Although the entire population is susceptible to acquiring the virus that causes COVID-19, when the transmission is no longer isolated to initial cases—which in many parts of Latin America are associated with travel abroad and a high socioeconomic position—the greatest risk of exposure to the virus is transferred to people living in overcrowded conditions, where there is no access to water and sanitation, and where daily subsistence depends on informal jobs that require contact with others. These are precisely the characteristics of households in urban slums and the reasons why following hygiene, confinement, and physical distance recommendations are more difficult, if not impossible, to carry out. On the other hand, the prevalence of chronic diseases that predispose to the more severe complications of COVID-19, such as hypertension, obesity, or diabetes, are more prevalent in populations living in poverty. Therefore, the analysis of the social determination of health, particularly in these populations, is an essential tool in the response to the COVID-19 pandemic.
In poor, rural communities, where the pandemic is arriving or will arrive, the difficulties are different from those of overcrowded slums. On the one hand, they are more distant from public services, in particular from health facilities equipped to care for people who develop complications from COVID-19. On the other, according to the history of each country, the rural areas of greatest poverty may be populated by indigenous communities whose rights are systematically violated, both in access to opportunities and in discrimination in health facilities.
For these reasons, information campaigns and public policies must be transparent and adapted to different living conditions, and, in particular, to the populations that survive with greater difficulties in both urban and rural areas. To achieve greater appropriateness, it is essential to count with the participation of people who live in these communities and community organizations that have a track record and credibility in those areas, since they have the best knowledge of the needs of the population and of their ability to accept measures that will require a temporary or a medium-term adaptation to new forms of social organization. Given the advance of the pandemic, it is essential that urban slum and indigenous communities are part of the development of public policies that are equitable, that promote the prevention of transmission, that facilitate the isolation of those with symptoms, and the treatment of those who develop complications—without discrimination.
At the same time, it is essential that these public policies are established with a gender perspective, since the needs and wants of women, particularly if they are in charge of children, the elderly, or people with disabilities, or if they suffer violence from their partner, require a particular prioritization. It is important to note that the systems of care for school-age children have been transformed by the sudden closure of schools, which translates into a greater burden of responsibility for their caregivers—their mothers in most Latin American countries, many of whom are adolescent. Responsibility for caring for family members can delay seeking care when the caregiver develops symptoms of COVID-19 or other health conditions. Therefore, public policies and community action must be proactive in the search for women who feel unable to leave their homes to seek care and of older people who live alone, which can be even more difficult in contexts of high street violence.
The lack of access to water in urban slums and rural areas, which hinders the implementation of basic hygiene measures such as frequent hand washing, must be remedied, in the short term, with daily water distribution mechanisms that reach these communities (with trucks or other means of transportation) and, in the medium term, with the construction of water supply and sanitation systems that are part of urban planning programs that at the same time contribute to reducing overcrowding in homes.
Preventing the transmission of the virus in people who survive informal jobs requires, in the immediate term, the provision of cash transfers that allow them to survive, as is being done in the Dominican Republic with the Stay at Home Program, without needing to leave the home and getting exposed to the risk of acquiring the virus that causes COVID-19. In the medium term, the precariousness of various forms of work, such as unprotected domestic work, requires endowing it with social protections.
Due to the impossibility of isolating, in crowded homes, the elderly, people with chronic conditions such as hypertension or diabetes, or relatives who develop symptoms of COVID-19, it is essential to enable schools, hotels, and other public and private spaces—offered not for profit or temporarily nationalized—where people with suspected infection or with confirmed results can stay for days and where they can receive water, food, and clinical monitoring of the evolution of the disease. This form of care must be offered free of charge to the population, since any expense involved can create an access barrier. If these people are in charge of dependents, it is also imperative that community organizations, with the support of public funds, find strategies to facilitate the care of dependents without incurring any expense for people with COVID-19. The experiences that exist in maternity homes in urban slums and in rural areas in several Latin American countries can serve as models for organizing isolation care centers. Ideally, field epidemiology teams in each health district should test each person living with someone who has already been diagnosed, to isolate them and monitor their symptoms, and actively track other potential contacts.
If symptoms of people in isolation become complicated, there should be plans in place to transfer them to health facilities equipped with the technological density required to attend to severe cases of COVID-19. In rural areas, this will require investment in ambulances or in the provision of alternative modes of transportation that allow the safe transfer of patients to hospitals with intensive care units. It would be counterproductive to expect people living in urban slums and rural areas to find on their own—as has often been expected of them in so many places in the region—their way of getting to a hospital, to be admitted, and to receive the timely and quality care that they need.
At the same time that these mechanisms are being drawn up to transport people with COVID-19, they have to be used to serve those from the same communities that require healthcare that cannot be postponed, such as vaccination and care for infectious diseases, sexual and reproductive health care (including contraception, pregnancy, childbirth, and abortion), the provision of medicines for chronic and mental illnesses, emergency surgeries, and care for people who are victims of violence and accidents, among other actions.
Here the question arises to which hospitals should these people be directed: to the closest public or private hospital with available beds or to the one that is preassigned according to their rights or type of insurance? Due to the segmentation of health systems in many Latin American countries, the ministries of health must implement concerted and comprehensive actions, even when all health sectors need to become nationalized, as has been done in Spain to respond to the pandemic. This includes having trained and in training medical and nursing personnel, having an inventory of all health facilities, and access to hospital beds in intensive care units, whether public or private. The smaller the current segmentation, the smaller the challenge and the faster the response.
At the same time that the response to the pandemic is urgently developed, “it is essential, also urgently, to reflect on the structural causes not only of this, but also of other epidemic processes” and other public health priorities. Although the measures are designed for an immediate term, the success of these strategies will allow, when we overcome the pandemic, the strengthening of public health systems and the necessary rethinking of priorities oriented towards health equity for the coming decades.
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