As we speak, we are losing ground against HIV, TB and Viral Hepatitis, because resources are being diverted to the global Covid-19 response. Although a loss of gains is inevitable given the public health emergency, how much we lose, is up to us.
We must seize this unprecedented opportunity to transfer knowledge, skills and infrastructure from HIV to develop a multi-pronged strategy across all actors and across all diseases to safeguard – and continue – our progress. Without a holistic approach we are doomed to repeat the same mistakes while preventable new infections and needless deaths occur.
— ITPC Global (@ITPCglobal) September 10, 2020
Factors to consider as we move forward to safeguard gains & implement health as a human right
As we try to stabilize our world and recover from the acute shock and ripple effects across systems, we have to ensure a few things. I am going to list 5 short points that we should reflect on:
1. No silos: limit the implementation of predominantly COVID-19-only solutions
The first is that we should limit the implementation of predominantly Covid-19-only solutions. Instead, we need comprehensive and integrated interventions. It is insane that we still live in a world where a machine, capable of diagnosing multiple infections, is used for a single disease…because the cartridge was bought using $ from that disease’s donor. Why have we not addressed this as yet? Furthermore, today, that same machine is now overrun with Covid-19 testing at the expense of HIV and TB! We need to reverse this trend now, and quickly.
2. Deal with root causes: tackle non-biomedical, root causes of disease outcomes
Secondly, we have to address non-biomedical, root causes of disease outcomes. What accounts for the fact that black people are four times more likely to die from Covid-19 than white people? Are black people genetically pre-disposed to COVID-19? Even if biological differences play a role in health, inequalities, systemic racism and other social factors have a huge impact – and we can address them.
Social determinants of health are a major driver of morbidity and mortality as the world grows more and more unequal. We need to address the causes of risk, vulnerability and transmission at a structural level and remember that people are NOT high risk, situations are.
Focusing on structural and socio-economic drivers is a win for everyone; it helps to address HIV, Covid, Hep C, TB, and many non-communicable diseases. Just think about it, today…in post- apartheid South Africa, townships are hotspots for Covid-19 but if we enacted better housing policies, we could address both Covid-19 and TB. What about better policies to improve the availability of healthy food? These would reduce cardiovascular disease, save lives from heart disease and diabetes, and create more resilient populations for not only this pandemic but future ones.
3. Address stigma: tackle stigma by capturing it, calling it out and intervening
My third point is on stigma. We have to seriously tackle stigma. Not just capture it and call it out… but intervene. Spraying people with trainings doesn’t change their deeply entrenched beliefs. More data will not change your uncle’s belief about that “bad person”. Social, behavioral interventions and health education have their place, yet they seem to have taken a back seat to biomedical silver bullets, leaving stigma a pervasive and lethal barrier to health despite medical advances. Stigma blooms in environments of low health literacy, misinformation and disinformation, yet we scrape the bucket to find funding for this work. Let’s take our struggle to reach men – we speak about men being at higher risk for AIDS as if it’s a biological predisposition, when we know the main reason is that they are less likely to engage with health system because of stigma. Stigma has the power to cripple every single good thing we do in each disease. Let’s work to prevent this from happening.
4. Dismantle affordability barriers: use strategies that we know work, like TRIPS flexibilities, including compulsory licenses
We have to address affordability head on. When will we stop using World Bank classifications to determine which country can benefit from pricing deals? As if rich and middle- income countries don’t have severe and widening inequity! The city of Moscow currently pays…60 times more than Kiev…for the HCV cure of sofosbuvir and daclatasvir. Middle-income countries are the hardest hit, yet their funding is subject to the harshest cuts. In response, we contort ourselves in the global space to accommodate rich member states and their pharma lobby, in fear of backlash… and barely fund strategies we know work, like TRIPS Flexibilities, including dare I say, compulsory licenses. We know in our GUT that quality healthcare should not be linked to having a job or determined by market forces.
5. Build community systems: adequately support community groups to be more resilient to future shocks
And for my final point, we need to build community systems. Build them to be more resilient to future shocks, Covid-19 is just the start given the state of our world. After spending hundreds of million on studies, like POP ART and others, we know that strong community systems result in better health outcomes. So, how well are we investing in communities? We are up to our ears in member state commitments; we even have a brilliant commitment to ensure that by 2030 at least 30% of all service delivery is community-led (not civil society). Yet…up to now, we don’t have a shared definition and (apparently) we cannot track how much funding goes to community-led responses despite their contribution towards achieving global health targets. And so, here we are!
None of my five points is surprising—no silos, deal with root causes, address stigma, dismantle affordability barriers and build communities—yet we have been grappling with these points for over three decades, so what’s the issue? What is the barrier to real action?
Something is wrong with how current system is set up…Build it and they will come, right? But everyone is not coming! That mentality is the old guard, colonial, paternalistic, over-medicalized, and top down…I know what’s good for you, so come here.
Covid demonstrates that we can change!! All of sudden, multi-month dispensing is the norm, not just for ARVs but other chronic conditions, even telemedicine has been scaled! The future requires that we foster supportive self-management and truly detach ourselves from the notion that quality healthcare must be at the clinic with a medical doctor. It’s 2020, school is happening at home, shopping is happening at home, work is happening at home…we need better strategies for delivering healthcare outside of the clinic. We have strong examples of community responses ranging from home-based care for AIDS, all the way to simple no-touch hand-washing gadgets in villages…this is how, using a co-designing approach, we best meet the needs of people where they are.
Each of the five points I raised could be drastically improved if we seriously redistributed resources to strengthen and integrate community responses into our collective effort, because we all know the exponential return on good health outcomes when communities participate in design and delivery. Despite calls to “reimagine systems for health” there is no incentive for the established system to relinquish power.
Public health is political; good public health requires good leaders; good leaders require an activated civil society to elect them and hold them accountable for safeguarding health as a right. (not fluffy nice-to- haves, but an enforceable constitutional right); and an activated cs requires deliberate investment, development and access. Let me repeat for those connections that may have dropped, …people, civil society and communities must be where we invest.
Inherent in the principles of the Fast-Track Cities initiative is that the whole is made up of the sum of its parts…to effectively mount an attack on global and national issues, we should tackle epidemics at the city and local level and this strategy is working! So, as we think about safeguarding the gains of the past decades for HIV, TB and HCV… and we think about the geopolitical antics of the powerful, rich and high caste…the path to real change lives in the local, people-centered response.
If there is no incentive for the established system to relinquish power, it will be taken, BY THE PEOPLE!
These remarks were delivered by Solange Baptiste, Executive Director, ITPC Global, as part of the closing panel of the Fast-Track Cities virtual conference on September 10, 2020. The session was themed “Focusing on HIV Response Resilience to Confront Future Emerging Pandemics.” It featured other global public health leaders, including:
- Ren Minghui, World Health Organization
- Shannon Hader, UNAIDS
- Peter Sands, Global Fund to Fight AIDS, Tuberculosis and Malaria
- Ricardo Baptista Leite, UNITE, Lisbon, Portugal
- Angeli Achrekar, PEPFAR, Washington D.C., USA