The World Health Organization (WHO) declared COVID-19 a pandemic on March 11, 2020. Eighteen months later, the number of confirmed cases had exceeded 200 million in the world, with more than four million deaths from COVID-19. Since the beginning of vaccination programs, more than 2.3 billion persons have received a least one dose of the currently available vaccines, and approximately 50% of this total are completely vaccinated ¹1. Our World in Data. Coronavirus pandemic (COVID-19). https://ourworldindata.org/coronavirus (acessado em 08/Ago/2021).
https://ourworldindata.org/coronavirus... . From the geographic point of view, South America is the continent with the most cases and deaths per million inhabitants, while the proportion of completely vaccinated individuals in Europe (42%) and North America (39%) is nearly double that of South America (22%). Meanwhile, only 4% of the African population has received at least one dose of the vaccine ¹1. Our World in Data. Coronavirus pandemic (COVID-19). https://ourworldindata.org/coronavirus (acessado em 08/Ago/2021).
https://ourworldindata.org/coronavirus... . Major variations are also seen between countries and between different regions of the same country.

These data suggest that not only the pandemic affected the world differently, but also that national responses to COVID-19 have been unequal. Although most countries adopted similar policies in the early months of the pandemic, the responses began to vary as the pandemic progressed, according to data compiled by the Oxford COVID-19 Government Response Tracker, the largest repository of global evidence related to policies for COVID-19 ²2. Hale T, Angrist N, Goldszmidt R, Kira B, Petherick A, Phillips T, et al. A global panel database of pandemic policies (Oxford COVID-19 Government Response Tracker). Nat Hum Behav 2021; 5:529-38.. With the adoption of a mix of nonpharmacological interventions, a group of 39 countries including China, Taiwan, Vietnam, and New Zealand succeeded in containing the first wave and maintaining the transmission curves reasonably under control. However, other countries had less success and are still dealing with the subsequent waves of the disease, and many (e.g., United States, United Kingdom, South Africa, Iran, Brazil, and France) have adopted restrictive policies with varying intensities as the number of cases has increased or decreased ³3. Hale T. What we learned from tracking every COVID policy in the world. The Conversation 2021; 24 mar. https://theconversation.com/what-we-learned-from-tracking-every-covid-policy-in-the-world-157721.
https://theconversation.com/what-we-lear... .

The scientific literature suggests that less disruptive and costly measures such as awareness-raising and informative campaigns can be at least as effective as more drastic and intrusive interventions such as national lockdowns ⁴4. Haug N, Geyrhofer L, Londei A, Dervic E, Desvars-Larrive A, Loreto V, et al. Ranking the effectiveness of worldwide COVID-19 government interventions. Nat Hum Behav 2020; 4:1303-12.. However, as important as measuring the effectiveness of policies to deal with the pandemic is to understand which challenges are associated with their adoption and the factors that determine this process. Numerous studies in the fields of social sciences and public policies have attempted to provide answers to these questions ⁵5. Boin A, Lodge M, Luesink M. Learning from the COVID-19 crisis: an initial analysis of national responses. Policy Design and Practice 2020; 3:189-204.^,66. George B, Verschuere B, Wayenberg E, Zaki BL. A guide to benchmarking COVID-19 performance data. Public Adm Rev 2020; 80:696-700.^,77. Kettl DF. States divided: the implications of American federalism for COVID-19. Public Adm Rev 2020; 80:595-602.^,88. Toshkov D, Carroll B, Yesilkagit K. Government capacity, societal trust or party preferences: what accounts for the variety of national policy responses to the COVID-19 pandemic in Europe? J Eur Public Policy 2021; Ahead of print.^,99. Van Dooren W, Noordegraaf M. Staging science: authoritativeness and fragility of models and measurement in the COVID-19 crisis. Public Adm Rev 2020; 80:610-5.^,1010. Weible CM, Nohrstedt D, Cairney P, Carter DP, Crow DA, Durnová AP, et al. COVID-19 and the policy sciences: initial reactions and perspectives. Policy Sci 2020; 53:225-41.^,1111. Yang K. Unprecedented challenges, familiar paradoxes: COVID-19 and governance in a new normal state of risks. Public Adm Rev 2020; 80:657-64.. Such studies have generally highlighted that the way countries have reacted to the pandemic is a function of the existing public administrative systems’ capacities and characteristics. Particularly interesting are the results of a comparative study on decision-making in relation to COVID-19 involving 16 countries on five continents, suggesting that the diversity of responses is associated with preexisting weaknesses in three conjugated systems - public health, the economy, and the political system ¹²12. Jasanoff S, Hilgartner S, Hurlbut JB, O¨zgo¨de O, Rayzberg M. Comparative Covid response: crisis, knowledge, politics. Ithaca: CompCoRe Network, Cornell University; 2021.. Thus, even countries which had well-structured national immunization programs (e.g., Brazil) and those with major availability of financial and technological resources (e.g., United States) responded chaotically, due to other preexisting weaknesses such as high levels of socioeconomic inequality and political polarization. More recently, numerous challenges have emerged in efforts to immunize the population against COVID-19, including the on-going development of safe and effective vaccines, their global distribution, and the implementation of vaccination programs within countries ¹³13. Forman R, Shah S, Jeurissen P, Jit M, Mossialos E. COVID-19 vaccine challenges: what have we learned so far and what remains to be done? Health Policy 2021; 125:553-67.^,1414. Wouters OJ, Shadlen KC, Salcher-Konrad M, Pollard AJ, Larson HJ, Teerawattananon Y, et al. Challenges in ensuring global access to COVID-19 vaccines: production, affordability, allocation, and deployment. Lancet 2021; 397:1023-34.^,1515. Abi Younes G, Ayoubi C, Ballester O, Cristelli G, de Rassenfosse G, Foray D, et al. COVID-19: insights from innovation economists. Science and Public Policy 2020; 47:733-45..

Three articles in this edition of CSP aim to encourage this discussion. In Global Challenges for Equitable Access to COVID-19 Vaccination, Souza & Buss ¹⁶16. Souza LEPF, Buss PM. Desafios globais para o acesso equitativo à vacina contra a COVID-19. Cad Saúde Pública 2021; 37:e00056521. call attention to the need to expand the global vaccination production capacity while adopting ethical and epidemiological criteria for the vaccines’ distribution across different countries and population groups. Two strategies could contribute to increasing vaccine production on the global scale: the generalization of technology transfer processes, such as the partnerships between the Butantan Institute and Sinovac and Oswaldo Cruz Foundation (Fiocruz) and AstraZeneca, and the temporary suspension of intellectual property rights. However, the latter strategy has encountered resistance from several developed countries, who claim that a temporary patent suspension would not only jeopardize the development of new vaccines but would also be an ineffective measure, since most developing countries lack the installations, technologies, and qualified professionals for their production. As for the vaccines’ distribution, the authors emphasize that the creation of the Covax Facility is an important initiative, although limited, and that international competition for the available doses has contributed to unfair distribution of vaccines between countries. In Brazil, these problems have been exacerbated by the federal government, including delays in the purchase and distribution of vaccines and absence of national vaccination campaigns. Recalling that “no one is safe until everyone is safe” ¹⁶16. Souza LEPF, Buss PM. Desafios globais para o acesso equitativo à vacina contra a COVID-19. Cad Saúde Pública 2021; 37:e00056521. (p. 4), the authors argue that equitable access to vaccines will only be achieved through pressure by civil society on governments and multilateral agencies, forcing them to adopt “effective health diplomacy”.

The development and acquisition of COVID-19 vaccines in Brazil have been aggravated by the adoption of fiscal austerity policies focused on reducing public spending in the recent period. This topic is explored in the article Fiscal Austerity and Its Effects on the Brazilian Health Economic-Industrial Complex in the Context of the COVID-19 Pandemic, by Aragão & Funcia ¹⁷17. Aragão ES, Funcia FR. Austeridade fiscal e seus efeitos no Complexo Econômico-Industrial da Saúde no contexto da pandemia da COVID-19. Cad Saúde Pública 2021; 37:e00100521.. The article’s central argument is that external technological dependence in health products contributed to leaving the Brazilian population even more vulnerable during the pandemic - and that this vulnerability is associated with two phenomena exacerbated by fiscal austerity policies: chronic underfinancing of the Brazilian Unified National Health System (SUS) and the weakness of sectors comprising the Health Economic-Industrial Complex. In the case of underfinancing of the SUS (or would it be more appropriate to say funding cuts or freezes?), the authors emphasize the negative effects of Constitutional Amendment 95 on public spending in health, with estimated losses of more than BRL 20 billion (USD 4 billion) from 2018 to 2020. This reduced the capacity of the SUS to guarantee universal and equal access to health actions and services and to offer responses in moments of great pressure on the system, as in the case of the COVID-19 pandemic. Equally negative were the effects of austerity policies on budgets for research, development, and innovation in health, further undermining the country’s productive and technological base and aggravating its dependence on imported products and inputs. A typical case involves the active pharmaceutical ingredients used by Butantan and Fiocuz in the production of COVID-19 vaccines, frequently stalled due to the interruption or delay in the international supply. As highlighted by the authors, both the specialized literature and international experience have demonstrated the failure of austerity policies, which are not capable of “the combination of productive logic and social logic” ¹⁷17. Aragão ES, Funcia FR. Austeridade fiscal e seus efeitos no Complexo Econômico-Industrial da Saúde no contexto da pandemia da COVID-19. Cad Saúde Pública 2021; 37:e00100521. (p. 3), thereby evidencing the need to replace such policies.

Finally, Carvalho et al. ¹⁸18. Carvalho AR, Souza LR, Gonçalves SL, Almeida ERF. Vulnerabilidade social e crise sanitária no Brasil. Cad Saúde Pública 2021; 37:e00071721. discuss the hypothesis that social vulnerability and poverty amplify the effects of the health crisis, in their article Social Vulnerability and Health Crisis in Brazil. The authors argue that the pandemic has affected the most vulnerable groups more intensely, including ethnic and racial minorities, unemployed individuals and/or those with low schooling, temporary workers, workers subject to unhealthy and hazardous conditions, and individuals living in underserved areas and substandard housing. Another aspect addressed in the article is the importance, for families living in poverty, of earnings not related directly to paid work, such as retirement benefits, pensions, unemployment insurance, and income transfer programs. Using data from the Brazilian National Household Sample Survey (PNAD), the authors mention for example that 75% of chronically poor Brazilian families received some of these earnings from 2017 to 2019, while more than 70% of poor and extremely poor families had some member who was a beneficiary of the Emergency Aid, one of the benefits created by Law n. 13.982/2020, in response to COVID-19. These data allow verifying the importance of these sources of income for guaranteeing a minimum standard of consumption and well-being for an important share of the Brazilian population before and during the pandemic. Furthermore, estimates suggest that such sources contribute effectively to reducing the levels of poverty and inequality. However, the temporary nature of some of these benefits, such as the Emergency Aid, raises doubts on their perennial effects. The authors acknowledge the fundamental role of the SUS for serving the population’s health needs and underline the importance of comprehensive public policies for “overcoming the country’s inequality, which has been reinforced and exacerbated by the pandemic” ¹⁸18. Carvalho AR, Souza LR, Gonçalves SL, Almeida ERF. Vulnerabilidade social e crise sanitária no Brasil. Cad Saúde Pública 2021; 37:e00071721. (p. 4).

By underscoring political, economic, and social issues, the three articles converge with the approach proposed by Horton ¹⁹19. Horton R. Offline: COVID-19 is not a pandemic. Lancet 2020; 396:874., who calls attention to the need for a “syndemic” understanding of COVID-19 and the ways of confronting it, emphasizing that “the pursuit of a purely biomedical solution to COVID-19 will fail” ¹⁹19. Horton R. Offline: COVID-19 is not a pandemic. Lancet 2020; 396:874. (p. 874). They thus contribute to deepening the debate on the conditioning factors and effects of the COVID-19 pandemic in its multiple dimensions.

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