PERSPECTIVES
ON GLOBAL
PUBLIC HEALTH
AND OTHER
ISSUES
Collected Blogs II
October 2019—December 2020
Patricio V Marquez
Perspectives Of Global Public Health And Other Issues October 2019—December 2020
CONTENTS
A Few Reflections to Close the Year of COVID-19 | December 23, 2020
http://www.pvmarquez.com/reflectionsend2020
Some Reflections on World AIDS Day 2020 Amidst COVID-19 | November 30, 2020
http://www.pvmarquez.com/hivaids2020
What We Know About the New COVID-19 Vaccines:
Are We There Yet? | November 24, 2020
http://www.pvmarquez.com/covid19vaccine
How to Strengthen Health Care Systems to Support
COVID 19-Vaccination? | November 16, 2020
http://www.pvmarquez.com/covid-19vaccination
Health Systems Fit for the Future: How to Promote Better Health,
Economic Growth, and Social Cohesion? | October 23, 2020
http://www.pvmarquez.com/romehsystems
The World Bank’s health response to COVID-19 (Coronavirus) | October 19, 2020
https://blogs.worldbank.org/health/lets-invest-mental-health-inclusive-and-resilient-
recovery-covid-19
Let’s Invest in Mental Health for an Inclusive and Resilient Recovery
from COVID-19 | October 8, 2020
https://blogs.worldbank.org/health/lets-invest-mental-health-inclusive-and-resilient-
recovery-covid-19
Addressing Alcohol Use Disorders through Taxation: A Public Health
and Economic Win-Win in the time of COVID-19 | September 6, 2020
http://www.pvmarquez.com/alcoholuse
Let’s Not Forget About Mental Health during COVID-19! | August 22, 2020
http://www.pvmarquez.com/mentalhealandthcovid-19
Perspectives Of Global Public Health And Other Issues October 2019—December 2020
Taxes on tobacco, alcohol, and sugar-sweetened beverages reduce health risks
and expand fiscal space for Universal Health Coverage post-COVID 19 | August 11, 2020
https://blogs.worldbank.org/health/taxes-tobacco-alcohol-and-sugar-sweetened-
beverages-reduce-health-risks-and-expand-fiscal
While waiting for a COVID-19 vaccine, it’s time to focus on gaps in vaccine
distribution, cold chain, and uptake | July 26, 2020
http://www.pvmarquez.com/vaccinationsystems
Improving Health Services: A Global Imperative Amidst COVID-19 | June 22, 2020
http://www.pvmarquez.com/qualityimprovement
Sustaining Essential Health Services during the Covid-19 Pandemic:
A Social Imperative | June 15, 2020
http://www.pvmarquez.com/essentialhealthservices
Have South and Central America become the new coronavirus
(COVID-19) epicenter? | June 3, 2020
https://blogs.worldbank.org/health/have-south-and-central-america-become-new-
coronavirus-covid-19-epicenter
Tobacco use and coronavirus (COVID-19): A deadly but
preventable association | May 27, 2020
https://blogs.worldbank.org/voices/tobacco-use-and-coronavirus-covid-19-deadly-
preventable-association
Social distancing in the time of COVID-19 in Latin America and
the Caribbean: Costs and Benefits | May 14, 2020
http://pvmarquez.com/socialdistancing
Do BCG Vaccinated People Have Some Immunity Advantage Over
Non-Vaccinated People? | April 21, 2020
http://www.pvmarquez.com/bcg
Searching for Evidence in the COVID-19 Era: The BCG Case | April 17, 2020
http://www.pvmarquez.com/bcgcovid19
How to Prevent Jails and Prisons from Becoming New Hotspots for the Spread of
COVID-19? | April 13, 2020
http://www.pvmarquez.com/prisoncovid19
Does Tobacco Smoking Increases the Risk of Coronavirus Disease (COVID-19)
Severity? the Case of China | March 3, 2020
http://www.pvmarquez.com/Covid-19
The Unpredictable Social and Economic Cost of the Coronavirus
(COVID-19) Outbreak | February 27, 2020
http://www.pvmarquez.com/coronavirus
Public Health Investments and Economic Gains: Learning from Latin America and
Caribbean History in the Time of Coronavirus | February 10, 2020
http://www.pvmarquez.com/disease_control
Galapagos’ Charles Darwin Foundation: An International Good Practice
that Needs to be Supported | February 7, 2020
http://www.pvmarquez.com/Galapagos_CDF
Common Myths Against Tobacco Taxation: Not Borne Out by
Global Evidence | February 2, 2020
www.pvmarquez.com/tobacco_taxes
High Prices for Essential Drugs: A Risk for Public Health, Catastrophic Health Spending,
High-Debt Levels, and Impoverishment | January 28, 2020
http://pvmarquez.com/drug_prices
Mental Health and Healthy Futures: A Priority Theme at WEF
Davos 2020 | January 22, 2020
http://www.pvmarquez.com/mental_health_davos
How to Accelerate Universal Health Coverage in Latin America
and the Caribbean? | January 16, 2020
http://www.pvmarquez.com/health_reform
Perspectives Of Global Public Health And Other Issues October 2019—December 2020
Is the Growing Attachment to Smartphones and Digital Media Bad for
Our Health? An initial exploration | December 12, 2019
http://www.pvmarquez.com/digital%20media_impacts
Plastic Pollution: A "Clear and Present Danger" to the Galapagos Islands | November 27, 2019
http://www.pvmarquez.com/plastic_pollution_galapagos
Retracing Darwin’s Footsteps in the Galapagos | November 24, 2019
http://www.pvmarquez.com/node/5
An Ode to Halloween, Birthdays and Aging | October 30, 2019
http://www.pvmarquez.com/halloween_aging
Social Disparities Among Indigenous Peoples in the Americas:
A Legacy to Overcome | October 27, 2019
http://www.pvmarquez.com/legacy_to_overcome
1/12/2021 A Few Reflections to Close the Year of COVID-19 | Patricio V. Marquez
A Few Re ections to Close the Year of COVID-19
Submitted by Patricio V. Marquez on Wed, 12/23/2020 - 01 35 PM
A Few Re ections to Close the Year of COVID-19
Posted by Patricio V. Marquez on Wed, 12/23/2020 - 01 35 PM
“It was undoubtedly the feeling of exile—that sensation of a void within which never left us, that irrational longing to hark back to the past or else to speed up the
march of time, and those keen shafts of memory that stung like re.”
Albert Camus (1957 Nobel Prize Laureate for Literature). The Plague. Vintage, 1991.
As we approach the end of 2020, perhaps a few re ections are warranted on a period unlike any other in our global
collective memory. While the ceaseless movement of time, manifested in the passing of days and months, is mostly
an unconscious fact in our lives, only made visible by calendars, birthdays, and other celebrations, during this year it
was different. The sameness of the days, with their now well-established routines, fears, frustrations, rebellions,
and hopes, superseded our recent past by rmly imposing a very tangible present that continues to entrap us.
COVID-19 in the historical context of public health crises
Since the beginning of March, when the “Great Lockdown” gradually extended its tentacles across the world, as an
initial response to the exponential spread of a novel coronavirus, SARS-CoV-2, few may have thought that come
December we were going to still be ensconced as if in a state of siege. Indeed, this overwhelming reality has
separated us from our loved ones, friends, and coworkers, and has imposed rigid norms that have forced us to alter
and adapt our behaviors and routines to strict social distancing.
But paradoxical, our COVID-19 norms are not so different from the isolation and con nement measures followed in
Europe to control infectious disease outbreaks in the Middle Ages. Or that beginning in 1519, were also used in parts
of my native region, Latin America and the Caribbean, in accordance with the 1423 Venetian quarantine control
system, to detain ships and isolate their crews and passengers outside harbors until suf cient time had elapsed
without the outbreak of “pestilences.”
www.pvmarquez.com/reflectionsend2020 1/3
1/12/2021 A Few Reflections to Close the Year of COVID-19 | Patricio V. Marquez
The onslaught of COVID-19 has been relentless worldwide, with a growing accumulated damage painfully measured
as of today with close to 80 million infected people – and about 1.7 million premature deaths (not counting the
excess mortality due to other conditions), and millions of people unemployed or underemployed that has resulted
from the disintegration and slowdown of economic activity, trade, and the ow of people and capital across
countries.
Exposing inequalities – and an opportunity for renewal
This catastrophe has exposed and brought to the fore with great clarity the manifestations and impact of glaring,
pre-existing inequalities in our societies, where minorities and others at the bottom of the economic ladder, the frail
and the sicker, have been hit hardest, while the well-off, although still at risk and working from home, have been
able to resist better.
In our daily lives, like in a shipwreck, we have continued to hold on to memories of times past, as a way to recharge
and remind ourselves that this too shall pass, and we can look forward to future times when we can hug and laugh
with family and friends, work in close proximity to others, and travel and discover other geographies and people,
without the fear that COVID-19 is waiting for us “just around the corner”. But, more importantly, I think, we are
realizing and learning to accept that change is needed in our lives and in the existing social contracts of countries
and between countries.
Rising to the challenge – and looking forward with solidarity
We, as a global collective, have resisted, mounted a strong response, and have seen the potential wonders that
cooperation and solidarity can bring to enrich our arsenal against COVID-19. In an unprecedented historical feat, we
have new vaccines produced in less than a year (good to keep in mind that the eradication of smallpox through a
vaccine took several centuries, while the development of vaccines to deal with measles, in uenza, and yellow fever,
took several decades), as well as new diagnostics and treatment protocols that have reduced signi cantly the risk of
severity and death among the infected.
These scienti c leaps should amaze us: they have resulted from a mixture of accumulated knowledge and
technologies, and the human capacity and capability to learn (an initial milestone was the publication of the genome
sequence of the new virus on January 29, only weeks after the rst case was noti ed), innovate, develop new
knowledge, and translate that knowledge into applications to solve our needs. Also, we have come to realize that the
adoption of basic public health measures such as wearing masks, washing hands, and social distancing, are once
again helping us to keep the novel coronavirus virus at bay by preventing its uncontrolled spread as they have done
over the centuries in similar outbreaks of infectious diseases.
During the past 10 months, we have been able to come together not only as a duty imposed by present challenges,
but more importantly, we are realizing that the pandemic is offering us the opportunity to take stock and rebuild
better our collective lives. As we enter the holiday season and gaze with hope into 2021, perhaps it will do us good
to look back into history to learn that in the face of all types of past calamities – war, famine, and plagues – the
resilient human spirit has triumphed when acting as a collective and not as isolated individuals and countries.
Going forward, particularly in the face of the momentous task of having to vaccinate entire populations in the new
year, without leaving the most vulnerable and poor behind as our moral obligation, we could start planting the seeds
of a better world that is rooted in cooperation, solidarity, and respect for others, accepting our differences as a
source of strength and not of con ict, and trying every day to be there as men and women for others, giving our
best effort for the betterment of all.
www.pvmarquez.com/reflectionsend2020 2/3
1/12/2021 A Few Reflections to Close the Year of COVID-19 | Patricio V. Marquez
Indeed, together, as the gospel song (https://www.bing.com/videos/search?
q=bruce+springsteen+we+shall+overcome&docid=608005599646253213&mid=5C988E6B548AE2F887725C988E6B548AE
goes, “We shall overcome, We shall overcome, We shall overcome, some day!”
Photo: Long, socially-distanced lines to access services in Lima, Peru. © Victor Idrogo / World Bank
The original version of this blog was posted at the World Bank Group Investing in Health site on December 23, 2020:
A few re ections to close the year of COVID-19 (worldbank.org) (https://blogs.worldbank.org/health/few-
re ections-close-year-covid-19)
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/reflectionsend2020 3/3
1/12/2021 Some Reflections on World AIDS Day 2020 Amidst COVID-19 | Patricio V. Marquez
Some Re ections on World AIDS Day 2020 Amidst COVID-19
Submitted by Patricio V. Marquez on Mon, 11/30/2020 - 10 07 PM
Some Re ections on World AIDS Day 2020 Amidst COVID-
19
Posted by Patricio V. Marquez on Mon, 11/30/2020 - 10 07 PM
A lot has been accomplished over the past 20 years in the ght against HIV and AIDS. According to UNAIDS data
(https://aids2020.unaids.org/report/), of the 38 million people living with HIV, 25.4 million people are now on
treatment. New HIV infections have been reduced by 23% since 2010, largely due to a substantial decrease of 38% in
Eastern and Southern Africa.
Yet, challenges persist. HIV infections have increased by 72% in Eastern Europe and Central Asia, by 22% in the
Middle East and North Africa, and by 21% in Latin America. Across the world, there were 1.7 million new infections,
and still 690,000 AIDS-related deaths in 2019. The 2020 targets of reducing AIDS-related deaths to fewer than
500,000 and new HIV infections to fewer than 500,000 will not be met. And the impact of the COVID-19 pandemic
stands to further slow the required progress to end AIDS as a public health threat by 2030.
The Basis for Optimism
Looking back on what has been achieved in the past two decades, however, should ll us with optimism that
momentum will be regained. As recounted by Dr. Peter Piot, the former Executive Director of UNAIDS, in his
memoire, No Time to Lose (https://www.goodreads.com/book/show/13554374-no-time-to-lose), after overcoming
many obstacles and naysayers, the United Nations (UN) system, with its many organizations and agencies, working
www.pvmarquez.com/hivaids2020 1/3
1/12/2021 Some Reflections on World AIDS Day 2020 Amidst COVID-19 | Patricio V. Marquez
together with governments, civil society and religious leaders, groups representing people living with AIDS, and
eventually the pharmaceutical industry, came together in the rst decade of the XXI Century to rede ne existing
HIV and AIDS prevention and treatment paradigms.
There were also some landmark political events in this period, such as the UN Security Council Session held in
January 2000 (https:/ /www.un.org/press/en/2000/20000110.sc6781.doc.html) that for the rst time focused on
AIDS as a global health challenge, and the UN Special Session on AIDS held in June 2001, which paved the way for
establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria (https://www.theglobalfund.org/en/)and
the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) (https://www.state.gov/pepfar/), a great legacy of
former United States President George W. Bush (https:/ /www.bushcenter.org/explore-our-work/support-our-
work.html). Not only was the power of scienti c and technological developments leveraged to confront the global
epidemic, but an unprecedented commitment of funds helped scale up the international response.
In the early 2000s, I was blessed to be working in the Caribbean Region, at a time when it became a trailblazer in
the ght against HIV and AIDS. Beginning with a meeting at the World Bank Group (WBG) in Washington DC in June
2000, Caribbean nance ministers and of cials from international organizations placed the disease and its threat in
a sobering context. This was followed by a gathering in Barbados later that year where the international community,
heeding former Prime Minister Owen Arthur’s call— “We do not have a choice in the matter—we must act now”—
pledged millions of dollars to support a regional response. With the establishment of the Pan Caribbean Partnership
Against HIV/AIDS (PANCAP) (https:/ /pancap.org/pc/pcc/media/pancap_document/UNAIDS-BEST-PRACTICE-
COLLECTION_A-Study-of-PANCAP.pdf) in 2001, spearheaded by Sir George Alleyne
(https://www.amazon.com/Grooming-Chancellor-George-Alleyne/dp/9766406510/ref=sr_1_3?
dchild=1&keywords=sir+george+alleyne&qid=1606788737&sr=8-3), the Director Emeritus of the Pan American Health
Organization (https:/ /www.paho.org/en), and the Caribbean Community (CARICOM (https:/ /caricom.org/)), the
regional political umbrella organization, an international best practice evolved as a unique example of collective
action to strengthen a regional response to a health crisis. The World Bank Group contribution to that effort was
framed within the US$150 million multi-country program
(http://documents1.worldbank.org/curated/en/971971468238478200/pdf/709730WP0HIV0i0Box370064B000PUBLIC
that funded for the rst time globally, beginning in Barbados in 2001, antiretroviral treatment,
(http://documents1.worldbank.org/curated/en/287781468770370735/pdf/307240en0breve0450Barbados0HIV.pdf)
along with related health system strengthening investments and intersectoral prevention efforts.
As more and more HIV-infected people began to bene t from access to treatment, some cof n-makers were put
out of business as told in a story about Lesotho published in 2012 by the New York Times
(https://www.nytimes.com/2012/07/08/opinion/sunday/the-cof n-maker-benchmark.html), and HIV and AIDS
de facto became a chronic condition that requires long-term care across the world.
Some Lessons for the Future
In the face of newly emerging infectious diseases of animal origin such as COVID-19, and the still high prevalence of
old scourges such as HIV and AIDS, malaria, yellow fever, and tuberculosis, coupled with the rapid increase in the
relative importance of non-communicable diseases as a growing global health challenge, a major rethinking is
needed globally and sustained action is required to transform how health services are organized, funded, and
delivered to meet the changing health needs of the population in an interconnected world.
The social and economic devastation brought by the COVID-19 global crisis has shown that disease prevention and
public health preparedness can no longer be an afterthought in the universal health coverage agenda. Rather,
they need to be an integral element of a care continuum to anticipate, detect, and prevent the spread at the
www.pvmarquez.com/hivaids2020 2/3
1/12/2021 Some Reflections on World AIDS Day 2020 Amidst COVID-19 | Patricio V. Marquez
national, regional and global levels of uncontrolled infectious disease outbreaks that do not respect national
borders, and to facilitate timely access to quality health services when required by the population.
This also calls for integration and resource-sharing, leveraging resources, experience, and models of existing
programs to place greater emphasis on primary health care and community-based interventions that serve any
health condition and comorbidities. We must also advocate for the adoption of inclusive and sustainable schemes
to fund the effort at the country level, offering nancial protection to the population
(https://openknowledge.worldbank.org/handle/10986/31930) from the impoverishing effect of ill health,
premature mortality, and disability.
And, as the response to the HIV and AIDS epidemic clearly demonstrated over the past twenty years, knowledge
generation and sharing across the world and their adaptation to local conditions, are paramount to advance the
global health agenda in the future.
Indeed, the scienti c developments that helped understand, treat, and prevent HIV infection and AIDS, and the
unprecedented scienti c collaboration unleashed in 2020 to develop a safe and effective COVID-19 vaccine in a
record eight months (http://pvmarquez.com/covid19vaccine), bode well for the promise of a world free of the threat
of HIV and AIDS, and the improvement of people’s health and healthy longevity globally.
Photo Credit: AnomaliStudio (https://www.istockphoto.com/portfolio/AnomaliStudio?mediatype=illustration)
Stock illustration ID:1069507882
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/hivaids2020 3/3
1/12/2021 What We Know About the New COVID-19 Vaccines: Are We There Yet? | Patricio V. Marquez
What We Know About the New COVID-19 Vaccines: Are We
There Yet?
Submitted by Patricio V. Marquez on Tue, 11/24/2020 - 02 09 PM
What We Know About the New COVID-19 Vaccines: Are We
There Yet?
Posted by Patricio V. Marquez on Tue, 11/24/2020 - 02 09 PM
Patricio V Marquez and Betty Hanan
Typically, the development of new vaccines requires years of research and testing before being deployed. In the
case of the new COVID-19 vaccines, scientists have been racing to produce a safe and effective vaccine in record
time (https://www.sciencemag.org/news/2020/11/covid-19-vaccine-trial-complete-p zer-and-biontech-update-
their-promising-result). In a historical feat, the trials of some of the vaccines have taken less than a year.
As of today, (https://www.nytimes.com/interactive/2020/science/coronavirus-vaccine-tracker.html) researchers
are testing 54 vaccines in clinical trials on humans, and at least 87 preclinical vaccines are under active
investigation in animals.
In contrast, history shows that in some cases it took decades of work to develop vaccines
(https://www.businessinsider.com/how-long-it-took-to-develop-other-vaccines-in-history-2020-7). For example,
the eradication of smallpox through a vaccine--one of the biggest achievements in public health history —took
www.pvmarquez.com/covid19vaccine 1/7
1/12/2021 What We Know About the New COVID-19 Vaccines: Are We There Yet? | Patricio V. Marquez
several centuries. After a decade of work, Max Theiler, developed the rst safe and effective yellow fever vaccine in
1937, for which he receive the Nobel Prize in Physiology or Medicine in 1951. Similarly, it took years of research to
understand the complexities of the in uenza virus, before the rst vaccine was approved for use in the United
States in 1945. And then, two years later in 1947, researchers concluded that seasonal changes in the composition of
the virus rendered existing vaccines ineffective--there are two main types of in uenza viruses that cause epidemic
seasonal infections nearly every year, in uenza A and in uenza B, along with multiple new strains of the virus.
Because of this, scientists have had to adjust the in uenza vaccine every year.
In this blog, we provide a snapshot of the development of some leading COVID-19 vaccines based on a quick review
of available literature.
The Frontrunner COVID-19 Vaccine Candidates
1. Genetic Vaccines
P zer/BioNTech and Moderna have developed new COVID-19 vaccines using a new technology that has never
before been approved for human use. Both use a synthetic version of coronavirus genetic material, called mRNA, to
program a person’s cells to churn out many copies of a fragment of the virus. That fragment sets off alarms in the
immune system and stimulates it to attack as if the person were exposed to the real virus. The two companies are
the rst to announce interim data from large studies.
P zer/BioNTech Vaccine
The companies announced on November 18, 2020 that the vaccine was safe. Its 95% ef cacy was consistent across
age, race, and ethnicity, and it worked well in older people to prevent severe COVID-19 disease, well above the
50% ef cacy level that the U.S. Food and Drug Administration (FDA) had said it would accept in order to grant
emergency approval for vaccines. The most common serious adverse event was fatigue, with 3.7% of volunteers
reporting tiredness after they took the second dose. Two percent of volunteers reported a headache after the
second dose.
P zer submitted trial data and a request for emergency authorization for its COVID-19 vaccine to the FDA on
November 20, 2020, with the expectation that a decision by the FDA for the vaccine’s use will be made by mid-
December 2020.
The application will be reviewed by teams of the FDA’s Center for Biologics Evaluation and Research. Key moments
in the process are: the rst comes two days before members of the FDA Advisory Committee meet, when the FDA
typically releases its staff report on the clinical trial data, offering an insight into whether the agency is leaning
toward authorizing the vaccine; and the second is at the end of the Committee process scheduled for December 10,
2020, when the Committee will take a non-binding vote on whether the FDA should clear the vaccine for public use.
P zer has also begun regulatory submissions in Australia, Canada, the European Union, Japan and the United
Kingdom (UK). It has announced also that it plans to apply in other countries as well.
Moderna Vaccine
Positive interim results from a nal-stage trial have been released. The next step will be submission to the FDA of
a request for emergency authorization. This would follow shortly after the review of P zer’s vaccine. The Moderna
vaccine uses similar technology to the one from P zer and BioNTech. It is reported to have a 94.5% ef cacy, and
www.pvmarquez.com/covid19vaccine 2/7
1/12/2021 What We Know About the New COVID-19 Vaccines: Are We There Yet? | Patricio V. Marquez
appears to prevent the COVID-19 disease, including severe cases. A big unknown, however, is how long the
immunity provided by the vaccine will last.
Emergency Authorization Process
Both of the companies’ vaccine candidates began large human trials on July 27, 2020. Emergency authorization
(https://www.bloomberg.com/news/newsletters/2020-11-21/covid-vaccines-still-face-a-few-hurdles?
utm_campaign=news&utm_medium=bd&utm_source=applenews)allows drugs and vaccines targeting COVID-19 to
reach limited groups of people in the United States (US) much faster than through standard approval channels. The
FDA review process normally takes about six to ten months, depending on the candidate’s priority status.
P zer (https://www.nytimes.com/2020/11/18/health/p zer-covid-vaccine.html?referringSource=articleShare) has
indicated that if the FDA authorizes the two-dose vaccine, up to 50 million doses could be available by the end of the
2020, and up to 1.3 billion by the end of 2021. It is estimated that once the P zer/ BioNTech and the Moderna
vaccines are authorized for emergency use, there will be enough doses to immunize about 20 million people in the
United States before the end of 2020, a group that would most likely include health care workers and nursing home
residents (there are an estimated 17 million to 20 million health care workers in the United States, and about a
million people living in nursing homes). The 50 million doses would also allow older people with co-morbid
conditions to be immunized.
P zer/BioNTech and Moderna have arranged deals with the U.S. Government so that the vaccines will be free to
the population (https://www.nytimes.com/2020/11/20/health/p zer-covid-vaccine.html?
referringSource=articleShare) and distributed according to plans worked out between the federal government and
the states.
Cold Chain Requirements
After the FDA authorizes the use of the P zer/BioNTech and Moderna vaccines, the critical next step is vaccine
deployment. The P zer/BioNTech vaccine must be stored at minus 94 degrees Fahrenheit, colder than any other
vaccine in development. P zer will ship the vaccine in special boxes of 1,000 to 5,000 doses that are stuffed with dry
ice and equipped with GPS-enabled sensors. The vaccine can be stored in conventional freezers for up to ve days,
or in the special coolers for up to 15 days, as long as the dry ice is replenished and the boxes are not opened more
than twice a day. The Moderna vaccine must also be stored in a freezer long-term, but at minus 4 degrees
Fahrenheit. The company has indicated that its vaccine could be stored at standard refrigerator temperatures of
36 to 46 degrees Fahrenheit for up to 30 days, which could make it easier to store than the P zer vaccine.
2. Viral Vector Vaccines
These vaccines contain viruses engineered to carry coronavirus genes. Some viral vector vaccines enter cells and
cause them to make viral proteins. Other viral vectors slowly replicate, carrying coronavirus proteins on their
surface. And the viral proteins stimulate the body's production of antibodies to confer immunity.
AstraZeneca Vaccine
The British-Swedish company AstraZeneca and the University of Oxford have developed a vaccine based on a
chimpanzee adenovirus (these are common viruses that cause a range of illness, such as cold-like symptoms,
fever, sore throat, bronchitis, pneumonia, diarrhea, and conjunctivitis).
www.pvmarquez.com/covid19vaccine 3/7
1/12/2021 What We Know About the New COVID-19 Vaccines: Are We There Yet? | Patricio V. Marquez
In a press release on November 23, 2020 (https:/ /www.astrazeneca.com/media-centre/press-
releases/2020/azd1222hlr.html), the company reported interim ndings from two of their ongoing trials — one in
the UK and one in Brazil. The trials used different approaches to inoculating the more than 11,000 people who
participated, and found two levels of ef cacy, which they averaged to 70 percent. The researchers also found no
severe cases or hospitalizations in the study participants who got the vaccine.
According to the press reports (https:/ /ca.news.yahoo.com/astrazeneca-covid-19-vaccine-highly-073721980.html?
guccounter=1&guce_referrer=aHR0cHM6Ly93d3cuYmluZy5jb20v&guce_referrer_sig=AQAAAHK_GSFSL_VNzYKlDK3
CfAuM5Vixnq_c-5FO7d4VkoJJeFzU4eu-WS9a13JUMbZqQzWsR_SeZCsjeHbBEn_jIFwnNz-
ICgQAcJo7YhZfYv2xTArKHBEoDnDUW4xOyDlE4WgUb68R), AstraZeneca, has pledged it will not make a pro t on
the vaccine during the pandemic. It has reached agreements with governments and international health
organizations that its cost will be $3 to $4 a dose. In contrast, P zer’s vaccine is likely to cost about $20, while
Moderna’s is $15 to $25, based on agreements the companies have struck to supply their vaccines to the U.S.
Government.
The preliminary analysis (https://www.nytimes.com/2020/11/16/health/Covid-moderna-vaccine.html?
referringSource=articleShare) also indicates that the vaccine did not just reduce cases of COVID-19 with symptoms,
it also reduced the number of asymptomatic cases. This latter nding may mean that the vaccine will be good at
reducing the transmission of the virus from person to person. Another advantage of the vaccine is that it can be
kept in a refrigerator for up to six months, unlike P zer and Moderna’s vaccines, which have to be frozen.
AstraZeneca has secured a series of agreements to provide vaccines to governments should they prove effective,
including 300 million doses to the United States and 400 million doses to the European Union. The company has
noted that its total annual manufacturing capacity for the vaccine stands at three billion doses.
However, since unveiling the preliminary results and after the original version of this blog was posted,
AstraZeneca acknowledged on November 25, 2020, a key mistake in the vaccine dosage received by some study
participants, adding to questions about whether the vaccine’s apparently spectacular ef cacy will hold up under
additional testing (https://www.msn.com/en-us/money/companies/after-admitting-mistake-astrazeneca-faces-
dif cult-questions-about-its-vaccine/ar-BB1bmqfQ?ocid=msedgdhp). Scientists and industry experts said the error
and a series of other irregularities and omissions (https:/ /www.nytimes.com/2020/11/24/world/what-we-know-
about-astrazenecas-head-scratching-vaccine-results.html) in the way AstraZeneca initially disclosed the data have
eroded their con dence in the reliability of the results. Of cials in the United States have noted that the results were
not clear. The head of the agship federal vaccine initiative suggested that the vaccine’s most promising results may
not have re ected data from older people.
China’s CanSino Biologics Vaccine
The Chinese company CanSino Biologics has developed a vaccine based on an adenovirus called Ad5, in partnership
with the Institute of Biology at the country’s Academy of Military Medical Sciences. After publishing promising
results from a Phase 1 safety trial, and reports that Phase 2 trials that demonstrated the vaccine produced a strong
immune response, the Chinese military approved the vaccine on June 25, 2020 for a year as a “specially needed
drug”, but it is not clear whether vaccination would be mandatory or optional for soldiers. Starting in August 2020,
CanSino began running Phase 3 trials in a number of countries, including Saudi Arabia, Pakistan, and Russia.
Russia’s Sputnik V Vaccine
www.pvmarquez.com/covid19vaccine 4/7
1/12/2021 What We Know About the New COVID-19 Vaccines: Are We There Yet? | Patricio V. Marquez
The Gamaleya Research Institute, part of Russia’s Ministry of Health, launched clinical trials in June 2020 of a
COVID-19 vaccine. It is a combination of two adenoviruses, Ad5 and Ad26, both engineered with a coronavirus gene.
On August 11, 2020, President Vladimir V. Putin announced that a Russian health care regulator had approved the
vaccine, named Sputnik V, before Phase 3 trials had even begun. However, it was later indicated that the approval
was a “conditional registration certi cate,” which would depend on positive results from the Phase 3 trials. Those
trials, initially planned for just 2,000 volunteers, were expanded to 40,000. In addition to Russia, volunteers were
recruited in Belarus, the United Arab Emirates, and Venezuela. On October 17, 2020, a phase 2/3 trial was launched
in India. On September 4, 2020, Gamaleya researchers published the results of phase 1/2 trials.
(https:/ /www.nytimes.com/live/2020/11/11/world/covid-19-coronavirus-live-updates?
referringSource=articleShare#russias-vaccine-proves-effective-in-early-trial-data-company-says) In a small study,
they found that Sputnik-V yielded antibodies to the coronavirus and mild side effects. On November 11, 2020, the
Russian Direct Investment Fund announced preliminary evidence from the Phase 3 trial indicating that the
vaccine has a 92% ef cacy.
Russia has negotiated agreements to supply the vaccine to several countries including Argentina, Brazil, Mexico, and
India.
China’s Sinovac Biotech Vaccine
Sinovac Biotech’s CoronaVac is in Phase 3 of clinical trials (https://www.bloomberg.com/features/2020-
coronavirus-drug-vaccine-status/). It uses inactivated virus, which can help the body develop antibodies to the
pathogen without risking infection. The shot had already been approved in China for emergency use for doctors,
customs of cials, and other frontline workers, while simultaneously in Phase 3 trials in multiple other countries.
How do Pharmaceutical Companies Determine the Ef cacy of a Vaccine?
Clinical trials (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/effectiveness.html)provide data and
information about how well a vaccine prevents an infectious disease and about how safe it is. The fundamental logic
behind today’s vaccine trials was worked out by statisticians over a century ago.
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2004181/) Researchers vaccinate some people and give a
placebo to others, and then wait for participants to get sick and look at how many illnesses occur in each group.
From these numbers, researchers calculate the proportion of volunteers in each group who get sick. They determine
the relative difference between those two fractions and express that difference with a value they call ef cacy. If
there is no difference between the vaccine and placebo groups, the ef cacy is zero. If none of the sick people had
been vaccinated, the ef cacy is 100%.
A 95 percent ef cacy is compelling evidence that a vaccine works well
(https://www.nytimes.com/2020/11/20/health/covid-vaccine-95-effective.html?referringSource=articleShare),
but it does not tell what the chances are of a person becoming sick after being vaccinated. Also, it does not say how
well the vaccine will reduce COVID-19 across a country.
Difference Between Ef cacy and Effectiveness
Ef cacy and effectiveness are related to each other, but they are not the same thing
(https://www.sciencenews.org/article/coronavirus-what-does-covid-19-vaccine-ef cacy-mean). Both terms refer
to the ability to produce a desired or intended result, with a difference. While ef cacy refers to a result acquired
under ideal or controlled conditions (e.g., in a clinical trial where the patient population and other variable factors
can be controlled), effectiveness refers to how well a drug or vaccine works out in real-world situations, where the
www.pvmarquez.com/covid19vaccine 5/7
1/12/2021 What We Know About the New COVID-19 Vaccines: Are We There Yet? | Patricio V. Marquez
patient population and other variables cannot be controlled (e.g., differences in the underlying medical conditions of
people vaccinated in the real-world compared to those in the clinical trials, how a vaccine is transported and stored,
or even how patients are vaccinated).
It is therefore possible that the effectiveness of coronavirus vaccines will or will not match their impressive
ef cacy in clinical trials. But if previous vaccines are any guide, effectiveness may prove somewhat lower.
The Importance of Pharmacovigilance
Post-vaccine surveillance needs serious attention given the risk of possible adverse vaccine effects. Clinically
important, adverse events following any vaccination must be reported by healthcare providers to the
Pharmacovigilance System (PVS) as required of all vaccination providers. Adverse events can also be monitored
through electronic health record and claims-based systems.
This is important because before a vaccine is marketed, its safety and ef cacy exposure are limited to its use in
clinical trials. Generally, clinical trials cover a limited number of patients with strict inclusion criteria, often
excluding special patient groups like those with co-morbid conditions, children, elderly, and pregnant women.
Hence, they do not re ect the experience in larger populations and in different geographical regions. People from
different geographical regions differ from one another with respect to genetics, nutritional habits, lifestyle, and
clinical practices. This makes it obligatory to maintain a constant vigilance on the use of new vaccines during the
post-marketing period.
Strong testing systems are essential for vaccine surveillance. Testing is a critical tool to be used alongside vaccines,
given that: (i) vaccine-induced immunity must be monitored with testing at a population level; (ii) the real-world
effectiveness of COVID-19 vaccines will be largely uncertain and possibly variable across settings and populations;
and (iii) vaccine coverage will be incomplete and focused on priority populations.
It is also of paramount importance to get a baseline sero-surveillance study done - representative samples of target
populations to receive the COVID-19 vaccine to be able to distinguish between infection and vaccine-acquired
immunity.
Moving Forward
Vaccines not only protect the people who get them, but also, they can help drive down new infection rates and
protect society as a whole by slowing the spread of the virus. However, as observed in an editorial at The Lancet
(https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32472-7/fulltext), it should be clear that
whether the COVID-19 vaccines prevent transmission of the coronavirus or mainly just protect against illness is still
largely unknown. If the latter, achieving herd immunity through immunization becomes a dif cult prospect.
While the good news that a coronavirus vaccine could be available by late December 2020 should help boost our
optimism about “returning to normal times” in a not-too-distant future, it is imperative that we continue to follow
COVID-19 safety guidelines and remain vigilant about the risks posed by the pandemic. Indeed, as noted by Dr.
Tedros Adhanom Ghebreyesus, WHO Director-General, “while a vaccine will be essential for bringing the pandemic
under control, it is important to emphasize that a vaccine will complement the other tools that we have, not replace
them.” (https://twitter.com/AFP/status/1328314929741504513?s=20)
Until vaccines become widely available, therefore, it should be clear to all that basic public health measures, such as
disease surveillance, testing, contact tracing, medical isolation and quarantines, wearing masks in public spaces,
social distancing, and hand hygiene, will continue to be our best rewall against the spread of the coronavirus and
www.pvmarquez.com/covid19vaccine 6/7
1/12/2021 What We Know About the New COVID-19 Vaccines: Are We There Yet? | Patricio V. Marquez
to save lives.
Another key point to highlight, as shown in a recent study in Health Affairs
(https://www.healthaffairs.org/doi/10.1377/hlthaff.2020.02054), is that when it comes to cutting down on COVID-
19 infections, hospitalizations, and deaths, a well-coordinated and timely deployment of vaccines matters just as
much as their ef cacy. So, as we discussed in a previous post (http:/ /www.pvmarquez.com/covid-19vaccination),
the urgent preparation for the massive deployment of the vaccine in the months to come is a public health, social,
and economic imperative in countries across the world that cannot wait.
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/covid19vaccine 7/7
1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez
HOW TO STRENGTHEN HEALTH CARE
SYSTEMS TO SUPPORT COVID 19-
VACCINATION?
Submitted by Patricio V. Marquez on Mon, 11/16/2020 - 06 56 PM
HOW TO STRENGTHEN HEALTH CARE
SYSTEMS TO SUPPORT COVID 19-
VACCINATION?
Posted by Patricio V. Marquez on Mon, 11/16/2020 - 06 56 PM
Patricio V. Marquez, Betty Hanan, Sheila Dutta, Mary Mulusa
www.pvmarquez.com/covid-19vaccination 1/12
1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez
The announcement (https:/ /www.nature.com/articles/d41586-020-03248-
7) last week by P zer and the German company BioNTech, and early this
week by Moderna, that their COVID-19 vaccines are 90% and 94% effective,
respectively, is making the world optimistic about the possibility that we
may overcome the pandemic in a not too distant future. The optimism was
further reinforced by news that Russia’s Sputnik V vaccine may be as
effective as these two candidate vaccines.
While waiting for peer-reviewed data from the phase III clinical trials and
the formal approval of the vaccines by regulatory bodies, the critical
challenge facing all countries is how to ensure that “
(https://www.theguardian.com/world/2020/nov/16/us-coronavirus-
vaccine-distribution-challenges)the most logistically dif cult vaccination
campaign in history
(https://www.theguardian.com/world/2020/nov/16/us-coronavirus-
vaccine-distribution-challenges)”
(https://www.theguardian.com/world/2020/nov/16/us-coronavirus-
vaccine-distribution-challenges) is conducted in the face of a “hesitant and
weary public”, and at least one vaccine with “unprecedented cold chain
requirements.”
So, what needs to be in place at the country level to move from vaccine
promises to actual vaccination? On the basis of an initial review of
available literature, we prepared a summary that highlights some
key structural and process building blocks.
1. An integrated approach to healthcare delivery is key for a successful
immunization campaign effort
Accumulated experience with the delivery of vaccines under the essential
program of immunizations (EPI) suggests that a strong public health and
primary care partnership is vital to achieving national vaccination coverage
www.pvmarquez.com/covid-19vaccination 2/12
1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez
targets and control the spread of disease. While primary care bene ts from
public health’s role in policy, population health, health equity, and education,
public health bene ts from primary care’s ability to provide individual
patient assessment, disease management, screening of patients, care
coordination, and quality improvement.
To articulate this partnership for the delivery of a new COVID-19 vaccine,
sustained effort is needed to support governments in strengthening some
key Core Activity Areas, in accordance to country-speci c context and
epidemic status.
2. Core Activity Areas
Four core activity areas are identi ed and discussed below.
Core Activity Area 1 Planning and Management
Activities in this Area include:
Development of national deployment and vaccination plans. Since at
this time there are not as yet COVID-19 vaccines that have been
approved for use, the focus of national plans may center on two major
phases of vaccine availability and distribution: Phase 1 will be when there
is limited vaccine availability and will focus on target/priority groups to
receive vaccination. Phase 2 will be wide scale distribution vaccine
associated with broad availability to the general population.
Identi cation of target populations and development of micro-plans.
This is an important activity as it would help identify and prioritize
critical populations for the different phases of vaccine availability,
consistent with the World Health Organization (WHO) Fair Allocation
Framework (https:/ /www.who.int/publications/m/item/fair-allocation-
mechanism-for-covid-19-vaccines-through-the-covax-facility). More
speci cally, it would help estimate numbers for priority groups, and
www.pvmarquez.com/covid-19vaccination 3/12
1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez
establish a transparent allocation. For example, in some countries
vaccination could focus initially in the workforce that provides
healthcare and maintains essential functions of society, staff and
residents in long-term care facilities, elderly people and those with two
or more co-morbidities that put them at high risk for complications from
COVID-19.
Use and deployment of real-time monitoring tools such as RapidPro
(https://www.unicef.org/innovation/rapidpro), a free, open source
software, used by UNICEF, governments, and civil society partners.
RapidPro collects data via short message service (SMS) and other
communication channels (e.g. voice; social media channels, such as
Facebook Messenger, Telegram, WhatsApp) to enable real-time data
collection and mass-communication with target end-users, including
bene ciaries and frontline workers.
Strengthening national immunization budgeting and budget tracking
capacity. This would need to include the identi cation of options to
address the investment cost implications, including recurrent costs,
associated with the introduction of the vaccine for country health
spending, and how the vaccine can be sustainably deployed moving
forward. We should be clear that additional health workers/staff will be
required to carry out this unprecedented effort and their salaries should
be budgeted and funded. The new vaccine and its administration,
therefore, will require a substantial increase in public health nancing
in many countries.
Core Activity Area 2 Supply and Distribution
Key activities under this Area include:
Procurement and distribution of COVID-19 vaccine and ancillary
supplies
www.pvmarquez.com/covid-19vaccination 4/12
1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez
Some countries may choose to purchase vaccines through multilateral
mechanisms such as the COVAX Facility (https:/ /www.gavi.org/covax-
facility#what.), which is co-led by Gavi, the Coalition for Epidemic
Preparedness Innovations (CEPI) and WHO. Other countries may choose to
purchase vaccines directly via bilateral deals or may choose to pursue
multiple mechanisms for vaccine purchase.
In undertaking this activity, due consideration needs to be given to the
threshold for eligibility for vaccine purchase either: (i) approval by
Stringent Regulatory Authorities (SRAs)
(https://www.who.int/medicines/regulation/sras/en/), or (ii) WHO
prequali cation and approval by SRAs.
The procurement of ancillary supply kits may also be necessary, including
needles, syringes, alcohol prep pads, COVID-19 vaccination record cards for
each vaccine recipient, and a minimal supply of PPE, including surgical
masks and face shields, for vaccinators.
COVID-19 Vaccine Allocation
Support is needed to develop country-speci c mechanisms for the
allocations of the COVID-19 vaccine to jurisdictions in accordance with
multiple factors, including, but not limited to, priority populations, current
local spread and prevalence of COVID-19, and COVID-19 vaccine production
and availability. This would include coordination with manufacturers and
procurement agents on freight, logistics, insurance and storage to deliver
COVID-19 vaccine doses.
Key activities include:
www.pvmarquez.com/covid-19vaccination 5/12
1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez
Ensuring adequate logistics and transportation capacity, including
conducting eet assessments; and procurement and deployment of trucks
(e.g. cold trucks) and vehicles.
Strengthening immunization supply chain system, including capacity
building with respect to both supply chain systems and training of health
sector human resources; and adoption of global tools and best practices.
Leveraging innovations and technology to: test and pilot track & trace
technology; strengthen remote temperature monitoring systems; and
strengthen logistics information systems to accommodate COVID-19
vaccines
Ensure Quality of Vaccination Services
Quality assurance is very important for vaccine delivery. Vaccines must be
stored at correct temperatures and safely handled to ensure the best
protection. Training and technical assistance are needed to support health
personnel effectively implement vaccination programs. Also, support is
needed to conduct monitoring and supervision activities to ensure
appropriate vaccine storage and handling practices, and to identify
opportunities to improve vaccination coverage of target populations. To this
end, support would be required to further strengthen vaccine distribution
and cold chain systems while awaiting vaccine availability.
If current cold chain gaps and new requirements are addressed in a timely
way, it will facilitate widespread administration, not only of a new COVID-19
vaccine, but will also help revamp the delivery of routine vaccines,
particularly those for children. The latter task is of critical importance since
the pandemic has disrupted national immunization programs.
Core Activity Area 3 Program Delivery
www.pvmarquez.com/covid-19vaccination 6/12
1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez
Key activities to be supported under this Area include:
Community Engagement and Advocacy
Vaccine hesitancy is expected to be high, so public communication efforts
should focus on building a foundation of trust. Public communication
about COVID-19 vaccinations should aim to in uence the population in a
country to: trust the information that they receive from national and local
public health institutions, increasing knowledge of vaccine and the process
of COVID-19 vaccine development; understand the bene ts and risks,
setting and managing expectations by clearly informing about limited
availability of vaccines at the onset of the vaccine delivery and on the need
to prioritize administration of available vaccines to high risk group; make
informed decision; and know how and where to get a COVID-19 vaccination.
To this end, support would be needed to strengthen risk communication
and community engagement could be expanded, with a focus on increasing
awareness for COVID-19 prevention and to strengthen strategic
communication addressing demand-side challenges for vaccine uptake.
Such communications efforts need to address speci c national/subnational
knowledge, attitudes, and beliefs about vaccination.
Ensure vaccines reach the target populations. This will require: (i)
adequate amount of vaccinators / health workers; (ii) support training of
vaccinators and health workers; (iii) adopting global tools to local context;
and (iv) funding of targeted outreach to ensure prioritized population know
where and when to receive vaccinations.
De ne Access Points for Vaccine Administration
www.pvmarquez.com/covid-19vaccination 7/12
1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez
This would include identi cation and enrollment of providers into the
COVID-19 vaccination program for early narrow and later broad
vaccination plans, such as broad-based healthcare partners (primary and
specialty care providers, skilled nursing facilities, other long-term care
settings, local public health agencies, hospitals and health systems,
pharmacies, mobile vaccination providers, occupational health for large
employers, providers serving incarcerated populations, and payers);
preparations for vaccinations through regular healthcare channels and new
mobile or community-based mass vaccination sites; community partners to
increase accessibility, uptake, and reach by creating a transition plan from
low supply/high demand to high supply/low demand.
Support would also be provided for: creation of a registry to identify
priority target populations and develop strategies for outreach, speci cally a
list of front-line healthcare workers, the elderly, and those with pre-existing
conditions.
Adequate Waste Management System in Health Facilities
Good practices for safely managing health care waste and infection
prevention and control should be followed, including assigning
responsibility and suf cient human and material resources to dispose of
such waste safely. All health care waste produced during the care of
COVID-19 patients should be collected safely in designated containers and
bags, treated, and then safely disposed of or treated, or both, preferably on-
site. This also would be an opportunity to ensure that health facilities
possess at least a minimum level of WASH facilities.
Core Activity Area 4 Supporting Systems and Infrastructure
Key interventions under this Area include:
www.pvmarquez.com/covid-19vaccination 8/12
1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez
COVID-19 Vaccine Safety Monitoring
A comprehensive and effective vaccination program requires a robust data
infrastructure at different levels of a health system. This is needed to: (i)
further strengthen vaccination practices in both the public and private
sectors; (ii) assesses the impact of vaccination programs through disease
surveillance; (iii) provide credible evidence-based information to healthcare
consumers; (iv) support outbreak investigation and control; and (v) monitor
vaccine coverage, effectiveness, and safety.
Post-vaccine surveillance needs serious attention given risk of adverse
vaccine effects. Clinically important, adverse events following any
vaccination must be reported by healthcare providers to the
Pharmacovigilance System (PVS) as required of all COVID-19 vaccination
providers. Adverse events will also be monitored through electronic health
record and claims-based systems.
This is of importance because before a medicinal product is marketed, its
safety and ef cacy exposure are limited to its use in clinical trials.
Generally, clinical trials cover limited number of patients with strict
inclusion criteria, often excluding special patient groups like those with co-
morbid conditions, children, elderly and pregnant women. Hence, they do
not re ect the experience in larger population sand in different
geographical regions. People from different geographical regions differ
from one another with respect to genetics, food habits, life style, or clinical
practices. This makes it obligatory to maintain a constant vigil on the use of
medicinal products during the post-marketing period.
Strong testing systems are essential for vaccine surveillance. Testing is a
critical tool to be used alongside vaccines, given that: vaccine induced
immunity must be monitored with testing on a population level; the real-
world effectiveness of COVID-19 vaccines will be largely uncertain and
www.pvmarquez.com/covid-19vaccination 9/12
1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez
possibly variable across settings and populations; and vaccine coverage will
be incomplete and focused on priority populations. To this end, support may
be required for: developing/adapting the national diagnostic strategy and
plans as new diagnostic technologies become available, selecting of
diagnostic tests for appropriate use following international guidelines and
national priorities, and, training on infection prevention and control (IPC)
measures, provision of IPC supplies (e.g. hand hygiene products,
disinfectants), biosafety measures (e.g., safe specimen collection and
handling and appropriate disposal of diagnostic tests and supplies), and
availability of protocols for proper testing at facility and community levels.
It would also be of paramount importance to get a baseline sero-
surveillance study done - representative samples of target populations to
receive the COVID-19 vaccine to be able to distinguish between infection
and vaccine acquired immunity.
WASH in health care settings
Existing recommendations for water, sanitation and hygiene measures in
health care settings are important for providing adequate care for patients
and protecting patients, staff and caregivers from infection risks. Hand
hygiene is also extremely important. Cleaning hands with soap and water
or an alcohol-based hand rub should be performed according to
instructions. Functional hand hygiene facilities should be present for all
health care workers at all points of care and in areas where PPE is put on or
taken off.
3. How are governments going to address compensation issues related to
the liability shield offered to pharmaceutical rms that will be supplying
the COVID-19 vaccines?
www.pvmarquez.com/covid-19vaccination 10/12
1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez
This question is of particular importance for middle-income countries that
have to assume this obligation, including under COVAX arrangements. Low-
and lower middle-income countries are expected to be covered under a
proposed scheme co-led by WHO to set up a compensation fund for people
in poor nations who might suffer any side-effects from COVID-19 vaccines,
aiming to allay fears that could hamper a global rollout of shots.
The public sector guarantors of the liability shield offered to
pharmaceutical rms will have to look at how to manage this. It is critical,
therefore, to have clarity about this now, i.e. before vaccines start owing.
With the scale of distribution of the vaccines even rare side effects could
end up affecting thousands.
A recent review (https://journals.plos.org/plosone/article?
id=10.1371/journal.pone.0233334) (https://journals.plos.org/plosone/article?
id=10.1371/journal.pone.0233334)of existing compensation programs in the
world shows that the bene ts most referred to in existing no-fault
compensation programs were: fair compensation for individuals
inadvertently injured by a vaccine meant for public good and increasing
con dence in public vaccination programs. The most notable operational
challenge of existing programs was identi ed to be lack of public
awareness of programs existence, strict requirements for standard of proof
that vaccine caused injury, and long timelines for ling claims and receiving
compensation.
Conclusion
It should be clear to all that the approval of effective COVIX-19 vaccine is
only the rst step in the process to reverse the global pandemic. We also
have to realize that multiple vaccines to meet demand would add complexity
of the delivery effort. Besides the supply of vaccines, a key challenge to
www.pvmarquez.com/covid-19vaccination 11/12
1/12/2021 HOW TO STRENGTHEN HEALTH CARE SYSTEMS TO SUPPORT COVID 19-VACCINATION? | Patricio V. Marquez
deal with is gaining public trust, including among healthcare workers who
will be asked to take the vaccine rst as part of the priority population
groups.
Hence, the activities outlined above will need to be undertaken sooner,
rather than later, to address the logistical and cold chain challenges
enabling the rapid distribution and administration of COVID-19 vaccines.
Photo credit:
Luca Lorenzelli
Stock photo ID:1212565443
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/covid-19vaccination 12/12
1/12/2021 Health Systems Fit for the Future: How to Promote Better Health, Economic Growth, and Social Cohesion? | Patricio V. Marquez
Health Systems Fit for the Future: How
to Promote Better Health, Economic
Growth, and Social Cohesion?
Submitted by Patricio V. Marquez on Fri, 10/23/2020 - 04 47 PM
Health Systems Fit for the Future:
How to Promote Better Health,
Economic Growth, and Social
Cohesion?
Posted by Patricio V. Marquez on Fri, 10/23/2020 - 04 47 PM
I recently had the honor of serving as a panelist in plenary session 5 “Health
systems t for the future: promoting better health, economic growth, and
social cohesion”, that was held virtually as part of the 16th World Congress
www.pvmarquez.com/romehsystems 1/8
1/12/2021 Health Systems Fit for the Future: How to Promote Better Health, Economic Growth, and Social Cohesion? | Patricio V. Marquez
on Public Health: “Public health for the future of humanity: analysis,
advocacy and action” (https://wcph2020.com/), on October 15th, 2020.
While all the participants in the Congress regretted not having been able to
travel to Rome, the Eternal City, and participate in person due to the
COVID-19 pandemic, the organization of the virtual event was awless. So,
our sincere congratulations are conveyed to the organizers for a job well
done!
My session was chaired by Prof. Walter Ricciardi and Prof. Sheila Dinotshe
Tlou, Co-chairs of the 16th World Congress on Public Health, and included
as my fellow panelists Natasha Azzopardi Muscat, Director for Country
Health Policies and Systems at the WHO Regional Of ce for Europe and
Immediate Past President of the European Public Health Association
(EUPHA); Sara Cerdas, a Portuguese medical doctor and since July of 2019 a
Member of the European Parliament; Katie Gallagher, Senior Policy Adviser,
European Patients’ Forum; Rüdiger Krech, Director, Department of Health
Promotion, World Health Organization; and Gita Sen, Director of the
Ramalingaswami Centre on Equity and Social Determinants of Health at the
Public Health Foundation of India and Adjunct Professor of Global Health
and Population at the Harvard T. H. Chan School of Public Health.
In my presentation, I conveyed three action points to address the
overarching questions guiding the discussion in the session. These were:
Question 1 How can we improve health, wealth, and societal well-being
by investing in health systems?
Action 1 Prevent, detect, and respond to the threat posed by zoonotic
diseases and strengthen national systems for public health preparedness
www.pvmarquez.com/romehsystems 2/8
1/12/2021 Health Systems Fit for the Future: How to Promote Better Health, Economic Growth, and Social Cohesion? | Patricio V. Marquez
The worldwide spread of COVID-19 is demonstrating the impact that
infectious diseases of animal origin can exert on global health and
development. More than 70% of new infectious diseases are zoonotic. The
COVID-19 pandemic is currently affecting 188 countries and territories
across all regions. As of mid-October 2020, (https://coronavirus.jhu.edu/)
more than 37 million con rmed cases and more than 1 million con rmed
deaths have been reported.
Besides growing numbers of infected people and loss of life, the pandemic
has caused an economic free-fall not experienced since World War II.
International Monetary Fund (IMF) estimates show that 170 countries will
see income per capita go down.
(https:/ /www.imf.org/en/Publications/WEO/Issues/2020/09/30/world-
economic-outlook-october-
2020#Full%20Report%20and%20Executive%20Summary) And World Bank
Group projections (https:/ /www.worldbank.org/en/news/press-
release/2020/10/07/covid-19-to-add-as-many-as-150-million-extreme-
poor-by-2021) suggest that rising unemployment and loss of income,
including in some countries a signi cant drop in remittances, could push
between 88 million and 115 million people back into extreme poverty as a
result of the pandemic, with an additional increase of between 23 million
and 35 million in 2021, potentially bringing the total number of new people
living in extreme poverty to between 110 million and 150 million.
The pandemic is also putting at risk the past decade's progress in building
human capital, including gains in health, survival rates, school enrollment,
and reduced stunting. The economic impact of the pandemic has been
particularly deep for women and for the most disadvantaged families,
leaving many vulnerable to food insecurity and poverty.
www.pvmarquez.com/romehsystems 3/8
1/12/2021 Health Systems Fit for the Future: How to Promote Better Health, Economic Growth, and Social Cohesion? | Patricio V. Marquez
The COVID-19 pandemic, therefore, is a stark remainder of the ongoing
challenge of emerging and reemerging infectious diseases and the need for
(//blogs.worldbank.org/health/regional-disease-surveillance-globalized-
world) (https://blogs.worldbank.org/health/regional-disease-surveillance-
globalized-world)constant disease surveillance, prompt diagnosis, and
robust research (//blogs.worldbank.org/health/regional-disease-
surveillance-globalized-world) to understand the basic biology of new
organisms and our susceptibilities to them, as well as to develop effective
countermeasures to control them.
A critical long-term aspect of the response
(https://blogs.worldbank.org/health/world-banks-health-response-covid-
19-coronavirus) is strengthening and building a resilient health system able
to manage similar future health system shocks by supporting the realization
of the universal health coverage (UHC) agenda, which includes timely access
to health care when needed, nancial protection, and disease prevention
and preparedness. To this end, the universal health coverage agenda needs
to strengthen its focus on prevention to help guide investments, identify
and prioritize the biggest risks, and promote pandemic preparedness for
future outbreaks building upon the One Health Strategy.
(https://blogs.worldbank.org/health/one-health-approach-critical-de-
risk-human-animal-and-environmental-health)
Question 2 Which investments inside and beyond the health system
should be performed to increase quality and reduce inequities?
Action 2 Avoid the false dichotomy between physical health and mental
health
In this midst of a global pandemic, this year’s World Mental Health Day
campaign (https:/ /www.who.int/campaigns/world-mental-health-
day/world-mental-health-day-2020) called for greater investment in mental
www.pvmarquez.com/romehsystems 4/8
1/12/2021 Health Systems Fit for the Future: How to Promote Better Health, Economic Growth, and Social Cohesion? | Patricio V. Marquez
health. This is timely and justi ed. Recent estimates suggest that most low-
and middle-income countries spend less than $2 per person on the
treatment and prevention of mental and substance use disorders – and this
was prior to the global outbreak of the novel coronavirus.
A fundamental rethinking is needed to overcome the false dichotomy
between physical health and mental health in health services. Mental health
parity must be placed at the core of human capital development. The social
cost of mental illness and substance use disorders – which compound the
impact of poor physical health – are terribly high for individuals, families,
communities, and the economy. Yet the cost of effective treatments is
surprisingly low.
We must be wary of siloed approaches to increased mental health funding.
Rather, governments can mobilize new resources and leverage existing
funding streams by integrating mental health interventions
(https://blogs.worldbank.org/health/lets-invest-mental-health-inclusive-
and-resilient-recovery-covid-19?
CID=WBW_AL_BlogNoti cation_EN_EXT)into existing service delivery
platforms across sectors.
There are numerous potential cross-sectoral entry points that would align
funding, service provision, and population needs:
(i) Integrating mental and physical health services at primary health care
and community levels
(ii) School-based and youth interventions are critically important because 75
percent of mental and substance use disorders begin before age 25, and
suicide is a leading cause of death among youth
www.pvmarquez.com/romehsystems 5/8
1/12/2021 Health Systems Fit for the Future: How to Promote Better Health, Economic Growth, and Social Cohesion? | Patricio V. Marquez
(iii) Integrating mental health into wellness programs in the workplace can
mobilize private companies to invest in health promotion activities
(iv) Programs in fragile and con ict-affected settings can be leveraged to
mainstream integrated physical and mental health interventions alongside
other social services to address the needs of displaced populations and
refugees
(v) Microcredit schemes to provide low-interest, small business loans,
training, and mentorship to entrepreneurs with a history of mental health or
addiction challenges (including former prisoners), facilitate reintegration
into the community
Question 3 How can we guarantee that health systems are sustainable,
resilient, and accessible?
Action 3 Pro-health taxes reduce health risks, expand scal space for
universal health coverage, and enhance equity
Taxes on tobacco, alcohol, and sugar-sweetened beverages
(https://blogs.worldbank.org/health/taxes-tobacco-alcohol-and-sugar-
sweetened-beverages-reduce-health-risks-and-expand- scal) are effective
but underused policies of disease prevention and health promotion, that
could also help mobilize additional government revenue to fund investments
and programs that bene t the entire population and enhance equity.
Raising taxes on tobacco, in particular, can do more to reduce premature
mortality than any other single health policy. The evidence across a wide
range of countries shows that a 50% increase in cigarette price typically
leads to a 20% decline in cigarette consumption. Lowering consumption
reduces tobacco-attributable sickness and death: about half of this effect
comes from current smokers quitting and the other by reducing smoking
www.pvmarquez.com/romehsystems 6/8
1/12/2021 Health Systems Fit for the Future: How to Promote Better Health, Economic Growth, and Social Cohesion? | Patricio V. Marquez
initiation among young people. Taxing alcohol and sugar-sweetened
beverages helps to reduce consumption and prevent the onset of related
chronic diseases such as cardiovascular diseases, cirrhosis of the liver,
obesity, and diabetes. Moreover, taxation to increase the price of alcohol
products, along with strict enforcement of drunk-driving laws, can help
reduce the high human and economic cost of road traf c injuries, fatalities,
and domestic violence.
Emerging evidence shows positive health impacts from sugar-sweetened
beverages taxes by reducing consumption and hence helping to control the
growing obesity epidemic and its impact on NCDs.
Tobacco, alcohol, and sugar-sweetened beverage taxes can substantially
boost government revenues. This is of critical importance during COVID-19,
as policymakers must maintain their public health responses while also
mobilizing domestic revenue for investment in future pandemic
preparedness and other essential health services.
These health tax increases would have the additional advantage of reducing
future health care costs by curbing the growth of the non-communicable
diseases that tobacco, alcohol, and sugar-sweetened beverages can cause.
Elimination of fossil fuel subsidies, which impose large scal costs while
adding to negative environmental and health impacts, could also help
expand scal space for health.
Projections presented in a World Bank Group report for the G-20 meeting in
Osaka, Japan in 2019
(https://openknowledge.worldbank.org/handle/10986/31930) showed that
the substantial UHC nancing gap in low- and lower-middle-income
countries (now exacerbated by COVID-19), can be attenuated by excise tax
increases on tobacco, alcohol, and sugar-sweetened beverages. These
calculations showed that a 50% increase in prices for these products could
www.pvmarquez.com/romehsystems 7/8
1/12/2021 Health Systems Fit for the Future: How to Promote Better Health, Economic Growth, and Social Cohesion? | Patricio V. Marquez
generate additional revenues of approximately $24.7 billion in 54 low- and
middle-income countries by 2030. Importantly, the revenue raised can
additionally bene t poorer households when it is used progressively.
Take Away Message
As voiced by my fellow panelists during the session, it should be clear to all
going forward that high-quality health systems include not only the right to
quality health care but also equity. Evidence-based, cost-effective
investments and rigorous assessment are key to guarantee high quality
health systems for all.
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/romehsystems 8/8
1/12/2021 The World Bank’s health response to COVID-19 (Coronavirus)
Learn how the World Bank Group is helping countries with COVID-19 (coronavirus). Find Out
Publish d on Inv stin in H lth (/h lth)
Th World B nk’s h lth r spons to
COVID-19 (Coron virus)
PATRICIO V. MARQUEZ (/TEAM/PATRICIO-V-MARQUEZ), SHEILA DUTTA (/TEAM/SHEILA-DUTTA) & BETTY
HANAN (/TEAM/BETTY-HANAN) | OCTOBER 19, 2020
This page in: English
Freetown City Council community engagement to prevent the spread of COVID-19 in Sierra Leone. © Valena McEwen,
World Bank Health team in Sierra Leone
In response to the rapid spread of the COVID-19 pandemic, and building on
accumulated experience with health crises in the past 20 years, the World Bank
Group sprang into action in late February 2020. (https://twitter.com/intent/tweet?
text=In+response+to+the+rapid+spread+of+the+COVID-
19+pandemic%2C+and+building+on+accumulated+experience+with+health+crises+in+
banks-health-response-covid-19-coronavirus/?
https://blogs.worldbank.org/health/world-banks-health-response-covid-19-coronavirus 1/8
1/12/2021 The World Bank’s health response to COVID-19 (Coronavirus)
cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) Working closely with national
teams, WHO, UNICEF and other international partners to support countries’
responses, the World Bank prepared the $6 billion
(https://www.worldbank.org/en/news/press-release/2020/03/17/world-bank-group-
increases-covid-19-response-to-14-billion-to-help-sustain-economies-protect-
jobs#:~:text=WASHINGTON%2C%20March%2017%2C%202020%20%E2%80%94,rapid%
COVID-19 emergency health response in just a few weeks.
The Bank currently provides emergency health and social support to 111 countries
(https://www.worldbank.org/en/news/speech/2020/10/16/remarks-by-world-bank-
group-president-david-malpass-to-the-annual-meetings-2020-development-
committee), covering about 70% of the world’s population, including millions who
live in places a ected by con ict and fragility.
The progress has been fast and signi cant
The Bank’s goal is to assist countries in their e orts to prevent, detect and respond
to COVID-19, and to strengthen national public health preparedness systems.
(https://twitter.com/intent/tweet?
text=The+Bank%E2%80%99s+goal+is+to+assist+countries+in+their+e orts+to+prevent
19%2C+and+to+strengthen+national+public+health+preparedness+systems.+&url=http
banks-health-response-covid-19-coronavirus/?
cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) A menu of options allowed
World Bank country teams to tailor projects to the speci c circumstances of each
country.
Country examples illustrate how funding allocated under the program is aligned to
service provision and population needs.
Case detection, con rmation, contact tracing, recording, reporting
In Ghana, support has been provided to recruit and train 4,410 health professionals,
1,385 contact tracers and 318 laboratory technicians. Drone delivery of samples
from remote areas to test centers has also been initiated, along with the potentially
time saving practice of “pool testing,” in which multiple blood samples are tested
together and processed separately only if a positive result is found. This has led to
the identi cation and testing of 361,542 persons as of July 2020.
x
This site uses cookies to optimize functionality and give you the best possible experience. If you continue to
navigate this website beyond this page, cookies will be placed on your browser. To learn more about
cookies, click here. (https://www.worldbank.org/en/about/legal/privacy-notice)
https://blogs.worldbank.org/health/world-banks-health-response-covid-19-coronavirus 2/8
1/12/2021 The World Bank’s health response to COVID-19 (Coronavirus)
In Georgia, support is being provided to strengthen public health laboratories and
epidemiological capacity. As of the end of September 2020, an average of 9,000
polymerase chain reaction (PCR) tests and 1,700 rapid tests were being performed
daily.
In Cambodia, the Bank supports decentralized laboratories and helps strengthen
services in remote and underserved areas.
In Yemen, six central public-health laboratories have opened, and 930 health
professionals have been trained in COVID-19 case management.
In Ethiopia, in the rst 100 days after project approval, more than 11 million
households nationwide were screened, lab professionals trained, and about 23
laboratories throughout the country are now conducting COVID-19 tests. A parallel
project is also supporting the Africa Center for Disease Control’s region-wide
response.
Health system strengthening
In Afghanistan, initial support has included procurement of emergency supplies,
including 555,000 personal protective equipment (PPE) kits. These supplies have
enabled health care workers to improve clinical management of about 10,000
hospitalized COVID-19 patients.
In Papua New Guinea, 6,846 infection, prevention and control (IPC) supplies and
31,200 PPEs arrived in June 2020 for nationwide use.
In India, the Bank’s operation helps cover salaries of more than 50,000 contractual
frontline sta operating across the country’s 35 states and union territories.
In Argentina, Ecuador, Indonesia, Haiti, Iran, Senegal, Somalia, and Ukraine, the
Bank has been supporting the acquisition of medical equipment to enhance service
delivery capacity.
In Mongolia, as well as in China, support is being provided to strengthen capacities
for a multi-sectoral response, particularly the interface of environmental, veterinary,
and public health services to contain the spread of new viruses of animal origin at
their source.
Water, sanitation and hygiene (WASH) x
This site uses cookies to optimize functionality and give you the best possible experience. If you continue to
navigate this website beyond this page, cookies will be placed on your browser. To learn more about
cookies, click here. (https://www.worldbank.org/en/about/legal/privacy-notice)
https://blogs.worldbank.org/health/world-banks-health-response-covid-19-coronavirus 3/8
1/12/2021 The World Bank’s health response to COVID-19 (Coronavirus)
Many projects include actions on water and/or sanitation in health facilities. 57
projects include components of behavior change, hygiene and handwashing in
health facilities, and 47 projects include support for medical waste management.
In Senegal, for example, the project supports a mix of water supply, hand washing,
and sanitation activities in urban, peri-urban, and rural areas, including the
connection of unserved localities to existing water supply systems.
Social and nancial support to households
In Sri Lanka, additional nancing of $89 million supports temporary scaled-up cash
transfers under existing programs for registered elderly and disabled people and
those with chronic diseases.
In Pakistan cash support covers 15 million vulnerable families. Additional support is
being provided to 4 million female bene ciaries who were already receiving direct
income support under this program.
In Kosovo, under the government’s existing social assistance program, cash
transfers are being provided to 24,000 poor families, and to an additional 29,000
newly poor families.
In Rwanda, emergency cash transfers support 19,000 vulnerable households in
Kigali, 8,400 other vulnerable households, and 7,700 vulnerable agricultural
households (to enable access to seeds and fertilizers).
In Argentina, COVID-19 services are free when are delivered by public hospitals and
health centers.
In Paraguay and Uruguay, testing and treatment services for COVID-19 are free of
charge to the bene ciaries of the country’s public health and social health insurance
programs.
Mental health interventions
In many countries, including Bosnia and Herzegovina, Cambodia, Ecuador,
Guatemala, India, Lesotho, Liberia, Mali, Marshall Islands, Morocco, Mongolia,
Niger, Nigeria, Republic of Congo, Senegal, Sri Lanka, Turkey, and Yemen, Bank
projects support psychosocial interventions to help people deal with the negative
psychological e ects from stressors such as lockdowns, self-isolation and
quarantines, infection fears, inadequate information, job and nancial losses, and
stigma and discrimination.
https://blogs.worldbank.org/health/world-banks-health-response-covid-19-coronavirus 4/8
1/12/2021 The World Bank’s health response to COVID-19 (Coronavirus)
Community engagement
In Egypt, when movement was restricted, virtual communication tools helped to
prepare the project. These tools enabled consultations with a wide range of
stakeholders including governmental o cials, frontline health workers and NGO
partners. Virtual hospital visits guided by hospital sta equipped with PPE helped to
gather information on how projects were being implemented and to get stakeholder
feedback.
In Sierra Leone, building on the Ebola experience, the project has supported the
Freetown City Council and the mayor to implement risk communication campaigns
by forming teams of volunteers in each of the city’s wards, teamed with local
councilors, chiefs, tribal heads, Mammie Queens and youth leaders, to conduct
outreach activities and house visits to foster community engagement and in uence
behavior change.
In the Democratic Republic of Congo, a community-centered approach has been
successful to counter misinformation, with feedback mechanisms to communicate
critical risk and event information to all communities in the local languages.
As the COVID-19 pandemic continues to evolve, with new diagnostics and
therapeutics developed, and vaccines trials progressing, the exibility and agility of
the World Bank’s health response will continue to be critical to support the next
phase of country responses.
It is important to ensure that programs are adjusted and aligned with the spread of
COVID-19, the level of pandemic preparedness, the capacity of health and social
support systems, and lessons learned from the early phase of the pandemic
response. (https://twitter.com/intent/tweet?
text=It+is+important+to+ensure+that+programs+are+adjusted+and+aligned+with+the+
19%2C+the+level+of+pandemic+preparedness%2C+the+capacity+of+health+and+socia
banks-health-response-covid-19-coronavirus/?
cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank)
For a full list of the World Bank Group’s COVID-19 projects, please refer here
https://www.worldbank.org/en/about/what-we-do/brief/world-bank-group-
operational-response-covid-19-coronavirus-projects-list
https://blogs.worldbank.org/health/world-banks-health-response-covid-19-coronavirus 5/8
1/12/2021 Let’s Invest in Mental Health for an Inclusive and Resilient Recovery from COVID-19
Learn how the World Bank Group is helping countries with COVID-19 (coronavirus). Find Out
Publish d on Inv stin in H lth (/h lth)
L t’s Inv st in M nt l H lth for n
Inclusiv nd R sili nt R cov r from
COVID-19
PATRICIO V. MARQUEZ (/TEAM/PATRICIO-V-MARQUEZ) | OCTOBER 08, 2020
This page in: English
/ Mental health parity must be placed at the core of human capital development.
https://blogs.worldbank.org/health/lets-invest-mental-health-inclusive-and-resilient-recovery-covid-19
“I believe more than ever that we have the power to help change the world for people
who have mental illnesses and addictions, and for all of those whose lives are touched
by these brain diseases—which is to say, all of us.”- Patrick J. Kennedy
x
1/7
1/12/2021 Let’s Invest in Mental Health for an Inclusive and Resilient Recovery from COVID-19
In this midst of a global pandemic, this year’s World Mental Health Day
(https://www.who.int/campaigns/world-mental-health-day/world-mental-health-day-
2020) campaign is calling for greater investment in mental health. This focus is timely
and justi ed. Recent estimates
(https://documents.worldbank.org/en/publication/documents-
reports/documentdetail/270131468187759113/out-of-the-shadows-making-mental-
health-a-global-development-priority) suggest that most low- and middle-income
countries spend less than $2 per person on the treatment and prevention of mental
and substance use disorders – and this was prior to the global outbreak of the novel
coronavirus.
The pandemic has brought social isolation, bereavement, nancial hardship, and
interrupted health care services – which are negatively impacting the mental well-
being of people. (https://twitter.com/intent/tweet?
text=The+pandemic+has+brought+social+isolation%2C+bereavement%2C+ nancial+ha
being+of+people.+&url=https://blogs.worldbank.org/health/lets-invest-mental-
health-inclusive-and-resilient-recovery-covid-19/?
cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) New research also shows that
substance use disorders (https://www.nature.com/articles/s41380-020-00880-7),
including opioids, alcohol, and smoking, are tied to an increased risk for COVID-19
and serious adverse outcomes, including hospitalization and death.
A fundamental rethinking is needed to overcome the false dichotomy between
physical health and mental health in health services. Mental health parity must be
placed at the core of human capital development. The social cost
(https://www.goodreads.com/book/show/37651095-the-origins-of-happiness) of
mental illness and substance use disorders – which compound the impact of poor
physical health – are terribly high, for individuals, families, communities, and the
economy. But the cost of e ective treatments
(https://www.thelancet.com/pdfs/journals/lanpsy/PIIS2215-0366(16)30024-4.pdf) is
surprisingly low.
Integrating mental and physical health services
Faced with the global economic fall-out as the COVID-19 pandemic rages, budgetary
capacity of governments and international assistance co ers are stretched. What
can be done to deliver on this year’s World Mental Health Day call?
x
https://blogs.worldbank.org/health/lets-invest-mental-health-inclusive-and-resilient-recovery-covid-19 2/7
1/12/2021 Let’s Invest in Mental Health for an Inclusive and Resilient Recovery from COVID-19
We must be wary of siloed approaches to increased mental health funding. Rather,
governments can mobilize new resources and leverage existing funding streams by
integrating mental health interventions into existing service delivery platforms
across sectors. (https://twitter.com/intent/tweet?
text=governments+can+mobilize+new+resources+and+leverage+existing+funding+stre
invest-mental-health-inclusive-and-resilient-recovery-covid-19/?
cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank)
There are numerous potential cross-sectoral entry points that would align funding,
service provision, and population needs:
Experiences in Chile, Colombia, Ghana, and the United States demonstrate that
national mandates to cover mental and substance use disorders prevent the
use of preexisting conditions clauses
(https://www.penguinrandomhouse.com/books/317536/a-common-struggle-
by-patrick-j-kennedy-stephen-fried/) to deny health insurance coverage. In
Peru (https://blogs.worldbank.org/health/paradigm-shift-peru-leading-way-
reforming-mental-health-services), the inclusion of mental health services as
part of the bene ts package o ered by the Integrated Health Insurance (SIS)
scheme was an important step towards the achievement of mental health
parity, and for helping vulnerable people access these services when needed
without incurring high out-of-pocket expenditures. This measure was
complemented by the development of a fee schedule to reimburse health
facilities for services rendered, and a 10-year results-based budget allocation
by the Ministry of Economy and Finance exclusively to support community-
based mental health services.
Projects funded under the World Bank Group’s $6 billion COVID-19 Global
Health Emergency Response Program
(https://www.worldbank.org/en/topic/health/coronavirus) in countries such as
Bosnia and Herzegovina, Cambodia, Ecuador, India, Lesotho, Liberia, Morocco,
Marshall Islands, Mongolia, Nigeria, Sri Lanka, and Turkey support psychosocial
interventions to help people deal with negative psychological e ects associated
with stressors such as lockdowns, self-isolation and quarantines, infection fears,
inadequate information, job and nancial losses, and stigma and
discrimination.
Existing funding streams for maternal and child health, such as those under the
Global Financing Facility (GFF) in support of Every Woman, Every Child,
(https://www.global nancingfacility.org/)can be leveraged to deal with maternal
https://blogs.worldbank.org/health/lets-invest-mental-health-inclusive-and-resilient-recovery-covid-19 3/7
1/12/2021 Let’s Invest in Mental Health for an Inclusive and Resilient Recovery from COVID-19
depression, especially postnatal, and the associated stunting in children.
School-based interventions are critically important because 75 percent of
mental and substance use disorders begin before age 25 and suicide is a
leading cause of death among youth. Programs of social and emotional learning
along with promotion of physical health, work and study support, and alcohol
and other drug services, have a positive impact on healthy development, well-
being, and academic performance. Integrating school and clinic-based services
is an e ective approach to improve human capital
(https://www.worldbank.org/en/news/press-release/2020/09/16/pandemic-
threatens-human-capital-gains-of-the-past-decade-new-report-says) outcomes
by investing earlier in life.
Similarly, integrating mental health into wellness programs in the workplace
(https://blogs.worldbank.org/health/case-physical-and-mental-wellness-
programs-workplace) can mobilize private companies to invest in health
promotion activities such as cognitive-behavioral therapies to reduce stress.
These programs generate signi cant bene ts for workers, their families, and
employers, improving productivity and competitiveness, and tackling stigma
surrounding mental disorders.
Programs in fragile and con ict-a ected settings
(https://blogs.worldbank.org/voices/ida-securing-more-resilient-future-fragile-
and-con ict-a ected-settings) can be leveraged to mainstream integrated
physical and mental health interventions
(https://documents.worldbank.org/en/publication/documents-
reports/documentdetail/916131486730755271/mental-health-among-
displaced-people-and-refugees-making-the-case-for-action-at-the-world-bank-
group) alongside other social services to address the needs of displaced
populations and refugees who have been exposed to high levels of stress. For
example, in the Horn of Africa
(https://documents.worldbank.org/en/publication/documents-
reports/documentdetail/483981467990370653/africa-horn-of-africa-emergency-
health-and-nutrition-project), a World Bank Group-funded project supported
counseling services for Somali women and children impacted by gender-based
and sexual violence as part of a primary care package o ered in refugee camps
in Kenya and Ethiopia. Likewise, in Afghanistan
https://blogs.worldbank.org/health/lets-invest-mental-health-inclusive-and-resilient-recovery-covid-19
4/7
1/12/2021 Let’s Invest in Mental Health for an Inclusive and Resilient Recovery from COVID-19
distress-afghanistan) and Yemen (https://projects.worldbank.org/en/projects-
operations/project-detail/P161809), psychosocial support services are provided
to people who have personally experienced or witnessed traumatic events.
Pro-health taxes (https://blogs.worldbank.org/health/taxes-tobacco-alcohol-
and-sugar-sweetened-beverages-reduce-health-risks-and-expand- scal), such
as those on tobacco, alcohol, and sugar-sweetened beverages can help expand
the tax base and collect additional public revenue for priority social investments
and programs, including mental health services at primary care and community
levels, and reduce health risks associated with substance use
disorders. Botswana, Colombia, Moldova, Philippines
(https://documents.worldbank.org/en/publication/documents-
reports/documentdetail/491661505803109617/main-report), and Ukraine o er
good examples of the use of this scal policy for public resource mobilization
and health objectives.
Microcredit schemes, such as Rise Asset Development in Canada
(https://risehelps.ca/), which provides low-interest, small business loans,
training, and mentorship to entrepreneurs with a history of mental health or
addiction challenges (including former prisoners), facilitate reintegration
(https://blogs.worldbank.org/health/mental-health-prisons-how-overcome-
punishment-paradigm) into the community.
As the saying goes, a crisis should not go to waste. During the COVID-19 pandemic
and beyond, renewed e orts and dedicated funding are needed to achieve mental
health parity across sectors. A sustained focus on mental health will contribute to a
more resilient recovery and develop more equitable societies.
(https://twitter.com/intent/tweet?
text=+A+sustained+focus+on+mental+health+will+contribute+to+a+more+resilient+rec
invest-mental-health-inclusive-and-resilient-recovery-covid-19/?
cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank)
HEALTH (/SEARCH?F[0]=TOPIC:297&F[1]=LANGUAGE:EN), COVID-19 (CORONAVIRUS) (/SEARCH?
F[0]=SERIES:881&F[1]=LANGUAGE:EN)
https://blogs.worldbank.org/health/lets-invest-mental-health-inclusive-and-resilient-recovery-covid-19 5/7
1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez
Addressing Alcohol Use Disorders through Taxation: A
Public Health and Economic Win-Win in the time of COVID-
19
Submitted by Patricio V. Marquez on Sun, 09/06/2020 - 11 05 AM
Addressing Alcohol Use Disorders through Taxation: A
Public Health and Economic Win-Win in the time of COVID-
19
Posted by Patricio V. Marquez on Sun, 09/06/2020 - 11 05 AM
“Taxes should be levied not with the idea of lling the public treasury at whatever cost to public morality and e ciency, but as method of reducing the
consumption of alcohol”
---Raymond B. Fosdick and Albert L. Scott, Toward Liquor Control (1933)
For many of us who have experienced alcohol use disorders involving ourselves or family members, the
remembrance of these events brings painful memories of behaviors that negate everything that we have done well,
accomplished, or stand for; shattered dreams and aspirations; unintended damage to relationships with loved ones
and friends; and feelings of guilt and frustration that the temptation to have “one more” cannot be controlled
despite promises made of “never again.”
In some cultures, like the one that I grew up in, high tolerance of heavy alcohol use and binge drinking was not only
accepted but expected of men and peer-reinforced, both as a rite of passage from adolescence to adulthood, and
later in life as a sustained behavior. Common expressions, such as “por qué te vas, si todavía estás bien” (“why are you
leaving the party if you are still sober”), clearly portray these deep-rooted social norms.
Some may identify this condition as a social deviance, an outlier of what is considered “good behavior.” But more
than that, we need to be clear that alcohol abuse and dependency, with all their causes and manifestations, is a
damaging “social disease” affecting not only the mental and physical well-being of individual people, but also the
lives of others. Let’s elaborate on this topic.
www.pvmarquez.com/alcoholuse 1/12
1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez
The Nature of Alcohol Use Disorders
Alcohol use disorder (AUD), including alcoholism, is a chronic relapsing brain disorder
(https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-use-disorders), characterized
by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences.
The severity of the disorder is determined by speci c symptoms, including problems controlling drinking, being
preoccupied with alcohol, continuing to use alcohol even when it causes problems, having to drink more to get the
same effect, binge drinking, or having withdrawal symptoms (e.g., trouble sleeping, shakiness, irritability, anxiety,
depression, restlessness, nausea, or sweating) when a person rapidly decreases or stops drinking.
The impact of alcohol consumption on chronic and acute health outcomes in populations is largely determined by
two separate but related dimensions of drinking: the total volume of alcohol consumed, and the pattern of
drinking. Moderate alcohol consumption (https:/ /health.gov/our-work/food-nutrition/2015-2020-dietary-
guidelines/guidelines/) is up to 1 drink per day for women and up to 2 drinks per day for men. Patterns of drinking
associated with AUD (https:/ /www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-
drinking) include:
binge drinking, a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 percent (or
0.08 grams of alcohol per deciliter - or higher). For a typical adult, this pattern corresponds to consuming 5 or
more drinks (male), or 4 or more drinks (female), in about 2 hours.
heavy alcohol use as more than 4 drinks on any day for men or more than 3 drinks for women.
Alcohol Consumption
A study in The Lancet (https:/ /www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32744-2/fulltext) that
analyzes trends in alcohol intake in 189 countries from 1990–2017 and estimates the rates through 2030, shows
that between 1990 and 2017, global adult per-capita consumption (consumption in L of pure alcohol per adult [≥15
years]) in a given year) increased from 5.9 L to 6.5 L, and is predicted to reach 7.6 L by 2030. Globally, the prevalence
of lifetime abstinence decreased from 46% in 1990 to 43% in 2017, albeit not a signi cant reduction, while the
prevalence of current drinking increased from 45% in 1990 to 47% in 2017. The study forecast both trends to
continue, with abstinence decreasing to 40% by 2030 (annualized 0·2% decrease) and the proportion of current
drinkers increasing to 50% by 2030 (annualized 0·2% increase). In 2017, 20% of adults were heavy episodic drinkers
(compared with 1990 when it was estimated at 18·5%), and this prevalence is expected to increase to 23% in 2030.
Overall, men (70%) are more likely to drink than women (30%). The observed increase in alcohol use globally may be
explained by increased purchasing power of consumers due to grow in per capita income, particularly in China and
India.
Data compiled by Our World in Data (https:/ /ourworldindata.org/alcohol-consumption), show that while alcohol
consumption across North Africa and the Middle East is particularly low — in some countries, close to zero, alcohol
use across Europe is highest at around 15 liters per person per year in the Czech Republic, Lithuania, and Moldova
(equal to around two bottles of wine per person per week), and high in Germany, France, Portugal, Ireland, and
Belgium – at around 12 to 14 liters. Outside of Europe, the only other country in this category of high per capita
alcohol use is Nigeria.
When looking at consumption data within countries, it is observed that high-income people tend to drink more
frequently. While those in lower income or educational status groups often drink less overall, they are more likely to
have lower-frequency, higher-intensity drinking patterns.
www.pvmarquez.com/alcoholuse 2/12
1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez
Data on alcohol expenditure from North America, Europe, and Oceania show that it typically ranges from 0.5
percent up to 7.7 percent (in Ireland) of household expenditure.
Globally, 107 million people or 1.8% of the total population are estimated to have an alcohol use disorder. The share
of the population with alcohol use disorders across countries is shown in the map below, ranging from as low as 0.5
percent to almost 5 percent of the population.
Among youth, a study (https:/ /ghrp.biomedcentral.com/articles/10.1186/s41256-018-0070-2) that reviewed alcohol
consumption patterns and alcohol-related social and health issues among 15–29-year olds in Asian countries, found
that in a majority of the selected countries, over 15% of total deaths among young men and 6% among young women
are attributable to alcohol use. Alcohol use among young people was also found to be associated with a number of
harms, including stress, violence, injuries, suicide, and sexual and other risky behaviors.
In Canada (https://www.partnershipagainstcancer.ca/topics/key-statistics-alcohol-consumption-largest-cities-
canada/), approximately 80% of adults, aged 18 or older, consumed alcohol in the past year, with the proportion of
the adult population with alcohol consumption rates above cancer guidelines ranging from 5% of adults in Toronto,
Ontario to 15% of adults in Sherbrooke, Quebec (Canada’s Low-Risk Alcohol Drinking Guidelines for cancer
recommends no more than 2 drinks per day for men and no more than 1 drink per day for women).
Mental health disorders are a major risk factor for developing alcohol dependency. The results of a study
(https://www.sciencedirect.com/science/article/abs/pii/S104727970700021X) on mental health and alcohol use in
developing countries showed that the consumption of alcohol is heavily gendered and is characterized by a high
proportion of hazardous drinking among men. Hazardous drinkers not only consume large amounts of alcohol, but
also do so in high-risk patterns, such as drinking alone and binging, which are associated with depressive and
anxiety disorders as well as suicide and domestic violence. In the Americas
(http://www.pvmarquez.com/legacy_to_overcome), in countries such as Bolivia, Canada, Ecuador, Mexico, Peru,
and the United States, indigenous peoples, who account for some 13% of the region’s population, suffer substantial
alcohol use-induced conditions yet have limited access to care and other interventions.
Health Consequences
According to the World Health Organization (https:/ /www.who.int/news-room/fact-sheets/detail/alcohol) (WHO),
alcohol use is a risk factor in more than 200 disease and injury conditions. It is associated with the development
of mental and behavioral disorders, including alcohol dependence, major noncommunicable diseases such as liver
cirrhosis, some cancers, and cardiovascular diseases. A signi cant proportion of the disease burden attributable to
alcohol consumption arises from unintentional and intentional injuries, including those due to traf c injuries,
violence, and suicides, and fatal alcohol-related injuries tend to occur in relatively younger age groups. Also, there is
www.pvmarquez.com/alcoholuse 3/12
1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez
a causal relationship between harmful drinking and incidence of infectious diseases such as tuberculosis as well as
the incidence and course of HIV/AIDS. Alcohol consumption by an expectant mother may cause fetal alcohol
syndrome and pre-term birth complications, impacting human capital development.
Worldwide (https:/ /www.who.int/news-room/fact-sheets/detail/alcohol), about 3 million deaths every year result
from harmful use of alcohol, which represent 5.3 % of all deaths. More than three quarters of these deaths were
among men. Overall, 5.1 % of the global burden of disease and injury is attributable to alcohol, as measured in
disability-adjusted life years (DALYs), which re ect both mortality and morbidity.
WHO data (https:/ /www.who.int/substance_abuse/publications/global_alcohol_report/en/) for 2016 also show
that of all deaths attributable to alcohol consumption worldwide, 28.7% were due to injuries, 21.3% due to digestive
diseases, 19% due to cardiovascular diseases, 12.9% due to infectious diseases, and 12.6% due to cancers.
Additionally, alcohol use was responsible for 7.2% of all premature deaths (among persons 69 years of age and
younger), with younger people aged 20–39 years old disproportionately affected (13.5% of all deaths among this
group are attributed to alcohol use).
The age-standardized alcohol-attributable burden of disease and injury
(https://www.who.int/substance_abuse/publications/global_alcohol_report/en/) globally was 38.8 deaths and
1758.8 DALYs per 100 000 people, with the highest burden in the WHO African Region (AFR) (70.6 deaths and 3044
DALYs per 100 000 people). This is in contrast to the level of alcohol consumption which was highest in WHO’s
European Region (EUR). The alcohol-attributable burden of disease and injury in Africa was due, in part, to the large
burden of disease caused by tuberculosis, cardiovascular diseases, digestive diseases, and injuries (to which alcohol
is a contributing factor). This explains why Africa has the highest age-adjusted burden of disease and injury
attributable to alcohol consumption. The age-standardized burden of disease and injury attributable to alcohol
consumption was lowest in the Eastern Mediterranean Region (EMR) (7.0 deaths and 322 DALYs per 100 000
people). Data for the other regions are: Europe, 62.8 deaths and 2726.5 DALYs per 100 000 people; Americas, 34.1
deaths and 1821.9 DALYs per 100 000 people; South East Asia, 36.8 deaths and 1718.3 DALYs per 100 000 people; and
Western Paci c, 24.3 deaths and 1132.9 DALYs per 100 000 people.
The proportions of all deaths and DALYs caused by alcohol consumption were highest in the European Region,
where 10.1% of all deaths and 10.8% of all DALYs were attributable to alcohol consumption, and were lowest in the
Eastern Mediterranean Region, where 0.7% of all deaths and 0.7% of all DALYs were attributable to alcohol
consumption. Data for the other regions are: Africa, 5.1% of deaths and 4.1% of DALYs; Americas, 5.5% of deaths and
6.7% of DALYs; South East Asia, 4.6% of deaths and 4.6% of DALYs; and Western Paci c, 4.1% of deaths and 4.9% of
DALYs.
Social Impact
Broader negative social impacts of alcohol use are re ected in the statistics for road traf c-related injuries and
fatalities, violent crimes, and gender-based and sexual violence.
Drunk driving is an important risk factor
(https:/ /openknowledge.worldbank.org/bitstream/handle/10986/27840/516670v20WP0P110Box345565B01PUBLIC1.p
for all road users, and young drivers aged 18–25 are particularly at risk of crashing. As blood alcohol concentration
(BAC) increases, so does the likelihood of crashing, particularly above a BAC of 0.04 grams per deciliter (g/dl). WHO
estimates that nearly 2 million people are killed on the world’s roads annually, with an additional 20-50 million
people seriously injured. The share of all road traf c deaths attributed to alcohol consumption above the national
legal limit for alcohol consumption was estimated in 2013 to vary from a high 57.5% in South Africa to a low of 3.8%
www.pvmarquez.com/alcoholuse 4/12
1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez
in China. In 2014, alcohol-impaired driving fatalities
(https:/ /crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812219) accounted for 31% percent of total driving
fatalities in the United States.
A recent World Bank Group report, “The High Toll of Traf c Injuries: Unacceptable and Preventable,”
(https://openknowledge.worldbank.org/handle/10986/29129) showed that besides preventing loss of life of people
and the resulting pain and misery for families and communities, there are signi cant long-term economic gains to
be achieved from the adoption of simple, sustainable, affordable, and effective traf c safety policies and
interventions, including hiking up taxes to increase the price of alcohol products and regulating their marketing and
selling practices. The estimated impact in an initial set of ve countries (China, India, Philippines, Tanzania, and
Thailand) ranged from a 7% to 22% increase in GDP per capita over 24 years – that could be achieved through
substantial reduction in road traf c injuries and deaths in line with the target set under the UN’s Sustainable
Development Goals 2030 Agenda. This nding sends a clear message
(https://blogs.worldbank.org/health/preventable-traf c-injuries-and-deaths-hold-back-development-countries)
to governments: there is a signi cant economic loss associated with every year of inaction when LMICs fail to adopt
effective policies and interventions to substantially reduce road traf c injuries and deaths.
Research (https://www.tandfonline.com/doi/abs/10.1080/19371918.2013.759005) on the effects of alcohol abuse on
families shows that alcohol abuse and addiction play a role in intimate partner violence, cause family nancial
problems, impair decision-making skills, and contribute to child neglect and abuse.
The share of all crimes which are considered to be alcohol-related (https:/ /ourworldindata.org/alcohol-
consumption#alcohol-related-crime), including both offenses in which the alcohol consumption is part of the
crime such as driving with excess alcohol, liquor license violations, and drunkenness offenses, and all those crimes
in which the consumption of alcohol is thought to have played a role of some kind in the commission of the offense
(e.g., assault, criminal damage, and other public order offenses), is estimated to vary signi cantly: in some countries
– including Iran, Chile, and Scandinavian countries – the share is well below 5%, while in the UK, it is over 50%.
Additional country evidence illustrates the wider social and impact of AUD. As documented back in the mid-2000s
in the report “Dying Too Young,” (http://documents.worldbank.org/curated/en/867131468094164661/Main-report)
alcohol abuse contributed signi cantly to the dramatic decrease in life expectancy among males and the shrinking
of the total population experienced in Russia during rst decades of the post-Soviet period (1990-2000).
Are people drinking more amidst the COVID-19 pandemic?
Alcohol misuse is already a public health concern in many countries, and it has the potential to further complicate
the COVID-19 pandemic (https:/ /www.niaaa.nih.gov/directors-blog-alcohol-poses-different-challenges-during-
covid-19-pandemic) in multiple ways. Excessive alcohol consumption can in uence COVID-19 susceptibility and
severity, as it both activates the immune system, causing in ammation, and interferes with the body’s immune
response to viral and bacterial infections. And, in a vicious cycle, the broad effects of the pandemic are also likely to
lead to excessive alcohol consumption. As documented in a previous post
(http://www.pvmarquez.com/mentalhealandthcovid-19), people are more likely to drink more as a coping
mechanism "during times of uncertainty and duress", particularly in the face of raising unemployment and loss of
income. The COVID-19 crisis is not an exception. For example, with bars and restaurants closed in the United
States, sales of alcohol in the United States (https://www.nielsen.com/us/en/insights/article/2020/rebalancing-
the-covid-19-effect-on-alcohol-sales/) have spiked nearly 27% since the start of the pandemic, with consumers
gravitating to larger pack sizes.
www.pvmarquez.com/alcoholuse 5/12
1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez
Also, COVID-19 stress due to lockdown and isolation has the potential to increase the risk of developing AUD and of
relapses among people struggling to overcome this disorder. Studies have shown that there is a clear relationship
between anxiety and AUD. Both prolonged drinking and alcohol withdrawal
(https://www.ncbi.nlm.nih.gov/books/NBK64178/) are associated with an increased incidence of anxiety; people
with general anxiety and panic disorders
(https://www.sciencedirect.com/science/article/abs/pii/S0887618508000856) often self-medicate their condition
with alcohol; and people with anxiety who self-medicate with alcohol often develop AUD
(https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1107248).
How to control this problem?
The most cost-effective policies or “best buys” (https:/ /www.jsad.com/doi/abs/10.15288/jsad.2018.79.514?
journalCode=jsad) to reduce alcohol use include increasing taxes on alcoholic beverages, enacting and enforcing
bans or comprehensive restrictions on exposure to alcohol advertising across multiple types of media, and enacting
and enforcing restrictions on the retail availability of alcohol.
Other effective interventions include the enactment and enforcement of drunk-driving laws and blood alcohol
concentration limits via sobriety checkpoints. Indeed, the number of countries reporting the adoption of these
measures increased substantially between 2008 and 2016 the majority (97) of countries studied by WHO
(https://www.who.int/substance_abuse/publications/global_alcohol_report/en/) have a maximum permissible
blood alcohol concentration (BAC) limit to prevent drunk driving at or below 0.05%; 37 countries have a BAC limit of
0.08; and 31 countries have no BAC limits at all. Seventy countries (41%) reported using sobriety checkpoints and
random breath-testing as prevention strategies, but 37 (22%) used neither strategy.
Taxing alcohol
As observed by Richard M. Bird
(https://openknowledge.worldbank.org/bitstream/handle/10986/23464/Tobacco0and0al0ing0sin0and0virtue00.pdf
sequence=1&isAllowed=y), excise taxes on alcohol as well as on tobacco have long been a dependable and signi cant
revenue source in many countries globally. In recent years, increased attention has been paid to the way in which
such taxes may also be used to achieve public health objectives by reducing the consumption of products with
adverse health and social impacts.
Alcohol taxation and pricing policies have public health and economic bene ts: 1) control of alcohol consumption
and public health problems caused by alcohol consumption, 2) prevention of drinking initiation, and 3) tax revenue
generation.
Several types of alcohol excise taxation methods are employed around the world, including: uniform tax methods –
such as speci c taxation (where the tax is calculated based on the amount of ethanol a beverage contains), ad
valorem taxation (where the tax is based on the price of the alcoholic beverage), and unitary taxation (where the tax
is based on the volume of the alcoholic beverage) – and combination tax methods such as mixed speci c and ad
valorem taxation and ad valorem with speci c oor taxation. These methods have different attributes that may be
appropriate to different contexts and different alcohol control objectives
(https://www.researchgate.net/pro le/Kevin_Shield/publication/318233753_The_need_for_alcohol_taxation_and
need-for-alcohol-taxation-and-pricing-policies.pdf). For example, speci c taxation may be appropriate for high-
income countries that have a high prevalence of drinkers since it promotes consumption of beverages with low
alcohol content instead of beverages with high alcohol content, resulting in a reduction in total alcohol
consumption. Ad valorem with speci c oor taxation and mixed speci c and ad valorem taxation may be
appropriate for low- and middle-income countries since they promote consumption of medium alcohol content
www.pvmarquez.com/alcoholuse 6/12
1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez
beverages, which are expected to reduce total alcohol consumption among heavy drinkers and prevent drinking
initiation among young people. The government may also apply a minimum price measure to control problems
caused by inexpensive alcoholic beverages.
Hiking tax rates to increase the price of alcoholic beverages is one of the most cost-effective and cost-saving
approaches to reducing alcohol consumption and harm. As such, it is important to note that alcohol and tobacco
taxation may differ with respect to their public health goals. While there is no safe level of smoking, in terms of
alcohol consumption, the public health goal is moderation (except in the case of road safety, where no level of drunk
driving is safe). Hence, the public health goal for taxing alcohol beverages (https://www.worldcat.org/title/alcohol-
consumption-and-taxation/oclc/20754456) is to limit the harm caused by alcohol consumption, either by reducing
or preventing increases in the overall average consumption per person.
The WHO’s Global Strategy to Reduce the Harmful Use of Alcohol
(https://www.who.int/publications/i/item/9789241599931) recommends that countries establish a system for
speci c domestic taxation which may take into account the alcohol content of the beverage. The strategy also
encourages countries to review prices regularly in relation to in ation and income levels; to ban or restrict sales
below cost and other price promotions; and to establish minimum prices for alcohol where applicable. According to
the ndings of the 2015 WHO Global Survey on Progress in Alcohol Policy
(https://www.who.int/substance_abuse/publications/global_alcohol_report/en/), 59% of 164 reporting countries
indicated that they had established or increased the excise tax on alcohol since 2010, covering 5 billion people.
The results of a study (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4764336/#pmed.1001963.ref011) that
compared the scale and distribution across society of health impacts arising from alternative alcohol tax and price
policy options have shown that, compared to taxation based on product value, alcohol-content-based taxation or
minimum unit pricing would lead to larger reductions in health inequalities across income groups. The study also
estimated that alcohol-content-based taxation and minimum unit pricing would have the largest impact on harmful
drinking, with minimal effects on those drinking in moderation.
While the excise tax rate is an important factor in determining the price of alcoholic beverages, an important
variable to in uence consumption, as is also the case in tobacco taxation, is the extent to which increases in excise
taxes are passed along to consumers as opposed to being absorbed by rms, as people are sensitive to changes in
the price of alcohol products. Pricing policies therefore can be used to in uence demand and reduce underage
drinking, heavy drinking, and binge drinking. Consumer preferences and choice, per capita income variations,
alternative sources of alcohol in the country or in neighboring countries, the presence or absence of other alcohol
control policy measures, as well as opposition of industry groups, may in uence the effectiveness of this policy
measure. To help realize the bene ts of alcohol tax policies, strengthened tax administration, including control of
illicit tobacco and alcohol trade (https://documents.worldbank.org/en/publication/documents-
reports/documentdetail/677451548260528135/confronting-illicit-tobacco-trade-a-global-review-of-country-
experiences), plays a critical role.
Health impact of alcohol taxation
A recent study (https:/ /doi.org/10.15288/jsad.2018.79.514) provided evidence on the comparative cost-effectiveness
of alcohol control strategies. The results of the study showed that increasing alcohol excise taxes by 50% is the
most cost-effective policy to reduce harmful alcohol use, as it has a low cost (< $0.10 per capita) and a highly
favorable ratio of costs to effects (< $100 per healthy life year gained in both low- and high-income settings). This
measure is more ef cient than alternative options in the same price category. Availability and marketing
restrictions are also highly cost-effective (< $100 per healthy life year gained in low-income settings and < $500 per
www.pvmarquez.com/alcoholuse 7/12
1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez
healthy life year gained in high-income settings), while enforcement of drunk-driving laws and blood alcohol
concentration limits via sobriety checkpoints had cost-effectiveness ratios in the range of International (I) $1,500–
3,000 and brief psychosocial treatments were <I$150 and <I$1,500 in low- and high-income settings, respectively.
Different studies (https://www.who.int/substance_abuse/publications/global_alcohol_report/en/) also provide
evidence that increasing the price of alcohol is associated with reductions in harmful use of alcohol and alcohol-
related morbidity and mortality, including liver cirrhosis deaths, violence, teenage pregnancy, and sexually
transmitted diseases. There is also evidence that suggests that the bene ts of higher alcohol prices also extend to
the education sector, increasing the likelihood of secondary school graduation as well as post-secondary enrollment
and graduation.
Another recently-published study (https:/ /gh.bmj.com/content/bmjgh/5/3/e002143.full.pdf) that simulated the
health and economic effects of alcohol, as well as tobacco and sugar-sweetened beverages (SSB) over 50 years for
30–79 years old populations, shows that alcohol taxation generate a health bene t of years of life gained (YLG) over
50 years of 227million and 547million for 20% and 50% price increases, respectively. It also shows that consumer
expenditure increases by US$2958 billion and US$1549 billion over 50 years, and tax revenues increase by US$9428
billion and US$17778 billion for the 20% and 50% price increases, respectively.
Results from studies focusing on the State of Maryland (US) experience provide speci c evidence that alcohol tax
increases are an effective strategy for reducing health risks. One study
(https://www.ajpmonline.org/article/S0749-3797(15)00627-3/fulltext) showed that after the sales tax rate for
alcoholic beverages increased from 6% to 9% in 2011, on top of the existing state and federal excise tax rates that are
collected from manufacturers or wholesalers of alcoholic beverages which are passed on directly to the consumer in
the form of raised alcohol prices, per-capita alcohol consumption and sexually transmitted diseases were
reduced. Gonorrhea rates, for example, decreased 24% during the 1.5-year post-increase period. This implied that
an estimated 2,400 cases of gonorrhea were prevented, saving more than US$500,000 in direct medical expenses.
Another study showed that there was a signi cant though gradual annual reduction of 6% in the population-based
rate of all alcohol-positive drivers, and a more pronounced 12% reduction for drivers aged 15–34 years following
the 2011 alcohol sales tax increase. The ndings suggest that young drivers tend to be alcohol price-sensitive. The
sales tax increase, which has also raised about US$70 million a year for health and education programs, has proved
to be an important but often neglected intervention to reduce alcohol-impaired driving.
In the case of China (https://www.worldbank.org/content/dam/Worldbank/document/NCD_report_en.pdf),
modelling work has shown that for a few additional cents (US) or around 0.07 yuan per capita, a combination of anti-
tobacco measures with interventions for controlling alcohol abuse, e.g., increasing tax and banning advertising,
would help avert an additional 40 million DALYs lost annually.
The experience of Russia since 2010 is illustrative of the potential signi cant impact of raising alcohol and tobacco
taxes on good health outcomes. Over the past decade, life expectancy
(https://www.thelancet.com/action/showPdf?pii=S0140-6736%2818%2931485-5) for men in Russia increased to
65.4 years in 2016, up from 58 years in 2003, and among women it reached 76.2 years in 2016, up from 72 years in
2003. A big factor (http://www.euro.who.int/en/countries/russian-federation/publications/tobacco-control-a-
comprehensive-approach-at-country-level-in-the-russian-federation-2017) in this improvement was the effective
measures adopted to control the consumption of alcohol and tobacco.
It is worthwhile looking at the European Union (EU) experience, which shows that even countries in the same
economic block governed by a partially restrictive legal framework enact very different alcohol taxation policies. A
recent study (https://onlinelibrary.wiley.com/doi/full/10.1111/add.14631) found only limited evidence that alcohol
duties in the EU are designed to minimize public health harms by ensuring that drinks containing more alcohol are
www.pvmarquez.com/alcoholuse 8/12
1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez
taxed at higher rates. The ndings of the study indicate that only 50% of EU Member States levy any duty on wine,
and several levy duties on spirits and beer at or close to the EU minimum level. Duty rates are generally higher for
spirits than other beverage types and are generally lowest in Eastern Europe and highest in Finland, Sweden,
Ireland, and the United Kingdom.
Public revenue impact of alcohol taxation
When assessing the scal impact of alcohol taxation, it is important not only to focus on the generation of public
revenue but also on the expenditures required to address the social consequences of alcohol use disorders.
This consideration is of great importance, as total alcohol tax revenue collection tends to account for only a small
share of the total economic cost to the government of alcohol-related harm, and even a lower share of the total
economic cost of excessive drinking. For example, a CDC study (https:/ /www.cdc.gov/media/releases/2015/p1015-
excessive-alcohol.html) showed that excessive drinking cost the United States US$249 billion in 2010, or US$2.05 per
drink, a signi cant increase from US$223.5 billion, or $1.90 per drink, in 2006. Most of these costs were due to
reduced workplace productivity, crime, and the cost of treating people for health problems caused by excessive
drinking. As shown by data from another on the situation in the United States
(https://www.jsad.com/doi/10.15288/jsad.2019.80.408), speci c excise taxes accounted for a weighted median of
20.1% of total state alcohol tax revenue, and the median total alcohol tax per drink (based on all federal and state
taxes) was US$0.21, which accounted for 26.7% of the median cost to government and 10.3% of the median total
economic cost of excessive drinking.
The heavy burden of alcohol-related conditions on the health system is illustrated by data from 100 emergency
departments of 33 countries presented in a recent study (https:/ /movendi.ngo/reports/alcohols-healthcare-
burden-during-covid%E2%80%9019-pandemic/). In most countries, alcohol’s contribution is in the realm of 20% of
all presenting injuries, while alcohol’s contribution to non‐injury emergency department admissions averages 11.5%.
From a public revenue perspective, building on the experience in the Philippines
(https://openknowledge.worldbank.org/handle/10986/24617) with the “Sin Tax Law” adopted at the end of 2012,
considerable attention has been paid in recent years to promoting alcohol and tobacco tax increases as a policy
option to help mobilize additional resources to nance development priorities, particularly the expansion of
universal health coverage schemes. In large measure, the experience of the Philippines over 2013-2017 is one of the
most compelling examples of ambitious national alcohol and tobacco tax reform. It involved a fundamental
restructuring of the country’s tobacco excise tax structure, including reduction in the number of tax tiers;
indexation of tax rates to in ation; and substantial tax increases that generated more than US$5.2 billion additional
revenues or 1.1% of GDP in the rst 4 years of implementation, which expanded the scal space to increase the
number of low-income families enrolled in the health insurance scheme from 5.2 million primary members in 2012
to 15.3 million in 2017.
Likewise, as part of a broad scal reform package approved by Colombia’s Congress on December 23, 2016, excise
tax increases on alcohol and tobacco were adopted
(http://documents1.worldbank.org/curated/en/491661505803109617/pdf/119792-REVISED-v2-
OctFINALWBGTobaccoTaxReformFullReportweb.pdf) to achieve public health and revenue objectives. In addition,
the scal reform law mandates the earmarking of these tax revenues to nance health insurance coverage and
education programs at the departmental level. Similar scal reforms were enacted over the 2016-2019 period in
countries such as Armenia, Gabon, Lesotho, Montenegro, and Nigeria, with technical support from the World Bank
Group.
www.pvmarquez.com/alcoholuse 9/12
1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez
The “win-win” scal/public health nature of raising taxes on alcohol is further illustrated by the experience of
other countries. In the United States (https://www.cbo.gov/budget-
options/2018/54815#:~:text=Beginning%20in%202020%2C%20distilled%20spirits%20will%20be%20taxed,about%202
federal collections from taxes on alcoholic beverages totaled about US$11 billion in 2017. Distilled spirits are taxed at
a at rate of US$13.50 per proof gallon (a proof gallon denotes a liquid gallon that is 50 percent alcohol by volume),
which translates to about 21 cents per ounce of pure alcohol. Beer is generally subject to a tax rate of US$18 per
barrel, which is equivalent to about 10 cents per ounce of pure alcohol (under the assumption that the alcohol
content of the beer is 4.5 percent), and the excise tax on wine that is no more than 14 percent alcohol is US$1.07 per
liquid gallon, or about 6 cents per ounce of pure alcohol (assuming an alcohol content of 13 percent). As part of
options for reducing the federal government de cit over 2019-2028, a Congressional Budget Of ce simulation
showed that by increasing all taxes on alcoholic beverages to US$16 per proof gallon from current level and indexing
for in ation would increase revenues by US$83 billion from 2020 through 2028, while reducing costs for society that
are not re ected in the pretax price of alcoholic beverages---e.g., external costs including spending on health care
that is related to alcohol consumption and covered by the public, losses in productivity stemming from alcohol
consumption that are borne by entities or individuals other than the consumer, and the loss of lives and property
from alcohol-related injuries and crime.
The above ndings provide a strong justi cation for raising excise taxes on alcoholic beverages to levels where
revenues match or at least cover a larger share of the economic cost of alcohol use disorders. If this is not done, the
disparity that exists between alcohol-related costs to government and the collected alcohol tax revenue will be
perpetuated, which is tantamount to a large taxpayer-funded subsidy of excessive drinking.
(https://www.usnews.com/news/health-news/articles/2019-09-11/booze-taxes-dont-make-up-for-societal-
costs-of-excess-drinking-study)
Is alcohol taxation a regressive policy measure?
A common objection to increasing alcohol excise tax is that even if it is an effective public health measure, it is
poorly focused, in effect punishing all drinkers regardless of whether their drinking is problematic. As eloquently
argued by Prof. Philip J Cook of Duke University
(https://press.princeton.edu/books/hardcover/9780691125206/paying-the-tab), in a landmark book on the cost
and bene ts of alcohol control, alcohol taxation tends to be well focused on negative externalities of drinking.
That is, in the case of a price increase per drink that results from raising taxes on alcohol, those who abstain (a
signi cant proportion of most populations) would pay nothing and would be just a few extra dollars per year for
light/moderate drinkers (the majority of those consuming alcohol). The bulk of the additional excise revenue
would come from the top 15% of the drinkers (who average 8 or 9 drinks per day) who consume 75% of all the
alcohol and consequently would pay 75% of a new tax. That is also the group that accounts for most of the alcohol-
related harm, consequently yielding a well-targeted tax increase. Additionally, even if the direct effect of prices are
on the consumption habits of relatively moderate drinkers, heavy drinkers can be affected indirectly. There is
reliable evidence that alcohol consumers across the spectrum in uence each other. So, if alcohol prices affect the
drinking patterns at the median, then the upper tail of the distribution will shift inward - in other words, a reduced
prevalence of heavy drinking would be expected.
Seizing the COVID-19 crisis to reduce public health risks and mobilize public funding
The COVID-19 pandemic has impacted countries with an unprecedented double shock, public health and
economic, that is constraining the scal capacity of countries in the short- and medium-term. As argued in a
previous post (https://blogs.worldbank.org/health/taxes-tobacco-alcohol-and-sugar-sweetened-beverages-
reduce-health-risks-and-expand- scal), pro-health taxes, including excise tax increases on tobacco, alcohol, and
sugar-sweetened beverages, are a potential tool to help alleviate the ongoing health crisis and contribute to
www.pvmarquez.com/alcoholuse 10/12
1/12/2021 Addressing Alcohol Use Disorders through Taxation: A Public Health and Economic Win-Win in the time of COVID-19 | Patricio V. Marquez
recovery. While this scal measure can help reduce health risks associated with the onset of non-communicable
diseases and injuries and their nancial and economic impacts, it can also help mobilize public revenue to expand
scal space for health and other essential programs that bene t the entire population of countries. Indeed,
projections presented in a World Bank Group report (https:/ /openknowledge.worldbank.org/handle/10986/31930)
for the G-20 meeting in Osaka, Japan in 2019 showed that the substantial universal health coverage nancing gap in
low- and lower-middle-income countries (now exacerbated by COVID-19), can be attenuated by excise tax increases
on tobacco, alcohol, and sugar-sweetened beverages. These pro-health taxes can help further mobilize public
revenue while mitigating the affordability of these products by regularly adjusting the excise tax and sale tax
increases in accordance with in ation and per capita income growth.
It should be clear, however, that thus far governments have failed to take advantage of taxation
(https://newbooksinpolitics.com/political/phishing-for-phools/) as a cost-effective and cost-saving method of
alcohol control, despite the evidence that it could help generate signi cant public revenue to keep down taxes
elsewhere. In some measure this outcome is due to the in uence of powerful interest groups—from the alcohol
industry to owners of bars and restaurants, as well as doubts about the harms of alcohol among the general public
as alcohol use is associated with deep-rooted and well-accepted social and cultural norms and traditions. Dealing
with this reality, active community engagement, as exempli ed by the work of organizations such as Mothers
Against Drunk Driving (https:/ /www.madd.org/history/) (MADD), could be galvanized to lobby for the adoption of
tax increases and other measures to moderate alcohol abuse and prevent ruining the lives of alcohol-dependent
people and their loved ones, as well as of those people impacted or killed as a result of alcohol-impaired driving or
acts of violence.
As we move forward containing and mitigating the impact of the COVID-19 pandemic, the most significant global
public health crisis of the past 100 years, we need to be clear that disease and injury prevention is not only a public
health goal, but more importantly, a broad social goal that should matter to all of us since it is a key requirement for
building healthy, resilient, and productive societies. Measures such as alcohol taxation, as shown by the evidence
presented above, can contribute to this end by helping reduce the short- and long-term public health and economic
harms caused by destructive drinking.
Source of image: "Colorful drawing: father drinking alcohol and crying child", Stock photo ID:507843974.
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/alcoholuse 11/12
1/12/2021 Let’s not forget about Mental Health during COVID-19! | Patricio V. Marquez
Let’s not forget about Mental Health during COVID-19!
Submitted by Patricio V. Marquez on Sat, 08/22/2020 - 09 42 AM
Let’s not forget about Mental Health during COVID-19!
Posted by Patricio V. Marquez on Sat, 08/22/2020 - 09 42 AM
“Thus the rst thing that plague brought to our town was exile…….It was undoubtedly the feeling of exile—that sensation of a void within which never left us, the
irrational longing to hark back to the past or else to speed up the march of time, and those keen shafts of memory that stung like re.”
Albert Camus (1957 Nobel Prize Laureate for Literature), The Plague, 1947
Growing numbers of infected people, loss of life, and an economic free-fall not experienced since World War II, are
some of the casualties of the COVID-19 pandemic. IMF estimates (https:/ /blogs.imf.org/2020/04/20/a-global-
crisis-like-no-other-needs-a-global-response-like-no-other/) show that 170 countries will see income per capita
go down, and World Bank Group projections (https:/ /blogs.worldbank.org/opendata/updated-estimates-impact-
covid-19-global-poverty) suggest that rising unemployment and loss of income, including in some countries a
signi cant drop in remittances, could push between 71 and 100 million people into extreme poverty.
Daily personal routines have been altered by social distancing measures adopted to prevent the spread of the novel
coronavirus, impacting people in many different ways. The lack of interpersonal contact with loved ones and peers
is contributing to feelings of isolation and loneliness; detachment from our communities is depressing us; and fear
of becoming infected or of loved ones falling ill worries and makes us anxious. In large measure, a sense of being in
“exile” has engulfed us as we drift through the sameness of days, feeling unmoored and uncertain about the
repercussions of the pandemic.
Given the intense disruption brought by COVID-19 to our everyday life, it is of great importance to understand how
the pandemic is affecting mental well-being and what can be done to help people cope and deal with its
consequences in the short- and medium-terms. In answering this question, we need to learn from past crises as
well as to look at the emerging evidence from the current pandemic.
The Impacts of Unemployment and Loss of Income
www.pvmarquez.com/mentalhealandthcovid-19 1/6
1/12/2021 Let’s not forget about Mental Health during COVID-19! | Patricio V. Marquez
The layoffs and job losses brought on by lockdowns have been enormous, particularly for people with only basic
levels of education and in the poorer segments of society, while telework arrangements have protected the
employment of highly skilled and educated people. Across countries, ILO estimates
(https:/ /news.un.org/en/story/2020/04/1061322) show that full or partial lockdown measures are affecting almost
2.7 billion workers – four in ve of the world’s workforce. In particular, workers in sectors such as food and
accommodation (144 million workers), retail and wholesale (482 million), business services and administration (157
million), and manufacturing (463 million), which account for up to 37.5 per cent of global employment, are feeling the
“sharp end” of the impact of the pandemic. COVID-19 has had disproportionate effects on women
(https:/ /blogs.imf.org/2020/07/21/the-covid-19-gender-gap/)and their economic status, since women are more
likely than men to work in social sectors — such as service industries, retail, tourism, and hospitality, that require
face-to-face interactions, and hence, are hit hardest by social distancing and mitigation measures.
As discussed in a paper by researchers from the Urban Institute
(https://www.urban.org/research/publication/consequences-long-term-unemployment/view/full_report), the
experience from previous global crises, such as the Great Recession of 2008, shows than being out of work for six
months or more is associated with lower well-being among the unemployed, their families, and their communities.
While scal stimulus and targeted social transfer programs can help mitigate the consequences of long-term
unemployment, a decline in family income due to a worker’s lack of earnings directly reduces the quantity and
quality of goods and services the worker’s family can purchase and exacerbates stress as well. The erosion in the tax
base used to fund essential public services, such as essential medical care, can negatively affect individuals and
families by constraining access to these services when needed.
Impact on Mental Health
The devastating impact of COVID-19 disease on people’s physical health is well documented, with more than 22
million people infected, almost 800,000 deaths (https://coronavirus.jhu.edu/), and many that survived infection left
experiencing persistent symptoms long after hospital discharge. Much less understood is the impact of high levels
of stress on people resulting from the adoption of social distancing measures to contain and mitigate COVID-19 and
from the economic downturn and income loss to households. The graph below depicts a COVID-19 physical and
mental health impact timeline.
www.pvmarquez.com/mentalhealandthcovid-19 2/6
1/12/2021 Let’s not forget about Mental Health during COVID-19! | Patricio V. Marquez
Fear, pervasive anxiety, frustration, and anger
(https://academic.oup.com/qjmed/article/113/8/531/5860841)experienced by adults and children can be
overwhelming and aggravated by social isolation and loneliness (https:/ /www.nap.edu/catalog/25663/social-
isolation-and-loneliness-in-older-adults-opportunities-for-the) among the elderly, who are a higher risk of
developing severe symptoms or die from COVID-19 disease. These negative psychological effects are associated
with stressors (https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930460-8) such as long
duration of quarantines, infection fears, frustration, boredom, sadness, grief, inadequate supplies, inadequate
information, nancial loss, and stigma and discrimination
(https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30498-9/fulltext). Some of the symptoms of
mental health problems include changes in sleep or eating patterns; dif culty sleeping or concentrating; worsening
of chronic health problems and mental health conditions; and adoption of risky behaviors such as increase in
tobacco use, alcohol abuse, and substance use.
More speci cally, research in countries is showing how the pandemic is impacting the general population. A health
tracking poll (https://www.kff.org/coronavirus-covid-19/report/kff-health-tracking-poll-early-april-2020/)
conducted in April 2020 in the United States indicates that an increasing share of people reported worrying about
economic impacts, with more than half now reporting being worried that their investments will be negatively
impacted for a long time (59%) and that they will be laid off or lose their job (52%), nearly half worried they will lose
income due to a workplace closure or reduced hours (45%), more than half (53%) worried that they or a family will
get sick from coronavirus, and nearly six in ten adults (57%) being worried they will put themselves at risk of
exposure to coronavirus because they cannot afford to stay home and miss work. More troubling, the results of the
poll indicate that more than four in ten adults overall (45%) feel that worry and stress related to coronavirus have
had a negative impact on their mental health, up from 32% in early March 2020. Similarly, research
(https://doi.apa.org/fulltext/2020-52963-001.html)that examined whether intolerance of uncertainty and coping
responses in uence the degree of distress experienced by the U.K. general public during the COVID-19 pandemic,
indicates that around 25% of participants demonstrated signi cantly elevated anxiety and depression, with 14.8%
reaching clinical cutoff for health anxiety. Further research from China
(https://gpsych.bmj.com/content/33/2/e100213) found that 35% of people experienced mental distress, such as
panic disorder, anxiety, and depression, during the rst month of the COVID-19 outbreak and that these levels
continued as the disease spread over the following months.
How are Lockdowns Impacting Children and Young Adults?
The Great Lockdown has affected close to 1 billion children and adolescents worldwide, upending their daily routine
and isolating them from their social structures. A recent study (https://psyarxiv.com/5bpfz/)examining the
psychological impact on youth from Italy and Spain, shows that 85.7% of the parents perceived changes in their
children´ s emotional state and behaviors during this period. The most frequent symptoms identi ed included
dif culty concentrating (76.6%), boredom (52%), irritability (39%), restlessness (38.8%), nervousness (38%), feelings
of loneliness (31.3%), uneasiness (30.4%), and worries (30.1%). The study also reported that children of both
countries used electronic devices more frequently, spent less time on physical activity, and slept more hours.
Moreover, when family coexistence became more dif cult, the situation was more serious, the level of stress was
higher and parents tended to report more emotional problems in their children. Death of parents or other family
members due to COVID-19 may also spur a great amount of grief among children that would need to be dealt with.
In addition, long-term school closures may further impact negatively the well-being of school-age children
(https://www.cdc.gov/coronavirus/2019-ncov/downloads/considerations-for-school-closure.pdf) as they lose
access to meal programs, academic support, physical and social activities, and reduced face-to-face engagement
with peers.
www.pvmarquez.com/mentalhealandthcovid-19 3/6
1/12/2021 Let’s not forget about Mental Health during COVID-19! | Patricio V. Marquez
It has also been suggested (https:/ /theconversation.com/the-long-term-biological-effects-of-covid-19-stress-on-
kids-future-health-and-development-140533) that stressors from the pandemic, such as reduced family income,
food insecurity, parental stress, and child abuse, can negatively impact children’s developing brains, immune
systems, and ability to thrive. While some effects will be immediate, many will surface decades from now
(https://theconversation.com/the-long-term-biological-effects-of-covid-19-stress-on-kids-future-health-and-
development-140533) in the form of mental, social, and physical health problems (e.g., higher risk of metabolic
syndrome
(https://journals.lww.com/psychosomaticmedicine/Abstract/2017/06000/Early_Life_Socioeconomic_Disadvantage
and physical health problems in adulthood (https:/ /srcd.onlinelibrary.wiley.com/doi/abs/10.1111/cdep.12021)). A
related study in China (https:/ /onlinelibrary.wiley.com/doi/full/10.1111/jsr.13142?referringSource=articleShare) has
highlighted the importance of the link between sleep, health, and family factors, even during a period in which
families are confronted with dramatic lifestyle changes and grappling with heightened health concerns related to
the pandemic. Disrupted and insuf cient sleep has been linked to immune system dysfunction (e.g., increase in
cytokines, such as interleukin), impeding resilience to infection in young children during the COVID‐19 pandemic.
Isolation and lack of interaction with other people are also negatively impacting the mental health of young adults
ages 18-24. Existing mental illness among adolescents may also be exacerbated by the pandemic, and with school
closures, they may have limited access to mental health services. Recent data from the CDC
(https://www.baynews9.com/ /tampa/news/2020/08/15/cdc--young-adults-disproportionately-affected-by-
mental-health-impacts-of-covid-19) illustrate this problem by showing that young adults in the United States are
among the groups disproportionately affected by the mental health impacts of the COVID-19 pandemic, struggling
with issues such as anxiety/depression (31%), trauma/stressor-related disorders (26%), starting or increasing
substance use (13%), and seriously considering suicide (11%). Preliminary results of a study carried out by Uribe and
team at the Ponti cia Universidad Javeriana (Personal communication with Miguel Uribe, June 2020) focusing on
mental health and resilience in young adults in Bogota, Colombia during the COVID -19 lockdown, also evidence the
high mental health toll that social distancing measures are having on young adults aged 18-24 years. While 59% of
males and 70% of females presented depressive symptoms, 47% of males and 56% of females had anxiety symptoms.
Substance use and addiction (https:/ /www.cdc.gov/ncbddd/fasd/features/teen-substance-use.html), in particular,
can have long-term impacts on young people, as they can affect brain development, occur more frequently with
other risky behaviors, such as unprotected sex and dangerous driving, and contribute to the development of adult
health problems, such as heart disease, high blood pressure, and sleep disorders.
The daily attachment to laptops, desktops, and the multi-functional smartphone, which have become “virtual
bridges” for interacting with the outside world during the pandemic, may pose additional risks, particularly to
children and adolescents (http:/ /www.pvmarquez.com/digital%20media_impacts). Hyper connectivity
(http://www3.weforum.org/docs/WEFUSA_DigitalMediaAndSociety_Report2016.pdf) has the potential to further
change patterns of social interaction, as online interaction may become a “new normal,” substituting for face-to-
face interaction--essential to the give-and-take functioning of families, communities, and workplaces. Digital
media consumption may also facilitate bullying, harassment, social defamation, and hate speech because potential
costs of such behavior are reduced and the ease of engaging in behaviors that harm others or ourselves is
increased. And, excessive digital media use can negatively in uence the development of cognitive (thinking,
imagining, reasoning, and remembering abilities) and behavioral (reactions or actions that we take in response to
stimuli present in our environment) skills and even mental and physical health.
Impact on Frontline Health Workers
In many countries, as COVID-19 cases surged, hospitals were overwhelmed, and work demands on frontline health
care workers increased signi cantly, particularly in facilities with lower physician-or nurse-to-patient densities. As
a result, they are at increased risk of burnout and suffer from mental health issues
www.pvmarquez.com/mentalhealandthcovid-19 4/6
1/12/2021 Let’s not forget about Mental Health during COVID-19! | Patricio V. Marquez
(https://blogs.worldbank.org/health/supporting-mental-health-and-resilience-frontline-covid-19-coronavirus-
health-care-workers), including depression and substance use.
Risk of Suicides
Suicide is a terminal outcome in the spectrum of mental health problems. Accumulated evidence from countries
around the world indicates that global crises, that lead to severe social and economic disruptions, similar to those
caused now by the COVID-19 pandemic, are associated with increases in suicide, particularly in males of working
age. This occurs (https://pubmed.ncbi.nlm.nih.gov/24903684/) as the result of the negative effects of
unemployment and job insecurity, as well as effects of nancial loss, bankruptcy, and home repossession on
individuals and households, which may lead directly or indirectly to mental health problems such as depression,
anxiety, and binge drinking and then to suicidal behavior.
A study (https:/ /jech.bmj.com/content/73/4/311#article-bottom)that estimated what the suicide rates would have
been during and one year after economic/ nancial crises of the 1970-2011 period in 21 Organization for Economic
Co-operation and Development (OECD) countries if the suicide rates had followed the pre-crisis trends, found that
all the crises led to excess suicides. Among males, the excess suicide rate (per 100 000 persons) varied from 1.1 to 9,
and among females, from 0 to 2.4. In terms of actual numbers, these crises caused more than 60,000 excess
suicides in OECD countries. Another study (https:/ /journals.sagepub.com/doi/pdf/10.1177/0020764019879946?
casa_token=4hQ4Y4FwCiMAAAAA 6w3FYw1j44NqzVbCOIlBGycQgkT_SysZxVSweojU7BSaNLhngL8vMn0pmCJbaVBugT
that after the Great Recession of 2008 in the United States, the number of suicides increased due to the negative
effect of the crisis on the mental health of individuals and the decrease in their future expectations. These ndings
are corroborated by studies done in Ireland (https:/ /pubmed.ncbi.nlm.nih.gov/26082406/), that showed that ve
years of economic recession and austerity had a signi cant negative impact on rates of suicide in men and on self-
harm in both sexes, and in Greece (https:/ /bmjopen.bmj.com/content/5/3/e007295), that found a clear increase in
suicides among persons of working age that resulted from the economic crisis of 2011-2013.
What to Do?
While a vaccine and new diagnostics and therapies are on the horizon, it seems that we are at the cusp of a
transition from a world that we knew well at the beginning of 2020 and that in many ways has now been shattered,
to a yet unknown “new normal”.
Should we despair, or use this time as a “window of opportunity” to re ect, learn from the fact that no country, not
even the richest one in the world, was prepared to deal with the onslaught of the fast-spreading novel coronavirus,
and perhaps start thinking on how to build better for the long term? Looking at the glass half full, we will discover
that not everything is lost. As human beings we have the capacity to assess reality, learn from past experiences and
accumulated knowledge, and chart a path forward.
The mental health toll of the COVID-19 pandemic is only beginning to show itself. Although we cannot predict the
scale of its impact, lessons from past crises can offer guidance on how to mitigate and address this challenge.
Moving forward, it is crucial that we ensure that along with health and economic emergency response programs,
social and psycho-social support interventions are included to provide required support to people in need, both
those already suffering from mental disorders pre-pandemic and those newly affected. This would require the
allocation of resources targeted to develop effective communication to the population and improve the quality and
quantity of mental health services integrated as part of primary health care and social support service delivery
platforms at the community level. It will be of critical importance that these platforms include mechanisms for
surveillance, reporting, and intervention
www.pvmarquez.com/mentalhealandthcovid-19 5/6
1/12/2021 Let’s not forget about Mental Health during COVID-19! | Patricio V. Marquez
(https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2764404), particularly to track and address
gender and domestic violence and child abuse during lockdowns, and that services delivered be organized following
stepped-care approaches (https:/ /jamanetwork.com/journals/jamapsychiatry/fullarticle/2656183)—the practice of
delivering the most effective, least resource-heavy treatment to people in need, and then stepping up to more
resource-heavy treatment based on patients’ needs. Levering information technology will facilitate the provision of
online mental health and peer-to-peer support services while helping overcome stigma barriers, particularly among
adolescents.
Monitoring and additional research (https://www.nytimes.com/2020/08/21/opinion/covid-depression-
boredom.html?referringSource=articleShare) are also needed to track and understand the long-term mental health
impacts of the COVID-19 pandemic, to guide action on the basis of evidence.
Finally, it is important to keep in mind that while some people may require medication and social support to deal
with fear, loneliness, or grief (https://www.nytimes.com/2020/04/09/opinion/sunday/coronavirus-depression-
anxiety.html?action=click&module=RelatedLinks&pgtype=Article), we need to avoid rushing to medicalize the
response to “normal unpleasant emotions” such as feeling bored and confusion during lockdowns. Although these
feelings may be intolerable sometimes, they “do not need medical treatment any more than everyday unhappiness
requires an antidepressant” (https:/ /www.nytimes.com/2020/08/21/opinion/covid-depression-boredom.html?
referringSource=articleShare).
Image Credit: Srdjanns74, Stock Photos
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/mentalhealandthcovid-19 6/6
1/12/2021 Taxes on tobacco, alcohol, and sugar-sweetened beverages reduce health risks and expand fiscal space for Universal Health Coverage post-COVID 19
Learn how the World Bank Group is helping countries with COVID-19 (coronavirus). Find Out
Publish d on Inv stin in H lth (/h lth)
T x s on tob cco, lcohol, nd su r-
sw t n d b v r s r duc h lth
risks nd xp nd fisc l sp c for
Univ rs l H lth Cov r post-COVID
19
PATRICIO V. MARQUEZ (/TEAM/PATRICIO-V-MARQUEZ) & SHEILA DUTTA (/TEAM/SHEILA-
DUTTA) | AUGUST 11, 2020
This page in: English
3
https://blogs.worldbank.org/health/taxes-tobacco-alcohol-and-sugar-sweetened-beverages-reduce-health-risks-and-expand-fiscal 1/8
1/12/2021 Taxes on tobacco, alcohol, and sugar-sweetened beverages reduce health risks and expand fiscal space for Universal Health Coverage post-COVID 19
“If we want to improve global health, we need to tax the things that are killing us.
Taxing things that are bad for your health, like tobacco, over things like savings
and income, is as close to a free lunch as you can get in economics. The economic
rationale for taxing these products is strong if we want to save lives and make a
better, healthier world.” (https://www.bloomberg.org/program/public-
health/who-global-ambassador/#task-force- scal-policy-health)
LARRY SUMMERS, former Secretary of the U.S. Treasury and Director of the
National Economic Council, and former World Bank Group Chief Economist
(2019)
Seven months after the rst cases of a new coronavirus (COVID-19) were reported in
China, the pandemic’s toll continues to increase, despite global containment and
mitigation e orts. People of any age with certain underlying medical conditions
(https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-
medical-conditions.html?
CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-
ncov%2Fneed-extra-precautions%2Fgroups-at-higher-risk.html), such as
cardiovascular diseases, cancer, obstructive pulmonary diseases, and obesity and
diabetes, are at increased risk for severe illness and death from COVID-19. Tobacco
use, alcohol abuse, and consumption of unhealthy foods (such as sugar sweetened
beverages) are three leading risk factors for the development of these chronic health
conditions.
Pre-existing global health disparities, magni ed during the pandemic, re ect deep-
rooted inequalities in income, wealth, and voice. To address these challenges,
countries need to maintain essential health services to address concurrent health
needs, and particularly the needs and service delivery gaps targeting the most
vulnerable populations. Urgent steps are required to prevent a secondary global
health crisis, with many countries already reporting life-threatening health service
disruptions. (https://twitter.com/intent/tweet?
text=Urgent+steps+are+required+to+prevent+a+secondary+global+health+crisis%2C+w
threatening+health+service+disruptions.&url=https://blogs.worldbank.org/health/taxes
tobacco-alcohol-and-sugar-sweetened-beverages-reduce-health-risks-and-expand-
scal/?cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) There are particular
gaps with respect to maternal, infant, and child health; prevention and treatment of
other infectious diseases such as TB, malaria, HIV/AIDS, and noncommunicable
diseases.
https://blogs.worldbank.org/health/taxes-tobacco-alcohol-and-sugar-sweetened-beverages-reduce-health-risks-and-expand-fiscal 2/8
1/12/2021 Taxes on tobacco, alcohol, and sugar-sweetened beverages reduce health risks and expand fiscal space for Universal Health Coverage post-COVID 19
Looking forward, as noted by the Dean of the Johns Hopkins Bloomberg School of
Public Health (https://magazine.jhsph.edu/2020/lets- x-things-good), "we must start
talking now about the need to invest for the long term," building upon the “brutal
lessons” from the COVID-19 pandemic. This observation brings to the fore once
again the imperative of universal health coverage (UHC).
Up to now, the UHC e ort has largely focused on ensuring that medical care is
accessible and a ordable. The time has come to give equal importance to
disease prevention, health promotion, and emergency preparedness as part of
an integrated framework for action to achieve UHC.
(https://twitter.com/intent/tweet?
text=%3Cstrong%3EThe+time+has+come+to+give+equal+importance+to+disease+prev
tobacco-alcohol-and-sugar-sweetened-beverages-reduce-health-risks-and-expand-
scal/?cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank)
Taxation on tobacco, alcohol, and sugar-sweetened beverages are e ective but
underused policies of disease prevention and health promotion
(https://www.bbhub.io/dotorg/sites/2/2019/04/Health-Taxes-to-Save-Lives.pdf), that
could also help mobilize additional government revenue to fund investments and
programs that bene t the entire population and enhance equity. Let’s explain the
win-win-win nature of this policy.
Raising taxes on tobacco, in particular, can do more to reduce premature mortality
than any other single health policy. The evidence
(https://documents.worldbank.org/en/publication/documents-
reports/documentdetail/491661505803109617/main-report) across a wide range of
countries shows that a 50% increase in cigarette price typically leads to a 20% decline
in cigarette consumption. Lowering consumption reduces tobacco-attributable
sickness and death: about half of this e ect comes from current smokers quitting
and the other by reducing smoking initiation among young people.
Taxing alcohol
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951962/pdf/2270.pdf) and sugar-
sweetened beverages
(https://www.worldbank.org/en/topic/nutrition/publication/obesity-health-and-
economic-consequences-of-an-impending-global-challenge) helps to reduce
consumption and prevent the onset of related chronic diseases such as
cardiovascular diseases, cirrhosis of the liver, obesity and diabetes. Moreover, taxing
to increase the price of alcohol products, along with strict enforcement of drink-drive
laws, can help reduce the high human and economic cost of road tra c injuries,
https://blogs.worldbank.org/health/taxes-tobacco-alcohol-and-sugar-sweetened-beverages-reduce-health-risks-and-expand-fiscal 3/8
1/12/2021 Taxes on tobacco, alcohol, and sugar-sweetened beverages reduce health risks and expand fiscal space for Universal Health Coverage post-COVID 19
fatalities (https://www.worldbank.org/en/programs/global-road-safety-
facility/publication/the-high-toll-of-tra c-injuries-unacceptable-and-preventable),
and domestic violence.
Emerging evidence (https://openknowledge.worldbank.org/handle/10986/34082)
reported by the World Bank consistently identi es net positive economic impacts
from sugar-sweetened beverages taxes, including overall employment and
productivity gains, and increased government spending.
To help realize the bene ts of pro-health tax policies, strengthened tax
administration, including control of illicit tobacco and alcohol trade, play a critical
function (https://documents.worldbank.org/en/publication/documents-
reports/documentdetail/677451548260528135/confronting-illicit-tobacco-trade-a-
global-review-of-country-experiences).
Even as they lower consumption and improve public health, tobacco, alcohol, and
sugar-sweetened beverage taxes can substantially boost government revenues.
(https://twitter.com/intent/tweet?
text=Even+as+they+lower+consumption+and+improve+public+health%2C+tobacco%2C
sweetened+beverage+taxes+can+substantially+boost+government+revenues.+&url=ht
tobacco-alcohol-and-sugar-sweetened-beverages-reduce-health-risks-and-expand-
scal/?cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) This is of critical
importance during COVID-19, as policymakers must maintain their public health
responses while also mobilizing domestic revenue for investment in future pandemic
preparedness and other essential health services. Adoption of policies that reduce
future health risks has been found to (https://blogs.imf.org/2020/07/10/ scal-
policies-for-a-transformed-world/) contribute to public trust, thereby helping
economic activity and reducing strains on public nances. Investing in stronger
health systems for all can also contribute to tackling rising poverty and inequality.
Projections presented in a World Bank Group report for the G-20 meeting in Osaka,
Japan in 2019 (https://openknowledge.worldbank.org/handle/10986/31930) showed
that the substantial UHC nancing gap in low- and lower-middle-income countries
(now exacerbated by COVID-19), can be attenuated by excise tax increases on
tobacco, alcohol, and sugar-sweetened beverages. These calculations showed that a
50% increase in prices for these products could generate additional revenues of
approximately $24.7 billion in 54 low- and middle-income countries by 2030.
https://blogs.worldbank.org/health/taxes-tobacco-alcohol-and-sugar-sweetened-beverages-reduce-health-risks-and-expand-fiscal 4/8
1/12/2021 Taxes on tobacco, alcohol, and sugar-sweetened beverages reduce health risks and expand fiscal space for Universal Health Coverage post-COVID 19
These health tax increases would have the additional advantage of reducing future
health care costs by curbing the growth of the non-communicable diseases that
tobacco, alcohol, and sugar-sweetened beverages can cause. Importantly, the
revenue raised can additionally bene t poorer households
(https://documents.worldbank.org/en/publication/documents-
reports/documentdetail/893811554737147697/is-tobacco-taxation-regressive-
evidence-on-public-health-domestic-resource-mobilization-and-equity-
improvements) when it is used progressively. Elimination of fossil fuel subsidies
(https://openknowledge.worldbank.org/handle/10986/31930), which impose large
scal costs while adding to negative environmental and health impacts, could also
help expand scal space for health.
Pro-health taxes are a potential tool to help alleviate the ongoing health crisis and
contribute to recovery. (https://twitter.com/intent/tweet?text=Pro-
health+taxes+are+a+potential+tool+to+help+alleviate+the+ongoing+health+crisis+and+
tobacco-alcohol-and-sugar-sweetened-beverages-reduce-health-risks-and-expand-
scal/?cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) As such, they should be
considered essential components of health and scal policy building support of
healthier and more resilient societies.
Authors
(/team/patricio-v-marquez) (/team/patricio-v-marquez)
P tricio V. M rqu (/t m/p tricio-v-m rqu )
x
https://blogs.worldbank.org/health/taxes-tobacco-alcohol-and-sugar-sweetened-beverages-reduce-health-risks-and-expand-fiscal 5/8
1/12/2021 While waiting for a COVID-19 vaccine, it’s time to focus on gaps in vaccine distribution, cold chain, and uptake | Patricio V. Marquez
While waiting for a COVID-19 vaccine, it’s time to
focus on gaps in vaccine distribution, cold chain,
and uptake
Submitted by Patricio V. Marquez on Sun, 07/26/2020 - 11 12 PM
While waiting for a COVID-19 vaccine, it’s time to
focus on gaps in vaccine distribution, cold chain,
and uptake
Posted by Patricio V. Marquez on Sun, 07/26/2020 - 11 12 PM
Patricio V. Marquez, Betty Hanan, and Sheila Dutta
As the world waits anxiously for a COVID-19 vaccine to become available, countries have a “window
of opportunity” to focus on existing gaps in vaccine distribution and cold chain systems and
vaccination demand and uptake constraints. If these gaps are addressed in a timely way, it will
facilitate widespread administration, not only of a new COVID-19 vaccine, but will also help revamp
the delivery of routine vaccines, particularly those for children, that are part of the Expanded
Program on Immunization (EPI). The latter task is of critical importance since over the past 4-6
months, national immunization programs around the world have been disrupted due to the severe
health system constraints and physical distancing measures in place to mitigate the ongoing
www.pvmarquez.com/vaccinationsystems 1/8
1/12/2021 While waiting for a COVID-19 vaccine, it’s time to focus on gaps in vaccine distribution, cold chain, and uptake | Patricio V. Marquez
COVID-19 pandemic (Abbas, Procter, van Zandvoort, Clark, Funk, Mengistu, Hogan, Dansereau, Jit,
Flasche, LSHTM CMMID COVID-19 Working Group 2020
(https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30308-9/fulltext)).
The importance of vaccines and vaccination
The development of vaccines is a long, risky, and costly endeavor. On average, it takes 10.7 years to
develop a new vaccine, and there is only a 6% success rate for vaccine research—from start to nish
(Kuchler (https:/ /www.ft.com/hannah-kuchler), H. (https:/ /www.ft.com/content/1467b1da-28a5-
47d4-a5e2-a6f4b68484c3)Financial Times. Big Read. Medical Science, 2020
(https://www.ft.com/content/1467b1da-28a5-47d4-a5e2-a6f4b68484c3)). Indeed, determining that
a vaccine is safe and effective takes time.
The drive and race for a COVID-19 vaccine has picked up with the recent announcement of
promising results of ongoing trials conducted in different countries (Jackson, Anderson, Rouphael,
Roberts, Makhene, et al. 2020 (https:/ /www.nejm.org/doi/10.1056/NEJMoa2022483); F
(https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31604-4/fulltext)olegatti,
(https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31604-4/fulltext#)
(https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31604-4/fulltext)Ewer,
(https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31604-4/fulltext#)Aley,
(https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31604-4/fulltext#)Angus,
(https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31604-4/fulltext#)Becker,
(https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31604-4/fulltext#)Belij-
Rammerstorfer, et al. (https:/ /www.thelancet.com/journals/lancet/article/PIIS0140-
6736(20)31604-4/fulltext#) 2020 (https:/ /www.thelancet.com/journals/lancet/article/PIIS0140-
6736(20)31604-4/fulltext); Zhu, (https:/ /www.thelancet.com/journals/lancet/article/PIIS0140-
6736(20)31605-6/fulltext)Guan, (https:/ /www.thelancet.com/journals/lancet/article/PIIS0140-
6736(20)31605-6/fulltext#)Li, (https:/ /www.thelancet.com/journals/lancet/article/PIIS0140-
6736(20)31605-6/fulltext#)Huang, (https:/ /www.thelancet.com/journals/lancet/article/PIIS0140-
6736(20)31605-6/fulltext#)Jiang, (https:/ /www.thelancet.com/journals/lancet/article/PIIS0140-
6736(20)31605-6/fulltext#)Hou, et al.
(https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31605-
6/fulltext#) 2020). While there is hope that a COVID-19 vaccine will be available in 12 to 18 months
or earlier if the trials are successful, a lot of uncertainty still clouds that optimistic scenario.
While vaccines are important, as experts have observed, what matters is vaccination; that is, the
administration of a vaccine to people to help their immune systems develop protection from a
disease. Immunization programs often serve as the entry point for primary health care in many
countries, often providing the only access to mothers and young children on a regular basis (CDC,
2020 (https://www.cdc.gov/globalhealth/immunization/default.htm)). Vaccination not only
protects those immunized but can reduce the risk of disease among those not immunized in a
community through the development of “herd immunity.” The impact of vaccines in reducing
www.pvmarquez.com/vaccinationsystems 2/8
1/12/2021 While waiting for a COVID-19 vaccine, it’s time to focus on gaps in vaccine distribution, cold chain, and uptake | Patricio V. Marquez
vaccine-preventable disease morbidity and mortality is enormous: for example, in low-income
countries, 23.3 million deaths are estimated to have been averted over 2011-2020 (CDC, 2020
(https://www.cdc.gov/globalhealth/infographics/immunization/global_impact_of_vaccines.htm)).
COVID-19 is disrupting life-saving immunization services in both rich and poor countries, putting
millions of children at risk from vaccine-preventable diseases like diphtheria, measles, and polio.
According to UNICEF, this situation is due in large measure to a massive backlog in vaccine
shipments due to unprecedented logistical constraints related to COVID-19 mitigation measures
including lockdowns in some countries (UNICEF, 2020 (https:/ /www.unicef.org/press-
releases/geneva-palais-brie ng-note-impact-covid-19-mitigation-measures-vaccine-supply-
and)). It is estimated that vaccination saves between 2 to 3 million lives a year (CDC, 2020
(https:/ /www.cdc.gov/globalhealth/infographics/immunization/global_impact_of_vaccines.htm)).
Considerations for Strengthening/Reinstating Immunization Services
While the global effort nowadays is centered on containing the spread of the coronavirus and the
resulting disease (COVID-19) and mitigating its social and economic impact, it is of critical
importance to also maintain essential health service delivery to address other health needs of the
population and prevent excess morbidity and mortality in a society (Marquez, Wang, and Ndebele
2020 (http://pvmarquez.com/essentialhealthservices)).
Guidelines put forward by WHO can help adopt a balanced response at national, regional, and local
levels (WHO, June 2020 (https:/ /www.who.int/publications/i/item/covid-19-operational-
guidance-for-maintaining-essential-health-services-during-an-outbreak)). WHO advises that,
where immunization services are constrained or suspended, countries should reinstate their
immunization services, once local transmission of the COVID-19 virus has declined (WHO, March
2020 (https://www.who.int/publications/i/item/guiding-principles-for-immunization-activities-
during-the-covid-19-pandemic-interim-guidance)). WHO also notes that if resources for “catch-up”
immunization campaigns are limited, priority should be given to outbreak-prone diseases such as
measles, polio, diphtheria, and yellow fever.
Vaccine Logistics, Cold Chain, Tracking, and Communication
Building and sustaining safe and effective immunization programs are essential components of
health delivery systems. Successful programs are built on functional, end-to-end supply chain and
logistics systems. The role of the supply chain is to ensure effective vaccine storage, handling, and
stock management; rigorous temperature control in the cold chain; and maintenance of adequate
logistics management information systems. The ultimate goal is to ensure the uninterrupted
availability of quality vaccines from manufacturer to service-delivery levels, so that opportunities to
vaccinate are not missed because vaccines are unavailable (WHO, accessed on July 26, 2020
(https://www.who.int/immunization/documents/IIP2015_Module2.pdf)).
www.pvmarquez.com/vaccinationsystems 3/8
1/12/2021 While waiting for a COVID-19 vaccine, it’s time to focus on gaps in vaccine distribution, cold chain, and uptake | Patricio V. Marquez
The maintenance of cold chain is essential for vaccine effectiveness (WHO, accessed on July 26,
2020 (https://www.who.int/immunization/documents/IIP2015_Module2.pdf)). A cold chain is a
temperature-controlled supply chain from the point of manufacture to the point of use. It involves
an uninterrupted series of refrigerated production, storage, and distribution activities, along with
associated equipment and logistics, including uninterrupted access to electrical or solar energy, to
maintain the vaccines within a low-temperature range to ensure their potency.
Maintaining the cold chain requires that vaccines and diluents be consistently transported and
stored between 2-8◦C at all stages, including in primary/central/intermediate vaccine stores and
health facilities and also during outreach immunization sessions (WHO, accessed on July 26, 2020
(https://www.who.int/immunization/documents/IIP2015_Module2.pdf)). In addition to
temperature sensitivity, some vaccines (e.g., BCG and measles) also are sensitive to light. Any loss of
potency due to heat or light is cumulative, permanent, and irreversible, meaning that the vaccine is
rendered ineffective.
Tracking and monitoring vaccine coverage is also critical, as data and information inform decision-
making and outreach priorities. To this end, well-established arrangements need to be in place to
record and report every vaccine dose administered, adverse effects, and assess the population
served.
Cold Chain Challenges and Solutions
Some cold chain challenges that merit immediate review and attention include insuf cient and sub-
optimal cold chain capacity that hampers availability of safe vaccines; limited freezing and storage
capacity; inadequate temperature monitoring and maintenance systems; and costs.
As assessed in different countries, often cold chain systems are unable to ensure availability of safe
and potent vaccines (Ashok
(https://www.sciencedirect.com/science/article/pii/S0264410X16307307?via%3Dihub#!),
(https://www.sciencedirect.com/science/article/pii/S0264410X16307307?via%3Dihub)Brison
(https://www.sciencedirect.com/science/article/pii/S0264410X16307307?via%3Dihub#!), and
(https://www.sciencedirect.com/science/article/pii/S0264410X16307307?via%3Dihub)LeTallec
(https://www.sciencedirect.com/science/article/pii/S0264410X16307307?via%3Dihub#!), 2017
(https://www.sciencedirect.com/science/article/pii/S0264410X16307307?via%3Dihub)). To
address key performance gaps, the authors recommend the following actions: (i) development of an
accurate picture of cold chain capacity gaps based on current and future needs (including in-
country piloting of new equipment and a full understanding of equipment trade-offs); (ii)
improvement of planning and programming (particularly to ensure that vaccination covers hard-to-
reach populations); (iii) mobilization of resources to adequately fund programs; and (iv) effectively
monitoring the cold chain during implementation. In addition, to control temperature variations
www.pvmarquez.com/vaccinationsystems 4/8
1/12/2021 While waiting for a COVID-19 vaccine, it’s time to focus on gaps in vaccine distribution, cold chain, and uptake | Patricio V. Marquez
and equipment failures, the introduction of temperature monitoring and control devices and
practices is recommended, in addition to strengthening human resources for equipment repair and
the availability of spare parts.
Well-trained vaccinators at vaccination sites are also critical for the delivery of this intervention.
Hence, strengthening health workers’ knowledge, skills, and practices is of upmost importance for
the effective administration of vaccines. Human resources are the backbone of any system and the
key enabler for all other functions to perform effectively. It is no different with vaccination
programs, and more so in the current environment in which there is a need to have ready capacity
to manage the introduction and administration of a potential new COVID-19 vaccine, while at the
same time revamping the delivery of existing EPI vaccines.
Ensuring demand and uptake of vaccines, as well as their affordability
It should be clear that the ready availability of vaccines will not automatically generate their
demand and uptake in all population groups. This reality re ects a lack of trust in government
action and in some cases is the result of misinformation campaigns that are not backed by scienti c
evidence. So, serious community outreach and engagement to provide transparent information
about the importance of vaccines needs to be mounted to protect people, particularly the most
vulnerable. The communications effort, however, needs to address knowledge, attitudes, and beliefs
about vaccination particular to the social and cultural characteristics of different societies.
Another option for increasing vaccine uptake is to require it. As observed in a recent article (Mello,
Silverman, and Omer, 2020 (https:/ /www.nejm.org/doi/full/10.1056/NEJMp2020926)), mandatory
vaccination has proven effective in ensuring high childhood immunization rates in many high-
income countries. However, except for in uenza vaccination of health care workers, mandates have
not been widely used for adults. The operationalization of a vaccination mandate, for example for
some high-risk groups such as health workers, the elderly, and those with preexisting conditions,
would require that (i) the supply of the vaccine is suf cient to cover the population groups for
which a mandate is being considered; (ii) available evidence about the safety and ef cacy of the
vaccine has been transparently communicated; and (iii) established infrastructure to provide access
to vaccination without nancial or logistic barriers, compensation to those who suffer adverse
effects from a required vaccine, and real-time surveillance of vaccine side effects.
It is also important that countries implement effective communication strategies to allay concerns
and re-establish the demand for vaccinations within communities.The need to build public trust
requires that state of cials implement vaccination policy through transparent and inclusive
processes, involving local health of cers, health professional and hospital associations,
representatives of high-risk population groups, and groups concerned about vaccine safety. As was
observed during the Ebola response in West Africa in 2014-2015, building trust by engaging citizens
and community leaders is critical to the success of delivering health services (UNDP, UN Agencies,
World Bank Group, European Union, and African Development Bank, in consultation with the
www.pvmarquez.com/vaccinationsystems 5/8
1/12/2021 While waiting for a COVID-19 vaccine, it’s time to focus on gaps in vaccine distribution, cold chain, and uptake | Patricio V. Marquez
African Union and (https://www.undp.org/content/undp/en/home/librarypage/crisis-
prevention-and-recovery/recovering-from-the-ebola-crisis---full-report.html)Economic
Community of West African States and Mano River Union
(https://www.undp.org/content/undp/en/home/librarypage/crisis-prevention-and-
recovery/recovering-from-the-ebola-crisis---full-report.html), 2015
(https://www.undp.org/content/undp/en/home/librarypage/crisis-prevention-and-
recovery/recovering-from-the-ebola-crisis---full-report.html)).
Finally, equitable access to and utilization of vaccines is of paramount importance, particularly for
ensuring that all countries, including the poorest, have equal access to a new COVID-19
vaccine once they become available. A key question that needs to be clari ed across the world,
therefore, is how to make the new COVID-19 vaccines available free of charge or affordable to large
segments of the world population that lack or have limited access to essential public health services
and related nancial protection arrangements, such as social health insurance coverage.
This issue merits careful consideration and assessment of options given the negative impact of the
pandemic on countries’ macroeconomic situation, which might cascade down to health
systems. Indeed, World Bank Group's
(https://openknowledge.worldbank.org/handle/10986/33748)baseline forecast envisions a
5.2% contraction in global GDP in 2020—the deepest global recession in eight decades, despite
unprecedented policy support. Per capita incomes in the vast majority of emerging market and
developing economies (EMDEs) are expected to shrink in 2020, tipping many millions back into
poverty. Under the baseline scenario, World Bank Group estimates show that COVID-19 will push
more than 70 million people into extreme poverty, measured at the international poverty line of
$1.90 per day (Gerszon Mahler, Lakner, Castaneda Aguilar, Wu 2020
(https://blogs.worldbank.org/opendata/updated-estimates-impact-covid-19-global-poverty)).
Tighter scal space and shrinking revenue for employment-based insurance schemes may enlarge
the nancial gap for investing in the health system.
One option that should be considered for expanding the tax base and mobilizing additional scal
resources for health, while helping reduce associated health risks, is the adoption of higher tax
rates for tobacco and alcohol products, introducing or hiking taxes on sugary drinks, and phasing
out fuel subsidies. There is signi cant accumulated experience in different countries of the world
on the use of pro-health taxes, particularly to reduce tobacco use, and evidence on the positive
health, scal, and equity gains that are generated by this policy measure.
Looking forward
While the world is going through a “perfect storm” caused by the coronavirus, we should not
despair. We have evidence that proper application and population acceptance of basic public
health measures, such as testing, isolation of those infected, contact tracing, quarantines for those
people suspected of having being exposed to the virus, use of a cloth face covering
www.pvmarquez.com/vaccinationsystems 6/8
1/12/2021 While waiting for a COVID-19 vaccine, it’s time to focus on gaps in vaccine distribution, cold chain, and uptake | Patricio V. Marquez
(https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-
coverings.html) in public spaces, hand hygiene, and social distancing provisions, help prevent the
spread of the coronavirus.
Also, recent developments in treatments, such as antivirals (Remdesivir), glucocorticoids
(dexamethasone), and antibodies (blood injections from patients who have recovered from COVID-
19), are showing that they can help improve outcomes for COVID-19 patients
(Beigel,Tomashek, Dodd, Mehta, Zingman, et al. 2020
(https://www.nejm.org/doi/full/10.1056/NEJMoa2007764?
query=recirc_curatedRelated_article); The RECOVERY Collaborative Group 2020
(https://www.nejm.org/doi/full/10.1056/NEJMoa2021436?
query=recirc_mostViewed_railB_article); Casadevall and Pirofski 2020
(https://www.jci.org/articles/view/138003)).
Even if a COVID-19 vaccine is only 60% or 70% effective, it could have a signi cant impact in
reducing the contagiousness of the virus. Similarly, revamping and expanding the coverage of
essential health services will help address the larger health needs to the population, and reduce the
risk of the onset of other vaccine-preventable infectious diseases.
History is full of examples that suggest that the prevention, containment, mitigation, and
eventual suppression of COVID-19 is possible if political commitment, the alignment of
resources, and determined scienti c, technological and operational efforts converge around a
common objective. Indeed, as told by Dr. William Foege in “House on Fire”
(https://www.goodreads.com/book/show/9772046-house-on- re), his memoire about the ght to
eradicate smallpox in the 1960s and 1970s, well-structured and supported programs such as the one
for smallpox eradication illustrates that “humanity does not have to live in a world of plagues,
disastrous governments, con ict, and uncontrolled health risks” because “the coordinated action of
a group of dedicated people can plan for and bring about a better future.”
Source: Top Image by Katja Fuhlert (https://pixabay.com/users/kfuhlert-977338/?
utm_source=link-
attribution&utm_medium=referral&utm_campaign=image&utm_content=1215279) from Pixabay
(https://pixabay.com/?utm_source=link-
attribution&utm_medium=referral&utm_campaign=image&utm_content=1215279)
www.pvmarquez.com/vaccinationsystems 7/8
1/12/2021 While waiting for a COVID-19 vaccine, it’s time to focus on gaps in vaccine distribution, cold chain, and uptake | Patricio V. Marquez
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/vaccinationsystems 8/8
1/12/2021 Improving Health Services: A Global Imperative Amidst COVID-19 | Patricio V. Marquez
Improving Health Services: A Global
Imperative Amidst COVID-19
Submitted by Patricio V. Marquez on Mon, 06/22/2020 - 06 54 PM
Improving Health Services: A Global
Imperative Amidst COVID-19
Posted by Patricio V. Marquez on Mon, 06/22/2020 - 06 54 PM
Patricio V. Marquez and Lani Rice Marquez
"If you can't describe what you are doing as a process, you don't know what
you're doing”
W. Edwards Deming, 1900-1993
www.pvmarquez.com/qualityimprovement 1/5
1/12/2021 Improving Health Services: A Global Imperative Amidst COVID-19 | Patricio V. Marquez
Although “back to normal” in all spheres of life is still a distant aspiration
worldwide after six months of relentless coronavirus (COVID-19) onslaught,
restoring routine health services is a task that cannot wait. The diversion of
health care resources to contain and mitigate the COVID-19 pandemic,
coupled with a fear of health facilities among the population amid
lockdowns, has disrupted the delivery and utilization of services in different
parts of the world.
In the absence of a vaccine or effective treatment, the immediate priority is
to halt the spread of the deadly coronavirus through public health action,
including: testing and contact tracing to stop cases from becoming clusters
and outbreaks; isolation of infected people from people who are not sick;
quarantine to separate and restrict the movement of people believed to have
been exposed to the coronavirus to monitor if they become sick; and social
distancing measures and wearing face masks in public spaces for the general
population. The restoration and strengthening of health system capacity,
however, are equally essential tasks that should be planned and
implemented to ensure that critically ill patients receive appropriate care
and to reduce the overall impact of the pandemic. A false dichotomy
between COVID-19 emergency response and health system strengthening
priorities needs to be avoided.
The question that merits consideration, then, is how can quality
improvement be at the core of restoring health services? Does
improvement happen only by increasing providers’ knowledge and use of
new tools, technologies, and medicines to prevent disease and diagnose and
treat patients? Or is improvement a process that requires sustained effort
and participation of all actors involved in the delivery of services?
To answer these questions, a new open-access book "Improving Health
Care in Low-and Middle-Income Countries
(https://www.springer.com/us/book/9783030431112)" offers an
www.pvmarquez.com/qualityimprovement 2/5
1/12/2021 Improving Health Services: A Global Imperative Amidst COVID-19 | Patricio V. Marquez
interesting perspective rooted in the work of W. Edwards Deming, who
proposed in the 1950s that eliminating delays, duplications, and errors
would result in higher quality products and services at lower unit costs.
Deming’s ideas were initially embraced and applied with good results in
Japan to manufacture automobiles, electronic appliances, and other
consumer goods, and were later adapted by Don Berwick and others in the
United States and other countries in the 1990s for improving health care.
“Improvement”, therefore, as suggested by the book authors, should be
understood as “a directed effort to take what we know can improve health –
proven, high-impact interventions like active management of the third stage
of labor or keeping newborns warm – and ensure that those are implemented
reliably, in different contexts, every time, for every patient who needs them.”
The country case studies from Africa, Eastern Europe, South Asia, and Latin
America and the Caribbean presented in the book illustrate how a persistent
effort to identify gaps in care, propose changes to address those gaps, and
test the effectiveness of the changes can measurably improve health
processes and outcomes.
Overall, one can infer from the book that there is no “best way” to improve
health care. Rather, it is clear that engagement of health workers is the
critical element for improving care at different levels of the health system—
community, health center, district hospital, and referral hospital and for a
wide variety of health conditions--prevention of mother-to-child
transmission of HIV, tuberculosis-HIV co-infection, nutrition and health
promotion for pregnant women and children under two, maternal mortality,
and antimicrobial resistance due to overuse of antibiotics.
Indeed, key to success in all country case studies is a dedicated focus of
improvement teams on reaching explicit standards, identifying gaps in
meeting standards and taking action to address the gaps, including
brainstorming and thinking through new ways of improving adherence to
www.pvmarquez.com/qualityimprovement 3/5
1/12/2021 Improving Health Services: A Global Imperative Amidst COVID-19 | Patricio V. Marquez
standards. Some approaches introduced rewards for meeting standards, but
similar improvements in care were achieved by simply informing health
workers of gaps in care without explicit rewards for quality.
Measurement is a critical part of testing and implementing changes. The
development of data analysis skills among health workers, therefore, is
critical for the quality improvement process, particularly looking at changes
in data in a simple or intuitive way to allow improvement teams to easily
understand what worked—and what didn't.
Building in mechanisms to share learning across teams as they tested
different approaches improved the impact of quality improvement efforts in
many cases, as effective ways for improving care were shared among teams
and scaled up to more sites.
Teams were able to achieve better improvement results with strong support
structures around them, including management support, to help them
address system-level problems that are beyond the reach of individual
teams. Many of the cases also emphasize the value of coaching support to
help teams to translate standards into practice and for intervening in the
particular care area.
A pilot approach can be useful to demonstrate results on a small scale
before scaling up to multiple sites. Results at pilot sites can help create
buy-in and political support for the improvement at the political and
administrative level of the health system, which in turn can strengthen the
efforts at the service delivery level.
Benchmarking or comparing performance between facilities and districts,
while providing facility-speci c feedback, can stimulate efforts of teams
to modify practices. Indeed, health workers can be motivated by evidence
www.pvmarquez.com/qualityimprovement 4/5
1/12/2021 Improving Health Services: A Global Imperative Amidst COVID-19 | Patricio V. Marquez
of how their practices deviate from the established practices or from the
mean performance of other facilities in the same region.
It should be clear, however, that the medium- and long-term sustainability
of quality improvement efforts and their achievements will depend on their
institutionalization through policies, organizational and institutional
arrangements, performance management processes, and adequate and
predictable funding allocations. This will support the establishment of a
“quality improvement culture” that is ingrained at all levels of the health
system. The engagement of frontline teams, following clearly de ned
standards of work for the delivery of safe, effective, and ef cient health
care, that is monitored and adjusted as a team responsibility, would be key
to sustain performance and contribute to improving the health conditions of
the population. If this is done, it would help rebuild trust and con dence in
health services after the COVID-19 crisis has ended.
Picture: Picture of Quality Improvement (QI) Teams in Uganda, URC.
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/qualityimprovement 5/5
1/12/2021 Sustaining Essential Health Services during the Covid-19 Pandemic: A Social Imperative | Patricio V. Marquez
Sustaining Essential Health Services during the Covid-19
Pandemic: A Social Imperative
Submitted by Patricio V. Marquez on Mon, 06/15/2020 - 08 44 PM
Sustaining Essential Health Services during the Covid-19
Pandemic: A Social Imperative
Posted by Patricio V. Marquez on Mon, 06/15/2020 - 08 44 PM
Patricio V. Marquez, Huihui Wang, Lydia Ndebele
Background
The COVID-19 pandemic is currently affecting 188 countries and territories across all regions. In all but a handful
of countries, COVID-19 exploited weaknesses across health system platforms, pointing out strong need for resilient
health systems. Under-resourced surveillance platforms were unable to promptly detect community spread until
viral circulation was already widespread. Insuf cient stockpiling, contingency planning, and coordination across
regional, national, and international public health platforms led to shortages of essential supplies and equipment,
sparking bidding wars and leaving health workers without appropriate protective gear. Hospital platforms were
overwhelmed and stressed beyond capacity, with fragmentation hampering the ef cient ow of patients, staff, and
equipment.
For countries that had weaker health systems and less resources, the impact can be both signi cant and long-
lasting. COVID-19 may affect countries’ journey to Universal Health Coverage and the Sustainable Development
Goal 3 through several pathways:
1. Increased morbidity and mortality directly attributed to COVID-19
As of June 16, 2020, there have been close to 8 million con rmed cases of COVID-19 and more than 434,000
deaths (JHU&M 2020). Since testing capacity lags in most countries, the number of new cases is likely to be
underestimated. Similarly, mortality data should also be interpreted with caution, as many countries show
signi cant underreporting of COVID-19- related deaths (Table 1). Differences in data collection, as well as delays
in death registrations, contribute to the problem.
www.pvmarquez.com/essentialhealthservices 1/8
1/12/2021 Sustaining Essential Health Services during the Covid-19 Pandemic: A Social Imperative | Patricio V. Marquez
Unexplained deaths provide a proxy for underreporting. They are estimated as the difference between
observed deaths and the projected number of deaths based on historical and seasonal trends. The difference may
be attributed to COVID-19 or to other factors, such as a shortage or lack of essential medical services for other
conditions. While it is not possible to know the true death toll of COVID-19, it is clear that in some countries
daily deaths have reached rates 50% or higher than the historical average for periods of time.
Table 1. COVID-19 underreported deaths
Source: For all cases, except Mexico, The New York Times “74000 missing deaths: tracking the true toll of the coronavirus outbreak.” Updated May 19. For México City Nexos:
“¿Qué nos dicen las actas de defunción de la CDMX?”, May 25, 2020.
Based on currently available information and clinical expertise, older adults and people of any age who have
serious underlying medical conditions might be at higher risk for severe illness from COVID-19 (CDC 2020),
particularly those with weakened immune systems. People with chronic lung disease or moderate to severe
asthma, serious heart conditions, who are immunocompromised (many conditions can cause a person to be
immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune
de ciencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening
medications), severe obesity (body mass index [BMI] of 40 or higher), diabetes, chronic kidney disease
undergoing dialysis, and liver disease. Conditions such as ischemic heart disease, stroke, lower respiratory
infections, chronic obstructive pulmonary disease (COPD), HIV/AIDS, tuberculosis, are already among the ten
leading causes of premature death in the world, accounting for more than 1 million deaths each in 2017 (IHME
2018).
As the rst country to be impacted, China’s reported data provides insights into the biology, epidemiology,
and clinical characteristics of COVID-19 (Guan, Ni, Hu, Liang, et al 2020). A higher prevalence of smoking
among men, often resulting in compromised lung function, may help explain their higher COVID-19 fatality rate.
Tobacco use also contributes to the onset of co-occurring conditions such as cardiovascular diseases, lung
cancer, COPD, and diabetes, which are more prevalent among males, and which also increase the risk of disease
severity and death among COVID-19 patients. Data from Italy also shows that a high proportion of COVID-19
patients had a history of smoking and high rates of COPD and heart disease (Boccia, Ricciardi, Ioannidis 2020).
The Middle East and North Africa (MENA) region is also facing an increased pressure on health systems from
COVID-19 (coronavirus), with over 200,000 con rmed cases and almost 10,000 deaths reported, on top of a high
and growing burden of non-communicable diseases (NCDs) (Duran and Menon 2020).
Sub-Saharan African countries can be potentially hit hard with a large number of people are at higher risk of
infection due to preconditions: about 26 million live with HIV
(https://www.unaids.org/sites/default/ les/media_asset/UNAIDS_FactSheet_en.pdf) and 2.5 million fall ill
from tuberculosis (https://www.afro.who.int/health-topics/tuberculosis-tb) annually, while South Africa and
Namibia have high mortality rates from NCDs (Marquez and Farrington 2013). As experienced by some high-
income countries, people in low- and middle-income countries (especially the poor) may refrain themselves
seeking care or getting tested due to nancial barriers, which in turn will worsen the pandemic.
Simultaneous epidemics are overwhelming public health systems in different countries that had few
resources to begin with. In some countries, the threat of dengue fever is being taken as seriously as COVID-19.
For example, in Central America, Honduras has seen a steep climb in COVID-19 cases in the midst of a dengue
www.pvmarquez.com/essentialhealthservices 2/8
1/12/2021 Sustaining Essential Health Services during the Covid-19 Pandemic: A Social Imperative | Patricio V. Marquez
fever outbreak. San Pedro Sula, the business capital where gang violence makes Honduras one of the deadliest
countries in the world, is also now the epicenter of a COVID-19 outbreak (Gannon 2020). In Singapore dengue
infections may for 2020 exceed the all-time high of 22,170 set in 2013 (Goodman 2020), while in the state of Mato
Grosso do Sul in Brazil, health authorities are dealing with additional dengue fever cases, bringing the total this
year so far to 61,604 con rmed cases. (Newsdesk 2020). In Pakistan, the country’s toll of above 139,000
coronavirus cases surpasses that of neighboring China with 84,000 con rmed cases, and more than 2,600 people
in Pakistan have already died. At the same time, Pakistan continues to suffer some of the world’s worst outbreaks
of infectious diseases, with 4.3 million cases of malaria annually, and is also one of the top 10 countries for new
cases of tuberculosis each year, and is one of only three countries, including Afghanistan and Nigeria, where
polio is still endemic (Gannon 2020). Meanwhile, in the Democratic Republic of Congo (DRC), a new outbreak of
Ebola in Equateur Province is now compounding the public health challenge posed by COVID-19 pandemic, with
more than 4,000 con rmed cases reported (Schlein, 2020).
2. Increased morbidity and mortality due to interruption of essential
service delivery associated with COVID-19 containment measures
During the 2014-2015 Ebola epidemic in West Africa, it was observed an upsurge in mortality and morbidity
from other diseases and conditions (Bietsch, K, Williamson, J, and Reeves M. 2020; Camara BS et al. 2017; Hall KS
et al. 2020; Sochas, L, Channon, AA, and Nam, S. 2017), and this is happening again during the COVID-19
pandemic. Shortage of health workers is exacerbated as many of them are diverted to managing COVID-19 cases,
or hampered by lack of protective gears, or advised to discontinue service delivery. Local or national lockdowns,
along with the consequences of physical distancing, travel restrictions, disruptions on the supply chain for
contraceptive commodities, and the fear of health facilities among pregnant women, may risk undermining or
reversing the progress made in the past decade to improve the access to and quality of sexual and reproductive
health services and reduce unwanted teenage pregnancy and maternal mortality. Consequently, women and
children are affected disproportionately, especially those living in fragile contexts. For example:
Increased unmet need for modern contraceptive: Initial estimates show that a 10% proportional decline in use
of short- and long-acting reversible contraceptive methods in LMICs due to reduced access would result in an
additional 49 million women with an unmet need for modern contraceptives and an additional 15 million
unintended pregnancies over the course of a year ((Riley, Sully, Ahmed, and Biddlecom 2020).
Additional maternal and newborn deaths: An additional 1.7 million women who give birth and 2.6 million
newborns would experience major complications but would not receive the care they need, resulting in an
additional 28,000 maternal deaths and 168,000 newborn deaths (Riley, Sully, Ahmed, and Biddlecom 2020).
Wide-spread interruption of immunization program: A recent report by WHO (2020) indicates that since March
2020, routine childhood immunization services have been disrupted on a global scale that may be unprecedented
since the inception of expanded programs on immunization (EPI) in the 1970s. More than half (53%) of the 129
countries where data were available reported moderate-to-severe disruptions, or a total suspension of
vaccination services during March-April 2020. Many countries have temporarily suspended preventive mass
vaccination campaigns against diseases like cholera, measles, meningitis, polio, tetanus, typhoid and yellow fever,
due to risk of transmission and the need to maintain physical distancing during the early stages of the COVID-19
pandemic. Measles initiatives, for example, have been suspended in 27 countries, including Chad and Ethiopia,
and polio programs are on hold in 38, including Pakistan and the Democratic Republic of Congo (Hoffman
2020). The problem of slipping vaccine rates is not limited to developing countries. The Centers for Disease
Control and Prevention (CDC) reported drop in visits and fewer vaccine doses being administered in the United
States, leaving children at risk for vaccine-preventable diseases (Santoli, Lindley, DeSilva, et al 2020).
Transport delays of vaccines are exacerbating the situation. UNICEF has reported a substantial delay in planned
vaccine deliveries due to the lockdown measures and the ensuing decline in commercial ights and limited
availability of charters (UNICEF 2020). This particularly affects countries in FCV areas where immunization
delivery relies heavily on community outreach and campaign programs most of which are put on hold due to
social distancing requirements. As a result, at least 80 million children under one at risk of diseases such as
diphtheria, measles and polio as COVID-19 disrupts routine vaccination efforts (WHO 2020, 1).
www.pvmarquez.com/essentialhealthservices 3/8
1/12/2021 Sustaining Essential Health Services during the Covid-19 Pandemic: A Social Imperative | Patricio V. Marquez
In addition to physical health, mental health for all and especially the displaced also needs to be prioritized.
COVID-19 Exposed by the coronavirus crisis, everyone is affected mentally through losses such as the death of
loved ones, illness, diminished life’s savings, or in being con ned, having to forgo life’s signi cant occasions,
transitions, plans, or experiences. For displaced communities – for example refugees or asylum seekers – the
mental health fallout will be signi cantly more acute, while their access to health care reduces (Marquez 2017). In
Afghanistan, for example, which is in the midst of a displacement and refugee crisis (more than 400,000 IDPs;
505 000 refugees returning from Iran), one can anticipate a rapid exacerbation of these challenges (Pierre-Louise
2020). To restore economic activity in the aftermath of the pandemic, besides nancial and physical well-being
efforts are needed to address mental health of individuals and communities.
3. Uncertain nancing prospects for health system accompanied by
growing demand to look after the poor
While countries are mobilizing all potential resources for health system to ght against the pandemic, the
negative impact on countries’ macroeconomic situation might cascade down to health system. Indeed, World
Bank estimates indicate that as many as 90% of the 183 economies are expected to suffer from falling levels of
GDP in 2020. Tighter scal space and shrinking revenue for employment-based insurance schemes may enlarge
the nancial gap for investing in health. Furthermore, the World Bank estimates that under a baseline scenario
with global growth contracting by about 5% in 2020, and downside scenario with a global growth contraction of
8% in 2020, COVID-19 will push 71 million into extreme poverty, measured at the international poverty line of
$1.90 per day (Gerszon Mahler, Lakner, Castaneda Aguilar, Wu 2020). With the downside scenario, this increases
to 100 million people.
These scenarios pose signi cant nancing challenges for ensuring population access to essential services. If
not well managed, countries may be pushed to a situation in which the relative importance of out-of-pocket
payments may rise, a mechanism deemed most inequitable and least ef cient, and that poses a high risk of
impoverishment to the population. Even before the pandemic, the incidence of catastrophic health expenditure
(SDG indicator 3.8.2), de ned as large out-of-pocket spending in relation to household consumption or income,
increased continuously between 2000 and 2015 (WHO/WBG 2020). In 2015, 926.6 million people incurred out-
of-pocket health spending exceeding 10% of their household budget (total consumption or income), and 208.7
million incurred out of pocket health spending that even exceeded 25% of the household budget (WHO/WBG
2019). These people lived mostly in Asia (70%–76%), about 45% in lower-income countries and 41%–43% in
upper-middle-income countries. Asia, and Latin America and the Caribbean had the highest percentage of their
2015 population with catastrophic health spending as tracked by SDG indicator 3.8.2, while North America and
Oceania had the lowest.
In 2015, out-of-pocket health spending contributed to pushing more people below the poverty line: 89.7 million
people (1.2%) were pushed into extreme poverty (below $1.90 per person per day in 2011 purchasing power parity
terms), while 98.8 million (1.4%) were pushed below $3.20 per person per day and 183.2 million were pushed into
poverty de ned in relative terms (below 60% of median daily per capita consumption or income in their country)
(WHO/WBG 2019).
4. What to Do?
As the COVID-19 continues to evolve, it is imperative that countries adopt measures to balance the demands of
responding directly to COVID-19, while simultaneously engaging in strategic planning and coordinated action to
maintain the delivery of routine essential health services, mitigating the risk of system collapse (WHO 2020,2).
Travel restrictions and lockdowns, people putting off seeking needed health care for any number of conditions from
fear of becoming infected with COVID-19 in a health facility, disruptions in the global supply chain of essential
personal protective equipment, medicines and medical materials, demand solutions beyond the usual way of
operating to be able to continue caring for patients affected by concurrent conditions.
www.pvmarquez.com/essentialhealthservices 4/8
1/12/2021 Sustaining Essential Health Services during the Covid-19 Pandemic: A Social Imperative | Patricio V. Marquez
To ensure continuity of routine essential health services to meet all the health needs of the population, innovative
approaches have been launched in different countries. Some of them are presented below.
Use of family medicine and integrated networks at all three levels of care, as done in Costa Rica (Macaya 2020),
as well as in Cuba and in the Kerala State in India, where the whole organization of the health care system is
geared to be in close touch with the population, identify health problems as they emerge, and deal with them
immediately along a care continuum (Augustin 2020; Shailaja, K.K., Teacher, and Khobragade, RN, 2020). In these
countries, the primary health care system acts as the entry point to the integrated health system, facilitating
early identi cation and timely referral of cases to higher levels of care for appropriate management.
Improving the equity of health nancing and service delivery. Available data from the United States show the
estimated average cost for possible procedures that might occur for COVID-19 treatment and the signi cant
disparity between people with health insurance and those who lack insurance or have limited access to publicly-
funded health services. For people with health insurance who have met the required deductible, they would need
to pay only the co-pay or co-insurance, while the insurance plan would pay the remaining balance. In the case of
people without insurance, they would have to pay 100% of the price of COVID-19-related medical costs, which
could set a patient and his/her family back nancially (Abrams 2020). While health systems, nancial protection
arrangements, and medical cost structures vary from country to country, it should be clear that in countries
without universal health coverage, the nancial impact of COVID-19 on the population, particularly low-income
groups, could be signi cant or even catastrophic if adequate provisions are not taken to offer nancing
protection to the population. In the MENA region, for example, to mitigating the direct and indirect impacts of
COVID-19, particularly for the most vulnerable populations, the elimination of user fees and copayments has
been proposed for all health services (Duran and Menon 2020).
Drone delivery is changing the face of global logistics. The experience in Rwanda’s health system is
noteworthy. Beginning in 2017, Rwanda, in partnership with California-based robotics company Zipline
International Inc., became the rst country in the world to incorporate drone technology into its health care
system for delivering blood and medical supplies to hospitals across its Southern and Western provinces
(Marquez 2019). Establishment of drone delivery systems for transporting samples from remote areas to test
centers during the COVID-19 pandemic has also been initiated in Ghana, alongside the distribution of drugs and
blood products (Nsiah Asare 2020).
Increasing the availability of telemedicine for ambulatory services. This use of this technology helps to provide
online infection prevention and control trainings for care home workers, running health promotion campaigns
on social media, to managing WhatsApp groups of traditional healers (MSF 2020). Telemedicine can play a
critical role in ensuring that patients continue to receive non-urgent care, particularly those with chronic
conditions.
Engagement of community health workers and mobile health teams. To minimize the negative impact of the
reduction of recommended number of antenatal consultations for pregnant women in clinics, the engagement of
trusted people in their communities is critical to ensure that women can still receive the care they
need. Community personnel can help identify when a woman needs to go to hospital because of complications
(MSF 2020), or help organize service delivery by mobile teams, particularly to cover hard to reach rural areas.
Distribution of essential drugs to patients for longer periods (one to six months depending on the person’s
health condition) so that they do not have to visit a health facility as often for follow up care for HIV,
tuberculosis, hepatitis C and non-communicable diseases. At the same time, measures adopted to ensure that
patients receive follow-up through phone consultations, messaging apps and peer support networks (MSF 2020).
Use of smartphones for ‘video observed therapy’, for example for patients with multidrug-resistant tuberculosis
(MDR-TB), so they can lm themselves taking their medication and send the video to be checked by a nurse (MSF
2020).
Use of telephone hotlines for the provision of consultations by counselors and psychologists for patients with
mental disorders. This approach also helps to reduce the fear of stigma and discrimination that hinders service
demand and utilization (MSF 2020).
www.pvmarquez.com/essentialhealthservices 5/8
1/12/2021 Sustaining Essential Health Services during the Covid-19 Pandemic: A Social Imperative | Patricio V. Marquez
Planning efforts are needed to ramp up vaccinations for every missed child when the pandemic Covid-19 ends,
and to make advance provisions to ensure that when the COVID-19 vaccine is available, it reaches those most in
need.
Looking into the future, the global spread of COVID-19 clearly signals the need, hopefully once and for all, for
building and maintaining strong and sustainable public health and medical institutions and systems in
countries. This needs to be complemented by effective cross sectoral interface between environment,
veterinary and public health services to anticipate, prevent, and control the emergence of new infectious
pathogens of animal origin, the resurgence of known infectious diseases, and the ominous threat of anti-
microbial resistance. This task is of priority importance where health systems are weaker, living conditions often
more overcrowded, and populations most vulnerable.
Sources
Abrams, A. 2020. “Total Cost of Her COVID-19 Treatment: $34,927.43.” Time, Ma…
(https://time.com/5806312/coronavirus-treatment-cost/)
Augustin. E. 2020. “Cuba sets example with successful programme to contain cor…
(https://www.theguardian.com/world/2020/jun/07/cuba-coronavirus-success-contact-tracing-isolation)
Bietsch, K, Williamson, J, and Reeves M. 2020. “Family planning during and aft…
(https://pubmed.ncbi.nlm.nih.gov/32180246/)
Boccia S, Ricciardi W, Ioannidis JPA. 2020. “What Other Countries Can Learn Fro…
(https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2764369)
Camara BS et al. 2017. “Effect of the 2014/2015 Ebola outbreak on reproductive …
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5914332/)
CDC. 2020. “Groups at Higher Risk for Severe Illness.” (internet site). (https://www.cdc.gov/coronavirus/2019-
ncov/need-extra-precautions/groups-at-higher-risk.html)
Duran, D, and Menon, R. 2020. “COVID-19 (coronavirus): Ensuring continuity of …
(https://blogs.worldbank.org/health/covid-19-coronavirus-ensuring-continuity-health-services-middle-east-and-
north-africa)
Gannon, K. 2020. “COVID-19 just the latest epidemic in areas struck by diseas…
(https://apnews.com/1466c5ba97314f54cb32c8942e0a621b)
Gerszon Mahler, D, Lakner, C, Castaneda Aguilar, AR, Wu, H. 2020. “Updated esti…
(https://blogs.worldbank.org/opendata/updated-estimates-impact-covid-19-global-poverty)
Goodman, W. 2020. “Singapore Dengue Cases May Hit Record, Straits Times report…
(https://www.bloomberg.com/news/articles/2020-06-13/singapore-dengue-cases-may-hit-record-straits-times-
reports)
Guan, W, Ni, Z, Hu, Y, Liang, W, et al. 2020. “Clinical Characteristics of C…
(https://www.nejm.org/doi/full/10.1056/NEJMoa2002032?query=recirc_mostViewed_railB_article)
Hall KS et al. 2020. “Centring sexual and reproductive health and justice in th…
(http://dx.doi.org/10.1016/S01406736(20)30801-1.)
Hoffman, J. 2020. “Polio and Measles Could Surge After Disruption of Vaccine P…
(https://www.nytimes.com/2020/05/22/health/coronavirus-polio-measles-immunizations.html?
smtyp=cur&smid=tw-nythealth)
IHME. 2018. “Global trends in causes of death”. (http:/ /www.healthdata.org/infographic/gbd-2017-study-
highlights-causes-death)
International Monetary Fund. 2020. “World Economic Outlook, April 2020 World E…
(https://www.imf.org/en/Publications/WEO/Issues/2020/04/14/weo-april-2020)
Johns Hopkins University & Medicine. 2020. Coronavirus Resource Center. (in…
(https://coronavirus.jhu.edu/map.html)
Macaya, R. 2020. “Costa Rica’s experience in responding to COVID-19.” Present…
(https://worldbankgroup.webex.com/worldbankgroup/lsr.php?RCID=750dc08c6cf6507f107912ed2d73d999)
Marquez, PV, and Farrington, J. 2013. “The challenge of non-communicable disea…
(http://documents.worldbank.org/curated/en/844381468209068874/The-challenge-of-non-communicable-
diseases-and-road-traf c-injuries-in-Sub-Saharan-Africa-an-overview)
www.pvmarquez.com/essentialhealthservices 6/8
1/12/2021 Sustaining Essential Health Services during the Covid-19 Pandemic: A Social Imperative | Patricio V. Marquez
Marquez, PV. 2017. “Mental health among displaced people and refugees : making …
(http://documents.worldbank.org/curated/en/916131486730755271/Mental-health-among-displaced-people-and-
refugees-making-the-case-for-action-at-the-World-Bank-Group)
Marquez, PV, 2019. “Drones and blood safety can save lives.” World Bank Group…
(https://blogs.worldbank.org/health/drones-and-blood-safety-can-save-lives)
Médecins Sans Frontiers (MSF). 2020. “Continuing essential medical services dur… (https:/ /www.msf.org/essential-
medical-services-during-covid-19-pandemic)
Newsdesk. 2020. “Brazil: Mato Grosso do Sul sees worst dengue epidemic since 2…
(http://outbreaknewstoday.com/brazil-mato-grosso-do-sul-sees-worst-dengue-epidemic-since-2014/)
Nsiah Asare, A. 2020. “Ghana’s experience in responding to COVID-19.” Present…
(https://worldbankgroup.webex.com/worldbankgroup/lsr.php?RCID=750dc08c6cf6507f107912ed2d73d999)
Parker, E. 2020. “A rise in deaths from preventable diseases must not be part …
(https://www.theguardian.com/global-development/2020/apr/27/a-rise-in-deaths-from-preventable-diseases-
must-not-be-part-of-covid-19s-legacy)
Peeples, L. 2020. “In Poor Nations, a New Disease Stalls Efforts to Fight Old …
(https://undark.org/2020/04/14/covid-19-poor-nations-immunization-polio-measles/)
Pierre-Louise, M. 2020. “Policy Note on Health Impacts of COVID-19 in Fragile,… (https:/ /www.worldbank.org/)
Riley T, Sully E, Ahmed Z, Biddlecom A. 2020. “Estimates of the Potential Impac…
(https://pubmed.ncbi.nlm.nih.gov/32343244/)
Santoli JM, Lindley MC, DeSilva MB, et al. “Effects of the COVID-19 Pandemic on…
(http://dx.doi.org/10.15585/mmwr.mm6919e2)
Ross, J. 2020. “How Many People Die Each Day?” (internet publication using IHM…
(https://www.visualcapitalist.com/how-many-people-die-each-day/)
Schlein, L. 2020. “WHO Expects to Quickly Tackle DR Congo’s New Ebola Outbrea…
(https://www.voanews.com/africa/who-expects-quickly-tackle-dr-congos-new-ebola-outbreak)
Sochas, L, Channon, AA, and Nam, S. 2017. “Counting indirect crisis related de…
(http://dx.doi.org/10.1093/heapol/czx108.)
United Nations, Department of Economic and Social Affairs, Population Division…
(https://www.un.org/en/development/desa/population/publications/pdf/mortality/WMR2019/WorldMortality2019
UNICEF. 2020 (1). “Over 13 million children did not receive any vaccines at al… (https://www.unicef.org/press-
releases/over-13-million-children-did-not-receive-any-vaccines-all-even-covid-19-disrupted)
UNICEF. 2020 (2). “Geneva Palais brie ng note on the impact of COVID-19 mitig… (https:/ /www.unicef.org/press-
releases/geneva-palais-brie ng-note-impact-covid-19-mitigation-measures-vaccine-supply-and)
Washington Post. 2020. “Beijing Shuts Some Markets; London Stores to Open: Viru…
(https://www.washingtonpost.com/business/on-small-business/beijing-shuts-some-markets-london-stores-to-
open-virus-update/2020/06/12/35812aba-acf8-11ea-a43b-be9f6494a87d_story.html)
WHO. 2020 (1). “Global Immunization News (GIN).” March-April 2020.
(https://www.who.int/immunization/GIN_March-April_2020.pdf?ua=1)
WHO. 2020 (2). “Coronavirus disease (COVID-19) technical guidance: Maintaining …
(https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/maintainingessential-
health-services-and-systems))
WHO/WBG. 2020. “Global Monitoring Report on Financial Protection in Health 2019…
(https://www.who.int/healthinfo/universal_health_coverage/report/2019/en/)
World Bank, 2020. “Protecting People and Economies: Integrated Policy Responses…
(https://openknowledge.worldbank.org/handle/10986/33770)
Shailaja, K.K., Teacher, Minister of Health, Social Justice and Women and Child…
(https://worldbankgroup.webex.com/worldbankgroup/lsr.php?RCID=750dc08c6cf6507f107912ed2d73d999)
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/essentialhealthservices 7/8
1/12/2021 Have South and Central America become the new coronavirus (COVID-19) epicenter?
Learn how the World Bank Group is helping countries with COVID-19 (coronavirus). Find Out
Publish d on Inv stin in H lth (/h lth)
H v South nd C ntr l Am ric
b com th n w coron virus (COVID-19)
pic nt r?
PATRICIO V. MARQUEZ (/TEAM/PATRICIO-V-MARQUEZ), SANTIAGO HERRERA AGUILERA (/TEAM/SANTIAGO-
HERRERA-AGUILERA) & LUIGI BUTRON CALDERON (/TEAM/LUIGI-BUTRON-CALDERON) | JUNE 03, 2020
This page in: English
6
“There have been as many plagues as wars in history; yet always plagues and wars take people
equally by surprise.” - Albert Camus (1957 Nobel Prize Laureate for Literature), La Peste, Vintage, 1947
https://blogs.worldbank.org/health/have-south-and-central-america-become-new-coronavirus-covid-19-epicenter 1/11
1/12/2021 Have South and Central America become the new coronavirus (COVID-19) epicenter?
The coronavirus (COVID-19) pandemic has hit the entire world with devastating
e ects, both through lives lost (more than 370,000 deaths
(https://coronavirus.jhu.edu/)) and a severe economic downturn
(https://www.imf.org/en/Publications/WEO/Issues/2020/04/14/weo-april-2020).
Although the aggregate number of new cases has stabilized somewhat (Figure 1), the
tide has fallen in some places and risen in others, shifting the pandemic’s epicenter
from region to region. The latest data suggest that some South and Central
American countries have become the new COVID-19 epicenter
(https://twitter.com/intent/tweet?
text=The+latest+data+suggest+that+some+South+and+Central+American+countries+ha
19+epicenter&url=https://blogs.worldbank.org/health/have-south-and-central-
america-become-new-coronavirus-covid-19-epicenter/?
cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) , with daily infections in the
region now exceeding those in the United States and Europe
(https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200602-
covid-19-sitrep-134.pdf?sfvrsn=cc95e5d5_2) (Figure 2).
Figure 1. Daily confirmed new cases worldwide Figure 2. Daily confirmed new cases by region
(Number of cases) (Percent of total cases)
Note: Data as of May 25. Source: Prepared by authors using Our World in
Data.
The situation in the region
More than 70 days into the pandemic, new cases keep rising sharply in some
countries in South and Central America (Figure 3). There are now more than 1 million
COVID-19 cases here, half of them in Brazil (https://www.who.int/docs/default-
source/coronaviruse/situation-reports/20200602-covid-19-sitrep-134.pdf?
sfvrsn=cc95e5d5_2), which has surpassed Russia, the United Kingdom, and Spain to
https://blogs.worldbank.org/health/have-south-and-central-america-become-new-coronavirus-covid-19-epicenter 2/11
1/12/2021 Have South and Central America become the new coronavirus (COVID-19) epicenter?
reach the second highest number of cases in the world. More than 50,000 people
have died across the region. Countries that adopted late or lax social distancing,
such as Brazil and Mexico, are now seeing higher rates of infection. Other countries
that had stabilized the growth of new cases and relaxed their lockdowns, such as
Chile and Peru, have seen surges of new cases. Costa Rica and Uruguay are outliers,
as their cases seem to have leveled o .
Figure 3. Daily confirmed new cases (7-day moving average): South and Central American
countries
Note: Data as of May 25. Source: Prepared by authors using Our World in Data.
Since testing capacity lags behind other regions, the number of new cases is likely to
be underestimated. Similarly, mortality data should also be interpreted with caution,
as many countries show signi cant underreporting of COVID-19- related deaths
(Table 1).
Unexplained deaths provide a proxy for underreporting. They are estimated as the
di erence between observed deaths and the projected number of deaths based on
historical and seasonal trends. The di erence may be attributed to COVID-19 or to
other factors, such as a shortage or lack of essential medical services for other
conditions. In Ecuador, Chile, and Mexico, the unexplained deaths are 4 to 5 times
the reported deaths. In Brazil and Peru, the factor is somewhat smaller, around 2
times.
Table 1. COVID-19 underreported deaths
https://blogs.worldbank.org/health/have-south-and-central-america-become-new-coronavirus-covid-19- 3/11
epicenter
1/12/2021 Have South and Central America become the new coronavirus (COVID-19) epicenter?
What explains Latin America’s vulnerability?
Experts (https://www.cnn.com/2020/05/30/americas/latin-america-covid-19-
epicenter-intl/index.html) suggest that poverty and the region’s high levels of
inequality (https://blogs.worldbank.org/developmenttalk/inequality-and-social-
unrest-latin-america-tocqueville-paradox-revisited) have contributed to the relative
ine ectiveness of lockdowns. The average Gini coe cient, which measures the
distribution of income or consumption expenditure within a country, was estimated
at 0.51 in 2017 – the highest level of inequality in the world (Figure 4). In particular,
the region has many informal workers (about 140 million people, or 55% of total
workers), who must continue to work every day to earn a living, for example in
marketplaces, cleaning houses, or as street vendors. These workers are unlikely to
have much savings or to receive support from social protection programs at a level
that would allow them to feed their families while adhering to social distancing
measures.
The vulnerability of people in large metropolises such as Sao Paulo and Mexico City is further
increased by poor living conditions. Millions are crowded in densely packed neighborhoods, with
large families often sharing a single room and many lacking access to clean water, basic
sanitation, and health services. Some households are forced to shop for food every day in
crowded markets because they do not have a refrigerator or lack electricity, putting them at
higher risk of becoming infected.
https://blogs.worldbank.org/health/have-south-and-central-america-become-new-coronavirus-covid-19-epicenter 4/11
1/12/2021 Have South and Central America become the new coronavirus (COVID-19) epicenter?
Figure 4. Income inequality in selected Latin American countries, 2000-2017:
Gini coe cients
Meanwhile, the ongoing economic downturn caused by COVID-19 is taking a severe
toll on the ability of migrant workers to send money home. In South and Central
American countries, the decline in remittance ows
(https://www.worldbank.org/en/news/press-release/2020/04/22/world-bank-
predicts-sharpest-decline-of-remittances-in-recent-history) has been estimated at
20%. Remittances are a vital source of income in some countries such as Ecuador
and El Salvador, as they help the poorest communities a ord food, health care, and
basic needs.
https://blogs.worldbank.org/health/have-south-and-central-america-become-new-coronavirus-covid-19-epicenter 5/11
1/12/2021 Have South and Central America become the new coronavirus (COVID-19) epicenter?
The situation has been further aggravated by high debt burdens and signi cant
budget de cits, which have reduced investment in public health systems and
undermined their capacity to care for the sick.
What is the World Bank doing?
The World Bank is supporting COVID-19 health-relatd emergency responses in 19
Latin American and Caribbean countries. To date, 15 new COVID-19 health
operations are underway in 13 countries, amounting to $965 million. In addition,
resources allocated to existing World Bank projects are being redeployed, including
through restructuring ($176 million) and activating emergency provisions ($18.5
million).
Given the severity of the pandemic, the World Bank Group is committed to providing
$160 billion (https://www.worldbank.org/en/about/what-we-do/brief/world-bank-
group-operational-response-covid-19-coronavirus-projects-list) over 15 months to
help countries across the globe address the health, economic, and social impacts of
COVID-19. Emergency operations now reach 100 countries with emergency
containment and mitigation activities. Health operations also support governments
in strengthening their longer-term health system capacity to prevent the
reemergence of COVID-19 and other pathogens of animal origin, and to provide
essential services for other conditions.
What lessons are emerging?
In the landmark book “This Time is Di erent. Eight Centuries of Financial Folly”
(https://wc a.harvard.edu/publications/time-di erent-eight-centuries- nancial-folly),
Carmen Reinhart, the World Bank Group’s newly appointed chief economist
(https://www.worldbank.org/en/news/press-release/2020/05/20/carmen-reinhart-
appointed-as-world-bank-group-chief-economist), and her co-author, Kenneth
Rogo , noted that “long spans of history catch sight of ‘rare’ events that are all too
often forgotten, although they turn out to be far more common and similar that
people seem to think.”
This observation is apt in the context of COVID-19, which illustrates a collective failure to prepare
adequately for outbreaks of infectious diseases. As we saw in West Africa with Ebola, with the
Zika virus in Brazil and other countries, with SARS in East Asia and Canada, and with avian
influenza globally, novel viruses can spread quickly across borders and wreak havoc on
unsuspecting populations, countries, and regions. The challenge is continuing to grow with the
increased movement of goods, services, and people across the world.
https://blogs.worldbank.org/health/have-south-and-central-america-become-new-coronavirus-covid-19-epicenter 6/11
1/12/2021 Have South and Central America become the new coronavirus (COVID-19) epicenter?
Learning from what did or didn’t work well in past health crises will help countries in
rapidly detecting and responding to future infectious disease outbreaks.
(https://twitter.com/intent/tweet?
text=Learning+from+what+did+or+didn%E2%80%99t+work+well+in+past+health+crises
south-and-central-america-become-new-coronavirus-covid-19-epicenter/?
cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) Rebuilding better and
sustaining essential health services for all is a global public good and should be a
priority. Indeed, the COVID-19 pandemic should serve as a catalyst for institutional
reform and for improving nancing to boost the capacity and performance of health
systems. (https://twitter.com/intent/tweet?text=the+COVID-
19+pandemic+should+serve+as+a+catalyst+for+institutional+reform+and+for+improvin
south-and-central-america-become-new-coronavirus-covid-19-epicenter/?
cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank)
Now, more than ever, countries need to collaborate across sectors to reduce social
and economic vulnerabilities. We must address not just the symptoms of ill health,
but the root causes of disease and premature mortality.
(https://twitter.com/intent/tweet?
text=We+must+address+not+just+the+symptoms+of+ill+health%2C+but+the+root+cau
south-and-central-america-become-new-coronavirus-covid-19-epicenter/?
cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank)
HEALTH (/SEARCH?F[0]=TOPIC:297&F[1]=LANGUAGE:EN), BRAZIL (/SEARCH?F[0]=COUNTRIES:60&F[1]=LANGUAGE:EN),
LATIN AMERICA & CARIBBEAN (/SEARCH?F[0]=REGIONS:277&F[1]=LANGUAGE:EN), COVID-19 (CORONAVIRUS) (/SEARCH?
F[0]=SERIES:881&F[1]=LANGUAGE:EN)
Authors
(/team/patricio-v-marquez) (/team/patricio-v-marquez)
P tricio V. M rqu (/t m/p tricio-v-m rqu )
https://blogs.worldbank.org/health/have-south-and-central-america-become-new-coronavirus-covid-19-epicenter 7/11
1/12/2021 Tobacco use and coronavirus (COVID-19): A deadly but preventable association
Learn how the World Bank Group is helping countries with COVID-19 (coronavirus). Find Out
Publish d on Voic s (/voic s)
Tob cco us nd coron virus (COVID-
19): A d dl but pr v nt bl
ssoci tion
PATRICIO V. MARQUEZ (/TEAM/PATRICIO-V-MARQUEZ) | MAY 27, 2020
This page in: English
Initial evidence suggests smoking is also a risk factor for COVID-19, with smokers having 1.91 times the odds of progression
in COVID-19 severity compared to non-smokers. Photo: © ilkercelik/shutterstock
https://blogs.worldbank.org/voices/tobacco-use-and-coronavirus-covid-19-deadly-preventable-association
1/7
1/12/2021 Tobacco use and coronavirus (COVID-19): A deadly but preventable association
As we mark World No Tobacco Day on May 31, let’s consider the impact of tobacco
use on coronavirus (COVID-19) outcomes. (https://twitter.com/intent/tweet?
text=As+we+mark+World+No+Tobacco+Day+on+May+31%2C+let%E2%80%99s+conside
19%29+outcomes.&url=https://blogs.worldbank.org/voices/tobacco-use-and-
coronavirus-covid-19-deadly-preventable-association/?
cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) The virus has infected more
than 5.5 million people in 188 countries and territories
(https://coronavirus.jhu.edu/map.html), killing more than 350,000.
Tobacco use is causally linked (https://www.surgeongeneral.gov/library/reports/50-
years-of-progress/full-report.pdf) to diseases of nearly all organs of the body. Studies
(https://www.nejm.org/doi/full/10.1056/NEJMra1308383) in various countries have
found that middle-aged smokers have two to three times the mortality rate of non-
smokers of similar age, reducing lifespan by an average of 10 years. Smoking and e-
cigarette use increase the risk and severity of pulmonary infections because of
damage to upper airways, lung in ammation, and reduced lung and immune
function. (https://twitter.com/intent/tweet?text=Smoking+and+e-
cigarette+use+increase+the+risk+and+severity+of+pulmonary+infections+because+of+
use-and-coronavirus-covid-19-deadly-preventable-association/?
cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank)
It shouldn’t surprise us, then, that initial evidence
(https://academic.oup.com/ntr/advance-article/doi/10.1093/ntr/ntaa082/5835834)
suggests smoking is also a risk factor for COVID-19, with smokers having 1.91 times
the odds of progression in COVID-19 severity compared to non-smokers.
(https://twitter.com/intent/tweet?text=smoking+is+also+a+risk+factor+for+COVID-
19%2C+with+smokers+having+1.91+times+the+odds+of+progression+in+COVID-
19+severity+compared+to+non-
smokers.&url=https://blogs.worldbank.org/voices/tobacco-use-and-coronavirus-
covid-19-deadly-preventable-association/?
https://blogs.worldbank.org/voices/tobacco-use-and-coronavirus-covid-19-deadly-preventable-association 2/7
1/12/2021 Tobacco use and coronavirus (COVID-19): A deadly but preventable association
id=10.1371/journal.pone.0233147) showing that infection was associated with
substantially higher severity and mortality rates in patients with chronic obstructive
pulmonary disease (COPD) and among current smokers.
M n r t hi h r risk of COVID-19 pro r ssion
Data from China, the rst country to be a ected, provides insights into the biology,
epidemiology, and clinical characteristics of COVID-19. The sex distribution of
a ected patients shows a male predominance of cases. Chinese researchers
reported (https://www.nejm.org/doi/full/10.1056/NEJMoa2002032?
query=recirc_mostViewed_railB_article) in the New England Journal of Medicine that
58.1% of patients across 30 provinces were male. Also, among the initial 425 cases
that occurred in Wuhan, 56% were male. Moreover, an article
(https://jamanetwork.com/journals/jama/fullarticle/2762510) published at the
Journal of the American Medical Association noted that death rates among infected
men, particularly in their late 40s and older, have exceeded those among women.
In previous outbreaks of coronaviruses, such as SARS and MERS, men were also
disproportionally a ected. In Hong Kong in 2003, researchers found
(https://jamanetwork.com/journals/jama/fullarticle/2762510) that men with SARS
had a 50 percent higher risk of death than women.
Wh t xpl ins this discr p nc ?
https://blogs.worldbank.org/voices/tobacco-use-and-coronavirus-covid-19-deadly-preventable-association 3/7
1/12/2021 Tobacco use and coronavirus (COVID-19): A deadly but preventable association
A higher prevalence of smoking among men, often resulting in compromised lung
function, may help explain
(https://jamanetwork.com/journals/jama/fullarticle/2762510) their higher COVID-19
fatality rate.
Tobacco use also contributes to the onset of co-occurring conditions such as
cardiovascular diseases, lung cancer, COPD, and diabetes. These are more prevalent
among males and also increase the risk of disease severity and death among COVID-
19 patients. (https://www.cdc.gov/coronavirus/2019-ncov/need-extra-
precautions/people-at-higher-risk.html)
Data presented in the New England Journal of Medicine article further illustrates the
impact that smoking has on COVID-19 progression and mortality in China:
Among those severely a ected by the disease, 16.9% were current smokers and
5.2% former smokers.
Among patients who were admitted to an intensive care unit, put on ventilation,
or died, 25.8% were current smokers and 7.6% were former smokers.
Data from Italy
(https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2764369)
similarly shows that a high proportion of COVID-19 patients had a history of smoking
and high rates of COPD and heart disease. Researchers in Indonesia
(https://www.channelnewsasia.com/news/asia/covid-19-fatality-rate-highest-asia-
indonesia-12669500) have also found that the high prevalence of smoking among
men (one of the world’s highest) is contributing to the high COVID-19 fatality rate in
the country.
Th pid mic of tob cco us in Chin
China has the largest smoking population in the world, with around 316 million adult
smokers representing nearly one-third of smokers and 40% of tobacco consumption
globally. While the prevalence of smoking in women is relatively low at 1.9%, an
estimated 48.4% (https://data.worldbank.org/indicator/SH.PRV.SMOK.MA?
view=chart) of men are smokers.
In 2010, an estimated 1.2 million premature deaths were attributable to smoking in
China, and the three leading causes of death (stroke, heart disease, and COPD) were
linked to tobacco use. A recent study
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6546632/pdf/tlcr-08-S1-S21.pdf)
https://blogs.worldbank.org/voices/tobacco-use-and-coronavirus-covid-19-deadly-preventable-association 4/7
1/12/2021 Tobacco use and coronavirus (COVID-19): A deadly but preventable association
also nds China in the midst of a lung cancer epidemic on an unprecedented scale,
driven largely by tobacco use and accounting for 21.7% of the country’s total cancer
mortality in 2015.
How do s smokin ff ct lun h lth nd COVID-19 risk?
As explained in the 2004 U.S. Surgeon General Report
(https://www.ncbi.nlm.nih.gov/books/NBK44695/):
“Toxins in tobacco smoke harm the body from the moment they enter through the
mouth and nose. They damage tissue and cells all the way to the lungs. When
cigarette smoke is inhaled, chemicals from the smoke are absorbed in the lungs. As a
result, smoking causes lung diseases… makes chronic lung diseases more severe;
and increases the risk for respiratory infections…. Although the lung has ways to
protect itself from injury by inhaled agents, these defenses are overwhelmed when
cigarette smoke is inhaled repeatedly over time. After years of exposure to cigarette
smoke, lung tissue becomes scarred, loses its elasticity, and can no longer exchange air
e ciently.”
There is su cient evidence to infer a causal relationship between smoking and
acute respiratory illnesses, including pneumonia.
(https://twitter.com/intent/tweet?
text=There+is+su cient+evidence+to+infer+a+causal+relationship+between+smoking
+ use-and-coronavirus-covid-19-deadly-preventable-association/?
cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) Not only is smoking the
predominant underlying cause, but it might increase the frequency or severity of
infections. For example, a recent study
(https://journals.lww.com/epidem/Abstract/2019/05000/Smoking_and_In uenza_associ
showed that smoking was consistently associated with a higher risk of hospital
admission for in uenza. Researchers
(https://www.atsjournals.org/doi/10.1164/rccm.202003-0693LE) have also suggested
that it could cause an increase in the ACE2 protein in the lungs, the molecule that the
coronavirus uses to infect human cells, facilitating viral dissemination and possibly
resulting in a higher rate of morbidity in COVID-19 patients.
Wh t to do?
Besides monitoring smoking and e-cigarette use, governments have an obligation to
address smoking in their strategies to contain and mitigate the impact of COVID-19.
https://blogs.worldbank.org/voices/tobacco-use-and-coronavirus-covid-19-deadly-preventable-association 5/7
1/12/2021 Tobacco use and coronavirus (COVID-19): A deadly but preventable association
19.&url=https://blogs.worldbank.org/voices/tobacco-use-and-coronavirus-covid-19-
deadly-preventable-association/?
cid=SHR_BlogSiteTweetable_EN_EXT&via=worldbank) The most cost-e ective policy
measure (http://documents.worldbank.org/curated/en/491661505803109617/Main-
report) for tobacco control is taxation, so governments must act boldly and swiftly to
raise taxes on cigarettes and e-cigarettes. This has been shown to reduce and
prevent tobacco use, particularly among youth, and hence to improve health and
reduce the risk of premature mortality. Taxation would also help to expand the tax
base and mobilize additional public revenue for economic recovery initiatives after
the pandemic subsides.
RELATED
The World Bank Group and COVID-19 (https://www.worldbank.org/en/who-we-
are/news/coronavirus-covid19)
GENDER (/SEARCH?F[0]=TOPIC:295&F[1]=LANGUAGE:EN), HEALTH (/SEARCH?F[0]=TOPIC:297&F[1]=LANGUAGE:EN), CHINA
(/SEARCH?F[0]=COUNTRIES:74&F[1]=LANGUAGE:EN), HONG KONG SAR (/SEARCH?
F[0]=COUNTRIES:127&F[1]=LANGUAGE:EN), THE WORLD REGION (/SEARCH?F[0]=REGIONS:280&F[1]=LANGUAGE:EN),
COVID-19 (CORONAVIRUS) (/SEARCH?F[0]=SERIES:881&F[1]=LANGUAGE:EN)
Authors
(/team/patricio-v-marquez) (/team/patricio-v-marquez)
P tricio V. M rqu (/t m/p tricio-v-m rqu )
Senior Associate, Johns Hopkins University Bloomberg School of Public Health
MORE BLOGS BY PATRICIO (/TEAM/PATRICIO-V-MARQUEZ)
x
This site uses cookies to optimize functionality and give you the best possible experience. If you continue to
navigate this website beyond this page, cookies will be placed on your browser. To learn more about
cookies, click here. (https://www.worldbank.org/en/about/legal/privacy-notice)
https://blogs.worldbank.org/voices/tobacco-use-and-coronavirus-covid-19-deadly-preventable-association 6/7
1/12/2021 Social distancing in the time of COVID-19 in Latin America and the Caribbean: Costs and Benefits | Patricio V. Marquez
Social distancing in the time of COVID-19 in Latin America
and the Caribbean: Costs and Bene ts
Submitted by Patricio V. Marquez on Thu, 05/14/2020 - 07 37 PM
Social distancing in the time of COVID-19 in Latin America
and the Caribbean: Costs and Bene ts
Posted by Patricio V. Marquez on Thu, 05/14/2020 - 07 37 PM
Patricio V. Marquez, Santiago Herrera, and Luigi Butron Calderon
May 14, 2020
Since December 2019, following the diagnosis of the initial cases in Wuhan, Hubei Province, China, the number of
the coronavirus disease (COVID-19) cases outside China increased exponentially. As of May 14, 2020, the global
pandemic has resulted in over 4.4 million con rmed cases and 301,370 con rmed deaths in 188 countries/regions
(Johns Hopkins University Coronavirus Resource Center & Medicine 2020). Data from WHO show that 26.4 percent
of the total 1.8 million con rmed cases and 26 percent of the total 109,121 con rmed deaths in the Americas are from
countries in Latin America and the Caribbean (LAC)--the bulk of con rmed cases and deaths are from the United
States (WHO 2020).
Limiting face-to-face contact with others is the best way to reduce the spread of COVID-19 (CDC 2020). As such,
social distancing is one of the best tools to avoid being exposed to this virus and slowing its spread locally, within
countries, and across the world. People are reminded to stay at least 6 feet away from other people, not to gather in
groups, stay out of crowded places, and avoid mass gatherings. Social distancing is especially important for people
who are at higher risk (https:/ /www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-
risk.html) for severe illness from COVID-19.
pvmarquez.com/socialdistancing 1/7
1/12/2021 Social distancing in the time of COVID-19 in Latin America and the Caribbean: Costs and Benefits | Patricio V. Marquez
Contrary to what some people believe, the practice of “physical and social distancing” is not something new; it has
been around for centuries as a common public health tool to control the spread of infectious pathogens into the
population.
Social Distancing Measures are Centuries Old
The history of public health in LAC offers multiple examples of the use of this tool. Since colonial times, outbreaks of
disease were common in these countries, largely the result of maritime trade and export of agricultural products
and minerals that helped integrate the countries in this region into the world economy. The smallpox epidemic in
Hispaniola (now the Dominican Republic and Haiti), registered as the rst one in the colonial period, spread to
neighboring islands and countries, leaving a toll of thousands of victims.
In the sixteenth and following Centuries, epidemics of different kinds made devastating sweeps across the
Americas. As the spread of disease largely re ected the maritime basis for trade among the colonies, and between
the colonies and mercantile powers, such as Spain and Portugal, the principles of isolation and con nement (“social
distancing”) followed in Europe to control disease outbreaks were also applied in the region. In practice, beginning
in Hispaniola in 1519, in accordance with the 1423 Venetian quarantine control system, measures to cope with
epidemics centered on the detention of ships and the isolation of their crews and passengers outside the harbors
until suf cient time had elapsed without the outbreak of “pestilences.” The latter years of the 19th Century and the
early 20th Century saw various attempts by the Latin American and Caribbean countries and the United States to
adopt uniform quarantine regulations at different international conferences, under the aegis of the newly
established Pan American Sanitary Bureau in 1902 (now PAHO/WHO). These sought to remove barriers to steam
navigation and to codify new preventive measures into specific health legislation and programs based on the great
microbiological discoveries of Pasteur, Koch, and Klebs that had revolutionized public health practice in Europe.
Social Distancing in the Times of COVID-19
We should not be surprised, therefore, that in the absence of a vaccine or known therapies for COVID-19, and due to
low testing capacity and ability to do contact-tracing, governments in LAC countries as elsewhere have been forced
to impose once again strict social distancing measures to contain and mitigate the impact of the corona virus.
As such, the timing and severity of social distancing measures is key in containing the COVID-19 pandemic. The
graphs that we have prepared below illustrate how this has happened in LAC, using the Stringency Index developed
by the University of Oxford Coronavirus Government Response Tracker team, to capture variation in containment
and closure policies (Petherick, Kira, Angrist, Hale, Phillips, and Webster 2020). In general, government responses
have become more stringent over the course of the outbreak, and it should be expected that the stringency of
response measures broadly tracks the spread of the disease. However, variation can be seen across countries. The
rate at which such measures are adopted plays a critical role in stemming the infection.
In the country-speci c graphs in Figure 1, the speed of the policy response is proxied by the number of days after
the 100th case is con rmed (horizontal axis, with zero representing the day the 100th case was reported). In LAC,
countries such as Argentina, Colombia, Costa Rica, El Salvador, and Paraguay, are good examples of preemptive
policy action, while Mexico and Brazil illustrate a delayed social-distancing response. As a comparison with other
regions, Figure 1 shows that South Korea’s stringency index was moving up signi cantly before reaching the 100th
case, while the UK ramped it up after that.
Figure 1. Reported number of con rmed cases and stringency index (con rmed cases in log scale), by country
pvmarquez.com/socialdistancing 2/7
1/12/2021 Social distancing in the time of COVID-19 in Latin America and the Caribbean: Costs and Benefits | Patricio V. Marquez
Economic Cost of the COVID-19 Pandemic
The COVID-19 pandemic is in icting high human costs worldwide. Transmissibility and severity are the two most
critical factors that determine the effect of the pandemic. Protecting lives and allowing health care systems to cope
have required isolation, lockdowns, and widespread closures to slow the spread of the coronavirus. The health crisis
is therefore having a severe impact on economic activity. IMF projections indicate that the global economy is
expected to contract sharply by –3 percent in 2020, much worse than during the 2008–09 nancial crisis (IMF
2020).
In LAC, social distancing has reduced mobility among citizens and impacted economic activity. Individual mobility
is measured by Google data based on the history of cell phone locations to reveal if citizens have reduced their
mobility. Using the individual mobility data as an indicator of economic activity, it can be inferred that mobility has
decreased considerably across all the LAC countries listed in Figure 2 below. The combined index of Google mobility
is negatively correlated with the stringency index of social distancing (i.e., the relationship between these two
variables shows that as social distancing measures became more stringent, mobility decreased) (Figure 3).
Overall, economic activity in LAC is faltering. IMF projections point to severe economic slowdowns or outright
contractions in LAC: a negative growth forecast for the region as a whole of –5.2 percent; with Brazil’s growth
forecast at –5.3 percent and Mexico’s at –6.6 percent (IMF 2020).
pvmarquez.com/socialdistancing 3/7
1/12/2021 Social distancing in the time of COVID-19 in Latin America and the Caribbean: Costs and Benefits | Patricio V. Marquez
While the economic cost of the pandemic is signi cant, it is important to highlight that social distancing should be
interpreted as the price society must pay due to imperfect information about which individuals carry the virus and
the lack of adequate health care systems to manage the patient peak loads. Hence, countries that have ample
testing and contact-tracing capacity as well as ample health-care facilities, can afford less restrictive social
distancing. As shown in Figure 4 below, LAC countries have very low testing compared to the rest of the world,
therefore, they are being forced to adopt more stringent social distancing measures. The pandemic is also hitting
the region after a long economic stagnation, which led several countries to slash health care budgets, which further
aggravated lack of or limited preparedness.
Excess Deaths Better Gauges the COVID-19 Toll
Although worldwide, 3.4 percent of the people con rmed as having been infected have died, WHO has been careful
not to describe this gure as a case fatality rate or death rate. This is because during an evolving epidemic it can be
misleading to look simply at the estimate of deaths divided by cases to date. Given the large number of
asymptomatic cases, the denominator cannot be estimated without widespread testing. And there is substantial
evidence that the number of deaths is underreported, as case fatality perhaps only re ects deaths in health
facilities. In addition, to better gauge the pandemic’s toll, one also needs to include not only deaths from COVID-19,
but also those from other causes, including people who could not be treated as hospitals became overwhelmed with
patients, or those who did not seek treatment because they were afraid of being infected with the coronavirus.
For instance, in Ecuador the number of deaths reported in the period March-April 2020 exceeded the normally
reported number for those months by more than 8,000 cases, while the COVID19 reported deaths were only 1,561,
suggesting signi cant underreporting (Table 1). In Guayaquil, a port city in Ecuador, the sudden spike in fatalities in
pvmarquez.com/socialdistancing 4/7
1/12/2021 Social distancing in the time of COVID-19 in Latin America and the Caribbean: Costs and Benefits | Patricio V. Marquez
April 2020 was comparable to what New York City experienced during its worst month: more than ve times the
number of people died than in previous years (Kurmanaev, Andreoni, Casado, and Taj 2020).
From an economic perspective, it should be clear that excess mortality and morbidity across population groups have
the potential to undermine and reverse human capital development achieved in countries in recent decades.
Bene ts of Social Distancing Measures
COVID-19 infections have been growing exponentially in many countries across the world, with the doubling time
remaining between 2 and 4 days in several countries like the United States. This exponential growth is fueled by the
presence of three conditions: (i) there is at least one infected person in the population pool; (ii) regular contact
between infected and uninfected members of the population occurs; and (iii) there are large numbers of uninfected
potential hosts among the population. Exponential growth is so powerful, not because it is necessarily fast, but
because it is relentless (Siegel 2020). Without introducing a factor to suppress it, such as stringent social distancing
measures, exponential growth becomes a near impossible challenge, because it doubles its presence in the
population in a given amount of time.
Hence, it should be clear that while social distancing measures are disrupting economic activity, they help prevent
the spread of the corona virus and save lives, tilting the cost-bene t analysis in their favor (Thunstrom, et al. 2020).
We used recent literature to estimate the impact of isolation and contact-tracing on the number of infections in the
course of one month, taking into account that the number of lives saved will depend on the fatality rate that varies
by country. The estimation of the number of potential infections is based on key parameter assumptions: a) the
degree of contagiousness, measured by the parameter Ro; b) the extent of social isolation; c) the ability to do contact
tracing, and d) the speed with which the self-isolation takes place after the symptoms manifest.
The degree of contagiousness changes over time as shown by Arroyo et al. (2020). Hence, we assume different
values for the parameter, based on the LAC data. The degree of isolation can uctuate from zero (ignorance of any
restrictions) to 100% (complete isolation going out to only to purchase groceries). Using an online tool that
implements the Hellwell et al. model (IFLscience 2020), we estimate the number of lives saved, based on different
fatality rates, from 3.4% (cited by WHO) to 5% (a common rate in LAC). These back-of-the envelope estimations
show that the bene ts--the number of lives saved--increase with stringency and with assumptions of
infectiousness (Tables 2 and 3).
pvmarquez.com/socialdistancing 5/7
1/12/2021 Social distancing in the time of COVID-19 in Latin America and the Caribbean: Costs and Benefits | Patricio V. Marquez
The level of contagiousness, which changes over time (Arroyo et. al. 2020), is not completely exogenous, as it is
correlated with the stringency social distancing as measured by the stringency index of the Oxford COVID-19
Government Response Tracker. There is a high negative correlation between the two independent sources of data.
In fact, the purpose of the social distancing measures is to reduce the value of Ro, and the high negative correlation
indicates that the measures have been effective.
What Next?
It should be clear to all that in the absence of vaccines and cures, social distancing measures are a critical tool to
help suppress transmission of the coronavirus below the basic reproduction number of 1.0 (Ro), which is necessary
to rapidly reduce case incidence, keep cases to low levels, and maintain that situation over time.
As warned by different international experts, if countries reopen their economies too soon without ensuring that
they have in place critical testing capacity, ability to trace the contacts of those infected, and adequately prepared
medical care services to deal with a surge of severe cases in the event of a resurgence, the consequences would be
dire. With deaths now declining, governments are trying to restart their economies, by gradually releasing the
lockdown. But, local authorities’ fear of a new outbreak is pushing back central governments’ reopening decisions--
in Ecuador, for example, only two of the country’s 221 cities have moved toward relaxing the quarantine nearly a
week later after the central government announced the reopening.
As observed by leading global experts, the COVID-19 pandemic is a stark remainder of the ongoing challenge of
emerging and reemerging infectious diseases and the need for constant disease surveillance, prompt diagnosis, and
robust research to understand the basic biology of new organisms and our susceptibilities to them, as well as to
develop effective countermeasures to control them (Fauci, Lane, Clifford, and Red eld 2020).
Looking into the future, the global spread of COVID-19 clearly signals the need, hopefully once and for all, for
building and maintaining strong and sustainable public health and medical institutions and systems, and an effective
cross sectoral interface between environment, veterinary and public health services to anticipate, prevent, and
control the emergence of new infectious pathogens of animal origin, the resurgence of known infectious diseases,
and the ominous threat of anti-microbial resistance. This task is of priority importance where health systems are
weaker, living conditions often more overcrowded, and populations most vulnerable. If this is not done, as the
COVID-19 pandemic is demonstrating now, the risk posed by novel infectious diseases that can emerge in any part
of the world at any time, causing massive social and economic disruptions, will continue to threaten the entire
global community.
Note: *The Stringency Index collects publicly available information on 17 indicators of government responses. Eight of the policy indicators record information on
containment and closure policies, such as school closures and restrictions in movement. Four of the indicators record economic policies, such as income support to citizens or
provision of foreign aid, and ve indicators record health system policies such as the COVID-19 testing regime or emergency investments into healthcare. The index has a
numeric value ranging from 0 (less stringent) to 100 (more stringent). https://www.bsg.ox.ac.uk/research/research-projects/coronavirus-government-response-tracker
(https://www.bsg.ox.ac.uk/research/research-projects/coronavirus-government-response-tracker).
Source of Picture: Image Covid-19 | New Scientist
About the authors: Patricio V. Marquez, Former Lead Public Health Specialist, World Bank Group, Santiago Herrera, Lead Economist, Macroeconomics, Trade and Investment,
LAC Region, World Bank Group, and Luigi Butron Calderon, Research Assistant (consultant), Macroeconomics, Trade and Investment, LAC Region, World Bank Group
This note is a product of work done by the authors, and the ndings, interpretations, and conclusions expressed in this post do not necessarily re ect the views of the World Bank
Group, the Executive Directors of the World Bank Group or the governments they represent.
pvmarquez.com/socialdistancing 6/7
1/12/2021 Social distancing in the time of COVID-19 in Latin America and the Caribbean: Costs and Benefits | Patricio V. Marquez
Sources
Arroyo Marioli, F, Bullano, F, and Rondon-Moreno, C. 2020. “Dynamics of Transmi…
(https://www.medrxiv.org/content/10.1101/2020.04.19.20071886v1)
Blavatnik School of Government, University of Oxford. University of Oxford Cor…
(https://www.bsg.ox.ac.uk/research/research-projects/coronavirus-government-response-tracker)
Centers for Disease Control and Prevention (CDC). 2020. “Coronavirus Disease 2…
(https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html)
IFLscience. “Calculator Shows How Your Social Distancing Saves People.” Mar 30…
(https://www.i science.com/health-and-medicine/online-calculator-shows-how-many-lives-your-
socialdistancing-may-save/)
Fauci, AS, Lane, Clifford, L, and Red eld, RR. 2020. “Covid-19---Navigating th…
(https://www.nejm.org/doi/full/10.1056/NEJMe2002387?query%3DRP=)
International Monetary Fund. 2020. “World Economic Outlook, April 2020 The Gr…
(https://www.imf.org/en/Publications/WEO/Issues/2020/04/14/weo-april-2020)
Hellewell, J, Abbott, S, Gimma, A, Bosse, NI, Jarvis, CI, Russell, TW, Munday,…
(https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30074-7/fulltext)
Johns Hopkins University & Medicine Coronavirus Resource Center. “COVID-19 Map”…
(https://coronavirus.jhu.edu/map.html)
Kurmanaev, A, Andreoni, M, Casado, L, and Taj, M. 2020. “Latin America’s Outbr…
(https://www.nytimes.com/2020/05/12/world/americas/latin-america-virus-death.html?
referringSource=articleShare)
Petherick, A, Kira, B, Angrist, N, Hale, T, Phillips, T, and Webster, S. 2020…
(https://www.bsg.ox.ac.uk/research/publications/variation-government-responses-covid-19)
Siegel, S. 2020. “Why 'Exponential Growth' Is So Scary for the COVID-19 Corona…
(https://www.forbes.com/sites/startswithabang/2020/03/17/why-exponential-growth-is-so-scary-for-the-
covid-19-coronavirus/#744a71114e9b)
ThunströmL, NewboldS, FinnoffD, AshworthM, ShogrenJF. The bene ts and costs of…
(https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3561934)
Weiss, RA, and McMichael, AJ. 2004. “Social and environmental risk factors in …
(https://www.nature.com/articles/nm1150)
WHO Coronavirus disease (COVID-19) Situation Report – 115 Data, May 14 2020 (https://www.who.int/docs/default-
source/coronaviruse/situation-reports/20200514-covid-19-sitrep-115.pdf?sfvrsn=3fce8d3c_6)
Image Covid-19 | New Scientist (https:/ /www.bing.com/images/search?
view=detailV2&ccid=3cwl5OI9&id=9658B910E1B8479D840DA78F754EE538D2F2C78F&thid=OIP.3cwl5OI9IgTFZdVCNB3e
content/uploads/2020/02/11165812/c0481846-wuhan_novel_coronavirus_illustration-
spl.jpg&exph=800&expw=1200&q=free%20covid-
19%20pictures&simid=607991704663294897&selectedindex=0&ajaxhist=0&vt=0&eim=1&sim=11)
(https://twitter.com/pvmarquez1956)
pvmarquez.com/socialdistancing 7/7
1/12/2021 Do BCG Vaccinated People Have Some Immunity Advantage Over Non-Vaccinated People? | Patricio V. Marquez
Do BCG Vaccinated People Have Some
Immunity Advantage Over Non-
Vaccinated People?
Submitted by Patricio V. Marquez on Tue, 04/21/2020 - 03 24 PM
Do BCG Vaccinated People Have Some
Immunity Advantage Over Non-
Vaccinated People?
Posted by Patricio V. Marquez on Tue, 04/21/2020 - 03 24 PM
Second Installment of Preliminary Interrogation by Patricio V. Marquez, Albert
Figueras, Allison Ross, Giovanni S. Marquez, and Jaime Bayona
www.pvmarquez.com/bcg 1/9
1/12/2021 Do BCG Vaccinated People Have Some Immunity Advantage Over Non-Vaccinated People? | Patricio V. Marquez
“…government and municipal o cials were putting their heads together. So long as each individual doctor
has come across only two or three cases, not one had thought of taking action. But it was merely a matter
of adding up the gures and, once this had been done, the total was startling. In a very few days the
number of cases had risen by leaps and bounds, and it became evident to all observers of this strange
malady that a real epidemic had set in.”
Albert Camus, The Plague, 1947
In this post, we build upon the preliminary interrogation described in our
previous post “Searching for Evidence in the COVID-19 Era: The BCG Case”
(“Searching for Evidence in the COVID-19 Era: The BCG Case”, April 18,
2020, http://pvmarquez.com/bcgcovid19
(http://pvmarquez.com/bcgcovid19)).
The objective in this post is to present the results of a rapid statistical
analysis that we conducted to assess a hypothesis that has been put forward
by some researchers about the association between COVID-19 reported
deaths and Bacillus Calmette–Guérin (BCG) vaccination policy in countries.
The BCG vaccine, rst administered to a human in 1921, is one of the most
widely used of all current vaccines, covering >80% of neonates and infants
in countries where it is part of the national childhood immunization
program. The BCG vaccine has a documented protective effect against
meningitis and disseminated TB in children (disseminated TB is a contagious
mycobacterial infection in which mycobacteria have spread from the lungs
to other parts of the body through the blood or lymph system) (WHO 2020).
Overall, BCG vaccine ef cacy is estimated to be about 51 percent in
preventing any TB disease and up to 78 percent in protecting newborns
from disseminated or meningeal TB (Canadian Immunization Guide 2014).
The BCG vaccine is also of proven ef cacy in the control of leprosy.
The duration of BCG vaccine protection is not well-established, although
one study demonstrated a protective effect for as long as 60 years
(Nguipdop-Djomo, Heldal, Cunha Rodrigues, Abubakar, and Mangtani 2015).
www.pvmarquez.com/bcg 2/9
1/12/2021 Do BCG Vaccinated People Have Some Immunity Advantage Over Non-Vaccinated People? | Patricio V. Marquez
The BCG vaccine, however, will not prevent the development of active TB in
individuals who are already infected with M. tuberculosis.
If processes for early identi cation and treatment of latent TB infection are
not available, it is recommended that BCG vaccine may be considered for
workers (such as health care workers, laboratory workers, prison workers
and those working in shelters for the homeless) who may be repeatedly
exposed to persons with untreated, inadequately treated or drug-resistant
active TB, in conditions where protective measures against infection are not
feasible (Canadian Immunization Guide 2014).
BCG vaccination policies vary across countries. Countries with high TB
prevalence tend to have universal BCG vaccination policies, while those with
lower TB burden tend to vaccinate only high-risk groups (SAGE Working
Group on BCG Vaccines and WHO Secretariat 2017). Among 180 countries
with available data, 157 countries recommend universal BCG vaccination,
while 23 countries have either stopped BCG vaccination (due to a reduction
in TB incidence), or never recommended mass BCG immunization and
instead favored selective vaccination of “at risk” groups (Zwerling, Behr,
Verma, Brewer, Menzies, Pai 2011). For example, BCG vaccination in the
latter group of countries may be considered in exceptional circumstances,
such as for infants in high risk communities, for persons at high risk of
repeated exposure, for certain long-term travelers to high prevalence
countries, and in infants born to mothers with infectious TB disease.
As noted in our previous post, different studies involving the BCG vaccine
have found that it provides heterologous or "nonspeci c immunological
effects" by altering immune response to pathogens other than
Mycobacterium tuberculosis. The BCG vaccine has been found to reduce
non-TB respiratory infection, sepsis, and all-cause mortality among young
children, and it may prevent upper respiratory tract infections among the
www.pvmarquez.com/bcg 3/9
1/12/2021 Do BCG Vaccinated People Have Some Immunity Advantage Over Non-Vaccinated People? | Patricio V. Marquez
elderly. Although the mechanism, magnitude, and duration of these
nonspeci c effects remain uncertain, some researchers speculate that BCG
vaccination could moderate the severity of COVID-19 infections.
Results of an Additional Analysis
Data and Information Used. Our team conducted an initial, limited, analysis
of the available data and information. Data on country population size were
obtained from the World Bank Data Bank; data on COVID-19 deaths were
from the Johns Hopkins University Center for Systems Science and
Engineering (CSSE) database, and information on BCG vaccination policies,
by country, was from the BCG World Atlas. COVID-19 deaths per capita was
calculated using Johns Hopkins CSSE death counts and World Bank
population estimates; the data were then logarithmically transformed to
ensure normality.
Summary of Results
An analysis of variance (ANOVA), including both small states and low-
income countries, was conducted. Countries were divided into four
groups according to four different types of BCG vaccination policy (no
policy at all, universal BCG vaccination policy, previous BCG vaccination
policy, and policy to vaccinate certain high-risk groups). The analysis
showed that there is a statistically signi cant difference in the mean
number of deaths per 1,000 people between country groups (p < .01).
A second ANOVA was conducted excluding small states and low-income
countries. Countries were also divided into four groups according to the
four different types of BCG vaccination policy (no policy at all, universal
BCG vaccination policy, previous BCG vaccination policy, and policy to
vaccinate certain high-risk groups). The analysis showed that there is a
statistically signi cant difference in the mean number of deaths per
1,000 people between country groups (p < .01).
www.pvmarquez.com/bcg 4/9
1/12/2021 Do BCG Vaccinated People Have Some Immunity Advantage Over Non-Vaccinated People? | Patricio V. Marquez
A two-sample t-test assuming equal variances was conducted, testing
the difference in mean COVID-19 deaths per 1,000 population between
countries with a universal BCG vaccination policy and countries without
it (including no policy, only high-risk groups, and previous universal
policy) was conducted. The test included small states and low-income
countries and showed that there is a statistically signi cant difference in
the mean number of deaths per 1,000 people between the two groups (p
< .01).
Finally, another two-sample t-test assuming equal variances, testing the
difference in mean COVID-19 deaths per 1,000 population between
countries with a universal BCG vaccination policy and countries without
(including no policy, only high-risk groups, and previous universal policy)
was conducted. In this case, small states and low-income countries were
excluded. The results similarly showed that there is a statistically
signi cant difference in the mean number of deaths per 1,000 people
between the two groups (p < .01).
In conclusion, the results of our initial analyses show statistically signi cant
correlations, both when small states and low-income countries were
included and when they were excluded from the analyses.
Despite the interesting results that we obtained, substantial doubts arise
and should be taken into account when further assessing the plausibility of
the hypothesis:
At present, there are a lot of questions about how different countries are
reporting COVID-19 deaths. It seems that some countries only count
deaths occurring in hospitals but not those happening in nursing homes,
prisons, or at home (because testing was not done to con rm the
diagnosis). Moreover, large number of countries are facing supply-side
challenges related to the availability of test kits for case detection and
contact tracing. The latter may have a confounding effect on the
observed results.
www.pvmarquez.com/bcg 5/9
1/12/2021 Do BCG Vaccinated People Have Some Immunity Advantage Over Non-Vaccinated People? | Patricio V. Marquez
BCG vaccination policies and practices vary across time and countries.
For example, it is possible that a country with an 'only high-risk group'
vaccination policy at present had a 'universal vaccination policy' up to
1960. In cases like this, there are differences in previous BCG vaccination
coverage according to age groups. A proper analysis should take into
account these inter- and intra-country differences. In addition, the use
of different BCG vaccine strains in different countries and even within
the same countries may also have a confounding effect. Currently, ve
main strains account for more than 90 percent of the vaccines in use
worldwide with each strain possessing different characteristics, and
there is no standardized production of BCG vaccine between
manufacturers (WHO 2012).
The role of additional factors that have not yet been assumed,
investigated, or con rmed. For example, since the primary function of
the respiratory system--to supply oxygen to all the parts of the body--is
especially affected among COVID-19 infected individuals (probably
because of multiple clotting in the lungs), does the decreased respiratory
capacity observed among cigarette smokers play a major role in the
clinical evolution of COVID-19 disease, increasing the risk of disease
severity and death among COVID-19 infected individuals? As discussed
on a previous post, cigarette smoking makes chronic lung diseases more
severe and increases the risk for respiratory infections (“Does Tobacco
Smoking Increases the Risk of Coronavirus Disease (Covid-19) Severity?
The Case of China” of March 3, 2020, http:/ /pvmarquez.com/Covid-19
(http://pvmarquez.com/Covid-19)).
The Way Forward
Many clinical trials with different drugs treat COVID-19 disease patients are
currently being conducted in many countries. Antivirals (lopinavir/ritonavir,
lopinavir), monoclonal antibodies (tocilizumab) and other agents affecting
www.pvmarquez.com/bcg 6/9
1/12/2021 Do BCG Vaccinated People Have Some Immunity Advantage Over Non-Vaccinated People? | Patricio V. Marquez
the immune response (hydroxychloroquine and chloroquine) are being
tested. Different treatments are also being tested as preventive measures in
non-positive patients.
It should be clear, however, that research to nd an effective vaccine is one
of the most promising ways to suppress the pandemic (not the present
wave, but future waves that may happen).
At this stage, it is crucial to try to understand sets of factors and their
interactions, e.g., risk factors, protective factors, and infection periods.
Within this framework, the BCG hypothesis could be useful. There is a
plausible hypothesis: vaccinated people could show some immunity
advantage over non-vaccinated people (based on previous studies on the
nonspeci c effects of BCG on the immune response as described in our
above-mentioned previous post of April 18, 2020).
Conducting more accurate analyses, including evaluating differences in BCG
vaccination among infected people, recovered patients, and positive but
asymptomatic patients, should be of high interest, not only to understand
how COVID-19 interacts with people but also to inform the development of
a vaccine (or to understand potential failures or successes of future
vaccines). Another avenue of analysis that may offer some clarity on this
inquiry is related to the fact that some medical personnel working in
develop countries, such as the United States (without BCG), are actually
coming from low-and middle-income countries where BCG policy is in
place. Hence, a question that may need to be analyzed is whether there are
differences in terms of severity of COVID-19 disease among infected doctors
and nurses based on the country of origin of medical personnel that
emigrated and those who emigrated and are working in medical facilities in
developed countries?
www.pvmarquez.com/bcg 7/9
1/12/2021 Do BCG Vaccinated People Have Some Immunity Advantage Over Non-Vaccinated People? | Patricio V. Marquez
At this point, it is crucial is to ensure that decisions taken on BCG
vaccination are taken based on the available information for several reasons:
First, because it takes several weeks to develop the alleged positives
effects of BCG on immunity after vaccination (so, it would not be useful
for the present wave).
Second, because of the low availability of BCG vaccines and their low
production rate
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5777639/).
Third, and most important, because the hypothesis has to be tested with
more appropriate epidemiological and clinical methods before a causal
relationship can be ascertained.
Sources
Government of Canada. 2014. “Bacille Calmette-Guérin (BCG) vaccine:
Canadian Im… (https://www.canada.ca/en/public-
health/services/publications/healthy-living/canadian-immunization-
guide-part-4-active-vaccines/page-2-bacille-calmette-guerin-
vaccine.html)
Nguipdop-Djomo, P, Heldal, E, Cunha Rodrigues, L, Abubakar, I, Mangtani, P.
20… (https://www.thelancet.com/journals/laninf/article/PIIS1473-
3099(15)00400-4/fulltext)
WHO. 2020. “BCG vaccine”. (internet site).
(http://www9.who.int/biologicals/areas/vaccines/bcg/en/)
www.pvmarquez.com/bcg 8/9
1/12/2021 Searching for Evidence in the COVID-19 Era: The BCG Case | Patricio V. Marquez
Searching for Evidence in the COVID-19 Era: The BCG Case
Submitted by Patricio V. Marquez on Fri, 04/17/2020 - 10 41 PM
Searching for Evidence in the COVID-19 Era: The BCG
Case
Posted by Patricio V. Marquez on Fri, 04/17/2020 - 10 41 PM
A Preliminary Interrogation Conducted by Patricio V. Marquez [1], Albert Figueras [2],Allison
Ross [3],Giovanni S. Marquez [4], and Jaime Bayona [5]
“A pestilence is not a thing made to man’s measure; therefore, we tell ourselves that pestilence is a mere bogy of the mind, a bad dream that will pass away. But it does not
always pass away and, from one bad dream to another, it is men who pass away, and the humanists rst of all, because they have not taken their precautions.”
Albert Camus, The Plague. Vintage, 1947.
“For the rst time in history, we face the risk of a global decline. But we are also the rst to enjoy the opportunity of learning quickly from developments in societies anywhere
else in the world today, and from what has unfolded in societies at any time in the past.”
Jared Diamond. Collapse. How societies choose to fail or succeed. Penguin, 2005.
Across the world, the spread of the novel coronavirus disease (COVID-19) has been rapidly altering life as we
know it. With more than 2.2 million reported cases and more than 150,000 deaths as of April 17, 2020 (Johns
Hopkins Center for Systems Science and Engineering 2020), social distancing policies, including widespread
lockdowns, have been adopted out of societal fear of the high transmissibility, often by asymptomatic people,
and severity of a virus that transcends national boundaries. The global economy is experiencing an exceptional
negative shock as a result of COVID-19 massive layoffs and unemployment, supply chain and market disruption
directly affecting economic production, and the nancial impact on rms and nancial markets has been hard.
All this on top of the severe negative impact on human capital, including lives, learning, basic well-being, and
future productivity (World Bank/International Monetary Fund 2020). Still, despite its enormous health, social,
and economic impact, much about the disease is currently unknown.
www.pvmarquez.com/bcgcovid19 1/4
1/12/2021 Searching for Evidence in the COVID-19 Era: The BCG Case | Patricio V. Marquez
Given the novelty of COVID-19 and its clinical manifestations (Fauci, Lane, Clifford, and Red eld, 2020), as well
as the speed at which the pandemic is progressing, we are constantly learning and revising our understanding of
the virus and how to contain and mitigate its spread and impact, and hoping for eventual suppression. The
global scienti c community is conducting signi cant research into transmission methods, potential treatments,
and vaccine candidates, resulting in a plethora of information, in some cases con icting, for the general public to
sort through.
One such nding has been the association between a country's COVID-19 reported cases and deaths and its
Bacillus Calmette–Guérin (BCG) vaccination policy. BCG usually is given to newborns, protecting them
especially against severe forms of TB (e.g., TB meningitis, disseminated TB). However, vaccination policies vary
country to country. Countries with high TB prevalence tend to have universal BCG vaccination policies, while
those with lower TB burden tend to vaccinate only high-risk groups (SAGE Working Group on BCG Vaccines and
WHO Secretariat 2017).
According to a preprint, ecological study* (Miller et al. 2020), countries without universal policies of BCG
vaccination (e.g., Italy, United States) have been more severely affected by COVID-19 compared to countries with
universal and long-standing BCG policies. It is also shown in this study that countries that have had a late start
of universal BCG policy (e.g., Iran, 1984) have high COVID-19 mortality, consistent with the idea that BCG
protects the vaccinated elderly population. The results of another ecological study not yet published also show
that COVID-19-attributable mortality among BCG-using countries was 5.8 times lower than in non-BCG-using
countries (Shet et al. 2020). Accordingly, the authors of both studies have hypothesized that BCG vaccination
might offer some protection against COVID-19, reducing the severity of the disease. Data from another study
not yet peer reviewed corroborates the observation that universal BCG vaccination has a protective effect on the
course of COVID-19, probably preventing progression to severe disease and death (Dayal and Gupta 2020).
Since its introduction in the 1930s, epidemiological studies have shown that BCG also protects against childhood
mortality independent of its effect on TB. More speci cally, the studies involving the BCG vaccine have found
that it provides heterologous or "nonspeci c immunological effects," altering immune response to pathogens
other than Mycobacterium tuberculosis (Iglesias and Martin 2015). The ndings suggest that BCG at birth has
bene cial nontargeted effects on general infant morbidity and mortality in low-income countries--a BCG scar is
associated with better survival and 50 percent mortality reduction due to pneumonia in vaccinated
children (Roth, Garly, Jensen, Nielsen, Aaby 2006). Besides reducing non-TB respiratory infection, other studies
show that the BCG vaccine reduces sepsis, and all-cause mortality among young children (de Castro, Pardo-
Seco, and Martinón-Torres 2015; Higgins, JPT, Soares-Weiser, K, López-López, JA, Kakourou, A, Chaplin, K,
Christensen, H, et al. 2016). It is also shown that BCG prevents upper respiratory tract infections among the
elderly (Wardhana, Sultana, Mandang, and Jim 2011).
Although the mechanism, magnitude, and duration of these nonspeci c effects remain uncertain, a study
showed that BCG induces adaptive or trained immunity and nonspeci c protection from infections through
epigenetic reprogramming of innate immune cells (Kleinnijenhuis, Quintin, and Preijers 2012). The innate
immune response in a person’s organism is initiated when cells of the innate immune system, including PMNs,
monocytes, macrophages, and DCs, encounter pathogens. Some researchers now speculate that BCG
vaccination could moderate the severity of COVID-19 infections (Dayal and Gupta 2020; Hegarty, Kamat,
Za rakis, Dinardo 2020).
www.pvmarquez.com/bcgcovid19 2/4
1/12/2021 Searching for Evidence in the COVID-19 Era: The BCG Case | Patricio V. Marquez
While two of the above-mentioned ecological studies (Miller et al. 2020; Shet et al. 2020) observed an
association between national vaccination policies and country-level deaths, it should be clear, however, that this
relationship does not imply causation between the exposure and the disease. Uncontrolled confounding
variables could instead explain the association, including the fact that low and middle-income countries tend to
have both universal BCG policies and lower capacities to test for COVID-19. Additionally, it should be taken into
account that many countries have changed their BCG policies in the past 50 years, so even within a country,
immunization is not uniform (i.e., it can be different according to age).
Given what we know now, BCG vaccinations cannot prevent COVID-19 infections or reduce their severity, but
the association is worth evaluating in greater depth. Additional research could provide more accurate
characterizations of the relationship between vaccination and disease occurrence, accounting for variables like
population demographics, testing capacity, and epidemic timelines that affect national ecological studies.
Two randomized control trials are currently underway in Australia and the Netherlands to evaluate whether BCG
vaccination reduces COVID-19 incidence among healthcare workers (Murdoch Children’s Research Institute
2020; UMC Utrecht 2020). Perhaps the results of these trials will help provide much needed evidence on what
works in the ght against the novel coronavirus, contributing with additional insights into the mechanisms of
disease and host response.
We should keep an eye on the outcome of these trials, while recognizing that rushing to promote novel
treatments before evidence of their ef cacy and safety has been established can do public health more harm
than good.
Note. * Ecological studies are studies of risk-modifying factors on health or other outcomes based on populations de ned either geographically or temporally. The study by
John Snow in 1984, regarding a cholera outbreak in London is considered the rst ecological study to solve a health issue. He used a map of deaths from cholera to determine
that the source of the cholera was a pump on Broad Street.
About the authors:
[1] Consultant, World Bank Group (WBG) COVID-19 Global Emergency Response Program, and former Lead Public Health Specialist, WBG
[2] Director, Fundació Institut Català de Farmacologia (Catalan Pharmacology Institute), a collaborating center of the Department of Clinical Pharmacology of the
Hospital Vall d'Hebron, and associated center of the Department of Pharmacology, Therapeutics and Toxicology at the Autonomous University of Barcelona (UAB), and a
WHO Collaborating Center for Research and Training in Pharmacoepidemiology. Barcelona, Spain
[3] WBG Intern, and Graduate Student, Global Health Program, Georgetown University, Washington, D.C.
[4] Former Technical O cer, PAHO/WHO, WHO AFRO, and WHO EMRO (Health Systems, Expanded Programme on Immunization and Health Emergencies in Barbados, USA,
Haiti, Pakistan, and Nigeria)
[5] Senior TB/Health Specialist, WBG
Sources
de Castro, MJ, Pardo-Seco, J, and Martinón-Torres, F. 2015. "Nonspeci c (Heter…
(https://academic.oup.com/cid/article/60/11/1611/356084)
Higgins, JPT, Soares-Weiser, K, López-López, JA, Kakourou, A, Chaplin, K, Chris…
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5063034/)
Iglesias, M-J, and Martin, C. 2015. “Nonspecific Beneficial Effects of BCG Vacci…
(https://academic.oup.com/cid/article/60/11/1620/356166)
Johns Hopkins Center for Systems Science and Engineering (internet site).
(https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6)
Kleinnijenhuis, J, Quintin, J, Preijers, F, Joosten, LAB, Ifrim, DC, Saeed, …
(https://doi.org/10.1073/pnas.1202870109)
Miller, A, Reandelar, MS, Fasciglione, K, Roumenova, V, Li, Y, and Otazu, GH. …
(https://www.medrxiv.org/content/10.1101/2020.03.24.20042937v1)
www.pvmarquez.com/bcgcovid19 3/4
1/12/2021 Searching for Evidence in the COVID-19 Era: The BCG Case | Patricio V. Marquez
Murdoch Childrens Research Institute. "BCG Vaccination to Protect Healthcare Wo…
(https://clinicaltrials.gov/ct2/show/NCT04327206.)
SAGE Working Group on BCG Vaccines and WHO Secretariat. 2017. "Report on BCG …
(https://www.who.int/immunization/sage/meetings/2017/october/1_BCG_report_revised_version_online.pdf)
Shet, A, Ray, D, Malavige, N, Santosham, M, Bar-Zeev, N. 2020. "Differential…
(https://www.medrxiv.org/content/10.1101/2020.04.01.20049478v1)
UMC Utrecht. "Reducing Health Care Workers Absenteeism in Covid-19 Pandemic Thr…
(https://clinicaltrials.gov/ct2/show/NCT04328441)
Wardhana, DEA, Sultana A, Mandang VV, Jim E. 2011. “The ef cacy of Bacillus Ca…
(https://www.ncbi.nlm.nih.gov/pubmed/21979284)
World Bank/International Monetary Fund. WB/IMF Spring Meetings 2020. “Develop…
(https://www.worldbank.org/en/news/press-release/2020/04/17/world-bankimf-spring-meetings-2020-
development-committee-communique)
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/bcgcovid19 4/4
1/12/2021 How to Prevent Jails and Prisons from Becoming New Hotspots for the Spread of COVID-19? | Patricio V. Marquez
How to Prevent Jails and Prisons from Becoming New
Hotspots for the Spread of COVID-19?
Submitted by Patricio V. Marquez on Mon, 04/13/2020 - 05 11 PM
How to Prevent Jails and Prisons from Becoming New
Hotspots for the Spread of COVID-19?
Posted by Patricio V. Marquez on Mon, 04/13/2020 - 05 11 PM
Recent newspaper articles have reported on the potential role of jails and prisons as “ampli ers” of the coronavirus
pandemic (Ransom and Feuer 2020; Flagg and Neff 2020). For example, data from New York City jails show that 36
out of 1,000 inmates tested positive for the virus versus 4 out of 1,000 people in the city at large (The Legal Aid
Society 2020). Additional information indicates that 23 states across the United States have reported cases in
correctional facilities (Coppola and Pettersson 2020).
The gravity of this challenge in the rest of the world is evidenced by the fact that more than 10.3 million people are
held in penal institutions at any given time and more than 30 million people pass through prisons each year
(Walmsley 2015; Subramanian, Henrichson, and Kang-Brown, 2015). In addition, there is a large workforce, both
within institutions and in community supervision. With thousands of people owing in and out of jails and prisons
every week, this is a great risk not only for the detained population that could be hard hit by the coronavirus
pandemic, but also for correctional workers, families of released inmates, and surrounding communities (The
Marshall Project 2020).
Facilitating Factors in Jails and Prisons
Jails are transient, local level facilities, for the newly arrested, those awaiting trial or sentencing, those who have not
yet been convicted of a crime, and people serving shorter sentences. Prisons are run by states or central
governments and are for those convicted of crimes and serving longer sentences. The people who are incarcerated
are among the most vulnerable in society, often from low income and marginalized backgrounds (e.g., racial
www.pvmarquez.com/prisoncovid19 1/7
1/12/2021 How to Prevent Jails and Prisons from Becoming New Hotspots for the Spread of COVID-19? | Patricio V. Marquez
minorities, undocumented migrants). The vulnerability of prisoners is further exacerbated by restricted movement,
rampant overcrowding, poor hygiene, sanitation, and ventilation, and limited medical care in the facilities (Akiyama,
Spaulding, and Rich 2020).
Besides the sheer number of incarcerated people, often a “veil of oblivion” surrounds the dire conditions of jails and
prisons, which make them potential host spots for the spread of COVID-19 because of the ease with which it
transmits in congregate settings.
Another factor that may facilitate the rapid spread of COVID-19 in jails and prisons is the large share of those
incarcerated who are older adults affected by underlying chronic health conditions, including both infectious
diseases such as HIV, hepatitis C, and tuberculosis, and noncommunicable diseases such as chronic lung disease,
moderate to severe asthma, serious heart conditions, diabetes, chronic kidney disease, and liver disease, all of which
make them at higher risk of developing severe COVID-19 disease and having poor outcomes of infection (CDC (1)
2020).
Health risk factors that make respiratory diseases like COVID-19 more dangerous are far more common in the
incarcerated population than in the general population, such as the high prevalence of cigarette smoking. As
documented, cigarette smoking may help explain the negative progression and adverse outcomes of COVID-19 in
China among men, who are far more likely to smoke than women (Marquez 2020; Vardavas and Nikitara 2020). In
other countries such as Italy and South Korea, with sizable outbreaks of COVID-19, smoking rates in countries
remain high at approximately 19-27 percent of the population (Simons, Perski,Brown 2020).
An additional factor that further compounds the poor health and social conditions in the penal system is evidenced
by country data that shows that as many as half the people in jails and prisons have a mental disorder, which could
be aggravated by the fear of becoming severely ill or dying if infected with COVID-19 because of their age or health
conditions, and by other stressors such as frustration, boredom, inadequate supplies, and inadequate information
(Brooks, Webster, Smith, et al. 2020; Marquez, 2018). For example, as described in Alisa Roth's gripping book Insane
(2018), although the overall number of people behind bars in the United States has decreased in recent years, the
proportion of prisoners with mental illness has continued to go up. Data in the book indicate that in Michigan about
50 percent of people in county jails have a mental illness, and nearly 25 percent in state prisons do. This situation
tends to be more pronounced among women prisoners: one study by the US Bureau of Justice Statistics found that
75 percent of women incarcerated in jails and prisons had a mental illness, as compared to just over 60 percent of
men. De facto, as observed by Roth, jails and prisons, not only in the United States but across the world, have
become “warehouses for the mentally ill”, who tend to be among the most disadvantaged members of society, fare
worse than others, and who are susceptible to medical neglect and abuse, since ultimately the mission of jails and
prisons is punishment, not medical care.
Limited Resources in Jails and Prisons
What should be of concern is that in different countries across the world, penitentiary facilities often struggle with
limited resources to provide basic levels of healthcare and psychological support services to inmates. So, it is not a
far-fetched idea to assume that the risk of an exponential spread of COVID-19 infection in jails and prisons is real as
it will be greatly facilitated by the overcrowded and unsanitary conditions and the disease burden in these facilities.
The urgency for taking early and decisive action in correctional facilities is best illustrated by COVID-19 outbreaks
that have occurred in other con ned settings, such as in the long-term care skilled nursing home in King County,
Washington, where ineffective infection control and prevention procedures and staff members working in multiple
facilities contributed to intra- and inter-facility spread in the community (McMichael, Clark, Pogosjans, et al. 2020).
In addition, dozens of nursing homes across 42 states in the United States have suffered outbreaks (Coppola and
Pettersson 2020). Another warning sign of what could happen in the face of inaction in jails and prisons is the
www.pvmarquez.com/prisoncovid19 2/7
1/12/2021 How to Prevent Jails and Prisons from Becoming New Hotspots for the Spread of COVID-19? | Patricio V. Marquez
COVID-19 outbreaks on cruise ships, which are often settings for infectious disease transmission because of their
closed environment and contact between travelers from many countries. As documented, more than 800 cases of
laboratory-con rmed COVID-19 cases occurred during outbreaks on three cruise ship voyages, and cases linked to
several additional cruises have been reported across the United States (Moriarty, Plucinski, Marston, et al. 2020).
Places of worship could also become loci of infection if religious institutions facilitate the congregation of large
number of people by not closing services.
While case detection, contact tracing, medical isolation, quarantines, and social distancing, along with basic
sanitation measures such as hand washing, are critical measures to “ atten the curve” of the COVID-19 pandemic
among the civilian population, the adoption of these measures in the closed environment of jails and prisons
presents signi cant challenges. Given the nature and characteristics of these facilities, it would be dif cult or
impossible for most incarcerated people to follow guidelines on social distancing, since they are living in
overcrowded quarters, interact in dining halls, and sleep in rows of beds in a common room, have two or more
people in a single cell, and have to use group showers and bathrooms that serve dozens, often without running
water, with broken sanitation services, and lacking soap, towels to dry hands, and other supplies for disinfecting
surfaces (Flagg and Neff 2020).
Since these dire conditions are typical of jails and prison systems across the world, it is imperative that allocation of
required resources for supporting prevention, containment, and mitigation activities in these settings be included as
part of country-wide emergency response strategies to prevent that these facilities become “transmission centers”
for COVID-19. If widespread COVID-19 outbreaks occur in jails and prisoners, a large number of patients at once
may overwhelm the often-constrained capacity of the healthcare services in the penitentiary system but also of
referral hospitals in the community where the very sick and dying will be transferred.
Policy and Institutional Measures to Minimize COVID-19 Risk
Different observers and organizations have highlighted possible actions that if effectively implemented could help
inhibit the spread of this highly infectious virus among those already incarcerated, prison guards, correctional staff,
and administrators, and among people on probation or parole, who are in regular contact with the penal system
(Prison Policy Initiative 2020; CDC (2) 2020; American Correctional Association Resources 2020; Markham 2020).
Some of the proposed actions include the following:
Release people from jails and prisons following depopulation and de-incarceration policies and strategies. As
noted above, jails and prisons house large numbers of people with chronic health conditions and diseases that make
them more vulnerable to COVID-19. One way to protect these vulnerable populations is to reduce overcrowding in
correctional facilities by releasing inmates charged with low-level, non-violent crimes and elderly and in rm
inmates, and by focusing on preventing people with health issues who are charged with non-violent offenses from
going into the prison system in the rst place, for example, by allowing the posting of personal bonds. Different
states in the United States such as California, Ohio, New Jersey, and Texas have undertaken the controlled release of
low-level offense prisoners and have pushed for the “compassionate release” of inmates over age 50 facing
nonviolent charges (Tamkin 2020; Williams, Weiser, and Rashbaum 2020). In other countries, such as Iran, 54,000
prisoners have been temporarily released to combat the COVID-19 spread (BBC 2020). The adoption of these
measures would in turn help to reduce the risk of unrest and rioting by prisoners who fear being the last in line to
be tested and at high risk of being infected as recently seen in several countries such as Brazil, Colombia, France,
Italy and Venezuela (Turkewitz 2020; Amante 2020). The pandemic also offers the opportunity to release political
prisoners on humanitarian grounds.
www.pvmarquez.com/prisoncovid19 3/7
1/12/2021 How to Prevent Jails and Prisons from Becoming New Hotspots for the Spread of COVID-19? | Patricio V. Marquez
Reduce jail and prison admissions. This action will help slow down the rapid movement of people in and out of jails
and prisons, while also facilitating the reduction of the incarcerated population. Rather than arresting and locking
up more people in jail and prisons for misdemeanors and nonviolent felony offenses, and in some countries, for
nonviolent immigration or drug charges, public of cials have started to order the police to issue citations and to
strike plea deals to resolve cases quickly (Gillispie 2020). There are other innovative approaches that could be used
during the pandemic. For example, as reported in an article in The Financial Times, approaches being implemented
with good results in the United States, such as the “judge-led therapy programs”, offer non-violent offenders with
mental and substance use disorders the opportunity to avoid jail, by agreeing to intensive mentoring and support
(Waldmeir 2018). Among the vast majority of offenders who opt for this alternative approach, where they are
connected with housing and other services, it has been reported that recidivism is low, patients get the support they
need, and the judicial system saves a signi cant amount of funds that could be directed to improve the health and
sanitary conditions in jails and prisons.
Reduce or suspend visitation by community members, limit visits by legal representatives, and reduce facility
transfers for incarcerated persons. As observed in a recent article, physical contact between staff and the
incarcerated is often unavoidable: while of cers ngerprint, handcuff and supervise prisoners, as well as escort
them to court and drive them to medical appointments, many other people also ow in and out of jails, like family
members who visit; volunteers who counsel or teach or preach; contractors who stock vending machines; and
lawyers who meet their clients (Flagg and Neff 2020). The adoption of social distancing actions to limit visits,
services, and vendors, and by moving to online and phone communication, is a required disease prevention measure
to reduce the risk of asymptomatic cases spreading COVID-19 in jails and prisons.
Improve capacity for infection prevention and control, and well as care and treatment, in the penitentiary health
system. This would require that the penitentiary facilities have in place health promotion and disease prevention
measures, the capacity to monitor the onset of infectious diseases, test individuals who present COVID-19
symptoms (e.g., fevers, coughs, and symptoms of respiratory illness) and have a known exposure to the virus, record
and report to national health department positive COVID-19 cases, and conduct epidemiological investigations to
identify individuals who may have had close contact with infected individuals (CDC (2) 2020). Prison health services
need to also medically isolate suspected and con rmed cases from the prison general population, follow up the
progression of the infection by taking the temperatures of inmates who are elderly, are considered at risk for the
virus, or are in medical isolation, and treat or refer to specialized facilities patients with severe COVID-19 disease
and other co-occurring chronic health conditions in accordance with national standards. Additional measures
include medical screenings for all staff entering a prison, including temperature checks with no-touch
thermometers and denial of entry to a prison to anyone with a temperature of 100 degrees or more, has symptoms
of respiratory illness, or who has been exposed in the past 14 days to anyone who is suspected or diagnosed with
COVID-19. A 14-day quarantine period, in addition to previously noted medical screening, could be instituted for all
incoming prisoners to prevent the introduction of COVID-19 into the prison system. The use of washable masks
should also be promoted in all sites where there have been reported COVID-19 cases, as well as ensuring the
availability of personal protective equipment, face shields and masks, and protective gowns for prison health
workers and other staff in direct contact with infected inmates, as well as establishing designated rooms to separate
infected people from other inmates. A comprehensive response that connects correctional facilities and the
community is of great importance for managing transition in the care of people to and from the community given
the “revolving door” nature of jails and prisons.
Eliminate medical co-pays. In countries where universal nancial protection in health is lacking or limited such as
in the United States, incarcerated people are expected to make copayments for physician visits, medications, and
testing. As observed among the civilian population, the imposition of medical copayments becomes a barrier that
discourages demand and utilization of needed medical services, which in turn will only help increase the tally of
infected cases within the facility’s inmate population and security and administrative personnel.
www.pvmarquez.com/prisoncovid19 4/7
1/12/2021 How to Prevent Jails and Prisons from Becoming New Hotspots for the Spread of COVID-19? | Patricio V. Marquez
Way Forward
The impact of the adoption of the measures described above would have dual bene ts: on one hand, it would help
prevent the spread of COVID-19 among inmates and penitentiary system workers, and hence among their families
and surrounding communities, that could undermine efforts to atten the curve in countries. It would also help
contain a resurgence of the virus during the suppression phase of the pandemic. And, on the other hand, it would
help advance prison reform by depopulating jails and prisons in combination with the provision of health care,
rehabilitation, education and skills development, and social support programs as an alternative to incarceration. A
glimmer of hope? Yes, but one that is possible if political commitment and public and private efforts push forward
these policy choices as part of a multisectoral strategy for human capital development, and as a moral imperative in
society to offer vulnerable people a second chance for rebuilding their lives.
Picture 1 Inside the Prison Industrial Complex, Guess Contributor.
https://www.patheos.com/blogs/rhetoricraceandreligion/2015/09/inside-the-prison-industrial-complex.html
Picture 2 “Detainees in Manila City Jail, where most are still awaiting trial, and may stay for months or even years
before that happens.” By Hannah Reyes Morales for The New York Times
https://www.nytimes.com/2019/01/07/world/asia/philippines-manila-jail-overcrowding.html
(https://www.nytimes.com/2019/01/07/world/asia/philippines-manila-jail-overcrowding.html)
Sources
Amante, A. 2020. “Death toll rises from Italy's coronavirus prison riots.” Reu… (https://www.reuters.com/article/us-
health-coronavirus-italy-prisons/death-toll-rises-from-italys-coronavirus-prison-riots-idUSKBN20X2DG)
American Correctional Association Resources. 2020 [internet publication].
(http://www.aca.org/ACA_Prod_IMIS/ACA_Member/Healthcare_Professional_Interest_Section/Copy_of_Coronav
Akiyama, MJ, Spaulding, AC, and Rich, JD. 2020. “Flattening “Flattening the Cur…
(https://www.nejm.org/doi/pdf/10.1056/NEJMp2005687?articleTools=true)
BBC. 2020. “Coronavirus: Iran temporarily frees 54,000 prisoners to combat spre…
(https://www.bbc.com/news/world-middle-east-51723398)
Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine …
(https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30460-8/fulltext)
Centers for Disease Control and Prevention (1). “Coronavirus disease 2019 (COVI…
(https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e1.htm?s_cid=mm6912e1_w)
Centers for Disease Control and Prevention (2). 2020. “Interim Guidance on Man…
(https://www.cdc.gov/coronavirus/2019-ncov/community/correction-detention/guidance-correctional-
detention.html)
CNA Publication. 2020. “COVID-19 fears spark Thailand prison riot.” [internet …
(https://www.channelnewsasia.com/news/asia/covid-19-fears-spark-thailand-prison-riot-12587548?
cid=h3_referral_inarticlelinks_24082018_cna)
Coppola, G. and Pettersson, E. 2020. “Americans Most Likely to Be Infected: Th…
(https://www.bloomberg.com/news/articles/2020-04-11/americans-most-likely-to-be-infected-the-faithful-
jailed-or-old?utm_campaign=news&utm_medium=bd&utm_source=applenews)
Elinson, Z, and Gurman, S. 2020. “Prisoners Riot as Coronavirus Tensions Rise.”…
(https://www.wsj.com/articles/prisoners-riot-as-coronavirus-tensions-rise-11586469284)
Flagg, A and Neff, J. “Why Jails Are So Important in the Fight Against Coronav…
(https://www.nytimes.com/2020/03/31/upshot/coronavirus-jails-prisons.html)
www.pvmarquez.com/prisoncovid19 5/7
1/12/2021 How to Prevent Jails and Prisons from Becoming New Hotspots for the Spread of COVID-19? | Patricio V. Marquez
Gillispie, M. 2020. “Of cials taking steps to reduce county jail population…
(https://apnews.com/f169524cbc6ca3282938edac611593fc)
Markham, J. 2020. “The Correctional System Responds to COVID-19 (and Some Preli…
(https://nccriminallaw.sog.unc.edu/the-correctional-system-responds-to-covid-19-and-some-preliminary-
thoughts-on-minimizing-correctional-interactions/)
Marquez, PV. 2020. “Does Tobacco Smoking Increases the Risk of Coronavirus Dise…
(http://www.pvmarquez.com/Covid-19)
Marquez, PV. 2018. “Mental Health in Prisons: How to Overcome the Punishment Pa…
(https://blogs.worldbank.org/health/mental-health-prisons-how-overcome-punishment-paradigm)
McMichael TM, Clark S, Pogosjans S, et al. COVID-19 in a Long-Term Care Facilit…
(http://dx.doi.org/10.15585/mmwr.mm6912e1)
Moriarty LF, Plucinski MM, Marston BJ, et al. Public Health Responses to COVID-…
(http://dx.doi.org/10.15585/mmwr.mm6912e3)
Prison Policy Initiative. 2020. “No need to wait for pandemics: The public heal…
(https://www.prisonpolicy.org/blog/2020/03/06/pandemic/)
Ransom, J. and Feuer, A. 2020. “A Storm Is Coming’: Fears of an Inmate Epidemi…
(https://www.nytimes.com/2020/03/20/nyregion/nyc-coronavirus-rikers-island.html)
Roth, A. 2018. “Insane: America’s Criminal Treatment of Mental Illness.” Basic… (http://alisaroth.com/)
Simons, D, Perski, O, Brown, J. 2020 “Covid-19 The role of smoking cessation d…
(https://blogs.bmj.com/bmj/2020/03/20/covid-19-the-role-of-smoking-cessation-during-respiratory-virus-
epidemics/)
Subramanian, R, Henrichson, C, and Kang-Brown, J. 2015. “In Our Own Backyard: …
(https://www.vera.org/publications/in-our-own-backyard-confronting-growth-and-disparities-in-american-jails)
Tamkin, E. 2020. “What does coronavirus mean for the US’s prison population?” …
(https://www.newstatesman.com/world/north-america/2020/03/what-does-coronavirus-mean-us-s-prison-
population)
The Legal Aid Society. “COVID-19 Infection Tracking in NYC Jails.” [internet p… (https://legalaidnyc.org/covid-19-
infection-tracking-in-nyc-jails/)
The Marshall Project. 2020. Reporting on the COVID-19 pandemic, criminal justic…
(https://www.themarshallproject.org/2020/03/31/why-jails-are-so-important-in-the- ght-against-coronavirus)
Turkewitz, J. 2020. “Prison riots in Colombia over virus fears leave at least …
(https://www.nytimes.com/2020/03/22/world/americas/colombia-prison-riot-dead.html)
Vardavas CI, Nikitara K. COVID-19 and smoking: a systematic review of the evide…
(http://www.tobaccoinduceddiseases.org/COVID-19-and-smoking-A-systematic-review-of-the-
evidence,119324,0,2.html)
Waldmeir, P. 2018. “‘None of these people ever gave up on me’: America’s drug …
(https://www.ft.com/content/8a1ee8f0-a593-11e8-926a-7342fe5e173f)
Walmsley, R. “World Prison Population List.” Eleventh Edition. Institute for Cr…
(https://www.prisonstudies.org/sites/default/ les/resources/downloads/world_prison_population_list_11th_editi
Williams, T, Weiser, B, and Rashbaum, WK. 2020. “‘Jails Are Petri Dishes’: Inm…
(https://www.nytimes.com/2020/03/30/us/coronavirus-prisons-jails.html)
www.pvmarquez.com/prisoncovid19 6/7
1/12/2021 Does Tobacco Smoking Increases the Risk of Coronavirus Disease (Covid-19) Severity? The Case of China | Patricio V. Marquez
Does Tobacco Smoking Increases the Risk of Coronavirus
Disease (Covid-19) Severity? The Case of China
Submitted by Patricio V. Marquez on Tue, 03/03/2020 - 02 20 PM
Does Tobacco Smoking Increases the Risk of Coronavirus
Disease (Covid-19) Severity? The Case of China
Posted by Patricio V. Marquez on Tue, 03/03/2020 - 02 20 PM
Since December 2019, when Covid-19 emerged in Wuhan city and subsequently spread across China causing varying
degrees of illness, the virus has now infected 92,100 people in at least 70 countries. Data reported from China
provide insights into the biology, epidemiology, and clinical characteristics of Covid-19.
Men are at higher risk of Covid-19
When assessing the data on the personal characteristics of affected patients, the sex distribution of the disease
clearly shows a male predominance of Covid-19. Indeed, as reported by Chinese researchers in the New England
Journal of Medicine, (Guan, Ni et al 2020), among a sample of 1099 patients, with laboratory-con rmed disease, from
552 hospitals in 30 provinces, autonomous regions, and municipalities in China through January 29, 2020, the
median age of patients was 47 years and 58.1 percent of the patients were male. Also, among the initial 425 cases
of that occurred in Wuhan, Hubei Province, China, in December 2019 and January 2020, the median age was 59 years
and 56 percent were male (Li, Guan, et al 2020). Moreover, an article published at the Journal of the American
Medical Association (JAMA), noted that the death rates among men infected with the coronavirus, particularly
those in their late 40s and older, have exceeded those among women (del Rio and Malani 2020).
In previous coronavirus outbreaks, such as the SARS and MERS outbreaks, men were also disproportionally
affected. In Hong Kong in 2003, for example, men with SARS had a 50 percent excess risk of death than females
(Leung, Hedley, et al 2004).
What explains this discrepancy?
www.pvmarquez.com/Covid-19 1/5
1/12/2021 Does Tobacco Smoking Increases the Risk of Coronavirus Disease (Covid-19) Severity? The Case of China | Patricio V. Marquez
While that cause is not known, it is suggested that a higher prevalence of tobacco smoking among Chinese men,
often resulting in compromised lung function, may help explain it (del Rio, Milani 2020). Tobacco use also
contributes to the onset of other co-occurring conditions such as cardiovascular diseases, lung cancer, chronic
obstructive pulmonary disease (COPDs), and diabetes, which are more prevalent among males and account for a
signi cant share of the total disease burden in China (Wang, Marquez, Langenbrunner 2011). The existence of pre-
existing conditions increases the risk of disease severity and death among Covid-19 patients, similar to the
situation with in uenza (Fauci, Lane, Red eld 2020).
Data presented in above-mentioned New England Journal of Medicine article (Guan, Ni, et al 2020), further
illustrate the relative impact that tobacco smoking has on the spectrum of the Covid-19 progression and mortality in
a nationwide sample of 1099 Covid-19 patients, with laboratory-con rmed diseases:
12.6% of patients were current smokers, and 1.9% former smokers.
Among those that developed a severe disease (N=173), 16.9% were current smokers and 5.2% former smokers.
Among patients with presence of primary composite end point (admission to an intensive care unit, the use of
mechanical ventilation, or death) (N=67), 25.8% were current smokers and 7.6% former smokers.
The epidemic of tobacco use in China
We should not be surprised by the role of tobacco smoking in explaining the difference in the sex distribution and in
the severity of Covid-19 in China. China has the largest smoking population in the world, with around 316 million
adult smokers, and accounts for nearly one-third of smokers and 40 percent of tobacco consumption worldwide.
While the prevalence of smoking in women is still relatively low at 1.9 percent, among males, the prevalence was
estimated at 48.4 percent in 2016 (World Bank Development Indicators). Smoking prevalence also varies across
cities and provinces within China.
Since the lung is an organ directly affected by cigarette smoking, various respiratory diseases including lung
cancer, chronic obstructive pulmonary disease, interstitial lung diseases, and bronchial asthma, are caused and
worsened by cigarette smoking not only in the case of active smoking but also in the case of passive smoking. In
2010, an estimated 1.2 million premature deaths were attributable to smoking in China, and the three leading causes
of death (stroke, ischemic heart disease, and chronic obstructive pulmonary disease) were linked to tobacco
consumption. As documented in a recent study, China is in the midst of a lung cancer epidemic on an
unprecedented scale, and tobacco smoke exposure is the primary factor driving current lung cancer trends
(Parascandola and Xiao, 2019). Lung cancer is now the most commonly diagnosed cancer and the leading cause of
cancer mortality in China. In 2015, there were an estimated 733,000 new lung cancer cases (17 percent of total
cancer incidence) and 610,000 deaths (21.7 percent of total cancer mortality) in China.
How does smoking affect lung health?
Acute respiratory illnesses are divided into those that include the upper respiratory tract (nose and pharynx) and
larynx, and those that include the lower respiratory tract (below the larynx). In people with normal immune systems,
viruses account for most cases of upper respiratory syndromes (Gwaltney 1995c): acute bronchitis (Gwaltney 1995a,
as cited in U.S. Department of Health and Human Services 2004), bronchiolitis (Hall and Hall 1995, as cited U.S.
Department of Health and Human Services 2004), and a majority of pneumonia cases (Marrie et al. 1989, as cited in
U.S. Department of Health and Human Services 2004). Bacteria can cause pharyngitis (Gwaltney 1995b, as cited in
U.S. Department of Health and Human Services 2004) and some pneumonias (Marrie et al. 1989, as cited in U.S.
Department of Health and Human Services 2004).
As clearly explained in the 2004 US Surgeon General Report (U.S. Department of Health and Human Services. 2004),
www.pvmarquez.com/Covid-19 2/5
1/12/2021 Does Tobacco Smoking Increases the Risk of Coronavirus Disease (Covid-19) Severity? The Case of China | Patricio V. Marquez
“Toxins in tobacco smoke harm the body from the moment they enter through the mouth and nose. They damage
tissue and cells all the way to the lungs. When cigarette smoke is inhaled, chemicals from the smoke are absorbed in
the lungs. As a result, smoking causes lung diseases, including the majority of cases of chronic obstructive
pulmonary disease (COPD); makes chronic lung diseases more severe; and increases the risk for respiratory
infections. Genetic factors make some people more susceptible to lung disease from smoking. Although the lung
has ways to protect itself from injury by inhaled agents, these defenses are overwhelmed when cigarette smoke is
inhaled repeatedly over time. After years of exposure to cigarette smoke, lung tissue becomes scarred, loses its
elasticity, and can no longer exchange air ef ciently.”
The evidence is suf cient to infer a causal relationship between smoking and acute respiratory illnesses,
including pneumonia, in persons without underlying smoking-related chronic obstructive lung disease. In the
case of acute respiratory illnesses, it is presumed an infection is the predominant underlying cause, but smoking
might act to increase the frequency or severity of infections. A systematic review and meta-analysis, showed that
smoking was consistently associated with higher risk of hospital admissions after in uenza infection (Han, Ran, et al
2019).
As reported in the 2004 US Surgeon General report (U.S. Department of Health and Human Services. 2004), there
are several U.S. population-based studies that provide evidence of a link between cigarette smoking and acute lower
respiratory tract infections. A population based, case-control study of 205 cases of community acquired pneumonia
(Almirall et al. 1999a, b) reported an attributable risk of 23.0 percent for a history of ever smoking. The US Centers
for Disease Control and Prevention sponsored a case-control study of invasive pneumococcal disease based on a
population surveillance system (Nuorti et al. 2000), showed among cases for which pneumonia is likely to have been
the main diagnosis, the population attributable risk estimate for smoking was 51 percent, compared with 14 percent
for chronic illnesses. The authors estimated that reducing the prevalence of smoking to 15 percent among persons
aged 18 through 64 years would prevent 4,000 cases per year of invasive pneumococcal disease in the United States.
Of particular interest in this study was the observation that after 10 years of smoking cessation, the risk of invasive
pneumococcal disease reached that of nonsmokers.
What to do?
The initial data from the Covid-19 outbreak in China, shows that smoking among men may explain the difference
in the sex distribution of the disease, as well as in its severity. This on top of existing evidence on the high human
toll and economic impact of tobacco-attributable diseases in China, which as co-occurring conditions further
impact negatively Covid-19 patients.
Governments have an obligation and the means to protect their population’s wellbeing by adopting population-
based disease prevention measures (for example, scal and regulatory measures), in addition to providing
medical care to those persons who fall ill. In the case of tobacco control, the most cost-effective policy measure
is to control and prevent tobacco use, is tobacco taxation (Marquez and Moreno-Dodson 2017). On the basis of the
Covid-19 experience, and building upon the 2015 tobacco tax increase, it would be of paramount importance for the
government in China to act boldly and swiftly to reform tobacco taxation for health and scal gains, as well as to
promote human capital development.
While the 2015 tobacco tax increase has generated measurable public health and scal bene ts, the price of
cigarettes in China continues to be low and increasingly affordable for a population that enjoys rapid wage
increases (Marquez and Zheng 2016; Zheng, Hu, Wang, and Marquez, 2017). If the ultimate goal is to help smokers
quit and prevent the next generation from getting addicted to smoking cigarettes and hence signi cantly reduce
health risks, then additional tobacco tax policy reforms are urgently needed in China, especially for re-orienting the
excise tax structure towards speci c excise taxes at the retail level in the medium-term and towards a uniform tax
www.pvmarquez.com/Covid-19 3/5
1/12/2021 Does Tobacco Smoking Increases the Risk of Coronavirus Disease (Covid-19) Severity? The Case of China | Patricio V. Marquez
system at the retail level in the long-term. A recent study estimated that a 50 percent increase in tobacco price
through excise taxes would lead over 10 years to 5.3 million years of life gained and would reduce expenditures on
tobacco-related disease treatment by US$2.4 (Verguet, Gauvreau, Mishra, MacLennan, Murphy, Brouwer, Nugent,
Zhao, Jha, Jamison 2015).
Looking into the future, as evidenced in a World Bank study “Toward a Healthy and Harmonious Life in China:
Stemming the Rising Tide of Non-Communicable Diseases” (Wang, Marquez, Langenbrunner 2011), with stronger
tobacco control measures including steeper tobacco tax increases, the rapid rise in China's non-communicable
diseases, that compound the impact of infectious diseases as we are now witnessing with Covid-19, can be halted,
resulting in major gains for people’s health and the country’s social and economic development.
However, if an effective response is not mounted in China to control and reduce tobacco use after overcoming
Covid-19, the disease burden posed by these conditions will aggravate the economic and social impact of the
expected population explosion of older citizens and smaller workforce in China. And, a reduced ratio of healthy
workers to sicker, older dependents, will certainly increase the odds of a future economic slowdown and pose a
signi cant social challenge in China.
Sources of Photos:
First Photo: Mark Schiefelbein/Associated Press, as published in the NYT on March 3 2020
Second Photo: Agence France-Presse, Getty Images, as published in the NYT on March 3 2020
Sources
Almirall J, Bolíbar I, Balanzó X, González CA. 1999a. “Risk factors for communi…
(https://pubmed.ncbi.nlm.nih.gov/10065680-risk-factors-for-community-acquired-pneumonia-in-adults-a-
population-based-case-control-study/)
Almirall J, González CA, Balanzó X, Bolíbar I. 1999b. “Proportion of community-…
(https://journal.chestnet.org/article/S0012-3692(15)38022-3/fulltext)
Del Rio, C., and Malani, P.N. 2020. “Covid-19-New Insights on a Rapidly Changi…
(https://jamanetwork.com/journals/jama/fullarticle/2762510)
Fauci, AS., Lane, HC, M.D., and Red eld, RR. 2020. “Covid-19 — Navigating the …
(https://www.nejm.org/doi/full/10.1056/NEJMe2002387?query=recirc_curatedRelated_article)
Guan, W, Ni, Z, Hu, Y, et al. 2020. Clinical characteristics of coronavirus di…
(https://www.nejm.org/doi/full/10.1056/NEJMoa2002032?query=recirc_mostViewed_railB_article)
Han, L, Ran, J, Mak, Y-W; Suen, LK-; Lee, P, et al. 2019. “Smoking and In uen…
(https://journals.lww.com/epidem/Abstract/2019/05000/Smoking_and_In uenza_associated_Morbidity_and.15.as
Leung, G.M, Hedley, A.J, Ho, L.M, Chau, P, et al. 2004. “The epidemiology of s…
(https://www.ncbi.nlm.nih.gov/pubmed/15520422)
Li, Q, Guan, X, Wu, P, et al. 2020. Early transmission dynamics in Wuhan, Chin…
(https://www.nejm.org/doi/full/10.1056/NEJMoa2001316)
Marquez, PV, and Zheng, R. 2016. “China’s 2015 tobacco tax adjustment: a step i…
(https://blogs.worldbank.org/health/china-s-2015-tobacco-tax-adjustment-step-right-direction)
Marquez, PV, and Moreno-Dodson, B. 2017. “Tobacco tax reform at the crossroads …
(http://documents.worldbank.org/curated/en/491661505803109617/Main-report)
Nuorti JP, Butler JC, Farley MM, Harrison LH, McGeer A, Kolczak MS, Breiman RF…
(https://www.nejm.org/doi/full/10.1056/NEJM200003093421002)
www.pvmarquez.com/Covid-19 4/5
1/12/2021 Does Tobacco Smoking Increases the Risk of Coronavirus Disease (Covid-19) Severity? The Case of China | Patricio V. Marquez
Parascandola M, Xiao L. 2019. “Tobacco and the lung cancer epidemic in China.” …
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6546632/pdf/tlcr-08-S1-S21.pdf)
U.S. Department of Health and Human Services. 2004. “The Health Consequences of…
(https://www.ncbi.nlm.nih.gov/books/NBK44695/)
Verguet, S, Gauvreau, CL, Mishra, S., MacLennan, M, Murphy, SM, Brouwer, ED, Nu…
(https://www.thelancet.com/pdfs/journals/langlo/PIIS2214-109X(15)70095-1.pdf)
Wang, S, Marquez, PV, Langenbrunner, J. 2011. “Toward a Healthy and Harmonious …
(http://documents.worldbank.org/curated/en/618431468012000892/pdf/634260WP00Box30of cial0use0only090.pd
World Bank Development Indicators. Accessed at: (https:/ /data.worldbank.org/indicator/SH.PRV.SMOK.MA?
view=chart)
Zheng, R, Hu, X, Marquez, PV, Wang Y. 2017. “Cigarette affordability in China: …
(http://documents.worldbank.org/curated/en/130301492424519317/Cigarette-affordability-in-China-2001-2016)
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/Covid-19 5/5
1/12/2021 The Unpredictable Social and Economic Cost of the Coronavirus (Covid-19) Outbreak | Patricio V. Marquez
The Unpredictable Social and Economic Cost of
the Coronavirus (Covid-19) Outbreak
Submitted by Patricio V. Marquez on Thu, 02/27/2020 - 10 01 PM
The Unpredictable Social and Economic Cost of
the Coronavirus (Covid-19) Outbreak
Posted by Patricio V. Marquez on Thu, 02/27/2020 - 10 01 PM
With the realization that a novel coronavirus pandemic (Covid-19) is likely, people across the
globe are getting alarmed, and nancial markets are starting to tumble. Given inadequate
expenditures on public health and insuf cient disease prevention effort, perhaps this is an
opportune time for high level political authorities, ministers of nance, and other global
actors to once and for all be convinced that predictable and sustainable budgetary
allocations for disease prevention, early detection, surveillance, preparedness, and
response capacity across a medical care continuum is not an optional expenditure, that be
neglected due to political shortsightedness or per the whims of scal rectitude. Rather,
these allocations should be considered priority investments in country budgets to enhance
societal resilience and preparedness to prevent and control the emergence and reemergence
of highly infectious pathogens, such as Covid-19.
www.pvmarquez.com/coronavirus 1/8
1/12/2021 The Unpredictable Social and Economic Cost of the Coronavirus (Covid-19) Outbreak | Patricio V. Marquez
If we look at the consequences of recent infectious disease outbreaks, one learns about their
destructive potential, both in terms of human toll and severe economic disruptions. In
particular, in uenza, a zoonotic disease (animal to human transmission), poses an
unpredictable threat of international importance because of its potential capacity to mutate
in ways that allows sustained human-to-human transmission across national borders and
continents.
The impact of the 1918-1919 In uenza Pandemic, for example, was enormous (Garrett, TA,
2007). It killed 40 million people worldwide from the early spring of 1918 through the late
spring of 1919. Only the Black Death that spread throughout Europe from 1348-1351 killed
more people (roughly 60 million) over a similar time period. Data for the United States shows
that since males aged 18 to 40 were the hardest hit by the in uenza, it had serious economic
consequences for the families that had lost their primary breadwinner. Although the 1918-
1919 in uenza pandemic in the United States was short-lived, an assessment by the US
Federal Reserve Bank of St. Louis documented that many businesses, especially those in the
service and entertainment industries, suffered double-digit losses in revenue. Other
businesses that specialized in health care products, however, experienced an increase in
revenues (Garrett, TA, 2008).
More recently, the SARS outbreak in 2003 killed an estimated 10 percent of more than 8,000
individuals infected (National Institute of Medicine, 2004). Estimates done suggest that the
cost in 2003 of SARS for the world economy as a whole was close to US$40 billion. The SARS
shock disproportionately affected Hong Kong due to its economic dependence on services
(e.g., travel, tourism), and signi cant short-term losses also accrued in China as a result of a
sharp decrease in foreign investment.
What caused the economic loss? According to Jong-Wha Lee and Warwick J. McKibbin (2004),
researchers who studied the economic impact of the SARS epidemic, the impact was due not
to the consequence of the disease itself for the affected people, but to the impact of the
disease on the behavior of many people within these economies. They also observed that
the impact depended on the disease associated adjustment of expectations re ected in
integrated real and nancial markets. So, given the spread of the disease through droplet
transmission, people tried to minimize face-to-face interactions. The result was a drop in
demand in service sectors such as tourism, mass transportation, retail sales, hotels and
restaurants. Business costs also increased due to workplace absenteeism, disruption of
production processes and shifts to more costly procedures.
www.pvmarquez.com/coronavirus 2/8
1/12/2021 The Unpredictable Social and Economic Cost of the Coronavirus (Covid-19) Outbreak | Patricio V. Marquez
In low- and middle-income countries, infectious disease outbreaks have the potential to erase
development gains, aggravating poverty and inequality. World Bank Group estimates
showed that the Ebola epidemic in West Africa in 2014-2015 severely weakened the
economies of the affected countries (World Bank, 2015). The three affected countries were
growing briskly in the rst half of 2014, but full-year 2014 growth dropped to an estimated 0.5
percent in Guinea, although a growth rate of 4.5 percent was expected before the crisis. In
Liberia it fell to an estimated 2.2 percent from 5.9 percent expected before the crisis and, in
Sierra Leone, it fell to 4.0 percent from 11.3 percent expected before the crisis. While these
rates already imply shrinking economies in the second half of 2014, the estimates showed that
second-round effects and investor aversion led to a 2015 growth of -0.2 percent in Guinea,
3.0 percent in Liberia, and -2.0 percent in Sierra Leone. The estimates imply foregone
income of about US$1.6 billion across the three countries in 2015 alone. This is more than
12 percent of their combined GDP and has translated into weaker revenues, while
government spending needs grew, with a severe negative impact on public nances that
may derail country investments needed to attain the Sustainable Development Goals (SDG)
by 2030. Besides the nancial cost posed by these disease outbreaks, human capital
development stand to be affected due to the loss of lives, particularly of health workers who
were infected and died in the line of duty.
While the world is nowadays concerned about the Covid-19 spread, with an increasing
number of countries reporting new cases and deaths (as of today, 48 countries, 82,700
infected people per of cial counts, and at least 2,809 people have died, all but 65 in mainland
China), it is important to understand how this public health crisis is starting to impact
economic activity globally. As assessed in a Financial Times (FT) article (Greene, M, 2020),
one transmission mechanism from China’s coronavirus is the interruptions to global supply
chains which may cause problems for growth and international markets. While the Chinese
government has adopted measures to mitigate the impact on rms and households in the
country, the resumption of activity may be hindered by bottlenecks caused by depleted
inventories, delays in reopening factories, return of workers to places of work, reactivation of
transport, and the reopening of ports. Given that Chinese rms are integrated into
“complex, global supply chains” and western rms depend on Chinese inputs for their
production lines, the disruptions in China may cause rms in other countries to look for new
suppliers (not an easy task), halt production as it already happened with Korean rms
Hyundai and Kia, or simply go out of business. On the latter point, it is important to observe,
as highlighted in the FT article, that Hubei, the epicenter of the Covid-19 outbreak in China,
is a “cog” in global supply chain in cars, health care, electronics, aerospace and defense, and
construction materials.
www.pvmarquez.com/coronavirus 3/8
1/12/2021 The Unpredictable Social and Economic Cost of the Coronavirus (Covid-19) Outbreak | Patricio V. Marquez
In the nancial markets, fear of a potential hard hit to economic growth and markets if the
virus becomes a full-blown global pandemic, is behind the stock market plunge in global
markets as investors continued to dump stocks and seek safer investments. In the United
States, for example, the S&P 500 index plunged to its worst loss in almost nine years and
investors worldwide grew increasingly fearful that the coronavirus outbreak could cause a
recession as it squeezes corporate pro ts (New York Times, 2020). European stocks were also
trading about 2.5 percent lower after the Nikkei in Japan closed down 2.1 percent. Oil prices
have also fallen, while the price of gold rose, signaling continued nervousness among global
investors.
The New York Times (Phillips, M, 2020) is also reporting that the outbreak has taken a toll
on multinational companies. For instance, Anheuser-Busch InBev is forecasting a steep drop
in quarterly pro t, which led to sharp drop in the value of its shares, while Marriott, the
American hotel company, reported that the virus would weigh on its fee revenue this year.
Shares of Microsoft, the most valuable company in the United States, fell 7 percent after the
company announced that sales in the current quarter would be lower because of the
outbreak’s effect on its supply chain. Companies such as the French cosmetics giant L’Oréal,
and Nestlé, the Swiss-based food company, have announced that they are suspending all
international business for their staff until the end of March. The outbreak could crush
consumer demand as well, as people limit travel or stay home even without a government
order to do so, aggravating economic performance.
What to Do?
A question to pose is what can countries do to contain and mitigate the health, social, and
economic damage of the COVID-19 pandemic?
Dr. Tom Frieden (2020), the former director of the US CDC, has outlined some immediate
and medium-term actions to deal with the initiation and acceleration phases of the
pandemic. A summary of these actions is as follows:
Find out more about how Covid-19 spreads, how deadly it is, and what we can do to
reduce its harms. This information is critical as it would guide decisions about the
interventions to implement.
Reduce the number of people who get infected. The spread of the virus can be minimized
by quickly isolating those who are ill, cleaning potentially contaminated surfaces often,
and changing common routines. And the promotion and adoption of well-known hygienic
habits such as washing hands, covering coughs, and, if a person is sick, staying home or
wearing a mask. If it turns out that many of those infected become severely ill, drastic
social distancing measures such as closing or curtailing hours of schools, limiting public
www.pvmarquez.com/coronavirus 4/8
1/12/2021 The Unpredictable Social and Economic Cost of the Coronavirus (Covid-19) Outbreak | Patricio V. Marquez
gatherings, and reducing social contact may be warranted. We also need to keep in mind,
as advised by Dr. Anthony S. Fauci, director of the US National Institute of Allergy and
Infectious Diseases, that travel restrictions become ‘irrelevant’ in a potential pandemic
because “you can’t keep out the entire world” (Higgins-Dunn, 2020).
Protect health care workers. As witnessed during the West Africa Ebola epidemic of 2014-
2015, a large number of health workers and patients got infections in health care facilities.
To prevent this occurrence, fast and drastic improvements in triage, treatment, cleaning,
and overall infection prevention are required, including ensuring that enough medical
masks are available for health care workers.
Improve medical care and prevention of Covid-19. Since a vaccine is not yet available,
preparation for a worst-case scenario will require training, equipment, and detailed
operational plans for a surge in the number of patients who seek care and for the subset of
those who need to be mechanically ventilated.
Protect health services. During the 2014-2016 Ebola epidemic in West Africa, more people
died because of disruptions in day-to-day health care than died from Ebola. Telemedicine
needs to become much more accessible, and people with chronic conditions should
receive three months of medications whenever possible, in case there are supply
disruptions. Routine vaccinations and other preventive services need to be preserved.
Support social needs. Patients and their families will need support, especially those who
are isolated and less familiar with virtual social support or delivery services.
Protect economic stability. Continuing to plan, teach, learn, and work will reduce
disruption. Businesses need to be ready to maximize telecommuting, increase cross-
training, and operate with as many as 40 percent of their staff ill or quarantined. Mission-
critical enterprises need practical plans to continue to operate.
The Medium-Term Task
Assuming that the world learns from this new disease outbreak, investment and recurrent-
cost funding for veterinary and public health structures and functions in accordance with
one-health principles, coupled with timely access to essential medical care for all when
needed, are an inescapable budgetary priority for all countries to reduce vulnerability and
build resilience to deal effectively with zoonotic diseases that account for 70 percent of
emerging infectious diseases. Indeed, a collaborative, international, cross-sectoral,
multidisciplinary one-health is required to address threats and reduce risks of detrimental
infectious diseases at the animal-human-ecosystem interfaces.
Let’s be clear: globalization is not going to wither away, as it has been part of human history
for millennia. Rather, we are and will continue to live in an increasingly interconnected
world. While there are multiple bene ts from globalization, there are also public health risks
www.pvmarquez.com/coronavirus 5/8
1/12/2021 The Unpredictable Social and Economic Cost of the Coronavirus (Covid-19) Outbreak | Patricio V. Marquez
that are associated with demographic and economic pressures on ecosystems that facilitate
the transmission of new pathogens from animals to humans.
Moving forward, as a colleague from the World Bank Group mentioned to me today, we need
to work hard to ensure that public health investment becomes ingrained in the DNA of
country budgets and in the support programs of bilateral and multilateral organizations, as
well as of private donors. Neglecting to invest in public health will lead to new uncontrolled
infectious disease outbreaks, preventable deaths, and signi cant economic losses.
To this end, echoing a suggestion that I recently made, it would be critical that institutions
such as the World Bank Group and the International Monetary Fund spearhead efforts to
include robust, well-structured and -funded veterinary and public health platforms, including
disease surveillance and preparedness and essential medical care for all, as a critical
indicator in country credit and investment risk assessments ratings, which are used to
determine nancing terms and conditions of of cially supported export credits, as well as
for commercial loans and direct investment decisions by nancial and corporate sectors
(Marquez, PV 2020) This type of institutional “nudge” at the international level is needed to
prevent governments, along with other global stakeholders, from forgetting the lessons of
recent disease outbreaks, with their associated high human toll and signi cant economic
losses.
Although the task at hand is dif cult and will require sustained effort over the medium- and
longer terms, particularly in low- and lower-middle-income countries, it can be
accomplished if we start acting now.
As the saying goes, a crisis poses challenges but also offers opportunities to learn and
evolve. All of us in the global health community have an obligation not only to learn from the
current coronavirus outbreak and what has worked before but to avoid, paraphrasing the
Harvard philosopher George Santayana, being condemned to face unprepared similar crises
in the future.
Source of images:
First Image: Financial Times (FT Weekend), February 22/23 2020
Second Image: Coronavirus Map: Tracking the Spread of the Outbreak, New York Times; data
from The Center for Systems Science and Engineering at Johns Hopkins University; National
Health Commission of the People's Republic of China; local governments. Data as of 9 30 p.m.
E.T., Feb. 27, 2020.
www.pvmarquez.com/coronavirus 6/8
1/12/2021 The Unpredictable Social and Economic Cost of the Coronavirus (Covid-19) Outbreak | Patricio V. Marquez
Sources
Frieden, T. 2020. “Former CDC director: A coronavirus pandemic is inevitable. W…
(https://edition.cnn.com/2020/02/25/health/coronavirus-pandemic-frieden/index.html)
Garrett, TA. 2007. “Economic Effects of the 1918 In uenza Pandemic. Implicatio…
(https://www.stlouisfed.org/~/media/ les/pdfs/community-development/research-
reports/pandemic_ u_report.pdf?la=en)
Garrett, TA. 2008. “Pandemic Economics: The 1918 In uenza and Its Modern-Day I…
(https:// les.stlouisfed.org/ les/htdocs/publications/review/08/03/Garrett.pdf)
Greene, M. 2020. “Investors risk underestimating the impact of coronavirus.” F…
(https://www.ft.com/content/44c9391c-5489-11ea-a1ef-da1721a0541e)
Higgins-Dunn, N. 2020. “Travel restrictions ‘irrelevant’ if coronavirus becomes…
(https://www.cnbc.com/2020/02/26/fauci-travel-restrictions-irrelevant-if-coronavirus-
becomes-a-pandemic.html)
Institute of Medicine. 2004. “Learning from SARS: Preparing for the Next Diseas…
(https://www.nap.edu/catalog/10915/learning-from-sars-preparing-for-the-next-disease-
outbreak-workshop)
Marquez, PV. 2015. “Regional Disease Surveillance in a Globalized World.” World…
(https://blogs.worldbank.org/health/regional-disease-surveillance-globalized-world)
Marquez, PV. 2020 “Public Health Investments and Economic Gains: Learning from …
(http://www.pvmarquez.com/disease_control)
Phillips, M, 2020. “Coronavirus Fears Drive Stocks Down for 6th Day and Into C…
(https://www.nytimes.com/2020/02/27/business/stock-market-coronavirus.html)
Philipson, TJ. 2007. “Economic Epidemiology and Infectious Diseases.” NBER work…
(https://books.google.com/books/about/Economic_Epidemiology_and_Infectious_Dis.html?
id=iMUxAAAAMAAJ)
Jong-Wha Lee, J-W and McKibbin, WJ. “Estimating the Global Economic Cost of SA…
(https://www.nap.edu/catalog/10915/learning-from-sars-preparing-for-the-next-disease-
outbreak-workshop)
World Bank Group. 2015. “The economic impact of Ebola on sub-Saharan Africa: up…
(http://documents.worldbank.org/curated/en/2015/01/23831803/economic-impact-ebola-
sub-saharan-africa-updated-estimates-2015)
www.pvmarquez.com/coronavirus 7/8
1/12/2021 The Unpredictable Social and Economic Cost of the Coronavirus (Covid-19) Outbreak | Patricio V. Marquez
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/coronavirus 8/8
1/12/2021 Public Health Investments and Economic Gains: Learning from Latin America and Caribbean History in the Time of Coronavirus | Patricio V. Marquez
Public Health Investments and Economic Gains: Learning
from Latin America and Caribbean History in the Time of
Coronavirus
Submitted by Patricio V. Marquez on Mon, 02/10/2020 - 05 41 PM
Public Health Investments and Economic Gains: Learning
from Latin America and Caribbean History in the Time of
Coronavirus
Posted by Patricio V. Marquez on Mon, 02/10/2020 - 05 41 PM
With the advent of 2019-nCoV in China, the world has woken up once again to the inexorable reality that
globalization, both the movement of people and goods and services across countries and from continent to
continent, enables the spread of viruses and disease.
While the coronavirus appears to be more infectious than SARS but less lethal, it is already creating global
havoc. As the number of cases increases in China, and new cases are detected and con rmed in different countries,
airlines have cancelled ights to and from China, the global economy is taking a hit, and fear among the population
is rising. The World Health Organization (WHO) with support of social media companies is stepping up its ght
against “disinformation” and “fearmongering.” Countries are also starting to issue calls that the virus is a “serious”
health threat.
All this seems like the rerun of an old movie. I remember vividly the days when working at the World Bank Group
(I retired in August 2019 after 32 years of service globally), I was part of quickly assembled core task teams that were
mandated to prepare in a matter of days, program and budgetary proposals that eventually became the US$1.3
billion Global Avian In uenza Preparedness and Control Framework Program in 2006 and the US$390 million Ebola
Emergency Response Program for West Africa in 2014. In those days as today with coronavirus, panic and
uncertainty in different forms were common currency.
www.pvmarquez.com/disease_control 1/5
1/12/2021 Public Health Investments and Economic Gains: Learning from Latin America and Caribbean History in the Time of Coronavirus | Patricio V. Marquez
The question that we need to ask as these health events are not something new, is what have countries learned to
be ready to deal with these threats? Unfortunately, in many instances, it seems that once the sense of fear has
diminished and the outbreak controlled, it is back to the common practice of undervaluing the importance of having
in place strong “intelligence systems” in the form of disease surveillance systems, public health labs, and trained
personnel, both in the veterinary and public health sectors operating in a coordinated manner. It is clear that all
countries need to have in place robust early detection and con rmation of cases, as well as preparedness platforms,
including medical care systems, along a continuum of action, to deal on time and effectively with disease outbreaks.
Perhaps the most common “fatality” post-disease outbreaks is the lack of predictable and sustained funding for
disease surveillance and emergency preparedness in national budgets that are protected from budgetary cuts that
follow short-term “ scal rectitude” arguments or changing investment priorities that are assumed to have a higher-
rate of return.
Some Historical Antecedents
If we look back in history, there are plenty of examples that illustrate that this should not be the case. History shows
that travelers have spread contagious diseases for centuries. At the same time, the threat of disease has been a
driver for supporting the continuous development of global public health practices and institutions, building
upon accumulated and new scienti c knowledge and technological know-how. The history of public health in
Latin America and the Caribbean, for example, is replete with efforts in sanitation, hygiene, and disease control,
especially directed at old scourges such as yellow fever and malaria.
Since colonial times, outbreaks of disease were common in the countries of Latin America and the Caribbean,
largely as a result of maritime trade and export of agricultural products and minerals that helped integrate them
into the world economy, as well as the development of indigenous commercial interests. In 1515, a smallpox epidemic
in Hispaniola—now the Dominican Republic and Haiti—spread to neighboring islands and to the mainland, leaving a
toll of thousands of victims. This episode was to be registered as the rst epidemic in the colonial period. In the
sixteenth and following centuries, epidemics of different kinds made devastating sweeps across the Americas.
As the spread of disease largely re ected the maritime basis for trade among the colonies, and between the colonies
and the metropolitan powers, such as Spain and Portugal, the principles of isolation and con nement followed in
Europe to control disease outbreaks, were also applied in Latin America and the Caribbean. In practice, beginning in
Hispaniola in 1519, in accordance with the 1423 Venetian quarantine control system, measures to cope with
epidemics centered on the detention of ships and the isolation of their crews and passengers outside the harbors
until suf cient time had elapsed without the outbreak of “pestilences.”
The latter years of the 19th Century and the early 20th Century saw various attempts by the Latin American and
Caribbean countries and the United States to adopt uniform quarantine regulations at different international
conferences, under the aegis of the newly established Pan American Sanitary Bureau in 1902, that preceded the
establishment of WHO. These sought to remove barriers to steam navigation, and to codify new preventive
measures into specific health legislation and programs based on the great microbiological discoveries of Pasteur,
Koch, and Klebs that had revolutionized public health practice in Europe.
From 1880 to 1930, national health departments, the forerunners of the present-day ministries of health, were
created within the ministries of the interior in most Latin America countries. The initial mission of these
departments was to combat the infectious diseases that hampered maritime trade in major port cities and
diminished labor productivity in the countries' export-oriented economies, resting on the acceptance and
application of the germ theory in disease causation that was supported by leading Latin American scientists such as
the Brazilians Oswaldo Cruz and Carlos Chagas, the Cuban Carlos J. Finlay, as well as Walter Reed and others in the
United States. As a result of these efforts, great inroads were made in the conquest of many of the diseases that had
www.pvmarquez.com/disease_control 2/5
1/12/2021 Public Health Investments and Economic Gains: Learning from Latin America and Caribbean History in the Time of Coronavirus | Patricio V. Marquez
warranted quarantine, particularly yellow fever, commonly known as “Yellow Jack”. This represented the principal
scourge of international trade throughout the colonial period, up to the beginning of the 20th Century. As a result of
these efforts, yellow fever disappeared from its well-established foci, Havana, Panama, and Guayaquil.
The completion of the Panama Canal in 1914 was only possible because of the success of major public health
efforts against yellow fever and malaria, diseases that took a heavy toll in terms of lives lost among construction
workers. In turn, the activities undertaken to help build the canal added further impetus to the development of
sanitation programs in the countries of the region by supporting research on the etiology and transmission of
yellow fever and malaria which led to the design of more effective control measures.
In subsequent periods, the activities of the national health departments expanded with the support of the
International Health Commission of the Rockefeller Foundation to undertake land sanitation programs centered
on the control of hookworm infection and malaria, with the aim of improving the productivity of workers in
exporting regions, such as those growing bananas and coffee. The support of the Rockefeller Foundation was also
important for the establishment in 1918 of the School of Public Health, University of São Paulo, following the
example of the Johns Hopkins School of Hygiene and Public Health in Baltimore that was founded in 1916 also with a
grant from the Foundation. Additionally, the Foundation provided fellowships for the training of Latin American
public health cadres (for example, epidemiologists, biostatisticians) to staff the departments, manage public health
programs, and conduct public health research.
During the 1930s and 1940s, changing economic and socio-political conditions led to the elevation of the health
departments to the ministry level and the concurrent expansion of their activities to include the provision of
personal health services for the unemployed and indigent populations. Similarly, the development of medical care
programs under social insurance schemes was directly linked to the process of industrialization. In satisfying the
demands of organized labor forces, these programs served as an important mechanism of social stabilization. In the
last three decades of the 20th Century and in the early 21st Century, the most important public health achievements
in the Latin American and the Caribbean region have continued to be in the areas of infectious disease control.
Mortality rates have declined in virtually every country of the Americas, mainly at the expense of important declines
in infectious diseases.
Take-Away Message
As we have seen throughout history, infectious diseases have recurrent patterns of outbreak and control or silent
occurrence due to ecologic variables that are often difficult to manage, mainly because of social, political, and
economic limitations on the application of known, effective measures for controlling their spread and treating
infected people. The recent outbreaks of infectious disease in the world clearly signal the need, as we saw from
the historical examples in Latin America and the Caribbean, of building and maintaining strong institutions and
systems to prevent the spread of infectious diseases and protect public health and the social and economic well-
being of countries in an ever more interconnected world. And this risk stands to be more menacing in the face of
inaction and misplaced social and economic priorities when one adds the risks posed by rapid urbanization and the
conglomeration of people living in large mega-cities with limited access to basic services, climate change that is
driving the emergence of new pathogens such as the coronavirus and the reemergence of known pathogens such as
Ebola, social con ict and wars that not only breed social dislocation and the displacement of large numbers of
people, but also that hinder public health action, and massive disruption of global supply chains in interconnected
economies.
Indeed, commitment to public health objectives and program needs to be firmly entrenched in the development
programs of governments and supported with the necessary budgetary allocations in a sustainable way.
Financing essential public health functions is a government responsibility as it a basic public good. In most of the
www.pvmarquez.com/disease_control 3/5
1/12/2021 Public Health Investments and Economic Gains: Learning from Latin America and Caribbean History in the Time of Coronavirus | Patricio V. Marquez
world, however, misplaced priorities translate into very low budgetary allocations for essential public health
functions, sometimes amounting to less than 1% of the total public expenditure on health.
While donor contributions help, particularly in low-income countries, governments can mobilize additional tax
revenue as a share of GDP to fund and sustain public health and essential medical care services via better tax
administration (including value-added taxes), tackling tax avoidance and evasion (e.g., taxing nancial capital ows),
broadening the tax base by removing cost-ineffective tax expenditures (e.g., fuel subsidies), and increasing excise
taxes on unhealthy products (including on tobacco, alcohol, and sugar-sweetened drinks). This is needed, as clearly
articulated in a recent article in Foreign Affairs by Nobel Laurate in Economics, Joseph E. Stiglitz and two of his
colleagues, because
“The state requires something simple to perform its multiple roles: revenue. It takes money to build roads and ports, to
provide education for the young and health care for the sick, to nance the basic research that is the wellspring of all
progress, and to staff the bureaucracies that keep societies and economies in motion. No successful market can survive
without the underpinnings of a strong, functioning state.”
So, it would be critical that institutions such as the World Bank Group and the International Monetary Fund
spearhead efforts to include robust, well structured and funded public health platforms, including disease
surveillance and preparedness, as a critical indicator in country credit and investment risk assessments ratings,
which are used to determine nancing terms and conditions of of cially supported export credits, as well as for
commercial loans and direct investment decisions by nancial and corporate sectors. This type of institutional
“nudge” at the international level is needed to prevent governments, along with other global stakeholders, from
forgetting the lessons of recent disease outbreaks, with their associated high human toll and signi cant economic
losses.
The PHOTOGRAPH taken in 1918 at the US Army Hospital Number 30 in Royat, France, is from the Prints and
Photographs Collection, History of Medicine Division, National Library of Medicine. It was included in Fee E et al
article (2001). The pictures shows servicemen watching a movie during the In uenza Pandemic spread worldwide
through 1918–1919. The article notes that “while a civilian debate raged over the compulsory wearing of masks as a
means of slowing the transmission of in uenza, military authorities through the chain of command were more readily
able to impose this requirement on the troops.” (Fee, Brown, Lazarus, Theerman, 2001).
The second photo is from https://www.dominicavibes.dm/wp-content/uploads/2016/07/pp-zika-mosquitos-
getty.jpg
Sources
Fee E, Brown TM, Lazarus J, and Theerman P. 2001. “The In uenza Pandemic of 1…
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1446912/)
Garcia JC. 1981. “La Medicina Estatal en America Latin, 1880-1930.” Revista Lat…
(https://www.researchgate.net/publication/257074716_Social_thinking_in_health_in_Latin_America_revisiting_Ju
Marquez PV, Joly DA. 1986. “Historical Overview of the Ministries of Public Hea… (https://doi.org/10.2307/3342464)
Stiglitz JE, Tucker TN, and Zucman G. “The Starving State Why Capitalism’s Salv…
(https://www.foreignaffairs.com/articles/united-states/2019-12-10/starving-state)
www.pvmarquez.com/disease_control 4/5
1/12/2021 Public Health Investments and Economic Gains: Learning from Latin America and Caribbean History in the Time of Coronavirus | Patricio V. Marquez
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/disease_control 5/5
1/12/2021 Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported | Patricio V. Marquez
Galapagos’ Charles Darwin Foundation:
An International Good Practice that
Needs to be Supported
Submitted by Patricio V. Marquez on Fri, 02/07/2020 - 07 46 PM
Galapagos’ Charles Darwin
Foundation: An International Good
Practice that Needs to be Supported
Posted by Patricio V. Marquez on Fri, 02/07/2020 - 07 46 PM
A couple of weeks ago, I had the honor of being invited by the Charles
Darwin Foundation (CDF) to the screening of a new documentary directed
by Evert van den Bos, Galapagos, Hope for the Future. It was held in New
www.pvmarquez.com/Galapagos_CDF 1/10
1/12/2021 Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported | Patricio V. Marquez
York City as part of a meeting of the Foundation’s Board of Directors, which
offered me the opportunity to meet some of the members and learn more
about its work.
In watching the documentary, I was greatly struck once again by the sheer
beauty of these desolate islands and their unique animals and plants. The
documentary also presents with great clarity how, on a daily basis, teams of
the Foundation and its Research Station, working alongside teams of the
Galapagos National Park Service, conduct vital scienti c research and
complementary action to ensure the conservation of the environment and
biodiversity in the Galapagos Archipelago.
The Archipelago, located in the Paci c Ocean off the coast of Ecuador, is a
UNESCO World Natural Heritage Site. Figuratively speaking, the Galapagos
were “put on the map” and became a magnet of international curiosity and
scienti c interest, with the publication in 1858 of Charles Darwin’s
groundbreaking work of evolutionary biology, On the Origin of the Species.
Indeed, Darwin’s visit to some of the islands in the Archipelago during his
expedition on the HMS Beagle in 1835 helped him collect evidence of
evolution in the diversity of the Galapagos species that led to his
observation that species descending from a common ancestor evolve over
many generations through a process of natural selection (the process
whereby organisms better adapted to their environment tend to survive and
produce more offspring).
In 1959, the Government of Ecuador designated all parts of the islands that
were not inhabited by humans as a National Park (96% of the total
archipelago’s surface area). The same year, the Charles Darwin Foundation
was created, and in 1964, the Charles Darwin Research Station opened to
conduct scienti c studies aimed at protecting indigenous plant and animal
life. In 1968, the Galapagos National Park Service, a governmental
institution, was established to protect the Archipelago.
www.pvmarquez.com/Galapagos_CDF 2/10
1/12/2021 Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported | Patricio V. Marquez
Institutions, such as foundations, can play a major role in a society. Over the
past 60 years, the CDF, operating with limited resources, has become a
beacon of international good practice, offering valuable lessons for the rest
of the world. The vision statement of the CDF clearly illustrates how this
type of role can be operationalized for the common good: “to contribute to
a sustainable Galapagos by providing breakthrough research which informs
conservation actions and inspires humanity to conserve this extraordinary
Archipelago and our planet as a whole.”
As shown in the documentary and described in the CDF’s most recent
Annual Report, the range and value of the work conducted and supported by
the Foundation are outstanding. With a small team of staff and volunteers
(about 217 people), the Foundation oversees and supports work by scholars
and thesis students, both Ecuadorean and from other countries; visiting
scientists developing their own projects with a research permit issued by
the Galapagos National Park; and collaborating scientists who carry out
projects linked to CDF projects.
The research includes marine projects as varied as the study of the status
of the Galapagos penguin, ightless cormorant, and albatross populations;
research on marine invasive species for the prevention, detection, and
management of the Galapagos Marine Reserve (GMR); exploring and
surveying seamounts and other deep water environments between depths
of 40 to 3200 meters in the GMR ; and studies to reduce the threat of vessel
impact for the green turtle in the Islands.
Terrestrial ecosystem research projects include research on ecological
restoration and sustainable agriculture; analysis of satellite images and
drone image processing to map the expansion of invasive plant species;
restoration of scalesia forests, which have a very high biodiversity of
associated plants, birds, and invertebrates, compared to other ecosystems in
the Galapagos; and assessment of the health status of giant tortoise across a
www.pvmarquez.com/Galapagos_CDF 3/10
1/12/2021 Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported | Patricio V. Marquez
human-modi ed environment. The latter study is looking in depth at the
impact on the giant tortoise population of the cohabitation between
tortoises, domestic animals, and humans in the islands that are inhabited by
humans in terms of the spread of diseases and antimicrobial resistance that
can pose a risk for the conservation of this unique species.
The CDF’s work also includes critical communication, outreach, and
extension work, such as the Sharks Ambassadors education initiative
program for high school-aged students, that focuses on shark conservation.
In terms of knowledge management, the CDF is custodian of four Natural
History Collections—Herbarium (CDS), Terrestrial Invertebrates (ICCDRS);
Marine Invertebrates (MCCDRS); and Vertebrates (VCCDRS)—which
constitute the largest collections of endemic, native, and exotic species of
the Galapagos in the world. The library of the CDF is the main bibliographic
repository of the Scienti c Station and also manages the archival materials.
Additionally, resources from the CDF fund conservation activities, such as
the mangrove nch project, aimed to conserve this species and prevent its
disappearance (there are currently only around 100 individuals left in the
world).
The operation and work of the CDF relies 100 percent on private support
from individuals, institutions, and corporations. Therefore, for all of us
interested in preserving the unique ecosystem of the Galapagos Archipelago
as our legacy to future generations, a priority challenge is nancial resource
mobilization to ensure predictable and sustainable funding for the CDF.
How can this be done in the short- and medium-terms?
An expansion and diversi cation of the CDF’s funding sources is perhaps
required, involving both earmarked Ecuadorian Government contributions
and private donations, for the implementation of a results-oriented
medium-term strategy and action plan for the CDF.
www.pvmarquez.com/Galapagos_CDF 4/10
1/12/2021 Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported | Patricio V. Marquez
First, in Ecuador, as in other countries, there is the potential to mobilize
more in taxes as a share of GDP via better tax administration (including
value-added taxes), tackling tax avoidance and evasion, broadening the tax
base by removing cost-ineffective tax expenditures, and increasing excise
taxes on unhealthy products (including on tobacco, alcohol, and sugar-
sweetened drinks), and where feasible, some of which can ow to expand
scal space for conservation work under the CDF and the Galapagos
National Park.
Second, the national effort could be complemented with the establishment
of dedicated trust funds with grant resources mobilized from ecological
conservation and climate action-oriented governments in high-income
countries. The allocation of trust fund resources could be linked to the
achievement of pre-de ned activities and results, such as the development
of a monitoring program to assess the threat posed by marine plastic debris
as potential transport for introducing non-native species that could become
invasive and harmful to the ecosystem in the Islands.
Third, with the support of the Government of Ecuador, grant resources for
global public goods available under existing mechanisms in multilateral
nance institutions such as the World Bank Group and the Inter-American
Development Bank, could be explored and invite technical proposals from
the CDF for consideration by these organizations.
Fourth, diversi cation of private funding will be crucial. Different
foundations and philanthropies could be tapped to support the CDF as
some of them are already committed to support the achievement of the
Sustainable Development Goals (SDGs) of the United Nations by 2030, and
the work of the CDF is focused on supporting the achievement of several
SDGs’ economic, environmental, and social targets. Entities such as the
Bloomberg Philanthropies, The Bill and Melinda Gates Foundation, The
Nippon Foundation, The Rockefeller Foundation, and The Carlos Slim
www.pvmarquez.com/Galapagos_CDF 5/10
1/12/2021 Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported | Patricio V. Marquez
Foundation, are only a small sample of possible additional sources for
diversifying CDF funding. Donations from wealthy individuals, both in
Ecuador and at the international level, and the general public could help to
mobilize nancial support as well.
Fifth, in pursuing active resource mobilization options, raising the pro le of
the CDF and educating different stakeholders about the results and impact
of its conservation work will be required. Events organized by institutions
such as the Salzburg Global Seminar and the World Economic Forum, as well
as the Annual Meetings of the World Bank Group/International Monetary
Fund, could serve as potential venues for information, communication, and
education efforts geared to mobilize commitments and support from
different international stakeholders.
Naturally, any increase in funding levels would need to be accompanied by
strong administrative and nancial arrangements at the CDF, complemented
by robust monitoring, evaluation, and reporting mechanisms on resource
use, activities undertaken, results, and impact achieved.
Looking forward
The preservation of World Natural Heritages sites, such as the Galapagos
Archipelago, depends on the active and dedicated mobilization of support
from a broad group of committed stakeholders, both in Ecuador and across
the world. If done ef ciently and effectively, this effort would help to ensure
that the bene ts of this global public good will not be limited to the current
generations but will also be for the enjoyment of future generations as our
lasting legacy to them. In doing so, we will be contributing to preserve the
unique “natural history” of these islands, where, as observed by Charles
Darwin in The Voyage of the Beagle:
www.pvmarquez.com/Galapagos_CDF 6/10
1/12/2021 Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported | Patricio V. Marquez
“Most of the organic productions are aboriginal creations, found nowhere else;
there is even a difference between the inhabitants of the different islands; yet
all show a marked relationship with those of America, though separated from
the continent by an open space of ocean, between 500 and 600 miles in width.
The archipelago is a little world within itself, or rather a satellite attached to
America, whence it has derived a few stray colonists, and has received the
general character of its indigenous productions. Considering the small size of
the islands, we feel the more astonished at the number of their aboriginal
beings, and at their con ned range. Seeing every height crowned with its
crater, and the boundaries of most of the lava-streams still distinct, we are
led to believe that within a period geologically recent the unbroken ocean was
here spread out. Hence, both in space and time, we seem to be brought
somewhat near to the great fact—the mystery of mysteries—the rst
appearances of new beings on this earth.”
Contact information:
Charles Darwin Foundation for the Galapagos Islands
Puerto Ayora, Santa Cruz, Galapagos, Ecuador
T: +593 (5) 2526 146
E: cdrs@fcdarwin.org.ec (mailto:cdrs@fcdarwin.org.ec)
W: www.darwinfoundation.org (http://www.darwinfoundation.org)
PP Box 17-1-3891 Quito, Ecuador
To make a donation:
www.pvmarquez.com/Galapagos_CDF 7/10
1/12/2021 Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported | Patricio V. Marquez
www.pvmarquez.com/Galapagos_CDF 8/10
1/12/2021 Galapagos’ Charles Darwin Foundation: An International Good Practice that Needs to be Supported | Patricio V. Marquez
www.pvmarquez.com/Galapagos_CDF 9/10
1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez
Common Myths Against Tobacco Taxation:
Not Borne Out by Global Evidence
Submitted by Patricio V. Marquez on Sun, 02/02/2020 - 02 39 PM
Common Myths Against Tobacco Taxation:
Not Borne Out by Global Evidence
Posted by Patricio V. Marquez on Sun, 02/02/2020 - 02 39 PM
The newly-released Smoking Cessation: A Report of the Surgeon General of the United
States (U.S. Department of Health and Human Services, 2020) reaf rms, on the basis of
accumulated scienti c evidence over the past half century, that tobacco use leads to
many adverse health effects, including negative reproductive health outcomes,
www.pvmarquez.com/tobacco_taxes 1/13
1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez
cardiovascular diseases, chronic obstructive pulmonary disease, and the risk of twelve
cancers, including cancers of the lung; larynx; oral cavity and pharynx; esophagus;
pancreas; bladder; stomach; colon and rectum; liver; cervix; kidney; and acute myeloid
leukemia. The report is also clear in indicating that smoking cessation can be increased
by raising the price of cigarettes.
It is frequent, however, to come across common claims put forward by interest groups
that oppose the enactment of tobacco tax policies. These claims are often accepted
uncritically by policy makers in countries at different income levels, without due
consideration of available evidence. The question that we need to ask, then, is how do
these claims stand vis-à-vis accumulated global evidence? Are these claims part and
parcel of the “economics of deception and manipulation” that drive aggressive
industry-sponsored campaigns in the pursuit of pro ts and market share expansion?
Have the claims become just myths not borne out by accumulated country evidence?
The results of recent research done by World Bank Group teams across the world,
along with additional data and information, are presented below to shed light on these
questions.
Myth 1 Raising tobacco taxes undermines the tax base and lowers tobacco tax
revenue.
Evidence: A report from the International Monetary Fund (Petit and Nagy, 2016) is
clear in indicating that “in many countries, raising tobacco taxes can offer a “win–win”:
higher revenue and positive health outcomes.” Higher tobacco taxes help boost
cigarette prices, which are highly effective in reducing demand, which reduce use and
the health risks associated with smoking. The positive impacts of higher tobacco taxes
and prices go beyond direct health gains and indirect bene ts such as reduced health
care expenditures and higher productivity. Increasing tobacco taxes can also enlarge a
country’s tax base to augment domestic resource mobilization to fund priority
investments and programs, including the expansion of universal health coverage.
The experience of the Philippines since the adoption of the Sin Tax Law of 2012 is one
of the most compelling examples of ambitious national tobacco tax reform, including
reduction in the number of tax tiers, indexation of tax rates to in ation, and substantial
tax increases. As shown in Figure 1, excise tax revenue on tobacco and alcohol products
has more than doubled since 2012, reaching US$5.2 billion in additional revenues during
www.pvmarquez.com/tobacco_taxes 2/13
1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez
the rst 4 years of the Sin Tax Law implementation (about 1 percent of GDP). Tobacco
accounts for about 80 percent of these additional tax revenues, which largely are
earmarked under the budget to subsidize health insurance for low-income populations
(Kaiser, Bredenkamp and Iglesias, 2016).
The experience of Ukraine is also noteworthy (Smits et al 2017). The total tax burden
(including excise taxes, value-added tax [VAT], and other duties on tobacco as a
percentage of retail price) increased from 62 percent in 2015 to 77 percent in 2019. As a
result, national tobacco excise revenue increased from 22 billion UAH in 2015 (1.12% of
GDP) to 40 billion UAH in 2018 (1.34% of GDP) (see Figure 2).
Moldova has also been able to collect additional tax revenue since 2017 from hiking
tobacco taxes (Marquez et al, 2018). Cigarette excise tax revenue in the country
increased from MDL 1.73 billion (US$ 87 million) in 2016 to MDL 2.05 billion (US$ 110.6
million) in 2017, or about 1.16 percent of Moldova’s GDP. The tobacco tax increases
adopted by Moldova’s Parliament for 2018-2020 are projected to further increase excise
tax revenue, hitting 3.31 billion MDL (US$194 million) or 1.45 percent of GDP in 2020.
www.pvmarquez.com/tobacco_taxes 3/13
1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez
Colombia is another example (James et al, 2017). As part of a broad scal reform
package approved by Colombia’s Congress on December 23, 2016, the speci c excise
tax on a pack of 20 cigarettes was increased from COP 700 (US$ 0.25) in 2016 to COP
1,400 (US$ 0.50) in 2017, and COP 2,100 (US$ 0.75) in 2018, with annual adjustments of
Consumer Price Index (CPI) + 4 points in subsequent years. The ad valorem excise tax
component was maintained at 10 percent of the total sale price of a 20-cigarette pack,
and the general VAT rate was raised from 16 percent to 19 percent. As a result, the total
tax burden (as percentage of retail price of a pack of 20 cigarettes) increased from 50
percent in 2016 to 68 percent in 2018. The average price of a pack of 20 cigarettes
increased by 42.5 percent over 2017-2018. The expected scal and health impacts of this
measure are noteworthy. It is estimated that COP 1 trillion (about US$ 347 million) in
additional revenue will be generated through 2022.
The experience of Australia, United States, and the United Kingdom (UK) provide
additional evidence (Fuchs, Marquez, Dutta, Gonzalez Icaza, 2019). The annual increases
in tobacco excise taxes in the past decade have led Australia to have one of the highest
prices of cigarettes in the world--a 20-pack of Marlboro costs approximately US$19,
while the same pack costs only US$12 in the UK, US$7 in the United States, and US$3.88
in South Africa. The high tobacco tax level has also contributed massive yearly tax
revenue to the Government. In the United States, the federal cigarette tax for
cigarettes was increased signi cantly in 2009 from US$0.39 per pack to approximately
US$1.01 per pack. The tax increase was designed to help pay for the cost of children's
health insurance under the State Children's Health Insurance Program (SCHIP).
Revenues more than doubled from US$7.6 billion in 2008 to US$17.1 billion in 2010, once
the law fully took effect. Although revenues have declined from the high level reached
in 2010, they are still projected to represent in 2024 double the amount collected prior
to the 2009 tax hike. In the UK, as a result of high taxes and prices, smoking rates have
continued to decline over the past decade, and tobacco taxes contributed an estimated
£10 billion in tax revenue to the UK Government over 2016-2017.
Assessment done by the World Bank Group in Russia show that that life expectancy in
the country for men increased to 65.4 years in 2016, up from 58 years in 2003, and
among women, to 76.2 years in 2016, up from 72 years in 2003 (Marquez and Gonima,
2018). A big contributor to this change has been the effective measures adopted to
control the consumption of tobacco and alcohol over this period, including the
enactment of a law on tobacco control in 2013 and regular increases in tobacco excise
taxes since 2010. Because of tax and price increases, along with other tobacco control
www.pvmarquez.com/tobacco_taxes 4/13
1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez
interventions, tobacco sales fell by almost 30 percent over this decade. Not
surprisingly, the number of smokers also decreased, by 21 percent between 2009 and
2016, while higher tobacco taxes increased tax revenue for the country (Figure 3).
Similar experiences have been observed in other countries as varied as Botswana,
China, European Union-Member States, Republic of Korea, South Africa, Turkey, and
Uruguay (Marquez and Moreno-Dodson, 2017; Zheng, Hu, Marquez, Wang, Xiaoxia,
2017; Bouw, 2017; Eun Choi and Marquez, 2018; Cetinkaya and Marquez, 2017; Marquez,
2017).
Myth 2 Increased price of tobacco products due to higher taxes is regressive
because the poor are affected the most.
Evidence: Country-speci c research conducted by the World Bank Group, as well as
the work done in the United States, show that the poor tend to smoke more and are
more price responsive on average than richer individuals, so they get a far greater share
of health bene ts from higher tobacco taxes than they pay.
By discouraging consumption, taxes on tobacco products reduce the adverse health
effects of tobacco, as well as the large associated medical and human capital costs to
households and societies. Medical treatment of the numerous chronic diseases caused
or exacerbated by tobacco drives up annual health care costs in public health care
systems and households. Smoking reduces household earning potential and labor
www.pvmarquez.com/tobacco_taxes 5/13
1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez
productivity, negatively affecting human capital accumulation and development. Hence,
reducing tobacco use translates to lower smoking-related medical expenses, increases
in life expectancy at birth, and reductions in disability.
A World Bank Group assessment done for Armenia (Postolovska et al, 2017) shows that
increased excise taxes on tobacco would bring large health and nancial bene ts to
Armenian households and be pro-poor: about 88,000 premature deaths, US$ 63 million
of out-of-pocked medical expenditures, 22,000 poverty cases, and 33,000 cases of
catastrophic health expenditures would be averted. Government savings on tobacco-
related treatment costs would amount to US$26 million. Half of the premature deaths
and 27 percent of poverty cases averted would be concentrated among the bottom 40
percent of the population.
The net total distributional impact of tobacco taxation estimated in World Bank
assessments done in in Bosnia and Herzegovina, Chile, Moldova, Russia, South Africa,
and Ukraine (Fuchs et al 2019), is shown in Figure 4. Lower medical expenditures and
additional working years help offset the negative direct income effect of an increase
in tobacco prices. The total income effect associated with a 25 percent price increase is
positive in the case of several income groups, especially at the lower end of the income
distribution. However, most households in Bangladesh and Indonesia, and between 30
and 50 percent of the population in Bosnia and Herzegovina, Chile, and South Africa,
continue to be negatively affected. In the particular case of Indonesia, the distribution
continues to be U-shaped. The net effect becomes positive and more progressive with
higher price increases, as reduce affordability of cigarettes allows the health and
www.pvmarquez.com/tobacco_taxes 6/13
1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez
economic bene ts of the taxes on tobacco to kick in. In a 100 percent price increase
scenario, only the 40 percent richest households in Chile, and the top 60 percent in
Bangladesh—where medical expenses have lowest incidence—are negatively affected.
The results are generally progressive in all eight countries.
A most recent assessment done for Vietnam (Fuchs et al, 2019), con rms that above
ndings, as under moderate and to high price increase scenarios, the distribution of
the net bene ts is highly progressive. Poor households capture relatively large income
gains that increase with the magnitude of the price increase. Increasing the excise tax,
for example, by D 10,000 (US$0.43 cents) could bring income gains of over 1.5 percent
to the poorest 30 percent of the population in Vietnam. The effect among the top four
income deciles would be closer to zero under all scenarios.
In Tonga (Osornprasop 2019), the excise tax resulted in a price increase across all the
taxed products, making cigarettes less affordable and affecting smokers’ behaviors. Tax
on cigarettes has a greater effect on “less well-off” smokers, as a larger number of less
well-off smokers reduced consumption of manufactured cigarettes. This is consistent
with the other country ndings on the equity impacts of price policies, as low-income
households respond to price changes more readily than higher income households.
Price, rather than other factors, was the main reason among those who decided to
change behaviors and reduce consumption.
Assessing the situation in the United States, Furman (2017), concludes that the criticism
against tobacco taxes is backward. The health bene ts of tobacco taxes far exceed the
increase in tax liability, and they accrue disproportionately to lower-income
households. Moreover, as Furman observes, it is important to also evaluate what the
www.pvmarquez.com/tobacco_taxes 7/13
1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez
additional revenue raised by the tobacco tax may be used for. The most recent
increases in the United States, enacted in 1997 and 2009, were used to create and
expand a very progressive children’s health insurance program.
Myth 3 Higher taxes lead to increased smuggling and use of counterfeit tobacco
Evidence: A recent global report by the World Bank Group focusing on over 30
countries across the income and development spectrum (Dutta et al, 2019), shows that,
contrary to tobacco industry arguments, tobacco taxes and prices have only a limited
impact on the illicit market share at the country level. The evidence presented in the
report indicates that the illicit cigarette market is relatively larger in countries with
low taxes and prices, while relatively smaller in countries with higher cigarette taxes
and prices. Non-price factors such as governance status, weak regulatory framework,
and the availability of informal distribution networks appear to be far more important
factors. Countries reporting signi cant progress in the control of illicit tobacco trade
adopted some key policy and institutional measures which contributed to their success.
A good example is Ireland, where a high rate of tobacco excise taxes, and the
consequent high price of tobacco products, makes the country attractive to those
involved in the illicit tobacco trade. However, Ireland’s comprehensive and effective
system of customs and tax enforcement, alongside strong regulatory control of the
tobacco market, has contained the illicit ow of tobacco products onto the Irish
market. Indeed, Ireland’s most recent results indicate that the general trend for illicit
cigarettes between 2007-2017 has been downward (13 presently). Notably, this has
occurred during a period where price of cigarettes has risen and smoking prevalence
has declined (by about 10 percentage points). This suggest that, while the illicit trade
www.pvmarquez.com/tobacco_taxes 8/13
1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez
has not been eliminated, the extensive program of enforcement has contained it.
Analysis indicates that the main driver of illicit ows is not relative levels of
price/taxation, but the effectiveness of customs and tax enforcement.
A key lesson from the report’s country case studies is that strengthening the legal
framework and tax administration and enforcement is complementary to tobacco tax
policy reform as these measures reinforce one another. As outlined in the World Bank
Group report, experience shows that illicit tobacco trade can be controlled by legal
means (e.g., use of prominent tax stamps, serial numbers, special package markings,
health warning labels in local languages, adoption of uniform tax rates nationwide that
facilitate successful collection at the points of manufacture and import), and by
increased law enforcement (e.g., improving corporate auditing, better trace and
tracking systems, and good governance).
Myth 4 Tobacco tax hikes lead to signi cant job losses
Evidence: Policymakers considering tobacco tax hikes are often concerned about
negative impacts on employment. World Bank Group research provides fresh evidence
from eld studies and economic simulations focusing on Indonesia (Araujo et al 2018),
one of the world’s largest tobacco producers. The results provide clearer understanding
of the relationship between tobacco taxation and employment.
Tobacco manufacturing represents only a small share of Indonesia’s economy-wide
employment (0.60 percent) and a relatively low percentage of jobs in the
manufacturing sector (5.3 percent). This compares to the food (27.43 percent),
garment (11.43 percent), and textile (7.90 percent) sectors. The productivity of tobacco
manufacturing workers is also quite low relative to the productivity of workers in other
www.pvmarquez.com/tobacco_taxes 9/13
1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez
comparable sectors. Indonesia’s tobacco manufacturing is geographically concentrated
in East and Central Java (76 percent) and West Nusa Tenggara (18 percent). Only a few
districts are substantially dependent on tobacco sector employment.
Most tobacco farmers and manufacturing workers rely only partially on tobacco
income. Income from kretek rolling represents 43 percent of household income among
kretek households on average. About three-quarters of tobacco-farming households
derived less than 50 percent of their income from tobacco cultivation, and over half of
clove farmers generate less than 20 percent of their household income from cloves.
Tobacco cultivation is not pro table for most farmers, and producing tobacco has
high opportunity costs. This nding was mostly consistent across regions, type of
tobacco grown, and whether the farmer was on contract to grow tobacco. Despite poor
returns typically, farmers reported being drawn to the assured market, the better
prospects for credit, and the potential to earn cash.
Economic simulations suggest that raising cigarette taxes by an average of 12 percent
that increases cigarette prices by an average 5 percent and simplifying Indonesia’s
cigarette tax structure to six tiers will reduce cigarette demand by 1.89 percent,
increase government revenue by 6.41 percent, and reduce gross employment in the
tobacco manufacturing sector by 0.43 percent. This represents a reduction of less
than 3,000 tobacco manufacturing jobs, most of them in the handmade kretek industry
(2,245 fewer jobs). Importantly, these estimates do not consider the creation of jobs in
other sectors due to the shift in consumers’ spending away from tobacco (the net
effect).
The estimated total household income loss from reduced employment in the handmade
kretek industry amounts to a small fraction of 1 percent (0.16 percent) of the revenue
gain that Indonesia will obtain by increasing cigarette taxes.
To sum up, higher taxes, yielding higher retail prices, will cut tobacco consumption and
reduce economic losses due to health care costs and compromised productivity, with
low-income groups bene ting more as discussed above. Aggressive tobacco tax hikes
will generate additional revenue that can more than compensate for the income loss
following a reduction in employment in the kretek industry.
Take-Away Message
www.pvmarquez.com/tobacco_taxes 10/13
1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez
The common claims used by interest groups to oppose tobacco tax increases, price
hikes, and reductions in demand and use, are not supported nor borne out by
accumulated country evidence. Improved data availability and further research are
required for updating and expanding the global evidence base to confront these claims
as they have become widely-held “myths” often accepted uncritically by government
of cials and stakeholders, as well as the general public.
So, as stated in an article in The Economist (2017), the take-away message for policy
makers and other stakeholders around the world, should be unambiguously clear: "As
the success in rich countries shows, there is no mystery about how to get people to
stop smoking: a combination of taxes and public-health education does the job. This
makes the abysmal record in poor countries a grave failure of public policy. The good
news is that, following recent research, it is one that has just become easier to put
right."
By adopting the United Nations Sustainable Development Goals (SDGs), countries
across the world have committed to achieving a 30 percent reduction in death rates
from noncommunicable diseases like cancer, stroke, and heart disease by 2030.
Reducing tobacco use is critical for countries to reach this goal. To swiftly cut smoking
rates, bold increases in tobacco excise tax rates are by far the most powerful tool.
High smoking prevalence condemns large numbers of people to avoidable sickness
and death and weakens the country’s economic development. As observed by Jha and
Peto (2014), attainment of the SDG target requires decreases not only in high-income
countries but also in populous low- and middle-income countries “to prevent several
tens of millions of tobacco- attributable deaths during the next few decades, and about
200 million tobacco-attributable deaths during the century as a whole, mostly among
people who are already alive, both by helping smokers to quit and by helping
adolescents not to start.”
Sources
Araujo, EC, Harimurti, P, Sahadewo, GA, Nargis, N, Drope, J, Marquez, PV, Al Ri…
(http://documents.worldbank.org/curated/en/219251526070564098/pdf/126158-
REVISED-PUBLIC.pdf)
Bouw, A. 2017. “Tobacco taxation in the European Union: an overview.” WBG Globa…
(http://documents.worldbank.org/curated/en/493581492415549898/Tobacco-
www.pvmarquez.com/tobacco_taxes 11/13
1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez
taxation-in-the-European-Union-an-overview)
Cetinkaya, V, Marquez, P. 2017. “Tobacco taxation in Turkey: an overview of pol…
(http:/ /documents.worldbank.org/curated/en/320121492424907154/Tobacco-
taxation-in-Turkey-an-overview-of-policy-measures-and-results)
Dutta, S, Marquez, PV, Isenman, P, Ross, R. 2019. “Confronting Illicit Tobacco …
(http:/ /documents.worldbank.org/curated/en/677451548260528135/Confronting-
Illicit-Tobacco-Trade-a-Global-Review-of-Country-Experiences)
Eun Choi, S, Marquez, PV. 2018. “Reducing tobacco use through taxation: the exp…
(http:/ /documents.worldbank.org/curated/en/150681529071812689/Reducing-
tobacco-use-through-taxation-the-experience-of-the-Republic-of-Korea)
Fuchs Tarlovsky, A, Gonzalez Icaza. 2019. “The Welfare and Distributional Effe…
(http:/ /documents.worldbank.org/curated/en/758391561477648302/The-Welfare-
and-Distributional-Effects-of-Increasing-Taxes-on-Tobacco-in-Vietnam)
Fuchs Tarlovsky, A, Gonzalez Icaza, Paz, D. 2019. “Distributional Effects of To…
(http:/ /documents.worldbank.org/curated/en/358341554831537700/pdf/Distributional-
Effects-of-Tobacco-Taxation-A-Comparative-Analysis.pdf)
Fuchs Tarlovsky, A, Marquez, PV, Dutta, S, Gonzalez Icaza, MF. 2019. “Is Tobacc…
(http:/ /documents.worldbank.org/curated/en/893811554737147697/Is-Tobacco-
Taxation-Regressive-Evidence-on-Public-Health-Domestic-Resource-Mobilization-
and-Equity-Improvements)
Furman, J. 2016. “Policy, Politics, and the Tripling of Federal Tobacco Taxes i…
(http:/ /documents.worldbank.org/curated/en/820951485943150390/Summary-
report)
James E, Saxena A, Franco Restrepo C, Llorente B, Vecino Ortiz A, Villar Uribe…
(https:/ /openknowledge.worldbank.org/handle/10986/28598)
Jha P, Peto R. 2014. “Global effects of smoking, of quitting, and of taxing tob…
(https:/ /www.nejm.org/doi/pdf/10.1056/NEJMra1308383)
Kaiser K, Bredenkamp C, Iglesias R. 2016. “Sin Tax Reform in the Philippines: T…
(https:/ /openknowledge.worldbank.org/handle/10986/24617)
Marquez, PV, Gonima, A. 2018. “Reducing Tobacco Use Through Taxation in the Ru…
(http:/ /documents.worldbank.org/curated/en/873551539183125023/Reducing-
Tobacco-Use-Through-Taxation-in-the-Russian-Federation-A-Modelled-Assessment-
of-Two-Policy-Options)
Marquez, PV, et al. 2018. “Moldova – Why is Tobacco Taxation Important?”. WBG G…
(http:/ /documents.worldbank.org/curated/en/337481541098390886/Moldova-Why-
is-Tobacco-Taxation-Important)
Marquez, PV, ed. 2017. “Expanding the global tax base: Taxing to promote public…
(http:/ /documents.worldbank.org/curated/en/820951485943150390/Summary-
report)
www.pvmarquez.com/tobacco_taxes 12/13
1/12/2021 Common Myths Against Tobacco Taxation: Not Borne Out by Global Evidence | Patricio V. Marquez
Marquez PV, Moreno-Dodson B. eds. 2017. “Tobacco tax reform at the crossroads o…
(http://documents.worldbank.org/curated/en/491661505803109617/Main-report)
Osornprasop, S; Zheng, R; Hufanga, SV; Latu, CF; Lounkaew, K; Krahn, J; Ve’etut…
(http://documents.worldbank.org/curated/en/844811561475012529/Using-Taxation-
to-Address-Noncommunicable-Diseases-Lessons-from-Tonga)
Petit P and Nagy J. 2016. “How to design and enforce tobacco excises?” Washingt…
(http://pubdocs.worldbank.org/en/309561480947116095/howtonote1603.pdf)
Postolovska I, Lavado RF, Tarr G, Verguet S. 2017. “Estimating the distribution…
(http://documents.worldbank.org/curated/en/604501492414938391/Estimating-the-
distributional-impact-of-increasing-taxes-on-tobacco-products-in-Armenia-results-
from-an-extended-cost-effectiveness-analysis)
Smits, K, Golovach, A, Awasthi, R, Balabushko, O, Budagovskaya, S, Lunina, I, S…
(http://documents.worldbank.org/curated/en/476521500449393161/Ukraine-Public-
nance-review)
The Economist. 2017. “Cough up. How to cut smoking in poor countries.” Leaders,…
(https://www.economist.com/leaders/2017/06/01/how-to-cut-smoking-in-poor-
countries)
U.S. Department of Health and Human Services. 2020. “Smoking Cessation. A Repor…
(https://www.hhs.gov/sites/default/ les/2020-cessation-sgr-full-report.pdf)
Zheng, R, Hu, X, Marquez, PV, Wang, Y, Xiaoxia, E. 2017. “Cigarette Affordabili…
(http://documents.worldbank.org/curated/en/130301492424519317/Cigarette-
affordability-in-China-2001-2016)
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/tobacco_taxes 13/13
1/12/2021 High Prices for Essential Drugs: A Risk for Public Health, Catastrophic Health Spending, High-Debt Levels, and Impoverishment | Patricio V. Marquez
High Prices for Essential Drugs: A Risk
for Public Health, Catastrophic Health
Spending, High-Debt Levels, and
Impoverishment
Submitted by Patricio V. Marquez on Tue, 01/28/2020 - 06 11 PM
High Prices for Essential Drugs: A Risk
for Public Health, Catastrophic Health
Spending, High-Debt Levels, and
Impoverishment
Posted by Patricio V. Marquez on Tue, 01/28/2020 - 06 11 PM
pvmarquez.com/drug_prices 1/7
1/12/2021 High Prices for Essential Drugs: A Risk for Public Health, Catastrophic Health Spending, High-Debt Levels, and Impoverishment | Patricio V. Marquez
As all of us who have been sick or diagnosed with a chronic condition that
requires adherence to a daily drug regime know, timely access to required
medicines not only helps us get better or manage a health condition over
the long term, but saves us from hospitalization if the disease is not
controlled, helps us avoid being absent from work, improves our
productivity, and enhances our quality of life.
So, from an ethical, societal, and public health point of view, it should not
be accepted that the sick or those living with a chronic condition are put at
risk of ill health, premature mortality and disability, catastrophic health
spending, debt and impoverishment because they cannot afford essential
medicines when needed, or are forced by high drug prices to ration their
medication, aggravating their health condition and even putting them at risk
of death.
Although this dire reality is common in many countries of the world, the
current political debate in the United States is illustrative of this global
public health challenge as high drug prices are a top concern for families
across the country, who face common threats often found under private
health insurance arrangements: pre-existing clauses that do not cover a
medical condition that started before a person's health insurance bene ts
went into effect, as well as high deductibles, co-payments, and lifetime
limitations in services and drug coverage.
The high cost of insulin, a lifesaving medication needed to manage Type-1
diabetes, which affects about 5 percent of people with diabetes in the
United States, is a good example of the ironies, inequities, and negative
social impact of the lack of or limited access to essential drugs in the
country. Indeed, it is not only ironic but I would say it is morally wrong that
drug companies have been pro ting from selling insulin at high prices, in
spite of the fact that Frederick Banting and John Macleod, who were
pvmarquez.com/drug_prices 2/7
1/12/2021 High Prices for Essential Drugs: A Risk for Public Health, Catastrophic Health Spending, High-Debt Levels, and Impoverishment | Patricio V. Marquez
awarded the 1923 Nobel Prize in Medicine for its discovery, sold the patent
to the University of Toronto for $1 each because they felt that insulin
belonged to the world and not for their enrichment.
As described by Michael Fralick and Aaron S. Kesselheim, in a recent article
in the New England Journal of Medicine (NEJM), almost 100 years after its
discovery, insulin is inaccessible to thousands of Americans because of its
high cost. The information presented in the article shows that the price of
insulin in the United States has risen substantially over the past two
decades: “today, the price of 100 units of short-acting insulin for adults
without insurance is about $18. The usual dose for regular insulin is 0.5 to 1.0
units per kilogram per day (usually given before meals). Thus, for a person
with type 1 diabetes who weighs 70 kg and is taking a dose of 1 unit per
kilogram per day, 100 units will last less than 2 days. Most adults taking
short-acting insulin also require either intermediate- or long-acting insulin,
the latter of which is also quite costly” (see below table from the NEJM
article).
pvmarquez.com/drug_prices 3/7
1/12/2021 High Prices for Essential Drugs: A Risk for Public Health, Catastrophic Health Spending, High-Debt Levels, and Impoverishment | Patricio V. Marquez
The difference in drug prices between the United States and the rest of
the world, is mindboggling. In some cases, as with the fast-acting insulin
Novolog, it is 74% cheaper when ordered from a pharmacy in Canada. In
should not surprise us, then, that while the United States represents only
15% of the global insulin market, it generates almost half of the
pharmaceutical industry’s insulin revenue.
What can be done to deal with the rising cost of insulin and other
prescription drugs in the United States and elsewhere? How can essential
drugs become more accessible and affordable?
While the mandatory provision of an essential outpatient drug bene t
package for priority, high-burden diseases, such as Type 1 diabetes, under
publicly-funded arrangements or health insurance plans is a critical
measure to guarantee their timely access and affordability, additional
measures as those now being debated in the United States are needed,
including supply side measures such as price negotiation, changes in
patent laws, and the manufacture of generics.
An essential drug bene t program, that eliminates or caps-out out-of-
pocket drug spending for everyone, could be funded through an improved
allocation of overall public expenditures, including a shift toward long-
term social needs such as health and away from less productive categories
of public expenditures (for example, untargeted subsidies and transfers,
general administration expenditures and unproductive public investments).
Other funding options include, as already done in some countries,
increasing taxes on cigarettes, alcohol, and sugar sweetened drinks, since
current tax rates are evidently far below what is feasible in terms of revenue
potential and the generation of health bene ts.
pvmarquez.com/drug_prices 4/7
1/12/2021 High Prices for Essential Drugs: A Risk for Public Health, Catastrophic Health Spending, High-Debt Levels, and Impoverishment | Patricio V. Marquez
If we focus on insulin as a tracer of the problem, then the need for supply
side measures becomes clearer. As explained in Fralick and Kesselheim’s
article, the rising cost of insulin in the United States can be attributed
primarily to two phenomena: rst, the current law allows pharmaceutical
manufacturers to price their products at whatever level they believe the
market will bear and to raise prices over time without limit (this practice
is the opposite of what England does, where the government sets a
maximum price it will pay for a drug when directly negotiating with the
pharmaceutical industry); and second, direct competition in the insulin
market is lacking (approximately 90% of insulin sold in the United States is
manufactured by one of three companies: Eli Lilly, Novo Nordisk, and
Sano ).
The plan proposed by Michael Bloomberg, the former Mayor of New York
and Global Philanthropist, to lower the prices for essential medications for
everyone in the United States, offers a good road map that merits
consideration. It calls for the adoption of legal measures and requirements
that authorize governments and insurance companies to negotiate drug
prices with the pharmaceutical industry in order to lower prices for
everyone; it promotes the selection of most cost-effective drugs, including
generics; it allows for the importation of safe drugs from other countries
with good quality standards and where prices are lower; and it changes
patents and intellectual property laws to foster competition by bringing
generic drugs to the market faster (in the United States, brand-name drugs
account for 72% of total drug spending despite representing only 10% of all
prescriptions) to reduce drug costs.
While timely access to medications such as insulin is critical to manage
Type-1 diabetes, the promotion of health literacy (the capacity of
individuals to obtain, communicate, process, and understand basic health
information and services to make appropriate health decisions), is equally
pvmarquez.com/drug_prices 5/7
1/12/2021 High Prices for Essential Drugs: A Risk for Public Health, Catastrophic Health Spending, High-Debt Levels, and Impoverishment | Patricio V. Marquez
vital for the development of a disciplined daily nutritional regime, rich in
proteins and vegetables, with reduced or no carbohydrates from
processed foods, and physical activity, to manage this disease.
In pursuing universal health coverage, therefore, we need to remember that
besides putting in place arrangements that ensure access to medical care
and offer nancial protection to the population, investment in health
literacy can empower people to be in the “driver’s seat” of health
promotion and disease prevention, including the prevention of
complications from existing chronic health conditions such as Type-1
diabetes, to lead healthy, productive and happy lives.
Sources
Belluz, J. “The absurdly high cost of insulin, explained. Why Americans ration
… (https:/ /www.vox.com/2019/4/3/18293950/why-is-insulin-so-
expensive)
Bloomberg, M. 2020. Drug Prices Plan.
(https://www.mikebloomberg.com/2020/policies/drug-prices)
Cooperman, T. “20 Drugs That Cost a Lot Less Outside the U.S.” HUFFPOST,
Decemb… (https:/ /www.huffpost.com/entry/20-drugs-that-cost-a-lot-
less-outside-the-us_b_5a217e73e4b0545e64bf9277)
Fralick, M. and Kesselheim, AS. 2019. “The U.S. Insulin Crisis — Rationing a
Li… (https:/ /www.nejm.org/doi/full/10.1056/NEJMp1909402)
Image by Steve Buissinne from Pixabay
(https://pixabay.com/photos/diabetes-blood-sugar-diabetic-528678/)
Picture from freestocks.org (https:/ /unsplash.com/photos/nss2eRzQwgw)
pvmarquez.com/drug_prices 6/7
1/12/2021 High Prices for Essential Drugs: A Risk for Public Health, Catastrophic Health Spending, High-Debt Levels, and Impoverishment | Patricio V. Marquez
(https://twitter.com/pvmarquez1956)
pvmarquez.com/drug_prices 7/7
1/12/2021 Mental Health and Healthy Futures: A Priority Theme at WEF Davos 2020 | Patricio V. Marquez
Mental Health and Healthy Futures: A
Priority Theme at WEF Davos 2020
Submitted by Patricio V. Marquez on Wed, 01/22/2020 - 08 55 PM
Mental Health and Healthy Futures: A
Priority Theme at WEF Davos 2020
Posted by Patricio V. Marquez on Wed, 01/22/2020 - 08 55 PM
This week I have enjoyed participating in several livestreamed sessions of
the 50th annual meeting of the World Economic Forum (WEF) under the
theme “Stakeholders for a Cohesive and Sustainable World.” One of the 7
diverse topic areas being addressed during the Meeting is “Healthy
Futures”, which I found to be not only highly relevant to the overall theme
pvmarquez.com/mental_health_davos 1/9
1/12/2021 Mental Health and Healthy Futures: A Priority Theme at WEF Davos 2020 | Patricio V. Marquez
of the 2020 meeting, but highly evocative of Thomas Mann’s masterpiece
“The Magic Mountain” which takes place before World War I in a
tuberculosis sanatorium in Davos, the Swiss Alps town, where the WEF
meeting is held yearly.
I say this because a healthy population, both physically and mentally, should
be seen as a key goal of a country’s development, as it is an essential
building block for productive, inclusive, resilient, and happy societies. But,
as in Mann’s novel, this social outcome requires “community” action, with
active stakeholder participation, to deal with ill health and its multiple
determinants and manifestations.
I was quite pleased to watch Bollywood actor Deepika Padukone receive the
WEF’s Crystal Award 2020 for her work in raising mental health awareness
in India. On receiving the award and later in a one-on-one session with
Tedros Adhanom Ghebreyesus, the WHO Director General, she reinforced
the need to shine a collective light on the still widespread silence, stigma,
and discrimination that surrounds mental and substance use disorders
globally. She also conveyed hope and offered an example for other political,
private sector, and cultural leaders to follow and engage in this issue:
"Depression is a common yet serious illness. It is important to understand
that anxiety and depression are like any other illness and treatable. It was
experience with this illness that encouraged me to set up Live Love Laugh,"
she said while talking about the Foundation she has set up for this cause.
The session “Protecting Mental Health in Youth” offered diverse
perspectives on the challenges and options to scale up approaches to
dealing with mental illnesses among children, adolescents, and young adults
aged 14-25 years. The special focus on this group is warranted because
nearly 75% of mental health conditions begin before age 25, and suicide is a
leading cause of death among youth, particularly among young women aged
19-24 years in some countries, with research showing that early intervention
pvmarquez.com/mental_health_davos 2/9
1/12/2021 Mental Health and Healthy Futures: A Priority Theme at WEF Davos 2020 | Patricio V. Marquez
is the best means of prevention. Also, as argued by Patrick McGorry, a
noted psychiatrist from Australia known for his development of the early
intervention services for emerging mental disorders in young people, the
experience in his country shows that an initial focus on mental health in
youth helps bring the issue to the wider political arena since it can galvanize
the attention of parents and families, who are concerned about the
wellbeing of their children; organized community and interest groups;
voters; and governments. People living with mental health problems have a
major role to play in speaking out, sharing their stories, and articulating
their rights and demands, in the same manner as the movement of HIV-
positive people did a couple of decades ago to demand access to life-saving
drugs.
The activation of a wider “conversation”, anchored in empathetic listening,
is critical to overcome a range of social barriers, from the taboo of mental
illnesses, the stigmatization of individuals who are affected by these
disorders, the fear of discrimination among their families, to widespread
beliefs that these conditions are not “real” health problems, or are problems
brought on by one’s own choices or “social deviant” behavior in the case of
substance use disorders. Indeed, as illustrated from the lived experience of
Amornthep Sachamuneewongse, a WEF Global Shaper Bangkok who
participated in the panel, in many countries mentally ill individuals “live in
places where people really do not understand what mental illness is, where
there is no one to talk about it, or where one cannot express much, and
(ultimately) attempts suicide” to overcome loneliness, stress, grief,
depression, and anxiety.
Because the brain is extremely sensitive to environmental factors,
particularly in the rst two decades of life, and because most mental health
problems begin before young adulthood, the need to act early to prevent
their onset was stressed by panelists, who argue for ensuring nurturing and
safe environments for children and adolescents to thrive in schools, at
pvmarquez.com/mental_health_davos 3/9
1/12/2021 Mental Health and Healthy Futures: A Priority Theme at WEF Davos 2020 | Patricio V. Marquez
home, and in communities. Henrietta H. Fore, the Executive Director of
UNICEF, eloquently noted that as con ict exposes populations to violence
and high levels of stress, bottom-up, multisectoral approaches are required
in humanitarian and development programs to address the needs of
displaced population groups and refugees. Indeed, investment in
education, social protection, and employment training would ameliorate
social exclusion and build social resilience by serving the unique needs of
vulnerable groups, such as children and young people who have been
exposed to rape and other forms of violence, who have served as child
soldiers, or who have witnessed the killing of close family members. As she
argued, affected children and youth need to feel safe, have someone who
they can trust and talk to, and have access to the positive socialization
that schools and other social support programs can provide to help “bring
them back.”
Panelists also highlighted that private rms and enterprises have a vested
interest in having mentally healthy workers, not only for “bottom line
considerations”, but more importantly to increase productivity and
competitiveness —a “top line” consideration. As mental illnesses account
for a large share of absenteeism and presenteeism (a situation in which an
employee is present for duty but is not fully capable of performing
workplace tasks due to an illness or other condition) in the workplace,
companies reduce economic losses and increase productivity and
competitiveness by promoting the physical and mental wellbeing of
employees, and in some cases their families.
Although global healthcare spending has increased dramatically over the
past decade, greatly helping to expand access to health services, a
signi cant supply-side barrier across the world is the lack of mental health
parity in the provision and nancing of health services. To deal with this
situation, as voiced by different panelists, mental health needs should be
viewed in the same vein as physical health needs and be recognized as a
pvmarquez.com/mental_health_davos 4/9
1/12/2021 Mental Health and Healthy Futures: A Priority Theme at WEF Davos 2020 | Patricio V. Marquez
basic human right. Moving from advocacy to implementation, this would
require a wider acceptance of the idea that mental health disorders are
conditions of the brain that should not be treated differently than other
chronic health conditions, such as heart disease or cancer. Nor, in fact, are
they truly separable: If untreated, mental disorders can negatively affect
management of such co-occurring diseases as tuberculosis and HIV,
diabetes, hypertension, cardiovascular disease, and cancer.
As I have argued before, the realization of universal health coverage
commitments by countries should include strategies and plans for the
medium term to integrate mental health care into health services delivery
platforms that focus on the whole patient rather than an aggregation of
diseases. This, in turn, requires a de nition of what mental health
conditions to prioritize, as they range from autism and intellectual
disability in childhood, to anxiety and depression, bipolar disorders,
schizophrenia, to alcohol and substance use disorders in adulthood, and to
dementia in old age; how to select a menu of evidence-based, cost-
effective treatments to be offered for sets of conditions by service
providers at different levels of care (as is commonly done for physical health
conditions); and how these services will be funded and reimbursed without
perpetuating discrimination. Key barriers to overcome include lack of
trained personnel for the provision of psychosocial support; limited
availability of generic drugs in public facilities of peri-urban and rural areas;
and under health insurance arrangements, pre-existing clauses that do not
cover a medical condition that started before a person's health insurance
bene ts went into effect, as well as high deductibles, copayments, and
lifetime limitations in coverage, that increase the risk of catastrophic health
expenditures and impoverishment among vulnerable population groups.
As Jeremy Farrar, the Director of Wellcome Trust, observed, while it is
common for WEF participants to elaborate on problems and propose
solutions, what is needed for moving the “Healthy Futures” agenda,
pvmarquez.com/mental_health_davos 5/9
1/12/2021 Mental Health and Healthy Futures: A Priority Theme at WEF Davos 2020 | Patricio V. Marquez
particularly multisectoral and multidisciplinary action to address mental and
substance use disorders among youth, is to track commitments and make
public and private stakeholders accountable for their realization. Only if
the talk is translated into a walk for action and measurable impact will we be
able to ensure the availability of required investments for supporting scaled
up interventions globally. If this is done, as Fatima Azzahra El Azzouzi, the
moderator of the session, noted, we can aspire to achieve an “emotional
and mentally cohesive and sustainable future”.
Sources
World Economic Forum Annual Meeting, 21—24 January 2020. Explore the
World Eco… (https:/ /www.weforum.org/events/world-economic-forum-
annual-meeting-2020/themes)
World Economic Forum Annual Meeting, 21—24 January 2020. Session “The
26th Annu… (https:/ /www.weforum.org/events/world-economic-forum-
annual-meeting-2020/sessions/the-26th-annual-crystal-award-ceremony)
World Economic Forum Annual Meeting, 21—24 January 2020. Session “An
Insight, A… (https://www.weforum.org/events/world-economic-forum-
annual-meeting-2020/sessions/an-insight-an-idea-with-deepika-
padukone)
World Economic Forum Annual Meeting, 21—24 January 2020. Session
“Protecting Me… (https:/ /www.weforum.org/events/world-economic-
forum-annual-meeting-2020/sessions/protecting-mental-health-in-youth)
Marquez, PV, Hewlett, E. “Lessons from OECD countries: mental health is
critica… (https://blogs.worldbank.org/health/lessons-oecd-countries-
mental-health-critical-human-capital-development)
Marquez, PV, Dutta, S. “On World Mental Health Day: A call to invest in
interve… (https://blogs.worldbank.org/health/world-mental-health-day-
call-invest-interventions-young-people)
Marquez, PV. “Mental Health in Prisons: How to Overcome the Punishment
Paradigm… (https:/ /blogs.worldbank.org/health/mental-health-prisons-
how-overcome-punishment-paradigm)
pvmarquez.com/mental_health_davos 6/9
1/12/2021 Mental Health and Healthy Futures: A Priority Theme at WEF Davos 2020 | Patricio V. Marquez
Marquez, PV, Dutta, S. “Maternal Depression and Stunted Children: An
Avoidable … (https://blogs.worldbank.org/health/maternal-depression-
and-stunted-children-avoidable-reality)
Marquez, PV. “The case for physical and mental wellness programs in the
workpl… (https://blogs.worldbank.org/health/case-physical-and-mental-
wellness-programs-workplace)
Marquez, PV. 2017. “Mental health among displaced people and refugees:
making t…
(http://documents.worldbank.org/curated/en/916131486730755271/Mental-
health-among-displaced-people-and-refugees-making-the-case-for-
action-at-the-World-Bank-Group)
Marquez, PV, Walker, M. “Mental health services in situations of con ict,
frag… (https://blogs.worldbank.org/health/mental-health-services-
situations-con ict-fragility-and-violence-what-do)
Marquez, PV, Saxena, S. “Mental Health Parity in the Global Health and
Developm… (https:/ /blogs.worldbank.org/health/mental-health-parity-
global-health-and-development-agenda)
Marquez, PV. Invisible wounds: Mental health among displaced people and
refugee… (https://blogs.worldbank.org/voices/invisible-wounds-mental-
health-among-displaced-people-and-refugees)
pvmarquez.com/mental_health_davos 7/9
1/12/2021 Mental Health and Healthy Futures: A Priority Theme at WEF Davos 2020 | Patricio V. Marquez
pvmarquez.com/mental_health_davos 8/9
1/12/2021 How to Accelerate Universal Health Coverage in Latin America and the Caribbean? | Patricio V. Marquez
How to Accelerate Universal Health
Coverage in Latin America and the
Caribbean?
Submitted by Patricio V. Marquez on Thu, 01/16/2020 - 08 21 PM
How to Accelerate Universal Health
Coverage in Latin America and the
Caribbean?
Posted by Patricio V. Marquez on Thu, 01/16/2020 - 08 21 PM
In Memory of Miguel A. Marquez, 1934-2014
pvmarquez.com/health_reform 1/9
1/12/2021 How to Accelerate Universal Health Coverage in Latin America and the Caribbean? | Patricio V. Marquez
Over the past four decades, major policy reforms were introduced in several
Latin American and Caribbean countries to strengthen their health
systems. While countries such as Brazil, Costa Rica, and Cuba managed to
unify their health systems, and Chile, Colombia, and Mexico introduced
organizational changes to expand health service coverage to the poorest
populations as a right for all citizens, the institutional organization in most
countries of the region at the beginning of the 2020 decade continues to be
characterized by the coexistence of parallel subsystems that respond to the
needs of different social groups in an often uncoordinated and fragmented
manner. In spite of the regional heterogeneity, this segmented model of
heath care organization in most countries of the region segregates different
population groups according to employment and socioeconomic status into
three broad institutional arrangements for accessing health services: the
ministry of health, the social security institute (s), and the private sector.
Why does this matter? In 2014, PAHO/WHO Member States approved the
Strategy for Universal Access to Health and Universal Health Coverage
(UHC). The strategy emphasizes the need to strengthen health systems to
achieve universal access and coverage, namely by reducing health inequities;
expanding access to comprehensive, quality care; and improving the health
and well-being of the population. The progressive realization of the UHC
strategy in the region, therefore, requires a major health system
transformation to deal with the fragmentation of nancing and service
delivery and the differential access produced by population segregation.
In advancing the health reform process in Latin America and the Caribbean in
the new 2020 decade, several factors merit consideration. I will elaborate on
some of them given their importance for increasing the political feasibility of
reforms as well as for ensuring their nancial and institutional sustainability.
Factors to Consider
pvmarquez.com/health_reform 2/9
1/12/2021 How to Accelerate Universal Health Coverage in Latin America and the Caribbean? | Patricio V. Marquez
The history of health care reform in the region and elsewhere shows that
technically sound proposals backed by data and evidence are a vital but not
suf cient condition to effect this transformation. As public policy is an
inherently political process, a clear understanding and careful but active
modulation of the interrelationships among individuals, organized interest
groups, and governments in a given context and period of time are of
critical importance to in uence the design and enactment of policies, laws,
and regulations that shape a health system. This implies that reform
proposals in the health sector rst and foremost need to clearly articulate
how they will contribute to the achievement of broader social goals in a
country, or more broadly stated, to construct societies that are more
inclusive, where health care is a social good available to all on equal terms,
rather than a private consumption good like other services such as food and
housing, that is only fully afforded to the rich. The uni cation of vision and
social goals as the frame of reference for health reform proposals is key to
align the interests of different actors and mobilize their support for their
adoption and sustainable implementation over time.
Indeed, as Professor Uwe E. Reinhardt, the distinguished late Princeton
University health economist observed, having a clear understanding of “what
kind of a society a country wants to have”, will ultimately guide policy and
institutional decisions concerning the most appropriate and contextually
relevant organizational forms, health care nancing arrangements, and
service delivery mechanisms that could be adopted to attain the intermediate
goals of a health system (improved access, quality, ef ciency, and fairness),
which would in turn contribute to achievement of the ultimate goals of a
health system (improved health status, nancial protection, and patient
satisfaction with health care received).
The codi cation into laws of health as a right of citizenry is a vital step that
is required to transform health systems as it helps to translate speci c policy
proposals into legal mandates, institutionalizing a framework that ensures the
pvmarquez.com/health_reform 3/9
1/12/2021 How to Accelerate Universal Health Coverage in Latin America and the Caribbean? | Patricio V. Marquez
directionality and continuity of the reform process across political cycles and
helps withstand recurring bouts of political opposition and changed social
and economic interests in a country.
Recent examples in the Americas offer good lessons on the interplay of
policy formulation and advocacy and the sobering reality of the political
processes needed for their approval and enactment that have reshaped
health care organization and nancing, service delivery modalities, and
expanded population coverage:
Colombia, with the adoption of Law 100 in the mid-1990s, that introduced a
universal health insurance program, which was amended in 2008 per the
decision of the Constitutional Court that directed the Government to unify its
contributory and subsidized insurance schemes; the 2003 approval by the
Mexican Congress of revisions to the General Health Law that established the
System of Social Protection in Health, with Seguro Popular expanding health
insurance coverage to about half of the country’s population; and the Patient
Protection and Affordable Care Act adopted in the United States in 2010. In
previous decades, health as a human right and citizens’ entitlement were
codi ed in the Constitutions of countries such as Cuba, after the 1959
revolution; Costa Rica in the 1960s; Brazil in the Constitution adopted in 1988;
in Peru in 2002, with the introduction of the Comprehensive Health Insurance
for poor and uninsured populations; and in Chile, with the adoption in 2005 of
the Health Guarantees Law that introduced enforceable rights to health
services for a set of diseases.
Dealing with inequitable nancing, particularly needed to realize the promise
of timely access to medical care when needed and to reduce out-of-pocket
expenditures that create risks for catastrophic and impoverishing spending
among the poor and underserved populations, is of upmost importance.
Recent estimates show that out-of-pocket expenditures stood at 33 percent
in 2014 and 28 percent in 2016 of total health spending on average in several
countries; this level is far higher than the OECD countries average of 18
pvmarquez.com/health_reform 4/9
1/12/2021 How to Accelerate Universal Health Coverage in Latin America and the Caribbean? | Patricio V. Marquez
percent. This gures not only convey the stress households face in accessing
health care, but acquires added relevance when one considers that among the
world’s regions, Latin America and the Caribbean has one of the highest levels
of social and health inequity, especially in terms of inequality in income
distribution. Although income inequality has decreased over the past 15 years,
in 2017, the Gini index (the most common measure of inequality; a higher Gini
index indicates greater inequality, with high income individuals receiving
much larger percentages of the total income of the population) stood at 0.51,
the highest in the world. If, as envisioned, the targets for UHC and the
health- and poverty-related Sustainable Development Goals (SDGs) are to be
achieved by 2030, a sustained effort of domestic resource mobilization and
increase in the relative allocation for health in national budgets is required.
Given the middle-income status of most countries in Latin America and the
Caribbean, this effort, as outlined in a recent World Bank Group report for the
G20, would mean in practice that as part of scal consolidation initiatives,
governments would need to increase overall government revenue as a share
of GDP, and where feasible, some of which can ow to expand scal space
for health. To this end, there is an arsenal of measures to consider:
improvements in tax administration; expansion of tax bases by increasing the
range and level of taxes and charges; removal, although political dif cult, of
ineffective subsidies (e.g., on fossil fuel) that disproportionately bene t the
non-poor; raising taxes on tobacco products and other health-damaging
products, such as alcohol and sugary drinks, which not only help to reduce
health risks but also are more politically acceptable to the general
population than other taxes in spite of likely opposition from powerful
interest groups; and reduction of the reliance on wage-based deductions or
voluntary forms of insurance to bolster prepaid and pooled funding.
Leveraging health-related investments in other sectors—including, for
example, in transport to reduce road traf c injuries and fatalities that impose
a heavy burden on costly trauma care, in safe water and basic sanitation to
pvmarquez.com/health_reform 5/9
1/12/2021 How to Accelerate Universal Health Coverage in Latin America and the Caribbean? | Patricio V. Marquez
reduce the risk of gastrointestinal diseases and chronic malnutrition—would
improve population health, reducing need, demand and utilization of health
services.
While additional funds for health would help, an equally important task is
to improve the ef ciency of resource use in the region. For example, a
recent report suggested that 20 percent of all health expenditures in OECD
countries was wasted and did not contribute to the desired health outcomes;
in some Latin American and Caribbean countries, this gure may be higher.
As suggested in the World Bank Group report, improvements in performance-
informed planning and budgeting, enhanced budget execution, and stronger
systems of public nancial management in the health system would help.
Also, better allocation of existing resources is needed in order to prioritize
the delivery of cost-effective primary and community health services with
appropriate referral systems, away from hospital-centric models of care, and
strengthen public health functions, particularly disease surveillance, public
health labs for case con rmation, and epidemiological intelligence capacity,
to anticipate and control societal-wide health risks associated with the
reemergence of infectious diseases and the emergence of new pathogens that
cross borders and threatening loss of life, economic disruption, and costs to
health systems.
In the face of rapid demographic and health changes in Latin America and
the Caribbean, particularly the aging of the population and the increase in
the relative importance of chronic non-communicable diseases and
injuries, as well as mental and substance use disorders, another priority
area that merits attention for reforming health systems in the region is the
need to support a fundamental rethinking of how to best keep people
healthy and out of hospitals.
pvmarquez.com/health_reform 6/9
1/12/2021 How to Accelerate Universal Health Coverage in Latin America and the Caribbean? | Patricio V. Marquez
For starters, there has to be a widespread realization among policymakers,
employers, health insurers, service providers, and the population at large, that
the lion’s share of health care expenditures goes for treating diseases and
injuries that could be “prevented”.
The realization of health promotion and disease and injury prevention would
require supporting population-wide efforts to tackle social, environmental
and behavioral determinants of ill health, premature mortality, and disability,
such as scal and regulatory policies to curb tobacco use, second hand
smoke, alcohol and substance abuse, obesity, Type-2 diabetes, road traf c
injuries, and in some countries, gun violence. Insurance arrangements and
health care organization and payment innovations could also be used to
advance this public health agenda. For example, insurance companies, by
charging lower premiums for those who quit smoking, lose weight, and pass
screening tests for artery-clogging cholesterol, high blood pressure, and high
sugar levels, provide an incentive for individuals and families to assume
responsibility for their health.
Moving forward
Throughout the world there is an ongoing search for new and innovative ways
to address health system shortcomings to better respond to present and
future health challenges. Latin American and the Caribbean countries are not
an exception. Reforming long-entrenched health care organization and
nancing arrangements is not an easy task that can be completed in the
short-term.
Moving from policy intention toward the achievement of UHC as a broad
development and social goal will require political commitment at the
highest political level and the buy-in and active involvement of individuals,
organized interest groups, and governments over the medium- and long-
terms. Well informed and inclusive political strategies and sound technical
proposals would help pave the way for implementing needed health system
pvmarquez.com/health_reform 7/9
1/12/2021 How to Accelerate Universal Health Coverage in Latin America and the Caribbean? | Patricio V. Marquez
changes over the medium- and long-terms to eliminate social strati cation in
accessing and funding health services, build more inclusive and resilient
societies, and support the development of healthy populations in the region.
Opposition from interest groups and backpeddling by governments, however,
should be expected as an ever-present risk that will need to be monitored and
confronted during this process.
Sources
Atun, R. et al. 2015. “Health-system reform and universal health coverage in
La… (https:/ /doi.org/10.1016/S0140-6736(14)61646-9)
Londoño, JL and Frenk, J. 1997. “Structured pluralism: towards an innovative
m…
(https://www.sciencedirect.com/science/article/abs/pii/S0168851097000109)
Marquez, PV. 2016. “Time to put “health” into universal health coverage”.
World… (http:/ /blogs.worldbank.org/health/time-put-health-universal-
health-coverage)
World Bank Group. 2019. “High-Performance Health Financing for Universal
Health… (https:/ /openknowledge.worldbank.org/handle/10986/31930)
pvmarquez.com/health_reform 8/9
1/12/2021 How to Accelerate Universal Health Coverage in Latin America and the Caribbean? | Patricio V. Marquez
(https://twitter.com/pvmarquez1956)
pvmarquez.com/health_reform 9/9
1/12/2021 Is the Growing Attachment to Smartphones and Digital Media Bad for Our Health? An initial exploration | Patricio V. Marquez
Is the Growing Attachment to Smartphones and Digital
Media Bad for Our Health? An initial exploration
Submitted by Patricio V. Marquez on Sun, 12/08/2019 - 09 36 AM
Is the Growing Attachment to Smartphones and Digital
Media Bad for Our Health? An initial exploration
Posted by Patricio V. Marquez on Sun, 12/08/2019 - 09 36 AM
This note served as background to a presentation delivered per the invitation of the Ecuador Mission to the United Nations at
the Meeting on Social Media and Mental Health, organized by the Group of Friends on Mental Health and Well-Being, that is co-
led by the Permanent Missions of the Kingdom of Bahrain, Belgium, Canada and Ecuador to the United Nations. New York City,
December 12, 2019
Technological innovation is fueling momentous change in our daily lives. Indeed, as Professor Klaus Schwab, the
chairman of the World Economic Forum (WEF) describes, the physical, digital and biological trends underpinning
what he calls 'the fourth industrial revolution', are unleashing changes “unlike anything humankind has
experienced before" (WEF 2015). At the center of it all is the Internet, anchoring digital media.
The WEF de nes “digital media” as “products and services that come from the media, entertainment and
information industry and its subsectors. It includes digital platforms (e.g., websites and applications), digitized
content (e.g., text, audio, video and images), and services (e.g., information, entertainment, and communication) that
can be accessed and consumed through different digital devices” (WEF 2016). Laptops and desktops are still the
most widely used devices, but mobile devices, such as smartphones, are fast catching up in popularity and use.
The easy-to-carry and handle, multi-functional smartphone, is a common feature of modern life globally. Billions of
people are now connected to these mobile devices, with unprecedented processing power, storage capacity, and
access to knowledge. In emerging countries, mobile technology is allowing consumers to leapfrog from “no digital
use” straight to “mobile use” (WEF 2015).
www.pvmarquez.com/digital media_impacts 1/8
1/12/2021 Is the Growing Attachment to Smartphones and Digital Media Bad for Our Health? An initial exploration | Patricio V. Marquez
There is a growing concern that our attachment to them and “what is in them” not only captures our full attention
and a good share of our time, but is creating virtual barriers that hinder direct social interaction. There are also
concerns about their potential negative impact on the mental and physical health of people.
To learn about this topic, as it would not surprise anybody, I began searching the web for recent literature using the
Google app in my smartphone while waiting at the dentist’s of ce, before turning to a laptop at home to review and
write. A summary of my initial exploration follows.
Growing popularity and use
Hundreds of millions of people are using smartphones, downloading apps, and browsing web sites. Smartphone
subscriptions are growing at the rate of 17-19% per year and now total about 2.1 billion users, while consumer mobile
internet traf c is accelerating at more than 60% every year (WEF 2015). Smartphone ownership among young
people aged 9 to 16 is also growing; for example, almost half of young people in Europe have a smartphone,
according to a 2014 survey of 7 countries (Mascheroni and Ólafsson 2014).
In the US, 48% of 11-year-olds reported owning a mobile phone, and among 14-year-olds, it was 85% (unpublished
data; see go.nature.com/2eeffku, cited by Odgers 2018).
Smartphones have become essential to the life of people. It is not surprising to learn, then, that an estimated 87% of
US millennials say their smartphone never leaves their side (Ziv, S). Similarly, a survey by Qualtrics and Accel
Partners found that 79% of US millennials put their phones right by them when they sleep, 53% wake up at least
once every night to check them, and that nearly 60% check them before they use the bathroom in the morning.
Data reveals that 89% of mobile phone owners use them in social gatherings, to read texts or emails, take photo or
video; or to place a call (Ziv, S).
Social media, which have grown in popularity, are web platforms that allow individuals to create a pro le and
connect to other people to share information, ideas, interests, and other forms of expression on the site regardless
of location and time. The different types of social media platforms include: Social networking (Facebook, LinkedIn,
Google+); Microblogging (Twitter, Tumblr); Photo sharing (Instagram, Snapchat, Pinterest); and Video sharing
(YouTube, Facebook Live, Periscope, Vimeo).
About 3.2 billion people or 40% of the world’s population are estimated to use social media. Worldwide, as shown
in the graph below, Facebook tops the list with 2.23 billion active users as of mid-2018, or almost a third of the
world’s population, followed by YouTube and Instagram.
Source: Graph downloaded at https://www.dreamgrow.com/top-15-most-popular-social-networking-sites/
www.pvmarquez.com/digital media_impacts 2/8
1/12/2021 Is the Growing Attachment to Smartphones and Digital Media Bad for Our Health? An initial exploration | Patricio V. Marquez
Adult social media users spend on average 2 to 3 hours every day sharing, liking, tweeting, and updating. Use
prevalence among teenagers is growing rapidly. For example, survey data indicate that on average, US teens aged
13–18 engage with digital media (from watching television or online videos to reading online and using social media)
for more than 6.5 hours each day; mobile devices account for almost half this time (Rideout 2015).
What are the negative aspects of these trends?
We should not be surprised, then, that as individuals want to be connected more or less 24/7, the question that
many people are asking is, how is all this impacting us, our children, and our social lives?
The graph below depicts the negative psychological effects of social media:
Source: Graph from Kelly, Zilanawala, Booker and Sacker. 2019. “Social Media Use and Adolescent Mental Health:
Findings from the UK Millennium Cohort Study.” The Lancet.
The ndings of a 2016 assessment by the WEF expands on these negative effects:
Excessive digital media use can negatively in uence the development of cognitive (thinking, imagining,
reasoning, and remembering abilities) and behavioral (reactions or actions that we take in response to stimuli
present in our environment) skills and even mental and physical health of people.
Hyper connectivity has the potential to change patterns of social interaction, as face-to-face interaction, that is
essential to the give-and-take functioning of families, communities, and workplaces, may be substituted by
online interaction.
Levels of empathy (“understanding another’s situation or feelings and experiencing a sense of their emotional
state”) are declining, perhaps as a result of the decrease in face-to-face communication.
Digital media consumption may facilitate bullying, harassment, social defamation, and hate speech because
potential costs of such behavior are reduced and the ease of engaging in behaviors that harm either others or
ourselves is increased (Mascheroni and Cuman 2014). Data from a global YouGov survey sponsored by Vodafone
shows that of more than 4,700 teenagers surveyed worldwide, 50% felt that cyberbullying was worse than face-
to-face bullying; about one- fth reported having been cyberbullied; of those, 41% stated cyberbullying made
them feel depressed, and 18% said it had made them consider suicide (Vodafone/YouGov 2015).
Mental health risks
www.pvmarquez.com/digital media_impacts 3/8
1/12/2021 Is the Growing Attachment to Smartphones and Digital Media Bad for Our Health? An initial exploration | Patricio V. Marquez
Research indicates that excessive digital media consumption and the way digital media are being used pose a
number of risks to user health and well-being, particularly increased vulnerability to addiction, and harm mental
and physical health.
The ndings in the 2016 assessment by the WEF identify three potential major mental health risks:
Overload: Increased stress because of the volume and variety of social media contact,
Invasion: Intrusion of media connections into personal life, and,
Uncertainty: Continuous and unpredictable change in social media applications and requirements.
As I can attest from my own experience, uninterrupted access to digital media content tends to intrude in a user’s
work and personal lives, making one oblivious to the difference between business and personal activity and between
time on and time off.
Other potential risks identi ed in in the 2016 WEF assessment, include:
Envy-related stress related to constant updates on friends’ latest professional successes, fantastic vacations,
and personal triumphs.
Decline in civility, facilitated by electronically mediated interactions that are more anonymous and often more
bluntly negative than face-to-face encounters.
Addictive behavior, as shown by evidence that some video gamers experience symptoms similar to those felt by
people with substance abuse or gambling addiction and may be experiencing similar changes in brain chemistry
related to the release of dopamine, an important chemical messenger in the brain that it is involved in reward,
motivation, memory, attention, and even regulating body movements. When dopamine is released in large
amounts, it creates feelings of pleasure and reward, which motivates you to repeat a speci c behavior.
Association with depression. Distinct patterns of social media use help explain the association of digital media
with depression and anxiety symptoms. Those clustered as “Wired” and “Connected” in the research showed
increased odds of elevated depression and anxiety symptoms (Shensa, Sidani, Dew, Escobar-Viera, Primack 2018).
Similarly, a large longitudinal study of Americans aged 14-24 years found that heavy use of the internet and video
games is associated with an increase in depression. Findings from the UK Millennium Cohort Study show that the
magnitude of association between social media use and depressive symptoms was larger for girls than for boys.
Poor sleep, online harassment, poor body image, and low self-esteem appear to be important pathways via which
social media use is associated with depressive symptoms in young people (Kelly, Zilanawala, Booker, Sacker 2019).
Impact on cognition. Social media use has been shown to reduce attention span and lower recall rates for
information people believe they can access easily online.
Reduced downtime. Increased social media use reduces periods of inactivity, which are critical to allow the brain
to synthesize information, make connections between ideas, and develop a sense of self.
Physical health risks
Two major physical health risks from high digital media use can be highlighted:
Increased sedentary behavior. Time spent on digital technology displaces time that could be spent on physical
activity. Lack of physical activity has been identi ed as the fourth leading risk factor for global mortality (6% of
deaths globally). Moreover, physical inactivity is estimated to be the main cause for approximately 21–25% of
breast and colon cancers, 27% of diabetes cases, and approximately 30% of the ischemic heart disease burden.
Childhood obesity, which is one of the most serious public health challenges of the 21st Century, is steadily
affecting many low- and middle-income countries, particularly in urban settings. Globally, in 2016, the number of
overweight children under the age of ve was estimated to be over 41 million. Overweight and obese children are
www.pvmarquez.com/digital media_impacts 4/8
1/12/2021 Is the Growing Attachment to Smartphones and Digital Media Bad for Our Health? An initial exploration | Patricio V. Marquez
likely to stay obese into adulthood and more likely to develop noncommunicable diseases like diabetes and
cardiovascular diseases at a younger age (accessed WHO data).
Physical injury. The use of handheld smartphones is now a major cause of road traf c injuries and fatalities in
the world, particularly among young drivers. Studies in the United States show that dialing and texting when
driving pose a substantial increase in the risk of being involved in a crash or near crash (cited in Marquez et al
2009).
When driving light vehicles and cars:
Placing a call on a cell phone made the risk of a crash or near-crash event 2.8 times higher than non-distracted
driving.
Talking on or listening on a cell phone made the risk of crash or near-crash event 1.3 times higher than non-
distracted driving.
Reaching for an object such as an electronic device made the risk of a crash or near-crash event 1.4 times higher
than non-distracted driving.
When driving heavy vehicles and trucks:
Placing a call on a cell phone made the risk of a crash or near-crash event 5.9 times higher than non-distracted
driving.
Talking or listening on a cell phone made no difference to the risk of a crash or near-crash event compared to
non-distracted driving.
Use of or reaching for an electronic device made the risk of a crash or near-crash event 6.7 times higher than
non-distracted driving.
Text messaging made the risk of a crash or near-crash event 23.2 times higher than non-distracted driving (large
trucks made up close to 10% of all vehicles involved in fatal crashes in the US).
Impact on children’s well-being
Studies in the 2016 WEF highlighted the following potential negative impact on children:
Excessive new media use can lead to attention problems, school dif culties, sleep disorders (particularly for
children aged three to ve years when exposed to violent content), and eating disorders and obesity.
Digital media use is harmful to children if interaction with parents and others is replaced by interaction with
digital media. Research has shown that brain development depends on social interaction with others during a
critical period in early life and that lack of social interaction creates irreversible social and cognitive impairments
throughout life.
Healthy neurological development requires the engagement of all sensory systems, but heavy digital media
consumption favors the visual and auditory systems over the vestibular (sense of balance), proprioceptive
(sense of self-movement and body position), tactile (sense of touch), and attachment systems, creating possibly
permanent imbalances.
Delayed language development. Research has shown that very young children (aged 9-18 months) do not learn
language by watching educational videos without active interaction with another person.
Uncontrolled time spent on digital media often displaces time spent on academics, lowering academic
achievement.
Digital media make it easier to disseminate inaccurate as well as accurate information, and much that is online
is potentially harmful to younger audiences. For example, a recent New York Times article documents how
through video games and online chats sexual predators are making virtual connections with children right in
their victims’ homes. The criminals strike up a conversation and gradually build trust, often posing as children,
www.pvmarquez.com/digital media_impacts 5/8
1/12/2021 Is the Growing Attachment to Smartphones and Digital Media Bad for Our Health? An initial exploration | Patricio V. Marquez
con ding in their victims with false stories of hardship or self-loathing, with the goal of duping children into
sharing sexually explicit photos and videos of themselves — which they use as blackmail for more imagery, much
of it increasingly graphic and violent (Bowles N, Keller MH 2019).
Impact on Adolescents
Data show an increase in mental health problems among adolescents (Odgers 2018). Worldwide, it is estimated that
10–20% of adolescents experience mental health issues (Marquez, Dutta 2018).
Recent data suggest that adolescents do perceive social media as a threat to mental wellbeing because: (1) social
media is believed to cause mood and anxiety disorders for some adolescents, (2) social media is viewed as a platform
for cyberbullying, and (3) the use of social media itself was often framed as a kind of 'addiction' (O’Reilly, Dogra,
Whiteman, Hughes, Eruyar, Reilly 2018).
Research based on a large, nationally representative dataset in the US found that more US adolescents and young
adults in the late 2010s, as compared to the mid-2000s, are experiencing serious psychological distress, major
depression, and suicidal thoughts and more attempted suicide and took their own lives. These trends are weak or
nonexistent among adults 26 years old and over. These trends suggest a generational shift in mood disorders and
suicide-related outcomes rather than an overall increase across all ages; researchers posited that they may be
associated with lack of sleep and the rise of social media in teens (Twenge, Cooper, Joiner, Duffy, Binau 2019).
How can we leverage these tools and platforms to address mental and physical health risks?
We should be clear that access to and use of digital media, while posing risks, is also bene cial to both individuals
and society.
Digital tools and platforms are enabling unprecedented levels of communication, social interaction, and community
building across boundaries of time, place, and social context (Seabrook, Kern, Rickard 2016). In particular, as
indicated by 61% of respondents to the Implications of Digital Media Survey (WEF 2016), digital media is considered
helpful to maintaining existing relationships with friends, and 45% believe it is helpful in forming new ones. Also,
social media facilitates the rapid sharing of accumulated knowledge and experiences within countries and globally.
In the health sector, digital tools and platforms are now becoming an asset for individuals and healthcare
practitioners, to help improve access to care and reach vulnerable populations, particularly in low-income settings
where healthcare delivery systems are limited. A good example is the initiative by Mobile Technology for
Community Health (MoTeCH) and the Grameen Foundation in Ghana, piloted in the Upper East Region and now
being replicated in the Central, Greater Accra and Volta Regions, which allowed women with limited literacy skills
to be informed in the local language about the “do’s and don’ts” in pregnancy and childbirth (Marquez 2013). Women
also receive reminders on clinical appointments, due dates, and required medication and immunization through
their mobile phone. This technology also enables women, their partners and families, to recognize the signs of life-
threating complications during pregnancy and empowers them to seek immediate care. Other applications allow
community midwives and nurses to provide rapid response and care and to follow up with health service defaulters
in the community.
Mobile devices like smartphones are also giving the public, doctors, and researchers new ways to access help,
monitor progress, and increase understanding of mental wellbeing (information from the National Institute of
Mental Health website). For example, text messages can help contact a crisis center; apps might use the device’s
built-in sensors to collect information on a user’s typical behavior patterns, including detecting a change in
behavior, and provide a signal that help is needed before a crisis occurs. Some stand-alone apps could help improve
www.pvmarquez.com/digital media_impacts 6/8
1/12/2021 Is the Growing Attachment to Smartphones and Digital Media Bad for Our Health? An initial exploration | Patricio V. Marquez
memory or thinking skills, and others help the user connect to a peer counselor or to a healthcare professional. This
support can be very simple but effective. A meta-analysis found, for example, that brief interventions, such as
computer-assisted cognitive behavioral therapy delivered through mobile devices, improved people’s psychological
well-being and reduced reported symptoms of depression and anxiety (Versluis, Verkuil, Spinhoven, van der Ploeg,
Brosschot 2016).
In addition, digital media can facilitate education and life-long learning to build the skills of the future,
contributing to human capital development in countries.
Sources
Picture: Smartphones communicating through their apps. Found on Bing from freer… (https:/ /binged.it/2PjDkKM)
Second Picture: Texting and Driving Pictures. Found on Bing. (https:/ /www.bing.com/images/search?
view=detailV2&id=CC8FC54DB8246126E3D2016C4A33B5F104A9DD13&thid=OIP.g3-BDLiPijNVsU-
Q6AwXbgHaE6&mediaurl=http%3A/ /pugetsoundblogs.com/kitsap-crime/ les/2014/04/text-and-
drive.gif&exph=416&expw=626&q=texting%20and%20driving%20pictures&selectedindex=1&ajaxhist=0&vt=0&eim=3)
Bowles N and Keller MH. 2019. “Video Games and Online Chats Are ‘Hunting Ground…
(https://www.nytimes.com/interactive/2019/12/07/us/video-games-child-sex-abuse.html)
Kelly Y, Zilanawala A, Booker C, and Sacker A. 2019. “Social Media Use and Adol…
(https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(18)30060-9/fulltext)
Marquez PV et al. 2009. “Confronting “Death on Wheels” Making Roads Safe in Eu…
(http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/ECAEXT/0,,contentMDK 22398460~pagePK 146736~piP
Marquez PV. 2013. “Preventing Maternal Mortality - A Yardstick for Social Justi…
(http://blogs.worldbank.org/nasikiliza/preventing-maternal-mortality-yardstick-social-justice)
Marquez PV. 2014. “Diabetes and Overweight: A Growing Global Burden.” WBG Blog
(http://blogs.worldbank.org/health/diabetes-and-overweight-growing-global-burden)
Marquez PV et al. 2016. “Summary Report: Out of the Shadows: Making Mental Hea…
(http://pubdocs.worldbank.org/en/391171465393131073/0602-SummaryReport-GMH-event-June-3-2016.pdf)
Marquez PV and Dutta S. 2018. “On World Mental Health Day: A call to invest in …
(http://blogs.worldbank.org/health/world-mental-health-day-call-invest-interventions-young-people)
Mascheroni G and Cuman A. 2014. “No Children Go Mobile: Final Report.” (/node/4)
National Institute of Mental Health (NIMH) website. “Technology and the Future…
(https://www.nimh.nih.gov/health/topics/technology-and-the-future-of-mental-health-treatment/index.shtml)
Odgers C. 2018. “Smartphones are bad for some teens, not all.” Nature. (https:/ /www.nature.com/articles/d41586-
018-02109-8)
O'Reilly M, Dogra N, Whiteman N, Hughes J, Eruyar S, Reilly P. 2018. “Is social…
(https://www.ncbi.nlm.nih.gov/pubmed/29781314)
Rideout, V. 2015. “The Common Sense Census: Media Use by Tweens and Teens.” Na…
(http://go.nature.com/2c4dwew)
Seabrook EM, Kern ML, Rickard NS. 2016. “Social Networking Sites, Depression, a…
(https://mental.jmir.org/2016/4/e50/)
Shensa A, Sidani JE, Dew MA, Escobar-Viera CG, Primack BA. 2018. “Social Media …
(https://www.ingentaconnect.com/contentone/png/ajhb/2018/00000042/00000002/art00011)
Shukla A. 2019. “The Effect of Social Media on Mental Health and Well-Being.” C…
(https://cognitiontoday.com/2019/08/effect-of-social-media-on-mental-health-well-being/)
Spelman M. Co-Head, Future of the Internet Initiative, Member of the Executive …
(https://www.weforum.org/agenda/2015/12/what-does-the-future-hold-for-the-internet/)
Twenge JM, Cooper AB, Joiner TE, Duffy ME, Binau SG. 2019. “Age, Period, and Co…
(https://www.apa.org/pubs/journals/releases/abn-abn0000410.pdf)
Versluis A, Verkuil B, Spinhoven P, van der Ploeg MM, Brosschot JFJ. 2016. Smar…
(https://www.nature.com/articles/d41586-018-02109-8)
www.pvmarquez.com/digital media_impacts 7/8
1/12/2021 Is the Growing Attachment to Smartphones and Digital Media Bad for Our Health? An initial exploration | Patricio V. Marquez
Vodafone/YouGov. 2015. “Global Survey on Cyberbullying.” (https:/ /markets.ft.com/data/announce/full?
dockey=1323-12509304-1Q8SVKBQINRPVIK2IJ53QU6KG4)
WEF. 2015. “The Fourth Industrial Revolution: what it means, how to respond.”
(https://www.weforum.org/agenda/2016/01/the-fourth-industrial-revolution-what-it-means-and-how-to-
respond/)
WEF. 2016. “Digital Media and Society Implications in a Hyperconnected Era. Sec…
(http://www3.weforum.org/docs/WEFUSA_DigitalMediaAndSociety_Report2016.pdf)
WHO site. “Global Strategy on Diet, Physical Activity and Health.”
(https://www.who.int/dietphysicalactivity/childhood/en/.)
Ziv S. “7 Scary Cell Phone Facts That'll Make You Question Your Addiction.” (https://www.themuse.com/advice/cell-
phone-addiction-stats-scary)
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/digital media_impacts 8/8
1/12/2021 Plastic Pollution: A "Clear and Present Danger" to the Galapagos Islands | Patricio V. Marquez
Plastic Pollution: A "Clear and Present Danger" to the
Galapagos Islands
Submitted by Patricio V. Marquez on Wed, 11/27/2019 - 08 14 AM
Plastic Pollution: A "Clear and Present Danger" to the
Galapagos Islands
Posted by Patricio V. Marquez on Wed, 11/27/2019 - 08 14 AM
People of my generation remember well the 1967 coming of age lm, “The Graduate.” In the opening scene, a
confused, wide-eyed young man, just returning home after nishing his university studies, is offered advice about
his future by a middle-aged friend of his parents in a much-quoted exchange:
MR. MCGUIRE: I want to say one word to you. Just one word.
BENJAMIN: Yes, sir.
MR. MCGUIRE: Are you listening?
BENJAMIN: Yes, I am.
MR. MGGUIRE: Plastics.
www.pvmarquez.com/plastic_pollution_galapagos 1/6
1/12/2021 Plastic Pollution: A "Clear and Present Danger" to the Galapagos Islands | Patricio V. Marquez
As preadolescent in those years, I was precociously intrigued by the plot of the movie and captivated by the
wonderful soundtrack of Simon and Garfunkel, but completely oblivious to its 1960s counterculture message. Years
later, I found out that the reference to “plastics” in the lm was considered as analogous with the perceived
“unnatural”, “arti cial”, and “lifeless” materialism of the times.
Plastics have also been broadly appreciated economically for being low-cost, lightweight, strong, durable, resistant
to corrosion, and nonconductors of electricity. It has been estimated that global plastics production rose
exponentially since the 1950s, from 15 million tons in 1964 to over 311 million tons in 2014, or twenty-fold in 50 years.
Moving the clock forward to the end of the second decade of the XXI Century, mass consumption, so greatly
facilitated by plastics, is now widely understood and accepted as a direct threat to future life in our planet. While
the great versatility and usefulness of plastics is economically appealing, their broad use and fate can also harm.
Indeed, the manufacture, wide use, and waste of all things plastic, particularly their prominence in marine debris, is
comparable to climate change in terms of impact, breadth and complexity.
On a recent visit to the Galapagos Islands, I was struck to learn that despite being located 600 miles westward of the
South American continent and the dedicated work of Galapagos National Park’s rangers and volunteers to conduct
coastal clean ups regularly, plastic waste being carried by strong oceanic currents is putting its fragile ecosystem at
risk. Indeed, information from different international organizations such as the National Geographic Society shows
that a plethora of plastic bottles, oil containers, plastic takeaway containers, plastic cutlery, glass bottles, metal
tanks, shing nets and traps, and plastic- ber rope are washing onshore into pristine lava elds, sandy beaches, and
mangrove elds. As observed by the Galapagos Conservation Trust, the increase of visitors to the Islands in recent
years, as well as the increase in the permanent residents, also implies that the amount of waste created is growing,
adding to plastic pollution.
It should be clear to all of us, therefore, that in spite of their “splendid isolation”, man-made waste and pollution are
becoming a major risk that threatens the Galapagos Islands’ unique fauna and ora, both inland and in the Galapagos
Marine Reserve. In particular, the native wildlife of Galapagos, that includes animal species not found anywhere else
in the world, are highly vulnerable to the introduction of plastic pollution as it may cause adverse changes to natural
habitats and injury and death when animals get entangled in heaps of debris. Iconic creatures such as the giant land
tortoise and marine turtles are particularly affected when debris in the ocean is mistaken for food and ingested,
causing internal abrasions and gut blockages. The human population is also at health risk as the unintended
ingestion of plastic substances disrupts endocrine functions*, which can cause cancerous tumors, birth defects, and
other developmental disorders.
We also have to understand that this environmental risk to the preservation of the Galapagos Islands is part of a
growing interconnected problem across continental South America and the rest of the world. Indeed, World Bank
Group assessments have documented the magnitude of this challenge globally. In 2010 alone, 4-12 million tons of
plastic were estimated to wash ashore globally. Of the estimated 275 million tons of plastic waste generated in 2010,
over 60 percent is thought to have originated from plastic packaging, which is primarily designed for single use.
Effective action to minimize this risk will require robust advocacy grounded in scienti c evidence to mobilize high-
level political support to counter “commercial determinants” of environmental and public health risks and active
engagement of government entities, private enterprises, and the population as a whole; medium-and long term
policies and regulatory mechanisms such as the sustainability certi cation standards; raising consumer and farmer
awareness of and ability to address the challenges of plastics use, as well as nudging the immense market power of
consumers to shape and in uence farming practices; and predictable and suf cient funding levels to support
sustained action over the medium-and long term.
www.pvmarquez.com/plastic_pollution_galapagos 2/6
1/12/2021 Plastic Pollution: A "Clear and Present Danger" to the Galapagos Islands | Patricio V. Marquez
As noted by the World Bank, much is known about the major avenues for mitigating plastics pollution-- from
improving how plastics are managed once they enter the waste stream or even further upstream during their useful
life, to reducing how much is produced, used, or enters the waste stream. Promising approaches to deal with this
problem include:
Recycling to reduce the production of new plastic and how much enters the waste stream. Plastics have been
recycled for decades, and recycling is now accepted as a good practice globally.
Waste-to-energy: This involves turning plastics into fuel or directly into energy (through gasi cation using
pyrolysis and incineration, respectively). As with recycling, however, its effectiveness can be limited by collection
challenges upstream.
Materials innovation/biodegradable plastics: Certain plastics can be made biodegradable, thus lessening the
likelihood that they will persist for a very long term in their plastic state, as they have the potential to be
composted or to photodegrade (or to otherwise degrade).
Improved collection and waste management: Expanding collection, improving waste transport systems to
reduce illegal dumping, and closing or upgrading dumping sites located near waterways can prevent leakage of
plastics into the environment. When plastic waste is not collected, it is more than twice as likely to leak into the
ocean.
Similarly, as the global experience with “public health taxes” levied on cigarettes, alcohol, and sugary drinks shows,
imposition of or hiking the level of taxes to raise the price of single-use plastic bags to carry groceries or other
items, needs to be adopted as a win-win policy measure to discourage the use of thin, disposable plastic
shopping bags to help the environment and reduce plastic trash, while helping mobilize additional domestic
resources to fund environmental protection in national budgets. This measure is of upmost importance in periods
of economic austerity as currently facing the Ecuadorian Government and should be included and supported as part
of scal consolidation efforts.
To help address this issue globally, innovative nancing mechanisms are being tapped. For example, the World
Bank launched in April 2019 a Sustainable Development Bond targeting institutional and individual investors to
draw attention to the challenge of plastic waste pollution in oceans. This bond, which raised US$10 million, would
contribute to fund projects to support the sustainable use of ocean and marine resources, including through better
waste management, in developing countries.
The growing economic, environmental, human health, and aesthetic risk posed to the Galapagos Islands by marine
plastic debris from continental Ecuador and neighboring countries can be contained and minimized by collective
action. If this is not done, plastic waste stands to cause irreparable damage to the Galapagos Islands in an ominous
way similar to Charles Darwin’s observation in The Voyage of the Beagle with regard to the “havoc” that may be
caused by the “introduction of any new beast of pray…before the instincts of the indigenous inhabitants have become
adapted to the stranger’s craft or power”.
Note*: The endocrine system is the collection of glands that produce hormones that regulate metabolism, growth
and development, tissue function, sexual function, reproduction, sleep, and mood, among other things. This system
affects almost every organ and cell in the body, according to the Merck Manual.
Sources
www.pvmarquez.com/plastic_pollution_galapagos 3/6
1/12/2021 Plastic Pollution: A "Clear and Present Danger" to the Galapagos Islands | Patricio V. Marquez
Plastics Scene from “The Graduate” (1967). (https:/ /www.bing.com/videos/search?
q=plastic%20in%20the%20Graduate&qpvt=plastic%20in%20the%20Graduate&view=detail&mid=B10C80827D443C5C7
“What is the meaning behind the quote "plastics" from "The Graduate?" Comment b…
(https://www.quora.com/What-is-the-meaning-behind-the-quote-plastics-from-The-Graduate)
National Geographic. “Impact of plastic garbage reaches the Galapagos Islands” …
(https://blog.nationalgeographic.org/2018/04/22/impact-of-plastic-garbage-reaches-the-galapagos-islands/)
Galapagos Conservation Trust. As Tourism Increases in Galapagos so do Threats s…
(https://galapagosconservation.org.uk/about-galapagos/conservation/pollution/)
World Bank Group. Agricultural Pollution: Plastics.
(http://documents.worldbank.org/curated/en/122161521208357388/pdf/124346-repl-WB-Knowledge-Plastic.pdf)
Acharya, A. “World Oceans Day & plastic pollution: Is the planet overdosing on …
(https://blogs.worldbank.org/eastasiapaci c/world-oceans-day-plastic-pollution-planet-overdosing-miracle-
product)
World Bank Group. Tackling Increasing Plastic Waste. (http:/ /datatopics.worldbank.org/what-a-
waste/tackling_increasing_plastic_waste.html)
World Bank Launched Bonds to Highlight the Challenge of Plastic Waste in Oceans…
(https://www.worldbank.org/en/news/press-release/2019/04/03/world-bank-launches-bonds-to-highlight-the-
challenge-of-plastic-waste-in-oceans)
Darwin, C. “The Voyage of the Beagle. A Journal of researches into the natural …
(https://www.amazon.com/Voyage-National-Geographic-Adventure-Classics-ebook/dp/B000MAH7J0)
Kickbusch, I., Allen, L., and Franz, C. 2016. “The commercial determinants of h…
(https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(16)30217-0/fulltext)
Marquez, PV. 2019. “Retracing Darwin’s Footsteps in the Galapagos”. (http://pvmarquez.com/node/5)
www.pvmarquez.com/plastic_pollution_galapagos 4/6
1/12/2021 Plastic Pollution: A "Clear and Present Danger" to the Galapagos Islands | Patricio V. Marquez
www.pvmarquez.com/plastic_pollution_galapagos 5/6
1/12/2021 Retracing Darwin’s Footsteps in the Galapagos | Patricio V. Marquez
Retracing Darwin’s Footsteps in the Galapagos
Submitted by Patricio V. Marquez on Sun, 11/24/2019 - 12 37 PM
Retracing Darwin’s Footsteps in the Galapagos
Posted by Patricio V. Marquez on Sun, 11/24/2019 - 12 37 PM
In the latter part of February 1535, a caravel carrying Fray Tomas de Berlanga, bishop of Panama, enroute to Peru,
drifted off course in the Paci c Ocean amid the equatorial doldrums, disappearing wind, and strong currents to an
unknown and strange land. In his report to Charles V, King of Spain, who had mandated him to journey to settle
disputes in his new empire, he described the nature of the shore in vivid detail:
“There were some small stones that we stepped on as we landed, and they were diamond-like stones, and others amber
colored; but on the whole island I do not think that there is a place where one might sow a bushel of corn, because most
of it is full of very big stones, so much so that it seems as though at some time God had showered stones; and the earth
that there is, is like slag, worthless, because it does not have the virtue to create a little grass, but only some thistles, the
leaf of which I said we picked.”
Three centuries later, Charles Darwin, sailing in the H.M.S. Beagle, arrived in the Galapagos Islands, an archipelago
located six hundred miles westward of the coast of Ecuador, as part of his ve-year voyage to South America and
the South Paci c. Upon landing on Chatham Island (now San Cristobal), Darwin noted in similar terms that:
“Nothing could be less inviting that the rst appearance. A broken eld of black basaltic lava, thrown into the most
rugged waves, and crossed by great ssures, is covered by stunted, sun-burnt brushwood, which shows little signs of
life.”
www.pvmarquez.com/node/5 1/4
1/12/2021 Retracing Darwin’s Footsteps in the Galapagos | Patricio V. Marquez
As I found out on a recent visit to eight islands in the Galapagos aboard the Lindblad Expeditions/National
Geographic’s Endeavor II (https:/ /www.expeditions.com/why-us/our- eet/national-geographic-endeavour-
ii/overview/) vessel, the observations made by de Berlanga and Darwin have in large measure withstood the passage
of centuries. Indeed, one is not only captivated by a sense of distance and isolation from mainland Ecuador, but is
confronted by a strange mixture of volcanic terrain pummeled by strong ocean currents, tick mists that make the
islands disappear and then reappear at sunrise, lea ess shrubs, large cacti, and strange animals, that are not afraid
of humans.
While one nds scarce remains of visits by pirates, buccaneers, and whalers from the late 1500s through the early
1800s, and later of repeated, but failed, colonization attempts by penal colonies and settlers, the archipelago
continues to be, as observed by Darwin during his visit in 1835, “a little world within itself, or rather a satellite
attached to America, whence it has derived a few stray colonists, and has received the general character of its
indigenous productions.”
The geological formations in the islands combine rocky stretches of shoreline, pristine beaches with sand of various
colors (rust red as in Rábida, created from lava with high iron oxide; ash black in Togus Cove; and beautiful white in
Cerro Brujo or Wizard Hill), and active volcanos such as the Salcedo Volcano in Isabela Island and Fernandina Island,
at about 1 million years old, the youngest and most volcanic of the archipelago as well as long-extinguished ones
such as Ecuador Volcano, bisected by the Equator line on Isabela Island, that has collapsed and slumped away into
the Paci c Ocean. There are also verdant highland regions as in Santiago Island and patches of red Sesuvium, a
plant that adds color to the uninhabited areas of San Cristobal. Beautiful isolated rock outcroppings such as the
León Dormido (“Sleeping Lion”), facing San Cristobal Island, offer a dreamlike view at sunset. And “in vivo” geological
forces, such as the marine reef off the coast of Urbina Bay that was uplifted by as much as 15 feet, are a testament to
unrelentless volcanic forces, oceanic currents, and trade winds that shape the islands.
The unique fauna of the Galapagos Islands, which transports us to another era in time, stimulated “the origin” of
Darwin’s ideas about evolution. Indeed, an observation recorded in The Voyage of the Beagle, a journal that
underpinned his seminal work On the Origin of the Species, changed the scienti c understanding of the natural
world by putting forward his theory of “descent with modi cation” by noting:
“Considering the small size of the islands, we feel the more astonished at the number of their aboriginal beings, and at
their con ned range. Seeing every height crowned with its crater, and the boundaries of most of the lava-streams still
distinct, we are led to believe that within a period geologically recent the unbroken ocean was here spread out. Hence,
both in space and time, we seem to be brought somewhat near to that great fact--the mystery of mysteries--the rst
appearance of new beings on this earth.”
The richness of the species that inhabit the Galapagos Islands, “peculiar to the group” and some “found nowhere
else”, include the blue- and red-footed boobies, frigate birds, and several species of nches in different islands.
Other species, like the American amingo and land iguanas, have a more restricted distribution, and some species
are restricted to just one island, such as the waved albatross, that nests exclusively on Isla Española, and the
ightless cormorant, found only on Isabela and Fernandina Islands. The “saddle-shaped” giant tortoises, iconic
species of the archipelago, with an average life expectancy of close to 200 years, move between the highlands and
dry zones, depending on the island and season.
The wildlife at sea include cold-water penguins, green sea turtles, marine iguanas, sea lions, fur seals, and Sally
Lightfoot crabs, along with many species of sea and shore birds. There is also a rich and diverse underwater world,
nurtured by diverse ocean currents that converge on these remote shores, including tropical-reef sh, whales and
dolphins, and a variety of shark species, including white-tip, Galapagos, and hammerhead sharks.
www.pvmarquez.com/node/5 2/4
1/12/2021 Retracing Darwin’s Footsteps in the Galapagos | Patricio V. Marquez
About 30,000 people live in four of the 13 large islands in the archipelago, making a living from tourism, shing, and
farming. While Puerto Baquerizo Moreno, on San Cristobal Island, is the capital of the Ecuadorian Province of
Galapagos, over half of all Galapagueños live in the city of Puerto Ayora on Santa Cruz Island, which is the center of
tourism and conservation.
As an Ecuadorian living abroad for most of my adult life, I felt great pride for the work done by my compatriots in
preserving this UNESCO World Natural Heritage Site. After of cially taking possession of the Galapagos Islands in
1830, the Ecuadorian Government converted in 1959 all parts of the islands that were not inhabited by humans as a
National Park (96% of the total archipelago surface area). The same year, the Charles Darwin Foundation
(https://www.darwinfoundation.org/en/) was established with the objective of conserving the unique Galapagos
ecosystems, and the Charles Darwin Research Station (https:/ /www.darwinfoundation.org/en/about/cdrs) was
inaugurated in 1964 to conduct scienti c studies aimed at protecting indigenous plant and animal life. In 1968, the
Galapagos National Park Service, a governmental institution, was created to protect the archipelago.
I also felt great pride observing that the high-quality service standards aboard the Lindblad Expeditions/National
Geographic Endeavour II vessel, depends for its operation on a top-quality Ecuadorian crew and a superb team of
knowledgeable and diplomatic technical guides and staff, many of them Galapagueños, to offer to visitors an
environmental, historical, cultural, and culinary exploration at its best.
Herman Melville, the author of Moby Dick, observed in 1854 about the Galapagos Islands that “the special curse, as
one may call of the Encantadas*, that which exalts them in desolation...is that to them change never comes-neither the
change of seasons or of sorrows”. Echoing those words, I concluded my visit with a deep conviction that we all have
an obligation to protect the Galapagos Islands as a legacy of humanity for the enjoyment of future generations. This
realization acquires more relevance in periods of scal austerity as the one currently facing the Government of
Ecuador, when “siren calls”, both domestic and international, try to use cyclical downturns as an opportunity to
advance short-term, self-serving economic interests, without due consideration to the long-term impact on the
environment.
I also feel that globally we have an obligation to help mobilize additional nancial resources, to complement regular
budgetary allocations by the Ecuadorian Government, to support with adequate funding levels the critical
conservation work of the Galapagos National Park Service and the Charles Darwin Foundation.
For my part, I began to do so before departing, with a contribution to the Lindblad Expeditions-National Geographic
(LEX-NG) Fund (https:/ /www.expeditions.com/why-us/global-stewardship/Galapagos/), that supports in the
National Geographic’s Early Career Grant program and partner institutions such as the Galapagos National Park and
the Charles Darwin Research Station. We should all join the good ght of protecting the unique Galapagos
ecosystems, as I am planning to continue to do so. Indeed, I feel that we need to do so as the Galapagos Islands are
a global public good.
Note*: Early Spanish sailors called the islands “Las Encantadas,” meaning “the enchanted,” a reference to the fact
that the islands would seem to disappear and then reappear due to mists and ocean currents.
Sources
Darwin, C. “The Voyage of the Beagle. A Journal of researches into the natural …
(https://www.amazon.com/Voyage-National-Geographic-Adventure-Classics-ebook/dp/B000MAH7J0/)
Darwin, C. “On the Origin of Species (with an Introduction by Charles W. Eliot)… (https://www.amazon.com/Origin-
Species-Introduction-Charles-Eliot/dp/1420953125/ref=asc_df_1420953125/?tag=bingshoppinga-
20&linkCode=df0&hvadid=&hvpos=&hvnetw=o&hvrand=&hvpone=&hvptwo=&hvqmt=e&hvdev=c&hvdvcmdl=&hvlocint=
4584207577261323&psc=1/)
www.pvmarquez.com/node/5 3/4
1/12/2021 Retracing Darwin’s Footsteps in the Galapagos | Patricio V. Marquez
Stewart, P.D. “Galapagos The Islands that Changed the World (with a Foreword by…
(https://www.amazon.com/Galápagos-Islands-That-Changed-World/dp/0300122306/ref=asc_df_0300122306/?
tag=bingshoppinga-
20&linkCode=df0&hvadid=&hvpos=&hvnetw=o&hvrand=&hvpone=&hvptwo=&hvqmt=e&hvdev=c&hvdvcmdl=&hvlocint=
4584207580741912&psc=1/)
Lindblad Expeditions/National Geographic. “Expedition Guide. Galapagos Aboard N…
(https://www.expeditions.com/)
Perez, W. and Weisberg, M. “Galapagos Life in Motion.” (2018) (https:/ /www.amazon.com/Galápagos-Life-Motion-
Walter-Perez/dp/069117413X/ref=asc_df_069117413X/?tag=bingshoppinga-
20&linkCode=df0&hvadid=&hvpos=&hvnetw=o&hvrand=&hvpone=&hvptwo=&hvqmt=e&hvdev=c&hvdvcmdl=&hvlocint=
4583795261458359&psc=1/)
Lindblad Expeditions-National Geographic (LEX-NG) Fund
(https://www.expeditions.com/globalassets/pdf/lex_ng_fund_2018_2019_rpt.pdf/)
Charles Darwin Foundation (https:/ /www.darwinfoundation.org/en/donate)
For information on how to create a lasting legacy in Galapagos (https:/ /www.darwinfoundation.org/en/get-
involved/give/fundraise-for-us)
Melville, H. "The Encantadas, or Enchanted Isles" (2017; First published in Put…
(https://www.amazon.com/Encantadas-Enchanted-Isles-Melville-Illustrated/dp/1521134855/ref=sr_1_1?
keywords=melville%20herman%20enchanted&qid=1574695354&sr=8-1)
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/node/5 4/4
1/12/2021 An Ode to Halloween, Birthdays and Aging | Patricio V. Marquez
An Ode to Halloween, Birthdays and
Aging
Submitted by Patricio V. Marquez on Wed, 10/30/2019 - 10 39 AM
An Ode to Halloween, Birthdays and
Aging
Posted by Patricio V. Marquez on Wed, 10/30/2019 - 10 39 AM
www.pvmarquez.com/halloween_aging 1/5
1/12/2021 An Ode to Halloween, Birthdays and Aging | Patricio V. Marquez
With the arrival of Halloween, a celebration observed in several countries on
October 31st, I am celebrating my birthday and moving well into my early
sixties. Birthdays are usually the time of the year when I tend to pause and
look back to all that happened in the prior months while looking ahead with
new ideas, commitments, and resolutions. In a true sense, this is my real
“new year” rather than at the beginning of the year in January.
This Halloween is special. For the rst time, in more than 30 years, I am not
working or actively searching for a job. After retiring a couple months ago, I
have been immersed in nding a new modus operandi for this next chapter
in my life.
While the mirror clearly re ects the marks of time on my face--particularly
a whiter beard--I feel that nothing has really changed. I continue to take
long walks daily and enjoy riding my bike on some days, feeling physically t
although a little overweight. Intellectually, I am still as passionate as before
about exploring the complex social, economic, environmental, and political
web that interacts with the genetic and biological make-up of people to
impact and determine physical and mental health, mortality and survival,
disability, and general well-being. Devoting more time to reading
accumulated and new literature, magazines, newspapers, and Twitter;
watching Copa Libertadores and Champions League soccer matches, boxing
and ultimate ghting events, and over the past few days, the baseball World
Series; an occasional movie or two; and a couple of trips with my wife that
renewed our bond and expanded our minds, are helping me to tame feelings
of anxiety that tend to appear un-invited, questioning whether I should be
“working or searching for work”. I am starting to enjoy as well the good
feeling of sharing accumulated knowledge and experience as a guest
speaker at graduate classes in three universities covering various global
public health topics. Also, I guess my family is happy getting “a la carte”
www.pvmarquez.com/halloween_aging 2/5
1/12/2021 An Ode to Halloween, Birthdays and Aging | Patricio V. Marquez
services from a dedicated private UBER driver, grocery shopper, purchaser
of all kind of tickets, handyman, and grill master, who has also learned to
prepare good black beans, Cuban-style.
Life continues, not linearly, but with a certain direction in spite of
occasional steps backward or the inevitable U-turns. I wonder, however,
whether my situation is unique, given my good health, mental curiosity,
family support, and pension income?
Recently, I read an article by Camilla Cavendish at the Financial Times, that
argued that there is mounting evidence that retirement can be bad,
especially if you enjoy your job, which I did immensely, along with its
comradery and sense of meaning. Also, it is argued that work has many
bene ts and an important social function. Since we are on average living
longer lives, the question that we need to pose is why should not we push
retirement well into the late sixties or early seventies then?
Although global experiences show that working longer is feasible, the
answer to this question has multiple caveats. A key condition for staying at
work an extra decade or even more, as well argued in Cavendish’s article, is
not just increased average life expectancy, but more importantly, healthy life
expectancy. This is a key observation as not everybody will bene t from
working longer given the sometimes wide and growing gaps in healthy life
expectancy between different income groups and in different regions within
countries. Also, the decision to stay at work or “unretire” will depend on the
accumulated skill set of individual workers, effective life-long learning
opportunities to retrain and reskill older workers, existing health insurance
and pension bene ts, as well as public support systems to care for elderly
family members. Workplace facilitating environment and attitudes towards
older workers, including stigma and discrimination, are also important
considerations.
www.pvmarquez.com/halloween_aging 3/5
1/12/2021 An Ode to Halloween, Birthdays and Aging | Patricio V. Marquez
From a social perspective, we have to be mindful as well that the world
population is growing older. In some countries, the age structure of the
population is changing rapidly by falling birth rates, which is further
impacted by youth migration in some of them. This means that skills
shortages are nowadays a real challenge that will not be met solely by robots
or arti cial intelligence tools that take over many cognitive tasks. Rather,
older workers will not be easily be replaced. They are and will continue to be
needed given their accumulated formal and tacit knowledge, institutional
memory, skills set and wisdom, including interpersonal skills, that often cut
across disciplines, work streams, and interconnected but distinct country
social and cultural contexts.
So, on this Halloween, besides wishing myself a happy birthday, I should feel
happy and less anxious realizing that I although “retired” I am part of a
distinct population group that possesses valuable human capital that should
be put to use with good impact, either as a volunteer or in formal
employment, to help advance social and economic initiatives that bene t all,
particularly in the intergenerational transmission of knowledge,
experiences, and skills to younger generations. To realize this potential,
however, we “oldies” need to be mindful and disciplined in devoting time
and effort to engaging in health promotion and disease prevention, as well
as on life-long learning. Yes, we can or as I would say in Spanish, si se puede,
as we need to be t to purpose for that metaphorically “extra inning or
round” in life.
Sources
Cavendish, C. “The case for staying at work an extra decade—or event more”.
FTW… (https:/ /www.ft.com/content/f4cd91aa-c4d8-11e9-ae6e-
a26d1d0455f4)
www.pvmarquez.com/halloween_aging 4/5
1/12/2021 An Ode to Halloween, Birthdays and Aging | Patricio V. Marquez
Murray, J. “Work has many bene ts and an important social function” FT
Letter… (https://www.ft.com/content/4610cb60-bf5a-11e9-b350-
db00d509634e)
Marquez, P. 2016. “Income inequality and differential mortality: An ominous
com… (http:/ /blogs.worldbank.org/voices/income-inequality-and-
differential-mortality-ominous-combination)
Cavedish, C. 2019. “Extra Time: Ten Lessons for An Aging World”.
(https://www.harpercollins.com/9780008362829/extra-time-10-lessons-
for-an-aging-world/)
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/halloween_aging 5/5
1/12/2021 Social Disparities Among Indigenous Peoples in the Americas: A Legacy to Overcome | Patricio V. Marquez
Social Disparities Among Indigenous
Peoples in the Americas: A Legacy to
Overcome
Submitted by Patricio V. Marquez on Sun, 10/27/2019 - 08 19 PM
Social Disparities Among Indigenous
Peoples in the Americas: A Legacy to
Overcome
Posted by Patricio V. Marquez on Sun, 10/27/2019 - 08 19 PM
The recent social unrest in Ecuador brought to world attention the often ignored
and marginalized indigenous peoples that led the opposition to economic reform
proposals advanced by the Government. While the unrest ended after some of the
proposals were rescinded following a public dialogue between the Government
and the leaders of the indigenous movement, deep-seated grievances remain that
need to be addressed to improve the social conditions of indigenous peoples.
www.pvmarquez.com/legacy_to_overcome 1/6
1/12/2021 Social Disparities Among Indigenous Peoples in the Americas: A Legacy to Overcome | Patricio V. Marquez
The situation of indigenous peoples in Ecuador, however, is not different from that
in other Latin American countries, as well as in Canada and the United States, each
with considerable indigenous populations.
Overall, there are between 45 and 50 million indigenous peoples living in Central
and South America and the Caribbean, representing approximately 13 percent of
the total population. In the United States, approximately 5.2 million persons self-
identify as American Indian or Alaskan Native, and in Canada 1.4 million people
self-identify as indigenous. As shown in the graph below, Mexico, Bolivia, Peru, and
Guatemala have the largest populations in both absolute and proportional terms,
accounting for more than 34 million indigenous people. The indigenous peoples
represent more than 400 groups, with 560 diverse languages, cultures, and
knowledge systems.
World Bank research has shown that despite the social progress achieved in the
past couple of decades in Latin America, indigenous peoples did not bene t to the
same extent as the rest of the population. Poverty af icts 43 percent of the
indigenous population—more than twice the proportion of non-indigenous—while
24 percent of all indigenous people live in extreme poverty, 2.7 times more than the
proportion of non-indigenous people.
This situation is also apparent in in Canada, where over 60 percent of children
living on First Nations reserves live in poverty, compared with 41 percent of all
indigenous children and 18 percent of all children. In the United States, it is
estimated that the median income of Native American households is nearly
$30,000 less than the median income of white households.
Furthermore, being born to indigenous parents substantially increases the
probability of being raised in a poor household, contributing to a poverty trap that
hampers the full development of indigenous children. In Ecuador, the probability
of a household being poor increases by 13 percent if the household head belongs to
an indigenous group, regardless of his or her level of education, gender, urban or
rural location, and number of dependents. In Bolivia and Mexico, the probability is
11 percent and 9 percent higher, respectively.
www.pvmarquez.com/legacy_to_overcome 2/6
1/12/2021 Social Disparities Among Indigenous Peoples in the Americas: A Legacy to Overcome | Patricio V. Marquez
Contrary to common assumption, nearly half of Latin America’s indigenous
population now lives in urban areas, but often are exposed to new dimensions of
exclusion. About 36 percent of all indigenous urban dwellers live in insecure,
unsanitary, and polluted environments, which contribute to increased health risks.
For example, in Mexico, indigenous urban dwellers have less than half the access to
electricity and piped water than other city dwellers have, one- fth the access to
sanitation, and live nearly three times more often in houses with dirt oors.
World Bank data also show that while improved educational outcomes among
indigenous people have been one of the most important advances in the last
decade in Latin America, additional efforts are needed to increase education
quality, make it culturally appropriate and bilingual, and to reduce a wide gap in
education between indigenous men and women.
In cities, indigenous people work mostly in low-skill/low-paying jobs. In countries
with large urban indigenous populations, such as Peru, Ecuador, Bolivia, and
Mexico, the percentage of indigenous persons occupying high-skill and stable jobs
is two to three times smaller than the percentage of non-indigenous people.
Indigenous workers, who often are engaged in informal occupations, are less likely
to receive retirement and health insurance bene ts. Household data show that,
regardless of educational background, gender, age, number of dependents, and
place of residence, an indigenous person likely earns 12 percent less than a non-
indigenous person in urban Mexico and about 14 percent less in rural areas. In
Bolivia, an indigenous person likely earns 9 percent less in urban settings and 13
percent less in rural areas. In Peru and Guatemala, indigenous persons earn about
6 percent less than non-indigenous populations. And Bolivian indigenous women
earn about 60 percent less than non-indigenous women for the same type of jobs.
Another common problem in the Americas is glaring health disparities that re ect
not only high poverty levels but wide health care access gaps between indigenous
peoples and the rest of the population. PAHO/WHO data show that infant
mortality in consistently higher among indigenous children than among non-
indigenous children in 11 countries in Latin America for which data were available.
In Panama and Peru, for example, infant mortality among indigenous children was
three times higher than in non-indigenous children. The data also show greater
www.pvmarquez.com/legacy_to_overcome 3/6
1/12/2021 Social Disparities Among Indigenous Peoples in the Americas: A Legacy to Overcome | Patricio V. Marquez
maternal mortality among indigenous women and that under-5 mortality rates are
far higher for children of indigenous background than for those of other ethnic
groups. In a national survey study throughout Brazil, indigenous women were
found to have a higher prevalence of obesity, anemia, and hypertension. In
Canada, infant mortality was 4.6 times higher in Inuit-inhabited areas than that
reported in non-indigenous-inhabited areas. In the United States, under-5
mortality for Native Americans at 8 deaths per 1,000 births, is second highest after
African Americans at 11 deaths per 1,000 live births. From 2012–2015, compared
with white women, the incidence of severe maternal morbidity was 148% higher
for American Indian/Alaska Native women in the United States.
High rates of chronic undernutrition among indigenous children further
undermine their human capital development. In Latin America and the Caribbean,
prevalence rates of stunting in children are higher in indigenous than in non-
indigenous peoples. For example, in Guatemala, where levels of stunting are high
compared with other countries, 58 percent of indigenous children are stunted,
compared with 34 percent of non-indigenous children.
Higher prevalence of health risk factors, chronic diseases, and mental and
substance use disorders are also found among indigenous people. In the United
States, CDC reports evidence that colorectal cancer screening prevalence is
lowest, binge drinking is highest, motor vehicle crash rate is highest, and drug-
induced death rates are highest in American Indian/Alaskan Natives compared to
other ethnicities. Additionally, in the United States, smoking prevalence is highest
among indigenous youth compared to non-indigenous peers. In Canada, the
suicide rate for First Nations males aged 15–24 is four times higher than that of
non-indigenous young people. First Nations populations are particularly at risk for
substance abuse, contracting tuberculosis and/or HIV, and developing diabetes.
Indigenous women in Canada are ve to seven times more likely than other women
to die as the result of violence.
These data provide compelling evidence that poverty among indigenous people in
the Americas is about more than income. Indeed, unsafe and unsanitary living
conditions and wide health and education disparities are all measures of
multidimensional poverty that require broad, sustained, multisectoral efforts to
www.pvmarquez.com/legacy_to_overcome 4/6
1/12/2021 Social Disparities Among Indigenous Peoples in the Americas: A Legacy to Overcome | Patricio V. Marquez
overcome. To be effective, however, these efforts must be rooted in consultation
with and active participation of indigenous people, while respecting their cultures
and identities. As the recent experience in Ecuador shows, the voices of indigenous
peoples are now an integral part of the political process. They demand to be heard
and must be part of the planning and implementation of economic and social
policies and programs to ensure acceptance and sustainability.
Sources
World Bank Group. “Indigenous Latin America in the Twenty-First Century”.
(https://www.worldbank.org/en/region/lac/brief/indigenous-latin-america-in-
the-twenty- rst-century-brief-report-page)
United Nations. “State of the World’s Indigenous Peoples”.
(https://www.un.org/development/desa/indigenouspeoples/wp-
content/uploads/sites/19/2018/03/The-State-of-The-Worlds-Indigenous-
Peoples-WEB.pdf)
PAHO/WHO. “Just Societies: Health Equity and Digni ed Lives. Report of the
Com… (https:/ /www.paho.org/hq/index.php?
option=com_content&view=article&id=1245%3Apaho-
publications&Itemid=1497&lang=en)
PAHO/WHO. “Core Indicators 2019 Health Trends in the Americas”.
(https://www.paho.org/hq/index.php?
option=com_content&view=article&id=15499%3Acore-indicators-2019-health-
trends-in-the-americas&Itemid=1894&lang=en)
NIH. “MATERNAL MORBIDITY AND MORTALITY What Do We Know? How Are We
Addressing I…
(https://orwh.od.nih.gov/sites/orwh/ les/docs/ORWH_MMM_Booklet_508C.pdf)
Babyar, J. “In search of Pan-American indigenous health and harmony”.
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6381669/)
Picture in blog by David Diaz Arcos/Bloomberg
(https://www.bloomberg.com/news/articles/2019-10-12/ecuador-s-scorned-
indigenous-rise-up-as-moreno-s-biggest-threat)
www.pvmarquez.com/legacy_to_overcome 5/6
1/12/2021 Social Disparities Among Indigenous Peoples in the Americas: A Legacy to Overcome | Patricio V. Marquez
(https://twitter.com/pvmarquez1956)
www.pvmarquez.com/legacy_to_overcome 6/6