then stepping up to more resource-heavy treatment based on patients’ needs. Levering information technology will facilitate the provision of online mental health and peer-to-peer support services while helping overcome stigma barriers, particularly among adolescents. Monitoring and additional research (https://www.nytimes.com/2020/08/21/opinion/covid-depression- boredom.html?referringSource=articleShare) are also needed to track and understand the long-term mental health impacts of the COVID-19 pandemic, to guide action on the basis of evidence. Finally, it is important to keep in mind that while some people may require medication and social support to deal with fear, loneliness, or grief (https://www.nytimes.com/2020/04/09/opinion/sunday/coronavirus-depression- anxiety.html?action=click&module=RelatedLinks&pgtype=Article), we need to avoid rushing to medicalize the response to “normal unpleasant emotions” such as feeling bored and confusion during lockdowns. Although these feelings may be intolerable sometimes, they “do not need medical treatment any more than everyday unhappiness requires an antidepressant” (https://www.nytimes.com/2020/08/21/opinion/covid-depression-boredom.html? referringSource=articleShare). Image Credit: Srdjanns74, Stock Photos (https://twitter.com/pvmarquez1956) www.pvmarquez.com/mentalhealandthcovid-19 6/6 1/12/2021 Taxes on tobacco, alcohol, and sugar-sweetened beverages reduce health risks and expand fiscal space for Universal Health Coverage post-COVID 19 Learn how the World Bank Group is helping countries with COVID-19 (coronavirus). Find Out Publish d on Inv stin in H lth (/h lth) T x s on tob cco, lcohol, nd su r- sw t n d b v r s r duc h lth risks nd xp nd fisc l sp c for Univ rs l H lth Cov r post-COVID 19 PATRICIO V. MARQUEZ (/TEAM/PATRICIO-V-MARQUEZ) & SHEILA DUTTA (/TEAM/SHEILA- DUTTA) | AUGUST 11, 2020 This page in: English 3 https://blogs.worldbank.org/health/taxes-tobacco-alcohol-and-sugar-sweetened-beverages-reduce-health-risks-and-expand-fiscal 1/8 1/12/2021 Taxes on tobacco, alcohol, and sugar-sweetened beverages reduce health risks and expand fiscal space for Universal Health Coverage post-COVID 19 “If we want to improve global health, we need to tax the things that are killing us. Taxing things that are bad for your health, like tobacco, over things like savings and income, is as close to a free lunch as you can get in economics. The economic rationale for taxing these products is strong if we want to save lives and make a better, healthier world.” (https://www.bloomberg.org/program/public- health/who-global-ambassador/#task-force- scal-policy-health) LARRY SUMMERS, former Secretary of the U.S. Treasury and Director of the National Economic Council, and former World Bank Group Chief Economist (2019) Seven months after the rst cases of a new coronavirus (COVID-19) were reported in China, the pandemic’s toll continues to increase, despite global containment and mitigation e orts. People of any age with certain underlying medical conditions (https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with- medical-conditions.html? CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019- ncov%2Fneed-extra-precautions%2Fgroups-at-higher-risk.html), such as cardiovascular diseases, cancer, obstructive pulmonary diseases, and obesity and diabetes, are at increased risk for severe illness and death from COVID-19. Tobacco use, alcohol abuse, and consumption of unhealthy foods (such as sugar sweetened beverages) are three leading risk factors for the development of these chronic health conditions. Pre-existing global health disparities, magni ed during the pandemic, re ect deep- rooted inequalities in income, wealth, and voice. To address these challenges, countries need to maintain essential health services to address concurrent health needs, and particularly the needs and service delivery gaps targeting the most vulnerable populations. Urgent steps are required to prevent a secondary global health crisis, with many countries already reporting life-threatening health service disruptions. (https://twitter.com/intent/tweet? text=Urgent+steps+are+required+to+prevent+a+secondary+global+health+crisis%2C+w threatening+health+service+disruptions.&url=https://blogs.worldbank.org/health/taxes tobacco-alcohol-and-sugar-sweetened-beverages-reduce-health-risks-and-expand- scal/?cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) There are particular gaps with respect to maternal, infant, and child health; prevention and treatment of other infectious diseases such as TB, malaria, HIV/AIDS, and noncommunicable diseases. https://blogs.worldbank.org/health/taxes-tobacco-alcohol-and-sugar-sweetened-beverages-reduce-health-risks-and-expand-fiscal 2/8 1/12/2021 Taxes on tobacco, alcohol, and sugar-sweetened beverages reduce health risks and expand fiscal space for Universal Health Coverage post-COVID 19 Looking forward, as noted by the Dean of the Johns Hopkins Bloomberg School of Public Health (https://magazine.jhsph.edu/2020/lets- x-things-good), "we must start talking now about the need to invest for the long term," building upon the “brutal lessons” from the COVID-19 pandemic. This observation brings to the fore once again the imperative of universal health coverage (UHC). Up to now, the UHC e ort has largely focused on ensuring that medical care is accessible and a ordable. The time has come to give equal importance to disease prevention, health promotion, and emergency preparedness as part of an integrated framework for action to achieve UHC. (https://twitter.com/intent/tweet? text=%3Cstrong%3EThe+time+has+come+to+give+equal+importance+to+disease+prev tobacco-alcohol-and-sugar-sweetened-beverages-reduce-health-risks-and-expand- scal/?cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) Taxation on tobacco, alcohol, and sugar-sweetened beverages are e ective but underused policies of disease prevention and health promotion (https://www.bbhub.io/dotorg/sites/2/2019/04/Health-Taxes-to-Save-Lives.pdf), that could also help mobilize additional government revenue to fund investments and programs that bene t the entire population and enhance equity. Let’s explain the win-win-win nature of this policy. Raising taxes on tobacco, in particular, can do more to reduce premature mortality than any other single health policy. The evidence (https://documents.worldbank.org/en/publication/documents- reports/documentdetail/491661505803109617/main-report) across a wide range of countries shows that a 50% increase in cigarette price typically leads to a 20% decline in cigarette consumption. Lowering consumption reduces tobacco-attributable sickness and death: about half of this e ect comes from current smokers quitting and the other by reducing smoking initiation among young people. Taxing alcohol (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951962/pdf/2270.pdf) and sugar- sweetened beverages (https://www.worldbank.org/en/topic/nutrition/publication/obesity-health-and- economic-consequences-of-an-impending-global-challenge) helps to reduce consumption and prevent the onset of related chronic diseases such as cardiovascular diseases, cirrhosis of the liver, obesity and diabetes. Moreover, taxing to increase the price of alcohol products, along with strict enforcement of drink-drive laws, can help reduce the high human and economic cost of road tra c injuries, https://blogs.worldbank.org/health/taxes-tobacco-alcohol-and-sugar-sweetened-beverages-reduce-health-risks-and-expand-fiscal 3/8 1/12/2021 Taxes on tobacco, alcohol, and sugar-sweetened beverages reduce health risks and expand fiscal space for Universal Health Coverage post-COVID 19 fatalities (https://www.worldbank.org/en/programs/global-road-safety- facility/publication/the-high-toll-of-tra c-injuries-unacceptable-and-preventable), and domestic violence. Emerging evidence (https://openknowledge.worldbank.org/handle/10986/34082) reported by the World Bank consistently identi es net positive economic impacts from sugar-sweetened beverages taxes, including overall employment and productivity gains, and increased government spending. To help realize the bene ts of pro-health tax policies, strengthened tax administration, including control of illicit tobacco and alcohol trade, play a critical function (https://documents.worldbank.org/en/publication/documents- reports/documentdetail/677451548260528135/confronting-illicit-tobacco-trade-a- global-review-of-country-experiences). Even as they lower consumption and improve public health, tobacco, alcohol, and sugar-sweetened beverage taxes can substantially boost government revenues. (https://twitter.com/intent/tweet? text=Even+as+they+lower+consumption+and+improve+public+health%2C+tobacco%2C sweetened+beverage+taxes+can+substantially+boost+government+revenues.+&url=ht tobacco-alcohol-and-sugar-sweetened-beverages-reduce-health-risks-and-expand- scal/?cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank)This is of critical importance during COVID-19, as policymakers must maintain their public health responses while also mobilizing domestic revenue for investment in future pandemic preparedness and other essential health services. Adoption of policies that reduce future health risks has been found to (https://blogs.imf.org/2020/07/10/ scal- policies-for-a-transformed-world/) contribute to public trust, thereby helping economic activity and reducing strains on public nances. Investing in stronger health systems for all can also contribute to tackling rising poverty and inequality. Projections presented in a World Bank Group report for the G-20 meeting in Osaka, Japan in 2019 (https://openknowledge.worldbank.org/handle/10986/31930) showed that the substantial UHC nancing gap in low- and lower-middle-income countries (now exacerbated by COVID-19), can be attenuated by excise tax increases on tobacco, alcohol, and sugar-sweetened beverages. These calculations showed that a 50% increase in prices for these products could generate additional revenues of approximately $24.7 billion in 54 low- and middle-income countries by 2030. https://blogs.worldbank.org/health/taxes-tobacco-alcohol-and-sugar-sweetened-beverages-reduce-health-risks-and-expand-fiscal 4/8 1/12/2021 Taxes on tobacco, alcohol, and sugar-sweetened beverages reduce health risks and expand fiscal space for Universal Health Coverage post-COVID 19 These health tax increases would have the additional advantage of reducing future health care costs by curbing the growth of the non-communicable diseases that tobacco, alcohol, and sugar-sweetened beverages can cause. Importantly, the revenue raised can additionally bene t poorer households (https://documents.worldbank.org/en/publication/documents- reports/documentdetail/893811554737147697/is-tobacco-taxation-regressive- evidence-on-public-health-domestic-resource-mobilization-and-equity- improvements) when it is used progressively. Elimination of fossil fuel subsidies (https://openknowledge.worldbank.org/handle/10986/31930), which impose large scal costs while adding to negative environmental and health impacts, could also help expand scal space for health. Pro-health taxes are a potential tool to help alleviate the ongoing health crisis and contribute to recovery. (https://twitter.com/intent/tweet?text=Pro- health+taxes+are+a+potential+tool+to+help+alleviate+the+ongoing+health+crisis+and+ tobacco-alcohol-and-sugar-sweetened-beverages-reduce-health-risks-and-expand- scal/?cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) As such, they should be considered essential components of health and scal policy building support of healthier and more resilient societies. Authors (/team/patricio-v-marquez) (/team/patricio-v-marquez) P tricio V. M rqu (/t m/p tricio-v-m rqu ) x https://blogs.worldbank.org/health/taxes-tobacco-alcohol-and-sugar-sweetened-beverages-reduce-health-risks-and-expand-fiscal 5/8 1/12/2021 While waiting for a COVID-19 vaccine, it’s time to focus on gaps in vaccine distribution, cold chain, and uptake | Patricio V. Marquez While waiting for a COVID-19 vaccine, it’s time to focus on gaps in vaccine distribution, cold chain, and uptake Submitted by Patricio V. Marquez on Sun, 07/26/2020 - 11 12 PM While waiting for a COVID-19 vaccine, it’s time to focus on gaps in vaccine distribution, cold chain, and uptake Posted by Patricio V. Marquez on Sun, 07/26/2020 - 11 12 PM Patricio V. Marquez, Betty Hanan, and Sheila Dutta As the world waits anxiously for a COVID-19 vaccine to become available, countries have a “window of opportunity” to focus on existing gaps in vaccine distribution and cold chain systems and vaccination demand and uptake constraints. If these gaps are addressed in a timely way, it will facilitate widespread administration, not only of a new COVID-19 vaccine, but will also help revamp the delivery of routine vaccines, particularly those for children, that are part of the Expanded Program on Immunization (EPI). The latter task is of critical importance since over the past 4-6 months, national immunization programs around the world have been disrupted due to the severe health system constraints and physical distancing measures in place to mitigate the ongoing www.pvmarquez.com/vaccinationsystems 1/8 1/12/2021 While waiting for a COVID-19 vaccine, it’s time to focus on gaps in vaccine distribution, cold chain, and uptake | Patricio V. Marquez COVID-19 pandemic (Abbas, Procter, van Zandvoort, Clark, Funk, Mengistu, Hogan, Dansereau, Jit, Flasche, LSHTM CMMID COVID-19 Working Group 2020 (https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30308-9/fulltext)). The importance of vaccines and vaccination The development of vaccines is a long, risky, and costly endeavor. On average, it takes 10.7 years to develop a new vaccine, and there is only a 6% success rate for vaccine research—from start to nish (Kuchler (https://www.ft.com/hannah-kuchler), H. (https://www.ft.com/content/1467b1da-28a5- 47d4-a5e2-a6f4b68484c3)Financial Times. Big Read. Medical Science, 2020 (https://www.ft.com/content/1467b1da-28a5-47d4-a5e2-a6f4b68484c3)). Indeed, determining that a vaccine is safe and effective takes time. The drive and race for a COVID-19 vaccine has picked up with the recent announcement of promising results of ongoing trials conducted in different countries (Jackson, Anderson, Rouphael, Roberts, Makhene, et al. 2020 (https://www.nejm.org/doi/10.1056/NEJMoa2022483); F (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31604-4/fulltext)olegatti, (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31604-4/fulltext#) (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31604-4/fulltext)Ewer, (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31604-4/fulltext#)Aley, (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31604-4/fulltext#)Angus, (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31604-4/fulltext#)Becker, (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31604-4/fulltext#)Belij- Rammerstorfer, et al. (https://www.thelancet.com/journals/lancet/article/PIIS0140- 6736(20)31604-4/fulltext#) 2020 (https://www.thelancet.com/journals/lancet/article/PIIS0140- 6736(20)31604-4/fulltext); Zhu, (https://www.thelancet.com/journals/lancet/article/PIIS0140- 6736(20)31605-6/fulltext)Guan, (https://www.thelancet.com/journals/lancet/article/PIIS0140- 6736(20)31605-6/fulltext#)Li, (https://www.thelancet.com/journals/lancet/article/PIIS0140- 6736(20)31605-6/fulltext#)Huang, (https://www.thelancet.com/journals/lancet/article/PIIS0140- 6736(20)31605-6/fulltext#)Jiang, (https://www.thelancet.com/journals/lancet/article/PIIS0140- 6736(20)31605-6/fulltext#)Hou, et al. (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31605- 6/fulltext#) 2020). While there is hope that a COVID-19 vaccine will be available in 12 to 18 months or earlier if the trials are successful, a lot of uncertainty still clouds that optimistic scenario. While vaccines are important, as experts have observed, what matters is vaccination; that is, the administration of a vaccine to people to help their immune systems develop protection from a disease. Immunization programs often serve as the entry point for primary health care in many countries, often providing the only access to mothers and young children on a regular basis (CDC, 2020 (https://www.cdc.gov/globalhealth/immunization/default.htm)). Vaccination not only protects those immunized but can reduce the risk of disease among those not immunized in a community through the development of “herd immunity.” The impact of vaccines in reducing www.pvmarquez.com/vaccinationsystems 2/8 1/12/2021 While waiting for a COVID-19 vaccine, it’s time to focus on gaps in vaccine distribution, cold chain, and uptake | Patricio V. Marquez vaccine-preventable disease morbidity and mortality is enormous: for example, in low-income countries, 23.3 million deaths are estimated to have been averted over 2011-2020 (CDC, 2020 (https://www.cdc.gov/globalhealth/infographics/immunization/global_impact_of_vaccines.htm)). COVID-19 is disrupting life-saving immunization services in both rich and poor countries, putting millions of children at risk from vaccine-preventable diseases like diphtheria, measles, and polio. According to UNICEF, this situation is due in large measure to a massive backlog in vaccine shipments due to unprecedented logistical constraints related to COVID-19 mitigation measures including lockdowns in some countries (UNICEF, 2020 (https://www.unicef.org/press- releases/geneva-palais-brie ng-note-impact-covid-19-mitigation-measures-vaccine-supply- and)). It is estimated that vaccination saves between 2 to 3 million lives a year (CDC, 2020 (https://www.cdc.gov/globalhealth/infographics/immunization/global_impact_of_vaccines.htm)). Considerations for Strengthening/Reinstating Immunization Services While the global effort nowadays is centered on containing the spread of the coronavirus and the resulting disease (COVID-19) and mitigating its social and economic impact, it is of critical importance to also maintain essential health service delivery to address other health needs of the population and prevent excess morbidity and mortality in a society (Marquez, Wang, and Ndebele 2020 (http://pvmarquez.com/essentialhealthservices)). Guidelines put forward by WHO can help adopt a balanced response at national, regional, and local levels (WHO, June 2020 (https://www.who.int/publications/i/item/covid-19-operational- guidance-for-maintaining-essential-health-services-during-an-outbreak)). WHO advises that, where immunization services are constrained or suspended, countries should reinstate their immunization services, once local transmission of the COVID-19 virus has declined (WHO, March 2020 (https://www.who.int/publications/i/item/guiding-principles-for-immunization-activities- during-the-covid-19-pandemic-interim-guidance)). WHO also notes that if resources for “catch-up” immunization campaigns are limited, priority should be given to outbreak-prone diseases such as measles, polio, diphtheria, and yellow fever. Vaccine Logistics, Cold Chain, Tracking, and Communication Building and sustaining safe and effective immunization programs are essential components of health delivery systems. Successful programs are built on functional, end-to-end supply chain and logistics systems. The role of the supply chain is to ensure effective vaccine storage, handling, and stock management; rigorous temperature control in the cold chain; and maintenance of adequate logistics management information systems. The ultimate goal is to ensure the uninterrupted availability of quality vaccines from manufacturer to service-delivery levels, so that opportunities to vaccinate are not missed because vaccines are unavailable (WHO, accessed on July 26, 2020 (https://www.who.int/immunization/documents/IIP2015_Module2.pdf)). www.pvmarquez.com/vaccinationsystems 3/8 1/12/2021 While waiting for a COVID-19 vaccine, it’s time to focus on gaps in vaccine distribution, cold chain, and uptake | Patricio V. Marquez The maintenance of cold chain is essential for vaccine effectiveness (WHO, accessed on July 26, 2020 (https://www.who.int/immunization/documents/IIP2015_Module2.pdf)). A cold chain is a temperature-controlled supply chain from the point of manufacture to the point of use. It involves an uninterrupted series of refrigerated production, storage, and distribution activities, along with associated equipment and logistics, including uninterrupted access to electrical or solar energy, to maintain the vaccines within a low-temperature range to ensure their potency. Maintaining the cold chain requires that vaccines and diluents be consistently transported and stored between 2-8◦C at all stages, including in primary/central/intermediate vaccine stores and health facilities and also during outreach immunization sessions (WHO, accessed on July 26, 2020 (https://www.who.int/immunization/documents/IIP2015_Module2.pdf)). In addition to temperature sensitivity, some vaccines (e.g., BCG and measles) also are sensitive to light. Any loss of potency due to heat or light is cumulative, permanent, and irreversible, meaning that the vaccine is rendered ineffective. Tracking and monitoring vaccine coverage is also critical, as data and information inform decision- making and outreach priorities. To this end, well-established arrangements need to be in place to record and report every vaccine dose administered, adverse effects, and assess the population served. Cold Chain Challenges and Solutions Some cold chain challenges that merit immediate review and attention include insuf cient and sub- optimal cold chain capacity that hampers availability of safe vaccines; limited freezing and storage capacity; inadequate temperature monitoring and maintenance systems; and costs. As assessed in different countries, often cold chain systems are unable to ensure availability of safe and potent vaccines (Ashok (https://www.sciencedirect.com/science/article/pii/S0264410X16307307?via%3Dihub#!), (https://www.sciencedirect.com/science/article/pii/S0264410X16307307?via%3Dihub)Brison (https://www.sciencedirect.com/science/article/pii/S0264410X16307307?via%3Dihub#!), and (https://www.sciencedirect.com/science/article/pii/S0264410X16307307?via%3Dihub)LeTallec (https://www.sciencedirect.com/science/article/pii/S0264410X16307307?via%3Dihub#!), 2017 (https://www.sciencedirect.com/science/article/pii/S0264410X16307307?via%3Dihub)). To address key performance gaps, the authors recommend the following actions: (i) development of an accurate picture of cold chain capacity gaps based on current and future needs (including in- country piloting of new equipment and a full understanding of equipment trade-offs); (ii) improvement of planning and programming (particularly to ensure that vaccination covers hard-to- reach populations); (iii) mobilization of resources to adequately fund programs; and (iv) effectively monitoring the cold chain during implementation. In addition, to control temperature variations www.pvmarquez.com/vaccinationsystems 4/8 1/12/2021 While waiting for a COVID-19 vaccine, it’s time to focus on gaps in vaccine distribution, cold chain, and uptake | Patricio V. Marquez and equipment failures, the introduction of temperature monitoring and control devices and practices is recommended, in addition to strengthening human resources for equipment repair and the availability of spare parts. Well-trained vaccinators at vaccination sites are also critical for the delivery of this intervention. Hence, strengthening health workers’ knowledge, skills, and practices is of upmost importance for the effective administration of vaccines. Human resources are the backbone of any system and the key enabler for all other functions to perform effectively. It is no different with vaccination programs, and more so in the current environment in which there is a need to have ready capacity to manage the introduction and administration of a potential new COVID-19 vaccine, while at the same time revamping the delivery of existing EPI vaccines. Ensuring demand and uptake of vaccines, as well as their affordability It should be clear that the ready availability of vaccines will not automatically generate their demand and uptake in all population groups. This reality re ects a lack of trust in government action and in some cases is the result of misinformation campaigns that are not backed by scienti c evidence. So, serious community outreach and engagement to provide transparent information about the importance of vaccines needs to be mounted to protect people, particularly the most vulnerable. The communications effort, however, needs to address knowledge, attitudes, and beliefs about vaccination particular to the social and cultural characteristics of different societies. Another option for increasing vaccine uptake is to require it. As observed in a recent article (Mello, Silverman, and Omer, 2020 (https://www.nejm.org/doi/full/10.1056/NEJMp2020926)), mandatory vaccination has proven effective in ensuring high childhood immunization rates in many high- income countries. However, except for in uenza vaccination of health care workers, mandates have not been widely used for adults. The operationalization of a vaccination mandate, for example for some high-risk groups such as health workers, the elderly, and those with preexisting conditions, would require that (i) the supply of the vaccine is suf cient to cover the population groups for which a mandate is being considered; (ii) available evidence about the safety and ef cacy of the vaccine has been transparently communicated; and (iii) established infrastructure to provide access to vaccination without nancial or logistic barriers, compensation to those who suffer adverse effects from a required vaccine, and real-time surveillance of vaccine side effects. It is also important that countries implement effective communication strategies to allay concerns and re-establish the demand for vaccinations within communities.The need to build public trust requires that state of cials implement vaccination policy through transparent and inclusive processes, involving local health of cers, health professional and hospital associations, representatives of high-risk population groups, and groups concerned about vaccine safety. As was observed during the Ebola response in West Africa in 2014-2015, building trust by engaging citizens and community leaders is critical to the success of delivering health services (UNDP, UN Agencies, World Bank Group, European Union, and African Development Bank, in consultation with the www.pvmarquez.com/vaccinationsystems 5/8 1/12/2021 While waiting for a COVID-19 vaccine, it’s time to focus on gaps in vaccine distribution, cold chain, and uptake | Patricio V. Marquez African Union and (https://www.undp.org/content/undp/en/home/librarypage/crisis- prevention-and-recovery/recovering-from-the-ebola-crisis---full-report.html)Economic Community of West African States and Mano River Union (https://www.undp.org/content/undp/en/home/librarypage/crisis-prevention-and- recovery/recovering-from-the-ebola-crisis---full-report.html), 2015 (https://www.undp.org/content/undp/en/home/librarypage/crisis-prevention-and- recovery/recovering-from-the-ebola-crisis---full-report.html)). Finally, equitable access to and utilization of vaccines is of paramount importance, particularly for ensuring that all countries, including the poorest, have equal access to a new COVID-19 vaccine once they become available. A key question that needs to be clari ed across the world, therefore, is how to make the new COVID-19 vaccines available free of charge or affordable to large segments of the world population that lack or have limited access to essential public health services and related nancial protection arrangements, such as social health insurance coverage. This issue merits careful consideration and assessment of options given the negative impact of the pandemic on countries’ macroeconomic situation, which might cascade down to health systems. Indeed, World Bank Group's (https://openknowledge.worldbank.org/handle/10986/33748)baseline forecast envisions a 5.2% contraction in global GDP in 2020—the deepest global recession in eight decades, despite unprecedented policy support. Per capita incomes in the vast majority of emerging market and developing economies (EMDEs) are expected to shrink in 2020, tipping many millions back into poverty. Under the baseline scenario, World Bank Group estimates show that COVID-19 will push more than 70 million people into extreme poverty, measured at the international poverty line of $1.90 per day (Gerszon Mahler, Lakner, Castaneda Aguilar, Wu 2020 (https://blogs.worldbank.org/opendata/updated-estimates-impact-covid-19-global-poverty)). Tighter scal space and shrinking revenue for employment-based insurance schemes may enlarge the nancial gap for investing in the health system. One option that should be considered for expanding the tax base and mobilizing additional scal resources for health, while helping reduce associated health risks, is the adoption of higher tax rates for tobacco and alcohol products, introducing or hiking taxes on sugary drinks, and phasing out fuel subsidies. There is signi cant accumulated experience in different countries of the world on the use of pro-health taxes, particularly to reduce tobacco use, and evidence on the positive health, scal, and equity gains that are generated by this policy measure. Looking forward While the world is going through a “perfect storm” caused by the coronavirus, we should not despair. We have evidence that proper application and population acceptance of basic public health measures, such as testing, isolation of those infected, contact tracing, quarantines for those people suspected of having being exposed to the virus, use of a cloth face covering www.pvmarquez.com/vaccinationsystems 6/8 1/12/2021 While waiting for a COVID-19 vaccine, it’s time to focus on gaps in vaccine distribution, cold chain, and uptake | Patricio V. Marquez (https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face- coverings.html) in public spaces, hand hygiene, and social distancing provisions, help prevent the spread of the coronavirus. Also, recent developments in treatments, such as antivirals (Remdesivir), glucocorticoids (dexamethasone), and antibodies (blood injections from patients who have recovered from COVID- 19), are showing that they can help improve outcomes for COVID-19 patients (Beigel,Tomashek, Dodd, Mehta, Zingman, et al. 2020 (https://www.nejm.org/doi/full/10.1056/NEJMoa2007764? query=recirc_curatedRelated_article); The RECOVERY Collaborative Group 2020 (https://www.nejm.org/doi/full/10.1056/NEJMoa2021436? query=recirc_mostViewed_railB_article); Casadevall and Pirofski 2020 (https://www.jci.org/articles/view/138003)). Even if a COVID-19 vaccine is only 60% or 70% effective, it could have a signi cant impact in reducing the contagiousness of the virus. Similarly, revamping and expanding the coverage of essential health services will help address the larger health needs to the population, and reduce the risk of the onset of other vaccine-preventable infectious diseases. History is full of examples that suggest that the prevention, containment, mitigation, and eventual suppression of COVID-19 is possible if political commitment, the alignment of resources, and determined scienti c, technological and operational efforts converge around a common objective. Indeed, as told by Dr. William Foege in “House on Fire” (https://www.goodreads.com/book/show/9772046-house-on- re), his memoire about the ght to eradicate smallpox in the 1960s and 1970s, well-structured and supported programs such as the one for smallpox eradication illustrates that “humanity does not have to live in a world of plagues, disastrous governments, con ict, and uncontrolled health risks” because “the coordinated action of a group of dedicated people can plan for and bring about a better future.” Source: Top Image by Katja Fuhlert (https://pixabay.com/users/kfuhlert-977338/? utm_source=link- attribution&utm_medium=referral&utm_campaign=image&utm_content=1215279) from Pixabay (https://pixabay.com/?utm_source=link- attribution&utm_medium=referral&utm_campaign=image&utm_content=1215279) www.pvmarquez.com/vaccinationsystems 7/8 1/12/2021 While waiting for a COVID-19 vaccine, it’s time to focus on gaps in vaccine distribution, cold chain, and uptake | Patricio V. Marquez (https://twitter.com/pvmarquez1956) www.pvmarquez.com/vaccinationsystems 8/8 1/12/2021 Improving Health Services: A Global Imperative Amidst COVID-19 | Patricio V. Marquez Improving Health Services: A Global Imperative Amidst COVID-19 Submitted by Patricio V. Marquez on Mon, 06/22/2020 - 06 54 PM Improving Health Services: A Global Imperative Amidst COVID-19 Posted by Patricio V. Marquez on Mon, 06/22/2020 - 06 54 PM Patricio V. Marquez and Lani Rice Marquez "If you can't describe what you are doing as a process, you don't know what you're doing” W. Edwards Deming, 1900-1993 www.pvmarquez.com/qualityimprovement 1/5 1/12/2021 Improving Health Services: A Global Imperative Amidst COVID-19 | Patricio V. Marquez Although “back to normal” in all spheres of life is still a distant aspiration worldwide after six months of relentless coronavirus (COVID-19) onslaught, restoring routine health services is a task that cannot wait. The diversion of health care resources to contain and mitigate the COVID-19 pandemic, coupled with a fear of health facilities among the population amid lockdowns, has disrupted the delivery and utilization of services in different parts of the world. In the absence of a vaccine or effective treatment, the immediate priority is to halt the spread of the deadly coronavirus through public health action, including: testing and contact tracing to stop cases from becoming clusters and outbreaks; isolation of infected people from people who are not sick; quarantine to separate and restrict the movement of people believed to have been exposed to the coronavirus to monitor if they become sick; and social distancing measures and wearing face masks in public spaces for the general population. The restoration and strengthening of health system capacity, however, are equally essential tasks that should be planned and implemented to ensure that critically ill patients receive appropriate care and to reduce the overall impact of the pandemic. A false dichotomy between COVID-19 emergency response and health system strengthening priorities needs to be avoided. The question that merits consideration, then, is how can quality improvement be at the core of restoring health services? Does improvement happen only by increasing providers’ knowledge and use of new tools, technologies, and medicines to prevent disease and diagnose and treat patients? Or is improvement a process that requires sustained effort and participation of all actors involved in the delivery of services? To answer these questions, a new open-access book "Improving Health Care in Low-and Middle-Income Countries (https://www.springer.com/us/book/9783030431112)" offers an www.pvmarquez.com/qualityimprovement 2/5 1/12/2021 Improving Health Services: A Global Imperative Amidst COVID-19 | Patricio V. Marquez interesting perspective rooted in the work of W. Edwards Deming, who proposed in the 1950s that eliminating delays, duplications, and errors would result in higher quality products and services at lower unit costs. Deming’s ideas were initially embraced and applied with good results in Japan to manufacture automobiles, electronic appliances, and other consumer goods, and were later adapted by Don Berwick and others in the United States and other countries in the 1990s for improving health care. “Improvement”, therefore, as suggested by the book authors, should be understood as “a directed effort to take what we know can improve health – proven, high-impact interventions like active management of the third stage of labor or keeping newborns warm – and ensure that those are implemented reliably, in different contexts, every time, for every patient who needs them.” The country case studies from Africa, Eastern Europe, South Asia, and Latin America and the Caribbean presented in the book illustrate how a persistent effort to identify gaps in care, propose changes to address those gaps, and test the effectiveness of the changes can measurably improve health processes and outcomes. Overall, one can infer from the book that there is no “best way” to improve health care. Rather, it is clear that engagement of health workers is the critical element for improving care at different levels of the health system— community, health center, district hospital, and referral hospital and for a wide variety of health conditions--prevention of mother-to-child transmission of HIV, tuberculosis-HIV co-infection, nutrition and health promotion for pregnant women and children under two, maternal mortality, and antimicrobial resistance due to overuse of antibiotics. Indeed, key to success in all country case studies is a dedicated focus of improvement teams on reaching explicit standards, identifying gaps in meeting standards and taking action to address the gaps, including brainstorming and thinking through new ways of improving adherence to www.pvmarquez.com/qualityimprovement 3/5 1/12/2021 Improving Health Services: A Global Imperative Amidst COVID-19 | Patricio V. Marquez standards. Some approaches introduced rewards for meeting standards, but similar improvements in care were achieved by simply informing health workers of gaps in care without explicit rewards for quality. Measurement is a critical part of testing and implementing changes. The development of data analysis skills among health workers, therefore, is critical for the quality improvement process, particularly looking at changes in data in a simple or intuitive way to allow improvement teams to easily understand what worked—and what didn't. Building in mechanisms to share learning across teams as they tested different approaches improved the impact of quality improvement efforts in many cases, as effective ways for improving care were shared among teams and scaled up to more sites. Teams were able to achieve better improvement results with strong support structures around them, including management support, to help them address system-level problems that are beyond the reach of individual teams. Many of the cases also emphasize the value of coaching support to help teams to translate standards into practice and for intervening in the particular care area. A pilot approach can be useful to demonstrate results on a small scale before scaling up to multiple sites. Results at pilot sites can help create buy-in and political support for the improvement at the political and administrative level of the health system, which in turn can strengthen the efforts at the service delivery level. Benchmarking or comparing performance between facilities and districts, while providing facility-speci c feedback, can stimulate efforts of teams to modify practices. Indeed, health workers can be motivated by evidence www.pvmarquez.com/qualityimprovement 4/5 1/12/2021 Improving Health Services: A Global Imperative Amidst COVID-19 | Patricio V. Marquez of how their practices deviate from the established practices or from the mean performance of other facilities in the same region. It should be clear, however, that the medium- and long-term sustainability of quality improvement efforts and their achievements will depend on their institutionalization through policies, organizational and institutional arrangements, performance management processes, and adequate and predictable funding allocations. This will support the establishment of a “quality improvement culture” that is ingrained at all levels of the health system. The engagement of frontline teams, following clearly de ned standards of work for the delivery of safe, effective, and ef cient health care, that is monitored and adjusted as a team responsibility, would be key to sustain performance and contribute to improving the health conditions of the population. If this is done, it would help rebuild trust and con dence in health services after the COVID-19 crisis has ended. Picture: Picture of Quality Improvement (QI) Teams in Uganda, URC. (https://twitter.com/pvmarquez1956) www.pvmarquez.com/qualityimprovement 5/5 1/12/2021 Sustaining Essential Health Services during the Covid-19 Pandemic: A Social Imperative | Patricio V. Marquez Sustaining Essential Health Services during the Covid-19 Pandemic: A Social Imperative Submitted by Patricio V. Marquez on Mon, 06/15/2020 - 08 44 PM Sustaining Essential Health Services during the Covid-19 Pandemic: A Social Imperative Posted by Patricio V. Marquez on Mon, 06/15/2020 - 08 44 PM Patricio V. Marquez, Huihui Wang, Lydia Ndebele Background The COVID-19 pandemic is currently affecting 188 countries and territories across all regions. In all but a handful of countries, COVID-19 exploited weaknesses across health system platforms, pointing out strong need for resilient health systems. Under-resourced surveillance platforms were unable to promptly detect community spread until viral circulation was already widespread. Insuf cient stockpiling, contingency planning, and coordination across regional, national, and international public health platforms led to shortages of essential supplies and equipment, sparking bidding wars and leaving health workers without appropriate protective gear. Hospital platforms were overwhelmed and stressed beyond capacity, with fragmentation hampering the ef cient ow of patients, staff, and equipment. For countries that had weaker health systems and less resources, the impact can be both signi cant and long- lasting. COVID-19 may affect countries’ journey to Universal Health Coverage and the Sustainable Development Goal 3 through several pathways: 1. Increased morbidity and mortality directly attributed to COVID-19 As of June 16, 2020, there have been close to 8 million con rmed cases of COVID-19 and more than 434,000 deaths (JHU&M 2020). Since testing capacity lags in most countries, the number of new cases is likely to be underestimated. Similarly, mortality data should also be interpreted with caution, as many countries show signi cant underreporting of COVID-19- related deaths (Table 1). Differences in data collection, as well as delays in death registrations, contribute to the problem. www.pvmarquez.com/essentialhealthservices 1/8 1/12/2021 Sustaining Essential Health Services during the Covid-19 Pandemic: A Social Imperative | Patricio V. Marquez Unexplained deaths provide a proxy for underreporting. They are estimated as the difference between observed deaths and the projected number of deaths based on historical and seasonal trends. The difference may be attributed to COVID-19 or to other factors, such as a shortage or lack of essential medical services for other conditions. While it is not possible to know the true death toll of COVID-19, it is clear that in some countries daily deaths have reached rates 50% or higher than the historical average for periods of time. Table 1. COVID-19 underreported deaths Source: For all cases, except Mexico, The New York Times “74000 missing deaths: tracking the true toll of the coronavirus outbreak.” Updated May 19. For México City Nexos: “¿Qué nos dicen las actas de defunción de la CDMX?”, May 25, 2020. Based on currently available information and clinical expertise, older adults and people of any age who have serious underlying medical conditions might be at higher risk for severe illness from COVID-19 (CDC 2020), particularly those with weakened immune systems. People with chronic lung disease or moderate to severe asthma, serious heart conditions, who are immunocompromised (many conditions can cause a person to be immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune de ciencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications), severe obesity (body mass index [BMI] of 40 or higher), diabetes, chronic kidney disease undergoing dialysis, and liver disease. Conditions such as ischemic heart disease, stroke, lower respiratory infections, chronic obstructive pulmonary disease (COPD), HIV/AIDS, tuberculosis, are already among the ten leading causes of premature death in the world, accounting for more than 1 million deaths each in 2017 (IHME 2018). As the rst country to be impacted, China’s reported data provides insights into the biology, epidemiology, and clinical characteristics of COVID-19 (Guan, Ni, Hu, Liang, et al 2020). A higher prevalence of smoking among men, often resulting in compromised lung function, may help explain their higher COVID-19 fatality rate. Tobacco use also contributes to the onset of co-occurring conditions such as cardiovascular diseases, lung cancer, COPD, and diabetes, which are more prevalent among males, and which also increase the risk of disease severity and death among COVID-19 patients. Data from Italy also shows that a high proportion of COVID-19 patients had a history of smoking and high rates of COPD and heart disease (Boccia, Ricciardi, Ioannidis 2020). The Middle East and North Africa (MENA) region is also facing an increased pressure on health systems from COVID-19 (coronavirus), with over 200,000 con rmed cases and almost 10,000 deaths reported, on top of a high and growing burden of non-communicable diseases (NCDs) (Duran and Menon 2020). Sub-Saharan African countries can be potentially hit hard with a large number of people are at higher risk of infection due to preconditions: about 26 million live with HIV (https://www.unaids.org/sites/default/ les/media_asset/UNAIDS_FactSheet_en.pdf) and 2.5 million fall ill from tuberculosis (https://www.afro.who.int/health-topics/tuberculosis-tb) annually, while South Africa and Namibia have high mortality rates from NCDs (Marquez and Farrington 2013). As experienced by some high- income countries, people in low- and middle-income countries (especially the poor) may refrain themselves seeking care or getting tested due to nancial barriers, which in turn will worsen the pandemic. Simultaneous epidemics are overwhelming public health systems in different countries that had few resources to begin with. In some countries, the threat of dengue fever is being taken as seriously as COVID-19. For example, in Central America, Honduras has seen a steep climb in COVID-19 cases in the midst of a dengue www.pvmarquez.com/essentialhealthservices 2/8 1/12/2021 Sustaining Essential Health Services during the Covid-19 Pandemic: A Social Imperative | Patricio V. Marquez fever outbreak. San Pedro Sula, the business capital where gang violence makes Honduras one of the deadliest countries in the world, is also now the epicenter of a COVID-19 outbreak (Gannon 2020). In Singapore dengue infections may for 2020 exceed the all-time high of 22,170 set in 2013 (Goodman 2020), while in the state of Mato Grosso do Sul in Brazil, health authorities are dealing with additional dengue fever cases, bringing the total this year so far to 61,604 con rmed cases. (Newsdesk 2020). In Pakistan, the country’s toll of above 139,000 coronavirus cases surpasses that of neighboring China with 84,000 con rmed cases, and more than 2,600 people in Pakistan have already died. At the same time, Pakistan continues to suffer some of the world’s worst outbreaks of infectious diseases, with 4.3 million cases of malaria annually, and is also one of the top 10 countries for new cases of tuberculosis each year, and is one of only three countries, including Afghanistan and Nigeria, where polio is still endemic (Gannon 2020). Meanwhile, in the Democratic Republic of Congo (DRC), a new outbreak of Ebola in Equateur Province is now compounding the public health challenge posed by COVID-19 pandemic, with more than 4,000 con rmed cases reported (Schlein, 2020). 2. Increased morbidity and mortality due to interruption of essential service delivery associated with COVID-19 containment measures During the 2014-2015 Ebola epidemic in West Africa, it was observed an upsurge in mortality and morbidity from other diseases and conditions (Bietsch, K, Williamson, J, and Reeves M. 2020; Camara BS et al. 2017; Hall KS et al. 2020; Sochas, L, Channon, AA, and Nam, S. 2017), and this is happening again during the COVID-19 pandemic. Shortage of health workers is exacerbated as many of them are diverted to managing COVID-19 cases, or hampered by lack of protective gears, or advised to discontinue service delivery. Local or national lockdowns, along with the consequences of physical distancing, travel restrictions, disruptions on the supply chain for contraceptive commodities, and the fear of health facilities among pregnant women, may risk undermining or reversing the progress made in the past decade to improve the access to and quality of sexual and reproductive health services and reduce unwanted teenage pregnancy and maternal mortality. Consequently, women and children are affected disproportionately, especially those living in fragile contexts. For example: Increased unmet need for modern contraceptive: Initial estimates show that a 10% proportional decline in use of short- and long-acting reversible contraceptive methods in LMICs due to reduced access would result in an additional 49 million women with an unmet need for modern contraceptives and an additional 15 million unintended pregnancies over the course of a year ((Riley, Sully, Ahmed, and Biddlecom 2020). Additional maternal and newborn deaths: An additional 1.7 million women who give birth and 2.6 million newborns would experience major complications but would not receive the care they need, resulting in an additional 28,000 maternal deaths and 168,000 newborn deaths (Riley, Sully, Ahmed, and Biddlecom 2020). Wide-spread interruption of immunization program: A recent report by WHO (2020) indicates that since March 2020, routine childhood immunization services have been disrupted on a global scale that may be unprecedented since the inception of expanded programs on immunization (EPI) in the 1970s. More than half (53%) of the 129 countries where data were available reported moderate-to-severe disruptions, or a total suspension of vaccination services during March-April 2020. Many countries have temporarily suspended preventive mass vaccination campaigns against diseases like cholera, measles, meningitis, polio, tetanus, typhoid and yellow fever, due to risk of transmission and the need to maintain physical distancing during the early stages of the COVID-19 pandemic. Measles initiatives, for example, have been suspended in 27 countries, including Chad and Ethiopia, and polio programs are on hold in 38, including Pakistan and the Democratic Republic of Congo (Hoffman 2020). The problem of slipping vaccine rates is not limited to developing countries. The Centers for Disease Control and Prevention (CDC) reported drop in visits and fewer vaccine doses being administered in the United States, leaving children at risk for vaccine-preventable diseases (Santoli, Lindley, DeSilva, et al 2020). Transport delays of vaccines are exacerbating the situation. UNICEF has reported a substantial delay in planned vaccine deliveries due to the lockdown measures and the ensuing decline in commercial ights and limited availability of charters (UNICEF 2020). This particularly affects countries in FCV areas where immunization delivery relies heavily on community outreach and campaign programs most of which are put on hold due to social distancing requirements. As a result, at least 80 million children under one at risk of diseases such as diphtheria, measles and polio as COVID-19 disrupts routine vaccination efforts (WHO 2020, 1). www.pvmarquez.com/essentialhealthservices 3/8 1/12/2021 Sustaining Essential Health Services during the Covid-19 Pandemic: A Social Imperative | Patricio V. Marquez In addition to physical health, mental health for all and especially the displaced also needs to be prioritized. COVID-19 Exposed by the coronavirus crisis, everyone is affected mentally through losses such as the death of loved ones, illness, diminished life’s savings, or in being con ned, having to forgo life’s signi cant occasions, transitions, plans, or experiences. For displaced communities – for example refugees or asylum seekers – the mental health fallout will be signi cantly more acute, while their access to health care reduces (Marquez 2017). In Afghanistan, for example, which is in the midst of a displacement and refugee crisis (more than 400,000 IDPs; 505 000 refugees returning from Iran), one can anticipate a rapid exacerbation of these challenges (Pierre-Louise 2020). To restore economic activity in the aftermath of the pandemic, besides nancial and physical well-being efforts are needed to address mental health of individuals and communities. 3. Uncertain nancing prospects for health system accompanied by growing demand to look after the poor While countries are mobilizing all potential resources for health system to ght against the pandemic, the negative impact on countries’ macroeconomic situation might cascade down to health system. Indeed, World Bank estimates indicate that as many as 90% of the 183 economies are expected to suffer from falling levels of GDP in 2020. Tighter scal space and shrinking revenue for employment-based insurance schemes may enlarge the nancial gap for investing in health. Furthermore, the World Bank estimates that under a baseline scenario with global growth contracting by about 5% in 2020, and downside scenario with a global growth contraction of 8% in 2020, COVID-19 will push 71 million into extreme poverty, measured at the international poverty line of $1.90 per day (Gerszon Mahler, Lakner, Castaneda Aguilar, Wu 2020). With the downside scenario, this increases to 100 million people. These scenarios pose signi cant nancing challenges for ensuring population access to essential services. If not well managed, countries may be pushed to a situation in which the relative importance of out-of-pocket payments may rise, a mechanism deemed most inequitable and least ef cient, and that poses a high risk of impoverishment to the population. Even before the pandemic, the incidence of catastrophic health expenditure (SDG indicator 3.8.2), de ned as large out-of-pocket spending in relation to household consumption or income, increased continuously between 2000 and 2015 (WHO/WBG 2020). In 2015, 926.6 million people incurred out- of-pocket health spending exceeding 10% of their household budget (total consumption or income), and 208.7 million incurred out of pocket health spending that even exceeded 25% of the household budget (WHO/WBG 2019). These people lived mostly in Asia (70%–76%), about 45% in lower-income countries and 41%–43% in upper-middle-income countries. Asia, and Latin America and the Caribbean had the highest percentage of their 2015 population with catastrophic health spending as tracked by SDG indicator 3.8.2, while North America and Oceania had the lowest. In 2015, out-of-pocket health spending contributed to pushing more people below the poverty line: 89.7 million people (1.2%) were pushed into extreme poverty (below $1.90 per person per day in 2011 purchasing power parity terms), while 98.8 million (1.4%) were pushed below $3.20 per person per day and 183.2 million were pushed into poverty de ned in relative terms (below 60% of median daily per capita consumption or income in their country) (WHO/WBG 2019). 4. What to Do? As the COVID-19 continues to evolve, it is imperative that countries adopt measures to balance the demands of responding directly to COVID-19, while simultaneously engaging in strategic planning and coordinated action to maintain the delivery of routine essential health services, mitigating the risk of system collapse (WHO 2020,2). Travel restrictions and lockdowns, people putting off seeking needed health care for any number of conditions from fear of becoming infected with COVID-19 in a health facility, disruptions in the global supply chain of essential personal protective equipment, medicines and medical materials, demand solutions beyond the usual way of operating to be able to continue caring for patients affected by concurrent conditions. www.pvmarquez.com/essentialhealthservices 4/8 1/12/2021 Sustaining Essential Health Services during the Covid-19 Pandemic: A Social Imperative | Patricio V. Marquez To ensure continuity of routine essential health services to meet all the health needs of the population, innovative approaches have been launched in different countries. Some of them are presented below. Use of family medicine and integrated networks at all three levels of care, as done in Costa Rica (Macaya 2020), as well as in Cuba and in the Kerala State in India, where the whole organization of the health care system is geared to be in close touch with the population, identify health problems as they emerge, and deal with them immediately along a care continuum (Augustin 2020; Shailaja, K.K., Teacher, and Khobragade, RN, 2020). In these countries, the primary health care system acts as the entry point to the integrated health system, facilitating early identi cation and timely referral of cases to higher levels of care for appropriate management. Improving the equity of health nancing and service delivery. Available data from the United States show the estimated average cost for possible procedures that might occur for COVID-19 treatment and the signi cant disparity between people with health insurance and those who lack insurance or have limited access to publicly- funded health services. For people with health insurance who have met the required deductible, they would need to pay only the co-pay or co-insurance, while the insurance plan would pay the remaining balance. In the case of people without insurance, they would have to pay 100% of the price of COVID-19-related medical costs, which could set a patient and his/her family back nancially (Abrams 2020). While health systems, nancial protection arrangements, and medical cost structures vary from country to country, it should be clear that in countries without universal health coverage, the nancial impact of COVID-19 on the population, particularly low-income groups, could be signi cant or even catastrophic if adequate provisions are not taken to offer nancing protection to the population. In the MENA region, for example, to mitigating the direct and indirect impacts of COVID-19, particularly for the most vulnerable populations, the elimination of user fees and copayments has been proposed for all health services (Duran and Menon 2020). Drone delivery is changing the face of global logistics. The experience in Rwanda’s health system is noteworthy. Beginning in 2017, Rwanda, in partnership with California-based robotics company Zipline International Inc., became the rst country in the world to incorporate drone technology into its health care system for delivering blood and medical supplies to hospitals across its Southern and Western provinces (Marquez 2019). Establishment of drone delivery systems for transporting samples from remote areas to test centers during the COVID-19 pandemic has also been initiated in Ghana, alongside the distribution of drugs and blood products (Nsiah Asare 2020). Increasing the availability of telemedicine for ambulatory services. This use of this technology helps to provide online infection prevention and control trainings for care home workers, running health promotion campaigns on social media, to managing WhatsApp groups of traditional healers (MSF 2020). Telemedicine can play a critical role in ensuring that patients continue to receive non-urgent care, particularly those with chronic conditions. Engagement of community health workers and mobile health teams. To minimize the negative impact of the reduction of recommended number of antenatal consultations for pregnant women in clinics, the engagement of trusted people in their communities is critical to ensure that women can still receive the care they need. Community personnel can help identify when a woman needs to go to hospital because of complications (MSF 2020), or help organize service delivery by mobile teams, particularly to cover hard to reach rural areas. Distribution of essential drugs to patients for longer periods (one to six months depending on the person’s health condition) so that they do not have to visit a health facility as often for follow up care for HIV, tuberculosis, hepatitis C and non-communicable diseases. At the same time, measures adopted to ensure that patients receive follow-up through phone consultations, messaging apps and peer support networks (MSF 2020). Use of smartphones for ‘video observed therapy’, for example for patients with multidrug-resistant tuberculosis (MDR-TB), so they can lm themselves taking their medication and send the video to be checked by a nurse (MSF 2020). Use of telephone hotlines for the provision of consultations by counselors and psychologists for patients with mental disorders. This approach also helps to reduce the fear of stigma and discrimination that hinders service demand and utilization (MSF 2020). www.pvmarquez.com/essentialhealthservices 5/8 1/12/2021 Sustaining Essential Health Services during the Covid-19 Pandemic: A Social Imperative | Patricio V. Marquez Planning efforts are needed to ramp up vaccinations for every missed child when the pandemic Covid-19 ends, and to make advance provisions to ensure that when the COVID-19 vaccine is available, it reaches those most in need. Looking into the future, the global spread of COVID-19 clearly signals the need, hopefully once and for all, for building and maintaining strong and sustainable public health and medical institutions and systems in countries. This needs to be complemented by effective cross sectoral interface between environment, veterinary and public health services to anticipate, prevent, and control the emergence of new infectious pathogens of animal origin, the resurgence of known infectious diseases, and the ominous threat of anti- microbial resistance. This task is of priority importance where health systems are weaker, living conditions often more overcrowded, and populations most vulnerable. Sources Abrams, A. 2020. “Total Cost of Her COVID-19 Treatment: $34,927.43.” Time, Ma… (https://time.com/5806312/coronavirus-treatment-cost/) Augustin. E. 2020. “Cuba sets example with successful programme to contain cor… (https://www.theguardian.com/world/2020/jun/07/cuba-coronavirus-success-contact-tracing-isolation) Bietsch, K, Williamson, J, and Reeves M. 2020. “Family planning during and aft… (https://pubmed.ncbi.nlm.nih.gov/32180246/) Boccia S, Ricciardi W, Ioannidis JPA. 2020. “What Other Countries Can Learn Fro… (https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2764369) Camara BS et al. 2017. “Effect of the 2014/2015 Ebola outbreak on reproductive … (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5914332/) CDC. 2020. “Groups at Higher Risk for Severe Illness.” (internet site). (https://www.cdc.gov/coronavirus/2019- ncov/need-extra-precautions/groups-at-higher-risk.html) Duran, D, and Menon, R. 2020. “COVID-19 (coronavirus): Ensuring continuity of … (https://blogs.worldbank.org/health/covid-19-coronavirus-ensuring-continuity-health-services-middle-east-and- north-africa) Gannon, K. 2020. “COVID-19 just the latest epidemic in areas struck by diseas… (https://apnews.com/1466c5ba97314f54cb32c8942e0a621b) Gerszon Mahler, D, Lakner, C, Castaneda Aguilar, AR, Wu, H. 2020. “Updated esti… (https://blogs.worldbank.org/opendata/updated-estimates-impact-covid-19-global-poverty) Goodman, W. 2020. “Singapore Dengue Cases May Hit Record, Straits Times report… (https://www.bloomberg.com/news/articles/2020-06-13/singapore-dengue-cases-may-hit-record-straits-times- reports) Guan, W, Ni, Z, Hu, Y, Liang, W, et al. 2020. “Clinical Characteristics of C… (https://www.nejm.org/doi/full/10.1056/NEJMoa2002032?query=recirc_mostViewed_railB_article) Hall KS et al. 2020. “Centring sexual and reproductive health and justice in th… (http://dx.doi.org/10.1016/S01406736(20)30801-1.) Hoffman, J. 2020. “Polio and Measles Could Surge After Disruption of Vaccine P… (https://www.nytimes.com/2020/05/22/health/coronavirus-polio-measles-immunizations.html? smtyp=cur&smid=tw-nythealth) IHME. 2018. “Global trends in causes of death”. (http://www.healthdata.org/infographic/gbd-2017-study- highlights-causes-death) International Monetary Fund. 2020. “World Economic Outlook, April 2020 World E… (https://www.imf.org/en/Publications/WEO/Issues/2020/04/14/weo-april-2020) Johns Hopkins University & Medicine. 2020. Coronavirus Resource Center. (in… (https://coronavirus.jhu.edu/map.html) Macaya, R. 2020. “Costa Rica’s experience in responding to COVID-19.” Present… (https://worldbankgroup.webex.com/worldbankgroup/lsr.php?RCID=750dc08c6cf6507f107912ed2d73d999) Marquez, PV, and Farrington, J. 2013. “The challenge of non-communicable disea… (http://documents.worldbank.org/curated/en/844381468209068874/The-challenge-of-non-communicable- diseases-and-road-traf c-injuries-in-Sub-Saharan-Africa-an-overview) www.pvmarquez.com/essentialhealthservices 6/8 1/12/2021 Sustaining Essential Health Services during the Covid-19 Pandemic: A Social Imperative | Patricio V. Marquez Marquez, PV. 2017. “Mental health among displaced people and refugees : making … (http://documents.worldbank.org/curated/en/916131486730755271/Mental-health-among-displaced-people-and- refugees-making-the-case-for-action-at-the-World-Bank-Group) Marquez, PV, 2019. “Drones and blood safety can save lives.” World Bank Group… (https://blogs.worldbank.org/health/drones-and-blood-safety-can-save-lives) Médecins Sans Frontiers (MSF). 2020. “Continuing essential medical services dur… (https://www.msf.org/essential- medical-services-during-covid-19-pandemic) Newsdesk. 2020. “Brazil: Mato Grosso do Sul sees worst dengue epidemic since 2… (http://outbreaknewstoday.com/brazil-mato-grosso-do-sul-sees-worst-dengue-epidemic-since-2014/) Nsiah Asare, A. 2020. “Ghana’s experience in responding to COVID-19.” Present… (https://worldbankgroup.webex.com/worldbankgroup/lsr.php?RCID=750dc08c6cf6507f107912ed2d73d999) Parker, E. 2020. “A rise in deaths from preventable diseases must not be part … (https://www.theguardian.com/global-development/2020/apr/27/a-rise-in-deaths-from-preventable-diseases- must-not-be-part-of-covid-19s-legacy) Peeples, L. 2020. “In Poor Nations, a New Disease Stalls Efforts to Fight Old … (https://undark.org/2020/04/14/covid-19-poor-nations-immunization-polio-measles/) Pierre-Louise, M. 2020. “Policy Note on Health Impacts of COVID-19 in Fragile,… (https://www.worldbank.org/) Riley T, Sully E, Ahmed Z, Biddlecom A. 2020. “Estimates of the Potential Impac… (https://pubmed.ncbi.nlm.nih.gov/32343244/) Santoli JM, Lindley MC, DeSilva MB, et al. “Effects of the COVID-19 Pandemic on… (http://dx.doi.org/10.15585/mmwr.mm6919e2) Ross, J. 2020. “How Many People Die Each Day?” (internet publication using IHM… (https://www.visualcapitalist.com/how-many-people-die-each-day/) Schlein, L. 2020. “WHO Expects to Quickly Tackle DR Congo’s New Ebola Outbrea… (https://www.voanews.com/africa/who-expects-quickly-tackle-dr-congos-new-ebola-outbreak) Sochas, L, Channon, AA, and Nam, S. 2017. “Counting indirect crisis related de… (http://dx.doi.org/10.1093/heapol/czx108.) United Nations, Department of Economic and Social Affairs, Population Division… (https://www.un.org/en/development/desa/population/publications/pdf/mortality/WMR2019/WorldMortality2019 UNICEF. 2020 (1). “Over 13 million children did not receive any vaccines at al… (https://www.unicef.org/press- releases/over-13-million-children-did-not-receive-any-vaccines-all-even-covid-19-disrupted) UNICEF. 2020 (2). “Geneva Palais brie ng note on the impact of COVID-19 mitig… (https://www.unicef.org/press- releases/geneva-palais-brie ng-note-impact-covid-19-mitigation-measures-vaccine-supply-and) Washington Post. 2020. “Beijing Shuts Some Markets; London Stores to Open: Viru… (https://www.washingtonpost.com/business/on-small-business/beijing-shuts-some-markets-london-stores-to- open-virus-update/2020/06/12/35812aba-acf8-11ea-a43b-be9f6494a87d_story.html) WHO. 2020 (1). “Global Immunization News (GIN).” March-April 2020. (https://www.who.int/immunization/GIN_March-April_2020.pdf?ua=1) WHO. 2020 (2). “Coronavirus disease (COVID-19) technical guidance: Maintaining … (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/maintainingessential- health-services-and-systems)) WHO/WBG. 2020. “Global Monitoring Report on Financial Protection in Health 2019… (https://www.who.int/healthinfo/universal_health_coverage/report/2019/en/) World Bank, 2020. “Protecting People and Economies: Integrated Policy Responses… (https://openknowledge.worldbank.org/handle/10986/33770) Shailaja, K.K., Teacher, Minister of Health, Social Justice and Women and Child… (https://worldbankgroup.webex.com/worldbankgroup/lsr.php?RCID=750dc08c6cf6507f107912ed2d73d999) (https://twitter.com/pvmarquez1956) www.pvmarquez.com/essentialhealthservices 7/8 1/12/2021 Have South and Central America become the new coronavirus (COVID-19) epicenter? Learn how the World Bank Group is helping countries with COVID-19 (coronavirus). Find Out Publish d on Inv stin in H lth (/h lth) H v South nd C ntr l Am ric b com th n w coron virus (COVID-19) pic nt r? PATRICIO V. MARQUEZ (/TEAM/PATRICIO-V-MARQUEZ), SANTIAGO HERRERA AGUILERA (/TEAM/SANTIAGO- HERRERA-AGUILERA) & LUIGI BUTRON CALDERON (/TEAM/LUIGI-BUTRON-CALDERON) | JUNE 03, 2020 This page in: English 6 “There have been as many plagues as wars in history; yet always plagues and wars take people equally by surprise.” - Albert Camus (1957 Nobel Prize Laureate for Literature), La Peste, Vintage, 1947 https://blogs.worldbank.org/health/have-south-and-central-america-become-new-coronavirus-covid-19-epicenter 1/11 1/12/2021 Have South and Central America become the new coronavirus (COVID-19) epicenter? The coronavirus (COVID-19) pandemic has hit the entire world with devastating e ects, both through lives lost (more than 370,000 deaths (https://coronavirus.jhu.edu/)) and a severe economic downturn (https://www.imf.org/en/Publications/WEO/Issues/2020/04/14/weo-april-2020). Although the aggregate number of new cases has stabilized somewhat (Figure 1), the tide has fallen in some places and risen in others, shifting the pandemic’s epicenter from region to region. The latest data suggest that some South and Central American countries have become the new COVID-19 epicenter (https://twitter.com/intent/tweet? text=The+latest+data+suggest+that+some+South+and+Central+American+countries+ha 19+epicenter&url=https://blogs.worldbank.org/health/have-south-and-central- america-become-new-coronavirus-covid-19-epicenter/? cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank), with daily infections in the region now exceeding those in the United States and Europe (https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200602- covid-19-sitrep-134.pdf?sfvrsn=cc95e5d5_2) (Figure 2). Figure 1. Daily confirmed new cases worldwide Figure 2. Daily confirmed new cases by region (Number of cases) (Percent of total cases) Note: Data as of May 25. Source: Prepared by authors using Our World in Data. The situation in the region More than 70 days into the pandemic, new cases keep rising sharply in some countries in South and Central America (Figure 3). There are now more than 1 million COVID-19 cases here, half of them in Brazil (https://www.who.int/docs/default- source/coronaviruse/situation-reports/20200602-covid-19-sitrep-134.pdf? sfvrsn=cc95e5d5_2), which has surpassed Russia, the United Kingdom, and Spain to https://blogs.worldbank.org/health/have-south-and-central-america-become-new-coronavirus-covid-19-epicenter 2/11 1/12/2021 Have South and Central America become the new coronavirus (COVID-19) epicenter? reach the second highest number of cases in the world. More than 50,000 people have died across the region. Countries that adopted late or lax social distancing, such as Brazil and Mexico, are now seeing higher rates of infection. Other countries that had stabilized the growth of new cases and relaxed their lockdowns, such as Chile and Peru, have seen surges of new cases. Costa Rica and Uruguay are outliers, as their cases seem to have leveled o . Figure 3. Daily confirmed new cases (7-day moving average): South and Central American countries Note: Data as of May 25. Source: Prepared by authors using Our World in Data. Since testing capacity lags behind other regions, the number of new cases is likely to be underestimated. Similarly, mortality data should also be interpreted with caution, as many countries show signi cant underreporting of COVID-19- related deaths (Table 1). Unexplained deaths provide a proxy for underreporting. They are estimated as the di erence between observed deaths and the projected number of deaths based on historical and seasonal trends. The di erence may be attributed to COVID-19 or to other factors, such as a shortage or lack of essential medical services for other conditions. In Ecuador, Chile, and Mexico, the unexplained deaths are 4 to 5 times the reported deaths. In Brazil and Peru, the factor is somewhat smaller, around 2 times. Table 1. COVID-19 underreported deaths https://blogs.worldbank.org/health/have-south-and-central-america-become-new-coronavirus-covid-19- 3/11 epicenter 1/12/2021 Have South and Central America become the new coronavirus (COVID-19) epicenter? What explains Latin America’s vulnerability? Experts (https://www.cnn.com/2020/05/30/americas/latin-america-covid-19- epicenter-intl/index.html) suggest that poverty and the region’s high levels of inequality (https://blogs.worldbank.org/developmenttalk/inequality-and-social- unrest-latin-america-tocqueville-paradox-revisited) have contributed to the relative ine ectiveness of lockdowns. The average Gini coe cient, which measures the distribution of income or consumption expenditure within a country, was estimated at 0.51 in 2017 – the highest level of inequality in the world (Figure 4). In particular, the region has many informal workers (about 140 million people, or 55% of total workers), who must continue to work every day to earn a living, for example in marketplaces, cleaning houses, or as street vendors. These workers are unlikely to have much savings or to receive support from social protection programs at a level that would allow them to feed their families while adhering to social distancing measures. The vulnerability of people in large metropolises such as Sao Paulo and Mexico City is further increased by poor living conditions. Millions are crowded in densely packed neighborhoods, with large families often sharing a single room and many lacking access to clean water, basic sanitation, and health services. Some households are forced to shop for food every day in crowded markets because they do not have a refrigerator or lack electricity, putting them at higher risk of becoming infected. https://blogs.worldbank.org/health/have-south-and-central-america-become-new-coronavirus-covid-19-epicenter 4/11 1/12/2021 Have South and Central America become the new coronavirus (COVID-19) epicenter? Figure 4. Income inequality in selected Latin American countries, 2000-2017: Gini coe cients Meanwhile, the ongoing economic downturn caused by COVID-19 is taking a severe toll on the ability of migrant workers to send money home. In South and Central American countries, the decline in remittance ows (https://www.worldbank.org/en/news/press-release/2020/04/22/world-bank- predicts-sharpest-decline-of-remittances-in-recent-history) has been estimated at 20%. Remittances are a vital source of income in some countries such as Ecuador and El Salvador, as they help the poorest communities a ord food, health care, and basic needs. https://blogs.worldbank.org/health/have-south-and-central-america-become-new-coronavirus-covid-19-epicenter 5/11 1/12/2021 Have South and Central America become the new coronavirus (COVID-19) epicenter? The situation has been further aggravated by high debt burdens and signi cant budget de cits, which have reduced investment in public health systems and undermined their capacity to care for the sick. What is the World Bank doing? The World Bank is supporting COVID-19 health-relatd emergency responses in 19 Latin American and Caribbean countries. To date, 15 new COVID-19 health operations are underway in 13 countries, amounting to $965 million. In addition, resources allocated to existing World Bank projects are being redeployed, including through restructuring ($176 million) and activating emergency provisions ($18.5 million). Given the severity of the pandemic, the World Bank Group is committed to providing $160 billion (https://www.worldbank.org/en/about/what-we-do/brief/world-bank- group-operational-response-covid-19-coronavirus-projects-list) over 15 months to help countries across the globe address the health, economic, and social impacts of COVID-19. Emergency operations now reach 100 countries with emergency containment and mitigation activities. Health operations also support governments in strengthening their longer-term health system capacity to prevent the reemergence of COVID-19 and other pathogens of animal origin, and to provide essential services for other conditions. What lessons are emerging? In the landmark book “This Time is Di erent. Eight Centuries of Financial Folly” (https://wc a.harvard.edu/publications/time-di erent-eight-centuries- nancial-folly), Carmen Reinhart, the World Bank Group’s newly appointed chief economist (https://www.worldbank.org/en/news/press-release/2020/05/20/carmen-reinhart- appointed-as-world-bank-group-chief-economist), and her co-author, Kenneth Rogo , noted that “long spans of history catch sight of ‘rare’ events that are all too often forgotten, although they turn out to be far more common and similar that people seem to think.” This observation is apt in the context of COVID-19, which illustrates a collective failure to prepare adequately for outbreaks of infectious diseases. As we saw in West Africa with Ebola, with the Zika virus in Brazil and other countries, with SARS in East Asia and Canada, and with avian influenza globally, novel viruses can spread quickly across borders and wreak havoc on unsuspecting populations, countries, and regions. The challenge is continuing to grow with the increased movement of goods, services, and people across the world. https://blogs.worldbank.org/health/have-south-and-central-america-become-new-coronavirus-covid-19-epicenter 6/11 1/12/2021 Have South and Central America become the new coronavirus (COVID-19) epicenter? Learning from what did or didn’t work well in past health crises will help countries in rapidly detecting and responding to future infectious disease outbreaks. (https://twitter.com/intent/tweet? text=Learning+from+what+did+or+didn%E2%80%99t+work+well+in+past+health+crises south-and-central-america-become-new-coronavirus-covid-19-epicenter/? cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank)Rebuilding better and sustaining essential health services for all is a global public good and should be a priority. Indeed, the COVID-19 pandemic should serve as a catalyst for institutional reform and for improving nancing to boost the capacity and performance of health systems. (https://twitter.com/intent/tweet?text=the+COVID- 19+pandemic+should+serve+as+a+catalyst+for+institutional+reform+and+for+improvin south-and-central-america-become-new-coronavirus-covid-19-epicenter/? cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) Now, more than ever, countries need to collaborate across sectors to reduce social and economic vulnerabilities. We must address not just the symptoms of ill health, but the root causes of disease and premature mortality. (https://twitter.com/intent/tweet? text=We+must+address+not+just+the+symptoms+of+ill+health%2C+but+the+root+cau south-and-central-america-become-new-coronavirus-covid-19-epicenter/? cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) HEALTH (/SEARCH?F[0]=TOPIC:297&F[1]=LANGUAGE:EN), BRAZIL (/SEARCH?F[0]=COUNTRIES:60&F[1]=LANGUAGE:EN), LATIN AMERICA & CARIBBEAN (/SEARCH?F[0]=REGIONS:277&F[1]=LANGUAGE:EN), COVID-19 (CORONAVIRUS) (/SEARCH? F[0]=SERIES:881&F[1]=LANGUAGE:EN) Authors (/team/patricio-v-marquez) (/team/patricio-v-marquez) P tricio V. M rqu (/t m/p tricio-v-m rqu ) https://blogs.worldbank.org/health/have-south-and-central-america-become-new-coronavirus-covid-19-epicenter 7/11 1/12/2021 Tobacco use and coronavirus (COVID-19): A deadly but preventable association Learn how the World Bank Group is helping countries with COVID-19 (coronavirus). Find Out Publish d on Voic s (/voic s) Tob cco us nd coron virus (COVID- 19): A d dl but pr v nt bl ssoci tion PATRICIO V. MARQUEZ (/TEAM/PATRICIO-V-MARQUEZ) | MAY 27, 2020 This page in: English Initial evidence suggests smoking is also a risk factor for COVID-19, with smokers having 1.91 times the odds of progression in COVID-19 severity compared to non-smokers. Photo: © ilkercelik/shutterstock https://blogs.worldbank.org/voices/tobacco-use-and-coronavirus-covid-19-deadly-preventable-association 1/7 1/12/2021 Tobacco use and coronavirus (COVID-19): A deadly but preventable association As we mark World No Tobacco Day on May 31, let’s consider the impact of tobacco use on coronavirus (COVID-19) outcomes. (https://twitter.com/intent/tweet? text=As+we+mark+World+No+Tobacco+Day+on+May+31%2C+let%E2%80%99s+conside 19%29+outcomes.&url=https://blogs.worldbank.org/voices/tobacco-use-and- coronavirus-covid-19-deadly-preventable-association/? cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) The virus has infected more than 5.5 million people in 188 countries and territories (https://coronavirus.jhu.edu/map.html), killing more than 350,000. Tobacco use is causally linked (https://www.surgeongeneral.gov/library/reports/50- years-of-progress/full-report.pdf) to diseases of nearly all organs of the body. Studies (https://www.nejm.org/doi/full/10.1056/NEJMra1308383) in various countries have found that middle-aged smokers have two to three times the mortality rate of non- smokers of similar age, reducing lifespan by an average of 10 years. Smoking and e- cigarette use increase the risk and severity of pulmonary infections because of damage to upper airways, lung in ammation, and reduced lung and immune function. (https://twitter.com/intent/tweet?text=Smoking+and+e- cigarette+use+increase+the+risk+and+severity+of+pulmonary+infections+because+of+ use-and-coronavirus-covid-19-deadly-preventable-association/? cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) It shouldn’t surprise us, then, that initial evidence (https://academic.oup.com/ntr/advance-article/doi/10.1093/ntr/ntaa082/5835834) suggests smoking is also a risk factor for COVID-19, with smokers having 1.91 times the odds of progression in COVID-19 severity compared to non-smokers. (https://twitter.com/intent/tweet?text=smoking+is+also+a+risk+factor+for+COVID- 19%2C+with+smokers+having+1.91+times+the+odds+of+progression+in+COVID- 19+severity+compared+to+non- smokers.&url=https://blogs.worldbank.org/voices/tobacco-use-and-coronavirus- covid-19-deadly-preventable-association/? https://blogs.worldbank.org/voices/tobacco-use-and-coronavirus-covid-19-deadly-preventable-association 2/7 1/12/2021 Tobacco use and coronavirus (COVID-19): A deadly but preventable association id=10.1371/journal.pone.0233147) showing that infection was associated with substantially higher severity and mortality rates in patients with chronic obstructive pulmonary disease (COPD) and among current smokers. M n r t hi h r risk of COVID-19 pro r ssion Data from China, the rst country to be a ected, provides insights into the biology, epidemiology, and clinical characteristics of COVID-19. The sex distribution of a ected patients shows a male predominance of cases. Chinese researchers reported (https://www.nejm.org/doi/full/10.1056/NEJMoa2002032? query=recirc_mostViewed_railB_article) in the New England Journal of Medicine that 58.1% of patients across 30 provinces were male. Also, among the initial 425 cases that occurred in Wuhan, 56% were male. Moreover, an article (https://jamanetwork.com/journals/jama/fullarticle/2762510) published at the Journal of the American Medical Association noted that death rates among infected men, particularly in their late 40s and older, have exceeded those among women. In previous outbreaks of coronaviruses, such as SARS and MERS, men were also disproportionally a ected. In Hong Kong in 2003, researchers found (https://jamanetwork.com/journals/jama/fullarticle/2762510) that men with SARS had a 50 percent higher risk of death than women. Wh t xpl ins this discr p nc ? https://blogs.worldbank.org/voices/tobacco-use-and-coronavirus-covid-19-deadly-preventable-association 3/7 1/12/2021 Tobacco use and coronavirus (COVID-19): A deadly but preventable association A higher prevalence of smoking among men, often resulting in compromised lung function, may help explain (https://jamanetwork.com/journals/jama/fullarticle/2762510) their higher COVID-19 fatality rate. Tobacco use also contributes to the onset of co-occurring conditions such as cardiovascular diseases, lung cancer, COPD, and diabetes. These are more prevalent among males and also increase the risk of disease severity and death among COVID- 19 patients. (https://www.cdc.gov/coronavirus/2019-ncov/need-extra- precautions/people-at-higher-risk.html) Data presented in the New England Journal of Medicine article further illustrates the impact that smoking has on COVID-19 progression and mortality in China: Among those severely a ected by the disease, 16.9% were current smokers and 5.2% former smokers. Among patients who were admitted to an intensive care unit, put on ventilation, or died, 25.8% were current smokers and 7.6% were former smokers. Data from Italy (https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2764369) similarly shows that a high proportion of COVID-19 patients had a history of smoking and high rates of COPD and heart disease. Researchers in Indonesia (https://www.channelnewsasia.com/news/asia/covid-19-fatality-rate-highest-asia- indonesia-12669500) have also found that the high prevalence of smoking among men (one of the world’s highest) is contributing to the high COVID-19 fatality rate in the country. Th pid mic of tob cco us in Chin China has the largest smoking population in the world, with around 316 million adult smokers representing nearly one-third of smokers and 40% of tobacco consumption globally. While the prevalence of smoking in women is relatively low at 1.9%, an estimated 48.4% (https://data.worldbank.org/indicator/SH.PRV.SMOK.MA? view=chart) of men are smokers. In 2010, an estimated 1.2 million premature deaths were attributable to smoking in China, and the three leading causes of death (stroke, heart disease, and COPD) were linked to tobacco use. A recent study (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6546632/pdf/tlcr-08-S1-S21.pdf) https://blogs.worldbank.org/voices/tobacco-use-and-coronavirus-covid-19-deadly-preventable-association 4/7 1/12/2021 Tobacco use and coronavirus (COVID-19): A deadly but preventable association also nds China in the midst of a lung cancer epidemic on an unprecedented scale, driven largely by tobacco use and accounting for 21.7% of the country’s total cancer mortality in 2015. How do s smokin ff ct lun h lth nd COVID-19 risk? As explained in the 2004 U.S. Surgeon General Report (https://www.ncbi.nlm.nih.gov/books/NBK44695/): “Toxins in tobacco smoke harm the body from the moment they enter through the mouth and nose. They damage tissue and cells all the way to the lungs. When cigarette smoke is inhaled, chemicals from the smoke are absorbed in the lungs. As a result, smoking causes lung diseases… makes chronic lung diseases more severe; and increases the risk for respiratory infections…. Although the lung has ways to protect itself from injury by inhaled agents, these defenses are overwhelmed when cigarette smoke is inhaled repeatedly over time. After years of exposure to cigarette smoke, lung tissue becomes scarred, loses its elasticity, and can no longer exchange air e ciently.” There is su cient evidence to infer a causal relationship between smoking and acute respiratory illnesses, including pneumonia. (https://twitter.com/intent/tweet? text=There+is+su cient+evidence+to+infer+a+causal+relationship+between+smoking + use-and-coronavirus-covid-19-deadly-preventable-association/? cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) Not only is smoking the predominant underlying cause, but it might increase the frequency or severity of infections. For example, a recent study (https://journals.lww.com/epidem/Abstract/2019/05000/Smoking_and_In uenza_associ showed that smoking was consistently associated with a higher risk of hospital admission for in uenza. Researchers (https://www.atsjournals.org/doi/10.1164/rccm.202003-0693LE) have also suggested that it could cause an increase in the ACE2 protein in the lungs, the molecule that the coronavirus uses to infect human cells, facilitating viral dissemination and possibly resulting in a higher rate of morbidity in COVID-19 patients. Wh t to do? Besides monitoring smoking and e-cigarette use, governments have an obligation to address smoking in their strategies to contain and mitigate the impact of COVID-19. https://blogs.worldbank.org/voices/tobacco-use-and-coronavirus-covid-19-deadly-preventable-association 5/7 1/12/2021 Tobacco use and coronavirus (COVID-19): A deadly but preventable association 19.&url=https://blogs.worldbank.org/voices/tobacco-use-and-coronavirus-covid-19- deadly-preventable-association/? cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) The most cost-e ective policy measure (http://documents.worldbank.org/curated/en/491661505803109617/Main- report) for tobacco control is taxation, so governments must act boldly and swiftly to raise taxes on cigarettes and e-cigarettes. This has been shown to reduce and prevent tobacco use, particularly among youth, and hence to improve health and reduce the risk of premature mortality. Taxation would also help to expand the tax base and mobilize additional public revenue for economic recovery initiatives after the pandemic subsides. RELATED The World Bank Group and COVID-19 (https://www.worldbank.org/en/who-we- are/news/coronavirus-covid19) GENDER (/SEARCH?F[0]=TOPIC:295&F[1]=LANGUAGE:EN), HEALTH (/SEARCH?F[0]=TOPIC:297&F[1]=LANGUAGE:EN), CHINA (/SEARCH?F[0]=COUNTRIES:74&F[1]=LANGUAGE:EN), HONG KONG SAR (/SEARCH? F[0]=COUNTRIES:127&F[1]=LANGUAGE:EN), THE WORLD REGION (/SEARCH?F[0]=REGIONS:280&F[1]=LANGUAGE:EN), COVID-19 (CORONAVIRUS) (/SEARCH?F[0]=SERIES:881&F[1]=LANGUAGE:EN) Authors (/team/patricio-v-marquez) (/team/patricio-v-marquez) P tricio V. M rqu (/t m/p tricio-v-m rqu ) Senior Associate, Johns Hopkins University Bloomberg School of Public Health MORE BLOGS BY PATRICIO (/TEAM/PATRICIO-V-MARQUEZ) x This site uses cookies to optimize functionality and give you the best possible experience. If you continue to navigate this website beyond this page, cookies will be placed on your browser. To learn more about cookies, click here. (https://www.worldbank.org/en/about/legal/privacy-notice) https://blogs.worldbank.org/voices/tobacco-use-and-coronavirus-covid-19-deadly-preventable-association 6/7 1/12/2021 Social distancing in the time of COVID-19 in Latin America and the Caribbean: Costs and Benefits | Patricio V. Marquez Social distancing in the time of COVID-19 in Latin America and the Caribbean: Costs and Bene ts Submitted by Patricio V. Marquez on Thu, 05/14/2020 - 07 37 PM Social distancing in the time of COVID-19 in Latin America and the Caribbean: Costs and Bene ts Posted by Patricio V. Marquez on Thu, 05/14/2020 - 07 37 PM Patricio V. Marquez, Santiago Herrera, and Luigi Butron Calderon May 14, 2020 Since December 2019, following the diagnosis of the initial cases in Wuhan, Hubei Province, China, the number of the coronavirus disease (COVID-19) cases outside China increased exponentially. As of May 14, 2020, the global pandemic has resulted in over 4.4 million con rmed cases and 301,370 con rmed deaths in 188 countries/regions (Johns Hopkins University Coronavirus Resource Center & Medicine 2020). Data from WHO show that 26.4 percent of the total 1.8 million con rmed cases and 26 percent of the total 109,121 con rmed deaths in the Americas are from countries in Latin America and the Caribbean (LAC)--the bulk of con rmed cases and deaths are from the United States (WHO 2020). Limiting face-to-face contact with others is the best way to reduce the spread of COVID-19 (CDC 2020). As such, social distancing is one of the best tools to avoid being exposed to this virus and slowing its spread locally, within countries, and across the world. People are reminded to stay at least 6 feet away from other people, not to gather in groups, stay out of crowded places, and avoid mass gatherings. Social distancing is especially important for people who are at higher risk (https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher- risk.html) for severe illness from COVID-19. pvmarquez.com/socialdistancing 1/7 1/12/2021 Social distancing in the time of COVID-19 in Latin America and the Caribbean: Costs and Benefits | Patricio V. Marquez Contrary to what some people believe, the practice of “physical and social distancing” is not something new; it has been around for centuries as a common public health tool to control the spread of infectious pathogens into the population. Social Distancing Measures are Centuries Old The history of public health in LAC offers multiple examples of the use of this tool. Since colonial times, outbreaks of disease were common in these countries, largely the result of maritime trade and export of agricultural products and minerals that helped integrate the countries in this region into the world economy. The smallpox epidemic in Hispaniola (now the Dominican Republic and Haiti), registered as the rst one in the colonial period, spread to neighboring islands and countries, leaving a toll of thousands of victims. In the sixteenth and following Centuries, epidemics of different kinds made devastating sweeps across the Americas. As the spread of disease largely re ected the maritime basis for trade among the colonies, and between the colonies and mercantile powers, such as Spain and Portugal, the principles of isolation and con nement (“social distancing”) followed in Europe to control disease outbreaks were also applied in the region. In practice, beginning in Hispaniola in 1519, in accordance with the 1423 Venetian quarantine control system, measures to cope with epidemics centered on the detention of ships and the isolation of their crews and passengers outside the harbors until suf cient time had elapsed without the outbreak of “pestilences.” The latter years of the 19th Century and the early 20th Century saw various attempts by the Latin American and Caribbean countries and the United States to adopt uniform quarantine regulations at different international conferences, under the aegis of the newly established Pan American Sanitary Bureau in 1902 (now PAHO/WHO). These sought to remove barriers to steam navigation and to codify new preventive measures into specific health legislation and programs based on the great microbiological discoveries of Pasteur, Koch, and Klebs that had revolutionized public health practice in Europe. Social Distancing in the Times of COVID-19 We should not be surprised, therefore, that in the absence of a vaccine or known therapies for COVID-19, and due to low testing capacity and ability to do contact-tracing, governments in LAC countries as elsewhere have been forced to impose once again strict social distancing measures to contain and mitigate the impact of the corona virus. As such, the timing and severity of social distancing measures is key in containing the COVID-19 pandemic. The graphs that we have prepared below illustrate how this has happened in LAC, using the Stringency Index developed by the University of Oxford Coronavirus Government Response Tracker team, to capture variation in containment and closure policies (Petherick, Kira, Angrist, Hale, Phillips, and Webster 2020). In general, government responses have become more stringent over the course of the outbreak, and it should be expected that the stringency of response measures broadly tracks the spread of the disease. However, variation can be seen across countries. The rate at which such measures are adopted plays a critical role in stemming the infection. In the country-speci c graphs in Figure 1, the speed of the policy response is proxied by the number of days after the 100th case is con rmed (horizontal axis, with zero representing the day the 100th case was reported). In LAC, countries such as Argentina, Colombia, Costa Rica, El Salvador, and Paraguay, are good examples of preemptive policy action, while Mexico and Brazil illustrate a delayed social-distancing response. As a comparison with other regions, Figure 1 shows that South Korea’s stringency index was moving up signi cantly before reaching the 100th case, while the UK ramped it up after that. Figure 1. Reported number of con rmed cases and stringency index (con rmed cases in log scale), by country pvmarquez.com/socialdistancing 2/7 1/12/2021 Social distancing in the time of COVID-19 in Latin America and the Caribbean: Costs and Benefits | Patricio V. Marquez Economic Cost of the COVID-19 Pandemic The COVID-19 pandemic is in icting high human costs worldwide. Transmissibility and severity are the two most critical factors that determine the effect of the pandemic. Protecting lives and allowing health care systems to cope have required isolation, lockdowns, and widespread closures to slow the spread of the coronavirus. The health crisis is therefore having a severe impact on economic activity. IMF projections indicate that the global economy is expected to contract sharply by –3 percent in 2020, much worse than during the 2008–09 nancial crisis (IMF 2020). In LAC, social distancing has reduced mobility among citizens and impacted economic activity. Individual mobility is measured by Google data based on the history of cell phone locations to reveal if citizens have reduced their mobility. Using the individual mobility data as an indicator of economic activity, it can be inferred that mobility has decreased considerably across all the LAC countries listed in Figure 2 below. The combined index of Google mobility is negatively correlated with the stringency index of social distancing (i.e., the relationship between these two variables shows that as social distancing measures became more stringent, mobility decreased) (Figure 3). Overall, economic activity in LAC is faltering. IMF projections point to severe economic slowdowns or outright contractions in LAC: a negative growth forecast for the region as a whole of –5.2 percent; with Brazil’s growth forecast at –5.3 percent and Mexico’s at –6.6 percent (IMF 2020). pvmarquez.com/socialdistancing 3/7 1/12/2021 Social distancing in the time of COVID-19 in Latin America and the Caribbean: Costs and Benefits | Patricio V. Marquez While the economic cost of the pandemic is signi cant, it is important to highlight that social distancing should be interpreted as the price society must pay due to imperfect information about which individuals carry the virus and the lack of adequate health care systems to manage the patient peak loads. Hence, countries that have ample testing and contact-tracing capacity as well as ample health-care facilities, can afford less restrictive social distancing. As shown in Figure 4 below, LAC countries have very low testing compared to the rest of the world, therefore, they are being forced to adopt more stringent social distancing measures. The pandemic is also hitting the region after a long economic stagnation, which led several countries to slash health care budgets, which further aggravated lack of or limited preparedness. Excess Deaths Better Gauges the COVID-19 Toll Although worldwide, 3.4 percent of the people con rmed as having been infected have died, WHO has been careful not to describe this gure as a case fatality rate or death rate. This is because during an evolving epidemic it can be misleading to look simply at the estimate of deaths divided by cases to date. Given the large number of asymptomatic cases, the denominator cannot be estimated without widespread testing. And there is substantial evidence that the number of deaths is underreported, as case fatality perhaps only re ects deaths in health facilities. In addition, to better gauge the pandemic’s toll, one also needs to include not only deaths from COVID-19, but also those from other causes, including people who could not be treated as hospitals became overwhelmed with patients, or those who did not seek treatment because they were afraid of being infected with the coronavirus. For instance, in Ecuador the number of deaths reported in the period March-April 2020 exceeded the normally reported number for those months by more than 8,000 cases, while the COVID19 reported deaths were only 1,561, suggesting signi cant underreporting (Table 1). In Guayaquil, a port city in Ecuador, the sudden spike in fatalities in pvmarquez.com/socialdistancing 4/7 1/12/2021 Social distancing in the time of COVID-19 in Latin America and the Caribbean: Costs and Benefits | Patricio V. Marquez April 2020 was comparable to what New York City experienced during its worst month: more than ve times the number of people died than in previous years (Kurmanaev, Andreoni, Casado, and Taj 2020). From an economic perspective, it should be clear that excess mortality and morbidity across population groups have the potential to undermine and reverse human capital development achieved in countries in recent decades. Bene ts of Social Distancing Measures COVID-19 infections have been growing exponentially in many countries across the world, with the doubling time remaining between 2 and 4 days in several countries like the United States. This exponential growth is fueled by the presence of three conditions: (i) there is at least one infected person in the population pool; (ii) regular contact between infected and uninfected members of the population occurs; and (iii) there are large numbers of uninfected potential hosts among the population. Exponential growth is so powerful, not because it is necessarily fast, but because it is relentless (Siegel 2020). Without introducing a factor to suppress it, such as stringent social distancing measures, exponential growth becomes a near impossible challenge, because it doubles its presence in the population in a given amount of time. Hence, it should be clear that while social distancing measures are disrupting economic activity, they help prevent the spread of the corona virus and save lives, tilting the cost-bene t analysis in their favor (Thunstrom, et al. 2020). We used recent literature to estimate the impact of isolation and contact-tracing on the number of infections in the course of one month, taking into account that the number of lives saved will depend on the fatality rate that varies by country. The estimation of the number of potential infections is based on key parameter assumptions: a) the degree of contagiousness, measured by the parameter Ro; b) the extent of social isolation; c) the ability to do contact tracing, and d) the speed with which the self-isolation takes place after the symptoms manifest. The degree of contagiousness changes over time as shown by Arroyo et al. (2020). Hence, we assume different values for the parameter, based on the LAC data. The degree of isolation can uctuate from zero (ignorance of any restrictions) to 100% (complete isolation going out to only to purchase groceries). Using an online tool that implements the Hellwell et al. model (IFLscience 2020), we estimate the number of lives saved, based on different fatality rates, from 3.4% (cited by WHO) to 5% (a common rate in LAC). These back-of-the envelope estimations show that the bene ts--the number of lives saved--increase with stringency and with assumptions of infectiousness (Tables 2 and 3). pvmarquez.com/socialdistancing 5/7 1/12/2021 Social distancing in the time of COVID-19 in Latin America and the Caribbean: Costs and Benefits | Patricio V. Marquez The level of contagiousness, which changes over time (Arroyo et. al. 2020), is not completely exogenous, as it is correlated with the stringency social distancing as measured by the stringency index of the Oxford COVID-19 Government Response Tracker. There is a high negative correlation between the two independent sources of data. In fact, the purpose of the social distancing measures is to reduce the value of Ro, and the high negative correlation indicates that the measures have been effective. What Next? It should be clear to all that in the absence of vaccines and cures, social distancing measures are a critical tool to help suppress transmission of the coronavirus below the basic reproduction number of 1.0 (Ro), which is necessary to rapidly reduce case incidence, keep cases to low levels, and maintain that situation over time. As warned by different international experts, if countries reopen their economies too soon without ensuring that they have in place critical testing capacity, ability to trace the contacts of those infected, and adequately prepared medical care services to deal with a surge of severe cases in the event of a resurgence, the consequences would be dire. With deaths now declining, governments are trying to restart their economies, by gradually releasing the lockdown. But, local authorities’ fear of a new outbreak is pushing back central governments’ reopening decisions-- in Ecuador, for example, only two of the country’s 221 cities have moved toward relaxing the quarantine nearly a week later after the central government announced the reopening. As observed by leading global experts, the COVID-19 pandemic is a stark remainder of the ongoing challenge of emerging and reemerging infectious diseases and the need for constant disease surveillance, prompt diagnosis, and robust research to understand the basic biology of new organisms and our susceptibilities to them, as well as to develop effective countermeasures to control them (Fauci, Lane, Clifford, and Red eld 2020). Looking into the future, the global spread of COVID-19 clearly signals the need, hopefully once and for all, for building and maintaining strong and sustainable public health and medical institutions and systems, and an effective cross sectoral interface between environment, veterinary and public health services to anticipate, prevent, and control the emergence of new infectious pathogens of animal origin, the resurgence of known infectious diseases, and the ominous threat of anti-microbial resistance. This task is of priority importance where health systems are weaker, living conditions often more overcrowded, and populations most vulnerable. If this is not done, as the COVID-19 pandemic is demonstrating now, the risk posed by novel infectious diseases that can emerge in any part of the world at any time, causing massive social and economic disruptions, will continue to threaten the entire global community. Note: *The Stringency Index collects publicly available information on 17 indicators of government responses. Eight of the policy indicators record information on containment and closure policies, such as school closures and restrictions in movement. Four of the indicators record economic policies, such as income support to citizens or provision of foreign aid, and ve indicators record health system policies such as the COVID-19 testing regime or emergency investments into healthcare. The index has a numeric value ranging from 0 (less stringent) to 100 (more stringent). https://www.bsg.ox.ac.uk/research/research-projects/coronavirus-government-response-tracker (https://www.bsg.ox.ac.uk/research/research-projects/coronavirus-government-response-tracker). Source of Picture: Image Covid-19 | New Scientist About the authors: Patricio V. Marquez, Former Lead Public Health Specialist, World Bank Group, Santiago Herrera, Lead Economist, Macroeconomics, Trade and Investment, LAC Region, World Bank Group, and Luigi Butron Calderon, Research Assistant (consultant), Macroeconomics, Trade and Investment, LAC Region, World Bank Group This note is a product of work done by the authors, and the ndings, interpretations, and conclusions expressed in this post do not necessarily re ect the views of the World Bank Group, the Executive Directors of the World Bank Group or the governments they represent. pvmarquez.com/socialdistancing 6/7 1/12/2021 Social distancing in the time of COVID-19 in Latin America and the Caribbean: Costs and Benefits | Patricio V. Marquez Sources Arroyo Marioli, F, Bullano, F, and Rondon-Moreno, C. 2020. “Dynamics of Transmi… (https://www.medrxiv.org/content/10.1101/2020.04.19.20071886v1) Blavatnik School of Government, University of Oxford. University of Oxford Cor… (https://www.bsg.ox.ac.uk/research/research-projects/coronavirus-government-response-tracker) Centers for Disease Control and Prevention (CDC). 2020. “Coronavirus Disease 2… (https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html) IFLscience. “Calculator Shows How Your Social Distancing Saves People.” Mar 30… (https://www.i science.com/health-and-medicine/online-calculator-shows-how-many-lives-your- socialdistancing-may-save/) Fauci, AS, Lane, Clifford, L, and Red eld, RR. 2020. “Covid-19---Navigating th… (https://www.nejm.org/doi/full/10.1056/NEJMe2002387?query%3DRP=) International Monetary Fund. 2020. “World Economic Outlook, April 2020 The Gr… (https://www.imf.org/en/Publications/WEO/Issues/2020/04/14/weo-april-2020) Hellewell, J, Abbott, S, Gimma, A, Bosse, NI, Jarvis, CI, Russell, TW, Munday,… (https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30074-7/fulltext) Johns Hopkins University & Medicine Coronavirus Resource Center. “COVID-19 Map”… (https://coronavirus.jhu.edu/map.html) Kurmanaev, A, Andreoni, M, Casado, L, and Taj, M. 2020. “Latin America’s Outbr… (https://www.nytimes.com/2020/05/12/world/americas/latin-america-virus-death.html? referringSource=articleShare) Petherick, A, Kira, B, Angrist, N, Hale, T, Phillips, T, and Webster, S. 2020… (https://www.bsg.ox.ac.uk/research/publications/variation-government-responses-covid-19) Siegel, S. 2020. “Why 'Exponential Growth' Is So Scary for the COVID-19 Corona… (https://www.forbes.com/sites/startswithabang/2020/03/17/why-exponential-growth-is-so-scary-for-the- covid-19-coronavirus/#744a71114e9b) ThunströmL, NewboldS, FinnoffD, AshworthM, ShogrenJF. The bene ts and costs of… (https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3561934) Weiss, RA, and McMichael, AJ. 2004. “Social and environmental risk factors in … (https://www.nature.com/articles/nm1150) WHO Coronavirus disease (COVID-19) Situation Report – 115 Data, May 14 2020 (https://www.who.int/docs/default- source/coronaviruse/situation-reports/20200514-covid-19-sitrep-115.pdf?sfvrsn=3fce8d3c_6) Image Covid-19 | New Scientist (https://www.bing.com/images/search? view=detailV2&ccid=3cwl5OI9&id=9658B910E1B8479D840DA78F754EE538D2F2C78F&thid=OIP.3cwl5OI9IgTFZdVCNB3e content/uploads/2020/02/11165812/c0481846-wuhan_novel_coronavirus_illustration- spl.jpg&exph=800&expw=1200&q=free%20covid- 19%20pictures&simid=607991704663294897&selectedindex=0&ajaxhist=0&vt=0&eim=1&sim=11) (https://twitter.com/pvmarquez1956) pvmarquez.com/socialdistancing 7/7 1/12/2021 Do BCG Vaccinated People Have Some Immunity Advantage Over Non-Vaccinated People? | Patricio V. Marquez Do BCG Vaccinated People Have Some Immunity Advantage Over Non- Vaccinated People? Submitted by Patricio V. Marquez on Tue, 04/21/2020 - 03 24 PM Do BCG Vaccinated People Have Some Immunity Advantage Over Non- Vaccinated People? Posted by Patricio V. Marquez on Tue, 04/21/2020 - 03 24 PM Second Installment of Preliminary Interrogation by Patricio V. Marquez, Albert Figueras, Allison Ross, Giovanni S. Marquez, and Jaime Bayona www.pvmarquez.com/bcg 1/9 1/12/2021 Do BCG Vaccinated People Have Some Immunity Advantage Over Non-Vaccinated People? | Patricio V. Marquez “…government and municipal o cials were putting their heads together. So long as each individual doctor has come across only two or three cases, not one had thought of taking action. But it was merely a matter of adding up the gures and, once this had been done, the total was startling. In a very few days the number of cases had risen by leaps and bounds, and it became evident to all observers of this strange malady that a real epidemic had set in.” Albert Camus, The Plague, 1947 In this post, we build upon the preliminary interrogation described in our previous post “Searching for Evidence in the COVID-19 Era: The BCG Case” (“Searching for Evidence in the COVID-19 Era: The BCG Case”, April 18, 2020, http://pvmarquez.com/bcgcovid19 (http://pvmarquez.com/bcgcovid19)). The objective in this post is to present the results of a rapid statistical analysis that we conducted to assess a hypothesis that has been put forward by some researchers about the association between COVID-19 reported deaths and Bacillus Calmette–Guérin (BCG) vaccination policy in countries. The BCG vaccine, rst administered to a human in 1921, is one of the most widely used of all current vaccines, covering >80% of neonates and infants in countries where it is part of the national childhood immunization program. The BCG vaccine has a documented protective effect against meningitis and disseminated TB in children (disseminated TB is a contagious mycobacterial infection in which mycobacteria have spread from the lungs to other parts of the body through the blood or lymph system) (WHO 2020). Overall, BCG vaccine ef cacy is estimated to be about 51 percent in preventing any TB disease and up to 78 percent in protecting newborns from disseminated or meningeal TB (Canadian Immunization Guide 2014). The BCG vaccine is also of proven ef cacy in the control of leprosy. The duration of BCG vaccine protection is not well-established, although one study demonstrated a protective effect for as long as 60 years (Nguipdop-Djomo, Heldal, Cunha Rodrigues, Abubakar, and Mangtani 2015). www.pvmarquez.com/bcg 2/9 1/12/2021 Do BCG Vaccinated People Have Some Immunity Advantage Over Non-Vaccinated People? | Patricio V. Marquez The BCG vaccine, however, will not prevent the development of active TB in individuals who are already infected with M. tuberculosis. If processes for early identi cation and treatment of latent TB infection are not available, it is recommended that BCG vaccine may be considered for workers (such as health care workers, laboratory workers, prison workers and those working in shelters for the homeless) who may be repeatedly exposed to persons with untreated, inadequately treated or drug-resistant active TB, in conditions where protective measures against infection are not feasible (Canadian Immunization Guide 2014). BCG vaccination policies vary across countries. Countries with high TB prevalence tend to have universal BCG vaccination policies, while those with lower TB burden tend to vaccinate only high-risk groups (SAGE Working Group on BCG Vaccines and WHO Secretariat 2017). Among 180 countries with available data, 157 countries recommend universal BCG vaccination, while 23 countries have either stopped BCG vaccination (due to a reduction in TB incidence), or never recommended mass BCG immunization and instead favored selective vaccination of “at risk” groups (Zwerling, Behr, Verma, Brewer, Menzies, Pai 2011). For example, BCG vaccination in the latter group of countries may be considered in exceptional circumstances, such as for infants in high risk communities, for persons at high risk of repeated exposure, for certain long-term travelers to high prevalence countries, and in infants born to mothers with infectious TB disease. As noted in our previous post, different studies involving the BCG vaccine have found that it provides heterologous or "nonspeci c immunological effects" by altering immune response to pathogens other than Mycobacterium tuberculosis. The BCG vaccine has been found to reduce non-TB respiratory infection, sepsis, and all-cause mortality among young children, and it may prevent upper respiratory tract infections among the www.pvmarquez.com/bcg 3/9 1/12/2021 Do BCG Vaccinated People Have Some Immunity Advantage Over Non-Vaccinated People? | Patricio V. Marquez elderly. Although the mechanism, magnitude, and duration of these nonspeci c effects remain uncertain, some researchers speculate that BCG vaccination could moderate the severity of COVID-19 infections. Results of an Additional Analysis Data and Information Used. Our team conducted an initial, limited, analysis of the available data and information. Data on country population size were obtained from the World Bank Data Bank; data on COVID-19 deaths were from the Johns Hopkins University Center for Systems Science and Engineering (CSSE) database, and information on BCG vaccination policies, by country, was from the BCG World Atlas. COVID-19 deaths per capita was calculated using Johns Hopkins CSSE death counts and World Bank population estimates; the data were then logarithmically transformed to ensure normality. Summary of Results An analysis of variance (ANOVA), including both small states and low- income countries, was conducted. Countries were divided into four groups according to four different types of BCG vaccination policy (no policy at all, universal BCG vaccination policy, previous BCG vaccination policy, and policy to vaccinate certain high-risk groups). The analysis showed that there is a statistically signi cant difference in the mean number of deaths per 1,000 people between country groups (p < .01). A second ANOVA was conducted excluding small states and low-income countries. Countries were also divided into four groups according to the four different types of BCG vaccination policy (no policy at all, universal BCG vaccination policy, previous BCG vaccination policy, and policy to vaccinate certain high-risk groups). The analysis showed that there is a statistically signi cant difference in the mean number of deaths per 1,000 people between country groups (p < .01). www.pvmarquez.com/bcg 4/9 1/12/2021 Do BCG Vaccinated People Have Some Immunity Advantage Over Non-Vaccinated People? | Patricio V. Marquez A two-sample t-test assuming equal variances was conducted, testing the difference in mean COVID-19 deaths per 1,000 population between countries with a universal BCG vaccination policy and countries without it (including no policy, only high-risk groups, and previous universal policy) was conducted. The test included small states and low-income countries and showed that there is a statistically signi cant difference in the mean number of deaths per 1,000 people between the two groups (p < .01). Finally, another two-sample t-test assuming equal variances, testing the difference in mean COVID-19 deaths per 1,000 population between countries with a universal BCG vaccination policy and countries without (including no policy, only high-risk groups, and previous universal policy) was conducted. In this case, small states and low-income countries were excluded. The results similarly showed that there is a statistically signi cant difference in the mean number of deaths per 1,000 people between the two groups (p < .01). In conclusion, the results of our initial analyses show statistically signi cant correlations, both when small states and low-income countries were included and when they were excluded from the analyses. Despite the interesting results that we obtained, substantial doubts arise and should be taken into account when further assessing the plausibility of the hypothesis: At present, there are a lot of questions about how different countries are reporting COVID-19 deaths. It seems that some countries only count deaths occurring in hospitals but not those happening in nursing homes, prisons, or at home (because testing was not done to con rm the diagnosis). Moreover, large number of countries are facing supply-side challenges related to the availability of test kits for case detection and contact tracing. The latter may have a confounding effect on the observed results. www.pvmarquez.com/bcg 5/9 1/12/2021 Do BCG Vaccinated People Have Some Immunity Advantage Over Non-Vaccinated People? | Patricio V. Marquez BCG vaccination policies and practices vary across time and countries. For example, it is possible that a country with an 'only high-risk group' vaccination policy at present had a 'universal vaccination policy' up to 1960. In cases like this, there are differences in previous BCG vaccination coverage according to age groups. A proper analysis should take into account these inter- and intra-country differences. In addition, the use of different BCG vaccine strains in different countries and even within the same countries may also have a confounding effect. Currently, ve main strains account for more than 90 percent of the vaccines in use worldwide with each strain possessing different characteristics, and there is no standardized production of BCG vaccine between manufacturers (WHO 2012). The role of additional factors that have not yet been assumed, investigated, or con rmed. For example, since the primary function of the respiratory system--to supply oxygen to all the parts of the body--is especially affected among COVID-19 infected individuals (probably because of multiple clotting in the lungs), does the decreased respiratory capacity observed among cigarette smokers play a major role in the clinical evolution of COVID-19 disease, increasing the risk of disease severity and death among COVID-19 infected individuals? As discussed on a previous post, cigarette smoking makes chronic lung diseases more severe and increases the risk for respiratory infections (“Does Tobacco Smoking Increases the Risk of Coronavirus Disease (Covid-19) Severity? The Case of China” of March 3, 2020, http://pvmarquez.com/Covid-19 (http://pvmarquez.com/Covid-19)). The Way Forward Many clinical trials with different drugs treat COVID-19 disease patients are currently being conducted in many countries. Antivirals (lopinavir/ritonavir, lopinavir), monoclonal antibodies (tocilizumab) and other agents affecting www.pvmarquez.com/bcg 6/9 1/12/2021 Do BCG Vaccinated People Have Some Immunity Advantage Over Non-Vaccinated People? | Patricio V. Marquez the immune response (hydroxychloroquine and chloroquine) are being tested. Different treatments are also being tested as preventive measures in non-positive patients. It should be clear, however, that research to nd an effective vaccine is one of the most promising ways to suppress the pandemic (not the present wave, but future waves that may happen). At this stage, it is crucial to try to understand sets of factors and their interactions, e.g., risk factors, protective factors, and infection periods. Within this framework, the BCG hypothesis could be useful. There is a plausible hypothesis: vaccinated people could show some immunity advantage over non-vaccinated people (based on previous studies on the nonspeci c effects of BCG on the immune response as described in our above-mentioned previous post of April 18, 2020). Conducting more accurate analyses, including evaluating differences in BCG vaccination among infected people, recovered patients, and positive but asymptomatic patients, should be of high interest, not only to understand how COVID-19 interacts with people but also to inform the development of a vaccine (or to understand potential failures or successes of future vaccines). Another avenue of analysis that may offer some clarity on this inquiry is related to the fact that some medical personnel working in develop countries, such as the United States (without BCG), are actually coming from low-and middle-income countries where BCG policy is in place. Hence, a question that may need to be analyzed is whether there are differences in terms of severity of COVID-19 disease among infected doctors and nurses based on the country of origin of medical personnel that emigrated and those who emigrated and are working in medical facilities in developed countries? www.pvmarquez.com/bcg 7/9 1/12/2021 Do BCG Vaccinated People Have Some Immunity Advantage Over Non-Vaccinated People? | Patricio V. Marquez At this point, it is crucial is to ensure that decisions taken on BCG vaccination are taken based on the available information for several reasons: First, because it takes several weeks to develop the alleged positives effects of BCG on immunity after vaccination (so, it would not be useful for the present wave). Second, because of the low availability of BCG vaccines and their low production rate (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5777639/). Third, and most important, because the hypothesis has to be tested with more appropriate epidemiological and clinical methods before a causal relationship can be ascertained. Sources Government of Canada. 2014. “Bacille Calmette-Guérin (BCG) vaccine: Canadian Im… (https://www.canada.ca/en/public- health/services/publications/healthy-living/canadian-immunization- guide-part-4-active-vaccines/page-2-bacille-calmette-guerin- vaccine.html) Nguipdop-Djomo, P, Heldal, E, Cunha Rodrigues, L, Abubakar, I, Mangtani, P. 20… (https://www.thelancet.com/journals/laninf/article/PIIS1473- 3099(15)00400-4/fulltext) WHO. 2020. “BCG vaccine”. (internet site). (http://www9.who.int/biologicals/areas/vaccines/bcg/en/) www.pvmarquez.com/bcg 8/9 1/12/2021 Searching for Evidence in the COVID-19 Era: The BCG Case | Patricio V. Marquez Searching for Evidence in the COVID-19 Era: The BCG Case Submitted by Patricio V. Marquez on Fri, 04/17/2020 - 10 41 PM Searching for Evidence in the COVID-19 Era: The BCG Case Posted by Patricio V. Marquez on Fri, 04/17/2020 - 10 41 PM A Preliminary Interrogation Conducted by Patricio V. Marquez [1], Albert Figueras [2],Allison Ross [3],Giovanni S. Marquez [4], and Jaime Bayona [5] “A pestilence is not a thing made to man’s measure; therefore, we tell ourselves that pestilence is a mere bogy of the mind, a bad dream that will pass away. But it does not always pass away and, from one bad dream to another, it is men who pass away, and the humanists rst of all, because they have not taken their precautions.” Albert Camus, The Plague. Vintage, 1947. “For the rst time in history, we face the risk of a global decline. But we are also the rst to enjoy the opportunity of learning quickly from developments in societies anywhere else in the world today, and from what has unfolded in societies at any time in the past.” Jared Diamond. Collapse. How societies choose to fail or succeed. Penguin, 2005. Across the world, the spread of the novel coronavirus disease (COVID-19) has been rapidly altering life as we know it. With more than 2.2 million reported cases and more than 150,000 deaths as of April 17, 2020 (Johns Hopkins Center for Systems Science and Engineering 2020), social distancing policies, including widespread lockdowns, have been adopted out of societal fear of the high transmissibility, often by asymptomatic people, and severity of a virus that transcends national boundaries. The global economy is experiencing an exceptional negative shock as a result of COVID-19 massive layoffs and unemployment, supply chain and market disruption directly affecting economic production, and the nancial impact on rms and nancial markets has been hard. All this on top of the severe negative impact on human capital, including lives, learning, basic well-being, and future productivity (World Bank/International Monetary Fund 2020). Still, despite its enormous health, social, and economic impact, much about the disease is currently unknown. www.pvmarquez.com/bcgcovid19 1/4 1/12/2021 Searching for Evidence in the COVID-19 Era: The BCG Case | Patricio V. Marquez Given the novelty of COVID-19 and its clinical manifestations (Fauci, Lane, Clifford, and Red eld, 2020), as well as the speed at which the pandemic is progressing, we are constantly learning and revising our understanding of the virus and how to contain and mitigate its spread and impact, and hoping for eventual suppression. The global scienti c community is conducting signi cant research into transmission methods, potential treatments, and vaccine candidates, resulting in a plethora of information, in some cases con icting, for the general public to sort through. One such nding has been the association between a country's COVID-19 reported cases and deaths and its Bacillus Calmette–Guérin (BCG) vaccination policy. BCG usually is given to newborns, protecting them especially against severe forms of TB (e.g., TB meningitis, disseminated TB). However, vaccination policies vary country to country. Countries with high TB prevalence tend to have universal BCG vaccination policies, while those with lower TB burden tend to vaccinate only high-risk groups (SAGE Working Group on BCG Vaccines and WHO Secretariat 2017). According to a preprint, ecological study* (Miller et al. 2020), countries without universal policies of BCG vaccination (e.g., Italy, United States) have been more severely affected by COVID-19 compared to countries with universal and long-standing BCG policies. It is also shown in this study that countries that have had a late start of universal BCG policy (e.g., Iran, 1984) have high COVID-19 mortality, consistent with the idea that BCG protects the vaccinated elderly population. The results of another ecological study not yet published also show that COVID-19-attributable mortality among BCG-using countries was 5.8 times lower than in non-BCG-using countries (Shet et al. 2020). Accordingly, the authors of both studies have hypothesized that BCG vaccination might offer some protection against COVID-19, reducing the severity of the disease. Data from another study not yet peer reviewed corroborates the observation that universal BCG vaccination has a protective effect on the course of COVID-19, probably preventing progression to severe disease and death (Dayal and Gupta 2020). Since its introduction in the 1930s, epidemiological studies have shown that BCG also protects against childhood mortality independent of its effect on TB. More speci cally, the studies involving the BCG vaccine have found that it provides heterologous or "nonspeci c immunological effects," altering immune response to pathogens other than Mycobacterium tuberculosis (Iglesias and Martin 2015). The ndings suggest that BCG at birth has bene cial nontargeted effects on general infant morbidity and mortality in low-income countries--a BCG scar is associated with better survival and 50 percent mortality reduction due to pneumonia in vaccinated children (Roth, Garly, Jensen, Nielsen, Aaby 2006). Besides reducing non-TB respiratory infection, other studies show that the BCG vaccine reduces sepsis, and all-cause mortality among young children (de Castro, Pardo- Seco, and Martinón-Torres 2015; Higgins, JPT, Soares-Weiser, K, López-López, JA, Kakourou, A, Chaplin, K, Christensen, H, et al. 2016). It is also shown that BCG prevents upper respiratory tract infections among the elderly (Wardhana, Sultana, Mandang, and Jim 2011). Although the mechanism, magnitude, and duration of these nonspeci c effects remain uncertain, a study showed that BCG induces adaptive or trained immunity and nonspeci c protection from infections through epigenetic reprogramming of innate immune cells (Kleinnijenhuis, Quintin, and Preijers 2012). The innate immune response in a person’s organism is initiated when cells of the innate immune system, including PMNs, monocytes, macrophages, and DCs, encounter pathogens. Some researchers now speculate that BCG vaccination could moderate the severity of COVID-19 infections (Dayal and Gupta 2020; Hegarty, Kamat, Za rakis, Dinardo 2020). www.pvmarquez.com/bcgcovid19 2/4 1/12/2021 Searching for Evidence in the COVID-19 Era: The BCG Case | Patricio V. Marquez While two of the above-mentioned ecological studies (Miller et al. 2020; Shet et al. 2020) observed an association between national vaccination policies and country-level deaths, it should be clear, however, that this relationship does not imply causation between the exposure and the disease. Uncontrolled confounding variables could instead explain the association, including the fact that low and middle-income countries tend to have both universal BCG policies and lower capacities to test for COVID-19. Additionally, it should be taken into account that many countries have changed their BCG policies in the past 50 years, so even within a country, immunization is not uniform (i.e., it can be different according to age). Given what we know now, BCG vaccinations cannot prevent COVID-19 infections or reduce their severity, but the association is worth evaluating in greater depth. Additional research could provide more accurate characterizations of the relationship between vaccination and disease occurrence, accounting for variables like population demographics, testing capacity, and epidemic timelines that affect national ecological studies. Two randomized control trials are currently underway in Australia and the Netherlands to evaluate whether BCG vaccination reduces COVID-19 incidence among healthcare workers (Murdoch Children’s Research Institute 2020; UMC Utrecht 2020). Perhaps the results of these trials will help provide much needed evidence on what works in the ght against the novel coronavirus, contributing with additional insights into the mechanisms of disease and host response. We should keep an eye on the outcome of these trials, while recognizing that rushing to promote novel treatments before evidence of their ef cacy and safety has been established can do public health more harm than good. Note. * Ecological studies are studies of risk-modifying factors on health or other outcomes based on populations de ned either geographically or temporally. The study by John Snow in 1984, regarding a cholera outbreak in London is considered the rst ecological study to solve a health issue. He used a map of deaths from cholera to determine that the source of the cholera was a pump on Broad Street. About the authors: [1] Consultant, World Bank Group (WBG) COVID-19 Global Emergency Response Program, and former Lead Public Health Specialist, WBG [2] Director, Fundació Institut Català de Farmacologia (Catalan Pharmacology Institute), a collaborating center of the Department of Clinical Pharmacology of the Hospital Vall d'Hebron, and associated center of the Department of Pharmacology, Therapeutics and Toxicology at the Autonomous University of Barcelona (UAB), and a WHO Collaborating Center for Research and Training in Pharmacoepidemiology. Barcelona, Spain [3] WBG Intern, and Graduate Student, Global Health Program, Georgetown University, Washington, D.C. [4] Former Technical O cer, PAHO/WHO, WHO AFRO, and WHO EMRO (Health Systems, Expanded Programme on Immunization and Health Emergencies in Barbados, USA, Haiti, Pakistan, and Nigeria) [5] Senior TB/Health Specialist, WBG Sources de Castro, MJ, Pardo-Seco, J, and Martinón-Torres, F. 2015. "Nonspeci c (Heter… (https://academic.oup.com/cid/article/60/11/1611/356084) Higgins, JPT, Soares-Weiser, K, López-López, JA, Kakourou, A, Chaplin, K, Chris… (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5063034/) Iglesias, M-J, and Martin, C. 2015. “Nonspecific Beneficial Effects of BCG Vacci… (https://academic.oup.com/cid/article/60/11/1620/356166) Johns Hopkins Center for Systems Science and Engineering (internet site). (https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6) Kleinnijenhuis, J, Quintin, J, Preijers, F, Joosten, LAB, Ifrim, DC, Saeed, … (https://doi.org/10.1073/pnas.1202870109) Miller, A, Reandelar, MS, Fasciglione, K, Roumenova, V, Li, Y, and Otazu, GH. … (https://www.medrxiv.org/content/10.1101/2020.03.24.20042937v1) www.pvmarquez.com/bcgcovid19 3/4 1/12/2021 Searching for Evidence in the COVID-19 Era: The BCG Case | Patricio V. Marquez Murdoch Childrens Research Institute. "BCG Vaccination to Protect Healthcare Wo… (https://clinicaltrials.gov/ct2/show/NCT04327206.) SAGE Working Group on BCG Vaccines and WHO Secretariat. 2017. "Report on BCG … (https://www.who.int/immunization/sage/meetings/2017/october/1_BCG_report_revised_version_online.pdf) Shet, A, Ray, D, Malavige, N, Santosham, M, Bar-Zeev, N. 2020. "Differential… (https://www.medrxiv.org/content/10.1101/2020.04.01.20049478v1) UMC Utrecht. "Reducing Health Care Workers Absenteeism in Covid-19 Pandemic Thr… (https://clinicaltrials.gov/ct2/show/NCT04328441) Wardhana, DEA, Sultana A, Mandang VV, Jim E. 2011. “The ef cacy of Bacillus Ca… (https://www.ncbi.nlm.nih.gov/pubmed/21979284) World Bank/International Monetary Fund. WB/IMF Spring Meetings 2020. “Develop… (https://www.worldbank.org/en/news/press-release/2020/04/17/world-bankimf-spring-meetings-2020- development-committee-communique) (https://twitter.com/pvmarquez1956) www.pvmarquez.com/bcgcovid19 4/4 1/12/2021 How to Prevent Jails and Prisons from Becoming New Hotspots for the Spread of COVID-19? | Patricio V. Marquez How to Prevent Jails and Prisons from Becoming New Hotspots for the Spread of COVID-19? Submitted by Patricio V. Marquez on Mon, 04/13/2020 - 05 11 PM How to Prevent Jails and Prisons from Becoming New Hotspots for the Spread of COVID-19? Posted by Patricio V. Marquez on Mon, 04/13/2020 - 05 11 PM Recent newspaper articles have reported on the potential role of jails and prisons as “ampli ers” of the coronavirus pandemic (Ransom and Feuer 2020; Flagg and Neff 2020). For example, data from New York City jails show that 36 out of 1,000 inmates tested positive for the virus versus 4 out of 1,000 people in the city at large (The Legal Aid Society 2020). Additional information indicates that 23 states across the United States have reported cases in correctional facilities (Coppola and Pettersson 2020). The gravity of this challenge in the rest of the world is evidenced by the fact that more than 10.3 million people are held in penal institutions at any given time and more than 30 million people pass through prisons each year (Walmsley 2015; Subramanian, Henrichson, and Kang-Brown, 2015). In addition, there is a large workforce, both within institutions and in community supervision. With thousands of people owing in and out of jails and prisons every week, this is a great risk not only for the detained population that could be hard hit by the coronavirus pandemic, but also for correctional workers, families of released inmates, and surrounding communities (The Marshall Project 2020). Facilitating Factors in Jails and Prisons Jails are transient, local level facilities, for the newly arrested, those awaiting trial or sentencing, those who have not yet been convicted of a crime, and people serving shorter sentences. Prisons are run by states or central governments and are for those convicted of crimes and serving longer sentences. The people who are incarcerated are among the most vulnerable in society, often from low income and marginalized backgrounds (e.g., racial www.pvmarquez.com/prisoncovid19 1/7 1/12/2021 How to Prevent Jails and Prisons from Becoming New Hotspots for the Spread of COVID-19? | Patricio V. Marquez minorities, undocumented migrants). The vulnerability of prisoners is further exacerbated by restricted movement, rampant overcrowding, poor hygiene, sanitation, and ventilation, and limited medical care in the facilities (Akiyama, Spaulding, and Rich 2020). Besides the sheer number of incarcerated people, often a “veil of oblivion” surrounds the dire conditions of jails and prisons, which make them potential host spots for the spread of COVID-19 because of the ease with which it transmits in congregate settings. Another factor that may facilitate the rapid spread of COVID-19 in jails and prisons is the large share of those incarcerated who are older adults affected by underlying chronic health conditions, including both infectious diseases such as HIV, hepatitis C, and tuberculosis, and noncommunicable diseases such as chronic lung disease, moderate to severe asthma, serious heart conditions, diabetes, chronic kidney disease, and liver disease, all of which make them at higher risk of developing severe COVID-19 disease and having poor outcomes of infection (CDC (1) 2020). Health risk factors that make respiratory diseases like COVID-19 more dangerous are far more common in the incarcerated population than in the general population, such as the high prevalence of cigarette smoking. As documented, cigarette smoking may help explain the negative progression and adverse outcomes of COVID-19 in China among men, who are far more likely to smoke than women (Marquez 2020; Vardavas and Nikitara 2020). In other countries such as Italy and South Korea, with sizable outbreaks of COVID-19, smoking rates in countries remain high at approximately 19-27 percent of the population (Simons, Perski,Brown 2020). An additional factor that further compounds the poor health and social conditions in the penal system is evidenced by country data that shows that as many as half the people in jails and prisons have a mental disorder, which could be aggravated by the fear of becoming severely ill or dying if infected with COVID-19 because of their age or health conditions, and by other stressors such as frustration, boredom, inadequate supplies, and inadequate information (Brooks, Webster, Smith, et al. 2020; Marquez, 2018). For example, as described in Alisa Roth's gripping book Insane (2018), although the overall number of people behind bars in the United States has decreased in recent years, the proportion of prisoners with mental illness has continued to go up. Data in the book indicate that in Michigan about 50 percent of people in county jails have a mental illness, and nearly 25 percent in state prisons do. This situation tends to be more pronounced among women prisoners: one study by the US Bureau of Justice Statistics found that 75 percent of women incarcerated in jails and prisons had a mental illness, as compared to just over 60 percent of men. De facto, as observed by Roth, jails and prisons, not only in the United States but across the world, have become “warehouses for the mentally ill”, who tend to be among the most disadvantaged members of society, fare worse than others, and who are susceptible to medical neglect and abuse, since ultimately the mission of jails and prisons is punishment, not medical care. Limited Resources in Jails and Prisons What should be of concern is that in different countries across the world, penitentiary facilities often struggle with limited resources to provide basic levels of healthcare and psychological support services to inmates. So, it is not a far-fetched idea to assume that the risk of an exponential spread of COVID-19 infection in jails and prisons is real as it will be greatly facilitated by the overcrowded and unsanitary conditions and the disease burden in these facilities. The urgency for taking early and decisive action in correctional facilities is best illustrated by COVID-19 outbreaks that have occurred in other con ned settings, such as in the long-term care skilled nursing home in King County, Washington, where ineffective infection control and prevention procedures and staff members working in multiple facilities contributed to intra- and inter-facility spread in the community (McMichael, Clark, Pogosjans, et al. 2020). In addition, dozens of nursing homes across 42 states in the United States have suffered outbreaks (Coppola and Pettersson 2020). Another warning sign of what could happen in the face of inaction in jails and prisons is the www.pvmarquez.com/prisoncovid19 2/7 1/12/2021 How to Prevent Jails and Prisons from Becoming New Hotspots for the Spread of COVID-19? | Patricio V. Marquez COVID-19 outbreaks on cruise ships, which are often settings for infectious disease transmission because of their closed environment and contact between travelers from many countries. As documented, more than 800 cases of laboratory-con rmed COVID-19 cases occurred during outbreaks on three cruise ship voyages, and cases linked to several additional cruises have been reported across the United States (Moriarty, Plucinski, Marston, et al. 2020). Places of worship could also become loci of infection if religious institutions facilitate the congregation of large number of people by not closing services. While case detection, contact tracing, medical isolation, quarantines, and social distancing, along with basic sanitation measures such as hand washing, are critical measures to “ atten the curve” of the COVID-19 pandemic among the civilian population, the adoption of these measures in the closed environment of jails and prisons presents signi cant challenges. Given the nature and characteristics of these facilities, it would be dif cult or impossible for most incarcerated people to follow guidelines on social distancing, since they are living in overcrowded quarters, interact in dining halls, and sleep in rows of beds in a common room, have two or more people in a single cell, and have to use group showers and bathrooms that serve dozens, often without running water, with broken sanitation services, and lacking soap, towels to dry hands, and other supplies for disinfecting surfaces (Flagg and Neff 2020). Since these dire conditions are typical of jails and prison systems across the world, it is imperative that allocation of required resources for supporting prevention, containment, and mitigation activities in these settings be included as part of country-wide emergency response strategies to prevent that these facilities become “transmission centers” for COVID-19. If widespread COVID-19 outbreaks occur in jails and prisoners, a large number of patients at once may overwhelm the often-constrained capacity of the healthcare services in the penitentiary system but also of referral hospitals in the community where the very sick and dying will be transferred. Policy and Institutional Measures to Minimize COVID-19 Risk Different observers and organizations have highlighted possible actions that if effectively implemented could help inhibit the spread of this highly infectious virus among those already incarcerated, prison guards, correctional staff, and administrators, and among people on probation or parole, who are in regular contact with the penal system (Prison Policy Initiative 2020; CDC (2) 2020; American Correctional Association Resources 2020; Markham 2020). Some of the proposed actions include the following: Release people from jails and prisons following depopulation and de-incarceration policies and strategies. As noted above, jails and prisons house large numbers of people with chronic health conditions and diseases that make them more vulnerable to COVID-19. One way to protect these vulnerable populations is to reduce overcrowding in correctional facilities by releasing inmates charged with low-level, non-violent crimes and elderly and in rm inmates, and by focusing on preventing people with health issues who are charged with non-violent offenses from going into the prison system in the rst place, for example, by allowing the posting of personal bonds. Different states in the United States such as California, Ohio, New Jersey, and Texas have undertaken the controlled release of low-level offense prisoners and have pushed for the “compassionate release” of inmates over age 50 facing nonviolent charges (Tamkin 2020; Williams, Weiser, and Rashbaum 2020). In other countries, such as Iran, 54,000 prisoners have been temporarily released to combat the COVID-19 spread (BBC 2020). The adoption of these measures would in turn help to reduce the risk of unrest and rioting by prisoners who fear being the last in line to be tested and at high risk of being infected as recently seen in several countries such as Brazil, Colombia, France, Italy and Venezuela (Turkewitz 2020; Amante 2020). The pandemic also offers the opportunity to release political prisoners on humanitarian grounds. www.pvmarquez.com/prisoncovid19 3/7 1/12/2021 How to Prevent Jails and Prisons from Becoming New Hotspots for the Spread of COVID-19? | Patricio V. Marquez Reduce jail and prison admissions. This action will help slow down the rapid movement of people in and out of jails and prisons, while also facilitating the reduction of the incarcerated population. Rather than arresting and locking up more people in jail and prisons for misdemeanors and nonviolent felony offenses, and in some countries, for nonviolent immigration or drug charges, public of cials have started to order the police to issue citations and to strike plea deals to resolve cases quickly (Gillispie 2020). There are other innovative approaches that could be used during the pandemic. For example, as reported in an article in The Financial Times, approaches being implemented with good results in the United States, such as the “judge-led therapy programs”, offer non-violent offenders with mental and substance use disorders the opportunity to avoid jail, by agreeing to intensive mentoring and support (Waldmeir 2018). Among the vast majority of offenders who opt for this alternative approach, where they are connected with housing and other services, it has been reported that recidivism is low, patients get the support they need, and the judicial system saves a signi cant amount of funds that could be directed to improve the health and sanitary conditions in jails and prisons. Reduce or suspend visitation by community members, limit visits by legal representatives, and reduce facility transfers for incarcerated persons. As observed in a recent article, physical contact between staff and the incarcerated is often unavoidable: while of cers ngerprint, handcuff and supervise prisoners, as well as escort them to court and drive them to medical appointments, many other people also ow in and out of jails, like family members who visit; volunteers who counsel or teach or preach; contractors who stock vending machines; and lawyers who meet their clients (Flagg and Neff 2020). The adoption of social distancing actions to limit visits, services, and vendors, and by moving to online and phone communication, is a required disease prevention measure to reduce the risk of asymptomatic cases spreading COVID-19 in jails and prisons. Improve capacity for infection prevention and control, and well as care and treatment, in the penitentiary health system. This would require that the penitentiary facilities have in place health promotion and disease prevention measures, the capacity to monitor the onset of infectious diseases, test individuals who present COVID-19 symptoms (e.g., fevers, coughs, and symptoms of respiratory illness) and have a known exposure to the virus, record and report to national health department positive COVID-19 cases, and conduct epidemiological investigations to identify individuals who may have had close contact with infected individuals (CDC (2) 2020). Prison health services need to also medically isolate suspected and con rmed cases from the prison general population, follow up the progression of the infection by taking the temperatures of inmates who are elderly, are considered at risk for the virus, or are in medical isolation, and treat or refer to specialized facilities patients with severe COVID-19 disease and other co-occurring chronic health conditions in accordance with national standards. Additional measures include medical screenings for all staff entering a prison, including temperature checks with no-touch thermometers and denial of entry to a prison to anyone with a temperature of 100 degrees or more, has symptoms of respiratory illness, or who has been exposed in the past 14 days to anyone who is suspected or diagnosed with COVID-19. A 14-day quarantine period, in addition to previously noted medical screening, could be instituted for all incoming prisoners to prevent the introduction of COVID-19 into the prison system. The use of washable masks should also be promoted in all sites where there have been reported COVID-19 cases, as well as ensuring the availability of personal protective equipment, face shields and masks, and protective gowns for prison health workers and other staff in direct contact with infected inmates, as well as establishing designated rooms to separate infected people from other inmates. A comprehensive response that connects correctional facilities and the community is of great importance for managing transition in the care of people to and from the community given the “revolving door” nature of jails and prisons. Eliminate medical co-pays. In countries where universal nancial protection in health is lacking or limited such as in the United States, incarcerated people are expected to make copayments for physician visits, medications, and testing. As observed among the civilian population, the imposition of medical copayments becomes a barrier that discourages demand and utilization of needed medical services, which in turn will only help increase the tally of infected cases within the facility’s inmate population and security and administrative personnel. www.pvmarquez.com/prisoncovid19 4/7 1/12/2021 How to Prevent Jails and Prisons from Becoming New Hotspots for the Spread of COVID-19? | Patricio V. Marquez Way Forward The impact of the adoption of the measures described above would have dual bene ts: on one hand, it would help prevent the spread of COVID-19 among inmates and penitentiary system workers, and hence among their families and surrounding communities, that could undermine efforts to atten the curve in countries. It would also help contain a resurgence of the virus during the suppression phase of the pandemic. And, on the other hand, it would help advance prison reform by depopulating jails and prisons in combination with the provision of health care, rehabilitation, education and skills development, and social support programs as an alternative to incarceration. A glimmer of hope? Yes, but one that is possible if political commitment and public and private efforts push forward these policy choices as part of a multisectoral strategy for human capital development, and as a moral imperative in society to offer vulnerable people a second chance for rebuilding their lives. Picture 1 Inside the Prison Industrial Complex, Guess Contributor. https://www.patheos.com/blogs/rhetoricraceandreligion/2015/09/inside-the-prison-industrial-complex.html Picture 2 “Detainees in Manila City Jail, where most are still awaiting trial, and may stay for months or even years before that happens.” By Hannah Reyes Morales for The New York Times https://www.nytimes.com/2019/01/07/world/asia/philippines-manila-jail-overcrowding.html (https://www.nytimes.com/2019/01/07/world/asia/philippines-manila-jail-overcrowding.html) Sources Amante, A. 2020. “Death toll rises from Italy's coronavirus prison riots.” Reu… (https://www.reuters.com/article/us- health-coronavirus-italy-prisons/death-toll-rises-from-italys-coronavirus-prison-riots-idUSKBN20X2DG) American Correctional Association Resources. 2020 [internet publication]. (http://www.aca.org/ACA_Prod_IMIS/ACA_Member/Healthcare_Professional_Interest_Section/Copy_of_Coronav Akiyama, MJ, Spaulding, AC, and Rich, JD. 2020. “Flattening “Flattening the Cur… (https://www.nejm.org/doi/pdf/10.1056/NEJMp2005687?articleTools=true) BBC. 2020. “Coronavirus: Iran temporarily frees 54,000 prisoners to combat spre… (https://www.bbc.com/news/world-middle-east-51723398) Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine … (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30460-8/fulltext) Centers for Disease Control and Prevention (1). “Coronavirus disease 2019 (COVI… (https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e1.htm?s_cid=mm6912e1_w) Centers for Disease Control and Prevention (2). 2020. “Interim Guidance on Man… (https://www.cdc.gov/coronavirus/2019-ncov/community/correction-detention/guidance-correctional- detention.html) CNA Publication. 2020. “COVID-19 fears spark Thailand prison riot.” [internet … (https://www.channelnewsasia.com/news/asia/covid-19-fears-spark-thailand-prison-riot-12587548? cid=h3_referral_inarticlelinks_24082018_cna) Coppola, G. and Pettersson, E. 2020. “Americans Most Likely to Be Infected: Th… (https://www.bloomberg.com/news/articles/2020-04-11/americans-most-likely-to-be-infected-the-faithful- jailed-or-old?utm_campaign=news&utm_medium=bd&utm_source=applenews) Elinson, Z, and Gurman, S. 2020. “Prisoners Riot as Coronavirus Tensions Rise.”… (https://www.wsj.com/articles/prisoners-riot-as-coronavirus-tensions-rise-11586469284) Flagg, A and Neff, J. “Why Jails Are So Important in the Fight Against Coronav… (https://www.nytimes.com/2020/03/31/upshot/coronavirus-jails-prisons.html) www.pvmarquez.com/prisoncovid19 5/7 1/12/2021 How to Prevent Jails and Prisons from Becoming New Hotspots for the Spread of COVID-19? | Patricio V. Marquez Gillispie, M. 2020. “Of cials taking steps to reduce county jail population… (https://apnews.com/f169524cbc6ca3282938edac611593fc) Markham, J. 2020. “The Correctional System Responds to COVID-19 (and Some Preli… (https://nccriminallaw.sog.unc.edu/the-correctional-system-responds-to-covid-19-and-some-preliminary- thoughts-on-minimizing-correctional-interactions/) Marquez, PV. 2020. “Does Tobacco Smoking Increases the Risk of Coronavirus Dise… (http://www.pvmarquez.com/Covid-19) Marquez, PV. 2018. “Mental Health in Prisons: How to Overcome the Punishment Pa… (https://blogs.worldbank.org/health/mental-health-prisons-how-overcome-punishment-paradigm) McMichael TM, Clark S, Pogosjans S, et al. COVID-19 in a Long-Term Care Facilit… (http://dx.doi.org/10.15585/mmwr.mm6912e1) Moriarty LF, Plucinski MM, Marston BJ, et al. Public Health Responses to COVID-… (http://dx.doi.org/10.15585/mmwr.mm6912e3) Prison Policy Initiative. 2020. “No need to wait for pandemics: The public heal… (https://www.prisonpolicy.org/blog/2020/03/06/pandemic/) Ransom, J. and Feuer, A. 2020. “A Storm Is Coming’: Fears of an Inmate Epidemi… (https://www.nytimes.com/2020/03/20/nyregion/nyc-coronavirus-rikers-island.html) Roth, A. 2018. “Insane: America’s Criminal Treatment of Mental Illness.” Basic… (http://alisaroth.com/) Simons, D, Perski, O, Brown, J. 2020 “Covid-19 The role of smoking cessation d… (https://blogs.bmj.com/bmj/2020/03/20/covid-19-the-role-of-smoking-cessation-during-respiratory-virus- epidemics/) Subramanian, R, Henrichson, C, and Kang-Brown, J. 2015. “In Our Own Backyard: … (https://www.vera.org/publications/in-our-own-backyard-confronting-growth-and-disparities-in-american-jails) Tamkin, E. 2020. “What does coronavirus mean for the US’s prison population?” … (https://www.newstatesman.com/world/north-america/2020/03/what-does-coronavirus-mean-us-s-prison- population) The Legal Aid Society. “COVID-19 Infection Tracking in NYC Jails.” [internet p… (https://legalaidnyc.org/covid-19- infection-tracking-in-nyc-jails/) The Marshall Project. 2020. Reporting on the COVID-19 pandemic, criminal justic… (https://www.themarshallproject.org/2020/03/31/why-jails-are-so-important-in-the- ght-against-coronavirus) Turkewitz, J. 2020. “Prison riots in Colombia over virus fears leave at least … (https://www.nytimes.com/2020/03/22/world/americas/colombia-prison-riot-dead.html) Vardavas CI, Nikitara K. COVID-19 and smoking: a systematic review of the evide… (http://www.tobaccoinduceddiseases.org/COVID-19-and-smoking-A-systematic-review-of-the- evidence,119324,0,2.html) Waldmeir, P. 2018. “‘None of these people ever gave up on me’: America’s drug … (https://www.ft.com/content/8a1ee8f0-a593-11e8-926a-7342fe5e173f) Walmsley, R. “World Prison Population List.” Eleventh Edition. Institute for Cr… (https://www.prisonstudies.org/sites/default/ les/resources/downloads/world_prison_population_list_11th_editi Williams, T, Weiser, B, and Rashbaum, WK. 2020. “‘Jails Are Petri Dishes’: Inm… (https://www.nytimes.com/2020/03/30/us/coronavirus-prisons-jails.html) www.pvmarquez.com/prisoncovid19 6/7 1/12/2021 Does Tobacco Smoking Increases the Risk of Coronavirus Disease (Covid-19) Severity? The Case of China | Patricio V. Marquez Does Tobacco Smoking Increases the Risk of Coronavirus Disease (Covid-19) Severity? The Case of China Submitted by Patricio V. Marquez on Tue, 03/03/2020 - 02 20 PM Does Tobacco Smoking Increases the Risk of Coronavirus Disease (Covid-19) Severity? The Case of China Posted by Patricio V. Marquez on Tue, 03/03/2020 - 02 20 PM Since December 2019, when Covid-19 emerged in Wuhan city and subsequently spread across China causing varying degrees of illness, the virus has now infected 92,100 people in at least 70 countries. Data reported from China provide insights into the biology, epidemiology, and clinical characteristics of Covid-19. Men are at higher risk of Covid-19 When assessing the data on the personal characteristics of affected patients, the sex distribution of the disease clearly shows a male predominance of Covid-19. Indeed, as reported by Chinese researchers in the New England Journal of Medicine, (Guan, Ni et al 2020), among a sample of 1099 patients, with laboratory-con rmed disease, from 552 hospitals in 30 provinces, autonomous regions, and municipalities in China through January 29, 2020, the median age of patients was 47 years and 58.1 percent of the patients were male. Also, among the initial 425 cases of that occurred in Wuhan, Hubei Province, China, in December 2019 and January 2020, the median age was 59 years and 56 percent were male (Li, Guan, et al 2020). Moreover, an article published at the Journal of the American Medical Association (JAMA), noted that the death rates among men infected with the coronavirus, particularly those in their late 40s and older, have exceeded those among women (del Rio and Malani 2020). In previous coronavirus outbreaks, such as the SARS and MERS outbreaks, men were also disproportionally affected. In Hong Kong in 2003, for example, men with SARS had a 50 percent excess risk of death than females (Leung, Hedley, et al 2004). What explains this discrepancy? www.pvmarquez.com/Covid-19 1/5 1/12/2021 Does Tobacco Smoking Increases the Risk of Coronavirus Disease (Covid-19) Severity? The Case of China | Patricio V. Marquez While that cause is not known, it is suggested that a higher prevalence of tobacco smoking among Chinese men, often resulting in compromised lung function, may help explain it (del Rio, Milani 2020). Tobacco use also contributes to the onset of other co-occurring conditions such as cardiovascular diseases, lung cancer, chronic obstructive pulmonary disease (COPDs), and diabetes, which are more prevalent among males and account for a signi cant share of the total disease burden in China (Wang, Marquez, Langenbrunner 2011). The existence of pre- existing conditions increases the risk of disease severity and death among Covid-19 patients, similar to the situation with in uenza (Fauci, Lane, Red eld 2020). Data presented in above-mentioned New England Journal of Medicine article (Guan, Ni, et al 2020), further illustrate the relative impact that tobacco smoking has on the spectrum of the Covid-19 progression and mortality in a nationwide sample of 1099 Covid-19 patients, with laboratory-con rmed diseases: 12.6% of patients were current smokers, and 1.9% former smokers. Among those that developed a severe disease (N=173), 16.9% were current smokers and 5.2% former smokers. Among patients with presence of primary composite end point (admission to an intensive care unit, the use of mechanical ventilation, or death) (N=67), 25.8% were current smokers and 7.6% former smokers. The epidemic of tobacco use in China We should not be surprised by the role of tobacco smoking in explaining the difference in the sex distribution and in the severity of Covid-19 in China. China has the largest smoking population in the world, with around 316 million adult smokers, and accounts for nearly one-third of smokers and 40 percent of tobacco consumption worldwide. While the prevalence of smoking in women is still relatively low at 1.9 percent, among males, the prevalence was estimated at 48.4 percent in 2016 (World Bank Development Indicators). Smoking prevalence also varies across cities and provinces within China. Since the lung is an organ directly affected by cigarette smoking, various respiratory diseases including lung cancer, chronic obstructive pulmonary disease, interstitial lung diseases, and bronchial asthma, are caused and worsened by cigarette smoking not only in the case of active smoking but also in the case of passive smoking. In 2010, an estimated 1.2 million premature deaths were attributable to smoking in China, and the three leading causes of death (stroke, ischemic heart disease, and chronic obstructive pulmonary disease) were linked to tobacco consumption. As documented in a recent study, China is in the midst of a lung cancer epidemic on an unprecedented scale, and tobacco smoke exposure is the primary factor driving current lung cancer trends (Parascandola and Xiao, 2019). Lung cancer is now the most commonly diagnosed cancer and the leading cause of cancer mortality in China. In 2015, there were an estimated 733,000 new lung cancer cases (17 percent of total cancer incidence) and 610,000 deaths (21.7 percent of total cancer mortality) in China. How does smoking affect lung health? Acute respiratory illnesses are divided into those that include the upper respiratory tract (nose and pharynx) and larynx, and those that include the lower respiratory tract (below the larynx). In people with normal immune systems, viruses account for most cases of upper respiratory syndromes (Gwaltney 1995c): acute bronchitis (Gwaltney 1995a, as cited in U.S. Department of Health and Human Services 2004), bronchiolitis (Hall and Hall 1995, as cited U.S. Department of Health and Human Services 2004), and a majority of pneumonia cases (Marrie et al. 1989, as cited in U.S. Department of Health and Human Services 2004). Bacteria can cause pharyngitis (Gwaltney 1995b, as cited in U.S. Department of Health and Human Services 2004) and some pneumonias (Marrie et al. 1989, as cited in U.S. Department of Health and Human Services 2004). As clearly explained in the 2004 US Surgeon General Report (U.S. Department of Health and Human Services. 2004), www.pvmarquez.com/Covid-19 2/5 1/12/2021 Does Tobacco Smoking Increases the Risk of Coronavirus Disease (Covid-19) Severity? The Case of China | Patricio V. Marquez “Toxins in tobacco smoke harm the body from the moment they enter through the mouth and nose. They damage tissue and cells all the way to the lungs. When cigarette smoke is inhaled, chemicals from the smoke are absorbed in the lungs. As a result, smoking causes lung diseases, including the majority of cases of chronic obstructive pulmonary disease (COPD); makes chronic lung diseases more severe; and increases the risk for respiratory infections. Genetic factors make some people more susceptible to lung disease from smoking. Although the lung has ways to protect itself from injury by inhaled agents, these defenses are overwhelmed when cigarette smoke is inhaled repeatedly over time. After years of exposure to cigarette smoke, lung tissue becomes scarred, loses its elasticity, and can no longer exchange air ef ciently.” The evidence is suf cient to infer a causal relationship between smoking and acute respiratory illnesses, including pneumonia, in persons without underlying smoking-related chronic obstructive lung disease. In the case of acute respiratory illnesses, it is presumed an infection is the predominant underlying cause, but smoking might act to increase the frequency or severity of infections. A systematic review and meta-analysis, showed that smoking was consistently associated with higher risk of hospital admissions after in uenza infection (Han, Ran, et al 2019). As reported in the 2004 US Surgeon General report (U.S. Department of Health and Human Services. 2004), there are several U.S. population-based studies that provide evidence of a link between cigarette smoking and acute lower respiratory tract infections. A population based, case-control study of 205 cases of community acquired pneumonia (Almirall et al. 1999a, b) reported an attributable risk of 23.0 percent for a history of ever smoking. The US Centers for Disease Control and Prevention sponsored a case-control study of invasive pneumococcal disease based on a population surveillance system (Nuorti et al. 2000), showed among cases for which pneumonia is likely to have been the main diagnosis, the population attributable risk estimate for smoking was 51 percent, compared with 14 percent for chronic illnesses. The authors estimated that reducing the prevalence of smoking to 15 percent among persons aged 18 through 64 years would prevent 4,000 cases per year of invasive pneumococcal disease in the United States. Of particular interest in this study was the observation that after 10 years of smoking cessation, the risk of invasive pneumococcal disease reached that of nonsmokers. What to do? The initial data from the Covid-19 outbreak in China, shows that smoking among men may explain the difference in the sex distribution of the disease, as well as in its severity. This on top of existing evidence on the high human toll and economic impact of tobacco-attributable diseases in China, which as co-occurring conditions further impact negatively Covid-19 patients. Governments have an obligation and the means to protect their population’s wellbeing by adopting population- based disease prevention measures (for example, scal and regulatory measures), in addition to providing medical care to those persons who fall ill. In the case of tobacco control, the most cost-effective policy measure is to control and prevent tobacco use, is tobacco taxation (Marquez and Moreno-Dodson 2017). On the basis of the Covid-19 experience, and building upon the 2015 tobacco tax increase, it would be of paramount importance for the government in China to act boldly and swiftly to reform tobacco taxation for health and scal gains, as well as to promote human capital development. While the 2015 tobacco tax increase has generated measurable public health and scal bene ts, the price of cigarettes in China continues to be low and increasingly affordable for a population that enjoys rapid wage increases (Marquez and Zheng 2016; Zheng, Hu, Wang, and Marquez, 2017). If the ultimate goal is to help smokers quit and prevent the next generation from getting addicted to smoking cigarettes and hence signi cantly reduce health risks, then additional tobacco tax policy reforms are urgently needed in China, especially for re-orienting the excise tax structure towards speci c excise taxes at the retail level in the medium-term and towards a uniform tax www.pvmarquez.com/Covid-19 3/5 1/12/2021 Does Tobacco Smoking Increases the Risk of Coronavirus Disease (Covid-19) Severity? The Case of China | Patricio V. Marquez system at the retail level in the long-term. A recent study estimated that a 50 percent increase in tobacco price through excise taxes would lead over 10 years to 5.3 million years of life gained and would reduce expenditures on tobacco-related disease treatment by US$2.4 (Verguet, Gauvreau, Mishra, MacLennan, Murphy, Brouwer, Nugent, Zhao, Jha, Jamison 2015). Looking into the future, as evidenced in a World Bank study “Toward a Healthy and Harmonious Life in China: Stemming the Rising Tide of Non-Communicable Diseases” (Wang, Marquez, Langenbrunner 2011), with stronger tobacco control measures including steeper tobacco tax increases, the rapid rise in China's non-communicable diseases, that compound the impact of infectious diseases as we are now witnessing with Covid-19, can be halted, resulting in major gains for people’s health and the country’s social and economic development. However, if an effective response is not mounted in China to control and reduce tobacco use after overcoming Covid-19, the disease burden posed by these conditions will aggravate the economic and social impact of the expected population explosion of older citizens and smaller workforce in China. And, a reduced ratio of healthy workers to sicker, older dependents, will certainly increase the odds of a future economic slowdown and pose a signi cant social challenge in China. Sources of Photos: First Photo: Mark Schiefelbein/Associated Press, as published in the NYT on March 3 2020 Second Photo: Agence France-Presse, Getty Images, as published in the NYT on March 3 2020 Sources Almirall J, Bolíbar I, Balanzó X, González CA. 1999a. “Risk factors for communi… (https://pubmed.ncbi.nlm.nih.gov/10065680-risk-factors-for-community-acquired-pneumonia-in-adults-a- population-based-case-control-study/) Almirall J, González CA, Balanzó X, Bolíbar I. 1999b. “Proportion of community-… (https://journal.chestnet.org/article/S0012-3692(15)38022-3/fulltext) Del Rio, C., and Malani, P.N. 2020. “Covid-19-New Insights on a Rapidly Changi… (https://jamanetwork.com/journals/jama/fullarticle/2762510) Fauci, AS., Lane, HC, M.D., and Red eld, RR. 2020. “Covid-19 — Navigating the … (https://www.nejm.org/doi/full/10.1056/NEJMe2002387?query=recirc_curatedRelated_article) Guan, W, Ni, Z, Hu, Y, et al. 2020. Clinical characteristics of coronavirus di… (https://www.nejm.org/doi/full/10.1056/NEJMoa2002032?query=recirc_mostViewed_railB_article) Han, L, Ran, J, Mak, Y-W; Suen, LK-; Lee, P, et al. 2019. “Smoking and In uen… (https://journals.lww.com/epidem/Abstract/2019/05000/Smoking_and_In uenza_associated_Morbidity_and.15.as Leung, G.M, Hedley, A.J, Ho, L.M, Chau, P, et al. 2004. “The epidemiology of s… (https://www.ncbi.nlm.nih.gov/pubmed/15520422) Li, Q, Guan, X, Wu, P, et al. 2020. Early transmission dynamics in Wuhan, Chin… (https://www.nejm.org/doi/full/10.1056/NEJMoa2001316) Marquez, PV, and Zheng, R. 2016. “China’s 2015 tobacco tax adjustment: a step i… (https://blogs.worldbank.org/health/china-s-2015-tobacco-tax-adjustment-step-right-direction) Marquez, PV, and Moreno-Dodson, B. 2017. “Tobacco tax reform at the crossroads … (http://documents.worldbank.org/curated/en/491661505803109617/Main-report) Nuorti JP, Butler JC, Farley MM, Harrison LH, McGeer A, Kolczak MS, Breiman RF… (https://www.nejm.org/doi/full/10.1056/NEJM200003093421002) www.pvmarquez.com/Covid-19 4/5 1/12/2021 Does Tobacco Smoking Increases the Risk of Coronavirus Disease (Covid-19) Severity? The Case of China | Patricio V. Marquez Parascandola M, Xiao L. 2019. “Tobacco and the lung cancer epidemic in China.” … (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6546632/pdf/tlcr-08-S1-S21.pdf) U.S. Department of Health and Human Services. 2004. “The Health Consequences of… (https://www.ncbi.nlm.nih.gov/books/NBK44695/) Verguet, S, Gauvreau, CL, Mishra, S., MacLennan, M, Murphy, SM, Brouwer, ED, Nu… (https://www.thelancet.com/pdfs/journals/langlo/PIIS2214-109X(15)70095-1.pdf) Wang, S, Marquez, PV, Langenbrunner, J. 2011. “Toward a Healthy and Harmonious … (http://documents.worldbank.org/curated/en/618431468012000892/pdf/634260WP00Box30of cial0use0only090.pd World Bank Development Indicators. Accessed at: (https://data.worldbank.org/indicator/SH.PRV.SMOK.MA? view=chart) Zheng, R, Hu, X, Marquez, PV, Wang Y. 2017. “Cigarette affordability in China: … (http://documents.worldbank.org/curated/en/130301492424519317/Cigarette-affordability-in-China-2001-2016) (https://twitter.com/pvmarquez1956) www.pvmarquez.com/Covid-19 5/5 1/12/2021 The Unpredictable Social and Economic Cost of the Coronavirus (Covid-19) Outbreak | Patricio V. Marquez The Unpredictable Social and Economic Cost of the Coronavirus (Covid-19) Outbreak Submitted by Patricio V. Marquez on Thu, 02/27/2020 - 10 01 PM The Unpredictable Social and Economic Cost of the Coronavirus (Covid-19) Outbreak Posted by Patricio V. Marquez on Thu, 02/27/2020 - 10 01 PM With the realization that a novel coronavirus pandemic (Covid-19) is likely, people across the globe are getting alarmed, and nancial markets are starting to tumble. Given inadequate expenditures on public health and insuf cient disease prevention effort, perhaps this is an opportune time for high level political authorities, ministers of nance, and other global actors to once and for all be convinced that predictable and sustainable budgetary allocations for disease prevention, early detection, surveillance, preparedness, and response capacity across a medical care continuum is not an optional expenditure, that be neglected due to political shortsightedness or per the whims of scal rectitude. Rather, these allocations should be considered priority investments in country budgets to enhance societal resilience and preparedness to prevent and control the emergence and reemergence of highly infectious pathogens, such as Covid-19. www.pvmarquez.com/coronavirus 1/8 1/12/2021 The Unpredictable Social and Economic Cost of the Coronavirus (Covid-19) Outbreak | Patricio V. Marquez If we look at the consequences of recent infectious disease outbreaks, one learns about their destructive potential, both in terms of human toll and severe economic disruptions. In particular, in uenza, a zoonotic disease (animal to human transmission), poses an unpredictable threat of international importance because of its potential capacity to mutate in ways that allows sustained human-to-human transmission across national borders and continents. The impact of the 1918-1919 In uenza Pandemic, for example, was enormous (Garrett, TA, 2007). It killed 40 million people worldwide from the early spring of 1918 through the late spring of 1919. Only the Black Death that spread throughout Europe from 1348-1351 killed more people (roughly 60 million) over a similar time period. Data for the United States shows that since males aged 18 to 40 were the hardest hit by the in uenza, it had serious economic consequences for the families that had lost their primary breadwinner. Although the 1918- 1919 in uenza pandemic in the United States was short-lived, an assessment by the US Federal Reserve Bank of St. Louis documented that many businesses, especially those in the service and entertainment industries, suffered double-digit losses in revenue. Other businesses that specialized in health care products, however, experienced an increase in revenues (Garrett, TA, 2008). More recently, the SARS outbreak in 2003 killed an estimated 10 percent of more than 8,000 individuals infected (National Institute of Medicine, 2004). Estimates done suggest that the cost in 2003 of SARS for the world economy as a whole was close to US$40 billion. The SARS shock disproportionately affected Hong Kong due to its economic dependence on services (e.g., travel, tourism), and signi cant short-term losses also accrued in China as a result of a sharp decrease in foreign investment. What caused the economic loss? According to Jong-Wha Lee and Warwick J. McKibbin (2004), researchers who studied the economic impact of the SARS epidemic, the impact was due not to the consequence of the disease itself for the affected people, but to the impact of the disease on the behavior of many people within these economies. They also observed that the impact depended on the disease associated adjustment of expectations re ected in integrated real and nancial markets. So, given the spread of the disease through droplet transmission, people tried to minimize face-to-face interactions. The result was a drop in demand in service sectors such as tourism, mass transportation, retail sales, hotels and restaurants. Business costs also increased due to workplace absenteeism, disruption of production processes and shifts to more costly procedures. www.pvmarquez.com/coronavirus 2/8 1/12/2021 The Unpredictable Social and Economic Cost of the Coronavirus (Covid-19) Outbreak | Patricio V. Marquez In low- and middle-income countries, infectious disease outbreaks have the potential to erase development gains, aggravating poverty and inequality. World Bank Group estimates showed that the Ebola epidemic in West Africa in 2014-2015 severely weakened the economies of the affected countries (World Bank, 2015). The three affected countries were growing briskly in the rst half of 2014, but full-year 2014 growth dropped to an estimated 0.5 percent in Guinea, although a growth rate of 4.5 percent was expected before the crisis. In Liberia it fell to an estimated 2.2 percent from 5.9 percent expected before the crisis and, in Sierra Leone, it fell to 4.0 percent from 11.3 percent expected before the crisis. While these rates already imply shrinking economies in the second half of 2014, the estimates showed that second-round effects and investor aversion led to a 2015 growth of -0.2 percent in Guinea, 3.0 percent in Liberia, and -2.0 percent in Sierra Leone. The estimates imply foregone income of about US$1.6 billion across the three countries in 2015 alone. This is more than 12 percent of their combined GDP and has translated into weaker revenues, while government spending needs grew, with a severe negative impact on public nances that may derail country investments needed to attain the Sustainable Development Goals (SDG) by 2030. Besides the nancial cost posed by these disease outbreaks, human capital development stand to be affected due to the loss of lives, particularly of health workers who were infected and died in the line of duty. While the world is nowadays concerned about the Covid-19 spread, with an increasing number of countries reporting new cases and deaths (as of today, 48 countries, 82,700 infected people per of cial counts, and at least 2,809 people have died, all but 65 in mainland China), it is important to understand how this public health crisis is starting to impact economic activity globally. As assessed in a Financial Times (FT) article (Greene, M, 2020), one transmission mechanism from China’s coronavirus is the interruptions to global supply chains which may cause problems for growth and international markets. While the Chinese government has adopted measures to mitigate the impact on rms and households in the country, the resumption of activity may be hindered by bottlenecks caused by depleted inventories, delays in reopening factories, return of workers to places of work, reactivation of transport, and the reopening of ports. Given that Chinese rms are integrated into “complex, global supply chains” and western rms depend on Chinese inputs for their production lines, the disruptions in China may cause rms in other countries to look for new suppliers (not an easy task), halt production as it already happened with Korean rms Hyundai and Kia, or simply go out of business. On the latter point, it is important to observe, as highlighted in the FT article, that Hubei, the epicenter of the Covid-19 outbreak in China, is a “cog” in global supply chain in cars, health care, electronics, aerospace and defense, and construction materials. www.pvmarquez.com/coronavirus 3/8 1/12/2021 The Unpredictable Social and Economic Cost of the Coronavirus (Covid-19) Outbreak | Patricio V. Marquez In the nancial markets, fear of a potential hard hit to economic growth and markets if the virus becomes a full-blown global pandemic, is behind the stock market plunge in global markets as investors continued to dump stocks and seek safer investments. In the United States, for example, the S&P 500 index plunged to its worst loss in almost nine years and investors worldwide grew increasingly fearful that the coronavirus outbreak could cause a recession as it squeezes corporate pro ts (New York Times, 2020). European stocks were also trading about 2.5 percent lower after the Nikkei in Japan closed down 2.1 percent. Oil prices have also fallen, while the price of gold rose, signaling continued nervousness among global investors. The New York Times (Phillips, M, 2020) is also reporting that the outbreak has taken a toll on multinational companies. For instance, Anheuser-Busch InBev is forecasting a steep drop in quarterly pro t, which led to sharp drop in the value of its shares, while Marriott, the American hotel company, reported that the virus would weigh on its fee revenue this year. Shares of Microsoft, the most valuable company in the United States, fell 7 percent after the company announced that sales in the current quarter would be lower because of the outbreak’s effect on its supply chain. Companies such as the French cosmetics giant L’Oréal, and Nestlé, the Swiss-based food company, have announced that they are suspending all international business for their staff until the end of March. The outbreak could crush consumer demand as well, as people limit travel or stay home even without a government order to do so, aggravating economic performance. What to Do? A question to pose is what can countries do to contain and mitigate the health, social, and economic damage of the COVID-19 pandemic? Dr. Tom Frieden (2020), the former director of the US CDC, has outlined some immediate and medium-term actions to deal with the initiation and acceleration phases of the pandemic. A summary of these actions is as follows: Find out more about how Covid-19 spreads, how deadly it is, and what we can do to reduce its harms. This information is critical as it would guide decisions about the interventions to implement. Reduce the number of people who get infected. The spread of the virus can be minimized by quickly isolating those who are ill, cleaning potentially contaminated surfaces often, and changing common routines. And the promotion and adoption of well-known hygienic habits such as washing hands, covering coughs, and, if a person is sick, staying home or wearing a mask. If it turns out that many of those infected become severely ill, drastic social distancing measures such as closing or curtailing hours of schools, limiting public www.pvmarquez.com/coronavirus 4/8 1/12/2021 The Unpredictable Social and Economic Cost of the Coronavirus (Covid-19) Outbreak | Patricio V. Marquez gatherings, and reducing social contact may be warranted. We also need to keep in mind, as advised by Dr. Anthony S. Fauci, director of the US National Institute of Allergy and Infectious Diseases, that travel restrictions become ‘irrelevant’ in a potential pandemic because “you can’t keep out the entire world” (Higgins-Dunn, 2020). Protect health care workers. As witnessed during the West Africa Ebola epidemic of 2014- 2015, a large number of health workers and patients got infections in health care facilities. To prevent this occurrence, fast and drastic improvements in triage, treatment, cleaning, and overall infection prevention are required, including ensuring that enough medical masks are available for health care workers. Improve medical care and prevention of Covid-19. Since a vaccine is not yet available, preparation for a worst-case scenario will require training, equipment, and detailed operational plans for a surge in the number of patients who seek care and for the subset of those who need to be mechanically ventilated. Protect health services. During the 2014-2016 Ebola epidemic in West Africa, more people died because of disruptions in day-to-day health care than died from Ebola. Telemedicine needs to become much more accessible, and people with chronic conditions should receive three months of medications whenever possible, in case there are supply disruptions. Routine vaccinations and other preventive services need to be preserved. Support social needs. Patients and their families will need support, especially those who are isolated and less familiar with virtual social support or delivery services. Protect economic stability. Continuing to plan, teach, learn, and work will reduce disruption. Businesses need to be ready to maximize telecommuting, increase cross- training, and operate with as many as 40 percent of their staff ill or quarantined. Mission- critical enterprises need practical plans to continue to operate. The Medium-Term Task Assuming that the world learns from this new disease outbreak, investment and recurrent- cost funding for veterinary and public health structures and functions in accordance with one-health principles, coupled with timely access to essential medical care for all when needed, are an inescapable budgetary priority for all countries to reduce vulnerability and build resilience to deal effectively with zoonotic diseases that account for 70 percent of emerging infectious diseases. Indeed, a collaborative, international, cross-sectoral, multidisciplinary one-health is required to address threats and reduce risks of detrimental infectious diseases at the animal-human-ecosystem interfaces. Let’s be clear: globalization is not going to wither away, as it has been part of human history for millennia. Rather, we are and will continue to live in an increasingly interconnected world. While there are multiple bene ts from globalization, there are also public health risks www.pvmarquez.com/coronavirus 5/8 1/12/2021 The Unpredictable Social and Economic Cost of the Coronavirus (Covid-19) Outbreak | Patricio V. Marquez that are associated with demographic and economic pressures on ecosystems that facilitate the transmission of new pathogens from animals to humans. Moving forward, as a colleague from the World Bank Group mentioned to me today, we need to work hard to ensure that public health investment becomes ingrained in the DNA of country budgets and in the support programs of bilateral and multilateral organizations, as well as of private donors. Neglecting to invest in public health will lead to new uncontrolled infectious disease outbreaks, preventable deaths, and signi cant economic losses. To this end, echoing a suggestion that I recently made, it would be critical that institutions such as the World Bank Group and the International Monetary Fund spearhead efforts to include robust, well-structured and -funded veterinary and public health platforms, including disease surveillance and preparedness and essential medical care for all, as a critical indicator in country credit and investment risk assessments ratings, which are used to determine nancing terms and conditions of of cially supported export credits, as well as for commercial loans and direct investment decisions by nancial and corporate sectors (Marquez, PV 2020) This type of institutional “nudge” at the international level is needed to prevent governments, along with other global stakeholders, from forgetting the lessons of recent disease outbreaks, with their associated high human toll and signi cant economic losses. Although the task at hand is dif cult and will require sustained effort over the medium- and longer terms, particularly in low- and lower-middle-income countries, it can be accomplished if we start acting now. As the saying goes, a crisis poses challenges but also offers opportunities to learn and evolve. All of us in the global health community have an obligation not only to learn from the current coronavirus outbreak and what has worked before but to avoid, paraphrasing the Harvard philosopher George Santayana, being condemned to face unprepared similar crises in the future. Source of images: First Image: Financial Times (FT Weekend), February 22/23 2020 Second Image: Coronavirus Map: Tracking the Spread of the Outbreak, New York Times; data from The Center for Systems Science and Engineering at Johns Hopkins University; National Health Commission of the People's Republic of China; local governments. Data as of 9 30 p.m. E.T., Feb. 27, 2020. www.pvmarquez.com/coronavirus 6/8 1/12/2021 The Unpredictable Social and Economic Cost of the Coronavirus (Covid-19) Outbreak | Patricio V. Marquez Sources Frieden, T. 2020. “Former CDC director: A coronavirus pandemic is inevitable. W… (https://edition.cnn.com/2020/02/25/health/coronavirus-pandemic-frieden/index.html) Garrett, TA. 2007. “Economic Effects of the 1918 In uenza Pandemic. Implicatio… (https://www.stlouisfed.org/~/media/ les/pdfs/community-development/research- reports/pandemic_ u_report.pdf?la=en) Garrett, TA. 2008. “Pandemic Economics: The 1918 In uenza and Its Modern-Day I… (https:// les.stlouisfed.org/ les/htdocs/publications/review/08/03/Garrett.pdf) Greene, M. 2020. “Investors risk underestimating the impact of coronavirus.” F… (https://www.ft.com/content/44c9391c-5489-11ea-a1ef-da1721a0541e) Higgins-Dunn, N. 2020. “Travel restrictions ‘irrelevant’ if coronavirus becomes… (https://www.cnbc.com/2020/02/26/fauci-travel-restrictions-irrelevant-if-coronavirus- becomes-a-pandemic.html) Institute of Medicine. 2004. “Learning from SARS: Preparing for the Next Diseas… (https://www.nap.edu/catalog/10915/learning-from-sars-preparing-for-the-next-disease- outbreak-workshop) Marquez, PV. 2015. “Regional Disease Surveillance in a Globalized World.” World… (https://blogs.worldbank.org/health/regional-disease-surveillance-globalized-world) Marquez, PV. 2020 “Public Health Investments and Economic Gains: Learning from … (http://www.pvmarquez.com/disease_control) Phillips, M, 2020. “Coronavirus Fears Drive Stocks Down for 6th Day and Into C… (https://www.nytimes.com/2020/02/27/business/stock-market-coronavirus.html) Philipson, TJ. 2007. “Economic Epidemiology and Infectious Diseases.” NBER work… (https://books.google.com/books/about/Economic_Epidemiology_and_Infectious_Dis.html? id=iMUxAAAAMAAJ) Jong-Wha Lee, J-W and McKibbin, WJ. “Estimating the Global Economic Cost of SA… (https://www.nap.edu/catalog/10915/learning-from-sars-preparing-for-the-next-disease- outbreak-workshop) World Bank Group. 2015. “The economic impact of Ebola on sub-Saharan Africa: up… (http://documents.worldbank.org/curated/en/2015/01/23831803/economic-impact-ebola- sub-saharan-africa-updated-estimates-2015) www.pvmarquez.com/coronavirus 7/8 1/12/2021 The Unpredictable Social and Economic Cost of the Coronavirus (Covid-19) Outbreak | Patricio V. Marquez (https://twitter.com/pvmarquez1956) www.pvmarquez.com/coronavirus 8/8 1/12/2021 Public Health Investments and Economic Gains: Learning from Latin America and Caribbean History in the Time of Coronavirus | Patricio V. Marquez Public Health Investments and Economic Gains: Learning from Latin America and Caribbean History in the Time of Coronavirus Submitted by Patricio V. Marquez on Mon, 02/10/2020 - 05 41 PM Public Health Investments and Economic Gains: Learning from Latin America and Caribbean History in the Time of Coronavirus Posted by Patricio V. Marquez on Mon, 02/10/2020 - 05 41 PM With the advent of 2019-nCoV in China, the world has woken up once again to the inexorable reality that globalization, both the movement of people and goods and services across countries and from continent to continent, enables the spread of viruses and disease. While the coronavirus appears to be more infectious than SARS but less lethal, it is already creating global havoc. As the number of cases increases in China, and new cases are detected and con rmed in different countries, airlines have cancelled ights to and from China, the global economy is taking a hit, and fear among the population is rising. The World Health Organization (WHO) with support of social media companies is stepping up its ght against “disinformation” and “fearmongering.” Countries are also starting to issue calls that the virus is a “serious” health threat. All this seems like the rerun of an old movie. I remember vividly the days when working at the World Bank Group (I retired in August 2019 after 32 years of service globally), I was part of quickly assembled core task teams that were mandated to prepare in a matter of days, program and budgetary proposals that eventually became the US$1.3 billion Global Avian In uenza Preparedness and Control Framework Program in 2006 and the US$390 million Ebola Emergency Response Program for West Africa in 2014. In those days as today with coronavirus, panic and uncertainty in different forms were common currency. www.pvmarquez.com/disease_control 1/5 1/12/2021 Public Health Investments and Economic Gains: Learning from Latin America and Caribbean History in the Time of Coronavirus | Patricio V. Marquez The question that we need to ask as these health events are not something new, is what have countries learned to be ready to deal with these threats? Unfortunately, in many instances, it seems that once the sense of fear has diminished and the outbreak controlled, it is back to the common practice of undervaluing the importance of having in place strong “intelligence systems” in the form of disease surveillance systems, public health labs, and trained personnel, both in the veterinary and public health sectors operating in a coordinated manner. It is clear that all countries need to have in place robust early detection and con rmation of cases, as well as preparedness platforms, including medical care systems, along a continuum of action, to deal on time and effectively with disease outbreaks. Perhaps the most common “fatality” post-disease outbreaks is the lack of predictable and sustained funding for disease surveillance and emergency preparedness in national budgets that are protected from budgetary cuts that follow short-term “ scal rectitude” arguments or changing investment priorities that are assumed to have a higher- rate of return. Some Historical Antecedents If we look back in history, there are plenty of examples that illustrate that this should not be the case. History shows that travelers have spread contagious diseases for centuries. At the same time, the threat of disease has been a driver for supporting the continuous development of global public health practices and institutions, building upon accumulated and new scienti c knowledge and technological know-how. The history of public health in Latin America and the Caribbean, for example, is replete with efforts in sanitation, hygiene, and disease control, especially directed at old scourges such as yellow fever and malaria. Since colonial times, outbreaks of disease were common in the countries of Latin America and the Caribbean, largely as a result of maritime trade and export of agricultural products and minerals that helped integrate them into the world economy, as well as the development of indigenous commercial interests. In 1515, a smallpox epidemic in Hispaniola—now the Dominican Republic and Haiti—spread to neighboring islands and to the mainland, leaving a toll of thousands of victims. This episode was to be registered as the rst epidemic in the colonial period. In the sixteenth and following centuries, epidemics of different kinds made devastating sweeps across the Americas. As the spread of disease largely re ected the maritime basis for trade among the colonies, and between the colonies and the metropolitan powers, such as Spain and Portugal, the principles of isolation and con nement followed in Europe to control disease outbreaks, were also applied in Latin America and the Caribbean. In practice, beginning in Hispaniola in 1519, in accordance with the 1423 Venetian quarantine control system, measures to cope with epidemics centered on the detention of ships and the isolation of their crews and passengers outside the harbors until suf cient time had elapsed without the outbreak of “pestilences.” The latter years of the 19th Century and the early 20th Century saw various attempts by the Latin American and Caribbean countries and the United States to adopt uniform quarantine regulations at different international conferences, under the aegis of the newly established Pan American Sanitary Bureau in 1902, that preceded the establishment of WHO. These sought to remove barriers to steam navigation, and to codify new preventive measures into specific health legislation and programs based on the great microbiological discoveries of Pasteur, Koch, and Klebs that had revolutionized public health practice in Europe. From 1880 to 1930, national health departments, the forerunners of the present-day ministries of health, were created within the ministries of the interior in most Latin America countries. The initial mission of these departments was to combat the infectious diseases that hampered maritime trade in major port cities and diminished labor productivity in the countries' export-oriented economies, resting on the acceptance and application of the germ theory in disease causation that was supported by leading Latin American scientists such as the Brazilians Oswaldo Cruz and Carlos Chagas, the Cuban Carlos J. Finlay, as well as Walter Reed and others in the United States. As a result of these efforts, great inroads were made in the conquest of many of the diseases that had www.pvmarquez.com/disease_control 2/5 1/12/2021 Public Health Investments and Economic Gains: Learning from Latin America and Caribbean History in the Time of Coronavirus | Patricio V. Marquez warranted quarantine, particularly yellow fever, commonly known as “Yellow Jack”. This represented the principal scourge of international trade throughout the colonial period, up to the beginning of the 20th Century. As a result of these efforts, yellow fever disappeared from its well-established foci, Havana, Panama, and Guayaquil. The completion of the Panama Canal in 1914 was only possible because of the success of major public health efforts against yellow fever and malaria, diseases that took a heavy toll in terms of lives lost among construction workers. In turn, the activities undertaken to help build the canal added further impetus to the development of sanitation programs in the countries of the region by supporting research on the etiology and transmission of yellow fever and malaria which led to the design of more effective control measures. In subsequent periods, the activities of the national health departments expanded with the support of the International Health Commission of the Rockefeller Foundation to undertake land sanitation programs centered on the control of hookworm infection and malaria, with the aim of improving the productivity of workers in exporting regions, such as those growing bananas and coffee. The support of the Rockefeller Foundation was also important for the establishment in 1918 of the School of Public Health, University of São Paulo, following the example of the Johns Hopkins School of Hygiene and Public Health in Baltimore that was founded in 1916 also with a grant from the Foundation. Additionally, the Foundation provided fellowships for the training of Latin American public health cadres (for example, epidemiologists, biostatisticians) to staff the departments, manage public health programs, and conduct public health research. During the 1930s and 1940s, changing economic and socio-political conditions led to the elevation of the health departments to the ministry level and the concurrent expansion of their activities to include the provision of personal health services for the unemployed and indigent populations. Similarly, the development of medical care programs under social insurance schemes was directly linked to the process of industrialization. In satisfying the demands of organized labor forces, these programs served as an important mechanism of social stabilization. In the last three decades of the 20th Century and in the early 21st Century, the most important public health achievements in the Latin American and the Caribbean region have continued to be in the areas of infectious disease control. Mortality rates have declined in virtually every country of the Americas, mainly at the expense of important declines in infectious diseases. Take-Away Message As we have seen throughout history, infectious diseases have recurrent patterns of outbreak and control or silent occurrence due to ecologic variables that are often difficult to manage, mainly because of social, political, and economic limitations on the application of known, effective measures for controlling their spread and treating infected people. The recent outbreaks of infectious disease in the world clearly signal the need, as we saw from the historical examples in Latin America and the Caribbean, of building and maintaining strong institutions and systems to prevent the spread of infectious diseases and protect public health and the social and economic well- being of countries in an ever more interconnected world. And this risk stands to be more menacing in the face of inaction and misplaced social and economic priorities when one adds the risks posed by rapid urbanization and the conglomeration of people living in large mega-cities with limited access to basic services, climate change that is driving the emergence of new pathogens such as the coronavirus and the reemergence of known pathogens such as Ebola, social con ict and wars that not only breed social dislocation and the displacement of large numbers of people, but also that hinder public health action, and massive disruption of global supply chains in interconnected economies. Indeed, commitment to public health objectives and program needs to be firmly entrenched in the development programs of governments and supported with the necessary budgetary allocations in a sustainable way. Financing essential public health functions is a government responsibility as it a basic public good. In most of the www.pvmarquez.com/disease_control 3/5 1/12/2021 Public Health Investments and Economic Gains: Learning from Latin America and Caribbean History in the Time of Coronavirus | Patricio V. Marquez world, however, misplaced priorities translate into very low budgetary allocations for essential public health functions, sometimes amounting to less than 1% of the total public expenditure on health. While donor contributions help, particularly in low-income countries, governments can mobilize additional tax revenue as a share of GDP to fund and sustain public health and essential medical care services via better tax administration (including value-added taxes), tackling tax avoidance and evasion (e.g., taxing nancial capital ows), broadening the tax base by removing cost-ineffective tax expenditures (e.g., fuel subsidies), and increasing excise taxes on unhealthy products (including on tobacco, alcohol, and sugar-sweetened drinks). This is needed, as clearly articulated in a recent article in Foreign Affairs by Nobel Laurate in Economics, Joseph E. Stiglitz and two of his colleagues, because “The state requires something simple to perform its multiple roles: revenue. It takes money to build roads and ports, to provide education for the young and health care for the sick, to nance the basic research that is the wellspring of all progress, and to staff the bureaucracies that keep societies and economies in motion. No successful market can survive without the underpinnings of a strong, functioning state.” So, it would be critical that institutions such as the World Bank Group and the International Monetary Fund spearhead efforts to include robust, well structured and funded public health platforms, including disease surveillance and preparedness, as a critical indicator in country credit and investment risk assessments ratings, which are used to determine nancing terms and conditions of of cially supported export credits, as well as for commercial loans and direct investment decisions by nancial and corporate sectors. This type of institutional “nudge” at the international level is needed to prevent governments, along with other global stakeholders, from forgetting the lessons of recent disease outbreaks, with their associated high human toll and signi cant economic losses. The PHOTOGRAPH taken in 1918 at the US Army Hospital Number 30 in Royat, France, is from the Prints and Photographs Collection, History of Medicine Division, National Library of Medicine. It was included in Fee E et al article (2001). The pictures shows servicemen watching a movie during the In uenza Pandemic spread worldwide through 1918–1919. The article notes that “while a civilian debate raged over the compulsory wearing of masks as a means of slowing the transmission of in uenza, military authorities through the chain of command were more readily able to impose this requirement on the troops.” (Fee, Brown, Lazarus, Theerman, 2001). The second photo is from https://www.dominicavibes.dm/wp-content/uploads/2016/07/pp-zika-mosquitos- getty.jpg Sources Fee E, Brown TM, Lazarus J, and Theerman P. 2001. “The In uenza Pandemic of 1… (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1446912/) Garcia JC. 1981. “La Medicina Estatal en America Latin, 1880-1930.” Revista Lat… (https://www.researchgate.net/publication/257074716_Social_thinking_in_health_in_Latin_America_revisiting_Ju Marquez PV, Joly DA. 1986. “Historical Overview of the Ministries of Public Hea… (https://doi.org/10.2307/3342464) Stiglitz JE, Tucker TN, and Zucman G. “The Starving State Why Capitalism’s Salv… (https://www.foreignaffairs.com/articles/united-states/2019-12-10/starving-state) www.pvmarquez.com/disease_control 4/5 1/12/2021 Public Health Investments and Economic Gains: Learning from Latin America and Caribbean History in the Time of Coronavirus | Patricio V. Marquez (https://twitter.com/pvmarquez1956) www.pvmarquez.com/disease_control 5/5 1/12/2021 Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported | Patricio V. Marquez Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported Submitted by Patricio V. Marquez on Fri, 02/07/2020 - 07 46 PM Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported Posted by Patricio V. Marquez on Fri, 02/07/2020 - 07 46 PM A couple of weeks ago, I had the honor of being invited by the Charles Darwin Foundation (CDF) to the screening of a new documentary directed by Evert van den Bos, Galapagos, Hope for the Future. It was held in New www.pvmarquez.com/Galapagos_CDF 1/10 1/12/2021 Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported | Patricio V. Marquez York City as part of a meeting of the Foundation’s Board of Directors, which offered me the opportunity to meet some of the members and learn more about its work. In watching the documentary, I was greatly struck once again by the sheer beauty of these desolate islands and their unique animals and plants. The documentary also presents with great clarity how, on a daily basis, teams of the Foundation and its Research Station, working alongside teams of the Galapagos National Park Service, conduct vital scienti c research and complementary action to ensure the conservation of the environment and biodiversity in the Galapagos Archipelago. The Archipelago, located in the Paci c Ocean off the coast of Ecuador, is a UNESCO World Natural Heritage Site. Figuratively speaking, the Galapagos were “put on the map” and became a magnet of international curiosity and scienti c interest, with the publication in 1858 of Charles Darwin’s groundbreaking work of evolutionary biology, On the Origin of the Species. Indeed, Darwin’s visit to some of the islands in the Archipelago during his expedition on the HMS Beagle in 1835 helped him collect evidence of evolution in the diversity of the Galapagos species that led to his observation that species descending from a common ancestor evolve over many generations through a process of natural selection (the process whereby organisms better adapted to their environment tend to survive and produce more offspring). In 1959, the Government of Ecuador designated all parts of the islands that were not inhabited by humans as a National Park (96% of the total archipelago’s surface area). The same year, the Charles Darwin Foundation was created, and in 1964, the Charles Darwin Research Station opened to conduct scienti c studies aimed at protecting indigenous plant and animal life. In 1968, the Galapagos National Park Service, a governmental institution, was established to protect the Archipelago. www.pvmarquez.com/Galapagos_CDF 2/10 1/12/2021 Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported | Patricio V. Marquez Institutions, such as foundations, can play a major role in a society. Over the past 60 years, the CDF, operating with limited resources, has become a beacon of international good practice, offering valuable lessons for the rest of the world. The vision statement of the CDF clearly illustrates how this type of role can be operationalized for the common good: “to contribute to a sustainable Galapagos by providing breakthrough research which informs conservation actions and inspires humanity to conserve this extraordinary Archipelago and our planet as a whole.” As shown in the documentary and described in the CDF’s most recent Annual Report, the range and value of the work conducted and supported by the Foundation are outstanding. With a small team of staff and volunteers (about 217 people), the Foundation oversees and supports work by scholars and thesis students, both Ecuadorean and from other countries; visiting scientists developing their own projects with a research permit issued by the Galapagos National Park; and collaborating scientists who carry out projects linked to CDF projects. The research includes marine projects as varied as the study of the status of the Galapagos penguin, ightless cormorant, and albatross populations; research on marine invasive species for the prevention, detection, and management of the Galapagos Marine Reserve (GMR); exploring and surveying seamounts and other deep water environments between depths of 40 to 3200 meters in the GMR ; and studies to reduce the threat of vessel impact for the green turtle in the Islands. Terrestrial ecosystem research projects include research on ecological restoration and sustainable agriculture; analysis of satellite images and drone image processing to map the expansion of invasive plant species; restoration of scalesia forests, which have a very high biodiversity of associated plants, birds, and invertebrates, compared to other ecosystems in the Galapagos; and assessment of the health status of giant tortoise across a www.pvmarquez.com/Galapagos_CDF 3/10 1/12/2021 Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported | Patricio V. Marquez human-modi ed environment. The latter study is looking in depth at the impact on the giant tortoise population of the cohabitation between tortoises, domestic animals, and humans in the islands that are inhabited by humans in terms of the spread of diseases and antimicrobial resistance that can pose a risk for the conservation of this unique species. The CDF’s work also includes critical communication, outreach, and extension work, such as the Sharks Ambassadors education initiative program for high school-aged students, that focuses on shark conservation. In terms of knowledge management, the CDF is custodian of four Natural History Collections—Herbarium (CDS), Terrestrial Invertebrates (ICCDRS); Marine Invertebrates (MCCDRS); and Vertebrates (VCCDRS)—which constitute the largest collections of endemic, native, and exotic species of the Galapagos in the world. The library of the CDF is the main bibliographic repository of the Scienti c Station and also manages the archival materials. Additionally, resources from the CDF fund conservation activities, such as the mangrove nch project, aimed to conserve this species and prevent its disappearance (there are currently only around 100 individuals left in the world). The operation and work of the CDF relies 100 percent on private support from individuals, institutions, and corporations. Therefore, for all of us interested in preserving the unique ecosystem of the Galapagos Archipelago as our legacy to future generations, a priority challenge is nancial resource mobilization to ensure predictable and sustainable funding for the CDF. How can this be done in the short- and medium-terms? An expansion and diversi cation of the CDF’s funding sources is perhaps required, involving both earmarked Ecuadorian Government contributions and private donations, for the implementation of a results-oriented medium-term strategy and action plan for the CDF. www.pvmarquez.com/Galapagos_CDF 4/10 1/12/2021 Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported | Patricio V. Marquez First, in Ecuador, as in other countries, there is the potential to mobilize more in taxes as a share of GDP via better tax administration (including value-added taxes), tackling tax avoidance and evasion, broadening the tax base by removing cost-ineffective tax expenditures, and increasing excise taxes on unhealthy products (including on tobacco, alcohol, and sugar- sweetened drinks), and where feasible, some of which can ow to expand scal space for conservation work under the CDF and the Galapagos National Park. Second, the national effort could be complemented with the establishment of dedicated trust funds with grant resources mobilized from ecological conservation and climate action-oriented governments in high-income countries. The allocation of trust fund resources could be linked to the achievement of pre-de ned activities and results, such as the development of a monitoring program to assess the threat posed by marine plastic debris as potential transport for introducing non-native species that could become invasive and harmful to the ecosystem in the Islands. Third, with the support of the Government of Ecuador, grant resources for global public goods available under existing mechanisms in multilateral nance institutions such as the World Bank Group and the Inter-American Development Bank, could be explored and invite technical proposals from the CDF for consideration by these organizations. Fourth, diversi cation of private funding will be crucial. Different foundations and philanthropies could be tapped to support the CDF as some of them are already committed to support the achievement of the Sustainable Development Goals (SDGs) of the United Nations by 2030, and the work of the CDF is focused on supporting the achievement of several SDGs’ economic, environmental, and social targets. Entities such as the Bloomberg Philanthropies, The Bill and Melinda Gates Foundation, The Nippon Foundation, The Rockefeller Foundation, and The Carlos Slim www.pvmarquez.com/Galapagos_CDF 5/10 1/12/2021 Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported | Patricio V. Marquez Foundation, are only a small sample of possible additional sources for diversifying CDF funding. Donations from wealthy individuals, both in Ecuador and at the international level, and the general public could help to mobilize nancial support as well. Fifth, in pursuing active resource mobilization options, raising the pro le of the CDF and educating different stakeholders about the results and impact of its conservation work will be required. Events organized by institutions such as the Salzburg Global Seminar and the World Economic Forum, as well as the Annual Meetings of the World Bank Group/International Monetary Fund, could serve as potential venues for information, communication, and education efforts geared to mobilize commitments and support from different international stakeholders. Naturally, any increase in funding levels would need to be accompanied by strong administrative and nancial arrangements at the CDF, complemented by robust monitoring, evaluation, and reporting mechanisms on resource use, activities undertaken, results, and impact achieved. Looking forward The preservation of World Natural Heritages sites, such as the Galapagos Archipelago, depends on the active and dedicated mobilization of support from a broad group of committed stakeholders, both in Ecuador and across the world. If done ef ciently and effectively, this effort would help to ensure that the bene ts of this global public good will not be limited to the current generations but will also be for the enjoyment of future generations as our lasting legacy to them. In doing so, we will be contributing to preserve the unique “natural history” of these islands, where, as observed by Charles Darwin in The Voyage of the Beagle: www.pvmarquez.com/Galapagos_CDF 6/10 1/12/2021 Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported | Patricio V. Marquez “Most of the organic productions are aboriginal creations, found nowhere else; there is even a difference between the inhabitants of the different islands; yet all show a marked relationship with those of America, though separated from the continent by an open space of ocean, between 500 and 600 miles in width. The archipelago is a little world within itself, or rather a satellite attached to America, whence it has derived a few stray colonists, and has received the general character of its indigenous productions. Considering the small size of the islands, we feel the more astonished at the number of their aboriginal beings, and at their con ned range. Seeing every height crowned with its crater, and the boundaries of most of the lava-streams still distinct, we are led to believe that within a period geologically recent the unbroken ocean was here spread out. Hence, both in space and time, we seem to be brought somewhat near to the great fact—the mystery of mysteries—the rst appearances of new beings on this earth.” Contact information: Charles Darwin Foundation for the Galapagos Islands Puerto Ayora, Santa Cruz, Galapagos, Ecuador T: +593 (5) 2526 146 E: [email protected] (mailto:[email protected]) W: www.darwinfoundation.org (http://www.darwinfoundation.org) PP Box 17-1-3891 Quito, Ecuador To make a donation: www.pvmarquez.com/Galapagos_CDF 7/10 1/12/2021 Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported | Patricio V. Marquez www.pvmarquez.com/Galapagos_CDF 8/10 1/12/2021 Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported | Patricio V. Marquez www.pvmarquez.com/Galapagos_CDF 9/10 1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence Submitted by Patricio V. Marquez on Sun, 02/02/2020 - 02 39 PM Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence Posted by Patricio V. Marquez on Sun, 02/02/2020 - 02 39 PM The newly-released Smoking Cessation: A Report of the Surgeon General of the United States (U.S. Department of Health and Human Services, 2020) reaf rms, on the basis of accumulated scienti c evidence over the past half century, that tobacco use leads to many adverse health effects, including negative reproductive health outcomes, www.pvmarquez.com/tobacco_taxes 1/13 1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez cardiovascular diseases, chronic obstructive pulmonary disease, and the risk of twelve cancers, including cancers of the lung; larynx; oral cavity and pharynx; esophagus; pancreas; bladder; stomach; colon and rectum; liver; cervix; kidney; and acute myeloid leukemia. The report is also clear in indicating that smoking cessation can be increased by raising the price of cigarettes. It is frequent, however, to come across common claims put forward by interest groups that oppose the enactment of tobacco tax policies. These claims are often accepted uncritically by policy makers in countries at different income levels, without due consideration of available evidence. The question that we need to ask, then, is how do these claims stand vis-à-vis accumulated global evidence? Are these claims part and parcel of the “economics of deception and manipulation” that drive aggressive industry-sponsored campaigns in the pursuit of pro ts and market share expansion? Have the claims become just myths not borne out by accumulated country evidence? The results of recent research done by World Bank Group teams across the world, along with additional data and information, are presented below to shed light on these questions. Myth 1 Raising tobacco taxes undermines the tax base and lowers tobacco tax revenue. Evidence: A report from the International Monetary Fund (Petit and Nagy, 2016) is clear in indicating that “in many countries, raising tobacco taxes can offer a “win–win”: higher revenue and positive health outcomes.” Higher tobacco taxes help boost cigarette prices, which are highly effective in reducing demand, which reduce use and the health risks associated with smoking. The positive impacts of higher tobacco taxes and prices go beyond direct health gains and indirect bene ts such as reduced health care expenditures and higher productivity. Increasing tobacco taxes can also enlarge a country’s tax base to augment domestic resource mobilization to fund priority investments and programs, including the expansion of universal health coverage. The experience of the Philippines since the adoption of the Sin Tax Law of 2012 is one of the most compelling examples of ambitious national tobacco tax reform, including reduction in the number of tax tiers, indexation of tax rates to in ation, and substantial tax increases. As shown in Figure 1, excise tax revenue on tobacco and alcohol products has more than doubled since 2012, reaching US$5.2 billion in additional revenues during www.pvmarquez.com/tobacco_taxes 2/13 1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez the rst 4 years of the Sin Tax Law implementation (about 1 percent of GDP). Tobacco accounts for about 80 percent of these additional tax revenues, which largely are earmarked under the budget to subsidize health insurance for low-income populations (Kaiser, Bredenkamp and Iglesias, 2016). The experience of Ukraine is also noteworthy (Smits et al 2017). The total tax burden (including excise taxes, value-added tax [VAT], and other duties on tobacco as a percentage of retail price) increased from 62 percent in 2015 to 77 percent in 2019. As a result, national tobacco excise revenue increased from 22 billion UAH in 2015 (1.12% of GDP) to 40 billion UAH in 2018 (1.34% of GDP) (see Figure 2). Moldova has also been able to collect additional tax revenue since 2017 from hiking tobacco taxes (Marquez et al, 2018). Cigarette excise tax revenue in the country increased from MDL 1.73 billion (US$ 87 million) in 2016 to MDL 2.05 billion (US$ 110.6 million) in 2017, or about 1.16 percent of Moldova’s GDP. The tobacco tax increases adopted by Moldova’s Parliament for 2018-2020 are projected to further increase excise tax revenue, hitting 3.31 billion MDL (US$194 million) or 1.45 percent of GDP in 2020. www.pvmarquez.com/tobacco_taxes 3/13 1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez Colombia is another example (James et al, 2017). As part of a broad scal reform package approved by Colombia’s Congress on December 23, 2016, the speci c excise tax on a pack of 20 cigarettes was increased from COP 700 (US$ 0.25) in 2016 to COP 1,400 (US$ 0.50) in 2017, and COP 2,100 (US$ 0.75) in 2018, with annual adjustments of Consumer Price Index (CPI) + 4 points in subsequent years. The ad valorem excise tax component was maintained at 10 percent of the total sale price of a 20-cigarette pack, and the general VAT rate was raised from 16 percent to 19 percent. As a result, the total tax burden (as percentage of retail price of a pack of 20 cigarettes) increased from 50 percent in 2016 to 68 percent in 2018. The average price of a pack of 20 cigarettes increased by 42.5 percent over 2017-2018. The expected scal and health impacts of this measure are noteworthy. It is estimated that COP 1 trillion (about US$ 347 million) in additional revenue will be generated through 2022. The experience of Australia, United States, and the United Kingdom (UK) provide additional evidence (Fuchs, Marquez, Dutta, Gonzalez Icaza, 2019). The annual increases in tobacco excise taxes in the past decade have led Australia to have one of the highest prices of cigarettes in the world--a 20-pack of Marlboro costs approximately US$19, while the same pack costs only US$12 in the UK, US$7 in the United States, and US$3.88 in South Africa. The high tobacco tax level has also contributed massive yearly tax revenue to the Government. In the United States, the federal cigarette tax for cigarettes was increased signi cantly in 2009 from US$0.39 per pack to approximately US$1.01 per pack. The tax increase was designed to help pay for the cost of children's health insurance under the State Children's Health Insurance Program (SCHIP). Revenues more than doubled from US$7.6 billion in 2008 to US$17.1 billion in 2010, once the law fully took effect. Although revenues have declined from the high level reached in 2010, they are still projected to represent in 2024 double the amount collected prior to the 2009 tax hike. In the UK, as a result of high taxes and prices, smoking rates have continued to decline over the past decade, and tobacco taxes contributed an estimated £10 billion in tax revenue to the UK Government over 2016-2017. Assessment done by the World Bank Group in Russia show that that life expectancy in the country for men increased to 65.4 years in 2016, up from 58 years in 2003, and among women, to 76.2 years in 2016, up from 72 years in 2003 (Marquez and Gonima, 2018). A big contributor to this change has been the effective measures adopted to control the consumption of tobacco and alcohol over this period, including the enactment of a law on tobacco control in 2013 and regular increases in tobacco excise taxes since 2010. Because of tax and price increases, along with other tobacco control www.pvmarquez.com/tobacco_taxes 4/13 1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez interventions, tobacco sales fell by almost 30 percent over this decade. Not surprisingly, the number of smokers also decreased, by 21 percent between 2009 and 2016, while higher tobacco taxes increased tax revenue for the country (Figure 3). Similar experiences have been observed in other countries as varied as Botswana, China, European Union-Member States, Republic of Korea, South Africa, Turkey, and Uruguay (Marquez and Moreno-Dodson, 2017; Zheng, Hu, Marquez, Wang, Xiaoxia, 2017; Bouw, 2017; Eun Choi and Marquez, 2018; Cetinkaya and Marquez, 2017; Marquez, 2017). Myth 2 Increased price of tobacco products due to higher taxes is regressive because the poor are affected the most. Evidence: Country-speci c research conducted by the World Bank Group, as well as the work done in the United States, show that the poor tend to smoke more and are more price responsive on average than richer individuals, so they get a far greater share of health bene ts from higher tobacco taxes than they pay. By discouraging consumption, taxes on tobacco products reduce the adverse health effects of tobacco, as well as the large associated medical and human capital costs to households and societies. Medical treatment of the numerous chronic diseases caused or exacerbated by tobacco drives up annual health care costs in public health care systems and households. Smoking reduces household earning potential and labor www.pvmarquez.com/tobacco_taxes 5/13 1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez productivity, negatively affecting human capital accumulation and development. Hence, reducing tobacco use translates to lower smoking-related medical expenses, increases in life expectancy at birth, and reductions in disability. A World Bank Group assessment done for Armenia (Postolovska et al, 2017) shows that increased excise taxes on tobacco would bring large health and nancial bene ts to Armenian households and be pro-poor: about 88,000 premature deaths, US$ 63 million of out-of-pocked medical expenditures, 22,000 poverty cases, and 33,000 cases of catastrophic health expenditures would be averted. Government savings on tobacco- related treatment costs would amount to US$26 million. Half of the premature deaths and 27 percent of poverty cases averted would be concentrated among the bottom 40 percent of the population. The net total distributional impact of tobacco taxation estimated in World Bank assessments done in in Bosnia and Herzegovina, Chile, Moldova, Russia, South Africa, and Ukraine (Fuchs et al 2019), is shown in Figure 4. Lower medical expenditures and additional working years help offset the negative direct income effect of an increase in tobacco prices. The total income effect associated with a 25 percent price increase is positive in the case of several income groups, especially at the lower end of the income distribution. However, most households in Bangladesh and Indonesia, and between 30 and 50 percent of the population in Bosnia and Herzegovina, Chile, and South Africa, continue to be negatively affected. In the particular case of Indonesia, the distribution continues to be U-shaped. The net effect becomes positive and more progressive with higher price increases, as reduce affordability of cigarettes allows the health and www.pvmarquez.com/tobacco_taxes 6/13 1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez economic bene ts of the taxes on tobacco to kick in. In a 100 percent price increase scenario, only the 40 percent richest households in Chile, and the top 60 percent in Bangladesh—where medical expenses have lowest incidence—are negatively affected. The results are generally progressive in all eight countries. A most recent assessment done for Vietnam (Fuchs et al, 2019), con rms that above ndings, as under moderate and to high price increase scenarios, the distribution of the net bene ts is highly progressive. Poor households capture relatively large income gains that increase with the magnitude of the price increase. Increasing the excise tax, for example, by D 10,000 (US$0.43 cents) could bring income gains of over 1.5 percent to the poorest 30 percent of the population in Vietnam. The effect among the top four income deciles would be closer to zero under all scenarios. In Tonga (Osornprasop 2019), the excise tax resulted in a price increase across all the taxed products, making cigarettes less affordable and affecting smokers’ behaviors. Tax on cigarettes has a greater effect on “less well-off” smokers, as a larger number of less well-off smokers reduced consumption of manufactured cigarettes. This is consistent with the other country ndings on the equity impacts of price policies, as low-income households respond to price changes more readily than higher income households. Price, rather than other factors, was the main reason among those who decided to change behaviors and reduce consumption. Assessing the situation in the United States, Furman (2017), concludes that the criticism against tobacco taxes is backward. The health bene ts of tobacco taxes far exceed the increase in tax liability, and they accrue disproportionately to lower-income households. Moreover, as Furman observes, it is important to also evaluate what the www.pvmarquez.com/tobacco_taxes 7/13 1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez additional revenue raised by the tobacco tax may be used for. The most recent increases in the United States, enacted in 1997 and 2009, were used to create and expand a very progressive children’s health insurance program. Myth 3 Higher taxes lead to increased smuggling and use of counterfeit tobacco Evidence: A recent global report by the World Bank Group focusing on over 30 countries across the income and development spectrum (Dutta et al, 2019), shows that, contrary to tobacco industry arguments, tobacco taxes and prices have only a limited impact on the illicit market share at the country level. The evidence presented in the report indicates that the illicit cigarette market is relatively larger in countries with low taxes and prices, while relatively smaller in countries with higher cigarette taxes and prices. Non-price factors such as governance status, weak regulatory framework, and the availability of informal distribution networks appear to be far more important factors. Countries reporting signi cant progress in the control of illicit tobacco trade adopted some key policy and institutional measures which contributed to their success. A good example is Ireland, where a high rate of tobacco excise taxes, and the consequent high price of tobacco products, makes the country attractive to those involved in the illicit tobacco trade. However, Ireland’s comprehensive and effective system of customs and tax enforcement, alongside strong regulatory control of the tobacco market, has contained the illicit ow of tobacco products onto the Irish market. Indeed, Ireland’s most recent results indicate that the general trend for illicit cigarettes between 2007-2017 has been downward (13 presently). Notably, this has occurred during a period where price of cigarettes has risen and smoking prevalence has declined (by about 10 percentage points). This suggest that, while the illicit trade www.pvmarquez.com/tobacco_taxes 8/13 1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez has not been eliminated, the extensive program of enforcement has contained it. Analysis indicates that the main driver of illicit ows is not relative levels of price/taxation, but the effectiveness of customs and tax enforcement. A key lesson from the report’s country case studies is that strengthening the legal framework and tax administration and enforcement is complementary to tobacco tax policy reform as these measures reinforce one another. As outlined in the World Bank Group report, experience shows that illicit tobacco trade can be controlled by legal means (e.g., use of prominent tax stamps, serial numbers, special package markings, health warning labels in local languages, adoption of uniform tax rates nationwide that facilitate successful collection at the points of manufacture and import), and by increased law enforcement (e.g., improving corporate auditing, better trace and tracking systems, and good governance). Myth 4 Tobacco tax hikes lead to signi cant job losses Evidence: Policymakers considering tobacco tax hikes are often concerned about negative impacts on employment. World Bank Group research provides fresh evidence from eld studies and economic simulations focusing on Indonesia (Araujo et al 2018), one of the world’s largest tobacco producers. The results provide clearer understanding of the relationship between tobacco taxation and employment. Tobacco manufacturing represents only a small share of Indonesia’s economy-wide employment (0.60 percent) and a relatively low percentage of jobs in the manufacturing sector (5.3 percent). This compares to the food (27.43 percent), garment (11.43 percent), and textile (7.90 percent) sectors. The productivity of tobacco manufacturing workers is also quite low relative to the productivity of workers in other www.pvmarquez.com/tobacco_taxes 9/13 1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez comparable sectors. Indonesia’s tobacco manufacturing is geographically concentrated in East and Central Java (76 percent) and West Nusa Tenggara (18 percent). Only a few districts are substantially dependent on tobacco sector employment. Most tobacco farmers and manufacturing workers rely only partially on tobacco income. Income from kretek rolling represents 43 percent of household income among kretek households on average. About three-quarters of tobacco-farming households derived less than 50 percent of their income from tobacco cultivation, and over half of clove farmers generate less than 20 percent of their household income from cloves. Tobacco cultivation is not pro table for most farmers, and producing tobacco has high opportunity costs. This nding was mostly consistent across regions, type of tobacco grown, and whether the farmer was on contract to grow tobacco. Despite poor returns typically, farmers reported being drawn to the assured market, the better prospects for credit, and the potential to earn cash. Economic simulations suggest that raising cigarette taxes by an average of 12 percent that increases cigarette prices by an average 5 percent and simplifying Indonesia’s cigarette tax structure to six tiers will reduce cigarette demand by 1.89 percent, increase government revenue by 6.41 percent, and reduce gross employment in the tobacco manufacturing sector by 0.43 percent. This represents a reduction of less than 3,000 tobacco manufacturing jobs, most of them in the handmade kretek industry (2,245 fewer jobs). Importantly, these estimates do not consider the creation of jobs in other sectors due to the shift in consumers’ spending away from tobacco (the net effect). The estimated total household income loss from reduced employment in the handmade kretek industry amounts to a small fraction of 1 percent (0.16 percent) of the revenue gain that Indonesia will obtain by increasing cigarette taxes. To sum up, higher taxes, yielding higher retail prices, will cut tobacco consumption and reduce economic losses due to health care costs and compromised productivity, with low-income groups bene ting more as discussed above. Aggressive tobacco tax hikes will generate additional revenue that can more than compensate for the income loss following a reduction in employment in the kretek industry. Take-Away Message www.pvmarquez.com/tobacco_taxes 10/13 1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez The common claims used by interest groups to oppose tobacco tax increases, price hikes, and reductions in demand and use, are not supported nor borne out by accumulated country evidence. Improved data availability and further research are required for updating and expanding the global evidence base to confront these claims as they have become widely-held “myths” often accepted uncritically by government of cials and stakeholders, as well as the general public. So, as stated in an article in The Economist (2017), the take-away message for policy makers and other stakeholders around the world, should be unambiguously clear: "As the success in rich countries shows, there is no mystery about how to get people to stop smoking: a combination of taxes and public-health education does the job. This makes the abysmal record in poor countries a grave failure of public policy. The good news is that, following recent research, it is one that has just become easier to put right." By adopting the United Nations Sustainable Development Goals (SDGs), countries across the world have committed to achieving a 30 percent reduction in death rates from noncommunicable diseases like cancer, stroke, and heart disease by 2030. Reducing tobacco use is critical for countries to reach this goal. To swiftly cut smoking rates, bold increases in tobacco excise tax rates are by far the most powerful tool. High smoking prevalence condemns large numbers of people to avoidable sickness and death and weakens the country’s economic development. As observed by Jha and Peto (2014), attainment of the SDG target requires decreases not only in high-income countries but also in populous low- and middle-income countries “to prevent several tens of millions of tobacco- attributable deaths during the next few decades, and about 200 million tobacco-attributable deaths during the century as a whole, mostly among people who are already alive, both by helping smokers to quit and by helping adolescents not to start.” Sources Araujo, EC, Harimurti, P, Sahadewo, GA, Nargis, N, Drope, J, Marquez, PV, Al Ri… (http://documents.worldbank.org/curated/en/219251526070564098/pdf/126158- REVISED-PUBLIC.pdf) Bouw, A. 2017. “Tobacco taxation in the European Union: an overview.” WBG Globa… (http://documents.worldbank.org/curated/en/493581492415549898/Tobacco- www.pvmarquez.com/tobacco_taxes 11/13 1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez taxation-in-the-European-Union-an-overview) Cetinkaya, V, Marquez, P. 2017. “Tobacco taxation in Turkey: an overview of pol… (http://documents.worldbank.org/curated/en/320121492424907154/Tobacco- taxation-in-Turkey-an-overview-of-policy-measures-and-results) Dutta, S, Marquez, PV, Isenman, P, Ross, R. 2019. “Confronting Illicit Tobacco … (http://documents.worldbank.org/curated/en/677451548260528135/Confronting- Illicit-Tobacco-Trade-a-Global-Review-of-Country-Experiences) Eun Choi, S, Marquez, PV. 2018. “Reducing tobacco use through taxation: the exp… (http://documents.worldbank.org/curated/en/150681529071812689/Reducing- tobacco-use-through-taxation-the-experience-of-the-Republic-of-Korea) Fuchs Tarlovsky, A, Gonzalez Icaza. 2019. “The Welfare and Distributional Effe… (http://documents.worldbank.org/curated/en/758391561477648302/The-Welfare- and-Distributional-Effects-of-Increasing-Taxes-on-Tobacco-in-Vietnam) Fuchs Tarlovsky, A, Gonzalez Icaza, Paz, D. 2019. “Distributional Effects of To… (http://documents.worldbank.org/curated/en/358341554831537700/pdf/Distributional- Effects-of-Tobacco-Taxation-A-Comparative-Analysis.pdf) Fuchs Tarlovsky, A, Marquez, PV, Dutta, S, Gonzalez Icaza, MF. 2019. “Is Tobacc… (http://documents.worldbank.org/curated/en/893811554737147697/Is-Tobacco- Taxation-Regressive-Evidence-on-Public-Health-Domestic-Resource-Mobilization- and-Equity-Improvements) Furman, J. 2016. “Policy, Politics, and the Tripling of Federal Tobacco Taxes i… (http://documents.worldbank.org/curated/en/820951485943150390/Summary- report) James E, Saxena A, Franco Restrepo C, Llorente B, Vecino Ortiz A, Villar Uribe… (https://openknowledge.worldbank.org/handle/10986/28598) Jha P, Peto R. 2014. “Global effects of smoking, of quitting, and of taxing tob… (https://www.nejm.org/doi/pdf/10.1056/NEJMra1308383) Kaiser K, Bredenkamp C, Iglesias R. 2016. “Sin Tax Reform in the Philippines: T… (https://openknowledge.worldbank.org/handle/10986/24617) Marquez, PV, Gonima, A. 2018. “Reducing Tobacco Use Through Taxation in the Ru… (http://documents.worldbank.org/curated/en/873551539183125023/Reducing- Tobacco-Use-Through-Taxation-in-the-Russian-Federation-A-Modelled-Assessment- of-Two-Policy-Options) Marquez, PV, et al. 2018. “Moldova – Why is Tobacco Taxation Important?”. WBG G… (http://documents.worldbank.org/curated/en/337481541098390886/Moldova-Why- is-Tobacco-Taxation-Important) Marquez, PV, ed. 2017. “Expanding the global tax base: Taxing to promote public… (http://documents.worldbank.org/curated/en/820951485943150390/Summary- report) www.pvmarquez.com/tobacco_taxes 12/13 1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez Marquez PV, Moreno-Dodson B. eds. 2017. “Tobacco tax reform at the crossroads o… (http://documents.worldbank.org/curated/en/491661505803109617/Main-report) Osornprasop, S; Zheng, R; Hufanga, SV; Latu, CF; Lounkaew, K; Krahn, J; Ve’etut… (http://documents.worldbank.org/curated/en/844811561475012529/Using-Taxation- to-Address-Noncommunicable-Diseases-Lessons-from-Tonga) Petit P and Nagy J. 2016. “How to design and enforce tobacco excises?” Washingt… (http://pubdocs.worldbank.org/en/309561480947116095/howtonote1603.pdf) Postolovska I, Lavado RF, Tarr G, Verguet S. 2017. “Estimating the distribution… (http://documents.worldbank.org/curated/en/604501492414938391/Estimating-the- distributional-impact-of-increasing-taxes-on-tobacco-products-in-Armenia-results- from-an-extended-cost-effectiveness-analysis) Smits, K, Golovach, A, Awasthi, R, Balabushko, O, Budagovskaya, S, Lunina, I, S… (http://documents.worldbank.org/curated/en/476521500449393161/Ukraine-Public- nance-review) The Economist. 2017. “Cough up. How to cut smoking in poor countries.” Leaders,… (https://www.economist.com/leaders/2017/06/01/how-to-cut-smoking-in-poor- countries) U.S. Department of Health and Human Services. 2020. “Smoking Cessation. A Repor… (https://www.hhs.gov/sites/default/ les/2020-cessation-sgr-full-report.pdf) Zheng, R, Hu, X, Marquez, PV, Wang, Y, Xiaoxia, E. 2017. “Cigarette Affordabili… (http://documents.worldbank.org/curated/en/130301492424519317/Cigarette- affordability-in-China-2001-2016) (https://twitter.com/pvmarquez1956) www.pvmarquez.com/tobacco_taxes 13/13 1/12/2021 High Prices for Essential Drugs: A Risk for Public Health, Catastrophic Health Spending, High-Debt Levels, and Impoverishment | Patricio V. Marquez High Prices for Essential Drugs: A Risk for Public Health, Catastrophic Health Spending, High-Debt Levels, and Impoverishment Submitted by Patricio V. Marquez on Tue, 01/28/2020 - 06 11 PM High Prices for Essential Drugs: A Risk for Public Health, Catastrophic Health Spending, High-Debt Levels, and Impoverishment Posted by Patricio V. Marquez on Tue, 01/28/2020 - 06 11 PM pvmarquez.com/drug_prices 1/7 1/12/2021 High Prices for Essential Drugs: A Risk for Public Health, Catastrophic Health Spending, High-Debt Levels, and Impoverishment | Patricio V. Marquez As all of us who have been sick or diagnosed with a chronic condition that requires adherence to a daily drug regime know, timely access to required medicines not only helps us get better or manage a health condition over the long term, but saves us from hospitalization if the disease is not controlled, helps us avoid being absent from work, improves our productivity, and enhances our quality of life. So, from an ethical, societal, and public health point of view, it should not be accepted that the sick or those living with a chronic condition are put at risk of ill health, premature mortality and disability, catastrophic health spending, debt and impoverishment because they cannot afford essential medicines when needed, or are forced by high drug prices to ration their medication, aggravating their health condition and even putting them at risk of death. Although this dire reality is common in many countries of the world, the current political debate in the United States is illustrative of this global public health challenge as high drug prices are a top concern for families across the country, who face common threats often found under private health insurance arrangements: pre-existing clauses that do not cover a medical condition that started before a person's health insurance bene ts went into effect, as well as high deductibles, co-payments, and lifetime limitations in services and drug coverage. The high cost of insulin, a lifesaving medication needed to manage Type-1 diabetes, which affects about 5 percent of people with diabetes in the United States, is a good example of the ironies, inequities, and negative social impact of the lack of or limited access to essential drugs in the country. Indeed, it is not only ironic but I would say it is morally wrong that drug companies have been pro ting from selling insulin at high prices, in spite of the fact that Frederick Banting and John Macleod, who were pvmarquez.com/drug_prices 2/7 1/12/2021 High Prices for Essential Drugs: A Risk for Public Health, Catastrophic Health Spending, High-Debt Levels, and Impoverishment | Patricio V. Marquez awarded the 1923 Nobel Prize in Medicine for its discovery, sold the patent to the University of Toronto for $1 each because they felt that insulin belonged to the world and not for their enrichment. As described by Michael Fralick and Aaron S. Kesselheim, in a recent article in the New England Journal of Medicine (NEJM), almost 100 years after its discovery, insulin is inaccessible to thousands of Americans because of its high cost. The information presented in the article shows that the price of insulin in the United States has risen substantially over the past two decades: “today, the price of 100 units of short-acting insulin for adults without insurance is about $18. The usual dose for regular insulin is 0.5 to 1.0 units per kilogram per day (usually given before meals). Thus, for a person with type 1 diabetes who weighs 70 kg and is taking a dose of 1 unit per kilogram per day, 100 units will last less than 2 days. Most adults taking short-acting insulin also require either intermediate- or long-acting insulin, the latter of which is also quite costly” (see below table from the NEJM article). pvmarquez.com/drug_prices 3/7 1/12/2021 High Prices for Essential Drugs: A Risk for Public Health, Catastrophic Health Spending, High-Debt Levels, and Impoverishment | Patricio V. Marquez The difference in drug prices between the United States and the rest of the world, is mindboggling. In some cases, as with the fast-acting insulin Novolog, it is 74% cheaper when ordered from a pharmacy in Canada. In should not surprise us, then, that while the United States represents only 15% of the global insulin market, it generates almost half of the pharmaceutical industry’s insulin revenue. What can be done to deal with the rising cost of insulin and other prescription drugs in the United States and elsewhere? How can essential drugs become more accessible and affordable? While the mandatory provision of an essential outpatient drug bene t package for priority, high-burden diseases, such as Type 1 diabetes, under publicly-funded arrangements or health insurance plans is a critical measure to guarantee their timely access and affordability, additional measures as those now being debated in the United States are needed, including supply side measures such as price negotiation, changes in patent laws, and the manufacture of generics. An essential drug bene t program, that eliminates or caps-out out-of- pocket drug spending for everyone, could be funded through an improved allocation of overall public expenditures, including a shift toward long- term social needs such as health and away from less productive categories of public expenditures (for example, untargeted subsidies and transfers, general administration expenditures and unproductive public investments). Other funding options include, as already done in some countries, increasing taxes on cigarettes, alcohol, and sugar sweetened drinks, since current tax rates are evidently far below what is feasible in terms of revenue potential and the generation of health bene ts. pvmarquez.com/drug_prices 4/7 1/12/2021 High Prices for Essential Drugs: A Risk for Public Health, Catastrophic Health Spending, High-Debt Levels, and Impoverishment | Patricio V. Marquez If we focus on insulin as a tracer of the problem, then the need for supply side measures becomes clearer. As explained in Fralick and Kesselheim’s article, the rising cost of insulin in the United States can be attributed primarily to two phenomena: rst, the current law allows pharmaceutical manufacturers to price their products at whatever level they believe the market will bear and to raise prices over time without limit (this practice is the opposite of what England does, where the government sets a maximum price it will pay for a drug when directly negotiating with the pharmaceutical industry); and second, direct competition in the insulin market is lacking (approximately 90% of insulin sold in the United States is manufactured by one of three companies: Eli Lilly, Novo Nordisk, and Sano ). The plan proposed by Michael Bloomberg, the former Mayor of New York and Global Philanthropist, to lower the prices for essential medications for everyone in the United States, offers a good road map that merits consideration. It calls for the adoption of legal measures and requirements that authorize governments and insurance companies to negotiate drug prices with the pharmaceutical industry in order to lower prices for everyone; it promotes the selection of most cost-effective drugs, including generics; it allows for the importation of safe drugs from other countries with good quality standards and where prices are lower; and it changes patents and intellectual property laws to foster competition by bringing generic drugs to the market faster (in the United States, brand-name drugs account for 72% of total drug spending despite representing only 10% of all prescriptions) to reduce drug costs. While timely access to medications such as insulin is critical to manage Type-1 diabetes, the promotion of health literacy (the capacity of individuals to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions), is equally pvmarquez.com/drug_prices 5/7 1/12/2021 High Prices for Essential Drugs: A Risk for Public Health, Catastrophic Health Spending, High-Debt Levels, and Impoverishment | Patricio V. Marquez vital for the development of a disciplined daily nutritional regime, rich in proteins and vegetables, with reduced or no carbohydrates from processed foods, and physical activity, to manage this disease. In pursuing universal health coverage, therefore, we need to remember that besides putting in place arrangements that ensure access to medical care and offer nancial protection to the population, investment in health literacy can empower people to be in the “driver’s seat” of health promotion and disease prevention, including the prevention of complications from existing chronic health conditions such as Type-1 diabetes, to lead healthy, productive and happy lives. Sources Belluz, J. “The absurdly high cost of insulin, explained. Why Americans ration … (https://www.vox.com/2019/4/3/18293950/why-is-insulin-so- expensive) Bloomberg, M. 2020. Drug Prices Plan. (https://www.mikebloomberg.com/2020/policies/drug-prices) Cooperman, T. “20 Drugs That Cost a Lot Less Outside the U.S.” HUFFPOST, Decemb… (https://www.huffpost.com/entry/20-drugs-that-cost-a-lot- less-outside-the-us_b_5a217e73e4b0545e64bf9277) Fralick, M. and Kesselheim, AS. 2019. “The U.S. Insulin Crisis — Rationing a Li… (https://www.nejm.org/doi/full/10.1056/NEJMp1909402) Image by Steve Buissinne from Pixabay (https://pixabay.com/photos/diabetes-blood-sugar-diabetic-528678/) Picture from freestocks.org (https://unsplash.com/photos/nss2eRzQwgw) pvmarquez.com/drug_prices 6/7 1/12/2021 High Prices for Essential Drugs: A Risk for Public Health, Catastrophic Health Spending, High-Debt Levels, and Impoverishment | Patricio V. Marquez (https://twitter.com/pvmarquez1956) pvmarquez.com/drug_prices 7/7 1/12/2021 Mental Health and Healthy Futures: A Priority Theme at WEF Davos 2020 | Patricio V. Marquez Mental Health and Healthy Futures: A Priority Theme at WEF Davos 2020 Submitted by Patricio V. Marquez on Wed, 01/22/2020 - 08 55 PM Mental Health and Healthy Futures: A Priority Theme at WEF Davos 2020 Posted by Patricio V. Marquez on Wed, 01/22/2020 - 08 55 PM This week I have enjoyed participating in several livestreamed sessions of the 50th annual meeting of the World Economic Forum (WEF) under the theme “Stakeholders for a Cohesive and Sustainable World.” One of the 7 diverse topic areas being addressed during the Meeting is “Healthy Futures”, which I found to be not only highly relevant to the overall theme pvmarquez.com/mental_health_davos 1/9 1/12/2021 Mental Health and Healthy Futures: A Priority Theme at WEF Davos 2020 | Patricio V. Marquez of the 2020 meeting, but highly evocative of Thomas Mann’s masterpiece “The Magic Mountain” which takes place before World War I in a tuberculosis sanatorium in Davos, the Swiss Alps town, where the WEF meeting is held yearly. I say this because a healthy population, both physically and mentally, should be seen as a key goal of a country’s development, as it is an essential building block for productive, inclusive, resilient, and happy societies. But, as in Mann’s novel, this social outcome requires “community” action, with active stakeholder participation, to deal with ill health and its multiple determinants and manifestations. I was quite pleased to watch Bollywood actor Deepika Padukone receive the WEF’s Crystal Award 2020 for her work in raising mental health awareness in India. On receiving the award and later in a one-on-one session with Tedros Adhanom Ghebreyesus, the WHO Director General, she reinforced the need to shine a collective light on the still widespread silence, stigma, and discrimination that surrounds mental and substance use disorders globally. She also conveyed hope and offered an example for other political, private sector, and cultural leaders to follow and engage in this issue: "Depression is a common yet serious illness. It is important to understand that anxiety and depression are like any other illness and treatable. It was experience with this illness that encouraged me to set up Live Love Laugh," she said while talking about the Foundation she has set up for this cause. The session “Protecting Mental Health in Youth” offered diverse perspectives on the challenges and options to scale up approaches to dealing with mental illnesses among children, adolescents, and young adults aged 14-25 years. The special focus on this group is warranted because nearly 75% of mental health conditions begin before age 25, and suicide is a leading cause of death among youth, particularly among young women aged 19-24 years in some countries, with research showing that early intervention pvmarquez.com/mental_health_davos 2/9 1/12/2021 Mental Health and Healthy Futures: A Priority Theme at WEF Davos 2020 | Patricio V. Marquez is the best means of prevention. Also, as argued by Patrick McGorry, a noted psychiatrist from Australia known for his development of the early intervention services for emerging mental disorders in young people, the experience in his country shows that an initial focus on mental health in youth helps bring the issue to the wider political arena since it can galvanize the attention of parents and families, who are concerned about the wellbeing of their children; organized community and interest groups; voters; and governments. People living with mental health problems have a major role to play in speaking out, sharing their stories, and articulating their rights and demands, in the same manner as the movement of HIV- positive people did a couple of decades ago to demand access to life-saving drugs. The activation of a wider “conversation”, anchored in empathetic listening, is critical to overcome a range of social barriers, from the taboo of mental illnesses, the stigmatization of individuals who are affected by these disorders, the fear of discrimination among their families, to widespread beliefs that these conditions are not “real” health problems, or are problems brought on by one’s own choices or “social deviant” behavior in the case of substance use disorders. Indeed, as illustrated from the lived experience of Amornthep Sachamuneewongse, a WEF Global Shaper Bangkok who participated in the panel, in many countries mentally ill individuals “live in places where people really do not understand what mental illness is, where there is no one to talk about it, or where one cannot express much, and (ultimately) attempts suicide” to overcome loneliness, stress, grief, depression, and anxiety. Because the brain is extremely sensitive to environmental factors, particularly in the rst two decades of life, and because most mental health problems begin before young adulthood, the need to act early to prevent their onset was stressed by panelists, who argue for ensuring nurturing and safe environments for children and adolescents to thrive in schools, at pvmarquez.com/mental_health_davos 3/9 1/12/2021 Mental Health and Healthy Futures: A Priority Theme at WEF Davos 2020 | Patricio V. Marquez home, and in communities. Henrietta H. Fore, the Executive Director of UNICEF, eloquently noted that as con ict exposes populations to violence and high levels of stress, bottom-up, multisectoral approaches are required in humanitarian and development programs to address the needs of displaced population groups and refugees. Indeed, investment in education, social protection, and employment training would ameliorate social exclusion and build social resilience by serving the unique needs of vulnerable groups, such as children and young people who have been exposed to rape and other forms of violence, who have served as child soldiers, or who have witnessed the killing of close family members. As she argued, affected children and youth need to feel safe, have someone who they can trust and talk to, and have access to the positive socialization that schools and other social support programs can provide to help “bring them back.” Panelists also highlighted that private rms and enterprises have a vested interest in having mentally healthy workers, not only for “bottom line considerations”, but more importantly to increase productivity and competitiveness —a “top line” consideration. As mental illnesses account for a large share of absenteeism and presenteeism (a situation in which an employee is present for duty but is not fully capable of performing workplace tasks due to an illness or other condition) in the workplace, companies reduce economic losses and increase productivity and competitiveness by promoting the physical and mental wellbeing of employees, and in some cases their families. Although global healthcare spending has increased dramatically over the past decade, greatly helping to expand access to health services, a signi cant supply-side barrier across the world is the lack of mental health parity in the provision and nancing of health services. To deal with this situation, as voiced by different panelists, mental health needs should be viewed in the same vein as physical health needs and be recognized as a pvmarquez.com/mental_health_davos 4/9 1/12/2021 Mental Health and Healthy Futures: A Priority Theme at WEF Davos 2020 | Patricio V. Marquez basic human right. Moving from advocacy to implementation, this would require a wider acceptance of the idea that mental health disorders are conditions of the brain that should not be treated differently than other chronic health conditions, such as heart disease or cancer. Nor, in fact, are they truly separable: If untreated, mental disorders can negatively affect management of such co-occurring diseases as tuberculosis and HIV, diabetes, hypertension, cardiovascular disease, and cancer. As I have argued before, the realization of universal health coverage commitments by countries should include strategies and plans for the medium term to integrate mental health care into health services delivery platforms that focus on the whole patient rather than an aggregation of diseases. This, in turn, requires a de nition of what mental health conditions to prioritize, as they range from autism and intellectual disability in childhood, to anxiety and depression, bipolar disorders, schizophrenia, to alcohol and substance use disorders in adulthood, and to dementia in old age; how to select a menu of evidence-based, cost- effective treatments to be offered for sets of conditions by service providers at different levels of care (as is commonly done for physical health conditions); and how these services will be funded and reimbursed without perpetuating discrimination. Key barriers to overcome include lack of trained personnel for the provision of psychosocial support; limited availability of generic drugs in public facilities of peri-urban and rural areas; and under health insurance arrangements, pre-existing clauses that do not cover a medical condition that started before a person's health insurance bene ts went into effect, as well as high deductibles, copayments, and lifetime limitations in coverage, that increase the risk of catastrophic health expenditures and impoverishment among vulnerable population groups. As Jeremy Farrar, the Director of Wellcome Trust, observed, while it is common for WEF participants to elaborate on problems and propose solutions, what is needed for moving the “Healthy Futures” agenda, pvmarquez.com/mental_health_davos 5/9 1/12/2021 Mental Health and Healthy Futures: A Priority Theme at WEF Davos 2020 | Patricio V. Marquez particularly multisectoral and multidisciplinary action to address mental and substance use disorders among youth, is to track commitments and make public and private stakeholders accountable for their realization. Only if the talk is translated into a walk for action and measurable impact will we be able to ensure the availability of required investments for supporting scaled up interventions globally. If this is done, as Fatima Azzahra El Azzouzi, the moderator of the session, noted, we can aspire to achieve an “emotional and mentally cohesive and sustainable future”. Sources World Economic Forum Annual Meeting, 21—24 January 2020. Explore the World Eco… (https://www.weforum.org/events/world-economic-forum- annual-meeting-2020/themes) World Economic Forum Annual Meeting, 21—24 January 2020. Session “The 26th Annu… (https://www.weforum.org/events/world-economic-forum- annual-meeting-2020/sessions/the-26th-annual-crystal-award-ceremony) World Economic Forum Annual Meeting, 21—24 January 2020. Session “An Insight, A… (https://www.weforum.org/events/world-economic-forum- annual-meeting-2020/sessions/an-insight-an-idea-with-deepika- padukone) World Economic Forum Annual Meeting, 21—24 January 2020. Session “Protecting Me… (https://www.weforum.org/events/world-economic- forum-annual-meeting-2020/sessions/protecting-mental-health-in-youth) Marquez, PV, Hewlett, E. “Lessons from OECD countries: mental health is critica… (https://blogs.worldbank.org/health/lessons-oecd-countries- mental-health-critical-human-capital-development) Marquez, PV, Dutta, S. “On World Mental Health Day: A call to invest in interve… (https://blogs.worldbank.org/health/world-mental-health-day- call-invest-interventions-young-people) Marquez, PV. “Mental Health in Prisons: How to Overcome the Punishment Paradigm… (https://blogs.worldbank.org/health/mental-health-prisons- how-overcome-punishment-paradigm) pvmarquez.com/mental_health_davos 6/9 1/12/2021 Mental Health and Healthy Futures: A Priority Theme at WEF Davos 2020 | Patricio V. Marquez Marquez, PV, Dutta, S. “Maternal Depression and Stunted Children: An Avoidable … (https://blogs.worldbank.org/health/maternal-depression- and-stunted-children-avoidable-reality) Marquez, PV. “The case for physical and mental wellness programs in the workpl… (https://blogs.worldbank.org/health/case-physical-and-mental- wellness-programs-workplace) Marquez, PV. 2017. “Mental health among displaced people and refugees: making t… (http://documents.worldbank.org/curated/en/916131486730755271/Mental- health-among-displaced-people-and-refugees-making-the-case-for- action-at-the-World-Bank-Group) Marquez, PV, Walker, M. “Mental health services in situations of con ict, frag… (https://blogs.worldbank.org/health/mental-health-services- situations-con ict-fragility-and-violence-what-do) Marquez, PV, Saxena, S. “Mental Health Parity in the Global Health and Developm… (https://blogs.worldbank.org/health/mental-health-parity- global-health-and-development-agenda) Marquez, PV. Invisible wounds: Mental health among displaced people and refugee… (https://blogs.worldbank.org/voices/invisible-wounds-mental- health-among-displaced-people-and-refugees) pvmarquez.com/mental_health_davos 7/9 1/12/2021 Mental Health and Healthy Futures: A Priority Theme at WEF Davos 2020 | Patricio V. Marquez pvmarquez.com/mental_health_davos 8/9 1/12/2021 How to Accelerate Universal Health Coverage in Latin America and the Caribbean? | Patricio V. Marquez How to Accelerate Universal Health Coverage in Latin America and the Caribbean? Submitted by Patricio V. Marquez on Thu, 01/16/2020 - 08 21 PM How to Accelerate Universal Health Coverage in Latin America and the Caribbean? Posted by Patricio V. Marquez on Thu, 01/16/2020 - 08 21 PM In Memory of Miguel A. Marquez, 1934-2014 pvmarquez.com/health_reform 1/9 1/12/2021 How to Accelerate Universal Health Coverage in Latin America and the Caribbean? | Patricio V. Marquez Over the past four decades, major policy reforms were introduced in several Latin American and Caribbean countries to strengthen their health systems. While countries such as Brazil, Costa Rica, and Cuba managed to unify their health systems, and Chile, Colombia, and Mexico introduced organizational changes to expand health service coverage to the poorest populations as a right for all citizens, the institutional organization in most countries of the region at the beginning of the 2020 decade continues to be characterized by the coexistence of parallel subsystems that respond to the needs of different social groups in an often uncoordinated and fragmented manner. In spite of the regional heterogeneity, this segmented model of heath care organization in most countries of the region segregates different population groups according to employment and socioeconomic status into three broad institutional arrangements for accessing health services: the ministry of health, the social security institute (s), and the private sector. Why does this matter? In 2014, PAHO/WHO Member States approved the Strategy for Universal Access to Health and Universal Health Coverage (UHC). The strategy emphasizes the need to strengthen health systems to achieve universal access and coverage, namely by reducing health inequities; expanding access to comprehensive, quality care; and improving the health and well-being of the population. The progressive realization of the UHC strategy in the region, therefore, requires a major health system transformation to deal with the fragmentation of nancing and service delivery and the differential access produced by population segregation. In advancing the health reform process in Latin America and the Caribbean in the new 2020 decade, several factors merit consideration. I will elaborate on some of them given their importance for increasing the political feasibility of reforms as well as for ensuring their nancial and institutional sustainability. Factors to Consider pvmarquez.com/health_reform 2/9 1/12/2021 How to Accelerate Universal Health Coverage in Latin America and the Caribbean? | Patricio V. Marquez The history of health care reform in the region and elsewhere shows that technically sound proposals backed by data and evidence are a vital but not suf cient condition to effect this transformation. As public policy is an inherently political process, a clear understanding and careful but active modulation of the interrelationships among individuals, organized interest groups, and governments in a given context and period of time are of critical importance to in uence the design and enactment of policies, laws, and regulations that shape a health system. This implies that reform proposals in the health sector rst and foremost need to clearly articulate how they will contribute to the achievement of broader social goals in a country, or more broadly stated, to construct societies that are more inclusive, where health care is a social good available to all on equal terms, rather than a private consumption good like other services such as food and housing, that is only fully afforded to the rich. The uni cation of vision and social goals as the frame of reference for health reform proposals is key to align the interests of different actors and mobilize their support for their adoption and sustainable implementation over time. Indeed, as Professor Uwe E. Reinhardt, the distinguished late Princeton University health economist observed, having a clear understanding of “what kind of a society a country wants to have”, will ultimately guide policy and institutional decisions concerning the most appropriate and contextually relevant organizational forms, health care nancing arrangements, and service delivery mechanisms that could be adopted to attain the intermediate goals of a health system (improved access, quality, ef ciency, and fairness), which would in turn contribute to achievement of the ultimate goals of a health system (improved health status, nancial protection, and patient satisfaction with health care received). The codi cation into laws of health as a right of citizenry is a vital step that is required to transform health systems as it helps to translate speci c policy proposals into legal mandates, institutionalizing a framework that ensures the pvmarquez.com/health_reform 3/9 1/12/2021 How to Accelerate Universal Health Coverage in Latin America and the Caribbean? | Patricio V. Marquez directionality and continuity of the reform process across political cycles and helps withstand recurring bouts of political opposition and changed social and economic interests in a country. Recent examples in the Americas offer good lessons on the interplay of policy formulation and advocacy and the sobering reality of the political processes needed for their approval and enactment that have reshaped health care organization and nancing, service delivery modalities, and expanded population coverage: Colombia, with the adoption of Law 100 in the mid-1990s, that introduced a universal health insurance program, which was amended in 2008 per the decision of the Constitutional Court that directed the Government to unify its contributory and subsidized insurance schemes; the 2003 approval by the Mexican Congress of revisions to the General Health Law that established the System of Social Protection in Health, with Seguro Popular expanding health insurance coverage to about half of the country’s population; and the Patient Protection and Affordable Care Act adopted in the United States in 2010. In previous decades, health as a human right and citizens’ entitlement were codi ed in the Constitutions of countries such as Cuba, after the 1959 revolution; Costa Rica in the 1960s; Brazil in the Constitution adopted in 1988; in Peru in 2002, with the introduction of the Comprehensive Health Insurance for poor and uninsured populations; and in Chile, with the adoption in 2005 of the Health Guarantees Law that introduced enforceable rights to health services for a set of diseases. Dealing with inequitable nancing, particularly needed to realize the promise of timely access to medical care when needed and to reduce out-of-pocket expenditures that create risks for catastrophic and impoverishing spending among the poor and underserved populations, is of upmost importance. Recent estimates show that out-of-pocket expenditures stood at 33 percent in 2014 and 28 percent in 2016 of total health spending on average in several countries; this level is far higher than the OECD countries average of 18 pvmarquez.com/health_reform 4/9 1/12/2021 How to Accelerate Universal Health Coverage in Latin America and the Caribbean? | Patricio V. Marquez percent. This gures not only convey the stress households face in accessing health care, but acquires added relevance when one considers that among the world’s regions, Latin America and the Caribbean has one of the highest levels of social and health inequity, especially in terms of inequality in income distribution. Although income inequality has decreased over the past 15 years, in 2017, the Gini index (the most common measure of inequality; a higher Gini index indicates greater inequality, with high income individuals receiving much larger percentages of the total income of the population) stood at 0.51, the highest in the world. If, as envisioned, the targets for UHC and the health- and poverty-related Sustainable Development Goals (SDGs) are to be achieved by 2030, a sustained effort of domestic resource mobilization and increase in the relative allocation for health in national budgets is required. Given the middle-income status of most countries in Latin America and the Caribbean, this effort, as outlined in a recent World Bank Group report for the G20, would mean in practice that as part of scal consolidation initiatives, governments would need to increase overall government revenue as a share of GDP, and where feasible, some of which can ow to expand scal space for health. To this end, there is an arsenal of measures to consider: improvements in tax administration; expansion of tax bases by increasing the range and level of taxes and charges; removal, although political dif cult, of ineffective subsidies (e.g., on fossil fuel) that disproportionately bene t the non-poor; raising taxes on tobacco products and other health-damaging products, such as alcohol and sugary drinks, which not only help to reduce health risks but also are more politically acceptable to the general population than other taxes in spite of likely opposition from powerful interest groups; and reduction of the reliance on wage-based deductions or voluntary forms of insurance to bolster prepaid and pooled funding. Leveraging health-related investments in other sectors—including, for example, in transport to reduce road traf c injuries and fatalities that impose a heavy burden on costly trauma care, in safe water and basic sanitation to pvmarquez.com/health_reform 5/9 1/12/2021 How to Accelerate Universal Health Coverage in Latin America and the Caribbean? | Patricio V. Marquez reduce the risk of gastrointestinal diseases and chronic malnutrition—would improve population health, reducing need, demand and utilization of health services. While additional funds for health would help, an equally important task is to improve the ef ciency of resource use in the region. For example, a recent report suggested that 20 percent of all health expenditures in OECD countries was wasted and did not contribute to the desired health outcomes; in some Latin American and Caribbean countries, this gure may be higher. As suggested in the World Bank Group report, improvements in performance- informed planning and budgeting, enhanced budget execution, and stronger systems of public nancial management in the health system would help. Also, better allocation of existing resources is needed in order to prioritize the delivery of cost-effective primary and community health services with appropriate referral systems, away from hospital-centric models of care, and strengthen public health functions, particularly disease surveillance, public health labs for case con rmation, and epidemiological intelligence capacity, to anticipate and control societal-wide health risks associated with the reemergence of infectious diseases and the emergence of new pathogens that cross borders and threatening loss of life, economic disruption, and costs to health systems. In the face of rapid demographic and health changes in Latin America and the Caribbean, particularly the aging of the population and the increase in the relative importance of chronic non-communicable diseases and injuries, as well as mental and substance use disorders, another priority area that merits attention for reforming health systems in the region is the need to support a fundamental rethinking of how to best keep people healthy and out of hospitals. pvmarquez.com/health_reform 6/9 1/12/2021 How to Accelerate Universal Health Coverage in Latin America and the Caribbean? | Patricio V. Marquez For starters, there has to be a widespread realization among policymakers, employers, health insurers, service providers, and the population at large, that the lion’s share of health care expenditures goes for treating diseases and injuries that could be “prevented”. The realization of health promotion and disease and injury prevention would require supporting population-wide efforts to tackle social, environmental and behavioral determinants of ill health, premature mortality, and disability, such as scal and regulatory policies to curb tobacco use, second hand smoke, alcohol and substance abuse, obesity, Type-2 diabetes, road traf c injuries, and in some countries, gun violence. Insurance arrangements and health care organization and payment innovations could also be used to advance this public health agenda. For example, insurance companies, by charging lower premiums for those who quit smoking, lose weight, and pass screening tests for artery-clogging cholesterol, high blood pressure, and high sugar levels, provide an incentive for individuals and families to assume responsibility for their health. Moving forward Throughout the world there is an ongoing search for new and innovative ways to address health system shortcomings to better respond to present and future health challenges. Latin American and the Caribbean countries are not an exception. Reforming long-entrenched health care organization and nancing arrangements is not an easy task that can be completed in the short-term. Moving from policy intention toward the achievement of UHC as a broad development and social goal will require political commitment at the highest political level and the buy-in and active involvement of individuals, organized interest groups, and governments over the medium- and long- terms. Well informed and inclusive political strategies and sound technical proposals would help pave the way for implementing needed health system pvmarquez.com/health_reform 7/9 1/12/2021 How to Accelerate Universal Health Coverage in Latin America and the Caribbean? | Patricio V. Marquez changes over the medium- and long-terms to eliminate social strati cation in accessing and funding health services, build more inclusive and resilient societies, and support the development of healthy populations in the region. Opposition from interest groups and backpeddling by governments, however, should be expected as an ever-present risk that will need to be monitored and confronted during this process. Sources Atun, R. et al. 2015. “Health-system reform and universal health coverage in La… (https://doi.org/10.1016/S0140-6736(14)61646-9) Londoño, JL and Frenk, J. 1997. “Structured pluralism: towards an innovative m… (https://www.sciencedirect.com/science/article/abs/pii/S0168851097000109) Marquez, PV. 2016. “Time to put “health” into universal health coverage”. World… (http://blogs.worldbank.org/health/time-put-health-universal- health-coverage) World Bank Group. 2019. “High-Performance Health Financing for Universal Health… (https://openknowledge.worldbank.org/handle/10986/31930) pvmarquez.com/health_reform 8/9 1/12/2021 How to Accelerate Universal Health Coverage in Latin America and the Caribbean? | Patricio V. Marquez (https://twitter.com/pvmarquez1956) pvmarquez.com/health_reform 9/9 1/12/2021 Is the Growing Attachment to Smartphones and Digital Media Bad for Our Health? An initial exploration | Patricio V. Marquez Is the Growing Attachment to Smartphones and Digital Media Bad for Our Health? An initial exploration Submitted by Patricio V. Marquez on Sun, 12/08/2019 - 09 36 AM Is the Growing Attachment to Smartphones and Digital Media Bad for Our Health? An initial exploration Posted by Patricio V. Marquez on Sun, 12/08/2019 - 09 36 AM This note served as background to a presentation delivered per the invitation of the Ecuador Mission to the United Nations at the Meeting on Social Media and Mental Health, organized by the Group of Friends on Mental Health and Well-Being, that is co- led by the Permanent Missions of the Kingdom of Bahrain, Belgium, Canada and Ecuador to the United Nations. New York City, December 12, 2019 Technological innovation is fueling momentous change in our daily lives. Indeed, as Professor Klaus Schwab, the chairman of the World Economic Forum (WEF) describes, the physical, digital and biological trends underpinning what he calls 'the fourth industrial revolution', are unleashing changes “unlike anything humankind has experienced before" (WEF 2015). At the center of it all is the Internet, anchoring digital media. The WEF de nes “digital media” as “products and services that come from the media, entertainment and information industry and its subsectors. It includes digital platforms (e.g., websites and applications), digitized content (e.g., text, audio, video and images), and services (e.g., information, entertainment, and communication) that can be accessed and consumed through different digital devices” (WEF 2016). Laptops and desktops are still the most widely used devices, but mobile devices, such as smartphones, are fast catching up in popularity and use. The easy-to-carry and handle, multi-functional smartphone, is a common feature of modern life globally. Billions of people are now connected to these mobile devices, with unprecedented processing power, storage capacity, and access to knowledge. In emerging countries, mobile technology is allowing consumers to leapfrog from “no digital use” straight to “mobile use” (WEF 2015). www.pvmarquez.com/digital media_impacts 1/8 1/12/2021 Is the Growing Attachment to Smartphones and Digital Media Bad for Our Health? An initial exploration | Patricio V. Marquez There is a growing concern that our attachment to them and “what is in them” not only captures our full attention and a good share of our time, but is creating virtual barriers that hinder direct social interaction. There are also concerns about their potential negative impact on the mental and physical health of people. To learn about this topic, as it would not surprise anybody, I began searching the web for recent literature using the Google app in my smartphone while waiting at the dentist’s of ce, before turning to a laptop at home to review and write. A summary of my initial exploration follows. Growing popularity and use Hundreds of millions of people are using smartphones, downloading apps, and browsing web sites. Smartphone subscriptions are growing at the rate of 17-19% per year and now total about 2.1 billion users, while consumer mobile internet traf c is accelerating at more than 60% every year (WEF 2015). Smartphone ownership among young people aged 9 to 16 is also growing; for example, almost half of young people in Europe have a smartphone, according to a 2014 survey of 7 countries (Mascheroni and Ólafsson 2014). In the US, 48% of 11-year-olds reported owning a mobile phone, and among 14-year-olds, it was 85% (unpublished data; see go.nature.com/2eeffku, cited by Odgers 2018). Smartphones have become essential to the life of people. It is not surprising to learn, then, that an estimated 87% of US millennials say their smartphone never leaves their side (Ziv, S). Similarly, a survey by Qualtrics and Accel Partners found that 79% of US millennials put their phones right by them when they sleep, 53% wake up at least once every night to check them, and that nearly 60% check them before they use the bathroom in the morning. Data reveals that 89% of mobile phone owners use them in social gatherings, to read texts or emails, take photo or video; or to place a call (Ziv, S). Social media, which have grown in popularity, are web platforms that allow individuals to create a pro le and connect to other people to share information, ideas, interests, and other forms of expression on the site regardless of location and time. The different types of social media platforms include: Social networking (Facebook, LinkedIn, Google+); Microblogging (Twitter, Tumblr); Photo sharing (Instagram, Snapchat, Pinterest); and Video sharing (YouTube, Facebook Live, Periscope, Vimeo). About 3.2 billion people or 40% of the world’s population are estimated to use social media. Worldwide, as shown in the graph below, Facebook tops the list with 2.23 billion active users as of mid-2018, or almost a third of the world’s population, followed by YouTube and Instagram. Source: Graph downloaded at https://www.dreamgrow.com/top-15-most-popular-social-networking-sites/ www.pvmarquez.com/digital media_impacts 2/8 1/12/2021 Is the Growing Attachment to Smartphones and Digital Media Bad for Our Health? An initial exploration | Patricio V. Marquez Adult social media users spend on average 2 to 3 hours every day sharing, liking, tweeting, and updating. Use prevalence among teenagers is growing rapidly. For example, survey data indicate that on average, US teens aged 13–18 engage with digital media (from watching television or online videos to reading online and using social media) for more than 6.5 hours each day; mobile devices account for almost half this time (Rideout 2015). What are the negative aspects of these trends? We should not be surprised, then, that as individuals want to be connected more or less 24/7, the question that many people are asking is, how is all this impacting us, our children, and our social lives? The graph below depicts the negative psychological effects of social media: Source: Graph from Kelly, Zilanawala, Booker and Sacker. 2019. “Social Media Use and Adolescent Mental Health: Findings from the UK Millennium Cohort Study.” The Lancet. The ndings of a 2016 assessment by the WEF expands on these negative effects: Excessive digital media use can negatively in uence the development of cognitive (thinking, imagining, reasoning, and remembering abilities) and behavioral (reactions or actions that we take in response to stimuli present in our environment) skills and even mental and physical health of people. Hyper connectivity has the potential to change patterns of social interaction, as face-to-face interaction, that is essential to the give-and-take functioning of families, communities, and workplaces, may be substituted by online interaction. Levels of empathy (“understanding another’s situation or feelings and experiencing a sense of their emotional state”) are declining, perhaps as a result of the decrease in face-to-face communication. Digital media consumption may facilitate bullying, harassment, social defamation, and hate speech because potential costs of such behavior are reduced and the ease of engaging in behaviors that harm either others or ourselves is increased (Mascheroni and Cuman 2014). Data from a global YouGov survey sponsored by Vodafone shows that of more than 4,700 teenagers surveyed worldwide, 50% felt that cyberbullying was worse than face- to-face bullying; about one- fth reported having been cyberbullied; of those, 41% stated cyberbullying made them feel depressed, and 18% said it had made them consider suicide (Vodafone/YouGov 2015). Mental health risks www.pvmarquez.com/digital media_impacts 3/8 1/12/2021 Is the Growing Attachment to Smartphones and Digital Media Bad for Our Health? An initial exploration | Patricio V. Marquez Research indicates that excessive digital media consumption and the way digital media are being used pose a number of risks to user health and well-being, particularly increased vulnerability to addiction, and harm mental and physical health. The ndings in the 2016 assessment by the WEF identify three potential major mental health risks: Overload: Increased stress because of the volume and variety of social media contact, Invasion: Intrusion of media connections into personal life, and, Uncertainty: Continuous and unpredictable change in social media applications and requirements. As I can attest from my own experience, uninterrupted access to digital media content tends to intrude in a user’s work and personal lives, making one oblivious to the difference between business and personal activity and between time on and time off. Other potential risks identi ed in in the 2016 WEF assessment, include: Envy-related stress related to constant updates on friends’ latest professional successes, fantastic vacations, and personal triumphs. Decline in civility, facilitated by electronically mediated interactions that are more anonymous and often more bluntly negative than face-to-face encounters. Addictive behavior, as shown by evidence that some video gamers experience symptoms similar to those felt by people with substance abuse or gambling addiction and may be experiencing similar changes in brain chemistry related to the release of dopamine, an important chemical messenger in the brain that it is involved in reward, motivation, memory, attention, and even regulating body movements. When dopamine is released in large amounts, it creates feelings of pleasure and reward, which motivates you to repeat a speci c behavior. Association with depression. Distinct patterns of social media use help explain the association of digital media with depression and anxiety symptoms. Those clustered as “Wired” and “Connected” in the research showed increased odds of elevated depression and anxiety symptoms (Shensa, Sidani, Dew, Escobar-Viera, Primack 2018). Similarly, a large longitudinal study of Americans aged 14-24 years found that heavy use of the internet and video games is associated with an increase in depression. Findings from the UK Millennium Cohort Study show that the magnitude of association between social media use and depressive symptoms was larger for girls than for boys. Poor sleep, online harassment, poor body image, and low self-esteem appear to be important pathways via which social media use is associated with depressive symptoms in young people (Kelly, Zilanawala, Booker, Sacker 2019). Impact on cognition. Social media use has been shown to reduce attention span and lower recall rates for information people believe they can access easily online. Reduced downtime. Increased social media use reduces periods of inactivity, which are critical to allow the brain to synthesize information, make connections between ideas, and develop a sense of self. Physical health risks Two major physical health risks from high digital media use can be highlighted: Increased sedentary behavior. Time spent on digital technology displaces time that could be spent on physical activity. Lack of physical activity has been identi ed as the fourth leading risk factor for global mortality (6% of deaths globally). Moreover, physical inactivity is estimated to be the main cause for approximately 21–25% of breast and colon cancers, 27% of diabetes cases, and approximately 30% of the ischemic heart disease burden. Childhood obesity, which is one of the most serious public health challenges of the 21st Century, is steadily affecting many low- and middle-income countries, particularly in urban settings. Globally, in 2016, the number of overweight children under the age of ve was estimated to be over 41 million. Overweight and obese children are www.pvmarquez.com/digital media_impacts 4/8 1/12/2021 Is the Growing Attachment to Smartphones and Digital Media Bad for Our Health? An initial exploration | Patricio V. Marquez likely to stay obese into adulthood and more likely to develop noncommunicable diseases like diabetes and cardiovascular diseases at a younger age (accessed WHO data). Physical injury. The use of handheld smartphones is now a major cause of road traf c injuries and fatalities in the world, particularly among young drivers. Studies in the United States show that dialing and texting when driving pose a substantial increase in the risk of being involved in a crash or near crash (cited in Marquez et al 2009). When driving light vehicles and cars: Placing a call on a cell phone made the risk of a crash or near-crash event 2.8 times higher than non-distracted driving. Talking on or listening on a cell phone made the risk of crash or near-crash event 1.3 times higher than non- distracted driving. Reaching for an object such as an electronic device made the risk of a crash or near-crash event 1.4 times higher than non-distracted driving. When driving heavy vehicles and trucks: Placing a call on a cell phone made the risk of a crash or near-crash event 5.9 times higher than non-distracted driving. Talking or listening on a cell phone made no difference to the risk of a crash or near-crash event compared to non-distracted driving. Use of or reaching for an electronic device made the risk of a crash or near-crash event 6.7 times higher than non-distracted driving. Text messaging made the risk of a crash or near-crash event 23.2 times higher than non-distracted driving (large trucks made up close to 10% of all vehicles involved in fatal crashes in the US). Impact on children’s well-being Studies in the 2016 WEF highlighted the following potential negative impact on children: Excessive new media use can lead to attention problems, school dif culties, sleep disorders (particularly for children aged three to ve years when exposed to violent content), and eating disorders and obesity. Digital media use is harmful to children if interaction with parents and others is replaced by interaction with digital media. Research has shown that brain development depends on social interaction with others during a critical period in early life and that lack of social interaction creates irreversible social and cognitive impairments throughout life. Healthy neurological development requires the engagement of all sensory systems, but heavy digital media consumption favors the visual and auditory systems over the vestibular (sense of balance), proprioceptive (sense of self-movement and body position), tactile (sense of touch), and attachment systems, creating possibly permanent imbalances. Delayed language development. Research has shown that very young children (aged 9-18 months) do not learn language by watching educational videos without active interaction with another person. Uncontrolled time spent on digital media often displaces time spent on academics, lowering academic achievement. Digital media make it easier to disseminate inaccurate as well as accurate information, and much that is online is potentially harmful to younger audiences. For example, a recent New York Times article documents how through video games and online chats sexual predators are making virtual connections with children right in their victims’ homes. The criminals strike up a conversation and gradually build trust, often posing as children, www.pvmarquez.com/digital media_impacts 5/8 1/12/2021 Is the Growing Attachment to Smartphones and Digital Media Bad for Our Health? An initial exploration | Patricio V. Marquez con ding in their victims with false stories of hardship or self-loathing, with the goal of duping children into sharing sexually explicit photos and videos of themselves — which they use as blackmail for more imagery, much of it increasingly graphic and violent (Bowles N, Keller MH 2019). Impact on Adolescents Data show an increase in mental health problems among adolescents (Odgers 2018). Worldwide, it is estimated that 10–20% of adolescents experience mental health issues (Marquez, Dutta 2018). Recent data suggest that adolescents do perceive social media as a threat to mental wellbeing because: (1) social media is believed to cause mood and anxiety disorders for some adolescents, (2) social media is viewed as a platform for cyberbullying, and (3) the use of social media itself was often framed as a kind of 'addiction' (O’Reilly, Dogra, Whiteman, Hughes, Eruyar, Reilly 2018). Research based on a large, nationally representative dataset in the US found that more US adolescents and young adults in the late 2010s, as compared to the mid-2000s, are experiencing serious psychological distress, major depression, and suicidal thoughts and more attempted suicide and took their own lives. These trends are weak or nonexistent among adults 26 years old and over. These trends suggest a generational shift in mood disorders and suicide-related outcomes rather than an overall increase across all ages; researchers posited that they may be associated with lack of sleep and the rise of social media in teens (Twenge, Cooper, Joiner, Duffy, Binau 2019). How can we leverage these tools and platforms to address mental and physical health risks? We should be clear that access to and use of digital media, while posing risks, is also bene cial to both individuals and society. Digital tools and platforms are enabling unprecedented levels of communication, social interaction, and community building across boundaries of time, place, and social context (Seabrook, Kern, Rickard 2016). In particular, as indicated by 61% of respondents to the Implications of Digital Media Survey (WEF 2016), digital media is considered helpful to maintaining existing relationships with friends, and 45% believe it is helpful in forming new ones. Also, social media facilitates the rapid sharing of accumulated knowledge and experiences within countries and globally. In the health sector, digital tools and platforms are now becoming an asset for individuals and healthcare practitioners, to help improve access to care and reach vulnerable populations, particularly in low-income settings where healthcare delivery systems are limited. A good example is the initiative by Mobile Technology for Community Health (MoTeCH) and the Grameen Foundation in Ghana, piloted in the Upper East Region and now being replicated in the Central, Greater Accra and Volta Regions, which allowed women with limited literacy skills to be informed in the local language about the “do’s and don’ts” in pregnancy and childbirth (Marquez 2013). Women also receive reminders on clinical appointments, due dates, and required medication and immunization through their mobile phone. This technology also enables women, their partners and families, to recognize the signs of life- threating complications during pregnancy and empowers them to seek immediate care. Other applications allow community midwives and nurses to provide rapid response and care and to follow up with health service defaulters in the community. Mobile devices like smartphones are also giving the public, doctors, and researchers new ways to access help, monitor progress, and increase understanding of mental wellbeing (information from the National Institute of Mental Health website). For example, text messages can help contact a crisis center; apps might use the device’s built-in sensors to collect information on a user’s typical behavior patterns, including detecting a change in behavior, and provide a signal that help is needed before a crisis occurs. Some stand-alone apps could help improve www.pvmarquez.com/digital media_impacts 6/8 1/12/2021 Is the Growing Attachment to Smartphones and Digital Media Bad for Our Health? An initial exploration | Patricio V. Marquez memory or thinking skills, and others help the user connect to a peer counselor or to a healthcare professional. This support can be very simple but effective. A meta-analysis found, for example, that brief interventions, such as computer-assisted cognitive behavioral therapy delivered through mobile devices, improved people’s psychological well-being and reduced reported symptoms of depression and anxiety (Versluis, Verkuil, Spinhoven, van der Ploeg, Brosschot 2016). In addition, digital media can facilitate education and life-long learning to build the skills of the future, contributing to human capital development in countries. Sources Picture: Smartphones communicating through their apps. Found on Bing from freer… (https://binged.it/2PjDkKM) Second Picture: Texting and Driving Pictures. Found on Bing. (https://www.bing.com/images/search? view=detailV2&id=CC8FC54DB8246126E3D2016C4A33B5F104A9DD13&thid=OIP.g3-BDLiPijNVsU- Q6AwXbgHaE6&mediaurl=http%3A//pugetsoundblogs.com/kitsap-crime/ les/2014/04/text-and- drive.gif&exph=416&expw=626&q=texting%20and%20driving%20pictures&selectedindex=1&ajaxhist=0&vt=0&eim=3) Bowles N and Keller MH. 2019. “Video Games and Online Chats Are ‘Hunting Ground… (https://www.nytimes.com/interactive/2019/12/07/us/video-games-child-sex-abuse.html) Kelly Y, Zilanawala A, Booker C, and Sacker A. 2019. “Social Media Use and Adol… (https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(18)30060-9/fulltext) Marquez PV et al. 2009. “Confronting “Death on Wheels” Making Roads Safe in Eu… (http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/ECAEXT/0,,contentMDK 22398460~pagePK 146736~piP Marquez PV. 2013. “Preventing Maternal Mortality - A Yardstick for Social Justi… (http://blogs.worldbank.org/nasikiliza/preventing-maternal-mortality-yardstick-social-justice) Marquez PV. 2014. “Diabetes and Overweight: A Growing Global Burden.” WBG Blog (http://blogs.worldbank.org/health/diabetes-and-overweight-growing-global-burden) Marquez PV et al. 2016. “Summary Report: Out of the Shadows: Making Mental Hea… (http://pubdocs.worldbank.org/en/391171465393131073/0602-SummaryReport-GMH-event-June-3-2016.pdf) Marquez PV and Dutta S. 2018. “On World Mental Health Day: A call to invest in … (http://blogs.worldbank.org/health/world-mental-health-day-call-invest-interventions-young-people) Mascheroni G and Cuman A. 2014. “No Children Go Mobile: Final Report.” (/node/4) National Institute of Mental Health (NIMH) website. “Technology and the Future… (https://www.nimh.nih.gov/health/topics/technology-and-the-future-of-mental-health-treatment/index.shtml) Odgers C. 2018. “Smartphones are bad for some teens, not all.” Nature. (https://www.nature.com/articles/d41586- 018-02109-8) O'Reilly M, Dogra N, Whiteman N, Hughes J, Eruyar S, Reilly P. 2018. “Is social… (https://www.ncbi.nlm.nih.gov/pubmed/29781314) Rideout, V. 2015. “The Common Sense Census: Media Use by Tweens and Teens.” Na… (http://go.nature.com/2c4dwew) Seabrook EM, Kern ML, Rickard NS. 2016. “Social Networking Sites, Depression, a… (https://mental.jmir.org/2016/4/e50/) Shensa A, Sidani JE, Dew MA, Escobar-Viera CG, Primack BA. 2018. “Social Media … (https://www.ingentaconnect.com/contentone/png/ajhb/2018/00000042/00000002/art00011) Shukla A. 2019. “The Effect of Social Media on Mental Health and Well-Being.” C… (https://cognitiontoday.com/2019/08/effect-of-social-media-on-mental-health-well-being/) Spelman M. Co-Head, Future of the Internet Initiative, Member of the Executive … (https://www.weforum.org/agenda/2015/12/what-does-the-future-hold-for-the-internet/) Twenge JM, Cooper AB, Joiner TE, Duffy ME, Binau SG. 2019. “Age, Period, and Co… (https://www.apa.org/pubs/journals/releases/abn-abn0000410.pdf) Versluis A, Verkuil B, Spinhoven P, van der Ploeg MM, Brosschot JFJ. 2016. Smar… (https://www.nature.com/articles/d41586-018-02109-8) www.pvmarquez.com/digital media_impacts 7/8 1/12/2021 Is the Growing Attachment to Smartphones and Digital Media Bad for Our Health? An initial exploration | Patricio V. Marquez Vodafone/YouGov. 2015. “Global Survey on Cyberbullying.” (https://markets.ft.com/data/announce/full? dockey=1323-12509304-1Q8SVKBQINRPVIK2IJ53QU6KG4) WEF. 2015. “The Fourth Industrial Revolution: what it means, how to respond.” (https://www.weforum.org/agenda/2016/01/the-fourth-industrial-revolution-what-it-means-and-how-to- respond/) WEF. 2016. “Digital Media and Society Implications in a Hyperconnected Era. Sec… (http://www3.weforum.org/docs/WEFUSA_DigitalMediaAndSociety_Report2016.pdf) WHO site. “Global Strategy on Diet, Physical Activity and Health.” (https://www.who.int/dietphysicalactivity/childhood/en/.) Ziv S. “7 Scary Cell Phone Facts That'll Make You Question Your Addiction.” (https://www.themuse.com/advice/cell- phone-addiction-stats-scary) (https://twitter.com/pvmarquez1956) www.pvmarquez.com/digital media_impacts 8/8 1/12/2021 Plastic Pollution: A "Clear and Present Danger" to the Galapagos Islands | Patricio V. Marquez Plastic Pollution: A "Clear and Present Danger" to the Galapagos Islands Submitted by Patricio V. Marquez on Wed, 11/27/2019 - 08 14 AM Plastic Pollution: A "Clear and Present Danger" to the Galapagos Islands Posted by Patricio V. Marquez on Wed, 11/27/2019 - 08 14 AM People of my generation remember well the 1967 coming of age lm, “The Graduate.” In the opening scene, a confused, wide-eyed young man, just returning home after nishing his university studies, is offered advice about his future by a middle-aged friend of his parents in a much-quoted exchange: MR. MCGUIRE: I want to say one word to you. Just one word. BENJAMIN: Yes, sir. MR. MCGUIRE: Are you listening? BENJAMIN: Yes, I am. MR. MGGUIRE: Plastics. www.pvmarquez.com/plastic_pollution_galapagos 1/6 1/12/2021 Plastic Pollution: A "Clear and Present Danger" to the Galapagos Islands | Patricio V. Marquez As preadolescent in those years, I was precociously intrigued by the plot of the movie and captivated by the wonderful soundtrack of Simon and Garfunkel, but completely oblivious to its 1960s counterculture message. Years later, I found out that the reference to “plastics” in the lm was considered as analogous with the perceived “unnatural”, “arti cial”, and “lifeless” materialism of the times. Plastics have also been broadly appreciated economically for being low-cost, lightweight, strong, durable, resistant to corrosion, and nonconductors of electricity. It has been estimated that global plastics production rose exponentially since the 1950s, from 15 million tons in 1964 to over 311 million tons in 2014, or twenty-fold in 50 years. Moving the clock forward to the end of the second decade of the XXI Century, mass consumption, so greatly facilitated by plastics, is now widely understood and accepted as a direct threat to future life in our planet. While the great versatility and usefulness of plastics is economically appealing, their broad use and fate can also harm. Indeed, the manufacture, wide use, and waste of all things plastic, particularly their prominence in marine debris, is comparable to climate change in terms of impact, breadth and complexity. On a recent visit to the Galapagos Islands, I was struck to learn that despite being located 600 miles westward of the South American continent and the dedicated work of Galapagos National Park’s rangers and volunteers to conduct coastal clean ups regularly, plastic waste being carried by strong oceanic currents is putting its fragile ecosystem at risk. Indeed, information from different international organizations such as the National Geographic Society shows that a plethora of plastic bottles, oil containers, plastic takeaway containers, plastic cutlery, glass bottles, metal tanks, shing nets and traps, and plastic- ber rope are washing onshore into pristine lava elds, sandy beaches, and mangrove elds. As observed by the Galapagos Conservation Trust, the increase of visitors to the Islands in recent years, as well as the increase in the permanent residents, also implies that the amount of waste created is growing, adding to plastic pollution. It should be clear to all of us, therefore, that in spite of their “splendid isolation”, man-made waste and pollution are becoming a major risk that threatens the Galapagos Islands’ unique fauna and ora, both inland and in the Galapagos Marine Reserve. In particular, the native wildlife of Galapagos, that includes animal species not found anywhere else in the world, are highly vulnerable to the introduction of plastic pollution as it may cause adverse changes to natural habitats and injury and death when animals get entangled in heaps of debris. Iconic creatures such as the giant land tortoise and marine turtles are particularly affected when debris in the ocean is mistaken for food and ingested, causing internal abrasions and gut blockages. The human population is also at health risk as the unintended ingestion of plastic substances disrupts endocrine functions*, which can cause cancerous tumors, birth defects, and other developmental disorders. We also have to understand that this environmental risk to the preservation of the Galapagos Islands is part of a growing interconnected problem across continental South America and the rest of the world. Indeed, World Bank Group assessments have documented the magnitude of this challenge globally. In 2010 alone, 4-12 million tons of plastic were estimated to wash ashore globally. Of the estimated 275 million tons of plastic waste generated in 2010, over 60 percent is thought to have originated from plastic packaging, which is primarily designed for single use. Effective action to minimize this risk will require robust advocacy grounded in scienti c evidence to mobilize high- level political support to counter “commercial determinants” of environmental and public health risks and active engagement of government entities, private enterprises, and the population as a whole; medium-and long term policies and regulatory mechanisms such as the sustainability certi cation standards; raising consumer and farmer awareness of and ability to address the challenges of plastics use, as well as nudging the immense market power of consumers to shape and in uence farming practices; and predictable and suf cient funding levels to support sustained action over the medium-and long term. www.pvmarquez.com/plastic_pollution_galapagos 2/6 1/12/2021 Plastic Pollution: A "Clear and Present Danger" to the Galapagos Islands | Patricio V. Marquez As noted by the World Bank, much is known about the major avenues for mitigating plastics pollution-- from improving how plastics are managed once they enter the waste stream or even further upstream during their useful life, to reducing how much is produced, used, or enters the waste stream. Promising approaches to deal with this problem include: Recycling to reduce the production of new plastic and how much enters the waste stream. Plastics have been recycled for decades, and recycling is now accepted as a good practice globally. Waste-to-energy: This involves turning plastics into fuel or directly into energy (through gasi cation using pyrolysis and incineration, respectively). As with recycling, however, its effectiveness can be limited by collection challenges upstream. Materials innovation/biodegradable plastics: Certain plastics can be made biodegradable, thus lessening the likelihood that they will persist for a very long term in their plastic state, as they have the potential to be composted or to photodegrade (or to otherwise degrade). Improved collection and waste management: Expanding collection, improving waste transport systems to reduce illegal dumping, and closing or upgrading dumping sites located near waterways can prevent leakage of plastics into the environment. When plastic waste is not collected, it is more than twice as likely to leak into the ocean. Similarly, as the global experience with “public health taxes” levied on cigarettes, alcohol, and sugary drinks shows, imposition of or hiking the level of taxes to raise the price of single-use plastic bags to carry groceries or other items, needs to be adopted as a win-win policy measure to discourage the use of thin, disposable plastic shopping bags to help the environment and reduce plastic trash, while helping mobilize additional domestic resources to fund environmental protection in national budgets. This measure is of upmost importance in periods of economic austerity as currently facing the Ecuadorian Government and should be included and supported as part of scal consolidation efforts. To help address this issue globally, innovative nancing mechanisms are being tapped. For example, the World Bank launched in April 2019 a Sustainable Development Bond targeting institutional and individual investors to draw attention to the challenge of plastic waste pollution in oceans. This bond, which raised US$10 million, would contribute to fund projects to support the sustainable use of ocean and marine resources, including through better waste management, in developing countries. The growing economic, environmental, human health, and aesthetic risk posed to the Galapagos Islands by marine plastic debris from continental Ecuador and neighboring countries can be contained and minimized by collective action. If this is not done, plastic waste stands to cause irreparable damage to the Galapagos Islands in an ominous way similar to Charles Darwin’s observation in The Voyage of the Beagle with regard to the “havoc” that may be caused by the “introduction of any new beast of pray…before the instincts of the indigenous inhabitants have become adapted to the stranger’s craft or power”. Note*: The endocrine system is the collection of glands that produce hormones that regulate metabolism, growth and development, tissue function, sexual function, reproduction, sleep, and mood, among other things. This system affects almost every organ and cell in the body, according to the Merck Manual. Sources www.pvmarquez.com/plastic_pollution_galapagos 3/6 1/12/2021 Plastic Pollution: A "Clear and Present Danger" to the Galapagos Islands | Patricio V. Marquez Plastics Scene from “The Graduate” (1967). (https://www.bing.com/videos/search? q=plastic%20in%20the%20Graduate&qpvt=plastic%20in%20the%20Graduate&view=detail&mid=B10C80827D443C5C7 “What is the meaning behind the quote "plastics" from "The Graduate?" Comment b… (https://www.quora.com/What-is-the-meaning-behind-the-quote-plastics-from-The-Graduate) National Geographic. “Impact of plastic garbage reaches the Galapagos Islands” … (https://blog.nationalgeographic.org/2018/04/22/impact-of-plastic-garbage-reaches-the-galapagos-islands/) Galapagos Conservation Trust. As Tourism Increases in Galapagos so do Threats s… (https://galapagosconservation.org.uk/about-galapagos/conservation/pollution/) World Bank Group. Agricultural Pollution: Plastics. (http://documents.worldbank.org/curated/en/122161521208357388/pdf/124346-repl-WB-Knowledge-Plastic.pdf) Acharya, A. “World Oceans Day & plastic pollution: Is the planet overdosing on … (https://blogs.worldbank.org/eastasiapaci c/world-oceans-day-plastic-pollution-planet-overdosing-miracle- product) World Bank Group. Tackling Increasing Plastic Waste. (http://datatopics.worldbank.org/what-a- waste/tackling_increasing_plastic_waste.html) World Bank Launched Bonds to Highlight the Challenge of Plastic Waste in Oceans… (https://www.worldbank.org/en/news/press-release/2019/04/03/world-bank-launches-bonds-to-highlight-the- challenge-of-plastic-waste-in-oceans) Darwin, C. “The Voyage of the Beagle. A Journal of researches into the natural … (https://www.amazon.com/Voyage-National-Geographic-Adventure-Classics-ebook/dp/B000MAH7J0) Kickbusch, I., Allen, L., and Franz, C. 2016. “The commercial determinants of h… (https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(16)30217-0/fulltext) Marquez, PV. 2019. “Retracing Darwin’s Footsteps in the Galapagos”. (http://pvmarquez.com/node/5) www.pvmarquez.com/plastic_pollution_galapagos 4/6 1/12/2021 Plastic Pollution: A "Clear and Present Danger" to the Galapagos Islands | Patricio V. Marquez www.pvmarquez.com/plastic_pollution_galapagos 5/6 1/12/2021 Retracing Darwin’s Footsteps in the Galapagos | Patricio V. Marquez Retracing Darwin’s Footsteps in the Galapagos Submitted by Patricio V. Marquez on Sun, 11/24/2019 - 12 37 PM Retracing Darwin’s Footsteps in the Galapagos Posted by Patricio V. Marquez on Sun, 11/24/2019 - 12 37 PM In the latter part of February 1535, a caravel carrying Fray Tomas de Berlanga, bishop of Panama, enroute to Peru, drifted off course in the Paci c Ocean amid the equatorial doldrums, disappearing wind, and strong currents to an unknown and strange land. In his report to Charles V, King of Spain, who had mandated him to journey to settle disputes in his new empire, he described the nature of the shore in vivid detail: “There were some small stones that we stepped on as we landed, and they were diamond-like stones, and others amber colored; but on the whole island I do not think that there is a place where one might sow a bushel of corn, because most of it is full of very big stones, so much so that it seems as though at some time God had showered stones; and the earth that there is, is like slag, worthless, because it does not have the virtue to create a little grass, but only some thistles, the leaf of which I said we picked.” Three centuries later, Charles Darwin, sailing in the H.M.S. Beagle, arrived in the Galapagos Islands, an archipelago located six hundred miles westward of the coast of Ecuador, as part of his ve-year voyage to South America and the South Paci c. Upon landing on Chatham Island (now San Cristobal), Darwin noted in similar terms that: “Nothing could be less inviting that the rst appearance. A broken eld of black basaltic lava, thrown into the most rugged waves, and crossed by great ssures, is covered by stunted, sun-burnt brushwood, which shows little signs of life.” www.pvmarquez.com/node/5 1/4 1/12/2021 Retracing Darwin’s Footsteps in the Galapagos | Patricio V. Marquez As I found out on a recent visit to eight islands in the Galapagos aboard the Lindblad Expeditions/National Geographic’s Endeavor II (https://www.expeditions.com/why-us/our- eet/national-geographic-endeavour- ii/overview/) vessel, the observations made by de Berlanga and Darwin have in large measure withstood the passage of centuries. Indeed, one is not only captivated by a sense of distance and isolation from mainland Ecuador, but is confronted by a strange mixture of volcanic terrain pummeled by strong ocean currents, tick mists that make the islands disappear and then reappear at sunrise, lea ess shrubs, large cacti, and strange animals, that are not afraid of humans. While one nds scarce remains of visits by pirates, buccaneers, and whalers from the late 1500s through the early 1800s, and later of repeated, but failed, colonization attempts by penal colonies and settlers, the archipelago continues to be, as observed by Darwin during his visit in 1835, “a little world within itself, or rather a satellite attached to America, whence it has derived a few stray colonists, and has received the general character of its indigenous productions.” The geological formations in the islands combine rocky stretches of shoreline, pristine beaches with sand of various colors (rust red as in Rábida, created from lava with high iron oxide; ash black in Togus Cove; and beautiful white in Cerro Brujo or Wizard Hill), and active volcanos such as the Salcedo Volcano in Isabela Island and Fernandina Island, at about 1 million years old, the youngest and most volcanic of the archipelago as well as long-extinguished ones such as Ecuador Volcano, bisected by the Equator line on Isabela Island, that has collapsed and slumped away into the Paci c Ocean. There are also verdant highland regions as in Santiago Island and patches of red Sesuvium, a plant that adds color to the uninhabited areas of San Cristobal. Beautiful isolated rock outcroppings such as the León Dormido (“Sleeping Lion”), facing San Cristobal Island, offer a dreamlike view at sunset. And “in vivo” geological forces, such as the marine reef off the coast of Urbina Bay that was uplifted by as much as 15 feet, are a testament to unrelentless volcanic forces, oceanic currents, and trade winds that shape the islands. The unique fauna of the Galapagos Islands, which transports us to another era in time, stimulated “the origin” of Darwin’s ideas about evolution. Indeed, an observation recorded in The Voyage of the Beagle, a journal that underpinned his seminal work On the Origin of the Species, changed the scienti c understanding of the natural world by putting forward his theory of “descent with modi cation” by noting: “Considering the small size of the islands, we feel the more astonished at the number of their aboriginal beings, and at their con ned range. Seeing every height crowned with its crater, and the boundaries of most of the lava-streams still distinct, we are led to believe that within a period geologically recent the unbroken ocean was here spread out. Hence, both in space and time, we seem to be brought somewhat near to that great fact--the mystery of mysteries--the rst appearance of new beings on this earth.” The richness of the species that inhabit the Galapagos Islands, “peculiar to the group” and some “found nowhere else”, include the blue- and red-footed boobies, frigate birds, and several species of nches in different islands. Other species, like the American amingo and land iguanas, have a more restricted distribution, and some species are restricted to just one island, such as the waved albatross, that nests exclusively on Isla Española, and the ightless cormorant, found only on Isabela and Fernandina Islands. The “saddle-shaped” giant tortoises, iconic species of the archipelago, with an average life expectancy of close to 200 years, move between the highlands and dry zones, depending on the island and season. The wildlife at sea include cold-water penguins, green sea turtles, marine iguanas, sea lions, fur seals, and Sally Lightfoot crabs, along with many species of sea and shore birds. There is also a rich and diverse underwater world, nurtured by diverse ocean currents that converge on these remote shores, including tropical-reef sh, whales and dolphins, and a variety of shark species, including white-tip, Galapagos, and hammerhead sharks. www.pvmarquez.com/node/5 2/4 1/12/2021 Retracing Darwin’s Footsteps in the Galapagos | Patricio V. Marquez About 30,000 people live in four of the 13 large islands in the archipelago, making a living from tourism, shing, and farming. While Puerto Baquerizo Moreno, on San Cristobal Island, is the capital of the Ecuadorian Province of Galapagos, over half of all Galapagueños live in the city of Puerto Ayora on Santa Cruz Island, which is the center of tourism and conservation. As an Ecuadorian living abroad for most of my adult life, I felt great pride for the work done by my compatriots in preserving this UNESCO World Natural Heritage Site. After of cially taking possession of the Galapagos Islands in 1830, the Ecuadorian Government converted in 1959 all parts of the islands that were not inhabited by humans as a National Park (96% of the total archipelago surface area). The same year, the Charles Darwin Foundation (https://www.darwinfoundation.org/en/) was established with the objective of conserving the unique Galapagos ecosystems, and the Charles Darwin Research Station (https://www.darwinfoundation.org/en/about/cdrs) was inaugurated in 1964 to conduct scienti c studies aimed at protecting indigenous plant and animal life. In 1968, the Galapagos National Park Service, a governmental institution, was created to protect the archipelago. I also felt great pride observing that the high-quality service standards aboard the Lindblad Expeditions/National Geographic Endeavour II vessel, depends for its operation on a top-quality Ecuadorian crew and a superb team of knowledgeable and diplomatic technical guides and staff, many of them Galapagueños, to offer to visitors an environmental, historical, cultural, and culinary exploration at its best. Herman Melville, the author of Moby Dick, observed in 1854 about the Galapagos Islands that “the special curse, as one may call of the Encantadas*, that which exalts them in desolation...is that to them change never comes-neither the change of seasons or of sorrows”. Echoing those words, I concluded my visit with a deep conviction that we all have an obligation to protect the Galapagos Islands as a legacy of humanity for the enjoyment of future generations. This realization acquires more relevance in periods of scal austerity as the one currently facing the Government of Ecuador, when “siren calls”, both domestic and international, try to use cyclical downturns as an opportunity to advance short-term, self-serving economic interests, without due consideration to the long-term impact on the environment. I also feel that globally we have an obligation to help mobilize additional nancial resources, to complement regular budgetary allocations by the Ecuadorian Government, to support with adequate funding levels the critical conservation work of the Galapagos National Park Service and the Charles Darwin Foundation. For my part, I began to do so before departing, with a contribution to the Lindblad Expeditions-National Geographic (LEX-NG) Fund (https://www.expeditions.com/why-us/global-stewardship/Galapagos/), that supports in the National Geographic’s Early Career Grant program and partner institutions such as the Galapagos National Park and the Charles Darwin Research Station. We should all join the good ght of protecting the unique Galapagos ecosystems, as I am planning to continue to do so. Indeed, I feel that we need to do so as the Galapagos Islands are a global public good. Note*: Early Spanish sailors called the islands “Las Encantadas,” meaning “the enchanted,” a reference to the fact that the islands would seem to disappear and then reappear due to mists and ocean currents. Sources Darwin, C. “The Voyage of the Beagle. A Journal of researches into the natural … (https://www.amazon.com/Voyage-National-Geographic-Adventure-Classics-ebook/dp/B000MAH7J0/) Darwin, C. “On the Origin of Species (with an Introduction by Charles W. Eliot)… (https://www.amazon.com/Origin- Species-Introduction-Charles-Eliot/dp/1420953125/ref=asc_df_1420953125/?tag=bingshoppinga- 20&linkCode=df0&hvadid=&hvpos=&hvnetw=o&hvrand=&hvpone=&hvptwo=&hvqmt=e&hvdev=c&hvdvcmdl=&hvlocint= 4584207577261323&psc=1/) www.pvmarquez.com/node/5 3/4 1/12/2021 Retracing Darwin’s Footsteps in the Galapagos | Patricio V. Marquez Stewart, P.D. “Galapagos The Islands that Changed the World (with a Foreword by… (https://www.amazon.com/Galápagos-Islands-That-Changed-World/dp/0300122306/ref=asc_df_0300122306/? tag=bingshoppinga- 20&linkCode=df0&hvadid=&hvpos=&hvnetw=o&hvrand=&hvpone=&hvptwo=&hvqmt=e&hvdev=c&hvdvcmdl=&hvlocint= 4584207580741912&psc=1/) Lindblad Expeditions/National Geographic. “Expedition Guide. Galapagos Aboard N… (https://www.expeditions.com/) Perez, W. and Weisberg, M. “Galapagos Life in Motion.” (2018) (https://www.amazon.com/Galápagos-Life-Motion- Walter-Perez/dp/069117413X/ref=asc_df_069117413X/?tag=bingshoppinga- 20&linkCode=df0&hvadid=&hvpos=&hvnetw=o&hvrand=&hvpone=&hvptwo=&hvqmt=e&hvdev=c&hvdvcmdl=&hvlocint= 4583795261458359&psc=1/) Lindblad Expeditions-National Geographic (LEX-NG) Fund (https://www.expeditions.com/globalassets/pdf/lex_ng_fund_2018_2019_rpt.pdf/) Charles Darwin Foundation (https://www.darwinfoundation.org/en/donate) For information on how to create a lasting legacy in Galapagos (https://www.darwinfoundation.org/en/get- involved/give/fundraise-for-us) Melville, H. "The Encantadas, or Enchanted Isles" (2017; First published in Put… (https://www.amazon.com/Encantadas-Enchanted-Isles-Melville-Illustrated/dp/1521134855/ref=sr_1_1? keywords=melville%20herman%20enchanted&qid=1574695354&sr=8-1) (https://twitter.com/pvmarquez1956) www.pvmarquez.com/node/5 4/4 1/12/2021 An Ode to Halloween, Birthdays and Aging | Patricio V. Marquez An Ode to Halloween, Birthdays and Aging Submitted by Patricio V. Marquez on Wed, 10/30/2019 - 10 39 AM An Ode to Halloween, Birthdays and Aging Posted by Patricio V. Marquez on Wed, 10/30/2019 - 10 39 AM www.pvmarquez.com/halloween_aging 1/5 1/12/2021 An Ode to Halloween, Birthdays and Aging | Patricio V. Marquez With the arrival of Halloween, a celebration observed in several countries on October 31st, I am celebrating my birthday and moving well into my early sixties. Birthdays are usually the time of the year when I tend to pause and look back to all that happened in the prior months while looking ahead with new ideas, commitments, and resolutions. In a true sense, this is my real “new year” rather than at the beginning of the year in January. This Halloween is special. For the rst time, in more than 30 years, I am not working or actively searching for a job. After retiring a couple months ago, I have been immersed in nding a new modus operandi for this next chapter in my life. While the mirror clearly re ects the marks of time on my face--particularly a whiter beard--I feel that nothing has really changed. I continue to take long walks daily and enjoy riding my bike on some days, feeling physically t although a little overweight. Intellectually, I am still as passionate as before about exploring the complex social, economic, environmental, and political web that interacts with the genetic and biological make-up of people to impact and determine physical and mental health, mortality and survival, disability, and general well-being. Devoting more time to reading accumulated and new literature, magazines, newspapers, and Twitter; watching Copa Libertadores and Champions League soccer matches, boxing and ultimate ghting events, and over the past few days, the baseball World Series; an occasional movie or two; and a couple of trips with my wife that renewed our bond and expanded our minds, are helping me to tame feelings of anxiety that tend to appear un-invited, questioning whether I should be “working or searching for work”. I am starting to enjoy as well the good feeling of sharing accumulated knowledge and experience as a guest speaker at graduate classes in three universities covering various global public health topics. Also, I guess my family is happy getting “a la carte” www.pvmarquez.com/halloween_aging 2/5 1/12/2021 An Ode to Halloween, Birthdays and Aging | Patricio V. Marquez services from a dedicated private UBER driver, grocery shopper, purchaser of all kind of tickets, handyman, and grill master, who has also learned to prepare good black beans, Cuban-style. Life continues, not linearly, but with a certain direction in spite of occasional steps backward or the inevitable U-turns. I wonder, however, whether my situation is unique, given my good health, mental curiosity, family support, and pension income? Recently, I read an article by Camilla Cavendish at the Financial Times, that argued that there is mounting evidence that retirement can be bad, especially if you enjoy your job, which I did immensely, along with its comradery and sense of meaning. Also, it is argued that work has many bene ts and an important social function. Since we are on average living longer lives, the question that we need to pose is why should not we push retirement well into the late sixties or early seventies then? Although global experiences show that working longer is feasible, the answer to this question has multiple caveats. A key condition for staying at work an extra decade or even more, as well argued in Cavendish’s article, is not just increased average life expectancy, but more importantly, healthy life expectancy. This is a key observation as not everybody will bene t from working longer given the sometimes wide and growing gaps in healthy life expectancy between different income groups and in different regions within countries. Also, the decision to stay at work or “unretire” will depend on the accumulated skill set of individual workers, effective life-long learning opportunities to retrain and reskill older workers, existing health insurance and pension bene ts, as well as public support systems to care for elderly family members. Workplace facilitating environment and attitudes towards older workers, including stigma and discrimination, are also important considerations. www.pvmarquez.com/halloween_aging 3/5 1/12/2021 An Ode to Halloween, Birthdays and Aging | Patricio V. Marquez From a social perspective, we have to be mindful as well that the world population is growing older. In some countries, the age structure of the population is changing rapidly by falling birth rates, which is further impacted by youth migration in some of them. This means that skills shortages are nowadays a real challenge that will not be met solely by robots or arti cial intelligence tools that take over many cognitive tasks. Rather, older workers will not be easily be replaced. They are and will continue to be needed given their accumulated formal and tacit knowledge, institutional memory, skills set and wisdom, including interpersonal skills, that often cut across disciplines, work streams, and interconnected but distinct country social and cultural contexts. So, on this Halloween, besides wishing myself a happy birthday, I should feel happy and less anxious realizing that I although “retired” I am part of a distinct population group that possesses valuable human capital that should be put to use with good impact, either as a volunteer or in formal employment, to help advance social and economic initiatives that bene t all, particularly in the intergenerational transmission of knowledge, experiences, and skills to younger generations. To realize this potential, however, we “oldies” need to be mindful and disciplined in devoting time and effort to engaging in health promotion and disease prevention, as well as on life-long learning. Yes, we can or as I would say in Spanish, si se puede, as we need to be t to purpose for that metaphorically “extra inning or round” in life. Sources Cavendish, C. “The case for staying at work an extra decade—or event more”. FTW… (https://www.ft.com/content/f4cd91aa-c4d8-11e9-ae6e- a26d1d0455f4) www.pvmarquez.com/halloween_aging 4/5 1/12/2021 An Ode to Halloween, Birthdays and Aging | Patricio V. Marquez Murray, J. “Work has many bene ts and an important social function” FT Letter… (https://www.ft.com/content/4610cb60-bf5a-11e9-b350- db00d509634e) Marquez, P. 2016. “Income inequality and differential mortality: An ominous com… (http://blogs.worldbank.org/voices/income-inequality-and- differential-mortality-ominous-combination) Cavedish, C. 2019. “Extra Time: Ten Lessons for An Aging World”. (https://www.harpercollins.com/9780008362829/extra-time-10-lessons- for-an-aging-world/) (https://twitter.com/pvmarquez1956) www.pvmarquez.com/halloween_aging 5/5 1/12/2021 Social Disparities Among Indigenous Peoples in the Americas: A Legacy to Overcome | Patricio V. Marquez Social Disparities Among Indigenous Peoples in the Americas: A Legacy to Overcome Submitted by Patricio V. Marquez on Sun, 10/27/2019 - 08 19 PM Social Disparities Among Indigenous Peoples in the Americas: A Legacy to Overcome Posted by Patricio V. Marquez on Sun, 10/27/2019 - 08 19 PM The recent social unrest in Ecuador brought to world attention the often ignored and marginalized indigenous peoples that led the opposition to economic reform proposals advanced by the Government. While the unrest ended after some of the proposals were rescinded following a public dialogue between the Government and the leaders of the indigenous movement, deep-seated grievances remain that need to be addressed to improve the social conditions of indigenous peoples. www.pvmarquez.com/legacy_to_overcome 1/6 1/12/2021 Social Disparities Among Indigenous Peoples in the Americas: A Legacy to Overcome | Patricio V. Marquez The situation of indigenous peoples in Ecuador, however, is not different from that in other Latin American countries, as well as in Canada and the United States, each with considerable indigenous populations. Overall, there are between 45 and 50 million indigenous peoples living in Central and South America and the Caribbean, representing approximately 13 percent of the total population. In the United States, approximately 5.2 million persons self- identify as American Indian or Alaskan Native, and in Canada 1.4 million people self-identify as indigenous. As shown in the graph below, Mexico, Bolivia, Peru, and Guatemala have the largest populations in both absolute and proportional terms, accounting for more than 34 million indigenous people. The indigenous peoples represent more than 400 groups, with 560 diverse languages, cultures, and knowledge systems. World Bank research has shown that despite the social progress achieved in the past couple of decades in Latin America, indigenous peoples did not bene t to the same extent as the rest of the population. Poverty af icts 43 percent of the indigenous population—more than twice the proportion of non-indigenous—while 24 percent of all indigenous people live in extreme poverty, 2.7 times more than the proportion of non-indigenous people. This situation is also apparent in in Canada, where over 60 percent of children living on First Nations reserves live in poverty, compared with 41 percent of all indigenous children and 18 percent of all children. In the United States, it is estimated that the median income of Native American households is nearly $30,000 less than the median income of white households. Furthermore, being born to indigenous parents substantially increases the probability of being raised in a poor household, contributing to a poverty trap that hampers the full development of indigenous children. In Ecuador, the probability of a household being poor increases by 13 percent if the household head belongs to an indigenous group, regardless of his or her level of education, gender, urban or rural location, and number of dependents. In Bolivia and Mexico, the probability is 11 percent and 9 percent higher, respectively. www.pvmarquez.com/legacy_to_overcome 2/6 1/12/2021 Social Disparities Among Indigenous Peoples in the Americas: A Legacy to Overcome | Patricio V. Marquez Contrary to common assumption, nearly half of Latin America’s indigenous population now lives in urban areas, but often are exposed to new dimensions of exclusion. About 36 percent of all indigenous urban dwellers live in insecure, unsanitary, and polluted environments, which contribute to increased health risks. For example, in Mexico, indigenous urban dwellers have less than half the access to electricity and piped water than other city dwellers have, one- fth the access to sanitation, and live nearly three times more often in houses with dirt oors. World Bank data also show that while improved educational outcomes among indigenous people have been one of the most important advances in the last decade in Latin America, additional efforts are needed to increase education quality, make it culturally appropriate and bilingual, and to reduce a wide gap in education between indigenous men and women. In cities, indigenous people work mostly in low-skill/low-paying jobs. In countries with large urban indigenous populations, such as Peru, Ecuador, Bolivia, and Mexico, the percentage of indigenous persons occupying high-skill and stable jobs is two to three times smaller than the percentage of non-indigenous people. Indigenous workers, who often are engaged in informal occupations, are less likely to receive retirement and health insurance bene ts. Household data show that, regardless of educational background, gender, age, number of dependents, and place of residence, an indigenous person likely earns 12 percent less than a non- indigenous person in urban Mexico and about 14 percent less in rural areas. In Bolivia, an indigenous person likely earns 9 percent less in urban settings and 13 percent less in rural areas. In Peru and Guatemala, indigenous persons earn about 6 percent less than non-indigenous populations. And Bolivian indigenous women earn about 60 percent less than non-indigenous women for the same type of jobs. Another common problem in the Americas is glaring health disparities that re ect not only high poverty levels but wide health care access gaps between indigenous peoples and the rest of the population. PAHO/WHO data show that infant mortality in consistently higher among indigenous children than among non- indigenous children in 11 countries in Latin America for which data were available. In Panama and Peru, for example, infant mortality among indigenous children was three times higher than in non-indigenous children. The data also show greater www.pvmarquez.com/legacy_to_overcome 3/6 1/12/2021 Social Disparities Among Indigenous Peoples in the Americas: A Legacy to Overcome | Patricio V. Marquez maternal mortality among indigenous women and that under-5 mortality rates are far higher for children of indigenous background than for those of other ethnic groups. In a national survey study throughout Brazil, indigenous women were found to have a higher prevalence of obesity, anemia, and hypertension. In Canada, infant mortality was 4.6 times higher in Inuit-inhabited areas than that reported in non-indigenous-inhabited areas. In the United States, under-5 mortality for Native Americans at 8 deaths per 1,000 births, is second highest after African Americans at 11 deaths per 1,000 live births. From 2012–2015, compared with white women, the incidence of severe maternal morbidity was 148% higher for American Indian/Alaska Native women in the United States. High rates of chronic undernutrition among indigenous children further undermine their human capital development. In Latin America and the Caribbean, prevalence rates of stunting in children are higher in indigenous than in non- indigenous peoples. For example, in Guatemala, where levels of stunting are high compared with other countries, 58 percent of indigenous children are stunted, compared with 34 percent of non-indigenous children. Higher prevalence of health risk factors, chronic diseases, and mental and substance use disorders are also found among indigenous people. In the United States, CDC reports evidence that colorectal cancer screening prevalence is lowest, binge drinking is highest, motor vehicle crash rate is highest, and drug- induced death rates are highest in American Indian/Alaskan Natives compared to other ethnicities. Additionally, in the United States, smoking prevalence is highest among indigenous youth compared to non-indigenous peers. In Canada, the suicide rate for First Nations males aged 15–24 is four times higher than that of non-indigenous young people. First Nations populations are particularly at risk for substance abuse, contracting tuberculosis and/or HIV, and developing diabetes. Indigenous women in Canada are ve to seven times more likely than other women to die as the result of violence. These data provide compelling evidence that poverty among indigenous people in the Americas is about more than income. Indeed, unsafe and unsanitary living conditions and wide health and education disparities are all measures of multidimensional poverty that require broad, sustained, multisectoral efforts to www.pvmarquez.com/legacy_to_overcome 4/6 1/12/2021 Social Disparities Among Indigenous Peoples in the Americas: A Legacy to Overcome | Patricio V. Marquez overcome. To be effective, however, these efforts must be rooted in consultation with and active participation of indigenous people, while respecting their cultures and identities. As the recent experience in Ecuador shows, the voices of indigenous peoples are now an integral part of the political process. They demand to be heard and must be part of the planning and implementation of economic and social policies and programs to ensure acceptance and sustainability. Sources World Bank Group. “Indigenous Latin America in the Twenty-First Century”. (https://www.worldbank.org/en/region/lac/brief/indigenous-latin-america-in- the-twenty- rst-century-brief-report-page) United Nations. “State of the World’s Indigenous Peoples”. (https://www.un.org/development/desa/indigenouspeoples/wp- content/uploads/sites/19/2018/03/The-State-of-The-Worlds-Indigenous- Peoples-WEB.pdf) PAHO/WHO. “Just Societies: Health Equity and Digni ed Lives. Report of the Com… (https://www.paho.org/hq/index.php? option=com_content&view=article&id=1245%3Apaho- publications&Itemid=1497&lang=en) PAHO/WHO. “Core Indicators 2019 Health Trends in the Americas”. (https://www.paho.org/hq/index.php? option=com_content&view=article&id=15499%3Acore-indicators-2019-health- trends-in-the-americas&Itemid=1894&lang=en) NIH. “MATERNAL MORBIDITY AND MORTALITY What Do We Know? How Are We Addressing I… (https://orwh.od.nih.gov/sites/orwh/ les/docs/ORWH_MMM_Booklet_508C.pdf) Babyar, J. “In search of Pan-American indigenous health and harmony”. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6381669/) Picture in blog by David Diaz Arcos/Bloomberg (https://www.bloomberg.com/news/articles/2019-10-12/ecuador-s-scorned- indigenous-rise-up-as-moreno-s-biggest-threat) www.pvmarquez.com/legacy_to_overcome 5/6 1/12/2021 Social Disparities Among Indigenous Peoples in the Americas: A Legacy to Overcome | Patricio V. Marquez (https://twitter.com/pvmarquez1956) www.pvmarquez.com/legacy_to_overcome 6/6