CASES IN PANDEMIC PREPAREDNESS AND RESPONSE AND DYNAMIC HEALTH SYSTEM RESILIENCE

Module 1 March 2021

COVID-19, Global Health

Equity, and Dynamic Health
System Resilience
 The public provision of health care at all times for all people is the foundation for
pandemic preparedness. It is also a basic human right—the right to health (About
the Right to Health and Human Rights, n.d.). It is the core requirement of productive,
peaceful societies. The integration of universally available health care with community-
based, government funded public health systems able to stop disease outbreaks, and
global collaboration ensuring equity in access to medical goods are the prerequisites
of pandemic preparedness and dynamic health system resilience.

No country fully met these requirements when COVID-19 emerged—although a few

performed much better or much worse than others. As the COVID-19 pandemic
continues more than a year later, the prospect of control—including through newly
available vaccines—pivots on implementation of intentional equity-centered action
from local to global levels.

The World Bank
[projected] that by
2021, approximately
A year after the first cases of pneumonia of unknown causes were reported in Wuhan,
China, on December 31, 2019, nearly 100 million people had been infected by COVID-19
and nearly two million had died (CSSE Johns Hopkins, 2020). Meanwhile, millions of
people lost access to a wide range of health services, from childhood vaccinations
to cancer screenings and neonatal care. In addition, the loss of income and jobs had
deepened poverty, hunger and malnutrition, with the World Bank projecting that by 2021,
approximately 150 million people would be pushed into extreme poverty (World Bank,
2020).

150 million
people would be
Nowhere have these impacts been evenly distributed. Job losses globally that have been
four times worse than those from the financial crisis in 2009 have hit lower-wage workers
hardest. On the other hand, the world’s 1,000 richest people had already made back their
pushed into extreme losses and the wealthiest 10 had earned more than $500 billion during the first year of the
poverty. pandemic (Hassan, 2021).

...On the other hand,
the world’s 1,000
richest people had
already made back
their losses and the
wealthiest 10 had
earned more than
Vast economic and social inequities, within and among nations, create the rough landscape
across which the virus spreads, raging in some areas and leaving others far less scathed.
Although the virus is fundamentally the same wherever it ranges (albeit with variants), the
conditions it meets are not. And these conditions more so than the virus itself have been
responsible for excessive morbidity and mortality.
The social determinants of health—a broad set of social and economic forces that shape
daily life from conception to birth to death—determine risk of exposure, severity of

500
disease and risk of death. Particularly with infectious diseases, crowded living and working
$ conditions, lack of water and sanitation, food insecurity, and lack of access to timely quality
billion health care are major determinants of health.

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Epicenters of inequity
“Ending inequality is the only way to achieve the right to health for all
and it is everyone’s business to ensure that we do so.”
Tlaleng Mofokeng, United Nations Special Rapporteur on the Right to Health (Tlaleng Mofokeng, 2021).

While the world has long feared the health and economic impact of a “pandemic flu” and
ostensibly prepared for the same, those preparations have largely overlooked the role of
social, economic and racial inequity as both contributor to and consequence of pandemics
(Lau et al., 2019) (Meltzer et al., 1999).

Scene from Freetown,

Sierra Leone. Photo by Evidence of grossly unequal impacts of the COVID-19 pandemic were visible at its outset,
Jon Lascher / PIH and continue to emerge. Even in China—a country with near universal health coverage
(Tikkanen et al., 2020)—there were early warnings. While it was immediately recognized
that the elderly were far more likely to die due to COVID-19, and that those with certain
pre-existing conditions had higher fatality rates (Zhou et al., 2020), less publicized was that
people with COVID-19 coming from poorer and polluted districts in China and Italy had
poorer outcomes (Davis, 2020).

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 Indeed, in the pandemic’s first year, the countries with the worst outbreaks were
among those that are most unequal. The United States, Brazil, India, and Mexico are all
ranked among the top ten offenders in terms of income inequality among nations of the
Organization for Economic Co-operation and Development (OECD). Russia is number 11
on the list, and the United Kingdom is number 13 (Suneson & Stebbins, 2019).

Almost one year into the pandemic, these same countries had the highest number of cases
and deaths from COVID-19. The U.S., India, Brazil, Russia and the United Kingdom had the
Poor housing highest case counts (Jan 31, 2021). The U.S., Brazil, Mexico, India, and the United Kingdom,
conditions (with Russia ranking #7) had the most deaths (Johncox, 2021).
and higher
occupational In France, which suffered early and severely from the COVID-19 pandemic, researchers
exposure found that mortality rates from COVID-19 were twice as large in municipalities below the
accounted for 25th percentile of the national income distribution compared to those municipalities above

77%
of the difference
this threshold. Poor housing conditions and higher occupational exposure accounted for
77 percent of the difference observed between rich and poor communities. (Brandily et al.,
2020).

observed between
Even in countries that have instituted relatively comprehensive public health responses that
rich and poor
included testing, contact tracing, and quarantine, inequity has been the deadly Achilles
communities in
heel of pandemic response. In countries like Malaysia, Singapore and Thailand, low-paid
France.
migrant workers, sometimes held in slave-like conditions, have died by the hundreds and
thousands while overall national mortality rates have remained low.

The Achilles heel of pandemic response

In Malaysia, some
5,000 workers
were infected. The
outbreak later spread
to hundreds more
factory workers living
in cramped metal
shipping containers.
In Malaysia, a country that the World Health Organization (WHO) had praised for “rapid
and robust health security measures” that facilitated a systematic response to COVID-19,
the pandemic’s epicenter arose among workers at Top Glove, the world’s biggest maker of
medical gloves. Some 5,000 workers were infected (Medical X press, 2020). The outbreak
later spread to hundreds more factory workers living in cramped metal shipping containers
(Workers at Malaysian Glove Maker Found Living in Shipping Containers, 2020).
In Singapore, dubbed by some as the “gold standard” of COVID-19 detection, 152,000
migrant workers—about half of the country’s total—became infected with COVID-19 in the
first nine months of the pandemic. Meanwhile, fewer than 4,000 non-migrants had tested
positive in the country. The migrants were subsequently imprisoned in the crowded rooms
of their giant dormitories, while the majority of the population continued to operate with
relative freedom (Illmer, 2020).

In South Africa, where cases surpassed 1.47 million, and deaths topped 46,000 by early
February 2021, just 17 percent of South Africans had medical insurance, while more than

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 half of the country’s 6,000 critical care beds were in private hospitals (Cocks, 2020).
Segregation along racial lines persists 27 years after the end of apartheid and indications
are that overcrowded impoverished neighborhoods known as townships are bearing the
brunt of the outbreak, compared to small, affluent and more often white communities
(Nwosu & Oyenubi, 2021).

Age-adjusted
mortality rates
from COVID-19 in the
U.S. show that Pacific
Islanders, Latinx,
Lockdowns, business and school closures have also hit poorer communities hardest. Early
in the pandemic, 190 countries faced complete or partial school closures, affecting more
than 1.7 billion students. Developed countries distributed laptops and Chromebooks and
ensured access to internet. Poor countries tried to use local and national TV and radio
stations. However, in most of countries where <50% of the population has access to
electricity, online learning opportunities were very limited (The World Bank, 2020).

Black and Indigenous Similar inequities emerge in the pandemic response of high-income countries. For those
Americans all who practice social medicine, it is not surprising that the pandemic epicenter arose in a
have a COVID-19 country where the factor most associated with a shortened life span is zip code (The 21st
death rate of Century Pandemic: COVID-19 and Health Equity, 2020). Zip code itself can be seen as

double
or more that of White
and Asian Americans
a proxy for structural racism, encoding centuries of slavery, stolen native lands, forcibly
outlined reservations, decades of Jim Crow, red-lining, impoverished school systems,
unsafe working conditions, and mass incarceration. The difference in life expectancy
between the poorest communities in the U.S. and the richest ones is about 30 years
(Mukherjee, 2017). This is similar to the differences in life expectancy between the U.S.
overall and an impoverished country like Liberia (World Bank, 2018).

Age-adjusted mortality rates from COVID-19 in the U.S. show that Pacific Islanders,
Latinx, Black and Indigenous Americans all have a COVID-19 death rate of double or more
that of White and Asian Americans, who experience the lowest age-adjusted rates. The
highest rate is among Indigenous Americans, claiming the lives of one in every 475 Native
Americans since the pandemic began (APM Research Lab Staff, 2021).

Preparedness: blind to history

“Indigenous collective memory is marked by pandemics, as diseases such
as smallpox, measles and influenza were spread by colonizers, sometimes
deliberately, ravaging and decimating their communities. In the COVID-19
pandemic, indigenous peoples have already reported alarming levels of
transmission among their communities and sometimes higher rates of fatalities.”
José Francisco Calí Tzay, 2020

Pandemics have always disproportionally affected the poor and marginalized (Collazos,
2000). From the time of the Black Plague, the rich attempted to avoid the pestilence by
“fleeing fast and far” while the poor, materially trapped in confined quarters suffered and

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 died (The 21st Century Pandemic: COVID-19 and Health Equity, 2020). Fast forward to the
2009 influenza pandemic: the mortality rate was 20 times higher in some South American
countries than in Europe, and three times higher in the poorer parts of England compared to
the affluent parts (Mamelund, 2017).

But despite this well-chronicled history, issues of inequity have been notably absent from
global and national frameworks meant to guide policymakers in their planning and funding of
pandemic preparedness and response.

This includes the U.S. CDC’s updated preparedness and response framework for pandemics
(Holloway et al., 2014), published in 2014, and the Global Health Security Index (GHSI)
(Global Health Security Index, 2019), published in 2019, shortly before COVID-19 erupted.

What went wrong in the US

“If you have a health The GHSI is described as the “the first comprehensive assessment and benchmarking
system like we of health security” in the face of rising biological threats, whether natural, intentional or
do in the United accidental. Although meticulous in its accounting of a large number of possible factors,
States, that is organized across six categories and 34 indicators, the index failed to capture the reality of
deeply racist and pandemic risk.
delivers extremely
inequitable
Neither its six major elements (Prevent, Detect, Rapid Response, Health, Compliance with
outcomes, you’re
International Norms, and Risk) nor its 140 questions adequately addressed issues of equity.
not going to be
Instead, the focus was on more quantitative and technical measures. Also absent was
able to fight a
consideration of interactions among the six major elements. Given the omission of crucial
pandemic.”
dimensions of preparedness, the United States ranked #1 for pandemic preparedness when
Dr. Joia Mukherjee,
compared with 194 other countries.
Chief Medical Officer,
Partners In Health
But the first, it turned out, was last.

Vaccines and equity

“Ensuring equitable access to vaccines globally during a pandemic
is not only a moral issue, but an economic imperative to protect
the wellbeing of people everywhere. But when will Africa get the
protection it needs? If all lives are equal, why isn’t access to vaccines?”
Paul Kagame, President of Rwanda (Kagame, 2021)

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The first vaccine
shot was given to a
grandmother in the
UK on Dec. 8, 2020.
Two months later,
23
countries
had begun
vaccination
programs, most
in rich- or middle-
income countries,
and only one
(Morocco) in Africa.
The Africa Centers
for Disease Control
and Prevention was
launched by the
African Union in 2016,
on the heels of the
worst Ebola epidemic
in history. When
COVID-19 hit, the
Africa CDC was ready
to steer pandemic
response across
the continent.
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The blind spot regarding equity emerged acutely in relationship to vaccines – a key
preventive measure. The first vaccine shot was given to a grandmother in the United
Kingdom on December 8, 2020. Two months later, 23 countries had begun vaccination
programs, most in high- or middle-income countries, and only one (Morocco) in Africa
(Ritchie et al., 2021).
COVAX, an international consortium supporting global vaccine distribution, was set
up by WHO, Gavi (the Vaccine Alliance), and the Coalition for Epidemic Preparedness
Innovations (CEPI) to help address this inequity (World Health Organization, 2021). Its
goal is to provide 2 billion doses of vaccine by the end of 2021. This could cover 20 percent
of the vaccine required in low- and middle-income (LMIC) countries. However, closer to
80 percent coverage may be needed to achieve herd immunity. This leaves a huge gap
in vaccine access for impoverished nations, which may not achieve meaningful vaccine
coverage until 2023 at the soonest (The Economist, 2021).
Meanwhile, some countries had procured enough doses to vaccinate their populations
several times over. The situation has prompted WHO’s Director General Tedros Adhanom
Ghebreyesus, to warn that “the world is on the brink of a catastrophic moral failure –
and the price of this failure will be paid with lives and livelihoods in the world’s poorest
countries.” (Gnebreyesus, 2021).
But African countries were not holding their breath while waiting for the largesse of
rich nations.
The Africa Centers for Disease Control and Prevention (Africa CDC) was launched by
the African Union in 2016, on the heels of the worst Ebola epidemic in history. When
COVID-19 hit, the Africa CDC was ready to steer pandemic response across the continent.
By June 2020, it was running the Africa Medical Supplies Platform, and had secured an
initial order of 270 million vaccine doses by early February 2021. It was also bulk procuring
testing kits and personal protective equipment (Carien du Plessis, 2020). Meanwhile, as
the highly transmissible SARS-CoV-2 variant that had first appeared in South Africa spread
to other African countries, the Africa CDC kept a sharp watch on vaccine effectiveness
against the new variant, and adjusted its purchases and recommendations accordingly.
African countries negotiating vaccine deals independently have run in to their own
roadblocks, particularly around vaccine price. Some pharmaceutical companies quoted
higher prices for African purchasers than European. AstraZeneca, for example, quoted a
price to South Africa was 2.5 times higher than that in most European countries
(Sullivan, 2021).
Tripping on vaccine supply
“As a global community we must say that we need patents waived,
technology and know-how shared, and mass production of the vaccine
to eliminate the falsely created vaccine scarcity.”
Dr. Joia Mukherjee, Chief Medical Offer, Partners In Heath

As of February 2020, however, the bigger problem was limited vaccine supply. Global
vaccine manufacturing capacity does not come close to meeting global demand as the
major COVID-19 vaccine producers—many substantially financed with public tax dollars—
have maintained tight control over patents.

South Africa and India have therefore led a global call to remove intellectual property
barriers to production that are codified in the World Trade Organization’s intellectual
property rule known as the TRIPS Agreement (Agreement on Trade-Related Aspects of
Intellectual Property Rights). Suspension of some elements of TRIPS would enable generic
manufacturers from India to Indonesia to produce COVID-19 vaccines and therapeutics
affordably and at scale (Callaway, 2020).

One hundred countries and the People’s Vaccine Alliance have lined up in support of
suspending TRIPS. The Alliance is calling on governments and corporations to treat
COVID-19 vaccines as a global public good, and ensure it is purchased at true cost prices
and provided free of charge to people (People’s Vaccine Alliance, n.d.).

In New York City...
among the 125,000
vaccinated New
Yorkers aged
65 and up, only
Global inequity in vaccine access is mirrored on a smaller scale within countries, including
rich countries like the United States. In New York City, vaccination data reported on
February 2, 2021, demonstrated that inequity is most pronounced among the most
vulnerable: among the 125,000 vaccinated New Yorkers aged 65 and up, only 9 percent
were Black. Overall, while 24 percent of city residents are Black, only 11 percent of vaccine
recipients were (Fitzsimmons, 2021).

9%
were Black. Overall,
while 24% of the city
residents are Black,
only 11% of vaccine
recipients were.
Immokalee is a city of 27,000-40,000 (depending on the harvest season) with a large
community of migrant farmworkers in Florida’s Collier County. County vaccination efforts
initially bypassed Immokalee in favor of the nearby city of Naples, one of the wealthiest in
the U.S. Even after local organizers convinced government agencies to set up a vaccination
clinic in Immokalee, wealthy white residents from Naples quickly filled the queue. Only
after the Healthcare Network, PIH, CIW and other local partners went door-to-door
informing and signing up residents, many who do not speak English, were they able to get
the shots (Walk-up Vaccine Clinic Serves Immokalee Community, 2021).

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The Meaning of Health System Resilience
“We had little infrastructure, equipment or laboratory testing. It took
a while to get test results. Patients would be anxious. If you are in a
rural area, and need to send a lab sample to Monrovia, it is an 18-hour
drive in the dry season. It is quite a challenge.”
Viola Karanja, Nurse Midwife, Deputy Executive Director, Partners In Health, Liberia

In 2018, high income
countries spent an
average of
The issue of global health equity defines every aspect of pandemic response in low-income
countries, where public health care systems are severely underfunded. There is more
than a 100-fold difference in per capita health spending between the world’s richest and
poorest nations. In 2018, high income countries spent an average of $5,562 per person per
year on health (the U.S. was an outlier, spending $10,624 per capita), while low-income
countries spent on average $36 per capita on health (The World Bank, n.d.).
This paucity of resources in impoverished countries means that there is never enough

$5,562
per person per year
on health... while
low-income countries
spent on average
$36 per capita
money to adequately fund systems (administrative, technical); staff (doctors, nurses,
midwives, community health workers); space (hospitals, Intensive Care Units, clinics,
community health centers); supplies (Personal Protective Equipment, diagnostics,
medicines, vaccines, oxygen); or social support.
3.1
High income countries:

on health.

Doctors per Middle income: 1.4

1,000 people
Low income: 0.3

High income countries: 10.9

Nurses and
SO U RCE S

https://data.worldbank.org/
midwives per 2.7
Middle income:
indicator/SH.MED.PHYS.ZS 1,000 people
https://data.worldbank.org/ Low income: 0.9
indicator/SH.MED.NUMW.P3

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True resilience of
any health system
can only be claimed
based on the
consistent delivery
of quality care to all
patients and the
health outcomes
that result.
Nurse Thamar Julmiste (right),
known for singing to her tiny
patients, attends to a newborn
in the Neonatal Intensive Care
Unit at St. Thérèse Hospital in
Hinche, Haiti. Photo by Cecille
Joan Avila / PIH
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Such inequities flow from history. They are the legacy of four centuries of colonialism,
resource exploitation, and slavery from which many countries still struggle to rebuild.
The victories of independence from colonial powers did not suddenly level the global
playing field of economic development, or abolish the structures and ideologies of global
exploitation.
As low-income countries struggle to cover even a bare minimum of health care for
their populations, the concept of resilience is often invoked as the goal of health system
development, and interpreted to refer to the ability of a health system to absorb a shock
(an epidemic, a financial crash) and regain its original shape. However, returning to a
system of scarcity can never achieve the right to health.
“Resilience,” in that narrow sense of the term, is no substitute for strong. True resilience of
any health system can only be claimed based on the consistent delivery of quality care to
all patients and the health outcomes that result.
Key to such resiliency is equity of health care delivery, redundancy of services to allow for
surge capacity in times of crisis, and integrated health care and public health systems.
The Ebola epidemic of 2014-2016 in West Africa revealed the full impact of weak health
systems as a matter of both local and global concern. In Liberia and Sierra Leone, already
skeletal heath systems quickly crumbled under the weight of the epidemic.
 To understand why, one need only look at maternal health, which can be seen as a proxy
for a country’s health overall. Well before Ebola hit, maternal mortality in Sierra Leone
claimed the lives of 1 in 17 women during pregnancy or childbirth (Mason, 2016).
Public health clinics and hospitals in both countries, typically had neither electricity,
running water, nor a regular supply of oxygen. The term resilience has limited relevance
in such conditions.

Health systems all over the world have struggled to deliver care while also coping with the
pandemic, although the challenges vary in both degree and kind. The job of strengthening
public health care falls primarily to governments. But that doesn’t mean partners can’t
provide assistance when asked.

Strengthening health systems before,

during and after pandemics
How many of these deaths [from Ebola] were caused more by the virulence of social
conditions than by the virulence of the pathogen? If it came down solely to the virulence of a
particular strain or species, as is still commonly alleged, then why have mortality rates varied
so widely among people infected with the same variants of Ebola? With the exception of one
Liberian-born U.S. citizen, every American who fell ill ... survived. So did most Europeans.
That’s because they were medevacked out of the clinical desert, fell ill shortly after returning
from it, or were among the handful of professional caregivers infected beyond its borders.
Dr. Paul Farmer, co-founder Partners In Health, in Fevers, Feuds and Diamonds (Farmer, 2020)

In 2014, at the request of the government of Sierra Leone, Partners In Health (PIH)
sent teams of health care providers to help end the Ebola epidemic. PIH accompanied
government and community partners desperately fighting to move from a singular focus
on containing the epidemic (which was not working) to also treating those who fell ill.
PIH also placed a
high priority on When PIH arrived in West Africa, treatment, including the urgent replacement of body
strengthening networks fluids lost through vomit, diarrhea, sweat and fever, was largely impossible. While Oral
of Community Health Rehydration Salts were available, many patients could not keep them down; there was
Workers (CHWs) neither clinical tracking of fluid loss nor equipment to support intravenous infusion of fluids
able to bridge the and electrolytes. As a result, thousands who could have lived, died. Among their numbers
frightening world of were more than 500 professional health care givers working in Liberia and Sierra Leone.
Ebola Treatment Units
and communities long PIH also placed a high priority on strengthening networks of Community Health Workers
neglected by formal (CHWs) able to bridge the frightening world of Ebola Treatment Units and communities
health systems. long neglected by formal health systems.

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 Among their many responsibilities, CHWs played a central role in ensuring patients and
their families received the material and social support they needed to isolate or quarantine
when they had been infected or exposed to Ebola. They walked house-to-house in affected
communities, provided education, dispelled myths, provided PPE, offered psychological
support, and identified patient’s needs—whether for food, money, cooking utensils, or
hospital transport.

Dr. Bailor Barrie, a Sierra Leonean physician with PIH, notes, “We cannot care for patients
“We cannot care if we cannot provide basic social support like access to food, to water. As clinicians, we
for patients if we should listen, just listen to the patient, to what they need, and try to fight and provide that
cannot provide basic to them.”
social support like
access to food, to Indeed, the provision of social support is one of the most crucial—and neglected—aspects
water. As clinicians, of epidemic response and health system strengthening. During today’s COVID-19
we should listen, pandemic it plays a crucial—and under-resourced—role in engaging and protecting
just listen to the communities. (See Module 3 for more on the role of CHWs.)
patient, to what
they need, and try to During and after the West African Ebola epidemic, PIH also invested heavily in clinical
fight and provide training of nurses and physicians; infection prevention; upgrading health facilities, and
that to them.” strengthening the supply chain. In Liberia, PIH worked with community members to
Dr. Bailor Barrie, improve infection prevention through the installation of hand hygiene supplies (water, soap,
PIH, Sierra Leone or hand sanitizer), increasing their availability from 28 percent to 82 percent within eight
weeks at health facilities and public services.

But while water buckets with faucets helped prevent the spread of Ebola and likely saved
lives, they do not make for a strong or resilient health system, says PIH’s Mukherjee. Much
more is needed. She notes that after the Ebola epidemic, PIH made building oxygen plants
one of its priorities, not because it was needed to fight Ebola, but because it is a basic
requirement for the medial treatment of many critically ill patients.

“As part of our health system strengthening, we built oxygen plants in many places. We
never knew the next epidemic would be a respiratory disease. But when it hit, we had those
ready,” she reflects.

PIH supported Sierra Leone through building a blood bank; maternal waiting homes and an
emergency room; and establishing an ambulance service (Sierra Leone, n.d.).

Nonetheless, says Barrie, “It’s not enough. The national government does not have
resources to do this for the entire country.”

And as COVID-19 hit African countries with increasing intensity in late 2020 and
early 2021, health systems across the continent were bowing under the pressure.
Hospitalizations and deaths were rising, and vaccines had yet to arrive.

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What is needed for pandemic control and
global recovery?
“The pandemic has told us that health is not a luxury item, but a human
right and the foundation for social and economic development.”
Dr. Tedros Adhanom Ghebreyesus, Director-General of WHO
(“COVID-19 Is More than a Health Crisis,” Warns Dr Tedros, 2020)

As of February 2021, the COVID-19 pandemic had shown no signs of letting up, and its
economic blows kept coming. The global economy contracted by 4.3% in 2020 (World
Bank Expects Global Economy to Expand by 4% in 2021, 2021), catapulting most countries
into recession. In poor countries, in particular, restrictions put in place to control the virus
caused massive economic shocks.

The human consequences have been staggering. At least 225 million full-time jobs
disappeared worldwide in 2020 because of the pandemic, disproportionately affecting
low-paid and low-skilled jobs (International Labor Organization, 2021). The United
Nations’ World Food Program warned that the number of people “marching towards
starvation” spiked from 135 million to 270 million as the pandemic unfolded—and
predicted that 2021 would be catastrophic (United Nations, 2020). The Global Fund
estimated that an additional 1 million people could die of AIDS and tuberculosis in the
...rich countries coming year due to pandemic-related disruptions in health screening and care (The Global
spent an average of Found, 2020).

20%
of their Gross
But governments’ abilities to blunt those blows varied widely. According to Nobel-winning
economist Dr. Esther Duflo, rich countries spent an average of 20 percent of their Gross
Domestic Product Domestic Product (GDP) to protect their economies; middle income and emerging market
(GDP) to protect countries spent 6 percent; and low-income countries spent 2 percent (Zakaria et al., 2021).
their economies; The options available to low-income countries were not only limited by the size of their
middle income and budgets, but also by the conditions imposed by lenders: World Bank loans prohibit heavily
indebted countries from running a deficit.
emerging market
countries spent

6%
However, although a country’s income level and spending can mitigate impacts, it in no
way assures an effective, equitable pandemic response. The U.S.’s $2.2 trillion COVID-
relief CARES Act, for example, has been faulted for favoring large companies over small
and low-income
businesses, and even for dispersing more aid to hospitals serving wealthier patients than
countries spent
those serving the poor (Abramson, 2020).

2% . Highly unequal societies, with huge gaps in wealth and access to opportunity, are divided
societies, in which governments have earned the deep mistrust felt by many sectors of the

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 population. Such societies are more vulnerable to misinformation and disinformation that
Governments whose makes effective pandemic response impossible. Governments whose response is to assign
response is to assign blame, deny pain, or distort science and truth to maintain power cannot lead the all-of-
blame, deny pain, or society unified effort needed to contain or end a pandemic.
distort science and
truth to maintain The opposite approach is needed. Communities that are most affected by adverse
power cannot lead the social forces and diseases have a central role to play in responding to crises. Their lived
all-of-society unified experience positions them well to find and attend to the vulnerable, trace contacts, inform
effort needed to communities of threats, and devise solutions.
contain or end a
pandemic.
Basic principles for equitable, effective response
remain constant:

Æ Leadership that is science-based, transparent, equity-centered and accountable for the

health outcomes of the most vulnerable;

Æ Attention to the social determinants of health. Governments and citizens must

understand their own histories and acknowledge and redress health inequities, targeting
resources to serve vulnerable populations;

Æ Commitment to high quality affordable health care delivery, integrated with community-
based public health systems that offer social support to affected individuals;

Æ Global collaboration to end the pandemic and promote economic recovery, including
through massive aid for poor countries; support for global organizations such as
the World Health Organization; and support for a dramatically increased supply of
COVID-19 vaccines, diagnostics and therapeutics.

The ability for a nation to act in solidarity, to listen to and learn from communities,
is key to effective pandemic response. The ability to act in solidarity as humanity,
across borders, and guided by the common good will determine how quickly this
pandemic will end, and whether the next one can be prevented.

14 Cases in Pandemic Preparedness and Response and Dynamic Health System Resilience | Module 1 March 2021
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16 Cases in Pandemic Preparedness and Response and Dynamic Health System Resilience | Module 1 March 2021