COVID-19 has upended the world’s healthcare infrastructures and its economies, casting a glaring light on the failings and flaws already in place, all suffered unequally. This has forced leaders and the public at large to face the stark contrast between human society as it exists and the society that is possible, with both the world’s majority and the planet leaping to the top of a new agenda...an agenda as urgently needed as a new vaccine.

The pandemic has revealed the fatal results of the decades-long systematic dismantling of public institutions, including those for health care. Nowhere is this more evident than in the Americas and Latin America in particular, which remains the world’s most unequal region.[¹1. Latin America remains the most unequal region in the world: Oxfam International Blogs [Internet]. Oxfam International Blogs. 2017 [cited 2020 May 6]. Available at: https://blogs.oxfam.org/en/blogs/17-12-18-latin-america-remains-most-unequal-region-world/index.html
https://blogs.oxfam.org/en/blogs/17-12-1... ] Latin America and the Caribbean are facing an uphill battle in confronting both the virus and the economic recession following close on its heels. While the pandemic has hit the region later than some others, allowing countries to learn from other nations’ efforts to flatten their curves, many will struggle due to their weakened public health structures and limited ability to scale up public health and social programs. Unemployment in the region is expected to rise sharply, especially for those in the informal economy, who are among the most vulnerable. A reduction in trade and tourism will exacerbate economic contraction, and pre-existing inequalities driven by social conflict and poverty are likely to be reinforced.[²2. Economic Commission for Latin America and the Caribbean (ECLAC). Measuring the impact of COVID-19 with a view to reactivation. New York: United Nations; 2020 Apr 21. 21 p.,³3. Werner A. COVID-19 Pandemic and Latin America and the Caribbean: Time for Strong Policy Actions [Internet]. Washington, D.C.: International Monetary Fund, IMF Blog; 2020 Mar 19 [cited 2020 May 4]; [about 3 screens]. Available at: https://blogs.imf.org/2020/03/19/covid-19-pandemic-and-latin-america-and-the-caribbean-time-for-strong-policy-actions/
https://blogs.imf.org/2020/03/19/covid-1... ]

In a MEDICC Review exclusive, Alicia Bárcena, Executive Secretary of the UN Economic Commission for Latin America and the Caribbean (ECLAC) outlines the extent of COVID-19’s human and economic costs, and calls for “universal, redistributive and solidarity-based policies with a rights-oriented approach” that leave no one behind. She also argues that the dichotomy between revitalizing economies and protecting health is a false one, noting no economy can advance without a healthy workforce. Her interview introduces the “Leading Voices on COVID-19” section of this issue, reflecting the journal’s commitment to publishing the scientists, health and other professionals of Latin America and the Caribbean. The section, offering pointed, knowledgeable perspectives on COVID-related policy, strategies, ethics, research and clinical practice, intentionally begins with those of the Americas’ women leaders.

Fierce opposition to Bárcena’s assertion—that only solidarity-based policies and investing in public institutions can successfully address the pandemic and enable sustainable societies—will certainly be mounted by powerful defenders of private interests over public ones. Nevertheless, as pointed out by Dr Jeanette Vega, Chilean member of the Global Preparedness Monitoring Board, health as a public good is paramount if we are to overcome this crisis and successfully meet the next.

The Global Preparedness Monitoring Board was one of the most important voices warning of an impending pandemic, issuing its report in early fall 2019.[⁴4. Global Preparedness Monitoring Board [Internet]. Geneva: Global Preparedness Monitoring Board; c2020. Documents and Resources. A world at risk: annual report on global preparedness for health emergencies; 2019 [cited 2020 May 5]. 46 p. Available at: https://apps.who.int/gpmb/annual_report.html
https://apps.who.int/gpmb/annual_report.... ] And there were many others well before, all essentially unheeded by most of those in positions to make real prevention possible. Such sustainable prevention of course means redesigning not only society but also the relation between humans and our natural environment, given the zoonotic origin of these emerging and re-emerging diseases. MEDICC Review’s editorial team itself was unaware of the prescient nature of our expanded purview, announced in the January 2020 issue to: address “today’s critical interactions between human health, development of sustainable societies, and the health of our planet.”

Two of our leading voices this April delve into the need to reformulate relations between human activity and the environment: Dr Michele Barry of Stanford University, founder of WomenLift Health and Board Chair-elect of the Consortium of Universities for Global Health, notes our need to rethink this relationship beyond climate change to reorient all of human action. Drs Cárdenas-González and Álvarez-Buylla of Mexico’s National Council of Science and Technology (CONACYT) address anthropogenic environmental changes resulting from current livestock and agroindustrial models, sounding the alarm on their relation to novel disease outbreaks and calling for open, collaborative science to provide the evidence needed for a “One Health” policy framework.

Indeed, open science, interdisciplinary, intersectoral and international collaboration is a key theme running through this entire issue. Sharing research and findings—in such areas as diagnosis, treatment and vaccine development—is a scientific and ethical imperative. Nearly a dozen Cuban specialists underscore this approach while discussing novel therapeutic products, other research and clinical protocols in two roundtables: Bringing Cuban Biotech Research to Bear on COVID-19 and Cuba’s Pedro Kourí Tropical Medicine Institute: Battling COVID-19 One Study, One Test, One Patient at a Time.

In the spirit of sharing new perspectives, we also recommend the contribution by Dr Machado-Curbelo, chair of the Department of Clinical Neurophysiology at Cuba’s Institute of Neurology and Neurosurgery, who appeals for more research on the possible link between brainstem dysfunction and acute respiratory distress in patients with COVID-19.

If collaboration in the clinical realm is vital, perhaps even greater is this need when it comes to prevention and control strategies: discovering what are the most apparent challenges, and what is working to address them. Globally, we know the most vulnerable populations are the hardest hit, and while it’s been widely publicized that case-fatality rates are the highest for the elderly and those with pre-existing comorbidities like heart disease and diabetes,[⁵5. Oke J, Heneghan C. Global Covid-19 Case Fatality Rates [Internet]. Oxford: The Centre for Evidence-Based Medicine. 2020 Mar 17 [updated 2020 Apr 30; cited 2020 May 4]. Available at: https://www.cebm.net/covid-19/global-covid-19-case-fatality-rates/
https://www.cebm.net/covid-19/global-cov... ] we are also seeing stark divisions along lines of race/ethnicity and socioeconomic status,[⁶6. Wendland T. African Americans In Louisiana Are Dying At An Alarming Rate During Pandemic [Internet]. Washington, D.C.: National Public Radio (NPR); 2020 Apr 7 [cited 2020 May 4]; [about 3 screens]. Available at: https://www.npr.org/2020/04/07/828688358/african-americans-in-louisiana-are-dying-at-an-alarming-rate-during-pandemic
https://www.npr.org/2020/04/07/828688358... ] which are as predictable as they are understudied.[⁷7. Kendi IX. Why Don’t We Know Who the Coronavirus Victims Are? [Internet]. Washington, D.C.: The Atlantic; 2020 Apr 2 [cited 2020 May 4]. Available at: https://www.theatlantic.com/ideas/archive/2020/04/stop-looking-away-race-covid-19-victims/609250/
https://www.theatlantic.com/ideas/archiv... ] Systemic racism and implicit bias, combined with structural inequalities in access to primary care and other resources, leave marginalized populations with the triple burden of excessive risk factors, pre-existing chronic conditions and less access to health care at any level—much less the ability to navigate health systems in these times of crisis.

A strong, universal health system incorporating intersectoral policies and specific strategies designed for the most vulnerable is the approach used in Cuba, as discussed by Dr Castell-Florit of the National School of Public Health and Dr Durán, National Director of Epidemiology at Cuba’s Ministry of Public Health. Facing resource constraints, the Cuban approach has to take full advantage not only of its strong biotech and infectious disease experts, but also its formidable primary care subsystem, posting some 20,000 family doctors and nurses throughout the country. Their COVID-19 experience, contribution and protocols are detailed in two articles this issue: Mobilizing Primary Health Care: Cuba’s Powerful Weapon against COVID-19 and COVID-19 Case Detection: Active Screening Approach. Readers will find in Cuba’s COVID-19 Strategy: Main Actions through April 23, 2020 a complete chronology of main public health and intersectoral actions taken in Cuba to confront the pandemic.

Yet, Cuba too faces uphill battles, as burgeoning home and institutional access to Internet threatens to introduce misinformation and disinformation with the “infodemic” accompanying COVID-19, as the paper by Dr Alonso-Galbán and Alemañy-Castilla asserts; and waning risk perception as a result of relatively low case numbers (under 2000 as of April 30), is a continuing concern to health authorities and professionals across the country.

As a journal, we are party to what we believe are important international forums for broadening communication and urging greater collaboration: MEDICC Review is among over 300 signatories of an open letter to UN Secretary-General António Guterres calling for the formation of a WHO Global Health Equity Task Force charged with coordinating a global response for fair needs-based resource allocation to all countries facing the COVID-19 pandemic.[⁸8. Chiriboga D, Buss P, Garay J, Tobar S, Galvao LA. Open letter to the United Nations Health Inequity during the Pandemic: A Cry for Ethical Global Leadership [Internet]. [place unknown]: Sustainable Health Equity; [date unknown; cited 2020 May 4]. 2 p. Available at: https://static1.squarespace.com/static/5ea092b0deed6c2ca1d50f8a/t/5eabdc788536765024972f8e/1588321402570/UN Letter standalone.pdf
https://static1.squarespace.com/static/5... ] Undoubtedly, WHO deserves greater support than ever from governments worldwide. And MEDICC Review was a co-sponsor, with Cuba’s Pedro Kourí Tropical Medicine Institute, of the first bilateral teleconference involving Cuban and US researchers and health professionals, learning from each other to more successfully stem the spread of COVID-19 and obtain better patient results.

We are also witness once again to Cuban cooperation in health, this time specifically to assist other countries’ response to the pandemic: the Henry Reeve Emergency Medical Contingent now has teams in more than 20 countries, reflected in our feature Global Collaboration in Times of COVID-19: Cuba’s Emergency Medical Contingent by senior editor Gorry, the only US journalist who has bunked with these health professionals (in Pakistan and Haiti). Interestingly, at least one team is comprised entirely of women, and another entirely of nurses.

New York City’s “pandemic epicenter” is also the scene of Cuban cooperation, this time involving dozens of US physicians trained on full scholarships at the six-year Latin American School of Medicine in Havana. MEDICC Review offers the experience of one: Dr Joaquín Morante, a pulmonologist and critical care specialist, who is an attending physician at Jacobi Medical Center in The Bronx, a public hospital affiliated with the Albert Einstein College of Medicine.

At the same time that Cuban health professionals and foreign graduates of its medical schools collaborate to confront the pandemic, the US administration has not only refused to lift its sanctions, but has actually toughened them, blocking vital supplies for Cuba’s health system. In fact, the US has seized much-needed food, medical supplies and pharmaceuticals that would otherwise have been destined for Cuba. This journal joins UN human rights experts in calling for an immediate end to US sanctions against Cuba, and in times of COVID-19, against all other countries. As these experts point out: the sanctions undermine the ability of countries to respond to the COVID-19 pandemic and will cost lives.[⁹9. United Nations [Internet]. New York: United Nations; c2020. UN News. Lift Cuba embargo or risk many lives lost to COVID-19, UN rights experts warn; 2020 Apr 30 [cited 2020 May 4]; [about 3 screens]. Available at: https://news.un.org/en/story/2020/04/1062982
https://news.un.org/en/story/2020/04/106... ]

As we go forward, MEDICC Review will continue to publish interviews, peer-reviewed scientific manuscripts, and perspectives on COVID-19 from some of the most engaged scholars and physicians throughout Latin America and the Caribbean, and we will do so under the guiding principles of equity, evidence-based science and solidarity. We are, after all, in this together.

P.S. On a personal note, two members of our editorial team are preparing to welcome new family members in the midst of this pandemic: Executive Editor Gail Reed is expecting a grandchild this spring, and Dr Caitlin Baird, Senior Editor of our English edition, is expecting her first child at the end of May. These two children will be among the first of the cohort now referred to as “Generation C,”[¹⁰10. Yong E. How the Pandemic Will End [Internet]. Washington, D.C.: The Atlantic; 2020 Mar 25 [cited 2020 May 4]; [about 8 screens]. Available at: https://www.theatlantic.com/health/archive/2020/03/how-will-coronavirus-end/608719/
https://www.theatlantic.com/health/archi... ] born into a world irrevocably shaped by the coronavirus pandemic, and we can’t help but wonder what kind of world that will be. In the words of Julia Belluz, Senior Health Correspondent at Vox, we’re curious if this will be a world “where pandemics, climate devastation, and financial crises that seemed far-fetched only weeks ago will be the norm, or one where the intelligence and good in society—the spirit of cooperation—will prevail, and we finally start preparing long before new, catastrophic threats emerge. In the latter version, people work together on evidence-based measures to deal with these predictable risks of globalization. I’m hoping desperately for that reality.”[¹¹11. Belluz J. What it’s like to have a baby during the coronavirus pandemic [Internet]. Washington, D.C.: Vox Media; 2020 Mar 18 [cited 2020 May 4]. Available at: https://www.vox.com/2020/3/18/21172874/coronavirus-pandemic-having-a-baby-pregnancy-hospitals
https://www.vox.com/2020/3/18/21172874/c... ] We are, too.

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