COVID-19 y Justicia social: un enfoque sindémico de la resistencia a la vacunación <span class="so-article-trans-title" dir="auto"> Translated title: COVID-19 i Justícia social: un enfocament sindèmic de la resistència a la vacunació </span> <span class="so-article-trans-title" dir="auto"> Translated title: COVID-19 and Social Justice: A syndemic approach to vaccine hesitancy </span>

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Abstract

Resumen Las afectaciones por la pandemia de COVID-19 dependen de determinantes socio-culturales que blindan a algunos individuos o grupos de los efectos más severos o vuelven a otros más susceptibles de sufrir daños a su salud, posición social o estabilidad económica. El caso de la vacunación es sintomático de cómo grupos específicos sufren mayor vulnerabilidad por inequidades socioeconómicas y determinantes culturales. Consecuentemente, la resistencia a la vacunación entre estos grupos puede profundizar la vulnerabilidad, por lo que es necesario diseñar estrategias que, al confrontar la resistencia a la vacunación, no dejen de lado aquellas inequidades estructurales que, de no atenderse, seguirán alimentando la suspicacia y renuencia a vacunarse. En este trabajo sostenemos que las políticas de salud pública enfocadas a promover la vacunación pueden beneficiarse de un enfoque sindémico que considere las sinergias entre enfermedades y determinantes socioeconómicas y culturales. Esto implica introducir problemas de justicia social en la planificación de estrategias de salud pública. Haciendo un análisis crítico del trabajo del bioeticista Norman Daniels -quien aborda la importancia moral de la salud pública desde una interpretación de la teoría de la justicia de John Rawls- retomamos las críticas a la justicia como imparcialidad de las posturas comunitarista y de las políticas de la diferencia (específicamente I. M. Young), para mostrar que un enfoque sindémico de la salud pública es indispensable para lograr una vacunación completa: el diseño de estrategias tendrá que considerar los contextos específicos de grupos renuentes a vacunarse para lograr eficiencia a corto, mediano y largo plazo.

Translated abstract

Resum Les afectacions per la pandèmia de COVID-19 depenen de determinants socioculturals que blinden a alguns individus o grups dels efectes més severs o tornen a uns altres més susceptibles de sofrir danys a la seva salut, posició social o estabilitat econòmica. El cas de la vacunació és simptomàtic de com grups específics sofreixen major vulnerabilitat per inequitats socioeconòmiques i determinants culturals. Conseqüentment, la resistència a la vacunació entre aquests grups pot aprofundir la vulnerabilitat, per la qual cosa és necessari dissenyar estratègies que, en confrontar la resistència a la vacunació, no deixin de costat aquelles inequitats estructurals que, de no atendre's, continuaran alimentant la suspicàcia i renuència a vacunar-se. En aquest treball sostenim que les polítiques de salut pública enfocades a promoure la vacunació poden beneficiar-se d'un enfocament sindèmic que consideri les sinergies entre malalties i determinants socioeconòmiques i culturals. Això implica introduir problemes de justícia social en la planificació d'estratègies de salut pública. Fent una anàlisi crítica del treball del bioeticista Norman Daniels -qui aborda la importància moral de la salut pública des d'una interpretació de la teoria de la justícia de John Rawls- reprenem les crítiques a la justícia com a imparcialitat de les postures comunitarista i de les polítiques de la diferència (específicament I. M. Young), per a mostrar que un enfocament sindèmic de la salut pública és indispensable per a aconseguir una vacunació completa: el disseny d'estratègies haurà de considerar els contextos específics de grups renuents a vacunar-se per a aconseguir eficiència a curt, mitjà i llarg termini.

Translated abstract

Abstract The effects of COVID-19 pandemic depend on socio-cultural determinants that shield some individuals or groups from the most severe effects or make others more vulnerable to suffering harms to their health, social position, or economic stability. The case of vaccination is symptomatic of how specific groups suffer a higher degree of vulnerability due to socioeconomic inequalities and cultural determinants. Consequently, vaccine hesitancy among these groups might deepen the vulnerabilities, which is why it is necessary to design strategies that, while confronting vaccine hesitancy, do not ignore those structural inequalities which could continue feeding skepticism and resistance to vaccination, if unattended. In this work we claim that public health policies focused on promoting vaccination may benefit from a syndemic approach that considers the synergies between diseases and socioeconomic and cultural determinants. This implies introducing social justice issues into the planning of public health strategies. By critically analyzing the work of bioethicist Norman Daniels -who goes over the moral importance of public health from an interpretation of John Rawls' theory of justice- we explore the criticism to justice as fairness made by the communitarian and the politics of difference standpoints (specifically, I. M. Young), to show that a syndemic approach to public health is essential to achieve complete vaccination: the design of strategies will have to consider the specific contexts of vaccine hesitant groups, to achieve efficiency vaccinating in the short, medium and long term.

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Offline: COVID-19 is not a pandemic

Richard Horton (2020)

As the world approaches 1 million deaths from COVID-19, we must confront the fact that we are taking a far too narrow approach to managing this outbreak of a new coronavirus. We have viewed the cause of this crisis as an infectious disease. All of our interventions have focused on cutting lines of viral transmission, thereby controlling the spread of the pathogen. The “science” that has guided governments has been driven mostly by epidemic modellers and infectious disease specialists, who understandably frame the present health emergency in centuries-old terms of plague. But what we have learned so far tells us that the story of COVID-19 is not so simple. Two categories of disease are interacting within specific populations—infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and an array of non-communicable diseases (NCDs). These conditions are clustering within social groups according to patterns of inequality deeply embedded in our societies. The aggregation of these diseases on a background of social and economic disparity exacerbates the adverse effects of each separate disease. COVID-19 is not a pandemic. It is a syndemic. The syndemic nature of the threat we face means that a more nuanced approach is needed if we are to protect the health of our communities. © 2020 Peter Scholey Partnership/Getty Images 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. The notion of a syndemic was first conceived by Merrill Singer, an American medical anthropologist, in the 1990s. Writing in The Lancet in 2017, together with Emily Mendenhall and colleagues, Singer argued that a syndemic approach reveals biological and social interactions that are important for prognosis, treatment, and health policy. Limiting the harm caused by SARS-CoV-2 will demand far greater attention to NCDs and socioeconomic inequality than has hitherto been admitted. A syndemic is not merely a comorbidity. Syndemics are characterised by biological and social interactions between conditions and states, interactions that increase a person's susceptibility to harm or worsen their health outcomes. In the case of COVID-19, attacking NCDs will be a prerequisite for successful containment. As our recently published NCD Countdown 2030 showed, although premature mortality from NCDs is falling, the pace of change is too slow. The total number of people living with chronic diseases is growing. Addressing COVID-19 means addressing hypertension, obesity, diabetes, cardiovascular and chronic respiratory diseases, and cancer. Paying greater attention to NCDs is not an agenda only for richer nations. NCDs are a neglected cause of ill-health in poorer countries too. In their Lancet Commission, published last week, Gene Bukhman and Ana Mocumbi described an entity they called NCDI Poverty, adding injuries to a range of NCDs—conditions such as snake bites, epilepsy, renal disease, and sickle cell disease. For the poorest billion people in the world today, NCDIs make up over a third of their burden of disease. The Commission described how the availability of affordable, cost-effective interventions over the next decade could avert almost 5 million deaths among the world's poorest people. And that is without considering the reduced risks of dying from COVID-19. © 2020 Allison Michael Orenstein/Getty Images 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. The most important consequence of seeing COVID-19 as a syndemic is to underline its social origins. The vulnerability of older citizens; Black, Asian, and minority ethnic communities; and key workers who are commonly poorly paid with fewer welfare protections points to a truth so far barely acknowledged—namely, that no matter how effective a treatment or protective a vaccine, the pursuit of a purely biomedical solution to COVID-19 will fail. Unless governments devise policies and programmes to reverse profound disparities, our societies will never be truly COVID-19 secure. As Singer and colleagues wrote in 2017, “A syndemic approach provides a very different orientation to clinical medicine and public health by showing how an integrated approach to understanding and treating diseases can be far more successful than simply controlling epidemic disease or treating individual patients.” I would add one further advantage. Our societies need hope. The economic crisis that is advancing towards us will not be solved by a drug or a vaccine. Nothing less than national revival is needed. Approaching COVID-19 as a syndemic will invite a larger vision, one encompassing education, employment, housing, food, and environment. Viewing COVID-19 only as a pandemic excludes such a broader but necessary prospectus. © 2020 xavierarnau/Getty Images 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.