PROJECTS AND FEATURED ARTICLES

GLOBAL DISPARITIES IN HEALTH CARE: THE CASE OF COVID-19 VACCINE INEQUITY
MAR 7, 2022

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Written By Infectious Disease Working Group DLSPH

By: Gagandeep Johal

As the world continues down the path of enhanced globalization, the ethical and moral need to invest in global health, vaccine innovation and or infectious disease research is becoming increasingly more imperative. Throughout the pandemic, stark differences between the ‘global north’ and ‘global south’ highlighted disparities in accessing lifesaving medical equipment and the lack of an equity based global agenda for health. More nations such as the United States, Canada and United Kingdom, countries that fall into the category of the global north, have moved towards providing booster doses for their populations, while only 11% of all people in poorer countries of the global south are vaccinated with the first dose (Hunter et al., 2022). Currently, to address vaccine inequity, many countries of the global north have donated vaccines to COVAX which is co-led by the World Health Organization (WHO) and Coalition for Epidemic Preparedness Innovations (CEPI) (WHO, 2021). The lack of support for the global south already struggling with basic delivery of health care services points to the failure of many western countries in meeting their pledges to establish equitable global access to vaccines through COVAX (Bowdish & Chakraborty, 2021). According to the WHO, most COVID-19 vaccines have been administered in the global north, with many of these countries having the privilege of multiple vaccine options (WHO, 2021). Vaccine costs alongside the failure to share resources and knowledge has contributed to vaccine inequity resulting in the prolongation of the pandemic.

Over 225 million vaccines that have been administered globally, but a failure to share vaccines in an equitable manner, continues to put the world’s most vulnerable populations at risk, and gives rise to more variants (Ghebreyesus, 2021). Many wealthy countries have exceeded 90% of vaccine coverage for their populations, but as a comparison, only 25% of healthcare workers in Africa are fully vaccinated as of November 2021 and less than 2% of global vaccines have been administered in Africa overall (Hunter et al., 2022). With approximately 3 billion people across the world waiting to receive a single dose, numerous experts have linked the rise of the Omicron variant to be resultant of the lack of support being directed towards vaccine manufacturing capacity in the global south and vaccine inequity in general, which led to opportunities for the virus to mutate, evade current vaccines and spread worldwide (Hunter et al., 2022). Not only does this detrimentally impact trade and travel, but it forces many countries of the global south to sit and wait for accessible vaccine supplies. India continues to manufacture and supply vaccines for the COVAX vaccine access program, however, increased measures to ramp up vaccine supply for the many countries that continue to experience barriers to vaccine access is still needed. Assistance in boosting vaccine manufacturing requires commitment from governments and pharmaceutical companies. AstraZeneca has already shared their licenses to increase access to vital information needed to manufacture and increase the supply of COVID-19 vaccines (Ghebreyesus, 2021). Although these are significant steps, there is still more that needs to be done with waving patents being a place to start. Waving patents would allow for the suspension of protections on intellectual properties for COVID-19 vaccines allowing for countries like India to ramp up mass production of licensed COVID-19 vaccines, which pharmaceutical companies oppose (Ghebreyesus, 2021). Supporting countries in the global south to build their own manufacturing and health systems capacity would also enable increased access to COVID-19 vaccines, which is recently has been done with the domestic manufacture of yellow fever vaccines in Senegal (Ghebreyesus, 2021). As a part of equitable access to vaccines, health systems also play a vital role in the distribution of vaccines.

The pandemic has illuminated the crucial need for well-functioning and robust healthcare systems, with stories of some of the wealthiest nations still struggling to keep up with COVID-19 cases. Struggles to respond to growing COVID-19 cases highlighted the ramifications of underinvestment, disorganization, and fragmentation of healthcare systems in some of the most developed nations of the world such as the United States of America, thereby exposing the fragility of healthcare systems in these nations. Even so, the pandemic also highlighted the effective measures taken by some of the less resourced countries or countries of the ‘global south’ to mitigate the impacts of COVID-19 on their already vulnerable health systems. This points to the greater understanding that many of the health and social constraints exhibited throughout the pandemic are not just limited to the ‘global south’, demonstrating the need for a focus on a global health agenda that utilizes an equity approach (Jenson et al., 2021). Eliminating the gap in health care between the most and least advantaged requires a perspective that encourages distinctions-based approaches that avoid the homogenization of vaccine distribution measures but instead encourage tailored methods to vaccine roll out in different countries and a global commitment to evolve the global health field. Through this approach, the need for a multidisciplinary understanding of healthcare systems is also effectively reinforced as weakened health systems are not an isolated occurrence but rather resultant of various factors including investment and resource availability (Jenson et al., 2021).

As for equitable access to COVID-19 vaccines, many have reiterated the need for collective enthusiasm to meet targets for COVAX, but also to empower technology and knowledge sharing with the global south. Long term access to vaccines and vital health promoting and preventative measures can only be accomplished through the capacity building of vulnerable populations. Increased investment in vaccine building by countries like Canada, which have primarily been vaccine consumers, would elicit greater vaccine equity and limit the burden of future infectious diseases as well (Bowdish & Chakraborty, 2021). With many developed nations already having utilized their privilege of administering booster shots, it is critical that increased effort is dedicated to ensuring vaccination for populations of the global south.

Resources

Bowdish, D., & Chakraborty, C. (December 14, 2021). Analysis: COVID-19 Vaccine Inequity    Allowed Omicron to Emerge. McMaster University. Retrieved from      https://brighterworld.mcmaster.ca/articles/analysis-covid-19-vaccine-inequity-allowed-omicron-to-emerge/

Ghebreyesus, T.A. (March 5, 2021). A ‘Me First’ Approach to Vaccination Wont Defeat COVID. The Guardian. Retrieved from      https://www.theguardian.com/commentisfree/2021/mar/05/vaccination-covid-vaccines-rich-nations

Hunter, D., Karim, S.A., Baden, L., Farrar, J., Hamel, M., Longo, D., Morrissey, S., & Rubin, E. (2022). Addressing Vaccine Inequity: COVID-19 Vaccines as a Global Public Good. The New England Journal of Medicine, DOI: 10.1056/NEJMe2202547

Jensen, N., Kelly, A.H. & Avendano, M. (2021). The COVID-19 pandemic underscores the need for an equity-focused global health agenda. Humanit Soc Sci Commun 8, 15. https://doi.org/10.1057/s41599-020-00700-x

World Health Orgaization. (2021). Vaccine Equity. Retrieved from https://www.who.int/campaigns/vaccine-equity

AGEISM & COVID-19 (OP-ED) FEB 3 2022

Written By Infectious Disease Working Group DLSPH

By: Parya Borhani

We are quickly approaching 35,000 total deaths due to the COVID-19 pandemic in Canada, over 90% of which have been among individuals aged 60 or older. While it became clear early on in the pandemic that increasing age is a risk factor for severe illness, our response to this fact — or at times, lack-thereof— from individual to structural levels has woefully revealed that beyond just biological age, it is to a great extent ageism, that has likely imparted such disproportionate negative outcomes to older adults. Two years and five waves deep, with an undeterminable amount of this pandemic remaining, we are well over-due for some serious conversations about how we have been failing older adults, and the need for intergenerational collaboration  to end age stigmatization as we move through, and beyond this pandemic.

Ageism, or negative attitudes, stereotypes and discrimination based on chronological age— most often targeted towards older adults— has been aptly described as the “most socially accepted” form of prejudice. Think about how regularly we see or hear older people singularly represented as frail, incapable, or dependent. Even the rarer and seemingly “positive” stereotypes can be problematic as they are reductionist and fail to reflect the true complexity of an entire age-group. Ageism as well as ageist narratives and imagery are so deeply ingrained in our daily lives that we are often blinded to their presence. But when you really reflect, is it not fascinating that while each and every one of us are growing older, we have collectively constructed such negative attitudes on a process that could really be viewed as a privilege? Is it not ironic that the very group we hope to live long enough to gain membership to, we ridicule, stigmatize and exclude from society? The consequences of this biased disposition are significant, and as the pandemic has reinforced, can even be deadly.

I remember very clearly the state of public discourse during the first wave of the pandemic, hearing comments along the lines of “it’s okay, it only affects old people,” as if human lives somehow devalue with age. The perceived expendability of older adults could not have been more cruelly reflected than in the “#BoomerRemover”, infamously trending on social media platforms, making light of the sizeable death toll in this population as the virus spread. These remarks may be played-off as harmless or simple banter, but I think we would be less comfortable accepting the use and proliferation of this language if we were all aware of its detrimental effects when internalized. There is already a substantial body of evidence that reveals significant associations between negative self-perceptions of aging and a variety of poor health outcomes including anxiety, depression, functional decline, and even reduced life-span. If the health consequences to the individual are not reason enough to worry, a study that applied a pre-pandemic U.S.-specific model predicted that the healthcare costs resulting from ageism amount to $63 billion in a single year, with $33.7 billion attributed specifically to negative self-perceptions of aging. Unsurprisingly, ageism along with negative self-perceptions of aging became significantly more salient during the pandemic, and given what we know about its deteriorative effects on overall health, these trends only work to exacerbate pre-existing risks of serious COVID-19 illness. 

The problem with the pervasiveness of ageist attitudes at the individual level is that these very biases get carried up to set the foundation for our public policies and systemic decision making — ones with very consequential impacts on public health. As I write this, we are seeing outbreaks in long-term care (LTC) facilities in Ontario that are comparable to those in the first wave, with deaths concomitantly rising. Beyond infection prevention and control measures, which have been largely inadequate thanks to chronic underinvestment and abhorrent living conditions, there has been a dangerously limited regard for the overall biopsychosocial wellbeing of residents. For example, overly-restrictive and non-evidence based visitor policies have been enforced throughout the pandemic, leaving residents without access to their essential family caregivers or care partners. This has left residents in severe social isolation for extended periods of time. These policies were not only at odds with the needs and wants of many residents and their loved ones, but also with re-opening guidelines that were being applied for the rest of the public. Denying residents of the social connections so vital to their care while simultaneously opening up almost all spaces and business to the general public is a prime example of the disparities in policy-making. The shockingly detrimental effects of social isolation were highlighted in a recent study of Ontario LTC residents, which showed almost 35% greater excess mortality in residents who did not have any personal contact (including by phone) with family or friends compared to those who did.

Experts in gerontology have used the terms “vulnerability narrative” or “burden narrative,” which describe the way we have homogenously described older adults as frail, weak and in need of protection, and how we have used this to rationalize isolating or segregating all older adults (including the vast majority who live in the community) at any cost. Time and again, we have been missing the mark by continuously making decisions for older people, with presumptions of uniform needs or desires, and without consideration for their autonomy or dignity.

In light of a rapidly aging global population, concerted efforts to promote healthy aging and the wellbeing of older adults have been taking shape. This includes the Global Report on Ageism from the World Health Organization which includes a framework for reducing ageism for actors at a variety of societal levels, and the United Nations’ declaration of the “Decade of Healthy Ageing (2021-2030)” which has identified the need to combat ageism as one of its primary action areas. Building this global awareness is an important first step, which must be met with national and organizational strategies, and individual-level efforts to end the stigmatization of older adults. Importantly, these landmark documents both emphasize the need for intergenerational solidarity in this process.  

As a younger adult myself, I see intergenerational contact and allyship as an invaluable opportunity to learn, build social cohesion, and to challenge stereotypes of both “young” and “old”. This same collaboration is vital at government and systems-levels, and we must recognize the value and actively encourage the participation of older adults in decision-making. We certainly cannot in good faith continue with our paternalistic practices, assuming we know what is best for a diverse group of individuals— the COVID-19 pandemic has revealed in many ways why this does not work.

Let’s not forget that aging is universal, and that healthy aging is a lifelong process. When we work together to promote the health, well-being and social inclusion of older adults now, it is not only benefiting the older adults of today, but all of society and every generation to come. And while we cannot predict what the next pandemic-causing virus has in store for us, we do have the ability to challenge age-stigmatizing narratives now, and to support more equitable, age-friendly societies that are resilient to any challenges introduced by future “unprecedented times.”

REPERCUSSIONS OF THE GLOBAL PANDEMIC: DISRUPTIONS IN TB CARE (DEC 16 2021)

By: Gagandeep Johal

Tuberculosis (TB) is an infectious disease caused by bacteria that mainly affects the lungs and is spread by airborne droplets released from an infected individual via coughing or sneezing (Centers for Disease Control and Prevention, 2011). It is the most researched infectious disease, yet TB care and prevention have taken a back seat with increased global focus being placed on the COVID-19 pandemic. As some have dubbed it “the forgotten pandemic”, TB is one of the deadliest infectious diseases, claiming 1.5 million lives per year, and this number has increased since the COVID-19 pandemic provoked disruptions in TB treatment and access to care (King, 2021). There are many parallels between TB and COVID-19 with both infectious diseases affecting the respiratory system, but also being fueled by various social drivers such as overcrowded living situations that disproportionately impact socially and economically disenfranchised populations, such as people living in poverty. However, there are many complexities related to the similarities and dissimilarities between the two diseases. The positive impacts of wearing masks can potentially have a positive impact on TB control (Behera, 2021). Despite this potential, the extreme pressures of the COVID-19 pandemic on health systems have resulted in TB patients being more likely to experience challenges in receiving effective TB care (Behera, 2021).

According to a recent news release by the World Health Organization (WHO), TB deaths increased for the first time in history, with the average number of global deaths from TB rising in 2020 compared to 2019 (World Health Organization, 2021). With this increase in numbers occurring largely in high TB burden countries, where cases or incidence of TB is already high (e.g., India), concerns raise as to why and how this incredibly researched disease is still being inadequately addressed, with the WHO estimating TB progress being set back a decade (Douglas & Wilmer, 2021). This further brings into question the need for increased funding and allocation of resources, something that can be accomplished the same way in which human resources were mobilised to respond to the COVID-19 pandemic. Resources such as diagnostic technologies and molecular testing needed to detect TB and drug resistant TB continue to be scarcely available in countries, like India, which contributes to almost 25% of all global TB cases (Pai et al., 2016). This is incredibly concerning considering that modelling projections from the WHO predict the numbers of TB-related deaths to further increase in 2021 and 2022 (WHO, 2021). These alarming figures and projections will impact TB care and prevention and they will have dire consequences for the global targets for the End TB Strategy proposed by the WHO. The End TB Strategy is a global strategy with the goal of ending the global epidemic of TB through targets which have been set for upcoming years. This includes the target of reducing TB deaths by 75% (compared with 2015 data) by the year 2025 (WHO, 2014).

Many of the detrimental impacts of the COVID-19 pandemic have affected access to TB care, diagnosis efforts, notification of cases and overall quality of care provided. With TB patients being fearful of receiving care in treatment facilities due to lack of PPE, fears of COVID-19 infections and accessibility issues related to travel and affordability, many patients were left powerless and unable to adhere to treatment regimens (Behera, 2021). Lockdowns, health facilities, workforces and resources being redirected to contain the COVID-19 outbreak had an extreme effect on TB services, largely impacting TB detection and mortality rates (Douglas & Wilmer, 2021). Extreme lockdowns, as witnessed in India, brought into question the stability of entire health systems and care for the most disenfranchised populations across the world. Reasons such as reduced services, lack of healthcare workers on site or decreased public transportation were all ramifications of the pandemic which affected accessibility to TB services (Behera, 2021). But these concerns extend further to the failure to produce adequate measures that address care for the world’s poorest, who are disproportionally affected by infectious diseases.

Even more worrisome is the potential rise of drug-resistant TB. Not only does this incredibly challenging form of TB pose risks for treatment success, but it also adds to greater risks for humanity. Trends of increasing cases of drug resistant TB have been documented in India prior to the COVID-19 pandemic, however, may be even more exasperated following the decreased access to TB services throughout the COVID-19 pandemic. One of the major disruptions posed by the COVID-19 pandemic was disruptions in drug supply, which inadvertently left many TB patients without essential medications needed to complete their treatment regimens (Pai et al., 2016). Disruptions in treatment regimens not only pose a risk for the development of drug-resistant TB, but also for increased spread and lack of trust between patients and TB services (Pai et al., 2016). Many have posed questions regarding why there was a relative failure to address TB as a pandemic prior to the COVID-19 pandemic, considering many TB researchers have long advocated for increased funding and dedication to creating effective TB care programs across different nations. Issues around access to effective and up-to-date diagnostic tools, laboratory services and active case finding techniques continue to afflict the TB programs implemented within many countries across the world. For instance, in India, challenges around TB case detection in remote and rural populations continue despite the rigorous efforts and policies implemented through the National TB Elimination Program (Pai et al., 2016). With the COVID-19 pandemic dominating government and international agenda’s it is incredibly imperative that we do not lose sight of the need to address other infectious diseases like TB that continue to impact the health of millions every year. 

One prominent issue that has been brought up by researchers and those working within TB care is about the way TB has been framed within the public as a disease inflicting the impoverished or affecting developing nations. These conclusions lack context and perpetuate a narrative that fails to address globalization and our responsibilities as global citizens. Increased awareness and calls for increased funding for national TB programs especially following funding cuts that resulted in response to the COVID-19 pandemic, would help assist in establishing TB care programs that are able to meet the marks needed to build back the momentum that was lost following the diversion of focus onto COVID-19. Active case finding techniques and even discoveries made throughout the COVID-19 pandemic could prove to be useful to help mitigate the setback in TB progress. As voiced by Peter Sands, the executive director of Global Fund to Fight AIDs, Tuberculosis, and Malaria, we need to change the narrative around TB by capitalizing on the shock of the COVID-19 pandemic and the realization of threats posed by infectious diseases; both of which are thoughts that have captured the attention of people across the world (Douglas & Wilmer, 2021). 

References

• Behera, D.(2021). TB control in India in the COVID era. Indian Journal of Tuberculosis, 68.128-133. https://doi.org/10.1016/j.ijtb.2020.08.019

• CDC.(2011, October 28). Tuberculosis General Information. Centers for Disease Control and Prevention. https://www.cdc.gov/tb/publications/factsheets/general/tb.htm

• Douglas, R., & Wilmer, G.(2021, March 23). TB Progress Set Back A Decade By COVID-19-WHO. SciDevNet. https://www.scidev.net/global/news/tb-progress-set-back-a-decade-by-covid-19-who/

• King, A.(2021, July 1). Tuberculosis: The Forgotten Pandemic. The Scientist. https://www.the-scientist.com/features/tuberculosis-the-forgotten-pandemic-68894

• Pai, M., Daftary, A., & Satyanarayana. (2016). TB control: challenges and opportunities for India. The Royal Society of Tropical Medicine and Hygiene, 110. 158-160. https://doi.org/10.1093/trstmh/trw003

• World Health Organization. (2014). The End TB Strategy. Sixty Seventh World Health Assembly: WHO. https://www.who.int/tb/strategy/End_TB_Strategy.pdf

• World Health Organization.(2021, October 14). Tuberculosis Deaths Rise for The First Time in More Than A Decade Due To The COVID-19 Pandemic. World Health Organization. https://www.who.int/news/item/14-10-2021-tuberculosis-deaths-rise-for-the-first-time-in-more-than-a-decade-due-to-the-covid-19-pandemic