The Latin American Perspective: A Conversation with Colombia’s Former Minister of Health

The now infamous coronavirus first arrived in Latin America on February 26th when Brazil confirmed their first case. One month after the United States, January 20, and Europe, January 24, confirmed their first cases. Although the reported case was the first one that tested positive, it is highly unlikely that an entire continent and its surrounding countries were unaffected for a month. The coronavirus can impact Latin America in a disproportionate way, since all countries, with the exception of Chile, are developing countries. For this reason, OCA sat down with Juan Pablo Uribe, Colombia’s former Minister of Health, to discuss how Latin America is and will be affected.

IC: How have you seen the response of the coronavirus crisis in Latin America, and in Colombia?

JPU: The handling has been a little uneven. Some countries took lessons learned from Asia and Europe and managed to move fast with effective measures to control an explosion of contagion. Among them, we can mention Chile, Colombia, Costa Rica. At the same time, other countries chose not to take advantage of that time and took another path, among which Brazil and Mexico, in particular, stand out. But in conclusion, the response has been heterogeneous, even though all countries had the same time to learn from those who were already facing the pandemic.

IC: In your opinion, what does Colombia have to do in the next six months to reactivate the economy and flatten the curve at the same time?

JPU: I think that it is not well understood what is meant by flattening the curve, nor which curve because these are mathematical models. I believe that the objective of every country should be to have as few fatal cases as possible, without being bothered by having a high number of asymptomatic or mild symptoms, trying to do as little collateral damage to the economy and social welfare as it is. These are determining factors for the same level of health of the entire population. To achieve this, we must go to the nature of the disease and I will describe natural aspects that we already know about the disease and give us the weighted intervention steps, which I believe are correct.

The first thing is that this is a highly contagious respiratory disease. Therefore, citizen pedagogy measures on personal hygiene and prevention are basic and effective. Social distancing, in the sense of avoiding nuances and having distance from people, helps as well as hand washing, not touching your face, wearing a mask, and covering your mouth when we have flu-like symptoms.

The second is that it is a disease that concentrates its severity on very specific segments of the population. More than 90% of the fatal cases have been of patients over 65-70 years. The lethality, which is very low in young people, can reach more than 30% in those over 80 years of age and those who have pre-existing cardiac, pulmonary, renal, and immune diseases also have a much higher probability of dying. So this is not a disease that should scare the whole population in general. It is very strange that a minor, a young person, or a young adult dies from COVID, there always will be cases, but it is very rare. This second characteristic suggests that we must have very specific and precise policies to protect the segments of the population at risk.

Third, the disease can be diagnosed. We can diagnose who has it, first with a symptomatic approach, -although 20-30%  are asymptomatic- looking for fever, looking for respiratory disease, flu, we can begin to find cases early and we have the capacity in the laboratory to confirm these diagnoses. So an intelligent use of diagnostic tests and subsequent intelligent use of antibody tests will open our eyes to how the virus is moving, where it is concentrated, those who already have it, whom we have to isolate, what contacts we have to follow, whom we have to monitor critically and finally, those who have already survived the disease. This third characteristic leads us to an intelligent use of diagnostic tests.

To conclude, we are learning every day more about what we must do to seek to improve the prognosis of those who end up in intensive care and avoid death. This is very important in the fourth part, strengthening the hospital capacity, not only ventilators but the training and protection of health personnel, the availability of the necessary medications, and of course, the infrastructure, in order to understand the small fraction of patients in critical condition who will appear. Lastly, I believe that the industrial and business sectors are going to have to commit to effective measures against this disease. I mean, that the productive private sector or the productive public, is going to have to follow rules of hygiene, prevention, distancing, protection, and case identification, use of exams, case isolation, as if they were a unit of public health. Here there must be a commitment of the entire economic sector and of all society in these basic things, which effectively reduce the risk of respiratory disease. 

In summary of a long answer: prevention with all the basic hygiene and distance measures. Two, a fundamental issue, being precise when handling in high-risk groups. Three, intelligent use of diagnostic tests, and four, a strengthening of medical assistance capacity.

IC: From your knowledge of the Colombian public health system, which regions are the most vulnerable? Why?

JPU: I would say that they are all vulnerable. If a city like New York, if a country like France, or like England, if China itself has been overwhelmed at the intense moment of a new respiratory disease, I think it would be irresponsible to think that there are regions in Colombia or countries in Latin America that have less vulnerability. I believe that we are vulnerable everywhere. Large cities, in our country and in Latin America have immense areas of population congestion with low incomes and poor infrastructure, and extremely high informality, high vulnerability. At the same time, our regions lack sufficient infrastructure, professional personnel and equipment to face a new disease on a smaller scale. Think for a second about isolated, marginalized indigenous communities, think about Chocó or La Guajira, if there were to be massive circulation of this new virus in those populations it would also generate a lot of pain.

IC: Of the Latin American countries, which ones have you seen that are better prepared? Why?

JPU: I find it very interesting, although without claiming victory, of the efforts Chile has taken. It has made massive use of PCR (Polymerase Chain Reaction)  tests with an immediate diagnosis. This massive use has allowed them to follow the dynamics of the virus with great precision, having georeferenced all these tests, which has allowed him to use drastic measures of focused or localized social distancing in common areas. For example, in the metropolitan area of ​​Santiago, or in precise geographical areas of the country without simultaneously closing the entire country. By doing this, in a more precise way, they have also managed to contain the explosion of the virus, and have time to strengthen the entire public and private hospital network to carry out an economic stimulus and rescue measures for small, medium, and large companies. Today, Chile does not have a complete blockade, it has a very good knowledge of how the virus is moving. It has achieved very interesting results in the “curve” to avoid an explosion. There will always be cases and deaths, but not in an uncontrolled way and it has a very interesting assistance response capacity. So I think that this is a very good example, and again I think that this case, similar to the case of European countries, is showing us particularly for Colombia, that the measures that were taken in Chile are correct, but cannot be sustained indefinitely. They are going to have to be changed, by very great efforts of pedagogy, of containment of risk groups, of social distancing, and of a productive sector, hopefully, committed to the protocols that allow us to take care of each other producing and living.

IC: Of the Latin American countries, which ones have you seen that are the least prepared? Why?

JPU: The most visible, and I am not an expert in it, but without a doubt is Brazil. In Brazil there has been a permanent discussion between a forced quarantine and an, let’s say, open society on a daily basis. This has resulted in a political debate, which has generated a lot of instability. Not taking uniform measures has put the dynamics of the virus in Brazil on a very worrying path. Both the increase in cases, and especially the increase in deaths, throughout its vast geography. To emphasize, our countries must ensure that there is no fragmentation in political leadership, and in the response that this may be. These discussions between, for example, the presidential level, governors, and mayors, of having huge cities or regions doing different things individually from other regions of the country. I think they generate immense risk for everyone. The ideal situation would be an articulated response within the countries. One point that I want to underline: hopefully also an articulated and coordinated response between all countries. I believe that the United Nations, the World Health Organization, and many other global organizations have an immense responsibility, and that is that we do not fall into “save yourself” with individual and isolated responses, which are not spoken with those of the neighboring country, or with those of a fully interconnected global economy.

IC: In other words, the importance of Solidarity nations

JPU: Yes, completely. Without a doubt, there will be “breakthroughs”, advances, discoveries in science, both in diagnosis and treatment, and finally in the prevention of this viral disease through a vaccine. That is what we all hope for, the narrative suggests that it should be so. But we also know that if countries that have the capacity to achieve these innovations, that give us all hope, leave those innovations in the hands of particular markets or capture it only for their populations, this tragedy in low and middle-income countries will only grow, and global inequality and imbalance will increase. It seems fundamental to me that from now on there is a commitment by all nations to be, as you said, supportive, compassionate, and generous globally.

IC: Under what scenario would the Colombian health system collapse? What does this collapse mean?

JPU: In our countries, health systems work to the maximum with very little margin. Very little margin with respect to everything: in supplies, in human talent, in hospital beds, in financial resources. So they don’t have much extra oxygen. What we want is to strengthen the health system to the maximum, within a practical effort. The first and most important thing is to protect health personnel with all the equipment that allows them to work safely, with trust. The second is to be able to strengthen without critical supplies for an avalanche of respiratory patients where the concern for ventilators and intensive care beds rises, but it is much more than that. There are also medicines, hospital supplies, other types of machines, and circuits that are required. The third is that these hospitals need a financial flow, to be able to buy this equipment, buy all the consumables, and pay their workers. Today, hospitals, while preparing for the COVID, have emptied themselves of everything that is not COVID, have suspended all the programmable surgeries, all consultations, and have been left waiting for the explosion of COVID patients. To be empty itself, is to make the financial situation worse, and weaken. So there is a big paradox here, it requires quick measures to strengthen the Colombian hospitals so they can do their best. Realistically, I believe that in Colombia, like Peru, Brazil, or Chile, there will be a week or two similar to how it was in Wuhan, China, Italy, France, the US, or Spain, where the volume of cases concentrated in a short time will exceed capacity. But it is essential that we do our best, and that on the other side of the peak of that curve, we can have healthy, proud health care workers, hospitals that are financially healthy and can continue to treat not only this disease but all diseases typical of human nature that are next to the COVID.

IC: From your point of view, what are the consequences of keeping borders open, as in the case of Brazil and Mexico?

JPU: I believe borders are not too important right now since all the countries have the virus circulating inside of them. I would even begin to think of quick ways to reopen borders for the many other good things that happen across borders. I think that any country that wants to stay isolated doesn’t make much sense anymore. If it is kept isolated, what it is going to lose is much more than it is going to contain. I would always prefer an intelligent reopening of the borders, seeing that through the good things that we acquire as a country, are far more than the bad things. Not only disease, contraband, illegal immigration, human trafficking. So I would look for a quick, smart and responsible opening of all borders.

IC: When the vaccine is ready, including all necessary procedures, how long will it take to make it accessible to Latin America, especially in Colombia?

JPU: It is going to be very important first to test the efficacy of the vaccine, which is essential, know what level of protection or general immunity, and to what percentage of the population. The second is going to be its production to scale, which is now a global scale. The bulk of the population will want to have the vaccine. We’ll have to see how it goes. For that to occur, the third and fundamental thing is the price that will determine how affordable it is particularly for low and middle-income countries. Those three things again, the efficacy of the vaccine, its stagnation in production, and its price and access, are going to depend a lot again on what we were talking about, as the countries that reach and handle issues related to the private sector, patents, etc. That’s where I think there should be a global commitment so that we can all have access to it in due course.

IC: Finally, do you have anything else to add or do you want to tell the NYU Shanghai community?

IC: I believe that it is essential to recognize the effort of all health providers in China who confronted an unknown enemy. They have given us immense lessons, and insight to all others to prepare. For that, I have an immense sense of gratitude. Recently, I had the opportunity to hear a medical group recounting their efforts, and it is incredible what they bring to the world with their experience. The second is a personal reflection, and I believe that fragility and death are inherent in the human condition. It is very important that we responsibly achieve an intermediate response, that reasonably produces the risks of this new disease. But that allows us to understand without fear, that we have to go out there and live. To generate well-being with equity and face not only this but the hundreds of diseases that accompany us as human beings in a sensible and responsible way. I hope that our countries find an intermediate path, responsible that does not destroy in the attempt to defend life, that does not destroy well-being, and life itself.

Special thanks to Juan Pablo Uribe for taking the time during these times.

This article was written by Isabella Cuellar. Please send an email to ic1104@nyu.edu to get in touch.
Photo Credit: 190503-continuidad-servicios-afiliados-medimas-1800.jpg 

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