The Fight Against COVID-19: A Perspective From Latin America and the Caribbean

Countries in Latin America and the Caribbean (LAC) have made great efforts over recent decades to increase effective coverage of health services although large inequities persist among and within the countries.¹ The urban–rural gap is the most notable inequity in this region. However, unlike most of the public health problems that are predominant in LAC,² COVID-19 has primarily affected urban areas, especially areas of concentrated poverty.³

Managing the pandemic has primarily been an urban challenge that has substantially affected the most marginalized areas of the most densely populated cities and municipalities. In those areas, the COVID-19 crisis has predominantly affected the poorest populations, which is owing to the size of the informal workforce, health service access barriers, and malnutrition.⁴ Compared with high-income countries, LAC presumed early on that it was relatively protected from COVID-19 because the region is more geographically dispersed and its populations tend to be younger. However, it turned out to be one of the areas that is most vulnerable to the pandemic because of regional disparities in health capacities, weak health authority, and structural and historical inequalities that undergird social determinants of health. The role of health systems has been fundamental, but the structural determinants put the region in a sociohistorical position of vulnerability, particularly for the large metropolitan regions.

The H1N1 (influenza A virus subtype H1N1), Zika, and Chikungunya pandemics provided important lessons.⁵ However, the lessons learned were insufficient in the face of COVID-19, with its magnitude and duration and the deep social complexity of mitigation measures that were to be adopted in highly uncertain contexts—many of which had not been used for several decades. Nonetheless, the region’s countries had prepared antipandemic response plans, including improvements in its epidemiological surveillance systems, information systems, and alert and response systems, which made it possible to adapt the response quickly. Although these plans were unevenly executed, the impact undoubtedly would have been worse without these resources, the experience, and the preparation.

Unfortunately, during the first months of the pandemic, there was little scientific evidence of the effectiveness and applicability of control measures, particularly nonpharmacological measures (e.g., hand washing, mask wearing) in contexts such as LAC. Most of the evidence that was initially available came from high-income countries. Opportunely, the evidence base was supplemented by scientific publications led primarily by Chile, Brazil, and Colombia. As decision makers, we were faced not only with developing interventions to protect life and the capacities of the health system but also with preventing our decisions from deepening inequalities—inequalities that also determine opportunities for health and well-being for individuals and populations as well as public health over the medium and long terms.

Implementing COVID-19 control measures in LAC has not been easy. It has involved a battle that we knew from the very beginning nobody would win. Historical structural determinants in the region, such as the informal workforce, affected the impact of the virus by producing the incidence of severe cases and a clear socioeconomic gradient of mortality, as we have previously shown in Colombia.³ Garzón-Orjuela et al. (p. S586) drew similar conclusions in their study about the effects of socioeconomic inequalities on COVID-19 outcomes.

Those structural determinants also affected the effectiveness of measures, such as contact-tracing programs, that promised to be less detrimental than general quarantines. Nevertheless, contact tracing depended on isolating suspected cases, which was impossible for some people because of their socioeconomic situation.⁶ The measures could not be expected to have the same effectiveness as in high-income countries, nor could the implementation be expected to not involve problems with adherence, acceptability, and applicability among a population facing food insecurity, employment insecurity, hopelessness and uncertainty about the future, desperation, and a lack of social well-being.

As mentioned, the socioeconomic conditions in the LAC region influenced the effectiveness of the measures and intensified their indirect consequences. Compared with high-income countries, the social cost of restrictions on mobility was more significant, the resources available to mitigate their impacts were fewer, and citizens were less willing or able to comply with the measures. Closing airports, businesses, educational institutions, and other entities had a greater impact on deepening inequalities and on economic growth in our countries. Furthermore, with an economy that was less resilient and less able to recover,⁷ the impact of the measures in our context had more weight. Another difference was owing to the model of the state in most LAC countries versus the impositions and control of measures by authoritarian governments. Although these can be effective in terms of temporarily suppressing transmission, they have a high social cost and are incompatible with the principles and guarantees of modern democracies.

The COVID-19 pandemic and its measures have had a large impact on health systems throughout LAC countries. In one notable example, Cuadrado et al. (p. S591) examined the impact of the pandemic on access to cancer care in Chile. Additionally, health personnel have had to take on heavy workloads, which both puts them at risk for COVID-19 and affects their mental health, as shown by Paniagua-Avila et al. in their study in Guatemala (p. S602).

Today, more than two years since the first case of COVID-19 was reported in LAC, it is clear that the restrictions on mobility in the LAC region had high social, human, and economic costs. The decision of some countries, such as Colombia, to open their economy early, just when cases began to decrease, likely saved thousands of lives, decreased the impact on inequalities, and contributed to the future quality of life of the most vulnerable. Proof of this is that Colombia quickly recovered thousands of jobs and income increased when the economy opened, although the country has not yet been able to reach 2019 levels.⁸

When the vaccines were approved for emergency use, they quickly became precious and scarce, and market logic imposed by high-income countries spread to the LAC region, outstripping international cooperation capacities. Existing mechanisms were insufficient for ensuring earlier access for countries that were less able to sign bilateral agreements—such as Haiti, Jamaica, Bolivia, Paraguay, and Nicaragua, where vaccination started to ramp up between the second and the third quarters of 2021 (with the exception of Haiti, where, to date, coverage with the full scheme still does not rise above 1%). In the end, those agreements ensured early access for most middle- and high-income countries but were never a good alternative for low-income countries. Donations of vaccines were valuable, being the only source of vaccines in some countries, and arrived during the most critical vaccination times for others. However, for certain nations, donations were not enough, and they have suffered more from the limitations of the well-intentioned multilateral COVAX (COVID-19 Vaccines Global Access) cooperation mechanisms, as well as from noncompliance by some of the laboratories. A reflection of these facts is the global inequity that is currently observed, particularly that which was seen during the first quarter of 2021 when saving lives was more urgent.⁹

In high-income countries, nationalism displaced global health principles of solidarity and equity, creating excessive vaccine concentrations in those countries and diminishing the effectiveness of multilateral mechanisms. Additionally, although there is more inequity on the global scale than in the LAC region, inequity threatens the LAC region’s ability to reactivate commercial activities; it clearly should be a political priority for the global health of the region now and over the coming years.

Today, the pandemic clearly cannot be controlled across the world, and low vaccination coverage and the circulation of the virus through the poorest regions are obviously not safe for high-income countries themselves, because globalization processes necessarily determine that transmission in an affected country will inevitably affect others. Likewise, the pandemic’s economic ramifications for one country have regional and global effects. For this reason, it is ethical and fair to control the pandemic throughout the world, and there is no controlling it without global action.¹⁰

It is necessary to continue to strengthen basic public health capabilities, epidemiological surveillance, local capacity to produce vaccines, health information systems, health authority, and health governance. Under this framework, the digital transformation of the health sector is one of the most important challenges in the LAC region, as discussed in this supplement by García Saisó (p. S621).

Over the coming decades, there is still much to be understood and to work toward, including redressing the other impacts that the pandemic has had on public health. As Báscolo et al. discuss in this supplement (p. S615), the future agenda needs to prioritize improving structural elements while strengthening the stewardship capacities of health authorities and developing institutional structures to achieve universal health care coverage in the LAC region.

COVID-19 has been a trial by fire for global health, especially for the LAC region. It is evident that the response to new pandemics requires stronger international cooperation within and outside the region, cooperation that moves beyond discourse and translates into effective mechanisms to achieve equity in health.