Abstract
Introduction
Despite the significant improvements in living standards in the last century, the world is witnessing emerging and re-emerging diseases at an unprecedented number and frequency. This concerning scenario is, to a great extent, the result of anthropogenic modification of the natural environment leading to a more frequent interface between humans and animals, which is occurring in the setting of worsening socioeconomic inequalities.
By the end of 2019, the Global Health Security Index launched an ‘SOS’ signal denouncing the lack of global preparedness to detect and control events or pathogens that could jeopardize human security. This multifactorial vulnerability served as the prime substrate for the SARS-CoV-2 pandemic, creating a powerful synergy that has affected every aspect of human life in every region of the world.
There is an urgent need to create, implement, and enforce a global agenda that prioritizes human well-being over economic profits.
Plagues, human societies, and climate change
The history of mankind contains accounts of the demographic, social, and economic devastation caused by epidemics and pandemics of infectious pathogens. Throughout history, socially marginalized people have been particularly vulnerable to the ravages elicited by these plagues. For example, the Ebola virus disease (EVD) crisis was a wake-up call for the world to transform and strengthen the health services globally and specially across developing countries. The EVD outbreak in West Africa took more than 11,000 lives, slowed down economic growth constraining government budgets and thereby limiting their capacity to provide basic services for the poorest and most vulnerable people in West Africa. In addition, the crisis eroded trust among communities, stigmatizing victims and survivors, and destroying confidence in health and government services. The EVD outbreak demonstrated that under-resourced, understaffed and fragmented health services were unable to contain outbreaks of serious infectious diseases or adequately respond to health emergencies. 1
The emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic occurred amid a major structural vulnerability crisis for many people across the globe. The 2019 Global Multidimensional Poverty Index (MPI), which offers data for 101 countries or 76 percent of the global population, showed widening inequalities across countries and among the poor themselves. 2 The MPI complements traditional monetary poverty measures and offers a multidimensional assessment by simultaneously capturing the acute deprivations in health, education, and living standards that a person faces. Some of the 2019 figures were alarming: 1.3 billion people (23.1%) were multidimensionally poor, half of the 1.3 billion multidimensionally poor people were children under age 18, and a third were children under age 10. Women represented the majority of the poor in most regions and among some age groups. More than 40% of the global poor live in economies affected by social vulnerability, conflict, violence, and climate change. The 2019 MPI also reported a wide variation in inequality among multidimensionally impoverished communities, even in high-income countries.
Climate change is one of the most important global health threats of the 21st century affecting directly (e.g. droughts, hurricanes, flooding, wildfires and sea-level rise) or indirectly (e.g. vector-borne and airways diseases, food and water insecurity, undernutrition, and forced displacements) the wellbeing of society. 3 Human contribution to climate change will drive 68 million to 132 million into poverty by 2030 and is a particularly acute threat for countries in Sub-Saharan Africa and South Asia, the regions where most of the global poor are concentrated. 4 A large share of the poor live in areas that are affected by conflict and are at high risk of famine due to floods or droughts. 5 Paradoxically, countries with a low human development index are least responsible for the emission of greenhouse gas emissions but carry the highest disease-burden attributable to climate change. 6
Climate change exacerbates health disparities for many people already struggling with poverty, malnutrition, and the effects of natural disasters. 3 The health effects of climate change are substantially diverse, with regional differences in vulnerability to climate sensitive diseases due to variable forms of climate exposures, public infrastructure/adaptability, or baseline climate-sensitive disease rates.3,7 If climate change alters the balance of disease emergence or resurgence in developing countries, where there is currently inadequate disease surveillance, then both developed and developing countries may encounter an increased risk from new emerging infectious agents.
Chronicle of a foretold global pandemic disaster
The Global Health Security (GHS) Index is a comprehensive assessment that benchmarks health security and related capabilities across the 195 countries that comprise the States Parties to the International Health Regulations. 8 The GHS Index includes indicators of nations’ capacities and capabilities to reduce Global Catastrophic Biological Risks (GCBRs). 9 One of the 2019-GHS Index conclusions was that ‘national health security was fundamentally weak around the world’. Every country in the world needed to prepare for epidemics or pandemics, and every country had significant gaps to address. The 2019-GHS Index delineated weaknesses in the ability of countries to prevent, detect, and respond to health emergencies. These deficiencies stem from severe gaps in health systems; vulnerabilities to political, socioeconomic, and environmental risks that can confound outbreak preparedness and response; and a lack of adherence to international norms. One key 2019-GHS Index recommendation was that ‘given the enormous national need, the UN Secretary-General should call a heads-of-state-level summit on biological threats by 2021 focused on creating sustainable health security financing and new international emergency response capabilities’.
The emergence of the 2019 SARS CoV-2 pandemic occurred amid a high global burden of non-communicable diseases (NCDs), very often undiagnosed, untreated, and uncontrolled. NCDs include heart disease, stroke, cancer, diabetes, and chronic lung disease. These emerging global health threats are responsible for almost 70% of all deaths worldwide. More than half of adults ages 18 and older have at least one chronic condition, and more than one-quarter have at least two. The NCDs pandemic is primarily driven by four major risk factors: tobacco use, physical inactivity, the harmful use of alcohol, and unhealthy diets. 10 Other essential cofactors are rapid and disorganized urbanization due to increasing migration from rural to urban areas, changes in lifestyles and nutritional patterns, lack of health-related awareness, low educational level, social inequities, and low socioeconomic status.11,12
By the end of 2019, several early warning signals for future major disasters were evident:
Nearly 25% of the world’s population was poor and socially excluded.
A lack of global, regional, and national capacity to detect and respond to global health threats opportunely.
Global climate changes and its deleterious effect on health were at the frontline.
A pandemic of undiagnosed, untreated, and uncontrolled NCDs severely affected morbidity and mortality across countries
This complex manufactured vulnerability created an ideal scenario for a ‘perfect storm’ where multiple factors colluded for an explosive outbreak of a new pathogen with devastating worldwide consequences.
The COVID-19 pandemic and social exclusion
Similar to the recent experience with HIV/AIDS 13 and Ebola virus disease, 14 stigma and discrimination have limited access to opportune diagnosis and critical care for sick people and survivors. The call for social distance overlapped with structural differences and amplified existing inequalities of income, race, gender, ethnicity, migratory status, age-group, and sexual diversity. The COVID-19 pandemic has created a dramatic shift from people’s need to live in mutual association toward a desire to stigmatize distinctive others, taking the forms of social rejection, gossip, physical violence, and denial of services.15,16
Family members of people with the infection and healthcare providers caring or working with people with COVID-19 have experienced stigma from others and even death threats or pressure from their neighbors to move to another location.17,18 Stigma and racial discrimination have been directed at Asian countries, people of Asian descent, and those who have traveled to areas affected by the pandemic. 19
The social stigma of COVID-19 has even influenced the end-of-life practices of human beings. There have been violent disruptions or prohibitions of funeral ceremonies and burials of COVID-19-related deaths. Across cultures, religious leaders have refused to perform the end-of-life practices of the infected dead bodies. 20 Similarly, people have protested against the selection of ‘safe coffins’, sites for mass graves, condemning open funerals, and public cremations of bodies with COVID-19.21,22
As fear, stigma, discrimination, and xenophobia reached its peak during the pandemic, the developing world has been forced to be part of an unequal fight with the major powers of the planet for access to personal protective equipment, reagents, and equipment needed to develop diagnostic tests, and life-saving treatment interventions such as oxygen.23,24 For example, the World Trade Organization reported on 24 April 2020, that 80 countries and customs territories have banned or limited the export of face masks, protective gear, gloves, and other goods to mitigate shortages since the coronavirus outbreak began.25,26 Lack of transparency about restrictions and failure to cooperate internationally undermined efforts to slow the spread of the virus.
As the pandemic evolves around the world, imposed social isolation continues to cause an enormous disruption of daily routines for the global community, especially among children and adolescents. Many schools have closed, and education has been moved to home-based or online learning to encourage and adhere to social distancing guidelines. The effects of the pandemic on children’s education has been devastating, increasing the educational urban–rural and the rich–poor gaps and posing a high risk to the mental well-being of children, women, and families. 27 To compound the educational and mental-health crisis in children in developing countries, many of their parents who survive in an informal economy have lost their only form of income, translating to high rates of domestic violence, alcoholism, and suicide.28–30
Finally, the call by global health leaders for the ethical and equal distribution of vaccines across the world has fallen short. Prioritization for profit over human life, coupled with the politicization of the vaccine and lack of consistent public health recommendations, have continued to cripple vaccine equity. In addition, the distrust of some sectors of the community in their governments, is to a degree, deep-rooted to the legacy of exploitation of minorities and vulnerable groups and current forms of structural racism.31,32
Lessons learned for future pandemics
There is a perennial risk for the emergence of future pandemics for which there are currently limited opportunities for intervention. Adverse social determinants of health and social exclusion are pivotal in the origin of the pandemics and their associated morbidity and mortality. There is, therefore, an urgent need to invest in reducing structural vulnerability to the impact of future pandemics by improving the baseline health status of populations at risk and reducing the social asphyxia that occurs in marginalized communities in many settings. As the present pandemic has unveiled, those residing at the lowest social scale have suffered the greatest impact. In this context, social improvements targeting educational opportunities, overall well-being, and improving the nutritional status of impoverished populations remain major public health priorities. More equitable redistribution of income, wealth, and social welfare can spur economic growth. Health systems remodeling in the primary healthcare context needs to be implemented, especially in low-income countries.
As stated by the World Health Organization, ‘climate change is the single biggest health threat facing humanity’. 33 Genuine global collaboration to avert the crisis has been long overdue. Although there are glimpses of hope from commitments to decrease greenhouse emissions made by most of the international community, the ill-prepared global response to the current pandemic should be used as a deterrent to the continued retrograde and selfish thinking of the society. There is an urgent need for new legislations, policies, and regulatory actions to safeguard our planet’s biodiversity. As individuals, we need to be more empathetic, selfless, and compassionate toward our congeners and to the other living entities with whom we share the planet. 34
The world constantly faces the old Greek dilemma known as ‘The Sword of Damocles’. Despite modern advances in every aspect of human life, poverty, climate change, pandemics, chronic diseases, and the overall health system crisis hang as a sharpened sword above and aiming at every head in the world. The Greek accounts affirm that the sword was held only by a single hair of a horse’s tail to evoke the sense of what it is like to have much fortune and at the same time always having to watch in fear and anxiety against dangers that might try to overtake Damocles. ‘Illnesses do not come upon us out of the blue. They are developed from small daily sins against Nature. When enough sins have accumulated, illnesses will suddenly appear’. (Hippocrates, 479–377bc).
The global response to the COVID-19 pandemic unveiled the fact that we practice medicine and public health in an increasingly unequal world. Our task is to become global societal leaders focused on reducing remediable injustices and ameliorating structural vulnerability.
