Health equity in a time of global crisis

What are we seeing in the world of global health during the COVID-19 pandemic?

What happens in these kinds of global health crises is that it’s a testing of the current values, principles, and implications of norms in the systems or lack of systems throughout the world. It’s an unfolding of natural ‘experiments’ testing our global, national and local systems, or lack thereof, in global public health.

Some countries have a considered and thought-through approach, others have responses that are ad hoc, patchwork, or spontaneous. Our difficulty in the United States is that we have a more fragmented approach with considerable variation because we have local, state, and federal agencies. We have more of a bottom-up approach to public health, where local authorities have significant authority. Testing is a good example of this; we have a lot of regional variation in the access and distribution of coronavirus tests. The delays and inadequacy in testing compromised our ability to know who had the virus and to use public health measures of contact tracing and isolating early on to contain the virus.

Remember, we did not have a strong and effective national system for testing. Now we’re bringing in private companies. I think that’s fine, but we need to have innovative ways of producing for the public, for everyone as a public good. For example, it’s important to have testing available as knowledge of who is infected so that public health measures can be implemented to contain a virus, which benefits us all, rather than solely as a private good available to some.

The other problem that we’re currently experiencing in this country is that we don’t have a resilient public health system across the United States. There’s not a centralized authority that is currently focused on these public health issues. There’s too much variation across the country, and it’s creating a lot of confusion and chaos. That’s where the hysteria comes in. An excellent public health system is proactive, logical, controlled, and standardized. It uses data from one prior year to the next to avert and prevent threats; it is intentional and unflappable, with outstanding public capabilities to anticipate and act quickly, decisively, and successfully.

The United States also has a history of privileging individual rights over federal authority and power. That plays out in our hesitancy with quarantining. The execution of authority tends to focus more on the federal capacity than on an individual’s rights.

What is the United States doing well?

One thing we are seeing is the regulatory capacity of the U.S. We now know that the coronavirus outbreak likely originated in wet markets in China. Those are markets in which you see animals and different cuts of meat being sold. There are people interacting with live and dead animals all in a very confined space. They are not very well regulated, and there’s a mixing of wildlife, domesticated animals, and people. Unfortunately, it’s pretty much what we call a ‘perfect storm’ in terms of a virus hopping from one species to another. Both SARS [Severe Acute Respiratory Syndrome] and the coronavirus are believed to have come from these sorts of sites. Of the roughly 30 new pathogens detected in humans in the last 30 or so years, 75% have originated in animals.

The selling of meat in the United States, while not perfect, is controlled. We do have federal regulatory requirements for meat products. We have had outbreaks in our food supply (E. coli, samonella), also from animals, typically through feces, but they haven’t tended to be this type of virulent disease, with the exception of swine flu, which was found in pigs.

China temporarily banned wet markets immediately after the coronavirus outbreak, but now it appears to be a permanent ban.

How do we talk about logistical issues in epidemiology, like wet markets, without it becoming a cultural issue?

We need to make sure that we are being true to health equity, which is respecting everyone equally. One way that public health systems address this issue is to focus specifically on risk rather than on a particular race or ethnicity. So understanding people’s travel and interaction history, using contact tracing, and assessing their risk level, is really what the focus should be on.

The Taiwanese have dealt with this crisis more effectively, and they learned that from prior epidemics, like SARS. Also, the Taiwanese were more effective in the initial stages. When they found out there was a disease with respiratory risk from China, they tested people and were able to identify and isolate cases. They also sent a group of experts on a fact-finding mission to China, restricted travel, employed quarantine measures, and educated the public. This is an example of focusing on the risk rather than ethnicity or race.

What lessons are we going to learn globally when this is over?

I think this should be a clear awakening. I think that we will recognize that investing in public health and public health systems and learning from prior public health outbreaks are worth significant investments in terms of global health equity. Schools, jobs, global and domestic financial markets, trade are all affected. We need a centralized global policy to manage global health. COVID-19 has made it clear that we are all interdependent. We coproduce the conditions for health or illness.

I believe in the abilities of people at the Centers for Disease Control and Prevention. I have confidence in the people there and would like to see them have a more assertive role in public health in the United States as well as globally. We have an emerging zoonotic diseases center. That could be focused more proactively on surveilling what diseases are out there and working on potential vaccines and treatments as well as new and innovative ways to prevent viruses from jumping from animals to humans and to prepare logistically and operationally for what’s coming down the pike.

What’s happened previously is that once a disease is past, we lose interest and the CDC and other public health agencies, local, state and global, lose funding. Unfortunately, the CDC is tied to the ebb and flow of public or political attention. We should look at the economic and social impact and say, ‘This is worth investing in, and we have the scientific and economic capacity to do this.’

Ebola, as we know, killed many, many people in western Africa. We had a few cases in the U.S., and the death rate was low because the response was good and our health care quality is high. But we didn’t have the numbers that we’re seeing with coronavirus. The people who did have the virus, we were able to treat; the ability to treat people was compromised in western Africa. For global health equity, everyone should have the ability to be healthy, regardless of where they live.

The solution is to have a much better system to understand and control emerging zoonotic diseases and how to respond to them from the earliest stages of transmission, from animals to humans, all the way through to the various stages of disease spread through human populations. We need to be thinking forward in terms of what could be coming and setting up uniform policies and practices. We’re all feeling it now because we didn’t know that’s how the system worked or failed to work. People are saying that’s crazy and asking why isn’t the federal government doing something. It’s because the federal government isn’t set up to work that way. It’s not an issue of incompetence; people at the CDC as well as basic and social scientists in the United States and elsewhere are incredibly competent, but they have not been organized and empowered  to work for the American people, or people throughout the globe, in the way that I know they can.